In October 2015, the United States transitioned healthcare diagnosis codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), to the Tenth Revision (ICD-10-CM). Trend analyses of alcohol-related stays could show discontinuities solely from the change in classification systems. This study examined the impact of the ICD-10-CM coding system on estimates of hospital stays involving alcohol-related diagnoses.
This analysis used 2014 to 2017 administrative data from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Inpatient Databases for 17 states. Quarterly ICD-9-CM data from second quarter 2014 through third quarter 2015 were concatenated with ICD-10-CM data from fourth quarter 2015 through first quarter 2017. Quarterly counts of alcohol-related stays were examined overall and then by 6 diagnostic subgroups: withdrawal, abuse, dependence, alcohol-induced mental disorders (AIMD), nonpsychiatric alcohol-induced disease, and intoxication or toxic effects. Within each group, we calculated the difference in the average number of stays between ICD-9-CM and ICD-10-CM coding periods.
On average, the number of stays involving any alcohol-related diagnosis in the 6 quarters before and after the ICD-10-CM transition was stable. However, substantial shifts in stays occurred for alcohol abuse, AIMD, and intoxication or toxic effects. For example, the average quarterly number of stays involving AIMD was 170.7% higher in the ICD-10-CM period than in the ICD-9-CM period. This increase was driven in large part by 1 ICD-10-CM code, Alcohol use, unspecified with unspecified alcohol-induced disorder.
Researchers conducting trend analyses of inpatient stays involving alcohol-related diagnoses should consider how ongoing modifications in the ICD-10-CM code system and coding guidelines might affect their work. An advisable approach for trend analyses across the ICD-10-CM transition is to aggregate diagnosis codes into broader, clinically meaningful groups-including a single global group that encompasses all alcohol-related stays-and then to select diagnostic groupings that minimize discontinuities between the 2 coding systems while providing useful information on this important indicator of population health.

Epidemiological and health services research often use International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify patients with clinical conditions in administrative databases. We determined whether there are systematic variations between stroke patient clinical diagnoses and ICD-9-CM codes, stratified by hospital characteristics and stroke severity.
We used the records of patients discharged from hospitals participating in the Paul Coverdell National Acute Stroke Program in 2013. Within this stroke-enriched cohort, we compared agreement between the attending physician\'s clinical diagnosis and principal ICD-9-CM code and determined whether disagreements varied by hospital characteristics (presence of a stroke unit, stroke team, number of hospital beds, and hospital location). For patients with a documented National Institutes of Health Stroke Scale score at admission, we assessed whether diagnostic agreement varied by stroke severity. Agreement was generally high (>89%); differences between the physician diagnosis and ICD-9-CM codes were primarily attributed to discordance between ischemic stroke and transient ischemic attack (TIA), and subarachnoid and intracerebral hemorrhage. Agreement was higher for patients in metropolitan hospitals with stroke units, stroke teams, and >200 beds (all P<0.001). Agreement was lowest (60.3%) for rural hospitals with ≤200 beds and without stroke units or teams. Agreement was also lower for milder (94.9%) versus more-severe (96.4%) ischemic strokes (P<0.001).
We identified disagreements in stroke/TIA coding by hospital characteristics and stroke severity, particularly for milder ischemic strokes. Such systematic variations in ICD-9-CM coding practices can affect stroke case identification in epidemiological studies and may have implications for hospital-level quality metrics.

BACKGROUND: Drugs are a common cause of anaphylaxis, which is potentially life threatening.
OBJECTIVE: We sought to describe US patients with an emergency department (ED) visit or hospitalization for drug-induced anaphylaxis (DIA), including postdischarge follow-up care.
METHODS: By using International Classification of Diseases, Ninth Revision codes in the MarketScan Database, we identified all patients with an ED visit and/or hospitalization for DIA between 2002 and 2008 (index date = initial ED visit and/or hospitalization). Inclusion required continuous full insurance coverage ≥1 year in the pre- and postindex period. We examined patient factors during the preindex period, characteristics of the index event, and outcomes during the postindex period.
RESULTS: The cohort included 716 patients with an ED visit and/or hospitalization for DIA (mean age, 48 years; 71% women). Most patients (71%) were managed in the ED, and only 8% of the patients with DIA treated in the ED received epinephrine. For those admitted, patients were hospitalized for a median of 3 days, and 41% spent time in the intensive care unit. Cardiorespiratory failure occurred in 5% of the patients in the ED and 23% of the patients who were hospitalized. The patients with a concomitant allergic condition were more likely to see an allergist/immunologist than those without a concomitant allergic condition, but 82% did not receive any subsequent care with an allergist/immunologist in the 1 year after the ED visit and/or hospitalization for DIA.
CONCLUSIONS: Drugs are a common, yet under-recognized, cause of anaphylaxis. Only a small number of patients with DIA received epinephrine in the ED or had subsequent care with an allergist/immunologist. These findings are novel and identify areas for improvement in the care of individuals with DIA.

OBJECTIVE: To investigate whether patients with traumatic brain injury (TBI) have an increased risk of stroke or poststroke mortality.
METHODS: Using Taiwan\'s National Health Insurance Research Database, we conducted a retrospective cohort study of 30,165 patients with new TBI and 120,660 persons without TBI between January 1, 2000, and December 31, 2004. The risk of stroke was compared between 2 cohorts through December 31, 2008. To investigate the association between in-hospital mortality after stroke and history of TBI, we conducted a case-control study of 7751 patients with newly diagnosed stroke between January 1, 2005, and December 31, 2008.
RESULTS: The TBI cohort had an increased stroke risk (hazard ratio [HR], 1.98; 95% CI, 1.86-2.11). Among patients with stroke, those with a history of TBI had a higher risk of poststroke mortality compared with those without TBI (odds ratio, 1.57; 95% CI, 1.13-2.19). In the TBI cohort, factors associated with stroke were history of TBI hospitalization (HR, 3.14; 95% CI, 2.77-3.56), emergency care for TBI (HR, 3.37; 95% CI, 2.88-3.95), brain hemorrhage (HR, 2.69; 95% CI, 2.43-2.99), skull fracture (HR, 3.00; 95% CI, 2.42-3.71), low income (HR, 2.65; 95% CI, 2.16-3.25), and high medical expenditure for TBI care (HR, 2.26; 95% CI, 2.09-2.43). The severity of TBI was also correlated with poststroke mortality.
CONCLUSIONS: Traumatic brain injury was associated with risk of stroke and poststroke mortality. The relationship between TBI and poststroke mortality does not seem to transcend all age groups. This research shows the importance of prevention, early recognition, and treatment of stroke in this vulnerable population.

OBJECTIVE: To determine if bisphosphonates are associated with reduced risk of acute myocardial infarction (AMI).
METHODS: A cohort of 14,256 veterans 65 years or older with femoral or vertebral fractures was selected from national administrative databases operated by the US Department of Veterans Affairs and was derived from encounters at Veterans Affairs facilities between October 1, 1998, and September 30, 2006. The time to first AMI was assessed in relationship to bisphosphonate exposure as determined by records from the Pharmacy Benefits Management Database. Time to event analysis was performed using multivariate Cox proportional hazards regression. An adjusted survival analysis curve and a Kaplan-Meier survival curve were analyzed.
RESULTS: After controlling for atherosclerotic cardiovascular disease risk factors and medications, bisphosphonate use was associated with an increased risk of incident AMI (hazard ratio, 1.38; 95% CI, 1.08-1.77; P=.01). The timing of AMI correlated closely with the timing of bisphosphonate therapy initiation.
CONCLUSIONS: Our observations in this study conflict with our hypothesis that bisphosphonates have antiatherogenic effects. These findings may alter the risk-benefit ratio of bisphosphonate use for treatment of osteoporosis, especially in elderly men. However, further analysis and confirmation of these findings by prospective clinical trials is required.

OBJECTIVE: There is limited information regarding the true incidence of and risk factors for chylothorax after pediatric cardiac surgery. The objective of this study was to determine, from a large multi-institution database, incidence, associated factors, and treatment strategy in patients undergoing pediatric cardiac surgery.
METHODS: All patients younger than 18 years in the Pediatric Health Information System (PHIS) database who underwent congenital heart surgery or heart transplant from 2004 to 2011 were included. Procedure complexity was assessed by Risk Adjustment for Congenital Heart Surgery-1.
RESULTS: In all, 77,777 patients (55% male) of median age 6.7 months were included. Overall incidence of chylothorax was 2.8% (n = 2205), significantly associated with increased procedure complexity, younger age, genetic syndromes, vein thrombosis, and higher annual hospital volume. Patients with multiple congenital procedures had the highest incidence. Incidence increased with time, from 2% in 2004 to 3.7% in 2011 (P < .0001). Chylothorax was associated with longer stay (P < .0001), increased adjusted risk for in-hospital mortality (odds ratio, 2.13; 95% confidence interval, 1.75-2.61), and higher cost (P < .0001), regardless of procedure complexity. Of all patients with chylothorax, 196 (8.9%) underwent thoracic duct ligation or pleurodesis a median of 18 days after surgery. Total parenteral nutrition, medium-chain fatty acid supplementation, and octreotide were used in 56%, 1.7%, and 16% of patients, respectively.
CONCLUSIONS: Chylothorax is a significant problem in pediatric cardiac surgery and is associated with increased mortality, cost, and length of stay. Strategies should be developed to improve prevention and treatment.

OBJECTIVE: The relationship between pyogenic liver abscess (PLA) and gastrointestinal (GI) cancer was first reported more than 20 years ago, yet little is known about this connection. We evaluated this association in a population-based, retrospective, cohort study.
METHODS: Using Taiwan National Health Insurance claims data, we collected data on a cohort of 14,690 patients with PLA diagnosed from 2000 to 2007. A reference cohort of 58,760 persons without PLA (controls) was selected from the same database, frequency matched by age, sex, and index year. Both cohorts were followed up until the end of 2009, and incidences of GI cancer were calculated.
RESULTS: The incidence of GI cancer was 4.30-fold higher among patients with PLA compared with controls (10.8 vs 2.51/1000 person-years). Site-specific analysis showed that the highest incidence of colorectal cancer was among patients with PLA and diabetes mellitus, followed by patients with PLA without diabetes and controls with diabetes (9.58, 5.76, and 1.49/10,000 person-years, respectively). The PLA cohort also had a high risk of small intestine cancer (adjusted hazard ratio [aHR], 12.7; 95% confidence interval [CI], 5.79-27.7) and biliary tract cancer (aHR, 9.56; 95% CI, 6.68-13.7). Their risk of pancreatic cancer (aHR, 2.51; 95% CI, 1.68-3.76) was also significant. However, patients with PLA did not have an increased risk of gastric cancer compared with controls.
CONCLUSIONS: In a population-based study, we found that the incidence of GI cancer is increased more than 4-fold among patients with PLA compared with controls. PLA might therefore be an indicator of GI cancer. Patients with PLA had the highest incidence of colorectal cancer, followed by cancers of the biliary tract, pancreas, and small intestine.

BACKGROUND: Epidemic levels of tinea capitis (TC) have previously been reported in children.
OBJECTIVE: We sought to determine new epidemiologic trends for TC among northern California children from 1998 through 2007.
METHODS: Annual incidence of TC was based on diagnosis code or first-time antifungal prescriptions in all children up to age 15 years at Kaiser Permanente Northern California.
RESULTS: An average of 672,373 children/y met the inclusion criteria. Trend analyses showed decreases in TC by diagnosis code and by prescriptions (73.7% and 23.7%, respectively). Girls had lower incidence rates than boys by diagnosis (111.9 vs 146.4, P < .001 for 1998, and 27.9 vs 39.9, P < .001 for 2007). African Americans had the highest incidence rates by diagnosis (447.3 in 1998 and 184.1 in 2007) compared with other ethnic groups. Trichophyton tonsurans was the predominant organism (89.4% of all positive fungal cultures in 1998 and 91.8% in 2007). Prescriptions for griseofulvin declined, whereas the prescriptions for other antifungals increased.
CONCLUSIONS: This was a retrospective study.
CONCLUSIONS: In this cohort, there was a significant decrease in incidence of TC over the study period. Trichophyton tonsurans continued to be the predominant organism. These trends may be a result of improved education, recognition, diagnosis, and treatment of TC and increased use of new oral antifungals.

BACKGROUND: Medically ill, hospitalized patients are at increased risk for venous thromboembolism (VTE) after discharge. This study aimed to examine thromboprophylaxis patterns, risk factors, and post-discharge outcomes.
METHODS: This was a retrospective claims analysis involving administrative claims data and in-patient data abstracted from a sample of hospital charts. Patients aged ≥ 40 years hospitalized for ≥ 2 days for nonsurgical reasons between 2005 and 2009 were included. Hospital chart data were abstracted for a random sample of patients without evidence of anticoagulant use at 30 days post-discharge. The combined data determined whether in-patient thromboprophylaxis (anticoagulant or mechanical prophylaxis) reduces risk of VTE at 90 days post-discharge. Hazard ratios (HR) and odds ratios (OR) were calculated using Cox proportional hazard models and logistic regression.
RESULTS: Of 141,628 patients in the claims analysis, 3.9% received anticoagulants (3.6% warfarin). VTE, rehospitalization, and mortality rates were 1.9%, 17.2%, and 6.2%, respectively. The strongest predictors of post-discharge VTE were history of VTE (HR=4.0, 95% confidence interval [CI]: 3.3-4.8), and rehospitalization (HR=3.9, 95% CI: 3.6-4.3). Of 504 medical charts, 209 (41.5%) reported in-patient thromboprophylaxis. There was no statistically significant difference in post-discharge VTE rates between patients who did and did not receive in-patient thromboprophylaxis. All-cause mortality was greater among patients without use of VTE prophylaxis.
CONCLUSIONS: Utilization rates of in-hospital and post-discharge VTE prophylaxis were low. In-hospital VTE prophylaxis did not reduce the risk of post-discharge VTE in the absence of post-discharge anticoagulation. Combined in-patient and post-discharge thromboprophylaxis lowered the odds of short-term, all-cause post-discharge mortality.

BACKGROUND: Differentiating large lipomas from atypical lipomatous tumors (ALT) is challenging, and preoperative management guidelines are not well defined. The diagnostic ambiguity leads many surgeons to refer all patients with large lipomatous masses to an oncologic specialist, perhaps unnecessarily.
METHODS: In this retrospective cohort study of patients with nonretroperitoneal lipomatous tumors, preoperative characteristics discernible without invasive diagnostic procedures were evaluated for diagnostic predictive value.
RESULTS: We identified 319 patients (256 with lipomas, 63 with ALTs) treated between 1994 and 2012. Patients with ALTs were older (60.5 vs 53.5 years, p < 0.0001), had larger tumors (16.0 vs 8.3 cm, p < 0.0001), had tumors more often located on an extremity (88.9% vs 60.5% torso, p < 0.0001), and more frequently had a history of previous operations at the same site, exclusive of excision leading to diagnosis and referral (20.6% vs 5.9%, p = 0.001). Local recurrence was observed in 2 patients with lipomas (0.8%) vs 14 with ALTs (22.6%, p < 0.0001). No patients with ALTs developed distant metastases or disease-specific mortality, with a median follow-up of 27.4 months (range 0 to 164.6 months). On multivariate analysis, age ≥ 55 years, tumor size ≥ 10 cm, extremity location, and history of previous resections were predictors for diagnosis of ALT (p < 0.05).
CONCLUSIONS: Characteristics of lipomatous masses associated with a diagnosis of ALT include patient age ≥ 55 years, tumor size ≥ 10 cm, previous resection, and extremity location (vs torso). These easily identifiable traits may guide surgical management or referral to a specialist.