Comparison of physician based reporting of tobacco attributable deaths and computer derived estimates of smoking attributable deaths, Oregon, 1989 to 1996.

BACKGROUND: Tobacco use prevention programmes need accurate information about smoking related mortality. Beginning in 1989, Oregon began asking physicians to report on death certificates whether tobacco use contributed to the death. OBJECTIVE: To determine the long term comparability of this method of estimating tobacco attributable mortality to estimates of smoking attributable mortality derived from a computer model. DESIGN: For the period 1989 to 1996, we compared mortality resulting from tobacco use reported by Oregon physicians to estimates of smoking attributable deaths (SADs) derived by "Smoking attributable mortality, morbidity and economic costs" software version 3.0 (SAMMEC 3.0), a widely used software program that estimates SADs on the basis of smoking prevalence and relative risks of specific diseases among current and former smokers. MAIN OUTCOME MEASURES: Numbers of deaths, age, sex, and category of disease. RESULTS: Of 212, 448 Oregon deaths during 1989-1996, SAMMEC 3.0 estimated that 42, 778 (20.1%) were attributable to cigarette smoking. For the same 27 diagnoses, physicians reported that tobacco contributed to 42, 839 (20.2%) deaths-a cumulative difference of only 61 deaths over the eight year period. The age and sex distributions of tobacco and smoking attributable deaths reported by the two systems were also similar. By category of disease, the ratio of SAMMEC 3.0 estimates to physician reported deaths was 1.11 for neoplasms, 0.88 for heart disease, and 1.04 for respiratory disease. CONCLUSIONS: Physician reporting provides comparable estimates of smoking attributable mortality and can be a valuable source of data for communicating the risks of tobacco use to the public.

Contaminated drinking water in one town manifesting as an outbreak of cryptosporidiosis in another.

In early 1992 we identified an outbreak of cryptosporidiosis in Oregon and sought to identify and control its source. We used a series of studies to identify risk factors for illness: (i) a case-control study among employees of a long-term-care facility (LTCF); (ii) a matched case-control study of the general community; (iii) a cohort study of wedding attendees; and (iv) a cross-sectional survey of the general community. Drinking Talent water was associated with illness in the LTCF (OR = 22.7, 95 % CI = 2.7-1009.0), and in the community (matched OR = 9.5, 95% CI 2.3-84.1). Drinking Talent water was associated with illness only among non-Talent residents who attended the wedding (P < 0.001) and in the community (RR = 6.5, 95 % CI 3.3-12.9). The outbreak was caused by contaminated municipal water from Talent in the absence of a discernible outbreak among Talent residents, suggesting persons exposed to contaminated water may develop immunity to cryptosporidiosis.

Where's the beef? The role of cross-contamination in 4 chain restaurant-associated outbreaks of Escherichia coli O157:H7 in the Pacific Northwest.

BACKGROUND: From March through August 1993, outbreaks of Escherichia coli O157:H7 occurred at 4 separate Oregon and Washington steak and salad bar restaurants affiliated with a single national chain. OBJECTIVE: To determine the cause of outbreaks of E coli O157:H7 at 4 chain restaurants. METHODS: Independent case-control studies were performed for each outbreak. Available E coli O157:H7 isolates were subtyped by pulse-field gel electrophoresis and by phage typing. RESULTS: Infection was not associated with beef consumption at any of the restaurants. Implicated foods varied by restaurant but all were items served at the salad bar. Among the salad bar items, no single item was implicated in all outbreaks, and no single item seemed to explain most of the cases at any individual restaurant. Molecular subtyping of bacterial isolates indicated that the first 2 outbreaks, which occurred concurrently, were caused by the same strain, the third outbreak was caused by a unique strain, and the fourth was multiclonal. CONCLUSIONS: Independent events of cross-contamination from beef within the restaurant kitchens, where meats and multiple salad bar items were prepared, were the likely cause of these outbreaks. Meat can be a source of E coli O157:H7 infection even if it is later cooked properly, underscoring the need for meticulous food handling at all stages of preparation.

Health care reform in Oregon: the impact of the Oregon Health Plan on utilization of mammography.

BACKGROUND: In 1994, Oregon implemented the Oregon Health Plan (OHP), extending health care coverage under a system of capitated managed care to uninsured citizens living below the Federal Poverty Level (FPL). We conducted a study to measure receipt of clinical preventive services among women newly enrolled in the OHP. METHODS: Six hundred and sixty six women aged 52-64, and living below the FPL in Oregon were randomly selected from OHP enrollment rosters and interviewed by telephone. A follow-up survey was conducted 1 year later. The main outcome of interest was receipt of a screening mammogram during the first year in the OHP. RESULTS: At enrollment 17% (65/383) of participants had never had health care coverage. Sixty-six percent of the women (220/333) were overdue for a mammogram. Fifty-five percent (121/220) reported cost as the main reason they had not had this procedure. Mammography rates doubled under the OHP (21% to 52%, 95% CI = 0.25-0.38, p < 0.001). Among women who were overdue for a mammogram at the time they enrolled, an expressed plan to get a mammogram (OR3.0, 95% CI = 1.1-8.7, p = 0.04), citing cost as the main reason for being overdue (OR3.0, 95% CI = 1.3-7.2, p = 0.014), receipt of a routine checkup (OR9.5, 95%CI = 3.7-24.9, p < 0.001), and health care provider's (HCP's) recommendation for mammography (OR8.1,95% CI = 2.9-23.0, p < 0.001) were independently associated with receipt of a mammogram. CONCLUSION: The OHP enrolled and successfully delivered clinical preventive services to a medically under served population. Even after removing the financial barrier, obstacles to mammography remain. These may be overcome by health systems changes to insure receipt of routine checkups and appropriate provider recommendations.

Emergence of antimicrobial-resistant shigellosis in Oregon.

Ampicillin and trimethoprim-sulfamethoxazole (TMP-SMZ) are currently considered acceptable empirical therapy for shigellosis in developed countries. However, there are few recently reported studies on antimicrobial resistance among shigellae isolated in the United States. We examined the epidemiology of shigellosis and the antimicrobial susceptibility of Shigella species isolated in Oregon from July 1995 through June 1998. Of 430 isolates, 410 were identified to the species level: Shigella sonnei accounted for 55% of isolates, and Shigella flexneri, for 40%. The overall annual incidence of shigellosis was 4.4 cases per 100,000 population. Children aged <5 years (annual incidence, 19.6 cases per 100,000 population) and Hispanics (annual incidence, 28.4 cases per 100,000 population) were at highest risk. Of 369 isolates tested, 59% were resistant to TMP-SMZ, 63% were resistant to ampicillin, 1% were resistant to cefixime, and 0.3% were resistant to nalidixic acid; none of the isolates were resistant to ciprofloxacin. Thirteen percent of the isolates had multidrug resistance to ampicillin, chloramphenicol, streptomycin, sulfisoxazole, and tetracycline. Infections due to multidrug-resistant shigellae are endemic in Oregon. Neither ampicillin nor TMP-SMZ should be considered appropriate empirical therapy for shigellosis any longer; when antibiotics are indicated, a quinolone or cefixime should be used.

Legalized physician-assisted suicide in Oregon--the second year.

BACKGROUND AND METHODS: In 1997, Oregon legalized physician-assisted suicide. We have previously reported data on terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. We now report similar data for 1999, obtained from physicians' reports, death certificates, and interviews with physicians. We also report data from interviews with family members. RESULTS: Information on 33 persons who received prescriptions for lethal medications in 1999 was reported to the Oregon Health Division; 26 died after taking the lethal medications, 5 died from their underlying illnesses, and 2 were alive as of January 1, 2000. One additional patient, who received a prescription in 1998, died after taking the medication in 1999. Thus, 27 patients died after ingesting lethal medications in 1999 (9 per 10,000 deaths in Oregon), as compared with 16 patients in 1998 (6 per 10,000). The median age of the 27 patients who died in 1999 after taking lethal medications was 71 years. The most frequent underlying illnesses were cancer (in 17 patients), amyotrophic lateral sclerosis (in 4), and chronic obstructive pulmonary disease (in 4). All 27 patients had health insurance, 21 were receiving hospice care, and 13 were college graduates. According to both physicians and family members, patients requested assistance with suicide for several reasons, including loss of autonomy, loss of control of bodily functions, an inability to participate in activities that make life enjoyable, and a determination to control the manner of death. CONCLUSIONS: In the second as compared with the first year of legalized physician-assisted suicide in Oregon, the number of patients who died after ingesting lethal medications increased, but it remained small in relation to the total number of persons in Oregon who died. Patients who request assistance with suicide appear to be motivated by several factors, including loss of autonomy and a determination to control the way in which they die.

Tracking drug-resistant Streptococcus pneumoniae in Oregon: an alternative surveillance method.

With the emergence of drug-resistant Streptococcus pneumoniae, community-specific antimicrobial susceptibility patterns have become valuable determinants of empiric therapy for S. pneumoniae infections. Traditionally, these patterns are tracked by active surveillance for invasive disease, collection of isolates, and centralized susceptibility testing. We investigated whether a simpler and less expensive method aggregating existing hospital antibiograms--could provide community-specific antimicrobial susceptibility data. We compared 1996 active surveillance data with antibiogram data from hospital laboratories in Portland, Oregon. Of the 178 S. pneumoniae active surveillance isolates, 153 (86% [95% confidence interval (CI) = 80% to 91%]) were susceptible to penicillin. Of the 1,092 aggregated isolates used by hospitals to generate antibiograms, 921 (84% [95% CI = 82%-87%]) were susceptible to penicillin. With the exception of one hospital's erythromycin susceptibility results, hospital-specific S. pneumoniae susceptibilities to penicillin, cefotaxime, trimethoprim-sulfamethoxazole, and erythromycin from the two methods were statistically comparable. Although yielding fewer data than active surveillance, antibiograms provided accurate, community-specific drug-resistant S. pneumoniae data in Oregon.

Vancomycin in Oregon: who's using it and why.

OBJECTIVE: To determine the proportion of vancomycin orders that are appropriate according to national guidelines and to identify targets for educational messages. DESIGN: Population-based study of vancomycin use in Oregon during a 3-week period. Survey of pharmacists, prospective flagging of vancomycin orders, and data abstraction from patient charts using standardized forms. SETTING: Nonpsychiatric hospitals in Oregon. RESULTS: Four (6%) of the 66 Oregon hospitals had pharmacy restrictions on initial vancomycin orders. Sixty-four (97%) of the hospitals participated in the study of indications for use; 293 vancomycin orders were reported; 3.8 courses were initiated per 1,000 patient-days. Indications for use were determined for 266 (91%); of these, 159 (60%) were deemed appropriate. Of uses for prophylaxis, empirical treatment of suspected gram-positive infection, and treatment of documented gram-positive infection, 57%, 56%, and 65%, respectively, were appropriate. Of hospitals with <250, 251-475, and >475 licensed beds, 65%, 58%, and 57% of vancomycin orders were appropriate. No single medical specialty accounted for >16% of inappropriate vancomycin use. CONCLUSIONS: Vancomycin was used inappropriately by physicians of many different specialties, in hospitals of all sizes, and in sundry clinical situations. The problem of inappropriate vancomycin use does not lend itself to solution by educational strategies targeted at specific subgroups; restrictions by hospital pharmacies may be required.

Legalized physician-assisted suicide in Oregon--the first year's experience.

BACKGROUND AND METHODS: On October 27, 1997, Oregon legalized physician-assisted suicide. We collected data on all terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. The data were obtained from physicians' reports, death certificates, and interviews with physicians. We compared persons who took lethal medications prescribed under the act with those who died from similar illnesses but did not receive prescriptions for lethal medications. RESULTS: Information on 23 persons who received prescriptions for lethal medications was reported to the Oregon Health Division; 15 died after taking the lethal medications, 6 died from underlying illnesses, and 2 were alive as of January 1, 1999. The median age of the 15 patients who died after taking lethal medications was 69 years; 8 were male, and all 15 were white. Thirteen of the 15 patients had cancer. The case patients and controls were similar with regard to sex, race, urban or rural residence, level of education, health insurance coverage, and hospice enrollment. No case patients or controls expressed concern about the financial impact of their illness. One case patient and 15 controls expressed concern about inadequate control of pain (P=0.10). The case patients were more likely than the controls to have never married (P=0.04) and were more likely to be concerned about loss of autonomy due to illness (P=0.01) and loss of control of bodily functions (P=0.02). At death, 21 percent of the case patients and 84 percent of the controls were completely disabled (P<0.001). CONCLUSIONS: During the first year of legalized physician-assisted suicide in Oregon, the decision to request and use a prescription for lethal medication was associated with concern about loss of autonomy or control of bodily functions, not with fear of intractable pain or concern about financial loss. In addition, we found that the choice of physician-assisted suicide was not associated with level of education or health insurance coverage.

Tobacco smoke as a risk factor for meningococcal disease.

BACKGROUND: Since 1992 the US Pacific Northwest has experienced a substantial increase in the incidence of serogroup B meningococcal disease. The current meningococcal polysaccharide vaccine is poorly immunogenic in young children and does not protect against N. meningitidis serogroup B. Defining alternative approaches to the prevention and control of meningococcal disease is of considerable public health importance. METHODS: We performed a case-control study comparing 129 patients in Oregon and southwest Washington with 274 age- and area-matched controls. We used conditional logistic regression analysis to determine which exposures remained associated with disease after adjusting for other risk factors and confounders and calculated the proportion of disease attributable to modifiable exposures. RESULTS: After adjustment for all other significant exposures identified, having a mother who smokes was the strongest independent risk factor for invasive meningococcal disease in children < 18 years of age [odds ratio (OR), 3.8; 95% confidence interval (CI) 1.6 to 8.9)], with 37% (CI 15 to 65) of all cases in this age group potentially attributable to maternal smoking. Adult patients were more likely than controls to have a chronic underlying illness (OR 10.8, CI 2.7 to 43.3), passive tobacco smoke exposure (OR 2.5, CI 0.9 to 6.9) and to smoke tobacco (OR 2.4, CI 0.9 to 6.6). Dose-response effects were seen for passive smoke exposure and risk of disease in all age groups. CONCLUSION: Tobacco smoke exposure independently increases the risk of developing meningococcal disease.

A prolonged outbreak of Escherichia coli O157:H7 infections caused by commercially distributed raw milk.

A protracted outbreak of Escherichia coli O157:H7 infections was caused by consumption of unpasteurized ("raw") milk sold at Oregon grocery stores. Although it never caused a noticeable increase in reported infections, the outbreak was recognized because of routine follow-up interviews. Six of 16 Portland-area cases reported between December 1992 and April 1993 involved people who drank raw milk from dairy A. By pulsed-field gel electrophoresis (PFGE), E. coli O157:H7 isolates from these cases and from the dairy A herd were homologous (initially, 4 of 132 animals were E. coli O157:H7-positive). Despite public warnings, new labeling requirements, and increased monitoring of dairy A, retail sales and dairy-associated infections continued until June 1994 (a total of 14 primary cases). Seven distinguishable PFGE patterns in 3 homology groups were identified among patient and dairy herd E. coli O157:H7 isolates. Without restrictions on distribution, E. coli O157:H7 outbreaks caused by raw milk consumption can continue indefinitely, with infections occurring intermittently and unpredictably.

Combining tabular, rule-based, and procedural knowledge in computer-based guidelines for childhood immunization.

IMM/Serve is a computer program which implements the clinical guidelines for childhood immunization. IMM/Serve accepts as input a child's immunization history. It then indicates which vaccinations are due and which vaccinations should be scheduled next. The clinical guidelines for immunization are quite complex and are modified quite frequently. As a result, it is important that IMM/Serve's knowledge be represented in a format that facilitates the maintenance of that knowledge as the field evolves over time. To achieve this goal, IMM/Serve uses four representations for different parts of its knowledge base: (1) Immunization forecasting parameters that specify the minimum ages and wait-intervals for each dose are stored in tabular form. (2) The clinical logic that determines which set of forecasting parameters applies for a particular patient in each vaccine series is represented using if-then rules. (3) The temporal logic that combines dates, ages, and intervals to calculate recommended dates, is expressed procedurally. (4) The screening logic that checks each previous dose for validity is performed using a decision table that combines minimum ages and wait intervals with a small amount of clinical logic. A knowledge maintenance tool, IMM/Def, has been developed to help maintain the rule-based logic. The paper describes the design of IMM/Serve and the rationale and role of the different forms of knowledge used.

Improved AIDS surveillance through laboratory-initiated CD4 cell count reporting.

OBJECTIVE: To evaluate laboratory-initiated CD4 reporting (LICR) for AIDS surveillance and for differences in cases found by LICR and traditional surveillance methods (i.e., health care provider or death certificate reports and medical record searches). METHODS: We compared the characteristics of persons reported with AIDS between May 1993 and April 1994 by traditional methods or by LICR reports <200/microl. RESULTS: We received 643 LICR reports and 278 AIDS case reports. HIV status was available on 94% of LICR reports; 96% of these persons were HIV-infected. LICR reports were received on 250 (90%) AIDS cases. Cases found by LICR were less likely to be persons of color and to have opportunistic illnesses and more likely to live in rural areas. Cost of LICR to the health department was less than the salary of one research analyst. CONCLUSIONS: LICR, with a high positive predictive value, is a highly sensitive, timely, and relatively inexpensive method of surveillance and its use should be considered in other jurisdictions.

An evaluation of measles revaccination among school-entry-aged children.

BACKGROUND: A two dose measles vaccination schedule is recommended routinely for all school-entry-aged children. We evaluated this recommendation by determining both measles antibody seroprevalence and the response to revaccination in seronegative children in this age group. METHODS: Children 4 to 6 years of age who had received a single dose of measles vaccine between the ages of 15 to 17 months were tested for measles antibody by using enzyme-linked immunosorbent assay (ELISA) microneutralization technique. Seronegative children were revaccinated and again tested for measles antibody (immunoglobulin M [IgM] and neutralizing). RESULTS: Of 679 children tested, 37 (5.4%) were seronegative. Seronegativity was not significantly associated with age, sex, race, age at initial vaccination, time since vaccination, or maternal year of birth. However, children mothers with a college degree were 12 times more likely to be seronegative than children of mothers who never attended college (P < .01). Of the 37 seronegative children, 36 seroconverted after revaccination--33 producing IgM measles antibody, suggestive of a primary immune response. The cost per seroconversion would have been an estimated $415 if all 679 children had been revaccinated. CONCLUSIONS: Revaccination reduces the pool of children who are susceptible to measles. Although the cost per seroconversion is high, a two-dose schedule should reduce the substantial costs of controlling measles out breaks by reducing the number of outbreaks.

IMM/Serve: a rule-based program for childhood immunization.

A rule-based program, IMM/Serve, is being developed to help guide childhood immunization for initial use, within Oregon. The program is designed primarily for automated use with an online immunization registry, but can also be used interactively by a single user. The paper describes IMM/Serve and discusses 1) the sources of complexity in immunization logic, 2) the potential advantages of a rule-based approach for representing that logic, and 3) the potential advantage of such a program evolving to become the standard of care. Related projects include 1) a computer-based tool to help verify the completeness of the logic, 2) a tool that allows a central part of the logic to be generated automatically, and 3) an approach that allows visualization of the logic graphically.

Missed opportunities for tuberculosis prevention.

BACKGROUND: With the recent resurgence of tuberculosis in the United States, it is unclear whether existing prevention strategies can successfully control and eliminate the disease. We determined the extent to which opportunities for prevention were missed among patients with tuberculosis. METHODS: For all patients with active tuberculosis reported to the Oregon Health Division, Portland, from July 1991 through June 1992, we determined previous history of tuberculosis therapy, previous tuberculin skin test status, the presence of medical conditions for which skin testing is recommended, and previous health care. We then determined whether they had undergone preventive procedures in accordance with current recommendations of the Advisory Council for the Elimination of Tuberculosis. RESULTS: Of 153 patients with active tuberculosis, 90 (59%) had indications for--but had not previously undergone--recommended procedures. Ten patients (7%) did not complete therapy for previous disease; two (1%) did not complete preventive therapy; 12 (8%) with known previous positive tuberculin skin tests and an indication for preventive therapy never received it; and 66 (43%) with known indications for screening never received a skin test. Indications for skin testing included exposure to active tuberculosis (44%), predisposing medical conditions (83%), previous residence in an institution (24%), and birth in a country with a high prevalence of tuberculosis (29%). CONCLUSIONS: Based on their known effectiveness, a major reduction in tuberculosis morbidity could occur if preventive measures were fully implemented. Appropriate skin testing is a prevention strategy of major importance. Priorities should include working to change provider practice to better ensure that persons with indications routinely receive tuberculin skin tests.