Emergency Hospital Admissions Research Articles

Identifying key health system components associated with improved outcomes to inform the re-configuration of services for adults with rare autoimmune rheumatic diseases: a mixed-methods study

Adults with rare autoimmune rheumatic diseases face unique challenges and struggles to navigate health-care systems designed to manage common conditions. Evidence to inform an optimal service framework for their care is scarce. Using systemic vasculitis as an exemplar, we aimed to identify and explain the key service components underpinning effective care for rare diseases. In this mixed-methods study, data were collected as part of a survey of vasculitis service providers across the UK and Ireland, interviews with patients, and from organisational case studies to identify key service components that enable good care. The association between these components and patient outcomes (eg, serious infections, mortality) and provider outcomes (eg, emergency hospital admissions) were examined in a population-based data linkage study using routine health-care data obtained from patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis from national health datasets in Scotland. We did univariable and multivariable analyses using Bayesian poisson and negative binomial regression to estimate incident rate ratios (IRRs), and Cox proportional hazards models to estimate hazard ratios (HRs). People with lived experiences were involved in the research and writing process. Good care was characterised by service components that supported timely access to services, integrated care, and expertise. In 1420 patients with ANCA-associated vasculitis identified from national health datasets, service-reported average waiting times for new patients of less than 1 week were associated with fewer serious infections (IRR 0·70 [95% credibility interval 0·55-0·88]) and fewer emergency hospital admissions (0·78 [0·68-0·92]). Nurse-led advice lines were associated with fewer serious infections (0·76 [0·58-0·93]) and fewer emergency hospital admissions (0·85 [0·74-0·96]). Average waiting times for new patients of less than 1 week were also associated with reduced mortality (HR 0·59 [95% credibility interval 0·37-0·93]). Cohorted clinics, nurse-led clinics, and specialist vasculitis multi-disciplinary team meetings were associated with fewer serious infections (IRR 0·75 [0·59-0·96] for cohorted clinics; 0·65 [0·39-0·84] for nurse-led clinics; 0·72 [0·57-0·90] for specialist vasculitis multi-disciplinary team meetings) and emergency hospital admissions (0·81 [0·71-0·91]; 0·75 [0·65-0·94]; 0·86 [0·75-0·96]). Key components were characterised by their ability to overcome professional tensions between specialties. Key service components associated with important health outcomes and underpinning factors were identified to inform initiatives to improve the design, delivery, and effectiveness of health-care models for rare autoimmune rheumatic diseases. Versus Arthritis.

Early Access to First-Seizure Clinics, Subsequent Outcomes, and Factors Associated With Attendance

First-seizure clinics (FSCs) aim to deliver prompt specialist care to patients with new-onset undifferentiated seizure events. To determine whether FSC attendance and time to FSC are associated with subsequent health care utilization and mortality and to investigate factors associated with FSC nonattendance. This was a record-linkage, retrospective, cohort study of patients who booked appointments at 2 FSCs between 2007 and 2018. Patients' records were linked to state-wide administrative databases between 2000 and 2021. The setting comprised the FSCs of 2 major metropolitan public hospitals in Melbourne, Australia, providing national inpatient and outpatient adult epilepsy services. Of patients who booked appointments at the FSCs, those who were successfully linked for analysis were included in the study. Patients who recorded only canceled appointments were excluded from analysis of outcomes. Study data were analyzed from January 2000 to December 2021. FSC attendance. Subsequent all-cause and seizure-related emergency department (ED) presentations and hospital admissions. Of 10 162 patients with appointments at FSCs, 9392 were linked for analysis, with mean (SD) follow-up time 6.9 (2.8) years after FSC referral. A total of 703 patients were excluded. Among 9392 linked patients, 5398 were male (57.5%; mean [SD] age, 59.7 [11.2] years). FSC attendance was associated with reduced subsequent all-cause emergency presentations (adjusted incidence rate ratio [aIRR], 0.72; 95% CI, 0.66-0.79) and all-cause hospitalization (aIRR, 0.81; 95% CI, 0.75-0.88). Those who attended at the first-scheduled appointment, compared with those who attended only a rescheduled, delayed appointment, had reduced subsequent all-cause emergency presentations (aIRR, 0.83; 95% CI, 0.76-0.91), all-cause hospitalization (aIRR, 0.71; 95% CI, 0.65-0.79), seizure-related presentations (aIRR, 0.40; 95% CI, 0.33-0.49), and mortality (hazard ratio, 0.82; 95% CI, 0.69-0.98). Male sex was associated with nonattendance (adjusted relative risk [aRR], 1.12; 95% CI, 1.03-1.22), as were injury at emergency presentation (aRR, 1.12; 95% CI, 1.01-1.24), psychiatric comorbidity (aRR, 1.68; 95% CI, 1.55-1.81), previous seizure-related presentations (aRR, 1.35; 95% CI, 1.22-1.49), and delays (>14 days) between FSC referral and appointment (aRR, 1.35; 95% CI, 1.18-1.54). Hospitalization at referral was associated with reduced nonattendance (aRR, 0.80; 95% CI, 0.72-0.90), as were non-English language preference (aRR, 0.81; 95% CI, 0.69-0.94), distance greater than 6 mi from home to clinic (aRR, 0.85; 95% CI, 0.76-0.95), and physical comorbidity (aRR, 0.80; 95% CI, 0.72-0.89). Results of this cohort study suggest that FSC attendance, particularly early attendance, was associated with reduced rates of subsequent hospital utilization. This knowledge may support adequately resourcing FSCs to improve equitable, timely access. Future study directions include assessing interventions that may support FSC attendance for at-risk groups.

Development of a Multivariable Risk Prediction Tool to Predict Adverse Outcomes among Children with Type 1 Diabetes: A Pilot Study

Background. Children and adolescents with type 1 diabetes mellitus (T1DM) are frequently hospitalised for severe hypoglycaemia, hyperglycaemia, and diabetic ketoacidosis (DKA). While several risk factors have been recognised, clinically identifying these children at high risk of acute decompensation remains challenging. Objective. To develop a risk prediction model to accurately estimate the risk of acute healthcare utilisation due to severe hypoglycaemia, hyperglycaemia, and DKA in children and adolescents with T1DM. Materials and Methods. Using a retrospective dataset, baseline demographic and clinical data were collected from patients (<18 years) seen at a regional paediatric diabetes clinic from 1 January 2018 to 1 January 2020. The outcome was the number of emergency department presentations or hospital admissions for severe hypoglycaemia, hyperglycaemia, and DKA across the study period. Variables that were significant in univariate analysis were entered into a multivariable model. Receiver operator characteristic (ROC) curves assessed the model’s discrimination and generated cut-offs for risk group stratification (low, medium, and high). Kaplan–Meier survival analysis measured time to acute healthcare utilisation across the risk groups. Results. Our multivariable risk prediction model consisted of five predictors (continuous glucose monitoring device, previous acute healthcare utilisation, missed appointments, and child welfare services involvement and socioeconomic status). The model exhibited good discrimination (area under the ROC = 0.81), accurately stratified children into low-, medium-, and high-risk groups, and demonstrated significant differences between median time to healthcare utilisation. Conclusion. Our model identified patients at an increased risk of acute healthcare utilisation due to severe hypoglycaemia, hyperglycaemia, and DKA.

Patterns and correlates of health service contact prior to serious offences by people with severe mental illness.

Contact with health services prior to offences committed by people with mental illness is an opportunity for intervention and prevention. This study examines the pattern and correlates of health service contact by people with severe mental illness before a serious offence. Linkage of a cohort of 477 Forensic Patients found not guilty due to mental illness between 1990 and 2016, and statewide databases of contact with emergency departments, hospital admission and outpatient mental health services in the state of New South Wales, Australia. A total of 84% of the sample had contact with any health service and 76% had contact with an outpatient mental health service prior to the index offence. About two-thirds of the sample had contact with a mental health service in the year before the offence. Factors independently associated with the absence of contact at any point prior to the index offence were non-English-speaking background, being engaged in employment or study, and an absence of childhood abuse or neglect. Although nearly every Forensic Patient had a psychotic illness at the time of the index offence, psychosis was not diagnosed at the time of 61/106 (57.5%) emergency department presentations, in 54/174 (31.0%) hospital admissions and 149/222 (67.1%) attendances at outpatient mental health services prior to the offence. Most Forensic Patients had contact with health services prior to their offences but many were not identified as having a psychotic illness. Although the symptoms of psychosis may have emerged in the period between contact and the offence, the findings suggest that emerging or underlying psychosis were missed or attributed to other conditions.

Multimorbidity-associated emergency hospital admissions: a “screen and link” strategy to improve outcomes for high-risk patients in sub-Saharan Africa: a prospective multicentre cohort study protocol

Background The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub–Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Primary objectives Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Secondary objectives Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. Methods This is a prospective longitudinal cohort study of adult (≥18 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng’ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.

Evaluation of laparoscopic peritoneal lavage for perforated diverticulitis: a national registry-based study.

Laparoscopic lavage (LPL) has been suggested for treatment of non-feculent perforated diverticulitis. In this observational study, the surgical treatment of diverticular disease in Sweden outside prospective trials was investigated. This population-based study used the National Patient Register to identify all patients in Sweden with emergency admissions for diverticular disease, as defined by ICD codes from July 2014 to December 2020. Demographics, surgical procedures and outcomes were assessed. In addition, register data since 1997 were retrieved to assess co-morbidities, previous abdominal surgeries, and previous admissions for diverticular disease. Among 47 294 patients with emergency hospital admission, 2035 underwent LPL (427 patients) or sigmoid resection (SR, 1608 patients) for diverticular disease. The mean follow-up was 30.8 months. Patients selected for LPL were younger, healthier and with less previous abdominal surgery for diverticular disease than those in the SR group (P < 0.01). LPL was associated with shorter postoperative hospital stay (mean 9.4 versus 14.9 days, P < 0.001) and lower 30-day mortality (3.5% versus 8.7%, P < 0.001). Diverticular disease-associated subsequent surgery was more common in the SR group than the LPL group except during the first year (P < 0.001). LPL had a lower mortality rate during the study period (stratified HR 0.70, 95% c.i. 0.53-0.92, P = 0.023). Laparoscopic lavage constitutes a safe alternative to sigmoid resection for selected patients judged clinically to require surgery.

Contacts with primary and secondary healthcare before suicide by those under the care of mental health services: case-control, whole-population-based study using person-level linked routine data in Wales, UK during 2000-2015.

People under the care of mental health services are at increased risk of suicide. Existing studies are small in scale and lack comparisons. To identify opportunities for suicide prevention and underpinning data enhancement in people with recent contact with mental health services. This population-based study includes people who died by suicide in the year following a mental health services contact in Wales, 2001-2015 (cases), paired with similar patients who did not die by suicide (controls). We linked the National Confidential Inquiry into Suicide and Safety in Mental Health and the Suicide Information Database - Cymru with primary and secondary healthcare records. We present results of conditional logistic regression. We matched 1031 cases with 5155 controls. In the year before their death, 98.3% of cases were in contact with healthcare services, and 28.5% presented with self-harm. Cases had more emergency department contacts (odds ratio 2.4, 95% CI 2.1-2.7) and emergency hospital admissions (odds ratio 1.5, 95% CI 1.4-1.7), but fewer primary care contacts (odds ratio 0.7, 95% CI 0.6-0.9) and out-patient appointments (odds ratio 0.2, 95% CI 0.2-0.3) than controls. Odds ratios were larger in females than males for injury and poisoning (odds ratio: 3.3 (95% CI 2.5-4.5) v. 2.6 (95% CI 2.1-3.1)). We may be missing existing opportunities to intervene, particularly in emergency departments and hospital admissions with self-harm presentations and with unattributed self-harm, especially in females. Prevention efforts should focus on strengthening routine care contacts, responding to emergency contacts and better self-harm care. There are benefits to enhancing clinical audit systems with routinely collected data.

Association between socioeconomic status and hospitalisation requirement in older patients attended at the emergency department: A retrospective cohort study

Introduction and objectiveA low socioeconomic status (SES) has been associated with poor health results. The present study aimed to investigate if SES of older patients attending the emergency department is associated with the use of healthcare resources and outcomes. Patients and methodsObservational, retrospective study including consecutive patients 65 years or older admitted to the emergency department. Variables at baseline, index episode, and follow-up were recorded. SES was measured using an indirect theoretical index and patients were categorised into two groups according to whether they lived in a neighbourhood with a low or high SES. Primary outcomes included hospitalisation after the emergency department visit and prolonged hospitalisation (>7 days) at index episode. Secondary outcomes included emergency department re-consultant and hospital admission in the following 3 months after the index episode, and all-cause mortality after long-term follow-up. Logistic regression and cumulative hazards regression models were used to investigate associations between SES and outcomes. ResultsThe cohort included 553 patients (80 years [73–85], 50.5% female, 55.9% with low SES). After the emergency department visit, 234 patients (42.3%) required hospital admission. A low SES was inversely associated with hospitalisation with an adjusted odds ratio=0.654 (95% CI 0.441–0.970). Among hospitalised patients, a low SES was associated with prolonged hospitalisation (adjusted odds ratio=2.739; 95% CI 1.470–5.104). Follow-up outcomes, including all-cause mortality, were not associated with SES. ConclusionsOlder patients living in more deprived urban areas were hospitalised less often after emergency department care, but hospital stays were longer. Understanding the effect of social determinants in healthcare use is mandatory to tailor resources to patient needs.

Cancer diagnosis after emergency presentations in people with mental health and substance use conditions: a national cohort study

BackgroundCancer survival and mortality outcomes for people with mental health and substance use conditions (MHSUC) are worse than for people without MHSUC, which may be partly explained by poorer access to timely and appropriate healthcare, from screening and diagnosis through to treatment and follow-up. Access and quality of healthcare can be evaluated by comparing the proportion of people who receive a cancer diagnosis following an acute or emergency hospital admission (emergency presentation) across different population groups: those diagnosed with cancer following an emergency presentation have lower survival.MethodsNational mental health service use datasets (2002–2018) were linked to national cancer registry and hospitalisation data (2006–2018), to create a study population of people aged 15 years and older with one of four cancer diagnoses: lung, prostate, breast and colorectal. The exposure group included people with a history of mental health/addiction service contact within the five years before cancer diagnosis, with a subgroup of people with a diagnosis of bipolar disorder, schizophrenia or psychotic disorders. Marginal standardised rates were used to compare emergency presentations (hospital admission within 30 days of cancer diagnosis) in the exposure and comparison groups, adjusted for age, gender (for lung and colorectal cancers), ethnicity, area deprivation and stage at diagnosis.ResultsFor all four cancers, the rates of emergency presentation in the fully adjusted models were significantly higher in people with a history of mental health/addiction service use than people without (lung cancer, RR 1.19, 95% CI 1.13, 1.24; prostate cancer RR 1.69, 95% CI 1.44, 1.93; breast cancer RR 1.42, 95% CI 1.14, 1.69; colorectal cancer 1.31, 95% CI 1.22, 1.39). Rates were substantially higher in those with a diagnosis of schizophrenia, bipolar disorder or psychotic disorders.ConclusionsImplementing pathways for earlier detection and diagnosis of cancers in people with MHSUC could reduce the rates of emergency presentation, with improved cancer survival outcomes. All health services, including cancer screening programmes, primary and secondary care, have a responsibility to ensure equitable access to healthcare for people with MHSUC.

Association between opioid use disorder and palliative care: a cohort study using linked health administrative data in Ontario, Canada.

People with opioid use disorder (OUD) are at risk of premature death and can benefit from palliative care. We sought to compare palliative care provision for decedents with and without OUD. We conducted a cohort study using health administrative databases in Ontario, Canada, to identify people who died between July 1, 2015, and Dec. 31, 2021. The exposure was OUD, defined as having emergency department visits, hospital admissions, or pharmacologic treatments suggestive of OUD within 3 years of death. Our primary outcome was receipt of 1 or more palliative care services during the last 90 days before death. Secondary outcomes included setting, initiation, and intensity of palliative care. We conducted a secondary analysis excluding sudden deaths (e.g., opioid toxicity, injury). Of 679 840 decedents, 11 200 (1.6%) had OUD. Compared with people without OUD, those with OUD died at a younger age and were more likely to live in neighbourhoods with high marginalization indices. We found people with OUD were less likely to receive palliative care at the end of their lives (adjusted relative risk [RR] 0.84, 95% confidence interval [CI] 0.82-0.86), but this difference did not exist after excluding people who died suddenly (adjusted RR 0.99, 95% CI 0.96-1.01). People with OUD were less likely to receive palliative care in clinics and their homes regardless of cause of death. Opioid use disorder can be a chronic, life-limiting illness, and people with OUD are less likely to receive palliative care in communities during the 90 days before death. Health care providers should receive training in palliative care and addiction medicine to support people with OUD.

What can hospital emergency admissions prior to cancer diagnosis tell us about socio-economic inequalities in cancer diagnosis? Evidence from population-based data in England.

More deprived cancer patients are at higher risk of Emergency Presentation (EP) with most studies pointing to lower symptom awareness and increased comorbidities to explain those patterns. With the example of colon cancer, we examine patterns of hospital emergency admissions (HEAs) history in the most and least deprived patients as a potential precursor of EP. We analysed the rates of hospital admissions and their admission codes (retrieved from Hospital Episode Statistics) in the two years preceding cancer diagnosis by sex, deprivation and route to diagnosis (EP, non-EP). To select the conditions (grouped admission codes) that best predict emergency admission, we adapted the purposeful variable selection to mixed-effects logistic regression. Colon cancer patients diagnosed through EP had the highest number of HEAs than all the other routes to diagnosis, especially in the last 7 months before diagnosis. Most deprived patients had an overall higher rate and higher probability of HEA but fewer conditions associated with it. Our findings point to higher use of emergency services for non-specific symptoms and conditions in the most deprived patients, preceding colon cancer diagnosis. Health system barriers may be a shared factor of socio-economic inequalities in EP and HEAs.

Hyponatremia-associated hospital visits are not reduced by early electrolyte testing in older adults starting antidepressants.

Clinical practice guidelines recommend early serum electrolyte monitoring when starting antidepressants in older adults due to the increased risk of hyponatremia. It is unclear whether this monitoring improves outcomes. Population-based, retrospective cohort study of Ontario adults aged ≥66 years who initiated therapy with a selective serotonin reuptake inhibitor (SSRI) or selective norepinephrine reuptake inhibitor (SNRI) between April 1, 2013, and January 31, 2020. The index date was the date of the first such prescription, and the exposure of interest was serum electrolyte measurement during the subsequent 7 days. The primary outcome was any emergency department or hospital admission with hyponatremia within 8-60 days of antidepressant initiation. Poisson regression models compared individuals who had versus did not have their serum electrolytes tested in the week following SSRI/SNRI initiation, weighting by propensity score-based overlap weights. Among the 420,085 patients aged ≥66 years initiating treatment with an SSRI/SNRI, 26,808 (6.4%) had serum electrolytes measured in the subsequent 7 days and 6109 (1.5%) subsequently presented to hospital with hyponatremia. The time from drug initiation to hospitalization varied (median 29, interquartile range [IQR] 17-44 days), and the median sodium concentration measured in the community (136, IQR 133-138 mmol/L) was marginally higher than those at the time of hospitalization (132, IQR 130-134 mmol/L). Patients who underwent electrolyte testing in the week following SSRI/SNRI treatment were more likely to attend an emergency department (ED) or hospital with hyponatremia within 8-60 days relative to those who did not (relative risk = 2.31, 95% confidence interval: 2.16-2.46). Testing serum electrolytes in the week after starting an SSRI/SNRI is not associated with a reduced risk of a hospital visit with hyponatremia. These findings do not support current guidelines recommending routine electrolyte monitoring.

A Comparison of Emergency Room Visits and Hospital Admissions Between People with Prediabetes and Diabetes.

The purpose of this study was to characterize risk factors and groups at risk among people with diabetes and prediabetes for increased hospital utilization. Electronic health records for all people who visited the emergency department (ED) and had type II diabetes mellitus (PWD) or prediabetes (PWPD) were collected. ED use, hospital admissions, demographics, and clinical characteristics were compared between the groups. Multivariable logistic regression was used to compare the odds of ED high utilization (HU) (3+ visits per year) and hospital admissions between PWD and PWPD with interactions for socioeconomic status, race, marital status, and total comorbidities. PWD had higher mean ED visits per year compared with PWPD (1.5 vs. 1.2) and were more likely to be admitted (57.3% vs. 34.9%). PWD had higher odds of ED HU (2.1 [1.6, 2.7]) and hospital admissions (1.9 [1.6, 2.1]). Among PWD, Black, not married, and those with more than one comorbidity had the highest odds of ED HU. Among PWPD, those of low SES, Black, and divorced had the higher odds of ED HU. Hospital admissions were a risk for PWD and PWPD with increasing comorbidities. Early recognition and identification of prediabetes and clear criteria for diagnosis could reduce ED visits and hospital admissions.

Health service use of infants involved in family justice care and supervision proceedings in Wales: a data linkage study

IntroductionWhen a child has suffered, or is at risk of suffering, significant harm from parents or caregivers, the local authority may issue Section 31 (s.31) Care and Supervision proceedings under the Children Act (1989). ObjectivesWe compared the healthcare use of infants less than one year old subject to s.31 proceedings in Wales (n = 1,332),to that of a comparison group of infants not subject to s.31 proceedings (n = 204,417), between January 2011 and February 2020. MethodsPopulation-based e-cohort study utilising data held in the Secure Anonymised Information Linkage (SAIL) Databank. Infants in s.31 proceedings were identified using the Children and Family Court Advisory and Support Service dataset. This was linked to demographic and healthcare datasets, to identify General Practice (GP) visits, emergency department (ED) attendances, and hospital admissions (emergency and elective); before the study end date or the child's first birthday for the comparison group, orbefore the s.31 application date.Regression analysis calculated event rate ratios [RR] and incidence rate ratios [IRR] for healthcare events, adjusting for widerdeterminants of health (e.g. perinatal factors, maternal mental health, deprivation), and investigated reasons for healthcare use. ResultsInfants in s.31 proceedings had ahigher number and incidence of healthcare events compared with the comparison group, across all healthcare settings. Differences were greatest for emergency hospital admissions (IRR = 4.03, 95% confidence interval [CI] = 3.53 - 4.59; RR = 4.60, CI = 3.90 - 5.41). "Injury and poisoning" was the main reason for emergency admissions amongst infants in s.31 proceedings. For ED presentations, emergency hospital admissions, and GP visits, there were proportionally more events for these infants across all top ten reasons for healthcare. ConclusionsFindings highlight greater healthcare utilisation for infants involved in s.31 proceedings in Wales, helping to build a better understanding of their needs and vulnerabilities.

Pedestrians injuries in the north east region of Jamaica: a cross sectional study

To describe the sociodemographic data of injured pedestrians, temporal patterns of injury, injury patterns, and the independent predictors of hospital admission. A two year cross-sectional study was conducted at the Saint Ann’s Bay Regional Hospital in pedestrians with injuries post collision with a motor vehicle. A census was performed in all patients who received either emergency room treatment, hospital admission, or surgical intervention. A 30-item interviewer questionnaire was administered to collect the data. A logical regression model was used to determine independent predictors for hospital admission. Ninety pedestrians were included. Age range: 6-86 years old (Mean=39.9). Males were 63.3%, 75.6% were employed, 31% had a chronic illness and 27% reported marijuana use. Most injuries occurred in April, lowest injury rates occurred in August and September. Twenty two percent of collisions occurred on Saturdays. Most injuries occurred at 5pm and 3pm. Many (54.4%) had a fracture, 73.5% were closed. Approximately 32% had contusions and 6.7% had lacerations. Independent predictors of admission were history of marijuana use and having a fracture. Those with history of marijuana use were 4.21 times more likely to be admitted. Those with fractures were 7.10 times more likely to be admitted. Injury patterns spanned a wide age range. They often involved a high energy mechanism of injury as evidenced by the frequency of fractures, hospital admission and surgery intervention rates. The data also suggests a need to implement marijuana testing programmes in our road users.

The Time to Inflammatory Bowel Disease Diagnosis for Patients Presenting with Abdominal Symptoms in Primary Care and its Association with Emergency Hospital Admissions and Surgery: A Retrospective Cohort Study.

Patients with inflammatory bowel disease (IBD) presenting to primary care may experience diagnostic delays. We aimed to evaluate this and assess whether time to diagnosis is associated with clinical outcomes. A retrospective cohort study using English primary care data from January 1, 2010, to December 31, 2019, linked to hospital admission data was undertaken. Patients were followed from the first IBD-related presentation in primary care to IBD diagnosis. Associations of time to diagnosis exceeding a year were assessed using a Robust Poisson regression model. Associations between time to diagnosis and IBD-related emergency hospital admissions and surgery were assessed using Poisson and Cox proportional hazards models, respectively. Of 28 092 IBD patients, 60% had ulcerative colitis (UC) and 40% had Crohn's disease (CD). The median age was 43 (interquartile range, 30-58) years and 51.9% were female. Median time to diagnosis was 15.6 (interquartile range, 4.3-28.1) months. Factors associated with more than a year to diagnosis included female sex (adjusted risk ratio [aRR], 1.23; 95% CI, 1.21-1.26), older age (aRR, 1.05; 95% CI, 1.01-1.10; comparing >70 years of age with 18-30 years of age), obesity (aRR, 1.03; 95% CI, 1.00-1.06), smoking (aRR, 1.05; 95% CI, 1.02-1.08), CD compared with UC (aRR, 1.13; 95% CI, 1.11-1.16), and a fecal calprotectin over 500 μg/g (aRR, 0.89; 95% CI, 0.82-0.95). The highest quartile of time to diagnosis compared with the lowest was associated with IBD-related emergency admissions (incidence rate ratio, 1.06; 95% CI, 1.01-1.11). Longer times to IBD diagnoses were associated with being female, advanced age, obesity, smoking, and Crohn's disease. More IBD-related emergency admissions were observed in patients with a prolonged time to diagnosis.

Economics of Emergency Department Visits by Patients With Inflammatory Bowel Disease: A Real-World Analysis.

Inflammatory bowel disease (IBD) is associated with significant psychosocial, economic, and physical burden on patients. IBD care in the United States results in significant healthcare expenditure with recurring emergency department (ED) care and hospital admissions. Despite advances in therapy and improved access to specialty care, there is still room for improvement in cost-efficient care. Specialty medical homes and interdisciplinary care models have emerged as ways to improve medical care, patient outcomes, and quality of life, as well as improve the impact of healthcare costs. There is limited real-world data on cost in the United States, with many articles citing cost estimates from models. We analyzed real-world data from our tertiary care center with a focus on recurrent ED visits by IBD patients. Descriptive statistics were used for a cost analysis of multiple ED visits by IBD patients. Patients with ≥4 visits to the ED in a 6-month period were described as SuperUsers and were included in a separate analysis. The cost of hospitalization was also included. Total cost associated with all ED visits from SuperUsers were $72999.57 with an average of $6636.32 per patient. When the patients were admitted, the total cost of ED visits and hospitalizations was $721461.52, with an average of $65587.41 per patient. ED utilization by IBD patients with or without hospitalization is expensive and is typically driven by a cohort of SuperUsers. More work needs to be done to improve cost-effectiveness in IBD care, including reducing the frequency of ED visits.

Short-Term Nitrogen Dioxide Exposure and Emergency Hospital Admissions for Asthma in Children: A Case-Crossover Analysis in England.

There is an increasing body of evidence associating short-term ambient nitrogen dioxide (NO2) exposure with asthma-related hospital admissions in children. However, most studies have relied on temporally resolved exposure information, potentially ignoring the spatial variability of NO2. We aimed to investigate how daily NO2 estimates from a highly resolved spatio-temporal model are associated with the risk of emergency hospital admission for asthma in children in England. We conducted a time-stratified case-crossover study including 111,766 emergency hospital admissions for asthma in children (aged 0-14 years) between 1st January 2011 and 31st December 2015 in England. Daily NO2 levels were predicted at the patients' place of residence using spatio-temporal models by combining land use data and chemical transport model estimates. Conditional logistic regression models were used to obtain the odds ratios (OR) and confidence intervals (CI) after adjusting for temperature, relative humidity, bank holidays, and influenza rates. The effect modifications by age, sex, season, area-level income deprivation, and region were explored in stratified analyses. For each 10 µg/m³ increase in NO2 exposure, we observed an 8% increase in asthma-related emergency admissions using a five-day moving NO2 average (mean lag 0-4) (OR 1.08, 95% CI 1.06-1.10). In the stratified analysis, we found larger effect sizes for male (OR 1.10, 95% CI 1.07-1.12) and during the cold season (OR 1.10, 95% CI 1.08-1.12). The effect estimates varied slightly by age group, area-level income deprivation, and region. Short-term exposure to NO2 was significantly associated with an increased risk of asthma emergency admissions among children in England. Future guidance and policies need to consider reflecting certain proven modifications, such as using season-specific countermeasures for air pollution control, to protect the at-risk population.

Investigating the impact of air pollution and temperature changes on emergency admissions (cardiovascular + respiratory) disease in the city of Bojnord, northeastern Iran

Cardiovascular (CVD) + Respiratory diseases are recognized as the main cause of death worldwide. Fluctuations in temperature and air pollution have been reported as one of the most important causes of cardiovascular & respiratory diseases. Therefore, in the current study, we assessed the relationship between ambient air temperature and pollution on the number of total emergency hospital admission due to cardiovascular and respiratory conditions in the City of Bojnord, northeastern Iran. The meteorological data, including daily temperature, relative humidity and concentrations of five air pollutants CO, NO2, NOX SO2, and PM10 were obtained from online electronic sensors at the Bojnurd meteorological station from 21th March 2018 to 20th March 2020. Statistical analysis, penalized distributed lag non-linear method was applied using R Software. Also, sensitivity analysis test was calculated by using appropriate application.The results of the study revealed that the effect of higher and lower temperatures was observed immediately from the first day and the second week, respectively. Also result showed with increase and decrease temperature, significantly increased the risk of hospitalization by 36% (RR, 1.36; 95% CI (1), 0.95 to 1.95) and 17% (RR, 1.17; 95% CI (1), 0.88 to 1.55) until the lag 25th day, respectively. Based on the results, increasing temperature significantly increased the hospitalization rate of cardiopulmonary patients, but the effect of cold was not significant on the population as well as age and gender subgroups. Study have also proved that there is no significance correlation between air pollutant and Cardiovascular & respiratory diseases.

Association between Ambient Volatile Organic Compounds Exposome and Emergency Hospital Admissions for Cardiovascular Disease.

The limited research on volatile organic compounds (VOCs) has not taken into account the interactions between constituents. We used the weighted quantile sum (WQS) model and generalized linear model (GLM) to quantify the joint effects of ambient VOCs exposome and identify the substances that play key roles. For a 0 day lag, a quartile increase of WQS index for n-alkanes, iso/anti-alkanes, aromatic, halogenated aromatic hydrocarbons, halogenated saturated chain hydrocarbons, and halogenated unsaturated chain hydrocarbons were associated with 1.09% (95% CI: 0.13, 2.06%), 0.98% (95% CI: 0.22, 1.74%), 0.92% (95% CI: 0.14, 1.69%), 1.03% (95% CI: 0.14, 1.93%), 1.69% (95% CI: 0.48, 2.91%), and 1.85% (95% CI: 0.93, 2.79%) increase in cardiovascular disease (CVD) emergency hospital admissions, respectively. Independent effects of key substances on CVD-related emergency hospital admissions were also reported. In particular, an interquartile range increase in 1,1,1-trichloroethane, methylene chloride, styrene, and methylcyclohexane is associated with a greater risk of CVD-associated emergency hospital admissions [3.30% (95% CI: 1.93, 4.69%), 3.84% (95% CI: 1.21, 6.53%), 5.62% (95% CI: 1.35, 10.06%), 8.68% (95% CI: 3.74, 13.86%), respectively]. We found that even if ambient VOCs are present at a considerably low concentration, they can cause cardiovascular damage. This should prompt governments to establish and improve concentration standards for VOCs and their sources. At the same time, policies should be introduced to limit VOCs emission to protect public health.