Biomedical subjects

J Michael Dean

Publications and source records attributed to J Michael Dean.

17 recordsLinked to original sources

PubMed2006

Crossing county lines: the impact of crash location and driver's residence on motor vehicle crash fatality.

INTRODUCTION: Studies have demonstrated that the fatality risk for motor vehicle crashes (MVCs) is higher in rural than urban areas. The purpose of this study was to quantify the risk of a fatal outcome associated with a crash by the urban/rural classification of the driver's county of residence and the county of crash before and after adjusting for potentially confounding factors. METHODS: County of crash and driver's county of residence were classified as urban or rural for 514,648 Utah crash participants. Multivariate regression analysis was used to assess the impact of rural versus urban crash location on fatality outcomes for both urban and rural drivers. RESULTS: Before adjusting for confounding factors the relative risk of fatality in a rural versus urban crash was 9.7 (95% CI: 8.0-11.7) for urban drivers and their passengers compared to 1.8 (95% CI: 1.3-2.6) for rural residents. Adjustment for behavioral, road, and crash characteristics reduced risk estimates to 2.8 (95% CI: 2.2-3.5) and 1.2 (95% CI: 0.8-1.7), respectively. CONCLUSION: Urban and rural drivers may have distinct risk factors for MVC fatality in rural areas. Interventions to reduce the risk of fatality in rural areas should evaluate the needs of both urban and rural drivers.

Accidents, Traffic↗

PubMed2006

Collaborative Pediatric Critical Care Research Network (CPCCRN).

Pediatric critical care was formally recognized as a separate subspecialty in pediatrics in 1987. Since that time the numbers of pediatric intensivists, pediatric intensive care units, and pediatric intensive care beds in the United States have increased dramatically. Research efforts have lagged behind, however, as this new discipline has struggled to identify the necessary time, funding, and other resources to pursue clinical and laboratory investigation. In April 2004, the National Center for Medical Rehabilitation Research of the National Institute for Child Health and Human Development issued a request for applications to establish the Collaborative Pediatric Critical Care Research Network (CPCCRN). The CPCCRN provides an infrastructure to pursue collaborative clinical trials and descriptive studies in pediatric critical care medicine. Six pediatric centers involving seven intensive care units and a data-coordinating center were identified through a competitive application process. Network goals include the support of collaborative clinical trials otherwise impracticable in single institutions and the establishment of a framework for developing the scientific basis for pediatric critical care practice. This article describes how the CPCCRN was established, its organization, and its goals and future plans.

Child↗

PubMed2006

Risk of pediatric back-over injuries in residential driveways by vehicle type.

OBJECTIVE: Research suggests that children experience driveway back-over injuries at a significant rate and the severity of the resulting injuries differ by type of vehicle. Yet, no US study attempted to quantify "back-over risk" for classes of vehicles because of the difficulties with determining exposure. Using vehicle registration information, we set out to estimate the relative risk of driveway back-over injuries to children by type of vehicle. METHODS: Driveway back-over events were identified from state police reports and medical records from the state level 1 pediatric trauma center and compared with vehicle registration information to estimate injury incidence for 4 classes of vehicles (passenger cars, trucks, sport utility vehicles, and minivans) over 6 years in the state of Utah. RESULTS: Reported driveway back-over injuries represent an incidence of 7.09 per 100,000 children (<10 years old) per year. Overall, passenger cars account for 1.62 injuries per 100,000 registered vehicles. Compared with passenger cars, children were 53% more likely to be injured by a truck (P = 0.01) and 2.4 times more likely to be injured by a minivan (P < 0.001). Among children transported to a trauma center, admission (P = 0.01) and need for surgery (P = 0.03) were greater among children backed over by trucks, sport utility vehicles, and minivans compared with passenger cars. CONCLUSIONS: Findings suggest that when assessing driveway back-over injuries, larger high-profile vehicles are associated with a higher incidence and severity of injuries when compared with injuries resulting from passenger cars.

Accidents, Home↗

PubMed2006

Epidemiology of a pediatric emergency medicine research network: the PECARN Core Data Project.

OBJECTIVE: To examine the epidemiology of pediatric patient visits to emergency departments (ED). METHODS: We conducted a cross-sectional study of pediatric ED visits at the participating Pediatric Emergency Care Applied Research Network (PECARN) hospitals in 2002. We provide descriptive characteristics of pediatric ED visits and a comparison of the study database to the National Hospital Ambulatory Medical Care Survey (NHAMCS). Bivariate analyses were calculated to assess characteristics associated with hospital admission, death in the ED, and length of ED visit. We also performed multivariate regression to model the likelihood of admission to the hospital. RESULTS: Mean patient age was 6.2 years; 53.5% were boys; 47.5% black; and 43.2% had Medicaid insurance. The most common ED diagnoses were fever, upper respiratory infection, asthma, otitis media, and viral syndromes. The inpatient admission rate was 11.6%. The most common diagnoses requiring hospitalization were asthma, dehydration, fever, bronchiolitis, and pneumonia. In multivariate analysis, patients who were black or Hispanic, had Medicaid insurance or were uninsured, or were older than 1 year were less likely to be hospitalized. Demographics of the PECARN population were similar to NHAMCS, with notable exceptions of a larger proportion of black patients and of admitted patients from the PECARN EDs. CONCLUSION: We describe previously unavailable epidemiological information about childhood illnesses and injuries that can inform development of future studies on the effectiveness, outcomes, and quality of emergency medical services for children. Most pediatric ED patients in our study sought care for infectious causes or asthma and were discharged from the ED. Hospital admission rate differed according to age, payer type, race/ethnicity, and diagnosis.

Adolescent↗

PubMed2005

Availability of pediatric emergency visit data from existing data sources.

OBJECTIVES: To determine the availability and completeness of selected data elements from administrative and clinical sources for emergency department (ED) visits in a national pediatric research network. METHODS: This was a retrospective study of 25 EDs in the Pediatric Emergency Care Applied Research Network. Data were obtained from two sources at each ED: 1) extant electronic administrative data for all visits during a 12-month period in 2002 and 2) data abstracted from medical records by trained abstractors for visits during ten randomly selected days over a three-month period in 2003. Epidemiologic data were obtained for all visits and additional clinical data for patients with two target conditions: asthma and fractures. RESULTS: A total of 749,036 visits were analyzed from administrative sources and 12,756 medical records abstracted. Data availability varied by element, method of capture, and site. From administrative sources, data on insurance type were the most complete (1.3% overall missing; range, 0%-18.5% for individual sites), whereas mode of arrival (25.5% missing) and triage time (65.3%) were the least complete. Disposition was missing in only 1.2% of medical records overall (range, 0%-5%) and diagnosis was missing in 3% (range, 0%-16%); these were missing from 14.4% and 10.5%, respectively, of administrative sources. Among visits with injury diagnoses, E-codes were missing in 27% of cases. For patients with asthma (n = 861), documentation of specific elements of the clinical examination by nurses and physicians was also variable. CONCLUSIONS: Data elements important in emergency medical care for children are frequently missing in existing administrative and medical record sources; completeness varies widely across EDs. Researchers must be aware of these limitations in the use of existing data when planning studies.

Data Collection↗

PubMed2005

Health insurance, neighborhood income, and emergency department usage by Utah children 1996-1998.

BACKGROUND: It is estimated that approximately half of emergency department (ED) usage in the U.S. and other developed countries is for non-urgent conditions and that this usage is related to availability, social, and economic factors. We examined pediatric ED usage in a U.S. state with respect to income, health insurance status, types of medical conditions, and whether introduction of managed care affected utilization by Medicaid children. METHODS: Emergency department usage rates were calculated from 1996 through 1998 using Utah ED data for children with commercial health insurance, Medicaid, for uninsured children, and by income group estimating neighborhood household income from Zip code of residence. We analyzed usage following the July 1996 transition of Utah Medicaid to managed care. RESULTS: Children with Medicaid had approximately 50% greater ED utilization rates than children with commercial health insurance or uninsured children. The majority of usage for Medicaid and uninsured children was for non-traumatic conditions. Only 35% of total ED usage was for non-emergent or non-urgent conditions and this was related to both Medicaid and low household income. Children lacking health insurance were more likely to be discharged against medical advice (OR = 2.36, 95% C.I. 1.88-2.96). There was no reduction in Medicaid ED usage following the transition to managed care. CONCLUSION: Usage of ED services is related to both health insurance status and income. Children lacking health insurance and Medicaid children have excessive usage for conditions which could be treated in a primary care setting. That managed care does not reduce Medicaid ED usage is consistent with findings of other studies.

Adolescent↗

PubMed2004

Resource utilization and its management in splenic trauma.

BACKGROUND: This study compared resource utilization and its management for splenic injury at 2 level-I trauma centers and a pediatric referral center with other facilities in a state currently developing a trauma system. METHODS: Management strategy, length of stay, and total charges for children were compared among the pediatric referral center, trauma centers, and other facilities. Adult management, length of stay, and total charges were compared between trauma centers and other facilities. RESULTS: Nonoperative management was more frequent in children at the pediatric referral center than trauma centers or other facilities and was more common in adults at trauma centers than at other facilities. Mean length of stay and total charges for children were significantly greater at the pediatric referral center and trauma centers than at other facilities and for adults at trauma centers than at other facilities. Facility type was associated with length of stay and total charges when injury type and severity were controlled. CONCLUSIONS: Nonoperative management of splenic injury is more common at trauma centers, and splenic trauma management may be more costly at trauma centers.

Adult↗

PubMed2004

National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 kids' inpatient database.

OBJECTIVES: To identify and to generate national estimates of the principal gastrointestinal (GI) diagnoses associated with hospital utilization and to describe national hospital utilization patterns associated with pediatric GI disorders. STUDY DESIGN: We analyzed a nationwide and stratified probability sample of 1.9 million hospital discharges from 1997 of children 18 years and younger, weighted to 6.7 million discharges nationally. Principal GI diagnoses were identified through the use of the Clinical Classification Software and Major Diagnostic Categories. RESULTS: In 1997 in the United States, there were 329,825 pediatric discharges associated with a principal GI diagnosis, accounting for more than 2.6 billion US dollars in hospital charges and more than 1.1 million hospital days. Appendicitis, intestinal infection, noninfectious gastroenteritis, abdominal pain, esophageal disorders, and digestive congenital anomalies combined accounted for 75.1% of GI discharge diagnoses, 64.2% of GI hospital charges, and 68.0% of GI hospital days. Excluding normal newborn infants and conditions related to pregnancy, GI disorders were the third leading cause of hospitalization. CONCLUSIONS: GI disorders are a leading cause of hospitalization of children. A minority of GI conditions account for the majority of measures of utilization. Children are hospitalized for GI conditions and at institutions that are distinct from adults.

Adolescent↗

PubMed2004

Effect of repeal of the national maximum speed limit law on occurrence of crashes, injury crashes, and fatal crashes on Utah highways.

Speed limits were increased in Utah and other States after repeal of the national maximum speed limit law (NMSL) in 1995. This study analyzed effects of the increased speed limit on Utah highways on crash rates, fatality crash rates, and injury crash rates. Annual (1992-1999) rates of crashes, fatality crashes, and injury crashes for the following highway categories were calculated: urban Interstate segments (current speed limit 60-65 miles per hour (mph)); rural Interstate segments (current speed limit 70-75 mph); 55 mph rural non-Interstate highway segments; and high-speed non-Interstate highways (current speed limit 60-65 mph). Data were analyzed using autoregressive integrative moving average intervention time series analysis techniques. There were significant increases in total crash rates on urban (60-65 mph) Interstate segments (confounded by extensive ongoing highway construction on these highways), and in fatal crash rates on high-speed (60-65 mph) rural non-Interstate segments. The following variables were unaffected: total, fatality, and injury crash rates on rural Interstate segments; fatality and injury crash rates on urban Interstate segments; total and injury crash rates on high-speed non-Interstate segments. These results show an adverse effect on crash occurrence for subsets of crash types and highways, but do not show a major overall effect of NMSL repeal and increased speed limit on crash occurrence on Utah highways.

Accidents, Traffic↗

PubMed2004

Trends of behavioral risk factors in motor vehicle crashes in Utah, 1992-1997.

OBJECTIVE: Measure changes in the prevalence of behavioral factors including police-reported fatigue and alcohol intoxication, as well as self-reported seatbelt use, and assess their effect on hospitalization or death after a motor vehicle crash. METHODS: Probabilistic linkage was used to match drivers in motor vehicle crashes with hospital discharge records for the years 1992-1997. Frequencies of specific behavioral factors were evaluated using the Cochran-Armitage test for trend. Odds ratios and corresponding 95% confidence intervals were calculated using generalized estimating equations (GEEs) with crash and driver characteristics as independent variables and hospitalization or death as the dependent variable. RESULTS: The analysis database consisted of 450,286 crash driver records, which linked to 4219 (0.9%) hospitalizations or deaths. There was an increasing trend for self-reported seatbelt use among crash-involved drivers from 80.5% in 1992 to 89.3% in 1997 (P<0.001). Police-reported alcohol intoxication among crash-involved drivers showed a decreasing trend from 2.4% in 1992 to 1.5% in 1997 (P<0.001). There was no trend for police-reported fatigue-related crashes. Odds ratios of hospitalization or death for seatbelt use, alcohol involvement, and fatigue were significant and did not fluctuate considerably between 1992 and 1997. Seatbelt use offered a protective effect from hospitalization or death, while alcohol intoxication and fatigue contributed to increased likelihood of hospitalization or death. CONCLUSIONS: These results suggest that while some improvement has been made in decreasing seatbelt non-use and driver alcohol intoxication among crash-involved drivers, no improvement has been made in reducing fatigue-related crashes.

Accidents, Traffic↗

PubMed2004

Repeat patients to the emergency department in a statewide database.

OBJECTIVES: To describe the epidemiology of repeat users of the emergency department (ED) using a statewide database. METHODS: Probabilistic linkage was used to convert three years of statewide ED visit data into a longitudinal, patient-based data set. Patients were classified as single, repeat (at least two visits within three years), or serial (four or more visits within a 365-day period) users of the ED. Serial patients were further stratified by the number of EDs attended. Descriptive statistics were used to assess differences between patient types. RESULTS: There were 1,370,607 separate visits associated with 780,074 patients from 1996 to 1998. While repeat and serial patients represented 33% of the patients, they accounted for 62% of the ED visits during the study period. Repeat and serial patients were younger and had smaller median ED charges per visit than single-use patients. Serial patients attending five or more EDs were more likely to be coded as self-pay than other serial patients. Diagnosis codes relating to sprains, back problems, and headaches were prevalent among serial patients who visited five or more EDs. Approximately 30% of serial patients during the first year remained serial patients in the second year. CONCLUSIONS: Due to the high turnover in serial patients, control groups in future studies are necessary to evaluate interventions aimed at decreasing serial ED use. The likelihood of serial ED users to use multiple EDs indicates that those studying serial ED use should collect data from multiple EDs.

Adolescent↗

PubMed2003

Effect of motor vehicle crashes on adverse fetal outcomes.

OBJECTIVE: To assess the effect of maternal involvement in motor vehicle crashes on the likelihood of adverse pregnancy outcomes and to estimate the effect of seatbelt use in reducing the occurrence of those outcomes. METHODS: Statewide motor vehicle crash, birth, and fetal death records from 1992 to 1999 were probabilistically linked. Logistic regression was used to compare the likelihood of adverse birth and fetal outcomes including low birth weight, prematurity, placental abruption, fetal distress, excessive bleeding, fetal death, and other complications among pregnant women in crashes and those not in crashes. RESULTS: Of 322,704 single live resident births, 8938 mothers (2.8%) experienced a crash during pregnancy. Pregnant women using seatbelts were not significantly more at risk for adverse fetal outcomes than pregnant women not in crashes. However, pregnant women who did not wear seatbelts during a crash were 1.3 times more likely to have a low birth weight infant than pregnant women not in a crash (95% confidence interval [CI] 1.0, 1.6) and twice as likely to experience excessive maternal bleeding than belted pregnant women in a crash (95% CI 1.0, 4.2). Forty-five of 2645 fetal deaths were linked to a motor vehicle crash, with unbelted pregnant women 2.8 times more likely to experience a fetal death than belted pregnant women in crashes (95% CI 1.4, 5.6). CONCLUSION: Pregnant women should be counseled to wear seatbelts throughout pregnancy and reduce crash risk.

Accidents, Traffic↗

PubMed2003

Against all advice: an analysis of out-of-hospital refusals of care.

STUDY OBJECTIVE: We examine the characteristics of patients involved in out-of-hospital emergency medical services (EMS) incidents that result in refusal of care and determine the rates of subsequent EMS, emergency department (ED), and inpatient care, as well as death within 7 days. METHODS: Utah statewide EMS data identifying refusals of care were probabilistically linked to Utah statewide ED, inpatient, and death certificate data within 7 days of the initial EMS refusals for 1996 to 1998. Refusals were defined as incidents in which field treatment or transport was refused and did not include incidents in which EMS providers deemed care or transport unnecessary. RESULTS: Of 277244 EMS incidents, 14109 (5.1%) resulted in refusals of care. For all age groups, motor vehicle crash dispatches resulted in the highest rate of refusal of care, ranging from 8.0% to 11.7%. Slightly more than 3% of patients involved in a refusal of care incident had a subsequent EMS dispatch within a week. One fifth of the patients involved in EMS refusals of care had a subsequent ED visit. Less than 2% of the EMS refusal patients were hospitalized; hospitalization was highest among children younger than 3 years and adults older than 64 years. Twenty-five adults died within a week of refusing EMS care, of whom 19 (76.0%) were older than 64 years. CONCLUSION: Refusal of care incidents are a small segment of all EMS incidents. They arise from a variety of situations, and the risk for missed intervention may be minimal.

Accidents, Traffic↗

PubMed2002

Evaluating the crash and citation rates of Utah drivers licensed with medical conditions, 1992-1996.

BACKGROUND: Medical problems may affect the ability to drive motor vehicles, and programs that control the issuing of driver licenses to individuals with medical conditions exist in most states. The main activity of these programs is the imposition of restrictions upon the driving privileges of individuals with medical conditions that are deemed to pose some risk to public safety. However, little is known about the effectiveness of these licensing programs. OBJECTIVE: The objective of this study was to compare the rates of adverse driving events (crash, at-fault crash and citations) experienced by drivers licensed with medical conditions to those of age-, sex- and location-matched controls. Separate comparisons were made for drivers reporting medical conditions licensed with full driving privileges, and those with restricted driving privileges (e.g. speed, area and time of day). DESIGN: Retrospective case-control. METHODS: The study population was all drivers licensed in the state of Utah who reported a medical condition on their driver license application, over the 5-year period 1992-1996. Drivers enter the program by self-reporting their medical problems. Control drivers were chosen from the entire population of drivers licensed in Utah for the same period. Information on driver license status, participation in the medical conditions program, citations, involvement in crashes, and death certificate data was obtained from the relevant state agencies. Probabilistic linkage methodology was used to link the records in these disparate databases for eventual analysis. Rates of citation, crashes and at-fault crashes, expressed as events per 10000 license days, were calculated separately for program drivers and their corresponding control groups for each medical condition category and restriction status. These data were used to determine an estimate of relative risk (RR) and 95% confidence intervals. RESULTS: As a group, medical conditions drivers had modestly elevated rates of adverse driving events compared with control drivers (RR 1.09-1.74). Rates in the largest medical category, 'cardiovascular conditions', were not higher than controls. Rates were higher than control for some conditions, such as 'alcohol' and 'learning and memory', for some adverse events (RR 2.2 -5.75). Drivers with more than one medical condition appeared comparable to the general group of medical conditions program drivers. CONCLUSIONS: Drivers in Utah medical conditions program had modestly elevated rates of adverse driving events compared to matched controls. Possible underreporting of medical conditions and accurate assessment of exposure rates are potential weaknesses in the program.

Accidents, Traffic↗

PubMed2002

Development of a pediatric age- and disease-specific severity measure.

OBJECTIVES: To adapt the adult Comprehensive Severity Index (CSI) for hospitalized pediatric patients and evaluate the ability of the CSI to predict common outcomes. STUDY DESIGN: Adult CSI was modified by a panel of pediatric subspecialists from 10 children's hospitals. Predictive power was evaluated by using retrospective data collected from 16,495 randomly selected children admitted to these hospitals from April 1995 through September 1996. Outcomes were mortality, length of stay (LOS), and cost. RESULTS: Admission CSI score predicted mortality well (Hosmer-Lemeshow tests: P =.41-.98) and discriminated well (area under receiver operating characteristic [ROC] curve range = 0.80-0.99) within 9 case-mix groups with > or =10 deaths (P <.0001). Maximum CSI score explained the variation in LOS (r2 = 0.13-0.67) and cost (r2 = 0.08-0.73) within 32 case-mix groups (P <.005). Significant differences existed in admission and maximum average CSI scores across sites in 26 and 29 of 32 case-mix groups, respectively (P <.05). CSI had better predictability than Pediatric Risk of Mortality. CONCLUSIONS: The age- and disease-specific pediatric CSI score correlates highly with LOS, cost, and mortality in hospitalized children and can help determine the best clinical practices for specific diseases and adjust for differences in severity of illness across providers.

Adolescent↗

PubMedDate not supplied

Validation of a predictive model for automated external defibrillator placement in rural America.

OBJECTIVE: The development of Automated External Defibrillators (AEDs) to treat out-of-hospital cardiac arrest (OOHCA) has greatly expanded the availability of life saving defibrillatory shocks in various settings. However, placement of AEDs in rural areas remains perplexing since OOHCAs are rare and unpredictable. We set out to develop a cost-effective rural AED placement model and to test the validity of the resulting model using OOHCAs attended by EMS. METHODS DESIGN: A population-based cross-sectional study. Analytic Plan: An exhaustive literature search was conducted to identify community attributes correlated with successful placement of AEDs in rural regions. Identified attributes were characterized using U.S. Census and CDC heart disease mortality data to estimate the potential risk for AED use and applied this estimate to rural census tracts in all 50 states. Based upon risk, AEDS were assigned to each tract using a first responder model and cost effectiveness was assessed. Using Utah State EMS data, the predicted placement of AEDs in each tract was validated using the actual number of OOHCAs attended by EMS. RESULTS: A total of 14,586 rural census tracts in 50 U.S. states were evaluated. On average, 2,600 AEDs were situated within each state. AED placement in rural areas proved as cost effective as health screening programs. In Utah, predicted AED placement correlated with the frequency of OOHCAs attended by EMS personnel (rho= 0.55, p < 0.001). CONCLUSIONS: The resulting model illustrates one potential way to determine the most beneficial location for rural AED placement.

Adult↗

PubMedDate not supplied

The use of national highway traffic safety administration uniform prehospital data elements in state emergency medical services data collection systems.

OBJECTIVE: Although the concept of emergency medical services (EMS) has existed for 30 years, there is little scientific evidence validating its impact on morbidity and mortality. A significant barrier to conducting meaningful assessments relates to the lack of reliable and uniform EMS data. The objective of this study was to determine the extent to which states incorporate the Uniform Prehospital EMS Data Elements into statewide EMS data collection systems. METHODS: Study investigators requested and compared data elements from all states with a statewide prehospital data collection system. RESULTS: During the study period, 43 states with statewide EMS data collection systems captured, on average, 79% of the Uniform Prehospital EMS Data Set. Variables considered essential to EMS evaluation were more likely collected (84%) than variables considered desirable (72%). Only eight (10%) of the 81 uniform data elements are collected by all 43 participating states. CONCLUSIONS: Findings suggest that related EMS data variables are collected by the majority of states across the country. This degree of similarity provides a foundation for establishing common fields that can be used to develop a national EMS registry.

Accidents, Traffic↗