INTRODUCTION
All-cause pneumonia is an important clinical endpoint for determining vaccine effectiveness (VE) for 23-valent pneumococcal polysaccharide vaccine (23vPPV) and influenza vaccine. It represents a greater part of the burden of disease due to these organisms, and a trade-off between a highly specific but insensitive outcome measure such as pneumonia associated with pneumococcal bacteraemia or microbiologically proven influenza and a sensitive, but non-specific surrogate outcome such as all-cause mortality. However, accurate identification of pneumonia cases is not straightforward. Clinical criteria alone are imprecise [Reference Smith1]. There remains no internationally agreed definition for pneumonia based on clinical symptoms and signs and no one sign or symptom, nor combination of these has ever been shown to clearly differentiate pneumonia from other respiratory illnesses [Reference Fine, Chowdhry and Ketema2-Reference Marrie4]. There is also no ideal diagnostic test for microbiological diagnosis [Reference Smith1], and while chest radiograph (CXR) is often useful to confirm the diagnosis of pneumonia and its severity [Reference Smith1], it also has limitations [Reference Albaum5, Reference Syrjala6]. Because of the difficulties in defining and identifying cases of pneumonia using clinical, radiological or microbiological criteria, codes from the International Classification of Diseases (ICD), overseen by the World Health Organization (WHO), are frequently used as surrogate measures to identify hospitalized patients with pneumonia in studies of VE for 23vPPV and influenza vaccine [Reference Nichol7-Reference Fisman11]. These codes have become the international standard for disease classification [12].
Use of standardized codes to retrospectively identify cases of pneumonia among hospitalized patients is appealing to researchers primarily because of time efficiencies (compared with the alternative of reviewing hospital records for clinical, radiological and/or laboratory evidence consistent with pneumonia). Despite the practical advantages and continued use of ICD codes by researchers to identify cases of pneumonia, at the time of this research only two small studies (<150 subjects) have examined the validity of this approach for all-cause pneumonia [Reference Marrie, Durant and Sealy13, Reference Whittle14], while a third has examined codes for pneumococcal pneumonia [Reference Guevara15]. These studies, all from North America, used ICD-9-CM codes and suggested ICD codes may be a valid tool for case ascertainment of pneumonia. However, further examination is prudent given the paucity of available data and the potential for differences in other settings. As part of a case-cohort study [Reference Comstock16, Reference Wacholder17] examining VE for 23vPPV and influenza vaccine against pneumonia in the elderly in Australia where these vaccines are provided free of charge, we examined the validity of ICD-10-AM codes to identify cases of pneumonia among hospitalized patients.
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