Abstract
This study examines discharge trends for opioid-related admissions from 2016-2020 with a focus on admissions with opioid use disorder and an injection-related infection.
It is unknown how often patients with opioid use disorder (OUD) are discharged before medically advised (BMA) in the current fentanyl era. Discharge BMA, also known as discharge against medical advice,1 was associated with twice the odds of all-cause death and hospital readmission within 30 days in the general population in 2002-2014.2,3 Patients who use drugs cite untreated withdrawal and pain as primary reasons for BMA discharge.4 Methadone and buprenorphine treat opioid withdrawal, reduce BMA discharges, and are effective for OUD but are rarely started during hospitalization.5 Fentanyl, a potent opioid, has spread in unregulated drug supplies since 2014. It is now involved in 88% of US opioid overdoses and has led to new challenges treating withdrawal.6
We report BMA discharge trends for opioid-related admissions from 2016-2020 with a focus on admissions with OUD and an injection-related infection. Given low use of methadone and buprenorphine amid more severe withdrawal from fentanyl, we hypothesized that BMA discharge rates are increasing.
Methods
We obtained data from the Nationwide Readmissions Database, which aggregates all-payer admissions from over 30 states and assigns weights to generate nationally representative data. We identified cohorts with International Classification of Diseases, 10th Revision, Clinical Modification codes (eTable in Supplement 1). We identified opioid-related admissions as those with opioid use, dependence, abuse, or overdose. To examine a cohort more likely to have severe OUD and fentanyl use, we identified patients with OUD and an injection-related infection based on an opioid-related diagnosis concurrent with infections such as bacteremia, endocarditis, or osteomyelitis.
We compared annual changes in the BMA discharge rate for these cohorts with those for nonopioid mental health or substance use admissions and for all nonopioid admissions. For the opioid cohorts, we examined changes in the proportion of BMA discharges before the third admission day, when opioid withdrawal is most severe, and changes in the proportion with stimulant use disorder.
We used the Seasonal Kendall test with a 2-sided significance threshold of P < .05 and conducted analyses with Stata (version 17.0) and R (version 4.2.2). A University of Pennsylvania institutional review board approved this study with a waiver of informed consent.
Results
From 2016-2020, there were 87 million unweighted hospital admissions among 64 million unique individuals. Of 175 million weighted admissions, 0.3% involved OUD and an injection-related infection, 1.7% were opioid related, and 5.3% were nonopioid mental health or substance use related.
From 2016-2020, the annual BMA rate for admissions with OUD and an injection-related infection increased from 9.3% (95% CI, 8.8%-9.9%) to 17.0% (95% CI, 16.3%-17.8%) (annual growth rate, 1.8%; P < .001) (Figure). The BMA rate for all opioid-related admissions increased from 7.5% (95% CI, 6.9%-8.0%) to 11.3% (95% CI, 10.7%-11.8%) (annual growth rate, 0.7%; P < .001). In contrast, the BMA rate increased only marginally, from 3.1% (95% CI, 2.8%-3.4%) to 3.5% (95% CI, 3.1%-3.6%) (annual growth rate, 0.1%; P = .002) for nonopioid mental health or substance use admissions and from 1.1% (95% CI, 1.1%-1.2%) to 1.5% (95% CI, 1.5%-1.6%) (annual growth rate, 0.1%; P < .001) for all nonopioid admissions.
Figure. Hospital Admissions Ending With Before Medically Advised (BMA) Discharge by Cohort, 2016-2020.
The proportion of BMA discharges occurring before the third day increased for admissions with OUD and an injection-related infection (42.6% vs 48.0%; annual growth rate, 1.1%; P < .001) but did not significantly change for all opioid-related admissions (63.6% vs 62.1%; annual growth rate, −0.3%; P = .11) (Table). The rate of co-occurring stimulant use disorder did not significantly change among BMA discharges with OUD and an injection-related infection but increased for opioid-related admissions overall (Table).
Table. Hospital Disposition by Cohort, 2016 vs 2020.
| 2016 | 2020 | Annual growth rate, %a | P valuea | |||
|---|---|---|---|---|---|---|
| Unweighted, No. | Weighted (95% CI), %b | Unweighted, No. | Weighted (95% CI), %b | |||
| Admissions with OUD and an injection-related infection | 48 280 | 57 370 | ||||
| BMA discharges | 9.3 (8.8-9.9) | 17.0 (16.3-17.8) | 1.8 | <.001 | ||
| BMA discharges with LOS ≤2 d | 42.6 (40.6-44.9) | 48.0 (46.7-49.2) | 1.1 | <.001 | ||
| BMA discharges with concurrent StUD | 40.9 (39.1-42.7) | 45.3 (43.7-46.9) | 1.9 | .07 | ||
| Opioid-related admissions | 333 725 | 293 361 | ||||
| BMA discharges | 7.5 (6.9-8.0) | 11.3 (10.7-11.8) | 0.7 | <.001 | ||
| BMA discharges with LOS ≤2 d | 63.6 (61.9-65.3) | 62.1 (61.1-63.1) | −0.3 | .11 | ||
| BMA discharges with concurrent StUD | 35.9 (33.4-37.3) | 43.1 (41.7-44.5) | 2.1 | <.001 | ||
| Nonopioid mental health and substance use admissions | 900 211 | 905 175 | ||||
| BMA discharges | 3.1 (2.8-3.4) | 3.5 (3.1-3.6) | 0.1 | .002 | ||
| All nonopioid admissions | 16 863 958 | 16 399 333 | ||||
| BMA discharges | 1.1 (1.1-1.2) | 1.5 (1.5-1.6) | 0.1 | <.001 | ||
Abbreviations: BMA, before medically advised; LOS, length of stay; OUD, opioid use disorder; StUD, stimulant use disorder.
Using the Seasonal Kendall test with quarterly data.
For BMA discharges as a proportion of all weighted admissions in that cohort; for LOS ≤2 days and for concurrent StUD as a proportion of BMA discharges in that cohort.
Discussion
From 2016 through 2020, BMA discharges increased for admissions with OUD and an injection-related infection and for all opioid-related admissions but increased only minimally for nonopioid mental health or substance use admissions and for nonopioid admissions overall. Among admissions with OUD and an injection-related infection, a higher proportion of BMA discharges occurred before the third day in 2020 vs 2016, suggesting that untreated withdrawal might contribute to increasing BMA discharges in this cohort. Study limitations include that there was no diagnosis code for OUD and that diagnosis codes can be inaccurate; however, codes remained consistent across the study period.
Future studies should determine whether widespread implementation of evidence-based treatment with methadone and buprenorphine mitigates increasing BMA rates among patients with OUD.
Section Editors: Jody W. Zylke, MD, Deputy Editor; Karen Lasser, MD, and Kristin Walter, MD, Senior Editors.
eTable. Cohort Selection by Diagnosis Code and Service Line
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
eTable. Cohort Selection by Diagnosis Code and Service Line
Data Sharing Statement