Adult Visits Research Articles

Clarifying Causes of Increasing Cannabis-Related ED Visits in Older Adults.

Clarifying Causes of Increasing Cannabis-Related ED Visits in Older Adults.

Standardized Patient Communication and Low-Value Spinal Imaging

Acute back pain is a common reason for primary care visits and often results in low-value spinal imaging. To evaluate the effect of a standardized patient-delivered intervention on rates of low-value spinal imaging among primary care patients with acute low back pain. In this randomized clinical trial, physicians or advanced practice clinicians were recruited from March 22 to August 5, 2021, from 10 adult primary care or urgent care clinics in Sacramento, California. The intervention period was from May 1, 2021, to March 30, 2022, with follow-up from October 28, 2021, to June 30, 2023. Analyses were performed from April 1 to June 25, 2024. Clinicians were randomized 1:1 to intervention or control. Intervention clinicians received 3 simulated office visits, each with a standardized patient instructor (SPI) portraying a patient with acute uncomplicated back pain. At each visit, SPIs provided clinician feedback guided by a 3-step model: (1) set the stage for deferred imaging by building trust, (2) convey empathy, and (3) communicate optimism while advocating watchful waiting without imaging. Control clinicians received no intervention. The primary outcome was lumbar spinal imaging completion within 90 days of acute low back pain visits, with study clinicians assessed up to 18 months of follow-up. Secondary outcomes were cervical spine imaging completion after acute neck pain visits, any imaging completion after an adult visit, patient experience ratings of clinicians (scale range, 0-100), and use of targeted communication skills during an audio-recorded standardized patient evaluation visit at median follow-up of 16.8 months (range, 14.1-18.0 months). The analysis included 53 clinicians; mean (SD) age was 46.7 (1.0) years, and 35 (66.0%) reported female gender. A total of 25 were in the intervention group and 28 in the control group. After adjustment for prerandomization rates, patients with acute low back pain who saw intervention and control clinicians during follow-up had similar rates of lumbar imaging (194 of 1234 clinic visits [15.7%] vs 226 of 1306 clinic visits [17.3%]; adjusted ratio of postintervention vs preintervention odds ratios [AORR], 1.00; 95% CI, 0.72-1.40). Adjusted follow-up rates of imaging for acute neck pain (AORR, 1.16; 95% CI, 0.83-1.63) and overall imaging (AORR, 1.07; 95% CI, 0.97-1.19) were not significantly different among patients of intervention and control clinicians. Intervention and control clinicians had similar mean (SD) patient experience ratings during follow-up (88.6 [28.7] vs 88.8 [28.3]; adjusted mean difference-in-differences, -1.0; 95% CI, -3.0 to 0.9). During audio-recorded standardized patient visits, intervention clinicians had significantly better ratings than controls on eliciting the patient's perspective (adjusted standardized difference [ASD], 0.62; 95% CI, 0.05-1.19) and conveying empathy (ASD, 1.16; 95% CI, 0.55-1.77). In this randomized clinical trial of an educational intervention using simulated office visits to encourage a watchful waiting approach for acute low back pain, the intervention had no significant effect on low-value spinal imaging rates or patient experience ratings. ClinicalTrials.gov Identifier: NCT04255199.

Primary care utilization in Bulgaria: some effects of the COVID-19 pandemic

Abstract Background Disruptions to primary care provision during the pandemic set back prior advancements in screening and chronic disease management. Delays in routine vaccination added to preexisting hesitancy and sustained the downward trend in vaccination rates. The study examines the magnitude and duration of primary care disruptions in Bulgaria between 2020 and 2022. Methods The impact of the pandemic on primary care is assessed using administrative data from the National Health Insurance Fund covering the annual number of primary care services. To evaluate the effect on healthcare utilization, the average number of check-ups per person during the pandemic is compared to a pre-pandemic period (2017-2019). Results After the onset of the pandemic, all visits declined significantly on an annual basis. In 2020, overall prophylactic check-ups dropped by 6-13% and remained lower than the baseline until 2022. Initial figures for 2023 suggest some recovery, while specific services are likely to experience an ongoing decrease. During the pandemic, the average number of prophylactic examinations for children fell between 6.9 and 9.3%. In 2022, there was a modest resumption, although these services did not reach the preceding levels. Adult prophylactic visits declined by approximately 10-12% between 2020 and 2021, but following a U-shaped pattern, they rebounded in 2022. Visits associated with chronic diseases experienced a drop of 7.8% in 2020 and continued to decrease in the next two years. Child vaccination was affected for a shorter period. In 2022, the coverage for most vaccine-preventable diseases was close to the pre-pandemic levels. However, the uptake of MMR and pneumococcal vaccines failed to demonstrate a clear path to recovery. Conclusions During the pandemic, a considerable drop in primary care utilization has been recorded. Effective recovery requires sustained service delivery and a rapid post-lockdown rebound to mitigate the negative impact on health outcomes. Key messages • Primary care needs additional recovery measures to prevent long-term harmful impacts on health outcomes. • Investing in service delivery innovations can boost resilience during disruptive events.

A public health/hospital partnership to improve Emergency Department transitions of care for vulnerable older adults.

Community-dwelling older adults are at high risk for unmet social service needs. We describe a novel partnership embedding county services case managers in the Emergency Department (ED) to connect older adults to community services alongside their medical care. Setting: A medium-sized urban ED with 55,000 patient visits a year. Case managers from the Franklin County, Ohio Office on Aging (OA) were embedded within the ED. The OA team worked with the ED social work team to identify community-dwelling older patients, perform an in-person intake assessment, and initiate needed community services (including home-delivered meals, emergency response systems, house repairs, and transportation). Program logic model and development are reported in detail. From June to December 2023, there were 7284 ED visits for adults ≥60 years old. Referrals to the OA case manager ranged from 1 to 13 per day. The OA case managers performed 252 full intake assessments on unique patients. The population was 51% men. Only 11% (n = 28) were currently connected to OA services, and of those already connected 29% (n = 8) needed increased services. Of the remaining unconnected patients (n = 224), 8% (n = 20) were not county residents and the OA team connected them with other county OAs. Half 53% (n = 120) were accepting of services and had services from the OA or other community health programs initiated during the ED visit. The OA team made three new Adult Protective Services referrals and one referral to the long-term care ombudsman. The program did not increase ED length of stay or hospital admission rates. Embedding county service enrollment within a community ED is a cost neutral intervention that reached a population without previous services. Future plans include expansion of the program and evaluation of the program's ability to detect elder mistreatment and self-neglect.

DiaBetter Together: Clinical trial protocol for a strengths-based Peer Mentor intervention for young adults with type 1 diabetes transitioning to adult care

BackgroundType 1 diabetes (T1D) management is challenging for young adults, who are expected to transfer from the pediatric to adult T1D healthcare system while also managing typical developmental demands (e.g., social, financial, work/school, residential). Many young adults have extended gaps in care before following up in adult care, increasing risk for poor health outcomes. There are few evidence-based programs to support young adults with T1D to promote a timelier transition during this period. This paper reports on the design of DiaBetter Together, a randomized controlled trial to evaluate a 12-month Peer Mentor-delivered intervention compared to usual care among young adults with T1D during the transfer from pediatric to adult care. MethodsOne-hundred young adults (age 17–25) with T1D and 29 Peer Mentors enrolled in this randomized clinical trial. Peer Mentors are experienced, older young adults with T1D, trained by the study team to share transition experiences and strategies to successfully navigate the adult healthcare system, help young adults prepare for the first adult care visit, and use strengths-based support strategies to teach and model skills for managing T1D-related challenges. ResultsThe primary outcome of the trial is HbA1c, and secondary outcomes include time to adult care, engagement in diabetes self-management behaviors, and psychosocial well-being. ConclusionThe goal of this research is to evaluate a developmentally appropriate, supportive intervention that can improve T1D self-management and successful transfer of care during the difficult young adult years and promote optimal T1D health outcomes.

Association between lifetime criminal legal involvement and acute healthcare utilization in middle-aged and older US adults, 2015-2019.

Five decades into the era of mass incarceration, a growing number of older adults have experienced criminal legal involvement (CLI) in their lifetime. Studies have shown that prior incarceration is associated with substantial disease burden, but little is known about the distinct needs and utilization patterns of middle-aged and older adults with lifetime CLI compared to those without. Using a nationally representative data set, we tested the association between lifetime CLI exposure and use of acute care services among middle-aged and older adults. Our sample included 44,007 US adults (25,074 middle-aged-50-64 years; 18,709 older- ≥65 years) who participated in the National Survey of Drug Use and Health (2015-2019). The data is publicly available. Our independent variable was lifetime CLI. Using separate negative binomial regression models for middle-aged and older adults, we tested the association between lifetime CLI and acute healthcare utilization (ED visits and nights spent inpatient) controlling for relevant sociodemographic covariates. For middle-aged respondents, 19.1% reported lifetime CLI; for older adults, the rate of exposure was 9.6%. In multivariate models, CLI was associated with increased ED visits in middle-aged adults (IRR 1.18, 95% CI 1.06-1.31) but not older adults (IRR 0.99, 95% CI 0.85-1.16). CLI was associated with increased nights hospitalized in both groups (middle-aged: IRR 1.33, 95% CI 1.08-1.62; older adults: IRR 1.26, 95% CI 1.01, 1.57). Middle-aged and older adults with lifetime CLI experience higher rates of acute care utilization than their peers with no lifetime CLI, even after adjustment for confounders. As the cohort of adults from the era of mass incarceration ages, understanding the mechanisms by which lifetime CLI impacts health outcomes is crucial in designing interventions to improve outcomes and reduce unnecessary acute healthcare utilization.

Socioeconomic status and emergency department visits in adults with a history of severe childhood asthma: a register-based study

ABSTRACT Background and Objective Our knowledge of socioeconomic status (SES) and emergency department (ED) visits in adults with a history of severe childhood asthma is limited. Our aim was, therefore, to investigate these variables in individuals with a history of severe childhood asthma compared to a control population. Methods The Kongsberg cohort comprises Danish individuals with a history of severe childhood asthma and a previous 4-month stay at an asthma care facility in Kongsberg, Norway, between 1950 and 1979. The cohort was compared 1:1 to sex and age matched controls with no previous diagnosis of or treatment for obstructive airway disease (OAD). Data from the national Danish health registries were used for comparing cases and controls. Results A total of 1394 adults from the Kongsberg cohort were alive and residing in Denmark (mean age 63 years, 43% females) at the index date (June 2022). A Charlson comorbidity index score of ≥1 was higher in the study cohort compared to controls (7% versus 3%) (p < 0.01). Cases had a 1.5-fold increased likelihood of having a high educational level (p < 0.001) compared to controls. Compared to the controls, cases had a higher risk of all-cause ED visits, with individuals having lower educational levels showing the highest proportion of ED visits. Furthermore, 31.2% and 22.9%, respectively, of cases and controls with high educational levels had had ED visits. Compared to controls, logistic regression analysis revealed a 1.7-fold higher risk of all-cause ED visits in cases (p < 0.001). Conclusions In adults with a history of severe childhood asthma, educational level, comorbidity burden, and risk of ED visit were higher compared to matched controls with no history of obstructive airway disease.

The effectiveness of continuous glucose monitoring with remote telemonitoring-enabled virtual educator visits in adults with non-insulin dependent type 2 diabetes: A randomized trial

AimsEstimate the effectiveness of continuous glucose monitoring (CGM) with remote telemonitoring-enabled virtual diabetes educator visits for improving glycemic management in adults with type 2 diabetes, not on insulin. MethodsParticipants with type 2 diabetes, not on insulin, and HbA1c > 7.0 % were enrolled in an open-label randomized trial of 6 weeks of CGM with telemonitoring versus enhanced usual care. Both groups received educator visits. HbA1c was assessed at 12 weeks. ResultsOf 105 participants (mean age 57.3 years, 49.5 % females, mean baseline HbA1c 8.0 %), 86 remained at follow-up. Change in HbA1c was −0.69 % (CGM) versus −0.33 % (enhanced usual care). Adjusting for baseline HbA1c, CGM was superior (0.65 % greater HbA1c reduction [95 % CI 0.17–1.12 %], p = 0.008). CGM participants were 92 % (RR = 1.92, 1.19–3.06, p = 0.007) more likely to have an HbA1c reduction ≥ 0.5 %, lost more weight (difference in weight reduction 2.17 kg, 0.22–4.11, p = 0.029) and were more satisfied with their treatment. No treatment-related adverse events were observed. ConclusionsCGM with virtual diabetes educator visits is effective, safe, and acceptable in adults with type 2 diabetes not on insulin and should be considered as an alternative to drug therapy for improving blood glucose.

Association between Homelessness and Temperature-Related Health Emergencies in the United States

Abstract Temperature-related illness (TRI) encompasses heat-related illness, such as heat exhaustion and heatstroke, and cold-related illness, such as frostbite and hypothermia. TRI is typically the result of exposure to ambient weather conditions; because of this, unhoused individuals are hypothesized to have higher risk of TRI. However, no national epidemiological studies have been completed to determine this risk. The objective of this study was to determine the association between homelessness and emergency department (ED) diagnosis of TRI in the United States. We conducted a cross-sectional study of adult ED visits in the United States from 2005 through 2020 using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative sample of nonfederal ED patient visits. Housing status (housed versus unhoused) was measured using NHAMCS patient residence category, with blank responses excluded. TRI was defined as ED clinician diagnosis of heat- or cold-related illness using International Classification of Disease, versions 9 and 10 (ICD-9 and ICD-10) codes. Multivariable logistic regression was used to determine adjusted odds of TRI by housing status. There were 323 606 nonpediatric ED visits in the NHAMCS sample. TRI diagnosis was present in 288 (0.09%) visits. 4099 visits (0.9%) were categorized as unhoused. After adjusting for sex, mental health diagnosis, and alcohol or substance use or use disorder, the odds ratio of TRI diagnosis in unhoused individuals was 4.08 (95% CI 2.09, 7.95) compared to housed individuals. We found a higher adjusted odds ratio of TRI diagnosis at an ED visit among unhoused individuals compared with housed individuals. Significance Statement Temperature-related health emergencies, or illnesses caused by exposure to ambient weather conditions, affect numerous Americans each year and are expected to become more common as climate change continues. We wanted to understand whether unhoused individuals are at higher risk of these health emergencies. We used a national sample of emergency department visits in the United States to study this and found out that unhoused individuals are at more than four times the risk of these illnesses than housed individuals. Our work highlights the need for prevention of homelessness, stable housing for housing insecure populations, and heating and cooling centers during weather emergencies.

Experiences of Older Adults with Heart Failure Using Telemedicine During the COVID-19 Pandemic: A Qualitative Study.

Background: Telemedicine (TM) usage increased rapidly during the COVID-19 pandemic. This study is part of a larger mixed-methods study comparing TM and in-person visits of older adults with heart failure (HF) and describes patient's TM experiences during the pandemic. Methods: This study employed qualitative design using survey responses and individual interviews. Study eligibility requirements included >55 years old, HF diagnosis, and TM visit between September 1, 2020 and May 31, 2021, at one of two participating health systems in the southern United States. Results: Twenty-two TM recipients completed qualitative interviews, and 91 of 125 online survey respondents answered open-ended questions. Data were gathered, sorted, and revealed five themes. Discussion: Interview respondents identified benefits, e.g., convenience, inclusion, decreased exposure, and problems, e.g., connectivity issues, inadequate equipment, and medical conditions impacting use. Recommendations included allocating sufficient appointment time, tailoring visits, and increasing written communication. This study was part of a larger clinical trial registered at ClinicalTrials.gov: NCT04304833.

End-of-life emergency department use and healthcare expenditures among older adults: A nationally representative study.

Emergency department (ED) visits at end-of-life may cause financial strain and serve as a marker of inadequate access to community services and health care. We sought to examine end-of-life ED use, total healthcare spending, and out-of-pocket spending in a nationally representative sample. Using Medicare Current Beneficiary Survey data, we conducted a pooled cross-sectional analysis of Medicare beneficiaries aged 65+ years with a date of death between July 1, 2015 and December 31, 2021. Our primary outcomes were ED visits, total healthcare spending, and out-of-pocket spending in the 7, 30, 90, and 180 days preceding death. We estimated a series of zero-inflated negative binomial models identifying patient characteristics associated with the primary outcomes. Among 3812 older adult decedents, 610 (16%), 1207 (31.7%), 1582 (41.5%), and 1787 (46.9%) Medicare beneficiaries had ED visits in the final 7, 30, 90, and 180 days, respectively, of life. For Medicare beneficiaries with at least one ED visit in the final 30 days of life, the median total and out-of-pocket costs were, respectively, $12,500 and $308, compared, respectively, with $278 and $94 for those without any ED visits (p < 0.001 for both comparisons). Having a diagnosis of dementia (odds ratio [OR] 0.71; 95% confidence interval [CI] 0.51-0.99; p = 0.04) and being on hospice status during the year of death (OR 0.56; 95% CI 0.48-0.66; p = <0.001) were associated with a decreased likelihood of having an ED visit. Having dementia was associated with a decreased likelihood of having any healthcare spending (OR 0.50; 95% CI 0.36-0.71; p = 0.001) and any out-of-pocket spending (OR 0.51; 95% CI 0.36-0.72; p = <0.001). One in three older adults visit the ED in the last month of life, and approximately one in two utilize ED services in the last half-year of life, with evidence of associated considerable total and out-of-pocket spending.

Enhancing hypertension education of community health extension workers in Nigeria’s federal capital territory: the impact of the extension for community healthcare outcomes model on primary care, a quasi-experimental study

BackgroundHealthcare workers (HCWs) including community health extension workers (CHEWs) in the Federal Capital Territory, Nigeria participated in a hypertension training series following the Extension for Community Healthcare Outcomes (ECHO) model which leverages technology and a practical peer-to-peer learning framework to virtually train healthcare practitioners. We sought to evaluate the patient-level effects of the hypertension ECHO series.MethodsHCWs from 12 of 33 eligible primary healthcare centers (PHCs) in the Hypertension Treatment in Nigeria Program (NCT04158154) were selected to participate in a seven-part hypertension ECHO series from August 2022 to April 2023. Concurrent Hypertension Treatment in Nigeria Program patient data were used to evaluate changes in hypertension treatment and control rates, and adherence to Nigeria’s hypertension treatment protocol. Outcomes were compared between the 12 PHCs in the ECHO program and the 21 which were not.ResultsBetween July 2022 and June 2023, 16,691 PHC visits were documented among 4340 individuals (ECHO: n = 1428 [33%], non-ECHO: n = 2912 [67%]). Patients were on average (SD) 51.5 (12.0) years old, and one-third were male (n = 1372, 32%) with no differences between cohorts in either characteristic (p ≥ 0.05 for both). Blood pressures at enrollment were higher in the ECHO cohort compared to the non-ECHO cohort (systolic p < 0.0001 and diastolic p = 0.0001), and patients were less likely to be treated with multiple medications (p < 0.0001). Treatment rates were similar at baseline (ECHO: 94.0% and Non-ECHO: 94.7%) and increased at a higher rate (interaction p = 0.045) in the ECHO cohort over time. After adjustment for baseline and within site variation, the difference was attenuated (interaction p = 0.37). Over time, control rates increased and medication protocol adherence decreased, with no differences between cohorts. Staffing levels, adult patient visits, and rates of hypertension screening and empanelment were similar between ECHO and non-ECHO cohorts (p ≥ 0.05 for all).ConclusionsThe ECHO series was associated with moderately increased hypertension treatment rates and did not adversely affect staffing or clinical capacity among PHCs in the Federal Capital Territory, Nigeria. These results may be used to inform strategies to support scaling hypertension education among frontline HCWs throughout Nigeria, and use of the ECHO model for CHEWs.Trial RegistrationThe Hypertension Treatment in Nigeria Program was prospectively registered on November 8, 2019 at www.clinicaltrials.gov (NCT04158154; https://clinicaltrials.gov/ct2/show/NCT04158154).

Variation in patient-sharing network characteristics of health care professionals treating different mental and substance use disorder patient sub-groups in primary care.

Providing efficient and targeted services for patients with mental health problems requires efficient collaboration and coordination within healthcare providers, but measuring collaboration using traditional methods is challenging. To explore the patient-sharing networks of professionals taking care of different groups of patients with mental or substance use disorders. We used data that covered adult patients' visits to the primary care service providers of seven municipalities in Finland during year 2021. Data included 8,217 patients (147,430 visits) with mental or substance use disorders who were treated by 1,566 health care professionals. We calculated descriptive network metrics to examine the connectivity of professionals in three different patient groups (patients with substance use disorders, psychotic disorders, and depressive disorders) and compared these characteristics to a network based on all patients. We also analyzed whether patient sharing was associated with the health care professionals' attributes (occupational group, municipality) using Exponential Random Graph Models (ERGM). Diagnosis-specific networks were denser and more connected compared to the all-patients network. Nurses were the most central occupation in all the diagnosis-specific networks and especially in the substance use disorder patients network. When examining all patients, two professionals were more likely to share patients when they belonged to the same occupational group. However, in the network with depressive disorder patients we found the opposite: professionals were more likely to share patients if they were of different occupational groups. Patient-sharing networks within patients with a specific mental or substance use disorders are denser and more connected than networks based on all patients with mental or substance use disorders. In the substance use disorder patients network particularly, nurses were the most central occupation. Multi-professional connections were more likely in depressive disorder networks than in the all-patients network.

Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis

BackgroundAccurate and timely diagnosis relies on sharing perspectives among team members and avoiding information asymmetries. Patients/Families hold unique diagnostic process (DxP) information, including knowledge of diagnostic safety blindspots—information that patients/families...

Neighborhood Deprivation and Crime on Asthma Exacerbations and Utilization in Mild Adult Asthma

Social determinants of health (SDOH) have a significant impact on asthma outcomes, with factors such as income level and neighborhood environment playing crucial roles. This study aimed to assess the impact of Neighborhood Deprivation Index (NDI) and Total Crime Index (TCI) on acute asthma exacerbation (AAE) and asthma-related Emergency Department and urgent care (ED/UC) visits in adults with mild asthma. This retrospective cohort study utilized administrative data from Kaiser Permanente Southern California among 198,873 mild adult asthma patients between January 1, 2013, and December 31, 2018. Robust Poisson regression models, adjusted for age and sex, were employed to investigate the associations of NDI and TCI with AAE and asthma-related ED/UC visits. Data analysis included subgroup assessments by race and ethnicity and BMI categories to explore potential disparities in asthma outcomes. Among the cohort, 12,906 patients (6.5%) experienced AAE in one year, with Black patients having the highest AAE percentage (7.1%). Higher NDI quintiles were associated with increased AAE risk (aRRs: 1.11-1.27), with similar trends across BMI categories and race or ethnicity, except for Black patients. TCI showed weaker associations with AAE. Regarding ED/UC visits, 5.0% had such visits within one year. Higher NDI quintiles were associated with higher ED/UC visit risk (aRRs: 1.23-1.75), while TCI associations were weaker. Addressing socioeconomic disparities, as indicated by NDI, may be crucial in mitigating asthma exacerbations and reducing healthcare utilization, highlighting the importance of incorporating social determinants into asthma management strategies even in patients with mild asthma.

Physician Follow-Up of Pediatric and Young Adult Emergency Department Visits for Substance Use in Ontario, Canada

PurposeTo study the proportion and predictors of outpatient physician follow-up within 60 days of substance-related emergency department (ED) visits for Ontario youth. MethodsWe examined administrative data on substance-related ED visits before and during the COVID-19 pandemic among youths aged 10–24 years in Ontario, Canada. Substance-related visits were identified using International Classification of Diseases-10-CA codes. We described demographic characteristics, receipt of mental health services in the year before the ED visit, disposition from the ED, and follow-up services within 60 days of the ED visit. ResultsBetween April 1, 2017, and May 31, 2021, 64,236 youth had at least one ED visit for substance use. Visits for alcohol were the most common (49%), followed by cannabis (32.3%). ED visits for all substances were more prevalent during the pandemic than prepandemic, except visits for alcohol. The receipt of follow-up physician care for substance use was low (33.2% prepandemic) but increased during the pandemic (41.7%; adjusted odds ratio 1.34, 95% CI 1.28, 1.39) and varied between substances. Mental health service history in the year before the substance-related ED visit had the strongest association with receipt of follow-up physician care within 60 days (adjusted odds ratio 6.86, 95% CI 6.57, 7.17). DiscussionYouth frequently do not receive physician follow-ups within two months of the substance-related ED visit, although higher follow-up proportions were seen during the pandemic after the implementation of virtual care. Further research is required to understand why follow-up is low and to examine interventions that can increase connection to care.

National Case Volumes and Gender Disparities in Emergency Department Utilization for Psychiatric Emergencies: A Population-Based Claims Data Analysis.

Introduction The utilization of emergency departments (EDs) for managing psychiatric emergencies has significantly increased in the United Statesbecause of the increasing prevalence of mental health disorders. This study examined national case volumes and sex disparities in ED visits for psychiatric emergencies usingdata from the Nationwide Emergency Department Sample (NEDS). Methods This retrospective analysis included adult ED visits for psychiatric emergencies identified using relevant International Classification of Diseases, 10th Revision (ICD-10) codes. Primary endpoints included national case volumes by sex. Hospitalizations with age < 18 years and those with missing data on sex were excluded. Secondary endpoints included inpatient mortality, ED and inpatient costs, admission rates, discharge disposition, length of stay (LOS), and number of procedures. Results In 2021, there were approximately 143.5 million ED visits in the United States, with 7,978,490 of these being for psychiatric emergencies. The most common presentations were substance abuse and intoxication (5,119,086 (64.2%)), severe bipolar disorder (1,912,670 (24%)), and anxiety or panic attacks (1,015,486 (12.7%)). Approximately 3,997,223 (50.1%) were women, and 3,981,267 (49.9%) were men. Men were older (mean age: 45 versus 43 years; P<0.001), were more likely to be uninsured (712,647 (17.9%) versus 497,658 (12.5%); P<0.001), and had a higher Charlson Comorbidity Index (CCI) (CCI ≥ 2: 792,272 (19.9%) versus 643,552 (16.1%); P<0.001). More men than women presented to the ED with acute substance abuse or intoxication (3,196,945 (80.3%) versus 1,922,142 (48.1%)), bipolar disorder with or without psychosis (958,275 (24.1%) versus 954,395 (23.9%); P<0.001), and suicidal ideation (267,638 (6.7%) versus 208,989 (5.2%); P<0.001). More women than men presented with severe depression (455,683 (11.4%)versus 441,921 (11.1%)), anxiety and panic attacks (615,572 (15.4%) versus402,108 (10.1%)), acute stress reaction (35,975 (0.9%) versus 23,888 (0.6%)), eating disorders (3,997 (0.1%) versus27,869 (0.07%)), and a history of abuse (21,164 (0.53%) versus19,569 (0.49%); P<0.001). Women had lower mortality rates (27,980 (0.7%) versus 63,956 (1.6%); P<0.001), lower mean ED costs (adjusted mean difference (AMD): $1,189; P<0.001), fewer in-hospital admissions (1,211,158 (30.3%) versus 1,453,162 (36.5%); P<0.001), and a higher number of prolonged hospitalizations (1,442,998 (36.1%) versus 1,194,380 (30%); P<0.001) compared with men. Conclusion Thisstudy highlights significant sex disparities in EDutilizationforpsychiatric emergencies.Men more frequently present with substance abuse and severe comorbidities, leading to higher healthcare costs and inpatient admissions. Women, while more likely to present with anxiety and depressive disorders, incur lower costs and have better overall outcomes.

Using electronic health record data for chronic disease surveillance in low- and middle-income countries: the example of hypertension in rural Guatemala

Hypertension is the leading preventable cause of death worldwide. Two-thirds of people with hypertension live in Low- and Middle-Income Countries (LMIC). However, epidemiological data necessary to address the growing burden of hypertension and other Non-Communicable Diseases (NCDs) in LMICs are severely lacking. Electronic Health Records (EHRs) are an emerging source of epidemiological data for LMICs, but have been underutilized for NCD monitoring. The objective of this study was to estimate the prevalence of hypertension in a rural Indigenous community in Guatemala using EHR data, describe hypertension risk factors and current treatment in this population, and demonstrate the feasibility of using EHR data for epidemiological surveillance of NCDs in LMIC. We conducted a cross-sectional analysis of 3646 adult clinic visits. We calculated hypertension prevalence using physician diagnosis, antihypertensive treatment, or Blood Pressure (BP) ≥140/90 mmHg. We noted antihypertensives prescribed and BP control (defined as BP&lt;140/90 mmHg) for a total of 2496 unique patients (21% of whom were men). We constructed mixed-effects models to investigate the relationship between BP and hypertension risk factors. The estimated hypertension prevalence was 16.7%. Two-thirds of these patients had elevated BP, but were not diagnosed with or treated for hypertension. Most patients receiving treatment were prescribed monotherapy and only 31.0% of those with recognized hypertension had controlled BP. Male sex, older age, increasing weight, and history of hypertension were associated with increasing systolic BP, while history of hypertension, history of diabetes, and increasing weight were associated with increasing diastolic BP. Using EHR data, we estimated comparable hypertension prevalence and similar risk factor associations to prior studies conducted in Guatemala, which used traditional epidemiological methods. Hypertension was underrecognized and undertreated in our study population, and our study was more efficient than traditional methods and provided additional data on treatment and outcomes; insights gleaned from this analysis were essential in developing a sustainable intervention. Our experience demonstrates the feasibility and advantages of using EHR-derived data for NCD surveillance and program planning in LMICs.

Activity and Participation Are Associated With Future Falls, Hospitalizations, and Emergency Visits in Community-Dwelling Older Adults.

Activity and participation are important for older adults as they are associated with well-being and quality of life. Falls, emergency department (ED) visits, and hospitalizations are adverse health outcomes that impact older adults. Limited research has investigated whether measurement of activity and participation are related to adverse health events in community dwelling older adults. This study sought to examine the association between activity and participation with falls, ED visits, and hospitalization over 1year in community dwelling older adults. A secondary analysis of a longitudinal clinical trial of 341 community dwelling older adults was conducted. The sample mean age was 80.9 (SD = 7.7) years and 83% were female. One-year risk of falls was associated with baseline Late Life Function and Disability Instrument (LLFDI) components of overall function and disability (frequency and limitations dimensions). Incident rate ratios (IRRs) and 95% CIs were calculated. For each five-point higher score (clinically meaningful difference) in activity as measured by LLFDI-overall function (adjusted for age, race, sex, comorbidities and fall history), there was an 18% lower rate of falls (IRR = 0.82, 95% CI = 0.74-0.92), 12% reduction in hospitalizations (IRR = 0.88; 95% CI = 0.77-0.99), and 11% lower rate of emergency room visits (IRR = 0.89, 95% CI = 0.81-0.98). Greater participation as measured by the LLFDI limitations dimension was related to fewer falls (IRR = 0.93, 95% CI = 0.87-1.00) and hospitalizations (IRR = 0.91, 95% CI = 0.83-0.99). Greater activity and participation are associated with a lower incidence of falls, ED visits, and hospitalizations representing an important consideration for targeted physical therapist interventions. Physical therapists are uniquely positioned to identify and address reduced activity and participation. If activity and participation are specifically targeted and improved through physical therapy, undesirable distal health outcomes might be prevented or minimized. Greater activity and participation were found to be related to lower rate of falls, ED visits, and hospitalizations in a sample of 341 older adults who lived in the community.

Healthcare use of young Finnish adults with mental disorders – profiles and profile membership determinants

BackgroundComprehensive, timely, and integrated primary care services have been proposed as a response to the increased demand for mental health and substance use services especially among young people. However, little is known about the care utilization patterns of young people with mental and substance use disorders. Our aim was to characterize profiles of care use in young Finnish adults with mental or substance use disorders, and the potential factors associated with the service use profiles.MethodsPrimary and specialized care visits of young adults (16–29 years) diagnosed with a psychiatric or a substance use disorder (n = 7714) were retrieved from the national health care register from years 2020 and 2021. K-Means clustering was used to detect different profiles based on the utilization of care services. Multinomial logistic regression was used to analyze the factors associated with different profiles of care use.ResultsFive different profiles were identified: low care use (75%), and use of principally primary health care (11%), student health services (9%), psychiatric services (5%), or substance use services (1%). Female gender was associated with membership in the primary health care focused profiles (OR 2.58 and OR 1.99), and patients in the primary health care and student health services profiles were associated with a better continuity of care (OR 1.04 and OR 1.05). Substance use disorders were associated with psychiatric service use (OR: 2.51) and substance use services (OR: 58.91). Living in smaller municipalities was associated with lower service use when comparing to the largest city.ConclusionsYoung adults diagnosed with a psychiatric or a substance use disorder had remarkably different and heterogeneous care patterns. Most of the participants had low care utilization, indicating potential gaps in service use and care needs. Measures should be taken to ensure equal access to and availability of mental health services. The profiles that utilized the most services highlights the importance of integrated services and patient-oriented improvement of treatment.