Tisamarie B. Sherry, MD, PhD; Adrienne Sabety, BA; Nicole Maestas, MPP, PhD
Acknowledgment: The authors thank Kevin Friedman for excellent research assistance.
Financial Support: By the National Institute on Aging (grant R01AG026290), the National Science Foundation Graduate Research Fellowship Program (grant DGE1144152 to Ms. Sabety), and a gift from Owen and Linda Robinson.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-0644.
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Sherry (e-mail, email@example.com). Data set: Available at www.cdc.gov/nchs/ahcd/datasets_documentation_related.htm.
Appendix Table. ICD-9 Codes for Pain Diagnoses*
Table 1. Diagnoses Assigned for Office Visits With an Opioid Prescription*
Table 2. Ten Most Common Diagnoses Assigned for Office Visits With an Opioid Prescription, by Presence or Absence of Pain Diagnosis*
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Daniel B. Horton, MD, MSCE, Theresa Juliano, BA, Matthew T. Taylor, BA, Tobias Gerhard, BSPharm, PhD
Rutgers Center for Pharmacoepidemiology and Treatment Science, Rutgers University, New Brunswick, NJ
September 23, 2018
Conflict of Interest:
DBH and TG have received grant funding from Bristol-Myers Squibb unrelated to the topic. TG has consulted for Eli Lilly on matters unrelated to the topic.
Unacknowledged limitations of the analysis and data source
The National Ambulatory Medical Care Survey (NAMCS) contains not just diagnostic information in ICD-9 codes but also clinical details about reasons for visit (RFV). RFV include various potentially painful conditions as well as codes for drug abuse/dependence, which could also warrant opioid treatment (e.g., methadone). Documentation of RFV does not necessarily correspond with listed diagnoses; indeed, recorded data in one field may relate to omissions in other fields, particularly when the number of entries (as for diagnoses) are limited. Furthermore, NAMCS contains checkboxes used to document the presence of certain chronic medical conditions—among them, arthritis, cancer, diabetes, and (added in 2014) substance abuse. Incorporating data from RFV (list available on request) and checkboxes, we showed substantially lower levels of missing data in NAMCS among opioid users than reported by Sherry et al: 20.3% (95% CI 19.3%, 21.4%) using RFV and 14.1% (95% CI 13.3%, 15.0%) using RFV plus checkboxes—roughly half of the original estimate of 28.5% (95% CI 27.2%, 29.7%), which we replicated using codes provided in the publication's Supplement. When stratifying results to explore whether underdocumentation varied across opioid types, we found that missing diagnoses (as recorded by ICD-9 codes alone) were particularly common for visits of patients given drugs for opioid dependence (57.6% [95% CI 47.5%, 67.0%]). These rates were improved when incorporating additional clinical data from RFV (38.6% [95% CI 30.0%, 47.9%]) along with the chronic disease checkboxes (27.8% [95% CI 19.8%, 37.6%]).In addition to these findings, we wanted to emphasize two additional, unmentioned limitations. Firstly, while methods for sampling and data recording within NAMCS are rigorous, we know of no evidence showing that recorded diagnoses are as accurate, valid, or complete as alternate data sources, such as administrative claims or EHRs. Secondly, as noted, NAMCS contains only cross-sectional, visit-level data, raising the possibility not only of missing drug exposure data but also of missing historical information on diagnoses from other visits and providers. In other words, the authors' findings likely reflect weaknesses of NAMCS' diagnostic data fields but not necessarily limitations of prescribers' documentation.For the above reasons, we suspect that the reported rates of missing diagnostic data overestimated the actual levels of inadequate documentation for opioid users, not only within NAMCS but also in longitudinal data sources such as claims or EHR data—a hypothesis that bears further investigation.
Sherry TB, Sabety A, Maestas N. Documented Pain Diagnoses in Adults Prescribed Opioids: Results From the National Ambulatory Medical Care Survey, 2006–2015. Ann Intern Med. [Epub ahead of print ]:. doi: 10.7326/M18-0644
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Published: Ann Intern Med. 2018.
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Tobacco, Alcohol, and Other Substance Abuse.
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