Last data update: Nov 11, 2024. (Total: 48109 publications since 2009)
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Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011
Sasser SM , Hunt RC , Faul M , Sugerman D , Pearson WS , Dulski T , Wald MM , Jurkovich GJ , Newgard CD , Lerner EB , Cooper A , Wang SC , Henry MC , Salomone JP , Galli RL . MMWR Recomm Rep 2012 61 1-20 In the United States, injury is the leading cause of death for persons aged 1-44 years. In 2008, approximately 30 million injuries were serious enough to require the injured person to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by Emergency Medical Services (EMS). On arrival at the scene of an injury, the EMS provider must determine the severity of injury, initiate management of the patient's injuries, and decide the most appropriate destination hospital for the individual patient. These destination decisions are made through a process known as "field triage," which involves an assessment not only of the physiology and anatomy of injury but also of the mechanism of the injury and special patient and system considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process through its "Field Triage Decision Scheme." This guidance was updated with each version of the decision scheme (published in 1986, 1990, 1993, and 1999). In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme; the revised version was published in 2006 by ACS-COT (American College of Surgeons. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006). In 2009, CDC published a detailed description of the scientific rationale for revising the field triage criteria (CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR 2009;58[No. RR-1]). In 2011, CDC reconvened the Panel to review the 2006 Guidelines in the context of recently published literature, assess the experiences of states and local communities working to implement the Guidelines, and recommend any needed changes or modifications to the Guidelines. This report describes the dissemination and impact of the 2006 Guidelines; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic, mechanism-of-injury, and special considerations criteria; updates the schematic of the 2006 Guidelines; and provides the rationale used by the Panel for these changes. This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a mass casualty or disaster triage tool. The Panel anticipates a review of these Guidelines approximately every 5 years. |
Spatial proximity and access to buprenorphine or methadone treatment for opioid use disorder in a sample of people misusing opioids in Southern California
Davidson PJ , Bowles JM , Faul M , Gaines TL . J Subst Abuse Treat 2021 132 108634 BACKGROUND: In response to the opioid crisis, over the last 10 years substantial strides have been made to increase the availability of evidence-based treatments for opioid use disorder, in particular buprenorphine maintenance, in the United States. Despite these worthwhile efforts, uptake rates of evidence-based treatment remain relatively low. As part of a broader study of opioid misuse, we examined proximity to evidence-based treatment as a potential barrier to treatment access. METHODS: In 2017-2018, we surveyed 218 individuals misusing prescription opioids or using street opioids in three Southern Californian counties. The study calculated driving distance from place of residence to the closest treatment provider offering buprenorphine or methadone treatment for opioid use disorders. RESULTS: Median distance to providers was 3.8 km (2.4 miles). Seventy one (33%) participants had received some form of treatment in the last 3 months; however, only 26 (40%) of these had received buprenorphine or methadone maintenance treatment. Participants receiving treatment at the time of their interview were traveling an average 16.8 km (10.4 miles) to reach treatment, indicating that as a group this population was both willing and able to seek and engage with treatment. CONCLUSIONS: In the suburban and exurban communities in which our study was based, our findings suggest that simple physical proximity to providers of evidence-based treatment for opioid use disorder is no longer a critical barrier. Other barriers to uptake of buprenorphine or methadone maintenance treatment clearly remain and need to be addressed. DISCLAIMER: Findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. |
Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic
Rowe CL , Eagen K , Ahern J , Faul M , Hubbard A , Coffin P . J Gen Intern Med 2021 37 (1) 117-124 BACKGROUND: After decades of liberal opioid prescribing, multiple efforts have been made to reduce reliance upon opioids in clinical care. Little is known about the effects of opioid prescribing policies on outcomes beyond opioid prescribing. OBJECTIVE: To evaluate the combined effects of multiple opioid prescribing policies implemented in a safety-net primary care clinic in San Francisco, CA, in 2013-2014. DESIGN: Retrospective cohort study and conditional difference-in-differences analysis of nonrandomized clinic-level policies. PATIENTS: 273 patients prescribed opioids for chronic non-cancer pain in 2013 at either the treated (n=151) or control clinic (n=122) recruited and interviewed in 2017-2018. INTERVENTIONS: Policies establishing standard protocols for dispensing opioid refills and conducting urine toxicology testing, and a new committee facilitating opioid treatment decisions for complex patient cases. MAIN MEASURES: Opioid prescription (active prescription, mean dose in morphine milligram equivalents [MME]) from electronic medical charts, and heroin and opioid analgesics not prescribed to the patient (any use, use frequency) from a retrospective interview. KEY RESULTS: The interventions were associated with a reduction in mean prescribed opioid dose in the first three post-policy years (year 1 conditional difference-in-differences estimate: -52.0 MME [95% confidence interval: -109.9, -10.6]; year 2: -106.2 MME [-195.0, -34.6]; year 3: -98.6 MME [-198.7, -23.9]; year 4: -72.6 MME [-160.4, 3.6]). Estimates suggest a possible positive association between the interventions and non-prescribed opioid analgesic use (year 3: 5.2 absolute percentage points [-0.1, 11.2]) and use frequency (year 3: 0.21 ordinal frequency scale points [0.00, 0.47]) in the third post-policy year. CONCLUSIONS: Clinic-level opioid prescribing policies were associated with reduced dose, although the control clinic achieved similar reductions by the fourth post-policy year, and the policies may have been associated with increased non-prescribed opioid analgesic use. Clinicians should balance the urgency to reduce opioid prescribing with potential harms from rapid change. |
Using ICD-10-CM codes to detect illicit substance use: A comparison with retrospective self-report
Rowe CL , Santos GM , Kornbluh W , Bhardwaj S , Faul M , Coffin PO . Drug Alcohol Depend 2021 221 108537 BACKGROUND: Understanding whether International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes can be used to accurately detect substance use can inform their use in future surveillance and research efforts. METHODS: Using 2015-2018 data from a retrospective cohort study of 602 safety-net patients prescribed opioids for chronic non-cancer pain, we calculated the sensitivity and specificity of using ICD-10-CM codes to detect illicit substance use compared to retrospective self-report by substance (methamphetamine, cocaine, opioids [heroin or non-prescribed opioid analgesics]), self-reported use frequency, and type of healthcare encounter. RESULTS: Sensitivity of ICD-10-CM codes for detecting self-reported substance use was highest for methamphetamine (49.5 % [95 % confidence interval: 39.6-59.5 %]), followed by cocaine (44.4 % [35.8-53.2 %]) and opioids (36.3 % [28.8-44.2 %]); higher for participants who reported more frequent methamphetamine (intermittent use: 27.7 % [14.6-42.6 %]; ≥weekly use: 67.2 % [53.7-79.0 %]) and opioid use (intermittent use: 21.4 % [13.2-31.7 %]; ≥weekly use: 52.6 % [40.8-64.2 %]); highest for outpatient visits (methamphetamine: 43.8 % [34.1-53.8 %]; cocaine: 36.8 % [28.6-45.6 %]; opioids: 33.1 % [25.9-41.0 %]) and lowest for emergency department visits (methamphetamine: 8.6 % [4.0-15.6 %]; cocaine: 5.3 % [2.1-10.5 %]; opioids: 6.3 % [3.0-11.2 %]). Specificity was highest for methamphetamine (96.4 % [94.3-97.8 %]), followed by cocaine (94.0 % [91.5-96.0 %]) and opioids (85.0 % [81.3-88.2 %]). CONCLUSIONS: ICD-10-CM codes had high specificity and low sensitivity for detecting self-reported substance use but were substantially more sensitive in detecting frequent use. ICD-10-CM codes to detect substance use, particularly those from emergency department visits, should be used with caution, but may be useful as a lower-bound population measure of substance use or for capturing frequent use among certain patient populations. |
The association between opioid discontinuation and heroin use: A nested case-control study
Binswanger IA , Glanz JM , Faul M , Shoup JA , Quintana LM , Lyden J , Xu S , Narwaney KJ . Drug Alcohol Depend 2020 217 108248 BACKGROUND: Opioid prescribing guidelines recommend reducing or discontinuing opioids for chronic pain if harms of opioid treatment outweigh benefits. As opioid discontinuation becomes more prevalent, it is important to understand whether opioid discontinuation is associated with heroin use. In this study, we sought to assess the association between opioid discontinuation and heroin use documented in the medical record. METHODS: A matched nested case-control study was conducted in an integrated health plan and delivery system in Colorado. Patients receiving opioid therapy in the study period (January 2006-June 2018) were included. Opioid discontinuation was defined as ≥45 days with no opioids dispensed after initiating opioid therapy. The heroin use onset date represented the index date. Case patients were matched to up to 20 randomly selected patients without heroin use (control patients) by age, sex, calendar time, and time between initiating opioid therapy and the index date. Conditional logistic regression models estimated matched odds ratios (mOR) for the association between an opioid discontinuation prior to the index date and heroin use. RESULTS: Among 22,962 patients prescribed opioid therapy, 125 patients (0.54%) used heroin after initiating opioid therapy, of which 74 met criteria for inclusion in the analysis. The odds of opioid discontinuation were approximately two times higher in case patients (n = 74) than control patients (n = 1045; mOR = 2.19; 95% CI 1.27-3.78). CONCLUSIONS: Among patients prescribed chronic opioid therapy, the observed increased risk for heroin use associated with opioid discontinuation should be balanced with potential benefits. |
Transitioning from pharmaceutical opioids: A discrete-time survival analysis of heroin initiation in suburban/exurban communities
Gaines TL , Wagner KD , Mittal ML , Bowles JM , Copulsky E , Faul M , Harding RW , Davidson PJ . Drug Alcohol Depend 2020 213 108084 INTRODUCTION: Research identifying pathways to heroin use has typically been conducted among urban populations. This study examined heroin initiation following pharmaceutical opioid use in three suburban/exurban Southern California counties. METHODS: Interviewer-administered surveys collected data among 330 participants (65.9 % male; 63.9 % non-Hispanic white) whose initial use of any opioid was a pharmaceutical opioid. Retrospective discrete-time survival analysis identified predictors of heroin initiation, measured as self-reported age of first heroin use. RESULTS: Median age of first pharmaceutical opioid use was 17 years; 50.6 % initially acquired pharmaceutical opioids from an illicit source, 56.7 % first used pharmaceutical opioids for recreational purposes, and 86 % initiated heroin use. Average time from first pharmaceutical opioid use to first heroin use was 8.2 years. Drug/alcohol treatment (adjusted Hazard Ratio [aHR]: 0.67, 95 % CI: 0.50, 0.88) was associated with delayed time to heroin initiation. Obtaining opioids from non-medical sources (aHR: 2.21, 95 % CI: 1.55, 3.14) was associated with accelerated time to heroin initiation. Reporting supply problems with obtaining pharmaceutical opioids (e.g., unable to acquire pharmaceutical opioids) was associated with accelerated time to heroin initiation, but the magnitude of this effect was dependent on one's history of methamphetamine use (p < 0.05). CONCLUSIONS: Time to heroin initiation following pharmaceutical opioid use was accelerated among those reporting supply problems and delayed among those with exposure to substance use treatment. Interventions interrupting supply of opioids might benefit from coordination with evidence-based medication-assisted treatment to minimize the risk of transitioning to heroin use, particularly among those with a long history of non-prescribed pharmaceutical opioid use. |
Mortality secondary to unintentional poisoning after inpatient rehabilitation among individuals with moderate to severe traumatic brain injury
Hammond F , Ketchum J , Dams-O'Connor K , Corrigan JD , Miller AC , Haarbauer-Krupa J , Faul M , Trexler LE , Harrison-Felix CL . J Neurotrauma 2020 37 (23) 2507-2516 Studies have shown reduced life expectancy following moderate-severe traumatic brain injury (TBI) with death due to unintentional poisoning (UP) 11x higher following TBI than in the general population. The characteristics of those who die of unintentional poisoning are compared to those who die of other causes (OC) in a retrospective cohort who received inpatient rehabilitation following traumatic brain injury (TBI) and enrolled in the TBI Model Systems National Database between 1989 and 2017 (n = 15,835 cases with 2,238 deaths recorded). Seventy-eight cases (3.5%) of deaths were due to UP, 76% were due to OC, and 20.5% died of unknown cause. Among the UP deaths, 90% involved drugs (of these 67% involved narcotic drugs and 14% psychostimulants) and 8% involved alcohol. Age- adjusted risk for UP death was associated with: White/Non-Hispanic race/ethnicity, living alone, non-institutionalization, pre- and post-injury illicit drug use and alcohol/drug problem use, any alcohol use at last follow up, better Functional Independence Measure TM (FIM) scores, history of arrest, moderate disability (vs severe disability or good recovery), less supervision needed, and greater anxiety. Adults who receive inpatient rehabilitation for TBI who die due to UP are distinguishable from those who die of OC. Factors such as pre-injury substance use in the context of functional independence may be regarded as targets for prevention and/or intervention to reduce substance use and substance-related mortality among survivors of moderate-severe TBI. The current findings may have implications for medical care, surveillance, prevention, and health promotion. |
Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain
Coffin PO , Rowe C , Oman N , Sinchek K , Santos GM , Faul M , Bagnulo R , Mohamed D , Vittinghoff E . PLoS One 2020 15 (5) e0232538 BACKGROUND: After decades of increased opioid pain reliever prescribing, providers are rapidly reducing prescribing. We hypothesized that reduced access to prescribed opioid pain relievers among patients previously reliant upon opioid pain relievers would result in increased illicit opioid use. METHODS AND FINDINGS: We conducted a retrospective cohort study among 602 publicly insured primary care patients who had been prescribed opioids for chronic non-cancer pain for at least three consecutive months in San Francisco, recruited through convenience sampling. We conducted a historical reconstruction interview and medical chart abstraction focused on illicit substance use and opioid pain reliever prescriptions, respectively, from 2012 through the interview date in 2017-2018. We used a nested-cohort design, in which patients were classified, based on opioid pain reliever dose change, into a series of nested cohorts starting with each follow-up quarter. Using continuation-ratio models, we estimated associations between opioid prescription discontinuation or 30% increase or decrease in dose, relative to no change, and subsequent frequency of heroin and non-prescribed opioid pain reliever use, separately. Models controlled for demographics, clinical and behavioral characteristics, and past use of heroin or non-prescribed opioid pain relievers. A total of 56,372 and 56,484 participant-quarter observations were included from the 597 and 598 participants available for analyses of heroin and non-prescribed opioid pain reliever outcomes, respectively. Participants discontinued from prescribed opioids were more likely to use heroin (Adjusted Odds Ratio (AOR) = 1.57, 95% CI: 1.25-1.97) and non-prescribed opioid pain relievers (AOR = 1.75, 1.45-2.11) more frequently in subsequent quarters compared to participants with unchanged opioid prescriptions. Participants whose opioid pain reliever dose increased were more likely to use heroin more frequently (AOR = 1.67, 1.32-2.12). Results held throughout sensitivity analyses. The main limitations were the observational nature of results and limited generalizability beyond safety-net settings. CONCLUSIONS: Discontinuation of prescribed opioid pain relievers was associated with more frequent non-prescribed opioid pain reliever and heroin use; increased dose was also associated with more frequent heroin use. Clinicians should be aware of these risks in determining pain management approaches. |
Bridging the gap in potentially excess deaths between rural and urban counties in the United States
Garcia MC , Faul M , Dowling NF , Thomas CC , Iademarco MF . Public Health Rep 2020 135 (2) 33354919900890 Twenty percent of the US population, or about 60 million persons, live in rural areas.1 Rural and urban counties differ in their demographic, environmental, economic, and social characteristics, which influences health and the prevalence of disease risk factors. The rates of cigarette smoking, hypertension, obesity, and physical inactivity during leisure time are higher in rural areas than in urban areas.2 About 30% of persons living in rural counties live in poverty, whereas 19% of persons living in large central and large fringe metropolitan counties and 15% of persons living in medium and small metropolitan counties live in poverty.3 The availability of preventive services and health care access also differ in rural and urban areas. Residents of rural counties are more likely to report lower levels of health care access and lower-quality care than residents of urban counties.2 Urban areas generally have a higher density and diversity of health care providers than rural areas.4,5 |
Potentially excess deaths from the five leading causes of death in metropolitan and nonmetropolitan counties - United States, 2010-2017
Garcia MC , Rossen LM , Bastian B , Faul M , Dowling NF , Thomas CC , Schieb L , Hong Y , Yoon PW , Iademarco MF . MMWR Surveill Summ 2019 68 (10) 1-11 PROBLEM/CONDITION: A 2017 report quantified the higher percentage of potentially excess (or preventable) deaths in nonmetropolitan areas (often referred to as rural areas) compared with metropolitan areas. In that report, CDC compared national, regional, and state estimates of potentially excess deaths among the five leading causes of death in nonmetropolitan and metropolitan counties for 2010 and 2014. This report enhances the geographic detail by using the six levels of the 2013 National Center for Health Statistics (NCHS) urban-rural classification scheme for counties and extending estimates of potentially excess deaths by annual percent change (APC) and for additional years (2010-2017). Trends were tested both with linear and quadratic terms. PERIOD COVERED: 2010-2017. DESCRIPTION OF SYSTEM: Mortality data for U.S. residents from the National Vital Statistics System were used to calculate potentially excess deaths from the five leading causes of death among persons aged <80 years. CDC's NCHS urban-rural classification scheme for counties was used to categorize the deaths according to the urban-rural county classification level of the decedent's county of residence (1: large central metropolitan [most urban], 2: large fringe metropolitan, 3: medium metropolitan, 4: small metropolitan, 5: micropolitan, and 6: noncore [most rural]). Potentially excess deaths were defined as deaths among persons aged <80 years that exceeded the number expected if the death rates for each cause in all states were equivalent to those in the benchmark states (i.e., the three states with the lowest rates). Potentially excess deaths were calculated separately for the six urban-rural county categories nationally, the 10 U.S. Department of Health and Human Services public health regions, and the 50 states and District of Columbia. RESULTS: The number of potentially excess deaths among persons aged <80 years in the United States increased during 2010-2017 for unintentional injuries (APC: 11.2%), decreased for cancer (APC: -9.1%), and remained stable for heart disease (APC: 1.1%), chronic lower respiratory disease (CLRD) (APC: 1.7%), and stroke (APC: 0.3). Across the United States, percentages of potentially excess deaths from the five leading causes were higher in nonmetropolitan counties in all years during 2010-2017. When assessed by the six urban-rural county classifications, percentages of potentially excess deaths in the most rural counties (noncore) were consistently higher than in the most urban counties (large central metropolitan) for the study period. Potentially excess deaths from heart disease increased most in micropolitan counties (APC: 2.5%) and decreased most in large fringe metropolitan counties (APC: -1.1%). Potentially excess deaths from cancer decreased in all county categories, with the largest decreases in large central metropolitan (APC: -16.1%) and large fringe metropolitan (APC: -15.1%) counties. In all county categories, potentially excess deaths from the five leading causes increased, with the largest increases occurring in large central metropolitan (APC: 18.3%), large fringe metropolitan (APC: 17.1%), and medium metropolitan (APC: 11.1%) counties. Potentially excess deaths from CLRD decreased most in large central metropolitan counties (APC: -5.6%) and increased most in micropolitan (APC: 3.7%) and noncore (APC: 3.6%) counties. In all county categories, potentially excess deaths from stroke exhibited a quadratic trend (i.e., decreased then increased), except in micropolitan counties, where no change occurred. Percentages of potentially excess deaths also differed among and within public health regions and across states by urban-rural county classification during 2010-2017. INTERPRETATION: Nonmetropolitan counties had higher percentages of potentially excess deaths from the five leading causes than metropolitan counties during 2010-2017 nationwide, across public health regions, and in the majority of states. The gap between the most rural and most urban counties for potentially excess deaths increased during 2010-2017 for three causes of death (cancer, heart disease, and CLRD), decreased for unintentional injury, and remained relatively stable for stroke. Urban and suburban counties (large central metropolitan and large fringe metropolitan, medium metropolitan, and small metropolitan) experienced increases in potentially excess deaths from unintentional injury during 2010-2017, leading to a narrower gap between the already high (approximately 55%) percentage of excess deaths in noncore and micropolitan counties. PUBLIC HEALTH ACTION: Routine tracking of potentially excess deaths by urban-rural county classification might help public health departments and decision-makers identify and monitor public health problems and focus interventions to reduce potentially excess deaths in these areas. |
What schools need to know about the Centers for Disease Control and Prevention's Guideline on Diagnosis/Management of Mild Traumatic Brain Injury in Children - a commentary
McAvoy K , Haarbauer-Krupa J . J Sch Health 2019 89 (12) 941-944 Traumatic brain injury (TBI) in children is a growing public health concern. In 2013, there were an estimated 641,935 TBI-related emergency department (ED) visits, 17,930 TBI-related hospitalizations, and 1,484 TBI-related deaths among children aged 0 to 14 years (Taylor et al., 2017). A recent research study on parent-reported TBI estimates that 1.8 million children in the United States have experienced TBI in their lifetime (Haarbauer-Krupa et al, 2018). Additionally, it is estimated that for children who seek care in an ED for a TBI, 70-90% of these are classified as mild (Cassidy et al., 2004; Faul et al., 2010). Recent research examining the point of entry for care in a large children’s healthcare network reported that children with mild TBI (mTBI) are more likely to be seen in their pediatrician’s office and not included in ED visit counts, broadening the diversity of locations where children receive medical care after TBI (Arbogast et al, 2016). In addition, some children may not be seen for a medical assessment at the time of injury. Children with mTBI are more likely to recover faster than children with more severe injuries (CDC, 2018). Current research suggests that 70% of children with mTBI will recover within 28 days post-injury (Zemek et al., 2016). | |
Evaluation of a safer opioid prescribing protocol (SOPP) for patients being discharged from a trauma service
Baird J , Faul M , Green TC , Howland J , Adams CAJr , Hodne MJ , Bohlen N , Mello MJ . J Trauma Nurs 2019 26 (3) 113-120 The aims of this study were to evaluate the effects on opioid medication prescribing, patient opioid safety education, and prescribing of naloxone following implementation of a Safer Opioid Prescribing Protocol (SOPP) as part of the electronic health record (EHR) system at a Level I trauma center. This was a prospective observational study of the EHR of trauma patients pre- (n = 191) and post-(n = 316) SOPP implementation between 2014 and 2016. At a comparison Level I trauma site not implementing SOPP, EHRs for the same time period were assessed for any historical trends in opioid and naloxone prescribing. After SOPP implementation, the implementation site increased the use of nonnarcotic pain medication, decreased dispensing high opioid dose (≥100 MME [milligram morphine equivalent]), significantly increased the delivery of opioid safety education to patients, and initiated prescribing naloxone. These changes were not found in the comparison site. Opioid prescribing for acute pain can be effectively reduced in a busy trauma setting with a guideline intervention incorporated into an EHR. Guidelines can increase the use of nonnarcotic medications for the treatment of acute pain and increase naloxone coprescription for patients with a higher risk of overdose. |
How well do EMS providers predict intracranial hemorrhage in head-injured older adults
Hon S , Gaona SD , Faul M , Holmes JF , Nishijima DK . Prehosp Emerg Care 2019 24 (1) 1-13 OBJECTIVE: To evaluate the accuracy of emergency medical services (EMS) provider judgment for traumatic intracranial hemorrhage (tICH) in older patients following head trauma in the field. We also compared EMS provider judgment with other sets of field triage criteria. METHODS: This was a prospective observational cohort study conducted with 5 EMS agencies and 11 hospitals in Northern California. Patients 55 years and older who experienced blunt head trauma, were transported by EMS between August 1, 2015 and September 30, 2016, and received an initial cranial computed tomography (CT) imaging, were eligible. EMS providers were asked, "What is your suspicion for the patient having intracranial hemorrhage (bleeding in the brain)?" Responses were recorded as ordinal categories (<1%, 1-5%, >5-10%, >10-50%, or >50%) and the incidences of tICH were recorded for each category. The accuracy of EMS provider judgment was compared to other sets of triage criteria, including current field triage criteria, current field triage criteria plus multivariate logistical regression risk factors, and actual transport. RESULTS: Among the 673 patients enrolled, 319 (47.0%) were male and the median age was 75 years (interquartile range 64-85). Seventy-six (11.3%) patients had tICH on initial cranial CT imaging. The increase in EMS provider judgment correlated with an increase in the incidence of tICH. EMS provider judgment had a sensitivity of 77.6% (95% CI 67.1-85.5%) and a specificity of 41.5% (37.7-45.5%) when using a threshold of 1% or higher suspicion for tICH. Current field triage criteria (Steps 1-3) was poorly sensitive (26.3%, 95% CI 17.7-37.2%) in identifying tICH and current field trial criteria plus multivariate logistical regression risk factors was sensitive (97.4%, 95% CI 90.9-99.3%) but poorly specific (12.9%, 95% CI 10.4-15.8%). Actual transport was comparable to EMS provider judgment (sensitivity 71.1%, 95% CI 60.0-80.0%; specificity 35.3%, 95% CI 31.6-38.3%). CONCLUSIONS: As EMS provider judgment for tICH increased, the incidence for tICH also increased. EMS provider judgment, using a threshold of 1% or higher suspicion for tICH, was more accurate than current field triage criteria, with and without additional risk factors included. |
Opioid prescribing rates in nonmetropolitan and metropolitan counties among primary care providers using an electronic health record system - United States, 2014-2017
Garcia MC , Heilig CM , Lee SH , Faul M , Guy G , Iademarco MF , Hempstead K , Raymond D , Gray J . MMWR Morb Mortal Wkly Rep 2019 68 (2) 25-30 Drug overdose is the leading cause of unintentional injury-associated death in the United States. Among 70,237 fatal drug overdoses in 2017, prescription opioids were involved in 17,029 (24.2%) (1). Higher rates of opioid-related deaths have been recorded in nonmetropolitan (rural) areas (2). In 2017, 14 rural counties were among the 15 counties with the highest opioid prescribing rates.* Higher opioid prescribing rates put patients at risk for addiction and overdose (3). Using deidentified data from the Athenahealth electronic health record (EHR) system, opioid prescribing rates among 31,422 primary care providers(dagger) in the United States were analyzed to evaluate trends from January 2014 to March 2017. This analysis assessed how prescribing practices varied among six urban-rural classification categories of counties, before and after the March 2016 release of CDC's Guideline for Prescribing Opioids for Chronic Pain (Guideline) (4). Patients in noncore (the most rural) counties had an 87% higher chance of receiving an opioid prescription compared with persons in large central metropolitan counties during the study period. Across all six county groups, the odds of receiving an opioid prescription decreased significantly after March 2016. This decrease followed a flat trend during the preceding period in micropolitan and large central metropolitan county groups; in contrast, the decrease continued previous downward trends in the other four county groups. Data from EHRs can effectively supplement traditional surveillance methods for monitoring trends in opioid prescribing and other areas of public health importance, with minimal lag time under ideal conditions. As less densely populated areas appear to indicate both substantial progress in decreasing opioid prescribing and ongoing need for reduction, community health care practices and intervention programs must continue to be tailored to community characteristics. |
Naloxone administration frequency during emergency medical service events - United States, 2012-2016
Cash RE , Kinsman J , Crowe RP , Rivard MK , Faul M , Panchal AR . MMWR Morb Mortal Wkly Rep 2018 67 (31) 850-853 As the opioid epidemic in the United States has continued since the early 2000s (1,2), most descriptions have focused on misuse and deaths. Increased cooperation with state and local partners has enabled more rapid and comprehensive surveillance of nonfatal opioid overdoses (3).* Naloxone administrations obtained from emergency medical services (EMS) patient care records have served as a useful proxy for overdose surveillance in individual communities and might be a previously unused data source to describe the opioid epidemic, including fatal and nonfatal events, on a national level (4-6). Using data from the National Emergency Medical Services Information System (NEMSIS),(dagger) the trend in rate of EMS naloxone administration events from 2012 to 2016 was compared with opioid overdose mortality rates from National Vital Statistics System multiple cause-of-death mortality files. During 2012-2016, the rate of EMS naloxone administration events increased 75.1%, from 573.6 to 1004.4 administrations per 100,000 EMS events, mirroring the 79.7% increase in opioid overdose mortality from 7.4 deaths per 100,000 persons to 13.3. A bimodal age distribution of patients receiving naloxone from EMS parallels a similar age distribution of deaths, with persons aged 25-34 years and 45-54 years most affected. However, an accurate estimate of the complete injury burden of the opioid epidemic requires assessing nonfatal overdoses in addition to deaths. Evaluating and monitoring nonfatal overdose events via the novel approach of using EMS data might assist in the development of timely interventions to address the evolving opioid crisis. |
Impact of Florida's prescription drug monitoring program and pill mill law on high-risk patients: A comparative interrupted time series analysis
Chang HY , Murimi I , Faul M , Rutkow L , Alexander GC . Pharmacoepidemiol Drug Saf 2018 27 (4) 422-429 PURPOSE: We quantified the effects of Florida's prescription drug monitoring program and pill mill law on high-risk patients. METHODS: We used QuintilesIMS LRx Lifelink data to identify patients receiving prescription opioids in Florida (intervention state, N: 1.13 million) and Georgia (control state, N: 0.54 million). The preintervention, intervention, and postintervention periods were July 2010 to June 2011, July 2011 to September 2011, and October 2011 to September 2012. We identified 3 types of high-risk patients: (1) concomitant users: patients with concomitant use of benzodiazepines and opioids; (2) chronic users: long-term, high-dose, opioid users; and (3) opioid shoppers: patients receiving opioids from multiple sources. We compared changes in opioid prescriptions between Florida and Georgia before and after policy implementation among high-risk/low-risk patients. Our monthly measures included (1) average morphine milligram equivalent per transaction, (2) total opioid volume across all prescriptions, (3) average days supplied per transaction, and (4) total number of opioid prescriptions dispensed. RESULTS: Among opioid-receiving individuals in Florida, 6.62% were concomitant users, 1.96% were chronic users, and 0.46% were opioid shoppers. Following policy implementation, Florida's high-risk patients experienced relative reductions in morphine milligram equivalent (opioid shoppers: -1.08 mg/month, 95% confidence interval [CI] -1.62 to -0.54), total opioid volume (chronic users: -4.58 kg/month, CI -5.41 to -3.76), and number of dispensed opioid prescriptions (concomitant users: -640 prescriptions/month, CI -950 to -340). Low-risk patients generally did not experience statistically significantly relative reductions. CONCLUSIONS: Compared with Georgia, Florida's prescription drug monitoring program and pill mill law were associated with large relative reductions in prescription opioid utilization among high-risk patients. |
Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma
Chenoweth JA , Gaona SD , Faul M , Holmes JF , Nishijima DK . JAMA Surg 2018 153 (6) 570-575 Importance: Current guidelines conflict on the management of older adults who have blunt head trauma taking anticoagulant and antiplatelet medications. This is partially due to the limited data comparing patients who are taking these medications with those who are not. Objective: To investigate the incidence of delayed traumatic intracranial hemorrhage in older adults with head trauma, including those taking anticoagulant and antiplatelet medications. Design, Setting, and Participants: This prospective observational cohort study included patients 55 years and older who had blunt head trauma and were transported via emergency medical services between August 1, 2015, and September 30, 2016. The setting was a multicenter study conducted at 11 hospitals in northern California. Patients were excluded if they had traumatic intracranial hemorrhage on the initial cranial computed tomographic scan, did not have a cranial computed tomographic scan performed at the initial emergency department visit, refused consent for a follow-up telephone call, or did not have reliable means of follow-up. Main Outcome and Measure: The primary outcome of this study was the incidence of delayed traumatic intracranial hemorrhage within 14 days of injury. Results: Among 859 patients enrolled in the study, the median age was 75 years (interquartile range, 64-85 years), and 389 (45.3%) were male. A total of 343 patients (39.9%) were taking an anticoagulant or antiplatelet medication. Three patients (0.3%; 95% CI, 0.1%-1.0%) had a delayed traumatic intracranial hemorrhage. Of the 3 patients, 1 of 75 patients (1.3%; 95% CI, 0.0%-7.2%) who were taking warfarin sodium alone and 2 of 516 patients (0.4%; 95% CI, 0.1%-1.4%) who were not taking any anticoagulant or antiplatelet medication had a delayed traumatic intracranial hemorrhage. Thirty-nine patients (4.5%; 95% CI, 3.2%-6.2%) were lost to follow-up. Conclusions and Relevance: Overall, the incidence of delayed intracranial hemorrhage in older adults who have blunt head trauma is low, including patients taking an anticoagulant or antiplatelet medication. These findings suggest that routine observation and serial cranial computed tomography may not be necessary in these patients. |
The incidence of traumatic intracranial hemorrhage in head-injured older adults transported by EMS with and without anticoagulant or antiplatelet use
Nishijima DK , Gaona SD , Waechter T , Maloney R , Blitz A , Elms AR , Farrales RD , Montoya J , Bair T , Howard C , Gilbert M , Trajano R , Hatchel K , Faul M , Bell JM , Coronado V , Vinson DR , Ballard DW , Tancredi DJ , Garzon H , Mackey KE , Shahlaie K , Holmes JF . J Neurotrauma 2017 35 (5) 750-759 Field triage guidelines recommend transport of head-injured patients on anticoagulants or antiplatelets to a higher-level trauma center based on studies suggesting a high incidence of traumatic intracranial hemorrhage (tICH). We compared the incidence of tICH in older adults transported by EMS with and without anticoagulation or antiplatelet use and evaluated the accuracies of different sets of field triage criteria to identify tICH. This was a prospective, observational study at 5 EMS agencies and 11 hospitals. Older adults (≥55 years) with head trauma and transported by EMS from Aug 2015 to Sept 2016 were eligible. EMS providers completed standardized data forms and patients were followed through ED or hospital discharge. We enrolled 1,304 patients; 1147 (88%) received a cranial CT scan and were eligible for analysis. 434 (33%) patients had anticoagulant or antiplatelet use and 112 (10%) had tICH. The incidence of tICH in patients with (11%, 95%CI 8-14%) and without (9%, 95%CI 7-11%) anticoagulant or antiplatelet use was similar. Anticoagulant or antiplatelet use was not predictive of tICH on adjusted analysis. Steps 1-3 criteria alone were not sensitive in identifying tICH (27%) while the addition of anticoagulant or antiplatelet criterion improved sensitivity (63%). Other derived sets of triage criteria were highly sensitive (>98%) but poorly specific (<11%). The incidence of tICH was similar between patients with and without anticoagulant or antiplatelet use. Use of anticoagulant or antiplatelet medications was not a risk factor for tICH. We were unable to identify a set of triage criteria that was accurate for trauma center need. |
A retrospective review of unintentional opioid overdose risk and mitigating factors among acutely injured trauma patients
Baird J , Faul M , Green TC , Howland J , Adams CA , George A , Mello MJ . Drug Alcohol Depend 2017 178 130-135 BACKGROUND: Opioid medication to treat acutely injured patients is usual care in trauma settings. A higher prevalence of alcohol and other substance misuse in this population compared to the general population increases the vulnerability of such patients to both misuse of their prescribed opioids, and also unintentional opioid overdose. The primary purpose of this study was to assess the prevalence of substance use and unintentional opioid overdose risk among acutely injured trauma patients, and to examine the frequency and predictors of high opioid dose at discharge. METHODS: A retrospective electronic medical record (EMR) review of three-months of data from two Level 1 trauma centers. We assessed the prevalence of substance misuse, unintentional opioid overdose risk, and presence of documentation of clinical strategies to mitigate these risks, such as co-prescription of the opioid agonist naloxone. RESULTS: In total, 352 patient EMRs were examined. Over 40% of the patients reviewed had at least one indication of substance misuse (42.5% [95%CI: 37.3, 47.7]); at least 1 unintentional opioid overdose risk factor was identified in 240 EMR reviewed (68.2% [95%CI: 63.3, 73.1]). Dose of opioid medication was not significantly different for patients with substance misuse versus those without. There was no co-prescription of naloxone for any of the discharged patients. CONCLUSIONS: Our results indicate that despite the high rates of substance misuse, the potential for misuse, dependence and unintentional overdose risk from prescribed opioid medications are prevalent among acutely injured trauma patients. Prescribing after acute trauma care should address these risk factors. |
Multiple naloxone administrations among emergency medical service providers is increasing
Faul M , Lurie P , Kinsman JM , Dailey MW , Crabaugh C , Sasser SM . Prehosp Emerg Care 2017 21 (4) 1-8 BACKGROUND: Opioid overdoses are at epidemic levels in the United States. Emergency Medical Service (EMS) providers may administer naloxone to restore patient breathing and prevent respiratory arrest. There was a need for contemporary data to examine the number of naloxone administrations in an EMS encounter. METHODS: Using data from the National Emergency Medical Services Information System, we examined data from 2012-5 to determine trends in patients receiving multiple naloxone administrations (MNAs). Logistic regression including demographic, clinical, and operational information was used to examine factors associated with MNA. RESULTS: Among all events where naloxone was administered only 16.7% of the 911 calls specifically identified the medical emergency as a drug ingestion or poisoning event. The percentage of patients receiving MNA increased from 14.5% in 2012 to 18.2% in 2015, which represents a 26% increase in MNA in 4 years. Patients aged 20-29 had the highest percentage of MNA (21.1%). Patients in the Northeast and the Midwest had the highest relative MNA (Chi Squared = 539.5, p < 0.01 and Chi Squared = 351.2, p < 0.01, respectively). The logistic regression model showed that the adjusted odds ratios (aOR) for MNA were greatest among people who live in the Northeast (aOR = 1.18, 95% CI = 1.13-1.22) and for men (aOR = 1.13, 95% CI = 1.10-1.16), but lower for suburban and rural areas (aOR = 0.76, 95% CI = 0.72-0.80 and aOR = 0.85, 95% CI = 0.80-0.89) and lowest for wilderness areas (aOR = 0.76, 95% CI = 0.68-0.84). Higher adjusted odds of MNA occurred when an advanced life support (ALS 2) level of service was provided compared to basic life support (BLS) ambulances (aOR = 2.15, 95% CI = 1.45-3.16) and when the dispatch complaint indicated there was a drug poisoning event (aOR = 1.12, 95% CI = 1.09-1.16). Reported layperson naloxone administration prior to EMS arrival was rare (1%). CONCLUSION: This study shows that frequency of MNA is growing over time and is regionally dependent. MNA may be a barometer of the potency of the opioid involved in the overdose. The increase in MNA provides support for a dosage review. Better identification of opioid related events in the dispatch system could lead to a better match of services with patient needs. |
Methadone prescribing and overdose and the association with Medicaid preferred drug list policies - United States, 2007-2014
Faul M , Bohm M , Alexander C . MMWR Morb Mortal Wkly Rep 2017 66 (12) 320-323 Drug overdose is a leading cause of injury death in the United States; 47,055 fatal drug overdoses were reported in 2014, a 6.5% increase from the previous year (1), driven by opioid use disorder (2,3). Methadone is an opioid prescribed for pain management and is also provided through opioid treatment programs to treat opioid use disorders. Because methadone might remain in a person's system long after the pain-relieving benefits have been exhausted, it can cause slow or shallow breathing and dangerous changes in heartbeat that might not be perceived by the patient (4,5). In December 2006, the Food and Drug Administration issued a Public Health Advisory that alerted health care professionals to reports of death and life-threatening adverse events, such as respiratory depression and cardiac arrhythmias, in patients receiving methadone (4); in January 2008, a voluntary manufacturer restriction limited distribution of the 40 mg formulation of methadone. CDC analyzed state mortality and health care data and preferred drug list (PDL) policies to 1) compare the percentage of deaths involving methadone with the rate of prescribing methadone for pain, 2) characterize variation in methadone prescribing among payers and states, and 3) assess whether an association existed between state Medicaid reimbursement PDL policies and methadone overdose rates. The analyses found that, from 2007 to 2014, large declines in methadone-related overdose deaths occurred. Prescriptions for methadone accounted for 0.85% of all opioid prescriptions for pain in the commercially insured population and 1.1% in the Medicaid population. In addition, an association was observed between Medicaid PDLs requiring prior authorization for methadone and lower rates of methadone overdose among Medicaid enrollees. PDL policies requiring prior authorization might help to reduce the number of methadone overdoses. |
Out-of-hospital triage of older adults with head injury: A retrospective study of the effect of adding "anticoagulation or antiplatelet medication use" as a criterion
Nishijima DK , Gaona SD , Waechter T , Maloney R , Bair T , Blitz A , Elms AR , Farrales RD , Howard C , Montoya J , Bell JM , Faul M , Vinson DR , Garzon H , Holmes JF , Ballard DW . Ann Emerg Med 2017 70 (2) 127-138 e6 STUDY OBJECTIVE: Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications. METHODS: This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 nontrauma centers). Patients aged 55 years or older with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of inhospital death or neurosurgery. RESULTS: Of the 2,110 patients included, 131 (6%) had intracranial hemorrhage and 41 (2%) had inhospital death or neurosurgery. There were 162 patients (8%) with steps 1 to 3 criteria. Of the remaining 1,948 patients without steps 1 to 3 criteria, 566 (29%) had anticoagulant or antiplatelet use. Of these patients, 52 (9%) had traumatic intracranial hemorrhage and 15 (3%) died or had neurosurgery. The sensitivity (adjusted for clustering by EMS agency) of steps 1 to 3 criteria was 19.8% (26/131; 95% confidence interval [CI] 5.5% to 51.2%) for identifying traumatic intracranial hemorrhage and 34.1% (14/41; 95% CI 9.9% to 70.1%) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5%; 95% CI 42.9% to 74.2%) and death or neurosurgery (29/41; 70.7%; 95% CI 61.0% to 78.9%). CONCLUSION: Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity. |
Head injuries (TBI) to adults and children in motor-vehicle crashes
Viano DC , Parenteau CS , Xu L , Faul M . Traffic Inj Prev 2017 18 (6) 0 PURPOSE: This is a descriptive study. It determined the annual, national incidence of head injuries (TBI) to adults and children in motor-vehicle crashes. It evaluated NASS-CDS (National Automotive Sampling System-Crashworthiness Data System) for exposure and incidence of various head injuries in towaway crashes. It evaluated three health databases for emergency department (ED) visits, hospitalizations and deaths due to TBI in motor-vehicle occupants. METHODS: Four databases were evaluated using 1997-2010 data on adult (15+ years old) and child (0-14 years old) occupants in motor-vehicle crashes: 1) NASS-CDS estimated the annual incidence of various head injuries and outcomes in towaway crashes, 2) NHAMCS (National Hospital Ambulatory Medical Care Survey) estimated ED visits for TBI, 3) NHDS (National Hospital Discharge Survey) estimated hospitalizations for TBI and 4) NVSS (National Vital Statistics System) estimated TBI deaths. The four databases provide annual, national totals for TBI related injury and death in motor-vehicle crashes based on differing definitions with TBI coded by AIS in NASS-CDS and by ICD in the health data. RESULTS: Adults: NASS-CDS had 16,980 +/- 2,411 (risk = 0.43% +/- 0.06%) with severe head injury (AIS 4+) out of 3,930,543 exposed adults in towaway crashes, annually. There were 49,881 +/- 9,729 (risk = 1.27% +/- 0.25%) hospitalized with AIS 2+ head injury, without death. There were 6,753 +/- 882 (risk = 0.17% +/- 0.02%) fatalities with a head injury cause. The public health data had 89,331 +/- 6,870 ED visits, 33,598 +/- 1,052 hospitalizations and 6,682 +/- 22 deaths with TBI. NASS-CDS estimated 48% more hospitalized with AIS 2+ head injury without death than NHDS occupants hospitalized with TBI. NASS-CDS estimated 29% more deaths with AIS 3+ head injury than NVSS occupant TBI deaths, but only 1% more deaths with a head injury cause. Children: NASS-CDS had 1,453 +/- 318 (risk = 0.32% +/- 0.07%) with severe head injury (AIS 4+) out of 454,973 exposed children, annually. There were 2,581 +/- 683 (risk = 0.57% +/- 0.15%) hospitalized with AIS 2+ head injury, without death. There were 466 +/- 132 (risk = 0.10% +/- 0.03%) fatalities with a head injury cause. The public health data had 19,251 +/- 2,803 ED visits, 3,363 +/- 255 hospitalizations and 488 +/- 6 deaths with TBI. NASS-CDS estimated 24% fewer hospitalized children with AIS 2+ head injury without death than NHDS hospitalization with TBI. NASS-CDS estimated 31% more deaths with AIS 3+ head injury than NVSS child deaths, but 5% fewer deaths with a head injury cause. CONCLUSIONS: The annual, national incidence of motor-vehicle related head injury (TBI) was estimated using 1997-2010 NASS-CDS from the Department of Transportation and NHAMCS (ED visits), NHDS (hospitalizations) and NVSS (deaths) from the Department of Health and Human Services. The transportation and health databases use different definitions and coding, which complicate direct comparisons. Future work is need where ICD to AIS translators are used if comparisons of serious head injuries in NASS and health datasets are to be made. |
Leading causes of death in nonmetropolitan and metropolitan areas- United States, 1999-2014
Moy E , Garcia MC , Bastian B , Rossen LM , Ingram DD , Faul M , Massetti GM , Thomas CC , Hong Y , Yoon PW , Iademarco MF . MMWR Surveill Summ 2017 66 (1) 1-8 PROBLEM/CONDITION: Higher rates of death in nonmetropolitan areas (often referred to as rural areas) compared with metropolitan areas have been described but not systematically assessed. PERIOD COVERED: 1999-2014 DESCRIPTION OF SYSTEM: Mortality data for U.S. residents from the National Vital Statistics System were used to calculate age-adjusted death rates and potentially excess deaths for nonmetropolitan and metropolitan areas for the five leading causes of death. Age-adjusted death rates included all ages and were adjusted to the 2000 U.S. standard population by the direct method. Potentially excess deaths are defined as deaths among persons aged <80 years that exceed the numbers that would be expected if the death rates of states with the lowest rates (i.e., benchmark states) occurred across all states. (Benchmark states were the three states with the lowest rates for each cause during 2008-2010.) Potentially excess deaths were calculated separately for nonmetropolitan and metropolitan areas. Data are presented for the United States and the 10 U.S. Department of Health and Human Services public health regions. RESULTS: Across the United States, nonmetropolitan areas experienced higher age-adjusted death rates than metropolitan areas. The percentages of potentially excess deaths among persons aged <80 years from the five leading causes were higher in nonmetropolitan areas than in metropolitan areas. For example, approximately half of deaths from unintentional injury and chronic lower respiratory disease in nonmetropolitan areas were potentially excess deaths, compared with 39.2% and 30.9%, respectively, in metropolitan areas. Potentially excess deaths also differed among and within public health regions; within regions, nonmetropolitan areas tended to have higher percentages of potentially excess deaths than metropolitan areas. INTERPRETATION: Compared with metropolitan areas, nonmetropolitan areas have higher age-adjusted death rates and greater percentages of potentially excess deaths from the five leading causes of death, nationally and across public health regions. PUBLIC HEALTH ACTION: Routine tracking of potentially excess deaths in nonmetropolitan areas might help public health departments identify emerging health problems, monitor known problems, and focus interventions to reduce preventable deaths in these areas. |
Reducing potentially excess deaths from the the five leading causes of death in the rural United States
Garcia MC , Faul M , Massetti G , Thomas CC , Hong Y , Bauer UE , Iademarco MF . MMWR Surveill Summ 2017 66 (2) 1-7 In 2014, the all-cause age-adjusted death rate in the United States reached a historic low of 724.6 per 100,000 population (1). However, mortality in rural (nonmetropolitan) areas of the United States has decreased at a much slower pace, resulting in a widening gap between rural mortality rates (830.5) and urban mortality rates (704.3) (1). During 1999-2014, annual age-adjusted death rates for the five leading causes of death in the United States (heart disease, cancer, unintentional injury, chronic lower respiratory disease (CLRD), and stroke) were higher in rural areas than in urban (metropolitan) areas (Figure 1). In most public health regions (Figure 2), the proportion of deaths among persons aged <80 years (U.S. average life expectancy) (2) from the five leading causes that were potentially excess deaths was higher in rural areas compared with urban areas (Figure 3). Several factors probably influence the rural-urban gap in potentially excess deaths from the five leading causes, many of which are associated with sociodemographic differences between rural and urban areas. Residents of rural areas in the United States tend to be older, poorer, and sicker than their urban counterparts (3). A higher proportion of the rural U.S. population reports limited physical activity because of chronic conditions than urban populations (4). Moreover, social circumstances and behaviors have an impact on mortality and potentially contribute to approximately half of the determining causes of potentially excess deaths (5). |
Bystander Intervention Prior to The Arrival of Emergency Medical Services: Comparing Assistance across Types of Medical Emergencies
Faul M , Aikman SN , Sasser SM . Prehosp Emerg Care 2016 20 (3) 317-23 OBJECTIVE: To determine the situational circumstances associated with bystander interventions to render aid during a medical emergency. METHODS: This study examined 16.2 million Emergency Medical Service (EMS) events contained within the National Emergency Medical Services Information System. The records of patients following a 9-1-1 call for emergency medical assistance were analyzed using logistic regression to determine what factors influenced bystander interventions. The dependent variable of the model was whether or not a bystander intervened. RESULTS: EMS providers recorded bystander assistance 11% of the time. The logistic regression model correctly predicted bystander intervention occurrence 71.4% of the time. Bystanders were more likely to intervene when the patient was male (aOR = 1.12, 95% CI = 1.12-1.3) and if the patient was older (progressive aOR = 1.10, 1.46 age group 20-29 through age group 60-99). Bystanders were less likely to intervene in rural areas compared to urban areas (aOR = 0.58, 95% CI = 0.58-0.59). The highest likelihood of bystander intervention occurred in a residential institution (aOR = 1.86, 95% CI = 1.85-1.86) and the lowest occurred on a street or a highway (aOR = 0.96, 95% CI = 0.95-0.96). Using death as a reference group, bystanders were most likely to intervene when the patient had cardiac distress/chest pain (aOR = 11.38, 95% CI = 10.93-11.86), followed by allergic reaction (aOR = 7.63, 95% CI = 7.30-7.99), smoke inhalation (aOR = 6.65, 95% CI = 5.98-7.39), and respiration arrest/distress (aOR = 6.43, 95% CI = 6.17-6.70). A traumatic injury was the most commonly recorded known event, and it was also associated with a relatively high level of bystander intervention (aOR = 5.81, 95% CI = 5.58-6.05). The type of injury/illness that prompted the lowest likelihood of bystander assistance was Sexual Assault/Rape (aOR = 1.57, 95% CI = 1.32-1.84) followed by behavioral/psychiatric disorder (aOR = 1.64, 95% CI = 1.57-1.71). CONCLUSION: Bystander intervention varies greatly on situational factors and the type of medical emergency. A higher risk of patient death is likely to prompt bystander action. These novel study results can lead to more effective first aid training programs. KEY WORDS: bystander; EMS; rural; cardiac distress; trauma. |
Hospitalized Traumatic Brain Injury: Low Trauma Center Utilization and High Interfacility Transfers among Older Adults
Faul M , Xu L , Sasser SM . Prehosp Emerg Care 2016 20 (5) 594-600 OBJECTIVE: Guidelines suggest that Traumatic Brain Injury (TBI) related hospitalizations are best treated at Level I or II trauma centers because of continuous neurosurgical care in these settings. This population-based study examines TBI hospitalization treatment paths by age groups. METHODS: Trauma center utilization and transfers by age groups were captured by examining the total number of TBI hospitalizations from National Inpatient Sample (NIS) and the number of TBI hospitalizations and transfers in the Trauma Data Bank National Sample Population (NTDB-NSP). TBI cases were defined using diagnostic codes. RESULTS: Of the 351,555 TBI related hospitalizations in 2012, 47.9% (n = 168,317) were directly treated in a Level I or II trauma center, and an additional 20.3% (n = 71,286) were transferred to a Level I or II trauma center. The portion of the population treated at a trauma center (68.2%) was significantly lower than the portion of the U.S. population who has access to a major trauma center (90%). Further, nearly half of all transfers to a Level I or II trauma center were adults aged 55 and older (p < 0.001) and that 20.2% of pediatric patients arrive by non-ambulatory means. CONCLUSION: Utilization of trauma center resources for hospitalized TBIs may be low considering the established lower mortality rate associated with treatment at Level I or II trauma centers. The higher transfer rate for older adults may suggest rapid decline amid an unrecognized initial need for a trauma center care. A better understanding of hospital destination decision making is needed for patients with TBI. |
Potentially preventable deaths among the five leading causes of death - United States, 2010 and 2014
Garcia MC , Bastian B , Rossen LM , Anderson R , Minino A , Yoon PW , Faul M , Massetti G , Thomas CC , Hong Y , Iademarco MF . MMWR Morb Mortal Wkly Rep 2016 65 (45) 1245-1255 Death rates by specific causes vary across the 50 states and the District of Columbia.* Information on differences in rates for the leading causes of death among states might help state health officials determine prevention goals, priorities, and strategies. CDC analyzed National Vital Statistics System data to provide national and state-specific estimates of potentially preventable deaths among the five leading causes of death in 2014 and compared these estimates with estimates previously published for 2010. Compared with 2010, the estimated number of potentially preventable deaths changed (supplemental material at https://stacks.cdc.gov/view/cdc/42472); cancer deaths decreased 25% (from 84,443 to 63,209), stroke deaths decreased 11% (from 16,973 to 15,175), heart disease deaths decreased 4% (from 91,757 to 87,950), chronic lower respiratory disease (CLRD) (e.g., asthma, bronchitis, and emphysema) deaths increased 1% (from 28,831 to 29,232), and deaths from unintentional injuries increased 23% (from 36,836 to 45,331). A better understanding of progress made in reducing potentially preventable deaths in the United States might inform state and regional efforts targeting the prevention of premature deaths from the five leading causes in the United States. |
Impact of prescription drug monitoring programs and pill mill laws on high-risk opioid prescribers: A comparative interrupted time series analysis
Chang HY , Lyapustina T , Rutkow L , Daubresse M , Richey M , Faul M , Stuart EA , Alexander GC . Drug Alcohol Depend 2016 165 1-8 BACKGROUND: Prescription drug monitoring programs (PDMPs) and pill mill laws were implemented to reduce opioid-related injuries/deaths. We evaluated their effects on high-risk prescribers in Florida. METHODS: We used IMS Health's LRx Lifelink database between July 2010 and September 2012 to identify opioid-prescribing prescribers in Florida (intervention state, N: 38,465) and Georgia (control state, N: 18,566). The pre-intervention, intervention, and post-intervention periods were: July 2010-June 2011, July 2011-September 2011, and October 2011-September 2012. High-risk prescribers were those in the top 5th percentile of opioid volume during four consecutive calendar quarters. We applied comparative interrupted time series models to evaluate policy effects on clinical practices and monthly prescribing measures for low-risk/high-risk prescribers. RESULTS: We identified 1526 (4.0%) high-risk prescribers in Florida, accounting for 67% of total opioid volume and 40% of total opioid prescriptions. Relative to their lower-risk counterparts, they wrote sixteen times more monthly opioid prescriptions (79 vs. 5, p<0.01), and had more prescription-filling patients receiving opioids (47% vs. 19%, p<0.01). Following policy implementation, Florida's high-risk providers experienced large relative reductions in opioid patients and opioid prescriptions (-536 patients/month, 95% confidence intervals [CI] -829 to -243; -847 prescriptions/month, CI -1498 to -197), morphine equivalent dose (-0.88mg/month, CI -1.13 to -0.62), and total opioid volume (-3.88kg/month, CI -5.14 to -2.62). Low-risk providers did not experience statistically significantly relative reductions, nor did policy implementation affect the status of being high- vs. low- risk prescribers. CONCLUSIONS: High-risk prescribers are disproportionately responsive to state policies. However, opioids-prescribing remains highly concentrated among high-risk providers. |
Older adult falls seen by emergency medical service providers: a prevention opportunity
Faul M , Stevens JA , Sasser SM , Alee L , Deokar AJ , Kuhls DA , Burke PA . Am J Prev Med 2016 50 (6) 719-726 INTRODUCTION: Among people aged ≥65 years, falling is the leading cause of emergency department visits. Emergency medical services (EMS) are often called to help older adults who have fallen, with some requiring hospital transport. Chief aims were to determine where falls occurred and the circumstances under which patients were transported by EMS, and to identify future fall prevention opportunities. METHODS: In 2012, a total of 42 states contributed ambulatory data to the National EMS Information System, which were analyzed in 2014 and 2015. Using EMS records from 911 call events, logistic regression examined patient and environmental factors associated with older adult transport. RESULTS: Among people aged ≥65 years, falls accounted for 17% of all EMS calls. More than one in five (21%) of these emergency 911 calls did not result in a transport. Most falls occurred at home (60.2%) and residential institutions such as nursing homes (21.7%). Logistic regression showed AORs for transport were greatest among people aged ≥85 years (AOR=1.14, 95% CI=1.13, 1.16) and women (AOR=1.30, 95% CI=1.29, 1.32); for falls at residential institutions or nursing homes (AOR=3.52, 95% CI=3.46, 3.58) and in rural environments (AOR=1.15, 95% CI=1.13, 1.17); and where the EMS impression was a stroke (AOR=2.96, 95% CI=2.11, 4.10), followed by hypothermia (AOR=2.36, 95% CI=1.33, 4.43). CONCLUSIONS: This study provides unique insight into fall circumstances and EMS transport activity. EMS personnel are in a prime position to provide interventions that can prevent future falls, or referrals to community-based fall prevention programs and services. |
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