Internationally comparable diagnosis-specific survival probabilities for calculation of the ICD-10-based Injury Severity Score.

BACKGROUND: The International Statistical Classification of Diseases, 10th Revision (ICD-10)-based Injury Severity Score (ICISS) performs well but requires diagnosis-specific survival probabilities (DSPs), which are empirically derived, for its calculation. The objective was to examine if DSPs based on data pooled from several countries could increase accuracy, precision, utility, and international comparability of DSPs and ICISS. METHODS: Australia, Argentina, Austria, Canada, Denmark, New Zealand, and Sweden provided ICD-10-coded injury hospital discharge data, including in-hospital mortality status. Data from the seven countries were pooled using four different methods to create an international collaborative effort ICISS (ICE-ICISS). The ability of the ICISS to predict mortality using the country-specific DSPs and the pooled DSPs was estimated and compared. RESULTS: The pooled DSPs were based on a total of 3,966,550 observations of injury diagnoses from the seven countries. The proportion of injury diagnoses having at least 100 discharges to calculate the DSP varied from 12% to 48% in the country-specific data set and was 66% in the pooled data set. When compared with using a country's own DSPs for ICISS calculation, the pooled DSPs resulted in somewhat reduced discrimination in predicting mortality (difference in c statistic varied from 0.006 to 0.04). Calibration was generally good when the predicted mortality risk was less than 20%. When Danish and Swedish data were used, ICISS was combined with age and sex in a logistic regression model to predict in-hospital mortality. Including age and sex improved both discrimination and calibration substantially, and the differences from using country-specific or pooled DSPs were minor. CONCLUSION: Pooling data from seven countries generated empirically derived DSPs. These pooled DSPs facilitate international comparisons and enables the use of ICISS in all settings where ICD-10 hospital discharge diagnoses are available. The modest reduction in performance of the ICE-ICISS compared with the country-specific scores is unlikely to outweigh the benefit of internationally comparable Injury Severity Scores possible with pooled data. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Effect of a fall prevention program on balance maintenance using a quasi-experimental design in real-world settings.

OBJECTIVES: To examine the effect of a fall prevention program offered under real-world conditions on balance maintenance several months after the program. To explore the program's impact on falls. METHOD: A quasi-experimental study was conducted among community-dwelling seniors, with pre- and postintervention measures of balance performance and self-reported falls. Ten community-based organizations offered the intervention (98 participants) and 7 recruited participants to the study's control arm (102 participants). An earlier study examined balance immediately after the 12-week program. The present study focuses on the 12-month effect. Linear regression (balance) and negative binomial regression (falls) procedures were performed.falls. RESULTS: During the 12-month study period, experimental participants improved and maintained their balance as reflected by their scores on three performance tests. There was no evidence of an effect on falls.falls. DISCUSSION: Structured group exercise programs offered in community-based settings can maintain selected components of balance for several months after the program's end.

Firearms regulation and declining rates of male suicide in Quebec.

OBJECTIVES: To examine whether significant changes in method-specific male suicide rates occurred in the province of Quebec after stronger firearms regulations were introduced in Canada in 1991; to ascertain whether more stringent firearms regulations influence firearms and total suicide trends among men and to determine whether different results are obtained according to the statistical methods used. STUDY DESIGN: Descriptive analyses of time trends in method-specific suicide rates for men from 1981 to 2006 using Joinpoint regression models and pre-post firearms regulation analyses. SETTING: Quebec (Canada). PATIENTS OR SUBJECTS: Men who have commited suicide aged 15-34, 35-64 and 65 years and over, based on the Quebec mortality database, 1981-2006. INTERVENTIONS: A national firearms control initiative enacted in 1991. RESULTS: The Joinpoint regression models suggest that firearm suicide rates declined towards the end of the 1990 s. Since 1996, the pace of decline was twice as great in men aged 15-34 years (annual percentage change (APC) -11.1%) compared with men aged 35-64 years (APC -5.6%). Total suicide rates also declined among men aged 15-34 and 35-64 years during this period. Pre-post firearms regulation Poisson regression analyses failed to detect the specific point in time when significant changes in the trend occurred. CONCLUSIONS: Male firearm suicide rates declined following the introduction of restrictive firearms regulations in Canada. Whether this represents a causal relationship requires further study.

Impact of a community-based falls prevention program on maintenance of physical activity among older adults.

OBJECTIVE: This study examines the 9-month impact of a 12-week falls prevention program (called Stand Up!) which included balance exercises and educational components on maintenance of physical activity among community-dwelling seniors. METHOD: Data were collected among 98 experimental and 102 control participants at baseline, immediately after the program and 9 months later. Involvement in physical activity was measured with three indicators. Program effects were examined using linear and logistic regression procedures. RESULTS: Both groups showed similar increases in weekly frequency of exercise at the 9-month posttest. However, the program's participants showed higher increases in their variety of exercises at the 9-month posttest (especially among those with greater baseline scores). Among seniors reporting lower levels of energy expenditure at baseline, the program's participants showed significantly greater increases in energy expenditure than control participants. DISCUSSION: These preliminary findings suggest that programs such as Stand Up! have the potential to stimulate continued involvement in physical activity.

Impact of a multifaceted community-based falls prevention program on balance-related psychologic factors.

OBJECTIVE: To assess the impact of a multifaceted falls prevention program including exercise and educational components on perceived balance and balance confidence among community-dwelling seniors. DESIGN: Quasi-experimental design. SETTING: Community-based organizations. PARTICIPANTS: Two hundred community-dwelling adults aged 60 years and over recruited by community-based organizations. INTERVENTION: A 12-week multifaceted falls prevention program including 3 components (a 1-hour group exercise class held twice a week, a 30-minute home exercise module to be performed at least once a week, a 30-minute educational class held once a week). MAIN OUTCOME MEASURES: Perceived balance and balance confidence. RESULTS: Multivariate analysis showed that the program was successful in increasing perceived balance in experimental participants. However, balance confidence was not improved by program participation. CONCLUSIONS: A multifaceted community-based falls prevention program that was successful in improving balance performance among community-dwelling seniors also had a positive impact on perceived balance. However, the program did not improve participants' balance confidence. These results suggest that balance confidence has determinants other than balance and that new components and/or modifications of existing components of the program are required to achieve maximal benefits for seniors in terms of physical and psychologic outcomes.

Evidence of the psychometric qualities of a simplified version of the Activities-specific Balance Confidence scale for community-dwelling seniors.

OBJECTIVE: To evaluate the validity, reliability, and item hierarchy of a modified version of the Activities-specific Balance Confidence (ABC) scale using an item-response theory framework and integrating modifications aimed at increasing user-friendliness and promoting better congruence of the scale with public health falls prevention strategies. DESIGN: Cross-sectional study. SETTING: Community-based. PARTICIPANTS: Two hundred community-dwelling seniors involved in an effectiveness study of a falls prevention program. Participants were recruited by community-based organizations. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Balance confidence. RESULTS: The modified ABC scale (called ABC-Simplified [ABC-S] scale) has high internal consistency (reliability index, .86) and good convergent validity (statistically significant associations with perceived balance; performances on the one-leg stance, tandem stance, tandem walking, functional reach, and lateral reach [on the right side] tests; fear of falling; and occurrence of falls in the previous 12 mo). Analyses also showed differing degrees of difficulty across items, allowing for a determination of the scale's item hierarchy. CONCLUSIONS: The ABC-S scale is a valid and reliable measure for the assessment of balance confidence among community-dwelling seniors. The fact that this measure was validated with high-functioning seniors makes it particularly well-suited for identifying community-dwelling seniors who are beginning to lose confidence in their balance and who could benefit from community falls prevention programs.

Implementing a community-based falls-prevention program: from drawing board to reality.

Several studies have demonstrated the efficacy of falls-prevention programs designed for community-dwelling seniors using randomized designs. However, little is known about the feasibility of implementing these programs under natural conditions and about the success of these programs when delivered under such conditions. The objectives of this paper are to (a) describe a multifactorial falls-prevention program (called Stand Up!) designed for independent community-dwelling seniors and (b) present the results of an analysis of the practicability of implementing this program in community-based settings. The program was implemented in the context of an effectiveness study in 10 community-based organizations in the Montreal metropolitan area. Data pertaining to the reach and delivery of the program as well as participation level show that a falls-prevention program addressing multiple risk factors can be successfully implemented in community-based settings.

Moving forward in fall prevention: an intervention to improve balance among older adults in real-world settings.

OBJECTIVES: We investigated the effectiveness of a group-based exercise intervention to improve balancing ability among older adults delivered in natural settings by staff in local community organizations. METHODS: The main component of the intervention consisted of biweekly group-based exercise sessions conducted over 12 weeks by a professional, coupled with home-based exercises. In a quasiexperimental design, 10 community organizations working with older adults offered the intervention to groups of 5 to 15 persons concerned about falls, while 7 organizations recruited similar groups to participate in the control arm of the study. Participants (98 experimental and 102 control) underwent balance assessments by a physiotherapist at registration and 3 months later. RESULTS: Eighty-nine percent of participants attended the 3-month measurement session (n=177). A linear regression analysis showed that after adjusting for baseline levels of balance and demographic and health characteristics, the intervention significantly improved static balance and mobility. CONCLUSION: Structured, group-based exercise programs offered by community organizations in natural settings can successfully increase balancing ability among community-dwelling older adults concerned about falls.

Effectiveness of helmets in skiers and snowboarders: case-control and case crossover study.

OBJECTIVE: To determine the effect of helmets on the risk of head and neck injuries in skiers and snowboarders. DESIGN: Matched case-control and case crossover study. SETTING: 19 ski areas in Quebec, Canada, November 2001 to April 2002. PARTICIPANTS: 1082 skiers and snowboarders (cases) with head and neck injuries reported by the ski patrol and 3295 skiers and snowboarders (controls) with non-head or non-neck injuries matched to cases at each hill. MAIN OUTCOME MEASURES: Estimates of matched odds ratios for the effect of helmet use on the risk of any head or neck injury and for people requiring evacuation by ambulance. RESULTS: The adjusted odds ratio for helmet use in participants with any head injury was 0.71 (95% confidence interval 0.55 to 0.92), indicating a 29% reduction in the risk of head injury. For participants who required evacuation by ambulance for head injuries, the adjusted odds ratio for helmet use was 0.44 (0.24 to 0.81). Similar results occurred with the case crossover design (odds ratio 0.43, 0.09 to 1.83). The adjusted odds ratio for helmet use for participants with any neck injury was 0.62 (0.33 to 1.19) and for participants who required evacuation by ambulance for neck injuries it was 1.29 (0.41 to 4.04). CONCLUSIONS: Helmets protect skiers and snowboarders against head injuries. We cannot rule out the possibility of an increased risk of neck injury with helmet use, but the estimates on which this assumption is based are imprecise.

The effect of helmet use on injury severity and crash circumstances in skiers and snowboarders.

The aim of this study was to examine the effect of helmet use on non-head-neck injury severity and crash circumstances in skiers and snowboarders. We used a matched case-control study over the November 2001 to April 2002 winter season. 3295 of 4667 injured skiers and snowboarders reporting to the ski patrol at 19 areas in Quebec with non-head, non-neck injuries agreed to participate. Cases included those evacuated by ambulance, admitted to hospital, with restriction of normal daily activities (NDAs) >6 days, with non-helmet equipment damage, fast self-reported speed, participating on a more difficult run than usual, and jumping-related injury. Controls were injured participants without severe injuries or high-energy crash circumstances and were matched to cases on ski area, activity, day, age, and sex. Conditional logistic regression was used to relate each outcome to helmet use. There was no evidence that helmet use increased the risk of severe injury or high-energy crash circumstances. The results suggest that helmet use in skiing and snowboarding is not associated with riskier activities that lead to non-head-neck injuries.

Home injury patterns in children: A comparison by hospital sites.

BACKGROUND: Many intervention studies typically require data from several centres to ensure adequate power. The usual intention is to pool data after testing for heterogeneity. Sites that differ in sample characteristics may, on the one hand, complicate the assessment of the intervention, but on the other hand, they may add important insights through analysis of site-specific findings. OBJECTIVES: The aims of the present paper were to compare the distribution of injuries and risk factors among children participating in a five-centre study of a home-based injury prevention program, and to contrast parental injury awareness and knowledge with home safety measures. METHODS: Five children's hospitals in Canada agreed to participate in a case-control study combined with a randomized controlled trial. Patients were children zero to seven years of age presenting to a hospital emergency department with a fall, burn, ingestion or choking. Two controls were matched to each case, one with another injury and another with a minor illness. A home visitor completed a home hazard assessment based on observed safety measures. To determine whether data could be pooled, comparisons across sites were made with respect to types of injuries seen, sociodemographic characteristics, observed hazards and the parents' reported beliefs about severity of injuries, safety measures, preventability of injuries and susceptibility to injuries. RESULTS: There were few differences between the five hospitals. The mean age was 2.2 years (range 1.4 to 3.3). There were 219 falls (56%), 80 burns (20.4%), 54 poisonings (13.8%), and 38 chokings (9.7%), all distributed in a proportionately similar manner, except for poisoning, at each site. There were significantly more well-educated fathers at one hospital and younger parents with less education at another. Homes were generally lacking five recommended safety measures. However, most parents at all sites perceived their home as being very safe for any of the specific injuries, and their child as being at low risk of sustaining any of these injuries. CONCLUSIONS: The similarity across sites supports the pooling of these data regarding hospital-treated injuries in young children in urban Canada. Most parents at all sites perceived their home as being very safe in spite of their homes lacking one-quarter of the recommended safety measures. This discrepancy between parental perception and home safety highlights the needs for further education and prevention efforts.

Recommendations for the prevention of osteoporosis and fragility fractures. International comparison and synthesis.

OBJECTIVES: This review included the following objectives: a) to synthesize recommendations made by public agencies in Western countries concerning screening for osteoporosis; b) to compare these recommendations and sort out the similarities and discrepancies; and c) to propose a strategy for the fight against osteoporosis and fragility fractures. METHODS: Eleven reports published by publicly financed agencies were included in the analysis: three international, four North American and four European agencies. Transcriptions of recommendations and arguments were classified using criteria for evaluation of screening technologies. RESULTS: Of eight reports that made a recommendation on mass screening, four made a recommendation against the use of densitometry, two remained vague with a conditionally positive recommendation, and two made no recommendation, arguing insufficient scientific evidence. Concerning screening of asymptomatic women in the perimenopause period, recommendations were uniformly opposed to the use of bone densitometry in five of nine reports, and the other four made no recommendation, arguing insufficient scientific evidence. Some of the discrepancies can be explained by the different definitions given to osteoporosis and by the confusion of terms between screening and diagnostic testing. A strategy is proposed to ensure that all women who are at risk of osteoporosis and fragility fracture have access to preventive measures. This strategy is based on the complementarity and coordination of roles between health promotion interventions and clinical interventions. CONCLUSIONS: Prevention of osteoporosis and fragility fractures is an attainable goal. Existing resources are currently badly targeted. Compromises must be negotiated between the different stakeholders and biomedical disciplines to achieve efficiency and accessibility in the reduction of fragility fractures. A first compromise to reconcile social and scientific realities would be to use a best-evidence synthesis instead of an evidence-based medicine approach in future analyses and recommendations by public authorities. A second compromise would be to recognize the complementary roles of public health and clinical professionals toward the common objective of preventing fragility fractures.