Sudden Infant Death Syndrome and prenatal maternal smoking: rising attributed risk in the Back to Sleep era

BACKGROUND: Parental smoking and prone sleep positioning are recognized causal features of Sudden Infant Death. This study quantifies the relationship between prenatal smoking and infant death over the time period of the Back to Sleep campaign in the United States, which encouraged parents to use a supine sleeping position for infants. METHODS: This retrospective cohort study utilized the Colorado Birth Registry. All singleton, normal birth weight infants born from 1989 to 1998 were identified and linked to the Colorado Infant Death registry. Multivariable logistic regression was used to analyze the relationship between outcomes of interest and prenatal maternal cigarette use. Potential confounders analyzed included infant gender, gestational age, and birth year as well as maternal marital status, ethnicity, pregnancy interval, age, education, and alcohol use. RESULTS: We analyzed 488,918 birth records after excluding 5835 records with missing smoking status. Smokers were more likely to be single, non-Hispanic, less educated, and to report alcohol use while pregnant (p < 0.001). The study included 598 SIDS cases of which 172 occurred in smoke-exposed infants. Smoke exposed infants were 1.9 times (95% CI 1.6 to 2.3) more likely to die of SIDS. The attributed risk associating smoking and SIDS increased during the study period from approximately 50% to 80%. During the entire study period 59% (101/172) of SIDS deaths in smoke-exposed infants were attributed to maternal smoking. CONCLUSIONS: Due to a decreased overall rate of SIDS likely due to changing infant sleep position, the attributed risk associating maternal smoking and SIDS has increased following the Back to Sleep campaign. Mothers should be informed of the 2-fold increased rate of SIDS associated with maternal cigarette consumption

Impact of prescription size on statin adherence and cholesterol levels

Abstract Background Therapy with 3-Hydroxy-3-methylglutaryl Co-enzyme A reductase inhibitors (statins) improve outcomes in a broad spectrum of patients with hyperlipidemia. However, effective therapy requires ongoing medication adherence; restrictive pharmacy policies may represent a barrier to successful adherence, particularly among vulnerable patients. In this study we sought to assess the relationship between the quantity of statin dispensed by the pharmacy with patient adherence and total cholesterol. Methods We analyzed a cohort of 3,386 patients receiving more than one fill of statin medications through an integrated, inner-city health care system between January 1, 2000 and December 31, 2002. Our measure of adherence was days of drug acquisition divided by days in the study for each patient, with adequate adherence defined as ≥ 80%. Log-binomial regression was used to determine the relative risk of various factors, including prescription size, on adherence. We also assessed the relationship between adherence and total cholesterol using multiple linear regression. Results After controlling for age, gender, race, co-payment, comorbidities, and insurance status, patients who obtained a majority of fills as 60-day supply compared with 30-day supply were more likely to be adherent to their statin medications (RR 1.41, 95% CI 1.28–1.55, P Conclusion In a healthcare system serving predominantly indigent patients, the provision of a greater quantity of statin medication at each prescription fill contributes to improved adherence and greater drug effectiveness.</p

Effect of Spanish Interpretation Method on Patient Satisfaction in an Urban Walk-in Clinic

OBJECTIVE: To examine the effect of Spanish interpretation method on satisfaction with care. DESIGN: Self-administered post-visit questionnaire. SETTING: Urban, university-affiliated walk-in clinic. PARTICIPANTS: Adult, English- and Spanish-speaking patients presenting for acute care of non-emergent medical problems. MEASUREMENTS AND MAIN RESULTS: Satisfaction with overall clinic visit and with 7 provider characteristics was evaluated by multiple logistic regression, controlling for age, gender, ethnicity, education, insurance status, having a routine source of medical care, and baseline health. “Language-concordant” patients, defined as Spanish-speaking patients seen by Spanish-speaking providers and English-speaking patients, and patients using AT&T telephone interpreters reported identical overall visit satisfaction (77%; P = .57), while those using family or ad hoc interpreters were significantly less satisfied (54% and 49%; P < .01 and P = .007, respectively). AT&T interpreter use and language concordance also yielded similar satisfaction rates for provider characteristics (P > .2 for all values). Compared to language-concordant patients, patients who had family members interpret were less satisfied with provider listening (62% vs 85%; P = .003), discussion of sensitive issues (60% vs 76%; P = .02), and manner (62% vs 89%; P = .005). Patients who used ad hoc interpreters were less satisfied with provider skills (60% vs 83%; P = .02), manner (71% vs 89%; P = .02), listening (54% vs 85%; P = .002), explanations (57% vs 84%; P = .02), answers (57% vs 84%; P = .05), and support (63% vs 84%; P = .02). CONCLUSIONS: Spanish-speaking patients using AT&T telephone interpretation are as satisfied with care as those seeing language-concordant providers, while patients using family or ad hoc interpreters are less satisfied. Clinics serving a large population of Spanish-speaking patients can enhance patient satisfaction by avoiding the use of untrained interpreters, such as family or ad hoc interpreters

Optimizing Antibiotic Prescribing for Acute Respiratory Tract Infections in an Urban Urgent Care Clinic

OBJECTIVE: To decrease unnecessary antibiotic use for acute respiratory tract infections in adults in a point-of-service health care setting. DESIGN: Prospective, nonrandomized controlled trial. SETTING: An urban urgent care clinic associated with the major indigent care hospital in Denver, Colorado between October 2000 and April 2001. PATIENTS/PARTICIPANTS: Adults diagnosed with acute respiratory tract infections (bronchitis, sinusitis, pharyngitis, and nonspecific upper respiratory infection). A total of 554 adults were included in the baseline period (October to December 2000) and 964 adults were included in the study period (January to April 2001). INTERVENTIONS: A provider educational session on recommendations for appropriate antibiotic use recently published by the Centers for Disease Control and Prevention, and placement of examination room posters were performed during the last week of December 2000. Study period patients who completed a brief, interactive computerized education (ICE) module were classified as being exposed to the full intervention, whereas study period patients who did not complete the ICE module were classified as being exposed to the limited intervention. MEASUREMENTS AND MAIN RESULTS: The proportion of patients diagnosed with acute bronchitis who received antibiotics decreased from 58% during the baseline period to 30% and 24% among patients exposed to the limited and full intervention, respectively (P < .001 for intervention groups vs baseline). Antibiotic prescriptions for nonspecific upper respiratory tract infections decreased from 14% to 3% and 1% in the limited- and full-intervention groups, respectively (P < .001 for intervention groups vs baseline). CONCLUSION: Antibiotic use for adults diagnosed with acute respiratory tract infections can be reduced in a point-of-service health care setting using a combination of patient and provider educational interventions