Opioid-Related Hospital Events in the Medicare Population Mindy Cohen 2018 AcademyHealth Annual Research Meeting
Overview ● 2007-2014 Trends ● Rates of hospital events per 100,000 beneficiaries ● By state, age, sex and race ● Changes to Opioid Diagnosis Codes ● ICD-10 coding granularity ● Hospital events by state ● Rates of death from opioids using National Death Index data 2
2007-2014 Trends - Methodology ● Opioid-related hospital events per 100,000 beneficiaries Inpatient hospital stays Hospital outpatient emergency department (ED) visits ● Opioid-related events identified by ICD-9 diagnosis codes on 2007- 2014 Medicare claims Includes any event that had a relevant ICD-9 code in either the primary or secondary diagnosis field Includes codes associated with prescription opioids and illegal opioids Excludes codes related to opioid dependence or abuse “in remission” 2015 and 2016 not included due to transition to ICD-10 ● Population: Fee-For-Service Medicare beneficiaries only Excludes Medicare Advantage beneficiaries, and beneficiaries who had a cancer diagnosis or who received hospice care at any point during the year Ages 65+ and under 65 shown separately Not risk adjusted 3
All Opioid-Related Hospital Events, by Age, 2007-2014 2,500 2,000 EVENTS PER 100,000 BENEFICIARIES Under 65 1,500 Total 65 and Over 1,000 500 0 2007 2008 2009 2010 2011 2012 2013 2014 4
All Opioid-Related Hospital Events, by State, 65 and Over, 2014 5
Events Per 100,000 Beneficiaries 100 150 200 250 300 350 400 450 50 - Opioid-Related Hospital Events, by State, 65 and NE 55 SD 62 157 per 100,000 IA 64 average: National HI 83 AR 90 KS 94 VA 95 TX 96 WI 97 LA 101 NH 102 MO 107 IL 108 Inpatient SC 109 OH 111 NJ 111 WV 114 WY 115 VT 122 Over, 2014 Outpatient ED MS 124 DE 125 KY 126 GA 139 PA 139 MN 141 AL 144 ND 144 IN 146 NM 148 NY 159 FL 162 2014 Average OK 165 RI 167 ME 168 NC 174 CT 176 TN 179 MA 180 MD 185 CO 185 MI 188 AK 190 NV 212 AZ 225 MT 234 ID 236 CA 256 WA 344 DC 358 UT 391 OR 418 6
2007 – 2014 Percent Change in Events 140% 190% 240% 290% 340% -10% 40% 90% -7% Rate of Change in All Opioid-Related Hospital NE AR 24% Events, by State, 65 and Over, 2007-2014 MS 39% KS 51% LA 54% AK 56% WY 63% VT 68% HI 68% NH 69% NJ 73% NV 75% ME 76% VA 77% TX 79% IA 82% AL 83% SD 87% MO 92% IL 93% WI 95% OK 95% CO 96% GA 99% SC 101% NM 102% KY 104% UT 107% ND 108% TN 109% OH 114% WV 115% MD 117% MA 120% AZ 120% IN 125% NY 127% RI 131% CA 142% FL 155% MT 162% CT 172% MI 180% MN 186% PA 203% NC 209% WA 209% ID 214% OR 272% DC 280% DE 314% 7
All Opioid-Related Hospital Events, by State, Under 65, 2014 8
Opioid-Related Hospital Events, by State, Under 65, Events Per 100,000 Beneficiaries 1,000 2,000 3,000 4,000 5,000 6,000 - IA 869 1,908 per 100,000 907 TX 934 AR average: NE 958 National 984 LA 1,007 SD SC 1,090 1,093 MS 1,107 GA KS 1,133 1,227 ND 1,263 VA Inpatient WY 1,297 1,316 OK 1,322 WV KY 1,441 1,454 MO 1,499 AL NC 1,594 Outpatient ED 1,627 WI 1,670 IN 2014 HI 1,705 1,706 MT 1,805 TN ID 1,855 1,932 NY 1,941 MI IL 1,979 2,021 NM 2,029 OH AK 2,033 2014 Average 2,052 FL 2,110 CA PA 2,131 2,179 NV 2,209 AZ MN 2,340 2,357 CO 2,411 DE VT 2,484 2,611 DC 2,637 OR ME 2,654 2,689 UT 2,711 NJ CT 2,985 3,195 WA 3,243 NH RI 3,526 3,989 MD 5,128 MA 9
2007 – 2014 Percent Change in Events 140% 190% 240% -10% 40% 90% -5% Rate of Change in All Opioid-Related Hospital IL TX 29% HI 31% MS 36% Events, by State, Under 65, 2007-2014 MT 38% MD 43% NY 45% RI 47% LA 53% KS 54% AR 56% NJ 58% AL 60% MI 60% AK 61% NV 64% OK 67% CT 69% NE 69% MA 69% MO 71% AZ 73% ME 79% SC 83% CA 85% GA 87% VA 87% UT 88% OH 90% IN 90% WA 91% WI 91% TN 92% WY 95% DC 95% CO 98% PA 99% MN 99% NM 103% IA 106% KY 107% OR 107% NC 109% WV 112% SD 114% FL 117% ID 120% VT 128% NH 134% DE 174% ND 208% 10
All Opioid-Related Hospital Events, by Age and Metro/Non-Metro Area, 2007-2014 2,500 2,000 EVENTS PER 100,000 BENEFICIARIES Metro Under 65 Non-Metro Under 1,500 65 Metro Total Non-Metro Total Metro 65 and Over 1,000 Non-Metro 65 and Over 500 0 2007 2008 2009 2010 2011 2012 2013 2014 11
All Opioid-Related Hospital Events, by Age and Sex, 2007-2014 2,500 2,000 EVENTS PER 100,000 BENEFICIARIES Female, Under 65 Male, Under 65 1,500 Male Total Female Total Female, 65 and 1,000 Over Male, 65 and Over 500 0 2007 2008 2009 2010 2011 2012 2013 2014 12
All Opioid-Related Hospital Events, by Age and Race, 2007-2014 65 and Over Under 65 400 2,500 350 2,000 EVENTS PER 100,000 BENEFICIARIES EVENTS PER 100,000 BENEFICIARIES 300 250 1,500 200 1,000 150 100 500 50 - - 2007 2008 2009 2010 2011 2012 2013 2014 2007 2008 2009 2010 2011 2012 2013 2014 American Indian/Alaska Native White Hispanic Black Asian/Pacific Islander 13
Total Count of Opioid-Related Hospital Events, by Race, 2007-2014 80,000 70,000 60,000 Total Count of Events 50,000 40,000 30,000 20,000 10,000 0 AI/AN, AI/AN, Asian/PI, Asian/PI, Hispanic, Hispanic, Black, Black, White, White, 65+ <65 65+ <65 65+ <65 65+ <65 65+ <65 2007 2008 2009 2010 2011 2012 2013 2014 Note: excludes missing and unknown categories 14
Summary of Findings – 2007-2014 ● In 2014, the national average of total opioid-related hospital events was 157 events per 100,000 beneficiaries over 65 and 1,908 events per 100,000 beneficiaries under 65 ● Total events per 100,000 beneficiaries ranged from a high of 5,128 in Massachusetts among the under 65 population to a low of 55 in Nebraska among the 65 and over population ● Age, location and race all impacted rates and counts of hospital events For example, beneficiaries under 65 had rates more than 25 times those 65 and over in some states in 2014 15
ICD-10 Levels of Granularity ● Beginning October 1, 2015, CMS required all providers to submit claims using ICD-10 diagnosis codes ● ICD-10 codes provide more granularity than ICD-9 codes for identifying opioid-related events, and therefore more opportunity to identify an opioid related event Use vs abuse vs dependence Accidental vs intentional vs assault Initial encounter vs subsequent encounter vs sequela ● Certain codes cannot be cross-walked between ICD-9 and ICD-10, making it difficult to examine trends across years Large increase in events seen from 2014 to 2016, but unclear if due to increase in actual events or due to changes in coding 16
Percent of Events by Code Type, 2016 Use, Abuse, Dependence Accidental vs. Intentional Use 9% Intentional/ Assault Abuse 18% 18% Dependence Accidental 73% 82% Poisoning vs. Adverse Effect Heroin, Methadone, All Other Methadone 5% Heroin Poisoning 19% (Overdose) 36% All Other Adverse Opioids Effect 64% and Narcotics 76% 17
Events Per 100,000 Beneficiaries 1,000 100 200 300 400 500 600 700 800 900 - Opioid-Related Events, by State, 65 and Over, HI 244 SD 284 443 per 100,000 SC 294 IA 314 average: National TX 317 MS 321 NY 325 NJ 327 Inpatient AR 330 LA 333 WV 337 NE 341 VT 348 OH 351 VA 361 Outpatient ED KS 372 DE 382 GA 382 IL 383 PA 387 AL 399 2016 MO 401 NM 407 IN 412 WY 418 RI 425 NH 428 2014 Average CT 439 MA 456 KY 456 OK 467 MD 468 WI 469 ND 472 ME 473 2016 Average FL 487 TN 491 NC 525 NV 543 CA 568 MI 576 AK 577 AZ 584 DC 596 CO 607 MN 610 MT 650 ID 685 UT 717 WA 760 OR 860 18
Events Per 100,000 Beneficiaries 1,000 2,000 3,000 4,000 5,000 6,000 7,000 - SD 1,398 Opioid-Related Events, by State, Under 65, TX 1,536 2,874 per 100,000 AR 1,549 IA 1,556 average: National LA 1,662 NE 1,703 MS 1,732 GA 1,750 Inpatient SC 2,008 WV 2,067 HI 2,106 OK 2,239 KS 2,250 WY 2,251 KY 2,317 Outpatient ED AL 2,343 VA 2,368 MO 2,449 NY 2,476 NM 2,580 IN 2,591 2016 MT 2,657 WI 2,728 OH 2,828 IL 2,861 AK 2,874 CA 2,912 2014 Average MI 2,954 NC 2,966 TN 2,998 PA 3,208 ID 3,228 CO 3,298 OR 3,298 ND 3,305 2016 Average VT 3,318 MN 3,530 FL 3,572 ME 3,584 AZ 3,620 NV 3,632 NJ 3,708 DC 3,773 WA 3,885 RI 3,903 DE 3,931 UT 4,087 CT 4,248 NH 4,900 MD 5,401 MA 6,351 19
Rates of Death Related to Opioids – Methodology ● Population: Fee-for-Service Beneficiaries ● Year: 2016 ● Data Source: National Death Index Data ● Opioid-related Hospital Events: Inpatient Stay or Outpatient Emergency Department Visit 20
Opioid Overdose Deaths ● Consistent with CDC Methodology ● Cause of Death: Unintentional Suicide Homicide Undetermined Intent ● Underlying Cause of Death: Natural and semisynthetic opioids Methadone Synthetic opioids, other than methadone Heroin Other Opium 21
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