Impacts of prescription drug monitoring program policy changes and county opioid safety coalitions on prescribing and overdose outcomes in California, 2015-2018.

In 2015, California received funding to implement the Prescription Drug Overdose Prevention Initiative, a 4-year program to reduce deaths involving prescription opioids by 1) leveraging improvements to California's prescription drug monitoring program (PDMP) (i.e., mandatory PDMP registration for prescribers and pharmacists), and 2) supporting county opioid safety coalitions. We used statewide data from 2011 to 2018 to evaluate the Initiative's impact on opioid prescribing and overdose rates. Prescribing data were obtained from California's PDMP; fatal and non-fatal overdose data were obtained from the California Department of Public Health. Outcomes were monthly opioid prescribing rates and opioid overdose rates, modeled using generalized linear mixed models. Exposures were mandatory PDMP registration, presence of county coalitions, and Initiative support for county coalitions. Mandatory PDMP registration was associated with a 25% decrease (95%CI, 0.71-0.79) in opioid prescribing rates after 24 months. Having a county coalition was associated with a 2% decrease (95%CI, 0.96-0.99) in the opioid prescribing rate; receiving Initiative support was associated with an additional 2% decrease (95%CI, 0.97-0.98). Mandatory PDMP registration and county coalitions were associated with a 35% decrease (95%CI, 0.43-0.97) and a 21% decrease (95% CI, 0.70-0.90), respectively in prescription opioid overdose deaths. Both interventions were also associated with significantly fewer deaths involving any opioid but had no significant association with non-fatal overdose rates. Findings add to the knowledge available to guide policy to prevent high-risk prescribing and opioid overdoses. While further study is needed, coalitions and mandatory PDMP registration may be important components in such efforts.

Assessing and improving child death review team recommendations.

BACKGROUND: Child death review teams (CDRTs) are multi-agency, multidisciplinary teams that review the circumstances surrounding child deaths. Although the potential of CDRTs to promote systems improvement and prevention is well recognised, teams often struggle to translate their findings into effective preventive actions. OBJECTIVE: To present results from a study assessing the quality of written recommendations in published CDRT reports; and provide guidelines for improving the quality and effectiveness of these written recommendations. METHODS: A descriptive, non-experimental design was used to analyse a set of 1093 recommendations from 21 randomly selected, publicly available state and local CDRT reports. An assessment instrument, modelled on the public health approach, was developed to score the quality of recommendations. It consists of three components divided into 10 dimensions: problem assessment; written recommendations; and action on recommendations. RESULTS: CDRT reports scored highest in the problem assessment component (mean score: 2.7/dimension), followed by written recommendations (2.2/dimension), and action on recommendations (1.9/dimension). Even among the highest ranked dimensions, the average scores were only in the mid range of quality on our assessment scale. CONCLUSIONS: The results suggest that CDRTs are doing a better job of 'assessing the problem' than in 'proposing solutions' as indicated by their written recommendations. CDRT reports often do not address follow-up of their written recommendations. Guidelines are offered for use as a practical tool to help CDRTs enhance the likelihood of producing effective recommendations that prevent future child injuries and deaths.

Collaborative process improvement to enhance injury prevention in child death review.

OBJECTIVE: To increase the number and quality of injury prevention recommendations made by Washington State (USA) child death review teams. DESIGN: Before and after study design involving four intervention teams and 21 comparison teams. METHODS: Intervention teams received injury prevention training, collaborative process improvement coaching, and access to web based prevention resources. An equal number of randomly selected child death review case reports filed with the state before the intervention by the intervention and comparison teams were included in the baseline sample. All reports submitted by the intervention and comparison teams after the intervention were included in the follow-up sample. Reports were scored on the completeness of prevention related data elements and on the quality of written prevention recommendations. RESULTS: Data completion for prevention relevant items increased in intervention teams from 73% at baseline to 88% at follow-up. In comparison teams, this measure fell from 77% to 56% over the same period. The quality of written recommendations produced by intervention teams increased from 4.3 (95% CI 3.4 to 5.1) to 7.6 (95% CI 6.7 to 8.5), while comparison teams showed no significant change (4.0 (95% CI 2.5 to 5.3) to 3.7 (95% CI 2.2 to 5.2)). Specifically, improvements were noted in the identification of evidence based best practices and the development of clear, actionable written recommendations. CONCLUSION: Injury prevention recommendations are generated in the systematic local review of child deaths. This process can be analysed, measured, supported, and improved.

Using capture-recapture methods to better ascertain the incidence of fatal child maltreatment.

OBJECTIVES: To (1) test the use of capture-recapture methods to estimate the total number of child maltreatment deaths in a single state using information from death certificates, child welfare reports, child death review teams, and uniform crime reports; and to (2) compare these estimates to the number of maltreatment deaths identified through an in-depth "gold standard" review. METHODS: Child maltreatment deaths were identified in four existing administrative data sources: (1) death reports in our state vital statistics (DC); (2) child death review team reports (CDR); (3) homicide reports filed by our state police agency as uniform crime report (UCR) supplements for the FBI; and (4) abstracted reports of a minor's death from our state child protective services (CPS) agency. Capture-recapture pair-wise and pooled comparisons were then applied to estimate the numbers of abuse and total maltreatment deaths and were compared to the number of cases identified by independent case review. RESULTS: There were a total of 194 child maltreatment deaths in Michigan during 2000-2001 with 66 due to physical abuse. Capture-recapture analysis estimated the mean number of total child maltreatment deaths as 101.02 (95%CI=92.52, 109.53), with abuse deaths of 64.55 (60.85, 68.25). Most pair-wise and pooled comparisons worked equally well for abuse deaths, but estimates for total child maltreatment deaths were low. CONCLUSIONS: Capture-recapture methods applied to existing administrative datasets produced accurate estimates of child abuse deaths but were not useful in producing reliable estimates of total child maltreatment deaths due to undercounting neglect-related deaths in all existing administrative data sets. The underlying assumptions for capture-recapture methods were not met for neglect deaths. Local and/or state teams conducting ongoing intensive case review may yet remain the best way to identify the total number of child maltreatment deaths. PRACTICE IMPLICATIONS: Capture-recapture methods allow for more accurate estimation of the true number of child physical abuse deaths than does using single existing sources of child fatality information, but deaths from causes other than abuse are undercounted. Child maltreatment fatality surveillance requires a systematic process and standard criteria for identifying cases of maltreatment, particularly neglect-related child deaths.

Passive surveillance of shaken baby syndrome using hospital inpatient data.

BACKGROUND: The conference from which these articles came addressed the question of public health surveillance for shaken baby syndrome (SBS) and explores one component of a comprehensive SBS surveillance system that would be relatively easy to implement and maintain: passive surveillance based on hospital inpatient data. Provisional exclusion and inclusion criteria are proposed for a two-level case definition of diagnosed SBS (strict definition) and cases presumed to be SBS (broad definition). The strict SBS definition is based on the single SBS code in the ICD-9-CM (995.55). The broader presumptive SBS definition is based on research studies that have identified a pattern of diagnostic codes often considered part of the clinical diagnosis of SBS. RESULTS: Based on 2006 analyses, California inpatient data are presented for 1998-2004. The strict SBS definition identified 366 cases over the 7 years, whereas the broader definition captured nearly 1000 cases. Annual rates show little fluctuation from the overall rate of 5.1 for strict SBS and 14.0 for broad SBS (per 100,000 children aged <2 years). Selected demographic and outcome characteristics are presented for each definition. The broad definition produces rates that are roughly comparable to those produced in careful clinical and population-based studies that also included children who died without being hospitalized. CONCLUSIONS: Despite the limitations of inpatient data, a passive surveillance system like the one proposed here can provide a critical component for a comprehensive SBS surveillance system and may be adequate for some purposes, including identifying high-risk areas or groups for intervention and monitoring trends over time.

Public health surveillance of fatal child maltreatment: analysis of 3 state programs.

OBJECTIVES: We sought to describe approaches to surveillance of fatal child maltreatment and to identify options for improving case ascertainment. METHODS: Three states--California, Michigan, and Rhode Island--used multiple data sources for surveillance. Potential cases were identified, operational definitions were applied, and the number of maltreatment deaths was determined. RESULTS: These programs identified 258 maltreatment deaths in California, 192 in Michigan, and 60 in Rhode Island. Corresponding maltreatment fatality rates ranged from 2.5 per 100,000 population in Michigan to 8.8 in Rhode Island. Most deaths were identified by child death review teams in Rhode Island (98%), Uniform Crime Reports in California (56%), and child welfare agency data in Michigan (44%). Compared with the total number of cases identified, child welfare agency (the official source for maltreatment reports) and death certificate data underascertain child maltreatment deaths by 55% to 76% and 80% to 90%, respectively. In all 3 states, more than 90% of cases ascertained could be identified by combining 2 data sources. CONCLUSIONS: No single data source was adequate for thorough surveillance of fatal child maltreatment, but combining just 2 sources substantially increased case ascertainment. The child death review team process may be the most promising surveillance approach.