Hierarchical Logistic Regression Models Research Articles

Abstract 4129075: Racial and Ethnic Differences in Semaglutide Prescriptions in the Veterans Affairs Healthcare System

Introduction: Recent advances in obesity treatment added incretin-based injectables like semaglutide to treatments ranging from lifestyle modification to bariatric surgery. While the burden of obesity in the United States is high and disproportionately affects minoritized individuals, obesity interventions may not be equitably distributed. Insurance coverage is often cited as a barrier to accessing novel treatments. Research Question: Do inequities in semaglutide use among patients with obesity persist without insurance barriers to care? Goals: Characterize the role of race and ethnicity in the receipt of semaglutide among Veterans with obesity. Methods: Among VA patients with BMI ≥27 from 2018-2023, we used a hierarchical multivariable mixed effects logistic regression model to evaluate the association between race and ethnicity (White, Non-Hispanic Black, Hispanic, Asian/Native Hawaiian/Pacific Islander, American Indian/Alaska Native) and receipt of semaglutide prescriptions. We adjusted for age, gender, diabetes status, Charlson Comorbidity Index, education, and urbanicity, with a random effect for diagnosis year. Results: Among Veterans with BMI ≥27 (n=2,423,070), 38.8% had Class I obesity (BMI 30-34.9), 18.2% had Class II obesity (BMI 35-39.9), and 9.8% had Class III obesity (BMI>40), with differences by race and ethnicity (p<0.01). Across the cohort, 184,690 (7.6%) received at least one prescription for semaglutide during the study period. Higher severity of obesity was associated with odds of semaglutide prescription (Figure). Compared to White Non-Hispanic patients, Black and Hispanic/Latino Veterans were less likely to receive a semaglutide prescription, with adjusted odds ratios (AOR) of 0.63 (95% confidence interval [CI]): 0.60-0.68) and 0.81 (95% CI: 0.74-0.90), respectively. Receipt of a semaglutide prescription was also highly associated with diabetes status, with an AOR of 35.2 (95% CI 32.5-38.0) for those with a diagnosis of diabetes compared to those without. Conclusions: Racial and ethnic minority Veterans with obesity are less likely to receive prescriptions for semaglutide in VA, suggesting that challenges to equitable obesity care are more complex than financial coverage alone.

Association Between Workplace Violence and Post-Traumatic Stress Disorder Among Healthcare Workers in China, 2020 to 2023.

This is the first study in China to investigate the prevalence of workplace violence (WPV) and its long-term association with post-traumatic stress disorder (PTSD) among healthcare workers. Conducted across various time points from March 27, 2020, to April 10, 2023, the research employed a four-wave repeated cross-sectional design involving 14,993 healthcare workers from 32 provincial administrative regions across the country. Nurses accounted for 34.3% of the sample, while doctors accounted for 65.7% of the sample, with a higher concentration in western China. Multivariate logistic regression analysis was employed to identify the risk factors for WPV, and hierarchical logistic regression models were used to examine the association between PTSD and WPV. The findings revealed that 71.4% of healthcare workers reported experiencing or witnessing WPV, with nearly half (47.5%) indicating exposure to violent incidents within the past year. Further analysis revealed significant associations between WPV incidence and various factors, including age, gender, work experience, work setting, and a history of contact with Coronavirus Disease 2019 (COVID-19) patients (the odds ratio [OR] of these influencing factors ranged from 1.10 to 2.03. All the p-values were less than .05). 28.5% of healthcare workers displayed symptoms of PTSD, with WPV identified as a major risk factor contributing to these symptoms (lifetime WPV: OR = 1.61, 95% CI [1.47-1.76]; 1-year WPV: OR = 1.75 [1.61-1.90]). Therefore, it is imperative to prioritize the mental health of healthcare workers and implement effective measures to prevent and mitigate WPV, ensuring their physical and psychological well-being as well as occupational safety.

Low HIV Viral Load Suppression and Its Implications for Controlling HIV among Refugee Adolescents and Youth Living in Refugee Settlements in Uganda: A Cross-sectional Analysis.

Viral load suppression (VLS) is considered crucial in the global efforts to end the HIV/AIDS pandemic and young people lag behind adults in this important indicator. However, little is known about VLS among refugee adolescents and youth (RAY), a vulnerable group, often ignored by research, with multiple intersecting risk factors and unique challenges. The goal of this study was to determine the prevalence of VLS and examine associated risk and protective factors among RAY in refugee settlements in Uganda, a country severely affected by the HIV/AIDS pandemic and currently hosting the most refugees in sub-Saharan Africa (SSA). We analyzed cross-sectional data from a pilot cluster randomized trial with 180 participants (ages 13-30) recruited from 20 health centers in three refugee settlements between July and December 2023. We employed a hierarchical (mixed-effects) logistic regression model to examine the association between selected demographic, psychosocial, and economic factors and VLS. The prevalence of VLS among RAY was very low at just 52%. Factors associated with VLS included financial stability, adherence self-efficacy, and HIV status disclosure. Having financial savings was associated with VLS (adjusted odds ratio:2.68; 95% CI: 1.48-5.11; p = 0.003). Treatment support from others including teachers and health care providers had five-fold odds of VLS (5.0, 1.64-15.24; p = 0.005). Conversely, older age and interactions between stigma/self-efficacy and stigma/HIV status disclosure were associated with viral load non-suppression. This study highlights the urgent need for tailored interventions targeting economic and psychosocial hardships like poverty, stigma, and food insecurity to enhance HIV VLS and other treatment outcomes among RAY.

Prevalence and severity of asthma among school children in Hong Kong.

This study presents contemporary epidemiological data regarding the prevalence and severity of asthma and wheezing among children in Hong Kong, which provides an update to the results of the International Study of Asthma and Allergies in Childhood (ISAAC) conducted in 1994-1995 and 2001-2003. This cross-sectional investigation was based on the ISAAC study protocol. Responses from 1100 children aged 6 to 7 years (Primary 1-2) and 1048 children aged 13 to 14 years (Secondary 2-3) in Hong Kong between September 2020 and August 2021 were analysed. Sex differences within each age-group were assessed using Chi squared and independent t tests. Demographic information was entered into hierarchical logistic regression models to identify potential predictive factors associated with asthma severity. Annual change in prevalence was calculated via division of the prevalence by the number of years between surveys. Logistic regression modelling was conducted to identify risk factors associated with asthma severity. The prevalences of current wheezing were 6.19% and 4.97% in the primary and secondary school groups, respectively. The prevalences of asthma ever were 5.55% and 6.12%, whereas those of wheezing ever were 20.38% and 12.05%, in the primary and secondary school groups, respectively. Asthma severity and prevalence have decreased in Hong Kong since 1994-1995. A followup study will explore the protective and risk factors contributing to these trends.

Abstract A114: Inequities in advanced stage at diagnosis of non-small cell lung cancer among people with and without HIV in the US

Abstract Background: Lung cancer is the leading cause of non-AIDS death among people with HIV (PWH). PWH are also more likely to die due to lung cancer compared to people with HIV. Late presentation at diagnosis due to barriers to lung cancer screening may contribute to disproportionate deaths among PWH. Our objective was to evaluate associations of HIV status with advanced stage at diagnosis and evaluate social determinants of health (SDoH) associated with advanced stage at diagnosis of lung cancer among PWH. Methods: We used data from the 2004-2020 National Cancer Database, including patients aged 18-89 years diagnosed with lung cancer (ICD-0-3 codes: C340-C349). PWH were identified using ICD9 (04200 to 04499, 07953, and V08) and ICD10 (B20 to B24, R75, Z21, B97.35).The primary outcome was advanced stage at diagnosis (stage 3/4). Our main SDoH exposures were quantified as quartiles (Q1-Q4) and included measures of area-level SDoH based on a patient’s zip code: (1) % of adults without a high school degree, or area-level education; (2) median household income of adults, or area-level income. We used hierarchical multivariable logistic regression models clustered by facility ID to estimate adjusted odds ratios(aOR) with 95% confidence intervals(95% CI), and evaluated each exposure separately adjusting for age, sex, year of diagnosis, and Charlson comorbidity score, and stratified by race/ethnicity and insurance status. Results: Overall, we identified 6,585 PWH and 1,665,030 without HIV. Seventy one percent of PWH were diagnosed with stage 3 or 4 lung cancer compared to 64.9% of people without HIV (p<0.001). PWH were more likely to be under the age of 60 (43.5% vs.15.1%, p<0.001), After adjustment for sex, age, and year of diagnosis, PWH had 15% higher odds of advanced stage at diagnosis compared to those without HIV (aOR: 1.15; 95% CI: 1.09-1.22). Residing in areas with larger proportions of the population without a HS diploma (Q4 vs. Q1: aOR:1.19; 95% CI: 1.01-1.41) and larger proportions with lower household income (Q1 vs. Q4: aOR: 1.15; 95% CI: 1.01-1.31) were positively associated with advanced stage-at-diagnosis of lung cancer. When we stratified by insurance status, only PWH who were Medicaid insured residing in the least educated areas (aOR: 1.84; 95% CI: 1.11-3.06) and in the lowest income areas (aOR: 1.86; 95% CI: 1.30-2.65) had higher odds of advanced stage at diagnosis with lung cancer. Conclusions: Living with HIV is independently associated with presenting at a later stage of lung cancer at diagnosis. Area-level measures of lower education and lower household income are significantly associated with advanced stage-at- diagnosis of lung cancer regardless, particularly among those who are Medicaid insured. Citation Format: Jessica Y Islam, Yi Guo, Kea Turner, Amir Alishahi Tabriz, Marlene Camacho-Rivera, Gita Suneja. Inequities in advanced stage at diagnosis of non-small cell lung cancer among people with and without HIV in the US [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A114.

Variations in antihypertensive medication treatment and blood pressure control among Veterans with HIV and existing hypertension

BackgroundHypertension is a leading risk factor for cardiovascular disease among patients living with HIV (PLWH). Understanding the predictors and patterns of antihypertensive medication prescription and blood pressure (BP) control among PLWH with hypertension (HTN) is important to improve the primary prevention efforts for this high-risk population. We sought to assess important patient-level correlates (eg, race) and inter-facility variations in antihypertension medication prescriptions and BP control among Veterans living with HIV (VLWH) and HTN. MethodsWe studied VLWH with a diagnosis of HTN who received care in the Veterans Health Administration (VHA) from January 2018 to December 2019. We evaluated HTN treatment and blood pressure control across demographic variables, including race, and by medical comorbidities. Data were also compared among VHA facilities. Predictors of HTN treatment and control were assessed in 2-level hierarchical multivariate logistic regression models to estimate odds ratios (ORs). The VHA facility random-effects parameters from the hierarchical models were used to calculate the median odds ratios to characterize the variation across the different VHA facilities. ResultsA total of 17,468 VLWH with HTN (mean age 61 years, 97% male, 54% Black, 40% White) who received care within the VHA facilities in 2018-2019 were included. 73% were prescribed antihypertension medications with higher prescription rates among Black vs White patients (75% vs 71%) and higher prescription rates among patients with a history of cardiovascular disease, diabetes, and kidney disease (>80%), and those receiving antiretroviral therapy and with controlled HIV viral load (∼75%). Only 27% of VLWH with HTN had optimal BP control of systolic BP <130 mmHg and diastolic BP <80 mmHg, with a lower rate of control among Black vs White patients (24% v. 31%). In multivariate regression, Black patients had a higher likelihood of HTN medication prescription (OR 1.32, 95% CI: 1.22-1.42) but were less likely to have optimal BP control (OR 0.82; 0.76-0.88). Important positive correlates of antihypertensive prescription and optimal BP control included: number of outpatient visits in prior year, and histories of diabetes, coronary artery disease, and heart failure. There was about 10% variability in both antihypertensive prescription and BP control patterns between VHA facilities for patients with similar characteristics. There was increased inter-facility variation in antihypertensive prescription among those with a history of heart failure and those not receiving antiretroviral therapy. ConclusionIn a retrospective analysis of large VHA data, we found that VLWH with HTN have suboptimal antihypertensive medication prescription and BP control. Black VLWH had higher HTN medication prescription rates but lower optimal BP control.

Caregiver burden and depression among lesbian, gay, bisexual, and other nonheterosexual individuals in the United States: Analysis of BRFSS 2015–2018

AbstractThe number of caregivers in the US continues to rise. However, the epidemiology and mental health among lesbian, gay, bisexual, and other nonheterosexual (LGB+) caregivers remain unknown. We aimed to characterize the epidemiology of caregiving burden/information among LGB+ caregivers in the United States, as well as to examine depression and related risk factors. By using the data from the 2015–2018 Behavioral Risk Factor Surveillance System (BRFSS), we conducted weighted hierarchical logistic regression models to explore the associations between depression, caregiving information, health behaviors, sex, and sexual orientation among an estimated population of 9,521,313 LGB+ caregivers. Among the caregivers aged 18–79 years, 4.81% identified as LGB+. Notably, 19.21% of the caregivers reported experiencing depression, with distinctive rates observed among male LGB+ caregivers and female LGB+ caregivers were 38.22% and 51.43%, respectively. Meanwhile, nearly 45.00% of male LGB+ caregivers offered care to nonrelatives, a significantly higher rate compared to their heterosexual counterparts (23.32%, p &lt; 0.001). The logistic regression models revealed that both male LGB+ caregivers (odds ratio [OR]: 3.56; 95% confidence interval [CI]: 1.45–8.77) and female LGB+ caregivers (OR: 2.38; 95% CI: 1.00–5.63) exhibited a higher likelihood of reporting depression compared to male heterosexual peers. Additionally, caregivers seeking support services for their caregiving responsibilities were more likely to report depression (OR: 1.47; 95% CI: 1.12–1.94). Our study revealed higher caregiving burden and depression among LGB+ caregivers in the United States, warranting further research and targeted support to address their unique challenges and improve services to caregivers.

Poor Work Ability Is Associated with Workplace Violence in Nurses: A Two-Wave Panel Data Analysis.

Healthcare personnel must deal with two problems of growing importance: violence in the workplace and the loss of work ability due to the aging of the workforce. Our objective was to evaluate, with a two-wave perspective design, the relationships of work ability, social support, and occupational stress with workplace violence in nurses. In an Italian public health company, we asked nurses to self-assess their work ability using the Work Ability Index (WAI) and we analyzed the relationship between this indicator and the violence experienced in the previous and following years. A total of 321 out of 344 nurses (99.3%) participated. In a logistic regression model, the WAI score was a significant protective factor for violence experienced in the previous year (OR = 0.94 CI95% = 0.90; 0.98 p < 0.01) and in the following year (OR = 0.88 CI95% = 0.84; 0.92 p < 0.01). In a hierarchical logistic regression model, social support acted as a protective factor (OR = 0.87 CI95% = 0.79; 0.95 for violence experienced in the previous year), while occupational stress was a significant determinant of the risk of aggression (OR = 3.65 CI95% = 1.90; 7.03 in the previous year, OR = 3.54 CI95% = 1.801; 6.947 in the following year). The difficulties that nurses encounter in carrying out their growing work demands in an environment that is not promptly adapted to their changing physical and mental states can lead to an increased risk of violence. Prevention of workplace violence should include organizational and ergonomic measures that reduce stress and increase staff support and work ability.

Factors Associated with Usage of Oral-PrEP among Female Sex Workers in Nairobi, Kenya, Assessed by Self-Report and a Point-of-Care Urine Tenofovir Immunoassay

Pre-exposure prophylaxis (PrEP) is highly effective at reducing HIV acquisition. We aimed to estimate usage of oral-PrEP, and factors associated with adherence among female sex workers (FSWs) in Nairobi, Kenya, using a novel point-of-care urine tenofovir lateral flow assay (LFA). The Maisha Fiti study randomly selected FSWs from Sex Worker Outreach Program clinics in Nairobi. Data were collected from 1003 FSWs from June-October 2019, including surveys on self-reported oral-PrEP adherence. Adherence was also measured using the LFA for HIV-negative FSWs currently taking oral-PrEP. Informed by a social-ecological theoretical framework, we used hierarchical multivariable logistic regression models to estimate associations between individual, interpersonal/community, and structural/institutional-level factors and either self-reported or LFA-assessed adherence. Overall, 746 HIV-negative FSWs aged 18–40 participated in the study, of whom 180 (24.1%) self-reported currently taking oral-PrEP. Of these, 56 (31.1%) were adherent to oral-PrEP as measured by LFA. In the multivariable analyses, associations with currently taking oral-PrEP included having completed secondary education, high alcohol/substance use, feeling empowered to use PrEP, current intimate partner, no recent intimate partner violence, having support from sex worker organisations, experiencing sex work-related stigma, and seeking healthcare services despite stigma. Associations with oral-PrEP LFA-measured adherence measured included having only primary education, experience of childhood emotional violence, belonging to a higher wealth tertile, and being nulliparous. Oral-PrEP adherence, measured by self-report or objectively, is low among FSWs in Nairobi. Programs to improve oral-PrEP usage among FSWs should work to mitigate social and structural barriers and involve collaboration between FSWs, healthcare providers and policymakers.

Intertemporal Decision-Making, Diabetes Self-Management, and Health Outcomes in Patients With Type 2 Diabetes.

The purpose of this study was to identify the independent factors associated with intertemporal decision-making and to examine its relationship with diabetes self-management behaviors, glucose variability, and diabetes complications in patients with diabetes. A cross-sectional study using convenience sampling (n = 368) was conducted in patients with type 2 diabetes (T2DM) between November 2021 and April 2023. Data were collected using self-reported questionnaires and retrieval of clinical information from medical records. Intertemporal decision-making was operationalized using delay discounting. The outcome variables included diabetes self-management behaviors, A1C, diabetic retinopathy, and carotid artery disease. Hierarchical regression and binary logistic regression models were used to explore the relationships among intertemporal decision-making, self-management, A1C, and carotid artery disease. The analyses showed that intertemporal decision-making was negatively associated with physical activity and carotid artery disease, in which individuals with lower delay discounting tended to have healthier physical activity; when the delay discounting rate increased 1 unit, the risk of the carotid artery disease increased by 39.8%. The study reveals that a lower delay discounting can promote healthier physical activity and decrease the incidence of carotid artery disease. These results offer new knowledge for researchers and clinicians to consider intertemporal decision-making in developing interventional programs to improve physical activity and reduce carotid artery complication in patients with T2DM when providing care.

Risk factors of pulmonary tuberculosis in Indonesia: A case-control study in a high disease prevalence region.

Tuberculosis (TB) remains one of the most widespread infectious diseases in the world, with high mortality and morbidity rates, contributing to a significant disease burden, particularly in developing countries. The aim of this study was to determine the risk factors of TB among the population aged 17 years (late adolescent) and above in one of the high TB prevalence countries, Indonesia. A case-control study was conducted in Banda Aceh, Indonesia, involving newly diagnosed pulmonary TB patients who visited one of the eleven community health centers in Banda Aceh. The controls were individuals matched by age and sex who lived near the cases and had no TB infection. A total of 16 risk factors were assessed. Hierarchical multivariable logistic regression models were used to examine the association between the risk factors and the occurrence of TB. A total of 196 cases and 196 controls were included in the study. Multivariable logistic regression analysis identified 11 independent predictors for the occurrence of TB after controlling possible confounders. Patients who lived in houses with insufficient light exposure were 77 times more likely to develop TB compared to those living in houses with sufficient light exposure (adjusted odds ratio (AOR): 77.69; 95%CI: 27.09, 222.79). The study also showed that people who had close contact with TB patients (AOR: 25.39; 95%CI: 2.10, 306.52), had poor knowledge of TB (AOR: 24.2; 95%CI: 6.89, 85.17), had comorbidities (AOR: 4.49; 95%CI: 1.35, 14.89), insufficient food utilization (AOR: 3.41; 95%CI: 1.51, 7.71), negative preventive behavior (AOR: 3.39; 95%CI: 1.49, 7.72), low education level (AOR: 3.08; 95%CI: 1.26, 7.55), and insufficient housing humidity (AOR: 2.89; 95%CI: 1.18, 7.12) were associated with increased the odds of having TB. Being employed, having income above minimum wage, and having good nutritional intake were protective factors for developing TB. In conclusion, the determinants of TB among people aged 17 years and older are a clear indication of the need for TB prevention programs targeting not only individual risk factors but also environmental risk factors, particularly providing adequate housing conditions. This study provided useful information that might help to develop and adopt effective policies for TB control in Indonesia.

A "Self-Milieux" perspective on help-seeking: examining the impact of a person's sociocultural background on help-seeking in people with untreated depressive symptoms.

Mental illness is a global concern and the leading cause of years lived with disability. Research on help-seeking behaviour has focused on individual factors, but there is still much unexplained variance. Suggesting complex interactions between determinants of human behaviour a new framework called Self-Milieux is proposed to represent a person's sociocultural background. The article introduces a statistical approach to determine Self-Milieux and exemplarily examines its predictive validity for health-related research. Self-Milieux are determined through a two-stage clustering method based on the determinants socioeconomic status and self-construal profile. Descriptive analyses are used to compare Self-Milieux characteristics. Hierarchical binary logistic regression models test the association between Self-Milieux and help-seeking behaviour, while controlling for socioeconomic status as an established predictor. The sample size was N = 1535 (Mage = 43.17 and 64.89% female participants). Average depression severity was M = 12.22, indicating mild to moderate symptoms. Six Self-Milieux were determined and named. Participants from privileged (aOR = 0.38) and self-sufficient (aOR = 0.37) milieux were less likely to seek help from a general practitioner than those from the entitled milieu. Participants from privileged (aOR = 0.30), collaborators (aOR = 0.50), disadvantaged (aOR = 0.33), and self-sufficient (aOR = 0.21) milieux were less likely to seek help from family members than those from the entitled and family-bound milieux. The study's strengths and limitations, as well as the cluster methodology, are discussed. The comparative results for the six Self-Milieux are interpreted based on current research. For example, participants from some milieux follow a help-seeking process proposed in previous research, while participants from other milieux seem to show a different process, one that ends in informal help-seeking.

Oral Anticoagulant Use and Post-Fall Mortality in Long-Term Care Home Residents

ObjectivesLong-term care (LTC) residents are susceptible to falling and the risk of subsequent morbidity and mortality may be compounded with concurrent anticoagulation use. Uncertainty exists around the benefit and harm of anticoagulation use for residents with a high risk for falls because of concerns of major bleeding complications. We aimed to examine if anticoagulant use increases mortality risk among LTC residents who fall. DesignA retrospective cohort study. Setting and ParticipantsOlder adults (≥65 years) admitted to a LTC facility in Ontario, Canada between January 1, 2010, and December 1, 2019, who were transferred to emergency departments for fall-related injuries. MethodsThe exposure was the use of an oral anticoagulant (OAC). The primary outcome was mortality within 30 days of transfer. Secondary outcomes were major hemorrhage and care utilization. We used hierarchical logistic regression models to examine the association between the use of OAC and 30-day mortality. ResultsThere were 56,419 residents transferred to the hospital for a fall, of whom 9611 (17.0%) were on an OAC. At 30 days, 5794 (10.3%) of the cohort had died: 12.0% (1151) on an OAC and 9.90% (4643) not on an OAC (risk difference [RD], 2.1%; 95% CI, 1.40%–2.82%). There were 485 major hemorrhage cases: 1.3% (125) on an OAC and 0.8% (360) not on an OAC (RD, 0.5%; 95% CI, 0.26%–0.74%). Multivariable analysis found no significant association between OAC use and 30-day mortality (odds ratio [OR], 0.98; 95% CI, 0.90–1.06), but an increased risk of major hemorrhage (OR, 1.31; 95% CI, 1.04–1.66). Both groups had similar health system and neurosurgical care utilization. Conclusions and ImplicationsAmong LTC residents transferred to the emergency department for fall-related injuries, OACs did not increase the risk of post-fall mortality. OAC prescribing for frail older adults who experience falls should consider their individual risk profile.

Trends and predictors of unfilled emergency medicine residency positions: A comparative analysis of the 2023 and 2024 Match cycles.

The emergency medicine (EM) landscape has evolved due to the increasing number of programs paired with fewer applicants. This study analyzed the characteristics of EM residency programs associated with unfilled positions during the 2024 Match and compared them with data from the 2023 Match to identify persistent and emerging trends influencing these outcomes. In this cross-sectional, observational study, we investigated factors associated with unfilled EM residency positions in the 2024 Match. We used publicly accessible data from the National Resident Matching Program. To identify program-level predictors of unfilled positions, we constructed a Bayesian hierarchical logistic regression model, incorporating data from the 2023 Match season. In 2024, 54 out of 281 (19.2%) residency programs remained unfilled. Our Bayesian analysis reaffirmed that smaller program size, geographical location, prior osteopathic accreditation, and corporate ownership continue to be significant factors. Programs with vacancies in the previous year were also more likely to remain unfilled. Thus, several factors identified in 2023 remained associated with this year's Match outcomes, with the impact of previous unfilled positions being particularly pronounced. This study identified several factors associated with a greater likelihood of having unfilled EM residency positions, with previous unfilled positions emerging as the most significant predictor. These findings offer critical insights for residency programs and governing bodies, providing a basis for enhancing recruitment strategies, addressing the cyclical nature of unfilled positions, and tackling workforce challenges in EM.

Characteristics of Pediatric In-Hospital Cardiac Arrests and Resuscitation Duration

Cardiopulmonary resuscitation (CPR) duration is associated with cardiac arrest survival. To describe characteristics associated with CPR duration among hospitalized children without return of circulation (ROC) (patient-level analysis) and determine whether hospital median CPR duration in patients without ROC is associated with survival (hospital-level analysis). This retrospective cohort study of patients undergoing pediatric in-hospital CPR between January 1, 2000, and December 31, 2021, used data from the Get With the Guidelines-Resuscitation registry. Children receiving chest compressions for at least 2 minutes and/or defibrillation were included in the patient-level analysis. For the hospital-level analysis, sites with at least 20 total events and at least 5 events without ROC were included. Data were analyzed from December 1, 2022, to November 15, 2023. For the patient-level analysis, the exposure was CPR duration in patients without ROC. For the hospital-level analysis, the exposure was quartile of median CPR duration in events without ROC at each hospital. For the patient-level analysis, outcomes were patient and event factors, including race and ethnicity and event location; we used a multivariable hierarchical linear regression model to assess factors associated with CPR duration in patients without ROC. For the hospital-level analysis, the main outcome was survival to discharge among all site events; we used a random intercept multivariable hierarchical logistic regression model to examine the association between hospital quartile of CPR duration and survival to discharge. Of 13 899 events, 3859 patients did not have ROC (median age, 7 months [IQR, 0 months to 7 years]; 2175 boys [56%]). Among event nonsurvivors, median CPR duration was longer in those with initial rhythms of bradycardia with poor perfusion (8.37 [95% CI, 5.70-11.03] minutes; P < .001), pulseless electrical activity (8.22 [95% CI, 5.44-11.00] minutes; P < .001), and pulseless ventricular tachycardia (6.17 [95% CI, 0.09-12.26] minutes; P = .047) (vs asystole). Shorter median CPR duration was associated with neonates compared with older children (-4.86 [95% CI, -8.88 to -0.84] minutes; P = .02), emergency department compared with pediatric intensive car7 e unit location (-4.02 [95% CI, -7.48 to -0.57] minutes; P = .02), and members of racial or ethnic minority groups compared with White patients (-3.67 [95% CI, -6.18 to -1.17]; P = .004). Among all CPR events, the adjusted odds of survival to discharge differed based on hospital quartile of median CPR duration among events without ROC; compared with quartile 1 (15.0-25.9 minutes), the adjusted odds ratio for quartile 2 (26.0-29.4 minutes) was 1.22 (95% CI, 1.09-1.36; P < .001); for quartile 3 (29.5-32.9 minutes), 1.23 (95% CI, 1.08-1.39; P = .002); and for quartile 4 (33.0-53.0 minutes), 1.04 (95% CI, 0.91-1.19; P = .58). In this retrospective cohort study of pediatric in-hospital CPR, several factors, including age and event location, were associated with CPR duration in event nonsurvivors. The odds of survival to discharge were lower for patients at hospitals with the shortest and longest median CPR durations among events without ROC. Further studies are needed to determine the optimal duration of CPR during pediatric in-hospital cardiac arrest and to provide training guidelines for resuscitation teams to eliminate disparities in resuscitation care.

Addiction Consultation Services for Opioid Use Disorder Treatment Initiation and Engagement

Medications for opioid use disorder (MOUD) are highly effective, but only 22% of individuals in the US with opioid use disorder receive them. Hospitalization potentially provides an opportunity to initiate MOUD and link patients to ongoing treatment. To study the effectiveness of interprofessional hospital addiction consultation services in increasing MOUD treatment initiation and engagement. This pragmatic stepped-wedge cluster randomized implementation and effectiveness (hybrid type 1) trial was conducted in 6 public hospitals in New York, New York, and included 2315 adults with hospitalizations identified in Medicaid claims data between October 2017 and January 2021. Data analysis was conducted in December 2023. Hospitals were randomized to an intervention start date, and outcomes were compared during treatment as usual (TAU) and intervention conditions. Bayesian analysis accounted for the clustering of patients within hospitals and open cohort nature of the study. The addiction consultation service intervention was compared with TAU using posterior probabilities of model parameters from hierarchical logistic regression models that were adjusted for age, sex, and study period. Eligible participants had an admission or discharge diagnosis of opioid use disorder or opioid poisoning/adverse effects, were hospitalized at least 1 night in a medical/surgical inpatient unit, and were not receiving MOUD before hospitalization. Hospitals implemented an addiction consultation service that provided inpatient specialty care for substance use disorders. Consultation teams comprised a medical clinician, social worker or addiction counselor, and peer counselor. The dual primary outcomes were (1) MOUD treatment initiation during the first 14 days after hospital discharge and (2) MOUD engagement for the 30 days following initiation. Of 2315 adults, 628 (27.1%) were female, and the mean (SD) age was 47.0 (12.4) years. Initiation of MOUD was 11.0% in the Consult for Addiction Treatment and Care in Hospitals (CATCH) program vs 6.7% in TAU, engagement was 7.4% vs 5.3%, respectively, and continuation for 6 months was 3.2% vs 2.4%. Patients hospitalized during CATCH had 7.96 times higher odds of initiating MOUD (log-odds ratio, 2.07; 95% credible interval, 0.51-4.00) and 6.90 times higher odds of MOUD engagement (log-odds ratio, 1.93; 95% credible interval, 0.09-4.18). This randomized clinical trial found that interprofessional addiction consultation services significantly increased postdischarge MOUD initiation and engagement among patients with opioid use disorder. However, the observed rates of MOUD initiation and engagement were still low; further efforts are still needed to improve hospital-based and community-based services for MOUD treatment. ClinicalTrials.gov Identifier: NCT03611335.

Alcohol use and its associated factors among Ethiopian military personnel

BackgroundStudies indicate that alcohol use is more prevalent in the military and that such use is related to coping mechanisms for stress. Alcohol use could result in health and social...

Correlation between hospital rates of survival to discharge and long-term survival for in-hospital cardiac arrest: Insights from Get With The Guidelines®-Resuscitation registry

AimGiven challenges in collecting long-term outcomes for survivors of in-hospital cardiac arrest (IHCA), most studies have focused on in-hospital survival. We evaluated the correlation between a hospital’s risk-standardized survival rate (RSSR) at hospital discharge for IHCA with its RSSR for long-term survival. MethodsWe identified patients ≥65 years of age with IHCA at 472 hospitals in Get With The Guidelines®–Resuscitation registry during 2000–2012, who could be linked to Medicare files to obtain post-discharge survival data. We constructed hierarchical logistic regression models to compute RSSR at discharge, and 30-day, 1-year, and 3-year RSSRs for each hospital. The association between in-hospital and long-term RSSR was evaluated with weighted Kappa coefficients. ResultsAmong 56,231 Medicare beneficiaries (age 77.2 ± 7.5 years and 25,206 [44.8%] women), 10,536 (18.7%) survived to discharge and 8,485 (15.1%) survived to 30 days after discharge. Median in-hospital, 30-day, 1-year, and 3-year RSSRs were 18.6% (IQR, 16.7–20.4%), 14.9% (13.2–16.7%), 10.3% (9.1–12.1%), and 7.6% (6.8–8.8%), respectively. The weighted Kappa coefficient for the association between a hospital’s RSSR at discharge with its 30-day, 1-year, and 3-year RSSRs were 0.72 (95% CI, 0.68–0.76), 0.56 (0.50–0.61), and 0.47 (0.41–0.53), respectively. ConclusionsThere was a strong correlation between a hospital’s RSSR at discharge and its 30-day RSSR for IHCA, although this correlation weakens over time. Our findings suggest that a hospital’s RSSR at discharge for IHCA may be a reasonable surrogate of its 30-day post-discharge survival and could be used by Medicare to benchmark hospital performance for this condition without collecting 30-day survival data.

Short-term outcomes of asphyxiated neonates depending on requirement for transfer in the first 24 h of life

ImportanceIn neonates with birth asphyxia (BA) and hypoxic-ischemic encephalopathy, therapeutic hypothermia (TH), initiated within six hours, is the only safe and established neuroprotective measure to prevent secondary brain injury. Infants born outside of TH centers have delayed access to cooling. ObjectiveTo compare in-hospital mortality, occurrence of seizures, and functional status at discharge in newborns with BA depending on postnatal transfer for treatment to another hospital within 24 h of admission (transferred (TN) versus non-transferred neonates (NTN)). DesignNationwide retrospective cohort study from a comprehensive hospital dataset using codes of the International Classification of Diseases, 10th modification (ICD-10). Clinical and outcome information was retrieved from diagnostic and procedural codes. Hierarchical multilevel logistic regression modeling was performed to quantify the effect of being postnatally transferred on target outcomes. SettingAll discharges from German hospitals from 2016 to 2021. ParticipantsFull term neonates with birth asphyxia (ICD-10 code: P21) admitted to a pediatric department on their first day of life. ExposuresPostnatal transfer to a pediatric department within 24 h of admission to an external hospital. Main outcomesIn-hospital death; secondary outcomes: seizures and pediatric complex chronic conditions category (PCCC) ≥ 2. ResultsOf 11,703,800 pediatric cases, 25,914 fulfilled the inclusion criteria. TNs had higher proportions of organ dysfunction, TH, organ replacement therapies, and neurological sequelae in spite of slightly lower proportions of maternal risk factors. In TNs, the adjusted odds ratios (OR) for death, seizures, and PCCC ≥ 2 were 4.08 ((95% confidence interval 3.41–4.89), 2.99 (2.65–3.38), and 1.76 (1.52–2.05), respectively. A subgroup analysis among infants receiving TH (n = 3,283) found less pronounced adjusted ORs for death (1.67 (1.29–2.17)) and seizures (1.26 (1.07–1.48)) and inverse effects for PCCC ≥ 2 (0.81 (0.64–1.02)) in TNs. Conclusion and relevanceThis comprehensive nationwide study found increased odds for adverse outcomes in neonates with BA who were transferred to another facility within 24 h of hospital admission. Closely linking obstetrical units to a pediatric department and balancing geographical coverage of different levels of care facilities might help to minimize risks for postnatal emergency transfer and optimize perinatal care.

Opioid Access among Advanced Cancer Patients in Low- and Middle-Income Countries in Asia

ContextMost cancer-associated pain is experienced in low- and middle-income countries (LMICs) due to inequitable access to opioids. ObjectiveTo determine opioid access as estimated by both patients and providers and to understand patient and facility-level factors influencing access among patients with advanced cancer in LMICs in Asia using the Behavioral Model of Health Services Use. MethodsThe APPROACH cross-sectional study was conducted in seven LMICs in Asia, involving in-depth surveys with providers and advanced cancer patients. A hierarchical logistic regression model was used to assess predisposing (i.e. individual factors), enabling (i.e. health care system and facility-level resources) and need (i.e. pain severity) factors predicting opioid access. ResultsAmong patient participants (n=1,933), approximately 40% reported opioid use. Meanwhile 80% of facilities, as reported by providers, indicated at least half of their advanced cancer patients receive oral morphine prescriptions. Predisposing characteristics factored in the least in the model, with patient education positively associated with access (Odds ratio (OR): 1.01; 95% CI=1.00, 1.03). Facility-level enabling resources, factoring the most, included oral morphine prescription duration >14 days (OR: 1.27; 95% CI=1.05, 1.53) and the extent of physician palliative care training (extensive (>160 hours) OR: 3.95; CI=3.19, 4.88; basic (up to 40 hours) OR: 1.03; CI=1.03, 1.04). Patient need as indicated by greater pain severity predicted access (OR: 1.55; CI=1.47, 1.64). ConclusionStudy findings emphasize the importance of palliative care training—even a minimal amount—in supporting access to opioids for advanced cancer patients. This study also highlights pragmatic site-level policies, such as extended morphine prescription durations, enabling access.