Abstract 3177: Drip and Ship V-code use in the United States - an Analysis of the Nationwide Inpatient Sample (NIS)

Abstract

Objective: Non-stroke center hospitals often utilize a “drip-and-ship” (DS) method in which the acute ischemic stroke (AIS) patients are emergently transferred to stroke centers after treatment with intravenous tissue plasminogen activator (IV tPA). In October 2008, a new ICD-9 ″V-code″ was approved by the Centers for Medicare and Medicaid Services to identify these patients. We analyzed the use of this V-code in the Nationwide Inpatient Sample (NIS) in order to characterize rates of use, regional differences, and safety among AIS patients in the United States (US). Methods: We searched the NIS, a database representative of 20% of inpatient admissions in the US, to identify patients with primary diagnosis of stroke using ICD-9 codes (430, 431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, or 436) in the last quarter of 2008 and all of 2009. We searched for “drip and ship” coding using the V-code (v45.88) among any of the 15 listed diagnostic codes and for secondary diagnoses of brain hemorrhage (430 or 431) complicating ischemic stroke. We included primary diagnoses of hemorrhage (430 or 431) only if ischemic stroke treatment was provided (DS, thrombolysis on day 0, or any mechanical embolectomy by procedure codes: v45.88, 99.10, and 39.72). We compared demographics, hospital characteristics, and outcomes in DS vs. non-DS thrombolysis patients using univariable statistics. Results: Of the 140,698 AIS discharges from October 2008 to December 2009, 4314 (3.1%) received intravenous thrombolysis and 929 (0.66%) were DS patients based on V-code reporting. V-code reporting increased in each quarter (0.5 to 0.8%, p<0.001 for trend) but varied by geographic region (highest in Midwest: 0.9% vs. lowest in South: 0.3%, p<0.001). The vast majority of DS patients were discharged from teaching hospitals compared to non-DS thrombolysis patients (82.9 vs. 60.9%, p<0.001). DS and non-DS patients were similar by age, sex, weekend admission, and urban location of the receiving hospital. Secondary hemorrhage was significantly lower in DS patients (3.2 vs. 4.9%, p=0.028) while in-hospital mortality was not different (8.6 vs. 10.3%, p=0.118). Conclusion: In our analysis, we found that the “drip-and-ship” method is not uncommon and appropriate coding is increasing in the US. The practice is most prevalent in the Midwest and most patients are transferred to teaching hospitals. The safety of this method appears similar to non-DS tPA use for ischemic stroke. Further studies are needed to validate our findings.