Hospitalizations Due to Infectious Disease Complications of Drug Use in Oregon, 2008–2015 Jeffrey Capizzi, Judith Leahy, Haven Wheelock, Ann Thomas, Jonathan Garcia, Sean Schafer, P. Todd Korthuis αOregon Health Authority, βOutside In, γOregon State University, δOregon Health and Science University 42nd Annual AMERSA Conference, San Francisco, CA November 10, 2018

Disclosures Dr. Korthuis has no financial conflicts. He serves as principal investigator for NIH- funded trials that accept manufacturer- donated buprenorphine/naloxone (from Indivior) and extended-release naltrexone (from Alkermes). Funder: NIH National Institute on Drug Abuse (UG3DA044831, UG1DA015815)

Background People who inject drugs are often hospitalized for serious bacterial infections (SBI) Prior studies document local increases in drug-related hospitalizations,1,2 but few population-based estimates exist The purpose of this study was to assess statewide trends in injection drug use (IDU)- related hospitalizations for SBI, diagnoses, and costs in Oregon over time. 1 Tookes H, PLOS One 2015 2 Fanucchi LC, J Addict Med 2018

Methods Study Design: Retrospective cohort study Data Source: Oregon Hospital Discharge Data State database of all hospitalizations in Oregon, excluding VA & psychiatric hospitalizations, 2008- 2015 IDU-Related SBI Hospitalizations: Hospitalization involving ≥ 1 ICD-9/10 codes for: Opioids, amphetamines, cocaine, sedatives, or other drug use and Serious bacterial infections (SBI): ≥ 1 ICD-9/10 codes for: bacteremia\sepsis Endocarditis Osteomyelitis Skin/soft tissue infection We used Oregon Hospital Discharge Data, which captures administrative claims data for most hospitalizations in Oregon, to identify IDU-related hospitalizations from January 2008 through September 2016. IDU-associated hospitalizations were those with at least one diagnostic code associated with use of opioids, amphetamines, cocaine, sedatives, or other drugs and at least one diagnosis code for bacteremia\sepsis, endocarditis, osteomyelitis, or skin/soft tissue infection. Cost was determined by adjusting the charged amount with Cost-to-Charge ratios by hospital.

Methods Cost Measurement Patient hospitalization charges adjusted using AHRQ hospital Cost-to-Charge ratios, and converted to 2015 U.S. dollars Analysis: Descriptive statistics reporting trends over time We used Oregon Hospital Discharge Data, which captures administrative claims data for most hospitalizations in Oregon, to identify IDU-related hospitalizations from January 2008 through September 2016. IDU-associated hospitalizations were those with at least one diagnostic code associated with use of opioids, amphetamines, cocaine, sedatives, or other drugs and at least one diagnosis code for bacteremia\sepsis, endocarditis, osteomyelitis, or skin/soft tissue infection. Cost was determined by adjusting the charged amount with Cost-to-Charge ratios by hospital.

Patient Characteristics at First Hospitalization, 2008-2015 IDU-Related (n = 65,783) Non-IDU-Related (n = 725,156) Mean Age (SD) 46 yrs (16.1) 63 yrs (20.7) Female 51.2% 50.5% Race/Ethnicity White (nonHisp.) Black Hispanic Native American Other/Unknown 65.6% 2.6% 2.1% 4.9% 23.5% 72.4% 1.4% 3.0% 18.7% Portland Metro residence 50.7% 36.6% Insurance Private Medicaid Medicare Uninsured 17.1% 27.2% 29.1% 23.3% 10.2% 56.4% 5.4% HIV-infected 2.2% 0.5% Chronic HCV 26.1% 3.8% At their first hospitalizations, Patients with IDU-related SBI hospitalizations were younger and more likely to have Medicaid or no Insurance, HIV, and Chronic HCV.

Results IDU-Related SBI Hospitalizations Account for Increasing Proportion of All Hospitalizations Over Time increased from 975 to 5,256 (0.26% to 1.44% of all hospitalizations) from 2008 to 2015, a 5.5-fold increase

IDU-Related SBI Hospitalizations, by Substance, 2008-2015 Opioids, n= 9,417 (62%) Amphetamines, n= 3,626 (24%) Cocaine, n=324 (2%) n=92 (1%) n=1,350 (9%) n=269 (2%) n=121 (1%)

Results Number of IDU-Related SBI Hospitalizations Over Time, by Drug Use

Results Number of IDU-Related SBI Hospitalizations Over Time, by Infection Category

IDU-Related SBI Hospitalizations, by County Oregon Population Density, by County High rates of IDU-related SBI hospitalizations in rural, low population density Counties.

Total Costs of IDU-Related SBI Hospitalizations in Oregon, Over Time* $218,987,964 $69,385,527 3.1-fold increase in costs due to IDU-Related SBI hospitalizations from 2008-2015. *Adjusted for charge-to-cost and inflation (2015 USD)

Limitations Administrative claims data may misclassify hospitalizations, drug use, and infections Likely resulting in a conservative estimate Experience in single state may not be generalizable to other states

Conclusions IDU-related SBI hospitalizations comprise an increasing proportion of all hospitalizations in Oregon Rural counties have high rates of IDU-related SBI hospitalization IDU-related SBI hospitalization costs increased 3.1-fold, 2008-2015 Policies that promote drug use disorder treatment and harm reduction services may decrease hospitalization costs

Discussion

Supplemental Slides

Results Proportion of IDU-Related SBI Hospitalizations of All Hospitalizations Over Time, by Drug Use

Results Proportion of IDU-Related SBI Hospitalizations Among All Hospitalizations Over Time, by Infectious Category

Longer Mean Length of Stay for IDU-Related Hospitalizations Year of Discharge Non-IDU Hospitalizations (days) IDU-Related Hospitalizations 2008 4.00 6.70 2009 3.98 6.09 2010 3.94 5.63 2011 3.89 5.07 2012 3.87 5.01 2013 3.93 5.16 2014 3.99 5.65 2015 4.05 7.04

Increasing Proportion of Total Drives Increased Costs Proportion of SBI Total hospital days and Cost attributable to IDU hospitalizations (2015 dollars)