A Mortality Surveillance Collaboration Between a Health System and Public Health Department.

We describe a collaboration between a health system and public health department to create a mortality surveillance system. The collaboration enabled the health system to identify more than six times the number of deaths identified through local system medical records alone. This powerful epidemiological process, combining the nuanced data captured through clinical care in health systems with subsequent data on mortality, drives quality improvement, scientific research, and epidemiology that can be of particular benefit to underserved communities. (Am J Public Health. 2023;113(9):943-946. https://doi.org/10.2105/AJPH.2023.307335).

The COVID-19-wildfire smoke paradox: Reduced risk of all-cause mortality due to wildfire smoke in Colorado during the first year of the COVID-19 pandemic.

BACKGROUND: In 2020, the American West faced two competing challenges: the COVID-19 pandemic and the worst wildfire season on record. Several studies have investigated the impact of wildfire smoke (WFS) on COVID-19 morbidity and mortality, but little is known about how these two public health challenges impact mortality risk for other causes. OBJECTIVES: Using a time-series design, we evaluated how daily risk of mortality due to WFS exposure differed for periods before and during the COVID-19 pandemic. METHODS: Our study included daily data for 11 counties in the Front Range region of Colorado (2010-2020). We assessed WFS exposure using data from the National Oceanic and Atmospheric Administration and used mortality counts from the Colorado Department of Public Health and Environment. We estimated the interaction between WFS and the pandemic (an indicator variable) on mortality risk using generalized additive models adjusted for year, day of week, fine particulate matter, ozone, temperature, and a smoothed term for day of year. RESULTS: WFS impacted the study area on 10% of county-days. We observed a positive association between the presence of WFS and all-cause mortality risk (incidence rate ratio (IRR) = 1.03, 95%CI: 1.01-1.04 for same-day exposures) during the period before the pandemic; however, WFS exposure during the pandemic resulted in decreased risk of all-cause mortality (IRR = 0.90, 95%CI: 0.87-0.93 for same-day exposures). DISCUSSION: We hypothesize that mitigation efforts during the first year of the pandemic, e.g., mask mandates, along with high ambient WFS levels encouraged health behaviors that reduced exposure to WFS and reduced risk of all-cause mortality. Our results suggest a need to examine how associations between WFS and mortality are impacted by pandemic-related factors and that there may be lessons from the pandemic that could be translated into health-protective policies during future wildfire events.

Epidemiologic assessment of benzodiazepine exposure among suicide deaths in Colorado, 2015-2017.

BACKGROUND: Suicide rates have been climbing in the U.S., particularly in Rocky Mountain states such as Colorado. Benzodiazepines have been linked with suicidal ideation, but there have been few population level assessments of this link. We conducted a public health assessment to determine the epidemiology and prevalence of recent benzodiazepine exposure, among suicide deaths in Colorado from 2015 to 17. METHODS: This epidemiologic assessment linked Colorado's Prescription Drug Monitoring Program, death certificate data, and Violent Death Reporting System to determine patterns of benzodiazepine exposure among suicide deaths in Colorado between 2015 and 2017. Recent benzodiazepine exposure was defined as receiving a prescription within 30 days of death or having a positive toxicology screen post-mortem. RESULTS: Among the 3465 suicide deaths in Colorado between 2015 and 2017, 20% had recent benzodiazepine exposure, and nearly 50% of those also had recent opioid exposure. Recent benzodiazepine exposure was more common among females than males (34% versus 16%). Among suicide deaths, those who died via drug overdose were more likely to have had recent benzodiazepine exposure (48%), compared to suicides by firearm (17%), hanging/asphyxiation (13%) and all other methods (approximately 20%). CONCLUSIONS: Benzodiazepines have been linked to suicidal ideation, but population level assessments of benzodiazepine exposure among suicide deaths are rare. Our epidemiologic assessment indicates a relatively high prevalence of recent benzodiazepine exposure that warrants further investigation from both clinical and public health perspectives.

High Altitude Continues to Reduce Birth Weights in Colorado.

Objectives Colorado's relatively high altitudes have been reported to lower birth weight but the most recent studies were conducted 20 years ago. Since then, the accuracy for assigning altitude of residence has been improved with the use of geocoding, and recommendations for pregnancy weight gain have changed. We therefore sought to determine whether currently, residence at high altitude (≥ 2500 m, 8250 ft) lowers birth weight in Colorado. Methods Birth certificate data for all live births (n = 670,017) to Colorado residents from 2007 to 2016 were obtained from the Colorado Department of Public Health and Environment. Geocoded altitude of maternal residence for the current birth was assigned to each birth record. Linear and logistic regression models were used to examine the effects of altitude on birth weight or low birth weight (< 2500 g) while controlling for other factors affecting birth weight, including pregnancy weight gain. Results Compared to low altitude, infants born at high altitude weighed 118 g less and were more often low birth weight (8.8% vs. 11.7%, p < 0.05). After accounting for other factors influencing birth weight, high altitude reduced birth weight by 101 g and increased the risk of low birth weight by 27%. The only factors with larger impacts on birth weight were hypertensive disorders of pregnancy and cigarette use during pregnancy. Conclusions for Practice High altitude remains an important determinant of elevated LBW rates in Colorado, and likely contributes to Colorado's comparative resistance towards meeting the Healthy People 2010/2020 nationwide goal to reduce the low birth weight rate to 7.2% by 2020.

Premeditated versus "passionate": patterns of homicide related to intimate partner violence.

BACKGROUND: Intimate partner violence (IPV) is prevalent but underrecognized; at least 25% of United States women experience IPV within their lifetime. We examined the most severe consequence of IPV by exploring the patterns of death from IPV in a statewide database of homicide victims. MATERIALS AND METHODS: This is a retrospective review of the Colorado Violent Death Reporting System from 2004 to 2015. Deaths were coded as IPV if the primary relationship between the suspect and victim fell into the following categories: spouse, ex-spouse, girlfriend/boyfriend, and ex-girlfriend/ex-boyfriend. RESULTS: We identified a total of 2279 homicide victims, with 295 cases of IPV homicide (12.9%). The majority was female victims of a male partner (n = 240, 81.4%). In nearly half of these (n = 108, 45%), the male suspect subsequently died by suicide as part of the same incident. These homicide-suicide incidents were more likely than homicide alone to involve a spousal relationship, more likely to involve firearms and less likely to involve intoxication or preceding arguments. They had a distinct demographic profile from other victims of IPV, mirroring suicide victims in terms of race and estimated income. CONCLUSIONS: These results indicate that there are two distinct groups of female IPV homicides, and recognizing this distinction may allow for the development of more effective trauma prevention strategies. Homicide-suicides showed a more premeditated pattern while homicide alone suggested a crime of passion, with a smaller proportion of firearm deaths and higher rates of positive toxicology findings and preceding conflict in the latter group.

Visual Functioning and Mortality of Age-Related Macular Degeneration Patients in a Colorado Cohort.

OBJECTIVE: To investigate the relationship between visual functioning as measured by the National Eye Institute 25-Item Visual Function Questionnaire (VFQ-25) and mortality in patients with various stages of age-related macular degeneration (AMD). DESIGN: Observational cohort study. PARTICIPANTS: Patients with AMD enrolled in the University of Colorado AMD Registry between July 9, 2014 and December 31, 2021 were included. METHODS: Age-related macular degeneration cases were classified into early AMD, intermediate AMD, geographic atrophy, neovascular AMD, or both advanced types of AMD (neovasuclar and geographic atrophy both present) using multimodal imaging and the Beckman and Classification of Atrophy Meetings criteria. Visual Function Questionnaire -25 composite and subscale scores at the time of study enrollment were calculated. Cox proportional hazards modeling was used to assess time to event for mortality utilizing univariate and multivariable models, which adjusted for all variables significantly associated with mortality. The measures of association were hazard ratios (HRs) and 95% confidence intervals (CIs). MAIN OUTCOME MEASURES: All-cause mortality statistics were obtained through a collaborative agreement with the Colorado Department of Public Health and Environment. Death rates through October 19, 2022 were compared by demographics and potential confounders. RESULTS: Analysis was completed on a cohort of 876 patients, of which 180 (20.6%) died during the follow-up period. Average follow-up time for this cohort was 52.5 (standard deviation: 26.6) months. In univariate analysis, composite VFQ-25 score and all subscale scores aside from ocular pain were significantly associated with time to mortality. Additionally, age, AMD category, marital status, history of smoking, and multiple chronic comorbid conditions were significantly associated with time to mortality. In multivariable analysis, for each 10-point increase in a patient's VFQ-25 scores for general health and driving, the risk of death decreased with HR of 0.85 (95% CI: 0.80, 0.91; P < 0.0001) and 0.92 (95% CI: 0.87, 0.97; P = 0.005), respectively. Composite and other subscale scores were not significantly associated with mortality after adjusting for confounding variables. CONCLUSIONS: This cohort of AMD patients had a 20% rate of death in the 52.5-month average follow-up time. Better general health and ability to drive, as measured by the VFQ-25, were each separately associated with significantly lower risk of death among individuals with AMD. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

High-altitude residence alters blood-pressure course and increases hypertensive disorders of pregnancy.

OBJECTIVES: To determine whether the full spectrum of hypertensive disorders of pregnancy (HDP) - comprising gestational hypertension; preeclampsia with or without severe features; eclampsia; and Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) Syndrome - is increased at high (≥2500 m, 8250 ft) compared with lower altitudes in Colorado independent of maternal background characteristics, and if so their relationship to neonatal well-being. METHODS: A retrospective cohort study was conducted using statewide birth-certificate data to compare the frequency of gestational hypertension, preeclampsia (with or without severe features), eclampsia, HELLP Syndrome, or all HDP combined in 617,958 Colorado women who lived at high vs. low altitude (<2500 m) and delivered during the 10-year period, 2007-2016. We also compared blood-pressure changes longitudinally during pregnancy and the frequency of HDP in 454 high (>2500 m)- vs. low (<1700 m)-altitude Colorado residents delivering in 2013 and 2014, and matched for maternal risk factors. Data were compared between altitudes using t-tests or chi-square, and by multiple or logistic regression analyses to adjust for risk factors and predict specific hypertensive or neonatal complications. RESULTS: Statewide, high-altitude residence increased the frequency of each HDP disorder separately or all combined by 33%. High-altitude women studied longitudinally also had more HDP accompanied by higher blood pressures throughout pregnancy. The frequency of low birth weight infants (<2500 g), 5-min Apgar scores <7, and NICU admissions were also greater at high than low altitudes statewide, with the latter being accounted for by the increased incidence of HDP. CONCLUSIONS: Residence at high altitude constitutes a risk factor for HDP and recommends increased clinical surveillance. The increased incidence also makes high altitude a natural laboratory for evaluating the efficacy of predictive biomarkers or new therapies for HDP.

Finding the elusive trauma denominator: Feasibility of combining data sets to quantify the true burden of firearm trauma.

BACKGROUND: Evidence guiding firearm injury prevention is limited by current data collection infrastructure. Trauma registries (TR) omit prehospital deaths and underestimate the burden of injury. In contrast, the National Violent Death Reporting System (NVDRS) tracks all firearm deaths including prehospital fatalities, excluding survivors. This is a feasibility study to link these data sets through collaboration with our state public health department, aiming to better estimate the burden of firearm injury and assess comparability of data. METHODS: We reviewed all firearm injuries in our Level I TR from 2011 to 2017. We provided the public health department with in-hospital deaths, which they linked to NVDRS using patient identifiers and time of injury/death. The NVDRS collates information about circumstances, incident type, and wounding patterns from multiple sources including death certificates, autopsy records, and legal proceedings. We considered only subjects with injury location in a single urban county to best estimate in-hospital and prehospital mortality. RESULTS: Of 168 TR deaths, 166 (99%) matched to NVDRS records. Based on data linkages, we estimate 320 prehospital deaths, 184 in-hospital deaths, and 453 survivors for a total of 957 firearm injuries. For the matched patients, there was near-complete agreement regarding simple demographic variables (e.g., age and sex) and good concordance between incident types (suicide, homicide, etc.). However, agreement in wounding patterns between NVDRS and TR varied. CONCLUSION: We demonstrate the feasibility of linking TR and NVDRS data with good concordance for many variables, allowing for good estimation of the trauma denominator. Standardized data collection methods in one data set could improve methods used by the other, for example, training NVDRS abstractors to utilize Abbreviated Injury Scale designations for injury patterns. Such data integration holds immediate promise for guiding prevention strategies. LEVEL OF EVIDENCE: Epidemiological study, level IV.

Differential Cardiopulmonary Health Impacts of Local and Long-Range Transport of Wildfire Smoke.

We estimated cardiopulmonary morbidity and mortality associated with wildfire smoke (WFS) fine particulate matter (PM2.5) in the Front Range of Colorado from 2010 to 2015. To estimate WFS PM2.5, we developed a daily kriged PM2.5 surface at a 15  × 15 km resolution based on the Environmental Protection Agency Air Quality System monitors for the western United States; we subtracted out local seasonal-average PM2.5 of nonsmoky days, identified using satellite-based smoke plume estimates, from the local daily estimated PM2.5 if smoke was identified by National Oceanic and Atmospheric Administration's Hazard Mapping System. We implemented time-stratified case-crossover analyses to estimate the effect of a 10 µg/m3 increase in WFS PM2.5 with cardiopulmonary hospitalizations and deaths using single and distributed lag models for lags 0-5 and distinct annual impacts based on local and long-range smoke during 2012, and long-range transport of smoke in 2015. A 10 µg/m3 increase in WFS was associated with all respiratory, asthma, and chronic obstructive pulmonary disease hospitalizations for lag day 3 and hospitalizations for ischemic heart disease at lag days 2 and 3. Cardiac arrest deaths were associated with WFS PM2.5 at lag day 0. For 2012 local wildfires, asthma hospitalizations had an inverse association with WFS PM2.5 (OR: 0.716, 95% CI: 0.517-0.993), but a positive association with WFS PM2.5 during the 2015 long-range transport event (OR: 1.455, 95% CI: 1.093-1.939). Cardiovascular mortality was associated with the 2012 long-range transport event (OR: 1.478, 95% CI: 1.124-1.944).

Trends in Retinopathy of Prematurity over 12 Years in a Colorado Cohort.

PURPOSE: To determine trends in retinopathy of prematurity (ROP) in a Colorado cohort between 2006 and 2017 and compare trends in risk factors between our cohort and statewide data. METHODS: A retrospective cohort study was conducted by the use of records from two registry databases: 1) an academic center's ROP registry, and 2) vital statistics birth data from the Colorado Department of Public Health and Environment (CDPHE). ROP was categorized as severe (type 1 or type 2), low grade (not type 1 or type 2), or no ROP. Other variables included in the analyses were gestational age and birth weight at delivery, and infant mortality. Trends over time were evaluated for both registry databases using generalized linear models. RESULTS: In our ROP registry cohort of 1,267 eligible infants, 134 (10.6%) developed severe ROP and 279 (22%) developed low-grade ROP. We found no overall trend in severe ROP rates (p = .23), and a decreasing trend in rates of low-grade ROP (p < .01) over the study period. Trends in gestational age, birth weight, and mortality rates remained stable during the study period in both the ROP registry and the CDPHE cohorts. CONCLUSION: The rate of severe ROP in our ROP registry cohort did not change over time. There was evidence of a decreasing trend in low grade ROP during the 12-year study period that was not explained by a change in the primary ROP risk factors in either the ROP registry cohort or the Colorado statewide data.

Geospatial Monitoring of Body Mass Index: Use of Electronic Health Record Data Across Health Care Systems.

OBJECTIVES: The Colorado BMI Monitoring System was developed to assess geographic (ie, census tract) patterns of obesity prevalence rates among children and adults in the Denver-metropolitan region. This project also sought to assess the feasibility of a surveillance system that integrates data across multiple health care and governmental organizations. MATERIALS AND METHODS: We extracted data on height and weight measures, obtained through routine clinical care, from electronic health records (EHRs) at multiple health care sites. We selected sites from 5 Denver health care systems and collected data from visits that occurred between January 1, 2013, and December 31, 2015. We produced shaded maps showing observed obesity prevalence rates by census tract for various geographic regions across the Denver-metropolitan region. RESULTS: We identified clearly distinguishable areas by higher rates of obesity among children than among adults, with several pockets of lower body mass index. Patterns for adults were similar to patterns for children: the highest obesity prevalence rates were concentrated around the central part of the metropolitan region. Obesity prevalence rates were moderately higher along the western and northern areas than in other parts of the study region. PRACTICE IMPLICATIONS: The Colorado BMI Monitoring System demonstrates the feasibility of combining EHRs across multiple systems for public health and research. Challenges include ensuring de-duplication across organizations and ensuring that geocoding is performed in a consistent way that does not pose a risk for patient privacy.

Suicide Among Health Care Practitioners and Technicians in Colorado: An Epidemiological Study.

Suicide is a public health concern with risks that vary between occupation groups. Many suicide victims with a health care occupation die by poisoning, but few studies have epidemiologically studied this association. The objective of this study was to quantify the increased risk of suicide death by poisoning among health care professionals in Colorado. Eleven years (2004-2014, N = 8,753) of suicide deaths in Colorado were compiled from the Colorado Violent Death Reporting System. A retrospective cohort study using multivariate logistic regression was conducted to examine the risk associated with having a health care occupation and eventual suicide death by poisoning, compared independently to firearm and hanging methods. Suicide victims with a health care occupation were more likely to die by poisoning rather than by hanging (RR 1.54, 95% CI: 1.41-1.68) or firearm (RR 1.79, 95% CI: 1.60-2.01), when compared to suicide victims without a health care occupation. The association between health care occupation and suicide method was significantly (p = .032) modified by gender. The results show that health care workers who die by suicide have an increased risk of eventual suicide death by poisoning rather than by firearm or hanging. These results can be used to inform tailored suicide prevention efforts in health care professionals.

Analysis of the Effects on Time Between Divorce Decree and Suicide.

Background: Divorced individuals carry unique suicide risks, from both acute and chronic exposure to stressors from divorce. Aims: Several statewide data sets were linked to assess the relationship between divorce and suicide. Method: Divorced suicide decedents in the Colorado Violent Death Reporting System, 2004-2015, were matched with divorce decree, using multiple identifiers. Statistically significant differences between the linked cohort and all divorced suicide decedents were assessed using chi-square statistics. Kaplan-Meier survival analyses were conducted assessing which demographics and circumstances had a significant effect on the time between divorce and death. Results: The linkage resulted in 381 divorced suicide decedents linked to a divorce decree. Time between divorce and death ranged from less than 1 year to more than 10 years. Age and intimate partner problems both had significant effects on reducing the survival probability at 1 year and beyond. Limitations: Only 14% of divorced suicide decedents were linked to a Colorado divorce decree. There were noted significant differences between the linked cohort and the total divorced suicide population. Conclusion: Better understanding the relationship between divorce and suicide is imperative to design effective prevention programs for this specific population.

Adolescent Interpregnancy Interval in Colorado Among Women With a Last Live Birth Between 2004 and 2013.

PURPOSE: The purpose of the article was to determine risk factors associated with interpregnancy interval (IPI) and how IPI is associated with subsequent pregnancy outcomes. METHODS: We performed bivariate and multivariable analyses of the Colorado Birth Certificate Registry data from women with a last live birth from 2004 to 2013, among Coloradan women aged 19 years and younger. RESULTS: Our multivariate analysis found that older adolescents aged 17-19 years had a reduced likelihood of an IPI >18 months (odds ratio [OR] .8; confidence interval [CI] .7-.9). Self-identifying as Hispanic increased the likelihood of an IPI <18 months, whereas delivering during or after 2009 or having Medicaid insurance significantly increased the odds that an adolescent would have an IPI >18 months (OR 1.5 [CI: 1.4-1.6]; OR 1.2 [CI: 1.1-1.2]; OR 1.5 [CI: 1.4-1.6], respectively). We found that an IPI >18 months was associated with the following dependent variables in unique logistic regressions adjusted for age, ethnicity, year of last live birth, and insurance status: reduced risk of neonatal complications (OR .9 [CI: .8-.9]), reduced risk of overweight/obesity (OR .9 [CI: .8-.9]), and an increased likelihood of normal birthweight (OR 1.2 [CI: 1.1-1.4]), term birth (OR 1.3 [CI: 1.1-1.4]), and attending 14 or more prenatal visits (OR 1.3 [CI: 1.2-1.4]. CONCLUSIONS: Having an IPI >18 months in adolescent Coloradan women is associated with an increased likelihood of prenatal care attendance, term birth, and normal birthweight and with a reduced likelihood of neonatal complications.

The Spatial Distribution of Adult Obesity Prevalence in Denver County, Colorado: An Empirical Bayes Approach to Adjust EHR-Derived Small Area Estimates.

OBJECTIVES: Measuring obesity prevalence across geographic areas should account for environmental and socioeconomic factors that contribute to spatial autocorrelation, the dependency of values in estimates across neighboring areas, to mitigate the bias in measures and risk of type I errors in hypothesis testing. Dependency among observations across geographic areas violates statistical independence assumptions and may result in biased estimates. Empirical Bayes (EB) estimators reduce the variability of estimates with spatial autocorrelation, which limits the overall mean square-error and controls for sample bias. METHODS: Using the Colorado Body Mass Index (BMI) Monitoring System, we modeled the spatial autocorrelation of adult (≥ 18 years old) obesity (BMI ≥ 30 kg m2) measurements using patient-level electronic health record data from encounters between January 1, 2009, and December 31, 2011. Obesity prevalence was estimated among census tracts with >=10 observations in Denver County census tracts during the study period. We calculated the Moran's I statistic to test for spatial autocorrelation across census tracts, and mapped crude and EB obesity prevalence across geographic areas. RESULTS: In Denver County, there were 143 census tracts with 10 or more observations, representing a total of 97,710 adults with a valid BMI. The crude obesity prevalence for adults in Denver County was 29.8 percent (95% CI 28.4-31.1%) and ranged from 12.8 to 45.2 percent across individual census tracts. EB obesity prevalence was 30.2 percent (95% CI 28.9-31.5%) and ranged from 15.3 to 44.3 percent across census tracts. Statistical tests using the Moran's I statistic suggest adult obesity prevalence in Denver County was distributed in a non-random pattern. Clusters of EB obesity estimates were highly significant (alpha=0.05) in neighboring census tracts. Concentrations of obesity estimates were primarily in the west and north in Denver County. CONCLUSIONS: Statistical tests reveal adult obesity prevalence exhibit spatial autocorrelation in Denver County at the census tract level. EB estimates for obesity prevalence can be used to control for spatial autocorrelation between neighboring census tracts and may produce less biased estimates of obesity prevalence.

Epidemiology and Molecular Characteristics of Mycoplasma pneumoniae During an Outbreak of M. pneumoniae-associated Stevens-Johnson Syndrome.

BACKGROUND: An increase in Mycoplasma pneumoniae-associated Stevens-Johnson syndrome (SJS) cases at a Colorado pediatric hospital led to an outbreak investigation. We describe the epidemiologic and molecular characteristics of M. pneumoniae among SJS case-patients and surrounding community members during the outbreak. METHODS: M. pneumoniae polymerase chain reaction-positive respiratory specimens from 5 Colorado hospitals and 4 referral laboratories underwent confirmatory polymerase chain reaction testing; positive specimens then underwent multilocus variable-number tandem-repeat analysis (MLVA) and macrolide resistance testing. Three SJS-M. pneumoniae case-patient households were surveyed using a standardized questionnaire, and nasopharyngeal/oropharyngeal swabs were obtained from all consenting/assenting household contacts. International Classification of Diseases, 9th revision codes were used to identify pneumonia cases among Colorado patients 5-21 years of age from January 2009 to March 2014. RESULTS: Three different M. pneumoniae MLVA types were identified among the 5 SJS case-patients with confirmed infection; MLVA type 3-X-6-2 was seen more commonly in SJS case-patients (60%) than in 69 non-SJS community specimens (29%). Macrolide resistance was identified in 7% of community specimens but not among SJS case-patients. Of 15 household contacts, 5 (33%) were M. pneumoniae positive; all MLVA types were identical to those of the corresponding SJS case-patient, although the specimen from 1 contact was macrolide resistant. Overall pneumonia cases as well as those caused by M. pneumoniae specifically peaked in October 2013, coinciding with the SJS outbreak. CONCLUSIONS: The outbreak of M. pneumoniae-associated SJS may have been associated with a community outbreak of M. pneumoniae; clinicians should be aware of the M. pneumoniae-SJS relationship. Household transmission of M. pneumoniae was common within the households investigated.

Previous Suicide Attempt and Its Association With Method Used in a Suicide Death.

INTRODUCTION: Non-fatal suicide attempts are a risk factor for suicide, but less is known about its effect on the method of injury used in an eventual suicide death. This study examines the association between history of non-fatal suicide attempt and the risk of a poisoning suicide versus firearm or hanging suicide in Colorado. METHODS: Nine years (2004-2012, N=7,020) of suicide deaths in Colorado were compiled through the National Violent Death Reporting System. With these data, a retrospective cohort study was conducted in 2015, examining the risk associated with a history of suicide attempt and an eventual suicide death by poisoning versus a firearm or hanging suicide death. Multivariable log-binomial regression modeling was used to analyze the possible confounders of age and county type and gender as an effect modifier. RESULTS: Suicide decedents with evidence of prior suicide attempt were twice as likely to eventually die by suicide via self-poisoning rather than by firearm injury (relative risk=1.94, 95% CI=1.8, 2.1, p<0.001). A significant interaction (p<0.001) between prior attempt and gender was identified and the relationship between prior attempt and method (poisoning versus firearm) was stronger among male than female suicides (female attempt history, 1.16, 95% CI=1.07, 1.27, p<0.001; male attempt history, 1.91, 95% CI=1.69, 2.16, p<0.001). CONCLUSIONS: Individuals with a history of non-fatal suicide attempt are more likely to die by suicide via poisoning rather than firearm. Gender has a significant effect on this association. This information can be useful when discussing means restriction and suicide prevention efforts.

Sudden infant death syndrome and residential altitude.

BACKGROUND: Theories of sudden infant death syndrome (SIDS) suggest hypoxia is a common pathway. Infants living at altitude have evidence of hypoxia; however, the association between SIDS incidence and infant residential altitude has not been well studied. METHODS: We performed a retrospective cohort study by using data from the Colorado birth and death registries from 2007 to 2012. Infant residential altitude was determined by geocoding maternal residential address. Logistic regression was used to determine adjusted association between residential altitude and SIDS. We evaluated the impact of the Back to Sleep campaign across various altitudes in an extended cohort from 1990 to 2012 to assess for interaction between sleep position and altitude. RESULTS: A total of 393 216 infants born between 2007 and 2012 were included in the primary cohort (51.4% boys; mean birth weight 3194 ± 558 g). Overall, 79.6% infants resided at altitude <6000 feet, 18.5% at 6000 to 8000 feet, and 1.9% at >8000 feet. There were no meaningful differences in maternal characteristics across altitude groups. Compared with residence <6000 feet, residence at high altitude (>8000 feet), was associated with an adjusted increased risk of SIDS (odds ratio 2.30; 95% confidence interval 1.01-5.24). Before the Back to Sleep campaign, the incidence of SIDS in Colorado was 1.99/1000 live births and dropped to 0.57/1000 live births after its implementation. The Back to Sleep campaign had similar effect across different altitudes (P = .45). CONCLUSIONS: Residence at high altitude was significantly associated with an increased adjusted risk for SIDS. Impact of the Back to Sleep campaign was similar across various altitudes.

Assessment of the quality of publicly reported central line-associated bloodstream infection data in Colorado, 2010.

BACKGROUND: Validation of self-reported health care-associated infection data is essential to verify correct understanding of definition criteria, surveillance practices, and reporting integrity. Recent studies have found significant under-reporting of central line-associated bloodstream infections (CLABSI) leading Colorado Department of Public Health and Environment to examine the quality of Colorado's CLABSI data. METHODS: Trained Colorado Department of Public Health and Environment staff members performed onsite validation visits that included interviews with infection preventionists to assess surveillance practices and retrospective chart reviews of patients with positive blood cultures in specific intensive care units (adult and neonatal) and long-term acute care hospitals during the first quarter of 2010. RESULTS: Fifty-five CLABSIs from the original sample were identified; 33 (60%) in the adult intensive care unit, 7 (12.7%) in the neonatal intensive care unit, and 15 (27.3%) in the long-term acute care hospital. Of the 55 CLABSIs identified by reviewers, 18 (32.7%) were not reported by the hospitals, 37 CLABSIs (67.3%) were reported correctly into the National Healthcare Safety Network, and 1 CLABSI was over-reported. CONCLUSIONS: There was wide variation noted in surveillance practices as well as in application of definition criteria. With 33% under-reported cases, it was concluded that ongoing validation of health care-associated infection data is necessary.