Editorials

Protecting American Families from Injury

SUE BINDER, M.D.
Atlanta, Georgia

See Practice Guidelines on page 2474.

In June 2004, the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control will celebrate its 12th anniversary. The vision of the Injury Center, which was founded in 1992 in response to an Institute of Medicine report, is to apply public health methods toward prevention and control of injuries. The anniversary provides an opportunity to review some of the accomplishments in this field and a discussion of the challenges that remain.

Causes of unintentional injuries include falls, drowning, improper use of firearms, driving-related wrecks, playground injuries, and accidental poisoning. Other injuries relate to violence, such as rape (including date rape), domestic violence, homicide, and suicide. Accidental injuries remain the number one cause of death in children and adults between one and 44 years of age. Suicide is a major cause of death in teenagers and young adults, and homicide is second only to accidental injuries in persons 15 to 24 years of age.¹ A major challenge is to convince policymakers, the medical community, and the public that injuries are preventable and that prevention is worth the effort.

See page 2321 for levels of evidence definitions.

Illustrative Case

While driving, a 25-year-old mother enters an intersection that has a four-way stop sign. A teenaged driver who has been drinking beer does not notice the stop sign and hits the passenger side of the woman's car. Her five-year-old child, unrestrained in the rear passenger-side seat, sustains a severe skull fracture. In the emergency department, the chief resident says, "What an unfortunate accident..."

Was this an accident? Could the child's skull fracture have been prevented? Studies have shown that injuries are not purely the result of random events.² They occur in predictable ways, with distinct patterns of risk and protective factors. The list of interventions that have been proven to prevent injuries is growing, and more disciplines and professions are recognizing their role in reducing the burden of injuries.

Each year, more than 40,000 persons die in motor vehicle crashes.³ Although some interventions for increasing safety, such as those related to automobile design, are out of the control of the health care professional, family physicians do have a role to play. Driving while impaired by alcohol dramatically increases the risk of death and injury, not only for the driver but also for passengers and those in other cars. For example, nearly two thirds of children killed in motor vehicle crashes were riding with a driver who had been drinking.⁴ Family physicians can help reduce traffic deaths by identifying and addressing problem drinking and counseling parents to appropriately restrain their children, preferably in the back seat of the vehicle.

Physicians face a complex counseling issue in attempting to reduce deaths and injuries among older drivers. Adjusted for the amount driven, death rates for drivers 85 years and older are nine times higher than rates for drivers 25 to 69 years of age.⁵ Nevertheless, many older drivers give up walking before they give up driving; taking away their car keys can have a profound impact on their mobility and quality of life. Better tools are needed to assist physicians and family members who are struggling with questions about when to stop an older adult from driving.

Family violence presents its own range of challenges for physicians, who must be alert to clues that a problem is occurring and be prepared to make appropriate diagnoses and referrals. Family violence includes child abuse and neglect, intimate partner violence, and elder abuse. In addition to injuries from the violence itself, victims of family violence seek health services for a wide range of conditions such as failure to thrive and behavior problems among children,⁶ and gastrointestinal disorders and conditions characterized by chronic pain among adult women.⁷ Even if the presenting injury or illness is not an emergency, the abuse may lead to one, and it needs to be addressed accordingly. Major challenges in family violence prevention range from the need to develop better methods for detection to the need for evidence-based approaches to prevention.

In the year 1900, the leading causes of death in this country were pneumonia, influenza, tuberculosis, and diarrhea. Societal changes such as better living conditions, improved sanitation, and better medical care contributed to reducing the mortality from these conditions. The United States mobilized to fight infectious diseases and has been remarkably successful. Another multifaceted, comprehensive effort should be launched against injuries, making use of environmental interventions, implementing safety programs, increasing awareness of the issue of injury prevention, and involving health care professionals. We challenge family physicians to be part of this movement.

Sue Binder, M.D., is director of the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Ga.

Address correspondence to Sue Binder, M.D., National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, K-02, Atlanta, GA 30341. Reprints are not available from the author.

REFERENCES

1. Minimo AM, Smith BL. National vital statistics report 2001;49:1-40. Accessed online March 4, 2004, at: http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_12.pdf.

2. Institute of Medicine. Reducing the burden of injury. Washington, D.C.: National Academy Press, 1999.

3. Centers for Disease Control and Prevention (2002). WISQARS Injury Mortality Reports. Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Accessed online March 10, 2004, at: http://webapp.cdc.gov/sasweb/ncipc/mortrate10.html.

4. Centers for Disease Control and Prevention. Child passenger deaths involving drinking drivers--United States, 1997-2002. MMWR 2004;53:77-9.

5. National Highway Traffic Safety Administration (NHTSA). Traffic safety facts 1999: older population. Publication no. DOT HS 809 091. Washington, D.C.: NHTSA, December, 2000.

6. National Research Council (U.S.). Understanding child abuse and neglect. Washington, D.C.: National Academy Press, 1993.

7. Coker AL, Smith PH, Bethea L, King MR, McKeown RE. Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med 2000;9:451-7.

Management of Newly Detected Atrial Fibrillation

MICHAEL L. LEFEVRE, M.D., M.S.P.H.
University of Missouri­Columbia
Columbia, Missouri

Atrial fibrillation is the most common type of arrhythmia in adults, with the prevalence increasing from less than 1 percent in persons younger than 60 years to more than 8 percent in those older than 80 years.¹ Each year in the United States, there are more than 700,000 admissions for cardiac dysrhythmias,² with about one third of these resulting from atrial fibrillation.³ The aging of the U.S. population will make this problem even more prevalent in the day-to-day practice of physicians providing primary care to adults.

In this issue of American Family Physician,⁴ the clinical practice guideline created by a joint panel of the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) in collaboration with the Johns Hopkins Evidence-Based Practice Center is summarized.⁵ This guideline is one product of the effort of the AAFP to promote evidence-based practice. When the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) first established the evidence-based practice centers and solicited topics for examination, the AAFP recommended an evidence review of the management of newly detected atrial fibrillation. AAFP members and staff served as consultants to the Johns Hopkins Evidence-Based Practice Center at the time. The Center's report on atrial fibrillation served as the foundation for the collaborative efforts of the ACP and the AAFP in the production of this guideline. This is the first guideline specifically created by a joint review and synthesis of the literature by these organizations, and it was clear during the process that they share the goal of promoting evidence-based, patient-centered practice. It is hoped that this will be the first of many collaborative efforts.

The evidence reviewed supports a straightforward approach to management for most patients with atrial fibrillation. The central question facing physicians is whether to restore and maintain sinus rhythm, or to control heart rate and prevent stroke. Rhythm control is not superior to the combination of rate control and chronic anticoagulation in reducing morbidity and mortality, and rhythm control may be associated with higher mortality rates in some patient subgroups.

Rate control and prevention of stroke are the mainstays of atrial fibrillation management. Rate control is best accomplished with atenolol, metoprolol, diltiazem, or verapamil. Prevention of stroke requires adjusted-dose warfarin unless the patient has a very low risk of stroke or a specific contraindication to the use of warfarin. As physicians, we tend to consider "soft" contraindications, such as risk of falling. Results from studies using adjusted-dose warfarin clearly show that the benefits generally outweigh the harms, so we must be cautious when avoiding warfarin in the context of relative or theoretical contraindications. We need to balance the theoretical, even unproven, risk of some adverse complication of anticoagulation with the proven benefit of stroke prevention.

This guideline provides an outline for the care of the majority of patients with atrial fibrillation. Care will be straightforward for most of these patients and can be accomplished in the office of the family physician.

Michael L. LeFevre, M.D., M.S.P.H., is professor and director of clinical services in the Department of Family and Community Medicine at the University of Missouri­Columbia. Dr. LeFevre is a member of the joint panel on atrial fibrillation.

Address correspondence to Michael LeFevre, M.D., M.S.P.H., University of Missouri­Columbia, Department of Family and Community Medicine, MA 303, Health Sciences Center, Columbia, MO 65212. (e-mail: lefevrem@health.missouri.edu). Reprints are not available from the author.

REFERENCES

1. McNamara RL, Tamariz LJ, Segal JB, Bass EB. Management of atrial fibrillation: review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography. Ann Intern Med 2003;139:1018-33.

2. Hall MJ, DeFrances CJ. 2001 National Hospital Discharge Survey. Adv Data 2003;332:1-20.

3. Bialy D, Lehmann MH, Schumacher DN, Steinman RT, Meissner MD. Hospitalization for arrhythmias in the United States: importance of atrial fibrillation. J Am Coll Cardiol 1992;19(3 suppl A):41A.

4. AAFP and ACP release practice guideline on management of newly detected atrial fibrillation. Am Fam Physician 2004;69:2474-5.

5. Snow V, Weiss KB, LeFevre M, McNamara R, Bass E, Green LA, et al. Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 2003;139:1009-17.