@article{Walsh_2017, title={Going Beyond Chief Complaints to Identify Opioid-Related Emergency Department Visits}, volume={9}, url={https://ojphi.org/ojs/index.php/ojphi/article/view/7617}, DOI={10.5210/ojphi.v9i1.7617}, abstractNote={<div style="left: 89.1818px; top: 317.842px; font-size: 14.0379px; font-family: sans-serif; transform: scaleX(1.08186);" data-canvas-width="63.1985303030303">Objective</div><div style="left: 104.045px; top: 332.657px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.987032);" data-canvas-width="374.3649590909088">To identify heroin- and opioid-related emergency department visits</div><div style="left: 89.1818px; top: 349.172px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.01269);" data-canvas-width="390.3063742424243">using pre-diagnositc data. To demonstrate the value of clinical notes</div><div style="left: 89.1818px; top: 365.688px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00228);" data-canvas-width="309.1702424242425">to public health surveillance and situational awareness.</div><div style="left: 89.1818px; top: 397.115px; font-size: 14.0379px; font-family: sans-serif; transform: scaleX(1.11811);" data-canvas-width="81.88294696969696">Introduction</div><div style="left: 104.045px; top: 411.93px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.02693);" data-canvas-width="378.23660606060594">Overdoses of heroin and prescription opioids are a growing</div><div style="left: 89.1818px; top: 428.445px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.95786);" data-canvas-width="391.1739151515151">cause of mortality in the United States. Deaths from opioids have</div><div style="left: 89.1818px; top: 444.96px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.985552);" data-canvas-width="389.5721931818179">contributed to a rise in the overall mortality rate of middle-aged white</div><div style="left: 89.1818px; top: 461.475px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.02725);" data-canvas-width="390.93667500000004">males during an era when other demographics are experiencing life</div><div style="left: 89.1818px; top: 477.991px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.997958);" data-canvas-width="389.8024143939393">expectancy gains.1 A successful public health intervention to reverse</div><div style="left: 89.1818px; top: 494.506px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.02214);" data-canvas-width="393.04656818181826">this mortality trend requires a detailed understanding of which</div><div style="left: 89.1818px; top: 511.021px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.97918);" data-canvas-width="389.53429090909066">populations are most affected and where those populations live. While</div><div style="left: 89.1818px; top: 527.536px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.973133);" data-canvas-width="391.71858484848457">mortality is the most relevant metric for this emerging challenge,</div><div style="left: 89.1818px; top: 544.051px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.03828);" data-canvas-width="393.50841439393923">increased burden on laboratory facilities can create significant</div><div style="left: 89.1818px; top: 560.566px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.01989);" data-canvas-width="390.6011696969697">delays in obtaining confirmation of which patients died from opioid</div><div style="left: 89.1818px; top: 577.082px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00191);" data-canvas-width="59.64694696969697">overdoses.</div><div style="left: 104.045px; top: 593.597px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.0315);" data-canvas-width="375.87683863636346">Emergency department visits for opioid overdoses can provide a</div><div style="left: 89.1818px; top: 610.112px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.981266);" data-canvas-width="389.38268181818177">more timely proxy measure of overall opioid use. Unfortunately, chief</div><div style="left: 89.1818px; top: 626.627px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.976504);" data-canvas-width="389.4949848484849">complaints do not always contain an indication of opioid involvement.</div><div style="left: 89.1818px; top: 643.142px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.985065);" data-canvas-width="391.8589636363636">Overdose patients are not always conscious at registration which</div><div style="left: 89.1818px; top: 659.657px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.991844);" data-canvas-width="391.82808030303016">limits the amount of information they can provide. Menu-driven</div><div style="left: 89.1818px; top: 676.172px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.968297);" data-canvas-width="391.15987727272716">registration systems can lump all overdoses together regardless of</div><div style="left: 89.1818px; top: 692.688px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.978603);" data-canvas-width="391.6694522727272">substance. A more complete record of the emergency department</div><div style="left: 89.1818px; top: 709.203px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.02761);" data-canvas-width="390.6460909090907">interaction, such as that provided by triage notes, could provide the</div><div style="left: 89.1818px; top: 725.718px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.994032);" data-canvas-width="389.56096287878785">information necessary to differentiate opioid-related visits from other</div><div style="left: 89.1818px; top: 742.233px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00191);" data-canvas-width="59.64694696969697">overdoses.</div><div style="left: 89.1818px; top: 773.66px; font-size: 14.0379px; font-family: sans-serif; transform: scaleX(1.07334);" data-canvas-width="57.70971969696969">Methods</div><div style="left: 104.045px; top: 788.476px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.04584);" data-canvas-width="379.04799545454534">Emergency department registration data was collected from</div><div style="left: 89.1818px; top: 804.991px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00319);" data-canvas-width="392.3966143939392">hospitals via the EpiCenter syndromic surveillance system. This</div><div style="left: 89.1818px; top: 821.506px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.96807);" data-canvas-width="391.180934090909">data included chief complaints, triage notes, discharge disposition,</div><div style="left: 89.1818px; top: 838.021px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00337);" data-canvas-width="390.01157878787876">and preliminary diagnosis codes. Data elements were linked across a</div><div style="left: 89.1818px; top: 854.536px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00411);" data-canvas-width="384.45538636363614">given visit using patient identifiers and visit numbers as appropriate.</div><div style="left: 104.045px; top: 871.051px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.01355);" data-canvas-width="377.9011007575757">Heroin- and opioid-related indicators were identified in chief</div><div style="left: 89.1818px; top: 887.566px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.963757);" data-canvas-width="391.26937272727224">complaints and triage notes using regular expressions. These were</div><div style="left: 89.1818px; top: 904.082px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00575);" data-canvas-width="390.09720984848485">separated into three categories: visits with an indication of overdose,</div><div style="left: 89.1818px; top: 920.597px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.01856);" data-canvas-width="393.01287727272705">visits for withdrawal symptoms, and visits where opioids were</div><div style="left: 89.1818px; top: 937.112px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00572);" data-canvas-width="392.71527424242385">mentioned in some other context such as history of use. These</div><div style="left: 89.1818px; top: 953.627px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00217);" data-canvas-width="285.7690984848484">categories were designed to be mutually exclusive.</div><div style="left: 104.045px; top: 970.142px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.06465);" data-canvas-width="379.5294946969696">Regular expression classification results were compared to</div><div style="left: 89.1818px; top: 986.657px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00464);" data-canvas-width="310.34942424242416">classifications based on opioid-related diagnosis codes.</div><div style="left: 89.1818px; top: 1018.08px; font-size: 14.0379px; font-family: sans-serif; transform: scaleX(1.08498);" data-canvas-width="50.70481818181818">Results</div><div style="left: 104.045px; top: 1032.9px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.963022);" data-canvas-width="374.40707272727286">A total of 2,934,610 ED registrations with triage notes and diagnosis</div><div style="left: 89.1818px; top: 1049.41px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00417);" data-canvas-width="390.0859795454545">codes were collected from 82 hospitals between January 1, 2015 and</div><div style="left: 89.1818px; top: 1065.93px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.01539);" data-canvas-width="390.5029045454545">August 21, 2016. Of these encounters, 24,012 referenced opioid use</div><div style="left: 89.1818px; top: 1082.45px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.996408);" data-canvas-width="389.66203560606056">in some way; 16,718 mentioned heroin specifically; 3,663 mentioned</div><div style="left: 89.1818px; top: 1098.96px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00708);" data-canvas-width="354.021265151515">fentanyl specifically; and 5,350 mentioned opioids generically.</div><div style="left: 104.045px; top: 1115.48px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.03523);" data-canvas-width="376.0986371212118">Table 1 shows the distribution of heroin-related ED visits across</div><div style="left: 89.1818px; top: 1131.99px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00534);" data-canvas-width="389.9891181818183">categories and source of the indicator. Column totals are not the sum</div><div style="left: 89.1818px; top: 1148.51px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.03353);" data-canvas-width="390.89736893939363">of individual row amounts; they have been adjusted so that a given</div><div style="left: 89.1818px; top: 1165.02px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00211);" data-canvas-width="186.75993939393942">registration is only counted once.</div><div style="left: 520.227px; top: 316.142px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.972511);" data-canvas-width="376.94512121212114">Table 2 shows the overlap of heroin-related ED visits between</div><div style="left: 505.364px; top: 332.657px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.01023);" data-canvas-width="390.2361848484847">sources of indicators. Triage notes showed the least overlap with the</div><div style="left: 505.364px; top: 349.172px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00192);" data-canvas-width="335.3087727272727">other two sources, while chief complaints showed the most.</div><div style="left: 505.364px; top: 380.6px; font-size: 14.0379px; font-family: sans-serif; transform: scaleX(1.10288);" data-canvas-width="84.24131060606061">Conclusions</div><div style="left: 520.227px; top: 395.415px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.945117);" data-canvas-width="376.14075075757574">While it is possible to find indicators of opioid use or overdose</div><div style="left: 505.364px; top: 411.93px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.0156);" data-canvas-width="392.63104696969685">in chief complaint data, that field alone does not provide total</div><div style="left: 505.364px; top: 428.445px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.987711);" data-canvas-width="392.1046265151514">information about which ED visits are related to opioids. Triage</div><div style="left: 505.364px; top: 444.96px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.974234);" data-canvas-width="391.8533484848484">notes in particular indicate opioid involvement in a large number</div><div style="left: 505.364px; top: 461.475px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.05255);" data-canvas-width="391.23427803030273">of visits not identified by other data sources. While many of these</div><div style="left: 505.364px; top: 477.991px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.955731);" data-canvas-width="391.0531893939393">are simply mentions of opioids, possibly indicating past history of</div><div style="left: 505.364px; top: 494.506px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.02982);" data-canvas-width="390.79910378787866">use or even in some cases just that questions about opioid use were</div><div style="left: 505.364px; top: 511.021px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.03254);" data-canvas-width="390.9549242424242">asked, a substantial number of visits with overdose indicators were</div><div style="left: 505.364px; top: 527.536px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.01567);" data-canvas-width="390.4411378787878">also detected solely from triage note data. These results suggest that</div><div style="left: 505.364px; top: 544.051px; font-size: 14.0379px; font-family: serif; transform: scaleX(0.975754);" data-canvas-width="389.5370984848483">triage notes can be a valuable additional data source for more complex</div><div style="left: 505.364px; top: 560.566px; font-size: 14.0379px; font-family: serif; transform: scaleX(1.00184);" data-canvas-width="226.51521212121216">health concerns such as opioid drug use.</div><div style="left: 505.364px; top: 588.462px; font-size: 12.3864px; font-family: serif; transform: scaleX(1.00644);" data-canvas-width="344.3532954545453">Table 1: Heroin-Related ED Visits By Indicator Source and Category</div><div style="left: 505.364px; top: 689.436px; font-size: 12.3864px; font-family: serif; transform: scaleX(1.00675);" data-canvas-width="325.4145454545453">Table 2: Overlap of Heroin-Related ED Visits between Indicators</div>}, number={1}, journal={Online Journal of Public Health Informatics}, author={Walsh, Andrew}, year={2017}, month={May} }