Table 3.
Synthetic Derivative Search Criteria for Risk Factor Determination
| Hypertension | ||
| Yes | Defined from combination of ICD9 coding and problem list search excluding common search confounders of the disease | Documentation of any of the following ICD9 codes: 401, 402, 403, 404, 405 OR All of the following criteria ● Presence of any of the following strings in the problem list: “hypertension”, “HTN” ● Presence of none of following strings in the problem list: “portal hypertension”, “pulmonary hypertension”, “RV hypertension”, “intracranial hypertension”, “pHTN” |
| No | Defined from lack of ICD9 code and lack of mention of disease in any clinical document | All of the following criteria: ● No documentation of ICD9 codes 401, 402, 403, 404, 405 ● No presence of any of the following strings in any clinical document: “Hypertension”, “HTN” |
| Unable to classify | Defined from lack of ICD9 coding but mention of disease in clinical document other than problem list | All of the following criteria: ● No documentation of any of the following ICD9 codes: 401, 402, 403, 404, 405 ● No presence of any of the following strings in the problem list: “hypertension”, “HTN” ● Presence of any of the following strings in any clinical document excluding problem list: “Hypertension”, “HTN” OR ● All of the following criteria: No documentation of any of the following ICD9 codes: 401, 402, 403, 404, 405 ● Presence of any of the following strings in the problem list: “portal hypertension”, “pulmonary hypertension”, “RV hypertension”, “intracranial hypertension”, “pHTN” |
| Coronary artery disease requiring intervention | ||
| Yes | Defined from combination of CPT coding and problem list search | Documentation of any of the following CPT codes: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33530, 33533, 33534, 33535, 33536, 92975, 92980, 92981, 92982, 92984, 92995, 92996 OR Presence of the any of the following strings in the problem list: “Coronary Artery Bypass”, “CABG”, “percutaneous coronary intervention”, “PCI” |
| No | Defined from lack of ICD9 and mention of disease in any clinical document | All of the following criteria: ● No documentation of any of the following CPT codes: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33530, 33533, 33534, 33535, 33536, 92975, 92980, 92981, 92982, 92984, 92995, 92996 ● No presence of any of following strings in any clinical document: “Coronary Artery Bypass”, “CABG”, “Percutaneous Coronary Intervention”, “PCI” |
| Unable to classify | Defined from lack of ICD9 coding but mention of disease in clinical document other than problem list | All of the following criteria: ● No documentation of any of the following CPT codes: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33530, 33533, 33534, 33535, 33536, 92975, 92980, 92981, 92982, 92984, 92995, 92996 ● No presence of the any of the following strings in the problem list: “coronary artery bypass”, “CABG”, “percutaneous coronary intervention”, “PCI” ● Presence of any of following strings in any clinical document other than the problem list: “coronary artery bypass”, “CABG”, “percutaneous coronary intervention”, “PCI” |
| Diabetes mellitus | ||
| Yes | Defined from combination of ICD9 coding and problem list search | Documentation of any ICD9 code that begins with 250 OR Presence of any of the following strings in the problem list: “diabetes mel”, “IDDM”, “NIDDM” |
| No | Defined from lack of ICD9 and mention of disease in any clinical document | All of the following criteria: ● No documentation of any ICD9 code that begins with 250 ● No presence of any of the following strings in any clinical document: “diabetes”, “IDDM”, “NIDDM” |
| Unable to classify | Defined from lack of ICD9 coding but mention of disease in clinical document other than problem list | All of the following criteria: ● No documentation of any ICD9 code that begins with 250 ● No presence of any of the following strings in the problem list: “diabetes mel”, “IDDM”, “NIDDM” ● Presence of any of the following strings in any clinical document: “diabetes”, “IDDM”, “NIDDM” |
| Statin use | ||
| Yes | Defined from presence of medication in medication search | Presence of any of the following in medication search: “atorvastatin”, “cerivastatin”, “fluvastatin”, “lovastatin”, “pravastatin”, “rosuvastatin”, “simvastatin”, “Altocor”, “Altoprev”, “Baycol”, “Caduet”, “Canef”, “Crestor”, “Lescol”, “Lipex”, “Lipitor”, “Lipobay”, “Lipostat”, “Mevacor”, “Pravachol”, “Simcor”, “Sortis”, “Torvacard”, “Torvast”, “Totalip”, “Tulip”, “Vytorin”, “Zocor” |
| No | Defined from lack of presence of medication in medication search | No presence of any of the following in medication search: “atorvastatin”, “cerivastatin”, “fluvastatin”, “lovastatin”, “pravastatin”, “rosuvastatin”, “simvastatin”, “Altocor”, “Altoprev”, “Baycol”, “Caduet”, “Canef”, “Crestor”, “Lescol”, “Lipex”, “Lipitor”, “Lipobay”, “Lipostat”, “Mevacor”, “Pravachol”, “Simcor”, “Sortis”, “Torvacard”, “Torvast”, “Totalip”, “Tulip”, “Vytorin”, “Zocor” |
Full Synthetic Derivative search criteria for hypertension, diabetes coronary artery disease and statin use are shown below. A combination of keyword search within problem lists and clinical charts, ICD9 codes, CPT codes and medication searches was used for each risk factor. All searches are case insensitive. ICD9: ninth revision of International Classification of Diseases.
Clinical documents includes clinical notes, procedure reports, radiology reports, problem lists, clinical communications, discharge summaries, patient letters, pathology reports or rehabilitation reports.