rx15 pdmp tues_330_1_brown_2fondario_3quesinberry
TRANSCRIPT
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PDMPs as Public Health Surveillance Tools:
Early Lessons from CDC’s Prevention Boost
Sheryll Brown, MPHOklahoma State Department of Health
Anna Fondario, MPHUtah Department of Health
Dana Quesinberry, JDKentucky Department for Public Health
Noah Aleshire, JDCenters for Disease Control
and Prevention
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Disclosure Statement
Sheryll Brown, MPH; Anna Fondario, MPH; Dana Quesinberry, JD; and Noah Aleshire, JD, have disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
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Disclosure Statement
• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
• The following planners/managers have the following to disclose:– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center– Carla Saunders – Speaker’s bureau: Abbott Nutrition
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Learning Objectives
• Outline prescription drug overdose prevention programs developed by five states through Prevention Boost cooperative agreements with CDC.
• Describe the PDMP components of four state programs.
• Evaluate three state programs using Prevention Boost to leverage PDMPs as public health surveillance tools.
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Prescription Drug Overdose:Boost for State Prevention
• Advance and evaluate comprehensive state-level interventions for preventing prescription drug overdose in 3 areas:
• Enhancing and maximizing PDMPs
• Improving and evaluating public insurer mechanisms
• Evaluating state-level laws, policies, and regulations
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Oklahoma Prescription Drug Overdose Prevention Program
Sheryll Brown, MPH
Injury Prevention Service
Oklahoma State Department of Health
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Overdose Mortality in Oklahoma
• Rates per 100,000 population more than doubled in the U.S. and increased nearly fourfold in OK since 1999.1
• Oklahoma has the 8th highest drug overdose death rate in the U.S.1
1. Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/injury/wisqars/index.html.
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Age-adjusted Motor Vehicle Crash and Poisoning Death Rates, Oklahoma, 1999-2013
0
5
10
15
20
25
1999 2001 2003 2005 2007 2009 2011 2013
Rat
e p
er 1
00,0
00 P
op
ula
tio
n
MVC All poisoning Drug poisoning Unintentional drug poisoning
Source: CDC WONDER http://wonder.cdc.gov/.
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Unintentional Opioid-related Overdose Death Rates1 and Opioid Sales per Person,2 Oklahoma,
2000-2012
0
200
400
600
800
1000
1200
0
2
4
6
8
10
12
14
2000 2002 2004 2006 2008 2010 2012
Mo
rph
ine
mg
eq
uiv
alen
ts/p
erso
n
Dea
th R
ate
per
100
,000
po
pu
lati
on
Death rate Opioid sales
1. Oklahoma State Department of Health, Injury Prevention Service, Unintentional Poisonings Database. 2. Department of Justice, Drug Enforcement Administration, Automation of Reports and Consolidated Orders
System, Report 4.
UP surveillance system created
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OK Injury Prevention ServiceDrug Overdose Data Sources
• Unintentional Poisoning Surveillance System
• Office of the Chief Medical Examiner– Statewide centralized system
– Receive reports for all non-natural deaths
– Narratives, autopsies, toxicology
• Vital Statistics death certificate data
• Hospital inpatient discharge data
• OK National Violent Death Reporting System
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Most Common Prescription Drugs by Year of Death, Unintentional Poisonings, Oklahoma, 2007-2013
Source: Oklahoma State Department of Health, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports).
0
20
40
60
80
100
120
140
160
180
2007 2008 2009 2010 2011 2012 2013
Nu
mb
er o
f D
eath
s
Year of Death
Hydrocodone
Oxycodone
Alprazolam
Methadone
Morphine
PMP checks mandated for methadone
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State Plan• Education
• Disposal/Storage
• Tracking and Monitoring
• Regulation and Enforcement
• Treatment and Interventions
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OK Prescription Monitoring Program (PMP)
• System within Bureau of Narcotics and Dangerous Drugs Control (OBNDDC)
• Established in 2006 – Includes Schedules II, III, IV and V
• Reporting requirements for dispensers– 2006 to 2010 = Reported to PMP every 30 days
– 2010 to 2012 = Reported to PMP every 24 hours
– 2012 to Today = Reported to PMP within 5 minutes of delivery to patient
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PMP Utilization
QTR 32010
QTR 42010
QTR 12011
QTR 22011
QTR 32011
QTR 42011
QTR 12012
QTR 22012
QTR 32012
QTR 42012
QTR 12013
QTR 22013
Doctor 112,346 120,190 141,086 173,052 196,016 202,346 244,168 273,163 303,317 309,411 345,730 377,059
Pharmacy 8,895 8,267 9,023 12,856 15,647 14,020 20,416 23,592 26,442 26,075 44,073 104,554
LE/Regulatory 3,332 4,655 5,585 5,958 6,294 5,531 8,076 8,293 7,391 7,663 8,946 7,582
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
Number of Patient Reports
Real Time Reporting Begins
WalgreenPolicy Change
Source: Oklahoma Bureau of Narcotics and Dangerous Drugs Control.
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2013 OK Legislation Enacted (HB 1781)
Effective November 1, 2013, Mental Health and Substance Abuse Services and State Department of Health given access to the PMP for statistical, research, substance abuse prevention or educational purposes (O.S., Title 63, Section 2-309D)
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Oklahoma Prescription Drug Overdose Prevention Program
• CDC Prevention Boost grant recipient
• Strategy 1. Expand and maximize the PDMP as a public health surveillance system
• Strategy 2. Develop and apply metrics for inappropriate prescribing and identify high-risk groups among the insured
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OK Prevention Boost Data PartnersP
MP
Dat
a
Bureau of Narcotics and Dangerous Drugs Control
Hea
lth
Ou
tco
me
Dat
a
State Department of Health
Stat
e M
edic
aid
Cla
ims
Dat
a
Health Care Authority
Men
tal H
ealt
h D
ata
Department of Mental Health and Substance Abuse Services
Office of Management Enterprise Services –Information Technology Services
Data Oversight
Committee QI Project
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Expand and Maximize the PMP as a Public Health Surveillance System – Activities
• Link PMP data to health outcome data
• Conduct public health surveillance with the PMP data, calculate measures and monitor trends
– Brandeis Prescription Behavior Surveillance System
– CDC Indicators
• Epidemiologic analyses and reporting
– Enhance proactive reporting criteria
– Inform data quality; improve PMP system
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Intermediate Outcomes
↓Percent of patients receiving high doses of opioids (>100 mme1/day) and dangerous drug combinations
↓Multiple provider episodes for opioids↓Opioid-naïve patients receiving long-acting or
extended-release opioids
↑Use of PMP↑Providers checking PMP the first time opioid
Rx is written1. Morphine milligram equivalents.
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Long-Term Outcomes
↓Hospitalizations for drug-related poisonings and opioid-related poisonings
• OK Hospital Inpatient Discharge Database
↓Mortality due to drug-related poisonings, prescription drug-related poisonings, and deaths from opioid painkillers
• Unintentional poisoning surveillance data, medical examiner data, Vital Statistics death data
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Successes and Challenges• Successes
– Receipt of PMP data 2010-2013– Technical support and IT support available– Partner with OBNDDC to support PMP quality tools– Brandeis PDMP Prescription Behavior Surveillance
System SAS code
• Challenges – ~10 million records per year in PMP– Data quality– Time, increased demands on system– Secured server space– High-powered computers– Subset to test analyses/programs
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PDMPs as Public Health Surveillance Tools: Early Lessons from CDC’s
Boost for State Prevention Grant
Utah’s ExperienceAnna Fondario, MPHInjury Epidemiologist
Utah Department of HealthViolence and Injury Prevention Program
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0
50
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200
250
300
350
Nu
mb
er
of
De
ath
s
Year
Rx Opioids
Motor Vehicle Crash
Heroin & Cocaine
ONEcause of injury deaths
in Utah
87
%are prescription opioids
70
%are prescription drugs
and of these
Poisoning is the
number
Number of unintentional and undetermined deaths by year and selected cause, Utah 2000-2013
Date Source: Utah Office of Vital Records and Statistics and Utah Office of the State Medical Examiner
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0
50
100
150
200
250
300
350
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Nu
mb
er
of
De
ath
s
Year
Pro
gram
Fu
nd
ed
Fun
din
g El
imin
ated443%
Number of occurrent prescription opioid deaths by year, Utah 2000-2013
28%
Date Source: Utah Office of Vital Records and Statistics and Utah Office of the State Medical Examiner
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% Increase or Decrease by Sex 2000-2010 2007-2010 2010-2012
Men 271% 28% 21%
Women 483% 27% 2%
Overall 293% 28% 11%
Date Source: Utah Office of Vital Records and Statistics and Utah Office of the State Medical Examiner
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Pain Medication Management and Education
• Investigate causes, risk factors and solutions for deaths and of prescription opiate use and misuse using the CSD
• Provide recommendations on the use of the CSD to identify and prevent:
– Misuse of opiates
– Inappropriate prescribing; and
– Adverse outcomes of prescription opiate medications
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Legislative Actions
2008
• Public education, misuse of the CSD a third degree felony, real-time reporting and access pilot program
2009• Expands access to CSD (designee)
2010
• All prescribers register to use the CSD, take a tutorial, pass a test
• Hospital / DUI impaired driving reporting of overdose to DOPL who then must notify each prescriber
• Expands access to CSD (UDOH)
2011• Four hours of controlled substance prescribing
education
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PDMP has the potential to be an informative public health data source
Data Information Action
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Utah’s Controlled Substance Database
• Purpose is to serve as a resource to aid in the prevention, enforcement, and treatment of prescription controlled substance misuse and diversion.
• Schedule II-V prescription records
• Over 47 million records
• Over 600 pharmacies
• Data due every seven days
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981 1,013 1,455 2,0382,958
9,899
13,46014,415
15,553
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014
Nu
mb
er
of
Re
gist
ere
d P
ract
itio
ne
rs
Fiscal Year
2010 Legislation requiring prescriber registration
Number of Registered Practitioners for the Controlled Substance Database, Utah FY2006-FY2014
Date Source: Division of Occupational and Professional Licensing, Utah Controlled Substance Database
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0.0
50.0
100.0
150.0
200.0
250.0
300.0
2004 2005 2006 2007 2008 2009 2010 2011 2012
Rat
e o
f d
eat
hs
pe
r 1
00
,00
0 p
resc
rip
tio
ns
Year
Methadone Fentanyl Oxycodone Hydrocodone
Rate of occurrent deaths per 100,000 prescriptions by year and prescription type, Utah, 2004-2012
Date Source: Utah Department of Health Violence and Injury Prevention Program, Prescription Pain Medication Program Database, Division of Occupational and Professional Licensing, Utah Controlled Substance Database
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0%
10%
20%
30%
40%
50%
60%
Indicated Drug Only
Other Drugs Involved
Percentage of occurrent deaths by selected prescription pain medication deaths, Utah, 2000-2012
Date Source: Utah Department of Health Violence and Injury Prevention Program, Prescription Pain Medication Program Database, Division of Occupational and Professional Licensing, Utah Controlled Substance Database
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15.5
20.6
8.9
29.0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
Methadone Fentanyl Oxycodone Hydrocodone
% C
han
gePercent change in the rate of occurrent prescription pain medication deaths by drug type, Utah, 2009-2012
Date Source: Utah Department of Health Violence and Injury Prevention Program, Prescription Pain Medication Program Database, Division of Occupational and Professional Licensing, Utah Controlled Substance Database
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Date Source: Christina A. Porucznik, Jacob Crook, Erin M. Johnson, Robert T. Rolfs, Brian C. Sauer, Poster Physician Specialty and Opioid Prescribing in the Utah Controlled Substance Database 2005-2009
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PDO: Boost For State Prevention
Expanding and maximizing the CSD
as a public health surveillance tool
Evaluate policy implementation
activities and create lessons
learned
Support policy evaluation activities
through multi-agency
collaboration
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Increased proactive reporting
Short-term Intermediate Long-term
Decreased rate of high-dose opioids by providers
Increased use of standard CSD reports for surveillance and to inform policy evaluation efforts
Decreased rate of dangerous drug combinations
Decreased drug overdose death rate
Increased use of CSD by providers, law enforcement, licensure boards
Increased enforcement actions against outlier providers
Decreased rate of patients using multiple providers for opioid prescriptions
Decreased prescribing patterns inconsistent with guidelines/rules
Decreased rate of ED visits due to misuse or abuse of controlled prescription drugs
CSD Goal Short-term,
Intermediate, and Long-term
Outcomes
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Emergency Department
Hospitalization Outpatient/Inpatient
Vital Records Births/Deaths
Child Health Databases
Medicaid
All Payer Claims Database
Immunization
Mas
ter
Pe
rso
n
Ind
ex
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• Linked data in addition to data on:• multiple-provider episode rates• prescription volumes by prescribers and pharmacies• mean daily opioid dosage prescribed• distance travelled• prescriber and patient behavior trends with a focus on
geographic, sex, and age disparities• Opportunity to collaborate with researchers• Utilize Use Only as Directed media initiatives
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Thank You
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Kentucky Prescription Drug Overdose Prevention Program
Dana Quesinberry, JDKentucky Injury Prevention and Research Center
University of KentuckyKentucky Department for Public Health
April 7, 2015
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Prescription Drug Abuse in Kentucky
• In 2012, Kentucky had the 2nd highest age-adjusted drug overdose fatality rate in the nation at 23.5 drug overdose fatalities/ 100,000 population. CDC WONDER data
• Rate of drug overdose fatalities has more than quadrupled since 1999
• In 2012, Kentucky recorded 1,031 drug overdose deaths (23.9/100,000)
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Top Two Causes of Unintentional Injury Deaths in Kentucky
0
200
400
600
800
1000
1200
2008 2009 2010 2011 2012 2013
Year
Unintentional MV Traffic Unintentional Poisoning
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2012 State Medical Examiner Most Frequently Detected Substances in Autopsy Cases
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2012 Year of Legislative Action
Kentucky passes ground-breaking PDO-related laws within HB 1
– Pain clinics– Decedent controlled
substances testing when the underlying cause of death is not known
– Expand annual report on drug-related deaths to include drugs involved in deaths and method by which they were obtained, if known
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HB 1 PDMP-related Components
Mandatory prescriber querying
Linkage to other state
PDMPs
Mandated Prescriber
Registration
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Kentucky PDO Boost Activities
1) Enhance and maximize KASPER’s effectiveness by
a. expanding and improving proactive KASPER reporting
b. expanding and maximizing KASPER as a public health surveillance system
2) Evaluate Kentucky laws designed to prevent prescription drug misuse, diversion, and overdose by
a. evaluating and performing an economic analysis of the regulations that require KASPER querying when prescribing schedule II-IV controlled substances
b. evaluating and performing an economic analysis of the law that requires decedent controlled substance testing when no other cause of death has been established
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Expanding and Increase Proactive Reporting
Data sharing with border states
Added Data Fields
Strengthening data quality and completeness
Enhanced analysis and reports
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Multi-Source Drug Overdose Fatality Surveillance System
OVS
Medical Examiner/Elected
Coroners
KASPER
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Conduct Non-Fatal Prescription Drug Overdose Surveillance
• Inpatient hospitalization Data
• Emergency Department Data
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Evaluate KASPER Querying Regulations Laws by Clinical Professions
• Examine the effectiveness of the law to change prescriber and patient behaviors
• Delineate implementation facilitators and barriers
• Analyze economic impact on cost bearers
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Evaluate Decedent Controlled Substance Abuse Testing Law
• Examine effectiveness of law
• Delineate implementation facilitators and barriers
• Determine process changes after law implementation
• Analyze economic impact on cost bearers
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1,020
1,032
980
950
960
970
980
990
1,000
1,010
1,020
1,030
1,040
2011 2012 2013
Kentucky Resident Drug Overdose Deaths, 2011 - 2013
Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky Vital Statistics electronic death certificate file. Data extract as of October 2014. Data are provisional and subject to change.
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4225
538
431
365
129
50
471
362
285
200
74
423
318
238
0
100
200
300
400
500
600
Heroin Cocaine Pharmaceutical Opioids Benzodiazepines Combination of Rxopioids and
benzodiazepines
Kentucky Resident Drug Overdose Deaths, 2011 - 2013
2011
2012
2013
Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky Vital Statistics electronic death certificate file. Data extract as of October 2014. Data are provisional and subject to change.
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6,4226,371
5,590
5,000
5,200
5,400
5,600
5,800
6,000
6,200
6,400
6,600
2011 2012 2013
Kentucky Resident Drug Overdose Hospitalizations
Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky inpatient hospitalization discharge data, Office of Health Policy. Data are provisional and subject to change.
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62
213
1,610
1,885
705
175219
1,504
1,709
619
263204
1,151
1,339
409
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
Heroin Cocaine PharmaceuticalOpioids
Benzodiazepines Combination of Rxopioids and
benzodiazepines
Kentucky Resident Drug Overdose Hospitalizations
2011
2012
2013
Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky inpatient hospitalizationdischarge data, Office of Health Policy. Data are provisional and subject to change.
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8,0018,292
7,627
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
2011 2012 2013
Kentucky Resident Drug Overdose Emergency Department Visits
Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky Outpatient Services Database, Office of Health Policy. Data are provisional and subject to change.
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278
96
1,048
1,310
312
865
116
991
1,213
257
1,111
120
772
853
150
0
200
400
600
800
1,000
1,200
1,400
Heroin Cocaine PharmaceuticalOpioids
Benzodiazepines Combination of Rxopioids and
benzodiazepines
Kentucky Resident Drug Overdose Emergency Department Visits
2011
2012
2013
Produced by the Kentucky Injury Prevention and Research Center, January 2015. Data source: Kentucky Outpatient Services Database, Office of Health Policy. Data are provisional and subject to change.
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Contact Information
Dana Quesinberry, JDHealth Policy and Program Evaluator; Kentucky Injury Prevention and Research CenterUniversity of Kentucky,College of Public Health333 Waller Ave., Suite 242Phone: [email protected]
Terry Bunn, PhDAssoc Professor, Dept of Prev Medicine & Environ Health; Director, Kentucky Injury Prevention and Research Center,University of Kentucky, College of Public Health333 Waller Ave., Suite 242Lexington, KY 40504Phone: [email protected]