Frederick P. Rivara

Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence

OBJECTIVE Alcoholism is the leading risk factor for injury. The authors hypothesized that providing brief alcohol interventions as a routine component of trauma care would significantly reduce alcohol consumption and would decrease the rate of trauma recidivism. METHODS This study was a randomized, prospective controlled trial in a level 1 trauma center. Patients were screened using a blood alcohol concentration, gamma glutamyl transpeptidase level, and short Michigan Alcoholism Screening Test (SMAST). Those with positive results were randomized to a brief intervention or control group. Reinjury was detected by a computerized search of emergency department and statewide hospital discharge records, and 6- and 12-month interviews were conducted to assess alcohol use. RESULTS A total of 2524 patients were screened; 1153 screened positive (46%). Three hundred sixty-six were randomized to the intervention group, and 396 to controls. At 12 months, the intervention group decreased alcohol consumption by 21.8+/-3.7 drinks per week; in the control group, the decrease was 6.7+/-5.8 (p = 0.03). The reduction was most apparent in patients with mild to moderate alcohol problems (SMAST score 3 to 8); they had 21.6+/-4.2 fewer drinks per week, compared to an increase of 2.3+/-8.3 drinks per week in controls (p < 0.01). There was a 47% reduction in injuries requiring either emergency department or trauma center admission (hazard ratio 0.53, 95% confidence interval 0.26 to 1.07, p = 0.07) and a 48% reduction in injuries requiring hospital admission (3 years follow-up). CONCLUSION Alcohol interventions are associated with a reduction in alcohol intake and a reduced risk of trauma recidivism. Given the prevalence of alcohol problems in trauma centers, screening, intervention, and counseling for alcohol problems should be routine.

A Case-Control Study of the Effectiveness of Bicycle Safety Helmets

Bicycling accidents cause many serious injuries and, in the United States, about 1300 deaths per year, mainly from head injuries. Safety helmets are widely recommended for cyclists, but convincing evidence of their effectiveness is lacking. Over one year we conducted a case-control study in which the case patients were 235 persons with head injuries received while bicycling, who sought emergency care at one of five hospitals. One control group consisted of 433 persons who received emergency care at the same hospitals for bicycling injuries not involving the head. A second control group consisted of 558 members of a large health maintenance organization who had had bicycling accidents during the previous year. Seven percent of the case patients were wearing helmets at the time of their head injuries, as compared with 24 percent of the emergency room controls and 23 percent of the second control group. Of the 99 cyclists with serious brain injury only 4 percent wore helmets. In regression analyses to control for age, sex, income, education, cycling experience, and the severity of the accident, we found that riders with helmets had an 85 percent reduction in their risk of head injury (odds ratio, 0.15; 95 percent confidence interval, 0.07 to 0.29) and an 88 percent reduction in their risk of brain injury (odds ratio, 0.12; 95 percent confidence interval, 0.04 to 0.40). We conclude that bicycle safety helmets are highly effective in preventing head injury. Helmets are particularly important for children, since they suffer the majority of serious head injuries from bicycling accidents.

Suicide in the home in relation to gun ownership

BACKGROUND It has been suggested that limiting access to firearms could prevent many suicides, but this belief is controversial. To assess the strength of the association between the availability of firearms and suicide, we studied all suicides that took place in the homes of victims in Shelby County, Tennessee, and King County, Washington, over a 32-month period. METHODS For each suicide victim (case subject), we obtained data from police or the medical examiner and interviewed a proxy. Their answers were compared with those of control subjects from the same neighborhood, matched with the victim according to sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods. RESULTS During the study period, 803 suicides occurred in the two counties, 565 of which (70 percent) took place in the home of the victim. Fifty-eight percent (326) of these suicides were committed with a firearm. After excluding 11 case subjects for various reasons, we were able to interview 80 percent (442) of the proxies for the case subjects. Matching controls were identified for 99 percent of these subjects, producing 438 matched pairs. Univariate analyses revealed that the case subjects were more likely than the controls to have lived alone, taken prescribed psychotropic medication, been arrested, abused drugs or alcohol, or not graduated from high school. After we controlled for these characteristics through conditional logistic regression, the presence of one or more guns in the home was found to be associated with an increased risk of suicide (adjusted odds ratio, 4.8; 95 percent confidence interval, 2.7 to 8.5). CONCLUSIONS Ready availability of firearms is associated with an increased risk of suicide in the home. Owners of firearms should weigh their reasons for keeping a gun in the home against the possibility that it might someday be used in a suicide.

The cost and frequency of hospitalization for fall-related injuries in older adults

Using a population-based hospital discharge registry with E codes, we examine the 1989 hospitalizations of older adults in Washington State for fall-related injuries. Fall-related trauma accounted for 5.3% of all hospitalizations of older adults, with hospital charges totaling

Management of severe head injury: Institutional variations in care and effect on outcome

53,346,191, and resulted in discharge to nursing care more often than other such hospitalizations. An annual hospitalization rate of 13.5 per 1000 persons and an annual cost of

Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation.

92 per person is reported. The importance of preventing fall-related injuries in older adults is discussed.

Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals: A Cost Benefit Analysis

ObjectiveThe purpose of this study was three-fold: a) to examine variations in care of patients with severe head injury in academic trauma centers across the United States; b) to determine the proportion of patients who received care according to the Brain Trauma Foundation guidelines; and c) to correlate the outcome from severe traumatic brain injury with the care received. DesignRetrospective data collection for consecutive patients with closed head injury and long bone fracture admitted over an 8-month period. SettingThirty-four academic trauma centers in the United States PatientsAll patients admitted with a presenting Glasgow Coma Scale score ≤8. Measurements and Main ResultsVariations in care were assessed, including prehospital intubation, intracranial pressure monitoring, use of osmotic agents, hyperventilation, and computed tomography scan utilization. Aggressive centers were defined as those placing intracranial pressure monitors in >50% of patients meeting the Brain Trauma Foundation criteria for intracranial pressure monitoring. The primary outcome variables were mortality, functional status at discharge, and length of stay. Kaplan-Meier survival analysis was performed for aggressive vs. nonaggressive centers. A Cox proportional hazard model was used to evaluate the association between type of center and mortality rate. Length of stay was evaluated by using linear regression. ResultsThere was considerable variation in the rates of prehospital intubation, intracranial pressure monitoring, intracranial pressure-directed therapy, and head computed tomography scan utilization across centers. Management at an aggressive center was associated with a significant reduction in the risk of mortality (hazard ratio, 0.43; 95% confidence interval, 0.27–0.66). There was no statistically significant difference in functional status at the time of discharge for survivors. Adjusted length of stay for survivors at aggressive centers was shorter, compared with the length of stay at nonaggressive centers: −6 days (95% confidence interval, −14 to 2 days). ConclusionConsiderable national variation in the care of severely head-injured patients persists. An “aggressive” management strategy is associated with decreased mortality rate for patients with severe head injury, with no significant difference in functional status at discharge among survivors.

Handgun regulations, crime, assaults, and homicide. a tale of two cities

BACKGROUND Regional trauma systems were proposed 2 decades ago to reduce injury mortality rates. Because of the difficulties in evaluating their effectiveness and the methodologic limitations of previously published studies, the relative benefits of establishing an organized system of trauma care remains controversial. METHODS Data on trauma systems were obtained from a survey of state emergency medical service directors, review of state statutes and a previously published trauma system inventory. Injury mortality rates were obtained from national vital statistics data, whereas motor vehicle crash (MVC) mortality rates were obtained from the Fatality Analysis Reporting System. Mortality rates were compared between states with and without trauma systems. RESULTS As of 1995, 22 states had regional trauma systems. States with trauma systems had a 9% lower crude injury mortality rate than those without. When MVC-related mortality was evaluated separately, there was a 17% reduction in deaths. After controlling for age, state speed laws, restraint laws, and population distribution, there remained a 9% reduction in MVC-related mortality rate in states with a trauma system. CONCLUSION These data demonstrate that a state trauma system is associated with a reduction in the risk of death caused by injury. The effect is most evident on analysis of MVC deaths.

Medical and Psychosocial Diagnoses in Women With a History of Intimate Partner Violence

Objective:To determine if brief alcohol interventions in trauma centers reduce health care costs. Summary Background Data:Alcohol-use disorders are the leading cause of injury. Brief interventions in trauma patients reduce subsequent alcohol intake and injury recidivism but have not yet been widely implemented. Methods:This was a cost-benefit analysis. The study population consisted of injured patients treated in an emergency department or admitted to a hospital. The analysis was restricted to direct injury-related medical costs only so that it would be most meaningful to hospitals, insurers, and government agencies responsible for health care costs. Underlying assumptions used to arrive at future benefits, including costs, injury rates, and intervention effectiveness, were derived from published nationwide databases, epidemiologic, and clinical trial data. Model parameters were examined with 1-way sensitivity analyses, and the cost-benefit ratio was calculated. Monte Carlo analysis was used to determine the strategy-selection confidence intervals. Results:An estimated 27% of all injured adult patients are candidates for a brief alcohol intervention. The net cost savings of the intervention was

Predictors of survival and severity of disability after severe brain injury in children.

89 per patient screened, or