Clinical Modification Billing Research Articles

Epidemiology of Cryptococcosis and Cryptococcal Meningitis in a Large Retrospective Cohort of Patients After Solid Organ Transplantation.

BackgroundCryptococcosis is the third most common invasive fungal infection in solid organ transplant (SOT) recipients. There are no nationally representative data describing the incidence, risk factors, and outcomes of cryptococcosis after SOT.MethodsWe assembled a large cohort of adult SOT recipients using Classification of Diseases, Ninth Revision, Clinical Modification billing data from Healthcare Cost and Utilization Project State Inpatient Databases of Florida (2006–2012), New York (2006–2011), and California (2004–2010). Demographics, comorbidities, death, and cryptococcal infections coded during hospitalization were identified.ResultsA total of 42634 adults with SOT were identified during the study period. Cryptococcal disease was identified in 0.37% (n = 158), 44% of which had meningitis (n = 69). Median time to diagnosis of cryptococcosis was 464 days (range, 4–2393). The median time to onset of cryptococcosis was earlier for lung (191 days; range, 7.5–1816), heart (195 days; range, 4–1061), and liver (200 days; range, 4–1581) compared with kidney transplant recipients (616 days; range, 12–2393; P < .001, log rank test). Very early-onset disease (<30 days after transplantation) more frequently occurred in liver and lung transplant recipients. Lung transplant recipients had the highest risk of cryptococcosis (hazard ratio [HR], 2.10; 95% confidence interval [CI], 1.21–3.60). Cryptococcosis was associated with death (HR, 2.29; 95% CI, 1.68–3.11), after adjusting for age, type of SOT, and other comorbidities.ConclusionsCryptococcosis is rare after SOT, but it is associated with significantly increased risk of death. Lung transplant recipients are at highest risk for cryptococcosis among SOTs. Nonkidney transplants have earlier onset of cryptococcosis and higher risk of death compared with kidney transplant recipients.

Assessing Geographic Variation in Strabismus Diagnosis among Children Enrolled in Medicaid

To determine how strabismus diagnosis varies within a given community and across communities among children with Medicaid health insurance. Retrospective cohort analysis. Children aged ≤10 years enrolled in Medicaid in Michigan or North Carolina during2009. Children who met the study inclusion criteria were identified from the Medicaid Analytic Extract database, which includes claims data for all children enrolled in Medicaid throughout the United States. Residential location was determined by the last known 5-digit ZIP code for each child, which was linked to the centroid of a ZIP Code Tabulation Area (ZCTA) for geo-referencing and spatial analyses. International Classification of Diseases, 9th Revision, Clinical Modification billing codes were used to identify children diagnosed with strabismus (code 378.xx). Bayesian hierarchical intrinsic conditional autoregressive spatial probit models were used to determine the risk of a child receiving a strabismus diagnosis in communities throughout Michigan and North Carolina. Maps display communities (ZCTAs) where the 95% credible intervals for the spatial random effects estimates do not cross zero, allowing for identification of locations with increased and decreased strabismus diagnosis risk relative to other communities in the states. Likelihood of receiving a diagnosis of strabismus. In 2009, among 519 212 eligible children in Michigan, 7535 (1.5%) received ≥1 strabismus diagnosis, and in North Carolina, 5827 of 523 886 eligible children (1.1%) were diagnosed with strabismus. In both states, the proportion receiving a strabismus diagnosis among black (0.9% in Michigan; 0.7% in North Carolina) and Hispanic (1.1% in Michigan; 0.8% in North Carolina) children was lower than the proportion for white children (1.8% in Michigan; 1.6% in North Carolina). Children living in poorer communities in both states were less likely to be diagnosed with strabismus independent of their race/ethnicity. A child's likelihood of being diagnosed with strabismus is associated with characteristics of the residential community where he or she resides. The findings of this study highlight the importance of ensuring that children who live in less affluent communities have access to the necessary services and eye care professionals to properly diagnose and treat them for this condition.

Epidemiology of Bloodstream Infections in a Multicenter Retrospective Cohort of Liver Transplant Recipients.

Although some studies have examined the epidemiology of bloodstream infections after liver transplantation, they were based in single centers and did not identify bloodstream infections treated in other hospitals. We retrospectively examined a cohort of 7912 adult liver transplant recipients from 24 transplant centers using 2004 to 2012 International Classification of Diseases, Ninth Revision, Clinical Modification billing data from 3 State Inpatient Databases, and identified bloodstream infections, inpatient death, and cumulative 1-year hospital costs. Multilevel Cox regression analyses were used to determine factors associated with bloodstream infections and death. Bloodstream infections were identified in 29% (n = 2326) of liver transplant recipients, with a range of 19% to 40% across transplant centers. Only 63% of bloodstream infections occurring more than 100 days posttransplant were identified at the original transplant center. Bloodstream infections were associated with posttransplant laparotomy (adjusted hazard ratio [aHR], 1.52), prior liver transplant (aHR, 1.42), increasing age (aHR, 1.07/decade), and some comorbidities. Death was associated with bloodstream infections with and without septic shock (aHR, 10.96 and 3.71, respectively), transplant failure or rejection (aHR, 1.41), posttransplant laparotomy (aHR, 1.40), prior solid-organ transplant (aHR, 1.48), increasing age (aHR, 1.15/decade), and hepatitis C cirrhosis (aHR, 1.20). The risk of bloodstream infections and death varied across transplant centers. Median 1-year cumulative hospital costs were higher for patients who developed bloodstream infections within 1 year of transplant compared with patients who were bloodstream infection-free (US $229 806 vs US $111 313; P < 0.001). Bloodstream infections are common and costly complications after liver transplantation that are associated with a markedly increased risk of death. The incidence and risk of developing bloodstream infections may vary across transplant centers.

Incidence, Risk Factors and Outcomes of Delayed-onset Cytomegalovirus Disease in a Large Retrospective Cohort of Lung Transplant Recipients.

Cytomegalovirus (CMV) replication and disease commonly occur in lung transplant recipients after stopping anti-CMV prophylaxis. The epidemiology of CMV disease is not well studied, given the difficulties in assembling representative study populations with prolonged follow-up. We hypothesized that delayed-onset CMV disease (>100 days after transplantation) occurs more commonly than early-onset CMV disease in lung transplant recipients, and is associated with an increased risk of death. We assembled a large cohort of lung transplant recipients using 2004 to 2010 International Classification of Diseases, Ninth Revision, Clinical Modification billing data from 3 Agency for Healthcare Research and Quality State Inpatient Databases, and identified demographics, comorbidities, CMV disease coded during hospital readmission and inpatient death. We used Cox proportional hazard multivariate analyses to assess for an independent association between delayed-onset CMV disease and death. In the cohort of 1528 lung transplant recipients from 12 transplant centers, delayed-onset CMV disease occurred in 13.7% (n = 210) and early-onset CMV disease occurred in 3.3% (n = 51). Delayed-onset CMV pneumonitis was associated with inpatient death longer than 100 days after transplantation (adjusted hazard ratio, 1.6; 95% confidence interval [95% CI], 1.1-2.5), after adjusting for transplant failure/rejection (aHR, 2.5; 95% CI, 1.5-4.1), bacterial pneumonia (aHR, 2.8; 95% CI, 2.0-3.9), viral pneumonia (aHR, 1.5; 95% CI, 1.1-2.1), fungal pneumonia (aHR, 1.8; 95% CI, 1.3-2.3), single lung transplant (aHR, 1.3; 95% CI, 1.0-1.7), and idiopathic pulmonary fibrosis (aHR, 1.4; 95% CI, 1.0-1.8). Delayed-onset CMV disease occurred more commonly than early-onset CMV disease among lung transplant recipients. These results suggest that delayed-onset CMV pneumonitis was independently associated with an increased risk of death.

Delayed-onset cytomegalovirus disease coded during hospital readmission in a multicenter, retrospective cohort of liver transplant recipients.

Delayed-onset cytomegalovirus (CMV) disease can occur among liver transplant recipients after CMV prophylaxis is stopped. We hypothesized that delayed-onset CMV disease (>100 days after transplant) occurs more commonly than early-onset CMV disease and is associated with clinical sepsis and death. Using 2004-2010 International Classification of Diseases, Ninth Revision, Clinical Modification billing data from 4 Healthcare Cost and Utilization Project state inpatient databases, we assembled a large and more representative cohort of 7229 adult liver transplant recipients from 26 transplant centers, and we identified demographics, comorbidities, CMV disease, and clinical sepsis coded during readmission and inpatient death. Multivariate analysis was performed with Cox proportional hazards models. Delayed-onset CMV disease occurred in 4.3% (n = 309), whereas early-onset CMV disease occurred in 2% (n = 142). Delayed-onset CMV disease was associated with previous transplant failure or rejection [adjusted hazard ratio (aHR), 1.4; 95% confidence interval (CI), 1.1-1.7]. Clinical sepsis > 100 days after transplant was associated with previous CMV disease (aHR, 1.3; 95% CI; 1.0-1.7), previous transplant failure or rejection (aHR, 2.1; 95% CI; 1.8-2.4), female sex (aHR, 1.3; 95% CI; 1.1-1.5), and several comorbidities. Death > 100 days after transplant was associated with delayed-onset CMV disease (aHR, 2.0; 95% CI; 1.6-2.6), transplant failure or rejection (aHR, 4.3; 95% CI; 3.4-5.5), increasing age by decade (aHR, 1.1; 95% CI; 1.0-1.2), and some comorbidities. In conclusion, delayed-onset CMV disease is more common than early-onset CMV disease among liver transplant recipients. Previous CMV disease may be a risk factor for clinical sepsis > 100 days after transplant, and delayed-onset CMV disease may be a risk factor for death > 100 days after transplant.

Risk factors for developing thyroid-associated ophthalmopathy among individuals with Graves disease.

Thyroid-associated ophthalmopathy (TAO) is a common and debilitating manifestation of Graves disease (GD). Presently little is known about factors that may increase the risk of developing TAO among patients with GD. To identify risk factors associated with the development of TAO among individuals with newly diagnosed GD. In this longitudinal cohort study, all beneficiaries 18 years of age or older with newly diagnosed GD who were continuously enrolled in a large nationwide US managed care network and who visited an eye care professional 1 or more times from 2001 to 2009 were identified. International Classification of Diseases, Ninth Revision, Clinical Modification billing codes were used to identify those who developed manifestations of TAO. Multivariable Cox regression was used to determine the hazard of developing TAO among persons with newly diagnosed GD, with adjustment for sociodemographic factors, systemic medical conditions, thyrotropin levels, and medical and surgical interventions for management of hyperthyroidism. Manifestations of TAO measured by hazard ratios (HRs) with 95% CIs. Of 8404 patients with GD who met the inclusion criteria, 740 (8.8%) developed TAO (mean follow-up, 374 days since initial GD diagnosis). After adjustment for potential confounders, surgical thyroidectomy, alone or in combination with medical therapy, was associated with a 74% decreased hazard for TAO (adjusted HR, 0.26 [95% CI, 0.12-0.51]) compared with radioactive iodine therapy alone. Statin use (for ≥60 days in the past year vs <60 days or nonuse) was associated with a 40% decreased hazard (adjusted HR, 0.60 [CI, 0.37-0.93]). No significant association was found for the use of nonstatin cholesterol-lowering medications or cyclooxygenase 2 inhibitors and the development of TAO. If prospective studies can confirm our finding that a thyroidectomy and statin use are associated with substantially reduced hazards for TAO among patients with GD, preventive measures for this burdensome manifestation of GD may become a reality.

Accuracy of International Classification of Diseases, Ninth Revision, Clinical Modification Billing Codes for Common Ophthalmic Conditions

Accuracy of International Classification of Diseases, Ninth Revision, Clinical Modification Billing Codes for Common Ophthalmic Conditions