Patients In Urban Settings Research Articles

Stop the Bleed-Wait for the Ambulance or Get in the Car and Drive? A Post Hoc Analysis of an EAST Multicenter Trial.

Background: The Stop the Bleed campaign gives bystanders an active role in prehospital hemorrhage control. Whether extending bystanders' role to private vehicle transport (PVT) for urban penetrating trauma improves survival is unknown, but past research has found benefit to police and PVT. We hypothesized that for penetrating trauma in an urban environment, where prehospital procedures have been proven harmful, PVT improves outcomes compared to any EMS or advanced life support (ALS) transport.Methods: Post-hoc analysis of an EAST multicenter trial was performed on adult patients with penetrating torso/proximal extremity trauma at 25 urban trauma centers from 5/2019-5/2020. Patients were allocated to PVT and any EMS or ALS transport using nearest neighbor propensity score matching. Univariate analyses included Wilcoxon signed rank or McNemar's Test and logistic regression.Results: Of 1999 penetrating trauma patients in urban settings, 397 (19.9%) had PVT, 1433 (71.7%) ALS transport, and 169 (8.5%) basic life support (BLS) transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. PVT patients were primarily male (90.5%), Black (71.2%), and sustained gunshot wounds (68.9%). ALS transport had significantly higher ED mortality (3.9% vs 1.9%, P = 0.03). There was no difference in in-hospital mortality rate, hospital LOS, or complications for all EMS or ALS only transport patients.Conclusion: Compared to PVT, ALS, which provides more prehospital procedures than BLS, provided no survival benefit for penetrating trauma patients in urban settings. Bystander education incorporating PVT for early arrival of penetrating trauma patients in urban settings to definitive care merits further investigation.

Collaborative Integration of Community Health Workers in Hospitals and Health Centers to Reduce Pediatric Asthma Disparities: A Quality Improvement Program Evaluation

To address pediatric asthma disparities on the South Side of Chicago, a community health worker (CHW) home visiting intervention was implemented collaboratively by academic institutions and community based health centers. This evaluation assessed the effectiveness of this longitudinal quality improvement CHW intervention in reducing asthma morbidity and healthcare utilization. All patients aged 2–18 who met the high-risk clinical criteria in outpatient settings or those who visited the ED due to asthma were offered the program. A within-subject study design analyzed asthma morbidity and healthcare utilization at baseline and follow-up. Multivariable mixed-effects regression models, adjusted for baseline demographic and asthma characteristics, were used to assess changes over time. Among 123 patients, the average age was 8.8 (4.4) years, and 89.3% were non-Hispanic black. Significant reductions were observed in the average daytime symptoms days (baseline 4.1 days and follow-up 1.6 days), night-time symptoms days (3.0 days and 1.2 days), and days requiring rescue medication (4.1 days and 1.6 days) in the past two weeks (all p < 0.001). The average number of emergency department visits decreased from 0.92 one year before to 0.44 one year after program participation, a 52% reduction (p < 0.001). No significant difference was found in hospital admissions. These results support the use of a collaborative approach to implement the CHW home visiting program as part of standard care for pediatric asthma patients in urban settings. This approach has the potential to reduce asthma disparities and underscores the valuable role of CHWs within the clinical care team.

Pharmacist-Led Follow-Up Program for Rural Patients with Acute Coronary Syndrome: The PLURAL-ACS Pilot Program.

Patients living in rural settings have poorer access to care and more frequent readmissions after treatment for acute coronary syndrome (ACS) than patients in urban settings. It is unclear what types of medication-related issues are encountered by this cohort and whether pharmacist-led care could resolve them. To describe the issues related to cardiac medications encountered by rural patients after treatment for ACS and the impact of a pharmacist-led virtual follow-up pilot program in this population. A quality improvement initiative was developed whereby a cardiology pharmacist provided follow-up to post-ACS rural patients in Alberta, Canada, between March and May 2022. For each patient, the pharmacist identified and resolved cardiac medication-related issues through regular telephone visits over a 30-day period following hospital discharge. The primary outcome was the number of cardiac medication-related issues identified. Secondary outcomes included the types of medication-related issues identified and actions taken by the pharmacist to resolve them. During the 15-week program, 40 patients received care, and 139 virtual visits were completed. The median time spent per visit was 60 (interquartile range [IQR] 50-80) minutes. In total, 255 cardiac medication-related issues (6 per patient, IQR 3.75-8.25) were identified, of which 233 (91%) were resolved by the pharmacist. Prescription errors, adverse effects, and drug therapy optimization were the most common issues identified on days 1, 10, and 30, respectively. The pharmacist commonly undertook patient counselling (n = 126, 54%) and medication prescribing (n = 63, 27%) to address medication-related issues. A substantial number of cardiac medication-related issues were identified and resolved through a pharmacist-led virtual follow-up program in rural post-ACS patients. These findings could assist in the development of future follow-up programs to improve care for this high-risk population.

How do Cancer Patients in Economically Marginalized Neighborhoods Decide Where to Seek Care: Perspectives From Cancer Patients and Healthcare Professionals.

The quality of cancer care affects patient outcomes. It is therefore important to understand what factors and/or barriers shape a cancer patient's decision about where to seek care. We sought to understand factors influencing decision-making for historically marginalized communities in a large metropolitan area with multiple options for cancer care, including a National Cancer Institute (NCI)-designated comprehensive cancer center. We conducted semi-structured interviews with cancer patients from economically marginalized neighborhoods in Washington D.C., and with healthcare professionals who work with patients from these areas. Participants were recruited through flyers, social media posts, and word of mouth. Two researchers analyzed the data using a combination of inductive and deductive approaches supported by the ATLAS. ti software. A total of 15 interviews were conducted. Analysis revealed 3 major factors influencing where patients decide to seek care: health insurance, transportation, and prioritization of needs. Participants repeatedly identified navigating the bureaucracy of insurance enrollment and high medical costs as prohibitive to seeking care. Transportation was often mentioned in terms of convenience of use and proximity to the care center. Prioritization of needs refers to circumstances such as unstable housing, poverty, and mental illness, that some patients prioritize over seeking quality cancer care. Across these themes 2 findings arose: a discrepancy between stated and actual factors in choosing an oncologist, and the extent to which a cancer patient is able to choose their oncologist. This study helps explain some of the factors that influence how cancer patients in urban settings choose an oncology center, and the barriers which prohibit access. This study aimed to understand how cancer patients decide where to seek treatment.

Urban and Rural Surgical Practice Patterns for Papillary Thyroid Carcinoma.

Background: The 2015 American Thyroid Association (ATA) guidelines shifted recommendations toward less aggressive management of papillary thyroid cancer (PTC). Subsequently, several studies demonstrated a trend in performing thyroid lobectomy (TL) over total thyroidectomy (TT). However, regional variation has persisted without a clear indication of what factors may be influencing practice variation. We aimed to evaluate the surgical management of PTC in patients in rural and urban settings to assess trends of TL compared with TT following the implementation of the 2015 ATA guidelines. Methods: A retrospective cohort analysis was performed using the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2019 of patients with localized PTC <4 cm who underwent TT or TL. Patients were classified as living in urban or rural counties based on the 2013 Rural-Urban Continuum Codes. Procedures performed from 2004 to 2015 were categorized as preguidelines, while those performed from 2016 to 2019 were categorized as postguidelines. Chi-square, Student's t-test, logistic regression, and Cochran-Mantel-Haenszel test were used. Results: A total of 89,294 cases were included in the study. Eighty thousand one hundred and fifty (89.8%) were from urban settings and 9144 (9.2%) were from rural settings. Patients from rural settings were older (52 vs. 50 years, p < 0.001) and had smaller nodules (p < 0.001). On adjusted analysis, patients in rural areas were less likely to undergo TT (adjusted odds ratio 0.81, confidence interval [CI] 0.76-0.87). Before the 2015 guidelines, patients in urban settings had a 24% higher odds of undergoing TT compared with those in rural settings (odds ratio 1.24, CI 1.16-1.32, p < 0.001). There was no difference in the proportions of TT and TL based on setting following guideline implementation (p = 0.185). Conclusions: The 2015 ATA guidelines led to a change in overall practice in surgical management of PTC toward increasing TL. While urban and rural practice variation existed before 2015, both settings had an increase in TL following the guideline change, emphasizing the importance of clinical practice guidelines to ensure best practice in both rural and urban settings.

Designing prenatal care for low-income, black patients in urban settings using human centered design

Black and low-income pregnant patients face significant inequities in health care access and outcomes in the United States. Yet, these patients’ voices have been largely absent from designing improved prenatal care models. Our objective was to use Human Centered Design to examine patients’ and health care workers’ experiences with prenatal care delivery in a largely low-income, Black population, to inform future care innovations to improve access, quality, and outcomes.

Rural/urban differences in discharge from rehabilitation in older adults with traumatic brain injury.

Rates of traumatic brain injury (TBI) among older adults and treatment of this population in nursing homes are increasing. The objective of this study is to examine differences in the quality of care and outcomes of older adults with TBI in rural and urban settings by (1) comparing the rates of successful community discharge; and (2) reasons for not achieving successful discharge among patients in rural and urban environments. Retrospective national cohort study of skilled nursing facility (SNF) patients using Medicare inpatient claims linked with Minimum Data Set assessments. Demographic, health, and facility characteristics were compared between rural and urban settings using descriptive statistics. Logistic regression with state random effects was used to identify characteristics that predicted successful discharge. U.S. skilled nursing facilities (n=11,771). Medicare beneficiaries aged 66 and older discharged to a SNF following hospitalization for TBI between 2011 and 2015 (n=61,021). Successful community discharge defined as discharge from SNF within 100 days of admission and remaining in the community for ≥30 days without dying or admission to an inpatient healthcare facility. Unadjusted rates of successful discharge were significantly lower for patients in rural settings compared with patients in urban settings (52.1% vs 58.5%, p < 0.01). Patients in rural settings had lower adjusted odds (odds ratio 0.84, 95% confidence interval=0.80-0.89) of successful discharge. Reasons for not discharging successfully differed between rural and urban settings with rural patients less likely to discharge from SNF within 100 days though also less likely to be rehospitalized within 30 days of SNF discharge. Given the low overall rate of successful community discharge and worse outcomes among rural patients, further research to explore interventions to improve SNF care and discharge planning in this population is warranted.

The Cost of Insanity in Nineteenth-Century Ireland: Public, Voluntary and Private Asylum Care, by Alice Mauger

Reviewed by: The Cost of Insanity in Nineteenth-Century Ireland: Public, Voluntary and Private Asylum Care by Alice Mauger Elizabeth J. Donaldson (bio) The Cost of Insanity in Nineteenth-Century Ireland: Public, Voluntary and Private Asylum Care, by Alice Mauger; pp. xvi + 281. Basingstoke and New York: Palgrave Macmillan, 2018, £20.00, $31.00. Alice Mauger's The Cost of Insanity in Nineteenth-Century Ireland: Public, Voluntary and Private Asylum Care builds on a well-established and abundant body of historical work about Victorian-era asylums and is part of a field focused specifically on Irish mental health care that includes the work of Catherine Cox, Brendan Kelly, Elizabeth Malcolm, Pauline M. Prior, and others. As comparisons to English institutions illustrate, the structures of nineteenth-century Irish mental health care are distinct. In Ireland, district asylums for the poor funded by the central government flourished while private asylums grew more slowly than in England, due largely to the fact that the Irish Poor Law did not compensate private asylums for care of the indigent. While the district asylums cared for the poor and the private asylums catered to the wealthy, other social classes—those not poor enough to be considered paupers and not wealthy enough to afford private asylums—were left without clearly defined institutional care options. Eventually legal provisions were made for the inclusion of paying, non-pauper patients in district asylums, and voluntary, non-profit charity asylums were also established and offered a lower-cost alternative to private asylums for this population. In turn, private asylums competed for patients, which led to what Mauger characterizes as an "institutional marketplace" of mental health care (14). While many readers are all too familiar with the fictional madwoman in the attic depicted in Charlotte Brontë's Jane Eyre (1847), relatively little is known about the actual historical conditions of non-pauper patients in institutional care outside of the home. Mauger's attention to the economics of Irish asylums and the historically-neglected group of paying patients in asylums makes her work unique. Mauger notes that traditional historical studies of Victorian madness focus almost exclusively on poor patients in urban settings. Mauger's work, however, broadens this scope to include the neglected urban and rural middling classes by examining the records of paying patients in three different types of institutions: district (public, non-profit) asylums, voluntary (religious-affiliated, charitable non-profit) asylums, and private (for profit) asylums. By 1900, there were twenty-two public asylums housing 16,000 total patients, but the number of paying patients was very low: only fifty-three were admitted in 1889, the last year inspectors recorded this number. For paying patients, voluntary asylums provided a more attractive middle ground between overcrowded and difficult-to-access district asylums and the more expensive private asylums: by 1900, thirteen private asylums housed 300 patients and four voluntary asylums housed 400 patients. Mauger's research tracks [End Page 529] this subset of patients, the great lengths that some asylums went to in order to determine their ability to pay, and the economic anxieties of these patients and their families. For male patients in particular, Mauger notes, fear of losing employment and "the evil effects of mental strain and overwork" loomed large in the attributed causes of their admissions to asylums (149). The Cost of Insanity is based on Mauger's doctoral thesis, and this open access book offers a wealth of information culled from archival research. Historians of Victorian asylums will find the book of interest for its compilation of data, which includes information about paying patient populations, maintenance fees, length of stay, and recorded outcomes as well as breakdowns of patients' religious affiliations, occupations, and attributed causes of illness by gender in the nine Irish asylums Mauger examines. The book is replete with tables organizing this information. Sometimes Mauger's discussion remains a little too granular, however, and misses opportunities to make this data more comprehensible to a wider range of readers. Mauger records, for example, that a non-pauper patient paid an average of twenty-one pounds per annum at St. Vincent's charity asylum in 1857. Yet the book does not put expenses like these into an overarching...

LVAD Care for the Rural Population: A Single-Center Experience

Objectives LVAD therapy is an established treatment for patients with advanced heart failure. However, the persistent risk of long-term complications including pump thrombosis, GI bleeds and infection, requires close follow-up and care of these patients. This attentive care can be complicated in patients living in rural communities, distant from the implanting LVAD center, and may therefore complicate the post-implant outcomes for these patients, compared to patients living in urban settings or in close proximity to an LVAD center. We therefore chose to compare the outcomes of patients living in rural vs urban settings after DT-LVAD implantation. Methods A retrospective review of all LVAD implants performed at our center was undertaken. Patients who died in the perioperative period were excluded. Midterm outcomes for patients living in rural Nebraska were compared to patients living in the two largest urban centers in the state. Results A total of 40 LVAD implants occurred in patients who were discharged alive after the implant procedure. Of those, 19 were performed in patients living in urban centers, within 30 miles of an LVAD center. Thirty-day readmissions were somewhat more frequent in patients in urban settings (16% vs 9%). However, 68% of patients living in a rural setting experienced at least 1 readmission in the first year after implant, while only 52% of patients in an urban setting experienced any readmission. In the first year, stroke rates were higher in the rural-residing patients (10% vs 5%) while rates of major bleeds (4.7% rural vs 5.2% urban) and driveline infection rates were similar. One patient in the rural group died within 1 year after discharge, while there were no deaths in the urban-residing patients within the 1st year. At 2 years the actual survival was 76% in the rural-residing patients and 89% in the urban-residing patients. Conclusions LVAD therapy can be safely instituted in patients residing in rural settings. Although geography may limit some access to care, mid-term outcomes after implantation are acceptable. Our data suggests a trend towards higher rates of strokes and bleeds in patients residing in rural settings. In addition, there is a suggestion that patients residing in an urban setting with LVADs may experience improved long-term survival.

Quality-of-Life Tradeoffs for Hepatitis C Treatment: Do Patients and Providers Agree?

The authors investigated differences between how patients and providers evaluate the quality-of-life tradeoffs associated with HCV treatment in computer-assisted interviews. They interviewed 92 treatment-naive HCV patients at gastroenterology, methadone maintenance, and HIV clinics at 3 hospitals in New York City and 23 physicians or nurses experienced in treating HCV at other hospitals in New York City. Subjects completed rating scale and standard gamble evaluations of current health and hypothetical descriptions of HCV symptoms and treatment side effects on a scale from 0 (death or worse than death) to 1 (best possible health). . Treatment side effects were rated worse by patients than providers using the rating scale (moderate side effects 0.42 v. 0.62; severe side effects 0.24 v. 0.40) and standard gamble (moderate side effects 0.61 v. 0.91; severe side effects 0.52 v. 0.75) (all P < or = 0.01). A year of severe side effects was equivalent to 4.1 years of mild HCV symptoms avoided for patients if they returned to their current health after treatment compared with 2.0 years avoided if they achieved average population health. For patients with depression symptoms, HCV treatment with severe side effects had lower value unless it would also improve their current health. . Patients have more concerns about treatment side effects than providers. Further research is warranted to develop HCV decision aids that elicit patient preferences and to evaluate how improved communication of the risks and benefits of HCV treatment and more effective treatment of depression may alter these preferences.

Molecular epidemiology of leptospirosis in the Amazon.

Leptospirosis is a zoonotic infectious disease that is transmitted from animals to humans primarily via water [1]. The causative agent is a bacterial spirochete that colonizes the renal tubules of infected animals and is shed in the urine for varying periods of time, depending on whether the animal is an accidental or reservoir host for that serovar (see Glossary). Rats are reservoir hosts for serovars of Leptospira interrogans (Figure 1) belonging to the Icterohaemorrhagiae serogroup, and infected rats probably remain infected, and infectious, for life [2]. A total of 17 species of Leptospira and hundreds of serovars have been described [3]. All leptospires are well suited to life in water. In fact, several leptospiral species, such as L. biflexa, are saprophytic organisms that are exclusively aquatic. However, even pathogenic species can survive for months in a nutrient-poor aqueous environment while waiting to encounter a new host [4]. Figure 1 Scanning Electron Micrograph of Leptospira interrogans (Strain RGA) In tropical regions of the world, leptospirosis is a widespread public health problem [5]. The disease is endemic wherever open sewers or agricultural practices lead to contamination of water with animal urine. Although most human leptospirosis infections are self-limited, complications are common, involving hepatorenal failure, pulmonary hemorrhage, and death in 10%–50% of severe cases [6]. Large outbreaks of leptospirosis occur when heavy rainfall and inadequate civil engineering result in urban flooding [7]. Rat-borne L. interrogans species are typically isolated from patients in urban settings, but—until the publication today of a study by Vinetz and colleagues in PLoS Medicine [8]—little was known about the species present in environmental water sources in either urban or rural settings. Given the laborious nature of leptospiral isolation and culture techniques, particularly from environmental samples, there was previously no systematic method available to determine the identity, spectrum, and density of leptospires in water samples.

Lead screening practices of pediatric residents.

As part of their training, pediatric residents provide primary care services to young children, including youngsters who may have elevated blood lead levels. We set out to (1) determine the percentage of pediatric residents who screen children for elevated blood lead levels according to the guidelines of the Centers for Disease Control and Prevention and the American Academy of Pediatrics; (2) assess the likelihood of lead screening by residents based on demographic and practice-setting characteristics; and (3) compare the attitudes of residents who report that they are universal screeners, selective screeners, or nonscreeners. Confidential, cross-sectional survey of a nationally representative sample of pediatric residents conducted as part of the American Academy of Pediatrics 28th Periodic Survey of Fellows. One hundred forty-three responding pediatric residents (51% response rate). Seventy-five percent of pediatric residents reported screening all patients aged 9 to 36 months for elevated blood lead levels, 21% reported screening some, and 4% reported screening none. Pediatric residents who cared for patients in urban settings were more likely to report screening patients for elevated blood lead levels than were pediatric residents who cared for patients in suburban or rural settings (100% vs 73%; P < .001) and pediatric residents in the Northeast were more likely to report screening universally than were residents in the rest of the country (93% vs 63%; P < .001). Overall, pediatric residents who reported screening patients universally were more likely to believe that the benefits of screening outweigh the costs than were residents who reported screening patients selectively (67% vs 17%; P < .001). Most pediatric residents reported that they screened patients for elevated blood lead levels, either universally or selectively. Nevertheless, the screening practices of pediatric resident and their opinions concerning the relative benefits and costs of lead screening largely reflect the areas of the country and the practice settings in which they had their primary care experiences.

Patients in the care of private psychiatric practitioners. Comparison with public hospital patients and the background districts' population.

In Western societies, the number of psychiatric hospital beds has decreased markedly in the past decades. The reduction in hospital beds has resulted in a relatively large number of mentally ill individuals residing in the community. They experience varying degrees of success. One form of treatment available to such patients is private psychiatric consultation. In Denmark and England (two countries with public supported health care systems) the number of psychiatrists in private practice (PPPs) has increased in recent years. These private practioners may offer a mode of treatment which may meet the needs of a subgroup of the psychiatric patients in the community. The fees of the PPPs are paid by the National Health Service. In this study we report on the characteristics of the patients attending the consultation of private psychiatrists and the treatment which they are offered. We compare the patients of the PPPs with 1. psychiatric patients residing in the same districts who are cared for by the public hospital system and 2. the background populations of these same districts. The results suggest that the patients in private psychiatric practice are distinct in a number of ways. Neurosis is the dominant diagnosis. Of the patients, 71% are women; the patients tend to be younger than the background districts population; after controlling for age, the marital status of the patients in PPPs' care does not differ significantly from that of the background population, and they are comparable to the background population in level of employment. These patients are more able to care for themselves than the psychiatric patients treated in the public hospital system. The results suggest that PPP is a means of caring for a subgroup of the psychiatric patients in urban settings.