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Scientific Articles: Edmund Lau, Kevin Ong, Steven Kurtz, Jordana Schmier, and Av Edidin Mortality Following the Diagnosis of a Vertebral Compression Fracture in the Medicare Population J Bone Joint Surg Am 2008; 90: 1479-1486 [Abstract] [Full text] [PDF]

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Limitations of Using Large Databases for Clinical Research

Alan C. Dang, MD, R. Alexander Mohr, MD, Robert A. Arciero, MD   (25 September 2008)

Limitations of Using Large Databases for Clinical Research 25 September 2008
Alan C. Dang, MD, Orthopaedic Surgery Resident Dept of Orthopaedics, New England Musculoskeletal Institute, University of Connecticut Health Center, R. Alexander Mohr, MD, Robert A. Arciero, MD Send letter to journal: Re: Limitations of Using Large Databases for Clinical Research alan.dang{at}stanfordalumni.org Alan C. Dang, MD, et al.	To the Editor: Lau et al. described a correlation between vertebral compression fractures and mortality using Medicare data 1.  To identify vertebral compression fractures, the authors used ICD-9-CM diagnosis codes 733.13, 805.0, 805.2, 805.4, 805.6, or 805.8.  Rao’s invited commentary noted that these codes do not account for the etiology and fail to discern between idiopathic and pathologic fractures 2.  Patients with metastatic disease would likely have higher mortality rates than the age-matched population.  Unfortunately, these codes are not specific for vertebral compression fractures (see Table 1).  ICD-9-CM codes in the 805.x group account for any vertebral body, column, neural arch, pedicle, spinous process, or transverse process fracture 3.  This imprecision makes definitive conclusions problematic. Increases in mortality may be associated with injuries from high-energy trauma responsible for a Chance fracture without spinal cord injury.  The authors should only claim correlation between closed vertebral fractures of any type without spinal cord injury and mortality. This issue highlights a critical limitation of using a billing database with inadequate clinical information for clinical research.  As we evolve toward a fully electronic medical record (EMR), an unprecedented opportunity to revolutionize clinical research exists.  Rather than using an incomplete billing database or relying on sheer effort to review individual charts, we should develop EMRs that also optimize clinical research.  With a sophisticated EMR, compression fractures can be identified through key phrases in a discharge summary or an X-ray report.  The amount of vertebral collapse can be determined while addressing differences between a dictation of "approximately 50% collapsed" and measurements entered into the EMR as part of a research study.   Current EMRs store data in incompatible formats and will be bottlenecked for future clinical research.  Our advance in medical charting has been modest.  Current EMRs “merely” simplify and organize the creation of chart records, improve legibility, standardize care, and prevent medication interactions.  These improvements fix the problems of yesterday’s handwritten charts. We must be proactive and invest today to improve the quality of care in a completely novel way. This is not a call for a standardized EMR, but a call to standardize the language that describes those electronic records to maximize future research potential.  Current initiatives for electronic health record interoperability provide a framework upon which we can build the language needed for storing clinical information in a machine- interpretable form that can be semantically analyzed for future research. To call these changes a monumental undertaking is an understatement. They require much more than a simple request to software developers; rather, they require a collaboration among surgeons, clinical researchers, and software developers to critically consider the most effective methods we can use to record and use clinical information in the next decade.  Orthopaedic surgery is a field of innovation, a leader in minimally invasive surgery, materials science, regenerative medicine, and even computational science. Taking charge of our future starts today by being innovative in information science. Table 1: ICD-9-CM codes and description ICD-9-CM Code Description 733.13 Pathologic facture of vertebrae / Collapse of vertebra NOS 805.0 Closed fracture of cervical vertebra without mention of spinal cord injury  805.2 Closed fracture of dorsal (thoracic) vertebra without spinal cord injury 805.4 Closed fracture of lumbar vertebra without spinal cord injury 805.6 Closed fracture of sacrum and coccyx without spinal cord injury 805.8 Closed fracture of unspecified part of vertebral column without spinal cord injury   The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References 1. Lau E, Ong K, Kurtz S, Schmier J, Edidin A. Mortality following the diagnosis of a vertebral compression fracture in the Medicare population. J Bone Joint Surg Am. Jul 2008;90(7):1479-1486. 2. Rao RD. Commentary and Perspective on "Mortality Following the Diagnosis of a Vertebral Compression Fracture in the Medicare Population" by Edmund Lau, MS, et al. J Bone Joint Surg Am. Vol 90; 2008. 3. ICD-9-CM Professional for Physicians. Vol 1-2. Salt Lake City, Utah: Ingenix; 2008.

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