European Journal of Heart Failure

European Journal of Heart Failure 2005 7(5):787-791; doi:10.1016/j.ejheart.2004.12.007

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© 2005 European Society of Cardiology

The validity of a diagnosis of heart failure in a hospital discharge register

Erik Ingelsson^a,*, Johan Ärnlöv^a, Johan Sundström^a and Lars Lind^b,c

^a Department of Public Health and Caring Sciences, Section of Geriatrics Uppsala University, Box 609, SE-75125 Uppsala, Sweden
^b Department of Medical Sciences Uppsala University, Sweden
^c Astra Zeneca R&D Mölndal, Sweden

^* Corresponding author. Visiting address: Kälsängsgränd 10D, 753 19, Uppsala, Sweden. Tel.: +46 18 6117662; fax: +46 18 6117976. E-mail address: erik.ingelsson{at}pubcare.uu.se

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
Background and aims: The accuracy of a diagnosis of heart failure (HF) in hospital discharge registers is largely unknown. We aimed to determine the validity of such a diagnosis in the Swedish hospital discharge register.

Methods and results: In a population-based study of 2322 middle-aged men (the ULSAM study), 321 participants were diagnosed with HF according to the Swedish hospital discharge register, during a median follow-up time of 29 years. A review board examined the validity of the diagnosis according to the European Society of Cardiology definition of HF.

Eighty-two percent of the possible cases were classified as having definite HF. An echocardiographic examination increased the validity to 88%. For patients treated at an internal medicine or cardiology clinic the validity was 86% and 91%, respectively. If HF was the primary diagnosis, the validity was 95%, irrespective of clinic type.

Conclusion: The HF diagnosis in the Swedish hospital discharge register appears slightly less precise than for acute myocardial infarction and stroke. For population-based research, only those with a primary diagnosis of HF in the hospital discharge register should be regarded as definite HF cases, or alternatively the cases should be validated individually.

Key Words: Heart failure • Hospital discharge register • Epidemiology • Validity

Received April 19, 2004; Revised October 25, 2004; Accepted December 20, 2004

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
In epidemiological studies, clinical disease end-points are often assessed using health registers. The reliability of such studies is dependent on the quality of the register data, which varies between different regions and different diagnoses. In many countries, data on hospitalizations are recorded in a national hospital discharge register. The overall quality of the Swedish hospital discharge register is commonly regarded as high, and the validity of the register has been evaluated for some diagnoses, e.g. acute myocardial infarction and acute stroke [1,2]. The reliability of these cardiovascular diagnoses in the register has been shown to be high, but to date, little is known about the validity of the diagnosis of heart failure (HF) in the Swedish, or any other, hospital discharge register.

The prevalence and incidence of HF is rising with higher age in both men and women [3,4], and the age-adjusted mortality for HF patients is four to eight times that of the general population [5], although recent reports suggest an improving prognosis [6,7]. HF is commonly described as a syndrome, caused by cardiac dysfunction, and is recognized by a constellation of signs and symptoms, however, there is no unequivocal definition of HF. There are several diagnostic definitions for HF, which use clinical criteria [8–14], with varying sensitivities and specificities, depending on the severity of HF and the degree of certainty in the diagnosis [15]. These diagnostic schemes usually comprise combinations of clinical signs and symptoms of HF, laboratory blood and radiological examinations. Assessments of left ventricular filling pressures or systolic function indices may or may not be included in the diagnostic criteria. As left ventricular systolic function is normal in a large proportion of HF patients [16–19], schemes that do not rely on a measurement of systolic function are possibly to be preferred. The definition of HF proposed by the European Society of Cardiology (ESC), is intended to be used in clinical practice, clinical trials and epidemiological research [14], and is based on both symptoms of HF and objective evidence of cardiac dysfunction at rest. In cases where the diagnosis is in doubt, the response to HF treatment is a useful check of the diagnosis.

Studies examining the validity of the HF diagnosis in different European and American patient samples have been published [20–22], but to our knowledge there is no published study of the validity of a HF diagnosis in any national hospital discharge register. Since the clinical definition of HF is less certain than that of acute myocardial infarction, we hypothesized that the hospital discharge register diagnosis of HF would be less valid. The primary aim of the present study was to determine the validity of a given diagnosis of HF in the Swedish hospital discharge register against the ESC definition, in order to be able to use this diagnosis as an end-point in future epidemiological studies of HF in Sweden. Secondary aims were to investigate if the presence of an echocardiographic examination, the type of hospitalization clinic or the position of the diagnosis code changed the accuracy of the HF diagnosis.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
2.1. Study population
This study uses the ULSAM (Uppsala Longitudinal Study of Adult Men) cohort, which is a health investigation aimed at identifying metabolic risk factors for cardiovascular disease. All 50-year-old men living in Uppsala, Sweden in 1970–1974 were invited (2841 men) to participate in the ULSAM study. Of these, 82% (2322 men) participated in the investigation [23]. In addition to regular re-examinations, the data has been completed with annual updates on mortality and in-hospital morbidity using national registers. The ULSAM study is described in detail on the Internet (http://www.pubcare.uu.se/ULSAM/). All subjects gave written consent and the Ethics Committee of Uppsala University approved the study.

2.2. Registers
The Swedish hospital discharge register is administered by the National Board of Health and Welfare, which started to collect data on individual patients who had been treated as in-patients at public hospitals, in the 1960s. For some 20 years, not all of the county councils reported their hospitalization data to the register since it was not compulsory. However, since 1987 when reporting was made compulsory, the hospital discharge register records all in-patient care in Sweden. It contains the dates of hospital admissions and discharges, hospital and clinic codes and up to six coded discharge diagnoses, the first being the principal cause of hospitalization. The register uses the codes of the International Classification of Diseases (ICD), edition eight (ICD-8) until the end of 1986, edition nine (ICD-9) from 1987 to the end of 1996 and edition ten (ICD-10) from 1997 onwards.

2.3. Selection of possible cases from the Swedish hospital discharge register
The ULSAM participants were linked to the Swedish hospital discharge register using the unique personal identification number of all citizens of Sweden. The diagnosis of HF was allowed in any of the six possible diagnosis positions in the hospital discharge register. As a diagnosis of HF, we considered ICD heart failure codes 427.00, 427.10, 428.99 (ICD-8), 428 (ICD-9), I50 (ICD-10) and hypertensive heart disease with heart failure, I11.0 (ICD-10). Three hundred and twenty-one men had a hospital discharge register diagnosis of HF between entry into the ULSAM study and the end of 2001, with the first subject registered with a diagnosis in 1976. The median follow-up time was 29 years. If a subject had multiple hospital discharge register diagnoses of HF over the years, only the first occasion was considered in the present analysis.

2.4. Data collected for review
Medical records, including referral notes, radiology reports, ECG reports, echocardiography reports if available, other journal records during the hospital stay and the discharge records were collected for each person with a diagnosis of HF in any diagnosis position in the hospital discharge register. Out of the 321 cases, two were excluded because of insufficient hospital and clinic coding in the hospital discharge register and two were excluded as their medical records could not be found, despite extensive searching in the archives.

2.5. Diagnostic classification
The hospital discharge register cases were then classified by a review board consisting of two experienced doctors, who accessed all the journal records described above, and classified the cases as either, definite, questionable or miscoded. The classification relied on the definition proposed by the European Society of Cardiology [14]. Thus, to be classified as a definite HF case, there had to be symptoms and signs of HF and "objective evidence" of cardiac dysfunction at rest. In cases of doubt, the response to HF treatment was a useful check of the diagnosis. The required "objective evidence" was echocardiography, however, since the study commenced prior to the widespread availability of echocardiography, electrocardiography and X-ray were also considered acceptable when an echocardiography report was not available. The hospital discharge register cases where the review board could not find supporting evidence of HF according to the ESC definition were classified as questionable. For example, left ventricular dysfunction classified by echocardiography but without symptoms of HF, or breathlessness without objective evidence of HF were both classified as questionable. In questionable cases the review board also looked at any previous and subsequent admissions to clarify the diagnosis. In the few cases where a possible case was coded with an obviously incorrect ICD-code, the case was classified as miscoded.

2.6. Statistical methods
The percentage of subjects with a register diagnosis of HF receiving a definite diagnosis in the review process was used to assess the validity of the hospital discharge register (positive predictive value). The hospital discharge register cases were divided into different sub-groups on the basis of which clinic they were hospitalized at (internal medicine, cardiology, lung medicine or other), if they underwent an echocardiographical examination during or within a few weeks of the hospital stay, and which position the HF diagnosis code was given (position 1, position 2 and position 3–6). All calculations were performed using JMP 3.2 (SAS Institute, Cary, NC, USA).

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
A total of 317 possible HF cases were enrolled in the study, based on the hospital discharge register diagnosis. Using the ESC definition, 259 (82%) of the possible hospital discharge register cases were classified as having definite HF by the review board. The presence of an echocardiographical examination increased the validity to 88%, and the absence of an echocardiographical examination gave a diagnostic validity of 76%. For patients treated at an internal medicine or cardiology clinic the validity was 86% and 91%, respectively. Furthermore, if the diagnosis was in the first position in the hospital discharge register (primary diagnosis) the validity was 95%. The percentages and total numbers of cases that were classified as definite, questionable or miscoded in different sub-groups are listed in Table 1. For patients treated at an internal medicine or cardiology clinic with a primary diagnosis of HF, the validity was 96%. When examining if the validity had changed over time, we could see that the highest validity was found in the earliest diagnosis dates, and had fallen from 88% to 78% during the last decade. This trend was not altered by the presence or non-presence of echocardiography (Table 2).

View this table: [in this window] [in a new window]   Table 1 Validity of the heart failure diagnosis in the hospital discharge register using the European Society of Cardiology definition as gold standard

 

View this table: [in this window] [in a new window]   Table 2 Validity of the heart failure diagnosis in the hospital discharge register over time using the European Society of Cardiology definition as gold standard

 

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
In the present study, we examined the validity of the diagnosis of HF in the Swedish hospital discharge register. Eighty-two percent of the HF cases in the hospital discharge register were classified as having definite HF according to the ESC definition. The validity of the hospital discharge register HF diagnosis was markedly higher in patients treated at an internal medicine or cardiology clinic, or when it was the primary diagnosis. We also found a tendency of decreasing diagnosis validity over time, and that the presence of an echocardiographical examination increased the validity only slightly. To our knowledge there is no published original study concerning the validity of the HF diagnosis in any national hospital discharge register, but in a recent preliminary report, the validity of the Scottish hospital discharge codes for HF was similar to our results [24]. In this report it was also concluded that the ICD codes alone failed to capture many HF admissions, and that using the hospital codes alone would underestimate the total burden of HF.

Previous validation studies of other cardiovascular diseases, such as acute myocardial infarction [1,2,25] and stroke [2,26], have shown a validity of approximately 95% in the hospital discharge registers in different countries, including Sweden. Since HF is a more complex disease to diagnose, with symptoms and signs that can easily be misinterpreted, this lower validity is not unexpected.

The presence of an echocardiographic examination increased the validity only slightly. This illustrates that HF is a disease defined by a constellation of clinical symptoms and signs, not just a measurement of left ventricular dysfunction. It may also reflect the clinician's uncertainty when facing the fact that echocardiographic left ventricular systolic function is normal in one out of two to three elderly patients with definite HF [16–19], in whom diastolic dysfunction may be the primary cause. The HF diagnosis in patients with a normal systolic function relies more heavily on clinical symptoms and signs, laboratory and X-ray findings and response to treatment.

Interestingly, diagnostic validity appeared to decrease over the last two decades. The trend was not dependent of the presence of echocardiography. This pattern might be a result of changed routines for examination and investigation of patients in later years, with a greater reliance on echocardiography and lesser use of pulmonary X-ray and clinical picture, which could have diminished the doctors' ability to correctly diagnose HF. More likely though, it is a result of less extensive medical records, i.e. not so carefully described signs and symptoms and shorter discharge records. This makes it harder to validate later hospital discharge register cases as definite, since this is a retrospective study. Another possible explanation of the decreasing validity over time may reflect that the study population has become 25 years older during the observation period and that diagnosing HF is more difficult in elderly people with a higher degree of co-morbidity. However, it should be noted that a longitudinal cohort study may not be the best study design to examine HF diagnosis validity at different time points. This observation therefore needs to be confirmed using cross-sectional studies at different time points.

Of course, some of the hospital discharge register cases that were classified as questionable could in fact be true HF cases, if the evidence in the medical records was insufficient. However, in future utilization of this cohort for HF studies, as in retrospective epidemiological population studies examining etiology and risk factors for HF generally, it is better to have some false negative cases in the large referent group, than false positive cases in the smaller case group. However, in other types of studies, e.g. assessment of the economic burden of HF or studies of total incidence and prevalence in the community, such high specificity at the expense of some sensitivity, should not be preferable.

A limitation of this study is that we only examined men of the same age with similar ethnic background (almost exclusively white), and from the same area of Sweden. Two hundred and eighty-nine (90%) of the discharges were from the local university hospital; hence the results could be biased by local routines. The results may therefore have limited generalisability to women and other age- and ethnic groups, as well as other settings. Strengths of the present study are the long follow-up time and the few cases lost to follow-up.

In conclusion, this study shows that the validity of the HF diagnosis in the Swedish hospital discharge register appears less precise than for other recently investigated cardiovascular diagnoses, such as acute myocardial infarction and stroke [1,2,25,26], at least when including all clinics and all diagnosis positions. However, when including only cases from internal medicine and cardiology clinics or cases with a primary diagnosis of HF, the validity is comparable to the above diagnoses. Our findings imply that for population-based research, only those with a primary diagnosis of HF in the hospital discharge register should be regarded as definite HF cases, or alternatively the cases should be validated individually.

	Acknowledgements

 
This study was supported by grants from Primary Health Care in Uppsala County, Royal Scientific Society Foundation (Kungliga vetenskapssamhällets fond), Swedish Heart Lung Foundation (Hjärt-Lungfonden) and Thuréus Foundation.

	References

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