Preventing deaths and injuries from house fires: an outcome evaluation of a community-based smoke alarm installation programme.

BACKGROUND: Few studies have examined the impact of community-based smoke alarm (SA) distribution programmes on the occurrence of house fire-related deaths and injuries (HF-D/I). OBJECTIVE: To determine whether the rate of HF-D/I differed for programme houses that had a SA installed through a community-based programme called Operation Installation, versus non-programme houses in the same census tracts that had not received such a SA. METHODS: Teams of volunteers and firefighters canvassed houses in 36 high-risk target census tracts in Dallas, TX, between April 2001 and April 2011, and installed lithium-powered SAs in houses where residents were present and gave permission. We then followed incidence of HF-D/I among residents of the 8134 programme houses versus the 24 346 non-programme houses. RESULTS: After a mean of 5.2 years of follow-up, the unadjusted HF-D/I rate was 68% lower among residents of programme houses versus non-programme houses (3.1 vs 9.6 per 100 000 population, respectively; rate ratio, 0.32; 95% CI 0.10 to 0.84). Multivariate analysis including several demographic variables showed that the adjusted HF-D/I rate in programme houses was 63% lower than non-programme houses. The programme was most effective in the first 5 years after SA installation, with declining difference in rates after the 6th year, probably due to SAs becoming non-functional during that time. CONCLUSIONS: This collaborative, community-based SA installation programme was effective at preventing deaths and injuries from house fires, but the duration of effectiveness was less than 10 years.

A controlled evaluation of the WHO Safe Communities model approach to injury prevention: increasing child restraint use in motor vehicles.

OBJECTIVE: To measure the effect of the WHO Safe Communities model approach to increasing child restraint use in motor vehicles. DESIGN: Pre- and post-intervention observations of restraint use in motor vehicles in several sites in the target area, and in a comparison area community. SETTING: Community; southeast Dallas, Texas, 2003-2005. INTERVENTIONS: A multifaceted approach to increasing use of child safety seats, booster seats and seat belts that included efforts in schools, day care centres, neighbourhoods and a local public clinic, along with child safety seat classes and a low-cost distribution programme. MAIN OUTCOME MEASURES: Prevalence of restraint use among children 0-8 years old riding in motor vehicles. RESULTS: In the target area, the adjusted child restraint use increased by 23.9 percentage points versus 11.8 in the comparison area (difference 12.1; 95% CI 9.9 to 14.3), and adjusted driver seat belt use increased by 16.3 percentage points in the target area versus 4.9 in the comparison area (difference 11.4; 95% CI 11.0 to 11.7). Multivariable multilevel analysis showed that the increase in the target area was significantly greater than in the comparison area for child restraint use (OR 1.6; 95% CI 1.2 to 2.2), as well as for driver seat belt use and proportion of children riding in the back seat. CONCLUSIONS: The Safe Communities approach was successful in promoting the use of child restraints in motor vehicles through a multifaceted intervention that included efforts in various community settings, instructional classes and child safety seat distribution.

Decreased preterm births in an inner-city public hospital.

OBJECTIVE: To examine preterm births among African-American and Hispanic women who delivered at an inner-city public hospital in the context of contemporaneously increasing rates in the United States. METHODS: The rates of preterm birth, defined as birth before 37 weeks of gestation, for singleton neonates with birth weights of 500 g or higher delivered to women who had prenatal care at Parkland Hospital between 1988 and 2006 were compared with similar births in the United States from 1995 to 2002. Preterm birth rates also were compared for white, African-American, and Hispanic women as were disparity in these rates using white women as the referent. RESULTS: The Parkland Memorial Hospital cohort included 260,197 women, of whom 70% were Hispanic, 20% African-American, and 8% white. The U.S. cohort included 29,366,816 women, of whom 61% were white, 19% Hispanic, and 14% African-American. Between 1995 and 2002, the rate of preterm birth in the United States increased from 9.4% to 10.1% (P<.001). Between 1988 and 2006, the rate of preterm births at Parkland decreased from 10.4% to 4.9% (P<.001). Moreover, the rates of preterm birth were significantly lower in Hispanic and African-American women who delivered at Parkland compared with the same ethnicity/race groups in the U.S. cohort. The decline in preterm births at Parkland Memorial Hospital coincided with increased prenatal care use. CONCLUSION: Preterm birth significantly decreased in minority women delivered at an inner-city public hospital. We hypothesize that the reduction in preterm births was the result of a public health care program specifically targeting minority pregnant women.

Comparing the financial condition of Texas hospitals using a novel definition for the safety net.

Lack of health insurance is more prevalent in the state of Texas than in the rest of the country. To get necessary medical care, uninsured Texans must rely on safety net hospitals. Economic turmoil and fluctuating public support routinely threaten the financial stability of these hospitals. Safety net hospitals must be identified to craft public policy solutions that ensure their viability. In this paper, we propose a new method to identify these hospitals by incorporating criteria established previously by economists with additional measures of community value. Our data indicate that safety net hospitals continue to face financial challenges. Texas will need to move forward along several policy fronts to preserve this vital system of care.

The "unintended pedestrian" on expressways.

OBJECTIVE: To explore the epidemiology of pedestrian deaths in Dallas County, Texas, and to compare factors associated with pedestrian deaths on expressways versus those that occurred on other roadways. METHODS: We studied all pedestrian deaths among persons 15 years of age or older in Dallas County, Texas, from 1997 to 2004 by linking data from Medical Examiner's office, the Fatality Analysis Reporting System, and local police records. Univariate and multivariate analysis compared various factors associated with death on an expressway. RESULTS: Among 437 pedestrian deaths who were 15 years of age or older, 197 (45%) occurred on expressways; the proportion that occurred on expressways was highest among 15- to 29-year-olds (65%) and was lower with advancing age group (p < 0.01, chi square for trend). At least 36% of these expressway-related pedestrian deaths were known to have been "unintended pedestrians," who had exited a vehicle after being on the roadway, compared with 11% of pedestrian deaths on surface streets (OR 4.6, 95% CI, 2.7-8.1), and this was also highest among younger age groups. Pedestrian deaths on an expressway, compared with deaths on surface streets, remained strongly associated with having been an "unintended pedestrian" (OR 6.2, 95% CI, 3.1-14.0), after controlling for several other variables, including age, sex, race, nighttime of crash, and alcohol involvement. CONCLUSIONS: Expressways are the predominant site of fatal pedestrian crashes among young adults in this urban area. Since many of these deaths were "unintended pedestrians," procedures for management of occupants of disabled vehicles on expressways could have a large impact on pedestrian deaths in young adults.

The quest for quality: perspectives from the safety net.

The American healthcare system is in need of fundamental change. With more than a decade of annual forums on quality improvement in healthcare and alarming statistics ranking medical errors among the top 10 causes of death in the United States, hospitals and health systems across the country are responding with a coordinated approach to quality improvement. Parkland Health & Hospital System believes the ideal public hospital system requires three critical components to achieve the Institute of Medicine's quality aims: (I) an emphasis on quality that is embraced by senior leadership, (2) careful measurement selection, and (3) the development of a robust infrastructure for outcomes research. This article describes Parkland's approach to each component and takes a look at selected processes and outcomes.

The role of U.S. public hospitals in urban health.

Public hospitals in the United States play a key role in urban health. In many metropolitan communities, public hospitals maintain the health care safety net. Most urban public hospitals have evolved to not only provide care for the indigent but also to serve their communities in other ways, including serving as major providers for tertiary services such as trauma and those that support homeland security; serving as the foundation for primary care services; continuing to train a significant number of physician, nurses, and other medical personnel; and providing laboratories for clinical medical research. Federal budget cuts such as those in the Balanced Budget Act of 1997, recent state budget deficits, competition for Medicaid Managed Care, and the growth in the number of uninsured have led to a decline in revenues among urban public hospitals. To be better stewards of scarce resources, public hospitals have moved to reduce inpatient demand by adopting prevention strategies that are aimed at addressing the determinants of health, the complex interactions among social and economic factors, the physical environment, and individual behavior. These factors contribute to health status and offer opportunities to intervene and improve community health. Urban public hospitals, to be successful in the next stage of their evolution, need to learn to manage the "in-betweens"--partnering with governmental and nongovernmental entities to identify and work together on common health and safety issues. If public hospitals engage the community successfully, building trust and establishing new capability and capacity, urban public hospitals will survive, evolve, and continue their tradition of service.

County hospitals and regional medical care in Texas: an analysis of out-of-county costs.

The current system of regional medical service delivery in Texas places large demands on the state's urban public hospitals. To assess the nature and scope of such demands, we examined financial data from five of the state's largest public hospital districts. During fiscal year 2002, these hospitals reported 103,381 encounters with out-of-county patients, resulting in 66 million dollars in unreimbursed costs. Given the current economic outlook, Texas requires a more effective regional model that centralizes tertiary care, disperses primary and secondary care, and preserves key public health goods.

Community-oriented primary care in action: a Dallas story.

Dallas County, Texas, is the site of the largest urban application of the community-oriented primary care (COPC) model in the United States. We summarize the development and implementation of Dallas's Parkland Health & Hospital System COPC program. The complexities of implementing and managing this comprehensive community-based program are delineated in terms of Dallas County's political environment and the components of COPC (assessment, prioritization, community collaboration, health care system, evaluation, and financing). Steps to be taken to ensure the future growth and development of the Dallas program are also considered. The COPC model, as implemented by Parkland, is replicable in other urban areas.

Predictors of short-term clinical response to acute asthma care in adults.

OBJECTIVE: We assessed the effects of potential patient risk factors on short-term clinical response to acute asthma care among adults who often require emergency department (ED) visits and hospitalizations to manage their asthma. DESIGN AND SETTING: Prospective cohort study that included adult patients treated for acute asthma, which was conducted in a US public hospital ED between March 1997 and August 1999, with a 2- to 3-week follow-up. STUDY PARTICIPANTS: Three hundred and nine patients completed the study. MAIN MEASURES: We identified patient risk factors that predicted lower peak expiratory flow rate (PEFR) change over 2-3 weeks following acute asthma care. Potential risk factors were ozone exposure, indoor allergy and exposure, smoking, upper respiratory infection in the last month, lower asthma knowledge, and medication non-adherence. RESULTS: Univariate analyses indicated that lower asthma knowledge significantly and positively correlated with lower PEFR change (r = 0.15, P = 0.01). Multivariate analysis that controlled for patient case-mix indicated that indoor allergy and exposure [b = 32.76, 95% confidence interval (CI) = 3.98-61.53, P = 0.03] significantly predicted lower PEFR change. There was no change in the multivariate analysis when the absence of treatment with corticosteroids during the 2-3 weeks before follow-up was added as a potential patient risk factor. CONCLUSION: The study suggests that interventions are needed to target the patient risk factors, indoor allergen exposure, and poor asthma knowledge, to promote short-term clinical response to acute asthma care in adults, especially among economically disadvantaged inner-city residents.