Outpatient Codes Research Articles

Nationwide trends in diagnosed sedative, hypnotic or anxiolytic use disorders in adolescents and young adults enrolled in Medicaid: 2001-2019.

Sedative, hypnotic or anxiolytic use disorders (SHA-UD) are defined by significant impairment or distress caused by recurrent sedative, hypnotic or anxiolytic use. This study aimed to measure trends in the prevalence of SHA-UD diagnoses in adolescent and young adult US Medicaid enrollees from 2001 to 2019. Annual, cross-sectional study, 2001-2019. Medicaid Analytic eXtracts (MAX) and Transformed Medicaid Analytic Files (TAF) from 42 US states with complete data. Adolescents (13-17 years) and young adults (18-29 years) with ≥10months Medicaid enrollment in the calendar year; analytic sample contained 5.7 (2001) to 13.2 (2019) million persons per year. Annual prevalence of SHA-UD in adolescent and young adult Medicaid enrollees [defined as an inpatient or outpatient ICD code (304.1x, 305.4x, F13.1x, F13.2x) in the calendar year] was stratified by sex, race/ethnicity, receipt of a benzodiazepine, z-hypnotic or barbiturate prescription, and selected mental health diagnoses. Absolute and relative percent-changes from 2001 vs. 2019 were summarized. Secondary analyses were restricted to states with more consistent data capture. The prevalence of SHA-UD diagnoses statistically significantly increased for adolescents (0.01% to 0.04%) and young adults (0.05% to 0.24%) from 2001 to 2019. Increasing trends were observed in sex and race/ethnicity subgroups, with greatest relative increases among Non-Hispanic Black (624%) and Hispanic (529%) young adults. The trend increased among those with and without a benzodiazepine, z-hypnotic or barbiturate prescription; i.e. young adults with (2001 = 0.39% to 2019 = 1.77%) and without (2001 = 0.03% to 2019 = 0.18%) a prescription. Most adolescents (76%) and young adults (91%) with a SHA-UD diagnosis in 2019 had a comorbid substance use disorder. Sedative, hypnotic or anxiolytic use disorders (SHA-UD) diagnoses increased 3- to 5-fold between 2001 and 2019 for adolescent and young adult US Medicaid enrollees, with prevalence remaining low in adolescents. The increase over two decades may be attributed to changes in the availability, use and misuse of sedative, hypnotic and anxiolytic medications and to increased detection, awareness and diagnosing of SHA-UD.

8139 Examining the Association of GLP1-RA or DPP4i with Bullous Skin Diseases in Veterans

Abstract Disclosure: S. Saad-Omer: None. M. Kinaan: None. N. Sami: None. I. Mansi: None. Introduction: Pemphigus vulgaris (PV) and bullous pemphigoid (BP) are Autoimmune Blistering Disorders (AIBDs). GLP-1 Receptor Agonists (GLP1-RA) and Dipeptidyl peptidase 4 inhibitors (DPP4i) have been noted in various case reports and case control studies to be linked with certain AIBDs; however, their overall role in these diseases is not completely understood, despite the exponential increase in use of these medications. This study aims to be the first study to investigate the association of DPP-4 inhibitors and GLP-1 agonists with incidence of AIBD, PV, and BP in a large cohort of American veterans. Methods: This retrospective cohort study of veterans enrolled in the Veterans Health Administration (VHA) used Corporate Data Warehouse (CDW). We extracted data of patients from fiscal years (FY) 2006 to end of FY 2021 who filled either GLP1-RA or DPP4i prescriptions. CDW is a comprehensive data source that encompasses vital status, demographic data, inpatient and outpatient diagnoses and procedure codes, vital signs, laboratory data, and pharmacy fill data. The study groups included: 1) GLP1-RA group: patients who initiated GLP1-RA; and 2) DPP4i group: patients who initiated DPP4i. Our primary outcome was the incidence of AIBDs. We compared baseline characteristics of patients who experienced the outcome and those who did not among GLP1-RA or DDP4i users. We, thereafter, examined factors associated with incidence of AIBD, PV, and BP among GLP1-RA users and DPP4i users. Results: The initial cohort of GLP1-RA or DPP4i users comprised a total of 415,895 patients, from which we excluded 397 (0.095%) patients with prior bullous skin diseases before starting GLP1-RA or DPP4i medications. Overall, a total of 154 patients developed PV/BP disease after initiation of either DPP4i or GLP1-RA. Of these 154 patients, 123 of these patients were on DPP4i and 31 of these patients were on GLP1-RA. The mean age (SD) of PV/BP patients was 72 (11) years compared to an average age of 66 (10) years in patients who did not develop PV/BP. Patients were also found to be predominately white (77.9%). Factors associated with increased risk of BP were use of DPP4i (Odds Ratio [OR] 1.90, 95% confidence interval [95% CI: 1.14-3.47, p=<0.01), and older age (OR: 1.07, 95%CI: 1.04-1.09, p<0.01). Use of GLP1-RA or DPP4i was not associated with PV incidence. (OR: 1.31, 95% CI: 0.65-2.62, p=<0.45). Conclusion: In conclusion, our study supports existing literature that DPP4i use is associated with an increased risk of developing BP. Our data does not find association with GLP-1 agonists nor DPP4 inhibitors in increasing the risk of PV. Presentation: 6/3/2024

Administratively reported fetal alcohol spectrum disorders in commercially- and Medicaid-insured samples of children in the United States, 2015 – 2021

BackgroundFetal alcohol spectrum disorders (FASDs) are lifelong conditions that can occur in a person with prenatal alcohol exposure. Although studies using intensive, in-person assessments of children in selected communities have found higher estimates of children with FASDs than studies of healthcare claims data, claims-based studies provide more current information about individuals with recognized FASDs from diverse populations. We estimated the proportion of children with administratively reported FASDs in two large healthcare claims databases. MethodsWe analyzed Merative™ MarketScan® commercial and Medicaid claims databases, that include nationwide data from employer-sponsored health plans and from Medicaid programs in 8–10 states, respectively. For each database, we estimated the proportion of children aged 0–17 years with administratively reported FASDs, identified by one inpatient or two outpatient codes for prenatal alcohol exposure or fetal alcohol syndrome during the entire seven-year period from 2015 to 2021 and during each year. ResultsDuring 2015–2021, 1.2 per 10,000 commercially-insured and 6.1 per 10,000 Medicaid-insured children had an administratively reported FASD; estimates varied by sex, geography, and other available demographics. Among commercially-insured children, 0.5 per 10,000 in 2015 and 0.6 per 10,000 children in 2021 had an administratively reported FASD; among Medicaid-insured, 1.2 per 10,000 in 2015 and 2.1 per 10,000 children in 2021 had an administratively reported FASD. ConclusionsAlthough an underestimate of the true population of children with FASDs, patterns in administratively reported FASDs by demographics were consistent with previous studies. Healthcare claims studies can provide timely, ongoing information about children with recognized FASDs to complement in-persons studies.

Trends in Bundled Outpatient Behavioral Health Services in VA-Direct Versus VA-Purchased Care.

The Veterans Health Administration (VA) increasingly purchases community-based care (CC) to improve healthcare access, including behavioral health. In 2018, VA introduced standardized episodes of care (SEOCs) to guide authorization and purchase of CC services for specific indications in a defined timeframe without bundling payment. In this retrospective cross-sectional study, we describe trends in VA and CC behavioral healthcare utilization using the VA Outpatient Psychiatry SEOC definition. Counts of Outpatient Psychiatry SEOC-allowable service and procedure codes during fiscal years 2016-2019 were organized according to four SEOC-defined service types (evaluation and management, laboratory services, psychiatry services, transitional care) and measured as percentages of all included codes. Trends comparing behavioral healthcare utilization between Veterans using any CC versus VA only were analyzed using a linear mixed effects model. We identified nearly 3million Veterans who registered 60million qualifying service and procedure codes, with overall utilization increasing 77.8% in CC versus 5.2% in VA. Veterans receiving any CC comprised 3.9% of the cohort and 4.7% of all utilization. When examining service type as a percent of all Outpatient Psychiatry SEOC-allowable care among Veterans using CC, psychiatry services increased 12.2%, while transitional care decreased 8.8%. In regression analysis, shifts in service type utilization reflected descriptive results but with attenuated effect sizes. In sum, Outpatient Psychiatry SEOC-allowable service utilization grew, and service type composition changed, significantly more in CC than in VA. The role of SEOCs and their incentives may be important when evaluating future behavioral healthcare quality and value in bundled services.

High Rates of Missed HIV Testing Among Oral PrEP Users in the United States From 2018-2021: A National Assessment on Compliance With HIV Testing Recommendations of the CDC PrEP Guidelines.

The US Centers for Disease Control and Prevention recommends HIV testing every 3 months in oral PrEP users. We performed a national assessment of HIV testing compliance among oral PrEP users. We analyzed 408 910 PrEP prescriptions issued to 39 809 PrEP users using a national insurance claims database that contained commercial and Medicaid claims. We identified PrEP use based on pharmacy claims and outpatient diagnostic coding. We evaluated the percentage of PrEP prescription refills without HIV testing (identified by CPT codes) within the prior 3, 6, and 12 months using time to event methods. We performed subgroup and multivariate analyses by age, gender, race, insurance type, and geography. Of 39 809 persons, 36 197 were commercially insured, 3612 were Medicaid-insured, and 96% identified as male; the median age (interquartile range) was 34 (29-44) years, and the Medicaid-insured PrEP users were 24% Black/African American, 44% White, and 9% Hispanic/Latinx. Within the prior 3, 6, and 12 months, respectively, the percentage of PrEP prescription fills in individuals without HIV Ag/Ab testing was 34.3% (95% CI, 34.2%-34.5%), 23.8% (95% CI, 23.7%-23.9%), and 16.6% (95% CI, 16.4%-16.7%), and the percentage without any type of HIV test was 25.8% (95% CI, 25.6%-25.9%), 14.6% (95% CI, 14.5%-14.7%), and 7.8% (95% CI, 7.7%-7.9%). Approximately 1 in 3 oral PrEP prescriptions were filled in persons who had not received an HIV Ag/Ab test within the prior 3 months, with evidence of health disparities. These findings inform clinical PrEP monitoring efforts and compliance with national HIV testing guidance to monitor PrEP users.

Alzheimer incidence and prevalence with and without asthma: A Medicare cohort study

International data suggest that asthma, like other inflammatory diseases, might increase Alzheimer disease (AD) risk. We sought to explore risk pathways and future mitigation strategies by comparing diagnostic claims-based AD incidence and prevalence among US patients with asthma with those without asthma. This cohort study included a national Medicare 20% random sample (2013-2015). Adult patients with asthma with more than 12 months continuous Medicare were compared with subjects without asthma overall and as matched. Asthma was defined by 1 inpatient or 2 outpatient codes for asthma. The main outcomes were 2-year incident or prevalent AD defined by International Classification of Diseases, Ninth Revision code 331.0 or Tenth Revision code G30.0, G30.1, G30.8, or G30.9. Among 5,460,732 total beneficiaries, 678,730 patients were identified with baseline asthma and more often identified as Black or Hispanic, were Medicaid eligible, or resided in a highly disadvantaged neighborhood than those without asthma. Two-year incidence of AD was 1.4% with asthma versus 1.1% without asthma; prevalence was 7.8% versus 5.4% (both P≤ .001). Per 100,000 patients over 2 years, 303 more incident AD diagnoses occurred in those with asthma, with 2,425 more prevalent cases (P< .001). Multivariable models showed that asthma had greater odds of 2-year AD incidence (adjusted odds ratio, 1.33 [95% CI, 1.29-1.36]; matched 1.2 [95% CI, 1.17-1.24]) and prevalence (adjusted odds ratio, 1.48 [95% CI, 1.47-1.50]; matched 1.25 [95% CI, 1.22-1.27]). Asthma was associated with 20% to 33% increased 2-year incidence and 25% to 48% increased prevalence of claims-based AD in this nationally representative US sample. Future research should investigate risk pathways of underlying comorbidities and social determinants as well as whether there are potential asthma treatments that may preserve brain health.

Effectiveness and safety of apixaban and rivaroxaban vs warfarin in patients with atrial fibrillation and chronic kidney disease.

Randomized controlled trials (RCTs) of direct oral anticoagulants (DOACs) included a low proportion of atrial fibrillation (AF) patients with chronic kidney disease (CKD), and suggested that DOACs are safe and effective in patients with mild-to-moderate CKD. In a metanalysis of RCTs and observational studies, DOACs were associated with better efficacy (vs warfarin) in early CKD and had similar efficacy and safety profiles in patients with stages IV-V CKD. But few studies have provided data on the safety and effectiveness of each DOAC vs warfarin in patients with stage III CKD. The effectiveness and safety of DOACs in those patients are still subject to debate. To assess and compare the effectiveness and safety of apixaban and rivaroxaban vs warfarin in this patient population. A cohort of patients with an inpatient or outpatient code for AF and stage III CKD who were newly prescribed apixaban and rivaroxaban was created using the administrative databases from the Quebec province of Canada between 2013 and 2017. The primary effectiveness outcome was a composite of ischemic stroke, systemic embolism, and death, whereas the primary safety outcome was a composite of major bleeding within a year of DOAC vs warfarin initiation. Treatment groups were compared in an under-treatment analysis using inverse probability of treatment weighting and Cox proportional hazards. A total of 8899 included patients filled out a new oral anticoagulation therapy claim; 3335 for warfarin and 5564 for DOACs. Compared with warfarin, 15 mg and 20 mg rivaroxaban presented a similar effectiveness and safety composite risk. Apixaban 5.0 mg was associated with a lower effectiveness composite risk [Hazard ratio (HR) 0.76; 95% confidence interval (CI): 0.65-0.88] and a similar safety risk (HR 0.94; 95%CI: 0.66-1.35). Apixaban 2.5 mg was associated with a similar effectiveness composite (HR 1.00; 95%CI: 0.79-1.26) and a lower safety risk (HR 0.65; 95%CI: 0.43-0.99. Although, apixaban 5.0 mg was associated with a better effectiveness (HR 0.76; 95%CI: 0.65-0.88), but a similar safety risk profile (HR 0.94; 95%CI: 0.66-1.35). The observed improvement in the effectiveness composite for apixaban 5.0 mg was driven by a reduction in mortality (HR 0.61; 95%CI: 0.43-0.88). In comparison with warfarin, rivaroxaban and apixaban appear to be effective and safe in AF patients with stage III CKD.

Validation of ICD-9-CM codes for major genitourinary birth defects in Military Health System administrative data, 2006-2014.

The Department of Defense Birth and Infant Health Research program is dedicated to birth defects research and surveillance among military families. Here, we assess and refine the validity of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for selected genitourinary birth defects in the Military Health System (MHS). We additionally outline methods for the calculation of positive predictive value (PPV) and negative predictive value (NPV), sensitivity, and specificity using a stratified sampling design. Among military infants born from 2006 through 2014, a random sample of ICD-9-CM screen-positive cases (for six genitourinary birth defects) and screen-negative cases were selected for chart review. PPV, NPV, sensitivity, and specificity were calculated for individual defects and any included defect (i.e., overall); measures were weighted by the inverse probability of being sampled. Of 461,557 infants, 686 were sampled for chart review. Bladder exstrophy was accurately reported (PPV: >90%), while the accuracy of renal dysplasia, renal agenesis/hypoplasia, and hypospadias was moderate (PPVs: 66%-68%) and congenital hydronephrosis was low (PPV: 20%). Specificity and NPVs always exceeded 98%. The overall PPV was 50%; however, excluding congenital hydronephrosis screen-positive cases and requiring at least two inpatient or outpatient diagnostic codes resulted in a PPV of 85%. The validity of major genitourinary birth defect codes varied in MHS administrative data. The accuracy of an overall defect measure improved by omitting congenital hydronephrosis and requiring at least two diagnostic codes. Although PPV is generally useful for research, additional calculation of NPV, sensitivity, and specificity better informs the identification of appropriate selection criteria across surveillance and research settings.

Hospital-physician Integration and Value-based Payment: Early Results From MIPS.

Hospital-physician integration is often justified as a driver of clinical quality improvement due to joint resources covering a broad spectrum of care. Value-based programs, such as the Medicare Merit-Based Incentive Payment System (MIPS), are intended to tie financial incentives to clinical quality, which may confer an advantage on such integrated practices. We assessed the relationship between hospital-physician integration and MIPS performance by comparing hospital-integrated practices and independent practices. This was a cross-sectional study using data from the Quality Payment Program for the performance year 2020. Physician practices with a valid MIPS composite score in performance year 2020. Hospital integration was based on whether at least 75% of a practice's physicians either billed most of their services using hospital outpatient department codes or billed through a hospital tax identifier. The primary outcome was the MIPS quality category score, and the secondary outcomes were the specific quality measures reported by practice groups. Of the 20 most frequently reported measures, 14 were common in both groups. No difference was observed in the quality category score between hospital-integrated practices and independent practices in either unadjusted comparisons or after adjusting for practice characteristics, including practice size, geography, specialty mix, and case mix. In the secondary outcome models for specific quality measures, hospital-integrated practices achieved higher scores on most overlap measures but not all. The findings on quality category score suggest that hospital integration does not confer much advantage in the context of MIPS quality performance.

Mental Health Conditions Among Children and Adolescents With Congenital Heart Disease: A Danish Population-Based Cohort Study.

Despite the known mental health burden among children with congenital heart disease (CHD), the literature is constrained by a lack of comparison cohorts and population-based follow-up data. We examined the incidence of mental health conditions among children with CHD, relative to 3 comparison cohorts. This population-based cohort study identified all children with CHD (<18 years of age; n=16 473) in Denmark from 1996 to 2017, through linkage of individual-level data across national registries. This allowed for complete follow-up of the population. Comparison cohorts included children from the general population (n=162 204), siblings of children with CHD (n=20 079), and children with non-CHD major congenital anomalies (n=47 799). Mental health conditions were identified using inpatient and outpatient hospital discharge codes, prescription data, and data on use of community-based psychology, psychiatry, and psychotherapy services. We computed cumulative incidence by 18 years of age, incidence rates, and adjusted hazard ratios (aHRs) using Cox regression. aHRs accounted for sex, year of CHD diagnosis, parental mental health, and socioeconomic status. All estimates were stratified by age, sex, and CHD complexity. The cumulative incidence of mental health conditions by 18 years of age in the CHD cohort was 35.1% (95% CI, 34.0%-36.1%), corresponding to aHRs of 1.64 (95% CI, 1.58-1.71), 1.41 (95% CI, 1.30-1.52), and 1.02 (95% CI, 0.98-1.07) compared with the general population, sibling, and major congenital anomaly cohorts, respectively. Mental health incidence rates showed prominent peaks in early childhood and adolescence. Males and children with severe or single-ventricle CHD demonstrated higher incidence rates of mental health conditions relative to females and children with mild or moderate CHD, respectively. Compared with the general population and sibling cohorts, incidence rates and aHRs in the CHD cohort were highest for severe stress reactions, attention deficit/hyperactivity disorder, intellectual disability, and autism spectrum disorder. Compared with children in the major congenital anomaly cohort, the aHRs were close to 1. More than one-third of children with CHD were diagnosed or treated for a mental health condition by 18 years of age. Mental health conditions began early in life and were most prominent among males and children with severe or single-ventricle heart disease.

Real-World Immunosuppressant Treatment Patterns for Patients with Lupus Nephritis in the United States.

Lupus nephritis (LN) treatment aims to control and prevent flares and irreversible kidney damage. Around 30% of patients are unresponsive to treatment; however, real-world LN treatment patterns have not been reported. Objectives of this retrospective cohort study (GSK 209758) were to quantify the time to switching/re-initiating induction therapy in patients with LN initiating immunosuppressant therapy and conversion from induction to maintenance immunosuppressant therapy, and to assess corticosteroid use. Patients with LN initiating induction or maintenance immunosuppressant therapy were identified using claims data. Patients were followed up from the index date (immunosuppressant initiation date) until treatment discontinuation, death, disenrollment, administrative censoring, or the end of follow-up period. The cumulative incidence of switching/re-initiating induction therapy and conversion to maintenance therapy was estimated using outpatient pharmacy claims and procedure codes. Corticosteroid use was estimated using pharmacy claims; a mean daily dose of ≥ 7.5mg/day was considered high. In total, 5000 patients with LN contributed 5516 treatment episodes (induction cohort, N = 372; maintenance cohort, N = 5144). In the induction cohort, the cumulative incidence (95% confidence interval) of switching between induction therapies was 24.6% (20.1-30.0) at 12months, while 59.6% (52.4-66.1) of patients converted to maintenance therapy at 12months. In the maintenance cohort, 21.2% (19.9-22.5) re-initiated induction therapy at 12months. Oral corticosteroid use decreased during the follow-up in both cohorts, but 21.5% of patients remained on a high dose at 12months in the induction cohort, while 15.8% in the maintenance cohort were taking a high dose at 24months. Around a quarter of patients with LN initiating immunosuppressant therapy switched within 12months, while a fifth re-initiated induction therapy within 12months. Use of high corticosteroid doses were observed during 24months of follow-up. These data suggest that many patients do not respond to existing standard LN therapies.

Validation of an algorithm to identify fractures among patients within the Veterans Health Administration.

To validate an algorithm that identifies fractures using billing codes from the International Classification of Diseases Ninth Revision (ICD-9) and Tenth Revision (ICD-10) for inpatient, outpatient, and emergency department visits in a population of patients. We identified and reviewed a random sample of 543 encounters for adults receiving care within a single Veterans Health Administration healthcare system and had a first fracture episode between 2010 and 2019. To determine if an encounter represented a true incident fracture, we performed chart abstraction and assessed the type of fracture and mechanism. We calculated the positive predictive value (PPV) for the overall algorithm and each component diagnosis code along with 95% confidence intervals. Inverse probabilities of selection sampling weights were used to reflect the underlying study population. The algorithm had an initial PPV of 73.5% (confidence interval [CI] 69.5, 77.1), with low performance when weighted to reflect the full population (PPV 66.3% [CI 58.8, 73.1]). The modified algorithm was restricted to diagnosis codes with PPVs > 50% and outpatient codes were restricted to the first outpatient position, with the exception of one high performing code. The resulting unweighted PPV improved to 90.1% (CI 86.2, 93.0) and weighted PPV of 91.3% (CI 86.8, 94.4). A confirmation sample demonstrated verified performance with PPV of 87.3% (76.0, 93.7). PPVs by location of care (inpatient, emergency department and outpatient) remained greater than 85% in the modified algorithm. The modified algorithm, which included primary billing codes for inpatient, outpatient, and emergency department visits, demonstrated excellent PPV for identification of fractures among a cohort of patients within the Veterans Health Administration system.

Trends in the use of maintenance therapy in ovarian cancer.

6585 Background: Emerging maintenance therapies in advanced ovarian cancer (OC) remain of high interest since 70% of patients (pts) will relapse and ultimately succumb to OC. This study analyzes nonclinical factors associated with maintenance therapy (MT) in OC. We define MT in OC as the use of polyADP-ribose polymerase inhibitors (PARPi) and/or bevacizumab (bev) following platinum-based chemotherapy. Methods: We used data from Optum’s de-identified Clinformatics Data Mart Database F to conduct an analysis of OC pts with Medicare or commercial health insurance. Pts were included if they had 1 inpatient or 2 outpatient diagnosis codes for OC from 01/2017 to 12/2020 and received platinum-based chemotherapy after diagnosis. Pts were excluded if they did not have continuous coverage from diagnosis until 6 months after completion of platinum-based chemotherapy or death. MT was identified by insurance claims for PARPi or bev received within 6 months after completion of platinum-based chemotherapy. Descriptive statistics were used to summarize patient characteristics. Multivariable logistic regression was used to evaluate associations between pts’ nonclinical characteristics and MT use. Trends in MT use were reviewed by year. Subgroup analysis comparing trends in PARPi use to bev use was also performed. The median time from last chemotherapy until initiation of MT was 22 days. Results: 5,652 pts were included in the study with a median age of 70 years. The majority were white (70.7%), Medicare-insured (71.8%), and treated in the South (42.8%). 33.6% of pts received MT and 66.4% of pts received neither PARPi nor bev. More pts received bev alone (19.6%) compared to PARPi alone (10.3%) or combination MT (3.7%). Olaparib was the most commonly prescribed PARPi. After adjusting for insurance type, both PARPi and bev use increased significantly over time from 2017 to 2021. Pts with more comorbidity burdens (i.e. higher Elixhauser comorbidity index) were more likely to receive MT compared to pts with less comorbidity [OR (95% CI): 1.44 (1.26-1.65)]. MT use was significantly associated with treatment in the South compared to the Northeast [1.22(1.01-1.46)] and younger age, pts &gt; 76 years were less likely to use MT compared to pts &lt; 56 years old [0.78 (0.62-0.98)]. In the subgroup analysis, PARPi use was significantly associated with age, race and region compared with no MT use, while bev use was not associated with these factors. Conclusions: Age, comorbidity status, and geographic location of treatment were associated with MT use. The increasing use of MT over time is consistent with published data since both agents have demonstrated a progression free survival advantage and have tolerable toxicity profiles. With increasing focus on MT in OC, a better understanding of nonclinical factors associated with MT use is imperative to eliminating potential disparities in OC outcomes.

An Implementation of Coding and Indexing Application for Outgoing Patients at Puskesmas Bringkoning Madura

Community health centers (Pusat Kesehatan Masyarakat - Puskesmas) must provide fast and appropriate health services. Regarding this role, Puskesmas Bringkoning Madura has developed a web-based outpatient coding and indexing system to provide the immediate service the patients need. The web-based application was created using the waterfall model method with the PHP and MySQL programming languages. This study aimed to describe the implementation of the coding and indexing application system for outpatients. The study employed a positivistic quantitative approach. The survey was conducted on medical record personnel, medical officers, and doctors as implementers of the outpatient coding and indexing application with 3 (three) indicators. Almost all respondents indicated that the outpatient coding and Indexing Application helped much in supporting the work of outpatient services. Keywords: indexing, application, outgoing patients

Association of Race and Neighborhood Socioeconomic Disadvantage with Incident Peripheral Artery Disease and Chronic Limb-threatening Ischemia

There are disparities in peripheral artery disease (PAD) outcomes according to both race and socioeconomic disadvantage separately. However, few studies have investigated the association of race and socioeconomic deprivation together with risk of PAD. We aimed to investigate the association of race and socioeconomic disadvantage with risk of incident PAD and incident chronic limb-threatening ischemia (CLTI). We included all non-Hispanic white and non-Hispanic Black adults in the Maryland Health Services Cost Review Commission from January 2013 through December 2019 without prevalent PAD or CLTI at their index visit. PAD and CLTI were defined by inpatient and outpatient diagnosis codes. Socioeconomic disadvantage was determined by the area deprivation index (ADI), a comprehensive measure of socioeconomic deprivation, using nine-digit zip codes. Patients living in neighborhoods with greater socioeconomic deprivation (ADI 3 and 4) were categorized as high ADI, while patients living in neighborhoods with lower socioeconomic deprivation (ADI 1 and 2) were categorized as low ADI. We estimated the cumulative incidence of PAD and CLTI and quantified hazard ratios (HR) using multivariable Cox proportional hazards models across four race and ADI groups after correcting for traditional demographic and cardiovascular risk factors. A total of 5,592,650 adult patients without PAD or CLTI at baseline (51.6% ≥65 years of age, 37.9% Black, 31.2% with high ADI) were followed for a median of 10.71 years (interquartile range, 5-31 years). The overall cumulative incidence of PAD and CLTI was 22% and 6%, respectively, and varied significantly by race and ADI (Figs 1 and 2). After adjusting for baseline differences between groups, the risk of incident PAD was highest for the Black-high ADI group (hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.38-1.43), followed by White-high ADI (HR, 1.22; 95% CI, 1.20-1.24) and Black-low ADI (HR, 1.00; 95% CI, 0.99- 1.01) compared to White-low ADI (Table). Similarly, the risk of incident CLTI was highest for the Black-high ADI group (HR, 1.52; 95% CI, 1.48-1.57), followed by White-high ADI (HR, 1.38; 95% CI, 1.33-1.42), then Black-low ADI (HR, 1.14; 95% CI, 1.11-1.17) compared to White-low ADI. Previously reported racial differences in risk of PAD and CLTI are largely explained by socioeconomic deprivation, as characterized by ADI. Adults living in areas with higher socioeconomic deprivation are at higher risk of incident PAD and CLTI than their less socioeconomically deprived counterparts.Fig 2Cumulative Incidence Function Curves of Incident CLTI in health Services Cost Review Commission Database from 2013 through 2019 Stratified by Race and ADI.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The Burden of Arboviral Infections in the Military Health System 2012-2019.

Arboviral infections, including dengue (DNV), chikungunya (CHIKV), and Zika (ZIKV), impact both travelers and native populations of endemic regions. We sought to assess the disease burden of arboviral infections in the Military Health System, the validity of arboviral diagnostic codes, and the role of pretravel counseling on insect avoidance precautions. We searched for diagnostic codes consistent with arboviral infection and grouped them into DNV, CHIKV, ZIKV, Japanese encephalitis virus (JEV), and Other. Demographic data were evaluated. A subset of charts in each category were reviewed for diagnostic validity and travel characteristics. In all, 10,547 unique subjects carried 17,135 arboviral diagnostic codes, including 1,606 subjects (15.2%) coded for DNV, 230 (2.2%) for ZIKV, 65 (0.6%) for CHIKV, and 4,317 (40.9%) for JEV. A chart review was performed on 807 outpatient charts, yielding outpatient diagnostic code positive predictive values of 60.5% (DNV), 15.3% (ZIKV), and 64.5% (CHIKV); there were no valid cases of JEV. Dengue represented the greatest burden of arboviral infections with 2.2 cases per 100,000 military healthcare enrollees over the 2012-2019 fiscal years. More than 80% of subjects with arboviral infection did not have documented pretravel counseling. Arboviral infections represent a significant disease burden in young travelers to endemic regions. After adjustment for diagnostic validity, DNV represented the greatest burden. Diagnostic codes for ZIKV and JEV overestimate the burden of these diseases. Low rates of pretravel visits represent an opportunity for increased emphasis on insect exposure precautions.

Abstract 4394: Feasibility analysis of querying EHR databases for cancer clinical trial criteria

Abstract Background: In order to enroll patients for clinical trials (CT), it is common to run queries in clinical databases using CT eligibility criteria as filters and specifications. However, CT eligibility criteria are often unavailable as discrete data fields, which can interfere with CT recruitment. The purpose of this study was to identify the most commonly needed eligibility criteria that are specified in cancer CT to investigate whether and how they could be found in clinical databases. Design: We examined the data elements needed for the trial eligibility criteria that would be used in queries for all the Breast, Gastrointestinal, Genitourinary, Head and Neck, and Cutaneous Cancer treatment trials open for enrollment across our health system. We then performed a sort-rank exercise for these eligibility criteria terms. Results: The analysis included 33 trials and 12 data elements. Table 1 shows the number of times each eligibility criterion appeared in the 33 CTs and its feasibility for an EHR query. The data elements that appeared most frequently were Organ/Cancer Site (100%), Tumor Morphology (66.7%), Presence of Metastases (51.5%), TN Staging (39.4%), and Days Since Diagnosis (24.2%). Of these, only Organ/Cancer Site and Days Since Diagnosis were accessible as structured datapoints in our clinical databases. Conclusions: The lack of feasibility for EHR query is likely due to the fact that healthcare information is generally stored in a discrete, structured form as a means of completing care transactions (drug orders or laboratory values) and ensuring billing compliance (ICD and outpatient CPT codes). This presents a critical challenge when data are required for CT enrollment, quality assurance metrics, and prospective and retrospective clinical research. Health systems—and by extension, their patients—would benefit from investing in structured data schemas involving AJCC staging, tumor morphology, and presence of metastases. Eligibility criteria with corresponding number of appearances in CTs and feasibility for EHR query Eligibility criterion Number of trials with each criterion Feasibility for EHR query Organ/Cancer Site 33 (100%) Accessible (ICD codes very detailed for site and used consistently for purpose of billing) Tumor Morphology 22 (66.7%) Not accessible (Code have not been created in ICD system, SNOMED is not widely adopted, not needed for billing) Presence of Metastases 17 (51.5%) Not accessible (Not coded consistently, coded in ICD as a “secondary” malignancy but generally does not affect billing) TN Staging 13 (39.4%) Not accessible (Not coded in ICD system) Days Since Diagnosis 8 (24.2%) Accessible (Structured data captured for purpose of initial transaction) Tumor Markers and Other Lab Results 4 (12.1%) Accessible (Structured data captured by laboratory instrument for purpose of initial transaction) Immunohistochemical Biomarkers 4 (12.1%) Not accessible (Pathologist assessment documented as narrative text) History of Systemic Therapy 3 (9.1%) Accessible (NDC drug code captured with initial order in order to complete the initial transaction) Feasibility of Resection 3 (9.1%) Not accessible (Surgeon assessment documented as narrative text) Disease progression 3 (9.1%) Not accessible (Radiologist assessment documented as narrative text) Surgical Procedure 2 (6.1%) Accessible as CPT codes for outpatient surgeries as needed for billing. Not accessible for inpatient surgeries where billing is capitated as a single fee for entire hospitalization based on disease related groups Margins 2 (6.1%) Not accessible (Pathologist assessment documented as narrative text) Citation Format: Dylan J. Cooper, Joseph Herman, Nalan Yurtsever, Sergio Garza, Daniel A. King, Yonah Ziemba. Feasibility analysis of querying EHR databases for cancer clinical trial criteria. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4394.

Racial, Ethnic, and Rural Disparities in U.S. Veteran COVID-19 Vaccine Rates

Race, ethnicity, and rurality-related disparities in coronavirus disease 2019 (COVID-19) vaccine uptake have been documented in the United States (US). We determined whether these disparities existed among patients at the Department of Veterans Affairs (VA), the largest healthcare system in the US. Using VA Corporate Data Warehouse data, we included 5,871,438 patients (9.4% women) with at least one primary care visit in 2019 in a retrospective cohort study. Each patient was assigned a single race/ethnicity, which were mutually exclusive, self-reported categories. Rurality was based on 2019 home address at the zip code level. Our primary outcome was time-to-first COVID-19 vaccination between December 15, 2020-June 15, 2021. Additional covariates included age (in years), sex, geographic region (North Atlantic, Midwest, Southeast, Pacific, Continental), smoking status (current, former, never), Charlson Comorbidity Index (based on ≥1 inpatient or two outpatient ICD codes), service connection (any/none, using standardized VA-cutoffs for disability compensation), and influenza vaccination in 2019-2020 (yes/no). Compared with unvaccinated patients, those vaccinated (n=3,238,532; 55.2%) were older (mean age in years vaccinated=66.3, (standard deviation=14.4) vs. unvaccinated=57.7, (18.0), p<.0001)). They were more likely to identify as Black (18.2% vs. 16.1%, p<.0001), Hispanic (7.0% vs. 6.6% p<.0001), or Asian American/Pacific Islander (AA/PI) (2.0% vs. 1.7%, P<.0001). In addition, they were more likely to reside in urban settings (68.0% vs. 62.8, p<.0001). Relative to non-Hispanic White urban Veterans, the reference group for race/ethnicity-urban/rural hazard ratios reported, all urban race/ethnicity groups were associated with increased likelihood for vaccination except American Indian/Alaskan Native (AI/AN) groups. Urban Black groups were 12% more likely (Hazard Ratio (HR)=1.12 [CI 1.12-1.13]) and rural Black groups were 6% more likely to receive a first vaccination (HR=1.06 [1.05-1.06]) relative to white urban groups. Urban Hispanic, AA/PI and Mixed groups were more likely to receive vaccination while rural members of these groups were less likely (Hispanic: Urban HR=1.17 [1.16-1.18], Rural HR=0.98 [0.97-0.99]; AA/PI: Urban HR=1.22 [1.21-1.23], Rural HR=0.86 [0.84-0.88]). Rural White Veterans were 21% less likely to receive an initial vaccine compared with urban White Veterans (HR=0.79 [0.78-0.79]). AI/AN groups were less likely to receive vaccination regardless of rurality: Urban HR=0.93 [0.91-0.95]; AI/AN-Rural HR=0.76 [0.74-0.78]. Urban Black, Hispanic, and AA/PI Veterans were more likely than their urban White counterparts to receive a first vaccination; all rural race/ethnicity groups except Black patients had lower likelihood for vaccination compared with urban White patients. A better understanding of disparities and rural outreach will inform equitable vaccine distribution.

Prevalence of Eye and Vision Disorders in the Military Health System, Fiscal Year 2018.

Eye and vision disorders are estimated to impact 7.08 million people in the United States, including 1.62 million under the age of 40. This study uses the Vision and Eye Health Surveillance System (VEHSS) case definitions to assess the burden of eye and vision disorders in a universally insured, nationally representative population. This retrospective, cross-sectional study applied the VEHSS case definitions to TRICARE claims data collected from the Military Health System Data Repository and Defense Enrollment Eligibility Reporting System during 2018. Beneficiaries aged 0-64 years during the fiscal year 2018 were identified with inpatient and outpatient codes matching to the VEHSS diagnostic case definitions, which were organized into 17 categories of eye and vision disorders classified by the ICD-10. Beneficiaries were recorded only once per category but allowed to match to multiple categories. Analyses included descriptive statistics of patient demographics and prevalence of eye disorders. We identified 4,548,897 TRICARE Prime/Plus beneficiaries (54.86% men and 45.14% women), of whom 22.93% were diagnosed with at least one disorder in 2018. Of those with a diagnosis, the majority were men (50.13%), adults (74.91%), and of or sponsored by a senior enlisted rank (57.83%), used as socioeconomic proxy. Disorders of refraction and accommodation were most prevalent, followed by infectious and inflammatory diseases. Potentially preventable and treatable conditions, including amblyopia and strabismus, infectious and inflammatory disease, and diabetic complications, affected up to 22% of those with vision disorders. This study represents the first use of VEHSS measures in a universally insured, socioeconomically diverse population. Identification of potentially treatable or preventable conditions indicates significant opportunity to mitigate the burden of eye and vision disorders in the Military Health System.

Rates of malignancies among patients with moderate to severe atopic dermatitis: a retrospective cohort study

ObjectivesPatients with atopic dermatitis (AD), also known as eczema, may be at an increased risk for malignancies compared with patients without AD; however, incidence rates (IRs) of malignancies in patients...