Middle-Aged and Older People with AIDS

This article explores the stability and changes in national trends related to AIDS rates, transmission routes, and risk factors from the mid-1980s to 1997. The authors show that while the numbers of AIDS cases have grown dramatically for all age groups, the proportion of cases for persons age 50 and older (at diagnosis) has remained a fairly stable 10% of the total case load, resulting in more than 60,000 cases in 1997. Contrary to popular belief, the most prevalent transmission route for middle-aged and older people has always been through sexual contact. While middle-aged and older people may be at reduced risk compared to younger age groups, these data also reveal a disturbing trend. People age 50 and older continue to be less knowledgeable about AIDS risks, perceive themselves to be at lower risk, and, for those with known AIDS-related risks, have made fewer behavioral accommodations to avoid such risksas compared to younger people. With recent data indicating a faster rise in new AIDScases among the 50-plus population, middle-aged and older people can no longer beignored in AIDS prevention or treatment efforts.

Changes in Obesity Prevalence Among Women Aged 50 Years and Older

Obesity is an important public health issue facing Americans of all ages. Behavioral Risk Factor Surveillance System data are used to illustrate the change in body mass index distribution in just one decade (1990-2000) in women aged = 50. The sample size ranged from 18,474women = 50 in 1990 to 45,820 in 2000. Forwomen aged = 50, there is a slight decline in the prevalence of underweight (from 3.1% in 1990 to 2.4% in 2000) and a significant increase in obesity (from 14.4% to 21.7%). Not smoking, having less education, being in poor health, having diabetes, and not exercising are all associated with increased odds of being obese. Although factors significantly related to obesity in older women are consistent with those previously identified in younger women, the weight group distributions in olderwomen differ. The physical and social influences of age and gender need to be incorporated into health promotion programs.

Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012

INTRODUCTION

Opioid analgesic prescriptions are driving trends in drug overdoses, but little is known about prescribing patterns among medical specialties. We conducted this study to examine the opioid-prescribing patterns of the medical specialties over time.

METHODS

IMS Health's National Prescription Audit (NPA) estimated the annual counts of pharmaceutical prescriptions dispensed in the U.S. during 2007-2012. We grouped NPA prescriber specialty data by practice type for ease of analysis, and measured the distribution of total prescriptions and opioid prescriptions by specialty. We calculated the percentage of all prescriptions dispensed that were opioids, and evaluated changes in that rate by specialty during 2007-2012. The analysis was conducted in 2013.

RESULTS

In 2012, U.S. pharmacies and long-term care facilities dispensed 4.2 billion prescriptions, 289 million (6.8%) of which were opioids. Primary care specialties accounted for nearly half of all dispensed opioid prescriptions. The rate of opioid prescribing was highest for specialists in pain medicine (48.6%); surgery (36.5%); and physical medicine/rehabilitation (35.5%). The rate of opioid prescribing rose during 2007-2010 but leveled thereafter as most specialties reduced opioid use. The greatest percentage increase in opioid-prescribing rates during 2007-2012 occurred among physical medicine/rehabilitation specialists (+12.0%). The largest percentage drops in opioid-prescribing rates occurred in emergency medicine (-8.9%) and dentistry (-5.7%).

CONCLUSIONS

The data indicate diverging trends in opioid prescribing among medical specialties in the U.S. during 2007-2012. Engaging the medical specialties individually is critical for continued improvement in the safe and effective treatment of pain.

Preventing unintentional injuries in the home using the Health Impact Pyramid

Injuries continue to be the leading cause of death for the first four decades of life. These injuries result from a confluence of behavioral, physical, structural, environmental, and social factors. Taken together, these illustrate the importance of taking a broad and multileveled approach to injury prevention. Using examples from fall, fire, scald, and poisoning-related injuries, this article illustrates the utility of an approach that incorporates a social-environmental perspective in identifying and selecting interventions to improve the health and safety of individuals. Injury prevention efforts to prevent home injuries benefit from multilevel modifications of behavior, public policy, laws and enforcement, the environment, consumer products and engineering standards, as demonstrated with Frieden's Health Impact Pyramid. A greater understanding, however, is needed to explain the associations between tiers. While interventions that include modifications of the social environment are being field-tested, much more work needs to be done in measuring social-environmental change and in evaluating these programs to disentangle what works best.

Prescription practices involving opioid analgesics among Americans with Medicaid, 2010

Recent state-based studies have shown an increased risk of opioid overdose death in Medicaid populations. To explore one side of risk, this study examines indicators of potential opioid inappropriate use or prescribing among Medicaid enrollees. We examined claims from enrollees aged 18-64 years in the 2010 Truven Health MarketScan® Multi-State Medicaid database, which consisted of weighted and nationally representative data from 12 states. Pharmaceutical claims were used to identify enrollees (n=359,368) with opioid prescriptions. Indicators of potential inappropriate use or prescribing included overlapping opioid prescriptions, overlapping opioid and benzodiazepine prescriptions, long acting/extended release opioids for acute pain, and high daily doses. In 2010, Medicaid enrollees with opioid prescriptions obtained an average 6.3 opioid prescriptions, and 40% had at least one indicator of potential inappropriate use or prescribing. These indicators have been linked to opioid-related adverse health outcomes, and methods exist to detect and deter inappropriate use and prescribing of opioids.

Variation among states in prescribing of opioid pain relievers and benzodiazepines--United States, 2012

INTRODUCTION

Overprescribing of opioid pain relievers (OPR) can result in multiple adverse health outcomes, including fatal overdoses. Interstate variation in rates of prescribing OPR and other prescription drugs prone to abuse, such as benzodiazepines, might indicate areas where prescribing patterns need further evaluation.

METHODS

CDC analyzed a commercial database (IMS Health) to assess the potential for improved prescribing of OPR and other drugs. CDC calculated state rates and measures of variation for OPR, long-acting/extended-release (LA/ER) OPR, high-dose OPR, and benzodiazepines.

RESULTS

In 2012, prescribers wrote 82.5 OPR and 37.6 benzodiazepine prescriptions per 100 persons in the United States. State rates varied 2.7-fold for OPR and 3.7-fold for benzodiazepines. For both OPR and benzodiazepines, rates were higher in the South census region, and three Southern states were two or more standard deviations above the mean. Rates for LA/ER and high-dose OPR were highest in the Northeast. Rates varied 22-fold for one type of OPR, oxymorphone.

CONCLUSIONS

Factors accounting for the regional variation are unknown. Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety.

IMPLICATIONS FOR PUBLIC HEALTH

State policy makers might reduce the harms associated with the abuse of prescription drugs by implementing changes that will make the prescribing of these drugs more cautious and more consistent with clinical recommendations.

Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse-related emergency department visits and drug-related deaths - United States, 2010

The abuse of prescription drugs has led to a significant increase in emergency department (ED) visits and drug-related deaths over the past decade. Opioid pain relievers (OPRs) and benzodiazepines are the prescription drugs most commonly involved in these events. Excessive alcohol consumption also accounts for a significant health burden and is common among groups that report high rates of prescription drug abuse. When taken with OPRs or benzodiazepines, alcohol increases central nervous system depression and the risk for overdose. Data describing alcohol involvement in OPR or benzodiazepine abuse are limited. To quantify alcohol involvement in OPR and benzodiazepine abuse and drug-related deaths and to inform prevention efforts, the Food and Drug Administration (FDA) and CDC analyzed 2010 data for drug abuse-related ED visits in the United States and drug-related deaths that involved OPRs and alcohol or benzodiazepines and alcohol in 13 states. The analyses showed alcohol was involved in 18.5% of OPR and 27.2% of benzodiazepine drug abuse-related ED visits and 22.1% of OPR and 21.4% of benzodiazepine drug-related deaths. These findings indicate that alcohol plays a significant role in OPR and benzodiazepine abuse. Interventions to reduce the abuse of alcohol and these drugs alone and in combination are needed.

Vital signs: variation among States in prescribing of opioid pain relievers and benzodiazepines - United States, 2012

BACKGROUND

Overprescribing of opioid pain relievers (OPR) can result in multiple adverse health outcomes, including fatal overdoses. Interstate variation in rates of prescribing OPR and other prescription drugs prone to abuse, such as benzodiazepines, might indicate areas where prescribing patterns need further evaluation.

METHODS

CDC analyzed a commercial database (IMS Health) to assess the potential for improved prescribing of OPR and other drugs. CDC calculated state rates and measures of variation for OPR, long-acting/extended-release (LA/ER) OPR, high-dose OPR, and benzodiazepines.

RESULTS

In 2012, prescribers wrote 82.5 OPR and 37.6 benzodiazepine prescriptions per 100 persons in the United States. State rates varied 2.7-fold for OPR and 3.7-fold for benzodiazepines. For both OPR and benzodiazepines, rates were higher in the South census region, and three Southern states were two or more standard deviations above the mean. Rates for LA/ER and high-dose OPR were highest in the Northeast. Rates varied 22-fold for one type of OPR, oxymorphone.

CONCLUSIONS

Factors accounting for the regional variation are unknown. Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety.

IMPLICATIONS FOR PUBLIC HEALTH

State policy makers might reduce the harms associated with abuse of prescription drugs by implementing changes that will make the prescribing of these drugs more cautious and more consistent with clinical recommendations.

Drug-induced deaths - United States, 1999-2010

Drug-induced deaths include all deaths for which drugs are the underlying cause, including those attributable to acute poisoning by drugs (drug overdoses) and deaths from medical conditions resulting from chronic drug use (e.g., drug-induced Cushing's syndrome). A drug includes illicit or street drugs (e.g., heroin and cocaine), as well as legal prescription and over-the-counter drugs; alcohol is not included. Deaths from drug overdose have increased sharply in the past decade. This increase has been associated with overdoses of prescription opioid pain relievers, which have more than tripled in the past 20 years, escalating to 16,651 deaths in the United States in 2010. Most drug-induced deaths are unintentional drug poisoning deaths, with suicidal drug poisoning and drug poisoning of undetermined intent comprising the majority of the remainder.

Associations between pain clinic density and distributions of opioid pain relievers, drug-related deaths, hospitalizations, emergency department visits, and neonatal abstinence syndrome in Florida

BACKGROUND

Community-level associations between pain clinics and drug-related outcomes have not been empirically demonstrated.

METHODS

To explore these associations we correlated overdose death rates, hospital-discharge rates for drug-related hospitalizations including neonatal abstinence syndrome, and emergency department rates for drug-related visits with registered pain clinic density and rate of opioid pills dispensed per person at the county-level Florida in 2009. Negative binomial regression was used to model the crude associations and associations adjusted for exposure measures and county demographic characteristics.

RESULTS

An estimated 732 pain clinics operated in Florida in 2009, a rate of 3.9/100,000 people. Among the 67 counties in Florida, 23 (34.3%) had no pain clinics, and three had 90 or more. Adjusted negative binomial regression determined no significant association between pain clinic rate and drug-related outcomes. However, rates of drug-caused, opioid-caused, and oxycodone-caused death correlated significantly with rates of opioid and oxycodone pills dispensed per person in adjusted analyses. For every increase of one pill in the rate of oxycodone pills per person, there was a 6% increase in the rate of oxycodone-related overdose death.

CONCLUSIONS

Although pain clinics, some of which are "pill mills," are clearly a source of drugs used nonmedically, their impact on health outcomes might be difficult to quantify because the pills they prescribe might be consumed in other counties or states. The impact of "pill mill" laws might be better measured by more proximal measures such as the number of such facilities.

Fatal unintentional injuries in the home in the U.S., 2000-2008

BACKGROUND

From 1992 to 1999, an average of more than 18,000 unintentional home injury deaths occurred in the U.S. annually.

PURPOSE

The objective of this study was to provide current prevalence estimates of fatal unintentional injury in the home.

METHODS

Data from the 2000-2008 National Vital Statistics System were used in 2011 to calculate average annual rates for unintentional home injury deaths for the U.S. overall, and by mechanism of injury, gender, and age group.

RESULTS

From 2000 to 2008, there was an annual average of 30,569 unintentional injury deaths occurring in the home environment in the U.S. (10.3 deaths per 100,000). Poisonings (4.5 per 100,000) and falls (3.5 per 100,000) were the leading causes of home injury deaths. Men/boys had higher rates of home injury death than women/girls (12.7 vs 8.2 per 100,000), and older adults (≥80 years) had higher rates than other age groups. Home injury deaths and rates increased significantly from 2000 to 2008.

CONCLUSIONS

More than 30,000 people die annually in the U.S. from unintentional injuries at home, with the trend rising since the year 2000. The overall rise is due in large part to the dramatic increase in deaths due to poisonings, and to a lesser degree falls at home. Unintentional home injuries are both predictable and preventable. Through a multifaceted approach combining behavioral change, adequate supervision of children, installation and maintenance of safety devices, and adherence to building codes, safety regulations and legislation, home injuries can be reduced.

Smoke alarm giveaway and installation programs: an economic evaluation

BACKGROUND

The burden of residential fire injury and death is substantial. Targeted smoke alarm giveaway and installation programs are popular interventions used to reduce residential fire mortality and morbidity.

PURPOSE

To evaluate the cost effectiveness and cost benefit of implementing a giveaway or installation program in a small hypothetic community with a high risk of fire death and injury through a decision-analysis model.

METHODS

Model inputs included program costs; program effectiveness (life-years and quality-adjusted life-years saved); and monetized program benefits (medical cost, productivity, property loss and quality-of-life losses averted) and were identified through structured reviews of existing literature (done in 2011) and supplemented by expert opinion. Future costs and effectiveness were discounted at a rate of 3% per year. All costs were expressed in 2011 U.S. dollars.

RESULTS

Cost-effectiveness analysis (CEA) resulted in an average cost-effectiveness ratio (ACER) of $51,404 per quality-adjusted life-years (QALYs) saved and $45,630 per QALY for the giveaway and installation programs, respectively. Cost-benefit analysis (CBA) showed that both programs were associated with a positive net benefit with a benefit-cost ratio of 2.1 and 2.3, respectively. Smoke alarm functional rate, baseline prevalence of functional alarms, and baseline home fire death rate were among the most influential factors for the CEA and CBA results.

CONCLUSIONS

Both giveaway and installation programs have an average cost-effectiveness ratio similar to or lower than the median cost-effectiveness ratio reported for other interventions to reduce fatal injuries in homes. Although more effort is required, installation programs result in lower cost per outcome achieved compared with giveaways.

The National Center for Injury Prevention and Control on its 20th Anniversary: a safe future and the importance of 20

In recognition of NCIPC's role in creating a safer world, we brought together 20 contributions for this Journal of Safety Research Anniversary Supplement that represents the breadth of our work while acknowledging that we cannot truly represent the depth of the work over the past two decades. The Center's current focal and cross-cutting areas are highlighted in the articles of this Supplement and cover a range of activities from violence prevention, unintentional injury, to acute care and rehabilitation. The Supplement also contains contributions from partners and highlights the resources of the Center.

Slipping and tripping: fall injuries in adults associated with rugs and carpets

BACKGROUND

Falls are a leading cause of unintentional injury among adults age 65 years and older. Loose, unsecured rugs and damaged carpets with curled edges, are recognized environmental hazards that may contribute to falls. To characterize nonfatal, unintentional fall-related injuries associated with rugs and carpets in adults aged 65 years and older.

METHODS

We conducted a retrospective analysis of surveillance data of injuries treated in hospital emergency departments (EDs) during 2001-2008. We used the National Electronic Injury Surveillance System-All Injury Program, which collects data from a nationally representative stratified probability sample of 66 U.S. hospital EDs. Sample weights were used to make national estimates.

RESULTS

Annually, an estimated 37,991 adults age 65 years or older were treated in U.S. EDs for falls associated with carpets (54.2%) and rugs (45.8%). Most falls (72.8%) occurred at home. Women represented 80.2% of fall injuries. The most common location for fall injuries in the home was the bathroom (35.7%). Frequent fall injuries occurred at the transition between carpet/rug and non-carpet/rug, on wet carpets or rugs, and while hurrying to the bathroom.

CONCLUSIONS

Fall injuries associated with rugs and carpets are common and may cause potentially severe injuries. Older adults, their caregivers, and emergency and primary care physicians should be aware of the significant risk for fall injuries and of environmental modifications that may reduce that risk.

Adult opinions about the age at which children can be left home alone, bathe alone, or bike alone: Second Injury Control and Risk Survey (ICARIS-2)

PROBLEM

This study describes adult opinions about child supervision during various activities.

METHODS

Data come from a survey of U.S. adults. Respondents were asked the minimum age a child could safely: stay home alone; bathe alone; or ride a bike alone. Respondents with children were asked if their child had ever been allowed to: play outside alone; play in a room at home for more than 10 minutes alone; bathe with another child; or bathe alone.

RESULTS

The mean age that adults believed a child could be home alone was 13.0 years (95% CI=12.9-13.1), bathe alone was 7.5 years (95% CI=7.4-7.6), or bike alone was 10.1 years (95% CI=10.0-10.3). There were significant differences by income, education, and race.

DISCUSSION

Assessing adult's understanding of the appropriate age for independent action helps set a context for providing guidance on parental supervision. Guidelines for parents should acknowledge social norms and child development stages.

IMPACT ON INDUSTRY

Knowledge of social norms can help guide injury prevention messages for parents.

Gender differences in seeking care for falls in the aged Medicare population

BACKGROUND

One third of adults aged ≥65 years fall annually, and women are more likely than men to be treated for fall injuries in hospitals and emergency departments.

PURPOSE

The aim of this study was to examine how men and women differed in seeking medical care for falls and in the information about falls they received from healthcare providers.

METHODS

This study, undertaken in 2010, analyzed population-based data from the 2005 Medicare Current Beneficiary Survey (MBCS), the most recent data available in 2010 from this survey. A sample of 12,052 community-dwelling Medicare beneficiaries aged ≥65 years was used to examine male-female differences among 2794 who reported falling in the previous year, sought medical care for falls and/or discussed fall prevention with a healthcare provider. Multivariable logistic regression analyses were conducted to determine the factors associated with falling for men and women. P-values ≤0.05 were considered significant.

RESULTS

Nationally, an estimated seven million Medicare beneficiaries (22%) fell in the previous year. Among those who fell, significantly more women than men talked with a healthcare provider about falls and also discussed fall prevention (31.2% [95% CI=28.8%, 33.6%] vs 24.3% [95% CI=21.6%, 27.0%]). For both genders, falls were most strongly associated with two or more limitations in activities of daily living and often feeling sad or depressed.

CONCLUSIONS

Women were significantly more likely than men to report falls, seek medical care, and/or discuss falls and fall prevention with a healthcare provider. Providers should consider asking all older patients about previous falls, especially older male patients who are least likely to seek medical attention or discuss falls with their doctors.

Nonfatal unintentional injuries in children aged <15 years in Nicaragua

The objective of this study was to describe the nonfatal unintentional injuries among children aged <15 years treated in four emergency departments (EDs) in Nicaragua. The 2004 Injury Surveillance System included all cases of injuries that attended the four hospital EDs (n = 37,577). We analysed the records of 13,426 children aged <15 years who sustained nonfatal unintentional injuries. The leading causes of injuries were falls (50.5%), blunt force trauma (13.2%) and transport-related incidents (11.5%). Transport-related injuries primarily involved cyclists (42.3%) and motor-vehicle passengers (32.5%). Ten per cent of the injured children were hospitalised. This is the first study to present the epidemiology of nonfatal unintentional injuries among children treated in EDs in Nicaragua. Unintentional injuries are an important cause of morbidity, but the burden remains largely unaddressed. The implementation of the already well-established transportation-related prevention strategies should be a priority. Prevention of falls (falls being the leading cause of injury among children) demands further study.

Home Injuries: Potential for Prevention

There are approximately 18 000 injury-related deaths at home each year. Some of the leading causes of home injury deaths are falls, fire/ burns, poisonings, choking/suffocations, and drownings. Many more home injuries are treated at emergency departments, in doctors’ offices, or with self-care at home. Children and older adults are especially at risk for home injuries, and environmental factors can contribute to population disparities in home injuries. The causes and circumstances of home injuries are complex and multifaceted. This article provides an overview of the epidemiology and burden of home injuries and reviews the evidence for prevention by life stage. Reducing the risk of injuries at home is challenging, but fortunately there many ways that practitioners can help promote safer behaviors and help change home environments for patients and their families.

Self-reported falls and fall-related injuries among persons aged>or=65 years--United States, 2006

PROBLEM

In 2005, 15,802 persons aged>or=65 years died from fall injuries. How many older adults seek outpatient treatment for minor or moderate fall injuries is unknown.

METHOD

To estimate the percentage of older adults who fell during the preceding three months, the Centers for Disease Control and Prevention (CDC) analyzed data from two questions about falls included in the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey.

RESULTS

Approximately 5.8 million (15.9%) persons aged>or=65 years reported falling at least once during the preceding three months, and 1.8 million (31.3%) of those who fell sustained an injury that resulted in a doctor visit or restricted activity for at least one day.

DISCUSSION

This report presents the first national estimates of the number and proportion of persons reporting fall-related injuries associated with either doctor visits or restricted activity.

SUMMARY

The prevalence of falls reinforces the need for broader use of scientifically proven fall-prevention interventions.

IMPACT ON INDUSTRY

Falls and fall-related injuries represent an enormous burden to individuals, society, and to our health care system. Because the U.S. population is aging, this problem will increase unless we take preventive action by broadly implementing evidence-based fall prevention programs. Such programs could appreciably decrease the incidence and health care costs of fall injuries, as well as greatly improve the quality of life for older adults.

Translation of an effective tai chi intervention into a community-based falls-prevention program

Tai chi--moving for better balance, a falls-prevention program developed from a randomized controlled trial for community-based use, was evaluated with the re-aim framework in 6 community centers. The program had a 100% adoption rate and 87% reach into the target older adult population. All centers implemented the intervention with good fidelity, and participants showed significant improvements in health-related outcome measures. This evidence-based tai chi program is practical to disseminate and can be effectively implemented and maintained in community settings.