Factors Associated With Opting Out of Automated Text and Telephone Messages Among Adult Members of an Integrated Health Care System.

Importance: Health care systems deliver automated text or telephone messages to remind patients of appointments and to provide health information. Patients who receive multiple messages may demonstrate message fatigue by opting out of future messages. Objective: To assess whether the volume of automated text or interactive voice response (IVR) telephone messages is associated with the likelihood of patients requesting to opt out of future messages. Design, Setting, and Participants: This retrospective cohort study was conducted at Kaiser Permanente Colorado (KPCO), an integrated health care system. All adult members who received 1 or more automated text or IVR message between October 1, 2018, and September 30, 2019, were included. Exposures: Receipt of automated text or IVR messages. Main Outcomes and Measures: Message volume and opt-out rates obtained from messaging systems over 1 year. Results: Of the 428 242 adults included in this study, 59.7% were women, and 66.5% were White; the mean (SD) age was 52.3 (17.7) years. During the study period, 84.1% received 1 or more text messages (median, 4 messages; interquartile range, 2-8 messages) and 67.8% received 1 or more IVR messages (median, 3 messages; interquartile range, 1-6 messages). A total of 8929 individuals (2.5%) opted out of text messages, and 4392 (1.5%) opted out of IVR messages. In multivariable analyses, individuals who received 10 to 19.9 or 20 or more text messages per year had higher opt-out rates for text messages compared with those who received fewer than 2 messages per year (adjusted odds ratio [aOR]: 10-19.9 vs <2 messages, 1.27 [95% CI, 1.17-1.38]; ≥20 vs <2 messages, 3.58 [95% CI, 3.28-3.91]), whereas opt-out rates increased progressively in association with IVR message volume, with the highest rates among individuals who received 10.0 to 19.9 messages (aOR, 11.11; 95% CI, 9.43-13.08) or 20.0 messages or more (aOR, 49.84; 95% CI, 42.33-58.70). Individuals opting out of text messages were more likely to opt out of IVR messages (aOR, 4.07; 95% CI, 3.65-4.55), and those opting out of IVR messages were more likely to opt out of text messages (aOR, 5.92; 95% CI, 5.29-6.61). Conclusions and Relevance: In this cohort study among adult members of an integrated health care system, requests to discontinue messages were associated with greater message volume. These findings suggest that, to preserve the benefits of automated outreach, health care systems should use these messages judiciously to reduce message fatigue.

Treating pediatric conjunctivitis without an exam: An evaluation of outcomes and antibiotic usage.

OBJECTIVE: The objective of this research paper is to compare antibiotic treatment, follow-up rates, and types of follow-up encounters among eVisits, phone calls, and in-person encounters for pediatric conjunctivitis. STUDY DESIGN: A retrospective chart review of pediatric patients evaluated for conjunctivitis between May 1, 2016 and May 1, 2017, was performed. A total of 101 eVisits, 202 in-person retail clinic visits, and 202 nurse phone calls for conjunctivitis were manually reviewed for outcomes. Exclusion criteria included previous encounter for conjunctivitis in the past 14 days, treatment with an oral antibiotic at the initial encounter, or patient outside Minnesota at the time of encounter. Comparison among the three encounter types with regard to follow-up rates, follow-up encounter type within 14 days of initial evaluation, and prescribing rates was performed. RESULTS: Patients completing non-face-to-face encounters were significantly more likely to have follow-up care (34.6% and 45.5%) than those who had a face-to-face visit at the retail clinic (7.4%), p ≤ 0.0001. Patients initially evaluated by eVisit were more likely to have follow-up at the retail clinic while patients initially evaluated by phone call were more likely to have follow-up in their primary care office. Treatment rates with antibiotics were significantly higher in phone call encounters (41.6%) than in eVisits (25.7%) or face-to-face encounters (19.8%), p < 0.0001. CONCLUSIONS: Non-face-to-face visits have significantly higher rates of follow-up when compared to face-to-face encounters. Antibiotic prescribing is greater with phone call triage encounters; however, there was no significant difference in antibiotic prescribing rates between eVisits and face-to-face visits. Follow-up type varied according to site of initial encounter.

Impact of Alternative Encounter Types on HIV Viral Suppression Rates in an Integrated Health System.

Kaiser Permanente Mid-Atlantic States (KPMAS) members are increasingly utilizing electronic encounter types, such as telephone appointments and secure messaging for healthcare purposes, although their impact on health outcomes is unknown. We evaluated whether use of alternative encounters by adult human immunodeficiency virus (HIV)-infected patients affected the likelihood of achieving viral suppression (VS). Our study population of 3114 patients contributed 6520 patient-years between 2014 and 2016. We compared VS (HIV RNA <200 copies/mL) by number of in-person visits (1 or ≥2), with further stratification for additional phone and/or e-mail encounters (none, phone only, e-mail only, and both phone and e-mail). Rate ratios (RRs) for VS by number of in-person visits and encounter types were obtained from Poisson modeling, adjusting for age, sex, race/ethnicity, and HIV risk. Compared to those with ≥2 visits, patients with one in-person visit alone were significantly less likely to achieve VS (RR = 0.93; 95% confidence interval, CI: [0.87-1.00]), as were those with one in-person visit plus a telephone encounter (0.93; [0.90-0.97]). We did not find significant differences in VS comparing patients with one in-person visit plus e-mail only (RR = 1.00; 95% CI: [0.97-1.02]) or plus e-mail and telephone (0.99; [0.97-1.01]) to those with ≥2 in-person visits. If supplemented by e-mail communications (with or without telephone contact), patients with one in-person visit per year had similar estimated rates of VS compared with ≥2 in-person visits. More research is needed to know if these findings apply to other care systems.

Improving Access to Collaborative Behavioral Health Care for Rural-Dwelling Older Adults.

OBJECTIVE: This study examined whether a telephone-delivered collaborative care intervention (SUpporting Seniors Receiving Treatment And INtervention [SUSTAIN]) improved access to mental health services similarly among older adults in rural areas and those in urban-suburban areas. METHODS: This cohort study of 8,621 older adults participating in the SUSTAIN program, a clinical service provided to older adults in Pennsylvania newly prescribed a psychotropic medication by a primary care or non-mental health provider, examined rural versus urban-suburban differences in rates of initial clinical interview completion, patient clinical characteristics, and program penetration. RESULTS: Participants in rural counties were more likely than those in urban-suburban counties to complete the initial clinical interview (27.0% versus 24.0%, p=.001). Program penetration was significantly higher in rural than in urban-suburban counties (p=.02). CONCLUSIONS: Telephone-based care management programs such as SUSTAIN may be an effective strategy to facilitate access to collaborative mental health care regardless of patients' geographic location.

Long term effects of an integrated care intervention on hospital utilization in patients with severe COPD: a single centre controlled study.

UNLABELLED: Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality globally. In Trondheim in 2008 an integrated care model (COPD-Home) consisting of an education program, self-management plan, home visits and a call centre for patient support and communication was developed. The objective was to determine the efficacy of an intervention according to the COPD-Home model in reducing hospital utilization among patients with COPD stage III and IV (GOLD 2007) discharged after hospitalization for acute exacerbations of COPD (AECOPD). METHODS: A single centre, prospective, open, controlled clinical study comparing COPD-Home integrated care (IC) with usual care (UC). RESULTS: Ninety-one versus 81 patients mean age 73.4 ± 9.3 years (57% women) were included in the IC group (ICG) and the UC group (UCG) respectively, and after 2 years 51 and 49 patients were available for control in the respective groups. During the year prior to study start there were 71 hospital admissions (HA) in the ICG and 84 in the UCG. There was a 12.6% reduction in HA in the ICG during the first year of follow-up and a 46.5% reduction during the second year (p = 0.01) compared to an 8.3% increase during the first year and no change during the second year in the ICG. During the year prior to study start, the number of hospital days (HD) was 468 in the ICG and 479 in the UCG. In the IC group, the number of HD was reduced by 48.3% during the first year (p = 0.01), and remained low during the second year of follow-up (p=0.02). In the UC group, the number of HD remained unchanged during the follow-up period. There was a trend towards a shorter survival time among patients in the ICG compared to the UCG, hazard ratio 1.33 [95% CI 0.77 to 2.33]. CONCLUSION: Intervention according to the COPD-Home model reduced hospital utilization in patients with COPD III and IV with a persisting effect throughout the 2 years of follow-up. However, there was a trend towards a shorter survival time in the intervention group.

Depressive symptoms prior to and following insulin initiation in patients with type 2 diabetes mellitus: Prevalence, risk factors and effect on physician resource utilisation.

AIMS: To study the frequency and intensity of depressive symptoms and associations with physician resource utilisation following insulin initiation in patients with type 2 diabetes mellitus. METHODS: SOLVE was a 24-week observational study. In this sub-analysis of data from Poland, depressive symptoms were evaluated using the Patient Health Questionnaire (PHQ)-9. RESULTS: PHQ-9 was completed by 942 of 1169 patients (80.6%) at baseline, and 751 (64.2%) at both baseline and final (24-week) visit. PHQ-9 scores indicated depressive symptoms in 45.6% (n=430) at baseline, and 27.2% (n=223) at final visit. Mean PHQ-9 change was -2.38 [95% CI -2.73, -2.02], p<0.001. Depressive symptoms at baseline (OR 6.32, p<0.001), microvascular disease (OR 2.45, p=0.016), number of physician contacts (OR 1.16, p=0.009), and change in HbA1c (OR 0.60, p=0.025) were independently associated with moderate/severe depressive symptoms at final visit. Patients with more severe depressive symptoms spent more time training to self-inject (p=0.0016), self-adjust (p=0.0023) and manage other aspects of insulin delivery (p<0.0001). Patients with persistent depressive symptoms had more telephone contacts and dose changes at final visit than those without (both p<0.05). CONCLUSIONS: Depressive symptoms are common with type 2 diabetes and associated with increased healthcare utilisation, reinforcing the need for holistic interdisciplinary management approaches.

Antenatal telephone support intervention and uterine artery Doppler screening: A qualitative exploration of women׳s views.

OBJECTIVES: to gain insight into low risk nulliparous women׳s experiences of a telephone support intervention (TSI) and TSI with uterine artery Doppler screening (UADS) intervention and their views of the structure of current antenatal care provision. DESIGN: postnatal semi-structured interviews were analysed using a thematic framework approach. The interviews formed a subset of data from a mixed methods study. SETTING AND PARTICIPANTS: participants were 45 low risk nulliparous women who had consented to take part in a randomised controlled trial of two antenatal support interventions; the trial was conducted at a large maternity unit in the North East of England, UK from 2004 to 2007. FINDINGS: most of the women in the study expressed positive views about the telephone support intervention (TSI) and the antenatal care they had received. Uterine artery Doppler screening was acceptable to women but did not feature highly when women recalled their antenatal experiences. Those who viewed their pregnancy as complicated by medical, social or emotional difficulties would have preferred more frequent antenatal visits. Views of antenatal care provision were influenced by women׳s perception of their pregnancy progression and the relationship developed with their midwife. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: although the TSI was viewed positively by women, it was valued most by those who required additional support. The intervention was not a substitute for face to face midwifery visits. Future research is needed to investigate the potential of utilising telephone contact to provide antenatal care for women who have pregnancies complicated by physical, psychological or emotional issues. The findings were consistent with previous evidence to show that the relationship between women and midwives is fundamental to women׳s experience of antenatal care.

Patient-initiated e-mails to providers: associations with out-of-pocket visit costs, and impact on care-seeking and health.

OBJECTIVES: To understand when patients use secure e-mail messaging with healthcare providers across several types of questions or concerns, associations between out-of-pocket costs for in-person visits and use of secure messaging, and to examine patient-reported impacts on care-seeking behavior and overall health. STUDY DESIGN: Cross-sectional survey of patients in an integrated healthcare delivery system, with access to a patient portal to send secure e-mail messages to providers at no out-of-pocket cost. METHODS: The study included patients with a chronic condition (N = 1041). We described patient-reported preferences for contacting providers and patient-reported impact of e-mail use on phone calls, in-person visits, and overall health. We used multivariate analyses to examine patient characteristics associated with using e-mail as a first contact method, and effects on care-seeking and health. RESULTS: Overall, 56% of patients sent their provider an e-mail within 1 year, and 46% reported e-mail as their first method of contact for 1 or more types of medical concerns. After adjustment, higher out-of-pocket costs for in-person visits were significantly associated with choosing e-mail as a first method of contact (P < .05). Among patients who had e-mailed their provider, 42% reported that it reduced their phone contacts, 36% reduced in-person office visits and 32% reported e-mailing improved their overall health. CONCLUSIONS: Patients reported using e-mail broadly to initiate conversations with their providers, and patients with higher out-of-pocket costs for in-person visits were more likely to choose e-mail as a first contact method. Use of secure e-mails reduced patients' use of other types of healthcare and resulted in improved overall health.

How do patients respond when confronted with telephone access barriers to care?

OBJECTIVE: To gain an in-depth understanding of patient barriers to accessing telephone care, subsequent responses to telephone access issues and recommendations for system improvement within a large integrated health-care system. STUDY DESIGN: Cross-sectional qualitative focus group study. METHODS: One focus group was conducted at each of 17 Veterans Affairs facilities with a total of 123 Veteran users of VA health care. All facilities followed a focus group discussion guide, and purposively sampled patients receiving care at their VA facility in primary and/or specialty care. Focus groups' recordings were sent to the authors' independent evaluation centre, transcribed verbatim and analysed using qualitative content analysis methodology. RESULTS: Participants described many issues with the phone system that resulted in delays to care needs being addressed, including difficulty getting someone to answer the phone, out-dated phone directories, frequent disconnections and incorrect transfers. Participants most frequently responded to access issues by doing nothing or waiting to contact at a later time, or seeking unscheduled in-person care in the emergency department or primary care clinic. Participants offered recommendations for improving telephone care, including access to direct extensions, and upgrades to the telephone system. CONCLUSIONS: Telephone access issues could result in increased patient harm and/or increased wait times for in-person primary care or emergency services. Periodic evaluation of telephone systems is necessary to ensure telephone systems adequately meet patient needs while using resources efficiently to optimize the delivery of high quality, safe health care.

Musculoskeletal triage: a mixed methods study, integrating systematic review with expert and patient perspectives.

BACKGROUND: Triage is implemented in healthcare settings to optimise access to appropriate care and manage waiting times. OBJECTIVES: To determine the optimum features of triage systems for patients with musculoskeletal conditions. DATA SOURCES: AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, MEDLINE, Cochrane Library, Web of Science and Google Scholar. STUDY SELECTION OR ELIGIBILITY CRITERIA: Studies that included non-musculoskeletal conditions, concerned patients aged <18 years or were set in emergency departments were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS: Study quality was graded using the Downs and Black quality index. Qualitative methods were used to further inform the findings of the literature review. RESULTS: Thirty-four studies met the inclusion criteria, with study quality ranging from eight to 24 out of a possible 27. Musculoskeletal triage is conducted via face-to-face consultation, paper referral letter or telephone consultation. Triage performed by physiotherapists, general practitioners, multidisciplinary teams, nurses, occupational therapists and speech therapists has been shown to be effective using a range of outcomes. Qualitative data revealed the value of supportive interdisciplinary teams, and suggested that this support is more important than choice of clinician. Patients trusted, and expressed preferences for, experienced clinicians to perform triage. CONCLUSION: Triage can be performed effectively via a number of methods and by a range of clinicians. Satisfaction, cost, diagnostic agreement, appropriateness of referral and waiting list time have been improved though triage. Multidisciplinary support mechanisms are critical elements of successful triage systems. Patients are more concerned with access issues than professional boundaries.

Motivos de participación en el Programa de Prevención del Cáncer Colorrectal de la Comunidad Valenciana según sexo, edad y clase social / Reasons for participating in the Valencian Community Colorectal Cancer Screening Programme by gender, age, and social class

Objetivo: conocer los motivos para participar o no participar en un Programa de Prevención de Cáncer Colorrectal (PPCCR) y analizar las diferencias de sexo, edad y clase social. Métodos: estudio transversal mediante encuesta telefónica a una muestra de hombres y mujeres entre 50 y 74 años, participantes (n = 383) y no participantes (n = 383) en el PPCCR de la Comunidad Valenciana. Análisis descriptivo y de regresión logística calculando las Odds Ratio (p < 0,05). Resultados: los motivos de participación mayoritarios son «es importante para su salud» (97,9 %) y «la prueba es sencilla» (97,6 %); y los de no participación la «ausencia de síntomas de CCR» (49,7 %) y «no recibió la carta de invitación» (48,3%). Es más probable que las mujeres no participen por el motivo «prueba desagradable» (OR 1,82; IC: 1,00-3,28), y los hombres por «falta de tiempo» (OR 0,51; IC: 0,27-0,97); las personas de 60 y más años por «miedo al diagnóstico» (OR 2,31; IC: 1,11-4,80), y las de 50-59 años por «falta de tiempo» (OR 0,44; IC: 0,23-0,85); las de clase social no manual por «falta de tiempo» (OR 2,66; IC: 1,40- 5,10); las mujeres de clase social manual por «vergüenza a hacerse la prueba» (OR 0,37; IC: 0,14-0,97); y los hombres de clase social no manual por «falta de tiempo» (OR 4,78; IC: 1,96-11,66). Conclusiones: existen desigualdades en los motivos de no participación por sexo, edad y clase social. Sería recomendable diseñar acciones que incorporen las necesidades específicas de diferentes grupos sociales para reducir las desigualdades en la participación (AU)

Objective: To know the reasons to participate or not in a colorectal cancer (CCR) screening programme and to analyze the differences by sex, age and social class. Methods: Cross-sectional study by a telephone survey directed to a sample of men and women aged between 50-74 year old, participants (n = 383) and non participants (n = 383) in the CCR screening programme of Valencian Community. Descriptive analysis and logistic regression models estimating the Odds Ratio (p < 0.05). Results: The main reasons to participate are «it is important for health» (97.9 %) and «the test is easy» (97.6 %); and to non participate are «no CCR symptoms» (49.7 %) and «didn’t receive invitation letter» (48.3 %). Women are more likely not to participate if the reason was to consider the «test unpleasant» (OR: 1.82; IC: 1.00-3.28), and men if the reason was «lack of time» (OR 0.51; IC: 0.27-0.97); persons 60 or more years old if the reason was «diagnostic fear» (OR: 2.31; IC: 1.11-4.80), and persons 50-59 years old if was «lack of time» (OR 0.44; IC: 0.23-0.85); non manual social class persons if the reason was «lack of time» (OR: 2.66; IC: 1.40-5.10); manual women if the reason was «embarrassment to perform the test» (OR: 0.37; IC: 0.14-0.97); and non manual men if was «lack of time» (OR: 4.78; IC: 1.96-11.66). Conclusions: There are inequalities in the reasons for not participating in CCR screening programmes by sex, age and social class. It would be advisable to design actions that incorporate specific social group needs in order to reduce inequalities in participation (AU)

Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in the PCMH.

PURPOSE: Telephone- and Internet-based communication are increasingly common in primary care, yet there is uncertainty about how these forms of communication affect demand for in-person office visits. We assessed whether use of copay-free secure messaging and telephone encounters was associated with office visit use in a population with diabetes. METHODS: We used an interrupted time series design with a patient-quarter unit of analysis. Secondary data from 2008-2011 spanned 3 periods before, during, and after a patient-centered medical home (PCMH) redesign in an integrated health care delivery system. We used linear regression models to estimate proportional changes in the use of primary care office visits associated with proportional increases in secure messaging and telephone encounters. RESULTS: The study included 18,486 adults with diabetes. The mean quarterly number of primary care contacts increased by 28% between the pre-PCMH baseline and the postimplementation periods, largely driven by increased secure messaging; quarterly office visit use declined by 8%. In adjusted regression analysis, 10% increases in secure message threads and telephone encounters were associated with increases of 1.25% (95% CI, 1.21%-1.29%) and 2.74% (95% CI, 2.70%-2.77%) in office visits, respectively. In an interaction model, proportional increases in secure messaging and telephone encounters remained associated with increased office visit use for all study periods and patient subpopulations (P<.001). CONCLUSIONS: Before and after a medical home redesign, proportional increases in secure messaging and telephone encounters were associated with additional primary care office visits for individuals with diabetes. Our findings provide evidence on how new forms of patient-clinician communication may affect demand for office visits.

Inter-method reliability of paper surveys and computer assisted telephone interviews in a randomized controlled trial of yoga for low back pain.

BACKGROUND: Little is known about the reliability of different methods of survey administration in low back pain trials. This analysis was designed to determine the reliability of responses to self-administered paper surveys compared to computer assisted telephone interviews (CATI) for the primary outcomes of pain intensity and back-related function, and secondary outcomes of patient satisfaction, SF-36, and global improvement among participants enrolled in a study of yoga for chronic low back pain. RESULTS: Pain intensity, back-related function, and both physical and mental health components of the SF-36 showed excellent reliability at all three time points; ICC scores ranged from 0.82 to 0.98. Pain medication use showed good reliability; kappa statistics ranged from 0.68 to 0.78. Patient satisfaction had moderate to excellent reliability; ICC scores ranged from 0.40 to 0.86. Global improvement showed poor reliability at 6 weeks (ICC = 0.24) and 12 weeks (ICC = 0.10). CONCLUSION: CATI shows excellent reliability for primary outcomes and at least some secondary outcomes when compared to self-administered paper surveys in a low back pain yoga trial. Having two reliable options for data collection may be helpful to increase response rates for core outcomes in back pain trials. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01761617. Date of trial registration: December 4, 2012.

Midwives' beliefs and concerns about telephone conversations with women in early labour.

OBJECTIVE: to explore midwives' concerns, experiences and perceptions of the purpose of telephone contacts with women in early labour. DESIGN: a qualitative design based on interpretive phenomenology. SETTING: two Maternity Units in the Midlands of England. PARTICIPANTS: three focus groups of labour ward midwife coordinators and labour ward midwives and nine in-depth interviews of midwives, obstetricians and labour ward receptionists. FINDINGS: the principal finding was that midwives are trying to reconcile gatekeeping of labour wards with individual support for women and these two aspects are often in conflict. Women experiencing prolonged or painful early labour often expect to be admitted to labour wards whereas midwives operate from a belief that women should only be accepted onto labour ward in active labour. They hold this view because labour wards are busy places and being admitted early contributes to unnecessary medical intervention. KEY CONCLUSIONS: because midwives are trying to reconcile the two conflicting priorities of responding to women's needs and protecting the labour ward from inappropriate admissions, the potential always exists for women's needs to be 'not heard' or marginalised. IMPLICATIONS FOR PRACTICE: the primary recommendation is that early labour telephone triage should be a discrete service, staffed by midwives who have been trained for this service, working independently of labour ward workloads.

Effect of short-term exposure to air pollution and pollen on medical emergency calls: a case-crossover study in Spain.

BACKGROUND: A symmetric case-crossover design was used to analyse the short-term relationship between air pollution, pollen and emergency calls to medical services. METHODS: This study covered patients who made medical emergency calls in the City of Vigo (Spain) during the period 1996-1999. Morbidity data were obtained from the records of the 061 Medical Emergency Control Center, in its capacity as the body officially coordinating all medical emergencies by telephone. Air pollution data were furnished by the Vigo Municipal Air Pollution Surveillance Grid. Pollen levels were provided by the staff of the Spanish Aerobiology Network in Vigo. RESULTS: A rise of 10 microg/m(3) in ambient particulate levels led to the risk of medical emergency calls requesting attention increasing by: (i) 1.97% [95% confidence interval (95% CI): 1.83-2.11%] for circulatory causes on the same day; (ii) 1.95% (95% CI: 1.76-2.14%) for respiratory causes at 2 days and (iii) 1.34% (95% CI: 1.23-1.45%) for combined circulatory and respiratory causes on the same day. A number of pollens displayed a statistically significant relationship with emergency calls. No interaction was in evidence between pollens and air pollutants. CONCLUSIONS: While elevations in particulate air pollution increase medical emergency calls because of cardiac or respiratory causes or both combined, elevations in pollen levels increase medical emergency calls because of respiratory causes.

Occupational risk factors for cancer of the central nervous system: a case-control study on death certificates from 24 U.S. states.

The risk of cancer of the central nervous system (CNS) by industry and occupation was investigated with a case-control analysis of the death certificates of 28,416 cases and 113,664 controls, selected from over 4.5 million deaths in 24 U.S. states between 1984 and 1992. Industries showing consistent increases in risk by gender and race included textile mills, paper mills, printing and publishing industries, petroleum refining, motor vehicles manufacturing, telephone and electric utilities, department stores, health care services, elementary and secondary schools, and colleges and universities. CNS cancer risk was increased for administrators in education and related fields, secondary school teachers, and other education- and health-related occupations. The application of job-exposure matrices to the industry/occupation combinations revealed a modest increase in risk for potential contact with the public at work and exposure to solvents. Occupational exposure to electromagnetic fields (EMF) was not associated with CNS cancer, although an association was observed with a few EMF-related occupations and industries. Agricultural exposures were associated with significant risk increases among white women and white men. Further work is required to investigate in more detail specific occupational exposures or possible confounders responsible for the observed associations.

[The telephone accessibility of the prior appointment program]. / Accesibilidad telefónica del programa de cita previa.

OBJECTIVE: To determine the ease of access by telephone when making medical appointments. DESIGN: Cross-sectional, observational, random sample. SETTING: Primary care, Murcia Region. PATIENTS AND OTHER PARTICIPANTS: Centres with a previous appointments system (n = 25) and a random sample of the 276 practitioners involved (n = 97). We ruled out 4 practitioners for not having a telephone in their outer consulting room. MEASUREMENTS AND MAIN RESULTS: We made telephone calls until we had obtained appointments with each of the practitioners, across three hour blocks. The result was an average of 2,333 calls/appointment, with a deflection of 2,271. The mode and median were 1, and the range 26. We found differences in the distribution of the calls across the three blocks (p < 0.05). Comparing rural centres with urban, we found a lower average number of calls in the first two blocks (p < 0.01). CONCLUSIONS: Telephone accessibility is at an appropriate level, both in rural and urban areas.

Toxic exposures and ingestions in Honolulu: I. A prospective pediatric ED cohort; II. A prospective poison center cohort.

Poisonings and toxic exposures are a frequent cause of preventable morbidity in children requiring emergency care. Ingestions and toxic substance exposures were studied in two prospective cohorts in Hawaii to examine the epidemiology of these events in this community in order to assess the effectiveness of current poison prevention practices and to identify additional measures to further prevent and reduce morbidity and mortality. During a 12-month period ending on 11/30/88, data were collected on 286 pediatric patients visiting a pediatric ED with an ingestion or a toxic substance exposure. Most of the younger children were males with unintentional incidents. Most of the adolescents were females with intentional ingestions. Syrup of ipecac was given in 16% of the patients. When given at home, ipecac was given an average of 1.3 hours after an ingestion. Activated charcoal was given to 32% of the patients. During a 13-month period ending 1/31/90, 14,408 phone calls to the Hawaii Poison Center were analyzed. Twenty-six percent of the callers had ipecac at home. Sixty-eight percent of callers with acute ingestions claimed to have called within 30 minutes of the ingestion, and 77% claimed to have called within 60 minutes of the ingestion. Of those calling within 60 minutes, 36% had ipecac at home. Although ipecac is widely recommended as a pre-hospital intervention, it use is limited owing to unavailability in the home and the short period of time during which it must be given. Since the dispensing of pharmaceuticals in limited quantities and in childproof containers began, it appears that other measures to further reduce morbidity and mortality owing to poisonings have had less additional effect. It appears that serious morbidity and mortality from poisonings in this cohort were uncommon.

Patterns of calling time and ipecac availability among poison center callers.

Over a one-month period all telephone calls from the public (n = 3828) to a regional poison center were analyzed. The proportion of early calls (within ten minutes of exposure) decreased with age. Late calls (greater than 30 minutes) were significantly associated with higher hospital referral rates when compared with earlier calls in children younger than 5 years (4.6% vs 1.8%) and adults (33% vs 15%). Ipecac was available in 59% of the homes of callers with children younger than 5 years. Hospital referrals were significantly less common among children who had ipecac at home (1%) compared with children who did not (3%). While the availability of ipecac was similar among callers and a matched sample of households who previously called the poison center (58%), ipecac was much less frequently available (24%) among households whose members had not previously called the center. These data infer that educating the public to call the poison center promptly may result in reduction of hospital referrals. Poison education efforts should be targeted to populations with low ipecac availability and low utilization of the poison center.