@article{Stephens_2017, title={Development of Syndrome Definitions for Acute Unintentional Drug and Heroin Overdose}, volume={9}, url={https://ojphi.org/ojs/index.php/ojphi/article/view/7593}, DOI={10.5210/ojphi.v9i1.7593}, abstractNote={<div style="left: 90px; top: 320.758px; font-size: 14.1667px; font-family: sans-serif; transform: scaleX(1.08129);" data-canvas-width="63.778333333333336">Objective</div><div style="left: 105px; top: 335.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.986997);" data-canvas-width="378.0856666666666">To develop and evaluate syndrome definitions for the identification</div><div style="left: 90px; top: 352.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.997624);" data-canvas-width="393.4295833333333">of acute unintentional drug overdose events including opioid, heroin,</div><div style="left: 90px; top: 369.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.992513);" data-canvas-width="393.0683333333331">and unspecified substances among emergency department (ED) visits</div><div style="left: 90px; top: 385.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.01801);" data-canvas-width="65.3225">in Virginia.</div><div style="left: 90px; top: 417.425px; font-size: 14.1667px; font-family: sans-serif; transform: scaleX(1.11768);" data-canvas-width="82.63416666666666">Introduction</div><div style="left: 105px; top: 432.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.04912);" data-canvas-width="382.3158333333332">Nationally, deaths due to opioid overdose have continually</div><div style="left: 90px; top: 449.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00683);" data-canvas-width="173.0245833333333">increased for the past 15 years</div><div style="left: 263.009px; top: 449.417px; font-size: 8.5px; font-family: serif;">1</div><div style="left: 267.259px; top: 449.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.01053);" data-canvas-width="216.52333333333334">. Deaths specifically related to heroin</div><div style="left: 90px; top: 465.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.986769);" data-canvas-width="327.27833333333353">increased more than four-fold between 2002 and 2014</div><div style="left: 417.437px; top: 466.084px; font-size: 8.5px; font-family: serif;">2</div><div style="left: 421.774px; top: 465.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.970122);" data-canvas-width="63.70466666666666">. Hospital</div><div style="left: 90px; top: 482.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00725);" data-canvas-width="393.8517499999999">inpatient discharge data provide information on non-fatal overdoses,</div><div style="left: 90px; top: 499.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.03079);" data-canvas-width="263.07499999999993">but include a significant lag in reporting time</div><div style="left: 353.126px; top: 499.417px; font-size: 8.5px; font-family: serif;">3</div><div style="left: 357.387px; top: 499.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.03192);" data-canvas-width="127.02966666666666">. Syndromic ED visit</div><div style="left: 90px; top: 515.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.01426);" data-canvas-width="394.0061666666667">data provide near real-time identification of public health issues and</div><div style="left: 90px; top: 532.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.962528);" data-canvas-width="395.03749999999985">can be leveraged to inform public health actions on the emerging</div><div style="left: 90px; top: 549.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.0005);" data-canvas-width="135.33416666666668">threat of drug overdose.</div><div style="left: 90px; top: 580.758px; font-size: 14.1667px; font-family: sans-serif; transform: scaleX(1.07287);" data-canvas-width="58.23916666666666">Methods</div><div style="left: 105px; top: 595.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.03619);" data-canvas-width="379.35074999999995">Virginia Department of Health (VDH) developed two syndrome</div><div style="left: 90px; top: 612.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.996706);" data-canvas-width="395.94133333333326">definitions in 2014 to capture acute unintentional drug overdose</div><div style="left: 90px; top: 629.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.02644);" data-canvas-width="394.2739166666669">events among syndromic ED visit data. Syndrome 1 captured visits</div><div style="left: 90px; top: 645.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.969291);" data-canvas-width="394.9539166666666">for overdose, whether or not a specific substance was mentioned.</div><div style="left: 90px; top: 662.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.980236);" data-canvas-width="395.18199999999996">Syndrome 2 captured only visits for heroin overdose. Definitions</div><div style="left: 90px; top: 679.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00113);" data-canvas-width="396.0985833333329">were based on free-text terms found within the chief complaint</div><div style="left: 90px; top: 695.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00889);" data-canvas-width="395.9045000000002">and standardized text or International Classification of Diseases</div><div style="left: 90px; top: 712.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.98547);" data-canvas-width="395.33783333333326">(ICD) codes within the diagnosis field. In 2016, both definitions</div><div style="left: 90px; top: 729.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.961208);" data-canvas-width="394.6238333333332">were revised to identify additional inclusion and exclusion criteria</div><div style="left: 90px; top: 745.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.993917);" data-canvas-width="393.11083333333335">according to CDC guidance documentation and syndrome definitions</div><div style="left: 90px; top: 762.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00078);" data-canvas-width="182.9766666666667">used by other state jurisdictions.</div><div style="left: 105px; top: 779.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.02495);" data-canvas-width="379.3167499999999">Microsoft SQL was used to modify both definitions based on the</div><div style="left: 90px; top: 795.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00766);" data-canvas-width="393.7610833333333">newly identified chief complaint and diagnosis criteria. Record level</div><div style="left: 90px; top: 812.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.986986);" data-canvas-width="393.0343333333334">data were analyzed for their adherence to established criteria using an</div><div style="left: 90px; top: 829.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00086);" data-canvas-width="158.55333333333334">iterative evaluation process.</div><div style="left: 105px; top: 845.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.960636);" data-canvas-width="380.13983333333323">The scope of Syndrome 1 (2016) was narrowed from the 2014</div><div style="left: 90px; top: 862.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.966838);" data-canvas-width="394.7116666666669">version by excluding visits for non-opioid substances, heroin, and</div><div style="left: 90px; top: 879.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.02217);" data-canvas-width="396.7389166666667">non-acute indicators. It included chief complaint and diagnosis</div><div style="left: 90px; top: 895.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.02903);" data-canvas-width="394.42833333333306">terms related to opioids, unspecified substance overdose, narcotics,</div><div style="left: 90px; top: 912.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00144);" data-canvas-width="396.15099999999967">and Narcan or naloxone, and excluded terms related to suicide,</div><div style="left: 90px; top: 929.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00572);" data-canvas-width="393.7228333333334">alcohol overdose alone, withdrawal, detoxification, rehab, addiction,</div><div style="left: 90px; top: 945.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.994456);" data-canvas-width="395.77699999999976">constipation, chronic pain, and any specified non-opioid drug or</div><div style="left: 90px; top: 962.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.981825);" data-canvas-width="392.99183333333326">medication. Syndrome 2 (2016) included chief complaint or diagnosis</div><div style="left: 90px; top: 979.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.998757);" data-canvas-width="393.44375">terms mentioning heroin overdose and excluded suicide, withdrawal,</div><div style="left: 90px; top: 995.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.0272);" data-canvas-width="394.4779166666663">detoxification, rehab, and addiction. Visits with mention of suicide,</div><div style="left: 90px; top: 1012.38px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.979665);" data-canvas-width="395.27833333333325">rehab, or addiction were identified during the evaluation process,</div><div style="left: 90px; top: 1029.04px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00326);" data-canvas-width="345.07166666666654">resulting in the exclusion of these terms in the revised query.</div><div style="left: 105px; top: 1045.71px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.989402);" data-canvas-width="381.13433333333336">From January 1, 2015 to July 31, 2016, the number of visits</div><div style="left: 90px; top: 1062.38px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.04411);" data-canvas-width="394.9156666666666">captured by the revised syndrome definitions was compared to the</div><div style="left: 90px; top: 1079.04px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.984597);" data-canvas-width="395.3647499999998">number captured by the 2014 definitions. Correlation coefficients</div><div style="left: 90px; top: 1095.71px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00097);" data-canvas-width="177.05499999999995">were calculated using SAS 9.3.</div><div style="left: 90px; top: 1127.42px; font-size: 14.1667px; font-family: sans-serif; transform: scaleX(1.08488);" data-canvas-width="51.17">Results</div><div style="left: 105px; top: 1142.38px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.05198);" data-canvas-width="385.322">The revised Syndrome 1 found 4296 fewer ED visits</div><div style="left: 90px; top: 1159.04px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.02734);" data-canvas-width="396.7587499999999">(29% decrease) for acute unintentional drug overdose between</div><div style="left: 90px; top: 1175.71px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.02172);" data-canvas-width="394.17899999999986">January 1, 2015 and July 31, 2016 compared to the 2014 definition.</div><div style="left: 90px; top: 1192.38px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.979813);" data-canvas-width="395.7954166666666">Despite the drop in volume, the monthly trends were similar for</div><div style="left: 90px; top: 1209.04px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.04509);" data-canvas-width="397.1695833333334">the 2014 and 2016 definitions (correlation coefficient = 0.95,</div><div style="left: 510px; top: 319.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.957244);" data-canvas-width="392.3741666666667">p < 0.001). For the same time period, the revised Syndrome 2 definition</div><div style="left: 510px; top: 335.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.982076);" data-canvas-width="393.12500000000017">returned 108 fewer visits (6% decrease) for acute unintentional heroin</div><div style="left: 510px; top: 352.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.979293);" data-canvas-width="393.12075000000004">overdose. The monthly trends were also similar for the 2014 and 2016</div><div style="left: 510px; top: 369.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00605);" data-canvas-width="303.5916666666667">definitions (correlation coefficient = 0.98, p < 0.001).</div><div style="left: 510px; top: 400.758px; font-size: 14.1667px; font-family: sans-serif; transform: scaleX(1.10336);" data-canvas-width="85.01416666666667">Conclusions</div><div style="left: 525px; top: 415.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.07311);" data-canvas-width="383.20833333333337">Both revised syndrome definitions improved specificity in</div><div style="left: 510px; top: 432.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.991804);" data-canvas-width="393.1179166666666">capturing overdose visits as Syndrome 1 (2016) identified 29% fewer</div><div style="left: 510px; top: 449.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.01617);" data-canvas-width="394.02033333333344">visits and Syndrome 2 (2016) identified 6% fewer visits found to be</div><div style="left: 510px; top: 465.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00052);" data-canvas-width="234.47250000000005">unrelated to the desired overdose criteria.</div><div style="left: 525px; top: 482.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00424);" data-canvas-width="378.6325">When developing the revised syndrome definitions, VDH decided</div><div style="left: 510px; top: 499.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.972278);" data-canvas-width="395.1338333333333">to exclude non-acute drug-related visits. Terms such as addiction,</div><div style="left: 510px; top: 515.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.984686);" data-canvas-width="393.2014999999999">detoxification, rehab, withdrawal, chronic pain, and constipation were</div><div style="left: 510px; top: 532.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.988081);" data-canvas-width="393.1575833333333">indicative of habitual drug use or abuse instead of acute overdose and</div><div style="left: 510px; top: 549.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.952938);" data-canvas-width="395.02475">were thus excluded. In narrowing the scope of Syndrome 1, VDH</div><div style="left: 510px; top: 565.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.01193);" data-canvas-width="393.85883333333334">also identified and excluded visits for specified drug and medication</div><div style="left: 510px; top: 582.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.993409);" data-canvas-width="395.3435000000001">overdose. Together, these expanded exclusion criteria resulted in</div><div style="left: 510px; top: 599.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.0036);" data-canvas-width="276.2075">greater specificity with both updated syndromes.</div><div style="left: 525px; top: 615.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.966081);" data-canvas-width="379.8791666666668">These revised syndrome definitions enable VDH to better track</div><div style="left: 510px; top: 632.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.04133);" data-canvas-width="397.25033333333266">opioid and heroin overdose trends in near real-time and over</div><div style="left: 510px; top: 649.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.966679);" data-canvas-width="395.4199999999998">extended time periods which can be used to inform public health</div><div style="left: 510px; top: 665.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.974252);" data-canvas-width="394.9779999999999">actions. Limitations include the inconsistency of diagnosis coding</div><div style="left: 510px; top: 682.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.976942);" data-canvas-width="395.31941666666665">among syndromic data submitters, which may lead to geographic</div><div style="left: 510px; top: 699.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.0371);" data-canvas-width="394.7541666666667">underrepresentation of unintentional drug overdose visits based on</div><div style="left: 510px; top: 715.709px; font-size: 14.1667px; font-family: serif; transform: scaleX(0.972867);" data-canvas-width="392.82749999999993">the location of health care systems. VDH will continue to evaluate and</div><div style="left: 510px; top: 732.376px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.03863);" data-canvas-width="394.6266666666667">refine these overdose syndrome definitions as this emerging health</div><div style="left: 510px; top: 749.043px; font-size: 14.1667px; font-family: serif; transform: scaleX(1.00143);" data-canvas-width="78.69583333333333">issue evolves.</div>}, number={1}, journal={Online Journal of Public Health Informatics}, author={Stephens, Em}, year={2017}, month={May} }