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Aims To evaluate the effect of an intimate partner violence intervention education component on nurses' attitudes in addressing intimate partner violence; complementary aims included understanding nurses' perceptions of the education and how it influenced their attitudes and confidence to address intimate partner violence in practice. Design An explanatory sequential mixed methods design embedded within a 15-site cluster randomized clinical trial that evaluated an intimate partner violence intervention within the Nurse-Family Partnership programme. Methods Data were collected between February 2011 and September 2016. Quantitative assessment of nurses' attitudes about addressing intimate partner violence was completed by nurses in the intervention (n = 77) and control groups (n = 101) at baseline, 12 months and at study closure using the Public Health Nurses' Responses to Women Who Are Abused Scale. Qualitative data were collected from nurses in the intervention group at two timepoints (n = 14 focus groups) and focused on their perceptions of the education component. Data were analysed using content analysis. Results Nurses in the intervention group reported large improvements in their thoughts, feelings and perceived behaviours related to addressing intimate partner violence; a strong effect of the education was found from baseline to 12 months and baseline to study closure timepoints. Nurses reported that the education component was acceptable and increased their confidence to address intimate partner violence. Conclusion Nurses reported improved attitudes about and confidence in addressing intimate partner violence after receiving the education component. However, these findings need to be considered together with trial results showing no main effects for clients, and a low level of intervention fidelity. Impact These evaluation findings underscore that improvement in nurses' self-reported educational outcomes about addressing intimate partner violence cannot be assumed to result in adherence to intervention implementation or improvement in client outcomes. These are important considerations for developing nurse education on intimate partner violence.

Objective Driving under the influence of drugs is a global traffic safety and public health concern. This trend analysis examines the changes in general drug usage other than alcohol, broad categories, and typical prescription and illegal drugs among drivers fatally injured in motor vehicle crashes from 1999 to 2010 in the U.S. Methods Data from the Fatality Analysis Reporting System were analyzed from 1999 to 2010. Drug prevalence rates and prevalence ratios (PR) were determined comparing rates in 2009–2010 to 1999–2000 using a random effects model. Changes in general drug usage, broad categories, and representative prescription and illegal drugs including, methadone, oxycodone, hydrocodone, barbiturates, benzodiazepines, and cocaine, were explored. Results Comparing 2009–2010 to 1999–2000, prevalence of drug usage increased 49% (PR = 1.49; 95% confidence interval [CI] 1.42, 1.55). The largest increases in broad drug categories were narcotics (PR = 2.73; 95% CI 2.41, 3.08), depressants (PR = 2.01; 95% CI 1.80, 2.25), and cannabinoids (PR = 1.99; 95% CI 1.84, 2.16). The PR were 6.37 (95% CI 5.07, 8.02) for hydrocodone/oxycodone, 4.29 (95% CI 2.88, 6.37) for methadone, and 2.27 (95% CI 2.00, 2.58) for benzodiazepines. Barbiturates declined in rate over the 12-year period (PR = 0.53; 95% CI 0.37, 0.75). Cocaine use increased until 2005 then progressively declined, though the rate remained relatively unchanged (PR = 0.94; 95% CI 0.84, 1.06). Conclusions While more drivers are being tested and found drug-positive, there is evidence that a shift from illegal to prescription drugs may be occurring among fatally injured drivers in the U.S. Driving under the influence of prescription drugs is a growing traffic concern.

Importance Intimate partner violence (IPV) is a public health problem with significant adverse consequences for women and children. Past evaluations of a nurse home visitation program for pregnant women and first-time mothers experiencing social and economic disadvantage have not consistently shown reductions in IPV. Objective To determine the effect on maternal quality of life of a nurse home visitation program augmented by an IPV intervention, compared with the nurse home visitation program alone. Design, Setting, and Participants Cluster-based, single-blind, randomized clinical trial at 15 sites in 8 US states (May 2011-May 2015) enrolling 492 socially disadvantaged pregnant women (≥16 years) participating in a 2.5-year nurse home visitation program. Interventions In augmented program sites (n = 229 participants across 7 sites), nurses received intensive IPV education and delivered an IPV intervention that included a clinical pathway to guide assessment and tailor care focused on safety planning, violence awareness, self-efficacy, and referral to social supports. The standard program (n = 263 participants across 8 sites) included limited questions about violence exposure and information for abused women but no standardized IPV training for nurses. Main Outcomes and Measures The primary outcome was quality of life (WHOQOL-BREF; range, 0-400; higher score indicates better quality of life) obtained through interviews at baseline and every 6 months until 24 months after delivery. From 17 prespecified secondary outcomes, 7 secondary end points are reported, including scores on the Composite Abuse Scale, SPAN (Startle, Physiological Arousal, Anger, and Numbness), Prime-MD Patient Health Questionnaire, TWEAK (Tolerance/Worry About Drinking/Eye-Opener/Amnesia/C[K]ut Down on Drinking), Drug Abuse Severity Test, and the 12-Item Short-Form Health Survey (physical and mental health), version 2. Results Among 492 participants enrolled (mean age, 20.4 years), 421 (86%) completed the trial. Quality of life improved from baseline to 24 months in both groups (change in WHOQOL-BREF scores from 299.5 [SD, 54.4] to 308.2 [SD, 52.6] in the augmented program group vs from 293.6 [SD, 56.4] to 316.4 [SD, 57.5] in the standard program group). Based on multilevel growth curve analysis, there was no statistically significant difference between groups (modeled score difference, −4.9 [95% CI, −16.5 to 6.7]). There were no statistically significant differences between study groups in any of the secondary participant end points. There were no adverse events recorded in either group. Conclusions and Relevance Among pregnant women experiencing social and economic disadvantage and preparing to parent for the first time, augmentation of a nurse home visitation program with a comprehensive IPV intervention, compared with the home visitation program alone, did not significantly improve quality of life at 24 months after delivery. These findings do not support the use of this intervention. Trial Registration ClinicalTrials.gov Identifier:NCT01372098

Background Muay Thai is a combat sport of Thailand that uses stand-up striking along with various clinching techniques. Currently, little is known about the injuries and risk factors for injuries among Muay Thai fighters. Gaining more insight into the nature and frequency of injury in this sport provides part of the overall sports injury picture, within the larger burden of injury as a public health issue. Generating this information is a critical first step toward the broader goal of improving the health and safety of Muay Thai fighters engaged in competition. Methods This study is based upon a survey of 195 Muay Thai fighters. Participants were asked to complete a retrospective web survey on fight-related injuries. Regression analyses were conducted to determine whether injuries during sanctioned fights were related to factors such as fight experience, use of protective equipment, and injury history. Results Participants were aged 18 to 47 years old (median 26), predominantly male (85.9%), and white (72.3%). Respondents were professional (n = 96, 49.2%) and amateur (n = 99, 50.8%). Fighters reported a mean fight experience of 15.8 fights. Of the 195 respondents, 108 (55.4%) reported sustaining an injury during the most recent fight. The primary body region injured was the extremities (58%) versus the head, with a lower amount of self-reported concussions (5.4%). Nearly 2/3 (66.7%) of all injured fighters reported that the injury did not interfere with the bout outcome. Nearly 25% reported they missed no training time as a result of the injury. Injuries were related to professional fighter status (OR = 2.5, 95% CI = 1.4–4.5), fight experience (OR = 2.7, 95% CI = 1.5–4.9), weight class (OR = 0.923 heavy versus light, 95% CI = .86–.99), age (OR = 0.90 > 26 versus ≤26, 95% CI = .85–.95), use of protective equipment (OR = .46, 95% CI = .26–.82) and previous injury (OR = 1.81, 95% CI = .98–3.3). Lighter, younger, and more experienced fighters were at increased odds for injury within this sample. Conclusions We identified a preliminary fight-related injury rate and identified fighter characteristics (experience level, protection level, and previous injury) associated with increased odds for fight-related injury outcome. While rigorous research into causality is required, these data provide plausible information that may be used to reduce injury outcomes among fighters.

Objective Pedestrians account for a third of the 1.2 million traffic fatalities annually worldwide, and men are overrepresented. We examined the factors that contribute to this male-female discrepancy: walking exposure (kilometres walked per person-year), vehicle-pedestrian collision risk (number of collisions per kilometres walked) and vehicle-pedestrian collision case fatality rate (number of deaths per collision). Design The decomposition method quantifies the relative contributions (RCs) of individual factors to death rate ratios among groups. The male-female ratio of pedestrian death rates can be expressed as the product of three component ratios: walking exposure, collision risk and case fatality rate. Data sources included the 2008–2009 US Fatality Analysis Reporting System, General Estimates System, National Household Travel Survey and population estimates. Setting USA. Participants Pedestrians aged 5 years and older. Main outcome measures Death rate per person-year, kilometres walked per person-year, collisions per kilometres walked and deaths per collision by sex. Results The pedestrian death rate per person-year for men was 2.3 times that for women. This ratio of male to female rates can be expressed as the product of three component ratios: 0.995 for walking exposure, 1.191 for collision risk and 1.976 for case fatality rate. The RCs of these components were 1%, 20% and 79%, respectively. Conclusions The majority of the male-female discrepancy in 2008–2009 pedestrian deaths in the US is attributed to a higher fatality per collision rate among male pedestrians.

Objectives. We have described national trends for the 5 leading external causes of injury mortality. Methods. We used negative binomial regression and annual underlying cause-of-death data for US residents for 2000 through 2009. Results. Mortality rates for unintentional poisoning, unintentional falls, and suicide increased by 128%, 71%, and 15%, respectively. The unintentional motor vehicle traffic crash mortality rate declined 25%. Suicide ranked first as a cause of injury mortality, followed by motor vehicle traffic crashes, poisoning, falls, and homicide. Females had a lower injury mortality rate than did males. The adjusted fall mortality rate displayed a positive age gradient. Blacks and Hispanics had lower adjusted motor vehicle traffic crash and suicide mortality rates and higher adjusted homicide rates than did Whites, and a lower unadjusted total injury mortality rate. Conclusions. Mortality rates for suicide, poisoning, and falls rose substantially over the past decade. Suicide has surpassed motor vehicle traffic crashes as the leading cause of injury mortality. Comprehensive traffic safety measures have successfully reduced the national motor vehicle traffic crash mortality rate. Similar efforts will be required to diminish the burden of other injury.

People without adequate insurance may separate financially from their families and move onto Medicaid after a catastrophic injury. Medicaid then covers all of their medical care costs. No estimates for Medicaid conversions due to injury exist in the literature.To estimate Medicaid conversions due to injury for people 21-64 years old.This study analyzes the 2003 Medicaid Analytic eXtract files (the most recently available in 2009) for 14 states. For each state, we assigned a conversion cutoff date by examining the pattern of admissions after enrollment. The last day before the injury hospital admission rate decreased to its background level was considered as a cutoff date for conversions.Medicaid enrollees aged 21 to 64 years who received coverage due to a catastrophic injury.Acute Medicaid conversions per 100 acute injury hospital admissions, estimated conversions remaining at least 1 year on Medicaid, and life-time public medical cost of disabled Medicaid recipients.Around 2.55% of all hospitalized injury patients not previously covered by Medicaid enrolled to cover their hospital bills. The average disabled recipient on Medicaid (possibly combined with Medicare) for 30 years has public medical payments exceeding $345,000.The Medicaid postinjury enrollment policy provides important financial support to safety-net hospitals, provides better access to long-term care for trauma patients who need it, and permits states to offload costs to the federal government.

The mandatory reporting of intimate partner violence (IPV) is a controversial issue that is receiving increased attention. A related concern is whether children’s exposure to IPV constitutes child maltreatment, making it reportable to child protective services. These issues have been relatively unexplored within the context of home visitation programs. A secondary analysis of qualitative data collected from community stakeholders, clients, and home visiting nurses in the Nurse–Family Partnership program was carried out. Participants’ perceptions about mandatory reporting of IPV and reporting of children’s exposure to IPV are highlighted. Emergent themes and implications for research, practice, and policy are discussed.

PURPOSE: Intimatepartnerviolence(IPV)isanimportantpublichealthissuewithseriousconsequences for the workplace. Workplace homicides occurring to U.S. women over a 6-year period, including those perpetrated by an intimate partner, are described. METHODS: Workplace homicides among U.S. women from 2003 to 2008 were categorized into type I (criminal intent), type II (customer/client), type III (co-worker), or type IV (personal relations) events using the Census of Fatal Occupational Injuries. Fatality rates were calculated and compared among workplace violence (WPV) types, occupations, and characteristics including location of homicide, type of workplace, time of day, and weapon used. RESULTS: Between 2003 and 2008, 648 women were feloniously killed on the job. The leading cause of workplace homicide for U.S. women was criminal intent, such as robbing a store (n Z 212; 39%), followed by homicides perpetrated by a personal relation (n Z 181; 33%). The majority of these personal relations were intimate partners (nZ142; 78%). Over half of workplace homicides perpetrated by intimate partners occurred in parking lots and public buildings (n Z 91; 51%). CONCLUSIONS: A large percentage of homicides occurring to women at work are perpetrated by intimate partners. WPV prevention programs should incorporate strategies to prevent and respond to IPV. Ann Epidemiol 2012;22:277–284. Published by Elsevier Inc.

In the United States, there is an ongoing debate about requiring health care professionals to report intimate partner violence (IPV) to law enforcement agencies. A comprehensive examination of the perspectives of those required to report abuse is critical, as their roles as mandated reporters often pose legal, practical, moral, and ethical questions. Even so, the perspective of health care professionals who are required to report is often overlooked and research is scarce on mandated reporters who work outside of clinical settings, such as nurses who engage in home visitation with clients. The purpose of this study was to examine nurse home visitors’ perspectives regarding the mandatory reporting of IPV, specifically focusing on their attitudes toward reporting, perceived awareness of reporting requirements, and intended reporting behaviors. A web-based survey was administered to nurses in the Nurse-Family Partnership home visitation program across the United States. A total of 532 completed surveys were returned (response rate = 49%). In terms of support for reporting IPV, 40% of nurses indicated that they should “always” be required to report. Almost half of the sample indicated that they would report a case of IPV, yet less than one-third of participants were aware of a legal mandate. Attitudes and support toward reporting as well as the perception of a reporting requirement significantly predicted intention to report. Furthermore, 29% of participants did not know if they were required to report IPV perpetrated against their clients. Comprehensive information about mandatory reporting duties is needed for health care professionals in home visitation settings. The findings of the current study highlight the need to reduce variation among practitioners and establish consistent program practices that are grounded in the program’s principals, supported by existing research, and compliant with existing state policies.

The purpose of this paper was to examine collaborative activities occurring between child welfare agencies and domestic violence service providers and to investigate whether there was a relationship between collaborative efforts and domestic violence policy and practice in child welfare agencies. Data were derived from the Children and Domestic Violence Services study, which obtained cross-sectional data from a large sample of child welfare agencies across the United States, and from the Greenbook evaluation, which conducted a longitudinal case study investigation of a federal initiative that provided support to several communities to establish collaborative mechanisms aimed at improving the effectiveness of child welfare policy related to domestic violence. Findings from the cross-sectional data revealed that in almost three-quarters of the communities, formal collaborative activities existed between child welfare and domestic violence agencies. However, the data did not demonstrate a relationship between these activities and child welfare policy and practice related to domestic violence. Longitudinal case study findings from the Greenbook evaluation did reveal some changes in child welfare policy and practice in association with the implementation of activities that increased collaboration between child welfare and domestic violence service providers. Improvements were found in child welfare agency screening and assessment, advocacy for adult domestic violence victims, and multidisciplinary approaches to case planning. The extent to which changes were observed varied across the sites, however, and appeared to be related to the specific planning approach undertaken in each community. Additional work is needed to identify optimal collaborative strategies to enhance domestic violence policy and practice and improve outcomes for families.

To determine the attitudes of teens and parents in Pennsylvania (PA) towards the enhanced graduated driver licensing (GDL) system implemented in 2000, and to assess their understanding of teen crash risk.Cross-sectional survey of teen drivers and their parents. Eligible teens were 16 or 17 years old when they obtained their first learner's permits in 2000. A simple random sample of 2500 was obtained from 48,372 meeting inclusion criteria. Questions were based on previous surveys and pre-tested in focus groups.Chi-square, McNemar, or t-tests, as appropriate.A total of 1561 surveys (811 parents and 750 teens) were included in the analysis. There were no differences between the sample and teen respondents. Their junior license had been achieved by 735 (98%) teens and had been driving unsupervised for a mean of 14.1 months (SD 4.89). Greater than ninety percent (90%) of parents approved of the overall system, the six-month learner phase, and the requirement for parental certification of 50 hours of supervised driving. The teens' reactions were less positive than the parents' (p0.001), but only 16% reported a negative overall reaction. 31.4% of the teens reported not completing the required 50 hours of supervised driving. 70.6% of parents felt the nighttime driving restriction was "just right" at 11 pm but 54.0% of teens preferred that it be returned to 12 mn (p0.001). When asked about the crash rate for teen drivers, 72.8% of teens and 74.0% of parents chose rates 2 to 100 times less than the reported crash rate (p = 0.8).In PA, the primary stakeholders, teen drivers and their parents, were poorly informed about teen crash risk. Parents were very positive and teens are generally neutral or weakly positive about the new restrictions imposed by the enhanced graduated driver licensing system. Better understanding of the crash rate for teen drivers might increase approval of system restrictions, enhance compliance, and further strengthen the system.

Objectives: There is substantial variation in the emergency department (ED) disposition of patients with transient ischemic attack (TIA), and the factors responsible for this variation have not been determined. In this study, the authors examined the influence of clinical, sociodemographic, and hospital characteristics on ED disposition. Methods: All ED-treated TIA cases from community hospitals in 11 states were identified from the 2002 Healthcare Cost and Utilization Project (HCUP). Using the aggregate data, descriptive analyses compared admitted and discharged cases. Pearson’s chi-square test was used to determine the statistical significance of these comparisons. Based on the results of the bivariate analyses, logistic regression models of the likelihood of hospital admission were derived, using a stepwise selection process. Adjusted risk ratios and 95% confidence intervals (CI) were calculated from the logistic regression models. Results: A total of 34,843 cases were identified in the 11 states, with 53% of cases admitted to the hospital. In logistic regression models, differences in admission status were found to be strongly associated with clinical characteristics such as age and comorbidities. After controlling for comorbidities, differences in admission status were also found to be associated to hospital type and with sociodemographic characteristics, including county of residence and insurance status. Conclusions: While clinical factors predictably and appropriately impact the ED disposition of patients diagnosed with TIA, several nonclinical factors are also associated with differences in disposition. Additional research is needed to better understand the basis for these disparities and their potential impact on patient outcomes.

OBJECTIVES: To estimate the incidence of all-terrain vehicle (ATV)-related injury hospitalizations in the United States from 2000 through 2004, and to describe the types of injuries and associated hospital costs for the entire population. METHODS: Data for 2000 through 2004 were obtained from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample-a stratified probability sample of 1004 community hospitals from 37 states. ATV injuries were defined by ICD-9-CM external cause of injury codes within E821. Variables included age, gender, primary diagnoses, patient disposition, primary payer, and hospital charges. Data were analyzed in 2007. RESULTS: There were an estimated 58,254 ATV-related hospitalizations, increasing 90% over the 5-year period. Eighty percent were men. Thirty percent of the cases involved youth under age 18, and 8% were over age 60. Passengers accounted for 9% of the hospitalizations. Eighty-five percent were routinely discharged to home while 13% required long-term rehabilitation or home health care. Payers included private insurance (62%), Medicaid/Medicare (19%), and self-pay (12%). Rural hospitals treated 23% of the cases and urban teaching hospitals 47%. Estimated total hospital charges were about $1.1 billion (20% paid from public funds) with an average charge per patient of $19,671. Leading injuries included fractures of lower limbs (22%; mean hospital charges of $19,626), other fractures (15%; $18,873), and intracranial injuries (14%; $26,906). The overall hospital admission rate was 4.4 per 100,000 population with variation by year, gender, and age. CONCLUSIONS: Voluntary industry and government safety efforts have had little impact on the increasing incidence and cost of ATV injuries. Renewed prevention efforts to making ATV riding safer are warranted. Language: en

Background and objective Injuries are a leading cause of death, significant disability, and utilization of acute medical care. This study describes patterns of acute care services use related to injury and associated costs among children and adolescents in a state Medicaid population. Methods A retrospective, cross-sectional, descriptive research design was used to analyze 2003 West Virginia Medicaid fee-for-service computerized claims for acute care medical services with a primary diagnosis of injury or complication due to injury for recipients below 21 years of age. Medical services utilization rates were calculated and stratified by demographic categories as well as by type of injury. Costs associated with the claims were from the perspective of Medicaid. Results There were 33,599 children who were hospitalized or visited the emergency department for injury or complication due to injury at a rate of 227.2 per 1,000. Children who were white, male, and 15–20 years of age had the highest rate of acute care use by demographic groups. Medicaid paid approximately $7.4 million for injury-related acute care visits. Acute care was mostly delivered in the emergency department, although hospitalizations contributed to one-third of the total costs. The average length of hospital stay for any type of injury or complication due to injury was 4 days. Overall, a diagnosis of traumatic complication was the most frequently occurring, followed by open wounds, contusions, sprains and strains, and fractures. E-codes were not readily recorded. Conclusion The use of injury-related acute medical care varied by demographic variables and diagnosis. Findings from this study can be used as a baseline for further surveillance, and to guide the development of interventions to contain preventable injuries and associated treatment costs.

As a result of the frequent co-occurrence of intimate partner violence (IPV) and child maltreatment, national organizations have recommended that child welfare systems (CWS) and domestic violence service (DVS) organizations be trained, co-trained, and cross-trained on IPV and child maltreatment. The objective of this study was to describe the training reported by local CWS and DVS agencies on the topic of co-occurring abuse. Structured telephone interviews were conducted with 73 CWS and 76 DVS agencies. Approximately half of the DVS agencies and two thirds of the CWS agencies achieved less than 50% of the total possible training score. However, several sites demonstrated strong training. Future research should identify additional factors that facilitate or impede the recommended training for CWS and DVS agencies.

This study compares U.S. motorcycle-related hospitalizations across states with differing helmet laws. Cross-sectional analyses of hospital discharge data from 33 states participating in the Healthcare Cost and Utilization Project in 2001 were conducted. Results revealed that motorcyclists hospitalized from states without universal helmet laws are more likely to die during the hospitalization, sustain severe traumatic brain injury, be discharged to long-term care facilities, and lack private health insurance. This study further illustrates and substantiates the increased burden of hospitalization and long-term care seen in states that lack universal motorcycle helmet use laws.

OBJECTIVE. This study tested the hypothesis that underutilization of poison control centers is associated with increased rates of hospitalizations attributable to poisonings in rural areas. METHODS. To measure the potential impact of poison control centers on hospitalization rates in rural areas among people who visit emergency departments because of poisoning, we estimated the reduction in hospitalization rates associated with increased rates of calls to centers. We used the 2003 State Inpatient Database and State Emergency Department Database from the Healthcare Cost and Utilization Project to calculate the numbers of emergency department visits and hospitalizations for each county in the 12 states analyzed. We used Toxic Exposure Surveillance System data from the American Association of Poison Control Centers to calculate the number of human exposure calls per capita according to county. RESULTS. In rural counties, a 1% higher poison control center human poison exposure call rate was associated with a 0.19% lower hospitalization rate among people who visited emergency departments because of poisoning. If the observed association is causative, then 43.3 calls would prevent 1 hospital admission, yielding $7321 in net cost savings and a return on investment of 5.9:1 (from the health care system perspective). CONCLUSIONS. Our results establish the existence of the hypothesized association between rural poison control center utilization rates and hospitalization rates among emergency department-treated poisoning patients.

The Children and Domestic Violence Services (CADVS) study is a project to collect detailed, contextual data at the state and local levels on the organization and relationship of child welfare services for children, and domestic violence services for women. Although previous research has found a high rate of domestic violence in families involved with child welfare services (CWS), little systematic research on a national scale is available about state and local policies and practices related to these families. The project reported in this article is a supplemental study of the National Survey of Child and Adolescent Well-Being (NSCAW), a national probability study of more than 5000 children and adolescents who become involved with CWS. Whereas, the NSCAW study contains detailed information on children and families, the CADVS study uses the same sample as NSCAW to gain information about the way that CWS and domestic violence service (DVS) agencies operate on behalf of victimized children and caregivers. The CADVS study design allows for linkage of this new contextual information to the individual level survey data collected in NSCAW. The purpose of this paper is to provide an overview of the methodology used in CADVS, including sampling, data collection, and instrument development. Future plans for data analyses, including linkage between CADVS and NSCAW, are discussed.

Objectives To estimate the prevalence of motorcycle-related hospitalization in the United States in 2001 and to describe the demographic, clinical, hospital, and financial characteristics associated with these injuries. Methods Cross-sectional analysis of the 2001 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project was conducted in 2003. Results There were an estimated 30,505 (confidence interval=26,566–34,445) motorcycle-related hospital discharges in 2001. Approximately 62% of cases were aged ≥30 years, and males accounted for 89% of cases. The most common principal diagnoses were fractures of the lower limb (29.4%), fractures of the upper limb (13.1%), and intracranial injuries (12.3%). The mean length of stay was 5 days, the median hospital charge was $15,404, and the total estimated hospital charges were >$841 million. The majority of patients (56.5%) were admitted to large urban teaching hospitals, and these hospitals accounted for nearly 70% of all hospital charges. Approximately 26% of cases were self-pay or listed public insurance as the expected payer. Conclusions These findings shed light on the substantial morbidity and financial impact of motorcycle-related injuries. Renewed and strengthened prevention efforts are warranted.

Objective: To obtain consensus among a panel of experts on performance measures useful for evaluating the quality of hospital-based domestic violence (DV) programs. Methods: The Delphi process of consensus development was used with a panel of 18 experts including DV researchers, program planners, and advocates. Three rounds were conducted over a period of six months, with each round involving the completion of a written questionnaire. Panelists were instructed to concentrate on structure and process measures of DV program performance. Health outcome measures were not considered. During each round, panelists rated (scale of 1-5) their level of agreement with each measure, in terms of the measure's usefulness for evaluating hospital-based DV programs. Data were entered into SPSS on a personal computer and frequency distributions, measures of central tendency, and variance were computed for each measure. Consensus development was defined as a reduction in the item-specific variance from one round to the next. Results: A total of 37 performance measures were agreed upon. These measures fell within nine different domains of DV program activities, including: Policies and Procedures, Hospital Physical Environment, Hospital Cultural Environment, Training of Providers, Screening and Safety Assessment, Documentation, Intervention Services, Evaluation Activities, and Collaboration. Conclusions: A number of measures have been identified as useful for evaluating hospital-based DV programs. Use of these measures should assist researchers, program planners, and administrators in assessing the quality of hospital-based DV programs.

Research has demonstrated that men will admit to the perpetration of domestic violence (DV), if questioned, in the medical setting. The opportunity to identify DV perpetrators, however, also depends on the frequency of contact between health care providers and perpetrators. The purpose of this study was to determine health care use among a group of DV perpetrators. A survey was administered to 133 men enrolled in the largest community-based batterer treatment program in a metropolitan region. Of the 133 men surveyed, 56 (42%) indicated they had visited a doctor, hospital, or received some other type of medical care within the preceding 6 months. Of men reporting health care visits, the majority (41%, n = 23) indicated that the Emergency Department was the location where care was provided. These data demonstrate that Emergency Departments are often visited by DV perpetrators in this community and may be important sites for screening and intervention protocols.

OBJECTIVE: To describe the incidence and patient characteristics of traumatic brain injuries (TBIs) treated in U.S. emergency departments (EDs). METHODS: A secondary analysis was performed on data from the National Hospital Ambulatory Medical Care Survey administered from 1992 to 1994. An ED visit was determined to represent a case of TBI if the case record contained ICD-9-CM codes of 800.0-801.9, 803.0-804.9, or 850.0-854.1. RESULTS: The average annual estimate of new TBI treated in U.S. EDs was 1,144,807, equaling 444 per 100,000 persons (95% CI = 390 to 498), which represents approximately 3,136 new cases of TBI per day and accounts for 1.3% of all ED visits. Males were 1.6 times as likely as females to suffer TBI until the age of 65 years, when the female rate exceeded the male. The rate for blacks was 35% higher than that for whites. The highest overall incidence rate of TBI occurred in the less-than-5-year age group (1,091 per 100,000), closely followed by the more-than-85-year age group (1,026 per 100,000). Falls represented the most common mechanism of TBI injury, followed by motor vehicle-related trauma. CONCLUSIONS: This study underscores the ongoing need for effective surveillance of all types of TBI and evaluation of prevention strategies targeting high-risk individuals. It serves as a clinically grounded and ED-based corroboration of prior survey research, providing a basis for comparison of incidence rates over time and a tool with which to measure the efficacy of future interventions.

Objective:To characterize injury frequency, injury patterns, and health care seeking behavior in women with intimate partners enrolled in batterer intervention programs. Methods: A standardized telephone interview was conducted on a sample of women with male partners enrolled in batterer intervention programs in four U.S. cities. Information on prior injuries and the utilization of health care services was sought. Results: Four hundred and eighty eight of the 648 women (75.3%) reported a history of prior injury as a result of abuse. Contusions were the most common injury. Of the women reporting contusions, 233 (51.4%) reported contusions as their only injuries. Another 220 women (48.6%) reported other injuries in addition to contusions. In the majority of cases (63.2%) the contusions were to multiple body parts. When the contusion involved only one anatomical region, it was mostly to the face. A total of 192 of the 488 injured women (39.3%) reported ever seeking medical care for injuries caused by their intimate partner. Twenty-three women (4.7% of the injured cohort or 3.5% of the total cohort) reported having ever been hospitalized for injuries sustained from abuse.

Objectives: To determine the prevalence of interpersonal physical violence (IPV) among Pennsylvania adults, to identify the personal characteristics of the victims, and to determine their health care use for resulting injuries. Methods: Population-based data describing physical violence were obtained through a statewide telephone survey of 3,620 Pennsylvania adults selected from households by random-digit dialing in 1994. The prevalence and 95% confidence interval (95% CI) of victimization from IPV along with ED or other medical care facility use for IPV-related injuries were computed by several personal characteristics. Logistic regression was used to compare victims of IPV and their levels of health care use. Results: The prevalence of reported victimization from IPV was 5.6% (95% CI = 4.9, 6.3). Significantly more victimization was reported by males, persons aged 18–29 years, those employed, and unmarried persons. The proportion of victims who reported to have gone to an ED or other medical care facility for IPV-related injury treatment was 12.9%. Significantly more persons with annual household incomes

Objective: To determine population-based firearm-related morbidity and mortality for Allegheny County, PA (population = 1.3 million), for the year 1994. Methods: Fatalities were identified from a review of death certificates. To identify nonfatal cases, an active surveillance was conducted at all 24 acute care EDs in the county. The ED surveillance used 2 existing sources of case identification from each hospital to minimize undercount. Results: Firearms were the leading cause of injury death to county residents, accounting for 155 deaths. The crude mortality rate from firearms was 11.7/100,000. Black males aged 15–19 years were most at risk for a firearm fatality (293/100,000). There were 514 nonfatal firearm injuries, producing a case fatality rate of 23%. The highest age-specific rate for nonfatal firearm-related injuries treated in the county EDs was observed for black males aged 15–19 years (2,245/100,000), which is 58 times higher than the firearm-related injury rate for the entire county population (38.7/100,000). Conclusion: Firearm-related injury and death are a significant public health problem in Allegheny County. Although the crude mortality rate from firearms in the county is lower than the reported national rate, the observed rate for nonfatal injuries in the black youth of this community is the highest firearm injury incidence rate ever reported. Local surveillance of firearm-related injuries, including nonfatal events, is needed to more accurately demonstrate the magnitude of this problem.

Objective: To determine the availability of and sample statewide ED injury information obtained from hospital billing data for the purpose of demonstrating the feasibility of information acquisition for subsequent data linkage. Methods: A retrospective, database investigation was conducted to obtain data describing a statewide stratified sample of ED patients. The aim was to collect a computerized billing summary record for each injured ED patient seen at each sampled hospital over a 1-year period. All 215 Pennsylvania acute care hospitals in 1991 were eligible for sample selection. Data collection for the project was conducted in 1993. Participants included directors of hospital medical records and billing departments. Results: Twenty-four hospitals contributed data sets from the original target goal of 31 strata. The final combined data set contained 187,404 records with injury diagnoses from approximately 616,000 ED patient visits, representing a 12% sample of all annual statewide ED visits. Age, sex, date of visit, and primary diagnosis fields were completed from the retrieved data >99% of the time. More than two-thirds of the sampled records had a social security number, and total charges were recorded >90% of the time. Other variables such as name and address were contained in

With data from the Center for Disease Control's Behavioral Risk Factor Surveillance System, we estimated the prevalence of homes with inadequate smoke detector protection from residential fires in Pennsylvania and identified the characteristics of these homes in an effort to identify useful prevention strategies for Pennsylvania and other regions with similar characteristics. Homes with inadequate smoke detector protection from residential fires were defined on three levels. Eight percent (95% CL = 6.8, 8.6) of homes lacked any installed smoke detectors, 14% (95% CL = 12.8, 15) lacked smoke detectors installed on the same floor where they slept, and 28% (95% CL = 26.6, 29.6) were found to engage in unsafe smoke detector practices. The strong predictors of unsafe smoke detector practices determined from logistic regression included black, non-Hispanic homes (OR = 1.53), homes with annual household income of less than +20,000 (OR = 1.29), and those with no children younger than 5 years old (OR = 1.55). These findings should assist policy makers in planning residential fire prevention programs for Pennsylvania, which has yet to meet the Healthy People 2000 objective regarding fire prevention.

Purpose Although myriad health disparities exist in Appalachia, limited research has examined traffic fatalities in the region. This study compared traffic fatality rates in Appalachia and the non-Appalachian United States. Methods Fatality Analysis Reporting System and Census data from 2008 through 2010 were used to calculate traffic fatality rates. Poisson models were used to estimate unadjusted (rate ratio [RR]) and adjusted rate ratios, controlling for age, gender, and county-specific population density levels. Results The Appalachian traffic fatality rate was 45% (95% confidence interval [CI], 1.42–1.47) higher than the non-Appalachian rate. Although only 29% of fatalities occur in rural counties in non-Appalachia versus 48% in Appalachia, rates in rural counties were similar (RR, 0.97; 95% CI, 0.95–1.00). However, the rate for urban, Appalachian counties was 42% (95% CI, 1.38–1.45) higher than among urban, non-Appalachian counties. Appalachian rates were higher for passenger vehicle drivers, motorcyclists, and all terrain vehicle riders, regardless of rurality, as well as for passenger vehicle passengers overall and for urban counties. Conversely, Appalachia experienced lower rates among pedestrians and bicyclists, regardless of rurality. Conclusions Disparities in traffic fatality rates exist in Appalachia. Although elevated rates are partially explained by the proportion of residents living in rural settings, overall rates in urban Appalachia were consistently higher than in urban non-Appalachia.

Motor vehicle crashes continue to be a leading cause of injury morbidity and mortality in the United States, and distracted driving is an increasing problem. From 2005 to 2009, despite considerable declines in overall crash-related fatalities, fatalities associated with driver distraction increased by 22%.1 In 2003, cell phone use while driving was estimated to cause 333 000 total injuries, 12 000 serious to critical injuries, and 2600 fatalities annually.2 A more recent analysis concluded that increasing texting volumes was estimated to result in more than 16 000 additional motor vehicle�related fatalities from 2001 to 2007.3 These concerns have led to an increasing number of educational and legislative efforts to reduce handheld phone use and texting while driving. This Viewpoint suggests that these efforts are inadequate and that new technological and regulatory approaches are needed.

Study objective: To assess current emergency department data collection practices in Pennsylvania and determine whether existing data sources can be used as part of a statewide injury surveillance system. Methods: Separate survey questionnaires requesting information on current ED patient data collection practices and attitudes were mailed to all directors of medical records, billing, and EDs in Pennsylvania (N=212). Results: Of the medical records department respondents, 92% indicated that ED registration data are retained in a computerized information system; 94% of respondents from billing departments reported that their ED patient registration system is integrated with an ED billing system. A total of 36% of EDs surveyed use a computerized ED patient logbook, and another 27% plan to begin a computerized log within 2 years. Dictation and transcription services that permit electronic retrieval of text are being used by 26% of EDs for patient medical records. Conclusion: Many elements for building a statewide ED injury surveillance system are in place in Pennsylvania, but they are as yet incomplete. Future studies should examine the feasibility of integrating existing ED data systems into statewide injury surveillance systems. [Weiss HB, Dill SM, Forjuoh SN, Garrison HG, Coben JH: Injury surveillance: A statewide survey of emergency department data collection practices. Ann Emerg Med December 1996;28:635-640.]

OBJECTIVE: To determine the household prevalence of firearms in Pennsylvania, and describe the storage practices for these weapons. DESIGN: A statewide telephone survey of 3,620 Pennsylvania adults selected from households by random digit dialing in 1994. MAIN OUTCOME MEASURES: Firearm ownership and storage practices were computed by household characteristics using logistic regression. RESULTS: The prevalence of firearm ownership was 37% (95% confidence interval = 35.4 to 38.6). Ownership of firearms was significantly higher for white residents, households with annual income of $20,000 or more, those in rural counties, and those with children and adolescents. Of the households with firearms, 23% contained a single firearm, the majority of which were handguns (40%) or rifles (40%); 76% had two or more firearms, with 57% reporting one handgun or more and 83% reporting one rifle or more. Storage of firearms in 72% of households involved two or more of these barriers: (1) taken apart; (2) trigger lock applied; (3) kept in a locked place; (4) unloaded; (5) no other ammunition; (6) locked ammunition; 6% stored at least one of their firearms with none of these barriers. The strongest predictor of storing a firearm with fewer than two protective barriers was households with no children or adolescents. CONCLUSIONS: Firearms are present in a large number of Pennsylvania homes. Many of these homes also contain children. To reduce the potential risks of firearms, optimal methods of storage of firearms in the home need to be determined.

STUDY OBJECTIVE: To evaluate existing emergency department logbooks as a source of population-based data on firearm-related injuries. METHODS: We examined the logbooks of the 24 acute care and specialty-hospital EDs in Allegheny County, Pennsylvania, to determine the number and type of data variables each contained and the completeness of reporting of each variable for selected firearm-related cases. The amount of missing data for certain variables was determined and the cause for the missing data described. RESULTS: Logbooks from 18 of the 24 eligible hospitals were reviewed. We identified 785 cases of firearm-related injury recorded between January 1, 1992, and December 31, 1993. Of the variables we selected for analysis, only date (100%), chief complaint or diagnosis (100%), name (98%), and time of admission (97%) were consistently documented. In 37% of cases the patient's county of residence could not be determined. Similarly incomplete data were found for body part injured (31%), race (28%), age (26%), sex (22%), and mode of arrival (21%). The factor most responsible for the high percentage of incomplete data was the considerable variation in the data elements contained in the different hospitals' logbooks. CONCLUSION: Missing data resulting from inconsistencies in the variables contained in different EDs' logbooks and errors of omission prevent ED logbooks, in their current state, from providing population-based data for surveillance of firearm-related injury. Standardization of such variables in ED logbooks would yield a more useful source of information for injury and disease surveillance. In lieu of standardized logbooks, multiple sources of data are necessary to establish a more comprehensive and useful system of surveillance of firearm-related injury.

Objective Graduated Driver Licensing (GDL) has been implemented in Australia, Canada, New Zealand, USA and Israel. We conducted an exploratory summary of available data to estimate whether GDL effects varied with age. Methods We searched MEDLINE and other sources from 1991–2011. GDL evaluation studies with crashes resulting in injuries or deaths were eligible. They had to provide age-specific incidence rate ratios with CI or information for calculating these quantities. We included studies from individual states or provinces, but excluded national studies. We examined rates based on person-years, not license-years. Results Of 1397 papers, 144 were screened by abstract and 47 were reviewed. Twelve studies from 11 US states and one Canadian province were selected for meta-analysis for age 16, eight were selected for age 17, and four for age 18. Adjusted rate ratios were pooled using random effects models. The pooled adjusted rate ratios for the association of GDL presence with crash rates was 0.78 (95% CI 0.72 to 0.84) for age 16 years, 0.94 (95% CI 0.93 to 0.96) for 17 and 1.00 (95% CI 0.95 to 1.04) for 18. The difference between these three rate ratios was statistically significant: p Conclusions GDL policies were associated with a 22% reduction in crash rates among 16-year-old drivers, but only a 6% reduction for 17-year-old drivers. GDL showed no association with crashes among 18-year-old drivers. Because we had few studies to summarise, particularly for older adolescents, our findings should be considered exploratory.

OBJECTIVES: To examine nurse home visitors' perspectives of and intentions to report children's exposure to intimate partner violence (IPV) in the context of the home visitation setting. DESIGN AND SAMPLE: Cross-sectional study of 532 nurse home visitors in the Nurse-Family Partnership home visitation program. MEASURES: A web-based questionnaire assessing nurse home visitors' support for and attitudes toward mandatory reporting of children's exposure to IPV. Nurses' considerations of what levels of exposure constitute maltreatment and their intended reporting behaviors were also examined. RESULTS: Variability and uncertainty were observed in participants' attitudes as well as in their determinations as to which situations constitute child maltreatment. Most of the sample believed reporting exposure to IPV can help the battered woman (67%) and can protect children (92%), while 56% indicated that reporting can negatively affect the nurse-client relationship. Nurses were more likely to endorse reporting children's exposure to IPV when the child was at greatest risk for being physically injured as a result of IPV. CONCLUSIONS: Training about maltreatment reporting procedures in home visitation programs should focus on the interpretation of child maltreatment laws as well as collaborations with local child protection service agencies to determine if children's exposure to IPV is reportable. Language: en

Background Intimate partner violence (IPV) and child maltreatment (CM) are major global public health problems. The Preventing Violence Across the Lifespan (PreVAiL) Research Network, an international group of over 60 researchers and national and international knowledge-user partners in CM and IPV, sought to identify evidence-based research priorities in IPV and CM, with a focus on resilience, using a modified Delphi consensus development process. Methods Review of existing empirical evidence, PreVAiL documents and team discussion identified a starting list of 20 priorities in the following categories: resilience to violence exposure (RES), CM, and IPV, as well as priorities that cross-cut the content areas (CC), and others specific to research methodologies (RM) in violence research. PreVAiL members (N = 47) completed two online survey rounds, and one round of discussions via three teleconference calls to rate, rank and refine research priorities. Results Research priorities were: to examine key elements of promising or successful programmes in RES/CM/IPV to build intervention pilot work; CC: to integrate violence questions into national and international surveys, and RM: to investigate methods for collecting and collating datasets to link data and to conduct pooled, meta and sub-group analyses to identify promising interventions for particular groups. Conclusions These evidence-based research priorities, developed by an international team of violence, gender and mental health researchers and knowledge-user partners, are of relevance for prevention and resilience-oriented research in the areas of IPV and CM.

Background Despite an increase in knowledge about the epidemiology of intimate partner violence (IPV), much less is known about interventions to reduce IPV and its associated impairment. One program that holds promise in preventing IPV and improving outcomes for women exposed to violence is the Nurse-Family Partnership (NFP), an evidence-based nurse home visitation program for socially disadvantaged first-time mothers. The present study developed an intervention model and modification process to address IPV within the context of the NFP. This included determining the extent to which the NFP curriculum addressed the needs of women at risk for IPV or its recurrence, along with client, nurse and broader stakeholder perspectives on how best to help NFP clients cope with abusive relationships. Methods Following a preliminary needs assessment, an exploratory multiple case study was conducted to identify the core components of the proposed IPV intervention. This included qualitative interviews with purposeful samples of NFP clients and community stakeholders, and focus groups with nurse home visitors recruited from four NFP sites. Conventional content analysis and constant comparison guided data coding and synthesis. A process for developing complex interventions was then implemented. Results Based on data from 69 respondents, an IPV intervention was developed that focused on identifying and responding to IPV; assessing a client's level of safety risk associated with IPV; understanding the process of leaving and resolving an abusive relationship and system navigation. A need was identified for the intervention to include both universal elements of healthy relationships and those tailored to a woman's specific level of readiness to promote change within her life. A clinical pathway guides nurses through the intervention, with a set of facilitators and corresponding instructions for each component. Conclusions NFP clients, nurses and stakeholders identified the need for modifications to the existing NFP program; this led to the development of an intervention that includes universal and targeted components to assist NFP nurses in addressing IPV with their clients. Plans for feasibility testing and evaluation of the effectiveness of the IPV intervention embedded within the NFP, and compared to NFP-only, are discussed.

Violence has reached epidemic proportions in the United States with particularly serious health implications for school-age children and adolescents. Schools that experience the daily threat of potential student violence have their primary mission of education eroded at great cost to students. This article reviews the problem of violence in public schools and summarizes existing knowledge on school violence prevention. Violence prevention programs that use educational, regulatory, technological, or combined approaches are reviewed. Recommendations are presented addressing both policy and program needs related to control of violence in public schools. School health professionals should be active participants in violence prevention efforts. A critical need exists to carefully evaluate any planned prevention program so future efforts can be built on methods proven successful. VioLit summary: OBJECTIVE: The aim of this article by Coben et al. was to examine the problem of violence in public schools and summarize the existing knowledge regarding school violence prevention. Violence prevention programs are also reviewed. METHODOLOGY: A non-experimental review of school-based violence prevention programs was discussed. FINDINGS/DISCUSSION: The authors summarized four violence prevention approaches: educational, environmental and technological, regulatory, and combined. The educational approach included a mentoring strategy where high risk students were trained as advocates for violence prevention. This mentoring method involves learning leadership skills, public speaking techniques, and the relationship of guns, drugs, and family tension to violence. The most acclaimed school based educational program cited by the authors is the "Resolving Conflict Creatively Program" which is based in New York City. The program emphasizes conflict resolution and intergroup relations. The program also offers a training course and curricula to teachers in conflict resolution, provides consultations to the classroom, offers parent workshops, and establishes student-peer mediation. The authors noted that although no quantifiable changes in adolescent violence have been documented, the program has been widely accepted and integrated in the schools by teachers. Environmental and technological approaches emphasized minimizing hazards and risks by modifying the social and physical environments. The environment would be modified by setting protective barriers, reducing access to danger, and limiting exposure to violent behavior (eg. limiting the number of potential entrances to a school, installing metal detectors, and increasing lighting in high risk areas). Therapeutic programs as well as recreational alternatives were also employed to alter environments. In the Baltimore (MD) City School District, dress codes have been implemented to reduce concealing weapons. As a result of the dress code, firearm and weapon-related incidents have dropped from 55, to 35, to 28 over three years. Regulatory approaches included legal interventions that applied academic, civil, and criminal penalties on inappropriate behaviors (eg. curfews, school policing, weapon carrying laws, and laws regulating sales of weapons). Success of regulation was noted by the authors to be dependent on community support. In 1976, the District of Columbia banned the purchase, sale, transfer, or possession of handguns by civilians and the homicide rate dropped 25% the first year after the ban went into effect. The authors noted that there has been no convincing data regarding the effectiveness of other commonly used regulatory approaches. Combined approaches incorporated both school and community based crisis intervention, job counseling, recreational opportunities, and a modification of the environment. Two examples of this type of intervention are the Violence Prevention Project based in Boston, Mass. and the Community Youth Gang Services in Los Angeles, Ca. Program evaluations of this type of intervention suggest that there has been some changes in knowledge and attitudes among students who complete the program as well as a limited change in self-reports of fighting. The authors noted that few programs have been evaluated and those that have are often limited to attitudinal changes and not behavioral changes. AUTHORS' RECOMMENDATIONS: The authors made seven recommendations for school health professionals: 1) Establish violence prevention as a long-term priority in school districts, 2) Establish structures that promote community, student, family, and teacher involvement, 3) Include violence prevention as part of school based health services, 4) Carefully evaluate any program or intervention that is implemented in the schools, 5) Allocate resources to children at highest risk of developing aggressive lifestyles, 6) Establish a consistent, developmentally and culturally sensitive curriculum teaching conflict management and peer mediation from elementary through high school, and 7) Technological and environmental controls should be integrated into a comprehensive violence prevention effort (p.312). (CSPV Abstract - Copyright © 1992-2007 by the Center for the Study and Prevention of Violence, Institute of Behavioral Science, Regents of the University of Colorado) Violence Prevention Prevention Recommendations Prevention Program School Security School Violence School Based Student Violence Juvenile Offender Juvenile Violence Program Evaluation Program Effectiveness Prevention Education Educational Factors Environmental Factors Conflict Resolution Prosocial Skills Social Skills Development Law Enforcement Legislation Criminal Justice System Curfew School Policy Community Based Recreation Employment Factors

Medical errors in emergency departments (EDs) may be an important "public health risk." Therefore, scientific public health approaches should be used to 1) assess the magnitude of emergency medical errors with surveillance methods, 2) identify causal factors of these medical errors with clinical epidemiologic methods, and 3) evaluate the effectiveness of interventions aimed at reducing or eliminating emergency medicine errors with health service research techniques. Since errors result from complex human-system interaction, research efforts should focus on actions taken by the patient, factors concerning the ED environment, and actions taken by health care workers. Other medical and nonmedical fields have already made great advancements in studying and reducing human error. Many of these advancements could readily be adapted to study emergency medical errors.

Background Unintentional poisoning deaths have been increasing dramatically over the past decade, and the majority of this increase has resulted from overdoses of specific prescription drugs. Despite this trend, there are limited existing data examining hospitalizations for poisonings, both unintentional and intentional, associated with prescription drugs. A better understanding of these hospitalizations may help identify high-risk populations in need of intervention to prevent subsequent mortality. Purpose This article aims to describe the incidence and characteristics of hospitalizations resulting from poisoning by prescription opioids, sedatives, and tranquilizers in the U.S. from 1999 to 2006 and make comparisons to hospitalizations for all other poisonings during this time period. Methods Hospitalizations for poisonings were selected from the Nationwide Inpatient Sample (NIS), a stratified, representative sample of approximately 8 million hospitalizations each year, according to the principal discharge diagnosis. Intentionality of the poisoning was determined by external cause of injury codes. SAS callable SUDAAN software was used to calculate weighted estimates of poisoning hospitalizations by type and intentionality. Demographic and clinical characteristics of poisoning cohorts were compared. Data were analyzed in 2009. Results From 1999 to 2006, U.S. hospitalizations for poisoning by prescription opioids, sedatives, and tranquilizers increased a total of 65%. This increase was double the increase observed in hospitalizations for poisoning by other drugs and substances. The largest increase in the number of hospitalized cases over the 7-year period was seen for poisonings by benzodiazepines, whereas the largest percentage increase was observed for methadone (400%). In comparison to patients hospitalized for poisoning from other substances, those hospitalized for prescription opioids, sedatives, and tranquilizers were more likely to be women, aged >34 years, and to present to a rural or urban nonteaching hospital. Conclusions Prescription opioids, sedatives, and tranquilizers are an increasing cause of hospitalization. The hospital admission provides an opportunity to better understand the contextual factors contributing to these cases, which may aid in the development of targeted prevention strategies.

Whether intimate partner violence (IPV) screening reduces violence or improves health outcomes for women is unknown.To determine the effectiveness of IPV screening and communication of positive results to clinicians.Randomized controlled trial conducted in 11 emergency departments, 12 family practices, and 3 obstetrics/gynecology clinics in Ontario, Canada, among 6743 English-speaking female patients aged 18 to 64 years who presented between July 2005 and December 2006, could be seen individually, and were well enough to participate.Women in the screened group (n=3271) self-completed the Woman Abuse Screening Tool (WAST); if a woman screened positive, this information was given to her clinician before the health care visit. Subsequent discussions and/or referrals were at the discretion of the treating clinician. The nonscreened group (n=3472) self-completed the WAST and other measures after their visit.Women disclosing past-year IPV were interviewed at baseline and every 6 months until 18 months regarding IPV reexposure and quality of life (primary outcomes), as well as several health outcomes and potential harms of screening.Participant loss to follow-up was high: 43% (148/347) of screened women and 41% (148/360) of nonscreened women. At 18 months (n = 411), observed recurrence of IPV among screened vs nonscreened women was 46% vs 53% (modeled odds ratio, 0.82; 95% confidence interval, 0.32-2.12). Screened vs nonscreened women exhibited about a 0.2-SD greater improvement in quality-of-life scores (modeled score difference at 18 months, 3.74; 95% confidence interval, 0.47-7.00). When multiple imputation was used to account for sample loss, differences between groups were reduced and quality-of-life differences were no longer significant. Screened women reported no harms of screening.Although sample attrition urges cautious interpretation, the results of this trial do not provide sufficient evidence to support IPV screening in health care settings. Evaluation of services for women after identification of IPV remains a priority.clinicaltrials.gov Identifier: NCT00182468.

Objectives: Falls represent an increasingly frequent source of injury among older adults. Identification of fall risk factors in geriatric patients may permit the effective utilization of scarce preventative resources. The objective of this study was to identify independent risk factors associated with an increased 6-month fall risk in community-dwelling older adults discharged from the emergency department (ED). Methods: This was a prospective observational study with a convenience sampling of noninstitutionalized elders presenting to an urban teaching hospital ED who did not require hospital admission. Interviews were conducted to determine the presence of fall risk factors previously described in non-ED populations. Subjects were followed monthly for 6 months through postcard or telephone contact to identify subsequent falls. Univariate and Cox regression analysis were used to determine the association of risk factors with 6-month fall incidence. Results: A total of 263 patients completed the survey, and 161 (61%) completed the entire 6 months of follow-up. Among the 263 enrolled, 39% reported a fall in the preceding year, including 15% with more than one fall and 22% with injurious falls. Among those completing the 6 months of follow-up, 14% reported at least one fall. Cox regression analysis identified four factors associated with falls during the 6-month follow-up: nonhealing foot sores (hazard ratio [HR] = 3.71, 95% confidence interval [CI] = 1.73 to 7.95), a prior fall history (HR = 2.62, 95% CI = 1.32 to 5.18), inability to cut one’s own toenails (HR = 2.04, 95% CI = 1.04 to 4.01), and self-reported depression (HR = 1.72, 95% CI = 0.83 to 3.55). Conclusions: Falls, recurrent falls, and injurious falls in community-dwelling elder ED patients being evaluated for non‐fall-related complaints occur at least as frequently as in previously described outpatient cohorts. Nonhealing foot sores, self-reported depression, not clipping one’s own toenails, and previous falls are all associated with falls after ED discharge. ACADEMIC EMERGENCY MEDICINE 2009; 16:211‐219 a 2009 by the Society for Academic Emergency

An estimated 1 out of 6 women and 1 out of 33 men has been a victim of sexual assault at some point in their lifetime. The objective of this study was to quantify the associations between sexual assault and negative health outcomes among males and females who reported being sexually assaulted in the past 12 months or at some point before the past 12 months. Data were obtained from the 2005 Behavioral Risk Factor Surveillance System core and sexual violence modules. A series of logistic regression models, including all respondents and stratified by gender, was used to identify differences associated with victimization. Among women, victimization before the past 12 months was significantly associated with poor health status, poor mental health, lower life satisfaction, activity limitations, smoking, and binge drinking. Women who reported victimization in the past 12 months were also significantly more likely to report poor mental health, lower life satisfaction, activity limitations, and binge drinking. Among males, significant associations were found with smoking (past 12 months), poor life satisfaction (before the past 12 months) and activity limitations (before the past 12 months). Results of this study suggest that poor mental and physical health associated with victimization are more prevalent in women and that these relationships persist over time. The broad range of outcomes associated with victimization suggests that further research is needed to better understand the consequences associated with sexual violence across the lifespan.

Despite prior research demonstrating higher injury-mortality rates among rural populations, few studies have examined the differences in nonfatal injury risk between rural and urban populations. The objective of this study was to compare injury-hospitalization rates between rural and urban populations using population-based national estimates derived from patient-encounter data.A cross-sectional analysis of the 2004 Nationwide Inpatient Sample was conducted in 2007. Rural-urban classifications were determined based on residence. SUDAAN software and U.S. Census population estimates were used to calculate nationally representative injury-hospitalization rates. Injury rates between rural and urban categories were compared with rate ratios and 95% CIs.An estimated 1.9 million (95% CI=1,800,250-1,997,801) injury-related hospitalizations were identified. Overall, injury-hospitalization rates generally increased with increasing rurality; rates were 27% higher in large rural counties (95% CI=10%, 44%) and 35% higher in small rural counties (95% CI=16%, 55%). While hospitalization rates for assaults were highest in large urban counties, the rates for unintentional injuries from motor vehicle traffic, falls, and poisonings were higher in rural populations. Rates for self-inflicted injuries from poisonings, cuttings, and firearms were higher in rural counties. The total estimated hospital charges for injuries were more than $50 billion. On a per-capita basis, hospital charges were highest for rural populations.These findings highlight the substantial burden imposed by injury on the U.S. population and the significantly increased risk for those residing in rural locations. Prevention and intervention efforts in rural areas should be expanded and should focus on risk factors unique to these populations.

Purpose: This study analyzes the association between center usage rates and the rates of nonadmitted visits to emergency departments (EDs) for poisoning. Basic Procedures: With a log-normal regression model, we analyzed the association between the number of human exposure calls per hospitalized poisoning patient and the number of nonhospitalized ED visits. The data were from 14 states at county level. Main Findings: A 1% higher poison control center (PCC) human exposure call rate for unintentional poisoning is associated, but not necessarily causally, with a 0.18% lower ED visit rate (P b.0001). If the observed association is causative, 15.5 PCC human poison exposure calls prevent one nonadmitted ED visit, yielding a $205 net cost saving and a benefit-cost ratio of 1.4. The savings ignore any reduction in hospital admissions. Principal Conclusions: Increased PCC exposure calls appear to be associated with reduced ED use for unintentional poisoning and appear to reduce net medical spending.

Objective To examine the association between physical domestic violence victimization (both recent and more than a year in past measured by self-report) and self-reported disciplinary practices among female parents/caregivers in a national sample of families referred to child welfare. Methods Cross-sectional survey of more than 3,000 female caregivers in the National Survey of Child and Adolescent Well-being (NSCAW) study, a nationally representative sample of children and their families referred to child welfare agencies for investigation of abuse and neglect. Women reported physical domestic violence victimization and their disciplinary practices for their child on different versions of the Conflict Tactics Scales. Results Four hundred and forty-three women reported prior year domestic violence, 1,161 reported domestic violence but not in the past 12 months, and 2,025 reported no domestic violence exposure. Any prior domestic violence exposure was associated with higher rates of self-reported psychological aggression, physical aggression and neglectful disciplinary behaviors as compared to those with no domestic violence victimization in bivariate comparisons. After controlling for child behavior, demographic factors, and maternal characteristics, those with remote and recent domestic violence victimization employed more self-reported psychological aggression, while only caregivers with recent DV reported more physical aggression or neglectful behaviors. Conclusions In a national child welfare sample, self-reported aggressive and neglectful parenting behaviors were common. In this sample, domestic violence victimization is associated with more self-reported aggressive and neglectful disciplinary behaviors among female caregivers. The mechanism for these associations is not clear. Practice implications Rates of aggressive and neglectful disciplinary practices are especially high among female parents/caregivers exposed to domestic violence. Child welfare agencies should plan routine and structured assessments for domestic violence among parents/caregivers and implement parenting interventions to reduce harmful disciplinary practices for those families identified.

Objectives: To determine the completeness of external cause of injury coding (E-coding) within healthcare administrative databases in the United States and to identify factors that contribute to variations in E-code reporting across states. Design: Cross sectional analysis of the 2001 Healthcare Cost and Utilization Project (HCUP), including 33 State Inpatient Databases (SID), a Nationwide Inpatient Sample (NIS), and nine State Emergency Department Databases (SEDD). To assess state reporting practices, structured telephone interviews were conducted with the data organizations that participate in HCUP. Results: The percent of injury records with an injury E-code was 86% in HCUP’s nationally representative database, the NIS. For the 33 states represented in the SID, completeness averaged 87%, with more than half of the states reporting E-codes on at least 90% of injuries. In the nine states also represented in the SEDD, completeness averaged 93%. Twenty two states had mandates for E-code reporting, but only eight had provisions for enforcing the mandates. These eight states had the highest rates of E-code completeness. Conclusions: E-code reporting in administrative databases is relatively complete, but there is significant variation in completeness across the states. States with mandates for the collection of E-codes and with a mechanism to enforce those mandates had the highest rates of E-code reporting. Nine statewide ED data systems demonstrate consistently high E-coding completeness.