The AIS-2005 Revision in Severe Traumatic Brain Injury: Mission Accomplished or Problems for Future Research?

The Abbreviated Injury Scale (AIS) is commonly used to score injury severity and describe types of injuries. In 2005, the AIS-Head section was revised to capture more detailed information about head injuries and to better reflect their clinical severity, but the impact of these changes is largely unknown. The purpose of this study was to compare AIS-1998 and AIS-2005 coding of traumatic brain injuries (TBI) using medical records at a single Level I trauma center. We included patients with severe TBI (Glasgow Coma Scale 3-8) after blunt injury, excluding those who were missing medical records. Detailed descriptions of injuries were collected, then manually coded into AIS-1998 and AIS-2005 by the same Certified AIS Specialist. Compared to AIS-1998, AIS-2005 coded the same injuries with lower severity scores [p<0.01] and with decreased mean and maximum AIS-Head scores [p<0.01]. Of the types of traumatic brain injuries, most of the changes occurred among cerebellar and cerebral injuries. Traumatic hypoxic brain injury secondary to systemic dysfunction was captured by AIS-2005 but not by AIS-1998. However, AIS-2005 captured fewer loss of consciousness cases due to changes in criteria for coding concussive injury. In conclusion, changes from AIS-1998 to AIS-2005 result in significant differences in severity scores and types of injuries captured. This may complicate future TBI research by precluding direct comparison to datasets using AIS-1998. TBIs should be coded into the same AIS-version for comparison or evaluation of trends, and specify which AIS-version is used.

Free child passenger restraints for patients in an urban pediatric medical home: effects on caregiver behavior

CONTEXT

Motor vehicle crashes are a leading cause of death in children despite the availability of effective child passenger restraints that reduce morbidity and mortality. Inappropriate restraint is more common in minority and low-income populations. Removing barriers by distributing child passenger restraint systems (CPRS) and providing education has been 1 approach to improve child safety. The objective of this study was to evaluate the efficacy of providing no-cost CPRS in combination with targeted education to improve restraint use for low-income, minority, and urban children in a medical home.

DESIGN

This prospective, non-randomized, community-based cohort study used a certified car seat technician to provide CPRS and training to the caregivers of 101 children when those caregivers reported not owning the appropriate type of restraint system during the index clinic visit.

RESULTS

In the first 3 months of follow-up, caregivers were 2.4 times more likely to report appropriate use of CPRS: relative risk 2.4 (95% confidence interval [CI] 1.7 to 3.5). Reported improvement declined slightly between months 4 and 9.

CONCLUSIONS

Appropriate restraint significantly improved, yet rates remained suboptimal. Multifactoral approaches are needed to understand why the set of patients studied and other at-risk populations may not use child restraints properly even when given access and information.

Injury deaths of US citizens abroad: new data source, old travel problem

BACKGROUND

Global travel continues to increase, including among US citizens. The global burden of injuries and violence, accounting for approximately 5 million deaths worldwide in 2000, is also growing. Travelers often experience heightened risk for this biosocial disease burden. This study seeks to further describe and improve our understanding of the variable risk of travel-related injury and death.

METHODS

Information on US civilian citizen deaths from injury while abroad was obtained from the US Department of State Web site. This information was categorized into regional and causal groupings. The groupings were compared to each other and to injury deaths among citizens in their native countries.

RESULTS

From 2004 to 2006, there were 2,361 deaths of US citizens overseas due to injury. Of these US citizen injury deaths, 50.4% occurred in the Americas region. Almost 40% (37.8%) of US citizen injury deaths in the low- to middle-income Americas were due to vehicle crashes compared to about half that (18.9%) (proportional mortality ratio [PMR] = 1.72, 95% confidence interval [CI] 1.59-1.62) for low- to middle-income Americas citizen injury deaths. Similar differences between US citizen injury death abroad and the in-country distributions were also found for vehicle crashes in Europe (35.9% vs 16.5%, PMR = 2.17, 95% CI 1.78-2.64; p < 0.0005), for drowning deaths in the Americas (13.1% vs 4.6%, PMR = 2.67, 95% CI 2.29-3.11) and many island nations (63.5% vs 3.5%, PMR = 11.38, 95% CI 8.17-15.84), and for homicides in the low- to middle-income European countries (16.9% vs 10.5%, PMR = 1.52, 95% CI .90-2.57).

CONCLUSIONS

US citizens should be aware of regional variation of injury deaths in foreign countries, especially for motor vehicle crashes, drowning, and violence. Improved knowledge of regional variations of injury death and risk for travelers can further inform travelers and the development of evidence-based prevention programs and policies. The State Department Web site is a new data source that furthers our understanding of this challenging travel-related health issue.

The association of driver age with traffic injury severity in Wisconsin

OBJECTIVES

To quantify the association of driver's age with the risk of being injured, dying, and experiencing injuries of different severity when involved in a motor vehicle crash.

METHODS

Data from the Wisconsin Crash Outcome Data Evaluation System (CODES) from 2002 to 2004 were used to study 602,964 drivers of a car or truck who were involved in a motor vehicle crash. Odds ratios (OR) or relative risk ratios (RRR) and their 95 percent confidence intervals (CIs) were calculated for age groups, in relation to the outcomes of injury, fatality, and injury severity using logistic regression models, which controlled for sex, alcohol use, urban/rural location, seat belt use, ejection, airbag deployment, vehicle type, and highway class.

RESULTS

Increasing age was strongly associated the risk of dying or experiencing severe injuries for drivers involved in motor vehicle crashes with the greatest risk in drivers 85 years and older. Compared to drivers aged 25-44, drivers 85 years and older had the highest risks for moderate injury (ISS = 9-15; RRR = 5.44, 95% CI: 3.97-7.47), severe injury (ISS = 16-74; (RRR = 4.32, 95% CI: 2.73-6.84), and fatality (OR = 10.93, 95% CI: 7.76-15.38). In contrast, drivers 85 years and older had no increase in risk for minor injury (ISS = 1-8; OR = 0.94, 95% CI: 0.84-1.05).

CONCLUSIONS

The oldest drivers involved in motor vehicle crashes had the highest risk for severe injury and fatality. In light of the increasing number of the oldest drivers and their poor outcomes from severe trauma, substantial morbidity can be expected to occur in the oldest drivers. Evidence-based measures to reduce the risks to older drivers should continue to be developed, evaluated, and implemented.

The burden of suicide in Wisconsin's older adult population

INTRODUCTION

Suicide rates in the older adult population are disproportionately high, yet most studies focus on youth suicide. This study characterized risk factors for elder suicide in Wisconsin.

METHODS

Wisconsin residents aged > or =65 who committed suicide from 2001-2006 were identified using the Violent Injury Reporting System (VIRS; 2001-2003) and the Wisconsin Violent Death Reporting System (WVDRS; 2004-2006). Multivariate regression was used to determine the risk of suicide and to adjust crude rates. Suicide circumstances and methods were also examined.

RESULTS

From 2001-2006, the rate of suicide of those > or =65 was 12.4 per 100,000 per year, lower than the national average of 14.7 per 100,000. Multivariate analysis in Caucasians found that compared to married individuals, those widowed, divorced, or never married had a 2.5- to nearly 5-fold increase in risk of suicide death. Males aged 65-74 had almost a 7-fold increased risk compared to females of that age, and the risk increased for males as they aged, compared to females 65-74 years old. Almost 40% of the cases had a medical examiner or coroner report that the victim had a diagnosed mental illness. Forty-two percent of victims had documented alcohol toxicology screening; of these, 16% were positive for alcohol at the time of death. The most common method of suicide was firearm use (66.9%).

DISCUSSION

Being single, male, and a male advancing in age are risk factors of suicide in the elderly. Health care workers, community advocates, and public health workers should be cognizant of these risk factors to facilitate early recognition and intervention.

Implementing an electronic medical record at a residency site: physicians' perceived effects on quality of care, documentation, and productivity

BACKGROUND

Electronic Medical Records (EMRs) are quickly becoming a standard component of medical practices.

OBJECTIVES

We longitudinally studied the impact of EMR implementation on physician perceptions of quality of care, documentation, and work hours, as well as on measured physician productivity.

METHODS

Physicians were surveyed at 3-month intervals regarding perceived impact of the EMR on quality of care, documentation, and productivity. Relative Value Units (RVUs) per clinic hours were used to measure productivity. Paired t-tests were used to compare the mean RVUs per clinic hour in the pre-EMR with the immediate post-EMR time period and the long-term post-EMR time period.

RESULTS

RVUs per hour increased significantly from the pre-EMR time period to the immediate post-EMR time period (means 1.49 and 1.82, respectively, P = 0.0007). The long-term post-EMR time period also showed a significant increase over the pre-EMR period (mean 1.79, P = 0.007). Sixty-six percent of physicians perceived that EMR implementation increased their work amount a little or much more.

CONCLUSION

Not only did physician production rise immediately, it stayed at the increased level for the duration of our study period. This may be due to improved documentation supporting more appropriate billing. However, physicians also perceived the EMR as taking up more of their time.

Does the number of system paramedics affect clinical benchmark thresholds?

OBJECTIVE

Competency is affected by skill exposure, skill complexity, and training program quality. The purpose of this study was to reevaluate the biennial (24-month) critical care skill and experience benchmark thresholds established by the Milwaukee County Emergency Medical Services (MCEMS) system in 1997.

METHODS

This was a retrospective review of annual experience profiles for paramedics working during 2001-2005 using the MCEMS patient care record (PCR) database. The number of patient contacts, role as team leader/report writer, adult and pediatric endotracheal intubations, adult and pediatric intravenous (IV) access initiations, medication administration, and 12-lead electrocardiogram (ECG) acquisitions were analyzed. t-tests and descriptive statistics were performed for comparison with the 1997 study.

RESULTS

Over the five-year study period, 1,215 paramedic profiles gleaned from 107,524 PCRs documented a total of 297,900 patient contacts. Annual means+/-standard deviations [ranges] were as follows: patient contacts 245+/-133 [12-788]; team leader: 106+/-119 [0-739]; intubations: adult 2.57+/-2.54 [0-20], pediatric 0.1+/-0.3 [0-3]; IV starts: adult 44+/-37 [0-267], pediatric 0.34+/-0.77 [0-5]; treated cardiac arrests: adult 8+/-6 [0-34], pediatric 0.26+/-0.61 [0-4]; treated hypotensive trauma: 5+/-6 [0-42]; and ECGs acquired: 31+/-19 [0-144]. The 1997 analysis (1987-1996 data) included 1,450 paramedic profiles representing 467,559 patient contacts generated from 172,131 filed PCRs. All comparable experiences decreased significantly between the 1997 analysis and the current study, except medication administration, which increased 25%.

CONCLUSION

These data show a decreased opportunity and a wide variability in the frequency of successfully completed paramedic technical skills and experiences in this EMS system. Limited exposure to critically ill adult and pediatric patients reaffirms that high-risk skills are performed infrequently. A multifaceted approach should be considered for maintaining provider competency.

Firearm death rates and association with level of firearm purchase background check

BACKGROUND

Past ecologic analyses of firearm deaths have studied the effects of various gun-control laws; however, no study has analyzed the effects of the differences among states in the background checks required for firearm purchase. Some states utilize a federal agency to conduct the background checks; others use a state agency; still others use a local agency. The information potentially available to checking agencies at different levels of government varies; the consequence of this variation is not known.

METHODS

In 2007, negative binomial regression models were used to assess the association between the Department of Justice classification of agencies conducting firearm background checks for each state in 2002-2004 and firearm suicide and homicide rates for the same years from the National Center for Injury Prevention and Control while controlling for age, race, unemployment, crime, income inequality, poverty, alcohol consumption, urbanization, and divorce rate.

RESULTS

Performing local-level background checks was associated with a 27%-lower firearm suicide rate (incidence rate ratio [IRR]=0.73, 95% CI=0.60, 0.89) and a 22%-lower homicide rate (IRR=0.78, 95% CI=0.61, 1.01) in adults>or=21 years.

CONCLUSIONS

Using local-level agencies to perform firearm background checks is associated with reduced rates of firearm suicide and homicide. Methods to increase local-level agency background checks, such as authorizing local police or sheriff's departments to conduct them, or developing the capability to share local-level records with federal databases, should be evaluated as a means of reducing firearm deaths.

Booster seat use in an inner-city day care center population

OBJECTIVE

To determine use and knowledge of belt positioning booster seats by drivers transporting children from day care centers in the central city of Milwaukee, Wisconsin.

METHODS

A prospective, direct observational, community-based, exploratory study was undertaken in May 2005. Eighteen day care centers in urban Milwaukee that met the predetermined criteria, including > 10 children ages 4-8 enrolled, were invited to participate. Volunteer observers, including Spanish-speaking members, from community organizations were trained in proper placement by certified car seat technicians. Teams visited sites, completed a standardized survey form with drivers who agreed to participate, and observed the type and placement of restraint in which each child was placed.

RESULTS

Of 841 children observed, 283 were determined to be booster-seat eligible. Only 21% were in the appropriate restraint. Latino, African American, and older children were significantly less likely than white and younger children to be appropriately restrained. Appropriate restraint use was more frequent among those living in the proper ZIP codes with higher median incomes.

CONCLUSIONS

This is the first observational study of booster seat use in this Milwaukee population with appropriate restraint use varying widely from reported state and national data. The low rates of appropriate booster seat use, particularly by Latino and African American caregivers and those living in low-income neighborhoods, in this large metropolitan center supports the need for further study and targeted interventions.

Fatal injuries of US citizens abroad

BACKGROUND

US citizens are increasingly traveling, working, and studying abroad as well as retiring abroad. The objective of this study was to describe the type and scope of injury deaths among US citizens abroad and to compare injury death proportions by region to those in the United States.

METHODS

A cross-sectional design using reports of US citizen deaths abroad for 1998, 2000, and 2002 on file at the US State Department was employed. The main outcome measures were the frequencies of injury deaths and proportional mortality ratios (PMRs) comparing deaths abroad to deaths in the United States.

RESULTS

Two thousand eleven injury deaths were reported in the 3 years, comprising 13% of all deaths. The overall age-adjusted PMR for injury fatalities abroad compared to the United States was 1.6 (95% confidence interval 1.6-1.7). The highest age-adjusted PMRs for motor vehicle crashes were found in Africa (2.7) and Southeast Asia (1.6). The proportion of drowning deaths was elevated in all regions abroad.

CONCLUSIONS

Injuries occur at a higher proportion abroad than in the United States. Motor vehicle crash and drowning fatalities are of particular concern. Improved data quality and surveillance of deaths would help government agencies create more evidence-based country advisories.

Predicting quality of life six months after traumatic injury

BACKGROUND

Many factors are known to impact quality of life (QoL) after injury, but predictors of diminished QoL and the time course of recovery remain incompletely understood. This study examines predictors and correlates of QoL measured by the Short Form-36 (SF-36) one and six months postinjury.

METHODS

Adults with nonneurologic blunt injury were prospectively enrolled. Demographic, injury, and socioeconomic data were collected. Patients were assessed with functional and psychologic measures. In all, 196 patients had 1-month data and 123 had 6-month data available. Scores were compared at each time point and also to population norms using t-tests. Multiple regression techniques were used to identify associations between the physical and mental component scores (PCS & MCS) of the SF-36 and patient characteristics.

RESULTS

PCS scores improved significantly (32.8 +/- 0.9 versus 41.3 +/- 1.0, p < 0.05) whereas MCS scores (47.5 +/- 1.1 versus 47.2 +/- 1.1, p = NS) did not. Both remained significantly below population norms. Functional Independence Measure (FIM) at one month was predictive of PCS at 6 months. Posttraumatic stress disorder (PTSD) was predictive of lower MCS, and depression was associated with poor MCS. Injury Severity Score was not associated with PCS or MCS.

CONCLUSIONS

Overall physical and mental QoL measured by the SF-36 remains significantly below population norms 6 months after traumatic injury. It is possible to identify patients at risk for diminished QoL early during recovery by screening for functional status, PTSD, social support, and depression. Interventions to address these areas should be further studied with respect to their impact on long-term QoL.

Excess mortality caused by medical injury

PURPOSE

We wanted to estimate excess risk of in-hospital mortality associated with medical injuries identified using an injury surveillance system, after controlling for risk of death resulting from comorbidities.

METHODS

The Wisconsin Medical Injuries Prevention Program (WMIPP) screening criteria were used to identify medical injuries, defined as "any untoward harm associated with a therapeutic or diagnostic healthcare intervention," among discharge diagnoses for all 562,317 patients discharged from 134 acute care hospitals in Wisconsin in 2002. We then derived estimates for crude and adjusted relative risk of in-hospital mortality associated with the presence of a medical injury diagnosis. Logistic regression adjusted for baseline risk of mortality using a comorbidity index, age, sex, Diagnosis Related Groups, hospital characteristics, and clustering within hospital.

RESULTS

There were 77,666 discharges that met WMIPP criteria for at least 1 medical injury (13.8%). Crude risk ratios for death ranged from 1.27 to 2.4 for those with medical injuries within 1 of 4 categories: drugs/biologics; devices, implants, and grafts; procedures; and radiation. After adjustment, estimates of excess mortality decreased, and significance persisted only for injuries related to procedures (39%; 95% confidence interval [CI], 28%-52%) and devices, implants, and grafts (16%; 95% CI, 3%-30%).

CONCLUSIONS

Estimates of excess mortality that do not account for baseline mortality risk may be exaggerated. Findings have implications for the care family physicians provide in the hospital and for the advice they give their patients who are concerned about the risks of hospitalization.

Rib fractures: Relationship with pneumonia and mortality*

OBJECTIVE

In single-institution studies, age is a risk factor for mortality after rib fracture. Sample size has limited the assessment of other risk factors. We used a national database to analyze suspected risk factors contributing to pneumonia and mortality in patients sustaining rib fractures.

DESIGN

: Database analysis.

PATIENTS

All patients with rib fractures discharged from hospitals submitting information to the Nationwide Inpatient Sample database.

INTERVENTIONS

The 1999 Nationwide Inpatient Sample was queried for all patients with rib fracture. Age, gender, number of rib fractures, Injury Severity Score, comorbidities, pneumonia, and mortality were abstracted from the database. Comorbidities were scored according to Elixhauser. Multivariate analysis identified independent risk factors for mortality and pneumonia.

MEASUREMENTS AND MAIN RESULTS

We identified 23,426 patients; 17,308 patients had a primary diagnosis of trauma and were included in the analysis. Mean age was 56. Mean Injury Severity Score was 13.1. The number of comorbidities ranged from 0 to 9. Overall mortality was 4%. Six percent of patients had pneumonia. In a multivariate model, age and Injury Severity Score were significantly associated with both mortality and pneumonia. Comorbidity score was associated with pneumonia and mortality only in patients with isolated thoracic trauma. Pneumonia was associated with mortality only in patients with isolated thoracic trauma.

CONCLUSIONS

In a model controlling for multiple known risk factors, age and Injury Severity Score were the only important predictors of mortality in patients with rib fractures and multiple-system injury. Pneumonia was significantly associated with mortality only in patients with isolated thoracic trauma.

Identifying risk factors for medical injury

OBJECTIVE

To examine multiple risk factors for medical injury using administrative data.

DESIGN

This cross-sectional study used logistic regression models to examine associations among patient characteristics such as age, sex, and insurance payer status and hospital characteristics such as ownership, teaching status and trauma level, and comorbidities and presence of a medical injury diagnosis. Data were from the Bureau of Health Information: Wisconsin hospital in-patient discharge records and hospital characteristics for the year 2001.

SETTING

All Wisconsin non-federal, acute-care hospitals.

PARTICIPANTS

A total of 556 899 patients discharged from 132 Wisconsin hospitals, excluding newborns, participated.

INTERVENTION

None. Main outcome measure. Medical injury, defined as untoward harm to a patient as a result of a medical intervention, was determined using discharge diagnosis criteria.

RESULTS

Medical injuries were found in 13.3% of 556 899 hospital discharge records. Covariates associated with increased risk of a recorded medical injury code included age 45-84 years, female sex, comorbidities, non-profit religious order ownership, proportion of cardiac intensive care in-patient days to total in-patient days, percent of board-certified medical staff, and community trauma center or regional trauma resource.

CONCLUSION

This article describes an innovative analysis of risk factors for medical injury that controlled for numerous potential confounding factors, including hospital coding characteristics. The associations we found, such as increased risk of medical injury in women, can be used to generate hypotheses for further testing through other methods and suggest intervention points for patient safety efforts.

Medical injuries among hospitalized children

BACKGROUND

Inpatient medical injuries among children are common and result in a longer stay in hospital and increased hospital charges. However, previous studies have used screening criteria that focus on inpatient occurrences only rather than on injuries that also occur in ambulatory or community settings leading to hospital admission.

OBJECTIVE

To describe the incidence and outcomes of medical injuries among children hospitalized in Wisconsin using the Wisconsin Medical Injury Prevention Program (WMIPP) screening criteria.

METHODS

Cross sectional analysis of discharge records of 318,785 children from 134 hospitals in Wisconsin between 2000 and 2002.

RESULTS

The WMIPP criteria identified 3.4% of discharges as having one or more medical injuries: 1.5% due to medications, 1.3% to procedures, and 0.9% to devices, implants and grafts. After adjusting for the All Patient Refined-Diagnosis Related Groups disease category, illness severity, mortality risk, and clustering within hospitals, the mean length of stay (LOS) was a half day (12%) longer for patients with medical injuries than for those without injuries. The similarly adjusted mean total hospital charges were 1614 dollars (26%) higher for the group with medical injuries. Excess LOS and charges were greatest for injuries due to genitourinary devices/implants, vascular devices, and infections/inflammation after procedures.

CONCLUSIONS

This study reinforces previous national findings up to 2000 using Wisconsin data to the end of 2002. The results suggest that hospitals and pediatricians should focus clinical improvement on medications, procedures, and devices frequently associated with medical injuries and use medical injury surveillance to track medical injury rates in children.

Obesity and risk for death due to motor vehicle crashes

OBJECTIVES

We examined the role of body mass index (BMI) and other factors in driver deaths within 30 days after motor vehicle crashes.

METHODS

We collected data for 22 107 drivers aged 16 years and older who were involved in motor vehicle crashes from the Crashworthiness Data System of the National Automotive Sampling System (1997-2001). We used logistic regression and adjusted for confounding factors to analyze associations between BMI and driver fatality and the associations between BMI and gender, age, seatbelt use, type of collision, airbag deployment, and change in velocity during a crash.

RESULTS

The fatality rate was 0.87% (95% confidence interval [CI]=0.50, 1.24) among men and 0.43% (95% CI=0.31, 0.56) among women involved as drivers in motor vehicle crashes. Risk for death increased significantly at both ends of the BMI continuum among men but not among women (P<.05). The association between BMI and male fatality increased significantly with a change in velocity and was modified by the type of collision, but it did not differ by age, seatbelt use, or airbag deployment.

CONCLUSIONS

The increased risk for death due to motor vehicle crashes among obese men may have important implications for traffic safety and motor vehicle design.

Correlation of SF-12 and SF-36 in a trauma population

BACKGROUND

The SF-36 is a commonly used general measure of health-related quality of life (QoL). The SF-12 is a related tool with less response burden, but its performance in a general trauma population is unknown.

HYPOTHESIS

The SF-12 would provide similar QoL information to the SF-36 in blunt trauma patients.

METHODS

Adults with nonneurological blunt injury were prospectively enrolled. Demographic, injury, and socioeconomic data were collected. Patients were assessed with functional and psychologic questionnaires 1 and 6 months after injury. Physical (PCS) and mental (MCS) component scores of the SF-36 and SF-12 were compared using Pearson's correlation coefficient. Linear regression identified factors associated with the SF-12 and SF-36 PCS and MCS. Responsiveness to change was assessed using the standardized response mean.

RESULTS

Correlation of the PCS was 0.924 and MCS was 0.925 (both P < 0.001). QoL remained below population norms at 6 months. PCS was moderately responsive to change and was equivalent using either the SF-12 or the SF-36. MCS was not responsive to change using either tool. At both time points, at least 25% of patients with normal SF-12 PCS or MCS had SF-36 subscale scores significantly below the normal population.

CONCLUSIONS

The SF-12 can be used to assess QoL in trauma patients. The lack of responsiveness to change of the MCS suggests other methods may be necessary to fully evaluate mental QoL. Summary scores may not be sufficient to fully assess QoL in this population. Combining the SF-12 with measures to assess psychosocial variables should be further investigated.

Graduated driver licensing in Wisconsin: does it create safer drivers?

OBJECTIVES

The purpose of this study was to measure the effectiveness of Wisconsin's graduated driver licensing law and determine whether a reduction in crash rates was due to reduced exposure, safer driving, or both.

METHODS

General population crash rates for 16 and 17 year olds were computed for years before and after graduated drivers licensing. The induced exposure method was used to measure exposure and compute the odds ratio of at-fault crash involvement.

RESULTS

For 16 year olds, general crash rates declined 13.8% while injury crash rates declined 15.6%. For 17 year olds, crash rates declined 6.2% for all crashes and 5.8% for injury crashes. There was no statistically significant change in the odds ratio of at-fault crash involvement for 16- or 17-year-old drivers, relative to the reference group. After graduated drivers licensing, 16-year-old drivers were more likely to have at least 1 adult present and less likely to carry 2 or more teen passengers. There was no statistically significant effect on driving habits by time for 16 year olds.

CONCLUSIONS

Graduated driver licensing in Wisconsin has resulted in a drop in the general population crash rates for 16 and 17 year olds. This decrease is the result of reduced exposure to the risk of collision rather than safer driving by teens.

Adolescent hospital discharges associated with self-poisonings in Wisconsin, 2000-2002

OBJECTIVE

This study investigates the Wisconsin adolescent self-poisoning problem, using state discharge data on medication-related self-inflicted injuries, focusing on medications used and risk factors.

METHODS

Wisconsin inpatient discharge files for 3 years (January 1, 2000-December 31, 2002) were evaluated. Medication-related injuries were analyzed for intentionality, medications used, discharge status, and risk factors such as mental illness, eating disorders, and alcohol abuse or dependence.

RESULTS

There were nearly 3000 medication-related injury hospitalizations--1150 of them self-poisoning hospitalizations--among Wisconsin 12-17 year olds during 2000-2002. Females 12-17 years had twice as many medication-related injuries as males. Sixty percent of medication-related injuries occurred in patients with a mental disorder diagnosis. Non-narcotic analgesics were most commonly used and had one of the highest rates of intentionality (65%). A large proportion of intentional/suicidal medication-related injuries were discharged to another facility (35%), compared to 14% among all medical injuries. Males with medication-related injuries were twice (95% CI: 1.60, 2.75) as likely and females 1.4 (95% CI: 1.2, 1.6) times as likely to have intentional/suicidal injuries if they also abused or depended on alcohol.

CONCLUSIONS

Given that a nonfatal suicide attempt is the strongest predictor of eventual suicide, the hundreds of self-poisoning discharges per year in Wisconsin 12-17 year olds is a serious public health concern. Both the medical community and public health community should heed the warnings of these nonfatal suicide attempts and implement educational programs addressing this issue.

Incidence of sports and recreation related injuries resulting in hospitalization in Wisconsin in 2000

OBJECTIVE

To describe the incidence and patterns of sports and recreation related injuries resulting in inpatient hospitalization in Wisconsin. Although much sports and recreation related injury research has focused on the emergency department setting, little is known about the scope or characteristics of more severe sports injuries resulting in hospitalization.

SETTING

The Wisconsin Bureau of Health Information (BHI) maintains hospital inpatient discharge data through a statewide mandatory reporting system. The database contains demographic and health information on all patients hospitalized in acute care non-federal hospitals in Wisconsin.

METHODS

The authors developed a classification scheme based on the International Classification of Diseases External cause of injury code (E code) to identify hospitalizations for sports and recreation related injuries from the BHI data files (2000). Due to the uncertainty within E codes in specifying sports and recreation related injuries, the authors used Bayesian analysis to model the incidence of these types of injuries.

RESULTS

There were 1714 (95% credible interval 1499 to 2022) sports and recreation-related injury hospitalizations in Wisconsin in 2000 (32.0 per 100,000 population). The most common mechanisms of injury were being struck by/against an object in sports (6.4 per 100,000 population) and pedal cycle riding (6.2 per 100,000). Ten to 19 year olds had the highest rate of sports and recreation related injury hospitalization (65.3 per 100,000 population), and males overall had a rate four times higher than females.

CONCLUSIONS

Over 1700 sports and recreation related injuries occurred in Wisconsin in 2000 that were treated during an inpatient hospitalization. Sports and recreation activities result in a substantial number of serious, as well as minor injuries. Prevention efforts aimed at reducing injuries while continuing to promote participation in physical activity for all ages are critical.

Domestic violence among male and female patients seeking emergency medical services

Gender differences among a cohort of injured patients seeking emergency medical services were examined with respect to their experiences as perpetrators and/or victims of domestic violence. Contextual issues, including violence initiation, emotional and behavioral responses to partner-initiated violence, and injury frequency and severity were analyzed. Women reported male partner-initiated violence more frequently than men reported female partner-initiated violence. Behavioral responses to partner initiated violence varied. Women were more likely to report using force back and to involve law enforcement. Women were more likely to be injured in a domestic assault over their lifetime, within the last year, and at the time of recruitment. Comparison of injury severity revealed that women reported higher rates of injuries than men in all possible severity categories. Women also reported experiencing more fear than men during partner-initiated violence, as well as being subjected to larger numbers of dominating and controlling behaviors, and greater intimidation secondary to their partner's size. Understanding contextual differences in partner violence for women and men has significant implications for policy development, identification, treatment, and referral of patients identified as living in violent relationships.

Upper extremity pain seen with fly-casting technique: a survey of fly-casting instructors

OBJECTIVE

To identify the prevalence of upper extremity pain symptoms in fly-casting instructors and examine the association between pain and casting style and equipment.

METHODS

We used a cross-sectional survey of a randomly selected group of 577 fly-casting instructor mailing-list members and recorded equipment; casting styles; pain symptoms; and Disability of the Arm, Shoulder, and Hand inventory. We used univariate statistical tests to examine the associations between pain and casters' equipment and styles.

RESULTS

In 292 usable surveys, pain was reported in the shoulder (50%), elbow (39%), and wrist (36%) of those surveyed and was characterized as moderate-to-severe by 25% of all respondents. Overhead casting was associated with less frequent wrist and elbow pain than was sidearm or elliptical casting. Respondents who used multiple casting styles had significantly less elbow pain than did single-style casters (7% vs 38% overhead, P = .04: 45% sidearm, P = .02; 71% elliptical, P = .003). Pain was significantly more frequent in those who cast with a haul (75% vs 33%, P = .04), used shooting heads (79% vs 66%, P = .04), or added weight to sinking flies (78% vs 60%, P = .01). Moderate-to-severe pain was more frequent in fishers of heavy saltwater fish.

CONCLUSIONS

Upper extremity pain was frequent, but not often severe, in this group of fly-casting instructors. Increased weight on the line and "haul" technique appeared to increase pain symptoms. Modifications in casting style and equipment may help in avoiding or reducing pain.

Clean indoor air policies in Wisconsin workplaces

OBJECTIVE

To describe the nature and extent of workplace environmental tobacco smoke exposures in Wisconsin.

METHODS

Descriptive data and confidence intervals from the Current Population Survey tobacco supplements of 1995-1996 and 1998-1999 are presented.

RESULTS

The percent of indoor workers working under a smoke-free policy increased slightly, from 62% in 1995-1996 to 65% in 1998-1999. Respondents with a college degree were more likely to work under a smoke-free policy than those with a high school education or less. Among respondents with a work policy in 1998-1999, a complete ban on smoking reduced any workplace exposure in the past 2 weeks (4%) compared to a partial ban (26%) or an unrestricted policy (30%).

CONCLUSION

Wisconsin has seen a small increase in workplace policies that ban smoking in the workplace. These policies are more likely to protect workers of higher socioeconomic status and may increase health disparities in tobacco-related diseases in the future.

Risk factors associated with hospitalization for unintentional falls: Wisconsin hospital discharge data for patients aged 65 and over

OBJECTIVE

To identify risk factors associated with hospitalizations for falls in Wisconsin in patients aged 65 and older.

METHODS

This study was a cross-sectional study of year 2000 hospital inpatient discharge records for patients aged 65 and older who did not have a diagnosis-related group code indicating rehabilitation, obtained from the Wisconsin Bureau of Health Information. The database includes all discharges from all non-federal Wisconsin hospitals.

RESULTS

Of 223,085 discharged older adults, 6.9% had an unintentional fall diagnosis. Independent predictors of an unintentional fall diagnosis were age, sex, time of year of discharge, region of residence, alcohol-related problems, dementia, Parkinson's disease, mechanical and motor problems, altered consciousness, convulsions/epilepsy, anemia, and glaucoma.

CONCLUSIONS

Alcohol-related problems and mechanical and motor problems significantly increased the risk of a fall diagnosis in hospitalized patients aged 65 and over.

The Effect of Exit-Interview Patient Education on No-Show Rates at a Family Practice Residency Clinic

BACKGROUND

Residency clinics with high no-show rates experience negative ramifications in patient health care, continuity, clinic productivity, and learning experiences for residents. This study tested patient education in the form of an exit interview to reduce no-show rates.

METHODS

All eligible new patients at St. Mary's Family Practice Center between 1 February 1996 and 30 April 1997 were offered study enrollment. Patients with initial appointments during 5 of 9 clinic sessions were offered an exit interview with visit debriefing, written patient information where appropriate, and review of clinic policies. Missed patients or those with initial appointments during the remaining 4 sessions formed the control group. Interviewers were social work, medical, and nursing students. Insurance and subsequent appointment data were obtained from billing records. Median household income of ZIP codes in which patients resided was obtained from the 1990 Federal Census data. Data were analyzed using chi(2) tests, Wilcoxon rank-sum tests, and logistic regression.

RESULTS

One hundred forty-six patients were enrolled into the intervention and 297 into the control group. Simple logistic regression showed a significant reduction in the risk of no-shows in the intervention group (odds ratio = 0.71, P =.04).

CONCLUSIONS

The exit interview improved attendance at subsequent visits.