Validation of Algorithms to Identify Acute Myocardial Infarction, Stroke, and Cardiovascular Death in German Health Insurance Data

Figures & data

Table 1 Excerpt from a Fictitious Exemplary Patient Profile for AMI Validation

ID	Age	Sex	Days from Event	Source	Code	Description of Code (German Modification)	Setting	Diagnosis Type	Physician Specification
1	75	F	−85	ICD	E789	Disorder of lipoprotein metabolism, unspecified	Outpatient	Certain	Primary care
1	75	F	−85	ICD	I109	Essential hypertension, unspecified	Outpatient	Certain	Primary care
1	75	F	−85	ICD	E049	Nontoxic goiter, unspecified	Outpatient	Certain	Primary care
1	75	F	−85	ICD	E039	Hypothyroidism, unspecified	Outpatient	Certain	Primary care
1	75	F	−85	ICD	G473	Sleep apnea	Outpatient	Certain	Primary care
1	75	F	−85	ICD	E669	Obesity, unspecified	Outpatient	Certain	Primary care
1	75	F	−85	ICD	G560	Carpal tunnel syndrome	Outpatient	Suspected	Primary care
1	75	F	−85	ICD	M179	Osteoarthritis of knee, unspecified	Outpatient	Certain	Primary care
1	75	F	−85	ICD	M545	Low back pain	Outpatient	Certain	Primary care
1	75	F	−85	ATC	C10AA01	Simvastatin	Outpatient		Primary care
1	75	F	−85	ATC	A02BC02	Pantoprazole	Outpatient		Primary care
1	75	F	−85	ATC	C03CA04	Torasemide	Outpatient		Primary care
1	75	F	−85	ATC	H03AA01	Levothyroxine-Sodium	Outpatient		Primary care
1	75	F	−70	ICD	H333	Retinal break without retinal detachment	Outpatient	Status post	Ophthalmology
1	75	F	−70	ICD	H521	Myopia	Outpatient	Certain	Ophthalmology
1	75	F	−70	ICD	H522	Astigmatism	Outpatient	Certain	Ophthalmology
1	75	F	−70	ICD	H524	Presbyopia	Outpatient	Certain	Ophthalmology
1	75	F	−70	ICD	H310	Chorioretinal scars	Outpatient	Certain	Ophthalmology
1	75	F	−70	ICD	H269	Unspecified cataract	Outpatient	Certain	Ophthalmology
1	75	F	−70	ICD	Z961	Presence of intraocular lens implant	Outpatient	Certain	Ophthalmology
1	75	F	0	EBM	32150	Immunological detection of troponin I and/or troponin T	Outpatient		Primary care
1	75	F	0			Hospital Admission	Inpatient
1	75	F	0	ICD	I100	Benign essential hypertension	Inpatient	Secondary diagnosis
1	75	F	0	ICD	I251	Atherosclerotic heart disease	Inpatient	Secondary diagnosis
1	75	F	0	ICD	E782	Mixed hyperlipidemia	Inpatient	Secondary diagnosis
1	75	F	0	ICD	I214	Acute subendocardial myocardial infarction*	Inpatient	Main admission diagnosis, main discharge diagnosis
1	75	F	0	OPS	12752	Transarterial left heart catheter examination: coronary angiography, pressure measurement and ventriculography in the left ventricle	Inpatient
1	75	F	0	OPS	6002k0	Application of drugs, list 2: Eptifibatid, parenterally: 30 mg up to under 75 mg	Inpatient
1	75	F	0	OPS	883700	Percutaneous transluminal vascular intervention on heart and coronary vessels: Balloon angioplasty: Single coronary artery	Inpatient
1	75	F	0	OPS	8837m1	Percutaneous transluminal vascular intervention on heart and coronary vessels: Placement of a drug-eluting stent: 2 stents in one coronary artery	Inpatient
1	75	F	0	OPS	883b0c	Additional information on materials: Everolimus-eluting stents or OPD systems with other polymer	Inpatient
1	75	F	0	OPS	883b50	Additional information on materials: Use of a modelling or double lumen balloon: 1 modelling balloon	Inpatient
1	75	F	0	OPS	883bc5	Additional information on materials: Use of a vascular occlusion system: resorbable plugs without anchor	Inpatient
1	75	F	0	OPS	8930	Monitoring of respiration, heart and circulation without measuring pulmonary artery pressure and central venous pressure	Inpatient
1	75	F	7			Hospital discharge, regular termination of treatment
1	75	F	8	ATC	B01AC06	Acetylsalicylic acid	Outpatient		Primary care
1	75	F	8	ATC	B01AC24	Ticagrelor	Outpatient		Primary care
1	75	F	8	ATC	C07AB07	Bisoprolol	Outpatient		Primary care
1	75	F	8	ATC	C10AA05	Atorvastatin	Outpatient		Primary care
1	75	F	8	ATC	C09AA05	Ramipril	Outpatient		Primary care
1	75	F	54	ICD	G560	Carpal tunnel syndrome	Outpatient	Certain	Neurology
1	75	F	54	EBM	27311	Clinical neurological basic diagnostics	Outpatient		Neurology
1	75	F	54	EBM	27331	Evaluation of a peripheral neuromuscular disease	Outpatient		Neurology
1	75	F	57	ICD	I2520	Old myocardial infarction: past 29 days to 4 months	Outpatient	Certain	Primary care
1	75	F	57	ICD	I2519	Atherosclerotic heart disease, unspecified	Outpatient	Certain	Primary care
1	75	F	57	ICD	E789	Disorder of lipoprotein metabolism, unspecified	Outpatient	Certain	Primary care
1	75	F	57	ICD	I109	Essential hypertension, unspecified	Outpatient	Certain	Primary care
1	75	F	57	ICD	E039	Hypothyroidism, unspecified	Outpatient	Certain	Primary care
1	75	F	57	ICD	G473	Sleep apnea	Outpatient	Certain	Primary care
1	75	F	57	ICD	E669	Obesity, unspecified	Outpatient	Certain	Primary care
1	75	F	57	EBM	3230	Problem-oriented medical consultation, which is necessary due to the nature and severity of the illness	Outpatient		Primary care
1	75	F	57	ATC	A02BC02	Pantoprazole	Outpatient		Primary care
1	75	F	57	ATC	H03AA01	Levothyroxine-Sodium	Outpatient		Primary care

Note: *Bold data indicate the inpatient discharge diagnosis defining the case.

Table 2 Agreement Between Reviewers Regarding AMI* Case Classification

		Reviewer 2
		Definite/Probable	Unlikely	Not Assessable
Reviewer1	Definite/probable	228^$	0	8	236
	Unlikely	7	4	1	12
	Not assessable	0	0	2	2
		235	4	11	250

Notes: *Acute myocardial infarction. ^$Bold text indicates numbers of cases where both reviewers agreed.

Table 3 Results of Validation of AMI*, Stroke and CV^$ Death Cases

Outcome	Sample	Sample size	Case classification				PPV^# (95% CI^§)
			Definite/probable	Unlikely	Cannot be excluded	Not assessable
Acute myocardial infarction	Total	250	242	6		2	97.6% (94.8–99.1)
	Stratified by sex
	Women	125	119	5		1	96.0% (90.8–98.7)
	Men	125	123	1		1	99.2% (95.6–100.0)
Stroke	Total	250	237	13		0	94.8% (91.3–97.2)
	Stratified by sex
	Women	125	119	6		0	95.2% (89.8–98.2)
	Men	125	118	7		0	94.4% (88.8–97.7)
	Stratified by stroke type
	Ischemic	173	170	3		0	98.3% (95.0–99.6)
	Hemorrhagic	74	64	10		0	86.5% (76.5–93.3)
	Unspecified	3	3	0		0	100% (29.2–100)
Cardio-vascular death	Total	250	199	18	32	1	79.9% (74.4–84.7)
	Stratified by sex
	Women	125	101	10	13	1	81.5% (73.5–87.9)
	Men	125	98	8	19	0	78.4% (70.2–85.3)

Notes: *Acute myocardial infarction. ^$Cardiovascular. ^#Positive predictive value. ^§Confidence interval.

Table 4 Agreement Between Reviewers Regarding Stroke Case Classification

		Reviewer 2
		Definite/probable	Unlikely	Not assessable
Reviewer1	Definite/probable	231*	2	4	237
	Unlikely	2	8	3	13
	Not assessable	0	0	0	0
		233	10	7	250

Note: *Bold text indicates numbers of cases where both reviewers agreed.

Table 5 Agreement Between Reviewers Regarding CV* Death Case Classification

		Reviewer 2
		Definite/probable	Cannot be excluded	Unlikely	Not assessable
Reviewer1	Definite/probable	162^$	6	2	0	170
	Cannot be excluded	28	20	19	3	70
	Unlikely	3	0	5	0	8
	Not assessable	2	0	0	0	2
		195	26	26	3	250

Notes: *Cardiovascular. ^$Bold text indicates numbers of cases where both reviewers agreed.