Use of diagnosis codes for detection of clinically significant opioid poisoning in the emergency department: A retrospective analysis of a surveillance case definition

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Abstract

Background

Although fatal opioid poisonings tripled from 1999 to 2008, data describing nonfatal poisonings are rare. Public health authorities are in need of tools to track opioid poisonings in near real time.

Methods

We determined the utility of ICD-9-CM diagnosis codes for identifying clinically significant opioid poisonings in a state-wide emergency department (ED) surveillance system. We sampled visits from four hospitals from July 2009 to June 2012 with diagnosis codes of 965.00, 965.01, 965.02 and 965.09 (poisoning by opiates and related narcotics) and/or an external cause of injury code of E850.0-E850.2 (accidental poisoning by opiates and related narcotics), and developed a novel case definition to determine in which cases opioid poisoning prompted the ED visit. We calculated the percentage of visits coded for opioid poisoning that were clinically significant and compared it to the percentage of visits coded for poisoning by non-opioid agents in which there was actually poisoning by an opioid agent. We created a multivariate regression model to determine if other collected triage data can improve the positive predictive value of diagnosis codes alone for detecting clinically significant opioid poisoning.

Results

70.1 % of visits (Standard Error 2.4 %) coded for opioid poisoning were primarily prompted by opioid poisoning. The remainder of visits represented opioid exposure in the setting of other primary diseases. Among non-opioid poisoning codes reviewed, up to 36 % were reclassified as an opioid poisoning. In multivariate analysis, only naloxone use improved the positive predictive value of ICD-9-CM codes for identifying clinically significant opioid poisoning, but was associated with a high false negative rate.

Conclusions

This surveillance mechanism identifies many clinically significant opioid overdoses with a high positive predictive value. With further validation, it may help target control measures such as prescriber education and pharmacy monitoring.

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Most cited references 11

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National surveillance of emergency department visits for outpatient adverse drug events.

Daniel S Budnitz, Daniel A Pollock, Kelly Weidenbach … (2006)

Adverse drug events are common and often preventable causes of medical injuries. However, timely, nationally representative information on outpatient adverse drug events is limited. To describe the frequency and characteristics of adverse drug events that lead to emergency department visits in the United States. Active surveillance from January 1, 2004, through December 31, 2005, through the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project. National estimates of the numbers, population rates, and severity (measured by hospitalization) of individuals with adverse drug events treated in emergency departments. Over the 2-year study period, 21,298 adverse drug event cases were reported, producing weighted annual estimates of 701,547 individuals (95% confidence interval [CI], 509,642-893,452) or 2.4 individuals per 1000 population (95% CI, 1.7-3.0) treated in emergency departments. Of these cases, 3487 individuals required hospitalization (annual estimate, 117,318 [16.7%]; 95% CI, 13.1%-20.3%). Adverse drug events accounted for 2.5% (95% CI, 2.0%-3.1%) of estimated emergency department visits for all unintentional injuries and 6.7% (95% CI, 4.7%-8.7%) of those leading to hospitalization and accounted for 0.6% of estimated emergency department visits for all causes. Individuals aged 65 years or older were more likely than younger individuals to sustain adverse drug events (annual estimate, 4.9 vs 2.0 per 1000; rate ratio [RR], 2.4; 95% CI, 1.8-3.0) and more likely to require hospitalization (annual estimate, 1.6 vs 0.23 per 1000; RR, 6.8; 95% CI, 4.3-9.2). Drugs for which regular outpatient monitoring is used to prevent acute toxicity accounted for 41.5% of estimated hospitalizations overall (1381 cases; 95% CI, 30.9%-52.1%) and 54.4% of estimated hospitalizations among individuals aged 65 years or older (829 cases; 95% CI, 45.0%-63.7%). Adverse drug events among outpatients that lead to emergency department visits are an important cause of morbidity in the United States, particularly among individuals aged 65 years or older. Ongoing, population-based surveillance can help monitor these events and target prevention strategies.

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Prescription drug monitoring programs and death rates from drug overdose.

Shuchi Desai, Amy Kilbourne, L J Paulozzi (2011)

Drug overdoses resulting from the abuse of prescription opioid analgesics and other controlled substances have increased in number as the volume of such drugs prescribed in the United States has grown. State prescription drug monitoring programs (PDMPs) are designed to prevent the abuse of such drugs. This study quantifies the relation of PDMPs to rates of death from drug overdose and quantities of opioid drugs distributed at the state level. Observational study of the United States during 1999-2005. Rates of drug overdose mortality, opioid overdose mortality, and opioid consumption by state. PDMPs were not significantly associated with lower rates of drug overdose or opioid overdose mortality or lower rates of consumption of opioid drugs. PDMP states consumed significantly greater amounts of hydrocodone (Schedule III) and nonsignificantly lower amounts of Schedule II opioids. The increases in overdose mortality rates and use of prescription opioid drugs during 1999-2005 were significantly lower in three PDMP states (California, New York, and Texas) that required use of special prescription forms. While PDMPs are potentially an important tool to prevent the nonmedical use of prescribed controlled substances, their impact is not reflected in drug overdose mortality rates. Their effect on overall consumption of opioids appears to be minimal. PDMP managers need to develop and test ways to improve the use of their data to affect the problem of prescription drug overdoses. Wiley Periodicals, Inc.

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Accuracy of external cause-of-injury coding in hospital records.

Adam Walker, E Enraght-Moony, Timothy J E Harrison … (2009)

To appraise the published evidence regarding the accuracy of external cause-of-injury codes in hospital records. Systematic review. Electronic databases searched included PubMed, PubMed Central, Medline, CINAHL, Academic Search Elite, Proquest Health and Medical Complete, and Google Scholar. Snowballing strategies were used by searching the bibliographies of retrieved references to identify relevant associated articles. Studies were included in the review if they assessed the accuracy of external cause-of-injury coding in hospital records via a recoding methodology. The papers identified through the search were independently screened by two authors for inclusion. Because of heterogeneity between studies, meta-analysis was not performed. Very limited research on the accuracy of external cause coding for injury-related hospitalisation using medical record review and recoding methodologies has been conducted, with only five studies matching the selection criteria. The accuracy of external cause coding using ICD-9-CM ranged from approximately 64% when exact code agreement was examined to approximately 85% when agreement for broader groups of codes was examined. Although broad external cause groupings coded in ICD-9-CM can be used with some confidence, researchers should exercise caution for very specific codes until further research is conducted to validate these data. As all previous studies have been conducted using ICD-9-CM, research is needed to quantify the accuracy of coding using ICD-10-AM, and validate the use of these data for injury surveillance purposes.

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Author and article information

Contributors

Joseph M. Reardon: (+1) 919-684-5537 , Joseph.Reardon@alumni.duke.edu

Katherine J. Harmon: KJHarmon@email.unc.edu

Genevieve C. Schult: GCSchult@gmail.com

Catherine A. Staton: Catherine.Lynch@dm.duke.edu

Anna E. Waller: Anna_Waller@med.unc.edu

Journal

Journal ID (nlm-ta): BMC Emerg Med

Journal ID (iso-abbrev): BMC Emerg Med

Title: BMC Emergency Medicine

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-227X

Publication date (Electronic): 8 February 2016

Publication date PMC-release: 8 February 2016

Publication date Collection: 2016

Volume: 16

Electronic Location Identifier: 11

Affiliations

[ ]Division of Emergency Medicine, Duke University, 2301 Erwin Rd, Box 3935, Durham, NC 27710 USA

[ ]Carolina Center for Health Informatics and the Injury Prevention Research Center, University of North Carolina at Chapel Hill, 100 Market St, Chapel Hill, 27516 NC USA

[ ]Department of Emergency Medicine, University of North Carolina at Chapel Hill, Box 7594, 170 Manning Dr, Chapel Hill, 27599 NC USA

[ ]Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, 27710 NC USA

Article

Publisher ID: 75

DOI: 10.1186/s12873-016-0075-4

PMC ID: 4746926

PubMed ID: 26856978

SO-VID: d882c572-fee1-43e9-a78c-e8c519dd7ace

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 13 March 2015

Date accepted : 1 February 2016

Custom metadata

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: opioid,narcotic,poisoning,overdose,emergency department,surveillance,diagnosis codes,naloxone

Data availability:

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: opioid, narcotic, poisoning, overdose, emergency department, surveillance, diagnosis codes, naloxone

Use of diagnosis codes for detection of clinically significant opioid poisoning in the emergency department: A retrospective analysis of a surveillance case definition

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Abstract

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Conclusions

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Preventive and Emergency Medicine Insights

Most cited references 11

National surveillance of emergency department visits for outpatient adverse drug events.

Prescription drug monitoring programs and death rates from drug overdose.

Accuracy of external cause-of-injury coding in hospital records.

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