Health Care Utilization and Outcomes Associated with Accidental Poisonous Mushroom Ingestions — United States, 2016–2018

Accidental consumption of poisonous mushrooms can result in serious illness and death (1). Reports of severe poisonings from consumption of foraged mushrooms for food or hallucinogenic purposes increased during 1999–2016 (2), and approximately 7,500 poisonous mushroom ingestions were reported annually to poison control centers across the United States (1). To estimate the frequency of emergency department (ED) visits, hospitalizations, and severe adverse outcomes associated with accidental poisonous mushroom ingestion in the United States, CDC analyzed 2016 data from the Healthcare Cost and Utilization Project’s* Nationwide Emergency Department Sample (HCUP-NEDS) and National Inpatient Sample (HCUP-NIS) databases as well as 2016–2018 data from three IBM MarketScan sources: Commercial Claims and Encounters (CCAE), Medicare Supplemental and Coordination of Benefits (Medicare), and Multi-State Medicaid databases. During 2016, 1,328 (standard error [SE] = 100) ED visits and 100 (SE = 22) hospitalizations (HCUP data) were associated with accidental poisonous mushroom ingestion. Among 556 patients with a diagnosis of accidental poisonous mushroom ingestion, 48 (8.6%) patients experienced a serious adverse outcome during 2016–2018 (MarketScan data). Serious adverse outcomes were more common among Medicaid-insured patients than among patients with commercial insurance or Medicare (11.5% versus 6.7%, p = 0.049). Because most mushroom poisonings are preventable, wild mushrooms should not be consumed unless they are identified by an expert; increased public health messaging about the potential dangers of mushroom poisoning is needed.

CDC analyzed 2016 data from HCUP-NEDS and HCUP-NIS, the largest publicly available databases for all-payer ED visits and hospitalizations, respectively. (At the time the analysis was performed, 2016 was the most recent year of data available). HCUP data were accessed through HCUPnet, a free, web-based platform (3). These databases produce national estimates of patient health care use and charges by insurance payer status, U.S. Census region, and urban-rural status of patient residence,^† without deduplication of multiple visits per patient. To produce patient-level analyses, this study also analyzed IBM MarketScan data, which were accessed through Treatment Pathways,^§ a web-based platform with data from patients whose health insurance plan or employer contributes prescription drug data to MarketScan. The 2016–2018 MarketScan CCAE and Medicare claims data included outpatient visits and hospitalizations for approximately 34,900,000 patients throughout the United States; the Medicare data set included retirees with employer-sponsored Medicare supplemental insurance. The 2016–2018 MarketScan Medicaid data sets included similar information for approximately 11,000,000 Medicaid patients from across several states. Data on race and ethnicity were available only in the Medicaid data sets. None of the databases (HCUP or MarketScan) included data on deaths from ingestion of poisonous mushrooms. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes^¶ were used to identify diagnoses for accidental poisonous mushroom ingestion and associated clinical signs, symptoms, diagnoses, hallucinogenic drug use, and serious adverse outcomes (defined as potentially dangerous cardiac arrhythmia, renal failure, liver failure, rhabdomyolysis, seizure, or respiratory failure) occurring within 72 hours of ingestion. Because most poisonous mushroom ingestions reported to U.S. poison centers occur in young children (1), patients from MarketScan were categorized as being ≤5 years or >5 years. HCUPnet provides fixed age categorizations (<1, 1–17, 18–44, 45–64, 65–84, and ≥85 years) for patients in its databases. This study used data from the MarketScan databases to compare differences in demographic characteristics, diagnoses, and adverse outcomes between these age groups and between insurance types (Medicaid versus CCAE or Medicare) using chi-square or Fisher’s exact tests for proportions. Analyses were performed using Epi Info (version 7.2.3.1; CDC); p-values <0.05 were considered statistically significant. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.^**

In the 2016 HCUP databases, an estimated 1,328 (SE = 100) ED visits associated with accidental poisonous mushroom ingestions occurred in the United States (Table 1). Among ED visits, the most common insurance types were private (567 [42.7%], SE = 69), Medicaid (451 [34.0%], SE = 53), and none (187 [14.1%], SE = 30). By region, most ED visits occurred in the West (495 [37.3%], SE = 67), followed by the South (372 [28%], SE = 43), the Midwest (246 [18.5%], SE = 44), and the North (214 [16.1%], SE = 42). The most common residence settings were medium and small metropolitan (497 [37.4%], SE = 58) and suburban (335 [25.2%], SE = 55) areas. An estimated 100 (SE = 22) hospitalizations associated with accidental mushroom ingestions occurred in 2016. The estimated mean length of stay for hospitalized patients was 2.4 days (SE = 0.4). The estimated mean annual cost per hospitalization was $7,626 (SE = 1,407), and aggregate national hospitalization costs were $762,574 (SE = 220,216).

Among 556 patients with diagnosed poisonous mushroom ingestion in the combined 2016–2018 MarketScan databases, 329 (59.2%) were from the CCAE and Medicare data sets, and 227 (40.8%) were from the Medicaid data set (Table 2). In the Medicaid data set, 61.7% of patients were White, 16.3% of patients were Black, and 22.0% of patients were classified as other or missing race. Overall, 144 (25.9%) patients were aged ≤5 years, 412 (74.1%) were aged >5 years, and 311 (55.9%) were male. The most common care setting for diagnosis of poisonous mushroom ingestion was an ED (79.5%), and diagnosis was more likely during summer (38.5%). Patients aged >5 years were hospitalized more often (p = 0.010). Compared with patients aged ≤5 years, older patients were more likely to have any documented symptoms or clinical findings associated with mushroom poisoning (68.9% versus 28.5%, p<0.001) and any documented laboratory abnormalities (14.1% versus 4.9%, p = 0.003). The most common associated symptoms were gastrointestinal (36.0%), neurologic/behavioral (18.3%), cardiac (16.5%), and respiratory (4.0%). Hallucinogenic drug use was documented in 43 (10.4%) patients aged >5 years.

During 2016–2018, serious adverse outcomes occurred in 48 (8.6%) patients overall and were more common in patients aged >5 years than in patients aged ≤5 years (p = 0.003). The most common serious adverse outcome was cardiac arrythmia (2.7%), followed by acute renal failure (2.2%), liver failure (1.8%), rhabdomyolysis (1.4%), and seizure (1.4%). Serious adverse outcomes were more common in Medicaid-insured patients than among patients with commercial insurance or Medicare (11.5% versus 6.7%, p = 0.049).

Corresponding author: Jeremy A.W. Gold, [email protected], 404-718-3650.

¹Epidemic Intelligence Service, CDC; ²Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; ³Agency for Toxic Substances and Disease Registry, Atlanta, Georgia; ⁴Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia.

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Abbreviation: SE = standard error.
* Healthcare Cost and Utilization Project (HCUP) data include weighted national estimates from HCUP Nationwide Emergency Department Sample. Poisonous mushroom ingestion-associated emergency department visits were identified using International Classification of Diseases, Tenth Revision (ICD-10) code T62.0X1.
^† Dashes indicate that statistics based on estimates with a relative SE (standard error/weighted estimate) >0.30 or with SE error = 0 are suppressed.
^§ Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
^¶ In HCUP data, patient residence is classified using the National Center for Health Statistics Urban-Rural Classification Scheme for Counties (https://www.cdc.gov/nchs/data_access/urban_rural.htm).

* IBM MarketScan Commercial Claims and Encounters/Medicare Supplemental and Coordination of Benefits, IBM MarketScan Multi-State Medicaid, and combined MarketScan databases during 2016–2018 were analyzed for patient demographics, health care setting, clinical features, and outcomes.
† P-values for IBM MarketScan Commercial Claims and Encounters/Medicare, IBM MarketScan Multi-State Medicaid, and combined databases were calculated using Fisher’s exact tests or chi-square tests for proportions comparing patient age groups.
^§ Patients might have received care in more than one setting.
^¶ Dashes indicate the number of patients was less than five, and values are suppressed.