Healthcare Encounters Research Articles

Time trends in the epidemiology of food allergy in England: an observational analysis of Clinical Practice Research Datalink data

Estimates for the prevalence of food allergy vary widely, with a paucity of data for adults. The aim of this analysis was to report trends in the incidence and prevalence of food allergy in England, using a national primary care dataset. We analysed data from Clinical Practice Research Datalink between 1998 and 2018, with linked data to relevant hospital encounters in England. The main outcomes were incidence and prevalence of food allergy, according to three definitions of food allergy: possible food allergy, probable food allergy, and probable food allergy with adrenaline autoinjectors prescription. We also evaluated the difference in proportion of patients prescribed adrenaline autoinjectors by English Index of Multiple Deprivation (IMD), age, and by previous food anaphylaxis, and explored differences in patient encounters (general practice vs emergency department setting). 7 627 607 individuals in the dataset were eligible for inclusion, of whom 150 018 (median age 19 years [IQR 4-34]; 82 614 [55·1%] female and 67 404 [44·9%] male) had a possible food allergy. 121 706 met diagnostic criteria for probable food allergy, of whom 38 288 were prescribed adrenaline autoinjectors. Estimated incidence of probable food allergy doubled between 2008 and 2018, from 75·8 individuals per 100 000 person-years (95% CI 73·7-77·9) in 2008 to 159·5 (156·6-162·3) individuals per 100 000 person-years in 2018. Prevalence increased from 0·4% (23 399 of 6 432 383) to 1·1% (82 262 of 7 627 607) over the same period and was highest in children under 5 years (11 951 [4·0%] of 296 406 in 2018) with lower prevalence in school-aged children (from 11 353 [2·4%] of 473 597 in 2018 for children aged 5-9 years to 6896 [1·7%] of 404 525 for those aged 15-19 years) and adults (42 848 [0·7%] of 5 992 454 in 2018). In those with previous food anaphylaxis, only 2321 (58·3%) of 3980 (975 [64·0%] of 1524 children and young people and 1346 [54·8%] of 2456 adults) had a prescription for adrenaline autoinjector. Adrenaline autoinjectors prescription was less common in those resident in more deprived areas (according to IMD). In the analysis of health-care encounters, 488 604 (97·1%) of 503 198 visits recorded for food allergy occurred in primary care, with 115 655 (88·4%) of 130 832 patients managed exclusively in primary care. These estimates indicate an important and increasing burden of food allergy in England. Our findings that most patients with food allergy are managed outside the hospital system, with low rates of adrenaline autoinjector prescription in those with previous anaphylaxis, highlight a need to better support those working in primary care to ensure optimal management of patients with food allergy. UK Food Standards Agency and UK Medical Research Council.

Patient experiences of remote consulting with chronic fatigue syndrome/myalgic encephalomyelitis and fibromyalgia: a qualitative study.

Remote and digital consulting in primary care has rapidly expanded since March 2020. It is important to understand patient experiences, particularly for those living with complex long-term conditions, to identify how care can best be delivered, including within the remote space. To explore the experiences of people living with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis [CFS/ME] and Fibromyalgia when consulting remotely in primary care. Semi-structured interviews with patients living with CFS/ME and fibromyalgia in general practice in England METHOD: Semi-structured interviews were carried out with 13 participants. The interviews were transcribed and analysed thematically according to a Foucauldian theoretical framework. All participants highlighted needing to feel believed by clinicians. Many reported difficulties with telephone and online consulting due to the lack of physical communication. Positive outcomes were reported when there was a good relationship with a clinician. Continuity in care and recognising the complexity of these conditions were also considered important. This study allowed people living with CFS/ME and Fibromyalgia to describe their experiences when consulting remotely. Participants highlighted needing to feel listened to and felt they benefited from an ongoing relationship with a clinician although this was difficult to achieve when consulting remotely. Some advantages of remoted consulting were reported, particularly when symptoms were troublesome. Flexible access systems with a range of consultation modalities or preferred clinician(s) availability could improve healthcare encounters, particularly given the increased use of remote consulting, in primary care.

Crafting the unsayable: Making meaning out of racialised maternal health-care encounters.

There are persistent and profound racialised inequalities in maternal and reproductive health in the UK. Yet in multiple settings, these disparities have been blamed on class or ethnicity, individuals and communities rather than the structures within which they live. In this study, we draw on narratives told within a 'slow-stitch' craft workshop, organised in southern England for racialised women with reproductive trauma, to show how processes of racialisation and racism shape experiences of maternal and reproductive healthcare. Experiences of reproductive trauma were multiple and cumulative. The burden of knowledge of racialised disparities was carried into health-care spaces, with plans made in advance to self-manage in risky spaces. The constant management of racialised stereotypes and subsequent strategies of bodily and emotional containment ultimately was not protective and there was little agency over levels of care received in health-care spaces. Perceptions surrounding racialised bodies shaped treatment, whilst proximities to whiteness afforded alternative realities. Taking a phenomenological approach we analyse race as a sensory, spatial and relational constellation haunted by long-standing histories of fraught inequality. Bringing together in the crafting circle a group of women racialised in different ways enabled the sharing of "unspeakable" stories surrounding racism and reproductive trauma, and allowed raceto be brought into being as a form of solidarity and connection.

Patient safety initiatives and practices in Nigerian healthcare settings: A comprehensive analysis of current knowledge, challenges, and barriers

The imperative of patient safety in healthcare takes a central stage, more so in the context of Nigeria. This review aims to provide a comprehensive understanding of the patient safety landscape in Nigeria, drawing on 12 empirical studies. This study aims to elucidate the multifarious challenges and barriers health-care professionals encounter in Nigeria concerning patient safety. Concurrently, it delves into the prevailing patient safety culture and the factors shaping it. This study used secondary data to conduct a systematic review of existing literature; 12 studies, spanning from 2015 to 2022, were meticulously examined. These explorations cover a broad spectrum of patient safety aspects in Nigeria, focusing particularly on the insights of nurses and doctors. Through the use of thematic analysis, the studies’ synthesis illuminates a significant gap between the envisioned safety protocols and their on-ground realization. Exacerbating this challenge is the acute lack of resources, which invariably hampers the quality of care. In addition, barriers to effective communication and inadequate reporting mechanisms emerge as significant obstacles. The deficiencies in consistent training and education are also prominent, which stand as potential vulnerabilities in the system. The palpable need for heightened awareness, emphasis on recurrent training initiatives, and strict adherence to established safety guidelines are amplifying these concerns. It was, thus, concluded that the healthcare trajectory in Nigeria, as informed by this review, underscores a pressing need for systemic interventions to elevate patient safety standards. Such a transformative journey demands the concerted efforts of all stakeholders, fostering an environment that prioritizes patient safety and enhances the overall trust in Nigeria’s healthcare system.

Prescription patterns of home rescue benzodiazepines for febrile seizures

ObjectiveTo describe the prescription patterns of home, non-intravenous rescue benzodiazepines (non-IV-rBZDs) for febrile seizures and the factors associated with their prescription. MethodsRetrospective descriptive study using the MarketScan Commercial Database, a large database of employer-sponsored privately insured patients in the United States. We used data from January 1st 2006 to December 31st 2022. We studied patients with febrile seizures as the main code for the healthcare encounter (identified with International Classification of Diseases codes) with age from 6 months to 5 years of age and with at least 1 month of follow-up. ResultsThere were a total of 82,835 patients [median (p25-p75) age 1.0 (1.0–2.0) years, 56.7 % males] with at least one febrile seizure, of whom 9,737 (11.8 %) filled at least one non-IV-rBZD prescription. Among the 9,737 patients who filled at least one prescription, the median (p25-p75) time from first febrile seizure to non-IV-rBZD prescription was 27 (2–186) days. Among the factors known at the time of the first febrile seizure, complex febrile seizure (OR: 3.51, 95 % CI: 3.24–3.79), and an initial inpatient hospitalization for febrile seizure (OR: 3.53, 95 % CI: 3.29–3.79) were the factors most strongly associated with filling a non-IV-rBZD prescription. In contrast, sex, rural patient's residence, and salary employment (versus other employment class) were not independently associated with filling a non-IV-rBZD prescription. Among the factors known at the end of follow-up, complex febrile seizures, type of initial encounter, and an eventual diagnosis of epilepsy were major independent factors associated with filling a non-IV-rBZD prescription. ConclusionOnly approximately 12 % of children with a febrile seizure filled a prescription for a home non-IV-rBZD. The major factors independently associated with prescription were complex febrile seizure, hospital admission, recurrent febrile seizures, and an eventual diagnosis of epilepsy.

Comparison of the rate of healthcare encounters for influenza from source-specific PM2.5 before and after tier 3 vehicle standards in New York state.

Influenza healthcare encounters in adults associated with specific sources of PM2.5 is an area of active research. Following 2017 legislation requiring reductions in emissions from light-duty vehicles, we hypothesized a reduced rate of influenza healthcare encounters would be associated with concentrations of PM2.5 from traffic sources in the early implementation period of this regulation (2017-2019). We used the Statewide Planning and Research Cooperative System (SPARCS) to study adult patients hospitalized (N = 5328) or treated in the emergency department (N = 18,247) for influenza in New York State. Using a modified case-crossover design, we estimated the excess rate (ER) of influenza hospitalizations and emergency department visits associated with interquartile range increases in source-specific PM2.5 concentrations (e.g., spark-ignition emissions [GAS], biomass burning [BB], diesel [DIE]) in lag day(s) 0, 0-3 and 0-6. We then evaluated whether ERs differed after Tier 3 implementation (2017-2019) compared to the period prior to implementation (2014-2016). Each interquartile range increase in DIE in lag days 0-6 was associated with a 21.3% increased rate of influenza hospitalization (95% CI: 6.9, 37.6) in the 2014-2016 period, and a 6.3% decreased rate (95% CI: -12.7, 0.5) in the 2017-2019 period. The GAS/influenza excess rates were larger in the 2017-2019 period than the 2014-2016 period for emergency department visits. We also observed a larger ER associated with increased BB in the 2017-2019 period compared to the 2014-2016 period. We present an accountability study on the impact of the early implementation period of the Tier 3 vehicle emission standards on the association between specific sources of PM2.5 air pollution on influenza healthcare encounters in New York State. We found that the association between gasoline emissions and influenza healthcare encounters did not lessen in magnitude between periods, possibly because the emissions standards were not yet fully implemented. The reduction in the rates of influenza healthcare encounters associated with diesel emissions may be reflective of past policies to reduce the toxicity of diesel emissions. Accountability studies can help policy makers and environmental scientists better understand the timing of pollution changes and associated health effects.

Barriers and facilitators to tuberculosis diagnosis in Lima, Peru: a mixed methods study

BackgroundTuberculosis (TB) infectiousness decreases significantly with only a few days of treatment, but delayed diagnosis often leads to late treatment initiation. We conducted a sequential explanatory mixed methods study to understand the barriers and facilitators to prompt diagnosis among people with TB.MethodsWe enrolled 100 adults who started TB treatment in the Carabayllo district of Lima, Peru, between November 2020 and February 2022 and administered a survey about their symptoms and healthcare encounters. We calculated total diagnostic delay as time from symptom onset to diagnosis. We conducted semi-structured interviews of 26 participants who had a range of delays investigating their experience navigating the health system. Interview transcripts were inductively coded for concepts related to diagnostic barriers and facilitators.ResultsOverall, 38% of participants sought care first from public facilities and 42% from the private sector. Only 14% reported being diagnosed with TB on their first visit, and participants visited a median of 3 (interquartile range [IQR] health facilities before diagnosis. The median total diagnostic delay was 9 weeks (interquartile range [IQR] 4–22), with a median of 4 weeks (IQR 0–9) before contact with the health system and of 3 weeks (IQR 0–9) after. Barriers to prompt diagnosis included participants attributing their symptoms to an alternative cause or having misconceptions about TB, and leading them to postpone seeking care. Once connected to care, variations in clinical management, health facility resource limitations, and lack of formal referral processes contributed to the need for multiple healthcare visits before obtaining a diagnosis. Facilitators to prompt diagnosis included knowing someone with TB, supportive friends and family, referral documents, and seeing a pulmonologist.ConclusionsMisinformation about TB among people with TB and providers, poor accessibility of health services, and the need for multiple encounters to obtain diagnostic tests were major factors leading to delays. Extending the hours of operation of public health facilities, improving community awareness and provider training, and creating a formal referral process between the public and private sectors should be priorities in the efforts to combat TB.

Interaction Processes between Health Professionals and Moroccan Immigrant Women in Reproductive Healthcare: The Disagreement in the Encounter-A Qualitative Study.

Spain is a multicultural society and has been defined by several authors as an immigrant-receiving country. Moroccan women of childbearing age constitute 28.20% of Moroccan immigrants. describe the interaction processes that occur between health professionals and Moroccan immigrant women in reproductive healthcare. Qualitative descriptive study based on Grounded Theory. Thirty immigrant women from Morocco and thirty-five health professionals participated in the study. Specific dimensions of analysis were defined and used to design the interview guide and focus groups. In the healthcare encounter, the construction of an effective communicative space between the people involved in it is essential; however, the language barrier and the interpersonal relationships characterized by silence in the encounter make a meaningful healthcare relationship difficult for those who participate in it. There are communication and relationship problems that alter healthcare and the professional-patient relationship which require the use of translation programs, the incorporation of intercultural meters, and the development of cultural competence in health professionals.

Economic burden of recurrent hyperkalemia in patients with chronic kidney disease.

Hyperkalemia is a common complication of chronic kidney disease (CKD) and can become recurrent in half of cases. However, the incremental economic burden associated with recurrent hyperkalemia is unknown. To evaluate all-cause health care resource utilization (HRU) and medical costs in patients with stage 3/4 CKD with recurrent hyperkalemia vs normokalaemia and vs nonrecurrent hyperkalemia. Data were from Optum's de-identified Market Clarity Data (January 1, 2016, to August 1, 2022). This retrospective observational cohort study compared patients with stage 3/4 CKD with recurrent hyperkalemia (≥2 hyperkalemia events within 1 year [hyperkalemia event: hyperkalemia diagnosis or potassium [K+]>5 mmol/l]; index was the first hyperkalemia event) with an exact- and propensity score-matched cohort of patients with normokalemia (K+ ≥3.5 to ≤5 mmol/l; random K+ as index) and separately with a matched cohort of patients with nonrecurrent hyperkalemia (1 hyperkalemia event within 1 year; index was hyperkalemia event). Patient characteristics, medication use, HRU, and medical costs were compared between cohorts using standardized mean differences during the 12-month baseline period. All-cause HRU and medical costs during the 12-month follow-up were compared using Wilcoxon rank sum tests for continuous variables and McNemar tests for categorical variables. Substudies of recurrent hyperkalemia vs normokalemia were conducted for patients with Medicare coverage and renin-angiotensin-aldosterone system inhibitor (RAASi) use. The recurrent hyperkalemia vs normokalemia sample comprised 4,549 matched pairs (Medicare substudy: 3,151; RAASi substudy: 3,535) and the recurrent hyperkalemia vs nonrecurrent hyperkalemia sample comprised 1,599 matched pairs. Baseline characteristics, HRU, and medical costs of the cohorts were similar after matching. During follow-up, patients with recurrent hyperkalemia had a mean of 11.2 more health care encounters (0.5 more inpatient admissions, 0.3 more emergency department visits, and 7.2 more outpatient visits) than patients with normokalemia. Patients with recurrent hyperkalemia also had double the total annual medical costs vs normokalemia ($34,163 vs $15,175; P < 0.001), mainly driven by inpatient costs ($21,250 vs $7,392), which accounted for 62.2% and 48.7% of total costs, respectively. Results were similar in the RAASi and Medicare substudies. Recurrent hyperkalemia was associated with a mean 4.3 more all-cause health care encounters and $14,057 higher medical costs (both P < 0.001) than nonrecurrent hyperkalemia. Recurrent hyperkalemia in patients with stage 3/4 CKD was associated with higher all-cause HRU and medical costs compared with normokalemia (including in patients with Medicare coverage and RAASi use) and nonrecurrent hyperkalemia. Research is needed to understand if long-term treatment strategies aimed at preventing hyperkalemia recurrence may alleviate this economic burden.

Accuracy of ICD-10 Diagnostic Codes for Identifying Housing Instability

This cohort study assesses the performance of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) Z59 codes for identifying housing instability during health care encounters.

The risk and risk factors of chikungunya virus infection and rheumatological sequelae in a cohort of U.S. Military Health System beneficiaries: Implications for the vaccine era.

Understanding the risk of chikungunya virus (CHIKV) infection and rheumatic sequelae across populations, including travelers and the military, is critical. We leveraged healthcare delivery data of over 9 million U.S. Military Health System (MHS) beneficiaries to identify cases, and sampled controls, to estimate the risk of post-CHIKV rheumatic sequelae. MHS beneficiary CHIKV infections diagnosed 2014-2018 were identified from the Disease Reporting System internet, TRICARE Encounter Data Non-Institutional, and Comprehensive Ambulatory/Professional Encounter Record systems. Non-CHIKV controls were matched (1:4) by age, gender, beneficiary status, and encounter date. The frequency of comorbidities and incident rheumatic diagnoses through December 2018 were derived from International Classification of Diseases codes and compared between cases and controls. Poisson regression models estimated the association of CHIKV infection with rheumatic sequelae. We further performed a nested case-control study to estimate risk factors for post-CHIKV sequelae in those with prior CHIKV. 195 CHIKV cases were diagnosed between July 2014 and December 2018. The median age was 42 years, and 43.6% were active duty. 63/195 (32.3%) of CHIKV cases had an incident rheumatic diagnosis, including arthralgia, polyarthritis, polymyalgia rheumatica, and/or rheumatoid arthritis, compared to 156/780 (20.0%) of controls (p < 0.001). CHIKV infection remained associated with rheumatic sequelae (aRR = 1.579, p = 0.008) after adjusting for prior rheumatic disease and demography. Those with rheumatic CHIKV sequelae had a median 7 healthcare encounters (IQR 3-15). Among CHIKV infections, we found no association between post-CHIKV rheumatic sequelae and demography, service characteristics, or comorbidities. CHIKV infection is uncommon but associated with rheumatic sequelae among MHS beneficiaries, with substantial healthcare requirements in a proportion of cases with such sequelae. No demographic, clinical, or occupational variables were associated with post-CHIKV rheumatic sequelae, suggesting that prediction of these complications is challenging in MHS beneficiaries. These findings are important context for future CHIKV vaccine decision making in this and other populations.

Screening Strategies and Methodologies.

While glaucoma is a leading cause of irreversible vision loss, it presents technical challenges in the design and implementation of screening. New technologies such as PRS and AI offer potential improvements in our ability to identify people at high risk of sight loss from glaucoma and may improve the viability of screening for this important disease. To review the current evidence and concepts around screening for glaucoma. A group of glaucoma-focused clinician scientists drew on knowledge and experience around glaucoma, its etiology, and the options for screening. Glaucoma is a chronic progressive optic neuropathy affecting around 76 million individuals worldwide and is the leading cause of irreversible blindness globally. Early stages of the disease are asymptomatic meaning a substantial proportion of cases remain undiagnosed. Early detection and timely intervention reduce the risk of glaucoma-related visual morbidity. However, imperfect tests and a relatively low prevalence currently limit the viability of population-based screening approaches. The diagnostic yield of opportunistic screening strategies, relying on the identification of disease during unrelated health care encounters, such as cataract clinics and diabetic retinopathy screening programs, focusing on older people and/or those with a family history, are hindered by a large number of false-positive and false-negative results. Polygenic risk scores (PRS) offer personalized risk assessment for adult-onset glaucoma. In addition, artificial intelligence (AI) algorithms have shown impressive performance, comparable to expert humans, in discriminating between potentially glaucomatous and non-glaucomatous eyes. These emerging technologies may offer a meaningful improvement in diagnostic yield in glaucoma screening. While glaucoma is a leading cause of irreversible vision loss, it presents technical challenges in the design and implementation of screening. New technologies such as PRS and AI offer potential improvements in our ability to identify people at high risk of sight loss from glaucoma and may improve the viability of screening for this important disease.

The association of experiences of medical mistrust and mistreatment and ever considering self-managing an abortion

ObjectiveTo assess the prevalence of ever considering self-managing an abortion (SMA) and its associations with experiences of medical mistrust and mistreatment in a nationally representative sample. Study designIn 2021–22, we conducted a national, cross-sectional, online probability-based survey of US people assigned female at birth ages 15–49. Among those who had ever been pregnant, we ran weighted multivariable logistic regressions to examine whether having had difficulty trusting medical providers and/or experiencing medical mistreatment was associated with SMA consideration. ResultsOf 4260 participants who had ever been pregnant, 5.2% (95% CI, 4.3%−6.3%) ever considered SMA. Additionally, 38.8% (95% CI, 36.8%−40.9%) reported prior moderate medical mistrust; 17.0% (15.4%−18.6%) experienced neglect of symptoms only, and 22.2% (20.6%−24.0%) experienced ridicule or humiliation in a previous healthcare encounter. In multivariable analyses, those who reported prior high medical mistrust had increased odds of considering SMA (aOR=5.2, [95% CI, 2.9–9.2]), compared to those who had no prior medical mistrust. Those who had experienced ridicule or humiliation by healthcare providers had increased odds of considering SMA (aOR=3.8, [95% CI, 2.3–6.1]), compared to those without such experiences. Participants who believed others perceived them as Black or Arab/Middle Eastern, were poor in their youth, or identified as Lesbian, Gay, Bisexual, Transgender, Queer, and other had higher proportions of considering SMA (p-values<0.01). ConclusionsExperiences of medical mistrust and mistreatment are common and are associated with increased likelihood of considering SMA. Those who identified with a structurally minoritized group were more likely to consider SMA, and those whose “street race” was Arab/Middle Eastern had the highest likelihood. ImplicationsIf restrictions on abortion continue to increase, individuals may further consider SMA. Our findings suggest a need to create healthcare environments that foster trust and respect, as well as to ensure people have access to safe options for SMA.

Characterizing the journey of Rett syndrome among females in the United States: a real-world evidence study using the Rett syndrome natural history study database

BackgroundWith the advent of the first targeted therapy for Rett Syndrome (RTT), a comprehensive assessment of the journey of RTT is needed to elucidate on present unmet needs in this population. This study characterized females with RTT in the United States and their disease journey with respect to longitudinal treatment patterns, RTT-related outcomes, and changes in disease severity.MethodsThis retrospective cohort study used registry data of females with RTT from the 5211 RTT Natural History Study (RNHS) (November 2015–July 2021). Pharmacological and supportive therapy use, RTT-related outcomes, and RTT severity, as measured by the Clinical Severity Scale and Motor Behavioral Assessment scale, were evaluated following the first RNHS visit. Analyses were conducted overall and in subgroups by RTT type (classic and atypical RTT) and age at first visit (pediatric and adult).ResultsA total of 455 females with RTT were included in the study, of whom 90.5% had classic RTT and 79.8% were pediatric individuals. Over a median follow-up of 4 years, use of pharmacological therapies, including prokinetic agents (42.7% vs. 28.3%), and supportive therapies, including physical therapy (87.3% vs. 40.2%) and speech-language therapy (86.8% vs. 23.9%), were more common in pediatric than adult individuals (all p < 0.05). Nearly half (44.6%) of all individuals had a hospital or emergency room visit, with a higher proportion of visits in individuals with classic RTT than atypical RTT and pediatric than adult individuals (both p = 0.001). An increasing trend in clinical severity was observed in pediatric individuals (mean change per year: 0.24; 95% confidence interval [CI]: 0.03, 0.44), while an increasing trend in motor-behavioral dysfunction was observed in pediatric individuals (mean change per year: 1.12; 95% CI: 0.63, 1.60) and those with classic RTT (mean change per year: 0.97; 95% CI: 0.53, 1.41).ConclusionsFindings from this study highlight the considerable burden of RTT across disease subtype and age. Despite reliance on supportive therapies and healthcare encounters, individuals with RTT experience increasing disease severity and motor-behavioral dysfunction in childhood and adolescence, underscoring the unmet needs of this population and the value of early intervention to manage RTT in the long-term.

Shared decision-making endorses intention to follow through treatment or vaccination recommendations: a multi-method survey study among older adults

BackgroundPrevious studies have shown that shared decision-making (SDM) between a practitioner and a patient strengthens the ideal of treatment adherence. This study employed a multi-method approach to SDM in healthcare to reinforce the theoretical and methodological grounds of this argument. As the study design, self-reported survey items and experimental vignettes were combined in one electronic questionnaire. This technique aimed to analyze the effects of previous experiences and the current preferences regarding SDM on the intentions to follow-through with the medical recommendations.MethodUsing quantitative data collected from the members of the Finnish Pensioners’ Federation (N = 1610), this study focused on the important and growing population of older adults as healthcare consumers. Illustrated vignettes were used in the evaluation of expected adherence to both vaccination and the treatment of an illness, depending on the decision-making style varying among the repeated scenarios. In a within-subjects study design, each study subject acted as their own control.ResultsThe findings demonstrated that SDM correlates with expected adherence to a treatment and vaccination. Both the retrospective experiences and prospective aspirations of SDM in clinical encounters supported the patients’ expected adherence to vaccination and treatment while decreasing the probability of pseudo-compliance. The association between SDM and expected adherence was not affected by the perceived health of the respondents. However, the associations among the expected adherence and decision-making styles were found to differ between the treatment and vaccination scenarios.ConclusionsSDM enables expected treatment adherence among older adults. Thus, the multi-method study emphasizes the importance of SDM in various healthcare encounters. The findings further imply that SDM research benefits from questionnaires combining self-report methods and experimental study designs. Further cross-validation studies using various types of written and illustrated scenarios are encouraged.

Emergency department utilization in Veterans with spinal cord injuries & disorders

ObjectiveTo determine frequency that ED visits are needed, and the most common chief complaints and medications prescribed to Veterans with spinal cord injuries and disorders (SCI/D). MethodsThe Veterans Health Administration (VHA) SCI and Disorders (SCI/D) Registry (VHA SCIDR) was used to identify Veterans with SCI/D over a five-year period (fiscal years 2018–2022). The primary outcome was the proportion of Veterans with SCI/D who had visits to the ED during the study period. Secondary outcomes included diagnostic codes and medications prescribed in the ED, and other healthcare encounters. ResultsOverall, 18,464 Veterans with SCI/D, including 80,661 patient-years were included. Of these Veterans, 10,234 (55.4%) had at least one ED visit and 8230 (44.6%) did not. ED visits were consistent, ranging from 33.5% to 36.4% annually. The number of in-person healthcare encounters decreased over the study period. The most common ED diagnostic codes were paraplegia or quadriplegia, discharge counseling, UTI, neuromuscular dysfunction of the bladder and low back pain. The most common medications prescribed in the ED were analgesics (e.g., acetaminophen, ketorolac), antimicrobials (e.g., ceftriaxone, vancomycin) and ondansetron. Antibiotics were among the most prescribed discharge medications, including ciprofloxacin, sulfamethoxazole/trimethoprim, cephalexin, and doxycycline. ConclusionThis national study of Veterans with SCI/D characterized ED healthcare utilization. Overall, more than half of Veterans with SCI/D required an ED visit during the five-year study period and over one third of Veterans in each fiscal year required an ED visit. Interventions to target prevention of ED visits and subsequent hospitalizations could focus on these areas.

PM2.5 and its components and respiratory disease healthcare encounters – Unanticipated increased exposure-response relationships in recent years after environmental policies

Prior studies reported excess rates (ERs) of cardiorespiratory events associated with short-term increases in PM2.5 concentrations, despite implementation of pollution-control policies. In 2017, Federal Tier 3 light-duty vehicle regulations began, and to-date there have been no assessments of population health effects of the policy. Using the NYS Statewide Planning and Research Cooperative System (SPARCS) database, we obtained hospitalizations and ED visits with a principal diagnosis of asthma or chronic obstructive pulmonary disease (COPD) for residents living within 15 miles of six urban PM2.5 monitoring sites in NYS (2014–2019). We used a time-stratified case-crossover design and conditional logistic regression (adjusting for ambient temperature, relative humidity, and weekday) to estimate associations between PM2.5, POC (primary organic carbon), SOC (secondary organic carbon), and rates of respiratory disease hospitalizations and emergency department (ED) visits from 2014 to 2019. We evaluated demographic disparities in these relative rates and compared changes in ERs before (2014–2016) and after Tier 3 implementation (2017–2019). Each interquartile range increase in PM2.5 was associated with increased ERs of asthma or COPD hospitalizations and ED visits in the previous 7 days (ERs ranged from 1.1%–3.1%). Interquartile range increases in POC were associated with increased rates of asthma ED visits (lag days 0–6: ER = 2.1%, 95% CI = 0.7%, 3.6%). Unexpectedly, the ERs of asthma admission and ED visits associated with PM2.5, POC, and SOC were higher during 2017–2019 (after Tier 3) than 2014–2016 (before Tier-3). Chronic obstructive pulmonary disease analyses showed similar patterns. Excess Rates were higher in children (<18 years; asthma) and seniors (≥65 years; COPD), and Black, Hispanic, and NYC residents. In summary, unanticipated increases in asthma and COPD ERs after Tier-3 implementation were observed, and demographic disparities in asthma/COPD and PM2.5, POC, and SOC associations were also observed. Future work should confirm findings and investigate triggering of respiratory events by source-specific PM.

High Healthcare Costs in Childhood Inflammatory Bowel Disease: Development of a Prediction Model Using Linked Clinical and Health Administrative Data.

The incidence of pediatric-onset inflammatory bowel disease (IBD) and the costs of caring for individuals with IBD are both increasing. We calculated the direct healthcare costs of pediatric IBD in the first year after diagnosis and developed a model to predict children who would have high costs (top 25th percentile). Using data from the Canadian Children IBD Network inception cohort (≤16 years of age, diagnosed between 2013 and 2019) deterministically linked to health administrative data from Ontario, Canada, we estimated direct healthcare and medication costs accrued between 31 and 365 days after diagnosis. Candidate predictors included age at diagnosis, sex, rural/urban residence location, distance to pediatric center, neighborhood income quintile, IBD type, initial therapy, disease activity, diagnostic delay, health services utilization or surgery around diagnosis, regular primary care provider, and receipt of mental health care. Logistic regression with stepwise elimination was used for model building; 5-fold nested cross-validation optimized and improved model accuracy while limiting overfitting. The mean cost among 487 children with IBD was CA$15 168±15 305. Initial treatment (anti-tumor necrosis factor therapy, aminosalicylates, or systemic steroids), having a mental health care encounter, undergoing surgery, emergency department visit at diagnosis, sex, and age were predictors of increased costs, while having a regular primary care provider was a predictor of decreased costs. The C-statistic for our model was 0.71. The cost of caring for children with IBD in the first year after diagnosis is immense and can be predicted based on characteristics at diagnosis. Efforts that mitigate rising costs without compromising quality of care are needed.

Neurodivergent patient experience in a tertiary children's hospital-a qualitative analysis.

Sensory processing challenges are commonly encountered in pediatric patients, particularly in those who are neurodivergent. We previously developed a novel clinical pathway (named "Sensory Pathway") which aimed at improving patient care for those with sensory barriers via staff training, provision of sensory toolkits and early integration of families throughout the hospital stay. We hypothesized that utilization of this pathway will result in improved patient experience and provide valuable feedback to improve care. A voluntary survey was made available to all patients who utilized this resource as part of our hospital wide patient satisfaction survey. Qualitative data was coded using open coding as part of the constant comparison method data using NVivo 12 for Windows software for analysis. Software was used to create word clouds and clusters for visualization, which confirmed the themes and patterns that were noted from initial open coding. Between 2021 and 2022, surveys were obtained from 160 patients who utilized the Sensory Pathway. More than 50% reported that the most helpful components of the pathway were the approach by the staff and sensory tools. The three major themes identified from the survey were (1) Tools and techniques that benefited their children; (2) Positive interactions and communication with the hospital staff, and (3) Suggestions for future improvement. The survey results highlight the importance of having tools readily available to aid with sensory regulation and comfort of patients during healthcare encounters, the value of a positive patient and staff encounter, as well as opportunities for improvement.

Are adverse events higher among patients with acute optic neuritis prescribed glucocorticoids? A retrospective, longitudinal cohort study

ObjectiveOptic neuritis (ON) is an acute focal inflammation of the optic nerve routinely treated with glucocorticoids. We aimed to compare adverse events (AE) among glucocorticoid-treated and untreated patients in the...