LETTER
NOTES & COMMENTS
The challenges of big data in dermatology
To the Editor: We read with interest the article by
Kaffenberger et al highlighting the comorbid disease
associations and impact of inpatient procedures on
patients hospitalized with pyoderma gangrenosum
(PG).1 We applaud the authors for recognizing the
prognosis of inpatients with PG is a subject that has
not been well described and deserves further
research. The results of this study were based on
data from the Nationwide Inpatient Sample (NIS), a
20% stratified sample of all discharges from US
community hospitals, including individuals covered
by Medicare, Medicaid, and private insurance and
those who are uninsured.2 All adult patients with an
ICD-9 [International Classification of Diseases, Ninth
Revision] code for PG (686.01) as the primary or
secondary discharge diagnosis were included in the
analysis.
Although the research question is important, we
have concerns about the validity of ICD-9ebased
identification of PG cases. Clinically, PG is a chal-
lenging diagnosis with a high misdiagnosis rate.3 The
use of ICD-9 codes for the diagnosis of PG was
recently evaluated in the electronic medical records,
and only 45.3% of patients with $1 ICD-9 code for
PG were found to have PG after review of the
medical records.4 This suggests that more than half
of the patients included in this analysis might not
actually have had PG. In the validation study, the
positive predictive value increased significantly
when patients had [1 code (69.2%) or when it was
a dermatologist-rendered code (84.6%),4 suggesting
it’s possible to design an algorithm to identify PG
within large, claims-based data sets. The NIS is
unfortunately not linked to the medical records,
and neither these advanced algorithms nor a
database-specific validation can be performed.
While we encourage dermatologists to continue
epidemiology and outcomes research for rare dis-
eases within the field of dermatology, it is paramount
that our research aims are held to the highest
standards. Ideally, validation of each database should
be done independently by using primary data. When
this is not possible, as with the NIS, researchers
conducting studies using administrative claims data
should employ validated algorithms to identify the
primary outcome and related comorbidities. This is
especially critical when using large databases to
identify rare diseases that are based on clinical
evaluation. Correct dermatologic diagnoses are
J AM ACAD DERMATOL
made by experienced clinicians carefully reviewing
patient history, clinical examination findings, and
skin pathology and not by an objective value like
blood pressure or HgA1C. Because of this
complexity, these diagnoses can be difficult to
correctly identify in data sets.
If these guidelines are followed, the use of large
administrative databases has the potential to play a
major role in advancing our understanding of rare
skin diseases. If nonvalidated approaches are taken,
these studies could undermine progress by present-
ing systematically biased and incorrect data. Big data
has the potential to make connections and find novel
associations that are otherwise impossible to identify
in smaller patient cohorts; the peril is that without
proper methods these insights might be erroneous.
Megan H. Noe, MD, MPH,a and Arash Mostaghimi,
MD, MPA, MPHb
From the Department of Dermatology, University of
Pennsylvania, Philadelphia, Pennsylvaniaa;
and Department of Dermatology, Brigham and
Women’s Hospital, Harvard Medical School, Bos-
ton, Massachusettsb
Funding sources: None.
Conflicts of interest: None disclosed.
Correspondence to: Megan H. Noe, MD, MPH, 3400
Civic Center Blvd, Perelman Center for
Advanced Medicine e 7 South, Philadelphia,
PA 19104
E-mail: megan.noe@uphs.upenn.edu
REFERENCES
1. Kaffenberger BH, Hinton A, Krishna S. The impact of underlying
disease state on outcomes in patients with pyoderma gangre-
nosum: a national survey. J Am Acad Dermatol. 2018. https:
//doi.org/10.1016/j.jaad.2018.02.007 [Epub ahead of print].
2. Overview of the National Inpatient Sample. Available at: www.
hcup-us.ahrq.gov/nisoverview.jsp#about. Accessed March 7,
2018.
3. Weening RH, Davis MDP, Dahl PR, Su DWP. Skin ulcers
misdiagnosed as pyoderma gangrenosum. N Engl J Med.
2002;347:1412-1418.
4. Lockwood SJ, Li DG, Butler D, Tsiaras W, Joyce C, Mostaghimi A.
The validity of the diagnostic code for pyoderma gangrenosum
in an electronic database. Br J Dermatol. 2018. https:
//doi.org/10.1111/bjd.16446 [Epub ahead of print].
https://doi.org/10.1016/j.jaad.2018.03.059
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