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Part II: Current Status and Opportunities3 Magnitude of the Problem
Pages 41-79

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From page 41...
... Part II Current Status and Opportunities
From page 43...
... As noted in Chapter 1, more than 2 million people contact poison control centers annually for advice on poisoning exposures (Watson et al., 2003)
From page 44...
... Figure 3-1 provides a schematic representation of the universe of poisoning and drug overdose and the relationships among mortality, poisoning resulting in hospitalization (that may or not result in death) , and cases that come to the attention of poison control centers, emergency departments, and private physicians (that may or may not lead to hospitalizations)
From page 45...
... . Although this may overlap with the mechanisms of other types of poisoning, many definitional schemes separately tally or exclude altogether illnesses defined as adverse therapeutic events, such as drug toxicity that results from multidrug interactions, increased susceptibility or true allergic sensitivity, or dosing error, all of which can be classified as "adverse drug effects." The toxic effects of ethanol present a specific set of definitional challenges.
From page 46...
... Defining adverse events associated with drugs of abuse is a particularly salient issue in this regard. For example, some events may or may not be categorized as a poisoning or drug overdose by health care providers, depending on whether the presenting medical complaint is viewed as an intended end-point effect.
From page 47...
... Definitions Used in This Report The following analyses attempt to be consistent in the coding that has been used to categorize the poisoning estimates derived and to highlight areas in which there are substantive differences in coding or case definition that might be likely to affect the estimates provided. Further methodological details and a discussion of the coding of poisoning and drug overdoses are also provided in Appendix 3-A.
From page 48...
... Second, summary data for total incidence from two additional data sources were also included to supplement a final tabulation of morbidity and mortality. These supplemental summary totals were derived from the American Association of Poison Control Centers' (AAPCC's)
From page 49...
... These data form the basis of Tables 3-2 through 3-9 and Table 3-11. national probability sample survey of patient visits made in the United States to the offices of nonfederally employed physicians classified by the American Medical Association and the American Osteopathic Association as working in settings that are "office-based patient care." · National Hospital Ambulatory Medical Care Survey (NHAMCS)
From page 50...
... An analysis of mortality data was carried out using the following source: · Mortality Vital Statistics: Electronic mortality vital statistics data are derived from a national file of death certificate-derived data maintained by NCHS. This data file is designed to capture all deaths on a yearly basis.
From page 51...
... Table 3-2 includes estimates of annual poisoning episodes overall and stratified by various demographic characteristics and whether direct treatment was given. Based on sampling weights, which allow mathematical calculation of the population frequency based on the observations (see Appendix 3-A for details)
From page 52...
... bEstimate has low statistical reliability (relative standard error >30 percent or sample N <30)
From page 53...
... . About one-quarter were treated only by telephone calls to a doctor's office and/or a poison control center, but had no ambulatory or inpatient visits reported (16 percent reported a telephone call to a poison control center, regardless of whether a subsequent ambulatory or inpatient visit was made; data not shown in table)
From page 54...
... of Total Total 263a 1,546 100 Phone call only (doctor's office or poison 59 375 24 control center) Ambulatory or inpatient visit 204 1,171 76 Visit to doctor's office/clinic/outpatient 97 568 37 department Visit to doctor's office/clinic/outpatient 90 521 34 department without hospitalization or emergency department treatment Visit to doctor's office 70 419 27 Visit to clinic/outpatient department 28 154b 10 Visit to emergency department 107 611 40 Visit to emergency department without 97 558 36 hospitalization Visit to hospital 17 92b 6 aSix respondents refused to answer this question.
From page 55...
... , including an ICD-9CM diagnosis or E-code for poisoning, was extracted from the National Ambulatory Care Medical Survey 1997­2001 data files, resulting in an annual estimate of approximately 1,582,000 visits (Table 3-4)
From page 56...
... bEstimate has low statistical reliability (relative standard error >30 percent or sample N <30)
From page 57...
... for the 1999­2000 period indicated that the patient would be admitted to the hospital. National Hospital Ambulatory Medical Care Survey Outpatient subset The National Hospital Ambulatory Care Survey 1997­ 2001 outpatient files (non-ED visits)
From page 58...
... bEstimate has low statistical reliability (relative standard error >30 percent or sample N <30)
From page 59...
... . This represents 1.5 percent of all TABLE 3-6 Annual Number and Rates of Emergency Department Visits as Confirmed by ICD-9-CM Codes, National Hospital Ambulatory Medical Care Survey (NHAMCS)
From page 60...
... . The percentage of total emergency department visits estimated to be associated with poisoning in this analysis is slightly higher here than one published by McCaig in 1996 using 1993­1996 NHAMCS emergency department files (1.1 percent of all visits in that study compared with 1.5 percent here)
From page 61...
... Sixteen percent describe their main reason for visit as an insect bite, while 10 percent indicate their primary reason as unintentional poisoning. The third primary reason/symptom was skin rash (7 percent)
From page 62...
... Outpatient and ED Files, 1997­2001 Number of Poisoning Sample Visits Percentage Number (thousands) of Total Total 2,313 3,173 100 Top 5 primary ICD-9 3-digit E-codes E905 -- Poisoning caused by venomous 392 652 21 animals and plants E866 -- Accidental poisoning by other and 168 409 13 unspecified solid and liquid substances E858 -- Accidental poisoning by other drugs 291 302 10 E950 -- Suicide and self-inflicted poisoning 384 301 9 by solids or liquids E980 -- Poisoning by solids or liquids, 146 163 5 accidental versus purposely inflicted not determined Subtotal 1,381 1,826 58 Top 5 primary ICD-9 3-digit diagnosis codes 989 -- Toxic effects of other substances, 422 603 19 chiefly nonmedicinal 977 -- Poisoning by other and unspecified 198 178 6 drugs and medicinal substances 995 -- Certain adverse effects not elsewhere 83 154 5 classified 965 -- Poisoning by analgesics, antipyretics, 130 120 4 and antirheumatics 969 -- Poisoning by psychotropic agents 100 98 3 Subtotal 933 1,154 36 Top 5 primary patient visit reason/symptom codes 5755.0 -- Insect bites 328 519 16 5900.2 -- Unintentional poisoning: Ingestion, 300 333 10 inhalation, or exposure to potentially poisonous products 1860.0 -- Skin rash 77 218 7 5820.1 -- Overdose, intentional 186 144 5 5910.0 -- Adverse effect of drug abuse 193 140 4 Subtotal 1,084 1,354 43 NOTE: NAMCS and NHAMCS are annual surveys of office-based physicians and hospital outpatient and emergency departments, respectively.
From page 63...
... Two-thirds of the poisoning inpatient visits had a poisoning ICD-9 code as the principal diagnosis on the discharge abstract, with the remainder as a secondary listing (e.g., a primary diagnosis of aspiration pneumonia in a concomitant drug overdose)
From page 64...
... (millions) a per Annum Total 11,533 291 271.56 110 Gender Male 4,896 124 132.52 90 Female 6,637 167 139.05 120 Age Under 18 2,020 43 72.02 60 18­64 8,048 199 167.09 120 65 and over 1,465 49 32.45 150 Race White 6,344 184 215.97 90 Black 1,678 35 33.11 110 Other 593 11 21.91 50 Unknown 2,918 61 Region Northeast 2,411 57 52.44 110 Midwest 3,655 72 66.46 110 South 3,883 105 96.68 110 West 1,584 57 55.99 100 Discharge status (percentage of total)
From page 65...
... National Electronic Injury Surveillance System -- All Injury Program NEISS-AIP provides a summary estimate of 742,606 poisoning episodes presenting at emergency departments in 2002. However, this figure excludes poisoning from insect stings or other venomous animal bites.
From page 66...
... . Toxic Exposure Surveillance System The 2001 TESS annual report included analysis of data from poison control centers in 48 states and the District of Columbia.
From page 67...
... TABLE 3-10 Poisoning and Drug Overdose Mortality, 2001 Category of Substance Involved All Underlying Cause of Death by Intent Drug Other Medicament Unintentional 13,024 1,054 14,078 Suicide 3,559 1,632 5,191 Homicide 42 22 64 Undetermined intent 2,769 140 2,909 Drug-related mental or behavioral disorder 1,931 NA 1,931 Subtotal 21,325 2,848 24,173 Alcohol-related behavioral disorder NA 6,627 6,627 Total 21,235 9,475 30,800a aExcludes fire and smoke deaths with carbon monoxide poisoning listed as a contributing cause. SOURCE: Fingerhut (2003)
From page 68...
... About one-fourth of suicides involving poisoning and toxic effects had mention of carbon monoxide poisoning, and 9 percent of unintentional deaths involving poisoning and toxic effects included mention of alcohol. Poisoning death rates increased with age from less than 1 per 100,000 for persons under 15 years of age to 19/100,000 at 35 to 44 years of age, and then declined again with age (Figure 3-2)
From page 69...
... . TESS data, by definition, only include poisoning cases for which a call was made to a poison control center.
From page 70...
... . The NHIS also appears to underestimate the total incidence of poisonings that are directly treated by health care providers.
From page 71...
... . This might be comparable to a question 8.0 Unintentional 7.0 Suicide Undetermined F codes 6.0 5.0 population 100,000 4.0 per Deaths 3.0 2.0 1.0 0.0 New Mid ENCentral WNCentral S Atlantic ESCentral WSCentral Mountain Pacific England Atlantic 8.4 8.4 6.2 10.2 8.3 7.8 12.3 6.1 10.6 Geographic Regions FIGURE 3-4 Poisoning death rates by geographic division, United States, 2001.
From page 72...
... bVisit estimate discounted to account for possible multiple visits per episode, as follows: NAMCS -- 50 percent, NHAMCS outpatient -- 14 percent, NHAMCS ED -- 5 percent, NHDS -- 3 percent. cNational Electronic Injury Surveillance System -- All Injury Program.
From page 73...
... . This ratio, however, is well within the range of that observed in selected studies that have attempted to determine the proportion of ED cases of poisoning or drug overdose that are reported to poison control centers (see Chapter 7)
From page 74...
... to the NHDS figure. Estimates of fatal poisonings range from 1,074 for TESS data to 24,173 for the NCHS analysis of death certificate data for 2001 (climbing to 30,800 when alcohol behavioral disorder coded deaths are included)
From page 75...
... See Chapter 7 for a detailed description of multiple surveillance resources relevant to various types of poisoning and drug overdose events. In summary, these analyses suggest that a conservative estimate of the annual incidence of poisoning episodes in the United States is 4 million cases per annum.
From page 76...
... phone call to poison control center; (4) visit to doctor's office; (5)
From page 77...
... In addition, poisoning events are relatively uncommon in the dataset; because only 2 years of data are used, some of the estimates are not as robust as desired. NATIONAL AMBULATORY MEDICAL CARE SURVEY This source is a national probability sample survey of visits made in the United States to the offices of nonfederally employed physicians classified as working in settings that are "office-based care." Visits to private, non-hospital-based clinics and health maintenance organizations are included, but those that occur in federally operated clinics are not.
From page 78...
... NATIONAL HOSPITAL DISCHARGE SURVEY This source covers discharges from a sample of short-stay hospital visits that are noninstitutional and nonfederal. Up to seven ICD-9 diagnosis codes (including ICD-9 CM and E-codes)
From page 79...
... Added instructions for coding deaths further impact definitions by requiring the principal cause of death to be categorized as due to a selected group of mental and behavioral disorders if such a disorder appears among contributing causes in a poisoning death. Thus an acute acetaminophen fatality in a chronic ethanol abuser (if this was listed as a contributing cause)


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