@article{Ramsey_Rubino_Hamilton_Atrubin_2017, title={Characterizing Fentanyl-Associated Mortality using the Literal Causes of Death}, volume={9}, url={https://ojphi.org/ojs/index.php/ojphi/article/view/7711}, DOI={10.5210/ojphi.v9i1.7711}, abstractNote={<div style="left: 78.2727px; top: 278.962px; font-size: 12.3207px; font-family: sans-serif; transform: scaleX(1.0823);" data-canvas-width="55.467823232323234">Objective</div><div style="left: 91.3182px; top: 291.965px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.00412);" data-canvas-width="329.2351664141414">To characterize fentanyl-associated mortality in Florida using free</div><div style="left: 78.2727px; top: 306.46px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.00326);" data-canvas-width="333.9527651515149">text queries of the literal causes of death listed on death certificates.</div><div style="left: 78.2727px; top: 334.043px; font-size: 12.3207px; font-family: sans-serif; transform: scaleX(1.11884);" data-canvas-width="71.86668434343434">Introduction</div><div style="left: 91.3182px; top: 347.046px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.02384);" data-canvas-width="329.9485353535353">In October 2015, the Centers for Disease Control and Prevention</div><div style="left: 78.2727px; top: 361.541px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.976263);" data-canvas-width="341.6433505050504">(CDC) released health advisory #384 to inform people about increases</div><div style="left: 78.2727px; top: 376.036px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.01277);" data-canvas-width="344.4105813131317">in fentanyl fatalities. Florida’s statewide syndromic surveillance</div><div style="left: 78.2727px; top: 390.531px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.01275);" data-canvas-width="342.6290070707071">system, Electronic Surveillance System for the Early Notification of</div><div style="left: 78.2727px; top: 405.026px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.992174);" data-canvas-width="343.47420757575765">Community-based Epidemics (ESSENCE-FL), captures electronic</div><div style="left: 78.2727px; top: 419.521px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.03082);" data-canvas-width="343.14401262626245">death record data in near real time which allows for the monitoring</div><div style="left: 78.2727px; top: 434.016px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.963572);" data-canvas-width="343.5456676767676">of mortality trends across the state. One limitation of using death</div><div style="left: 78.2727px; top: 448.511px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.00252);" data-canvas-width="342.27540277777774">record data for fentanyl surveillance is the lack of a fentanyl-specific</div><div style="left: 78.2727px; top: 463.006px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.983099);" data-canvas-width="343.9534830808079">overdose ICD-10 code; however, the literal cause of death fields</div><div style="left: 78.2727px; top: 477.501px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.957675);" data-canvas-width="343.7575838383838">(“literals”) provide a level of detail that is rich enough to capture</div><div style="left: 78.2727px; top: 491.996px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.05301);" data-canvas-width="343.33498358585825">mentions of fentanyl use. The “literals” are a free text field on the</div><div style="left: 78.2727px; top: 506.491px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.952416);" data-canvas-width="343.4889924242425">death certificate, recorded by a physician at the time of death and</div><div style="left: 78.2727px; top: 520.985px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.01579);" data-canvas-width="342.64132777777775">detail the factors that led to the death. ESSENCE-FL has the benefit</div><div style="left: 78.2727px; top: 535.48px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.954515);" data-canvas-width="343.5937184343435">of not only receiving death record data in near real-time, but also</div><div style="left: 78.2727px; top: 549.975px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.01702);" data-canvas-width="342.70293131313133">receiving the literal cause of death fields. This work analyzes trends</div><div style="left: 78.2727px; top: 564.47px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.970628);" data-canvas-width="343.7317103535352">in fentanyl-associated mortality in Florida over time by using the</div><div style="left: 78.2727px; top: 578.965px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.02503);" data-canvas-width="342.9567378787878">literal cause of death fields within death records data obtained from</div><div style="left: 78.2727px; top: 593.46px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.0019);" data-canvas-width="74.9591818181818">ESSENCE-FL.</div><div style="left: 78.2727px; top: 621.043px; font-size: 12.3207px; font-family: sans-serif; transform: scaleX(1.07424);" data-canvas-width="50.65042676767676">Methods</div><div style="left: 91.3182px; top: 634.046px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.964757);" data-canvas-width="330.3809921717172">The “literals” elements of Florida Vital Statistics mortality data</div><div style="left: 78.2727px; top: 648.541px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.959961);" data-canvas-width="343.2179368686869">from 2010 through 2015 accessed via ESSENCE-FL were queried</div><div style="left: 78.2727px; top: 663.036px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.01752);" data-canvas-width="342.7867121212121">for the term ^fent^. No necessary negations or extra term inclusions</div><div style="left: 78.2727px; top: 677.531px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.983903);" data-canvas-width="341.88976464646464">were deemed necessary after looking at the records pulled with ^fent^</div><div style="left: 78.2727px; top: 692.026px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.992748);" data-canvas-width="341.9686171717172">alone. Deaths were analyzed by various demographic and geographic</div><div style="left: 78.2727px; top: 706.521px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.980656);" data-canvas-width="343.932537878788">variables to characterize this population in order to assess which</div><div style="left: 78.2727px; top: 721.016px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.02725);" data-canvas-width="342.84338737373747">groups are most heavily burdened by fentanyl-associated mortality.</div><div style="left: 78.2727px; top: 735.511px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.991758);" data-canvas-width="341.9747775252524">Population estimates by county for 2015 were obtained from the U.S.</div><div style="left: 78.2727px; top: 750.006px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.989458);" data-canvas-width="341.8577308080808">Census Bureau to calculate mortality rates. Language processing in R</div><div style="left: 78.2727px; top: 764.501px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.982689);" data-canvas-width="341.877443939394">Studio was used to determine which other substances were commonly</div><div style="left: 78.2727px; top: 778.996px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.00249);" data-canvas-width="342.2680103535353">reported when fentanyl was listed on the death certificate, in order to</div><div style="left: 78.2727px; top: 793.491px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.00419);" data-canvas-width="285.7418383838382">assess polydrug use and its impact on increased mortality.</div><div style="left: 78.2727px; top: 821.073px; font-size: 12.3207px; font-family: sans-serif; transform: scaleX(1.08542);" data-canvas-width="44.50239393939395">Results</div><div style="left: 91.3182px; top: 834.076px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.986618);" data-canvas-width="328.7411060606061">Compared to the number of fentanyl-associated mortalities in 2010</div><div style="left: 78.2727px; top: 848.571px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.982941);" data-canvas-width="341.94890404040416">(82), fentanyl-associated mortality in 2015 (599) was 6.5 times higher</div><div style="left: 78.2727px; top: 863.066px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.04448);" data-canvas-width="343.39042676767656">after controlling for the natural increase in total mortality between</div><div style="left: 78.2727px; top: 877.561px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.989692);" data-canvas-width="341.95506439393955">2010 and 2015. Almost three-fourths of the deaths in 2015 were male</div><div style="left: 78.2727px; top: 892.056px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.04412);" data-canvas-width="342.924704040404">(73%), which is higher than the proportion of male deaths in 2010</div><div style="left: 78.2727px; top: 906.551px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.01241);" data-canvas-width="342.6511843434341">(55%). The age group with the largest burden of fentanyl-associated</div><div style="left: 78.2727px; top: 921.046px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.943804);" data-canvas-width="343.62328813131313">mortality was the 30 – 39 age group, with almost one-third of the</div><div style="left: 78.2727px; top: 935.541px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.01481);" data-canvas-width="342.6684333333332">deaths in 2015 coming from this age group (31%) compared to only</div><div style="left: 78.2727px; top: 950.036px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.98714);" data-canvas-width="341.7148106060607">10% in 2010, a roughly 200% increase. Fentanyl-associated mortality</div><div style="left: 78.2727px; top: 964.531px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.02499);" data-canvas-width="342.9431851010101">was almost exclusive to people that are Caucasian, with 94% of the</div><div style="left: 78.2727px; top: 979.026px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.999305);" data-canvas-width="342.1620522727273">fentanyl-associated mortalities in 2015 occurring among Caucasians.</div><div style="left: 78.2727px; top: 993.521px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.00472);" data-canvas-width="342.34193459595946">Multi-drug use was also identified for those with fentanyl-associated</div><div style="left: 78.2727px; top: 1008.02px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.990931);" data-canvas-width="341.9538323232322">mortality. Mentions of other drugs were present in at least 10% of the</div><div style="left: 78.2727px; top: 1022.51px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.01491);" data-canvas-width="342.6832181818182">deaths. Some of the other drugs mentioned in the “literals” included</div><div style="left: 78.2727px; top: 1037.01px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.0366);" data-canvas-width="343.25243484848494">heroin, cocaine, and alprazolam. There was county variation in the</div><div style="left: 78.2727px; top: 1051.5px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.955271);" data-canvas-width="343.18097474747464">number of fentanyl morality deaths ranging from 21.19 deaths per</div><div style="left: 443.545px; top: 277.47px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.01198);" data-canvas-width="342.5218169191918">100,000 to 0.29 deaths per 100,000 residents. Two counties with the</div><div style="left: 443.545px; top: 291.965px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.00397);" data-canvas-width="248.3977752525253">highest rates were located adjacent to one another.</div><div style="left: 443.545px; top: 319.548px; font-size: 12.3207px; font-family: sans-serif; transform: scaleX(1.10408);" data-canvas-width="73.93656313131314">Conclusions</div><div style="left: 456.591px; top: 332.551px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.04638);" data-canvas-width="332.64553813131295">Having death record data readily available within the state</div><div style="left: 443.545px; top: 347.046px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.0464);" data-canvas-width="345.5021959595954">syndromic surveillance system is beneficial for rapid analysis</div><div style="left: 443.545px; top: 361.541px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.985332);" data-canvas-width="344.22577070707047">of mortality trends and the analytic methods used for syndromic</div><div style="left: 443.545px; top: 376.036px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.03719);" data-canvas-width="343.1193712121214">surveillance can be applied to mortality data. Free text querying of</div><div style="left: 443.545px; top: 390.531px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.975212);" data-canvas-width="344.0384959595958">the “literals” in the vital statistics death records data allowed for</div><div style="left: 443.545px; top: 405.026px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.991699);" data-canvas-width="341.8220007575755">surveillance of fentanyl-associated mortality, similar to methods used</div><div style="left: 443.545px; top: 419.521px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.02227);" data-canvas-width="343.17481439393924">for querying emergency department chief complaint data. Although</div><div style="left: 443.545px; top: 434.016px; font-size: 12.3207px; font-family: serif; transform: scaleX(0.986599);" data-canvas-width="343.9941414141412">underlying ICD-10 codes can lack detail about certain causes of</div><div style="left: 443.545px; top: 448.511px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.04254);" data-canvas-width="343.116907070707">death, the “literals” provide a clearer picture as to what caused the</div><div style="left: 443.545px; top: 463.006px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.03986);" data-canvas-width="342.9468813131316">death. The “literals” also make it possible to look at potential drug</div><div style="left: 443.545px; top: 477.501px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.03435);" data-canvas-width="343.11074671717165">combinations that may have increased risk of mortality, which will</div><div style="left: 443.545px; top: 491.996px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.03894);" data-canvas-width="343.2154727272729">be explored more thoroughly. Further work will explore other data</div><div style="left: 443.545px; top: 506.491px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.03092);" data-canvas-width="343.15756540404016">sources for fentanyl usage and mortality trends, as well as examine</div><div style="left: 443.545px; top: 520.985px; font-size: 12.3207px; font-family: serif; transform: scaleX(1.00135);" data-canvas-width="189.22141919191918">potential risk factors and confounders.</div>}, number={1}, journal={Online Journal of Public Health Informatics}, author={Ramsey, Brandon and Rubino, Heather and Hamilton, Janet J. and Atrubin, David}, year={2017}, month={May} }