STATISTICAL BRIEF #258


May 2020


Hospital Burden of Opioid-Related Inpatient Stays: Metropolitan and Rural Hospitals, 2016


Pamela L. Owens, Ph.D., Audrey J. Weiss, Ph.D., and Marguerite L. Barrett, M.S.


Introduction

Reflective of the national opioid crisis, the rate of opioid-related hospitalizations has increased substantially in the United States, from 164.2 per 100,000 population in 2006 to 296.9 per 100,000 population in 2016.1 The escalation in opioid-related inpatient stays has been accompanied by a disproportionately large increase in the costs associated with these types of hospitalizations. One study estimated that charges for hospital stays involving opioid abuse or dependence nearly quadrupled between 2002 and 2012, reaching almost $15 billion.2

The dramatic rise in hospitalizations related to taking opioids (defined as abuse, dependence, or use) and associated conditions place an increased burden on hospitals to be able to manage, treat, and potentially help minimize opioid-related problems for their patients. In October 2017, the American Hospital Association published a toolkit to assist hospitals in their efforts to address the opioid crisis, covering areas such as appropriate prescribing practices, identification and treatment of opioid use disorder, and nonopioid pain management.3 In order to help better focus hospital resources, it is important to understand which hospitals are facing the most substantial burden of opioid-related cases.

This Healthcare Cost and Utilization Project (HCUP) Statistical Brief focuses on the hospital burden of opioid-related hospitalizations by hospital urban-rural location. The Statistical Brief presents hospital statistics on opioid-related inpatient stays using the 2016 State Inpatient Databases (SID) from 46 States and the District of Columbia. The hospital rate of opioid-related stays per 1,000 inpatient stays is examined for a total of 4,207 community hospitals (excluding rehabilitation and long-term acute care hospitals) classified based on the urban-rural location of the hospital: metropolitan (metro), rural and adjacent to a metropolitan area (rural-adjacent), and rural and not adjacent to a metropolitan area (rural-remote). The hospital rate of opioid-related stays is presented by hospital urban-rural location for each U.S. census division. The distribution of the rate is provided across all metropolitan and rural hospitals. Finally, the rate is presented by hospital urban-rural location for hospitals with different bed sizes and occupancy levels. All differences between estimates noted in the text are statistically significant at the .05 level or better.
Highlights
  • In 2016, hospitals located in metropolitan areas had a higher average rate of opioid-related inpatient stays than did hospitals located in rural areas adjacent to metropolitan areas (rural-adjacent) or rural-remote areas (30.8 vs. 20.1 and 16.2 per 1,000 stays, respectively).


  • Metropolitan hospitals had higher average hospital rates of opioid-related inpatient stays than rural-adjacent and/or rural-remote hospitals in most divisions, but in New England rates were high regardless of hospital location.


  • Rural-remote and rural-adjacent hospitals were more likely to have no opioid-related cases (19.3 and 11.6 percent, respectively) compared with metropolitan hospitals (4.3 percent).


  • Based on hospital bed size and occupancy level, the lowest opioid burden was among small hospitals regardless of location (11.7 to 14.9 per 1,000 stays) and the highest opioid burden was among metro hospitals with high occupancy levels (33.5 to 34.6 per 1,000 stays).
Findings

Burden of opioid-related stays in community hospitals by hospital urban-rural location, 2016
Figure 1 provides the average number and average hospital rate of opioid-related stays per 1,000 inpatient stays by hospital urban-rural location (metro, rural-adjacent to metro, and rural-remote) in 2016.


Figure 1. Average number and average hospital rate of opioid-related inpatient stays, by hospital urban-rural location, 2016

Figure 1 is two bar charts that illustrates the average number and average hospital rate of opioid-related stays by hospital urban-rural location in 2016.

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) from 46 States and the District of Columbia (from all States except Alabama, Georgia, Idaho, and New Hampshire), 2016

Figure 1 consists of two bar charts that show the average number and average hospital rate of opioid-related stays by hospital urban-rural location in 2016. The average hospital-level number of opioid-related stays was 312.2 for metro hospitals (n=2,564 hospitals), 43.8 for hospitals in rural-adjacent to metro areas (n=896 hospitals), and 33.3 for hospitals in rural-remote areas (n=747 hospitals). The average hospital-level rate of opioid-related stays per 1,000 stays was 30.8 for metro hospitals (n=2,564), 20.1 for hospitals in rural-adjacent to metro areas (n=896), and 16.2 for hospitals in rural-remote areas (n=747).



  • Metropolitan hospitals had more opioid-related stays and had a higher average rate of opioid-related inpatient stays compared with rural hospitals.

    Of the 4,207 community hospitals examined, 60.9 percent (2,564 hospitals) were located in metropolitan areas, 21.3 percent (896 hospitals) were in rural-adjacent areas, and 17.8 percent (747 hospitals) were in rural-remote areas. In 2016, metropolitan hospitals treated 7 to 9 times as many opioid-related cases on average as did rural-adjacent or rural-remote hospitals (312.2 vs. 43.8 and 33.3, respectively). Moreover, the average hospital rate of opioid-related stays at metropolitan hospitals also was higher than the rate at rural-adjacent and rural-remote hospitals (30.8 per 1,000 stays vs. 20.1 and 16.2, respectively).
Figure 2 presents the average hospital rate of opioid-related stays per 1,000 inpatient stays by hospital urban-rural location and U.S. census division in 2016. The number of hospitals in each hospital urban-rural location in each census division category is provided to the right of the figure, for reference.


Figure 2. Average hospital rate of opioid-related stays per 1,000 inpatient stays, by hospital urban-rural location and U.S. census division, 2016

Figure 2 is a horizontal bar chart that illustrates the average hospital rate of opioid-related stays per 1,000 inpatient stays by hospital urban-rural location and U.S. census division in 2016. Data are provided in Supplemental Table 1.

a Missing data from one State in the census division.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) from 46 States and the District of Columbia (from all States except Alabama, Georgia, Idaho, and New Hampshire), 2016

Figure 2 is a horizontal bar chart that shows the average hospital rate of opioid-related stays per 1,000 inpatient stays by hospital urban-rural location and U.S. census division in 2016. Data are provided in Supplemental Table 1.



  • The opioid burden based on hospital urban-rural location varied substantially across U.S. census divisions.

    Across U.S. census divisions, the average hospital rate of opioid-related inpatient stays ranged from 9.4 per 1,000 stays among rural-remote hospitals in the West South Central division to 40.7 per 1,000 stays among metropolitan hospitals in the New England division. Within U.S. census divisions, hospitals in the New England division had the smallest variation in the average hospital rate of opioid-related stays by hospital urban-rural location, ranging from 32.7 for rural-adjacent hospitals to 40.7 for metropolitan hospitals. Hospitals in the West North Central division had the largest variation, with the average hospital rate of opioid-related stays for metropolitan hospitals more than double the rate for rural-remote hospitals (22.1 vs. 9.9 per 1,000 stays).


  • For most divisions, metropolitan hospitals had a larger opioid burden than did rural hospitals.

    For eight of the nine divisions, metropolitan hospitals had average hospital rates of opioid-related inpatient stays that were higher than the rates for rural-adjacent and/or rural-remote hospitals. Only in the New England division were the rates of opioid-related stays similar for all three urban-rural hospital locations.
Distribution of hospital rates of opioid-related inpatient stays by hospital urban-rural location, 2016
Figure 3 displays the distribution of hospital rates of opioid-related inpatient stays among metropolitan hospitals compared with rural hospitals (rural-adjacent and rural-remote hospitals were combined for this analysis). In addition to the average hospital rate, the rate threshold for the 10 percent of hospitals with the highest rates also is noted.


Figure 3. Distribution of hospital rates of opioid-related stays per 1,000 inpatient stays across metropolitan and rural hospitals, 2016

Figure 3 is a horizontal bar chart that illustrates the distribution of opioid-related rate of stays per 1,000 inpatient stays across metropolitan and rural hospitals in 2016. Ten percent of metro hospitals had a rate above 57.7, and 10 percent of rural hospitals had a rate above 39.0. The average hospital rate for metro hospitals was 30.8 and for rural hospitals was 18.3. Data are provided in Supplemental Table 2.

Note: Hospitals with rates of 64 per 1,000 inpatient stays or larger were grouped into one category because of the small number of rural hospitals that exist in narrower rate groupings above this level.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) from 46 States and the District of Columbia (from all States except Alabama, Georgia, Idaho, and New Hampshire), 2016

Figure 3 is a horizontal bar chart that shows the distribution of opioid-related rate of stays per 1,000 inpatient stays across metropolitan and rural hospitals in 2016. Ten percent of metro hospitals had a rate above 57.7, and 10 percent of rural hospitals had a rate above 39.0. The average hospital rate for metro hospitals was 30.8 and for rural hospitals was 18.3. Data are provided in Supplemental Table 2.



  • The hospital rate of opioid-related stays was higher on average among metropolitan than among rural hospitals.

    In 2016, the average hospital rate of opioid-related stays among metropolitan hospitals was 30.8 per 1,000 inpatient stays, and 10 percent of metropolitan hospitals had a rate above 57.7. The average hospital rate of opioid-related stays was lower among rural hospitals—18.3 per 1,000 inpatient stays—and 10 percent of rural hospitals had a rate above 39.0.

    A larger percentage of metropolitan hospitals than rural hospitals had the highest rates of opioid-related inpatient stays (defined as 64 per 1,000 stays or higher): 7.9 percent or 202 metropolitan hospitals versus 3.2 percent or 53 rural hospitals, respectively.

    A smaller percentage of metropolitan hospitals than rural hospitals had no opioid-related stays (rate of zero) during the year: 4.3 percent or 109 metropolitan hospitals versus 15.1 percent or 248 rural hospitals, respectively.
Figure 4 displays the distribution in hospital rates of opioid-related inpatient stays among rural hospitals adjacent to metropolitan areas compared with rural hospitals in remote areas. In addition to the average hospital rate, the rate threshold for the 10 percent of hospitals with the highest rates also is noted.


Figure 4. Distribution of hospital rates of opioid-related stays per 1,000 inpatient stays across two types of rural hospitals, 2016

Figure 4 is a horizontal bar chart that illustrates the opioid-related rate of stays per 1,000 inpatient stays for rural-adjacent and rural-remote hospitals. Ten percent of rural-adjacent hospitals had a rate above 41.9, and 10 percent of rural-remote hospitals had a rate above 36.3. The average hospital rate for rural-adjacent hospitals was 20.1 and for rural-remote hospitals was 16.2. Data are provided in Supplemental Table 3.

Note: Hospitals with rates of 64 per 1,000 inpatient stays or larger were grouped into one category because of the small number of rural hospitals that exist in narrower rate groupings above this level.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) from 46 States and the District of Columbia (from all States except Alabama, Georgia, Idaho, and New Hampshire), 2016

Figure 4 is a horizontal bar chart that shows the opioid-related rate of stays per 1,000 inpatient stays for rural-adjacent and rural-remote hospitals. Ten percent of rural-adjacent hospitals had a rate above 41.9, and 10 percent of rural-remote hospitals had a rate above 36.3. The average hospital rate for rural-adjacent hospitals was 20.1 and for rural-remote hospitals was 16.2. Data are provided in Supplemental Table 3.



  • The hospital rate of opioid-related stays was slightly higher on average among rural-adjacent than among rural-remote hospitals.

    In 2016, the average hospital rate of opioid-related stays among rural-adjacent hospitals was 20.1 per 1,000 inpatient stays, and 10 percent of these hospitals had a rate above 41.9. The average hospital rate of opioid-related stays was slightly lower among rural-remote hospitals—16.2 per 1,000 inpatient stays—and 10 percent of rural-remote hospitals had a rate above 36.3.

    Compared with rural-remote hospitals, a slightly larger percentage of rural-adjacent hospitals had the highest rates of opioid-related inpatient stays (defined as 64 per 1,000 stays or higher): 3.9 percent or 35 rural-adjacent hospitals versus 2.4 percent or 18 rural-remote hospitals, respectively.

    A smaller percentage of rural-adjacent hospitals than rural-remote hospitals had no opioid-related stays (rate of zero) during the year: 11.6 percent or 104 rural-adjacent hospitals versus 19.3 percent or 144 rural-remote hospitals, respectively.
Differences in the average hospital rates of opioid-related inpatient stays by hospital urban-rural location, bed size, and occupancy level, 2016
Figure 5 presents the average hospital rate of opioid-related inpatient stays by hospital urban-rural location and bed size in 2016. The number of hospitals by urban-rural location and bed size is provided below the figure, for reference.


Figure 5. Average hospital rate of opioid-related stays per 1,000 inpatient stays, by hospital urban-rural location and bed size, 2016

Figure 5 is three bar charts that illustrates the average rate of opioid-related stays per 1,000 inpatient stays by hospital urban-rural location and bed size in 2016. A supplemental table is included that shows the number of hospitals by hospital urban-rural location and bed size in 2016. Data are provided in Supplemental Table 4.
Bed size Number of hospitals by hospital urban-rural location
Metro Rural-adjacent to metro Rural-remote
<=25 beds 323 463 451
26 to 100 beds 479 317 209
101 to 250 beds 872 107 74
251+ beds 890 9 13

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) from 46 States and the District of Columbia (from all States except Alabama, Georgia, Idaho, and New Hampshire), 2016

Three bar charts that show the average rate of opioid-related stays per 1,000 inpatient stays by hospital urban-rural location and bed size in 2016. A supplemental table is included that shows the number of hospitals by hospital urban-rural location and bed size in 2016. Data are provided in Supplemental Table 4.



  • Small hospitals had the lowest opioid burden across all hospital bed sizes and locations.

    Regardless of urban-rural location of the hospital, the average hospital rate of opioid-related stays was lowest among the smallest hospitals, those with 25 or fewer beds (range: 11.7 per 1,000 stays for rural-remote hospitals to 14.9 per 1,000 stays for rural-adjacent hospitals), compared with larger hospitals in each location.
Figure 6 presents the average hospital rate of opioid-related inpatient stays by hospital urban-rural location and occupancy level in 2016. The number of hospitals by urban-rural location and occupancy level is provided below the figure, for reference.


Figure 6. Average hospital rate of opioid-related stays per 1,000 inpatient stays, by hospital urban-rural location and occupancy level, 2016

Figure 6 is three bar charts that illustrates the average rate of opioid-related stays per 1,000 inpatient stays by hospital urban-rural location and occupancy level in 2016. A supplemental table is included that shows the number of hospitals by hospital urban-rural location and bed size in 2016. Data are provided in Supplemental Table 5.
Occupancy level Number of hospitals by hospital urban-rural location
Metro Rural-adjacent to metro Rural-remote
<25% 174 229 206
25% to <50% 451 335 235
50% to <75% 1,512 282 250
>=75% 427 50 56

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) from 46 States and the District of Columbia (from all States except Alabama, Georgia, Idaho, and New Hampshire), 2016

Three bar charts that show the average rate of opioid-related stays per 1,000 inpatient stays by hospital urban-rural location and occupancy level in 2016. A supplemental table is included that shows the number of hospitals by hospital urban-rural location and bed size in 2016. Data are provided in Supplemental Table 5.



  • Metropolitan hospitals with high occupancy levels had the greatest opioid burden across all hospital urban-rural locations and occupancy levels.

    Overall, metropolitan hospitals with 75 percent or greater occupancy and those between 50 and 75 percent occupancy had the highest average hospital rates of opioid-related inpatient stays (34.6 and 33.5 per 1,000 stays, respectively).
About Statistical Briefs

Healthcare Cost and Utilization Project (HCUP) Statistical Briefs provide basic descriptive statistics on a variety of topics using HCUP administrative healthcare data. Topics include hospital inpatient, ambulatory surgery, and emergency department use and costs, quality of care, access to care, medical conditions, procedures, and patient populations, among other topics. The reports are intended to generate hypotheses that can be further explored in other research; the reports are not designed to answer in-depth research questions using multivariate methods.

Data Source

The estimates in this Statistical Brief are based upon data from the HCUP 2016 State Inpatient Databases (SID) from 46 States and the District of Columbia: Alaska, Arkansas, Arizona, California, Connecticut, Colorado, Delaware, District of Columbia, Florida, Hawaii, Iowa, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maryland, Maine, Massachusetts, Michigan, Minnesota, Missouri, Mississippi, Montana, North Carolina, North Dakota, Nebraska, Nevada, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Wisconsin, West Virginia, and Wyoming.

Table 1 presents a summary of the number of hospitals for which HCUP 2016 inpatient data were available for analysis by U.S. census region and division.


Table 1. Hospitals with available HCUP inpatient data, 2016
U.S. census region/division Total number of U.S. hospitals (from AHA) Number of hospitals with HCUP inpatient data Hospitals with HCUP inpatient data, %
United States 4,654 4,207 90.4
Northeast 572 540 94.4
New Englanda 176 147 83.5
Middle Atlantic 396 393 99.2
Midwest 1,391 1,332 95.8
East North Central 715 701 98.0
West North Central 676 631 93.3
South 1,784 1,492 83.6
South Atlantica 679 540 79.5
East South Centrala 384 273 71.1
West South Central 721 679 94.2
West 907 843 92.9
Mountaina 378 319 84.4
Pacific 529 524 99.1
Abbreviation: AHA, American Hospital Association
Note: Hospitals were community hospitals, excluding rehabilitation and long-term acute care hospitals.
a Missing data from one State in the census division.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) from 46 States and the District of Columbia (from all States except Alabama, Georgia, Idaho, and New Hampshire), 2016


Definitions

Diagnoses and ICD-10-CM
The principal diagnosis is that condition established after study to be chiefly responsible for the patient's admission to the hospital. Secondary diagnoses are concomitant conditions that coexist at the time of admission or develop during the stay. All-listed diagnoses include the principal diagnosis plus these additional secondary conditions.

ICD-10-CM is the International Classification of Diseases, Tenth Revision, Clinical Modification. In October 2015, ICD-10-CM replaced the ICD-9-CM diagnosis with the ICD-10-CM diagnosis coding system for most inpatient and outpatient medical encounters. There are over 70,000 ICD-10-CM diagnosis codes.

Case definition
Opioid-related inpatient stays were defined using the all-listed ICD-10-CM diagnosis codes shown in Table 2.


Table 2. ICD-10-CM diagnosis codes defining opioid-related inpatient stays
ICD-10-CM diagnosis code Description
F11.10 Opioid abuse, uncomplicated
F11.120 Opioid abuse with intoxication, uncomplicated
F11.121 Opioid abuse with intoxication, delirium
F11.122 Opioid abuse with intoxication, with perceptual disturbance
F11.129 Opioid abuse with intoxication, unspecified
F11.14 Opioid abuse with opioid-induced mood disorder
F11.150 Opioid abuse with opioid-induced psychotic disorder, with delusions
F11.151 Opioid abuse with opioid-induced psychotic disorder, with hallucinations
F11.159 Opioid abuse with opioid-induced psychotic disorder, unspecified
F11.181 Opioid abuse with opioid-induced sexual dysfunction
F11.182 Opioid abuse with opioid-induced sleep disorder
F11.188 Opioid abuse with other opioid-induced disorder
F11.19 Opioid abuse with unspecified opioid-induced disorder
F11.20 Opioid dependence, uncomplicated
F11.220 Opioid dependence with intoxication, uncomplicated
F11.221 Opioid dependence with intoxication, delirium
F11.222 Opioid dependence with intoxication, with perceptual disturbance
F11.229 Opioid dependence with intoxication, unspecified
F11.23 Opioid dependence with withdrawal
F11.24 Opioid dependence with opioid-induced mood disorder
F11.250 Opioid dependence with opioid-induced psychotic disorder, with delusions
F11.251 Opioid dependence with opioid-induced psychotic disorder, with hallucinations
F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified
F11.281 Opioid dependence with opioid-induced sexual dysfunction
F11.282 Opioid dependence with opioid-induced sleep disorder
F11.288 Opioid dependence with other opioid-induced disorder
F11.29 Opioid dependence with unspecified opioid-induced disorder
F11.90 Opioid use, unspecified, uncomplicated
F11.920 Opioid use, unspecified with intoxication, uncomplicated
F11.921 Opioid use, unspecified with intoxication delirium
F11.922 Opioid use, unspecified with intoxication, with perceptual disturbance
F11.929 Opioid use, unspecified with intoxication, unspecified
F11.93 Opioid use, unspecified, with withdrawal
F11.94 Opioid use, unspecified, with opioid-induced mood disorder
F11.950 Opioid use, unspecified with opioid-induced psychotic disorder, with delusions
F11.951 Opioid use, unspecified with opioid-induced psychotic disorder, with hallucinations
F11.959 Opioid use, unspecified with opioid-induced psychotic disorder, unspecified
F11.981 Opioid use, unspecified with opioid-induced sexual dysfunction
F11.982 Opioid use, unspecified with opioid-induced sleep disorder
F11.988 Opioid use, unspecified with other opioid-induced disorder
F11.99 Opioid use, unspecified, with unspecified opioid-induced disorder
T40.0X1A Poisoning by opium, accidental (unintentional), initial encounter
T40.0X1D Poisoning by opium, accidental (unintentional), subsequent encounter
T40.0X2A Poisoning by opium, intentional self-harm, initial encounter
T40.0X2D Poisoning by opium, intentional self-harm, subsequent encounter
T40.0X3A Poisoning by opium, assault, initial encounter
T40.0X3D Poisoning by opium, assault, subsequent encounter
T40.0X4A Poisoning by opium, undetermined, initial encounter
T40.0X4D Poisoning by opium, undetermined, subsequent encounter
T40.0X5A Adverse effect of opium, initial encounter
T40.0X5D Adverse effect of opium, subsequent encounter
T40.1X1A Poisoning by heroin, accidental (unintentional), initial encounter
T40.IXID Poisoning by heroin, accidental (unintentional), subsequent encounter
T40.1X2A Poisoning by heroin, intentional self-harm, initial encounter
T40.1X2D Poisoning by heroin, intentional self-harm, subsequent encounter
T40.1X3A Poisoning by heroin, assault, initial encounter
T40.1X3D Poisoning by heroin, assault, subsequent encounter
T40.1X4A Poisoning by heroin, undetermined, initial encounter
T40.1X4D Poisoning by heroin, undetermined, subsequent encounter
T40.2X1A Poisoning by other opioids, accidental (unintentional), initial encounter
T40.2X1D Poisoning by other opioids, accidental (unintentional), subsequent encounter
T40.2X2A Poisoning by other opioids, intentional self-harm, initial encounter
T40.2X2D Poisoning by other opioids, intentional self-harm, subsequent encounter
T40.2X3A Poisoning by other opioids, assault, initial encounter
T40.2X3D Poisoning by other opioids, assault, subsequent encounter
T40.2X4A Poisoning by other opioids, undetermined, initial encounter
T40.2X4D Poisoning by other opioids, undetermined, subsequent encounter
T40.2X5A Adverse effect of other opioids, initial encounter
T40.2X5D Adverse effect of other opioids, subsequent encounter
T40.3X1A Poisoning by methadone, accidental (unintentional), initial encounter
T40.3X1D Poisoning by methadone, accidental (unintentional), subsequent encounter
T40.3X2A Poisoning by methadone, intentional self-harm, initial encounter
T40.3X2D Poisoning by methadone, intentional self-harm, subsequent encounter
T40.3X3A Poisoning by methadone, assault, initial encounter
T40.3X3D Poisoning by methadone, assault, subsequent encounter
T40.3X4A Poisoning by methadone, undetermined, initial encounter
T40.3X4D Poisoning by methadone, undetermined, subsequent encounter
T40.3X5A Adverse effect of methadone, initial encounter
T40.3X5D Adverse effect of methadone, subsequent encounter
T40.4X1A Poisoning by synthetic narcotics, accidental (unintentional), initial encounter
T40.4X1D Poisoning by synthetic narcotics, accidental (unintentional), subsequent encounter
T40.4X2A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter
T40.4X2D Poisoning by other synthetic narcotics, intentional self-harm, subsequent encounter
T40.4X3A Poisoning by other synthetic narcotics, assault, initial encounter
T40.4X3D Poisoning by other synthetic narcotics, assault, subsequent encounter
T40.4X4A Poisoning by synthetic narcotics, undetermined, initial encounter
T40.4X4D Poisoning by synthetic narcotics, undetermined, subsequent encounter
T40.4X5A Adverse effect of synthetic narcotics, initial encounter
T40.4X5D Adverse effect of synthetic narcotic, subsequent encounter
T40.601A Poisoning by unspecified narcotics, accidental (unintentional), initial encounter
T40.601D Poisoning by unspecified narcotics, accidental (unintentional), subsequent encounter
T40.602A Poisoning by unspecified narcotics, intentional self-harm, initial encounter
T40.602D Poisoning by unspecified narcotics, intentional self-harm, subsequent encounter
T40.603A Poisoning by unspecified narcotics, assault, initial encounter
T40.603D Poisoning by unspecified narcotics, assault, subsequent encounter
T40.604A Poisoning by unspecified narcotics, undetermined, initial encounter
T40.604D Poisoning by unspecified narcotics, undetermined, subsequent encounter
T40.605A Adverse effect of unspecified narcotics, initial encounter
T40.605D Adverse effect of unspecified narcotics, subsequent encounter
T40.691A Poisoning by other narcotics, accidental (unintentional), initial encounter
T40.691D Poisoning by other narcotics, accidental (unintentional), subsequent encounter
T40.692A Poisoning by other narcotics, intentional self-harm, initial encounter
T40.692D Poisoning by other narcotics, intentional self-harm, subsequent encounter
T40.693A Poisoning by other narcotics, assault, initial encounter
T40.693D Poisoning by other narcotics, assault, subsequent encounter
T40.694A Poisoning by other narcotics, undetermined, initial encounter
T40.694D Poisoning by other narcotics, undetermined, subsequent encounter
T40.695A Adverse effect of other narcotics, initial encounter
T40.695D Adverse effect of other narcotics, subsequent encounter
Abbreviation: ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification


Types of hospitals included in HCUP State Inpatient Databases
This analysis used State Inpatient Databases (SID) limited to data from community hospitals, which are defined as short-term, non-Federal, general, and other hospitals, excluding hospital units of other institutions (e.g., prisons). Community hospitals include obstetrics and gynecology, otolaryngology, orthopedic, cancer, pediatric, public, and academic medical hospitals. Excluded for this analysis are long-term care facilities such as rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. However, if a patient received long-term care, rehabilitation, or treatment for a psychiatric or chemical dependency condition in a community hospital, the discharge record for that stay was included in the analysis.

Unit of analysis
The unit of analysis in this Statistical Brief is the hospital. Hospital counts of opioid-related inpatient stays are based on the discharge (i.e., the hospital stay), not a person or patient. This means that a person who is admitted to the hospital multiple times in 1 year will be counted each time as a separate discharge from the hospital.

Urban-rural location of hospital
Hospital urban-rural location is based on the rural-urban continuum codes (RUCC) for U.S. counties developed by the United States Department of Agriculture (USDA).4 For this Statistical Brief, we collapsed the RUCC codes into the following three categories:

Metropolitan (metro) area:
  • Counties in metro areas of 1 million population or more
  • Counties in metro areas of 250,000 to 1 million population
  • Counties in metro areas of fewer than 250,000 population
Rural-adjacent to metro area:
  • Urban population of 20,000 or more, adjacent to a metro area
  • Urban population of 2,500 to 19,999, adjacent to a metro area
  • Completely rural or less than 2,500 urban population, adjacent to a metro area
Rural-remote area:
  • Urban population of 20,000 or more, not adjacent to a metro area
  • Urban population of 2,500 to 19,999, not adjacent to a metro area
  • Completely rural or less than 2,500 urban population, not adjacent to a metro area
Region and division
Region is one of the four regions defined by the U.S. Census Bureau. Division corresponds to the location of the hospital and is one of the nine divisions defined by the U.S. Census Bureau.
  • Northeast:
    • New England: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut
    • Middle Atlantic: New York, New Jersey, Pennsylvania
  • Midwest:
    • East North Central: Ohio, Indiana, Illinois, Michigan, Wisconsin
    • West North Central: Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas
  • South:
    • South Atlantic: Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida
    • East South Central: Kentucky, Tennessee, Alabama, Mississippi
    • West South Central: Arkansas, Louisiana, Oklahoma, Texas
  • West:
    • Mountain: Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada
    • Pacific: Washington, Oregon, California, Alaska, Hawaii
About HCUP

The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of healthcare databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). HCUP databases bring together the data collection efforts of State data organizations, hospital associations, and private data organizations (HCUP Partners) and the Federal government to create a national information resource of encounter-level healthcare data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to healthcare programs, and outcomes of treatments at the national, State, and local market levels.

HCUP would not be possible without the contributions of the following data collection Partners from across the United States:

Alaska Department of Health and Social Services
Alaska State Hospital and Nursing Home Association
Arizona Department of Health Services
Arkansas Department of Health
California Office of Statewide Health Planning and Development
Colorado Hospital Association
Connecticut Hospital Association
Delaware Division of Public Health
District of Columbia Hospital Association
Florida Agency for Health Care Administration
Georgia Hospital Association
Hawaii Laulima Data Alliance, a subsidiary of the Healthcare Association of Hawaii
Illinois Department of Public Health
Indiana Hospital Association
Iowa Hospital Association
Kansas Hospital Association
Kentucky Cabinet for Health and Family Services
Louisiana Department of Health
Maine Health Data Organization
Maryland Health Services Cost Review Commission
Massachusetts Center for Health Information and Analysis
Michigan Health & Hospital Association
Minnesota Hospital Association
Mississippi State Department of Health
Missouri Hospital Industry Data Institute
Montana Hospital Association
Nebraska Hospital Association
Nevada Department of Health and Human Services
New Hampshire Department of Health & Human Services
New Jersey Department of Health
New Mexico Department of Health
New York State Department of Health
North Carolina Department of Health and Human Services
North Dakota (data provided by the Minnesota Hospital Association)
Ohio Hospital Association
Oklahoma State Department of Health
Oregon Association of Hospitals and Health Systems
Oregon Office of Health Analytics
Pennsylvania Health Care Cost Containment Council
Rhode Island Department of Health
South Carolina Revenue and Fiscal Affairs Office
South Dakota Association of Healthcare Organizations
Tennessee Hospital Association
Texas Department of State Health Services
Utah Department of Health
Vermont Association of Hospitals and Health Systems
Virginia Health Information
Washington State Department of Health
West Virginia Department of Health and Human Resources, West Virginia Health Care Authority
Wisconsin Department of Health Services
Wyoming Hospital Association

About the SID

The HCUP State Inpatient Databases (SID) are hospital inpatient databases from data organizations participating in HCUP. The SID contain the universe of the inpatient discharge abstracts in the participating HCUP States, translated into a uniform format to facilitate multistate comparisons and analyses. Together, the SID encompass more than 95 percent of all U.S. community hospital discharges. The SID can be used to investigate questions unique to one State, to compare data from two or more States, to conduct market-area variation analyses, and to identify State-specific trends in inpatient care utilization, access, charges, and outcomes.

For More Information

For other information on mental and substance use disorders, refer to the HCUP Statistical Briefs located at www.hcup-us.ahrq.gov/reports/statbriefs/sb_mhsa.jsp.

For additional HCUP statistics, visit:
For more information about HCUP, visit www.hcup-us.ahrq.gov/.

For a detailed description of HCUP and more information on the design of the State Inpatient Databases (SID), please refer to the following database documentation:

Agency for Healthcare Research and Quality. Overview of the State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated November 2019. www.hcup-us.ahrq.gov/sidoverview.jsp. Accessed February 3, 2020.

Suggested Citation

Owens PL (AHRQ), Weiss AJ (IBM Watson Health), Barrett ML (M.L. Barrett, Inc.). Hospital Burden of Opioid-Related Inpatient Stays: Metropolitan and Rural Hospitals, 2016. HCUP Statistical Brief #258. May 2020. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb258-Opioid-Hospitalizations-Rural-Metro-Hospitals-2016.pdf.

Acknowledgments

The authors would like to acknowledge the contributions of Minya Sheng of IBM Watson Health.

***

AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of healthcare in the United States. We also invite you to tell us how you are using this Statistical Brief and other HCUP data and tools, and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please e-mail us at hcup@ahrq.gov or send a letter to the address below:

Joel W. Cohen, Ph.D., Director
Center for Financing, Access and Cost Trends
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857


This Statistical Brief was posted online on May 26, 2020.


1 Healthcare Cost and Utilization Project. HCUP Fast Stats, Opioid-Related Hospital Use. www.hcup-us.ahrq.gov/faststats/OpioidUseServlet?setting1=IP&location=US. Accessed January 26, 2020.
2 Ronan MV, Herzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections increased sharply, 2002-12. Health Affairs. 2016;35(5):832-7.
3 American Hospital Association. Stem the Tide: Addressing the Opioid Epidemic. 2017. Chicago: IL. www.aha.org/opioidtoolkit. Exit Disclaimer Accessed October 9, 2019.
4 United States Department of Agriculture. Rural-Urban Continuum Codes. www.ers.usda.gov/data-products/rural-urban-continuum-codes/. Accessed June 26, 2019.




Supplemental Table 1. Average hospital rate of opioid-related stays per 1,000 inpatient stays, by hospital urban-rural location and U.S. census division, 2016, for data presented in Figure 2
Region/division Metro Rural-adjacent to metro Rural-remote
Rate of stays No. of hospitals Rate of stays No. of hospitals Rate of stays No. of hospitals
Northeast
New England 40.7 110 32.7 21 34.7 16
Middle Atlantic 39.5 319 29.9 61 22.0 13
Midwest
East North Central 35.6 432 19.6 197 18.0 72
West North Central 22.1 206 16.3 167 9.9 258
South
South Atlantic 32.1 400 23.3 108 30.9 32
East South Central 32.8 111 16.8 78 22.7 84
West South Central 16.0 405 13.0 166 9.4 108
West
Mountain 34.8 164 25.2 47 19.0 108
Pacific 31.7 417 35.0 51 25.3 56


Supplemental Table 2. Distribution of hospital rates of opioid-related stays per 1,000 inpatient stays across metropolitan and rural hospitals, 2016, for data presented in Figure 3
Opioid-related rate of stays per 1,000 stays Percentage of hospitals
Metro hospitals Rural hospitals
>64 7.9 3.2
61 to <64 0.8 0.5
58 to <61 1.2 0.7
55 to <58 1.1 0.5
52 to <55 1.2 0.8
49 to <52 1.6 0.7
46 to <49 1.9 0.9
43 to <46 1.8 1.0
40 to <43 2.9 1.2
37 to <40 2.9 2.3
34 to <37 4.4 1.6
31 to <34 4.4 2.2
28 to <31 5.7 2.9
25 to <28 7.5 3.9
22 to <25 8.3 3.8
19 to <22 8.8 6.3
16 to <19 8.6 7.7
13 to <16 7.8 8.5
10 to <13 5.7 9.3
7 to <10 4.9 10.2
4 to <7 3.8 10.3
>0 to <4 2.6 6.7
0 4.3 15.1


Supplemental Table 3. Supplemental Table 3. Distribution of hospital rates of opioid-related stays per 1,000 inpatient stays across metropolitan and rural hospitals, 2016, for data presented in Figure 4
Opioid-related rate of stays per 1,000 stays Percentage of hospitals
Rural-adjacent hospitals Rural-remote hospitals
>64 3.9 2.4
61 to <64 0.7 0.3
58 to <61 0.4 0.9
55 to <58 0.7 0.3
52 to <55 1.2 0.3
49 to <52 0.3 1.1
46 to <49 1.1 0.7
43 to <46 1.1 0.8
40 to <43 1.5 0.8
37 to <40 2.2 2.3
34 to <37 1.6 1.6
31 to <34 2.2 2.1
28 to <31 2.6 3.2
25 to <28 4.5 3.2
22 to <25 3.3 4.3
19 to <22 6.0 6.6
16 to <19 8.7 6.4
13 to <16 8.5 8.6
10 to <13 9.2 9.4
7 to <10 11.5 8.7
4 to <7 10.6 10.0
>0 to <4 6.6 6.8
0 11.6 19.3


Supplemental Table 4. Average hospital rate of opioid-related stays per 1,000 inpatient stays, by hospital urban-rural location and bed size, 2016, for data presented in Figure 5
Number of beds Metro Rural-adjacent to metro Rural-remote
<=25 beds 14.1 14.9 11.7
26 to 100 beds 31.0 24.1 21.8
101 to 250 beds 34.6 29.8 23.4
251+ beds 32.9 32.3 41.0


Supplemental Table 5. Average hospital rate of opioid-related stays per 1,000 inpatient stays, by hospital urban-rural location and occupancy level, 2016, for data presented in Figure 6
Occupancy level, % Metro Rural-adjacent to metro Rural-remote
<25 13.0 17.3 10.2
25-50 25.0 18.8 18.1
50-75 33.5 23.9 19.6
>75 34.6 21.0 14.6

Internet Citation: Statistical Brief #258. Healthcare Cost and Utilization Project (HCUP). May 2020. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb258-Opioid-Hospitalizations-Rural-Metro-Hospitals-2016.jsp.
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