Stakeholder engagement in eight comparative effectiveness trials in African Americans and Latinos with asthma.

BACKGROUND: The effects of stakeholder engagement, particularly in comparative effectiveness trials, have not been widely reported. In 2014, eight comparative effectiveness studies targeting African Americans and Hispanics/Latinos with uncontrolled asthma were funded by the Patient-Centered Outcomes Research Institute (PCORI) as part of its Addressing Disparities Program. Awardees were required to meaningfully involve patients and other stakeholders. Using specific examples, we describe how these stakeholders substantially changed the research protocols and in other ways participated meaningfully as full partners in the development and conduct of the eight studies. METHODS: Using the method content analysis of cases, we identified themes regarding the types of stakeholders, methods of engagement, input from the stakeholders, changes made to the research protocols and processes, and perceived benefits and challenges of the engagement process. We used summaries from meetings of the eight teams, results from an engagement survey, and the final research reports as our data source to obtain detailed information. The descriptive data were assessed by multiple reviewers using inductive and deductive qualitative methods and discussed in the context of engagement literature. RESULTS: Stakeholders participated in the planning, conduct, and dissemination phases of all eight asthma studies. All the studies included clinicians and community representatives as stakeholders. Other stakeholders included patients with asthma, their caregivers, advocacy organizations, and health-system representatives. Engagement was primarily by participation in advisory boards, although six of the eight studies (75%) also utilized focus groups and one-on-one interviews. Difficulty finding a time and location to meet was the most reported challenge to engagement, noted by four of the eight teams (50%). Other reported challenges and barriers to engagement included recruitment of stakeholders, varying levels of enthusiasm among stakeholders, controlling power dynamics, and ensuring that stakeholder involvement was reflected and had true influence on the project. CONCLUSION: Engagement-driven modifications led to specific changes in study design and conduct that were felt to have increased enrollment and the general level of trust and support of the targeted communities. The level of interaction described, between investigators and stakeholders in each study and between investigator-stakeholder groups, is-we believe-unprecedented and may provide useful guidance for other studies seeking to improve the effectiveness of community-driven research.

The goal of comparative clinical effectiveness research is to compare healthcare options and learn which work best for patients depending on their preferences and circumstances. Research efforts can be more effective when researchers engage stakeholders, such as patients, healthcare providers, and other members of the community­especially those communities or groups targeted by the planned research. Stakeholders can give their input throughout the research process to make sure the study will address questions and concerns that are most important and useful for participants. In 2014, the PCORI funded eight research studies that evaluated various ways to help African Americans and Hispanics/Latinos with poorly controlled asthma. These groups are underrepresented in asthma research but have higher rates of and more severe asthma for reasons that are poorly understood. The goal of this report is to show how stakeholders­including patients with asthma from these underrepresented groups, healthcare providers who care for patients with asthma, key representatives from the communities and others­participated as full partners in the eight studies and helped to improve the overall quality of the research and the relationship between the researchers and the community.

Development of an Asthma Home-Visit Training Program for Community Health Workers and Their Supervisors in Washington State.

The community health worker (CHW) asthma home-visiting model developed by Public Health-Seattle & King County (PHSKC) is an evidence-based approach proven to improve health outcomes and quality of life. In addition, it has been shown to be an effective and culturally appropriate approach to helping people with asthma understand the environmental and behavioral causes of uncontrolled asthma, while acquiring the skills they need to control their asthma. This paper describes the development and implementation of training curricula for CHWs and supervisors in the asthma home visiting program. To facilitate dissemination, this program took advantage of the current healthcare landscape in Washington State resulting from Centers for Medicare & Medicaid Services (CMS) approval of the 1115 Medicaid Waiver project. Key aspects of the training program development included: (1) Engagement: forming a Community Advisory Board with multiple stakeholders to help prioritize training content; (2) Curriculum Development: building the training on evidence-based home-visit protocols previously developed at PHSKC; (3) Implementation of the training program; (4) Evaluation of the training; and (5) Adaptation of the training based on lessons learned. We describe key factors in the training program's improvement including the use of a community-based participatory approach to engage stakeholders at multiple phases of the project and ensure regional adaption; combining in-person and online modules for delivery; and holding learning collaboratives for post-training and technical support. We also outline our training program evaluation plan and the planned evaluation of the home visit program which the trainees will deliver, both of which follow the RE-AIM framework. However, because the COVID-19 pandemic has curtailed training activities and prohibited the trainees from implementation of these CHW home visit practices, our evaluation is currently incomplete. Therefore, this case study provides insight into the adaptation of the training program, but not the delivery of the home visit program, the outcomes of which remain to be seen.

Communication Training, Adverse Events, and Quality Measures: 2 Retrospective Database Analyses in Washington State Hospitals.

OBJECTIVE: Washington State's HealthPact program was launched in 2011 as part of AHRQ's Patient Safety and Medical Liability Reform initiative. HealthPact delivered interdisciplinary communication training to health-care professionals with the goal of enhancing safety. We conducted 2 exploratory, retrospective database analyses to investigate training impact on the frequency of adverse events (AEs) and select quality measures across 3 time frames: pretraining (2009-2011), transition (2012), and posttraining (2013). METHODS: Using administrative data from Washington State's Comprehensive Hospital Abstract Reporting System (CHARS) and clinical registry data from the Surgical Care and Outcomes Assessment Program (SCOAP), we compared proportions of AEs and quality measures between HealthPact (n = 4) and non-HealthPact (n = 93-CHARS; n = 48-SCOAP) participating hospitals. Risk ratios enabled comparisons between the 2 groups. Multivariable logistic regression enabled investigation of the association between training and the frequency of AEs. RESULTS: Approximately 9.4% (CHARS) and 7.7% (SCOAP) of unique patients experienced 1 AE or greater. In CHARS, the odds of a patient experiencing an AE in a HealthPact hospital were initially (pretraining) higher than in a non-HealthPact hospital (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.10-1.17), lower in transition (OR, 0.80; 95% CI, 0.76-0.83) and posttraining (OR, 0.72; 95% CI, 0.69-0.75) periods. In SCOAP, ORs were consistently lower in HealthPact hospitals: pretraining (OR, 0.87; 95% CI, 0.80-0.95), transition (OR, 0.75; 95% CI, 0.70-0.81), and posttraining (OR, 0.63; 95% CI, 0.58-0.68). The proportion of at-risk patients that experienced each individual AE was low (<1%) throughout. Adherence to quality measures was high. CONCLUSIONS: Interprofessional communication training is an area of intense activity nationwide. A broad-based training initiative may play a role in mitigating AEs.

Building a Practice-Based Research Agenda for Wildfire Smoke and Health: A Report of the 2018 Washington Wildfire Smoke Risk Communication Stakeholder Synthesis Symposium.

Background: As climate change is expected to result in more frequent, larger fires and associated smoke impacts, creating and sustaining wildfire smoke-resilient communities is an urgent public health priority. Following two summers of persistent and extreme wildfire smoke events in Washington state, the need for additional research on wildfire smoke health impacts, risk communication, and risk reduction, and an associated greater coordination between researcher and practitioner communities, is of paramount importance. Objectives: On 30 October 2018, the University of Washington hosted a Wildfire Smoke Risk Communication Stakeholder Synthesis Symposium in Seattle, Washington. The goals of the symposium were to identify and prioritize practice-based information gaps necessary to promote effective wildfire smoke risk communication and risk reduction across Washington state, foster collaboration among practitioners and academics to address information gaps using research, and provide regional stakeholders with access to the best available health and climate science about current and future wildfire risks. Methods: Seventy-six Washington state practitioners and academics with relevant professional responsibilities or expertise in wildfire smoke and health engaged in small group discussions using the "World Café Method" to identify practice-relevant research needs related to wildfire smoke and health. Notes from each discussion were coded and qualitatively analyzed using a content analysis approach. Discussion: Washington state's public health and air quality practitioners need additional evidence to communicate and reduce wildfire smoke risk. Exposure, health risk, risk communication, behavior change and interventions, and legal and policy research needs were identified, along with the need to develop research infrastructure to support wildfire smoke and health science. Practice-relevant, collaborative research should be prioritized to address this increasing health threat.

Enrolling African-American and Latino patients with asthma in comparative effectiveness research: Lessons learned from 8 patient-centered studies.

BACKGROUND: African-American and Latino patients are often difficult to recruit for asthma studies. This challenge is a barrier to improving asthma care and outcomes for these populations. OBJECTIVES: We sought to examine the recruitment experiences of 8 asthma comparative effectiveness studies that specifically targeted African-American and Latino patients, and identify the solutions they developed to improve recruitment. METHODS: Case report methodology was used to gather and evaluate information on study design, recruitment procedures and outcomes from study protocols and annual reports, and in-depth interviews with each research team. Data were analyzed for themes, commonalities, and differences. RESULTS: There were 4 domains of recruitment challenges: individual participant, institutional, research team, and study intervention. Participants had competing demands for time and some did not believe they had asthma. Institutional challenges included organizational policies governing monetary incentives and staff hiring. Research team challenges included ongoing training needs of recruitment staff, and intervention designs often were unappealing to participants because of inconveniences. Teams identified a host of strategies to address these challenges, most importantly engagement of patients and other stakeholders in study design and troubleshooting, and flexibility in data collection and intervention application to meet the varied needs of patients. CONCLUSIONS: Asthma researchers may have greater success with recruitment by addressing uncertainty among patients about asthma diagnosis, engaging stakeholders in all aspects of study design and implementation, and maximizing flexibility of study and intervention protocols. However, even with such efforts, engagement of African-American and Latino patients in asthma research may remain low. Greater investment in research on engaging these populations in asthma research may ultimately be needed to improve their asthma care and outcomes.

Trajectories to death in patients with burn injury.

BACKGROUND: With unprecedented survival rates in modern burn care, there is increasing focus on optimizing long-term functional outcomes. However, 3% to 8% of patients admitted to burn centers still die of injury. Patterns in which these patients progress to death remain poorly characterized. We hypothesized that burn nonsurvivors will follow distinct temporal distributions and patterns of decline, parallel to the trimodality of deaths previously described for trauma. METHODS: We retrospectively identified all adult deaths from 1995 to 2007 in the National Burn Repository database (n = 5,975) and at our regional burn center (n = 237). We stratified patients by age and analyzed injury and death characteristics. We used objective criteria to allocate nonsurvivors to one of four trajectories: early rapid decline, early organ failure, late sudden death, or late-onset decline. RESULTS: The greatest concentration of deaths in both samples and age groups occurred within 72 hours of injury and decreased subsequently with no later mortality peak. Death was most often caused by burn shock within the first week of injury, cardiogenic shock or lung injury in Weeks 1 to 2, and sepsis/multiorgan failure after Week 2. In decreasing frequency, trajectories to death fit the pattern of early rapid decline (58%), early organ failure (20%), late-onset decline (16%), and late sudden death (6%). CONCLUSION: Most burn deaths follow a pattern of early rapid decline or early organ failure manifested by death or critical illness within several days of the burn. These findings indicate that more than three quarters of burn deaths are attributable to failure or significant decompensation beginning in the resuscitation phase. Sporadic deaths later in hospitalization are uncommon. Despite significant advances in burn resuscitation, our data indicate that ongoing efforts to mitigate deaths in modern burn care should still focus on care improvements in the resuscitation phase. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Early withdrawal of life support in severe burn injury.

Despite many advances in modern burn care, deaths still occur in the burn intensive care unit. For patients with severe burns, providers may advocate to withdraw life support early during hospitalization when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Our regional burn center has implemented a stepwise withdrawal protocol since 2001 in an effort to standardize symptoms palliation at the end of life. In this study, the authors evaluated the frequency of early withdrawal and the protocol impact on end-of-life processes of care in burn patients who died within 72 hours of hospitalization. A 13-year review of all burn patients aged ≥18 years admitted to our burn center to identify all patients who died within 72 hours of hospitalization was performed. Patients were dichotomized to the periods before (1995 to mid-2001) and after implementation of standardized withdrawal protocol (mid-2001 to 2007). Descriptive analyses were performed to compare end-of-life care processes between the two periods. A total of 4374 adult patients with acute burns were admitted during the 13-year study period, of which 252 (6%) died during hospitalization. Of the patients who died within 72 hours, 106 (84%) had withdrawal of life support compared with 20 (16%) who died with ongoing life support. Higher mean TBSA distinguished patients who died by withdrawal (61 vs 48%, P = .06). Since mid-2001, all 61 patients who had life support withdrawn were by protocol. Implementation of the protocol has led to more frequent use of opioid infusion (98 vs 87%, P = .07) and benzodiazepine infusion (95 vs 49%, P < .01), without hastening time to death (median 5.0 vs 5.5 hours, P = .70). The large majority of early burn deaths at our regional center occur via withdrawal of life support. Implementation of a protocolized withdrawal has resulted in more consistent provision of analgesia and sedation without hastening death. Burn centers should consider using a protocol for withdrawal of life support to improve consistency in end-of-life symptoms palliation.

Variations in U.S. pediatric burn injury hospitalizations using the national burn repository data.

An understanding of population-specific variation in pediatric burn injuries is essential to the development of effective prevention strategies. The purpose of this study was to examine the etiology of pediatric burn injury considering age and race categories using the National Burn Repository. The authors reviewed the records of all pediatric patients (age <18 years) in the American Burn Association's National Burn Registry injured between 1995 and 2007. The authors compared patient and injury characteristics across race, age, etiology, and payor status. A total of 46,582 patients were included in this study. The etiology of burn injury varied by both age and race. Populations of color were younger, constituting 53.8% of patients younger than 5 years, whereas 53.9% of the total study population identified as Caucasian. Scald etiology was disproportionately less common in patients identifying as Caucasian (39.9 vs 61.4%, P < .001), and scald was a common etiology in older children identifying as African American, Asian, and Hispanic. Inhalation injuries were also higher in patients identifying as Native American (5.4%), Hispanic (4.2%), and African American (3.7%). Pediatric burn injury etiology varies with age and race. These data should encourage careful consideration of race, age, and other differences in formulating the most effective, population-specific prevention and outreach strategies.

Risk factors for the development of pneumonia in older adults with burn injury.

Older adults with burns are at risk for worse outcomes because of factors related to age, comorbidities, and response to treatment. Although the impact of pneumonia has been previously described in burn patients, less is known in the older adult population. In this study, we used the National Burn Repository to characterize patient and injury factors associated with pneumonia development in older adults with burns. We examined the records of all patients in the National Burn Repository aged 55 years and older from 1995 to 2007. To better characterize the effects of age on outcomes, patients were stratified into three categories: 55 to 64 years, 65 to 74 years, and 75 years and older. Pneumonia was identified by listed complications and ICD-9 codes. Comorbidities were classified by Charlson Comorbidity Index Score. Unadjusted and multivariate regression analyses were performed to distinguish the impact of age, comorbidities, and injury factors on pneumonia development and mortality. A total of 23,794 patient records met inclusion criteria during the study period, and 2,052 (8.6%) had pneumonia. Patients who developed pneumonia were more likely to be men (65 vs 56%, P < .001), have higher TBSA (21 vs 13%, P < .001), have sustained inhalation injury (21 vs 7%, P < .001), and have comorbid condition (34 vs 13%, P < .001). On multivariate analysis, factors significantly associated with pneumonia development were male sex, percent TBSA, inhalation injury, and presence of comorbidity. Specifically, chronic lung and heart disease had adjusted odds ratio (OR) of 2.70 and 3.48, respectively, for development of pneumonia (P < .001). By logistic regression, adjusted OR for pneumonia were 0.89 (95% CI 0.74-1.06, P = .18) in the 65 to 74 years age group and 1.26 (95% CI 1.07-1.48, P = .005) in the oldest group compared with the 55 to 64 years age group. Pneumonia during hospitalization was associated with an adjusted OR of 1.91 for death (95% CI 1.61-2.27, P < .001) after controlling for the factors of age, sex, comorbidity, TBSA, and inhalation injury. Injury factors and the presence of comorbidities consistently predicted the development of pneumonia in this large national patient sample. Higher age category also predicted higher pneumonia risk, although this association was only significant in the highest age group. This study, thus, highlights the importance of comorbidities over chronological age in pneumonia development in older adults with burn injuries.

Geographic access to burn center hospitals.

CONTEXT: The delivery of burn care is a resource-intensive endeavor that requires specialized personnel and equipment. The optimal geographic distribution of burn centers has long been debated; however, the current distribution of centers relative to geographic area and population is unknown. OBJECTIVE: To estimate the proportion of the US population living within 1 and 2 hours by rotary air transport (helicopter) or ground transport of a burn care facility. DESIGN AND SETTING: A cross-sectional analysis of geographic access to US burn centers utilizing the 2000 US census, road and speed limit data, the Atlas and Database of Air Medical Services database, and the 2008 American Burn Association Directory. MAIN OUTCOME MEASURE: The proportion of state, regional, and national population living within 1 and 2 hours by air transport or ground transport of a burn care facility. RESULTS: In 2008, there were 128 self-reported burn centers in the United States including 51 American Burn Association-verified centers. An estimated 25.1% and 46.3% of the US population live within 1 and 2 hours by ground transport, respectively, of a verified burn center. By air, 53.9% and 79.0% of the population live within 1 and 2 hours, respectively, of a verified center. There was significant regional variation in access to verified burn centers by both ground and rotary air transport. The greatest proportion of the population with access was highest in the northeast region and lowest in the southern United States. CONCLUSION: Nearly 80% of the US population lives within 2 hours by ground or rotary air transport of a verified burn center; however, there is both state and regional variation in geographic access to these centers.

Influence of comorbidities and age on outcome following burn injury in older adults.

Despite advances in medical and surgical techniques, older adults tend to be at high risk for adverse outcomes following burn injury. The purpose of this study was to examine the relative impacts of age and medical comorbidities on outcome following injury in a cohort of older adults. This was a retrospective study of all patients age 55 and over admitted to the University of Washington Burn Center from 1999 to 2003. To examine the effect of baseline medical comorbidities on outcome, a Charlson Comorbidity Index score was calculated for each patient. Multivariate regression analyses were used to examine the impact of age and comorbidities on mortality and other complications. Patient records were also matched with the National Death Index to determine the effects of age and comorbidities on mortality within 1 year following hospital discharge. A total of 325 patients who were of 55 years and older were admitted to the burn center during the 5-year study period. The overall mortality rate was 18.5%. Mortality was independently associated with age, inhalation injury, and burn size. One-year mortality was significantly associated with those older than age 75 and the Charlson score. Longer length of stay was significantly associated with burn size, inhalation injury, and total number of in-hospital complications. This study demonstrates that patient age-independent of baseline medical comorbidities-and TBSA burn are the most significant factors impacting in-hospital mortality risk following burn injury. Higher number of medical comorbidities was associated with increased mortality risk within 1 year following discharge.

The beneficial effects of plasma exchange after severe burn injury.

Severe burn injury results in a systemic inflammatory response that leads to increased capillary permeability and fluid leak into the interstitium. This global systemic capillary leak can be attributed, at least in part, to inflammatory mediators produced as a result of cellular injury. Plasma exchange has been used in the management of a number of illnesses with a significant inflammatory component, and, therefore, may have a role in the early management of burn injury. The purpose of this study was to review our institutional experience using plasma exchange in the management of severe burn injury. We performed a retrospective review of all patients receiving plasma exchange at our burn center between 2001 and 2005. Data collected included the following: burn size, presence of inhalation injury, resuscitation fluid received, urine output, lactate levels, base deficit levels, and hematocrit before and after the exchange procedure. A total of 37 patients underwent plasma exchange during the 5-year study period and seven patients underwent two plasma exchange treatments. Average TBSA burned was 48.6% (range 18-82) and 73% of patients sustained an inhalation injury. After plasma exchange, hourly fluid volume received significantly decreased (P < .05) and base deficit, lactate, and hematocrit levels significantly improved. Plasma exchange in the early resuscitation period was associated with decreased fluid administration, as well as increased urine output in the period during and immediately after the procedure. These data suggest that plasma exchange may provide a useful tool in the management of severe burn injury.

Epidemiology and outcomes of older adults with burn injury: an analysis of the National Burn Repository.

Improvements in outcomes for older adults sustaining burn injuries have lagged far behind those of younger patients. As this segment of the population grows, there has been an increasing interest in better understanding the epidemiology and outcomes of injury in older adults. The National Burn Repository (NBR) provides a unique opportunity to examine burn injuries on a national level. We aimed to characterize specific injury and outcome trends in older adult with burns through analysis of the NBR. We examined the records of all patients in the NBR aged 55 and older. To characterize age effects on injury and outcomes, patients were stratified into three age categories: 55 to 64 years, 65 to 74 years, and 75 years and older. Baseline characteristics, details of hospital treatment, mortality, and disposition were compared among these three age groups using chi or analysis of variance. Logistic regression analysis was performed to assess the impact of age on burn mortality. A total of 180,401 patient records were available from 1991 to 2005, of which 23,180 (14%) met age inclusion criteria. Mean burn size (9.6% TBSA) and percent with inhalation injury (11.3%) did not markedly differ by age. Men predominated overall (ratio 1.4:1), although women (4290) outnumbered men (3439) in the oldest age category. Length of stay per TBSA and median hospital charges increased with increasing age category, suggesting higher resource consumption with aging. Mean number of operations per patient, however, decreased with age. Mortality rates and discharge to nonindependent status increased with age. By logistic regression, the adjusted odds ratio for mortality was 2.3 (95% CI 2.1-2.7) in the 65 to 74 age group, and 5.4 (95% CI 4.8-6.1) in the oldest group when compared with the 55 to 64 age group. Mortality rates decreased significantly after 2001 across all age groups. This analysis demonstrates age-dependent differences in resource utilization and mortality risk within the older burn population and highlights the need for a national research agenda focused on management practices and outcomes in older adult with burns.

The application of genetic information for regulatory standard setting under the clean air act: a decision-analytic approach.

In 2002, the U.S. Environmental Protection Agency (EPA) released an "Interim Policy on Genomics," stating a commitment to developing guidance on the inclusion of genetic information in regulatory decision making. This statement was followed in 2004 by a document exploring the potential implications. Genetic information can play a key role in understanding and quantifying human susceptibility, an essential step in many of the risk assessments used to shape policy. For example, the federal Clean Air Act (CAA) requires EPA to set National Ambient Air Quality Standards (NAAQS) for criteria pollutants at levels to protect even sensitive populations from adverse health effects with an adequate margin of safety. Asthmatics are generally regarded as a sensitive population, yet substantial research gaps in understanding genetic susceptibility and disease have hindered quantitative risk analysis. This case study assesses the potential role of genomic information regarding susceptible populations in the NAAQS process for fine particulate matter (PM(2.5)) under the CAA. In this initial assessment, we model the contribution of a single polymorphism to asthma risk and mortality risk; however, multiple polymorphisms and interactions (gene-gene and gene-environment) are known to play key roles in the disease process. We show that the impact of new information about susceptibility on estimates of population risk or average risk derived from large epidemiological studies depends on the circumstances. We also suggest that analysis of a single polymorphism, or other risk factor such as health status, may or may not change estimates of individual risk enough to alter a particular regulatory decision, but this depends on specific characteristics of the decision and risk information. We also show how new information about susceptibility in the context of the NAAQS for PM(2.5) could have a large impact on the estimated distribution of individual risk. This would occur if a group were consequently identified (based on genetic and/or disease status), that accounted for a disproportionate share of observed effects. Our results highlight certain conditions under which genetic information is likely to have an impact on risk estimates and the balance of costs and benefits within groups, and highlight critical research needs. As future studies explore more fully the relationship between exposure, genetic makeup, and disease status, the opportunity for genetic information and disease status to play pivotal roles in regulation can only increase.

Hospital costs associated with pediatric burn injury.

Modern burn care is a resource intensive endeavor requiring specialized equipment, personnel, and facilities in order to provide optimum care. The costs associated with burn injury to both patients and society as a whole can be multifaceted and large. The purpose of this study was to evaluate the association between hospital costs, patient characteristics, and injury factors in a cohort of pediatric patients admitted to a regional burn center. We performed a review of the hospital charges accrued by pediatric patients (age <16 years) admitted to our burn center from 1994 to 2004 and explored the relationship between baseline patient, injury and hospital course characteristics and total costs. Hospital charges were converted to 2005 dollar costs using an inflation index and a cost to charge ratio. Univariate and multivariate regressions were performed to identify the factors most significantly associated with cost. In addition, we performed a subset cost analysis for patients with burns more than 20% TBSA. A total of 1443 pediatric patients (age <16) were admitted to our burn center during the study period. The overall mean hospital cost in 2005 dollars was dollars 9026 (SD = dollars 25,483; median = dollars 2138). Area of full thickness burn was the only patient or injury factor significantly associated with greater hospital costs (P < .05) on multivariate analysis. No single anatomic area was associated with increased hospital costs when adjusted for total overall burn size. Injury severity was the most significant factor impacting index hospitalization costs following pediatric burn injury. Further studies defining the long-term societal costs impact of burn injury are needed as are studies that evaluate the impact of burn injury on quality of life.

Assault and substance abuse characterize burn injuries in homeless patients.

The homeless are at an increased risk for traumatic injury, but little is known about the injury etiology and outcome of homeless persons who sustain burn injuries. In this study, we analyze patient and injury characteristics of homeless persons admitted to a regional burn center. This is a retrospective cohort study of patients admitted to our burn center between 1994 and 2005. A total of 3700 adult patients were admitted during the study period and, of these, 72 (1.9%) were homeless. The cohort of homeless patients was compared with domiciled adult patients admitted during the same time period, analyzing baseline patient and injury characteristics and injury outcomes. Overall, homeless patients had more extensive burn injuries than domiciled patients (17.8% vs 11.2%TBSA, P < .001) and overall longer lengths of hospital stay (22 vs 12 days, P < .001). The homeless population also had significantly higher rates of alcohol (80.6% vs 12.8%, P < .001) and drug abuse (59.4% vs 12.8%, P < .001), history of mental illness (45.2% vs 11.0%, P < .001), and injury by assault (13.9% vs 2.0%, P < .001). Homeless patients tended to have more severe injuries; higher rates of substance abuse and mental illness; increased incidence of assault by burning; and longer lengths of hospital stay. Hospitalization of a homeless patient following injury may provide a unique opportunity to address co-occurring substance abuse and mental illness and approach injury prevention to improve patients' outcomes and reduce injury recidivism.

Influence of injury characteristics and payer status on burn treatment location in Washington state.

The provision of optimal burn care is a resource-intensive endeavor. The American Burn Association has developed criteria to help guide the decision to refer a patient to a burn center for definitive injury care. The purpose of this study was to compare the patient and injury characteristics of patients admitted to the single verified burn center in Washington State with those treated at other facilities in the state. We performed a retrospective review of all patients admitted to a hospital with a burn injury in Washington State from 1987 to 2005 using the state's discharge database (Comprehensive Hospital Abstract Reporting System). Patient and injury factors of patients admitted to the state's single verified burn center or at other hospitals were compared. Multivariate poisson regression was used to calculate the relative risk of injury and patient factors that were significantly associated with admission to the verified burn center. From 1987 to 2005, a total of 16,531 patients were admitted to a Washington State hospital after burn injury. Of these patients, 8624 (52.2%) were treated definitively at the University of Washington Burn Center. Patients treated at this verified center had larger overall burn size (7.4% vs 4.5% TBSA, P < .001), higher percent full-thickness burn (4.3% vs 1.2%, P < .001), and higher rates of inhalation injury (2.3% vs 1.5%, P = .005). Uninsured status (relative risk = 1.46, 95% confidence interval = 1.4-1.5) was also significantly associated with treatment at the verified burn center. Injury severity and payer status were both found to be independent predictors of treatment at the single verified burn center in Washington.

Time to school re-entry after burn injury is quite short.

Returning to school is an important indicator of functional aptitude and emotional adjustment in school-aged patients after burn injury. Only two reports in the burn literature provide objective data on time to school re-entry. However, these analyses did not address the impact of patient and burn injury characteristics on time to return to school. The purpose of this study was to determine the time for school re-entry and to identify the factors associated with re-entry time in a cohort of burned children treated at our burn center. We performed a retrospective review of all school age children treated at our burn center from 1997 to 2003 who were entered into a federally funded longitudinal research database for patients with severe burn injury. Time to school re-entry after discharge was calculated for each patient, and multivariate regression was used to identify the factors associated with longer time to return to school. A total of 64 patients were included in this study. The average time to school re-entry was 10.5 days (range, 0-40) and the median time was 7.5 days. Gender (male), age, and length of hospital stay were significantly associated (P < .05) with longer time to return to school. The average time to school return is quite short. Further studies are needed to increase understanding of the factors influencing longer time to re-entry and also to examine children's experiences upon re-entry.

Policy implications of genetic information on regulation under the Clean Air Act: the case of particulate matter and asthmatics.

The U.S. Clean Air Act (CAA) explicitly guarantees the protection of sensitive human subpopulations from adverse health effects associated with air pollution exposure. Identified subpopulations, such as asthmatics, may carry multiple genetic susceptibilities to disease onset and progression and thus qualify for special protection under the CAA. Scientific advances accelerated as a result of the groundbreaking Human Genome Project enable the quantification of genetic information that underlies such human variability in susceptibility and the cellular mechanisms of disease. In epidemiology and regulatory toxicology, genetic information can more clearly elucidate human susceptibility essential to risk assessment, such as in support of air quality regulation. In an effort to encourage the incorporation of genomic information in regulation, the U.S. Environmental Protection Agency (EPA) has issued an Interim Policy on Genomics. Additional research strategy and policy documents from the National Academy of Science, the U.S. EPA, and the U.S. Department of Health and Human Services further promote the expansion of asthma genetics research for human health risk assessment. Through a review of these government documents, we find opportunities for the inclusion of genetic information in the regulation of air pollutants. In addition, we identify sources of information in recent scientific research on asthma genetics relevant to regulatory standard setting. We conclude with recommendations on how to integrate these approaches for the improvement of regulatory health science and the prerequisites for inclusion of genetic information in decision making.