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Biomedical subjects

W A Ray

Publications and source records attributed to W A Ray.

At least 19 recordsLinked to original sources
PubMed2000

Nonsteroidal antiinflammatory drugs and acute renal failure in elderly persons.

Renal prostaglandin inhibition by nonsteroidal antiinflammatory drugs (NSAIDs) may decrease renal function, especially under conditions of low effective circulating volume. To evaluate the risk of important deterioration of renal function due to this effect, the authors performed a nested case-control study using Tennessee Medicaid enrollees aged > or =65 years in 1987-1991. Cases were patients who had been hospitalized with community-acquired acute renal failure; they were selected on the basis of medical record review of Medicaid enrollees with selected discharge diagnoses. Information on the timing, duration, and dose of prescription NSAIDs used, demographic factors, and comorbidity was gathered from computerized Medicaid-Medicare data files. Of the 1,799 patients with acute renal failure (4.51 hospitalizations per 1,000 person-years), 18.1% were current users of prescription NSAIDs as compared with 11.3% of 9,899 randomly selected population controls. After control for demographic factors and comorbidity, use of NSAIDs increased the risk of acute renal failure 58% (adjusted odds ratio = 1.58; 95% confidence interval (CI): 1.34, 1.86). For ibuprofen, which accounted for 35% of NSAID use, odds ratios associated with dosages of < or =1,200 mg/day, >1,200-<2,400 mg/day, and > or =2,400 mg/day were 0.94 (95% CI: 0.58, 1.51), 1.89 (95% CI: 1.34, 2.67), and 2.32 (95% CI: 1.45, 3.71), respectively (test for linear trend: p = 0.009). Prescription NSAID use resulted in an estimated 25 excess hospitalizations associated with renal failure per 10,000 years of use. Thus, NSAIDs represent a relatively uncommon but avoidable cause of acute renal failure in frail elderly persons.

Acute Kidney Injury↗
PubMed1999

Early childhood mortality from community-acquired infections.

In this study, the authors identified maternal and child characteristics that were independent predictors of death from infectious diseases acquired in the community and determined if these factors could be used to identify groups of children with excess risk of mortality from infection. A historical cohort study was conducted of children less than 5 years of age between 1985 and 1994 (the study period), who were born in Tennessee, and had complete information on their birth certificates. The primary outcome was death from infection identified from death certificates and confirmed through medical record review. Among the 1,014,976 children less than 5 years of age, who contributed 3,351,568 child-years of follow-up, there were 247 deaths from infections (7.4 deaths from infections per 100,000 child-years). Respiratory infections accounted for approximately one half of the deaths. Children having three or more older siblings or birth weight of less than 1,500 g had a 3-fold and 10-fold increased risk of death from infection, respectively, while children with both characteristics had a nearly 20-fold increased risk that persisted beyond the first year of life. Interventions should be focused on prevention of these infections in vulnerable children. At-risk children should be targeted for careful follow-up and early hospitalization when signs of infection develop.

Child, Preschool↗
PubMed1999

Use of nonsteroidal anti-inflammatory drugs and incidence of colorectal cancer: a population-based study.

BACKGROUND: Previous observational studies have provided limited information on the effect of specific nonsteroidal anti-inflammatory drugs (NSAIDs) and different patterns of use (duration and dose) on the incidence of colorectal cancer. OBJECTIVE: To determine how patterns of use (duration, dose, and specific drug) of NSAIDs affect incidence of colorectal cancer. DESIGN: Population-based retrospective cohort study. SETTING: Tennessee Medicaid Program, 1985-1992. SUBJECTS: Enrollees (n = 104217) aged 65 years or older with at least 5 years of enrollment. MAIN OUTCOME MEASURES: Incident histologically confirmed colorectal cancer. RESULTS: Users of nonaspirin NSAIDs for at least 48 months of the previous 5 years had a relative risk (RR) of 0.49 (95% confidence interval [CI], 0.24-1.00) for colon cancer when compared with those with no use of NSAIDs. Among those with more than 12 months of cumulative use, those using NSAIDs in the past year (recent users) had an RR of 0.61 (95% CI, 0.48-0.77), whereas those with no recent use had an RR of 0.76 (95% CI, 0.50-1.15). No specific NSAID offered a unique protective effect and low doses of NSAIDs appeared to be at least as effective as higher doses. Protection was most pronounced for right-sided lesions. The RR among recent users with more than 12 months of cumulative use was 0.81 (95% CI, 0.49-1.32) for rectal cancer, 0.77 (95% CI, 0.55-1.08) for left-sided colon cancer, and 0.48 (95% CI, 0.34-0.68) for right-sided colon cancer. CONCLUSIONS: In this elderly population, long-term use of nonaspirin NSAIDs nearly halved the risk of colon cancer. This study was consistent with previous studies that suggest that duration of use but not daily dose of NSAIDs is an important factor for chemoprevention. Our data also suggest that the protective effect is shared by most NSAIDs, and not confined to a small number of these drugs.

Aged↗
PubMed1999

Changes in continuity of enrollment among high-risk children following implementation of TennCare.

BACKGROUND: TennCare, Tennessee's Medicaid managed care program, was introduced in 1994 with the goals of controlling spending and of improving access to health care. OBJECTIVE: To assess changes in the continuity of enrollment following the implementation of TennCare for 2 groups: infants in the first year of life (defined as persons aged 0-12 months in this study) and children hospitalized with a chronic health condition (defined as persons aged 0-18 years in this study). DESIGN: Retrospective cohort analysis. SETTING AND POPULATION: Infants born during 1992 or 1995 to women enrolled in Medicaid or TennCare and 0- to 18-year-old children enrolled in Medicaid or TennCare who were discharged from a hospital during 1992 or 1995 with a chronic health condition. MAIN OUTCOME MEASURES: For infants, failure to enroll an infant in the first 30 days of life or subsequent gaps in enrollment for 7 days or longer during the first year of life. For children hospitalized with a chronic health condition, any gap in enrollment lasting 7 days or longer by 1 year after discharge from a hospital. RESULTS: There was a reduction in the proportion of infants without continuous enrollment in the first year of life following TennCare (19.4% after vs 25.1% before TennCare; odds ratio, 0.69; 95% confidence interval, 0.67-0.72). Improvements in continuity of enrollment for infants occurred despite an increase in the proportion of infants who were not enrolled in TennCare in the first 30 days of life, even though their mother was enrolled at delivery (14.0% after vs 8.0% before TennCare; odds ratio, 1.86; 95% confidence interval, 1.78-1.96). There was a decrease in the proportion of children hospitalized with a chronic health condition who had subsequent gaps in enrollment by 1 year following discharge from a hospital (14.3% after vs 23.3% before TennCare; odds ratio, 0.52; 95% confidence interval, 0.46-0.59). CONCLUSION: For infants in the first year of life and for children hospitalized with a chronic health condition, implementation of TennCare improved continuity of coverage.

Adolescent↗
PubMed1999

Sociodemographic factors identify US infants at high risk of injury mortality.

OBJECTIVES: To identify sociodemographic predictors of infant injury mortality and to compare trends in injury mortality rates for high- and low-risk US infants from 1985 to 1991. DESIGN: Historical cohort. SETTING/STUDY PARTICIPANTS: The National Center for Health Statistics linked US infants (<1 year) born from 1985 to 1991 with death certificates. MAIN OUTCOME MEASURES: Multivariate regression was used to identify sociodemographic factors associated with injury mortality. The adjusted relative risks (RRs) of maternal age, education, marital status, number of other children, and infant birth weight were used to categorize infants into risk groups. We compared trends in injury rates for the highest and lowest risk groups. RESULTS: There were 5963 injury deaths and 18.6 million infant years or 32.1 injury deaths per 100 000 infant years. Highest risk infants were born to mothers who were younger than 20 years compared with older than 30 years (RR, 3.25; 95% CI, 2.92-3.63), had less than a high school education compared with a college education (RR, 2.22; 95% CI, 1.95-2.53), had more than 2 other children compared with no other children (RR, 3.15; 95% CI, 2.88-3.45), were unmarried (RR, 1.67; 95% CI, 1.57-1.78), or had birth weights </=1500 g compared with >2500 g (RR, 3.36; 95% CI, 2.94-3.84). Infants in the highest risk group (21.0% of the population) had a >10-fold increased risk of injury mortality compared with the lowest risk group (18.1% of the population) and there was no evidence that this disparity was narrowing. CONCLUSIONS: Sociodemographic predictors of infant injury mortality include maternal age, education, number of other children, marital status, and infant birth weight. Based on these factors, 1 in 5 infants in the United States can be identified at birth as having a >10-fold increased risk of injury mortality compared with infants in lowest risk group. Programs to reduce injuries in these high-risk groups are urgently needed.

Adolescent↗
PubMed1999

Comparison of perinatal outcomes among TennCare managed care organizations.

OBJECTIVE: To compare perinatal outcomes among the managed care organizations (MCOs) providing care to beneficiaries enrolled in TennCare, Tennessee's capitated Medicaid managed care program. DESIGN: Retrospective cohort analysis. SUBJECTS: Infants born in Tennessee during 1995 to women enrolled in TennCare. PRIMARY OUTCOME MEASURES: Prenatal care use, birth weight (BW), death in the first 60 days of life, and delivery of extremely low BW (<1000 g) infants in hospitals without level 3 neonatal intensive care units. RESULTS: During 1995, 34 402 infants were born to mothers enrolled in TennCare. The MCOs differed widely in the demographic characteristics of their enrollees. In addition, there were small differences in prenatal care utilization, but no differences in BW outcomes among the MCOs. In multivariate analysis, however, infants born to women enrolled in 1 MCO were 2.8 times more likely to die in the first 60 days of life than were infants born to women enrolled in the largest MCO (OR: 2.81; 95% CI: 1.31-6.03). Women enrolled in this same MCO seemed to have a higher proportion of extremely low BW (<1000 g) infants delivering in a hospital lacking a level 3 neonatal intensive care unit (38% vs 20% in the largest MCO). CONCLUSION: The differences among MCOs in early infant death and in the delivery of high-risk infants in hospitals lacking appropriate neonatal facilities suggest that monitoring of care delivery to vulnerable children should include assessment of appropriate use of specialized services.

Adult↗
PubMed1998

Prenatal exposure to metronidazole and risk of childhood cancer: a retrospective cohort study of children younger than 5 years.

BACKGROUND: To evaluate the role of in utero exposure to metronidazole (a carcinogen in some animal models) and the risk of subsequent cancer, the authors conducted a retrospective cohort study of childhood cancer. METHODS: The cohort included 328,846 children younger than 5 years born to women enrolled in Tennessee Medicaid at any time between the last menstrual period (LMP) and the date of delivery. The cohort was identified by linking files of Tennessee Medicaid mothers ages 15-44 years and children and the children's birth and death certificates for the period January 1, 1975 through December 31, 1992. Exposure data were obtained from Medicaid pharmacy records and exposure was defined as filling a metronidazole prescription that had at least a day's supply between the 30 days prior to the LMP and the date of delivery. Study cases were cohort children diagnosed with a first primary cancer before age 5 years, identified by linking the cohort with a statewide childhood cancer database for the study period. RESULTS: Cohort members contributed 1,172,696 person-years of follow-up for analysis, with children exposed (8.1%) and not exposed (91.9%) in utero to metronidazole contributing 79,716 and 1,092,980 person-years, respectively. Of 952 children younger than 5 years in the statewide cancer database, 175 met study eligibility criteria. Of these, 42 had leukemia, 30 had central nervous system (CNS) tumors, 28 had neuroblastoma, and 75 had other cancers. Using Poisson regression modeling, children exposed to metronidazole in utero had no significant increase in adjusted relative risk (RR) for all cancers (RR: 0.81; 95% confidence interval [95% CI], 0.41-1.59), leukemia (no exposed case), CNS tumors (RR: 1.23; 95% CI, 0.29-5.21), neuroblastomas (RR: 2.60; 95% CI, 0.89-7.59), and other cancers (RR: 0.57; 95% CI, 0.18-1.82). CONCLUSIONS: The authors conclude that although there was no increase in risk for all cancers associated with in utero exposure to metronidazole, the observed increased risk for neuroblastomas, although not significant, requires further evaluation.

Adolescent↗
PubMed1998

Antidepressants and the risk of falls among nursing home residents.

BACKGROUND: In nursing home residents, the use of tricyclic and other heterocyclic antidepressants is associated with an increased risk of falls. The newer selective serotonin-reuptake-inhibitor antidepressants are largely free of the side effects of the tricyclic agents thought to cause falls and so have been hypothesized to be safer for those at high risk for falls. METHODS: We retrospectively identified an inception cohort of 2428 nursing home residents in Tennessee who were new users of tricyclic antidepressants (665 subjects), selective serotonin-reuptake inhibitors (612 subjects), or trazodone (304 subjects) or nonusers of antidepressants (847 subjects). We ascertained the number of falls during therapy and during a similar follow-up period for nonusers, then calculated the rate ratios for falls with adjustments for an extensive set of potential confounding factors. RESULTS: The new users of each type of antidepressant had higher rates of falls than the nonusers, with adjusted rate ratios of 2.0 (95 percent confidence interval, 1.8 to 2.2) for tricyclic antidepressants, 1.8 (1.6 to 2.0) for selective serotonin-reuptake inhibitors, and 1.2 (1.0 to 1.4) for trazodone. The rate ratios increased with the daily dose for tricyclic antidepressants, reaching 2.4 (95 percent confidence interval, 2.1 to 2.8) for doses of 50 mg or more of amitriptyline or its equivalent, and for the serotonin-reuptake inhibitors, reaching 1.9 (1.7 to 2.2) for 20 mg or more of fluoxetine or its equivalent. The elevated rates of falls persisted through the first 180 days of therapy and beyond. CONCLUSIONS: In this large study of nursing home residents, there was little difference in rates of falls between those treated with tricyclic antidepressants and those treated with selective serotonin-reuptake inhibitors. Hence, the preferential use of the newer antidepressants is unlikely to reduce the higher rate of falls among nursing home residents taking antidepressants.

Accidental Falls↗
PubMed1998

No association between calcium channel blocker use and confirmed bleeding peptic ulcer disease.

Calcium channel antagonists are commonly used drugs that have recently been reported to be associated with an increased incidence of gastrointestinal hemorrhage. We performed a retrospective cohort study among 105,824 enrollees of the Tennessee Medicaid program 65 years of age or older between 1984 and 1986. Exposure to calcium channel blockers and other medications was determined from pharmacy files. Hospitalization for bleeding peptic ulcers was identified by hospital claims and verified by a review of the medical record. Univariate estimates of relative risk for current users of calcium channel blockers and beta-blocker users were 1.8 (95% confidence interval (CI) 1.2-2.7) and 1.1 (95% CI 0.7-1.6) (reference group was nonuse of either). After adjustment for potential confounders, the relative risks for bleeding peptic ulcer among current users of calcium channel blockers and beta blockers were 1.1 (95% CI 0.7-1.7) and 1.0 (95% CI 0.7-1.6), respectively, when compared with those who used neither drug. In this population, after controlling for important confounders, there was no increased risk for hospitalization with bleeding peptic ulcer among users of calcium channel blockers.

Adrenergic beta-Antagonists↗
PubMed1998

Perinatal outcomes following implementation of TennCare.

CONTEXT: The abrupt initiation of capitated Medicaid care in Tennessee (TennCare) in 1994 prompted many questions about changes in quality of care. OBJECTIVE: To evaluate the effect on perinatal outcomes of the transition to TennCare in 1994. DESIGN: Before and after retrospective cohort analysis. SETTING AND POPULATION: Births to women residing in Tennessee between 1990 and 1995 with complete demographic information on birth certificates, with a focus on women enrolled in Medicaid giving birth in 1993 (before TennCare) and 1995 (after TennCare). OUTCOME MEASURES: Late prenatal care (after the fourth month of pregnancy) or inadequate prenatal visits, low and very low birth weight, and death in the first 60 days of life. RESULTS: Tennessee residents had 72014 study births in 1993 and 72278 in 1995, of which 37543 (52.1%) and 35707 (49.4%) were to women enrolled in Medicaid at delivery. For these Medicaid births, there were no changes after TennCare in the proportions with late prenatal care (16.2% in 1993 vs 15.8% in 1995), inadequate prenatal visits (5.9% vs 5.6%), low birth weight (9.4% vs 9.0%), very low birth weight (1.6% vs 1.5%), and death in the first 60 days (0.6% both years). These findings were unchanged in multivariate analysis, in analysis of high-risk subgroups, and in analysis of women with demographics characteristic of Medicaid women. CONCLUSION: Study perinatal outcomes did not change among Medicaid births following the transition to TennCare.

Birth Weight↗
PubMed1998

Predictors of mortality from fires in young children.

BACKGROUND: In the United States in 1994, fires claimed 3.75 lives per 100 000 child years and accounted for 17.3% of all injury deaths in children <5 years of age. OBJECTIVES: To conduct a historical cohort study that uses maternal demographic characteristics to identify young children at high risk of fire-related deaths, thus defining appropriate targets for prevention programs. METHODS: The cohort consisted of children born to mothers who resided in the state of Tennessee between 1980 and 1995. Information was obtained by linking birth certificates, 1990 census data, and death certificates. Children were eligible for the study if they were <5 years of age at any time within the study period and if key study variables were present (99.2% of births). Birth certificates provided information on maternal characteristics including age, race, education, previous live births, use of prenatal care, and residence (in standard metropolitan statistical area). Child characteristics included gender, gestational age, and birth type (singleton/multiple gestation). Neighborhood income was estimated by linking the mother's address at the time of birth to the 1990 census (block group mean per capita income). The study outcome was a fire resulting in at least one fatality (fatal fire event) during the study period, identified from death certificates (coded E880 through E889 in the International Classification of Diseases, 9th rev). We calculated the fatal fire event rate corresponding to each stratum of maternal/child characteristics. We assessed the independent association between each characteristic and the risk of a fatal fire event from a Poisson regression multivariate analysis. RESULTS: During the study period, 1 428 694 children contributed 5 415 213 child years to the cohort: there were 270 deaths from fire (4.99 deaths per 100 000 child years) and 231 fatal fire events. In the multivariate analysis, factors associated with greater than a threefold increase in fatal fire events included maternal education, age, and number of other children. Compared with children whose mothers had a college education, children whose mothers had less than a high school education had 19.4 times (95% confidence interval [CI], 2.6-142.4) an increased risk of a fatal fire event. Children whose mothers had more than two other children had 6.1 times (95% CI, 3.8-9.8) an increased risk of a fatal fire event compared with children whose mothers had no other children. Children of mothers <20 years of age had 3.9 times (95% CI, 2.2-7.1) increased risk of a fatal fire event compared with children whose mothers were >/=30 years old. Although both maternal neighborhood income and race were associated strongly with increased rates of fatal fire events in the univariate analysis, this association did not persist in the multivariate analysis. Other factors that were associated with increased risk of fatal fire events in the multivariate analysis were male gender and having a mother who was unmarried or who had delayed prenatal care. The three factors associated most strongly with fire mortality were combined to create a risk score based on maternal education (>/=16 years, 0 points; 13 to 15 years, 1 point; 12 years, 2 points; <12 years, 3 points); age (>/=30 years, 0 points; 25 to 29 years, 1 point; 20 to 24 years, 2 points; <20 years, 3 points); and number of other children (none, 0 points; one, 1 point; two, 2 points; three or more, 3 points). The lowest-risk group (score <3) included 19% of the population and had 0.19 fatal fire events per 100 000 child years. In contrast, highest-risk children (score >7) comprised 1.5% of the population and had 28.6 fatal fire events per 100 000 child years, 150 times higher than low-risk children. Children with risk scores >5 contributed 26% of child years but experienced 68% of all fatal fire events. If the fatal fire event rate for all children had been equal to that of the low-risk group (risk score <3), then 95% of deaths from

Burns↗
PubMed1997

Policy and program analysis using administrative databases.

Administrative policies and programs play an important and growing role as determinants of the use of medical care. Although some policies and programs may be harmful or ineffectual, randomized, controlled trials or prospective evaluations are rarely done for political or logistic reasons. Most evaluations are retrospective and often use administrative databases. Major problems with such evaluations include poor data quality, lack of concurrent controls, inability to ascertain important study outcomes, and incomplete data on case mix. This article uses published evaluations to illustrate these problems and suggests strategies that can minimize their impact. Such strategies include thorough assessment of data quality, interrupted time-series or policy gradient analysis, restriction of studies to those clinical outcomes that reliably result in medical care, and use of data on medical encounters as surrogates for determining case mix. However, even when these strategies are used, adequate evaluation of the effects of many policies and programs may continue to be impossible. Prospective evaluations need to be used more frequently to ensure that changes are held to the same standard used for other therapeutic interventions.

Data Collection↗
PubMed1997

A randomized trial of a consultation service to reduce falls in nursing homes.

CONTEXT: Falls are a major health problem in nursing homes, but no interventions have been shown to prevent falls in nursing home residents. OBJECTIVE: To evaluate an intervention program designed to prevent falls and associated injuries in high-risk nursing home residents. DESIGN: Randomized controlled trial. SETTING AND PARTICIPANTS: Seven pairs of middle Tennessee nursing homes with 1 facility in each pair randomly assigned to the intervention. Facilities had 482 (261 control, 221 intervention) residents who qualified for the study because they had high risk of falls and a potential safety problem that could be addressed by the intervention. INTERVENTION: Comprehensive structured individual assessment with specific safety recommendations that targeted suboptimal practices for environmental and personal safety, wheelchair use, psychotropic drug use, and transferring and ambulation. Facility staff were encouraged to implement the individual recommendations and to improve overall facility safety. MAIN OUTCOME MEASURES: The mean proportion of recurrent fallers and incidence rate of injurious falls in the facility in the year following the intervention. RESULTS: The mean proportion of recurrent fallers in intervention facilities (43.8%) was 19.1% (95% confidence interval, 2.4%-35.8%) lower than that in control facilities (54.1%, P=.03). Intervention facilities had a nonsignificant trend toward a lower mean rate of injurious falls (13.7 vs 19.9 per 100 person-years, reduction of 31.2%, P=.22). Subgroup analyses suggested greatest benefits for residents for whom the recommended interventions were carried out or who had 3 or more falls in the preceding year. CONCLUSION: The high rate of falls and related injuries in nursing homes should not be viewed as inevitable, but as outcomes that can be substantially improved through structured safety programs.

Accident Prevention↗
PubMed1997

Antihypertensives and the risk of serious hypoglycemia in older persons using insulin or sulfonylureas.

CONTEXT: Beta-Blockers and angiotensin-converting enzyme (ACE) inhibitors are effective antihypertensive agents for patients with diabetes mellitus. However, beta-blockers attenuate some components of the autonomic response to hypoglycemia and could increase the risk of hypoglycemia. ACE inhibitors may increase insulin sensitivity and predispose users to hypoglycemia. OBJECTIVE: To determine whether use of cardioselective beta-blockers, nonselective beta-blockers, ACE inhibitors, thiazide diuretics, calcium channel blockers, or other antihypertensive drugs alters the risk of developing serious hypoglycemia among older persons prescribed insulin or sulfonylureas. DESIGN: Retrospective cohort study. SETTING: Tennessee Medicaid Program. PATIENTS: A total of 13,559 elderly (mean age, 78+/-7 years) Medicaid enrollees, who were prescribed insulin (n=5171, 38%) or sulfonylureas (n=8368, 62%) from 1985 through 1989. These enrollees contributed a total of 33,107 person-years of insulin or sulfonylurea use for follow-up. MEASUREMENTS: Hospitalization, emergency department admission, or death associated with hypoglycemic symptoms and a concomitant blood glucose determination of less than 2.8 mmol/L (50 mg/dL). RESULTS: We identified 598 persons with an episode of serious hypoglycemia during the study period. The rate of serious hypoglycemia was 2.01 per 100 person-years among those who were not prescribed antihypertensives. Crude rates of serious hypoglycemia were highest among users of ACE inhibitors (2.47 per 100 person-years) and lowest among users of cardioselective beta-blockers (1.23 per 100 person-years). However, when we controlled for demographic characteristics and markers of comorbidity, there was no statistically significant increase or decrease in risk of serious hypoglycemia among users of any class of antihypertensive agents compared with nonusers of antihypertensive drugs. Using nonselective beta-blockers as the reference group, each of these agents was associated with a lower, but not statistically significant, risk of hypoglycemia. CONCLUSIONS: In this population, specific antihypertensive drug therapy had little impact on the risk of hypoglycemia in older diabetic patients. Therapy should be chosen based on other considerations of safety and effectiveness.

Aged↗
PubMed1997

Persistently increased injury mortality rates in high-risk young children.

OBJECTIVE: To study trends in injury mortality for low- and high-risk young children. DESIGN AND METHODS: For Tennessee children 0 to 4 years of age, we used birth certificates to obtain data on maternal education, age, and parity; these risk factors were used to classify children into low- and high-risk groups. The outcome was death from injury, as determined from linked death certificates. Between 1978 and 1995, injury mortality rates were calculated for six 3-year periods for low- and high-risk children. RESULTS: There were 1.5 million children 0 to 4 years of age who contributed 4.9 million child-years. The high-risk group contributed 28% of all child-years. There were 673 injury deaths in the high-risk group, 48.9 deaths per 100,000 child-years, and 586 deaths in the low-risk group, 16.8 deaths per 100,000 child-years. The injury mortality rate for low-risk children decreased from 20.7 to 15.7 per 100,000 child-years between the 1978-1980 and 1981-1983 periods; thereafter it remained relatively stable. For high-risk children, the injury mortality rate decreased from 50.9 to 43.5 per 100,000 between the 1978-1980 and 1981-1983 periods, remained mostly unchanged through 1992, and then increased sharply in the 1993-1995 period to 64.1 per 100,000 child-years. The disparity between high- and low-risk children widened from 29.3 (95% confidence interval, 25.1-33.5) excess deaths per 100,000 for 1978 through 1991 to 46.9 (95% confidence interval, 35.9-57.9) in 1993 through 1995. CONCLUSIONS: In Tennessee, maternal education, age, and parity consistently identified a population of children at increased risk of injury mortality. For these high-risk children, there has been no substantial reduction in injury mortality in high-risk young children during the last 18 years.

Age Factors↗
PubMed1997

Predictors of antipsychotic withdrawal or dose reduction in a randomized controlled trial of provider education.

OBJECTIVES: To evaluate the effects of an educational program to reduce antipsychotic use in nursing homes that had high use rates post-OBRA-87 and to identify factors that predicted antipsychotic withdrawal or 50% or greater dose reduction. DESIGN/SETTING: A randomized controlled trial (RCT) of the educational program (nursing home the unit of randomization and analysis) was conducted in 12 Tennessee nursing homes (6 education/6 control). Cohort analysis in baseline antipsychotic users identified factors predicting withdrawal or dose reduction. SUBJECTS: The RCT analysis included 1152 patients in the homes at baseline and 6 months. The cohort analysis included 133 baseline antipsychotic users in the five education homes able to implement the recommendations of the educational program. OUTCOME MEASURES: Change in days of antipsychotic use per 100 days of nursing home residence, withdrawal from antipsychotics, reduction in antipsychotic dose by 50% or more. RESULTS: Following the educational intervention, use of antipsychotics in the six education homes decreased from 25.3 days per 100 at baseline to 19.7 days per 100 by month 6, a 23% reduction relative to control homes (P = .014). In the withdrawal analysis, 44 (33%) of 133 baseline antipsychotic users were withdrawn. Factors at baseline predicting successful withdrawal were low antipsychotic dose, no use of benzodiazepines or antidepressants, and behavioral symptoms score below the median. However, although an additional 22 patients had dose reductions > or = 50%, none of the predictors of withdrawal were associated with dose reductions. CONCLUSIONS: Focused provider education programs may facilitate antipsychotic reduction above and beyond that attributable to regulatory changes. Patients who are poor candidates for total antipsychotic withdrawal may tolerate substantial dose reductions, which should reduce their risk of adverse antipsychotic effects.

Aged↗
PubMed1997

Predictors of injury mortality in early childhood.

OBJECTIVE: To study the association between maternal/infant characteristics and mortality from injury for children 0 through 4 years of age. DESIGN: Historical cohort. SETTING: State of Tennessee. PARTICIPANTS: Children 0 through 4 years of age at any time between January 1, 1985 and December 31, 1994. We linked birth certificates and US census data to obtain information on maternal age, race, education, neighborhood income, parity, use of prenatal care, residence location, infant's gender, and gestational age. MAIN OUTCOME MEASURES: The outcome was death from injury, as determined from linked death certificates. The incidence density rates for each stratum (defined by maternal/child characteristics) were calculated by dividing the number of injury deaths by child years in the stratum. We used multivariate analysis to assess the independent contribution of each characteristic to risk of injury death. RESULTS: There were 1 035 504 children 0 through 4 years of age who contributed 3 414 436 child years. There were 803 deaths from injury, ie, 23.5 deaths per 100 000 child years. In the multivariate analysis, children had at least a 50% increased risk of injury mortality if they were born to a mother who had less than a high school education (relative risk [RR] = 2.88; 95% confidence interval [CI]: 1.92-4.34) compared with a college education, was <20 years of age (RR = 2.42; 95% CI: 1.76-3.31) compared with >30 years, or had >2 other children (RR = 2.97; 95% CI: 2.29-3.85) compared with no other children. Neither race nor income was significantly associated with childhood injury mortality in the multivariate analysis. Classification of children by maternal education, age, and parity defined a pronounced risk gradient in which high-risk children had an injury mortality rate >15 times that of low-risk children. The steep risk gradient was present for both infants (24-fold increase for high-risk children) and children 1 through 4 years of age (13-fold increase for high-risk children). If the injury mortality rate for all children were equal to that of the low-risk group, 614/803 (76.3%) of injury deaths would not have occurred. CONCLUSIONS: For young children, maternal education, age, and parity are strongly and independently associated with injury mortality. These factors define a steep gradient of risk, suggesting that many injury deaths could be prevented.

Birth Certificates↗