Types and origins of diagnostic errors in primary care settings

IMPORTANCE

Diagnostic errors are an understudied aspect of ambulatory patient safety.

OBJECTIVES

To determine the types of diseases missed and the diagnostic processes involved in cases of confirmed diagnostic errors in primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions.

DESIGN

We reviewed medical records of diagnostic errors detected at 2 sites through electronic health record-based triggers. Triggers were based on patterns of patients' unexpected return visits after an initial primary care index visit.

SETTING

A large urban Veterans Affairs facility and a large integrated private health care system.

PARTICIPANTS

Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007.

MAIN OUTCOME MEASURES

Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors.

RESULTS

In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). A total of 43.7% of cases involved more than one of these processes. Patient-practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). Most errors were associated with potential for moderate to severe harm.

CONCLUSIONS AND RELEVANCE

Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient-practitioner encounter.

Burns in low- and middle-income countries: A review of available literature on descriptive epidemiology, risk factors, treatment, and prevention

Burn prevention requires adequate knowledge of the epidemiological characteristics and associated risk factors. While much has been accomplished in the areas of primary and secondary prevention of fires and burns in many developed or high-income countries (HICs), such as the United States, due to sustained research on the descriptive epidemiology and risk factors, the same cannot be said of developing or low- and middle-income countries (LMICs). To move from data to action and assist preventive efforts in LMICs, a review of the available literature was conducted to assess the current status of burn preventive efforts. A MEDLINE search (1974-2003) was conducted on empirical studies published in English on the descriptive epidemiology, risk factors, treatment, and prevention of burns in LMICs. Review of the 117 identified studies revealed basically the same descriptive epidemiological characteristics but slightly different risk factors of burns including the presence of pre-existing impairments in children, lapses in child supervision, storage of flammable substances in the home, low maternal education, and overcrowding as well as several treatment modalities and preventive efforts including immediate application of cool water to a burned area. Continuous evaluation of promising interventions and those with unknown efficacy that have been attempted in LMICs, along with testing interventions that have proven effective in HICs in these LIMC settings, is needed to spearhead the move from data to action in preventing burns in LMICs.

Traffic-related injury prevention interventions for low-income countries

Traffic-related injuries have become a major public health concern worldwide. However, unlike developed or high-income countries (HICs), many developing or low-income countries (LICs) have made very little progress towards addressing this problem. Lack of the progress in LICs is attributable, in part, to their economic situation in terms of their governments' lack of resources to invest in traffic safety, cultural beliefs regarding the fatalism of injuries, competing health problems particularly with the emergence of HIV/AIDS, distinctive traffic mixes comprising a substantial number of vulnerable road users for whom less research has been done, low literacy rates precluding motorists to read and understand road signs, and peculiar political situations occasionally predominated by dictatorship and non-democratic governments. How then can LICs tackle the challenge of traffic safety from the experiences of HICs without reinventing the wheel? This paper reviews selected interventions and strategies that have been developed to counter traffic-related injuries in HICs in terms of their effectiveness and their applicability to LICs. Proven and promising interventions or strategies such as seat belt and helmet use, legislation and enforcement of seat belt use, sidewalks, roadway barriers, selected traffic-calming designs (e.g., speed ramps/bumps), pedestrian crossing signs combined with clearly marked crosswalks, and public education and behavior modification targeted at motorists are all feasible and useable in LICs as evidenced by data from many LICs. While numerous traffic-related injury policy interventions and strategies developed largely in HICs are potentially transferable to LICs, it is important to consider country-specific factors such as costs, feasibility, sustainability, and barriers, all of which must be factored into the assessment of effectiveness in specific LIC settings. Almost all interventions and strategies that have been proven effective in HICs will need to be evaluated in LICs and particular attention paid to the effectiveness of enforcement measures. It behooves LIC governments, however, to ensure that only standard, approved safety devices like helmets are imported into their countries. Additionally, LICs may need to improvise and innovate in the traffic safety technology transfer.

Electronic health record-based triggers to detect potential delays in cancer diagnosis

BACKGROUND

Delayed diagnosis of cancer can lead to patient harm, and strategies are needed to proactively and efficiently detect such delays in care. We aimed to develop and evaluate 'trigger' algorithms to electronically flag medical records of patients with potential delays in prostate and colorectal cancer (CRC) diagnosis.

METHODS

We mined retrospective data from two large integrated health systems with comprehensive electronic health records (EHR) to iteratively develop triggers. Data mining algorithms identified all patient records with specific demographics and a lack of appropriate and timely follow-up actions on four diagnostic clues that were newly documented in the EHR: abnormal prostate-specific antigen (PSA), positive faecal occult blood test (FOBT), iron-deficiency anaemia (IDA), and haematochezia. Triggers subsequently excluded patients not needing follow-up (eg, terminal illness) or who had already received appropriate and timely care. Each of the four final triggers was applied to a test cohort, and chart reviews of randomly selected records identified by the triggers were used to calculate positive predictive values (PPV).

RESULTS

The PSA trigger was applied to records of 292 587 patients seen between 1 January 2009 and 31 December 2009, and the CRC triggers were applied to 291 773 patients seen between 1 March 2009 and 28 February 2010. Overall, 1564 trigger positive patients were identified (426 PSA, 355 FOBT, 610 IDA and 173 haematochezia). Record reviews revealed PPVs of 70.2%, 66.7%, 67.5%, and 58.3% for the PSA, FOBT, IDA and haematochezia triggers, respectively. Use of all four triggers at the study sites could detect an estimated 1048 instances of delayed or missed follow-up of abnormal findings annually and 47 high-grade cancers.

CONCLUSIONS

EHR-based triggers can be used successfully to flag patient records lacking follow-up of abnormal clinical findings suspicious for cancer.

Electronic health record-based surveillance of diagnostic errors in primary care

BACKGROUND

Diagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice.

METHODS

The authors conducted a retrospective study of primary care visit records 'triggered' through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalisation within 14 days and Trigger 2: A primary care index visit followed by ≥1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between 1 October 2006 and 30 September 2007. Blinded physician-reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data were available at the index visit. Disagreements were resolved by an independent third reviewer.

RESULTS

Queries were applied to 212 165 visits. On record review, the authors found diagnostic errors in 141 of 674 Trigger 1-positive records (positive predictive value (PPV)=20.9%, 95% CI 17.9% to 24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI 3.7% to 7.1%). The control PPV of 2.1% (95% CI 0.1% to 3.3%) was significantly lower than that of both triggers (p≤0.002). Inter-reviewer reliability was modest, though higher than in comparable previous studies (к=0.37 (95% CI 0.31 to 0.44)).

CONCLUSIONS

While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.

Neighborhood safety factors associated with older adults' health-related outcomes: A systematic literature review

RATIONALE

Neighborhood safety is important for older adults' health and wellbeing, but there has not been a synthesis in the literature of what is currently known about this construct.

OBJECTIVES

This systematic literature review, following the PRISMA guidelines, focuses on identifying neighborhood safety factors associated with health-related outcomes and behaviors of older adults in the U.S.

METHODS

A search was conducted in 2014 via Academic Search Complete, CINAHL, Embase, MEDLINE, SportDis, and Transportation Databases. Based on our inclusion and exclusion criteria, we identified thirty-two articles for review.

RESULTS

Sixteen studies examined health outcomes such as health status, mental health, physical function, morbidity/mortality, and obesity; the other sixteen studies focused on health behaviors, such as physical activity and walking. Four domains of neighborhood safety were identified: overall/general neighborhood safety; crime-related safety; traffic-related safety; and proxies for safety (e.g., vandalism, graffiti). Overall/general neighborhood safety appeared most relevant to mental health and physical function. Traffic-related safety was most pertinent to physical activity, while crime-related safety was more consistently associated with mental health and walking. While all safety variables were significantly associated with mental health, no significant associations were found for obesity. We also found that specific measures or constructs of safety were not applied consistently across the examined studies, making it difficult to compare the results.

CONCLUSION

This review identified several important gaps in the existing studies dealing with neighborhood safety-health relationships among older adults. Further studies are needed that examine the different roles of multidimensional neighborhood safety in promoting the community health, not only in the U.S., but globally.

Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial

PURPOSE

We tested whether prospective use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays could prevent delays in diagnostic evaluation for cancer.

METHODS

We performed a cluster randomized controlled trial of primary care providers (PCPs) at two sites to test whether triggers that prospectively identify patients with potential delays in diagnostic evaluation for lung, colorectal, or prostate cancer can reduce time to follow-up diagnostic evaluation. Intervention steps included queries of the electronic health record repository for patients with abnormal findings and lack of associated follow-up actions, manual review of triggered records, and communication of this information to PCPs via secure e-mail and, if needed, phone calls to ensure message receipt. We compared times to diagnostic evaluation and proportions of patients followed up between intervention and control cohorts based on final review at 7 months.

RESULTS

We recruited 72 PCPs (36 in the intervention group and 36 in the control group) and applied the trigger to all patients under their care from April 20, 2011, to July 19, 2012. Of 10,673 patients with abnormal findings, the trigger flagged 1,256 patients (11.8%) as high risk for delayed diagnostic evaluation. Times to diagnostic evaluation were significantly lower in intervention patients compared with control patients flagged by the colorectal trigger (median, 104 v 200 days, respectively; n = 557; P < .001) and prostate trigger (40% received evaluation at 144 v 192 days, respectively; n = 157; P < .001) but not the lung trigger (median, 65 v 93 days, respectively; n = 19; P = .59). More intervention patients than control patients received diagnostic evaluation by final review (73.4% v 52.2%, respectively; relative risk, 1.41; 95% CI, 1.25 to 1.58).

CONCLUSION

Electronic trigger-based interventions seem to be effective in reducing time to diagnostic evaluation of colorectal and prostate cancer as well as improving the proportion of patients who receive follow-up. Similar interventions could improve timeliness of diagnosis of other serious conditions.

Childhood burns in Ghana: epidemiological characteristics and home-based treatment

The objectives of this research were to study the epidemiological characteristics and home-based treatment of childhood burns in the Ashanti Region of Ghana. Children aged 0-5 years with a burn history were identified through a community-based, multisite survey. A standard questionnaire was administered to mothers of 630 of these children to elicit information on their sociodemographic characteristics and the circumstances of the burn event. Ninety-two per cent of the burns occurred in the home, particularly in the kitchen (51 per cent) and the house yard (36 per cent), with most of them happening in the late morning and around the evening meal. The main causes of the burns were scalds (45 per cent), contact with a hot object (34 per cent) and flame (20 per cent). 'Cool' water was applied to the burned area in 30 per cent of cases. Otherwise, treatment with a traditional preparation was the most popular first-aid choice. Since a considerable proportion of burns happened between meals when children 'play with fire' in the house yard, the provision of alternative play activities and community play areas may reduce the incidence of burns to these children. Secondly, we recommend that education on first-aid management of burns be intensified, with special emphasis on alternatives to the use of traditional preparations.

Risk factors for childhood burns: a case-control study of Ghanaian children

STUDY OBJECTIVE

To study risk factors for childhood burns in order to identify possible preventive strategies.

DESIGN

Case-control design with pair matching of controls to cases in relation to age, sex, and area of residence. The cases and controls were identified by a community based, multisite survey. The effects of host and socioenvironmental variables reported by mothers were investigated in a multivariate analysis using conditional logistic regression.

SETTING

A developing country setting the Ashanti Region in Ghana.

PARTICIPANTS

These comprised 610 cases aged 0-5 years who had been burned (as evidenced by a visible scar) and 610 controls with no burn history.

MAIN RESULTS

The presence of a pre-existing impairment in a child was the strongest risk factor in this population (OR = 6.71; 95% CI 2.78, 16.16). Other significant risk factor included: sibling death from a burn (OR = 4.41; 95% CI 1.16, 16.68); history of burn in a sibling (OR = 1.79; 95% CI 1.24, 2.58); and storage of a flammable substance in the home (OR = 1.51; 95% CI 1.03; 2.21). Maternal education had a protective effect against childhood burns, although this effect was not strong (OR = 0.76; 95% CI 0.55, 1.05).

CONCLUSIONS

Community programmes to ensure adequate child supervision and general child wellbeing, particularly for those with impairments, as well as parental education about burns are recommended, to reduce childhood burns in this region of Ghana. The public should bed advised against storing flammable substances in the home.

Epidemiology of transport-related injuries in Ghana

To better elucidate the incidence, characteristics, and consequences of transport-related injuries in a less developed country in Africa, we undertook an epidemiologic survey in Ghana. A total of 21,105 persons were surveyed, in both an urban area (Kumasi, n = 11,663) and a rural area (Brong-Ahafo, n = 9442). In the preceding year, a total of 656 injuries were reported in the urban area and 928 injuries reported in the rural area. Transport-related mechanisms accounted for 16% of all injuries in the urban and 10% of all injuries in the rural area. The annual incidence of transport-related injuries was almost identical in the two settings, 997/100,000 persons in the urban area and 941/100,000 in the rural area. In both settings, transport-related injuries were more severe than other types of injuries in terms of mortality, length of disability, and economic consequences. In the urban area, the most common transport-related mechanisms were either to passengers involved in crashes of mini-buses or taxis (29%) or to pedestrians struck by these vehicles (21%). In the rural area, the most common transport-related mechanisms were bicycle crashes. The second most common rural mechanisms were motor vehicle crashes, which were the most severe and which involved commercial (83%) rather than private vehicles. Prevention strategies need to be different from those in developed countries and should target commercial drivers more than private road users.

Teaching medical students complementary and alternative medicine using evidence-based principles

OBJECTIVES

Introducing new ideas such as complementary and alternative medicine (CAM) and evidence-based medicine (EBM) to medical students early in their education may help to nurture their interest. This study evaluated the effectiveness of teaching CAM using EBM principles and assessed changes in student perceived knowledge, attitudes, and skills following a new curriculum on CAM.

DESIGN

A before-and-after evaluation using a one-page, anonymous questionnaire.

SETTING AND SUBJECTS

All third year students of a state, public medical school in Texas.

INTERVENTION

A new curriculum comprising interactive sessions on CAM, EBM, and basic principles of epidemiology and biostatistics.

OUTCOME MEASURES

Changes in student-perceived knowledge, attitudes, and skills.

RESULTS

Of 67 students, complete data were obtained for 54 (81%). The majority reported that the new instruction in CAM (98%), EBM (96%), biostatistics (91%), and epidemiology (87%) would be of some benefit in their future work. Significant changes were reported in the areas of appraising a clinical trial (p < 0.0001), critiquing the medical literature (p < 0.01), and the appropriateness of integrating EBM and CAM in the medical school curriculum (p < 0.05). There were modest increases in the mean responses on their skill level in reading/understanding the medical literature (3.40-3.52), comfort level in reading the medical literature (3.53-3.67), and preparedness in designing a research study (2.12-2.39) based on a five-point Likert scale, although not statistically significant.

CONCLUSIONS

Medical students could be effectively taught CAM using EBM principles. In addition, a short, interactive curriculum on an important topic has a positive impact on medical students' desires to acquire new knowledge. This should be a good motivational message to family medicine educators regarding the contribution to new knowledge such as CAM.

Improving diabetes self-care with a PDA in ambulatory care

Use of information technology in diabetes management has been shown to improve self-care. We determined whether enhancing type 2 diabetes (T2DM) self-care with a personal digital assistant (PDA) by patients in the ambulatory setting would improve glycemic control. A pretest/posttest intervention study was conducted in four family practice clinics in a large multispecialty group practice associated with an 186,000-member Health Maintenance Organization. Adults with T2DM and last measured glycosylated hemoglobin (HbA1c) of > or = 8.00% received one-on-one training on the use of a loaned PDA pre-installed with "Diabetes Pilot." Changes in HbA1c and other outcomes were assessed at 6 months from baseline for all participants and by participant-reported PDA use patterns, dichotomized into high PDA users (> or =3 days in past 7) and low PDA users (< 3 days). Of 43 subjects enrolled, 18 (41.90%) completed the 6-month intervention. Their mean HbA1c decreased 17.50% from 9.70% at baseline to 8.00%, a significant mean HbA1c change of -1.7% (95% CI = -2.60 to -0.90). The mean HbA1c change was higher among reported high PDA users (n = 9, mean difference = -1.90, 95% CI = -3.20 to -0.50) than among reported low PDA users (n = 9, mean difference = -1.50, 95% CI = -2.80 to -0.30). Significant increases were reported for the foot care and general diet subscales of the Summary of Diabetes Self-Care Activities from 3 to 6 months. Enhancing T2DM self-care by adults with a PDA was associated with significant reductions in HbA1c; the reductions were greater among reported high PDA users.

Using Walk Score™ and Neighborhood Perceptions to Assess Walking Among Middle-Aged and Older Adults

We aimed to determine the relationship between neighborhood characteristics (walkability, cohesion/safety) and recommended activity levels among community-dwelling middle-aged and older adults. Subjective and objective data on 394 individuals aged ≥50 years were used to assess the likelihood of walking ≥150 min/week. Environmental factors associated with a greater likelihood of any walking ≥150 min/week included living in a neighborhood with high perception of cohesion/safety versus low, living in walkable areas versus car-dependent, and living in an area with a low-moderate median income versus the lowest. Middle-aged and older adults were more likely to walk ≥150 min/week in a walkable, perceived safe/cohesive neighborhood. Identifying neighborhood factors associated with promoting walking among this population can enable stakeholders (e.g., researchers, planners, and policy makers) to direct interventions focusing on the built environment.

E-mail communications in primary care: what are patients’ expectations for specific test results?

OBJECTIVES

The objectives of this study were to assess patients' willingness to use e-mail to obtain specific test results, assess their expectations regarding response times, and identify any demographic trends.

METHODS

A cross-sectional survey of primary care patients was conducted in 19 clinics of a large multi-specialty group practice associated with an 186,000-member Health Maintenance Organization. The outcome measures were proportion of patients with current e-mail access, their willingness to use it for selected general clinical services and to obtain specific test results, and their expectations of timeliness of response.

RESULTS

The majority of patients (58.3%) reported having current e-mail access and indicated strong willingness to use it for communication. However, only 5.8% reported having ever used it to communicate with their physician. Patients were most willing to use e-mail to obtain cholesterol and blood sugar test results, but less willing to use it to obtain brain CT scan results. Patients' expectations of timeliness were generally very high, particularly for high-stakes tests such as brain CT scan. Significant differences of willingness and expectations were found by age group, education, and income.

CONCLUSIONS

These findings indicate that most patients are willing to use e-mail to communicate with their primary care providers even for specific test results and that patients will hold providers to high standards of timeliness regarding response. The implication is that integration of e-mail communications into primary care ought to assure prompt and accurate patient access to a plethora of specific clinical services.

Child death reviews: a gold mine for injury prevention and control

OBJECTIVES

The purpose of this study was to demonstrate how child death review teams can be used to prevent future deaths through retrospective, multiagency case analysis and recommendations for educational programs and policy change.

METHODS

A listing of all deaths to persons ages 21 years and younger in Philadelphia that occurred in 1995 was compiled by the Philadelphia Interdisciplinary Youth Fatality Review Team (PIYFRT), a multiagency, multidisciplinary, community based group created in 1993 with the mission to prevent future deaths through review, analysis, and initiation of corrective actions. Data were collected on demographic variables, as well as the circumstantial variables on injuries such as weapon type, alcohol and drug use, and contact with the criminal justice system, among others. Each case was reviewed thoroughly to determine whether or not the death was preventable. Selected injury related death cases were analyzed further by demographic and circumstantial variables.

RESULTS

In 1995, 607 children ages 21 years and younger died in Philadelphia from natural causes (61.6%), unintentional injuries (16.3%), homicide (18.6%), suicide (2.3%), and undetermined causes (1.2%). More than a third (37.2%) of all deaths were considered preventable. Of the injury deaths (n=224), 95% were judged to be preventable. Preventable fire/burn injury deaths (n=29) were associated with lack of a smoke detector, nonsupervision of children, and faulty home appliances. Violent deaths were associated with substance abuse, gang involvement, chronic truancy, academic failure, and access to weapons.

CONCLUSIONS

Relevant policies for these preventable or intervenable deaths are discussed such as use of non-battery powered smoke detectors.

A review of successful transport and home injury interventions to guide developing countries

Injury is recognized as an increasing public health problem in developing countries. Extensive research on injury control has been conducted in the U.S. and other industrialized countries in the past several decades, but research is still in its infancy in developing countries. In this paper, successful interventions for transport and home injuries are reviewed in the context of the developing country setting. The aim is to evaluate injury interventions developed in the industrialized countries and identify those likely to be usable in developing countries. The evaluation criteria used include the efficacy of the interventions, as well as their affordability, feasibility and sustainability. The review demonstrates that while several interventions are available in the field of injury prevention for developing countries to import, caution should be taken in doing this. The use of automobile safety seat belts, bicyclist and motorcyclist helmets, speed limits, laws banning the sale of alcohol at lorry parks, pedestrian crossing signs, adequate roadway lighting, separation of pedestrians from vehicles, conspicuity-enhancement measures, simple safety equipment, and poison prevention packaging should be seriously considered by developing countries to reduce the morbidity and mortality from transport and home injuries. Since injury prevention may often require a blend of several interventions due to the multifactorial nature of the causes of injury, interventions that appear to be most effective are those with multidimensional strategies including education, legislation and environmental modification. This review should serve as a useful guide to injury control efforts in developing countries which must grapple with limited resources and low levels of education.

Efficacy of a Mobile-Enabled Web App (iCanFit) in Promoting Physical Activity Among Older Cancer Survivors: A Pilot Study

BACKGROUND

The benefits of physical activity for cancer survivors are well documented. However, few older cancer survivors are engaged in regular physical activity. Mobile technologies may be an effective method to deliver physical activity promotion programs for older cancer survivors. iCanFit, a mobile-enabled Web-based app, was developed based on formative research and usability testing. This app includes interactive features of physical activity, goal setting and tracking, and receiving personalized visual feedback.

OBJECTIVE

The aim of this study is to pilot test the initial efficacy of iCanFit.

METHODS

Older cancer survivors (N=30) were recruited online through our collaborative partnership with a cancer survivor's organization. After the participants completed an online baseline survey, they were asked to use the iCanFit website. Instructional videos on how to use the web app were available on the website. Participants were asked to complete a follow-up survey 2-3 months later. Participants' physical activity, quality of life, and their experience with iCanFit were measured.

RESULTS

A total of 30 participants completed the baseline survey, and 26 of them (87%, 26/30) also completed a follow-up survey 2-3 months later. The median age of participants was 69 years (range 60-78). Participants' quality of life and engagement in regular physical activity improved significantly after the use of iCanFit. Participants indicated a general affinity towards the key function "Goals" in iCanFit, which motivated continued activity. They also provided suggestions to further improve the app (eg, adding a reminder functionality, easier or alternative ways of entering activities).

CONCLUSION

The interactive Web-based app iCanFit has demonstrated initial efficacy. Even though our study was limited by a small sample size, convenience sampling, and a short follow-up period, results suggest that using mobile tools to promote physical activity and healthy living among older cancer survivors holds promise. Next steps include refining iCanFit based on users' feedback and developing versatile functionality to allow easier physical activity goal setting and tracking. We also call for more studies on developing and evaluating mobile and web apps for older cancer survivors.

Social and environmental predictors of walking among older adults

BACKGROUND

Regular physical activity (PA) is a major factor in maintaining health in aging populations. This study examines the influences of sociodemographic, health, and environmental characteristics on older adults' walking behaviors, and the role physicians can play in promoting physical activity.

METHODS

Online and paper surveys (n = 272) were distributed to community-dwelling older (age ≥ 60) adults from a large integrated healthcare system in two counties in Central Texas. Descriptive statistics were utilized to characterize participant's walking behaviors and places. Multivariate logistic regression was employed to predict being: 1) a frequent walker (i.e., walking at least three times a week); and 2) meeting the Centers for Disease Control and Prevention (CDC) PA recommendation through walking (i.e., walking ≥150 min per week), while considering sociodemographic, health, and environmental factors.

RESULTS

Individuals had a median age of 69 years, were of both genders (50.37 % female), and were primarily non-Hispanic White (84.87 %). While the majority (59.55 %) walked at least three times a week, only 27.86 % walked ≥150 min a week. Factors associated with a lower likelihood of being frequent walkers included experiencing poor mental health in the past month (OR = 0.345, 95 % CI = 0.185-0.645) and residing in areas with low or moderate (versus high) perceived neighborhood cohesion (OR = 0.471, 95 % CI = 0.228-0.974), while those in Census Tracts reflecting populations with a lower median age were more likely to report frequent walking behavior (OR = 1.799, 95 % CI = 1.034-3.131). Factors associated with a lower likelihood of meeting the CDC PA recommendation included being 60-69 years (versus 70 years or older) (OR = 0.538, 95 % CI = 0.290-0.997), experiencing poor mental health in the past month (OR = 0.432, 95 % CI = 0.198-0.944), and lacking social support for walking (OR = 0.383, 95 % CI = 0.154-0.957).

CONCLUSION

Given the health benefits, PA promotion must be seen as a national responsibility. In particular, physicians have a major role to play in communicating the importance of PA to their older patients and making discussions about strategies for overcoming barriers to walking an integral part of their clinical encounter with these patients.

Factors affecting acceptability and usability of technological approaches to diabetes self-management: a case study

PURPOSE

This study explored the impact of personal digital assistant (PDA) features, users' perceptions, and other factors that may have hindered PDA acceptability and usability as technology advances in e-health diabetes self-management.

STUDY DESIGN AND RESULTS

An ongoing study on PDA usage is set within the context of the advancements of Web 2.0 for type 2 diabetes mellitus (T2DM) self-management e-interventions. Advancements in technology as it relates to the future of T2DM mobile applications are discussed as possible deterrents of PDA acceptability and usability.

CONCLUSIONS

This case study illustrates the importance of addressing factors that may impede the adoption of electronic devices intended for sustained health behavior change. Recognizing the importance of individual perception within the context of rapid technological advancements is imperative for designing future health interventions. Incorporating electronic devices that individuals are more inclined to utilize, such as smartphones, as the platform for health interventions is a promising strategy to improve acceptability and usability, allowing researchers to more accurately assess the health benefits of self-management programs.

Helmet use: a survey of 4 common childhood leisure activities

OBJECTIVE

To compare the distribution and observation of helmet use patterns among 4 common childhood leisure activities-bicycle riding, in-line skating, skateboarding, and scooter riding-in a setting with no helmet use legislation.

DESIGN

A cross-sectional, unobtrusive, direct observation of children engaged in 1 of the 4 activities was conducted during an 8-week period.

SETTING

Eight communities of at least 1000 persons each in a 2-county Central Texas area.

MAIN OUTCOME MEASURES

Prevalence of activity, helmet use, and correct helmet use.

RESULTS

Of 841 children observed, most rode bicycles (74.8%); only 4.2% rode skateboards. They included 127 children estimated to be younger than 6 years (15.1%) and 495 estimated to be aged between 6 and 12 years (58.9%). Most were male (67.3%) and observed in urban communities (61.7%). The locations of highest concentration of the 4 activities were minor streets for bicycle riding, playgrounds for in-line skating, and sidewalks for skateboarding and scooter riding. The rate of overall helmet use was 13.6% and did not vary significantly by activity: in-line skating, 18.2%; skateboarding, 14.3%; bicycle riding, 13.5%; and scooter riding, 11.5%. However, the observed correct helmet use prevalence of 72.6% differed significantly by activity. Most children riding scooters wore their helmets incorrectly. Helmet use was positively associated with helmet use by accompanying children and/or adults.

CONCLUSIONS

While bicycle riding was the most popular activity observed, helmet use was most prevalent among in-line skaters and least prevalent among scooter riders, many of whom also wore them incorrectly. Observed helmet use was influenced mostly by adult and peer helmet use, indicating that public education and interventions should target children and their parents as well as scooter riders.

Injury control in Africa: getting governments to do more

Despite increasing recognition of injury as a major public health problem worldwide, it has received limited attention and resources. This lack of attention is most notable in low-income countries. As part of efforts to develop coordinated injury control activities in Africa, a round table session was held at the Third International Conference on Injury Prevention and Control in Melbourne, Australia. The aims of the forum were to provide injury control researchers from Africa the opportunity to come together and reflect on issues of injury control in Africa, to deliberate on strategies of getting African governments to show more interest in injury control, and to solicit more assistance from the international donor community Participants from Ghana, Kenya, South Africa and Zimbabwe presented the magnitude of the injury burden in their respective countries, reflected on current research efforts and highlighted the preventive efforts being undertaken. The forum made many recommendations including several regarding specific actions required of African governments, individual researchers and donor agencies.

Burn-related physical impairments and disabilities in Ghanaian children: prevalence and risk factors

The prevalence, and risk factors for childhood burn-related physical impairments and disabilities in Ghana were determined with data from mothers of burned children. Of 650 identified burns 113 (174%) resulted in physical impairments, 5 (1%) resulted in physical disabilities. After multivariate adjustment, the odds of developing burn-related physical impairments were increased by burns with protracted healing (odds ratio [OR] = 5.80), burns to the head/neck (OR = 344), burns involving skin removal (OR = 3.04), and wound infection (OR = 2.03) and decreased by first aid (OR = 0.51) and maternal education (OR = 0.54). Education on the proper care of burns may prevent burn-related physical impairments. The results also underscore the link between maternal education and child morbidity.

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System--MEADERS

PURPOSE

In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices.

METHODS

We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports.

RESULTS

A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting.

CONCLUSIONS

It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.