Anal Sphincter Lacerations Underreported in Hospitals


SCOTTSDALE, ARIZ. — Anal sphincter laceration during childbirth is not accurately coded in many hospital discharge records and may be underestimated as a result.

The Pelvic Floor Disorders Network found mistakes in a about one-quarter of 392 hospital discharge records from nine institutions participating in one of its trials, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Linda Brubaker reported an average coding error rate of 24% across the nine centers. Just one institution was free of mistakes. The three highest error rates were 62%, 48.6%, and 27.2%.

Only two patients had codes listed for anal sphincter lacerations that did not occur, said Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill. All the other mistakes were omissions of coding for anal sphincter lacerations that had been recorded in clinical records as occurring during delivery.

Dr. Brubaker reported that the coding error rates were not related to the number of deliveries at each institution or to the number of hospital discharge codes for each patient. Women with anal sphincter lacerations tended to have more codes, however, with a range of 2.9–7.8 vs. 2.5–7.2 for women without these injuries.

The network warned that the result of this type of coding error could be a substantial underassessment of delivery-associated anal sphincter laceration as a maternal morbidity. It recommended against using hospital discharge coding as a source of data.

The discrepancies could have significant implications for quality assurance and research initiatives. Dr. Brubaker told this newspaper subsequently that both the Joint Commission on Accreditation of Health Care Organizations and the Annual Public Health Report will be using the incidence of obstetric third- and fourth-degree lacerations as indicators of care quality.

“So if an institution has a coding problem, they may seem to have 'better' quality than an institution with an identical rate and truly better coding,” she said.

“More importantly, researchers commonly use large databases that use discharge codes for estimating the number of 'events',” she added. “If our data can be reproduced, it suggests that research using discharge coding may not be wise.”

The bottom line, Dr. Brubaker concluded, is that these lacerations have not received the attention they deserve. “Improved coding [and the use of these events as quality indicators] may provide an opportunity to improve patient care and identify women who may benefit from postdelivery pelvic floor assessment,” she said.

Sponsored by the National Institutes of Health, the network has opened a Web site at

The trial is comparing women with anal sphincter lacerations at vaginal delivery with women who had cesarean delivery without labor and women who delivered vaginally without anal sphincter laceration in the trial. The two women with codes for anal sphincter lacerations that did not occur came from the control groups.

An institution with a coding problem may seem to have 'better' quality than one with an identical rate and better coding. DR. BRUBAKER

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