Selected by Daphne Plaut, MLS, Librarian, Center for Health Research

From Northern California
Use of a dummy (pacifier) during sleep and risk of sudden infant death syndrome (SIDS): population-based case-control study.
Li DK, Willinger M, Petitti DB, Odouli R, Liu L, Hoffman HJ. BMJ 2006 Jan 7;332(7532):18-22.

objectives: To examine the association between use of a dummy (pacifier) during sleep and the risk of sudden infant death syndrome (SIDS) in relation to other risk factors.
design: Population-based case-control study.
setting: Eleven counties in California.
participants: Mothers or carers of 185 infants whose deaths were attributed to SIDS and 312 randomly selected controls matched for race or ethnicity and age.
main outcome measure: Use of a dummy during sleep determined through interviews.
results: The adjusted odds ratio for SIDS associated with using a dummy during the last sleep was 0.08 (95% confidence interval 0.03 to 0.21). Use was associated with a reduction in risk in every category of sociodemographic characteristics and risk factors examined. The reduced risk associated with use seemed to be greater with adverse sleep conditions (such as sleeping prone or on side and sleeping with a mother who smoked), although the observed interactions were not significant. For example, infants who did not use a dummy and slept prone or on their sides (v on their back) had an increased risk of SIDS (2.61, 1.56 to 4.38). In infants who used dummies, there was no increased risk associated with sleeping position (0.66, 0.12 to 3.59). While cosleeping with a mother who smoked was also associated with increased risk of SIDS among infants who did not use a dummy (4.5, 1.3 to 15.1), there was no such association among those who did (1.1, 0.1 to 13.4).
conclusions: Use of a dummy seems to reduce the risk of SIDS and possibly reduces the influence of known risk factors in the sleep environment.
British Medical Journal, 2006, Jan 7;332(7532):18-22. Reproduced with permission from the BMJ Publishing Group.

clinical implication: This was a population-based case-control study conducted in 11 counties in California. The study found that use of a pacifier during sleep reduced the risk of SIDS by 90% compared to nonusers. In addition, use of a pacifier mitigates the other risk factors for SIDS, especially those related to adverse sleep environment including prone sleep position, sleep on soft bedding, and cosleep with a mother who smoked. ­DL

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From the Northwest
Trivalent inactivated influenza vaccine safety in children: Assessing the contribution of telephone encounters.
Mullooly JP, Crane B, Chun C. Vaccine 2006 Mar 20;24(13):2256-63.

We assessed the contribution of telephone medical care encounters to surveillance of adverse events (AE) following trivalent influenza vaccination in children age six months to 17 years. We used retrospective, self-controlled, case-series analysis to estimate adverse event incidence rate ratios for post-vaccination risk intervals relative to 15-28 days prior to vaccination. We confirmed possible vaccination reactions by medical record abstraction. Detection of 10 of 20 elevated incidence rate ratios required telephone data. We conclude that telephone encounters substantially contribute to the detection of possible influenza vaccination reactions, primarily local injection site and systemic reactions.
Reprinted from Vaccine 2006, Mar 20;24(13). Mullooly JP, Crane B, Chun C. Trivalent inactivated influenza vaccine safety in children: Assessing the contribution of telephone encounters, 2256-63. Copyright 2006, with permission from Elsevier.

From Northern California
Team assignment system: expediting emergency department care.
Patel PB, Vinson DR. Ann Emerg Med 2005 Dec;46(6):499-506.

study objective: We designed and implemented an emergency department (ED) team assignment system, each team consisting of one emergency physician, two nurses, and usually one technician. Patients were assigned in rotation upon arrival to a specific team that was responsible for their care. We monitored the time from arrival to physician assessment, percentage of patients who left without being seen by a physician, and patient satisfaction before and after team assignment system implementation.
methods: This study was done in a suburban community hospital with an annual ED census of approximately 39,000. Time to physician assessment was defined from the completion of the medical screening evaluation by an ED nurse at triage to initiation of emergency physician evaluation. Times were documented on the ED paper record and manually entered into a computerized registration by the clerical staff. Patients who left without being seen was reported as percentage of total ED visits. Patient satisfaction scores using a five-point Likert scale to assess satisfaction with the emergency physician, ED staff courtesy, and coordination of care were gathered every three months from random mailings to a subset of patients.
results: The 12-month ED census was 38,716 before team assignment system implementation and 39,301 afterwards. Complete time data were recorded for 34,152 (88.2%) and 32,537 (82.8%) of the patients, respectively. The mean time to physician assessment was 71.3 ±7.0 minutes before and 61.8 ±6.4 minutes after team assignment system implementation (absolute difference -9.5 minutes; 95% confidence interval [CI] -5.8 to -13.5 minutes). The percentage of patients seen by a physician within one hour was 56.3% before and 64.0% after team assignment system implementation (absolute difference 7.7%; 95% CI 5.1% to 10.3%). The percentage of patients who waited more than three hours for physician assessment was 17.8% before and 11.8% after team assignment system implementation (absolute difference -6.0%, 95% CI -4.0% to -8.1%). Before team assignment system, the left-without-being-seen rate was 2.3% compared to 1.6% after team assignment system (absolute difference -0.8%; 95% CI -0.4% to -1.1%). Patient satisfaction reported as very good or excellent showed improvement in satisfaction with the physician (absolute increase 3.1%; 95% CI 1.0% to 5.3%), staff courtesy (absolute increase 4.5%; 95% CI 2.3% to 6.7%), and coordination of care (absolute increase 3.6%; 95% CI 0.8% to 6.4%).
conclusion: The implementation of a team assignment system in our ED was associated with reduced time to physician assessment, a reduced percentage of patients who left without being seen, and improved patient satisfaction.
Reprinted from Annals of Emergency Medicine, 46(6), Patel PB, Vinson DR, Team assignment system: expediting emergency department care, 499-506, Copyright 2005, with permission from The American College of Emergency Physicians.

clinical implication: The implementation of a team assignment system at our Sacramento Emergency Departments (ED) improved patient flow and promoted fairness in the distribution of patients among the scheduled ED physicians. This system led to accountability to individual physician-led teams that helped expedite patient care and reduce waiting times for ED patients to be seen by their assigned physician. It also provided a direct incentive to physicians to complete the evaluation of their assigned patients so that physicians could complete their work. ­PP

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From Southern California
Response profiles to fluticasone and montelukast in mild-to-moderate persistent childhood asthma.
Zeiger RS, Szefler SJ, Phillips BR, et al; Childhood Asthma Research and Education Network of the National Heart, Lung, and Blood Institute. J Allergy Clin Immunol 2006 Jan;117(1):45-52.

background: Outcome data are needed to base recommendations for controller asthma medication use in school-aged children.
objective: We sought to determine intraindividual and interindividual response profiles and predictors of response to an inhaled corticosteroid (ICS) and a leukotriene receptor antagonist (LTRA).
methods: An ICS, fluticasone propionate (100 mug twice daily), and an LTRA, montelukast (5-10 mg nightly, age dependent), were administered to children ages 6 to 17 years with mild-to-moderate persistent asthma using only as-needed bronchodilators in a multicenter, double-masked, two-sequence, 16-week crossover trial. Clinical, pulmonary, and inflammatory responses to these controllers were evaluated.
results: Improvements in most clinical asthma control measures occurred with both controllers. However, clinical outcomes (asthma control days [ACDs], the validated Asthma Control Questionnaire, and albuterol use), pulmonary responses (FEV(1)/forced vital capacity, peak expiratory flow variability, morning peak expiratory flow, and measures of impedance), and inflammatory biomarkers (exhaled nitric oxide [eNO]) improved significantly more with fluticasone than with montelukast treatment. eNO was both a predictor of ACDs (p = .011) and a response indicator (p = .003) in discriminating the difference in ACD response between fluticasone and montelukast.
conclusions: The more favorable clinical, pulmonary, and inflammatory responses to an ICS than to an LTRA provide pediatric-based group evidence to support ICSs as the preferred first-line therapy for mild-to-moderate persistent asthma in children. eNO, as a predictor of response, might help to identify individual children not receiving controller medication who achieve a greater improvement in ACDs with an ICS compared with an LTRA.
Reprinted from Journal of Allergy and Clinical Immunology, 117(1), Zeiger RS, Szefler SJ, Phillips BR, Schatz M, Martinez FD, Chinchilli VM, Lemanske RF Jr, Strunk RC, Larsen G, Spahn JD, Bacharier LB, Bloomberg GR, Guilbert TW, Heldt G, Morgan WJ, Moss MH, Sorkness CA, Taussig LM; Childhood Asthma Research and Education Network of the National Heart, Lung, and Blood Institute, Response profiles to fluticasone and montelukast in mild-to-moderate persistent childhood asthma, 45-52, Copyright 2006, with permission from American Academy of Allergy Asthma and Immunology.

From Northern California
COPD and incident cardiovascular disease hospitalizations and mortality: Kaiser Permanente Medical Care Program.
Sidney S, Sorel M, Quesenberry CP Jr, DeLuise C, Lanes S, Eisner MD. Chest 2005 Oct;128(4):2068-75.

study objectives: To determine the relationship between diagnosed and treated COPD and the incidence of cardiovascular disease (CVD) hospitalization and mortality.
design: Retrospective matched cohort study.
setting: Northern California Kaiser Permanente Medical Care Program (KPNC), a comprehensive prepaid integrated health care system.
patients or participants: Case patients (n = 45,966) were all KPNC members with COPD who were identified during a four-year period from January 1996 through December 1999. An equal number of control subjects without COPD were selected from KPNC membership and were matched for gender, year of birth, and length of KPNC membership.
measurements and results: Follow-up conducted for hospitalization and mortality from CVD end points through December 31, 2000. CVD study end points included cardiac arrhythmias, angina pectoris, acute myocardial infarction, congestive heart failure (CHF), stroke, pulmonary embolism, all of the aforementioned study end points combined, other CVD, and all CVD end points. The mean follow-up time was 2.75 years for case patients and 2.99 years for control subjects. The risk of hospitalization was higher in COPD case patients than in control subjects for all CVD hospitalization and mortality end points. The relative risk (RR) for hospitalization for the composite measure of all study end points was 2.09 (95% confidence interval [CI], 1.99 to 2.20) after adjustment for gender, preexisting CVD study end points, hypertension, hyperlipidemia, and diabetes, and ranged from 1.33 (stroke) to 3.75 (CHF). The adjusted RR for mortality for the composite measure of all study end points was 1.68 (95% CI, 1.50 to 1.88), ranging from 1.25 (stroke) to 3.53 (CHF). Younger patients (ie, age <65 years) and female patients had higher risks than older and male participants.
conclusions: COPD was a predictor of CVD hospitalization and mortality over an average follow-up time of nearly three years. The finding of a stronger relationship of COPD to CVD outcomes in patients <65 years of age suggests that CVD risk should be monitored and treated with particular care in younger adults with COPD.

From Colorado
Late-stage breast cancer among women with recent negative screening mammography: do clinical encounters offer opportunity for earlier detection?
Mouchawar J, Taplin S, Ichikawa L, et al. J Natl Cancer Inst Monogr 2005;(35):39-46.

background: Opportunities to prevent late-stage breast cancer within the course of usual care are needed. We evaluate whether clinical encounters offer such opportunities.
methods: Within seven health care plans, we identified 1298 women aged more than 50 years with early (<3 cm), late-stage (3 cm), or metastatic invasive breast cancer diagnosed during 1995-1999, whose first screening mammogram 13-36 months prior to the diagnosis (index) was negative. We audited all care occurring in the health plans up to 36 months prior to the cancer diagnoses. Ordinal logistic regression compared the frequency of events by disease category. We hypothesized that during the 13-36 months prior to diagnosis, women with late-stage or metastatic breast cancer would have more symptoms and be more likely to have breast-related clinical visits but have less breast screening (clinical breast examination [CBE] or mammography) than women with early-stage disease, thereby indicating clinical opportunities for earlier detection.
results: We found no differences in demographic characteristics across breast cancer stage among the 1298 women. Both before and after the negative index mammogram but during the 13-36 months prior to diagnosis, few women had breast symptoms (5% before index, 8% after), but many sought breast care (86% before index, 90% after) and screening CBE (62% before index, 43% after). Only the occurrence of screening CBE (odds ratio [OR] = 0.73, 95% confidence interval [CI] = 0.56 to 0.95) or screening mammograms (OR = 0.74, 95% CI = 0.57 to 0.97) after the negative index mammogram reduced odds of more severe disease at diagnosis.
conclusion: Although the mortality benefit of CBE, or one compared to two year mammography has not been established, we found that women with late-stage breast cancers undetected by screening mammography did not experience opportunities for earlier detection except through CBE or additional screening mammography.
www.oxfordjournals.org/

clinical implication: Although screening mammography detects cancers at earlier stages for the majority of the general population, there remain a group of women destined to develop late-stage breast cancer that will have their cancer missed. Our results indicate that better screening technology is needed for these women because clinical encounters are not likely to lead to earlier detection. ­JM

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From Southern California
Improved asthma outcomes from allergy specialist care: a population-based cross-sectional analysis.
Schatz M, Zeiger RS, Mosen D, et al. J Allergy Clin Immunol 2005 Dec;116(6):1307-13. Epub 2005 Nov 8.

background: Prior studies suggest that allergist care improves asthma outcomes, but many of these studies have methodological shortcomings.
objective: We sought to compare patient-based and medical utilization outcomes in randomly selected asthmatic patients cared for by allergists versus primary care providers.
methods: A random sample of 3568 patients enrolled in a staff model health maintenance organization who were given diagnoses of persistent asthma completed surveys. Of these participants, 1679 (47.1%) identified a primary care provider as their regular source of asthma care, 884 (24.8%) identified an allergist, 693 (19.4%) reported no regular source of asthma care, and 195 (5.5%) identified a pulmonologist. Validated quality of life, control, severity, patient satisfaction, and self-management knowledge tools and linked administrative data that captured medication use were compared between groups, adjusting for demographics and baseline hospital and corticosteroid use.
results: Compared with those followed by primary care providers, patients of allergists reported significantly higher (p < .001) generic physical and asthma-specific quality of life, less asthma control problems, less severe symptoms, higher satisfaction with care, and greater self-management knowledge. Patients of allergists were less likely than patients of primary care providers to require an asthma hospitalization (odds ratio, 0.45) or unscheduled visit (odds ratio, 0.71) and to overuse beta-agonists (odds ratio, 0.47) and were more likely to receive inhaled steroids (odds ratio, 1.81) during their past year.
conclusions: Allergist care is associated with a wide range of improved outcomes in asthmatic patients compared with care provided by primary care providers.
Reprinted from Journal of Allergy and Clinical Immunology, 116(6), Schatz M, Zeiger RS, Mosen D, Apter AJ, Vollmer WM, Stibolt TB, Leong A, Johnson MS, Mendoza G, Cook EF, Improved asthma outcomes from allergy specialist care: a population-based cross-sectional analysis, 1307-13, Copyright 2005, with permission from American Academy of Allergy Asthma and Immunology.
www.sciencedirect.com/science/journal/00916749

From the Northwest
The near absence of osteoporosis treatment in older men with fractures.
Feldstein AC, Nichols G, Orwoll E, et al. Osteoporos Int 2005; 16(8):953-62.

The burden of osteoporotic fractures in older men is significant. The objectives of our study were to: 1) characterize older men with fractures associated with osteoporosis, 2) determine if medication treatment rates for osteoporosis are improving, and 3) identify patient, health care benefit and utilization, and clinician characteristics that are significantly associated with treatment. This retrospective cohort study assessed 1171 men aged 65 or older with any new fracture associated with osteoporosis between 1 January 1998 and 30 June 2001 in a nonprofit health maintenance organization in the United States. Multiple logistic regression was used to evaluate prefracture factors for their association with osteoporosis treatment in the six-month postfracture period. The main outcome measure was pharmacologic treatment for osteoporosis in the six months after the index fracture. Subjects' average age was 76.7 years; 3.3% had a diagnosis of osteoporosis and 15.2% a diagnosis or medication associated with secondary osteoporosis. Only 7.1% of the study population and 16.0% of those with a hip or vertebral fracture received a medication for osteoporosis following the index fracture, and treatment rates did not improve over time. In the multivariate model, factors significantly associated with drug treatment were a higher value on the Charlson Comorbidity Index (odds ratio 1.26, 95% confidence interval 1.05-1.51), having an osteoporosis diagnosis (odds ratio 8.11, 95% confidence interval 3.08-21.3), chronic glucocorticoid use (odds ratio 5.37, 95% confidence interval 2.37-12.2) and a vertebral fracture (odds ratio 16.6, 95% confidence interval 7.8-31.4). Bone mineral density measurement was rare (n = 13, 1.1%). Our findings suggest that there is underascertainment and undertreatment of osteoporosis and modifiable secondary causes in older men with fractures. Information systems merging diagnostic and treatment information can help delineate gaps in patient management. Interventions showing promise in other conditions should be evaluated to improve care for osteoporosis.
Available online at: www.osteofound.org/publications/osteoporosis_international.html

From the Northwest
Natural language processing in the electronic medical record assessing clinician adherence to tobacco treatment guidelines.
Hazlehurst B, Sittig DF, Stevens VJ, et al. Am J Prev Med 2005 Dec;29(5):434-9.

background: Comprehensively assessing care quality with electronic medical records (EMRs) is not currently possible because much data reside in clinicians' free-text notes.
methods: We evaluated the accuracy of MediClass, an automated, rule-based classifier of the EMR that incorporates natural language processing, in assessing whether clinicians: 1) asked if the patient smoked; 2) advised them to stop; 3) assessed their readiness to quit; 4) assisted them in quitting by providing information or medications; and 5) arranged for appropriate follow-up care (ie, the 5As of smoking-cessation care).
design: We analyzed 125 medical records of known smokers at each of four HMOs in 2003 and 2004. One trained abstractor at each HMO manually coded all 500 records according to whether or not each of the 5As of smoking cessation care was addressed during routine outpatient visits.
measurements: For each patient's record, we compared the presence or absence of each of the 5As as assessed by each human coder and by MediClass. We measured the chance-corrected agreement between the human raters and MediClass using the kappa statistic.
results: For "ask" and "assist," agreement among human coders was indistinguishable from agreement between humans and MediClass (p > 0.05). For "assess" and "advise," the human coders agreed more with each other than they did with MediClass (p < 0.01); however, MediClass performance was sufficient to assess quality in these areas. The frequency of "arrange" was too low to be analyzed.
conclusions: MediClass performance appears adequate to replace human coders of the 5As of smoking-cessation care, allowing for automated assessment of clinician adherence to one of the most important, evidence-based guidelines in preventive health care.
Reprinted from American Journal of Preventive Medicine, V29(5), Hazlehurst B, Sittig DF, Stevens VJ, Smith KS, Hollis JF, Vogt TM, Winickoff JP, Glasgow R, Palen TE, Rigotti NA, Natural language processing in the electronic medical record assessing clinician adherence to tobacco treatment guidelines, p 434-9, Copyright 2005, with permission from American Journal of Preventive Medicine.
www.sciencedirect.com/science/journal/07493797