Years of life lost associated with COVID-19 deaths in the USA during the first 2 years of the pandemic.

BACKGROUND: Prior estimates of the years of life lost (YLLs) in the USA associated with coronavirus disease 2019 (COVID-19) were 1.2 million through 11 July 2020 and 3.9 million through 31 January 2021 (which roughly coincides with the first full year of the pandemic). The aim of this study is to update YLL estimates through the first 2 years of the pandemic. METHODS: We employed data regarding COVID-19 deaths through 5 February 2022 by jurisdiction, gender and age group. We used actuarial life expectancy tables by gender and age to estimate YLLs. RESULTS: We estimated roughly 9.7 million YLLs due to COVID-19 deaths. The number of YLLs per 10 000 capita was 297.5, with the highest rate in Mississippi (482.7) and the lowest in Vermont (61.4). There was substantial interstate variation in the timing of YLLs and differences in YLLs by gender. YLLs per death increased from 9.2 in the first year of the pandemic to 10.8 through the first 2 years. CONCLUSIONS: Our findings improve our understanding of how the mortality effects of COVID-19 have evolved. This insight can be valuable to public health officials as the disease moves to an endemic phase.

Years of life lost associated with COVID-19 deaths in the USA during the first year of the pandemic.

BACKGROUND: Years of Life Lost (YLLs) measure the shortfall in life expectancy due to a medical condition and have been used in multiple contexts. Previously it was estimated that there were 1.2 million YLLs associated with coronavirus disease 2019 (COVID-19) deaths in the USA through 11 July 2020. The aim of this study is to update YLL estimates for the first full year of the pandemic. METHODS: We employed data regarding COVID-19 deaths in the USA through 31 January 2021 by jurisdiction, gender and age group. We used actuarial life expectancy tables by gender and age to estimate YLLs. RESULTS: We estimated roughly 3.9 million YLLs due to COVID-19 deaths, which correspond to roughly 9.2 YLLs per death. We observed a large range across states in YLLs per 10 000 capita, with New York City at 298 and Vermont at 12. Nationally, the YLLs per 10 000 capita were greater for males than females (136.3 versus 102.3), but there was significant variation in the differences across states. CONCLUSIONS: Our estimates provide further insight into the mortality effects of COVID-19. The observed differences across states and genders demonstrate the need for disaggregated analyses of the pandemic's effects.

An evaluation of the Veterans Health Administration National Nursing Education Initiative.

BACKGROUND: Since 1999, the Veterans Health Administration's (VHA) National Nursing Education Initiative (NNEI) has provided 16,294 scholarships for registered nurses to attain baccalaureate and advanced nursing degrees. PURPOSE: The goal of this evaluation was to determine factors that enhanced or hindered a scholarship recipient in the completion of their degree and service obligation. METHODS: A regression analysis was performed to identify predictors of degree completion for 10,043 participants in 162 VHA facilities. FINDINGS: Significant predictor variables for degree completion were intended occupation, entry degree, gender, age, and year entering the program. Eighty-six percent (86.7%) of participants completed the degree requirement. Of those who completed their degree, 97% completed the service obligation. DISCUSSION: As recruitment and retention initiative, NNEI scholarships are poised to address the VHA nursing staffing shortages as well as build a highly qualified nursing workforce capable of providing the best care to our Nation's Veterans.

Factors associated with the timing of abortions.

The timing of an abortion (often measured as gestational age) can have important effects on the woman's physical health and on the cost of the procedure. To the authors' knowledge, there has been only one national analysis of the factors associated with the gestational age at abortion, but it employed data from over 20 years ago. The state-specific studies that have explored abortion timing have typically examined the effects of a specific change in abortion regulations. In this study, we employ annual, state-level data covering the 1991-2014 period that measure the frequency of abortions by gestational age. We regress these measures of abortion utilization on policy, economic, demographic, and health care infrastructure characteristics. The estimates indicate that the introduction of state restrictions on Medicaid funding of abortions is associated with a 13% increase in the rate of abortions after the first trimester. We do not find a statistically significant association between parental involvement laws and the rate or percentage of post-first-trimester abortions.

Years of life lost associated with COVID-19 deaths in the United States.

BACKGROUND: The mortality effects of COVID-19 are a critical aspect of the disease's impact. Years of life lost (YLLs) can provide greater insight than the number of deaths by conveying the shortfall in life expectancy and thus the age profile of the decedents. METHODS: We employed data regarding COVID-19 deaths in the USA by jurisdiction, gender and age group for the period 1 February 2020 through 11 July 2020. We used actuarial life expectancy tables by gender and age to estimate YLLs. RESULTS: We estimated roughly 1.2 million YLLs due to COVID-19 deaths. The YLLs for the top six jurisdictions exceeded those for the remaining 43. On a per-capita basis, female YLLs were generally higher than male YLLs throughout the country. CONCLUSIONS: Our estimates offer new insight into the effects of COVID-19. Our findings of heterogenous rates of YLLs by geography and gender highlight variation in the magnitude of the pandemic's effects that may inform effective policy responses.

Healthcare utilization by children with asthma displaced by Hurricane Katrina.

OBJECTIVE: To assess the performance of TexKat, the largest Hurricane Katrina Medicaid Emergency Waiver, in providing care to asthmatic children. METHODS: Medicaid enrollment and encounter data for 2004 and 2006 from Louisiana and Texas were analyzed in a pre-post comparison. Changes in utilization by children in the waiver were compared to changes in utilization by children in Medicaid in three control groups: children in Louisiana counties that were designated as a disaster assistance area but who were not displaced; children in Louisiana counties that were not designated as a disaster assistance area, and children in Texas. The analysis included prescriptions for controller and quick-relief medications as well as encounters in inpatient, emergency, outpatient, and office settings. RESULTS: The sample proportion of TexKat enrollees who had a prescription filled for controller medications fell from 0.37 to 0.28 between 2004 and 2006. By contrast, the sample proportions for the three control groups were relatively unchanged or increased. The inferential analysis indicated that the 2004-2006 change in proportions for the TexKat group differed from the changes for each of the three control groups (p-value < 0.001). For office and emergency department visits, the 2004-2006 decreases in both the proportion of subjects with a visit and the average number of visits for the TexKat group were greater than the changes for the control groups (p-value < 0.001). CONCLUSIONS: While TexKat appears to have largely been successful in preventing extreme utilization disruptions, the analysis suggests that children in the program may have received inadequate care.

Psychopharmacology Utilization Among Children with Anxiety and Obsessive-Compulsive and Related Disorders Following Hurricane Katrina.

This study aimed to examine the impact of Hurricane Katrina exposure on medication utilization among children with pre-existing anxiety and obsessive-compulsive and related disorders (OCRDs). Medicaid claims data from 2004 to 2006 were analyzed. Children with pre-existing anxiety/OCRDs were compared as a function of those living in a Louisiana disaster area, Louisiana non-disaster area, or Texas in terms of filled prescriptions and average days medication supply. This was further examined as a function of disorder/medication type. Prescriptions filled and average days medication supply were lower for those who resided in the disaster area of Louisiana relative to non-disaster zones in Texas (but not Louisiana). Children with OCD who lived in a disaster zone in Louisiana had 16.6 fewer days supply of antidepressants relative to youth in Texas. Similarly, children with PTSD who lived in a disaster zone in Louisiana had approximately 7 fewer days supply of stimulant medication relative to those who lived in Texas. Medication utilization was reduced for those youth directly exposed to Katrina relative to children in Texas, suggesting potential service disruption. Children with OCD and PTSD may be more likely to experience treatment disruption. Following disasters, particular attention should be given to ensuring continued treatment access for youth with pre-existing anxiety and OCRDs (as well as other conditions).

Sex Work Regulation and Sexually Transmitted Infections in Tijuana, Mexico.

While reducing the transmission of sexually transmitted infections is a common argument for regulating sex work, relatively little empirical evidence is available regarding the effectiveness of these policies. We investigate the effects of highly publicized sex work regulations introduced in 2005 in Tijuana, Mexico on the incidence of trichomoniasis. State-level, annual data for the 1995-2012 period are employed that include the incidence rates of trichomoniasis by age group and predictor variables. We find that the regulations led to a decrease in the incidence rate of trichomoniasis. Specifically, while our estimates are somewhat noisy, the all-ages incidence rate in the 2005-2012 period is roughly 37% lower than what is predicted by our synthetic control estimates and corresponds to approximately 800 fewer reported cases of trichomoniasis per year. We find that the decreases are especially pronounced for 15-24 and 25-44 age cohorts. Copyright © 2016 John Wiley & Sons, Ltd.

Parent-Led Cognitive Behavioral Teletherapy for Anxiety in Autistic Youth: A Randomized Trial Comparing Two Levels of Therapist Support.

Parent-led cognitive behavioral therapy (CBT) is an efficient, promising form of therapy that may be well suited for autistic youth with anxiety disorders, though to date it has been minimally tested. In this study, 87 autistic youth (7 to 13 years old) with anxiety disorders and their parents were randomized to two forms of parent-led CBT in which parents led their child through a guided CBT workbook across 12 weeks: one with low therapist contact (four 30-minute telehealth calls), and one with standard therapist contact (ten 60-minute telehealth calls). Anxiety, functional impairment, and autism features significantly declined across therapy, without differences between groups. High satisfaction was reported in both groups, though significantly higher satisfaction ratings were reported in standard-contact CBT. Responder rates were 69% of completers at posttreatment (70% in standard contact, 68% in low contact) and 86% at 3-month follow-up (86% in standard contact, 87% in low contact). Low-contact CBT was estimated to incur an average cost of $755.70 per family compared with $1,978.34 in standard-contact CBT. Parent-led CBT with minimal or standard therapist contact both appear to be effective CBT delivery formats for autistic youth with anxiety disorders, with significant cost savings for low-contact CBT.

Closed-loop automated drug infusion regulator: A clinically translatable, closed-loop drug delivery system for personalized drug dosing.

BACKGROUND: Dosing of chemotherapies is often calculated according to the weight and/or height of the patient or equations derived from these, such as body surface area (BSA). Such calculations fail to capture intra- and interindividual pharmacokinetic variation, which can lead to order of magnitude variations in systemic chemotherapy levels and thus under- or overdosing of patients. METHODS: We designed and developed a closed-loop drug delivery system that can dynamically adjust its infusion rate to the patient to reach and maintain the drug's target concentration, regardless of a patient's pharmacokinetics (PK). FINDINGS: We demonstrate that closed-loop automated drug infusion regulator (CLAUDIA) can control the concentration of 5-fluorouracil (5-FU) in rabbits according to a range of concentration-time profiles (which could be useful in chronomodulated chemotherapy) and over a range of PK conditions that mimic the PK variability observed clinically. In one set of experiments, BSA-based dosing resulted in a concentration 7 times above the target range, while CLAUDIA keeps the concentration of 5-FU in or near the targeted range. Further, we demonstrate that CLAUDIA is cost effective compared to BSA-based dosing. CONCLUSIONS: We anticipate that CLAUDIA could be rapidly translated to the clinic to enable physicians to control the plasma concentration of chemotherapy in their patients. FUNDING: This work was supported by MIT's Karl van Tassel (1925) Career Development Professorship and Department of Mechanical Engineering and the Bridge Project, a partnership between the Koch Institute for Integrative Cancer Research at MIT and the Dana-Farber/Harvard Cancer Center.

The Patient Protection and Affordable Care Act's provisions regarding medical loss ratios and quality: evidence from Texas.

OBJECTIVES: The Patient Protection and Affordable Care Act (PPACA) includes a provision that penalizes insurance companies if their Medical Loss Ratio (MLR) falls below a specified threshold. The MLR is roughly measured as the ratio of health care expenses to premiums paid by enrollees. I investigate whether there is a relationship between MLRs and the quality of care provided by insurance companies. METHODS: I employ a ten-year sample of market-level financial data and quality variables for Texas insurers, as well as relevant control variables, in regression analyses that utilize insurer and market fixed effects. RESULTS: Of the 15 quality measures, only one has a statistically significant relationship with the MLR. For this measure, the relationship is negative. CONCLUSIONS: Although the MLR provision may provide incentives for insurance companies to lower premiums, this sample does not suggest that there is likely to be a beneficial effect on quality.

'More stressful than cancer': Treatment Experiences Lived During Hurricane Maria among Breast and Colorectal Cancer Patients in Puerto Rico.

Background: This study explored experiences in cancer care and disruption after Hurricanes Irma and Maria's aftermath in Puerto Rico (PR). Methods: A total of three focus groups were conducted among breast and colorectal cancer patients diagnosed six months before the disaster. Results: The most prevalent themes were (a) barriers related to their cancer treatment, (b) facilitators related to their cancer treatment, and (c) treatment experiences during the hurricane. Participants discussed struggles regarding their experience with treatment and access to care during and after Hurricanes Irma and Maria and how household limitations due to lack of electricity and water deter their intention to continue their treatment. Moreover, stressors directly linked with the disaster were the most challenging to cope with. Conclusions: Our study identifies the hardships experienced by cancer patients living during a disaster. Similarly, our study highlights the impending need to address in future emergency plans the individual and system needs of cancer patients in active treatment to minimize the delay in continuing cancer care.

Economic Analyses of Obsessive-Compulsive Disorder Interventions: A Systematic Review.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a neuropsychiatric condition featuring patterns of obsessions, compulsions, and avoidant behaviors that are often time consuming and distressing to affected individuals. Cognitive-behavioral therapy (CBT) with exposure and response prevention and/or serotonin reuptake inhibitors are first-line treatments for OCD, though other therapeutic interventions may serve as economically practical modalities under various circumstances. Exploring and understanding the cost effectiveness of all indicated OCD interventions are important to inform therapeutic decisions and provide quality patient-centered care at a cost that is not burdensome to the patient and/or healthcare system. METHODS: A systematic literature review was performed and studies were extracted from PubMed, Embase, Ovid MEDLINE, and Cochrane. All cost-effectiveness studies that included economic analyses with respect to OCD treatment modalities and were written in English and published between January 2010 and July 2022 were eligible for inclusion in the present study. We report a narrative synthesis of the findings and quality appraisal of the selected references. RESULTS: Of the 707 references returned in the literature search, a total of 18 cost-effectiveness studies were included for review. Compared with treatment as usual, several studies reported clinical superiority and cost effectiveness of Internet-based CBT programs for adults and children with OCD at various willingness-to-pay thresholds and economic reference indicators, though cost effectiveness relative to in-person CBT with exposure and response prevention is unclear and estimates of efficacy are likely lower for Internet-based CBT. One study favored the cost utility of serotonin reuptake inhibitor monotherapy over CBT with exposure and response prevention although efficacy estimates of the former tend to be lower, and relative cost differences were low. Five studies evaluated the cost effectiveness of high-intensity neuroaugmentation, including deep brain stimulation and stereotactic radiosurgical capsulotomy, in the context of treatment-refractory OCD. CONCLUSIONS: Despite the relatively high prevalence of OCD worldwide, cost-effectiveness data for therapeutic modalities remain sparse. Because of the chronic nature of OCD, the cost of treatment accumulates and may lead to a significant financial burden over time, particularly when non-evidence-based interventions are used. However, several alternative therapeutic modalities hold promise for economic practicality without significant sacrifice in clinical efficacy. Future studies are necessary to directly compare the cost effectiveness of such therapeutic alternatives with the current standard of care, CBT with exposure and response prevention.

The relationship between abortion rates and economic fluctuations.

We analyze the relationship between abortions and economic fluctuation at the U.S. state level for the 1995-2016 period. We do not find a statistically significant association between the overall abortion rate and the unemployment rate across the full sample period. However, we observe a procyclical association from approximately 2004 to 2010, during which a one percentage point increase in the unemployment rate is associated with a roughly 5% decrease in the abortion rate. This procyclical association is confirmed when we subsample our data to the 2005-2016 period. Our subgroup analysis indicates a procyclical association for the abortion rates for younger women, while we do not observe statistically significant associations when the analysis is stratified by race or ethnicity. The associations we observe for the younger age groups are especially pronounced in states with restrictions on Medicaid funding of abortions. Our analysis suggests that economic conditions may be an important factor in the reproductive choices by women.

Economic Evaluation of Dupilumab Versus Endoscopic Sinus Surgery for the Treatment of Chronic Rhinosinusitis With Nasal Polyps.

BACKGROUND: Dupilumab is a novel monoclonal antibody that recently received US Food and Drug Administration approval for the treatment of chronic rhinosinusitis with nasal polyps. Endoscopic sinus surgery (ESS) has been the mainstay of treatment for patients refractory to initial medical therapy. Data comparing the cost-effectiveness of these treatments are scarce. The objective of this study is to compare the cost-effectiveness of dupilumab and ESS treatment for patients with chronic rhinosinusitis with nasal polyps refractory to medical therapy. METHODS: A cohort-style Markov decision tree economic evaluation with 10-year time horizon was performed. The two comparative treatment strategies were dupilumab therapy or ESS followed by postoperative maintenance therapy. Patients with response to treatment continued with either maintenance or dupilumab therapy; patients with no response underwent ESS. The primary outcome measure was incremental cost per quality-adjusted life-year calculated from Sino-Nasal Outcome Test (SNOT-22) scores. Sensitivity analyses were performed including discounting scenarios and a probabilistic sensitivity analysis. RESULTS: The dupilumab strategy cost $195,164 and produced 1.779 quality-adjusted life-years. The ESS strategy cost $20,549 and produced 1.526 quality-adjusted life-years. This implies an incremental cost of $691,691 for dupilumab for every 1-unit increase in quality-adjusted life-year compared with ESS. Probability sensitivity analysis indicated that ESS was more cost-effective than dupilumab in all iterations. CONCLUSIONS: While dupilumab and ESS may demonstrate similar clinical effectiveness, ESS remains the most cost-effective treatment option and should remain the standard of care for patients with chronic rhinosinusitis with nasal polyps refractory to medical therapy.

Stepped Care Versus Standard Care for Children After Trauma: A Randomized Non-Inferiority Clinical Trial.

OBJECTIVE: Trauma-focused cognitive-behavioral therapy (TF-CBT) is an evidence-based therapist-led treatment for children after trauma. Parents often experience barriers to treatment engagement, including cost. Stepped care TF-CBT (SC-TF-CBT) was developed as an alternative delivery system. Step One is a parent-led therapist-assisted treatment. Step Two provides therapist-led TF-CBT for children who did not benefit from Step One and require more intensive treatment. This study compared SC-TF-CBT to standard TF-CBT in a community-based non-inferiority trial. METHOD: A total of 183 children (aged 4-12 years) experiencing posttraumatic stress symptoms (PTSS) and their caregivers were randomly assigned to SC-TF-CBT or standard TF-CBT within 6 community clinics. Assessments occurred at baseline, mid- and posttreatment, and 6 and 12 months. Primary outcomes included PTSS and impairment. Secondary outcomes included severity, diagnostic status, remission, and response. Treatment cost, acceptability, and satisfaction were measured. Difference and non-inferiority tests were applied. RESULTS: SC-TF-CBT participants changed at rates comparable to participants in TF-CBT for primary and secondary measures. SC-TF-CBT was non-inferior to TF-CBT for PTSS, impairment, and severity at all time points except for impairment at the 6-month assessment. Attrition did not differ between treatment arms (132 participants were completers). Baseline treatment acceptability was lower for SC-TF-CBT parents, although there was no difference in expected treatment improvements or treatment satisfaction at posttreatment. Based on regression estimates, total costs were 38.4% lower for SC-TF-CBT compared to TF-CBT, whereas recurring costs were 53.7% lower. CONCLUSION: Stepped Care TF-CBT provides an alternative way to deliver treatment for some children and parents, with reduced cost for providers and parents. CLINICAL TRIAL REGISTRATION INFORMATION: Stepped Care for Children after Trauma: Optimizing Treatment; https://clinicaltrials.gov; NCT02537678.

Intervention cost-effectiveness for pediatric anxiety and OCD: A systematic review and integrated database model.

BACKGROUND: While multiple treatments for pediatric anxiety and obsessive compulsive disorder (OCD) are efficacious, little is known about their cost-effectiveness. In response, we sought to provide relevant information through systematic review and cost-effectiveness simulation. METHODS: We evaluated the cost-effectiveness of treatment for pediatric anxiety and OCD in two ways. First, we conducted a systematic review following PRISMA guidelines. Second, we evaluated cost-effectiveness for antidepressant medication, cognitive behavioral therapy, and their combination via a simulation that integrated information from the Truven MarketScan database and the NIMH National Database for Clinical Trials Related to Mental Illness. RESULTS: Both systematic review and simulation found antidepressant medication and cognitive behavioral therapy to be cost-effective for pediatric anxiety and OCD. Antidepressant medication was the least costly approach, and cognitive behavioral therapy provided additional cost-effectiveness, especially for OCD. LIMITATIONS: During systematic review, relatively few articles provided information about both costs and effectiveness. While there was a notable margin of error to support multiple interventions as cost-effective, limited prior research decreased precision of point estimates and comparisons between interventions. CONCLUSIONS: Both antidepressant medication and cognitive behavioral therapy were found to be cost-effective for pediatric anxiety and OCD. Results supported investment from third party payers, who serve as critical gatekeepers that can increase treatment dissemination. However, more precise information would better inform the exact amount of investment needed, especially with regard to selection decisions between active interventions. Cost-effectiveness research would benefit from systematic collection of data on treatment costs and quality of life in future clinical trials.

Stepped-Care Cognitive Behavioral Therapy in Children on the Autism Spectrum with Co-occurring Anxiety.

This trial examined stepped-care cognitive-behavioral treatment (CBT) among 96 autistic youth with co-occurring anxiety. Step 1 included an open trial of parent-led, therapist-guided bibliotherapy. Step 2 was family-based CBT for those who did not respond to Step 1 or maintenance for those who did. Eighteen participants (28%) who completed Step 1 responded. Responders reported significantly lower pre-treatment anxiety, internalizing symptoms, and functional impairment than non-responders. After Steps 1 and 2, 80% of completers (55% intent-to-treat) were responders. Anxiety, impairment, and ASD-related impairments significantly improved. Youth in maintenance experienced faster improvement through post-treatment, though there were no group differences at 3-month-follow-up. A stepped approach may help some individuals in Step 1, particularly those who are less anxious.

Excess Mortality Associated With COVID-19 by Demographic Group: Evidence From Florida and Ohio.

OBJECTIVE: COVID-19 mortality varies across demographic groups at the national level, but little is known about potential differences in COVID-19 mortality across states. The objective of this study was to estimate the number of all-cause excess deaths associated with COVID-19 in Florida and Ohio overall and by sex, age, and race. METHODS: We calculated the number of weekly and cumulative excess deaths among adults aged ≥20 from March 15 through December 5, 2020, in Florida and Ohio as the observed number of deaths less the expected number of deaths, adjusted for population, secular trends, and seasonality. We based our estimates on death certificate data from the previous 10 years. RESULTS: The results were based on ratios of observed-to-expected deaths. The ratios were 1.17 (95% prediction interval, 1.14-1.21) in Florida and 1.15 (95% prediction interval, 1.11-1.19) in Ohio. Although the largest number of excess deaths occurred in the oldest age groups, in both states the ratios of observed-to-expected deaths were highest among adults aged 20-49 (1.21; 95% prediction interval, 1.11-1.32). The ratio of observed-to-expected deaths for the Black population was especially elevated in Florida. CONCLUSIONS: Although excess deaths were largely concentrated among older cohorts, the high ratios of observed-to-expected deaths among younger age groups indicate widespread effects of COVID-19. The high levels of observed-to-expected deaths among Black adults may reflect in part disparities in infection rates, preexisting conditions, and access to care. The finding of high excess deaths among Black adults deserves further attention.

Potential undercounting of overdose deaths caused by specific drugs in vital statistics data: An analysis of Florida.

INTRODUCTION: Due largely to ambiguous or incomplete information provided on death certificates, the widely cited Multiple Cause of Death (MCOD) data reported by the U.S. Centers for Disease Control and Prevention has been shown to undercount the number of fatal overdoses caused by specific drugs. However, the extent of the undercounts is unclear. METHODS: We obtained the number of fatal overdoses from 2003 to 2017 in Florida caused by the three drug groups (amphetamines, benzodiazepines, and opioids) and three drugs (methadone, cocaine, and heroin) that we could map across the MCOD data and data reported by the Florida Medical Examiners Commission (FMEC). The FMEC data are based on state-mandated reporting of the causal drugs in overdose deaths. We analyzed the differences across all deaths and by gender, age group, and race. RESULTS: Depending on the drug, the numbers of deaths across all individuals reported in the FMEC data ranged from 19 %-39 % higher than the counts in the MCOD data. The differences varied over time and by some demographic factors. CONCLUSIONS: The MCOD data appear to undercount the number of fatal overdoses caused by the drugs we investigated. Our analysis did not identify a cause or pattern to explain the differences. Efforts to improve the reporting of fatal overdoses may enhance our understanding of and subsequently may improve the response to the drug overdose epidemic.