Procedure without procedure

As discussed on the call, terms of the general form 'procedure without procedure' appear to be principally constructs of classifications of surgical procedures but are very rarely used if made available for selection in clinician-facing terminologies.

Their popularity as a pattern within surgical procedure classifications in particular was identified in Ye Olde GALEN-IN-USE project of the late 90s, within which a semi-formal decomposition of a final corpus of 20,782 rubrics from a range of European surgical procedure classifications (or parts thereof) identified 1,108 whose 'modelling' required the use of a WITHOUT operator; this modelling was usually reflecting an 'a without b' lexical pattern in the underlying term text to be modelled; see attached list (if your Dutch, Swedish, German and especially French are up to it...)

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Within the UKs clinician-facing terminologies in Primary Care, there are in fact fewer than 50 distinct codes that (a) are procedures and (b) include the word 'without'. Some are derived from the UKs own classification of surgical procedures, OPCS, which currently contains just 11 examples of the 'a without b' pattern within a scheme of 10,892 procedure codes.

This low volume of such codes being even available for selection by primary care clinicians is, I would suggest, prima facie evidence that the pattern is rarely clinically useful in that setting: we have not been asked to add more. Further, the very small set of codes that are available for selection manage, collectively, to account for less than 1 new coded EPR entry every 847,826 patient year (or, a grand total of only 460 out of over 17.1 billion new coded EPR entries entered somewhere in the entirety of UK Primary Care over the last 6 years). The 'Top Twenty' from this ersatz list - collectively accounting for 99% of the relevant (tiny volume of) coded data - were:

As a followup on the "Disorder without disorder" discussion.  We received the following from the UKTC:

 I think we’d be clinically OK to map them to the vanilla # or intracranial injury going forward. The whole ‘without mention of’ construct is deeply unsatisfactory anyway – it just means that the coder examining the paper record, not the patient, couldn’t find any evidence that the patient also had e.g. a spinal injury, and therefore not that they definitely did not. So strictly clinically its an intrinsically ambiguous statement. I would have thought we could/should therefore retire them all to AMBIGUOUS with a solitary MAYBE to the relevant vanilla #/injury code which should currently be its parent:

This is better than retiring them to e.g. LIMITED with the usual WAS-A to their prior parents, because some of them have several parents not all of which are really appropriate or useful candidate substitutes for reasoning. Also better than retire to INAPPROPRIATE with REPLACED_BY, because historically that construct is used rarely and when it is its quite close semantically to DUPLICATE/SAME_AS, which definitely doesn’t apply here. The relationship between the inactive concept and its active substitute is definitely one of a lossy map, and so we’d need to be using one of the lossy map flavours of historical relationship, which in turn limits which inactive concept bucket we can put them in.

For the existing historical data to be mapped to SNOMED, capturing forever within the computer processable coding that the patient did not also have either a spinal cord lesion or a skull fracture or an intracranial injury is IMHO unlikely to be of practical value. There are very few inference algorithms that specifically check for the an explicit statement that some clinical phenomenon is absent. Absence of clinical phenomena is more usually tested by confirming the absence of any relevant presence code, not the presence of a specific absence code.

And going forward for new data capture, I don’t think anybody is going to object to only having the basic # codes to use. If for some reason they want to also explicitly record that some related complication or comorbidity was NOT present, then they need to be made to use a more generic mechanism for doing that anyway as a second coded entry.

Comments from other members of the CMAG related to the topic of "Disorder without disorder" indicated that they had a few of this type of concept in their extensions.  Most felt that the content more appropriately belongs in the situation hierarchy.  Plan is to inactivate and recreate IF they are requested from members.