Validity of ICD-10-based algorithms to identify patients with influenza in inpatient and outpatient settings

PURPOSE

To evaluate the validity of ICD-10-CM code-based algorithms as proxies for influenza in inpatient and outpatient settings in the USA.

METHODS

Administrative claims data (2015-2018) from the largest commercial insurer in New Jersey (NJ), USA, were probabilistically linked to outpatient and inpatient electronic health record (EHR) data containing influenza test results from a large NJ health system. The primary claims-based algorithms defined influenza as presence of an ICD-10-CM code for influenza, stratified by setting (inpatient/outpatient) and code position for inpatient encounters. Test characteristics and 95% confidence intervals (CIs) were calculated using test-positive influenza as a reference standard. Test characteristics of alternative outpatient algorithms incorporating CPT/HCPCS testing codes and anti-influenza medication pharmacy claims were also calculated.

RESULTS

There were 430 documented influenza test results within the study period (295 inpatient, 135 outpatient). The claims-based influenza definition had a sensitivity of 84.9% (95% CI 72.9%-92.1%), specificity of 96.3% (95% CI 93.1%-98.0%), and PPV of 83.3% (95% CI 71.3%-91.0%) in the inpatient setting, and a sensitivity of 76.7% (95% CI 59.1%-88.2%), specificity of 96.2% (95% CI 90.6%-98.5%), PPV of 85.2% (95% CI 67.5%-94.1%) in the outpatient setting. Primary inpatient discharge diagnoses had a sensitivity of 54.7% (95% CI 41.5%-67.3%), specificity of 99.6% (95% CI 97.7%-99.9%), and PPV of 96.7% (95% CI 83.3%-99.4%). CPT/HCPCS codes and anti-influenza medication claims were present for few outpatient encounters (sensitivity 3%-10%).

CONCLUSIONS

In a large US healthcare system, inpatient ICD-10-CM codes for influenza, particularly primary inpatient diagnoses, had high predictive value for test-positive influenza. Outpatient ICD-10-CM codes were moderately predictive of test-positive influenza.

Drug overdose risk with benzodiazepine treatment in young adults: Comparative analysis in privately and publicly insured individuals

BACKGROUND AND AIMS

Benzodiazepines (BZDs) carry a risk for drug overdose and are prescribed alone or simultaneously with selective-serotonin reuptake inhibitors (SSRIs) for the treatment of anxiety and depression in young adults. We aimed to measure risks of drug overdose following BZD treatment initiation, and simultaneous BZD and SSRI initiation, compared with SSRI treatment alone in young adults with depression or anxiety.

DESIGN, SETTING, PARTICIPANTS

The cohort study used administrative databases covering privately (MarketScan, 1/1/2009-12/31/2018) and publicly (Medicaid, 1/1/2015-12/31/2016) insured young adults (18-29 years) in the United States. Those with depression or anxiety diagnoses newly initiating BZD or SSRI treatment (without BZD or SSRI prescriptions in prior year) were included. Simultaneous "BZD + SSRI" initiation was defined as starting BZD and SSRI treatment on the same day. The cohorts included 604 664 privately insured young adults (BZD = 22%, BZD + SSRI = 10%, SSRI = 68%) and 110 493 publicly insured young adults (BZD = 23%, BZD + SSRI = 5%, SSRI = 72%).

MEASUREMENTS

Incident medically treated drug overdose events were identified from emergency department and inpatient encounters (ICD poisoning codes) within 6 months of treatment initiation. Crude and propensity-score adjusted cumulative incidence and hazard ratios (HR) were estimated. Sub-analyses evaluated drug overdose intent.

FINDINGS

Adjusted HRs of drug overdose for BZD vs. SSRI treatment was 1.36 (95% confidence interval [CI]:1.23-1.51) in privately and 1.59 (95%CI:1.37-1.83) in publicly insured young adults. The adjusted HRs of drug overdose for BZD + SSRI treatment vs. SSRI treatment were 1.99 (95%CI:1.77-2.25) in privately and 1.98 (95%CI:1.47-2.68) in publicly insured young adults.

CONCLUSIONS

Among young adults in the United States, initiating benzodiazepine treatment for anxiety and depression, alone or simultaneously with selective-serotonin reuptake inhibitors (SSRI), appears to have an increased risk of medically treated drug overdose compared with SSRI treatment alone. These associations were observed in publicly and privately insured individuals.

Risk of clinically relevant hyperglycemia with metoprolol compared to carvedilol in older adults with heart failure and diabetes

BACKGROUND

Although prior literature suggests that metoprolol may worsen glucose control compared to carvedilol, whether this has clinical relevance among older adults with diabetes and heart failure (HF) remains an open question.

METHODS

This was a US retrospective cohort study utilizing data sourced from a 50% national sample of Medicare fee-for-service claims of patients with part D prescription drug coverage (2007-2017). Among patients with diabetes and HF, we identified initiators of metoprolol or carvedilol, which were 1:1 propensity score matched on >90 variables. The primary outcome was initiation of a new oral or injectable antidiabetic medication (proxy for uncontrolled diabetes); secondary outcomes included initiation of insulin and severe hyperglycemic event (composite of emergency room visits or hospitalizations related to hyperglycemia).

RESULTS

Among 24 239 propensity score-matched pairs (mean [SD] age 77.7 [8.0] years; male [39.1%]), there were 8150 (incidence rate per 100 person-years [IR] = 33.5) episodes of antidiabetic medication initiation among metoprolol users (exposure arm) compared to 8576 (IR = 33.4) among carvedilol users (comparator arm) compared to corresponding to an adjusted hazard ratio (aHR) of 0.97 (95% confidence interval [CI]: 0.94, 1.01). Similarly, metoprolol was not associated with a significant increase in the risk of secondary outcomes including insulin initiation: aHR of 0.98 (95% CI: 0.93, 1.04) and severe hyperglycemic events: aHR of 0.98 (95% CI: 0.93, 1.02).

CONCLUSIONS

In this large study of older adults with HF and diabetes, initiation of metoprolol compared to carvedilol was not associated with an increase in the risk of clinically relevant hyperglycemia.

IDENTIFYING PATIENTS WITH PROBABLE DELIRIUM AND DEMENTIA FROM ROUTINE HOME HEALTH CARE ASSESSMENTS

Timely education of patients and their family caregivers on dementia disease management and health behavior changes and referral to additional resources is an essential part of age-friendly and high quality care. Nearly one out-of-three home health care patients has been diagnosed with dementia, however, family members and front-line health care providers are frequently unaware that a diagnosis of dementia has made, and what to do. The aim of this study was to identify a small set of questions that are routinely collected during home health care assessment which can be used to rapidly identify patients with suspected dementia, who may benefit from additional screening and services. We developed the preliminary model from 100% national home health care assessment data from 2014 (4.1 million people). We validated the model with a sample of nearly 27,000 patients who received a new (start-of-care) home health assessment in 2016, from four home health agencies that share a common data warehouse. The final model consisting of five questions, performed well in national data (AUC 0.85) predicting any diagnosis of dementia contained in the Medicare Chronic Conditions warehouse or home health record. The final model performed similarly (AUC 0.87) in the validation sample, predicting a diagnosis of dementia or history of dementia medication during a 3-year window of time from clinical data warehouse. The potential applications of this model have the potential to accelerate timely identification of patients with probable dementia or delirium, patient and family caregiver education, and referral to rehabilitative and supportive services.

HOME HEALTH CARE AS A PREDICTOR OF SURVIVAL AMONG PEOPLE LIVING WITH ALZHEIMER’S DISEASE AND RELATED DEMENTIAS

Over the past 10 years, dementia care has been shifting to the community; however, there are significant regional and sociodemographic differences in the use of formal home health care services. Does the use of home health care improve survival and other outcomes among people diagnosed with dementia? The aim of the study was to determine the individual, societal, and health systems predictors of survival after a diagnosis of dementia. Using linked Medicare administrative, claims, and assessment data (N = 4,349,565); we found that home health care significantly reduced risk of death for males, but not females. This effect was strongest among older adults between the ages of 65 and 80. While men who were living alone or in a congregate/assisted living environment benefited the most (O.R. = 0.87) the effect was also strong for men living with a spouse or other caregiver (O.R. = 0.90). These findings suggest home health care may provide a survival advantage for men through the provision of rehabilitative and supportive services, as well as patient and family caregiver education. Further research is needed to understand if sex based survival differences are associated with the intensity of home health care services provided or social determinants of health.

Further studies on the binding of N1-substituted tryptamines at h5-HT6 receptors

N(1)-Arylsulfonyl-substituted analogs of N,N-dimethyltryptamine bind at 5-HT(6) receptors. Replacement of the aryl moiety with similarly hydrophobic alkyl substituents results in decreased affinity, as does replacement of a benzenesulfonyl moiety with a benzyl group. Current findings indicate that an aryl (or substituted aryl) sulfonyl (rather than alkylsulfonyl or benzyl) moiety is optimal for high-affinity binding, and further suggest that the N(1)-benzenesulfonyl- and their corresponding N(1)-benzyltryptamine counterparts bind in a different fashion.