Evidence Briefs: Public Health Topics
Injury Prevention
The Problem:
Medical injuries are widely recognized as one of the top ten leading causes of mortality in the United States. In 2000, the Institute of Medicine found that between 44,000 and 98,000 Americans die each year from avoidable medical errors. Institute of Medicine. More recent research suggests that more than 13% of hospitalized patients suffer an adverse event resulting in serious harm and that 44% of those events are preventable. The cost of these preventable harms is huge surpassing hundreds of millions of dollars each month. Department of Health and Human Services, Office of the Inspector General. One factor that has attracted attention as a plausible cause of medical error is long work hours for healthcare workers and especially resident physicians. In is not uncommon for residents and other emergency room physicians to work in excess of 100 hours a week. Such shifts raise questions about the influence of fatigue on medical decision-making.
The Law:
Medical care in United States is regulated primarily at the state level through professional organizations. Most regulation of work hours has been by state law. New York, for example, limited medical resident work hours in 1989 through regulations (NY Comp Codes R & Reg. Title 10 § 405 (1989)) often referred to as the Libby Zion law in honor of a child whose death was attributed to alleged mistakes by an overworked medical resident. Educational accreditation bodies, like the Accreditation Council for Graduate Medical Education (ACGME), also set requirements for residency programs. In 2003, for example, ACGME limited to 80 the number of hours that residents could work per week on average over a four week period. Report of the ACGME Work Group on Resident Duty Hours. These restrictions do not apply to health care workers that are not medical residents.
The Evidence:
Fletcher et al conducted a systematic review of studies evaluating the effectiveness of restrictions on HCW work hours aimed at improving patient care. Fletcher et al, Systematic Review: Effects of Resident Work Hours on Patient Safety, Ann Intern Med. 2004;141:851-857. The reviewers identified seven studies that met their inclusion criteria. The results of the studies were inconsistent across a number of measures and none provided statistically significant evidence that patient outcomes improved subsequent to limitation of healthcare worker hours. The reviewers note that while experimental and bio-psychosocial evidence supports a positive causal relationship between fatigue and diminished performance by healthcare workers, patient outcomes are also influenced by continuity of care. The reviewed studies provide some evidence that the benefits of reduced fatigue are offset by disruption in the care that healthcare workers provide due to the shortening of shifts. Overall, the reviewers did not find conclusive evidence supporting the effectiveness of laws limiting work hours as means of improving patient outcomes.
The Bottom Line:
According to the authors of a peer-reviewed systematic review, there is insufficient evidence to currently support the effectiveness of restrictions on healthcare worker hours in improving patient outcomes.
The Problem:
Firearms are the second leading cause of injury and deaths in the United States, accounting for 30,896 deaths and 71,417 injuries in 2006. More than 80 percent of teen homicides and almost half of teen suicides involved a gun in 2005. CDC: WISQUARS. More than half of all homicides involve a gun. U.S. Department of Justice: Crime Statistics.
The Law:
Much of the burden of gun violence and accidental gun injuries falls upon localities. As a result, localities have been at the vanguard of efforts to find new legal approaches to reducing the harms of unsafe gun practices. Some of these strategies – like local bans on gun possession and efforts to regulate gun retailers under public nuisance laws – have been overturned by courts. As a result, few localities in the United States currently have the authority to pass gun control legislation that address gun safety. Localities do, however, have significant latitude in how they enforce existing gun control laws. Law enforcement strategies for reducing the illegal possession of guns include directed patrols aimed at uncovering and deterring illegal gun possession in specific high risk areas.
The Evidence:
Koper and Mayo-Wilson systematically reviewed 4 studies that assessed the impact of directed patrol law enforcement strategies for decreasing gun-related crimes. Koper & Mayo-Wilson. Police crackdowns on illegal gun carrying: a systematic review of their impact on gun crime. Journal of Experimental Criminology 2006; 2:227-261. The four studies reported on a total of 7 nonrandomized tests. In 6 of the tests, directed patrols were associated with reductions in firearm crimes. Notwithstanding the small number of studies and limited study designs, the authors interpreted the review findings as evidence that directed patrols reduced gun crime in high-crime areas.
The Bottom Line:
According the authors of a peer-reviewed systematic review, there is strong evidence supporting the effectiveness of directed patrols as an intervention aimed at reducing gun-related crime in high risk areas.
The Problem:
Motor vehicle accidents are one of the largest sources of public health harms. For people ages 1 to 34, motor vehicle crashes are the number one cause of death. Almost five million people each year suffer injuries during motor vehicle crashes that require emergency care. CDC Fact Sheet: Motor Vehicle Safety. Adverse weather conditions including snow and ice contribute to the incidence of motor vehicle crashes. Some evidence suggests that studded tires reduce accidents in inclement weather by providing better traction for motor vehicles. Studded tires are also known to damage road surfaces.
The Law:
States have the authority to ban or limit the use of studded tires. Some ban all studded tires, see Fl Rev Stats 316.299 (Florida), 9 ID Statutes 49-948 (Idaho), and Wisc. Trans Code 306.01 (Wisconsin). Other states have enacted seasonal limitations on their use, see 90 MGL 60 (Massachusetts), Ca Vehicle Code § 27454 (California), 67 Pa. Code. § 175.80 (Pennsylvania) and OH R.S.5589.081 (Ohio).
The Evidence:
According to the author of a peer-reviewed meta-analysis, laws banning studded tires result in small increases in motor vehicle crashes during winter months. Elvik. The effects on accidents of studded tires and laws banning their use: a meta-analysis of evaluation studies. Accident Analysis & Prevention 1999; 31:125-134. Of the 7 studies that Elvik identified as meeting the inclusion criteria, two were based in the United States, one in Canada, one in Germany and three in Japan. Six of the studies found that laws banning studded tires were associated with small increases in accidents during winter seasons. A meta-analysis revealed a weighted mean increase in winter accidents of 4 percent. This finding is consistent with meta-analysis results in the same review indicating that actual studded tire use reduces accident rates during winter.
The Bottom Line:
According to the author of a peer-reviewed meta-analysis, the evidence suggests that banning studded tires causes a small increase in motor vehicle accidents during the winter.
The Problem:
Domestic violence – the physical, sexual, or emotional abuse of intimate partners or cohabiters – is a significant public health problem. Annually, intimate partner violence accounts for almost 5 million assaults or rapes of women and almost 3 million assaults or rapes of men; more than 1,500 of these incidents resulted in death in 2005. CDC Factsheet: Intimate Partner Violence. Sexual violence is a particularly common occurrence in intimate relationships. More than 10 percent of all women report being forced into sex at some time in their lives; almost 55 percent of rapes of women are committed by family members or intimate partners. CDC Factsheet: Sexual Violence.
The Law:
As cultural norms have changed over the last half century, the laws and legal response to domestic violence have changed markedly. Starting in the early 1980s states began to take domestic violence much more seriously by adopting mandatory arrest laws, which require police officers arriving at domestic disturbances to issue one or more arrests, and instituting court-mandated batterer intervention programs (BIPs). These intervention programs attired to prevent repeat domestic abuse by educating the batterer – typically male – to better understand gender equality and constructive anger management. Although they vary in some key aspects, these programs are widely implemented in U.S. jurisdictions. California law, for example, sets as a condition of probation or parole for individuals convicted of domestic abuse the completion of a batterer’s program that lasts at least one year and includes two hours or more of class time per week. Cal Pen Code § 1203.097(A)(6). For other examples laws requiring BIPs, see Fla. Stat. § 741.281 (Florida) and R.I. Gen. Laws § 12-29-5 (Rhode Island).
The Evidence:
Feder et al. reviewed and conducted a meta-analysis of studies that assess the impact of court-mandated batterer intervention programs. Feder et al. Court-mandated interventions for individuals convicted of domestic violence. Campbell Systematic Review 2008:12. Of the 10 studies that met the authors’ inclusion criteria, 4 employed experimental designs and 6 employed quasi-experimental designs. The measures that were subject to meta-analysis were official reports of post-BIP abuse and victim reports of post-BIP abuse. Across the studies, Feder et al. found a small association between BIPs and reductions in official reports of re-battery, though they caution that some of the underlying studies have been subject to reinterpretation and methodological criticism. For example, one of the studies initially presented as evidence of the effectiveness of BIP programs was subsequently reinterpreted by its authors as showing the impact of another intervention (monitoring) rather than the BIP. For victim reported re-battery, the evidence is inconsistent and statistically insignificant. According to Feder et al., the methodological problems in studies reporting a beneficial effect of BIPs, along with the weak effects found in meta-analysis, raise significant doubts about the effectiveness of BIPs in preventing repeat domestic violence.
The Bottom Line:
According to the authors of a systematic review sponsored by the Campbell Collaborative, there is not enough evidence to establish that batterer intervention programs effectively reduce recidivism.
Publication Date: 02/15/2011
The Problem:
Alcohol consumption is a risk factor for various public health harms. Impaired driving is one of the largest contributors to motor vehicle crashes. Each year in the United States roughly 13,400 people die and an additional 255,500 are injured in motor vehicle crashes involving an alcohol-impaired driver. In 2006, these crashes accounted for almost a third of all U.S. traffic-related deaths. CDC: Impaired Driving Factsheet. Alcohol consumption is also a risk factor for cancer and other chronic conditions such as cirrhosis.
The Law:
Tax law is a mechanism for reducing consumption of unhealthy products. Both the federal government and the states have used taxes as a means of increasing the cost of products associated with health risks. Taxes can be levied upon the production and or sale of alcohol. The former are often described as excise taxes. According to the Federation of Tax Administrators, almost every state taxes the sale or production of beer, liquor and wine. For examples of state laws taxing alcohol, see Ca Revenue & Taxation Code §§ 32201-32203 (California) and Pa Code §§ 74.1-74.21 (Pennsylvania).
The Evidence:
Wagenaar et al. systematically reviewed studies that assessed the relationship between alcohol prices, alcohol taxes, consumption, and sales. Wagenaar et al. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction 2009; 104(2): 179-190. The reviewers identified 112 studies that met their inclusion criteria. These studies contained 1003 estimates of the relationship – or elasticity – between price or tax amount and consumption of a specific type of alcohol. Wagenaar et al. calculated mean elasticities for specific kinds of alcohol and conducted a random effects meta-analysis on an entire collection of estimates. The mean elasticities for beer, wine and spirits were all negative and statistically significant, meaning that increases in price are associated with substantial decreases in consumption. The meta-analysis of all 1003 estimates revealed large inverse relationships between consumption and increases in taxes or prices for all types of alcohol.
The Bottom Line:
According to the authors of a peer-reviewed meta-analysis, taxes that increase the price of alcohol effectively reduce overall alcohol consumption.
© RWJF 2012
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Public Health Law Research is a national program of the Robert Wood Johnson Foundation. It is housed at the Temple University Beasley School of Law.