# Presentation: 293541

## Judy K. Ball, Ph.D., M.P.A.
Redesign of the Drug Abuse Warning Network
Prepared 7/2004

- Judy K. Ball, Ph.D., M.P.A.
- Redesign of the Drug Abuse Warning Network
- Prepared 7/2004

## Overview of DAWN

- Two components required by law:
- Drug-related emergency department visits
- Drug-related deaths reviewed by medical examiners/coroners
- Section 505, Public Health Service Act

## Short History of DAWN

-  _2003_  **New DAWN begins**

-  _1972_  DAWN begins

-  _1988_  Probability sample of EDs introduced

## Evaluating the Future of DAWN

- Expert panel convened November 1997
- To advise SAMHSA on DAWN’s future
- Question asked:  Should DAWN continue?
- Panel’s answer:  Yes, but improve it.

## Why Change?

- Timeliness
- Lack of focus on health
- Data quality issues
- Sample design limitations
- Health system change
- Population shifts
- Misuse of findings
- Improve usefulness

## Evaluation of Alternatives, 1999-2001

- Should DAWN continue?
- Is information from DAWN valuable?
- If yes, focus on:
- Who are DAWN's users?
- What information do they need?

## DAWN Users

- Office of National Drug Control Policy
- Food and Drug Administration
- Community Epidemiology Work Group
- Drug Enforcement Administration
- Participating facilities
- Treatment agencies, prevention coalitions
- Communities

## Key Design Issues

- Do we collect data from the right settings?
- Do we collect data on the right patients?
- Do we collect the right data?
- How can we collect data more efficiently?
- How can we deliver information more effectively?

## Key Design Issues

- Do we collect data from the right settings?

- Yes!

## Impact of Health System Change

- No consistent pattern nationally
- No decline in ED use; possible increase
- Varies by locality
- Emergent conditions will always go to ED
- Non-urgent care alternatives vary across place and time
- Therefore, continue to collect data in EDs

## DAWN ED Sample, 1988-2002

- Stratified probability sample
- Short-term, general, non-Federal hospitals operating 24-hour emergency departments
- Statistical estimates
- Coterminous U.S. (48 States)
- 21 major metropolitan areas

## DAWN “1988 Sample”

- 21 metro areas
- Coterminous U.S.

## Redesign of DAWN – ED

- Restructure sample
- Reflect changes in health care system
- Update metropolitan area boundaries
- Improve precision of estimates
- Reduce dependence on individual facilities
- Improve geographic and population coverage

## Adopt New Recruitment Strategies

- Recruit communities first
- Build on community leadership
- Provide benefits for participation

## DAWN “2003 Sample”

- 22 metro areas
- Full U.S.

## Mortality Component, 1988-2002

- Not a statistical sample
- Death investigation jurisdictions
- 140 jurisdictions
-  40 metropolitan areas
- Cannot generalize to
- Metro areas with incomplete participation
- U.S. as a whole

## Evaluation of Mortality Options

- No alternative source for:
- Timely data
- Specific drug information
- Criteria for death investigations vary across jurisdictions
- No basis for statistical sample

## Redesign of DAWN – Mortality

- Link morbidity and mortality components
- Recruit _all_ jurisdictions in ED target areas
- Add selected statewide systems
- Forego national estimates for drug mortality

## Key Design Issues:  Content

- Do we collect data on the right patients?

- No!

## DAWN Cases – 1972-2002

## DAWN Case Criteria, 1972-2002

- Age 6-97 treated in ED
- Visit related to drug abuse
- Motive for drug use
- Dependence
- Psychic effects
- Suicide attempt/gesture
- Alcohol-in-combination

**Notes:**
Retrospective chart review

## Problems in DAWN Case Finding

- Complex case criteria
- Applied inconsistently in the field
- Focused on _intent to abuse_ – often undocumented in source records
- Use of inferior case-finding methods
- Designed to minimize chart review
- Missed substantial numbers of cases
- Found cases inconsistently
- Yielded mix of history and current drug use

## Redesign of DAWN Case Criteria

- Age 6-97 treated in ED
- Visit related to drug abuse
- Motive for drug use
- Dependence
- Psychic effects
- Suicide attempt/gesture

**Notes:**
Retrospective chart review

## DAWN Case Criteria, 2003

- Was the ED visit related to recent drug use?
- Any age
- Any drug
- Any reason

## New DAWN Case Criteria

- Broad and simple
- Few exceptions
- Easy to implement consistently
- Recognize limitations of medical record documentation
- Yield diverse set of drug-related cases
- Parse into subgroups for analysis
- Interesting to more diverse audiences

## New DAWN Case Criteria, 2003+

- Any ED visit/death related to recent drug use
- Any age
- Any drug
- Any reason

## DAWN ED Case Types

- Suicide attempt
- Seeking detox
- Alcohol only (age <21)
- Adverse Reaction
- Overmedication
- Malicious poisoning
- Accidental ingestion
- “Other”

- i.e., everything else

## Higher Quality Data

- Case finding by direct (100%) chart review
- Eliminate reporter judgments about:
- Patient's intent to abuse
- Link between history and current visit
- Improve training

## Key Design Issues:  Content

- Do we collect the right data?

- No!

## Problems with DAWN Data Content

- Did not include
- Any information on health
- Any information to validate case
- Any information to validate drugs
- Did include
- Concepts unavailable from source records
- Frequently missing data
- Minimal quality control possible

## Solving Problems – Data Content

- Add data items to:
- Describe types of cases
- Understand health consequences
- Improve drug data
- Greater specificity
- Improved accuracy
- Omit current medications, if unrelated
- Add tox confirmation
- Improve training and edits

## ED Data Items

- _Before_
- Demographics
- 4 drugs & alcohol
- Route, form, source
- Disposition
- Reason for taking drug
- Reason for visit

- _New DAWN in 2003_
- Demographics
- 6 drugs & alcohol
- Route
- Disposition
- Type of case
- Presenting complaint
- Diagnoses
- Case narrative

## Mortality Data Items

- _Before_
- Demographics
- 6 drugs & alcohol
- Route
- Drug involvement
- Manner of death

- _New DAWN in 2003_
- Demographics
- 6 drugs & alcohol
- Route
- Drug involvement
- Manner of death
- Cause(s) of death
- Place of death

## Key Design Issues:  Operations

- How can we collect data more efficiently?

- Use computers & the Internet!

## e-DAWN

- All data submitted electronically
- Fast
- Secure
- Immediately available for online analysis
- Higher quality data
- Data validation at data entry
- Automatic prompts
- Intelligent drug look-up

## What is “New” About New DAWN?

- New case criteria
- New data items
- New case finding protocol
- New training methods
- New benefits for members
- New sample
- New metro definitions
- New baseline for trends

## DAWN Public Website

- _[http://](http://dawninfo.samhsa.gov/)__[DAWNinfo](http://dawninfo.samhsa.gov/)__[.](http://dawninfo.samhsa.gov/)__[samhsa](http://dawninfo.samhsa.gov/)__[.](http://dawninfo.samhsa.gov/)__[gov](http://dawninfo.samhsa.gov/)_