Query purpose:
To assist state, local, tribal, territorial, and federal public health practitioners in monitoring emergency department visits for suspected nonfatal stimulant-involved overdoses using syndromic surveillance data.
Definition description:
The CDC All Stimulant Overdose v4 Parsed syndrome definition was designed to be used to identify ED visits for suspected nonfatal stimulant-involved overdoses of unintentional or undetermined intent. The query relies on data in two fields from ED visit records to identify encounters that meet the definition criteria:
- the chief complaint free text field, which is a processed version of the reported chief complaint and may include terms indicating a stimulant-involved overdose or poisoning, as well as relevant exclusion terms (e.g., terms indicating stimulant withdrawal without acute intoxication, etc., which would exclude ED visit records from this syndrome definition), and
- the discharge diagnosis parsed field, which includes International Classification of Diseases, Clinical Modification, 9th Revision (ICD-9-CM),1 International Classification of Diseases, Clinical Modification, 10th Revision (ICD-10-CM),2 or Systematized Nomenclature of Medicine – Clinical Terms (SNOMED-CT)3 diagnosis codes, with descriptive code text removed, and which may indicate an acute stimulant-involved overdose or poisoning of unintentional or undetermined intent.
Within ESSENCE, the syndrome query is applied to the Chief Complaint Discharge Diagnosis (CCDD) Parsed field, which combines these two fields of interest.
How it was developed:
This revision was developed to serve three purposes: (1) Adapt the CDC All Stimulant Overdose v3 definition syntax to query the newly developed CCDD Parsed field, which removes extraneous text from the discharge diagnosis portion of CCDD, (2) nest the logic for CDC Cocaine Overdose v2 Parsed and CDC Methamphetamine Overdose v1 Parsed definitions within the CDC All Stimulant Overdose v4 Parsed definition to ensure capture of ED Visits for suspected stimulant-involved overdoses by the CDC Stimulant Overdose v4 Parsed definition, and (3) revise the query syntax to incorporate corrections to logic and other identified improvements. CDC NSSP staff used R code to update the syntax to meet CCDD Parsed field requirements. The CDC DOSE team reviewed the revisions and compared total visits captured by CCDD and CCDD Parsed versions of the definition, with a focus on diagnosis codes, to ensure correct restructuring.
The initial CDC All Stimulant Overdose definition6 development began with the DOSE team reviewing guidance from the United States Drug Enforcement Administration (DEA), Council of State and Territorial Epidemiologists (CSTE), and the Substance Abuse and Mental Health Services Administration (SAMHSA). First, ICD-9-CM, ICD-10-CM, and SNOMED-CT diagnosis codes indicating an acute stimulant poisoning were identified. Finally, overdose and stimulant terms that appeared in ED visit chief complaint text were iteratively added to the definition syntax and validated.
How it works:
The CCDD Parsed field is used to query both the diagnosis codes and chief complaint free text with exclusions (as necessary) to develop the syndrome definition.
- Automatic inclusion:
- If a diagnosis code (ICD-9-CM, ICD-10-CM, and/or SNOMED-CT) indicating a stimulant poisoning is present, the ED visit is automatically included in the syndrome.
- The ED visit is automatically included in the syndrome definition if the ED visit meets one or more of the nested drug overdose definitions:
- CDC Cocaine Overdose v2 Parsed
- CDC Methamphetamine Overdose v1 Parsed
- Conditional inclusion:
- If the ED visit does not include a diagnosis code for stimulant poisoning or overdose of unintentional or undetermined intent, then the visit is not automatically included. In these instances, the visit is captured only if it includes two components and no exclusion terms:
- 1) chief complaint text indicating an overdose or poisoning AND
- 2) chief complaint text indicating stimulant involvement OR the SNOMED-CT code for stimulant abuse.
- The exclusion terms are applied to the chief complaint text only when a discharge diagnosis code is not present for stimulant poisoning.
- If the ED visit does not include a diagnosis code for stimulant poisoning or overdose of unintentional or undetermined intent, then the visit is not automatically included. In these instances, the visit is captured only if it includes two components and no exclusion terms:
For consideration:
The definition was developed to capture suspected nonfatal stimulant-involved overdoses treated in EDs. However, it is subject to both misclassification and under/overreporting for several reasons, including limited point-of-care confirmatory testing to identify the drug(s) involved in the overdose, and reliance on self-report, bystander reports, and/or clinical presentations to determine the drug(s) involved in an overdose. The codes provided in the discharge diagnosis field from the ED visit record do not necessarily represent the final diagnosis of a patient and should be considered preliminary. Additionally, some hospitals may enter all diagnosis codes from a patient’s entire medical history, including codes for previous stimulant-involved overdose visits; the definition may incorrectly capture such encounters that were not for a true stimulant-involved overdose and thus result in overreporting. It is not possible in syndromic data to determine the primary reason for a patient’s visit, as syndromic data lack a primary diagnosis field. Therefore, all terms and codes are considered equally (i.e., not in any priority) regardless of what order they are in the record. Finally, stimulant-involved overdoses may be more difficult to identify than opioid-involved overdoses and thus reported in chief complaints due to the diverse range of associated symptoms, including some that may overlap with cardiovascular health and mental health-involved ED visits. For example, someone with heart palpitations and stimulant use may have been treated at an ED for cardiac symptoms and used a prescription stimulant as directed. This scenario could be captured as a stimulant-involved overdose. Future studies where provider triage notes are available may help further validate the use of chief complaints and discharge diagnoses to identify nonfatal stimulant-involved overdose visits in syndromic data. The team attempted to identify all appropriate inclusion and exclusion terms to capture any suspected nonfatal stimulant-involved overdose while avoiding capturing encounters that were not for an acute stimulant-involved overdose or poisoning; however, it is possible that some of these encounters were erroneously captured, leading to overreporting.
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