Introduction
Non-alcoholic fatty liver disease (NAFLD) associated with obesity and type 2 diabetes mellitus (T2DM) is now the most common chronic liver disease (CLD) worldwide and is reported to be a rising cause of advanced liver disease, primary liver cancer and liver-related mortality.1 However, it is difficult to determine an accurate prevalence of NAFLD-related cirrhosis and complications because it appears to be under-represented in databases that contain codes for disease aetiology and causes of death.
In a population-based study that examined International Classification of Diseases (ICD), Tenth Revision, Australian Modification (ICD-10-AM) codes among all people treated in hospital for cirrhosis in Queensland, Australia, during 2008-2016, only 4.8% of patients had a coded disease aetiology of NAFLD or non-alcoholic steatohepatitis (NASH).2 While the proportion of patients admitted with NAFLD/NASH-related cirrhosis increased from 3.6% in 2008-2010 to 6.0% in 2014-2016 (p<0.00001),2 this is likely an under-representation of disease prevalence based on observational and cohort studies, as well as modelling of NAFLD in Australia.3 4
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Similar findings have been reported elsewhere. NAFLD prevalence is underestimated in US Medicare datasets and administrative databases that define NAFLD using ICD codes.5 6 In European primary healthcare databases, the pooled prevalence of NAFLD was 1.9%,7 far less than the expected community prevalence of 20%-30%. In order to reduce misclassification of NAFLD in population-based data, some authors have used an extended definition of NAFLD that included cryptogenic liver disease or cirrhosis in the presence of metabolic abnormality and the absence of other causes of liver disease5 or inferred data from the prevalence of obesity and T2DM.8 However, these methods also rely on the accuracy of clinical documentation and administrative coding, which may be influenced by country-specific codes and coding rules. In Australia, only 3.7% of admissions with cirrhosis had a coded diagnosis of obesity2 despite a prevalence of obesity of 31% in Australian adults,9 illustrating the failure to capture or document important patient data that would help to determine liver disease aetiology or comorbidity.
Determining the accuracy of ICD coding in hospital admission data is necessary to understand the limitations and improve the reliability of health system databases for epidemiological studies and health services research. The primary aim of this study was to evaluate the performance and limitations of ICD-10-AM codes to identify NAFLD/NASH in admitted patient encounters with cirrhosis at a major tertiary hospital. The secondary aims were to investigate the accuracy of ICD-10-AM coding for NAFLD risk factors (obesity and T2DM) and other aetiologies of cirrhosis, namely alcohol-related liver disease (ALD), chronic hepatitis C virus (HCV) and hepatitis B virus (HBV) infection.
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