Patient risk factors for medical injury: a case-control study.

OBJECTIVE: To determine risk factors of medical injury, defined as untoward injury from diagnostic or therapeutic healthcare interventions. Identifying risk factors for medical injuries could inform the development of preventive interventions. METHODS: A hospital-based case-control study. Cases and controls were selected among patients discharged from a large Midwestern teaching hospital between 1 January 2003 and 31 December 2004. Cases (n=268) were selected in a three-step process. First, medical injuries in the discharge database were identified using the Wisconsin Medical Injury Prevention Programme Surveillance Criteria. Second, provisional cases were randomly chosen from patients flagged with a medical injury. Provisional controls were randomly selected from patients not flagged with a medical injury, matching for Diagnosis Related Group of the provisional cases. Third, a chart review determined ultimate case-control status. Severity of illness and risk of mortality were calculated using the All Patients Refined-Diagnosis Related Groups system. Zahn's comorbidity score was calculated. Conditional logistic regressions were run with injury status as the dependent variable. RESULTS: Among the 268 cases, 47.8% were procedure-related injuries and 44.8% were medication-related injuries. Conditional logistic regressions found higher severity of illness and higher risks of mortality were related to risk of medical injury (OR 3.29 (95% CI 1.05 to 10.31) and OR 5.16 (95% CI 1.42 to 18.79), respectively). Additional regressions showed the Zahn comorbidity score related to the risk of medical injury (OR 1.63, 95% CI 1.31 to 2.02). CONCLUSIONS: Patients with higher severity of illness, higher risk of inpatient mortality and multiple comorbidities are at increased risk for a medical injury.

Medical injuries among hospitalized children.

BACKGROUND: Inpatient medical injuries among children are common and result in a longer stay in hospital and increased hospital charges. However, previous studies have used screening criteria that focus on inpatient occurrences only rather than on injuries that also occur in ambulatory or community settings leading to hospital admission. OBJECTIVE: To describe the incidence and outcomes of medical injuries among children hospitalized in Wisconsin using the Wisconsin Medical Injury Prevention Program (WMIPP) screening criteria. METHODS: Cross sectional analysis of discharge records of 318,785 children from 134 hospitals in Wisconsin between 2000 and 2002. RESULTS: The WMIPP criteria identified 3.4% of discharges as having one or more medical injuries: 1.5% due to medications, 1.3% to procedures, and 0.9% to devices, implants and grafts. After adjusting for the All Patient Refined-Diagnosis Related Groups disease category, illness severity, mortality risk, and clustering within hospitals, the mean length of stay (LOS) was a half day (12%) longer for patients with medical injuries than for those without injuries. The similarly adjusted mean total hospital charges were 1614 dollars (26%) higher for the group with medical injuries. Excess LOS and charges were greatest for injuries due to genitourinary devices/implants, vascular devices, and infections/inflammation after procedures. CONCLUSIONS: This study reinforces previous national findings up to 2000 using Wisconsin data to the end of 2002. The results suggest that hospitals and pediatricians should focus clinical improvement on medications, procedures, and devices frequently associated with medical injuries and use medical injury surveillance to track medical injury rates in children.

Incidence of sports and recreation related injuries resulting in hospitalization in Wisconsin in 2000.

OBJECTIVE: To describe the incidence and patterns of sports and recreation related injuries resulting in inpatient hospitalization in Wisconsin. Although much sports and recreation related injury research has focused on the emergency department setting, little is known about the scope or characteristics of more severe sports injuries resulting in hospitalization. SETTING: The Wisconsin Bureau of Health Information (BHI) maintains hospital inpatient discharge data through a statewide mandatory reporting system. The database contains demographic and health information on all patients hospitalized in acute care non-federal hospitals in Wisconsin. METHODS: The authors developed a classification scheme based on the International Classification of Diseases External cause of injury code (E code) to identify hospitalizations for sports and recreation related injuries from the BHI data files (2000). Due to the uncertainty within E codes in specifying sports and recreation related injuries, the authors used Bayesian analysis to model the incidence of these types of injuries. RESULTS: There were 1714 (95% credible interval 1499 to 2022) sports and recreation-related injury hospitalizations in Wisconsin in 2000 (32.0 per 100,000 population). The most common mechanisms of injury were being struck by/against an object in sports (6.4 per 100,000 population) and pedal cycle riding (6.2 per 100,000). Ten to 19 year olds had the highest rate of sports and recreation related injury hospitalization (65.3 per 100,000 population), and males overall had a rate four times higher than females. CONCLUSIONS: Over 1700 sports and recreation related injuries occurred in Wisconsin in 2000 that were treated during an inpatient hospitalization. Sports and recreation activities result in a substantial number of serious, as well as minor injuries. Prevention efforts aimed at reducing injuries while continuing to promote participation in physical activity for all ages are critical.

All STDs are not created equal: an analysis of the differential effects of sexual behaviour changes on different STDs.

The same sexual behaviours that transmit HIV are implicated in the transmission of certain other STDs, including chlamydia, gonorrhoea, and syphilis. Consequently, it is often assumed that preventive methods that are effective against HIV should be equally effective against other STDs. The purpose of this study was to examine this assumption. We applied a mathematical model of HIV/STD transmission to empirical data from a large HIV prevention intervention that stressed sexual behaviour change. We modelled the effects of two behavioural strategies - reducing the number of sex partners and increasing condom use-on the proportionate change in intervention participants' cumulative risk of acquiring HIV or a highly-infectious STD, such as gonorrhoea. The results of this modelling exercise indicate that decreasing the number of partners is a more effective strategy for reducing STD risk than it is for HIV risk. In contrast, condoms are somewhat more effective at reducing the cumulative transmission risk for HIV than for highly infectious STDs. The protection provided by condoms for multiple acts of intercourse critically depends on the infectiousness of the STD. The results of this study suggest caution in extrapolating from one STD to another, or from one behavioural risk reduction strategy to another.

Redefining the need for faculty in family medicine: results of a 5-year follow-up survey.

BACKGROUND AND OBJECTIVES: A study was conducted in 1994 to determine the need for faculty in family medicine. This paper reports a comparative follow-up study in 1999. METHODS: This follow-up study determined faculty positions filled in the last 5 years, new faculty positions currently available, replacement faculty positions currently available, and new faculty positions anticipated to be available in the next 3 years. In addition, comparisons were made with the previous study regarding time available for clinical, educational, and research activities. RESULTS: In the 1994 survey, respondents reported 496 open faculty positions and anticipated that 677 would become available during the subsequent 3 years, for a total of 1,173 positions. The 1999 survey data indicated that the actual number of positions filled or still open since 1994 was 1,072. In contrast, new positions open in 1999 or anticipated to be open in the subsequent 3 years were 604. For both residencies and departments, most positions in both surveys were for clinicians. CONCLUSIONS: Despite a decrease in the number of available positions for family medicine faculty reported between the 1994 original survey and 1999 follow-up survey, there are still more than 600 faculty positions currently available, and additional new positions are anticipated over the next 3 years.

Racial trends in age-specific breast cancer mortality rates in US women.

OBJECTIVES: This study examined recent trends in age- and race-specific patterns of breast cancer mortality. METHODS: We analyzed breast cancer mortality data for 1979 through 1996. RESULTS: From 1993 to 1996, White women of all age groups experienced average annual decreases in breast cancer mortality. Throughout the study, young Black women had higher rates of breast cancer mortality than young White women. Older Black women had lower mortality rates than older White women in the earlier years of the study but experienced higher rates in the later years (1993-1996). CONCLUSIONS: Trends in risk factors and early detection do not provide an adequate explanation for this recent substantial increase in breast cancer mortality among older Black women.

Age and gender patterns in motor vehicle crash injuries: importance of type of crash and occupant role.

To evaluate the interaction of gender, age, type of crash, and occupant role in motor vehicle crash injuries leading to hospitalization, we analyzed 1997 Wisconsin hospital discharge data for patients with primary E-code diagnoses of motor vehicle injuries. The overall ratio of males to females (M/F ratio) hospitalized for motor vehicle crash injuries was 1.33 (95% confidence interval (CI): 1.26-1.41). The M/F ratio varied by type of crash and differed for passengers and drivers. For injuries sustained in collisions between vehicles, the M/F ratio was 0.96 (95% CI: 0.87-1.05); in loss of control accidents the M/F ratio was 1.95 (95% CI: 1.76-2.17). Within each type of crash, the M/F ratio for drivers was similar to that for the entire type; the M/F ratio for passengers was about half of the type total. Expressed as rates of hospitalization per 100,000 people in the general population, hospitalizations of drivers in collisions with another motor vehicle increased steeply in males, but not in females, beginning at about age 70. For drivers in loss of control crashes, male rates exceeded female rates in all age groups, with peaks in the groups 15-24 and 85-89. For passengers, injury rates from collisions with other motor vehicles were greater for females, especially in the elderly, and injury rates from loss of control crashes were similar for both genders, with peaks at 15-24 and 85-94. The higher fatality of men in loss of control motor vehicle crashes, compared to women, suggests an important area for further investigation.

Self-rated health status: a new vital sign for primary care?

Self-reported health status ratings depend on whether one references health problems or health behaviors. Pessimistic health perceptions may indicate underlying emotional distress or predict mortality. This study explores the association between a single-item health status question and self-reported health problems or behaviors among women in a Wisconsin family medicine clinic. All women who present for health maintenance complete a health history form that includes a single item health status rating. Health status ratings from 251 randomly selected records were compared with certain reported demographics, health behaviors (e.g. smoking, exercise), health concerns, depression and anxiety symptoms, vital signs and body mass index. Health status ratings of fair or poor were found to be associated with race, marital and employment status, obesity, exercise, and depressive symptoms. Smokers were 4.22 times more likely to report a less favorable health category than non-smokers. Implications for future research are discussed.

Evaluation of error in medicine: application of a public health model.

A case of a chest tube placed on the wrong side during a trauma resuscitation in the emergency department is presented as an example of medical injury. Two traditional models, the legal model and the managerial model, are described and their application to medical injury discussed. A new public health model is then applied to the case example as a more effective way to address medical injury. The public health model addresses the injury event rather than the error itself using Haddon's matrix as a framework. Pre-event, event, and post-event phases are examined to find the weakest link, where intervention has the highest likelihood of successfully preventing future injuries.

Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use.

BACKGROUND: The Veterans Affairs (VA) health system has been criticized for being inefficient based on comparisons of VA care with non-VA care. Whether such comparisons are biased by differences between the VA patient population and the non-VA patient population is not known. Our objective is to determine if VA patients are different from non-VA patients in terms of health status and medical resource use. METHOD: We analyzed 128,099 records from the National Health Interview Survey for the years 1993 and 1994. We compared the VA patient population with the general patient population for self report on health status, number of medical conditions, number of outpatient physician visits, number of hospital admissions, and number of hospital days each year. RESULTS: The VA patient population had poorer health status (odds ratio [OR], 14.7; 95% confidence interval [CI], 10.7-20.2), more medical conditions (OR, 14; 95% CI, 10.5-18.7), and higher medical resource use compared with the general patient population (OR, 3.7 for 3 or more physician visits per year; OR 5.4 for 3 or more hospital admissions per year; OR, 7.7 for 21 or more days spent in a hospital per year). However, after controlling for health and sociodemographic differences, VA patients had similar resource use compared with the general patient population. CONCLUSION: Large differences in sociodemographic status, health status, and subsequent resource use exist between the VA and the general patient population. Therefore, comparisons of VA care with non-VA care need to take these differences into account. Furthermore, health care planning and resource allocation within the VA should not be based on data extrapolated from non-VA patient populations. Arch Intern Med. 2000;160:3252-3257.

When is an HIV infection prevented and when is it merely delayed?

HIV prevention programs are typically evaluated using behavioral outcomes. Mathematical models of HIV transmission can be used to translate these behavioral outcomes into estimates of the number of HIV infections averted. Usually, intervention effectiveness is evaluated over a brief assessment period and an infection is considered to be prevented if it does not occur during this period. This approach may overestimate intervention effectiveness if participants continue to engage in risk behaviors. Conversely, this strategy underestimates the true impact of interventions by assuming that behavioral changes persist only until the end of the intervention assessment period. In this article, the authors (a) suggest a simple framework for distinguishing between HIV infections that are truly prevented and those that are merely delayed, (b) illustrate how these outcomes can be estimated, (c) discuss strategies for extrapolating intervention effects beyond the assessment period, and (d) highlight the implications of these findings for HIV prevention decision making.

Short- and long-term survival after cardiopulmonary resuscitation.

BACKGROUND: The objective was to evaluate the effect of patient characteristics and other factors on cardiopulmonary resuscitation (CPR) survival, hospital discharge survival and function, and long-term survival. METHODS: All patients 18 years and older experiencing in-hospital CPR from December 1983 through November 1991 at Marshfield Medical Center (Marshfield Clinic and adjoining St Joseph's Hospital), Marshfield, Wis, were selected. We performed a retrospective medical record review and augmented these data with updated vital status information. MAIN OUTCOME MEASURES: Cardiopulmonary resuscitation survival, hospital discharge survival and function, and long-term survival. RESULTS: Of 948 admissions during which CPR was performed, 61.2% of patients survived the arrest and 32.2% survived to hospital discharge. Mechanism of arrest was the most important variable associated with hospital discharge. Patients with pulseless electrical activity had the worst chance of hospital discharge, followed by those with asystole and bradycardia. Follow-up information was available for 298 patients who survived to discharge. One year after hospital discharge, 24.5% of patients, regardless of age, had died. Survival was 18.5% at 7 years in those 70 years or older, compared with 45.4% in those aged 18 to 69 years. Heart rhythm at the time of arrest strongly influenced long-term survival. Bradyarrhythmias produced a nearly 2-fold increased mortality risk compared with normal sinus rhythm. CONCLUSIONS: Survival until hospital discharge after CPR at our institution during an 8-year period was higher than previously reported for other institutions. Long-term survival after discharge was equal to or higher than reported estimates from other institutions. Hospital admission practices and selection of patients receiving CPR may account for these findings.

Quality of life and recurrence concern in survivors of head and neck cancer.

OBJECTIVES/HYPOTHESIS: A cohort of 3-year survivors of head and neck cancer was evaluated for persistent quality of life (QOL) concerns and long-term treatment effects. STUDY DESIGN: Mailed questionnaire. METHODS: The questionnaire with the University of Washington Quality of Life (UWQOL) scale, the Performance Status Scale for Head and Neck Cancer (PSS-HN), the Functional Assessment of Cancer Therapy (FACT) scale, and the Functional Assessment of Cancer Therapy Head and Neck (FACT-HN) scale and locally prepared questions was sent to 111 3-year disease-free survivors. Analysis was performed to statistically evaluate the effect of stage, site, treatment type, surgery, and cancer concern on QOL. Current smoking information was gathered. RESULTS: Seventy-two survivors completed the questionnaire. Advanced stage was correlated with lower QOL scores in the domains of disfigurement, chewing ability, speech, and eating in public. QOL scores did not vary by initial tumor site. Patients treated with irradiation alone had statistically better QOL scores than those treated with combined surgery/radiation therapy in the pain, disfigurement, chewing, and speech domains. Laryngectomy and composite resection survivors reported lower QOL scores than patients treated with irradiation alone. A low level of cancer concern persisted in about half of the long-term survivors. Cancer concern was associated with continued pain, disfigurement, and limitations on eating in public. Three-quarters of the tobacco users had quit by the time of the questionnaire. Nevertheless, the patients were not thoroughly convinced that tobacco had caused their cancer. CONCLUSIONS: Long-term survivors of head and neck cancer experience QOL effects well after completion of treatment. Effects are most pronounced in survivors who required combined surgery/radiation therapy. Continuing low levels of cancer concern persist in about half of the survivors. Many cancer survivors successfully quit smoking.

Physician understanding of patient resuscitation preferences: insights and clinical implications.

OBJECTIVE: To describe physician understanding of patient preferences concerning cardiopulmonary resuscitation (CPR) and to assess the relationship of physician understanding of patient preferences with do not resuscitate (DNR) orders and in-hospital CPR. DESIGN: We evaluated physician understanding of patient CPR preference and the association of patient characteristics and physician-patient communication with physician understanding of patient CPR preferences. Among patients preferring to forego CPR, we compared attempted resuscitations and time to receive a DNR order between patients whose preference was understood or misunderstood by their physician. PATIENTS/SETTING: Seriously ill hospitalized adult patients were enrolled in the Study to Understand Prognoses and Preferences for the Outcomes of Treatments. GENERAL RESULTS: Physicians understood 86% of patient preferences for CPR, but only 46% of patient preferences to forego CPR. Younger patient age, higher physician-estimated quality of life, and higher physician prediction of 6-month survival were independently associated with both physician understanding when a patient preferred to receive CPR and physician misunderstanding when a patient preferred to forego CPR. Physicians who spoke with patients about resuscitation and had longer physician-patient relationships understood patients' preferences to forego CPR more often. Patients whose physicians understood their preference to forego CPR more often received DNR orders, received them earlier, and were significantly less likely to undergo resuscitation. CONCLUSIONS: Physicians often misunderstand seriously ill, hospitalized patients' resuscitation preferences, especially preferences to forego CPR. Factors associated with misunderstanding suggest that physicians infer patients' preferences without asking the patient. Patients who prefer to forego CPR but whose wishes are not understood by their physician may receive unwanted treatment.

Asthma severity among children hospitalized in 1990 and 1995.

BACKGROUND: During the past decade, the number of children with asthma increased; however, the number of asthma hospitalizations for children decreased. OBJECTIVE: To assess the proportion of high-severity cases among children hospitalized with asthma and the association of high-severity asthma with patient and hospital characteristics. DESIGN: The data set used was the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Records were selected of patients 18 years and younger who had the principal diagnosis of asthma. Records were analyzed of 29077 patients at 746 hospitals in 1990 and 33 443 patients at 811 hospitals in 1995. Asthma severity was classified by All Patient Refined-Diagnosis-Related Groups. Cross-sectional logistic regression analysis was performed using survey data analysis software. RESULTS: The most common diagnoses associated with high-severity asthma were respiratory distress and respiratory failure. The proportion of high-severity asthma cases did not change significantly between 1990 (4.2%) and 1995 (4.6%) (P = .08). Adolescents and boys were more likely to have high-severity asthma than children aged 5 to 12 years and girls. Western, southern, and north-central hospitals and urban teaching hospitals had a higher proportion of high-severity asthma cases than northeastern hospitals and nonteaching hospitals. CONCLUSIONS: Between 1990 and 1995, the proportion of high-severity cases among children hospitalized with asthma did not change significantly. However, patient age, sex, region of the country, and hospital teaching status were associated with variations in the proportion of high-severity asthma cases.

Association of pesticide safety knowledge with beliefs and intentions among farm pesticide applicators.

Although a number of health hazards associated with pesticide exposure have been well documented, relatively little is known about the knowledge and health beliefs that may influence pesticide handling. This study measured knowledge levels concerning pesticide safety and precautionary handling among applicators and examined relationships between knowledge scores and intentions to use handling precautions, perceptions of pesticide safety peer norms, and perceived self-efficacy to prevent personal exposure. Telephone interviews were conducted with a randomly selected sample of 164 dairy farmers who were pesticide applicators residing in Wisconsin (response rate = 77.4%). The percentage of correct responses to 18 knowledge items ranged from 100% to 45.7%. Knowledge levels were positively related to intentions, beliefs, and self-efficacy regarding use of personal protective gear but were not significantly related to risk perceptions and peer norms concerning pesticide safety.

Incremental cost-effectiveness of two zidovudine regimens to prevent perinatal HIV transmission in the United States.

BACKGROUND: Recently concluded clinical trials in Thailand have demonstrated that a short course of zidovudine therapy administered to human immunodeficiency virus-infected women during late pregnancy and labor can substantially reduce the likelihood of perinatal transmission of HIV. This regimen is both less expensive and less effective than the full course of therapy recommended for use in the United States by the U.S. Public Health Service (PHS). The objective of the current study is to estimate the incremental cost-effectiveness of the full-course zidovudine regimen in comparison to the short-course regimen that was tested in Thailand and to determine conditions under which the PHS-recommended regimen produces a net savings in societal resource utilization, relative to the shorter regimen. METHODS: We used standard methods of incremental cost-effectiveness analysis and derived cost and effectiveness estimates from published studies. The main outcome measure is the incremental cost-effectiveness ratio, which is the additional cost per additional case of perinatal HIV infection averted by the full course of therapy. RESULTS: Full-course zidovudine therapy costs an additional $21,337 per additional case of HIV infection averted, relative to the shorter regimen; this is much less than the cost of treating a case of pediatric HIV infection. CONCLUSIONS: Economic and clinical findings both favor full-course zidovudine therapy over short-course therapy to prevent perinatal transmission of HIV in the United States.

The effect of hysterectomy on the risk of an abnormal screening Papanicolaou test result.

OBJECTIVE: Our aim was to determine the risk of cytologic abnormality on a screening Papanicolaou test for women >/=50 years old with and without a uterine cervix. STUDY DESIGN: The effect of hysterectomy on abnormal screening Papanicolaou test rates was determined in a cross-sectional analysis of 21,152 women aged >/=50 years who had screening Papanicolaou tests between January and August 1995. We then conducted a nested 1:1 case-control study of 172 case patients and 172 age-matched randomly selected control patients from the cohort. To control for potential confounders, conditional logistic regression was used to assess the effect of hysterectomy status on the risk of an abnormal Papanicolaou test. RESULTS: Compared with age-matched women with a uterine cervix, those who had a hysterectomy had a 10-fold lower risk of a screening Papanicolaou test abnormality (odds ratio 0.09, 95% confidence interval 0.02-0.24). The risk was further reduced among women taking estrogens (odds ratio 0.02, 95% confidence interval 0.004-0.14) compared with women not using estrogens (odds ratio 0.14, 95% confidence interval 0.04-0.56). CONCLUSIONS: The reduced risk of Papanicolaou test abnormalities among women aged >/=50 years who have had a hysterectomy should be considered when individual patients are being counseled, screening guidelines are being formulated, and health care resources are being allocated.

Association of pesticide safety beliefs and intentions with behaviors among farm pesticide applicators.

Telephone interviews were conducted on a random sample of 164 dairy farmers knowledge and beliefs about pesticide hazards, intentions to use precautions, perceptions of pesticide safety peer norms, perceived self-efficacy to prevent personal exposure, and use of protective equipment. Self-efficacy and risk perception appear less relevant to safety behavior than other variables. Future research should focus prospectively and on national samples.