Objective To estimate health care utilization and costs associated with adherence to clinical practice guidelines for the use of early MRI (within the first 6 weeks of injury) for acute occupational low back pain (LBP). Data sources Washington State Disability Risk Identification Study Cohort (D-RISC), consisting of administrative claims and patient interview data from workers’ compensation claimants (2002–2004). Study design In this prospective, population-based cohort study, we compared health care utilization and costs among workers whose imaging was adherent to guidelines (no early MRI) to workers whose imaging was not adherent to guidelines (early MRI in the absence of red flags). Data collection/extraction methods We identified workers (age>18) with work-related LBP using administrative claims. We obtained demographic, injury, health, and employment information through telephone interviews to adjust for baseline differences between groups. We ascertained health care utilization and costs from administrative claims for 1 year following injury. Principal findings Of 1,770 workers, 336 (19.0%) were classified as non-adherent to guidelines. Outpatient and physical/occupational therapy utilization was 52–54% higher for workers whose imaging was not adherent to guidelines compared to workers with guideline-adherent imaging; utilization of chiropractic care was significantly lower (18%). Conclusions Non-adherence to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for outpatient, inpatient, and non-medical services, and disability compensation.

Despite being a high-risk population, epidemiological research about injuries among homeless individuals is limited. We sought to describe injury characteristics among individuals identified as homeless in the National Electronic Injury Surveillance System (NEISS) and to compare them to age- and sex-matched controls. We searched text narratives for all patients with product-related injuries who presented to NEISS emergency departments from 2007-2011 to identify homeless cases (N = 268). A random sample of 2680 age- and sex-matched controls was identified for the same time period. Incident location differed between groups, and mention of substance use was significantly more common among homeless cases than controls. Body part injured differed significantly between cases and controls for all age groups, with the exception of older adults. Among homeless cases, injuries occurred most frequently to the lower extremities, and sprains/strains, contusions/abrasions, and burns were most common. Additional research on injury among homeless individuals is warranted in order to identify meaningful preventive strategies for this at-risk population.

The Nyando Integrated Child Health Education (NICHE) project was a collaborative effort by the U.S. Centers for Disease Control and local partners to assess the effectiveness of multiple interventions for improving child survival in western Kenya. To increase handwashing in schools, NICHE trained teachers and installed handwashing stations with treated water and soap in 51 primary schools. This cluster-randomized trial evaluated an additional educational strategy (a poster contest themed, "Handwashing with Soap") to improve handwashing behavior in 23 NICHE primary schools. Pupils were engaged in the poster development. Pupil handwashing behavior was observed unobtrusively at baseline and after four months. Intervention schools displayed a significant increase in the number of handwashing stations and proportion of teacher-supervised stations over the study period. No significant between-group differences of intervention in handwashing frequency, soap availability, or visibility of handwashing stations was observed. Despite finding a limited effect beyond the NICHE intervention, the trial appeared to promote sustainability across some measures.

Individually, moderate and severe TBI initially generated costs that were markedly higher than those of mild TBI. At the population level, costs following mild TBI far exceeded those of more severe cases, a result of the extremely high population burden of mild TBI.

Amidst the COVID-19 pandemic, interest in using telehealth to increase access to health and mental health care has grown, and school transitions to remote learning have heightened awareness of broadband inequities. The purpose of this study was to examine access and barriers to technology and broadband Internet service ("broadband") among rural and urban youth. Washington State public school districts were surveyed about youth's access to technology (ie, a device adequate for online learning) and broadband availability in spring 2020. Availability of and barriers to broadband (ie, geography, affordability, and smartphone-only connectivity) were assessed across rurality. Among responding districts, 64.2% (n = 172) were rural and 35.8% (n = 96) were urban. Rural districts reported significantly fewer students with access to an Internet-enabled device adequate for online learning (80.0% vs 90.1%, P < .01). Access to reliable broadband varied significantly across geography (P < .01). Compared with their urban peers, rural youth face more challenges in accessing the technology and connectivity needed for remote learning and telehealth. Given that inadequate broadband infrastructure is a critical barrier to the provision of telehealth services and remote learning in rural areas, efforts to improve policies and advance technology must consider geographical disparities to ensure health and education equity.

Objectives To compare health care costs and service utilization associated with mild traumatic brain injury (mTBI) in rural and urban commercially insured children. Data Source MarketScan Commercial Claims and Encounters Data, 2007‐2011. Study Design We compared health care costs and outpatient encounters for physical/occupational therapy, speech therapy, and psychiatry/psychology encounters 180 days after mTBI among rural versus urban children (<18 years). Principal Findings A total of 387 846 children had mTBI, with 13 percent residing in rural areas. Adjusted mean total health care costs in the 180 days after mTBI were $2778 (95% CI: 2660‐2897) among rural children, compared to $2499 (95% CI: 2471‐2528) among urban children (adjusted cost ratio 1.11, 95% CI 1.06‐1.16). Rural‐urban differences in utilization for specific services were also found. Conclusions Total health care costs were higher for rural compared to urban children despite lower utilization of certain services. Differences in health service utilization may exacerbate geographic disparities in adverse outcomes associated with mTBI.

Objectives To evaluate the incidence of snow-sports-related head injuries among children and adolescents reported to emergency departments (EDs), and to examine the trend from 1996 to 2010 in ED visits for snow-sports-related traumatic brain injury (TBI) among children and adolescents. Methods A retrospective, population-based cohort study was conducted using data from the National Electronic Injury Surveillance System for patients (aged ≤17 years) treated in EDs in the USA from 1996 to 2010, for TBIs associated with snow sports (defined as skiing or snowboarding). National estimates of snow sports participation were obtained from the National Ski Area Association and utilised to calculate incidence rates. Analyses were conducted separately for children (aged 4–12 years) and adolescents (aged 13–17 years). Results An estimated number of 78 538 (95% CI 66 350 to 90 727) snow sports-related head injuries among children and adolescents were treated in EDs during the 14-year study period. Among these, 77.2% were TBIs (intracranial injury, concussion or fracture). The annual average incidence rate of TBI was 2.24 per 10 000 resort visits for children compared with 3.13 per 10 000 visits for adolescents. The incidence of TBI increased from 1996 to 2010 among adolescents (p<0.003). Conclusions Given the increasing incidence of TBI among adolescents and the increased recognition of the importance of concussions, greater awareness efforts may be needed to ensure safety, especially helmet use, as youth engage in snow sports.

Objective Adherence to pediatric traumatic brain injury (TBI) guidelines has been associated with improved survival and better functional outcome. However, the relationship between guideline adherence and hospitalization costs has not been examined. To evaluate the relationship between adherence to pediatric severe TBI guidelines, measured by acute care clinical indicators, and the total costs of hospitalization associated with severe TBI. Design Retrospective cohort study Setting Five regional pediatric trauma centers affiliated with academic medical centers. Patients Demographic, injury, treatment, and charge data were included for pediatric patients (age under 17 years) with severe traumatic brain injury. Measurements Percent adherence to clinical indicators was determined for each patient. Cost-to-charge ratios were used to estimate ICU and total hospital costs for each patient. Generalized linear models evaluated the association between healthcare costs and adherence rate. Main Results Cost data for 235 patients were examined. Estimated mean adjusted hospital costs were $103,485 (95% CI: 98,553–108,416); adjusted ICU costs were $82,071 (95% CI: 78,559–85,582). No association was found between adherence to guidelines and total hospital or ICU costs, after adjusting for patient and injury characteristics. Adjusted regression model results provided cost ratio equal to 1.01 for hospital and ICU costs (95% CI: 0.99–1.03 and 0.99–1.02, respectively). Conclusions Adherence to severe pediatric traumatic brain injury guidelines at these 5 leading pediatric trauma centers was not associated with increased hospitalization and ICU costs. Therefore, cost should not be a factor as institutions and providers strive to provide evidence based guideline driven care of children with severe TBI.