Detection of Opioid Overdoses and Poisonings in Electronic Medical Records as Compared to Medical Chart Reviews

Transcription

1 Detection of Opioid Overdoses and Poisonings in Electronic Medical Records as Compared to Medical Chart Reviews Dennis McCarty, Shannon Janoff, Paul Coplan, Nancy Perrin, Cynthia Campbell, Elizabeth Shuster, G Thomas Ray, Howard Chilcoat, Carla Green 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH

2 Disclosures A Research Service Agreement between the Kaiser Permanente Center for Health Research & Purdue Pharma LP supported data extraction and analysis. Dr. McCarty is the PI on Research Service Agreements with Purdue Pharma LP and Alkermes and awards from NIH (U10 DA015815, P50 DA018165, R01 DA029716, R33 DA035640) 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 2

3 Affiliations Kaiser Permanente Center for Health Research Carla A. Green, Shannon L. Janoff, Nancy A. Perrin, Elizabeth Shuster Kaiser Permanente Division of Research Cynthia Campbell, G. Thomas Ray Purdue Pharma, LP Howard Chilcoat, Paul Coplan Oregon Health & Science University Dennis McCarty 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 3

4 SOURCE: Study of OxyContin Use, Risk & Critical Events Mixed methods study assessing change in opioid overdose and poisoning events following introduction of abuse-deterrent formulation of OxyContin Data from two integrated health plans Validation sub-study Identified opioid overdose and poisoning events using coded medical terminology verified against chart review 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 4

5 Design and Methods: Setting and Coded Medical Terminology Setting Kaiser Permanente Northwest and Kaiser Permanente Northern California Extracted OOP events between August October 2012 from EMR Used two sets of coded medical terminology ICD opioid poisoning codes ICD poisoning codes: , , , , E850.0, E850.1, E850.2, ICD poisoning COD codes: 9650, T40.0, T40.1, T40.2, T40.3, T40.4, X42, X62 and Y12 ICD and HCPCS opioid adverse effect codes plus codes for OD symptoms ICD adverse effect codes: E935.0, E935.1, E935.2, and Y45.0 Symptom codes: 276.4, 292.1, , 292.8, 486, 496, , , , 780.0, , , , , , 799.0, 970.1, E950-E959. E962.0, and J , KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 5

6 Design and Methods: Chart Audits & Interviews Chart audits to validate coded medical terminology Chart audits also determined: Drugs and medications involved, including alcohol Whether events were intentional (i.e., suicide attempts) Evidence of misuse and abuse Interviews to gain addition insight into OOP events 71 OOP event survivors 19 family members following fatal OOP events 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 6

7 Opioid Adverse Effect Codes vs. Chart Review 127 events Chart review 13% (n = 17) were OOP events Adverse effect codes plus overdose symptom codes had a low positive predictive value (13%) 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 7

8 Opioid Poisoning Codes vs. Chart Review 2100 events Chart review 1487 OOP events not related to inpatient anesthesia 71% (1487/2100) positive predictive value to detect OOP events not related to inpatient anesthesia Poisoning codes appear promising 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 8

9 ICD Poisoning Codes vs. Chart Review 2100 identified events events had information in chart, claims, or death data files 10 events (0.5%) had no information available from any data source 1849 events (88.0%) were not related to anesthesia 241 events were related to anesthesia or surgical procedures and were excluded 1 Includes 385 events based on claims or death data 2 Miscode: event documentation does not match with EMR codes used to identify event, meaning that the code does not match what happened at the time of the event 3 Unintentional events include both medical errors and misuse/abuse events 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 1776 events (84.6%) were single or poly-drug poisoning events and were correctly coded 73 events were miscoded 2 or a determination could not be made 1091 events (52.0%) were unintentional OOP events events (18.8%) were OOP events with an indication the event was a suicide attempt 285 events (13.6%) were opioid-related adverse events (not OOP events) 4 were events where a determination could not be made 9

10 Opioid Poisoning Codes Categorized Based on Medical Chart Review % of Opioid Poisoning codes that are Overdoses 60% 50% 40% 30% 20% 10% 0% 0.5% 3.5% 11.5% 13.6% 18.9% 52.1% 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 10

11 Potential Algorithms to Improve Positive Predictive Value Develop diagnostic algorithms that exclude events identified in the medical record and related to analgesia/surgery (n = 241) 80% PPV (1487/1859) exclude opioid adverse events (n = 285) and overdose related to anesthesia/surgery (n = 241) 94% PPV (1487/1574) 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 11

12 ICD Poisoning Codes vs. Chart Review Focus on Unintentional Events 2100 identified events events had information in chart, claims, or death data files 10 events (0.5%) had no information available from any data source 1849 events (88.0%) were not related to anesthesia 241 events were related to anesthesia or surgical procedures and were excluded 1 Includes 385 events based on claims or death data 2 Miscode: event documentation does not match with EMR codes used to identify event, meaning that the code does not match what happened at the time of the event 3 Unintentional events include both medical errors and misuse/abuse events 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 1776 events (84.6%) were single or poly-drug poisoning events and were correctly coded 73 events were miscoded 2 or a determination could not be made 1091 events (52.0%) were unintentional OOP events events (18.8%) were OOP events with an indication the event was a suicide attempt 285 events (13.6%) were opioid-related adverse events (not OOP events) 4 were events where a determination could not be made 12

13 Unintentional OOP Events With Chart Audit Data Abuse/Misuse 87% Illicit Drugs 79% Prescription Drug Abuse 60% Illicit Drug and Prescription Drug Abuse 52% 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 13

14 Interviews with OOP Survivors (n = 69) and Family Members of OOP Decedants (n = 18) Characteristics Number (N of cases=87) 1 Single opioid event 15 Polysubstance event 72 Active benzodiazepine prescription 32 Benzodiazepine present at OOP event 28 Cases involving heroin 17 Total active prescription opioids at time of event, mean (SD) 1.3 Total opioids involved in event including heroin, mean (SD) 1.5 Total prescription medications involved in event, including prescription opioids, mean (SD) 2.2 Total prescription and non-prescription drugs involved or present 2 in the event, mean (SD) We oversampled individuals who had no prescription opioid; 42% (n = 38) of interviews targeted events in this group. Data were derived from EMRs, chart audits, and interviews. 3 interviews were excluded after review because events could not be classified as OOP events (N = 90 prior to exclusions) 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 14

15 Interviews with Survivors and Family Members: Sources of Opioids 1 Number (N of events=87) Multiple sources for opoids involved in OOP event 4 Own active Rx(s) 47 Own expired Rx 7 Family member 8 Friend 8 Street 15 Stolen (not family or friend) 1 Unclear 5 1 Data derived from chart audits and interviews. Only opioids, not other medications or drugs involved in the event, are included. The remaining six events were determined from the interview data. Seven patients reported using their own expired prescription opioids, something that was not captured in the chart abstraction. 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 15

16 Qualitative Analysis Theme #1: Participants Lives Were Often in Disorder Family histories of AOD problems or drug initiation Personal addiction and/or mental health problems Stressful situations (e.g., familial or financial difficulties) Multiple chronic illnesses, chronic pain, and functional deficits Multiple prescriptions for medications, Increased risk of cognitive difficulties, other physical risks, or interactions with opioids Saving old prescriptions Using when not prescribed Using for suicide Easily stolen by family/friends/caregivers 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 16

17 Qualitative Analysis Theme #2: Involvement in Drug Subcultures and Crime Criminal or related activities Theft of medications Diversion of medications Purchase of drugs/medications from friends or on the street Altering route of administration for prescription medications Sharing drugs Taking other drugs/medications to enhance effects of opioids Using heroin 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 17

18 Implications for Policy & Practice Validation of ICD opioid overdose and poisoning codes facilitates and standardizes research methods Currently 71% positive predictive value Develop diagnostic algorithms to improve positive predictive value of coded medical terminology to 80% or 94% OOP events identified through EMRs can Monitor and track trends in OOP events Evaluate effects of regulatory changes Assess effects of new technologies (e.g., tamper-resistant opioid formulations) Interviews enrich description and understanding of OOP events 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 18

19 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 19

20 OOP Poisoning ICD Codes ICD 9 Code Poisoning by opium (alkaloids) unspecified Poisoning by heroin Poisoning by methadone Poisoning by other opiates and related narcotics Accidental poisoning by heroin E850.0 Accidental poisoning by methadone E850.1 Accidental poisoning by other opiates and related narcotics E850.2 COD: Poisoning by opiates and related narcotics (for the year of 1998 only; COD codes changed to ICD 10 in 1999; ICD 9 codes used for death data during 1998 did not include the fifth digit, which is why this particular 9650 code is four digits and without a decimal) ICD 10 Code COD: Poisoning by opium T40.0 COD: Poisoning by heroin T40.1 COD: Poisoning by other opioids T40.2 COD: Poisoning by methadone T40.3 COD: Poisoning by other synthetic narcotic T40.4 COD: Accidental poisoning by and exposure to narcotics and psychodysleptics, not elsewhere classified X42 COD: Intentional self-poisoning by and exposure to narcotics and psychodysleptics, not elsewhere classified X62 COD: Undetermined poisoning by and exposure to narcotics and psychodysleptics, not elsewhere classified Y , KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 20

21 Adverse Event* ICD Codes Code Category Diagnosis ICD 9 Code ICD 10 Code HCPCS Code 2a Adverse effects of heroin E a Adverse effects of methadone E a Adverse effects of other opioids and related narcotics E a COD: Adverse effects of opioids and related analgesics Y45.0 2b Mixed acid base balance disorder b Drug-induced psychotic disorders (including and ) b Drug-induced delirium b Drug-induced mental disorder (excluding ) 292.8** 2b Pneumonia, organism unspecified 486 2b Chronic airway obstruction, not elsewhere classified 496 2b Acute respiratory failure b Other pulmonary insufficiency, not elsewhere classified b Rhabdomyolysis b Alteration of consciousness 780.0** 2b Altered mental state b Apnea b Shortness of breath b Dyspnea and respiratory abnormalities other b Painful respiration b Asphyxia and hypoxemia 799.0** 2b Poisoning by opiate antagonists b Suicide and self-inflicted injury E950 E959 2b Assault by drugs and medicinal substances E b Injection, Naloxone Hydrochloride J2310 *Adverse event definition is met when a code from 2a and one or more 2b codes occur on the same date **includes all sub-codes except where noted 2014, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 21