Validity and reliability of the diagnostic codes for hypochondriasis and dysmorphophobia in the Swedish National Patient Register: a retrospective chart review

ObjectivesIn the International Classification of Diseases, Tenth Edition (ICD-10), hypochondriasis (illness anxiety disorder) and dysmorphophobia (body dysmorphic disorder) share the same diagnostic code (F45.2). However, the Swedish ICD-10 allows for these disorders to be coded separately (F45.2 and F45.2A, respectively), potentially offering unique opportunities for register-based research on these conditions. We assessed the validity and reliability of their ICD-10 codes in the Swedish National Patient Register (NPR).DesignRetrospective chart review.MethodsSix hundred individuals with a diagnosis of hypochondriasis or dysmorphophobia (300 each) were randomly selected from the NPR. Their medical files were requested from the corresponding clinics, located anywhere in Sweden. Two independent raters assessed each file according to ICD-10 definitions and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision and Fifth Edition criteria. Raters also completed the Clinical Global Impression–Severity (CGI-S) and the Global Assessment of Functioning (GAF).Primary outcome measurePer cent between-rater agreement and positive predictive value (PPV). Intraclass correlation coefficients for the CGI-S and the GAF.ResultsEighty-four hypochondriasis and 122 dysmorphophobia files were received and analysed. The inter-rater agreement rate regarding the presence or absence of a diagnosis was 95.2% for hypochondriasis and 92.6% for dysmorphophobia. Sixty-seven hypochondriasis files (79.8%) and 111 dysmorphophobia files (91.0%) were considered ‘true positive’ cases (PPV=0.80 and PPV=0.91, respectively). CGI-S scores indicated that symptoms were moderately to markedly severe, while GAF scores suggested moderate impairment for hypochondriasis cases and moderate to serious impairment for dysmorphophobia cases. CGI-S and GAF inter-rater agreement were good for hypochondriasis and moderate for dysmorphophobia.ConclusionsThe Swedish ICD-10 codes for hypochondriasis and dysmorphophobia are sufficiently valid and reliable for register-based studies. The results of such studies should be interpreted in the context of a possible over-representation of severe and highly impaired cases in the register, particularly for dysmorphophobia.

Association between baseline insulin resistance and psoriasis incidence: the Women’s Health Initiative

Small-scale studies offer conflicting evidence regarding the relationship/association between psoriasis and insulin resistance by HOMA-IR (homeostasis model assessment of insulin resistance). The purpose of this study was to assess the association between baseline HOMA-IR and psoriasis incidence in a large-scale longitudinal cohort of postmenopausal women. The analysis included 21,789 postmenopausal women from the Women’s Health Initiative. Psoriasis diagnosis was defined by fee-for-service Medicare ICD-9-CM codes assigned by dermatologists or rheumatologists, and a 2-year lookback period to exclude prevalent cases. Baseline HOMA-IR was calculated using the updated HOMA2 model. Hazard rates from the Cox regression models were stratified by age (10-year intervals), on WHI component (Clinical Trial or Observational Study), and on randomization status within each of the WHI clinical trials. The complete model also adjusted for ethnicity, waist–hip-ratio, and smoking and alcohol habits. Among participants free of psoriasis at entry, those with high baseline HOMA-IR (≥ 2) compared to low (< 1.4) had significantly higher risk for psoriasis over 21-year cumulative follow-up (HR: 1.39, 95% CI 1.08–1.79, P-trend: 0.011). In postmenopausal women, higher baseline HOMA-IR levels were significantly associated with higher incidence of psoriasis over 21-year cumulative follow-up. Results from this time-to-event analysis indicate that insulin resistance can precede and is associated with an increased risk of psoriasis. Study is limited by Medicare diagnostic code accuracy and cohort age.

Epidemiological Characteristics of Traumatic Spinal Cord Injury in Shaanxi, China

Study Design. A hospital-based retrospective epidemiological study.Summary of Background Data. TSCI is a highly disabling and deadly injury. Currently, there is little information regarding the epidemiological characteristics for TSCI in Shaanxi.Objective: To describe the demographic and epidemiological characteristics of patients with traumatic spinal cord injury (TSCI) in Shaanxi to help health-related institutions formulate corresponding measures.Methods. We retrospectively reviewed the medical records of the spine centers or orthopedic centers of the four cities in Shaanxi province according to the International Classification of Disease Version 10 (ICD-10) and diagnostic code of TSCI. Variables included gender, age, medical insurance, etiology, occupation, time of injury, level of injury, and severity of injury, multiple injury, treatment, and so on.Results: The study included the medical records of 694 patients with TSCI in 2018. The mean age of patients with TSCI was 48.4±14.9 years, and the male/female ratio was 3.45:1. The major causes of TSCI were high falls (40.2%) and low falls (26.7%). The most common injury site was the cervical spinal cord, accounting for 48.7%. The highest proportion of severity of injury was ASIA Grade D (37.8%). In addition, 74.6% of the patients had spinal fractures, the chest (38.0%) accounted for the highest proportion of all TSCI patients. Furthermore, 27.8% of the patients experienced clinical complications. 530 (76.4%) patients underwent surgery, 323 (46.5%) patients underwent inpatient rehabilitation.Conclusion: There are specific epidemiological characteristics of TSCI patients in Shaanxi, and preventive measures are suggested to be based on the characteristics of the different types of patients with TSCI and focused on high-risk groups.Level of Evidence: 3

Substance Use Disorders and Psychoactive Drug Poisoning in Medically Authorized Cannabis Patients: Longitudinal Cohort Study

Objectives Poisoning from psychoactive drugs and substance use disorders (SUD) have been reported among non-medical cannabis users. However, little is known about medical cannabis users and their risk for poisoning and/or development of SUD. This study assessed the risk of emergency department (ED) visits or hospitalization for 1) poisoning by psychoactive drugs and 2) mental/behavioural disorders due to the use of psychoactive drugs and other substances, in medically authorized cannabis patients in Ontario, Canada from 2014–2017. Methods A cohort study of adult patients authorized for medical cannabis that were matched to population-based controls. ED visit/hospitalization were assessed with a main diagnostic code for: 1) poisoning by psychoactive drugs; 2) mental and behavioural disorder due to psychoactive drugs or other substance use. Conditional Cox proportional hazards regressions were conducted. Results 18,653 cannabis patients were matched to 51,243 controls. During a median follow-up of 243 days, the incidence rate for poisoning was 4.71 per 1,000 person-years (95%CI: 3.71–5.99) for cases and 1.73 per 1,000 person-years (95% CI: 1.36–2.19) for controls. The adjusted hazard ratio (aHR) was 2.45 (95%CI: 1.56–3.84). For mental/behavioural disorders, the incident rates were 8.89 (95% CI: 7.47–10.57) and 5.01 (95% CI: 4.36–5.76) in the cannabis and the controls group. The aHR was 2.27 (95%CI: 1.66–3.11). No difference was observed between males and females ( P-value for interaction > 0.05). Conclusions Our study observed a short-term increased risk of ED visit/hospitalization for poisoning or for mental/behavioural disorders (from use of psychoactive drugs and other substances)- in medically authorized cannabis patients.

Impact of Inherited Bleeding Disorders on Maternal Bleeding and Other Pregnancy Outcomes: A Population-Based Cohort Study

Introduction: Increasing rate of postpartum hemorrhage (PPH) has been observed between 2003 and 2010 in Canada. Given that bleeding disorders contribute to the risk of PPH, it is important to identify the current trend in PPH in the last decade and assess the impact of inherited bleeding disorders on maternal bleeding and other pregnancy outcomes. Methods: This is a retrospective population-based cohort study using the Alberta Pregnancy Birth Cohort. The creation of this cohort using multiple linked administrative databases has been previously described. Number of deliveries per year in Alberta, Canada was determined by Vital Statistics birth registry from 2010 to 2018 and was linked with Discharge Abstract Database (DAD) to identify cases of PPH and other pregnancy outcomes. PPH was defined as a blood loss of ≥500 ml following vaginal delivery or ≥1000 ml following Caesarean section, or as a diagnosis noted by a health care provider. All diagnoses and procedures were identified by International Classification of Diseases (ICD)-10 codes and Canadian Classification of Interventions (CCI) codes, respectively. Previous validation study of diagnostic code for PPH in DAD showed high sensitivity and specificity. Inherited bleeding disorders including von Willebrand disease, hemophilia carriers, platelet function disorder, and hereditary deficiencies of other coagulation factors were identified by presence of at least two ICD codes. All analyses were restricted to hospitalized deliveries with live births. Temporal trend of PPH rate was assessed by Mann-Kendall test. Univariate logistic regression analyses were used to compute odds of pregnancy outcomes among women with inherited bleeding disorders compared with those without at their index pregnancies during the study period. Results: Between 2010 to 2018, 311,657 women had a total of 452,846 pregnancies with live births. The mean age of the study cohort was 29 years. Most (90%) of them reached term pregnancies. The total number of PPH was 47,602 (10.5 per 100 deliveries). The rate of PPH did not have any significant change from 10.3 in 2010 (95% confidence interval [CI] 10.0-10.6) to 10.8 (95% CI 10.6 -11.1) in 2018 (P for trend =0.28) [Figure 1]. Among 311,657 women, 345 (0.1%) had a diagnosis of inherited bleeding disorders [Table 1]. Women with bleeding disorders were more likely to experience PPH (odds ratio [OR] 1.4; 95% CI 1.1-1.9), antepartum hemorrhage (OR 4.3; 95% CI 2.9-6.4) and had a 3-fold increased risk of undergoing hysterectomy (OR 3.1; 95% CI 1.8-5.2). The bleeding cohort had 3.8 (95% CI: 2.4-6.0) times greater risk of being transfused with blood products. We observed a trend towards higher odds of caesarean delivery in women with bleeding disorders compared with those without (OR 1.2, 95% CI 0.9-1.5), albeit not statistically significant. However, there was no significant difference in prolonged labor, obstetric hematoma, low birth weight baby and induced labour. Conclusion: Despite a rise in the rate of PPH between 2003-2010, we observed no significant change in the rate of PPH in Alberta between 2010-2018. Women with inherited bleeding disorders are at an increased risk of bleeding events during pregnancy and childbirth. Further investigation into quality of care among this patient population is ongoing to identify areas for improvement. Figure 1 Figure 1. Disclosures Wu: BMS-Pfizer: Honoraria, Research Funding; Leo Pharma: Honoraria; Pfizer: Honoraria; Servier: Honoraria; Bayer: Research Funding; Daiichi-Sankyo: Research Funding. Sun: Pfizer: Consultancy; Novo Nordisk: Consultancy; Bayer: Consultancy; Octapharma: Consultancy, Research Funding; Shire: Consultancy.

P.113 A Population-based Study of the Epidemiology, Healthcare Resource Utilization and Costs of Duchenne Muscular Dystrophy in Alberta, Canada

Background: Duchenne muscular dystrophy (DMD) is a severe progressive neuromuscular disease. This study aimed to estimate the prevalence, healthcare resource utilization (HRU), and medical costs of DMD in Alberta. Methods: This retrospective study linked provincial healthcare administrative data to identify patients with DMD utilizing a modified diagnostic code algorithm, including males <30 years of age. Five-year (April 2012 to March 2017) prevalence estimates were calculated and all-cause direct HRU and costs were examined in the first-year post-diagnosis. Results: Overall, 111 patients (median age: 12.0 years (IQR 4.7-18.3)) with DMD were identified. The estimated five-year period prevalence was 35.72 (95% CI 31.88-39.91) per 100,000 persons. All-cause HRU in the first-year post-diagnosis included a mean (SD) of 0.48 (1.19) hospitalizations (length of stay: 9.37 days (36.47)), 3.96 (6.16) general practitioner visits, 28.52 (62.98) specialist visits, and 20.14 (16.49) ambulatory care visits. Mean (SD) all-cause direct costs were $18,868 ($29,206) CAD in the first-year post-diagnosis. Conclusions: Patients with DMD had multiple interactions with the healthcare system in the year following diagnosis, resulting in substantial direct medical costs. More effective treatment strategies are needed to improve health outcomes and reduce the burden of DMD.

115. Variable Use of Diagnostic Codes for Acute Respiratory Infections Across Emergency Departments and Urgent Care Clinics in an Integrated Healthcare System: Implications for Accuracy of Antibiotic Stewardship Metrics

Background Antibiotic stewardship initiatives can leverage metrics that make peer-peer comparisons. A commonly used metric measures how frequently a clinician prescribes antibiotics for acute respiratory infections (ARIs), as defined by diagnostic codes. However, it is unclear if clinicians differ in their use of ARI diagnostic codes. In this study, we evaluated differences in how frequently clinicians code for ARIs and factors that are associated with the use of ARI diagnostic codes in Emergency Department (ED) and Urgent Care (UC) visits across an integrated healthcare system. Methods We analyzed a retrospective cohort of all ED and UC patient-visits across 129 Veterans Affairs medical centers during 2016-2018. ARI visits were identified using ICD-10 codes for acute bronchitis, influenza, pharyngitis, sinusitis, and upper respiratory tract infections for clinicians with 100 or more visits. A generalized linear mixed model with a link logit function that accounted for clustering at the clinician and facility-level was used to calculate median odds ratios (OR) and to identify factors associated with increased likelihood of entering an ARI code. Results There were 6,016,499 patient-visits, and 519,389 (8.6%) were coded as an ARI (Table 1). The mean rate of ARI diagnoses across all visits was 8.9% (SD 2.5%) at the facility-level and 7.4% (SD 4.5%) at the clinician-level (Table 2). The median OR was 2.19 (95% CI 2.18, 2.22), suggesting there was between-clinician variation in coding for ARI diagnoses. Visits were significantly more likely to be coded as ARIs if seen by an advanced practice provider (OR=2.36, 95% CI 2.19, 2.54), if a fever was recorded (OR=4.20, 95% CI 4.18, 4.29), and if the visit occurred between December-March (OR=1.97, 95% CI 1.96, 1.98). Approximately 2/5th of the variability (41.4%) in assigning an ARI diagnostic code was explained by differences across individual clinicians. Conclusion There was substantial variability in how frequently ED and UC clinicians coded a visit as an ARI, and a large proportion of the variability was explained by differences across clinicians. Unmeasured factors could include different approaches to using diagnostic codes. ARI metrics based on diagnostic codes may need to account for differences in clinicians’ coding behavior. Disclosures All Authors: No reported disclosures

Severe Drug-Induced Liver Injury in the Military: A Retrospective Review

ABSTRACT Objectives Drug-induced liver injury (DILI) is a significant cause of morbidity and mortality. Establishing a diagnosis is challenging due to the broad differential diagnosis of liver injury. We retrospectively reviewed patients with severe idiosyncratic DILI at Walter Reed National Military Medical Center in order to define the scope and patterns of injury in the military population. Methods Using the military health database, we identified a total of 110 patients who had an International Classification of Disease (ICD)-10 code for toxic liver injury in the electronic medical record at Walter Reed National Military Medical Center between 2016 and 2019. Each patient record was reviewed, and all pertinent data for included patients were recorded into a database for analysis. Results Twenty-seven out of 110 patients with a diagnostic code for toxic liver injury met inclusion criteria for severe idiosyncratic DILI. Nine cases were caused by supplements, including 5 active duty service members using synthetic anabolic steroids or preworkout supplements. The majority of patients were men and one-third were serving on active duty. The ranges of liver enzyme elevation and patterns of liver injury widely varied. Conclusion Military service members are at particularly high risk for DILI given the frequent use of over-the-counter and other unregulated strength- and performance-enhancing supplements. These injuries not only have significant medical consequences but can profoundly impact military readiness and mission capability. Diagnosis of DILI among active duty service members requires a strong index of suspicion, and inquiry regarding all ingestions is crucial. Educating physicians, providers, and policy makers on the risks of supplement-induced liver injury among service members is crucial. These data will facilitate additional studies exploring susceptibility to severe idiosyncratic DILI among the military population.

The frequency of Raynaud’s phenomenon, very early diagnosis of systemic sclerosis, and systemic sclerosis in a large Veteran Health Administration database

Background We describe Raynauds phenomenon (RP), potential very early diagnosis of systemic sclerosis (VEDOSS), and systemic sclerosis (SSc) in Veterans deployed in support of Post-9/11 operations. We sought to describe the military occupation specialty, clinical features, and vasodilator use across the three diagnoses. Methods Individual Veterans medical records were assessed for RP (ICD-9443.0), VEDOSS with swelling of hands (ICD-9729.81) and RP (ICD-9443.0), and SSc (ICD-9710.1). The distribution of sociodemographic, military service branch, job classification, vasodilator use, and comorbidities were examined across the three classifications of disease. The chi-squared test and Fisher’s exact compared frequency of these categorical variables. Logistic regression assessed the likelihood of characteristics of the three classifications. Results In this population of 607,665 individual Veteran medical records, 857 had RP, 45 met possible VEDOSS criteria, and 71 had a diagnosis of SSc. The majority of RP, potential VEDOSS and SSc cases were white males. Those in craftworks, engineering or maintenance, and healthcare had a greater likelihood of RP. Less than half of RP and VEDOSS patients were on vasodilators. The most common comorbidities in this population were the diagnostic code for pain (highest in the potential VEDOSS group [81.6%]), followed by depression in all groups. Conclusion This is a unique Veteran population of predominately-male patients. Our data suggests that vasodilator medications are potentially being under-utilized for RP and potential VEDOSS. Our data highlights mood and pain management as an important aspect of SSc care.

Nationwide Data on the Characteristics of Linked-to-Care Chronic Hepatitis B in Korea

Linkage-to-care rate of chronic hepatitis B (CHB) is less well characterized. We aimed to evaluate the proportion, characteristics of CHB patients who are linked to care. We retrospectively analyzed insurance reimbursement claims data provided by the Korean National Health Insurance Service. CHB patients who had at least two clinic or hospital visits that were associated with a CHB diagnostic code during 2002–2006 were included. Those without a history of malignancy at baseline were followed up until 2018. Mean follow-up period was 14.5 ± 2.9 years. Among the participants, 553,085 patients (35.8%) were found to be linked to care. The rates were lower in men than women (35.7% vs. 36.0%, p = 0.006). By age, it was highest for the 40′s age group at 44.8% and lowest at 29.4% for the 20′s age group (All p < 0.0001). The linkage-to-care rate was higher in rural area than metropolitan area (p < 0.0001). The 15-year cumulative incidence of hepatocellular carcinoma and overall survival rates among linked-to-care CHB patients were 18.2% and 93.8%, respectively. Two thirds of CHB patients were not linked to care. Those who are male, dwelling in metropolitan areas, and not in life transition periods need to be targeted to improve the linkage-to-care rate in Korea.