International Classification Of Diseases Diagnoses Research Articles

Financial Burden and Outcomes of Firearm Injuries in U.S. Hospitals, 2003-2020

Firearm-related injuries (FRIs) are serious but a preventable public health issue. The objective of this study was to describe FRI inpatient costs by (1) patient insurance payer type, and (2) hospital safety-net mix. FRIs were identified using International Classification of Disease diagnosis codes in the National Inpatient Sample. All admissions between 2003 and 2020 were included. The primary outcome was consumer-price index adjusted inpatient stay costs. Mixed effects generalized linear regressions, with a random intercept at the hospital level, were used to describe costs. Analyses were sample weighted and performed between 2023 and 2024. Among 538,795 FRIs, the median age was 27 years (interquartile range: 21 - 37 years). Injuries by payer type were highest among self-pay (280,161; 39%), followed by Medicaid (182,716; 34%), private (113,650; 21%), and Medicare (30,110; 6%). Inflation-adjusted costs of FRI stays totaled $15.2 billion, with $6.2 billion from Medicaid and $5 billion from the self-pay group. After 2014, FRI incidence declined among self-pay/no-charge patients and increased among Medicaid-covered patients - representing a 127% total increase in Medicaid costs from $169 million in 2003 to $753 million in 2020. Among moderate-high and high safety-net mix hospitals, costs increased from $257 million in 2003 to $567 million in 2020. The incidence and costs of FRIs among Medicaid-insured has substantially increased since 2003. Importantly, these increased costs are disproportionately placed on disadvantaged patients and safety-net hospitals.

A Transdiagnostic, Hierarchical Taxonomy of Psychopathology Following Traumatic Brain Injury (HiTOP-TBI).

Psychopathology, including depression, anxiety, and post-traumatic stress, is a significant yet inadequately addressed feature of moderate-severe traumatic brain injury (TBI). Progress in understanding and treating post-TBI psychopathology may be hindered by limitations associated with conventional diagnostic approaches, specifically the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). The Hierarchical Taxonomy of Psychopathology (HiTOP) offers a promising, transdiagnostic alternative to psychiatric classification that may more effectively capture the experiences of individuals with TBI. However, HiTOP lacks validation in the TBI population. To address this gap, we administered a comprehensive questionnaire battery, including 56 scales assessing homogeneous symptom components and maladaptive traits within HiTOP, to 410 individuals with moderate-severe TBI. We evaluated the reliability and unidimensionality of each scale and revised those with psychometric problems. Using a top-down, exploratory latent variable approach (bass-ackwards modeling), we subsequently constructed a hierarchical model of psychopathological dimensions tailored to TBI. The results showed that, relative to norms, participants with moderate-severe TBI experienced greater problems in the established HiTOP internalizing and detachment spectra, but fewer problems with thought disorder and antagonism. Fourteen of the 56 scales demonstrated psychometric problems, which often appeared reflective of the TBI experience and associated disability. The Hierarchical Taxonomy of Psychopathology Following Traumatic Brain Injury (HiTOP-TBI) model encompassed broad internalizing and externalizing spectra, splitting into seven narrower dimensions: Detachment, Dysregulated Negative Emotionality, Somatic Symptoms, Compensatory and Phobic Reactions, Self-Harm and Psychoticism, Rigid Constraint, and Harmful Substance Use. This study presents the most comprehensive empirical classification of psychopathology after TBI to date. It introduces a novel, TBI-specific transdiagnostic questionnaire battery and model, which addresses the limitations of conventional DSM and ICD diagnoses. The empirical structure of psychopathology after TBI largely aligned with the established HiTOP model (e.g., a detachment spectrum). However, these constructs need to be interpreted in relation to the unique experiences associated with TBI (e.g., considering the injury's impact on the person's social functioning). By overcoming the limitations of conventional diagnostic approaches, the HiTOP-TBI model has the potential to accelerate our understanding of the causes, correlates, consequences, and treatment of psychopathology after TBI.

Economic burden of cardiorespiratory hospitalizations associated with respiratory syncytial virus among United States adults in 2017–2019

ABSTRACT Morbidity and mortality caused by respiratory syncytial virus (RSV) in older adults and those with underlying health conditions can be potentially alleviated through vaccination. To assist vaccine policy decision-makers and payers, we estimated the annual economic burden of RSV-associated cardiorespiratory hospitalizations among insured US adults aged ≥18 y in the Merative MarketScan claims database from September through August of 2017–2018 and 2018–2019. Negative binomial regression models were used to estimate the number of RSV-associated cardiorespiratory hospitalizations using MarketScan-identified cardiorespiratory diagnosis codes in the presence or absence of RSV circulation per weekly laboratory test positivity percentages from the Centers for Disease Control and Prevention. This number was multiplied by mean cardiorespiratory hospitalization costs to estimate total costs for RSV-associated cardiorespiratory hospitalizations. Number and cost for International Classification of Diseases (ICD)-coded RSV hospitalizations were quantified from MarketScan. In 2017–2018 and 2018–2019, respectively, 18,515,878 and 16,462,120 adults with commercial or Medicare supplemental benefits were assessed. In 2017–2018, 301,248 cardiorespiratory hospitalizations were observed; 0.32% had RSV-specific ICD codes, costing $44,916,324, and 5.52% were RSV-associated cardiorespiratory hospitalizations, costing $734,078,602 (95% CI: $460,826,580–$1,103,358,799). In 2018–2019, 215,525 cardiorespiratory hospitalizations were observed; 0.34% had RSV-specific ICD codes, costing $33,053,105, and 3.14% were RSV-associated cardiorespiratory hospitalizations, costing $287,549,472 (95% CI: $173,377,778–$421,884,259). RSV contributes to substantial economic burden of cardiorespiratory hospitalizations among US adults. Modeling excess risk using viral positivity data provides a comprehensive estimation of RSV hospitalization burden and associated costs, compared with relying on ICD diagnosis codes alone.

Positive predictive value and sensitivity of cancer-associated venous thromboembolism diagnoses in the Danish National Patient Register

IntroductionHospital discharge diagnoses from administrative registries are frequently used in studies of cancer-associated venous thromboembolism, but the validity of International Classification of Diseases (ICD) codes for identifying such events is unknown. Materials and methodsUsing patient samples from the Danish National Patient Register, we calculated positive predictive values (PPV), i.e., the proportion of registered ICD codes, which could be confirmed after manual search of the electronic health record. Sensitivity was estimated in a sample of patients with imaging-verified venous thromboembolism but without prior knowledge about their ICD coding status. Sensitivity was calculated as the proportion of these patients, who were discharged with an ICD code for venous thromboembolism. ResultsThe overall PPV of an ICD-10 diagnosis of cancer-associated venous thromboembolism was 75.9 % (95 % confidence interval 71.3–80.0). In subgroups, the PPV was particularly low for recurrent venous thromboembolism (44.2 %), diagnoses in a secondary position (55.7 %), outpatient diagnoses (65.3 %), and diagnoses given at surgical (66.7 %), emergency wards (48.4 %), or via hospices/palliative teams (0 %).The overall sensitivity was 68 %, meaning 32 % of patients with cancer diagnosed in hospital with venous thromboembolism were discharged without any registered ICD code for venous thromboembolism. ConclusionsThe positive predictive value of an ICD diagnosis of cancer-associated venous thromboembolism in the Danish Patient Register was overall adequate for research purposes, but with notable variation across subgroups. Sensitivity was limited, as 1/3 of patients with venous thromboembolism were discharged without any relevant ICD code. Cautious interpretation of incidence of cancer-associated venous thromboembolism based on administrative register-based data is warranted.

Classification Accuracy and Description of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome in an Integrated Health Care System, 2006-2017.

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic illness characterized by marked functional limitations and fatigue. Electronic health records can be used to estimate incidence of ME/CFS but may have limitations. The authors used International Classification of Diseases (ICD) diagnosis codes to identify all presumptive cases of ME/CFS among 9- to 39-year-olds from 2006 to 2017. The authors randomly selected 200 cases for medical record review to classify cases as confirmed, probable, or possible, based on which and how many current clinical criteria they met, and to further characterize their illness. The authors calculated crude annual rates of ME/CFS coding stratified by age and sex using only those ICD codes that had identified confirmed, probable, or possible ME/CFS cases in the medical record review. The authors identified 522 individuals with presumptive ME/CFS based on having ≥ 1 ICD codes for ME/CFS in their electronic medical record. Of the 200 cases selected, records were available and reviewed for 188. Thirty (15%) were confirmed or probable ME/CFS cases, 39 (19%) were possible cases, 119 (60%) were not cases, and 12 (6%) had no medical record available. Confirmed/probable cases commonly had chronic pain (80%) or anxiety/depression (70%), and only 13 (43%) had completed a sleep study. Overall, 37 per 100,000 had ICD codes that identified confirmed, probable, or possible ME/CFS. Rates increased between 2006 and 2017, with the largest absolute increase among those 30-39 years old. Using ICD diagnosis codes alone inaccurately estimates ME/CFS incidence.

Open versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database.

It is generally perceived that minimally invasive nephroureterectomy (MINU), especially in the form of robotic-assisted laparoscopy, is gaining an increasing role in many institutions. The aim of our study was to investigate contemporary trends in the adoption of MINU in the United States compared with open nephroureterectomy (ONU). Patients who underwent ONU or MINU between 2011 and 2021 were retrospectively analyzed using PearlDiver Mariner, an all-payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patients' characteristics, social determinants of health (SDOH), and perioperative complications. The primary objective assessed different trends and costs in NU adoption, while secondary objectives analyzed factors influencing the postoperative complications, including SDOH. Outcomes were compared using multivariable regression models. Overall, 15,240 patients underwent ONU (n=7675) and MINU (n=7565). Utilization of ONU declined over the study period, whereas that of MINU increased from 29 to 72% (p=0.01). The 60-day postoperative complication rate was 23% for ONU and 19% for MINU (p<0.001). At multivariable analysis, ONU showed a significantly higher risk of postoperative complications (odds ratio 1.33, 95% CI 1.20-1.48). Approximately 5% and 9% of patients reported at least one SDOH at baseline for both ONU and MINU (p<0.001). Contemporary trend analysis of a large national dataset confirms that there has been a significant shift towards MINU, which is gradually replacing ONU. A minimally invasive approach is associated with lower risk of complications. SDOH are non-clinical factors that currently do not have an impact on the outcomes of nephroureterectomy.

Receipt of Medications for Alcohol Use Disorder in the Veterans Health Administration: Comparison of Rates at the Intersections of Racialized and Ethnic Identity With Both Sex and Transgender Status.

Medications for alcohol use disorder (MAUDs) are recommended for patients with alcohol use disorder yet are underprescribed. Consistent with Minority Stress and Intersectionality theories, persons with multiple sociodemographically marginalized identities (eg, Black women) often experience greater barriers to care and have poorer health outcomes. We use data from the Veterans Health Administration to assess disparities in Federal Drug Administration (FDA)-approved MAUDs and all effective MAUDs between the following groups: racialized and ethnic identity, sex, transgender status, and their intersections. Among all Veterans Health Administration outpatients between August 1, 2015, and July 31, 2017, with documented alcohol screenings and an International Classification of Diseases diagnosis for alcohol use disorder in the 0-365 days prior (N = 308,238), we estimated the prevalence and 95% confidence intervals of receiving FDA-approved MAUDs and any MAUDs in the following year and compared them using χ2 or Fisher's exact test. Analyses are unadjusted to present true prevalence and group differences. The overall prevalence for MAUDs was low (FDA-MAUDs = 8.7%, any MAUDs = 20.0%). Within sex, Black males had the lowest rate of FDA-MAUDs (7.3%, [7.1-7.5]), whereas American Indian/Alaskan Native females had the highest (18.4%, [13.8-23.0]). Among those identified as transgender, Asian and Black transgender persons had the lowest rates of FDA-MAUDs (0%; 4.3%, [1.8-8.5], respectively), whereas American Indian/Alaskan Native transgender patients had the highest (33.3%, [2.5-64.1]). Similar patterns were observed for any MAUDs, with higher rates overall. Substantial variation exists in MAUD prescribing, with marginalized veterans disproportionately receiving MAUDs at lower and higher rates than average. Implementation and quality improvement efforts are needed to improve MAUD prescribing practices and reduce disparities.

Incidence, Complications, and Long-term Outcomes of Gender-affirming Phalloplasty: Analysis of a Large Statewide Population-based Dataset

ObjectiveTo evaluate the incidence of gender-affirming phalloplasty and complications in a large population-based dataset. MethodsRetrospective cohort study was done using the California Department of Health Care Access and Information datasets which include patient-level data from all licensed hospitals, emergency departments, and ambulatory surgery facilities in California. Adult patients 18 years or older undergoing gender-affirming phalloplasty in California from January 1, 2009 to December 31, 2019 were included. We examined phalloplasty-related complications using International Classification of Disease diagnosis and procedure codes and Current Procedural Terminology codes. Unique record linkage number identifiers were used to follow patients longitudinally. Statistical analysis included Kaplan-Meier survival analysis and Cox proportional hazards analysis. ResultsWe identified 766 patients who underwent gender-affirming phalloplasty in 23 facilities. Of 475 patients with record linkage numbers, 253 (55.3%) had subsequent re-presentations to the inpatient, emergency department, and ambulatory surgery settings related to phalloplasty complications. Survival analysis indicated that 50% of patients re-presented by 1 year post-phalloplasty. Asian/Pacific Islander patients had lower risk of complications, and California residents had higher risk of complications. ConclusionsThis population-based study confirms that gender-affirming phalloplasty has a high complication rate, and demonstrates for the first time an association with high rates of return to hospitals, emergency departments, and ambulatory centers. These findings provide additional higher-level evidence that may aid patient counseling, shared surgical decision making, and institutional and government policy.

Automated-detection of risky alcohol use prior to surgery using natural language processing.

Preoperative risky alcohol use is one of the most common surgical risk factors. Accurate and early identification of risky alcohol use could enhance surgical safety. Artificial Intelligence-based approaches, such as natural language processing (NLP), provide an innovative method to identify alcohol-related risks from patients' electronic health records (EHR) before surgery. Clinical notes (n = 53,629) from pre-operative patients in a tertiary care facility were analyzed for evidence of risky alcohol use and alcohol use disorder. One hundred of these records were reviewed by experts and labeled for comparison. A rule-based NLP model was built, and we assessed the clinical notes for the entire population. Additionally, we assessed each record for the presence or absence of alcohol-related International Classification of Diseases (ICD) diagnosis codes as an additional comparator. NLP correctly identified 87% of the human-labeled patients classified with risky alcohol use. In contrast, diagnosis codes alone correctly identified only 29% of these patients. In terms of specificity, NLP correctly identified 84% of the non-risky cohort, while diagnosis codes correctly identified 90% of this cohort. In the analysis of the full dataset, the NLP-based approach identified three times more patients with risky alcohol use than ICD codes. NLP, an artificial intelligence-based approach, efficiently and accurately identifies alcohol-related risk in patients' EHRs. This approach could supplement other alcohol screening tools to identify patients in need of intervention, treatment, and/or postoperative withdrawal prophylaxis. Alcohol-related ICD diagnosis had limited utility relative to NLP, which extracts richer information within clinical notes to classify patients.

Incidence of Adolescent Syncope and Related Injuries Following Vaccination and Routine Venipuncture

PurposeVaccination is associated with syncope in adolescents. However, incidence of vaccine-associated syncope and resulting injury, and how it compares to syncope incidence following other medical procedures, is not known. Here, we describe the incidence of syncope and syncope-related injury in adolescents following vaccination and routine venipuncture. MethodsWe identified all Kaiser Permanente Northwest members ages 9–18 years with a vaccination or routine venipuncture and a same-day International Classification of Diseases diagnosis of syncope from 2013 through 2019. All cases were chart reviewed to establish chronology of events (vaccination, venipuncture, syncope, and injury, as applicable) and to attribute cause to vaccination or venipuncture. Incidence rates for vaccine-associated and venipuncture-associated syncope were calculated overall, by sex and age group. Syncope events resulting in injury were assessed for each event type. ResultsOf 197,642 vaccination and 12,246 venipuncture events identified, 549 vaccination and 67 venipuncture events had same-day syncope codes. Chart validation confirmed 59/549 (10.7%) events as vaccine-associated syncope, for a rate of 2.99 per 10,000 vaccination events (95% confidence interval (CI): 2.27–3.85) and 20/67 (29.9%) events as venipuncture-associated syncope, for a rate of 16.33 per 10,000 venipuncture events (95% CI: 9.98–25.21). The incidence rate ratio of vaccine-associated to venipuncture-associated syncope events was 0.18 (95% CI: 0.11–0.31). The incidence of vaccine-associated syncope increased with each additional simultaneously administered vaccine, from 1.51 per 10,000 vaccination events (95% CI: 0.93–2.30) following a single vaccine to 9.94 per 10,000 vaccination events (95% CI: 6.43–14.67) following three or more vaccines. Syncope resulted in injury in about 15% of both vaccine and venipuncture events. DiscussionSyncope occurs more commonly following venipuncture than vaccination. The number of simultaneously administered vaccines is a risk factor for postvaccination syncope in adolescents.

Intentional Self-Harm Among US Veterans With Traumatic Brain Injury or Posttraumatic Stress Disorder: Retrospective Cohort Study From 2008 to 2017.

Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD. Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017. All veterans with encounters or hospitalizations for intentional self-harm were assigned "index dates" corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran's health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans' index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans' average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans' prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores. About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans' index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization. Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses.

Racial, Ethnic, and Socioeconomic Disparities in Glaucoma Onset and Severity in a Diverse Nationwide Cohort in the United States.

Racial/ethnic minorities are diagnosed with glaucoma at younger ages, and Blacks are more likely to be diagnosed with moderate-to-severe glaucoma. In addition, we highlight a gap in the use of diagnosis codes. The purpose of this study was to analyze patterns of diagnosis coding usage and validate epidemiologic patterns of glaucoma onset and severity among primary glaucoma patients within the National Institutes of Health All of Us database. We used International Classification of Disease diagnosis codes to build 4 cohorts of patients with mild, moderate, severe, and unspecified stage glaucoma (N=2982). Descriptive analyses were stratified by disease stage, and mean age at diagnosis was compared across racial and ethnic groups. Multivariable ordinal regression was used to examine risk factors for increasing glaucoma severity. Of 2982 participants, 1714 (57%) had unspecified severity staging. Black/African Americans and other races were diagnosed with glaucoma at significantly younger ages compared with Whites (means 60 and 60 vs. 66y; P <0.001). Hispanic/Latino participants also had an earlier mean age of diagnosis (61 vs. 65y; P =0.001). Black/African Americans had higher odds of more severe glaucoma (odds ratio: 2.20, 95% CI, 1.62-3.30; P <0.001) than Whites when adjusting for socioeconomic characteristics. Black, Hispanic/Latino, and other minority participants are diagnosed with glaucoma at younger ages, and Blacks are more likely to be diagnosed with moderate-to-severe glaucoma. These findings validate prior population-based studies. Furthermore, we observed a gap in the use of diagnosis codes, as only 43% of participants had a specified severity stage in this national cohort. This may have implications for large-scale observational research concerning glaucoma severity, as electronic health records and claims databases typically lack other measures of disease progression, such as imaging and visual field data.

Feasibility and Clinical Utility of Prediction Models for Breast Cancer–Related Lymphedema Incorporating Racial Differences in Disease Incidence

Breast cancer-related lymphedema (BCRL) is a common complication of axillary lymph node dissection (ALND) but can also develop after sentinel lymph node biopsy (SLNB). Several models have been developed to predict the risk of disease development before and after surgery; however, these models have shortcomings that include the omission of race, inclusion of variables that are not readily available to patients, low sensitivity or specificity, and lack of risk assessment for patients treated with SLNB. To create simple and accurate prediction models for BCRL that can be used to estimate preoperative or postoperative risk. In this prognostic study, women with breast cancer who underwent ALND or SLNB from 1999 to 2020 at Memorial Sloan Kettering Cancer Center and the Mayo Clinic were included. Data were analyzed from September to December 2022. Diagnosis of lymphedema based on measurements. Two predictive models were formulated via logistic regression: a preoperative model (model 1) and a postoperative model (model 2). Model 1 was externally validated using a cohort of 34 438 patients with an International Classification of Diseases diagnosis of breast cancer. Of 1882 included patients, all were female, and the mean (SD) age was 55.6 (12.2) years; 80 patients (4.3%) were Asian, 190 (10.1%) were Black, 1558 (82.8%) were White, and 54 (2.9%) were another race (including American Indian and Alaska Native, other race, patient refused to disclose, or unknown). A total of 218 patients (11.6%) were diagnosed with BCRL at a mean (SD) follow-up of 3.9 (1.8) years. The BCRL rate was significantly higher among Black women (42 of 190 [22.1%]) compared with all other races (Asian, 10 of 80 [12.5%]; White, 158 of 1558 [10.1%]; other race, 8 of 54 [14.8%]; P < .001). Model 1 included age, weight, height, race, ALND/SLNB status, any radiation therapy, and any chemotherapy. Model 2 included age, weight, race, ALND/SLNB status, any chemotherapy, and patient-reported arm swelling. Accuracy was 73.0% for model 1 (sensitivity, 76.6%; specificity, 72.5%; area under the receiver operating characteristic curve [AUC], 0.78; 95% CI, 0.75-0.81) at a cutoff of 0.18, and accuracy was 81.1% for model 2 (sensitivity, 78.0%; specificity, 81.5%; AUC, 0.86; 95% CI, 0.83-0.88) at a cutoff of 0.10. Both models demonstrated high AUCs on external (model 1: 0.75; 95% CI, 0.74-0.76) or internal (model 2: 0.82; 95% CI, 0.79-0.85) validation. In this study, preoperative and postoperative prediction models for BCRL were highly accurate and clinically relevant tools comprised of accessible inputs and underscored the effects of racial differences on BCRL risk. The preoperative model identified high-risk patients who require close monitoring or preventative measures. The postoperative model can be used for screening of high-risk patients, thus decreasing the need for frequent clinic visits and arm volume measurements.

Risk of stillbirth in United States patients with diagnosed intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy is associated with a 4- to 10-fold increase in the risk of stillbirth in the absence of intervention, leading to recommendations for antenatal assessment, ursodiol use, and often preterm or early term delivery. This study aimed to determine whether current management strategies for intrahepatic cholestasis of pregnancy mitigate the elevated risk of stillbirth at a population level. This was a retrospective cohort study using the 2015-2020 National Readmissions Database, an administrative database developed by the United States Agency for Healthcare Research and Quality. Our study identified delivery hospitalizations, gestational age at delivery, occurrence of intrahepatic cholestasis of pregnancy and stillbirth, and comorbid conditions using the International Classification of Diseases diagnosis and procedure codes. Moreover, this study compared the timing of delivery and stillbirth rates of pregnant patients with intrahepatic cholestasis of pregnancy vs those without intrahepatic cholestasis of pregnancy at the time of delivery hospitalization. This study identified a cohort of 9,987,705 delivery hospitalizations in the National Readmissions Database, corresponding to a weighted national estimate of 18,609,207 births. Of these births, 152,040 (0.8%) were noted to have an intrahepatic cholestasis of pregnancy diagnosis. Patients with an intrahepatic cholestasis of pregnancy diagnosis were older, with small differences in comorbidities, such as a higher rate of gestational diabetes mellitus, than patients without an intrahepatic cholestasis of pregnancy diagnosis at delivery hospitalization. The overall rates of stillbirth were lower among those with intrahepatic cholestasis of pregnancy than among those without intrahepatic cholestasis of pregnancy (252 vs 386 per 100,000 deliveries; risk difference, 133 fewer per 100,000 deliveries; 95% confidence interval, 98-170), a finding that persisted after adjustment for insurance status, socioeconomic factors, and comorbid conditions (risk difference, 160 fewer stillbirths per 100,000 deliveries; 95% confidence interval, 127-194). Furthermore, although patients with intrahepatic cholestasis of pregnancy were more likely to deliver before term than those without intrahepatic cholestasis of pregnancy (30.1% vs 9.3%; P<.001), increased rates of stillbirth were not noted at any point after stratification of the cohort by gestational age at delivery. Patients with intrahepatic cholestasis of pregnancy diagnosis codes delivered earlier than those without intrahepatic cholestasis of pregnancy diagnosis codes, but the percentage of births affected by stillbirth was lower, even when stratifying for gestational age at birth. These results may provide reassurance to patients receiving an intrahepatic cholestasis of pregnancy diagnosis that current management does mitigate stillbirth risk in intrahepatic cholestasis of pregnancy.

Association between gestational age at delivery and indicator-specific severe maternal morbidity

Objective Individuals who deliver preterm are disproportionately affected by severe maternal morbidity. Limited data suggest that indicator-specific maternal morbidity varies by gestational age at delivery. We sought to evaluate the relationship between gestational age at delivery and the incidence of severe maternal morbidity and indicator-specific severe maternal morbidity. Methods We used a hospital administrative delivery database to identify all singleton deliveries between 16 and 42 weeks gestation from 2002 to 2018. We defined severe maternal morbidity as the presence of any International Classification of Disease diagnosis or procedure codes outlined by the Centers for Disease Control and Prevention, intensive care unit admission, and/or prolonged postpartum hospital length of stay. Indicator-specific severe maternal morbidity was based on the diagnosis and procedure codes and was characterized across gestational age epochs. We categorized gestational age into three epochs to capture extremely preterm birth (less than 28 weeks gestation), preterm birth (28-36 weeks gestation) and term birth (37 weeks gestation and above). Multivariable binomial regression was used to assess the association between categories of gestational age at delivery and severe maternal morbidity adjusting for confounders including age, race, body mass index (BMI), insurance status, and preexisting hypertension or diabetes. Results Severe maternal morbidity occurred in 2.5% of all deliveries. The unadjusted incidence of severe maternal morbidity by gestational age epoch was 12% at less than 28 weeks gestation, 8.4% at 28 to 36 weeks of gestation, and 1.7% at greater than or equal to 37 weeks gestation. After controlling for potential confounders the predicted probability of severe maternal morbidity was 16% (95% CI 14,17%) at 24 weeks compared to 2.2% (95% CI 2.1,2.3%) at 38 weeks. Sepsis, acute respiratory distress syndrome, mechanical ventilation, and shock were the most common diagnostic codes in deliveries less than 28 weeks gestation. Heart failure and cardiac arrhythmias were more common in patients with severe maternal morbidity delivering at term. Conclusion A high proportion of severe maternal morbidity occurred in preterm patients, with the highest rates occurring at less than 28 weeks gestation. Individuals with severe maternal morbidity who deliver preterm had distinct indicators of morbidity compared to those who deliver at term.

Quantifying and Interpreting Inequality in Surgical Site Infections per Quarter Among Anesthetizing Locations and Specialties.

Background Earlier studies have shown that prevention of surgical site infection can achieve net cost savings when targeted to operating rooms with the most surgical site infections. Methodology This retrospective cohort study included all 231,057 anesthetics between May 2017 and June 2022 at a large teaching hospital. The anesthetics were administered in operating rooms, procedure rooms, radiology, and other sites. The 8,941 postoperative infections were identified from International Classification of Diseases diagnosis codes relevant to surgical site infections documented during all follow-up encounters over 90 days postoperatively. To quantify the inequality in the counts of infections among anesthetizing locations, the Gini index was used, with the Gini index being proportional to the sum ofthe absolute pairwise differences among anesthetizing locations inthe counts of infections. Results The Gini index for infections among the 112 anesthetizing locations at the hospital was 0.64 (99% confidence interval = 0.56 to 0.71). The value of 0.64 is so large that, for comparison, it exceeds nearly all countries' Gini index for income inequality. The 50% of locations with the fewest infections accounted for 5% of infections. The 10% of locations with the most infections accounted for 40% of infections and 15% of anesthetics. Among the 57 operating room locations, there was no association between counts of cases and infections (Spearman correlation coefficient r = 0.01). Among the non-operating room locations (e.g., interventional radiology), there was a significant association (Spearman r = 0.79). Conclusions Targeting specific anesthetizing locations is important for the multiple interventions to reduce surgical site infections that represent fixed costs irrespective of the number of patients (e.g., specialized ventilatory systems and nightly ultraviolet-C disinfection).

Perinatal outcomes of Aboriginal women with mental health disorders.

Maternal mental disorders have been associated with adverse perinatal outcomes such as low birthweight and preterm birth, although these links have been examined rarely among Australian Aboriginal populations. We aimed to evaluate the association between maternal mental disorders and adverse perinatal outcomes among Aboriginal births. We used whole population-based linked data to conduct a retrospective cohort study (N = 38,592) using all Western Australia singleton Aboriginal births (1990-2015). Maternal mental disorders were identified based on the International Classification of Diseases diagnoses and grouped into six broad diagnostic categories. The perinatal outcomes evaluated were preterm birth, small for gestational age, perinatal death, major congenital anomalies, foetal distress, low birthweight and 5-minute Apgar score. We employed log-binomial/-Poisson models to calculate risk ratios and 95% confidence intervals. After adjustment for sociodemographic factors and pre-existing medical conditions, having a maternal mental disorder in the five years before the birth was associated with adverse perinatal outcomes, with risk ratios (95% confidence intervals) ranging from 1.26 [1.17, 1.36] for foetal distress to 2.00 [1.87, 2.15] for low birthweight. We found similar associations for each maternal mental illness category and neonatal outcomes, with slightly stronger associations when maternal mental illnesses were reported within 1 year rather than 5 years before birth and for substance use disorder. This large population-based study demonstrated an increased risk of several adverse birth outcomes among Aboriginal women with mental disorders. Holistic perinatal care, treatment and support for women with mental disorders may reduce the burden of adverse birth outcomes.

Impact of an opioid use disorder consult service on hospitalized trauma patients with opioid use disorder.

Opioid use disorder (OUD) is common in the hospitalized trauma population, being a comorbid diagnosis in approximately 1% of operative trauma cases. The impact of an addiction consult service in this population has been less well studied but may lead to increased provision of evidence-based OUD treatment and improved postdischarge outcomes. One hundred thirteen patients with an International Classification of Diseases diagnosis of OUD who were admitted to the trauma service at a single academic hospital between January 2020 to December 2021 were included in a retrospective chart review. Wilcoxon rank-sum tests were used to evaluate differences between patients who received an OUD consult and those who did not. Regression analysis was used to assess differences in postdischarge acute care utilization, attendance of follow-up appointments, initiation of and discharge on medication for opioid use disorder (MOUD), naloxone prescribing at discharge, and length of stay (LOS) between the consult and no-consult groups. Eighty-one patients in the study population received a consult and 32 did not. Patients in the consult group were more likely to have started MOUD during their admission (odds ratio [OR], 2.09; p < 0.001), be discharged with naloxone (OR, 1.89; p < 0.001), have a plan in place for continued OUD treatment at discharge (OR, 1.43; p < 0.001), and attend scheduled follow-up appointments with the trauma team (OR, 1.76; p = 0.02). Differences in acute care utilization and LOS between the two groups were not statistically significant. An OUD consult service can provide benefit to hospitalized trauma patients by increasing likelihood of starting MOUD, of discharging with MOUD and naloxone, and of attending trauma follow-up appointments without increasing LOS or acute care utilization. Thus, addiction consult service interventions during hospital admissions for trauma may serve to facilitate both evidence-based OUD care and posthospitalization trauma care. Therapeutic/Care Management; Level IV.

Treatment patterns in myasthenia gravis: A United States health claims analysis.

Limited knowledge exists on treatment patterns in clinical practice in patients with myasthenia gravis (MG). In this study we examined MG treatment patterns in the United States. Adult patients newly diagnosed with MG were identified from the IBM MarketScan insurance claims database. Patients with ≥2 MG International Classification of Disease diagnosis codes ≥3 months apart were retrospectively followed from the date of their first MG diagnosis record or start of treatment with acetylcholinesterase inhibitors (AChEI), intravenous (IV) or subcutaneous (SC) immunoglobulin (Ig), or plasma exchange (PLEx) therapy. Based on treatment received at any time during the follow-up period, patients were segmented into six main treatment cohorts. Exacerbations and use of IVIg, SCIg, or PLEx after the index date were identified. During 2010 to 2019, 7,194 patients were followed for up to 10 (median, 2.3) years. Of 6,539 treated patients, 6,462 (99%) were ever treated with AChEI and/or corticosteroids (CS); 95% were first treated with AChEI and/or CS only; 33% received ≥1 nonsteroid immunosuppressive treatment (IST) and 2% received a biologic. During treatment with first IST (n = 2,166), patients experienced 42% and 94% higher incidence rates of exacerbations and IVIg, respectively, compared with AChEI and/or CS (n = 6,242), and 33% and 23% higher, respectively, compared with a second IST (n = 353). Many patients experienced exacerbations and received rescue therapy despite treatment, suggesting current treatments may not provide adequate disease control for some patients and that additional treatment options should be explored.

Healthcare resource use in myasthenia gravis: a US health claims analysis.

There are limited data on the impact of myasthenia gravis (MG) on real-world healthcare resource use (HCRU) and patient burden in the United States. This study aims to assess HCRU in patients with MG using data from a US health claims database. A retrospective, database study of adult patients newly diagnosed with MG, using the IBM® MarketScan® Commercial Claims and Encounters and Medicare supplemental health insurance claims database. Patients with ⩾2 MG International Classification of Disease diagnosis codes ⩾3 months apart were followed from the date of their first MG diagnosis record or start of treatment. HCRU and use of immunoglobulins and plasma exchange during follow-up was assessed, as well as comorbidities, hospitalizations, emergency room (ER) visits, intensive care unit (ICU) admissions, and specialist visits per year after diagnosis, and compared with age- and sex-matched non-MG controls. During 2010-2019, 7194 patients were followed for up to 10 years (median = 2.3 years). During follow-up, patients with MG were 2.6-fold more likely than controls to be hospitalized, and 4.5-fold more likely to be admitted to an ICU. Risk and numbers of ER admission, hospitalization, and ICU visits were the highest in the 12 months post-diagnosis of MG and were consistently higher than controls during follow-up. MG was the main cause for most hospitalizations. Patients with MG have higher HCRU, compared with the age- and sex-matched non-MG controls. The early years after MG diagnosis are a period of particularly high healthcare burden, with many patients requiring hospitalization and ICU care to manage serious exacerbations.