In Response to: Dicpinigaitis AJ, Ogulnick JV, Mayer AS, Gandhi CD, Al‐Mufti F. Increase in Ruptured Cerebral Arteriovenous Malformations and in the United States: Unintended Consequences of the ARUBA Trial? Stroke Vasc Interv Neurol . 2022;0:e000442. https://doi.org/10.1161/SVIN.122.000442

HomeStroke: Vascular and Interventional NeurologyVol. 3, No. 1In Response to: Dicpinigaitis AJ, Ogulnick JV, Mayer AS, Gandhi CD, Al‐Mufti F. Increase in Ruptured Cerebral Arteriovenous Malformations and in the United States: Unintended Consequences of the ARUBA Trial? Stroke Vasc Interv Neurol. 2022;0:e000442. https://doi.org/10.1161/SVIN.122.000442 Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessEditorialPDF/EPUBIn Response to: Dicpinigaitis AJ, Ogulnick JV, Mayer AS, Gandhi CD, Al‐Mufti F. Increase in Ruptured Cerebral Arteriovenous Malformations and in the United States: Unintended Consequences of the ARUBA Trial? Stroke Vasc Interv Neurol. 2022;0:e000442. https://doi.org/10.1161/SVIN.122.000442 Anthony S. Kim, MD, MAS, Elan L. Guterman, MD, MAS and Helen Kim, MPH, PhD Anthony S. KimAnthony S. Kim *Correspondence to: Anthony S. Kim, MD, MAS, University of California, San Francisco, San Francisco, CA 94143.E‐mail: E-mail Address: [email protected] , University of California, , San Francisco, , CA, Search for more papers by this author , Elan L. GutermanElan L. Guterman , University of California, , San Francisco, , CA, Search for more papers by this author and Helen KimHelen Kim , University of California, , San Francisco, , CA, Search for more papers by this author Originally published3 Jan 2023https://doi.org/10.1161/SVIN.122.000659Stroke: Vascular and Interventional Neurology. 2023;3:e000659To the EditorWe read the recent article “Increase in Ruptured Cerebral Arteriovenous Malformations and Mortality in the United States: Unintended Consequences of the ARUBA Trial?” in S:VIN with great interest.1 The provocative question in the subtitle is whether the ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) trial2 has shifted clinical practice away from surgical management of arteriovenous malformations (AVMs) and led to an apparent nearly 3‐fold increase in the proportion of AVM hospitalizations that were for AVM rupture and a 2‐fold increase in in‐hospital mortality for AVM.While the article points out that “[f]urther studies may be necessary to exclude other confounders contributing to this rise,” we are concerned that the observed trends may largely be an artifact of the International Classification of Diseases, Ninth Revision (ICD‐9) to Tenth Revision (ICD‐10) coding transition that occurred in the year following the publication of ARUBA's primary results.The pre‐ARUBA analysis relied on the ICD‐9 code 747.81 for “anomalies of the cerebrovascular system” since ICD‐9 lacks a specific code for AVMs. Validation studies suggest that AVMs account for only about 66% of encounters using this code, which also includes capillary telangiectasias and cavernous malformations, for example.3 Importantly, though, this code does not specify whether the AVM is ruptured or not, so additional codes for hemorrhage—generic ones that are also used for nontraumatic subarachnoid hemorrhage (ICD‐9 430) or nontraumatic intracerebral hemorrhage (ICD‐9 431) in general—were also applied.In contrast, for most of the post‐ARUBA period, a newly introduced and specific ICD‐10 code for AVMs was used (Q28.2)—one that is for unruptured AVMs only. Since the ICD‐10 codes for hemorrhage listed in the article (I60.8 and I61.8) and for unruptured AVM (Q28.2) are mutually exclusive, we would assume that AVM rupture would be captured differently in ICD‐9 versus ICD‐10. (Note: Coding for aneurysm and aneurysm rupture did not undergo the same type of fundamental change during this transition.)When using administrative data, some misclassification is to be expected—that is not at issue. Inferences about temporal trends are still possible when the pattern of misclassifications remains relatively consistent over time. In fact, a similar analysis from the same data source, but using ICD‐9 codes exclusively, failed to show a significant change in AVM management pre‐ and post‐ARUBA, albeit over a shorter time window.4 But in this case, the pattern of misclassification in the exclusively ICD‐9–based pre‐ARUBA period compared with the largely ICD‐10–based post‐ARUBA period is fundamentally different and places both the reported numerators and the denominators into question.For this reason, the Healthcare Cost and Utilization Project recommends that investigators conducting trend analyses using the National Inpatient Sample “analyze the data by discharge quarter to determine whether there is discontinuity in the categorization because of the transition from ICD‐9‐CM [ICD‐9‐Clinical Modification] to ICD‐10‐CM/PCS [ICD‐10‐CM/Procedure Coding System]” and to “report data in a way that acknowledges the discontinuity” if such a discontinuity exists.5We cannot exclude the possibility that there was a change in care or outcomes based on ARUBA. Nevertheless, the implications of such a marked apparent shift in outcomes and the possibility that a more direct and pedestrian explanation is available compels us to seek clarification on how the ICD‐9 to ICD‐10 transition was handled in the analysis and to suggest reporting the data by quarter to allow the reader to evaluate whether ARUBA or the ICD‐9/ICD‐10 transition is the more plausible explanation for any apparent shifts.Footnotes*Correspondence to: Anthony S. Kim, MD, MAS, University of California, San Francisco, San Francisco, CA 94143.E‐mail: anthony.[email protected]eduThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.References1 Dicpinigaitis AJ, Ogulnick JV, Mayer AS, Gandhi CD, Al‐Mufti F. Increase in ruptured cerebral arteriovenous malformations and mortality in the United States: unintended consequences of the ARUBA trial?Stroke Vasc Interv Neurol. 2022; 0:e000442. https://doi.org/10.1161/SVIN.122.000442Google Scholar2 Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Salman RA, Vicaut E, Young WL, Houdart E, et al. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non‐blinded, randomised trial. Lancet. 2014; 383:614‐621. https://doi.org/10.1016/S0140‐6736(13)62302‐8.CrossrefMedlineGoogle Scholar3 Berman MF, Stapf C, Sciacca RR, Young WL. Use of ICD‐9 coding for estimating the occurrence of cerebrovascular malformations. AJNR Am J Neuroradiol. 2002; 23:700–705.MedlineGoogle Scholar4 Reynolds AS, Chen ML, Merkler AE, Chatterjee A, Díaz I, Navi BB, Kamel H. Arteriovenous malformation on interventional treatment rates for unruptured arteriovenous malformations. Cerebrovasc Dis2019; 47:299‐302. https://doi.org/10.1159/000502314Google Scholar5 Elixhauser A, Heslin KC, Owens PL. Healthcare Cost and Utilization Project (HCUP) Recommendations for Reporting Trends Using ICD‐9‐CM and ICD‐10‐CM/PCS Data. Online. U.S. Agency for Healthcare Research and Quality. Revised July 5, 2017. Accessed August 20, 2022. https://www.hcup‐us.ahrq.gov/datainnovations/icd10_resources.jspGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails January 2023Vol 3, Issue 1Article InformationMetrics © 2023 The Authors. Published on behalf of the American Heart Association, Inc., and the Society of Vascular and Interventional Neurology by Wiley Periodicals LLC.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/SVIN.122.000659 Manuscript receivedAugust 20, 2022Manuscript acceptedOctober 4, 2022Originally publishedJanuary 3, 2023 PDF download