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Comment & Response
April 2017

Identifying Intraoperative Nerve Monitoring in Thyroid Surgery Using Administrative Databases—Reply

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City
  • 2Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye and Ear Infirmary, Boston
  • 3Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
JAMA Otolaryngol Head Neck Surg. 2017;143(4):428. doi:10.1001/jamaoto.2016.3656

In Reply We were pleased and interested to find that our article “Analysis of Variations in the Use of Intraoperative Nerve Monitoring in Thyroid Surgery” has stimulated a constructive critique prompted by Dr Megwalu in his letter “Identifying Intraoperative Nerve Monitoring in Thyroid Surgery Using Administrative Databases.”1

We agree and share the concerns that the coding of intraoperative nerve monitoring (IONM) in administrative databases is likely to be influenced by the setting in which it was performed and we have mentioned this in discussing our paper. Although administrative databases come with the convenience of a large sample size, they are not without major limitations and caveats.2 Analyses of these large databases, have produced controversial—and even contradictory—results. These analyses may influence national treatment guidelines; therefore, it is vital to understand their limitations. Evidently based on our results; the State Inpatient Database (SID) has an “undercoding” of IONM. However, by solely depending on our reported low percentages of IONM utilization, we cannot conclude that IONM coding was incorrect coding by surgeons or reported only when done by technicians. A critical question to be asked is whether IONM undercoding was differential or not, in other words whether undercoding is associated with certain types of settings. Unfortunately, this question cannot be addressed using a single data source, which prevents establishing the extent of our study generalizability. Of note, the analysis used International Classification of Disease, 9th Revision (ICD-9) for defining IONM utilization and not the Current Procedural Terminology which is usually used for billing purposes.

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