Severity of Coronavirus Disease 2019 Hospitalization Outcomes and Patient Disposition Differ by Disability Status and Disability Type.

BACKGROUND: Systemic inequities may place people with disabilities at higher risk of severe coronavirus disease 2019 (COVID-19) illness or lower likelihood to be discharged home after hospitalization. We examined whether severity of COVID-19 hospitalization outcomes and disposition differ by disability status and disability type. METHODS: In a retrospective analysis of April 2020-November 2021 hospital-based administrative data among 745 375 people hospitalized with COVID-19 from 866 US hospitals, people with disabilities (n = 120 360) were identified via ICD-10-CM codes. Outcomes compared by disability status included intensive care admission, invasive mechanical ventilation (IMV), in-hospital mortality, 30-day readmission, length of stay, and disposition (discharge to home, long-term care facility (LTCF), or skilled nursing facility (SNF). RESULTS: People with disabilities had increased risks of IMV (adjusted risk ratio [aRR]: 1.05; 95% confidence interval [CI]: 1.03-1.08) and in-hospital mortality (1.04; 1.02-1.06) compared to those with no disability; risks were higher among people with intellectual and developmental disabilities (IDD) (IMV [1.34; 1.28-1.40], mortality [1.31; 1.26-1.37]), or mobility disabilities (IMV [1.13; 1.09-1.16], mortality [1.04; 1.01-1.07]). Risk of readmission was increased among people with any disability (1.23; 1.20-1.27) and each disability type. Risks of discharge to a LTCF (1.45, 1.39-1.51) or SNF (1.78, 1.74-1.81) were increased among community-dwelling people with each disability type. CONCLUSIONS: Severity of COVID-19 hospitalization outcomes vary by disability status and type; IDD and mobility disabilities were associated with higher risks of severe outcomes. Disparities such as differences in discharge disposition by disability status require further study, which would be facilitated by standardized data on disability. Increased readmission across disability types indicates a need to improve discharge planning and support services.

Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management.

OBJECTIVE: To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes. STUDY DESIGN: A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients. RESULTS: Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations. CONCLUSIONS: Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion.

Risk of Repeat Concussion Among Patients Diagnosed at a Pediatric Care Network.

OBJECTIVE: To quantify the risk of repeat concussions for children and identify demographic and clinical aspects of the index concussion associated with repeat injury. STUDY DESIGN: For this retrospective cohort study, we queried the Children's Hospital of Philadelphia healthcare network's unified electronic health record to identify all 5- to 15-year-old patients who had their first clinical visit for an index concussion at a Children's Hospital of Philadelphia location from July 2012 through June 2013. A 25% random sample (n = 536) were selected. Clinical data were abstracted for their index concussion and all concussion-related visits for 2 years following the index concussion. RESULTS: Overall, 16.2% (n = 87) of patients experienced at least 1 repeat concussion within 2 years of their index concussion. The risk of repeat concussion increased with patient age (9.5% for ages 5-8 years; 10.7% for ages 9-11 years; and 19.8% for ages 12-15 years). After we adjusted for other factors, risk was particularly heightened among patients whose index concussion had a longer clinical course (>30 vs 0-7 days, adjusted risk ratio 1.65 [1.01-2.69]) and greater symptom burden (>11 vs 0-2 symptoms, adjusted risk ratio 2.12 [1.12-3.72]). CONCLUSIONS: We estimate that 1 in 6 youth diagnosed with a concussion are diagnosed with a subsequent concussion within 2 years and that several clinical characteristics of the index concussion increase this risk. Identifying factors associated with a repeat injury is essential to inform the clinical management of concussion and direct injury prevention efforts.

Variations in Mechanisms of Injury for Children with Concussion.

OBJECTIVES: To assess the distribution of injury mechanisms and activities among children with concussions in a large pediatric healthcare system. STUDY DESIGN: All patients, age 0-17 years, who had at least 1 clinical encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of concussion in the Children's Hospital of Philadelphia's electronic health record system from July 1, 2012 to June 30, 2014, were selected (N = 8233) and their initial concussion-related visit identified. Approximately, 20% of the patients (n = 1625) were randomly selected for manual record review to examine injury mechanisms and activities. RESULTS: Overall, 70% of concussions were sports related; however, this proportion varied by age. Only 18% of concussions sustained by children aged 0-4 were sports related, compared with greater proportions for older children (67% for age 5-11, 77% for age 12-14, and 73% for age 15-17). When the concussion was not sports related, the primary mechanisms of injury were struck by an object (30%) and falls (30%). CONCLUSIONS: Sports-related injuries in children older than 6 years of age contributed to the majority of concussions in this cohort; however, it is important to note that approximately one-third of concussions were from non-sports-related activities. Although there is increased participation in community and organized sports activities among children, a focus on prevention efforts in other activities where concussions occur is needed.

Prevention of injury and violence in the USA.

In the first three decades of life, more individuals in the USA die from injuries and violence than from any other cause. Millions more people survive and are left with physical, emotional, and financial problems. Injuries and violence are not accidents; they are preventable. Prevention has a strong scientific foundation, yet efforts are not fully implemented or integrated into clinical and community settings. In this Series paper, we review the burden of injuries and violence in the USA, note effective interventions, and discuss methods to bring interventions into practice. Alliances between the public health community and medical care organisations, health-care providers, states, and communities can reduce injuries and violence. We encourage partnerships between medical and public health communities to consistently frame injuries and violence as preventable, identify evidence-based interventions, provide scientific information to decision makers, and strengthen the capacity of an integrated health system to prevent injuries and violence.

Comparability of national estimates for traumatic brain injury-related medical encounters.

OBJECTIVE: To describe similarities and differences in the number of civilian traumatic brain injury (TBI)-related hospitalizations and emergency department visits between national databases that capture US hospital data. PARTICIPANTS: TBI-related hospitalizations included in the National Hospital Discharge Survey (NHDS) and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) and emergency department visits in the National Hospital Ambulatory Medical Care Survey (NHAMCS) and HCUP Nationwide Emergency Department Sample (HCUP-NEDS) for 2006-2010. DESIGN: Cross-sectional design. MAIN MEASURES: Nationwide counts of TBI-related medical encounters. RESULTS: Overall, the frequency of TBI is comparable when comparing NHDS with HCUP-NIS and NHAMCS with HCUP-NEDS. However, annual counts in both NHDS and NHAMCS are consistently unstable when examined in smaller subgroups, such as by age group and injury mechanism. Injury mechanism is consistently missing from many more records in NHDS compared with HCUP-NIS. CONCLUSION: Given the large sample size of HCUP-NIS and HCUP-NEDS, these data can offer a valuable resource for examining TBI-related hospitalization and emergency department visits, especially by subgroup. These data hold promise for future examinations of annual TBI counts, but ongoing comparisons with national probability samples will be necessary to ensure that HCUP continues to track with estimates from these data.

Indication-Specific Opioid Prescribing for US Patients With Medicaid or Private Insurance, 2017.

Importance: Although opioids can be effective medications in certain situations, they are associated with harms, including opioid use disorder and overdose. Studies have revealed unexplained prescribing variation and prescribing mismatched with patient-reported pain for many indications. Objective: To summarize opioid prescribing frequency, dosages, and durations, stratified across numerous painful medical indications. Design, Setting, and Participants: Retrospective cross-sectional analysis of 2017 US administrative claims data among outpatient clinical settings, including postsurgical discharge. Participants had any of 41 different indications associated with nonsurgical acute or chronic pain or postsurgical pain or pain associated with sickle cell disease or active cancer and were enrolled in either private insurance (including Medicare Advantage) in the OptumLabs Data Warehouse data set (n = 18 016 259) or Medicaid in the IBM MarketScan Multi-State Medicaid Database (n = 11 453 392). OptumLabs data were analyzed from October 2018 to March 2019; MarketScan data were analyzed from January to April 2019. Exposures: Nonsurgical acute or chronic pain or postsurgical pain; pain related to sickle cell disease or active cancer. Main Outcomes and Measures: Indication-specific opioid prescribing rates; days' supply per prescription; daily opioid dosage in morphine milligram equivalents; and for chronic pain indications, the number of opioid prescriptions. Results: During the study period, of 18 016 259 eligible patients with private insurance, the mean (95% CI) age was 42.7 (42.7-42.7) years, and 50.3% were female; of 11 453 392 eligible Medicaid enrollees, the mean (95% CI) age was 20.4 (20.4-20.4) years, and 56.1% were female. A pain-related indication under study occurred in at least 1 visit among 6 380 694 patients with private insurance (35.4%) and 3 169 831 Medicaid enrollees (27.7%); 2 270 596 (35.6% of 6 380 694) privately insured patients and 1 126 508 (35.5% of 3 169 831) Medicaid enrollees had 1 or more opioid prescriptions. Nonsurgical acute pain opioid prescribing rates were lowest for acute migraines (privately insured, 4.6% of visits; Medicaid, 6.6%) and highest for rib fractures (privately insured, 44.8% of visits; Medicaid, 56.3%), with variable days' supply but similar daily dosage across most indications. Opioid prescribing for a given chronic pain indication varied depending on a patient's opioid use history. Days' supply for postoperative prescriptions was longest for combined spinal decompression and fusion (privately insured, 9.5 days [95% CI, 9.4-9.7 days]) or spinal fusion (Medicaid, 9.1 days [95% CI, 8.9-9.2 days]) and was shortest for vaginal delivery (privately insured, 4.1 days [95% CI, 4.1-4.1 days] vs Medicaid, 4.2 days [95% CI, 4.2-4.2 days]). Conclusions and Relevance: Indication-specific opioid prescribing rates were not always aligned with existing guidelines. Potential inconsistencies between prescribing practice and clinical recommendations, such as for acute and chronic back pain, highlight opportunities to enhance pain management and patient safety.

Evaluation of community-based programs to increase booster seat use.

This manuscript reports the results of an evaluation of two community-based booster seat promotion programs in Michigan; one program focused on a low-income community, while the other focused on a Hispanic community. Each community received funding to develop and implement a booster seat intervention program specific to their community. To determine the effectiveness of each program, direct observation surveys of booster seat use were conducted in each community, as well as in similarly composed comparison communities, before and after program implementation. A process evaluation documented activities and provided additional information for interpreting the results of the direct observation survey. Target age children (4-8 years) were observed traveling in cars, vans/minivans, sport-utility vehicles, and pickup trucks in each community. Baseline booster seat use was 19.0+/-5.3% and 9.7+/-2.5% for the low-income and Hispanic program communities, respectively. Post program results showed no significant change for the low-income program community, and a significant increase within the Hispanic program community. The process evaluation revealed challenges for each program and suggestions to overcome those challenges. Findings from the study can be useful to other communities interested in implementing programs to increase the use of booster seats.

Child passenger restraint use and emergency department--reported injuries: a special study using the National Electronic Injury Surveillance System-All Injury Program, 2004.

INTRODUCTION: In 2004, more than 180,000 child passengers aged

Tai chi and perceived health status in older adults who are transitionally frail: a randomized controlled trial.

BACKGROUND AND PURPOSE: Tai chi, a Chinese exercise derived from martial arts, while gaining popularity as an intervention for reducing falls in older adults, also may improve health status. The purpose of this study was to determine whether intense tai chi (TC) exercise could improve perceived health status and self-rated health (SRH) more than wellness education (WE) for older adults who are transitionally frail. SUBJECTS: Study subjects were 269 women who were >or=70 years of age and who were recruited from 20 congregate independent senior living facilities. METHODS: Participants took part in a 48-week, single-blind, randomized controlled trial. They were randomly assigned to receive either TC or WE interventions. Participants were interviewed before randomization and at 1 year regarding their perceived health status and SRH. Perceived health status was measured with the Sickness Impact Profile (SIP). RESULTS: Compared with WE participants, TC participants reported significant improvements in the physical dimension and ambulation categories and borderline significant improvements in the body care and movement category of the SIP. Self-rated health did not change for either group. DISCUSSION AND CONCLUSION: These findings suggest that older women who are transitionally frail and participate in intensive TC exercise demonstrate perceived health status benefits, most notably in ambulation.

Factors influencing the use of booster seats: a state-wide survey of parents.

This study used telephone interview data on booster seat use from a state-wide probability sample of parents with children ages 4-8-years-old who were living in Michigan. Interviews were completed with parents of children in 350 households. Analyses examined the entire sample, and three sub-groups: always users, part-time booster seat users, and booster seat non-users. Results indicated that booster seat legislation was a key determinant of the level of use and the motivation to use booster seats. Nearly 70% of part-time users said that they used booster seats because they believed it was the law. Similarly, 60% of part-time and non-booster seat users said that they would be more likely to use booster seats if use were mandated by law, with non-users being 3.5 times more likely than part-time users to agree that a law would increase their booster seat use. Finally, over 90% of part-time and non-booster seat users said it would be easier for them to use booster seats if a law required it, and non-users were almost six times more likely than part-time users to agree that a law would make use easier. The need for booster seat laws, issues of social equity, and implications for intervention were discussed.

Factors influencing stroke survivors' quality of life during subacute recovery.

BACKGROUND AND PURPOSE: Health-related quality of life (HRQOL) is an important index of outcome after stroke and may facilitate a broader description of stroke recovery. This study examined the relationship of individual and clinical characteristics to HRQOL in stroke survivors with mild to moderate stroke during subacute recovery. METHODS: Two hundred twenty-nine participants 3 to 9 months poststroke were enrolled in a national multisite clinical trial (Extremity Constraint-Induced Therapy Evaluation). HRQOL was assessed using the Stroke Impact Scale (SIS), Version 3.0. The Wolf Motor Function Test documented functional recovery of the hemiplegic upper extremity. Multiple analysis of variance and regression models examined the influence of demographic and clinical variables across SIS domains. RESULTS: Age, gender, education level, stroke type, concordance (paretic arm=dominant hand), upper extremity motor function (Wolf Motor Function Test), and comorbidities were associated across SIS domains. Poorer HRQOL in the physical domain was associated with age, nonwhite race, more comorbidities, and reduced upper-extremity function. Stroke survivors with more comorbidities reported poorer HRQOL in the area of memory and thinking, and those with an ischemic stroke and concordance reported poorer communication. CONCLUSIONS: Although results may not generalize to lower functioning stroke survivors, individual characteristics of persons with mild to moderate stroke may be important to consider in developing comprehensive, targeted interventions designed to maximize recovery and improve HRQOL.

Intense tai chi exercise training and fall occurrences in older, transitionally frail adults: a randomized, controlled trial.

OBJECTIVES: To determine whether an intense tai chi (TC) exercise program could reduce the risk of falls more than a wellness education (WE) program in older adults meeting criteria for transitioning to frailty. DESIGN: Randomized, controlled trial of 48 weeks duration. SETTING: Twenty congregate living facilities in the greater Atlanta area. PARTICIPANTS: Sample of 291 women and 20 men aged 70 to 97. MEASUREMENTS: Demographics, time to first fall and all subsequent falls, functional measures, Sickness Impact Profile, Centers for Epidemiologic Studies-Depression Scale, Activities-specific Balance Confidence Scale, Falls Efficacy Scales, and adherence to interventions. RESULTS: The risk ratio (RR) of falling was not statistically different in the TC group and the WE group (RR=0.75, 95% confidence interval (CI)=0.52-1.08), P=.13). Over the 48 weeks of intervention, 46% (n=132) of the participants did not fall; the percentage of participants that fell at least once was 47.6% for the TC group and 60.3% for the WE group. CONCLUSION: TC did not reduce the RR of falling in transitionally frail, older adults, but the direction of effect observed in this study, together with positive findings seen previously in more-robust older adults, suggests that TC may be clinically important and should be evaluated further in this high-risk population.

Effectiveness of a brief parent-directed teen driver safety intervention (Checkpoints) delivered by driver education instructors.

BACKGROUND: The Checkpoints program (Checkpoints) uses a Parent-Teen Driving Agreement (PTDA) to help parents monitor teens' driving, and has shown efficacy in increasing parental restrictions on teens' driving and decreasing teens' risky driving. In previous trials, research staff administered Checkpoints. This study examined the effectiveness of Checkpoints when delivered by driver educators. It was hypothesized that Checkpoints would result in more PTDA use, greater PTDA limits on higher risk driving situations, and less high-risk driving. METHODS: Eight trained driving instructors were randomly assigned to intervention or control groups in a group randomized trial. Instructors enrolled 148 parent-teen dyads (intervention = 99, control = 49); 35% of those eligible. Intervention parents joined teens for a 30-minute Checkpoints session during driver education. The session included a video, persuasive messages, discussion, and PTDA initiation. Teens completed four surveys: baseline, licensure, and 3- and 6-months post-licensure. RESULTS: Intervention teens were more likely to report that they used a PTDA (OR= 15.92, p = .004) and had restrictions on driving with teen passengers (OR = 8.52, p = .009), on weekend nights (OR = 8.71, p = .021), on high-speed roads (OR = 3.56, p = .02), and in bad weather (b = .51, p = .05) during the first six months of licensure. There were no differences in offenses or crashes at six months, but intervention teens reported less high-risk driving (p = .04). CONCLUSIONS: Although challenges remain to encourage greater parent participation, Checkpoints conducted by driver education instructors resulted in more use of PTDAs, greater restrictions on high-risk driving, and less high-risk driving. Including Checkpoints in driver education parent meetings/classes has potential to enhance teen driver safety.

Twenty years of scientific progress in injury and violence research and the next public health frontier.

The establishment of the National Center for Injury Prevention and Control (NCIPC or Injury Center) in 1992 as part of the Centers for Disease Control and Prevention (CDC) firmly established the Injury Center as the lead federal agency for non-occupational injury prevention and control (Sleet et al., 2012). Since then, it has provided leadership and a strong scientific base for intramural and extramural-investigator funded injury research. The Injury Center's scientific mission encompasses efforts from primary prevention to treatment and rehabilitation. Early CDC efforts were primarily focused on describing the extent of the problem, identifying risk and protective factors that affect the extent of violence and injury in our society, and gaining visibility for violence and injury as a major public health problem. Efforts such as the development of injury-based surveillance systems provided population-based surveillance data regarding the extent and distribution of fatal and non-fatal injuries, helped to identify demographic characteristics for those who were most at risk, and identified risk and protective factors that influence that risk. Celebrating the Injury Center's 20th anniversary presents an opportunity not only to reflect on past accomplishments but also to look ahead at what still needs to be done.

Person-to-person interventions targeted to parents and other caregivers to improve adolescent health: a community guide systematic review.

CONTEXT: Adolescence marks a time when many young people engage in risky behaviors with potential implications for long-term health. Interventions focused on adolescents' parents and other caregivers have the potential to affect adolescents across a variety of risk and health-outcome areas. EVIDENCE ACQUISITION: Community Guide methods were used to evaluate the effectiveness of caregiver-targeted interventions in addressing adolescent risk and protective behaviors and health outcomes. Sixteen studies published during the search period (1966-2007) met review requirements and were included in this review. EVIDENCE SYNTHESIS: Effectiveness was assessed based on changes in whether or not adolescents engaged in specified risk and protective behaviors; frequency of risk and protective behaviors, and health outcomes, also informed the results. Results from qualifying studies provided sufficient evidence that interventions delivered person-to-person (i.e., through some form of direct contact rather than through other forms of contact such as Internet or paper) and designed to modify parenting skills by targeting parents and other caregivers are effective in improving adolescent health. CONCLUSIONS: Interventions delivered to parents and other caregivers affect a cross-cutting array of adolescent risk and protective behaviors to yield improvements in adolescent health. Analysis from this review forms the basis of the recommendation by the Community Preventive Services Task Force presented elsewhere in this issue.