No abstract

Purpose Opioid overdose death rates rose 36% from 2015 to 2016 in Missouri, indicating a worsening of the opioid overdose epidemic. To better understand urban and rural differences in nonfatal opioid overdoses treated in Missouri emergency departments, this paper analyzed hospital billing data from emergency departments due to opioid overdose from 2012 to 2016. Methods Emergency department records meeting the opioid overdose case definition were aggregated into 6 progressively rural groups using the National Center for Health Statistics (NCHS) urban‐rural county classification from 2013. These data were analyzed to determine significant trends amongst and between the geographic groups. Findings Generally, the magnitude of opioid overdose morbidity decreased as levels of rurality increased, using annual percentage change as the metric of change. Over the study period, Missouri's most urban counties had significantly higher rates of opioid overdose and saw larger percentage increases in rates compared to more rural areas. Statewide, all rural‐urban classifications experienced increases in heroin overdose morbidity; however, there was extreme variation in the trajectory of those increases. Heroin overdose rates were much higher in urban areas than rural areas. Conversely, rural and urban areas saw relatively similar patterns for non‐heroin opioid overdoses, though overall magnitude of these increases was more modest across all geographic groups. Conclusions The results from this analysis can help inform prioritization of strategies and resources to implement activities addressing the opioid overdose epidemic. Using a rich hospital discharge database could allow for further analysis of subpopulations to enhance personalization and customization of care.

ObjectiveIn this analysis we examine Missouri NAS discharge rates with special focus on the ICD-9-CM/ICD-10-CM transition and changes in code descriptions.IntroductionNeonatal Abstinence Syndrome (NAS) rates have tripled for Missouri residents in the past three years. NAS is a condition infants suffer soon after birth due to withdrawal after becoming opioid-dependent in the womb. NAS has significant immediate health concerns and can have long term effects on child development and quality of life.2 The Missouri Department of Health and Senior Services (MODHSS) maintains the Patient Abstract System (PAS), a database of inpatient, emergency room, and outpatient records collected from non-federal hospitals and ambulatory surgical centers throughout the state. PAS records contain extensive information about the visit, patient, and diagnosis. When examining 2015 annual PAS data for NAS-associated discharges, Missouri analysts noticed a greater than 50% increase in discharges, even larger than anticipated in light of the opioid epidemic. Provisional 2016 data produced similar high rates, dispelling the notion that the trend was a transitional problem. In fact, provisional 2016 rates are 115% higher than NAS rates in 2015. In contrast, percentage change of opioid misuse emergency department visits (as defined by MODHSS) for Missouri women age 18-44 was +13% in 2015 and -12% in 2016.MethodsNAS discharges for Missouri residents under the age of 1 were identified using all available diagnosis fields of the PAS record, using finalized data from 2014 and 2015 and provisional data from 2016. Results were stratified by quarter and ICD-CM code. Rates for each of these stratifications were calculated using Missouri resident live births as the denominator. Adhering to methodology used by MODHSS to calculate significance on its public data query tool, 95% confidence intervals were used to determine statistical significance. Depending on numerator size, either Poisson or the inverse gamma methodology was utilized to analyze changes in discharge rates over time. Two ICD-9-CM codes and four ICD-10-CM codes (identified as equivalents using an in-house crosswalk system) were used as NAS indicators (Figure 1).ResultsAn exploration of the data by quarter and diagnosis code (ICD-9-CM or ICD-10-CM), as well as supporting information from the Centers for Medicare & Medicaid Services, show that definitional changes to ICD-10-CM codes P044 and P0449, (previously 76072 in ICD-9-CM coding), was responsible for the majority of the NAS rate increase in Missouri. Annual rates for 76072 and its equivalents jumped significantly from a rate of 3.82 (per 1,000) to 8.22 Q3 to Q4-2015 (95% CI: 3.39-4.29, 7.57-8.87), while ICD-9-CM code 7795 and its equivalents had a more modest rise, from 5.57 to 6.17, which was not statistically significant (95% CI: 5.04-6.13, 5.62-6.76). Once this anomaly was identified, examination of the code’s description was conducted. This exposed a change in definition, with the words ‘suspected to be’ added to the ICD-10-CM long description, which were not present in the ICD-9-CM equivalent. Further complicating matters is a 2017 revision (effective Q3-2016) deleting the ‘suspected’ language from the description. This reversion to language more closely aligning with prior descriptions may be the reason for the slight decrease in discharges coded to P044 in the provisional Q4-2016 PAS data. Though this dataset is not finalized, there was a decrease in discharges that included code P044 from 27.50 in Q3-2016 to 23.15 in Q4-2016 (Figure 2, Figure 3).ConclusionsWhile NAS discharge rates are undoubtedly increasing in Missouri in tune with the opioid epidemic, the extreme escalation from 2014 to 2016 is, at least partially, the result of a definitional change that came with the transition from ICD-9-CM to ICD-10-CM and not a true indication of profound intensification. Indeed, the definitional change of a single ICD-CM code was responsible, in part, for a greater than three-fold increase in NAS discharge rates in Missouri. This analysis will allow public health program planners to better understand NAS trends and adjust intervention strategies accordingly. Further analysis exploring quarterly trends associated with the 2017 ICD-10-CM revision are ongoing.References1. Centers for Medicare & Medicaid Services. ICD-9-CM and ICD-10. https://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html.2. Stanford Children’s Health. Neonatal Abstinence Syndrome. http://www.stanfordchildrens.org/en/topic/default?id=neonatal-abstinence-syndrome-90-P02387.

ObjectiveLink emergency department (ED) with death certificate mortality data in order to examine the prior medical history of opioid overdose victims leading up to their death.IntroductionIn 2017, 951 Missouri residents died from an opioid overdose—a record number for the state.1 This continues the trend from 2016, which saw an increase of over 30% in opioid overdose deaths compared to 2015. The Missouri Department of Health and Senior Services (MDHSS) manages several public health surveillance data sources that can be used to inform about the opioid epidemic. Opioid overdose deaths are identified through death certificates which are collected through the vital records system. MDHSS also manages the Patient Abstract System (PAS), which contains ED and inpatient hospitalization data from approximately 132 non-federal Missouri hospitals. PAS contains about 130 variables, which include demographic data, diagnoses codes, procedures codes, and other visit information. Records can have up to 23 diagnosis fields, which are coded using ICD-10-CM (International Classification of Diseases, Clinically Modified). The first diagnosis field is the primary reason for a visit.MethodsLinkage and analysis of the data was performed using SAS Enterprise Guide 6.1. Opioid overdose deaths were identified through ICD-10 analysis looking for drug poisoning underlying cause of death codes and opioid-specific codes found in the multiple cause (contributing cause) of death fields. Table 1, below, summarizes the ICD-10 codes used. Mortality data from the 951 decedents were linked to ED data from 2016 and 2017. Records were linked using multiple passes over the ED records. Records were first linked on social security number. Following this linkage, ED records with no initial match went through a second pass and linked on name and date of birth. Finally, a third pass for records still without a match was conducted using date of birth, census tract, and sex. After these passes, the linkages were reviewed to identify any false positives. The 23 diagnosis fields contained in PAS were analyzed to look for patterns in diagnosis coding. ICD-10-CM codes were too broad so CCS (Clinical Classifications Software) categories were utilized.ResultsIn total, 3,500 ED records were linked to the 951 decedents. After removing false positives, the total number of ED records was 3,357. Approximately 70% (687) of decedents were linked to at least one ED record. One hundred and eighty-eight visits were due to drug overdose (153 opioid overdoses). The most common primary diagnosis CCS categories (category numbers in parentheses) were: substance-related disorders (661), Spondylosis; intervertebral disc disorders; other back problems (205), abdominal pain (251), and other nervous system disorders (95). Collectively, these four categories represented over 20% of all primary diagnoses. Across all 23 diagnosis fields there were similar results. The most common CCS categories were as follows: substance-related disorders (661), other aftercare (257), essential hypertension (98), and mood disorders (657). Pie charts (Fig. 1 and 2) below show proportions of CCS categories across all diagnoses fields and primary diagnosis broken into three major categories: pain/injury, substance abuse/mental health, and other. In order to reduce the impact of CCS categories with small numbers, these graphics represent only CCS categories that made up 1% or more of the total collection of diagnoses codes. Of the 687 decedents that were matched successfully to ED records, 96% had at least one pain/injury or one substance abuse/mental health ICD-CM code in at least one record, and 68% had both.ConclusionsThese findings suggest that many overdose decedents visited the ED in the years prior to death. Many of these visits were not due to an overdose; however, they could be indicative of a problem with opioids (i.e. pain, drug-seeking, substance use-related). ED staff and public health professionals could utilize these opportunities to refer patients to recovery services and recommend they heed caution when using opioids.References1. Missouri Department of Health and Senior Services. (2018). Missouri Resident Overdose Deaths by Opioid Type. Retrieved September 27, 2018 from https://health.mo.gov/data/opioids/pdf/opioid-dashboard-slide-9.pdf.

No abstract