Images in preventive medicine. Cause and effect.
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Aged↗
Biomedical subjects
S R Lowenstein
Publications and source records attributed to S R Lowenstein.
Drugs and traffic crash responsibility: a study of injured motorists in Colorado.
BACKGROUND: Alcohol is a contributing factor in a large proportion of traffic crashes. However, the role of other drugs is unknown. The objectives of this study are to determine the prevalence of recent drug use among drivers injured in traffic crashes, and to determine the extent to which drugs are responsible for crashes. METHODS: We studied 414 injured drivers who presented to an urban emergency department within 1 hour of their crash. Demographic and injury data were collected from medical records. Urine toxicologic assays were conducted for legal and illegal drugs. Traffic crash reports were analyzed for crash responsibility by a trained crash reconstructionist. The causal role of drugs in traffic crashes was measured by comparing drug assay results in drivers judged responsible for their crashes (cases) and those not responsible (controls). Odds ratios and 95% confidence intervals (CIs) were calculated. RESULTS: Thirty-two percent (95% CI = 27-37) of the urine samples were positive for at least one potentially impairing drug. Marijuana was detected most frequently (17%), surpassing alcohol (14%). Compared with drug- and alcohol-free drivers, the odds of crash responsibility were higher in drivers testing positive for alcohol alone (odds radio [OR] = 3.2, 95% CI = 1.1-9.4) and in drivers testing positive for alcohol in combination with other drugs (OR = 3.5, 95% CI = 1.2-11.4). Marijuana alone was not associated with crash responsibility (OR = 1.1, 95% CI = 0.5-2.4). In a multivariate analysis, controlling for age, gender, seat belt use, and other confounding variables, only alcohol predicted crash responsibility. CONCLUSION: Alcohol remains the dominant drug associated with injury-producing traffic crashes. Marijuana is often detected, but in the absence of alcohol, it is not associated with crash responsibility.
Accidents, Traffic↗
Antibiotic prescribing for patients with colds, upper respiratory tract infections, and bronchitis: A national study of hospital-based emergency departments.
STUDY OBJECTIVE: Antibiotics are often used to treat viral upper respiratory tract infections, even though they are usually ineffective. However, frequent inappropriate antibiotic use contributes to the emergence of drug-resistant bacterial pathogens. This study used a national database to evaluate antibiotic use in treating upper respiratory tract infections in emergency departments. METHODS: Data were obtained from the 1996 National Hospital Ambulatory Medical Care Survey. Antibiotic prescribing rates were examined for colds, upper respiratory tract infections, and acute bronchitis. Patients with comorbid conditions or secondary diagnoses, such as chronic obstructive pulmonary disease, pneumonia, sinusitis, and HIV, were excluded. Bivariate and multivariate analyses were used to assess predictors of antibiotic use. RESULTS: Overall, there were an estimated 2.7 million ED visits for colds, upper respiratory tract infections, and bronchitis by children and adults in 1996. Antibiotics were prescribed for 24.2% (95% CI 18.9, 29.5) of patients with common colds and upper respiratory tract infections and for 42.2% (95% CI 35.2, 49.2) of patients with bronchitis. There were no significant associations between antibiotic use and patient race, sex, Hispanic ethnicity, geographic location, or source of payment. Antibiotics were prescribed less often by interns or residents than by staff or other physicians (odds ratio 0.43; 95% CI 0.19, 0.98), and patients younger than 18 years were less likely to receive antibiotics than adults (odds ratio 0.32; 95% CI 0.20, 0.52). Smokers were 4.3 (95% CI 2.2, 8.3) times more likely to receive antibiotics than nonsmokers. CONCLUSION: Antibiotics are commonly prescribed for ED patients with upper respiratory tract infections even though they are usually ineffective in otherwise healthy adults. Efforts should be made to reduce inappropriate antibiotic use for the sake of containing costs, preventing side effects, and limiting the spread of antibiotic resistance.
Adolescent↗
Motor vehicle crash fatalities: A comparison of Hispanic and non-Hispanic motorists in Colorado.
STUDY OBJECTIVES: We compare the population-based death rates from traffic crashes in the Hispanic and non-Hispanic white populations in a single state, and compare fatally injured Hispanic and non-Hispanic drivers with respect to safety belt use, alcohol involvement, speeding, vehicle age, valid licensure, and urban-rural location. METHODS: Hispanic and non-Hispanic white motorists killed in traffic crashes in 1991-1995 were studied (n=2,272). Data from death certificates (age, sex, education, race, and ethnicity) and the Fatality Analysis Reporting System (FARS; driver, vehicle, and crash information) were merged. Average annual age-adjusted fatality rates were calculated; to compare Hispanic and non-Hispanic white motorists, rate ratios (RR) and 95% confidence intervals (CIs) were calculated. Odds ratios (ORs), adjusted for age, sex, and rural locale, were calculated to measure the association between Hispanic ethnicity and driver and crash characteristics. RESULTS: Eighty-five percent of FARS records were matched to death certificates. Compared with non-Hispanic white motorists, Hispanics had higher crash-related fatality rates overall (RR 1.75, 95% CI 1.60 to 1.92) and for drivers only (RR 1.62, 95% CI 1.41 to 1.85). After adjustment for age, sex, and rural locale, Hispanic drivers had higher rates of safety belt nonuse (OR 1.81, 95% CI 1.20 to 2.72), legal alcohol intoxication (OR 2.73, 95% CI 1.97 to 3.79), speeding (OR 1.36, 95% CI 0.99 to 1.88), and invalid licensure (OR 2.58, 95% CI 1.78 to 3.75). The average vehicle age for Hispanic drivers (10.1 years, 95% CI 9.3 to 11.0) was greater than for non-Hispanic white motorists (8.8 years, 95% CI 8.4 to 9.2). CONCLUSION: Compared with non-Hispanic whites, Hispanic drivers have higher rates of safety belt nonuse, speeding, invalid licensure and alcohol involvement, with correspondingly higher rates of death in traffic crashes. As traffic safety emerges as a public health priority in Hispanic communities, these data may help in developing appropriate and culturally sensitive interventions.
Accidents, Traffic↗
Measuring injury risk factors: question reliability in a statewide sample.
BACKGROUND: Recently (1996-98), Colorado added 15 questions pertaining to injury related risks and behaviors to the behavioral risk factor surveillance system (BRFSS). Questions addressed bicycle helmet use, traffic crashes, exposure to violence, suicidal behavior, and gun storage. OBJECTIVE: To measure the test-retest reliability of these injury related questions. METHODS: Of 330 BRFSS participants, 229 (69%) were called a second time and reasked nine selected injury questions. Retests were completed 7-28 days after the original interview. RESULTS: Test-retest agreement was very high (kappa >0.80) for bicycle helmet use, domestic police visits, and gun ownership. All other injury risk questions had substantial agreement (kappa >0.60). CONCLUSIONS: The injury related questions added to the Colorado BRFSS have high test-retest reliability.
Adult↗
Behavioral risk factors in emergency department patients: a multisite survey.
BACKGROUND: Many people rely on EDs for routine health care. Often, however, screening and counseling for health risks are not provided. OBJECTIVE: To determine prevalence rates of chronic disease and injury risk factors and access to routine health care in a random sample of ED patients in 3 cities. METHODS: A prospective survey was conducted at 3 hospital EDs in Akron, OH, Boston, MA, and Denver, CO. A modified version of the national Behavioral Risk Factor Surveillance Survey was administered by trained researchers to a convenience sample of non-critically ill patients during randomly selected shifts. RESULTS: Of 1,143 eligible patients, 923 (81%) agreed to participate. Their mean age was 39 (range = 17-96) years. Most were female (58%), white (60%), and unmarried (68%). Thirty-eight percent had no access to primary care. Injury-prone behaviors were prevalent: 53% of the respondents did not wear seat belts regularly; 15% had no working smoke detector; 3% kept loaded, unlocked handguns in their homes; 11% had attempted suicide; 23% had a positive CAGE screen for alcoholism; 3% had operated a motor vehicle in the preceding month while alcohol-intoxicated; and 11% had ridden in an automobile with an intoxicated driver. Cancer and chronic disease risks were also common: 48% smoked; 16% had not received a blood pressure check in the preceding year; and 4% reported unsafe sexual practices. Among women aged > 50 years, 42% had not received a Pap test in the prior 2 years and 14% had never had mammography. Many prevalence rates and access to care varied among the 3 sites. However, for most risk factors, prevalence rates did not differ in patients with and without access to primary health care. CONCLUSIONS: ED patients have high rates of injury and chronic disease risks, and many have no other source of routine health care. Research is needed to determine whether ED-based programs, designed to reduce injury and chronic disease risks, are feasible and cost-effective.
Adolescent↗
Accuracy of 3 brief screening questions for detecting partner violence in the emergency department.
OBJECTIVE: To devise a brief screening instrument to detect partner violence and to partially validate this screen against established instruments. DESIGN: Prospective survey. SETTING: Two urban, hospital-based emergency departments. PARTICIPANTS: Of 491 women presenting during 48 randomly selected 4-hour time blocks, 322 (76% of eligible patients) participated. Respondents had a median age of 36 years; 19% were black, 45% white, and 30% Hispanic, while 6% were of other racial or ethnic groups; 54% were insured. INTERVENTIONS: We developed a partner violence screen (PVS), consisting of 3 questions about past physical violence and perceived personal safety. We administered the PVS and 2 standardized measures of partner violence, the Index of Spouse Abuse (ISA) and the Conflict Tactics Scale (CTS). MAIN OUTCOME MEASURES: Sensitivity, specificity, and predictive values of the PVS were compared with the ISA and the CTS as criterion standards. RESULTS: The prevalence rate of partner violence using the PVS was 29.5% (95% confidence interval [CI], 24.6%-34.8%). For the ISA and CTS, the prevalence rates were 24.3% (95% CI, 19.2%-30.1 %) and 27.4% (95% CI, 21.7%-33.6%), respectively. Compared with the ISA, the sensitivity of the PVS in detecting partner abuse was 64.5%; the specificity was 80.3%. When compared with the CTS, sensitivity of the PVS was 71.4%; the specificity was 84.4%. Positive predictive values ranged from 51.3% to 63.4%, and negative predictive values ranged from 87.6% to 88.7%. Overall, 13.7% of visits were the result of acute episodes of partner violence. CONCLUSION: Three brief directed questions can detect a large number of women who have a history of partner violence.
Adult↗
Testing a test.
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Data Interpretation, Statistical↗
Intoxicated ED patients: a 5-year follow-up of morbidity and mortality.
STUDY OBJECTIVES: To determine the rates of alcohol-related morbidity and mortality in a cohort of intoxicated ED patients 5 years after presentation and to compare them with those of non-intoxicated ED patients. METHODS: The study group comprised 150 consecutive ED patients who presented with intoxication (blood alcohol level higher than 100 mg/dL) in June 1986 and 50 control patients matched for age, sex, ED arrival time, and date. The setting was an urban university hospital ED. Morbidity and mortality over a 5-year follow-up period were measured using hospital ED and admission records from all state Level I trauma centers and computerized statewide databases. RESULTS: The 5-year mortality rate among alcohol-intoxicated patients was 2.4 times that of the comparison group (95% confidence interval, .3 to 18.9). The 5-year death rate among intoxicated patients aged 40 to 69 years was especially high (19%). Thirty-seven percent of the intoxicated patients made at least one alcohol-related ED revisit during the follow-up period, compared with 6% of the comparison group (P < .001). Intoxicated patients were more likely to revisit EDs because of suicidal behavior or domestic violence (P = .001). Admission to an alcohol detoxification unit during the follow-up period occurred in 24% of the intoxicated patients, compared with 10% of the sober controls (P = .03). At least one arrest for drunk driving occurred in 47% of the intoxicated group; the rate was lower, but still substantial, in the comparison group (20%, P < .001). CONCLUSION: A single alcohol-related ED visit is an important predictor of continued problem drinking, alcohol-impaired driving and, possibly, premature death.
Adolescent↗
The Colorado motorcycle safety survey: public attitudes and beliefs.
BACKGROUND: Motorcycle riders have a high risk of traumatic brain injury, disability, and death. Epidemiologic studies have proven that helmets reduce the severity of brain injuries and the cost of care. Yet, Colorado remains one of three states with no helmet law for riders. OBJECTIVES: This study measured public support for (1) a mandatory motorcycle helmet use law and (2) mandatory motorcycle operator safety training. We also sought to ascertain citizens' attitudes toward traffic safety mandates from the federal government. METHODS: Structured telephone interviews were conducted with 407 Colorado adults selected by random-digit dialing. RESULTS: Sixty-five percent of respondents believed that motorcycle riders of all ages should be required to wear helmets. An additional 18% believed that only riders under age 21 should be required to wear helmets. Only 17% of respondents opposed all helmet laws. Even among motorcyclists, most supported helmet laws for all riders (47%) or for those <21 years of age (26%). In a multiple logistic regression, there were three significant independent predictors of a pro-helmet law stance: older age, female gender, and not possessing a motorcycle operator's license. Most respondents also supported mandatory motorcycle operator safety training. Despite supporting state helmet use regulations, a large proportion (41%) opposed mandatory Federal mandates to enact them. CONCLUSION: Even in Colorado, a state with no helmet use requirements, there is strong public support for a regulatory strategy of motorcycle helmet use laws.
Adult↗
Insufficient stocking of poisoning antidotes in hospital pharmacies.
OBJECTIVE: To determine whether antidotes for poisoning and overdose are available in hospitals that provide emergency department care. DESIGN: Written survey of hospital pharmacy directors, each of whom reported the amount currently in stock of 8 different antidotes: antivenin (Crotalidae) polyvalent, cyanide kit, deferoxamine mesylate, digoxin immune Fab, ethanol, naloxone hydrochloride, pralidoxime chloride, and pyridoxine hydrochloride. PARTICIPANTS: Pharmacy directors of all hospitals with emergency departments in Colorado, Montana, and Nevada. MAIN OUTCOME MEASURES: Proportions of hospitals with insufficient stocking of each antidote, defined as complete lack of the antidote or an amount inadequate to initiate treatment of 1 seriously poisoned 70-kg patient. RESULTS: Questionnaires were mailed to 137 hospital pharmacy directors and 108 (79%) responded. Only 1 (0.9%) of the 108 hospitals stocked all 8 antidotes in adequate amounts. The rate of insufficient stocking for individual antidotes ranged from 2% (for naloxone) to 98% (for digoxin immune Fab). In a multiple regression analysis, smaller hospital size and lack of a formal review of antidote stocking were independent predictors of the number of antidotes stocked insufficiently. CONCLUSIONS: Insufficient stocking of antidotes is a widespread problem in Colorado, Montana, and Nevada. Although these states are served by a certified regional poison center, potentially lifesaving antidotes are frequently not available when and where they might be needed to treat a single poisoned patient.
Analysis of Variance↗
Chart reviews in emergency medicine research: Where are the methods?
STUDY OBJECTIVE: Medical chart reviews are often used in emergency medicine research. However, the reliability of data abstracted by chart reviews is seldom examined critically. The objective of this investigation was to determine the proportion of emergency medicine research articles that use data from chart reviews and the proportions that report methods of case selection, abstractor training, monitoring and blinding, and interrater agreement. METHODS: Research articles published in three emergency medicine journals from January 1989 through December 1993 were identified. The articles that used chart reviews were analyzed. RESULTS: Of 986 original research articles that were identified, 244 (25%; 95% confidence interval [CI], 22% to 28%) relied on chart reviews. Inclusion criteria were described in 98% (95% CI, 96% to 99%), and 73% (95% CI, 67% to 79%) defined the variables being analyzed. Other methods were seldom mentioned: abstractor training, 18% (95% CI, 13% to 23%); standardized abstraction forms, 11% (95% CI, 7% to 15%); periodic abstractor monitoring, 4% (95% CI, 2% to 7%); and abstractor blinding to study hypotheses, 3% (95% CI, 1% to 6%). Interrater reliability was mentioned in 5% (95% CI, 3% to 9%) and tested statistically in .4% (95% CI, 0% to 2%). A 15% random sample of articles was reassessed by a second investigator; interrater agreement was high for all eight criteria. CONCLUSION: Chart review is a common method of data collection in emergency medicine research. Yet, information about the quality of the data is usually lacking. Chart reviews should be held to higher methodologic standards, or the conclusions of these studies may be in error.
Data Collection↗
Domestic violence against women. Incidence and prevalence in an emergency department population.
OBJECTIVE: To determine the incidence, 1-year prevalence, and cumulative prevalence of domestic violence (DV) among female emergency department (ED) patients. DESIGN: Descriptive written survey. SETTING: Two teaching EDs, two hospital walk-in clinics, and one private hospital ED in Denver, Colo. PARTICIPANTS: Of 833 women presenting during 30 randomly selected 4-hour time blocks, 648 (78%) agreed to participate. Most respondents were young (median age, 34 years) and unemployed (62%); half (49%) had annual household incomes less than $10,000. MAIN OUTCOME MEASURES: Domestic violence was defined as an assault, threat, or intimidation by a male partner. Acute DV (incidence) and past DV exposure (1-year prevalence and cumulative prevalence) were determined. RESULTS: The incidence of acute DV among the 418 women with a current male partner was 11.7% (95% confidence interval [CI], 8.7% to 15.2%). Only 11 (23%) of these 47 women subjected to acute DV presented for care because of trauma, and only six (13%) either told staff about DV or were asked about DV by ED professionals. Among 230 women without current partners, 13 (5.6%) reported an episode of DV within the previous 30 days. For the entire sample, the cumulative lifetime prevalence of DV exposure was 54.2% (95% CI, 50.2% to 58.1%). Women exposed to acute or prior DV were more likely than unexposed women to have made suicide attempts (26% vs 8%; P < .001) and to report excessive ethanol use (24% vs 13%; P = .001). CONCLUSIONS: The incidence of acute DV is not as common among women visiting an ED as previously reported, although the cumulative prevalence of DV is strikingly high. Women who have experienced DV are seldom identified by ED professionals.
Adult↗
Safety belt nonuse by internal medicine patients: a missed opportunity in clinical preventive medicine.
BACKGROUND: The United States Preventive Services Task Force recommends that physicians routinely counsel all patients to wear safety belts. We undertook this study to determine the prevalence of the nonuse of safety belts among internal medicine patients, to measure the association of nonuse with other health risk factors, and to ascertain the safety belt counseling practices of physicians. PATIENTS AND METHODS: A total of 492 consecutive patients attending a university-based general medicine clinic were given a validated, self-administered questionnaire, and 94% responded. A medical chart review was performed in a blinded fashion on 94% of the eligible charts. RESULTS: Of the 454 patients who provided safety belt information, 243 (54%) did not wear safety belts. Nonusers were more likely to be problem drinkers, inactive, obese, and to have a low income (adjusted odds ratios 1.8 to 2.0). Of patients with all four of these characteristics, 91% did not use safety belts. The leading reasons for safety belt nonuse were discomfort (35%), short driving distances (24%), and forgetfulness (13%). Obese patients were more likely to report discomfort as their reason for nonuse (odds ratio 2.4; 95% confidence limit 1.4 to 4.3). Eighteen patients (3.9%) reported that a physician had ever counseled them about safety belt use. Only two of 314 medical records (0.6%) noted physician questioning or counseling about safety belt use. CONCLUSIONS: The majority of patients attending an internal medicine clinic do not wear safety belts. Nonusers are more likely to be problem drinkers, inactive, obese, and to have a low income. Patients with multiple health risk factors are at significant risk of nonuse. The most common reason for nonuse is physical discomfort, especially among obese patients. Finally, physicians rarely counsel patients to use safety belts.
Alcoholism↗
Smoking habits of emergency department patients: an opportunity for disease prevention.
OBJECTIVE: To determine smoking habits, levels of addiction, readiness to quit, and access to primary care among ED patients. METHODS: A questionnaire was administered prospectively to all noncritical adult patients who presented to one university hospital ED during 23 randomly selected four-hour time blocks; 336 (89%) of 376 eligible patients responded. Self-reported smoking was validated by carbon monoxide breath testing in a pilot sample of 49 patients. RESULTS: The study patients were mostly young (mean age = 35 +/- 15 years), female (59%), white (62%), and high school-educated (73%). Of the 336 ED patients, 41% were current smokers (95% CI = 0.36-0.46); 42% of these were "moderately" to "very highly" dependent on nicotine (Fagerstrom Test for Nicotine Dependence > 4). Of those who smoked, 68% stated they wanted to quit, and 49% wanted to quit within the month. Fifty-six percent of all those who smoked stated that they had never been told to quit smoking by any physician. Thirty-five percent of the ED sample (118 patients) relied upon EDs for most or all of their routine, primary health care; 55% (95% CI = 0.46-0.64) of these patients were current smokers. CONCLUSIONS: The prevalence rates of smoking and nicotine addiction among ED patients are high. Almost half of ED smokers are ready to quit, but most state they have never been told by a physician to do so. Finally, a large proportion of ED smokers receive their primary care in EDs. Therefore, the ED may be an underused setting for smoking cessation intervention.
Adolescent↗
Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs.
OBJECTIVES: To determine: 1) the extent of emergency physicians' (EPs') training in smoking cessation counseling; 2) their understanding of counseling and pharmacologic treatment techniques; 3) their current practices in screening, counseling, and referring patients who smoke; and 4) perceived barriers to routine smoking cessation counseling in emergency medical practice. METHODS: A 26-item questionnaire addressing the above issues was mailed to all 256 members of the Colorado Chapter of the American College of Emergency Physicians. RESULTS: Completed questionnaires were returned by 196 physicians (77% response rate). The majority of respondents were men (80%), practiced in urban settings (87%), and were board-certified in emergency medicine (82%). Most EPs lacked formal smoking cessation training (55%) and felt poorly prepared to counsel patients about smoking cessation (65%). A minority (27%) of the physicians reported routinely asking patients to quit smoking. The physicians with formal smoking cessation training were more likely to counsel and refer patients routinely (34% vs 20%, p = 0.03). The physicians cited the following barriers to routine smoking cessation counseling: a lack of time; a perception that patients are not interested; a belief that the ED setting is inappropriate for counseling; and a sense that counseling is ineffective. Lack of reimbursement was cited by only 13% of the respondents. The physicians who had formal smoking cessation training perceived fewer barriers to ED-based counseling. CONCLUSIONS: Emergency physicians have received little training in smoking cessation and perceive many barriers to ED-based smoking cessation interventions. Not surprisingly, they infrequently take action to encourage or assist their patients to quit smoking.
Adult↗
Quality of life following spinal cord injury: knowledge and attitudes of emergency care providers.
STUDY OBJECTIVES: To measure emergency care providers' attitudes toward quality of life after spinal cord injury (SCI) and to determine if their perceptions influence the care they provide. DESIGN: A closed-ended questionnaire. SETTING AND PARTICIPANTS: Two hundred thirty-three emergency nurses, emergency medicine technicians, emergency medicine residents, and attending physicians at three level I trauma centers were surveyed. Their responses were compared with previously reported quality-of-life ratings of a group of 128 high-level SCI survivors. MEASUREMENTS AND RESULTS: One hundred fifty-three emergency care providers completed the survey (response rate, 63%). Forty-one percent believed that resuscitation efforts after severe SCI are too aggressive, and 28% believed that future quality of life should be a factor in determining the interventions that should be provided. If they sustained severe SCIs themselves, 22% of providers would want nothing done to ensure their survival, and 23% would want pain relief only. Only 18% imagined they would be glad to be alive with a severe SCI, compared with 92% of a true SCI comparison group. Seventeen percent of providers anticipated an average or better quality of life compared with 86% of the actual SCI comparison group. CONCLUSION: The quality of life, self-esteem, and outcomes that emergency health care providers imaging after SCI are considerably more negative than those reported by SCI survivors. Because providers' knowledge and attitudes may affect the care they provide and may influence patients and families struggling with critical treatment decisions, emergency care providers must be aware of outcomes, well-being, and life satisfaction following severe SCI.
Activities of Daily Living↗
Concordance versus correlation.
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Evaluation Studies as Topic↗