"We want to include him in that journey": A qualitative descriptive study of parental experiences and considerations for sibling inclusion in the paediatric ICU.

OBJECTIVES: Siblings are an important yet often forgotten part of the paediatric intensive care unit (PICU) family experience. Commonly, siblings are supported through the experience by their parents; however, very little is known about parental experiences of providing this support. This study aims to explore parental experiences of supporting sibling inclusion in PICU. RESEARCH METHODOLOGY/DESIGN: This study utilised a qualitative descriptive approach to conduct semi-structured interviews with 6 parents of 5 children with congenital heart disease who had spent time in PICU. Data were analysed using reflexive thematic analysis. SETTING: Australian PICUs. FINDINGS: Parental considerations and experiences for sibling inclusion were identified across three key phases: Pre-inclusion, The PICU visit, and Post-inclusion. Prior to including siblings in PICU, parents considered various ways of sharing information with siblings, and weighed up the risks and benefits of bringing siblings into PICU. Parents also recounted a number of challenges and facilitators to a positive sibling experience in PICU, including supportive staff and fun activities. Finally, parents, identified that siblings require ongoing support after their inclusion in PICU and made suggestions for ongoing availability of information and supportive resources. CONCLUSIONS: This study has illuminated key parental experiences when supporting sibling inclusion in PICU before, during and after their visit. By understanding these parental experiences, PICU staff can work with and support parents where needed, helping to achieve a positive sibling inclusion experience. IMPLICATIONS FOR CLINICAL PRACTICE: Parents need ongoing support to explain the PICU to siblings of critically ill children and may benefit from specific visual resources to aid communication. In addition, PICUs should aim to ensure the physical layout is supportive of sibling needs, with dedicated spaces for siblings to play and take time out during their experience.

Short midline catheters: High success rates for antibiotic therapy in children with cystic fibrosis.

OBJECTIVE: Short midline catheter use in paediatric populations appears to be increasing, however data on success rates and efficacy are sparse. This study aims to describe the success rate when midline venous catheters are employed as a single device for intravenous antibiotic therapy in paediatric patients with cystic fibrosis. METHODS: A retrospective cohort study was performed in a single institution, retrieving electronic medical record data from July 2017 through March 2020. The primary outcome was device success, defined as a catheter that remained functional until the end of antibiotic therapy. Reasons for device failure were categorized in a standard fashion. RESULTS: Primary outcome data were available for 116 catheter insertions, involving 49 patients and 55 proceduralists. The success rate was 84% (n = 98). Median age at insertion was 15 years (range 4-19) and median weight 52 kg (13-81). Soft, polyether block amide, Arrow® Seldinger Arterial Catheters were employed. Only 16 patients (14%) required general anaesthesia. Median time to failure was 6 days, and median time to successful completion of treatment was 13 days. Six of 18 failures occurred within 48 h and were likely insertion complications. The most common reasons for device failure were occlusion, extravasation, phlebitis and dislodgement. More than half of patients (56%) received antibiotic therapy at home. CONCLUSION: There is a high single device success rate when inserting short midlines for 13-day intravenous pulmonary antibiotic therapy in children with cystic fibrosis. These results should be confirmed with a prospective study.

Healthcare and associated costs related to type 2 diabetes in youth and adolescence: the TODAY clinical trial experience.

The economic issues related to medical treatments in youth with type 2 diabetes (T2D) are rarely reported and thus not fully understood. The Treatment Options for type 2 Diabetes in Adolescents and Youth clinical trial of youth recently diagnosed with T2D collected healthcare and related cost information from the largest cohort studied to date. Costs related to medical treatments and expenses faced by caregivers were identified over a 2-year period from 496 participants. Data were collected by surveys and diaries to document frequency of use of diabetes care (excluding study laboratory tests), non-diabetes care services and treatments, caregiver time, and expenses related to exercise and dietary activities recommended for patients. Economic costs were derived by applying national cost values to the reported utilization frequency data. Annual medical costs in the first year varied by the treatment group, averaging $1798 in those assigned to metformin alone (M), $2971 to combination drug therapy with metformin + rosiglitazone (M + R), and $2092 to metformin + an intensive lifestyle and behavior change program (M + L). Differences were primarily due to costs related to combination drug therapy. Adult caregiver support costs were higher for participants in the lifestyle program, which was delivered in weekly sessions in the first 6 months. Expenses for purchases to enhance diet and exercise change did not vary by treatment assignment. In year 2, medication costs increased in M and M + L due to the initiation of insulin in subjects who failed to maintain glycemic control on the assigned treatment. Data are reported for use by researchers and those providing healthcare to this vulnerable patient population.

Respiratory physicians and clinic coordinators' attitudes to population-based cystic fibrosis carrier screening.

BACKGROUND: Attitudes of Australian CF healthcare professionals toward population-based cystic fibrosis (CF) carrier screening were examined. METHOD: A purpose-designed questionnaire was distributed to 111 respiratory physicians and 30 CF clinic coordinators throughout Australia. RESULTS: Seventy-one questionnaires (52 physicians and 19 coordinators (46.8%, 63.3% respectively)) were returned. Forty respondents (56.3%) supported population-based carrier screening for CF. Support for screening was associated with rating the factors: carrier risk being 1 in 25 (OR 1.72 (1.12, 2.65)), reassurance when both partners test negative (OR 1.67 (1.12, 2.46)) and the daily treatment regimen for CF patients (OR 1.59 (1.05, 2.42)) as important. Opposition to screening was associated with identifying potential discrimination against carriers as a disadvantage (OR 0.3 (0.12, 0.88)), and limitations of predicting clinical outcomes as a barrier (OR 0.46 (0.25, 0.83)). CONCLUSIONS: There is moderate support for population-based carrier screening for CF by Australian CF healthcare professionals. Perceived barriers to implementation are surmountable.

The natural history and predictors of persistent problem behaviours in cystic fibrosis: a multicentre, prospective study.

BACKGROUND: In cystic fibrosis (CF), problems with sleep, eating/mealtime behaviours, physiotherapy adherence and parental mental health issues are common, yet their natural history and the extent of service use to address them are unknown. OBJECTIVE: Follow up the 2007 cohort to determine: (1) prevalence of child sleep, eating/mealtime behaviours, physiotherapy adherence, and externalising/internalising problem behaviours and primary caregiver mental health status after a 3-year period; (2) natural history of child behaviours; (3) potentially modifiable predictors of persistent problems; and (4) service use for behaviours. DESIGN: Prospective cohort. SETTING: Royal Children's Hospital, Monash Medical Centre and Sydney Children's Hospital (Australia) CF clinics. PARTICIPANTS: Caregivers, of children aged 3-8 years, who completed the baseline questionnaire. MAIN OUTCOME MEASURES: Child sleep, eating/mealtime behaviours, adherence with therapy and externalising and internalising behaviours. PREDICTORS: parenting style (low warmth), caregiver mental health status and sleep quality at baseline. RESULTS: 102 of 116 (88%) families participated. The prevalence of sleep and eating/mealtime problems at follow-up was similar to baseline. The prevalence of caregiver mental health symptoms remained higher than the community data. 71 out of 102 (70%) of the children experienced at least one persistent behaviour problem. Caregiver mental health difficulties predicted persistent child moderate to severe sleep problems (adjusted OR 6.5, 95% CI 1.2 to 36.2, p=0.03) and their persistently poor adherence to the physiotherapy regimen (adjusted OR 3.5, 95% CI 1.3 to 9.2, p=0.01). CONCLUSIONS: Child problem behaviours are common in children with CF, persist and are often predicted by the mental health of the parent. Routine surveillance for and management of child problem behaviours are recommended.

Effectiveness and cost of immunization recall at school-based health centers.

BACKGROUND AND OBJECTIVE: Effectiveness of recall for immunizations has not been examined in the setting of school-based health centers (SBHCs). We assessed (1) immunization rates achieved with recall among sixth-grade girls (demonstration study); (2) effectiveness of recall among sixth-grade boys (randomized controlled trial [RCT]); and (3) cost of conducting recall in SBHCs. METHODS: During October 2008 through March 2009, in 4 Denver public SBHCs, we conducted (1) a demonstration study among 265 girls needing ≥ 1 recommended adolescent vaccine and (2) an RCT among 264 boys needing vaccines, with half randomized to recall and half receiving usual care. Immunization rates for recommended adolescent vaccines were assessed 6 months after recall. First dose costs were assessed by direct observation and examining invoices. RESULTS: At the end of the demonstration study, 77% of girls had received ≥ 1 vaccine and 45% had received all needed adolescent vaccines. Rates of receipt among those needing each of the vaccines were 68% (160/236) for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, 57% (142/248) for quadrivalent meningococcal conjugate vaccine, and 59% (149/253) for the first human papillomavirus vaccine. At the end of the RCT, 66% of recalled boys had received ≥ 1 vaccine and 59% had received all study vaccines, compared with 45% and 36%, respectively, of the control group (P < .001). Cost of conducting recall ranged from $1.12 to $6.87 per recalled child immunized. CONCLUSIONS: SBHC-based recall was effective in improving immunization rates for all adolescent vaccines, with effects sizes exceeding those achieved with younger children in practice settings.

Effectiveness and net cost of reminder/recall for adolescent immunizations.

OBJECTIVE: To assess the effectiveness of reminder/recall (R/R) for immunizing adolescents in private pediatric practices and to describe the associated costs and revenues. METHODS: We conducted a randomized controlled trial in 4 private pediatric practices in metropolitan Denver. In each practice, 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations (tetanus-diphtheria-acellular pertussis, meningococcal conjugate, or first dose of human papillomavirus vaccine for female patients) were randomly selected and randomized to intervention (2 letters and 2 telephone calls) or control (usual care) groups. Primary outcomes were receipt of >1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines. RESULTS: Eight hundred adolescents were randomized to the intervention and 800 to the control group. Baseline rates of having already received tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and first dose of human papillomavirus vaccine before R/R ranged from 33% to 54%. Postintervention, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three practices had positive net revenues from R/R; 1 showed net losses. CONCLUSIONS: R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children. Practices conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low.

Lessons learned from 20 years of newborn screening for cystic fibrosis.

OBJECTIVE: To compare three cystic fibrosis (CF) newborn screening strategies used in Victoria since 1989. DESIGN, SETTING AND PARTICIPANTS: Retrospective review of newborn screening and clinical records for people with CF born in Victoria between 1989 and 2008 to compare screening strategies: repeat immunoreactive trypsinogen (IRT) testing (IRT/IRT, 1989-1990), IRT and p.F508del mutation analysis (IRT/p.F508del, 1991-2006) and IRT with analysis of 12 CFTR mutations (IRT/12 mutations, 2007-2008). MAIN OUTCOME MEASURES: Total number of infants screened, people identified with CF (by screening or clinical diagnosis), number of CF-affected terminations of pregnancy, and number of carriers detected. RESULTS: There were 420 people born with CF (live-birth prevalence, 1/3139; 95% CI, 1/2853-1/3462) and 78 CF-affected pregnancy terminations (overall prevalence, 1/2647; 95% CI, 1/2425-1/2896). Of the babies born with CF, 283 (67.4%) were detected by newborn screening alone, 61 (14.5%) had meconium ileus, 33 (7.9%) had a family history of CF, nine (2.1%) were diagnosed antenatally, and 34 (8.1%) were missed by screening (17 missed because IRT level was < 99th percentile, two with repeat IRT level not elevated, 14 without a screened CFTR mutation, and one with missing data). The sensitivities of the protocols were 86.6% for IRT/IRT, 89.9% for IRT/p.F508del, and 95.8% for IRT/12 mutations. Including 12 mutations in the analysis detected one patient who would otherwise have been missed and, had this protocol been implemented from 1989, it would have detected four others. CONCLUSION: Most babies with CF without meconium ileus, a family history or antenatal diagnosis are detected by newborn screening. Despite improved sensitivity with the 12-mutation analysis, most infants detected would have been diagnosed using the IRT/p.F508del protocol.

Cost of vaccine administration among pediatric practices.

OBJECTIVE: The goal was to describe variable costs to providers of delivering childhood immunizations. METHODS: We documented variable costs (costs that vary with the amount of services rendered), including time spent by pediatric staff members and physicians on immunization-related activities, as well as supply costs and medical waste disposal costs. Ten private pediatric practices in the Denver, Colorado, metropolitan area participated in the study. Among the 7 practices that provided us with payment data, 8 health plans were mentioned by > or = 2 practices. There were 37 different agreements between the health plans and practices for vaccine administration payments. RESULTS: The total documented variable cost per injection (excluding vaccine cost) averaged $11.51, calculated from the following categories: nursing time, $1.71; billing services, $2.67; nonroutine services, $1.64; registry use, $0.96; physician time, $4.05; supplies, $0.36; medical waste disposal, $0.12. Nonroutine activities primarily included performing vaccine inventory and ordering, providing vaccination records to requesters, and answering parent telephone questions about vaccinations. With the use of a simulation model to compensate for the small number of participating practices, the calculated total variable cost per injection was $11.83. When 2 vaccines were administered, we compared the sum of the 2 payments with the sum of the 2 variable costs ($23.02). More than one third of the payment agreements (13 of 37 agreements) paid the practices less than the combined variable costs for 2 immunizations. CONCLUSION: This study shows that the variable costs of vaccine administration exceeded reimbursement from some insurers and health plans.

Who is paying the bills? Health care costs for musculoskeletal back disorders, Washington State Union Carpenters, 1989-2003.

OBJECTIVE: Factors associated with private health insurance payment rates for musculoskeletal back disorders were examined among a 15-year cohort of union carpenters. Payment patterns were contrasted with work-related back injury rates over time. METHODS: Negative binomial regression was used to assess payment rates; generalized estimated equations accounted for multiple observations per person and cost correlation within subjects. RESULTS: Payment rates increased after work-related injury and with the number of injuries. Increasing private payments and deductibles (inflation-adjusted and discounted) were observed in contrast with a marked decline in reported work-related injuries. CONCLUSIONS: Private insurance payments do not appear to be independent of work-related back injury. Findings suggest cost-shifting from workers' compensation to the union-provided health insurance and to the worker; they also provide a warning regarding reliance on workers' compensation statistics for surveillance of work-related disorders or disease.

Compensation costs of work-related back disorders among union carpenters, Washington State 1989-2003.

BACKGROUND: We measured resources used to provide medical care and to estimate lost productivity represented by payments for lost work time or impairment for work-related back injuries among a large cohort of union carpenters over 15 years. METHODS: Using administrative data we identified a cohort of carpenters, their hours worked, their workers' compensation claims and associated costs. After adjustment for inflation and discounting to 2006 dollars, yearly costs for injuries and payment rates based on hours worked were calculated. Using negative binomial regression, dollars paid per claim were modeled based on age, gender, union tenure, and predominant type of work of the carpenter and whether the injury resulted from overexertion or acute trauma. RESULTS: Workers' compensation costs for back injuries exceeded $128 million dollars between 1998 and 2003, representing payments of $0.97 for each hour of work. Costs per hour of work declined substantively over time due largely to declining overexertion injury rates. Traumatic injuries, though less common than overexertion injuries, were more expensive. Costs increased with the number of prior back injuries and with increasing age, beginning as early as age 30. CONCLUSIONS: Increasing costs even among relatively young carpenters likely reflect the heavy nature of their work rather than simply the effects of biological aging. Musculoskeletal back problems remain a common, and consequently costly, source of injury among these carpenters that needs to be addressed through engineering modifications; there are also clearly needs for prevention of the often more costly back injuries associated with acute trauma.

Neonatal outcomes after elective cesarean delivery.

OBJECTIVE: To examine the outcomes of neonates born by elective repeat cesarean delivery compared with vaginal birth after cesarean (VBAC) in women with one prior cesarean delivery and to evaluate the cost differences between elective repeat cesarean and VBAC. METHODS: We conducted a retrospective cohort study of 672 women with one prior cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Women were grouped according to their intention to have an elective repeat cesarean or a VBAC (successful or failed). The primary outcome was neonatal intensive care unit (NICU) admission and measures of respiratory morbidity. RESULTS: Neonates born by cesarean delivery had higher NICU admission rates compared with the VBAC group (9.3% compared with 4.9%, P=.025) and higher rates of oxygen supplementation for delivery room resuscitation (41.5% compared with 23.2%, P<.01) and after NICU admission (5.8% compared with 2.4%, P<.028). Neonates born by VBAC required the least delivery room resuscitation with oxygen, whereas neonates delivered after failed VBAC required the greatest degree of delivery room resuscitation. The costs of elective repeat cesarean were significantly greater than VBAC. However, failed VBAC accounted for the most expensive total birth experience (delivery and NICU use). CONCLUSION: In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay. LEVEL OF EVIDENCE: II.

"Safety is everyone's job:" the key to safety on a large university construction site.

PROBLEM: Construction risk management is challenging. METHOD: We combined data on injuries, costs, and hours worked, obtained through a Rolling Owner-Controlled Insurance Program (ROCIP), with data from focus groups, interviews, and field observations, to prospectively study injuries and hazard control on a large university construction project. RESULTS: Lost-time injury rates (1.0/200,000 hours worked) were considerably lower than reported for the industry, and there were no serious falls from height. Safety was considered in the awarding of contracts and project timeline development; hazard management was iterative. A top-down management commitment to safety was clearly communicated to, and embraced by, workers throughout the site. DISCUSSION AND IMPACT: A better understanding of how contracting relationships, workers' compensation, and liability insurance arrangements influence safety could shift risk management efforts from worker behaviors to a broader focus on how these programs and relationships affect incentives and disincentives for workplace safety and health.

"Get smart Colorado": impact of a mass media campaign to improve community antibiotic use.

CONTEXT: Large-scale strategies are needed to reduce overuse of antibiotics in US communities. OBJECTIVES: To evaluate the impact of a mass media campaign-"Get Smart Colorado"-on public exposure to campaign, antibiotic use, and office visit rates. DESIGN: Nonrandomized controlled trial. SETTING: Two metropolitan communities in Colorado, United States. SUBJECTS: The general public, managed care enrollees, and physicians residing in the mass media (2.2 million persons) and comparison (0.53 million persons) communities. INTERVENTION: : The campaign consisting of paid outdoor advertising, earned media and physician advocacy ran between November 2002 and February 2003. PRINCIPAL MEASURES: Antibiotics dispensed per 1000 persons or managed care enrollees, and the proportion of office visits receiving antibiotics measured during 10 to 12 months before and after the campaign. RESULTS: After the mass media campaign, there was a 3.8% net decrease in retail pharmacy antibiotic dispenses per 1000 persons (P = 0.30) and an 8.8% net decrease in managed care-associated antibiotic dispenses per 1000 members (P = 0.03) in the mass media community. Most of the decline occurred among pediatric members, and corresponded with a decline in pediatric office visit rates. There was no change in the office visit prescription rates among pediatric or adult managed care members, nor in visit rates for complications of acute respiratory tract infections. CONCLUSIONS: A low-cost mass media campaign was associated with a reduction in antibiotic use in the community, and seems to be mediated through decreases in office visits rates among children. The campaign seems to be cost-saving.

Diabetes, minor depression and health care utilization and expenditures: a retrospective database study.

BACKGROUND: To estimate the prevalence of minor depression among US adults with diabetes, health care resource utilization, and expenditures by people with diabetes with and without minor depression. METHODS: Among adult 2003 Medical Expenditure Panel Survey respondents, diabetes was identified by diagnosis code and self-report. Depression was identified by diagnosis code plus > or = one antidepressant prescription. Odds of having depression was estimated in people with diabetes and the general population, adjusted for sociodemographic variables (e.g., age, sex, race/ethnicity). Multivariate regressions evaluated factors associated with utilization and log-transformed expenditures for ambulatory care, hospitalizations, emergency visits, and prescriptions. RESULTS: In 2003, 1932 respondents had diabetes, 435/1932 had diabetes and minor depression. Adults with diabetes were more likely than the general population to have depression (adjusted OR 1.81, 95% CI 1.56, 2.09). People with diabetes with versus without comorbid depression were more likely to be women, have lower incomes and health status, and more diabetes complications (all p < 0.05). In unadjusted analyses, ambulatory care visits were higher for those with versus without depression (17.9 vs. 11.4, p = 0.04), as were prescriptions (60.7 vs. 38.1, p = 0.05). In adjusted analyses, depression was not associated with increased resource use or higher expenditures in any category. Increased number of comorbid conditions was associated with increased resource use in all categories, and increased expenditures for ambulatory care and prescriptions. CONCLUSION: People with diabetes are twice as likely to have depression as the general population. Screening for and treatment of depression is warranted, as is additional research into a causal relationship between diabetes and depression.

Pediatric telephone call centers: how do they affect health care use and costs?

OBJECTIVES: After-hours call centers have been shown to provide appropriate triage with high levels of parental and provider satisfaction. However, few data are available on the costs and outcomes of call centers from the perspective of the health care system. With this study we sought to determine these outcomes. METHODS: Parents who called the Pediatric After-hours Call Center at the Children's Hospital of Denver from March 19, 2004, to April 19, 2004, were asked an open-ended question before triage: "We would like to know, what you would have done if you could not have called our call center this evening/today?" RESULTS: The response rate for the survey was 77.8% (N = 8980). Parents reported that they would have (1) gone to an emergency department or urgent care facility (46%), (2) treated the child at home (21%), (3) called a physician's office the next day (12%), (4) asked another person for advice (13%), (5) consulted a written source (2%), or (6) other (7%). Of the 46% of callers who would have sought emergent care, only 13.5% subsequently were given an urgent disposition by the call center. Fifteen percent of cases in which the parents would have stayed at home were given an urgent disposition by nurses. Assuming that all callers followed the advice provided, the estimated savings per call, based on local costs, was 42.61 dollars per call. Savings based on Medical Expenditure Panel Survey national payment data were 56.26 dollars per call. CONCLUSIONS: Two thirds of the cases in which parents reported initial intent to go to an emergency department or urgent care facility were not deemed urgent by the call center, whereas 15% of calls from parents who intended to stay home were deemed urgent. If call-center triage recommendations were followed in even half of all cases, then these results would translate into substantial cost savings for the health care system.

Cervicitis: to treat or not to treat? The role of patient preferences and decision analysis.

PURPOSE: Mucopurulent cervicitis is neither a sensitive nor a specific indicator of antibiotic sensitive infection. This analysis examines the positive and negative ramifications of treating cervicitis empirically as a Chlamydial (CT) infection. It begins where prior analyses leave off, with the number of cases of pelvic inflammatory disease (PID) prevented. METHODS: Three treatments were compared: 1) treat empirically/refer partner; 2) test, treat, and base partner treatment on results; 3) test, base treatment on results. The outcomes were the physical sequelae of PID and the psychological sequelae of being diagnosed with CT in a hypothetical cohort of 500 teenagers with cervicitis, among whom the prevalence of CT averaged 33%, but ranged between 10% and 70%. RESULTS: At a CT prevalence of 33%, Treatments 1 and 2 prevented three times as many cases of PID-related physical sequelae (n = 14) as Treatment 3 (n = 5). However, to prevent these 14 cases of physical sequelae, with Treatment 1, 163 teens needlessly suffer the psychological sequelae of a false CT diagnosis and with Treatment 2, 101 do so. The ratio of physical sequelae prevented to psychological sequelae caused, changed in relationship to the prevalence of CT, but was always numerically most favorable with Treatment 3. Moreover, it was the only therapeutic approach for which overall morbidity never exceeded the PID-related physical morbidity incurred in the absence of treatment. CONCLUSIONS: By including the effects of over diagnosing and treating CT, we have demonstrated how the risks and benefits of empiric and nonempiric cervicitis therapy vary in relationship to CT prevalence. Failure to consider both the physical and the psychological aspects of patient well-being may mean that well-intentioned policies to reduce physical morbidity do not result in an overall improvement in health of teenagers.

Refining the focus of construction injury surveillance.

We conducted two studies of construction injury occurring at Denver International Airport (DL4), whose construction required 31 million work hours. Initially we conducted a retrospective cohort study that allowed estimation of injury and workers' compensation (WC) payment rates for strata such as size of employer and type of work; risk factors were also estimated. The second study examined written injury reports for 4,000 injuries at DIA. We modified Haddon's matrix to classify factors contributing to injury. We identified 108 factors within 4 broad categories: human, object, environment and organization. This approach provided information on rates at which each factor contributed to injury and the WC payment rates for each factor. A study shortcoming was that injury reports varied in completeness and quality. In a third ongoing study, to compensate for the shortcomings of injury reports, particularly to improve consistency and completeness of data, we designed a worker questionnaire completed immediately after injury, which included questions specific to hazards associated with each type of injury. Upon completion, the interviewer (a safety professional) uses the modified Haddon's matrix to note contributors to the injury and explain briefly the reasons for each notation. This requires the interviewer to consider a full set of possible factors and determine whether they contributed to injury. This process elicits richer data and places specific factors within the four higher-level categories. This process confer advantages on both contractors and researchers. Contractors can become immediately aware of contributing factors and ameliorate them quickly. The data can also be used in post hoc analysis of injury etiology. Moreover, the data are sufficiently flexible and complete that they can be coded into schemes describing sequences of events leading to injury, as well as those simply identifying factors contributing to injury. Haddon's matrix is invaluable in such analysis because it leads to a fuller understanding of the origins of the most proximate contributors to injury than would otherwise occur. Particularly for contractors and owners with significant safety infrastructures, this approach may be attractive, because it allows for more complete and quicker correction of specific hazards and, with systematic evaluation, recognition of more general safety concerns present on many construction sites.

Changing their minds with time: a comparison of hypothetical and actual reproductive behaviors in parents of children with cystic fibrosis.

OBJECTIVE: Newborn screening for cystic fibrosis, with appropriate counseling, enables carrier parents to be informed early about future reproductive choices. Previous studies have assessed attitudes toward reproductive decisions in a hypothetical pregnancy or have measured reproductive behaviors. We aimed to measure parent attitudes to reproductive technologies and to compare prospectively these attitudes with later reproductive behaviors. METHODS: Parents of children who had cystic fibrosis and were aged 2 to 7 years were surveyed at baseline using a written questionnaire that explored attitudes to prenatal testing and termination of pregnancy in a hypothetical pregnancy. Parent knowledge and access to genetic counseling services also were assessed. Five years later, we compared attitudes with actual reproductive behaviors. RESULTS: Fifty-six mothers participated at baseline, and 43 were resurveyed 5 years later. Parent knowledge of cystic fibrosis and genetics was very good. A total of 93% had met a genetic counselor at the time of diagnosis, and more than half had on at least 1 subsequent occasion. At baseline, 82% reported that they would be likely to have prenatal diagnosis in a subsequent pregnancy, and 56% reported that they would be likely to terminate an affected pregnancy. Twenty-seven mothers since had been pregnant, with prenatal diagnosis used in 33 of the 55 pregnancies. In 67%, the hypothetically reported behavior regarding use of prenatal testing was the same as their actual behavior. Five of the 33 tested pregnancies were affected; all ended in termination. Reproductive choices in relationship to the number of children wanted, together with attitudes toward prenatal diagnosis and termination of pregnancy, were dynamic over time, with decisions having changed in both directions. CONCLUSIONS: This cohort of parents has actively used reproductive technologies since the birth of a child who has cystic fibrosis that was diagnosed by newborn screening. The dynamic aspect of reproductive choices highlights the importance of ongoing access to genetic counseling beyond the initial period of diagnosis and education, regardless of whether parents report that they expect to use reproductive technologies.

Injuries from slips and trips in construction.

Construction injuries preceded by a slip or trip were documented using data from the building of the Denver International Airport (Denver, Colorado, USA), the largest construction project in the world at the time. Slips and trips occurred at a rate of 5/200,000 h worked accounting for 18% of all injuries and 25% of workers' compensation payments, or more than $10 million. Slips contributed to the vast majority (85%) of same-level falls and over 30% of falls from height, as well as a significant number of musculoskeletal injures sustained after slipping or tripping but without falling. The injury burden would have been under-recognized in analyses of most coded compensation records. In contrast to other types of injuries, the most common contributing factors were environmental in nature including conditions of walking and working surfaces, terrain and weather. Due to the very dynamic nature of construction work, reducing slips and trips will require a focus on environmental and organizational solutions that evolve as the site changes and the construction project evolves.