Specific Diagnostic Codes Research Articles

Aortic Dissections in the Population-Based Danish National Patient Registry from 1996-2016: A Validation Study.

PurposeThis study evaluated the validity of the ICD-10 diagnostic codes for aortic dissections (ADs) in the Danish National Patient Registry (DNPR) based upon positive predictive values (PPV).Patients and methodsCases registered in the DNPR with the unspecific AD diagnostic code DI710 (unspecified AD) from 1996 to 2016, and the specific AD diagnostic codes DI710A (AD Type A) and DI710B (AD Type B) from 2006 to 2016, were included. Available medical records from all registered cases underwent review. Confirmed cases of AD served as “gold standard” when reporting PPV. PPV estimates were stratified by regional differences, date, age at time of diagnosis, and sex.ResultsA total of 5018 cases were identified in the DNPR. After merging of data and retrieval of medical records, 3767 cases were eligible for validation. Of these, 2677 cases were verified as AD type A (59.7%), AD type B (38.8%), and unspecified type of AD (1.5%). The average age at diagnosis was 65.1 ±13.0 years (67.3% males). The overall PPV for having an AD when one of the three diagnostic codes were registered from 1996 to 2016 was 71.1% (95% confidence interval (CI): 69.6–72.5) and increased significantly over time. From 2006 to 2016, the PPV for the specific AD diagnostic codes was 89.5% (95% CI: 87.4–91.3), whilst the PPV for the unspecific diagnostic code was 63.5% (95% CI: 61.1–65.9).ConclusionWe found the overall PPV for the pooled AD diagnostic codes in the DNPR acceptable. However, the two specific AD diagnostic codes presented remarkably higher PPV compared to the unspecific diagnostic code.

Similarity-based prediction of ejection fraction in heart failure patients

Biomedical research is increasingly employing real world evidence (RWE) to foster discoveries of novel clinical phenotypes and to better characterize long term effect of medical treatments. However, due to limitations inherent in the collection process, RWE often lacks key features of patients, particularly when these features cannot be directly encoded using data standards such as ICD-10. Here, we propose a novel data-driven statistical machine learning approach, named Feature Imputation via Local Likelihood (FILL), designed to infer missing features by exploiting feature similarity between patients. We test our method using a particularly challenging problem: differentiating heart failure patients with reduced versus preserved ejection fraction (HFrEF and HFpEF respectively). The complexity of the task stems from three aspects: the two share many common characteristics and treatments, only part of the relevant diagnoses may have been recorded, and the information on ejection fraction is often missing from RWE datasets. Despite these difficulties, our method is shown to be capable of inferring heart failure patients with HFpEF with a precision above 80% when considering multiple scenarios across two RWE datasets containing 11,950 and 10,051 heart failure patients. This is an improvement when compared to classical approaches such as logistic regression and random forest which were only able to achieve a precision < 73%. Finally, this approach allows us to analyse which features are commonly associated with HFpEF patients. For example, we found that specific diagnostic codes for atrial fibrillation and personal history of long-term use of anticoagulants are often key in identifying HFpEF patients.

Development and Evaluation of Best Practice Alerts: Methods to Optimize Care Quality and Clinician Communication.

Development and Evaluation of Best Practice Alerts: Methods to Optimize Care Quality and Clinician Communication.

1198. Lyme Disease Post-Exposure Prophylaxis by Single-Dose Doxycycline in Three Healthcare Systems

BackgroundLyme disease, the most common tickborne disease in the United States, may be prevented by taking a single 200-mg dose of oral doxycycline after a high-risk bite from a blacklegged tick. Currently, it is not known how Lyme disease post-exposure prophylaxis (PEP) might vary by region and healthcare system. We identified single-dose doxycycline medication orders in three healthcare systems in states with high incidence of Lyme disease and compared associated patient and provider characteristics. MethodsElectronic health record data during 2012 – 2016 were obtained from three healthcare systems: Geisinger (Pennsylvania), Marshfield Clinic (Wisconsin), and Mayo Clinic (Minnesota/Wisconsin). Creation of analytic variables and analysis were harmonized across the three sites. Medication orders for single-dose doxycycline ≤200 mg that were accompanied by specific key words or diagnostic codes (e.g., tick bite; Lyme disease prevention) were considered evidence of PEP. Manual chart review was performed from a random subset to evaluate the algorithms used to identify PEP. ResultsAmong 2,937,585 patients with at least one medication order or clinical encounter during the study period, 14,102 single-dose doxycycline orders for Lyme disease PEP for 13,172 unique patients were identified. The typical patient receiving PEP was older (mean age 51 – 58 years), male (56 – 59%), and non-Hispanic White (81 – 98%). The annual seasonality of medication orders was bimodal, with peaks occurring during April – July and October – November. The most common encounter setting was an outpatient clinic or urgent care center (80 – 91%); medication orders after patient phone calls in the absence of an in-person visit occurred frequently (14 – 19%) in two health systems. Chart abstractions (n=600) revealed instances of PEP prescribed inappropriately (e.g., bite from a non-blacklegged tick; patient with symptoms of acute Lyme disease).ConclusionLyme disease PEP with a single dose of doxycycline was frequently prescribed in healthcare systems where there is a high incidence of Lyme disease. PEP was most commonly prescribed to non-Hispanic Whites over the age of 50 years. Public health initiatives for tickborne disease prevention should include clinician education on the appropriate use of Lyme disease PEP.Disclosures Anna M. Schotthoefer, PhD, HelixBind (Other Financial or Material Support, salary support) John Zeuli, PharmD, INSMED (Other Financial or Material Support, honoraria for educational speaking)

Development and Internal Validation of a Disability Algorithm for Multiple Sclerosis in Administrative Data

Objective: We developed and internally validated an algorithm for disability status in multiple sclerosis (MS) using administrative data.Methods: We linked administrative data from Manitoba, Canada to a clinical dataset with Expanded Disability Status Scale (EDSS) scores for people with MS. Clinical EDSS scores constituted the reference standard. We created candidate indicators using the administrative data. These included indicators based on use of particular health care services (home care, long-term care, rehabilitation admission), use of specific diagnostic codes (such as spasticity, quadriplegia), and codes based on use of Employment and Income Insurance. We developed algorithms to predict severe disability (EDSS ≥6.0), and to predict disability as a continuous measure. We manually developed algorithms, and also employed regression approaches. After we selected our preferred algorithms for disability, we tested their association with health care use due to any cause and infection after potential confounders.Results: We linked clinical and administrative data for 1,767 persons with MS, most of whom were women living in urban areas. All individual indicators tested had specificities >90% for severe disability, and all but a diagnosis of visual disturbance had positive predictive values (PPV) >70%. The combination of home care or long-term care use or rehabilitation admission had a sensitivity of 61.9%, specificity of 90.76%, PPV of 70.06% and negative predictive of 87.21%. Based on regression modeling, the best-performing algorithm for predicting the EDSS as a continuous variable included age, home care use, long-term care admission, admission for rehabilitation, visual disturbance, other paralytic syndromes and spasticity. The mean difference between observed and predicted values of the EDSS was −0.0644 (95%CI −0.1632, 0.0304). Greater disability, whether measured using the clinical EDSS or either of the administrative data algorithms was similarly associated with increased hospitalization rates due to any cause and infection.Conclusion: We developed and internally validated an algorithm for disability in MS using administrative data that may support population-based studies that wish to account for disability status but do not have access to clinical data sources with this information. We also found that more severe disability is associated with increased health care use, including due to infection.

32 Accidental ingestions of cannabis in children pre- and post-legalization: Perspectives from a Canadian paediatric hospital

Abstract Primary Subject area Public Health and Preventive Medicine Background Cannabis is one of the most prevalent recreational substances worldwide. In 2018, Canada legalized the use of recreational cannabis. Cannabis is available in numerous forms, including a wide range of ingestible forms (baked goods, candies, gummies, etc.). This increasing availability and palatability of cannabis – coupled with a rise in the concentration of tetrahydrocannabinol (THC; the psychoactive component of cannabis) in many products – has made children particularly vulnerable. Research has demonstrated rising cases of pediatric accidental cannabis exposures, primarily in U.S. states, but there is a paucity of Canadian data. Objectives We sought to: i) Characterize the frequency and clinical features of children presenting with accidental cannabis ingestions to a Canadian tertiary pediatric hospital; and ii) Compare the rates and presentations in the pre- and post-legalization periods. Design/Methods A retrospective chart review of Emergency Department visits at the Children’s Hospital of Eastern Ontario (Ottawa, ON) between March 2013 and September 2020 was undertaken, with institutional ethics approval sought. Inclusion criteria were: (i) Age &amp;lt; 13 years; and (ii) Accidental cannabis ingestion, as identified by specific ICD-10 diagnostic codes (T40.7, X42). Data collected from each chart included basic demographics; type and quantity of cannabis ingested; timing and location of ingestion; vital signs and Glasgow Coma Scale (GCS) rating at triage; presenting symptoms; investigations and procedures performed; as well as length of stay in hospital. Data were analyzed using descriptive statistical methods. Results A total of 39 patients met inclusion criteria (23 male; 59%). The mean age of presentation was 5.2 years (± 3.3; range 1 month–12 years). The vast majority of visits (32/39; 82%) occurred in the last two years of data collection (i.e., after legalization of recreational cannabis in Canada in October 2018). A total of 15 patients (38%) required admission to hospital, with a mean length of stay of 1.3 (± 1.0) days. Details about each patient’s presenting symptoms, investigations, and disposition were analyzed. Conclusion Our data from a Canadian tertiary pediatric centre confirms an increased rate of unintentional cannabis ingestions among young children, particularly post-legalization. This is of significant public health concern. An understanding of the clinical presentation of cannabis intoxication, as well as advocacy for safe storage strategies is prudent for parents, pediatric providers, and public health policymakers.

Cesarean delivery on maternal request in the United States from 1999 to 2015

The rate of cesarean delivery has increased in the United States over the last several decades. However, the rate of cesarean delivery on maternal request remains undetermined, and recent data on cesarean delivery on maternal request are lacking. This study aimed to describe the prevalence and temporal trends of cesarean delivery on maternal request in the United States and characterize the population of women who elect to undergo a cesarean delivery in the absence of fetal or maternal indications. Maternal outcomes between women who delivered by cesarean delivery on maternal request and those who did not were compared. A retrospective cohort study was conducted using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 1999 to 2015. An algorithm based on International Classification of Diseases, Ninth Revision codes was created to identify patients who underwent a primary elective cesarean delivery in the absence of fetal or maternal indications. Maternal characteristics and outcomes between women who delivered by cesarean delivery on maternal request and those who did not were compared using descriptive and logistic regression analyses. Of the 13,698,835 deliveries included throughout the study period, 228,586 were identified as cesarean delivery on maternal request. Rates of cesarean delivery on maternal request among all live births increased throughout the study period, from 1% in 1999 to 1.62% in 2015 (P<.0001). Women who delivered by cesarean delivery on maternal request were more likely to be >35 years of age, were in the highest income quartile, and have private insurance. Cesarean delivery on maternal request was associated with an increased risk of venous thromboembolism (odds ratio, 1.9; 95% confidence interval, 1.8-2.0), myocardial infarction (odds ratio, 6.3; 95% confidence interval, 3.8-10.4), sepsis (odds ratio, 5.6; 95% confidence interval, 4.7-6.6), disseminated intravascular coagulation (odds ratio, 2.9; 95% confidence interval, 2.3-3.7), death (odds ratio, 14.5; 95% confidence interval, 11.4-18.6), and prolonged hospital stay (odds ratio, 4.9; 95% confidence interval, 4.8-5.1) and a lower risk of postpartum hemorrhage (odds ratio, 0.7; 95% confidence interval, 0.7-0.7). Our findings indicated that cesarean delivery on maternal request accounts for a small but increasing proportion of all cesarean deliveries in the United States. Cesarean delivery on maternal request was more prevalent among women with certain demographic characteristics, indicating that the option of cesarean delivery on maternal request may be more appealing or more frequently offered to a certain population of women. Although the overall risk of adverse events is low for individual births, population effects can result in increased morbidity and mortality. Therefore, the rates of cesarean delivery on maternal request should be monitored on a national level. Study findings were limited by the absence of a specific diagnostic code for cesarean delivery on maternal request.

Method used to identify adenomyosis and potentially undiagnosed adenomyosis in a large, U.S. electronic health record database.

The prevalence of adenomyosis is underestimated due to lack of a specific diagnostic code and diagnostic delays given most diagnoses occur at hysterectomy. To identify women with adenomyosis using indicators derived from natural language processing (NLP) of clinical notes in the Optum Electronic Health Record database (2014-2018), and to estimate the prevalence of potentially undiagnosed adenomyosis. An NLP algorithm identified mentions of adenomyosis in clinical notes that were highly likely to represent a diagnosis. The anchor date was date of first affirmed adenomyosis mention; baseline characteristics were assessed in the 12 months prior to this date. Characteristics common to adenomyosis cases were used to select a suitable pool of women from the underlying population, among whom undiagnosed adenomyosis might exist. A random sample of this pool was selected to form the comparator cohort. Logistic regression was used to compare adenomyosis cases to comparators; the predictive probability (PP) of being an adenomyosis case was assessed. Comparators having a PP ≥ 0.1 were considered potentially undiagnosed adenomyosis and were used to calculate the prevalence of potentially undiagnosed adenomyosis in the underlying population. Among 11 456 347 women aged 18-55 years in the underlying population, 19 503 were adenomyosis cases. Among 332 583 comparators, 22 696 women were potentially undiagnosed adenomyosis cases. The prevalence of adenomyosis and potentially undiagnosed adenomyosis was 1.70 and 19.1 per 1000 women aged 18-55 years, respectively. Considering potentially undiagnosed adenomyosis, the prevalence of adenomyosis may be 10x higher than prior estimates based on histologically confirmed adenomyosis cases only.

Knee osteonecrosis incidence from two real-world data sources

BackgroundAnti-nerve growth factor (NGF) has shown promise for osteoarthritis (OA) pain efficacy, but an unanticipated joint safety signal occurred in trials. To what extent this was related to OA natural history, or was a consequence of anti-NGF agents is unclear. Of the adverse joint safety events identified, osteonecrosis has specific diagnostic codes available in the medical record to enable assessment of its frequency in the general community. We therefore investigated the rates of knee osteonecrosis in three real-world cohorts using two data sources to place these trial data in context. MethodsWe used data from UK-based IQVIA Medical Research Data (IMRD) of adults diagnosed with incident knee OA between 2000 and 2018 to examine the incidence of knee osteonecrosis using different definitions. Additionally, we evaluated the incidence of knee osteonecrosis in the year prior to knee replacement in IMRD and among US Medicare beneficiaries who received a knee replacement in 2011–2014. ResultsIn IMRD, among 122,343 subjects with incident knee OA (mean age 68 years, 58% female), incidence estimates for knee osteonecrosis were 0.006–0.10%, with incidence rates of 0.01–0.17 per 1000 person-years. Among the 81,807 who had a knee replacement, the incidence of knee osteonecrosis in the year prior to knee replacement was 0.004–0.06%. In Medicare, among 316,593 with knee replacement (mean age 74, 68% female), the incidence of knee osteonecrosis was 0.24–0.7%. ConclusionKnee osteonecrosis is rare among people with knee OA, including in the year prior to knee replacement. These data provide context for interpreting osteonecrosis events in NGF trials.

Identification of a Warm Autoimmune Hemolytic Anemia (wAIHA) Population Using Predictive Analytics of a Known Clinically Profiled Cohort

Introduction The clinical presentation of warm autoimmune hemolytic anemia (wAIHA), a rare, Ig-G mediated disorder, has not been well studied. There is no diagnosis code specific for wAIHA, presenting challenges in identifying wAIHA patients and assessing the clinical course of the disease. For this study, we aimed to 1) identify a wAIHA cohort using a collection of specific diagnostic codes, 2) evaluate whether a collection of diagnostic codes could bisect severe versus non-severe wAIHA patients, 3) observe the frequency of comorbidities and anemia symptoms in severe and non-severe wAIHA groups, and 4) use a predictive model to validate clinical variables and prevalence estimates. Methods A de-identified, longitudinal, patient-level claims database of &amp;gt;300 million US patients was used for this study. wAIHA patients were identified based on a diagnosis code of "autoimmune hemolytic anemia" (AIHA) with multiple distinct events within 36 months. Patients were required to have at least 30 days use of steroids over 36 months, and utilization of a known drug regimen for treatment of an autoimmune disorder. Patients were classified as severe if claims related to transfusion or blood composition testing or if high frequency interactions with a hematologist were observed in the 36-month period were. Codes for comorbidities, treatments, and procedures were grouped and analyzed within the most recent 12 months for each patient. Prevalence was estimated using AI/ML Lookalike modeling, using the known wAIHA patients as the positive training class. Results A cohort of 1,548 wAIHA patients was identified. Median patient age was &amp;gt;65 years, and patients were evenly distributed by gender. Patients showed evidence of anemia, anemia symptomology (such as shortness of breath, cough, and fatigue), and wAIHA-specific testing and treatments. The rate of disease-relevant claims was disproportionately higher in the severe cohort versus the non-severe cohort; over the 12 month study period, variances ranged from 61% higher (for anemia-based comorbidity codes) to as high as 570% higher (for anemia-based procedural codes). Primary hypertension, hyperlipidemia, gastro-esophageal reflux, and evidence of chemotherapy use were also present in wAIHA patients; all of these conditions were observed more frequently for severe patients. Of interest, lupus was observed more frequently in the non-severe wAIHA cohort. Almost 44% of wAIHA claims for the full cohort were associated with Hospital/Emergency care - 48% for the severe group. AI/ML modeling predicted patients using claims variables for hemolytic anemia, other blood count abnormalities, and medical procedure claims commonly used for the diagnosis and management of wAIHA patients (such as Coombs and haptoglobin testing). The predicted population supports reported US prevalence estimates of 30,000-49,000 patients. Conclusions We developed and validated a method for defining wAIHA patients using de-identified claims data based on AIHA ICD-10 codes and relevant treatments. We observed that while disease manifestations are generally the same, there is an increased rate of occurrence in the severe cohort during the same 12-month period. This increase was associated with higher utilization of healthcare resources. The comorbidity of lupus was more commonly associated with less severe wAIHA patients; this may indicate that, despite comorbidities, a sharper clinical focus is placed on the wAIHA condition itself when managing more severe patients. Disclosures McCrae: Dova: Consultancy; Momenta Pharmaceuticals: Consultancy; Novartis: Honoraria; Rigel: Consultancy. Beachell:Momenta Pharmaceuticals: Current Employment. Gooljarsingh:Momenta Pharmaceuticals: Current Employment. Tjoa:Momenta Pharmaceuticals: Current Employment. Jones:IPM.ai: Current Employment. Gubitosa:IPM.ai: Current Employment.

Spine coding transition from ICD-9 to ICD-10: Not taking advantage of the specificity of a more granular system

BackgroundThe transition from International Classification of Diseases, 9th Edition (ICD-9) to the 10th edition (ICD-10) in 2015 increased the number and specificity of diagnostic codes with the goal of facilitating clinical care and research possibilities.Considering the potential to default to less specified ICD-10 codes, the current study evaluated the number of codes utilized for spine-related conditions before versus after the transition to ICD-10. MethodsThe numbers of patients with an index encounter for a primary spine-related non-deformity diagnosis codes indexed as “dorsopathies” were abstracted from the Humana PearlDiver dataset. As the transition from ICD-9 to ICD-10 occurred in 2015, the current study compared the year prior (ICD-9) to the year after (ICD-10). The number of ICD-9 and ICD-10 codes was assessed, and distribution of utilization was compared using the Kolmogorov-Smirnov test. Results:In 2014, 848,623 patients were assigned one of the 100 unique ICD-9 dorsopathy codes, of which 17 codes (17% of available codes) were used for more than 1% of the patients. In 2016, 840,310 patients were assigned one of the 504 unique ICD-10 dorsopathy codes, of which 21 (4% of available codes) were used for more than 1% of the patients. The top 20 codes in 2014 (ICD-9) and the top 20 codes in 2016 (ICD-10) both represented the majority of the patient population and were not statistically differently represented (p = 0.819). Further, analysis of ICD-10 codes demonstrated a clear bias toward utilizing less specified codes. ConclusionsDespite a five-fold increase in available diagnostic codes for spine conditions in ICD-10, in the year after implementation providers continued to select a small proportion of less specific diagnostic codes when treating spine patients.

The classic “Carrot-and-stick approach”: Addressing underutilization of ICD-10 increased data granularity

The classic “Carrot-and-stick approach”: Addressing underutilization of ICD-10 increased data granularity

GP coding behaviour for non-specific clinical presentations: a pilot study.

BackgroundClinical coding is an integral part of primary care. Disease incidence studies based on primary care electronic health records (EHRs) rely on the accuracy of these codes. Current code validation methods are not appropriate for non-specific conditions and provide limited information about GPs' decision-making behaviour around coding. Qualitative methods could offer insight into decision-making behaviour around coding of patients with non-specific conditions.AimTo investigate the decision-making behaviour of GPs when applying Read codes to non-specific clinical presentations, using Lyme disease as a case example.Design & settingA pilot study was undertaken, involving masked semi-structured interviews of eight GPs in the North West of England.MethodSemi-structured interviews were carried out based on 11 clinical cases representative of Lyme disease presentations. Discrete answers were described descriptively. Interview transcripts were analysed using a thematic approach.ResultsThemes underpinning GPs’ coding behaviour included: GP personal and professional experience; clinical evidence; diagnostic uncertainty; professional integrity and defensive practice; and patient-sourced health information and beliefs. GPs placed Lyme disease on their differential diagnosis list for five cases; in only two cases would GPs select a Lyme disease related Read code.ConclusionGPs were reluctant to code with specific diagnostic Read codes when they were presented with patients with vague or unfamiliar symptomology. This masked questionnaire methodology offers a new approach to validate incidence figures, based on Read codes of non-specific conditions. The reluctance to code poses many problems for primary care EHRs research. Further research is needed to understand what drives GPs’ coding behaviour.

Impact of Malnutrition on Outcomes in Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt Insertion.

Malnutrition is common in patients with cirrhosis and is associated with poor outcomes after hepatic resection and liver transplantation. Transjugular intrahepatic portosystemic shunt (TIPS) is performed for complications of cirrhosis. To assess the impact of malnutrition on TIPS outcomes. A retrospective analysis was performed using the Healthcare Cost and Utilization Project: National Inpatient Sample database for TIPS procedures from 2005 to 2014. The primary end point was in-hospital mortality. The association of specific malnutrition diagnostic codes and race-ethnicity on mortality was evaluated with survey-weighted logistic regression adjusted for age, gender, admission type, insurance payer, hospital region, comorbidities, and length of stay (LOS). From 2005 to 2014, an estimated 53,207 (95% CI 49,330-57,085) admissions with TIPS occurred. A diagnosis of malnutrition was present in 11%. In-hospital death post-TIPS occurred in 15.0% versus 10.7% (p value < 0.001) of patients with and without malnutrition, respectively. Patients with malnutrition had longer post-procedural LOS (median 6.7 vs. 2.9days, p value < 0.001) and greater total hospital charges (median $144,752 vs. $79,781, p value < 0.001) and were more likely to be discharged to a skilled nursing facility (21.6% vs. 9.7%) than patients without malnutrition. Patients with malnutrition had increased odds of mortality (OR 1.31, 95% CI 1.07, 1.59) compared to patients with no malnutrition. Malnutrition was associated with worse outcomes after TIPS. Further research is needed to understand the mechanism of malnutrition in post-procedure outcomes and the ability of interventions for nutritional optimization to improve outcomes.

Nuclear medical imaging as part of dementia diagnostics in psychiatric day-care clinics and inpatient care settings.

Current guidelines support the use of nuclear medical imaging (NMI) techniques for differential diagnostics of certain cases of dementia. We aimed at studying the association between using NMI and the accuracy of dementia diagnoses. Additionally, we evaluated the effect of conducting NMI on the duration of hospital treatment. This study was based on data collected according to §21 of the German hospital remuneration law, including relevant diagnostic and procedural codes for NMI in dementia patients. In total, more than 7.2 million cases treated in German psychiatric and somatic hospitals between 2015 and 2017 were included. Associations between the frequency of NMI and the accuracy of dementia diagnoses in terms of specific vs. unspecific diagnostic codes were analyzed using Fischer's exact test. In total, 351,106 cases with a dementia diagnosis were encoded during the study period. NMI was performed in 1.03% or 0.15% of all patients with dementia in psychiatric or somatic clinics, respectively. In psychiatric clinics, the proportion of unspecific dementia diagnoses decreased from 20.86% in 2015 to 17.73% in 2017. NMI was mainly performed within psychiatric day-care settings. Interestingly, patients receiving NMI stayed shorter within day-care settings (8.1 ± 16.0days) compared to inpatient settings (38.3 ± 44.7days). Nuclear medical imaging is often performed in psychiatric day-care settings. Further studies are warranted to understand the predictive diagnostic value of NMI in dementia diagnosis compared with clinical, CSF and structural imaging in different healthcare settings.

A blended training programme for healthcare professionals aimed at strengthening territorial networks for the prevention and contrast of gender-based violence.

a blended training programme combining residential meetings (de visu) and distance training course (DTC) have been developed in order to provide the key elements for prevention, individuation, and care of women victims of violence. the Project involved the identification and testing of a systematic methodology of blended training addressed to social and health operators of 28 Emergency Room (ER) Units in 4 Italian regions (Lombardy - Northern Italy, Lazio - Central Italy, Campania and Sicily - Southern Italy). Tuscany region (Central Italy) collaborated through experts in the field from the Grosseto Task Force. This training approach specifically aimed to increase the professional competences for diagnosis, management and treatment of gender-based violence, as well as to strengthen multidisciplinary territorial networks against violence. in this Project, 28 ERs in the four Italian regions mentioned above were selected because of their involvement in managing gender-based violence. This selection was performed by a coordinator, one for each region, who also coordinated the recruitment of personnel to be involved in the training programme. The programme has therefore been proposed to social and health operators and police officers in the ERs recruited. In each ER, two referents were identified (a doctor and a nurse) in order to ensure a constant connection between the course participants and the experts involved in the management of the Project and the DTC platform. evaluation of the increase of knowledge relatively to gender-based violence issue in the ER professionals who have concluded the blended training programme. A systematic analysis and comparison of all accesses concerning women aged ≥14 years in the period 1 July-31 December 2014 (before the blended training programme) and in the period 1 July-31 December 2016 (after the blended training program). among the 866 registered professionals, 636 participants (73.5%) completed the course, 202 (23.3%) professionals did not complete it, 21 (2.4%) did not pass the certification test, and 7 (0.8%) participated as Auditors. Among the participants who completed the course, most of them (70.8%) were females; the average age was 45 for both males and females. The most represented professional role was the nurse (61%), followed by the medical doctor (27.2%). Based on our data, in the post-training period, an increased number of cases of violence were correctly recorded in comparison to the pre-training period. the Project allowed to define a training strategy for health professionals of the ERs who respond daily to the health needs of women who are victims of violence. The blended training programme combining residential meetings (de visu) and distance training course has been developed in order to provide the key elements for prevention, individuation, and care of women victims of violence. The observed improvement in the recording and management of cases of gender-based violence is probably due to a greater competence in the awareness and use of specific diagnostic codes by ER professionals.

Epidemiology of axial spondyloarthritis: an update.

To provide an update of the prevalence and incidence of axial spondyloarthritis in the general population and in patients with spondyloarthritis-related conditions, environmental risk factors for ankylosing spondylitis, progression from nonradiographic axial spondyloarthritis to ankylosing spondylitis, mortality, and risks for cardiovascular events in patients with ankylosing spondylitis. Increasingly, administrative healthcare data have been used to study disease frequency and outcomes. The prevalence of ankylosing spondylitis ranged from 9 to 30 per 10 000 persons, which are lower than previous estimates. Data on whether childhood infections influence the risk of ankylosing spondylitis were equivocal, while having been breast-fed may be protective. Progression of patients with nonradiographic axial spondyloarthritis to ankylosing spondylitis is slow, with estimates of 5.1% in 5 years and 19% in 10 years. Risk of mortality is slightly increased in ankylosing spondylitis. Risks for cardiovascular events in ankylosing spondylitis were either not different from, or only slightly higher than in controls. No studies have examined these outcomes in the broader group of patients with axial spondyloarthritis. Expanded use of administrative and registry data has facilitated studies of the epidemiology of ankylosing spondylitis, but lack of specific diagnostic codes limits use of these resources for studying axial spondyloarthritis in general.

Intrauterine device embedded in omentum of postpartum patient with a markedly retroverted uterus: a case report

BackgroundThe intrauterine device is a popular form of long-acting reversible contraception. Although generally safe, one of the most serious complications of intrauterine device use is uterine perforation. Risk factors for perforation include position of the uterus, force exerted during intrauterine device insertion, postpartum period, and breastfeeding. This case is important and needs to be reported because it highlights the need to assess risk factors for uterine perforation. It adds to the medical literature because it examines the relationship between position of the uterus and the location of uterine perforation. This case report is unusual in that it describes the mechanism and specific location of uterine perforation in relation to the position of the uterus.Case presentationWe present a case of an intrauterine device found in the omentum of a 30-year-old white postpartum woman with a significantly retroverted uterus after the intrauterine device threads were not visualized on speculum examination during a 6-week placement check. The intrauterine device was located and removed via laparoscopy without complication.ConclusionsThis case report will be of interest to women’s health practitioners because it illustrates the importance of identifying patients with risk factors for uterine perforation, examining the relationship between uterine position and location of perforation. This is especially significant because the true incidence of perforation may be higher than the numbers reported in the literature. There is no specific diagnostic code for uterine perforation and it is unlikely that retrospective studies can accurately identify all cases.

LEVERAGING MEDICARE CLAIMS TO CHARACTERIZE DIAGNOSTIC PATHWAYS IN ALZHEIMER’S DISEASE

Real-world, administrative claims data is uniquely suited to help characterize the journey of Alzheimer's disease (AD) patients from the onset of disease symptoms through diagnosis and beyond. The primary aims of this analysis were to: (1) characterize the temporal relationship between diagnostic and treatment codes associated with AD; and (2) explore the pre-diagnostic claims record for the appearance of codes suggestive of AD-related symptoms. Medical and pharmacy claims data from a large, geographically diverse, commercial, US Medicare Advantage health plan, for the period 2009–2014, was used to identify cases of newly diagnosed AD. Beneficiaries with claims for AD-specific diagnostic codes and prescription fills for a medication indicated to treat AD were included in the analysis. Among the 4,039 beneficiaries identified for inclusion in the analysis: 31% received a treatment prior to their first Alzheimer's-specific diagnostic code, 14% received an AD diagnostic code prior to their first treatment; and 23% received their treatment and diagnostic codes within 60 days of one another. Thirty-percent of the diagnosed cohort had multiple diagnostic codes but no evidence of treatment at any time during the 48-month observation period (24 months prior to and after incident diagnosis). Notable gaps between treatment and diagnosis were observed. The median number of days between treatment and diagnosis among those receiving a treatment first was 577; the median number of days between diagnosis and treatment in those receiving a diagnosis first was 397. Sixty-three percent of the combined cohort had an average of 6.1 claims suggestive of AD-related symptoms (e.g. memory loss, mild cognitive impairment) before their incident diagnostic code. These data suggests there is considerable heterogeneity in the AD diagnostic and treatment pathways. While the first appearance of a diagnosis code is commonly used as the index date from which disease related health care use is attributed, measurable care-seeking behavior and therapy associated with AD begins much earlier. Further research is needed to better understand the factors influencing pathway variability and the risks associated with diagnostic and treatment delays.

The burden of HPV-related diseases in Italy, 2001–12

Human papillomavirus (HPV) infection is the main cause of cervical cancer and plays a relevant role in the development of genital warts and of the cancer of penis and anus, head/neck, oropharynx and genitourinary system. The aim of this study is the evaluation of hospitalizations due to HPV-related pathologies in 2001-12 in Italy. The national hospital discharge forms were provided by the Ministry of Health. The HPV-related hospitalizations were identified using specific diagnostic codes, accordingly to the ICD-9-CM coding system. The proportion of hospitalizations of potentially HPV-related pathologies, obtained from the literature, was evaluated as well as the hospitalization rates (hr) and their trend over time. Uterine cervical cancer and CIN III accounted for 40% of hospitalizations (hr: 15.6/100 000 and 17.6/100 000, respectively). Head/neck and oropharynx pathologies accounted for 24.5% of cases (hr: 16/100 000 and 3.9/100 000, in males and females, respectively), followed by genital warts (17.3% of hospitalizations; hr: 7.5/100 000 in males and 8.52/100 000 in females), anal (8.1% of hospitalizations), genitourinary (7.7%) and penis cancers (2.2%). The study, even if limited to the evaluation of hospitalizations, points out how HPV-related pathologies continue to be a relevant public health issue in Italy with a high impact on population.