DRHS-Consultation Paper



2501901247775Drug-Related Hospital StatisticsConsultationA consultation on a proposed new definition of a drug-related hospital stayIntroductionInformation Services Division (ISD) of NHS National Services Scotland publish Drug-Related Hospital Statistics annually (the most recently published report can be accessed here). ISD are committed to producing information that meets the needs of stakeholders, customers and the public. The purpose of this consultation is to seek feedback on a proposed change to the codes used to define a drug-related hospital stay in the Drug-Related Hospital Statistics publication. This consultation is in line with best practice for official statistics publishers, which encourages user engagement to ensure that publications are of value.The proposed new definition of a drug-related hospital stay will maintain the focus of the current definition on the ‘problematic’ use of psychoactive drugs (substances which alter brain function, resulting in temporary changes in perception, mood, consciousness and behaviour) which are a) illicit - legally controlled and not prescribed (e.g. cocaine), b) prescribed but could result in overuse or dependence (e.g. diazepam), or c) prescribed for the treatment of drug dependence (e.g. methadone). In this context, drug use is regarded as ‘problematic’ because it may have directly caused harm to the individual or have been a factor associated with the hospital admission. ISD are considering widening the current definition of a drug-related hospital stay to include stays due to drug poisoning/overdose. The purpose of the proposed change is to widen the range of drug-related harms captured in the statistics, ensuring relevant hospital activity is measured more comprehensively.How to respondWe would be grateful if you could respond using the anonymous online survey – see Appendix 1. As an alternative to the online survey, the form in Appendix 2 can be returned either by email to NSS.isdsubstancemisuse@ or by post to:Lee BarnsdaleNHS National Services Scotland (ISD),Area 114C, Gyle Square,1 South Gyle Crescent,Edinburgh, EH12 9EB.ISD will keep a record of the responses to this consultation. Note that this consultation asks for information on the type of organisation you work for – this will enable us to identify the different organisations responding. Information submitted via online survey/email/post in the consultation will be securely processed and analysed by ISD. Specific comments made to respondents may be included in the summary of responses. However, where applicable, these will be anonymised to remove identifiable references to people or places.Responses must be submitted no later than 30 November 2018.Please pass this consultation onto others who you think may be interested.What happens nextISD will consider all the feedback received in response to this consultation before making a final decision on any changes to future Drug-Related Hospital Statistics publications. A summary of the responses and information about any changes will be published on the ISD website at by 14 December 2018.Definition of a drug-related hospital stay1. Current definitionInformation on the reason a person is in hospital (either as an inpatient or a day case) is recorded in the diagnosis code on a hospital record. For each hospital record up to six diagnosis codes can be recorded. Diagnoses are coded using the International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10).Table 1 lists the ICD-10 diagnosis codes which are currently used to select drug-related hospital records. A hospital stay is counted as ‘drug-related’ if any of these diagnosis codes is recorded in any of the six diagnosis positions on any relevant hospital record for a person.Table 1: Current Drug-Related Hospital Statistics definitionICD-10 Diagnosis CodeDescriptionF11Mental and behavioural disorders due to: OpioidsF12Mental and behavioural disorders due to: CannabinoidsF13Mental and behavioural disorders due to: Sedatives / HypnoticsF14Mental and behavioural disorders due to: CocaineF15Mental and behavioural disorders due to: Other StimulantsF16Mental and behavioural disorders due to: HallucinogensF18Mental and behavioural disorders due to: Volatile SolventsF19Mental and behavioural disorders due to: Multiple / Other DrugsThe above definition excludes codes associated with drug poisonings or overdoses. Some overdoses occur as a result of using drugs in the course of normal therapeutic treatment, while others occur as a result of problematic drug use. ICD-10 drug poisoning/overdose codes name the drug type, but do not identify the context in which the drug was used. ISD propose that, where the substance associated with poisoning/overdose can confidently be identified as an illicit drug (e.g. Cocaine), these hospital records should be counted as drug-related hospital stays. For other drug poisoning/overdose diagnoses where it is not clear that use is illicit, we propose that they should be counted as drug-related hospital stays if other evidence of problematic drug use was included in the hospital record (i.e. if one of the ICD-10 codes in Table 1 (F11-F16, F18 or F19) is also recorded). Section 2 provides more information on this.2. Proposed drug poisoning/overdose definition As discussed in section 1, it is proposed that hospital stays occurring as a result of drug poisoning or overdose should be included in the Drug-Related Hospital Statistics publication so that drug-related hospital activity is measured more comprehensively. These drug-related hospital stays/records would be identified using the ICD-10 diagnosis codes shown in Table 2. Table 2: Proposed ‘overdose’ definitionICD-10 CodeDescriptionT40.0Poisoning by narcotics: Opium T40.1Poisoning by narcotics: HeroinT40.2 + ICD-10 ‘F’ code*Poisoning by narcotics: Other opioids + Mental and behavioural substance misuse disorder code*T40.3Poisoning by narcotics: MethadoneT40.4 + ICD-10 ‘F’ code*Poisoning by narcotics: Other synthetic narcotics + Mental and behavioural substance misuse disorder code*T40.5Poisoning by narcotics: CocaineT40.6Poisoning by narcotics: Unspecified NarcoticsT40.7Poisoning by narcotics: CannabisT40.8Poisoning by narcotics: LSDT40.9Poisoning by narcotics: Unspecified HallucinogensT42.3 + ICD-10 ‘F’ code*Poisoning by antiepileptic, sedative-hypnotic and antiparkinsonism drugs: Barbiturates + Mental and behavioural substance misuse disorder code*T42.4 + ICD-10 ‘F’ code*Poisoning by antiepileptic, sedative-hypnotic and antiparkinsonism drugs: Benzodiazepines + Mental and behavioural substance misuse disorder code*T43.6 + ICD-10 ‘F’ code*Poisoning by psychotropic drugs NEC: Psychostimulants with abuse potential + Mental and behavioural substance misuse disorder code*T52 + ICD-10 ‘F’ code*Toxic effect of organic solvents + Mental and behavioural substance misuse disorder code** Record should also include ICD-10 code F11, F12, F13, F14, F15, F16, F18 or F19 (as specified in Table 1).The ICD-10 section ‘Poisoning by drugs, medicaments and biological substances’ (ICD-10 codes: T36-T50) includes most of the codes in Table 2. Guidance for the use of these codes states that poisonings resulting from either ‘overdoses’ or ‘substance given or taken in error’ are to be included, creating potential difficulties distinguishing overdoses because of problematic drug use from drug administration errors in the course of normal therapeutic use. For the majority of ICD-10 diagnosis codes specified in Table 2, the drugs associated with the poisoning/overdose are exclusively or overwhelmingly associated with illicit use (e.g. cocaine). Exceptions to this are discussed below.Heroin and methadone are known to be used for pain relief in cancer treatment. However, during the period 1997/98 to 2016/17 only 0.15% of general acute hospital stays recorded as poisoning with heroin/poisoning with methadone (ICD-10 codes: T40.1/T40.3) also had a cancer diagnosis (ICD-10 codes: C00-C97) in the same hospital stay. Given the very low percentage of these cases and the possibility that these hospital stays may be for people who use drugs, it is proposed that these codes be included in their entirety.For six drug types, a combination of poisoning and mental and behavioural disorder ICD-10 (‘F’) codes within the same hospital stay will be used to identify drug poisoning/overdose.This is because these drug types are widely prescribed, but can also be used problematically. It is proposed that overdose as a result of problematic drug use can only be reliably determined where other evidence of problematic drug use is included in the hospital record (i.e. an ICD-10 Mental and Behavioural Disorder (‘F’) code currently used to identify a drug-related hospital stay is also present in one of the diagnosis positions). Although this additional validation measure will enhance the reliability of figures, it may produce an underestimate of overdoses associated with problematic use of these substances.These types of poisonings are dealt with in a different way in the definition of drug overdoses used in England & Wales.England & Wales exclude T40.4 (Other synthetic narcotics (e.g. tramadol)), T42.3 (Barbiturates (e.g. amobarbital)), T42.4 (Benzodiazepines (e.g. diazepam, etizolam)) and T52 (Organic Solvents (e.g. aerosols)) from their overdose definition. However, it is proposed that inclusion of these stays (where other evidence of problematic drug use was available in the hospital record) correctly acknowledges ongoing use of these substances (in particular, benzodiazepines) by people with a drug problem in Scotland. England & Wales include all overdoses associated with T40.2 (Other opioids (e.g. codeine)) and T43.6 (Psychostimulants with abuse potential (e.g. methylphenidate/Ritalin)). However, as these drugs are widely prescribed, it is proposed that overdoses associated with these substances be included where other evidence of problematic drug use is available in the hospital record.3. Proposed combined Drug-Related Hospital Statistics definitionAs described in sections 1 and 2, ISD propose to expand the list of ICD-10 diagnosis codes used to identify drug-related hospital stays to be included in the Drug-Related Hospital Statistics definition by adding drug poisonings/overdoses associated with problematic drug use. The proposed list of diagnosis codes to be used (including the current codes) when counting the total number of drug-related hospital stays is shown in Table 3. Table 3: Proposed combined Drug-Related Hospital Statistics definitionICD-10 CodeDescriptionF11Mental and behavioural disorders due to: OpioidsF12Mental and behavioural disorders due to: CannabinoidsF13Mental and behavioural disorders due to: Sedatives/ HypnoticsF14Mental and behavioural disorders due to: CocaineF15Mental and behavioural disorders due to: Other StimulantsF16Mental and behavioural disorders due to: HallucinogensF18Mental and behavioural disorders due to: Volatile SolventsF19Mental and behavioural disorders due to: Multiple / Other DrugsT40.0Poisoning by narcotics: Opium T40.1Poisoning by narcotics: HeroinT40.3Poisoning by narcotics: MethadoneT40.5Poisoning by narcotics: CocaineT40.6Poisoning by narcotics: Unspecified NarcoticsT40.7Poisoning by narcotics: CannabisT40.8Poisoning by narcotics: LSDT40.9Poisoning by narcotics: Unspecified HallucinogensFor the codes listed below relevant hospital stays would be identified via the presence in the same hospital stay of at least one of the ICD-10 Mental and Behavioural Disorder codes F11-F16, F18 or F19T40.2Poisoning by narcotics: Other opioidsT40.4Poisoning by narcotics: Other synthetic narcoticsT42.3Poisoning by antiepileptic, sedative-hypnotic and antiparkinsonism drugs: BarbituratesT42.4Poisoning by antiepileptic, sedative-hypnotic and antiparkinsonism drugs: BenzodiazepinesT43.6Poisoning by psychotropic drugs NEC: Psychostimulants with abuse potentialT52Toxic effect of organic solventsUsing the proposed combined Drug-Related Hospital Statistics definition, the total number of drug-related general acute hospital stays counted in each Financial Year will be higher than the total number of stays counted using the current definition. However, the total number of drug-related psychiatric hospital stays will be almost the same compared with the current definition.The percentage increase in the number of drug-related stays following application of the proposed combined Drug-Related Hospital Statistics definition is shown in Table 4. Table 4: Percentage increase in the total number of general acute and psychiatric hospital stays counted using the proposed combined Drug-Related Hospital Statistics compared with the current definition, by Financial Year% IncreaseFinancial yearGeneral Acute Psychiatric1997/982201998/991701999/002102000/011802001/021802002/031802003/041302004/051302005/061202006/071402007/081502008/091302009/101402010/111302011/121302012/131302013/141202014/151102015/161102016/1711x‘x’ - psychiatric hospital data is not available for 2016/17.Appendix 1 – Online SurveyThe anonymous online survey can be accessed at . Please note that the survey includes exactly the same questions as the form in Appendix 2.Appendix 2 – Response FormRespondent DetailsType of Organisation (please mark X): NHS Board:General Practice:Integrated Joint Board:Scottish Government:Local authority:Charity/ Third Sector:University/Academia:Media:Private sector:Member of the public:Other (please specify):Organisation (optional):Response to ConsultationPlease use the comments box located after each question to provide further feedback/suggestions. In particular, for responses of ‘No’, we would welcome more information on why this option was selected.Question 1:Should the current Drug-Related Hospital Statistics definition be broadened to include hospital stays due to drug poisoning/overdose?Please mark X:Yes: No:Don’t have opinion:Comments:Question 2:Do you agree with the selection of ICD-10 codes which are used in the proposed ‘overdose’ definition?Please mark X:Yes: No: Don’t have opinion: Comments:Question 3:Do you agree with the selection of ICD-10 codes used in the proposed combined Drug-Related Hospital Statistics definition?Please mark X:Yes: No: Don’t have opinion: Comments:Question 4:How often do you use the published Drug-Related Hospital Statistics?Please mark X:Daily: Weekly: Monthly: Occasionally:Never:Question 5:Any other comments?Comments: ................
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