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The Grand Unifying Theory of Poisoning/Overdose Surveillance

The Grand Unifying Theory of Poisoning/Overdose Surveillance. A Collaborative Effort June 9, 2013. Motor Vehicle Traffic, Poisoning, and Drug Poisoning Death Rates US 1980-2010. NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data.

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The Grand Unifying Theory of Poisoning/Overdose Surveillance

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  1. The Grand Unifying Theory of Poisoning/Overdose Surveillance A Collaborative Effort June 9, 2013

  2. Motor Vehicle Traffic, Poisoning, and Drug Poisoning Death RatesUS 1980-2010 NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data

  3. Opioid Analgesics:The National Picture • Fastest growing drug problem in United States • Enough prescription painkillers prescribed in 2010 to medicate every American adult around-the-clock for a month • ~12 million Americans report misuse of opioid analgesics within past year (2010) >16,000 overdose deaths from opioid analgesics (2010) • Considered an “epidemic”

  4. Background & History

  5. Background & History • Safe States Poisoning Workgroup- 2008 • Safe States formation of Injury Surveillance Workgroup (ISW-7) • Publication of ISW7- May 2012 • CDC/Safe States/CSTE conferences 2012 • CSTE Drug Overdose- • Willing and wanting to test ISW7 indicators • Providing organizational base for effort • SQI Year 2 focus on poisoning • Real partnership with Safe States – liaison/driving force • Scott Proescholdbell

  6. Why CSTE Overdose subcommittee choose this project • Increased attention by States to report and track drug overdose • Lack of consistent definitions and indicator • Variations across States and local level • Recognizing that lack of detail on death certificates underestimates deaths for specific drugs • Concern about shifting from opioid analgesics to heroin → accurate classification of opiates critical

  7. Timeline 2012-2013

  8. Timeline • August- Organizational Call • Creation of Poisoning Surveillance Workgroup • Fall 2012- Creation of tables shells and Levels I-IV (basic to complex) • Winter- submission of data by volunteer states and proposal to present data • Spring- Data results & write up of methods and process for Special Emphasis Report • Spring- April CDC mtg on poisoning for Core states

  9. Next Steps

  10. Next Steps • June- Presentations (Safe States & CSTE) • July- development of Special Emphasis Report and pilot testing • Transition from mortality to morbidity (SQI protocol) • Additional testing of codes, development of potential indicators and position statements

  11. Introduction to Mortality Surveillance: Levels 1-3 Daniella Bradley O’Brien

  12. Outline • Definition of terms • What is a drug poisoning (overdose) death? • What is an ICD Code? • What ICD-10 codes are used? • Intent • Underlying/Multiple Cause of Death • Surveillance levels 1-4 • How to surveil drug poisoning deaths

  13. Definition of Terms

  14. International Classification of Diseases-10th classification (ICD-10) • Standard diagnostic tool for epidemiology, health management and clinical purposes • Monitors the incidence and prevalence of diseases and other health problems • Defines the universe of diseases, disorders, injuries and other related health conditions. It allows for: • sharing and comparing health information between hospitals, regions, settings and countries; and • data comparisons in the same location across different time periods. • Does not always identify specific drugs causing death

  15. External Cause of Injury Mortality Matrix

  16. External Cause of Injury Mortality Matrix

  17. Underlying ICD-10 Drug Poisoning Codes

  18. Medical Examiner/Coroner: Determining cause and manner of death • Autopsy • Death scene • investigation • Toxicology • Determination of cause and manner of death • Context • Paraphernalia • Pill bottles • Witness accounts • Physical findings • Heart muscle (e.g. damaged by cocaine use) • Asthma • Drugs • Active (capable of causing death) • Synergistic • Contributing • Present, not active

  19. Part I Lines a-d Causes of death are entered sequentially starting with immediate cause and ending with the underlying cause. To Be Completed By: MEDICAL CERTIFIER Part II Other significant conditions contributing to death Manner X How injury occurred Generally determines external cause of death.

  20. “Literals” are the exact text entered on the death certificate Specialized software reads the literals and automatically codes both underlying and multiple cause of death Death Certificate Literals

  21. Automated coding of causes of death • Exact words from Part I, Part II, manner and how the injury occurred • Death Certificate • Cause of death • Part 1 • a. _Acute Intoxication • Due to combined___ effects of heroin and oxycodone. _________________ • d. _________________ • Part 2 :Asthma • Manner: Accident • Describe how injury occurred: • Acute and Chronic Substance Abuse UCOD: X42 MCOD: X42, T40.1, T40.2, Mortality Medical Data System • Cause of death by ICD-10 codes

  22. CSTE Validation of ISW-7: Methods • 4 levels • Level 1: Basic • Level 2: Multiple Cause • Level 3: Cross-Check • Level 4: Multi-stage • Year 2010 • Residents of each state that died in state • 11 states/jurisdictions

  23. Drug Poisoning Mortality Surveillance “Levels 1-4”

  24. Level 1: Basic Analysis Objective

  25. Level 1: Basic Analysis Required Resource: Death Certificate* Obtain Underlying Codes Use Underlying Codes: X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0), F19.0 Tabulate results for Level 1 *Note: To obtain Death Certificate contact your city/state’s Office of Vital Statistics or agency equivalent responsible for the reporting, processing, and analyzing all vital events (births, deaths, etc.)

  26. Level 1: Basic Analysis

  27. Level 1: Summary • Report on poisoning by intent • Provide demographic profile of the decedents • Age • Gender • Race/Ethnicity • Residential information available but not collected/tested as part of CSTE validation of ISW-7

  28. Level 2: Multiple Cause Objective

  29. T-codes • Are multiple cause codes • Identify specific drug or substance • For poisoning and toxic effects in ICD-10 these are T36-T65

  30. Multiple Cause T-Codes by Drug Type Opioid analgesics

  31. Level 2: Multiple Cause Analysis Required Resource: Death Certificate* Obtain Multiple Cause Codes: • 1. Underlying Cause Codes • 2. Contributing Cause Codes Use Multiple Cause Codes: X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0), F19.0, T36-T50.9 Tabulate results for Level 2

  32. Level 2: Multiple Cause Codes

  33. Level 2: Summary • Report major categories of drug types by intent

  34. Level 3: Cross-Check Objective

  35. Uses of literal text • Identifying specific substances in “other specified” ICD-10 drug categories • Monitoring increases in deaths associated with drug substances not specifically identified in ICD-10 • Potential for use as a sentinel surveillance system for new drugs associated with deaths

  36. Level 3: Cross-Check Analysis Required Resource: Death Certificate* Obtain Multiple Cause Codes: • 1.Underlying Cause Codes • 2.Contributing Cause Codes Use Multiple Cause Codes: X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0), F19.0, T40.1,T40.2,T40.3,T40.4,T40.6,T43.6,T50.9 Cross-check Death Certificate Literals against Multiple Cause Codes Tabulate results for Level 3

  37. Level 3: Cross-Check Analysis

  38. Level 3 Summary • Specificity of literals • ex: T40.2 Oxycodone/Hydrocodone/Morphine • Determine how literals are coded in your state/jurisdiction

  39. Introduction to Level 4:Multistage Analysis Denise Paone

  40. Drug overdose deaths – 4 “Levels”

  41. Definitions/Terms • Toxicology • Collected and analyzed as part of death investigation • Not always available

  42. Level 4: Multistage AnalysisObjective & Methods • Objective: • Compare toxicology results using ME findings, with ICD-10 codes and literals found on death certificates • Methods: • Restricted T-Codes to cases involving opioids/unspecified

  43. Level 4: Multistage Required Resource: Death Certificate* + Medical Examiner/Coroner files containing Toxicology Report Obtain Multiple Cause Codes: • 1. Underlying Cause Codes • 2. Contributing Cause Codes Use Multiple Cause Codes: X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0), F19.0, T40.1,T40.2,T40.3,T40.4,T40.6,T43.6,T50.9 Comparison of Death Certificate Multiple Cause Codes with confirmed Toxicology data Comparison of Death Certificate Literals with confirmed Toxicology data Comparison of Death Certificate Multiple Cause Codes, confirmed Toxicology data and Literals Tabulate results for Level 4 in table shell provided

  44. Level 4: Multistage Analysis

  45. Level 4 Summary • Raises more questions than it answers?! • Continue to refine this analysis

  46. Acknowledgements • CSTE Overdose sub-committee members • Safe States Members • CDC Staff • NYC DOHMH

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