Rates Of Emergency Room Visits Research Articles

Is mechanical bowel preparation necessary to reduce surgical site infection following colon surgery? Protocol for a multicentre Canadian randomized controlled trial.

There is significant practice variation with respect to the use of bowel preparation to reduce surgical site infection (SSI) following colon surgery. Although intravenous antibiotics + mechanical bowel preparation + oral antibiotics (IVA + MBP + OA) has been shown to be superior to IVA + MBP and IVA, there are insufficient high-quality data from randomized controlled trails (RCTs) that directly compare these options. This is an important question, because if IVA + OA has similar effectiveness to IVA + MBP + OA, mechanical bowel preparation can be safely omitted, and the associated side effects avoided. The aim of this work is to compare rates of SSI following IVA + OA + MBP (MBP) versus IVA + OA (OA) for elective colon surgery. This is a multicentre, parallel, two-arm, noninferiority RCT comparing IVA + OA + MBP versus IVA + OA. The primary outcome is the overall rate of SSI 30 days following surgery. Secondary outcomes are length of stay and 30-day emergency room visit and readmission rates. The planned sample size is 1062 subjects with four participating high-volume centres. Overall SSI rates 30 days following surgery between the treatment groups will be compared using a general linear model. Secondary outcomes will be analysed with linear regression for continuous outcomes, logistic regression for binary outcomes and modified Poisson regression for count data. It is expected that IVA + OA will work similarly to IVA + MBP + OA and that this work will provide definitive evidence showing that MBP is not necessary to reduce SSI. This is highly relevant to both patients and physicians as it will have the potential to significantly change practice and outcomes following colon surgery in Canada and beyond.

#608 Effects of shared decision-making on the prognosis of peritoneal dialysis patients

Abstract Background and Aims Patients with chronic kidney disease (CKD) require shared decision-making (SDM) processes when choosing a dialysis method. Peritoneal dialysis (PD) guarantees patient autonomy; thus, SDM is even more important. Based on these findings, we aim to highlight the benefits of PD and increase the rate in which patients choose PD. In order to increase the rate of PD implementation, patients must actively participate in dialysis decisions, and SDM process is necessary between doctors and patients. So, we investigated the effect of SDM on the prognosis of patients with CKD. We focused on the effects of SDM on patient death, survival rates, hemodialysis conversion, emergency room visits, hospitalization days, and outpatient visits. The results of this study suggest that SDM has a positive impact on increasing the number of patients who choose PD and reduce unnecessary medical cost. Method Among patients with chronic kidney failure from eight hospitals in Korea who started dialysis, 256 who participated in a pilot project for home management of PD were included in the present study. A mixed-methods study was conducted using questionnaires and semi-structured interviews. Our study focused on the effects of SDM on patient death, survival rate, hemodialysis conversion, emergency room visits, hospitalization days, and outpatient visits. Results A significant difference was observed in the number of days of hospitalization per admission (p = 0.0044) between the SDM and non-SDM groups. However, no significant differences were observed in survival rate, rate of conversion to hemodialysis (HD), survival rate after conversion to HD, emergency room visit rate, number of hospitalizations per patient, outpatient visit rate, medical cost, hospitalization cost, outpatient cost, and phosphate-binding agent prescription rate. Conclusion The number of hospitalization days per admission decreased throughout the SDM process. Continued communication between patients and medical staff on how to manage PD in the long term after making the decision to undergo dialysis will be beneficial in promoting the home management of PD patients.

Simultaneous versus staged bilateral carpal tunnel release via open and endoscopic surgeries: a retrospective propensity score-matched patient comorbidity analysis.

Carpal tunnel syndrome (CTS) presents bilaterally in nearly 60%-70% of affected patients. Bilateral carpal tunnel release (CTR) can be performed in a staged or simultaneous fashion. There remains a limited understanding of the optimal preoperative factors to use for patient selection when determining simultaneous versus staged bilateral CTR. Moreover, it is unclear how these factors influence postoperative outcomes. In this study, the authors aimed to identify and compare preoperative comorbidities and postoperative outcomes in patients who had undergone simultaneous versus staged open and endoscopic bilateral CTR. The authors performed a retrospective analysis of data collected from the TriNetX database. Patients with bilateral CTS who had been treated from February 1, 2002, to February 1, 2022, were dichotomized by their bilateral release approach: simultaneous or staged within 3 months. The resulting groups were analyzed separately by open versus endoscopic techniques. Next, cohorts were analyzed for preoperative comorbidities to identify possible factors for surgical determination. Then, they were propensity score matched on demographics and comorbidities. Postoperative outcomes within 6 months of surgery were measured with and without matching. After matching, 9286 and 3709 patients remained in the open and endoscopic groups, respectively. Those who had undergone staged surgeries via an open or endoscopic approach had more preoperative comorbidities. After matching, staged open release was associated with significantly higher rates of postprocedural care, hand/joint pain, limb pain, trigger finger, and upper respiratory tract infections. Simultaneous open release was associated with higher rates of emergency room visits. Staged endoscopic release was associated with significantly higher rates of postprocedural care, limb pain, and trigger finger. No significant outcomes were favored in the simultaneous endoscopic group. Before matching, patients who had undergone staged CTR had significantly higher rates of preoperative medical comorbidities compared with patients in the simultaneous CTR group. Moreover, staged CTR was significantly associated with higher rates of postoperative complications. After matching on demographics and comorbidities, staged CTR was still associated with higher rates of postoperative complications, suggesting that preoperative comorbidities do not influence postoperative outcome. Further prospective studies could be used to validate these results and provide new findings for the management and treatment of these groups.

Increasing tree cover and high-albedo surfaces reduces heat-related ER visits in Los Angeles, CA.

There is an urgent need for strategies to reduce the negative impacts of a warming climate on human health. Cooling urban neighborhoods by planting trees and vegetation and increasing albedo of roofs, pavements, and walls can mitigate urban heat. We used synoptic climatology to examine how different tree cover and albedo scenarios would affect heat-related morbidity in Los Angeles, CA, USA, as measured by emergency room (ER) visits. We classified daily meteorological data for historical summer heat events into discrete air mass types. We analyzed those classifications against historical ER visit data to determine both heat-related and excess morbidity. We used the Weather Research and Forecasting model to examine the impacts of varied tree cover and albedo scenarios on meteorological outcomes and used these results with standardized morbidity data algorithms to estimate potential reductions in ER visits. We tested three urban modification scenarios of low, medium, and high increases of tree cover and albedo and compared these against baseline conditions. We found that avoiding 25% to 50% of ER visits during heat events would be a common outcome if the urban environment had more tree cover and higher albedo, with the greatest benefits occurring under heat events that are moderate and those that are particularly hot and dry. We conducted these analyses at the county level and compared results to a heat-vulnerable, working-class Los Angeles community with a high concentration of people of color, and found that reductions in the rate of ER visits would be even greater at the community level compared to the county.

Psychological Distress, Emergency Room Utilization, and Mortality Risk Among US Adults With History of Prostate Cancer.

Adults with a history of prostate cancer experience several physical and mental stressors. However, limited information is available about the prevalence of psychological distress in this population and its association with clinical outcomes in a nationally representative sample. We identified adults with history of prostate cancer from a nationally representative cohort (2000-2018 US National Health Interview Survey) and its linked mortality files through December 31, 2019. The six-item Kessler Psychological Distress Scale (K6) was used to assess psychological distress. The associations between psychological distress severity, emergency room (ER) usage, and mortality risk were estimated using multivariable logistic and Cox proportional hazards models, which were both adjusted for age, survey year, race/ethnicity, region, education, health insurance, comorbidities, functional limitations, and time since cancer diagnosis. Among the 3,451 adults with history of prostate cancer surveyed, 96 (2.4%), 434 (11.3%), and 2,921 (86.3%) reported severe, moderate, or low/no mental distress, respectively. During the 12 months preceding the survey, 812 (22.8%) adults with history of prostate cancer visited the ER. After a median follow-up of 81 months, 937 (25.5%) deaths occurred. Compared with participants with low/no mental distress, those with severe mental distress reported the highest utilization of the ER (adjusted odds ratio [aOR], 2.57 [95% CI, 1.51 to 4.37]) and exhibited the highest all-cause mortality (adjusted hazard ratio [aHR], 1.83 [95% CI, 1.29 to 2.60]), followed by those with moderate mental distress (ER use aOR, 1.76 [95% CI, 1.29 to 2.42]; all-cause mortality aHR, 1.22 [95% CI, 0.92 to 1.62]). Among US adults with history of prostate cancer, psychological distress was associated with increased ER use and mortality risk. Notably, severe psychological distress was correlated with the highest rates of ER visits and mortality risk. However, given the retrospective nature of this study, uncontrolled confounding variables need to be considered when interpreting the findings.

Societal and economic burden of migraine in Spain: results from the 2020 National Health and Wellness Survey

BackgroundThe burden of migraine goes beyond the pain and associated symptoms. We aimed to describe the impact of migraine in healthcare resource utilization (HCRU), work productivity, and mood disorders, as well as its economic cost.MethodsCase–control study nested in a cross-sectional analysis of patient-reported data collected between 30/12/2019 and 20/04/2020 as part of the National Health and Wellness Survey, from respondents located in Spain. Adults (≥ 18 years old) who reported a physician diagnosis of migraine and ≥ 1 monthly headache days (MHD) in the previous 30 days were included. HCRU, health-related quality-of-life, depression scores, work and activity impairment, and the associated direct and indirect costs were assessed for four cohorts of migraine patients, according to the frequency of headache (MHD: 1–3, 4–7, 8–14, ≥ 15) and compared to a no-migraine control, matched to migraine cases by a propensity score based on demographic and clinical variables.ResultsThe survey was completed by 595 people with active migraine, of whom 461 (77.4%) experienced < 8 MHDs and 134 (22.6%) ≥ 8 MHDs, and 1,190 non-migraine matched controls. Migraine patients presented worse mental and physical health functioning (SF-12 MCS: 41.9 vs. 44.7, p < 0.001; SF-12 PCS: 48.6 vs. 51.5, p < 0.001), worse self-reported health (EQ-5D VAS: 65.8 vs. 73.5, p < 0.001), more severe depression (PHQ-9: 8.9 vs. 6.1, p < 0.001), and higher overall work impairment (WPAI: 41.4 vs. 25.5, p < 0.001). People with migraine had higher HCRU, twice higher hospitalization rates (17.0% vs. 8.3%, p < 0.001) and 1.6 higher emergency room (ER) visit rates (51.4% vs. 31.2%, p < 0.001). Having migraine translated into higher annual costs with HCRU (€894 vs. €530) and productivity losses (€8,000 vs. €4,780) per person. Respondents with more MHDs presented worse outcomes and higher costs but suffering from 1–3 MHD also increased costs by 51.3%.ConclusionsHaving migraine not only causes a massive impact on patients’ quality of life and ability to work, but it also generates considerable economic costs for society. In Spain, having migraine was associated to 1.7 higher costs per patient. The clinical and economic burden increases with the frequency of headaches but is higher than controls even in patients suffering from 1–3 MHD.Graphical

Impact of Prior Abdominal Procedures on Peritoneal Dialysis Catheter Outcomes: Findings From the North American Peritoneal Dialysis Catheter Registry

A history of prior abdominal procedures may influence the likelihood of referral for peritoneal dialysis (PD) catheter insertion. To guide clinical decision making in this population, this study examined the association between prior abdominal procedures and outcomes in patients undergoing PD catheter insertion. Retrospective cohort study. Adults undergoing their first PD catheter insertion between November 1, 2011 and November 1, 2020, at 11 institutions in Canada and the US participating in the International Society for Peritoneal Dialysis (ISPD) North American Catheter Registry. Prior abdominal procedure(s), defined as any procedure that enters the peritoneal cavity. Primary outcome: time to the first of abandonment of the PD catheter, or interruption/termination of PD. rates of emergency room visits, hospitalizations, and procedures. Cumulative incidence curves were used to describe the risk over time and an adjusted Cox proportional hazards model was used to estimate the association between the exposure and primary outcome. Models for count data were used to estimate the associations between the exposure and secondary outcomes. A total of 855 patients met the inclusion criteria. Thirty-one percent had a history of a prior abdominal procedure and 20% experienced at least one PD catheter-related complication that led to the primary outcome. Prior abdominal procedures were not associated with an increased risk of the primary outcome [Adjusted HR 1.12 (95% CI 0.68-1.84)]. Upper abdominal procedures were associated with a higher adjusted hazard of the primary outcome, but there was no dose-response relationship concerning the number of procedures. There was no association between prior abdominal procedures and other secondary outcomes. Observational study and cohort limited to sample of patients felt to be potential candidates for PD catheter insertion. A history of prior abdominal procedure(s) does not appear to influence catheter outcomes following PD catheter insertion. Such a history should not be a contraindication to peritoneal dialysis.

P399 Impact of Body Mass Index on Clinical Outcomes in Intestinal Behçet’s disease

Abstract Background The impact of underweight and obesity on clinical outcomes for intestinal Behçet’s disease (BD) is unknown. We aimed to identify the association between body mass index (BMI) and clinical outcomes in patients with intestinal BD. Methods We categorized 760 patients with intestinal BD according to the BMI at diagnosis into four groups (underweight, normal, overweight, obese) at Severance Hospital, Seoul, Korea between 1997 and 2021.We performed a Cox proportional hazard analysis to investigate the predictive capability of BMI for clinical outcomes such as biologics use, surgery, hospitalization and emergency room visit. Results Of the 760 patients, 130 patients were classified into underweight group (BMI&amp;lt;18.5), 384 patients into normal group (BMI 18.5~22.9), 152 patients into overweight group (BMI 23~24.9), and 94 patients into obese group (BMI≥25). Patients with a higher BMI group showed significantly lower cumulative rates of biologics use (p trend = 0.001), surgery (p trend = 0.008), hospitalization (p trend = 0.002), and emergency room visits (p trend = 0.003) than those with a lower BMI group. In a multivariate analysis, normal BMI group (HR: 0.667, 95% CI 0.483-0.992, p =0.014), overweight group (HR: 0.589, 95% CI 0.394-0.879,p=0.010), and obese group (HR: 0.515, 95% CI 0.321-0.828, p=0.006) were negatively associated with future hospitalization compared to underweight group. Overweight group (HR: 0.490, 95% CI 0.241-0.996, p =0.049) and obese group (HR: 0.312, 95% CI 0.116-0.840,p =0.021) were negatively associated with future biologics use compared to the underweight group. Normal BMI group (HR: 0.706, 95% CI 0.484- 1.029, p=0.070) and obese group (HR : 0.556, 95% CI 0.303-1.020,p=0.058) were negatively associated with future surgery compared to the underweight group. Normal BMI group (HR: 0.711, 95% CI 0.513-0.985, p=0.041) and obese group (HR: 0.602, 95% CI 0.376-0.963, p=0.034) were negatively associated with future emergency room visit compared to the underweight group. Conclusion Underweight could affect poor outcomes in intestinal Behçet’s disease. Physicians should pay attention to the patients with underweight and make an effort to improve nutritional status.

Randomized Trial of a Volunteer-Led Symptom Assessment Intervention on Documentation, Patient-Reported Outcomes, and Health Care Use Among Veterans With Lung Cancer.

Identification and documentation of Veterans' symptoms are crucial for optimal lung cancer care delivery. The objective of this study was to determine whether a volunteer-led proactive telephone symptom assessment intervention could improve comprehensive symptom documentation. Veterans with lung cancer were randomly assigned to usual care (control group) or usual care with proactive symptom assessment in which a peer volunteer made weekly phone calls to assess patient symptoms under nurse practitioner supervision. The primary outcome was oncologist documentation of symptoms in the electronic health record at all clinical visits within 6 months after enrollment. Secondary outcomes included patient satisfaction with decision, patient activation, health-related quality of life (HRQOL), and symptom burden, measured at baseline, and 3, 6, and 9 months after enrollment, and acute care use within 9 months after enrollment. Among 60 Veterans randomly assigned, median (range) age was 70.2 (50-86) years; 57 (95.0%) were male. More intervention participants had oncologist documentation of symptoms than control group participants (24 [77.4%] v seven [24.1%], respectively; odds ratio, 16.46 [95% CI, 4.58 to 59.16]). Intervention group participants had greater improvements over time in HRQOL (expected mean difference, 25.3 [95% CI, 15.00 to 35.70]) and patient activation (expected mean difference, 13.6 [95% CI, 3.79 to 23.39]), lower symptom burden (expected mean difference, -6.39 [95% CI, -15.21 to -2.46]), lower rates of emergency room visits (incidence rate ratio, 0.48 [95% CI, 0.30 to 0.75]), and hospitalizations (incidence rate ratio, 0.47 [95% CI, 0.28 to 0.77]) than control group participants. This symptom assessment intervention is an effective strategy for Veterans with lung cancer.

Improving patient outcomes with a mobile digital health platform for patients undergoing transcatheter aortic valve replacement.

ManageMySurgery (MMS) is a digital health application (app) for patients undergoing surgery, including Transcatheter Aortic Valve Replacement (TAVR). Patients using MMS review procedure-specific education, view FAQs, and report patient-reported outcomes. This study assessed the impact of app use on postoperative outcomes. Patients who underwent TAVR and invited to use MMS between March 2019 and November 2021 were identified. Patients received standard perioperative care and were defined as App users if they signed into the app at least once and engaged with at least one task or FAQ. Demographics and postoperative outcomes were collected via medical record review. Multivariable logistic regression models were used to determine odds of 90-day readmission, Emergency Room (ER) visits, and complications. 388 patients met inclusion criteria, of which 238 used the app. The average age at surgery was 76.4±7.7 years for users and 78.1±7.6 for non-users. 63.0% of users and 59.3% of non-users were male. App users had significantly lower 90-day readmission rates, (8.8% vs 16.0%, OR=0.51, p=0.0373), ER visit rates (12.6% vs 27.3%, OR=0.36, p=0.0003), and complication rates (Minor: 12.2% vs 20.7%, OR=0.48, P=0.0126; Major: 8.8% vs. 16%, OR=0.47, P=0.0235). In this non-randomized, retrospective study, we found significant decreases in 90-day readmissions, ER visits, and complications in TAVR patients using an app compared to traditional care. By engaging patients throughout their interventional journey with structured education and tasks, mobile health platforms may mitigate unnecessary use of emergency and inpatient care, thereby improving patient well-being and lowering the burden on healthcare resources.

EVALUATING A TRANSITIONAL CARE PROGRAM FOR OLDER ADULTS WITH FRAILTY BETWEEN HOSPITAL AND HOME

Abstract Older adults with frailty experience numerous health problems even after hospital discharge, highlighting the necessity of continued intervention until their recovery and return to daily routines. This mixed methods research (i.e., quantitative and qualitative studies) aimed to evaluate the effectiveness of a transitional care program developed for older adults with frailty during the transition from hospital to home and how it was helpful. From June to December 2021, 32 older adults with frailty were enrolled in a randomized controlled trial at a university-affiliated hospital in Korea. They were allocated to either an intervention group (n=16) or a control group (n=16) according to a random number sequence. The intervention group received a 12-week transitional care program that included inpatient care, structured discharge, and follow-up interventions (e.g., home visits and phone follow-ups); the control group received usual care only. At 12 weeks, program participants (eight frail older adults and eight family caregivers) had interviews for the qualitative research. The results showed that the intervention group had a higher score in knowledge readiness (p=.046) at discharge, empowerment (p=.032), and connectedness at four weeks (p=.037); community resource utilization (p &amp;lt;.001) and emergency room visit rate (p=.049) at 12 weeks; and improvement in depression (p &amp;lt;.001), family interaction (p=.045), and subjective health status (p=.002) over time. Participants described the program as a supportive, connected, timely, and personalized intervention. Overall, the study demonstrated that the transitional care program effectively improved the health outcomes of older adults with frailty and facilitated a safe transition between hospital and home.

Pediatric Patients with Tracheostomies and Its Multifacet Association with Lower Airway Infections: An 8-Year Retrospective Study in a Large Tertiary Center.

Background: Lower respiratory tract infections frequently complicate the care of children with chronic tracheostomies. Pediatric patients have significantly more risk to have tracheostomy infections than adults. Better understanding of modifiable risk factors for pulmonary exacerbations may improve the care of technology-dependent children. Methods: A retrospective single-center cohort study conducted on children with tracheostomy and chronic home ventilator to determine the incidence of pulmonary exacerbations leading to hospitalizations, emergency room (ER) visits, and antibiotic prescriptions. Oral and nebulized antibiotic prescriptions were collected and correlated to the type of exacerbation. Results: Gram-negative enteric organisms were the most common microbes seen in the lower airways, with Pseudomonas aeruginosa cultured in 86% of the subjects. P. aeruginosa presence predicted a 4-fold increased rate of pulmonary-related hospitalization. In pediatric patients with chronic respiratory failure, 64% of readmissions were pulmonary or tracheostomy related. When compared to standard care subjects on dual agent, alternating monthly nebulized antibiotic therapy (for chronic pseudomonas colonization) experienced 41% fewer hospitalizations [incidence rate ratios (IRR) 0.59 (0.18), P = 0.08], 46% fewer ER visits [IRR 0.56 (0.16), P = 0.04], and 41% fewer pulmonary-related ER visits [IRR 0.59 (0.19), P = 0.94]. Discussion: Children who require artificial airways are at an increased risk for bacterial bronchopulmonary infections. Most notable risk factors for hospitalization in tracheostomized children included neurologic impairment, dysphagia, aspiration, gastrotomy tube dependence, and gastroesophageal reflux disease. Pathogenic microbes such as P. aeruginosa species, certain gram-negative bacteria, candida, and yeast also predicted increased hospitalizations. Use of nebulized antibiotics prophylaxis in a subset of patients predicted lower rates of hospitalization or ER visits. More studies are needed to assess whether there is increased antimicrobial resistance with this strategy, and whether the benefits persist in the long-term nebulized antibiotics utilization.

A Comparison of Bleeding Events Among Patients on Apixaban, Rivaroxaban, and Warfarin for Atrial Fibrillation and/or Venous Thromboembolism

Introduction Apixaban and rivaroxaban are the most commonly used direct oral anticoagulants (DOACs) for atrial fibrillation (AF) and venous thromboembolism (VTE). Both have been compared to warfarin in landmark clinical trials. However, there are limited comparative efficacy data between these drugs in a real-world setting. We sought to assess patient characteristics and outcomes of apixaban, rivaroxaban, and warfarin in a non-trial based study cohort. Methods Retrospective registry-based cohort of adults starting apixaban, rivaroxaban, or warfarin therapy or switching between these anticoagulants for the indications of VTE and/or non-valvular AF. Through the Michigan Anticoagulation Quality Improvement Initiative (MAQI 2) collaborative of six anticoagulation clinics, warfarin treated patients were followed from January 2009 to June 2023. Four of these clinics contributed DOAC patient data from June 2011 to June 2023. Patients treated with other anticoagulants, with valvular AF, or with less than 3 months of follow-up were excluded. Propensity matched cohorts (apixaban versus warfarin [1:1], rivaroxaban versus warfarin [1:3], and apixaban versus rivaroxaban [1:1]) of patients were analyzed based on DOAC use at study enrollment, using 1:1-3:1 matching ratios. Patients were matched based on demographics, social history, comorbidities, medications, bleeding/thrombotic history, indication for anticoagulation, and follow-up. The primary outcome was any new bleeding event. Secondary outcomes included new episodes of thrombosis, bleeding event type (major, fatal, life threatening, central nervous system, and non-major bleeding), emergency room (ER) visits, hospitalizations, and death. Random chart audits were done to confirm the accuracy of the abstracted data. Event rates were compared using Poisson regression. Results Of 13,435 patients on OAC who met the study inclusion criteria (3,536 on apixaban, 1,395 on rivaroxaban, and 8,504 on warfarin), the average age was 66.7 years (standard deviation [SD] 14.9 years), 51.1% identified as male, most (58.0%) were on anticoagulation for AF, and the average follow-up was 28.2 months (SD 30.7 months). After propensity matching, 3,527 patients on apixaban were compared to 3,527 patients on warfarin. Any bleeding was similar between groups, but major bleeding was higher with warfarin (3.4 versus 4.7 events/100 patient years, p&amp;lt;0.001). Thrombotic event rates were higher with apixaban (2.6 versus 2.1 events/100 patient years, p=0.026), including the thrombotic subtype of other thrombosis (1.0 versus 0.5 events/100 patient years, p&amp;lt;0.001). Rates of ER visits and hospitalizations for bleeding were higher with warfarin. Mortality was higher with warfarin (3.7 versus 4.4 deaths/100 patient years, p=0.027). After propensity matching, 1,395 patients on rivaroxaban were compared to 4,185 patients on warfarin. Any bleeding and major bleeding were higher with rivaroxaban (37.9 versus 24.9 events/100 patient years, p&amp;lt;0.001; 4.7 versus 3.6 events/100 patient years, p=0.041 respectively). Thrombotic event rates were similar, aside from a higher rate of the thrombotic subtype of other thrombosis with rivaroxaban (1.0 versus 0.3 events/100 patient years, p=0.002). ER visits, hospitalizations, and mortality were similar between rivaroxaban and warfarin. After propensity matching, 1,395 patients on apixaban were compared to 1,395 patients on rivaroxaban. Any bleeding and major bleeding were higher with rivaroxaban (37.9 versus 25.7 events/100 patient years, p&amp;lt;0.001; 4.7 versus 2.6 events/100 patient years, p&amp;lt;0.001). Thrombotic event rates were similar. ER visits occurred more frequently on rivaroxaban (12.8 versus 10.1 events/100 patient years, p=0.003) as did patient mortality (3.5 versus 2.6 deaths/100 patient years, p=0.047). Conclusions For patients on oral anticoagulation for AF and/or VTE we observed that bleeding was highest with rivaroxaban, followed by warfarin, and then apixaban. Rates of thrombosis were higher with apixaban compared to warfarin, seemingly largely driven by “other” thrombotic events. Thrombotic event rates were otherwise similar between apixaban, rivaroxaban, and warfarin. We observed apixaban to be associated with lower mortality than rivaroxaban and warfarin. While these findings should be confirmed with randomized studies, they may have implications for anticoagulant selection.

Red Blood Cell Transfusion Dependence Is Associated with Greater Healthcare Resource Utilization, Higher Medical Cost, and Poorer Prognosis in Patients with Lower-Risk Myelodysplastic Syndromes: A 28-Year Retrospective Observation Study Result

Myelodysplastic syndromes (MDS) encompass a heterogeneous group of myeloid neoplasms characterized by cytopenia due to inefficient hematopoiesis, with a considerable risk of progression to acute myeloid leukemia (AML) or early mortality. In lower-risk MDS (LR-MDS) patients, anemia and its associated complications have been the focus of clinical attention. A significant portion of these patients eventually develop red blood cell transfusion dependence (RBC TD), which has been linked to a poorer prognosis. Given the limited efficacy of available treatments in reducing RBC TD, most patients face increased risks of chronic anemia and various complications. Moreover, RBC TD is known to be associated with reduced overall survival (OS) and leukemia-free survival (LFS). This study aimed to assess the impact of RBC TD on the socioeconomic burden and clinical prognosis of LR-MDS patients, utilizing an electronic medical records (EMR) database spanning nearly 30 years of MDS patient data. This retrospective observational study examined adult MDS patients (≥ 18 years of age) treated at Samsung Medical Center in the Republic of Korea. Eligible patients were diagnosed with MDS between Sep 1, 1994, to Apr 1, 2022 (index period), with the observation period spanning from Sep 1, 1994, to Sep 1, 2022. Baseline assessments included estimation of revised international prognostic scoring system (IPSS-R) scores, categorizing patients with very low, low or intermediate risks as lower-risk MDS (LR-MDS). TD was defined as the occurrence of any 16-week period with RBC transfusion of ≥ 2 units per 8 weeks, without consecutive 56-day period without transfusion. Healthcare resource utilization (HCRU), medical costs, and prognosis indicators including overall survival (OS) and AML-free survival (AFS) were analyzed and compared between patients who experiencing TD and those not (non-TD). Out of 831 MDS patients, 349 (42.0%) were classified as lower-risk at baseline. Among LR-MDS patients, 29.5% (103/349) experienced TD while 23.3% (194/831) experienced TD in the entire study population. The median age at diagnosis of MDS was 63 (ranging from 18 to 89), and 65.3% (543/831) were male. In LR-MDS patients, there were no significant differences in either baseline age (61 vs 63, P=0.16) or gender (71.8% vs 61.0% males, P=0.053) between TD and non-TD groups. However, TD group exhibited significantly higher median erythropoietin (EPO) level than non-TD group (290.5U/L vs. 112U/L, P&amp;lt;0.001) among LR-MDS patients with available baseline serum EPO levels (76 TD and 178 non-TD). Among the 76 TD LR-MDS patients with baseline serum EPO levels, 51 (67.1%) exhibited &amp;gt; 200U/L, which is considered a clinical threshold for erythropoiesis-stimulating agent (ESA) treatment. As shown in Table 1, RBC TD was consistently associated with greater HCRU and higher medical costs, especially in LR-MDS patients. TD LR-MDS patients had higher rates of outpatient department and emergency room visits (15676 vs. 8303 visits and 587 vs. 328 visits per 1000 person-years [PY], respectively), and increased hospitalizations (709 vs. 456 per 1000 PY), with longer hospital stays (13343 vs. 8272 days per 1000 PY). Furthermore, TD LR-MDS patients required over four-times of packed RBC units than non-TD patients (31107 vs. 7073 units per 1000 PY). Consequently, TD LR-MDS patients incurred higher total medical cost than their non-TD counterpart (13.5 million vs. 6.1 million USD per 1000 PY). Median OS (58.4 months vs. 103.1 months) and AFS (52.7 months vs. 102.7 months) were both significantly shorter in the TD group compared to the non-TD group among LR-MDS patients, while the differences in OS and AFS did not reach the level of significance in the entire study population (Table 1 and Figure 1). Notably, median OS after the first documented RBC TD event was 33.8 months (95% confidence interval: 24.7-58.5 months) in LR-MDS patients. The findings of this study indicate that RBC TD can be a strong predictor of increased HCRU and medical costs, as well as decreased OS and AFS over a 20-year period following the initial diagnosis of LR-MDS. Given that a majority of LR-MDS patients experiencing TD may not be eligible for ESA treatment due to elevated EPO levels exceeding 200U/L, and the use of cytotoxic agents is not usually recommended for these patients, these results highlight a substantial unmet need for alternative treatment options to address RBC TD in LR-MDS patients.

The effectiveness of a transitional care program for frail older adults between hospital and home: A randomized controlled trial

This study evaluated the effectiveness of a transitional care program developed for frail older adults. A single-blinded randomized controlled trial was conducted. Thirty-two frail older adults were enrolled in the study. The experimental group was provided the transitional care program for 12 weeks (e.g., inpatient intervention, discharge intervention, and follow-up intervention), while the control group was provided the usual care. The program improved transition conditions (i.e., family interaction and community resource utilization) and transition response (i.e., unplanned emergency room visit rate, depression, and self-rated health). The transitional care program was effective in improving some health service utilization and clinical outcomes of frail older adults experiencing hospital-to-home transition; it thus contributed to promoting a safe transition experience.

Do social vulnerability indices correlate with extreme heat health outcomes?

Introduction. Several frameworks exist to measure vulnerability to extreme heat events using a health equity approach, but little evidence validates these measures and their applications. We investigated the degree to which social vulnerability measures and their constituent elements correlate with excess emergency room visits as an outcome measure. Methods. The relationship between six commonly used social vulnerability indicators and measured excess emergency room visit rates (processed by including heat-related illnesses and all-internal causes diagnosis, with considerations for age and heat days) was tested through geospatial analytics and statistical regressions, for both California and Los Angeles County. Results. The vulnerability indicators and the outcome measure were significantly positively associated at the census tract-level but weaker (∼0.2 rs) at the scale of California and stronger (∼0.6 rs) at the scale of Los Angeles County. Hazard-specific vulnerability indicators showed stronger relationships with outcome measures regardless of scale. A Poisson regression model showed a significant inter-county variation, indicating the importance of localized assessments for equitable environmental policies. Conclusion. The findings identify communities that are overburdened by heat and pollution and highlight the need for use of both social vulnerability and indicators of adverse outcomes from excessive heat. Patterns are found across all measures that suggest that populations facing accessibility barriers may be less likely to visit emergency rooms. This suggestion needs to be tested in other environmental settings to draw broader conclusions but has direct implications for environmental scientists and mitigation planners who use these methods.

Different volatile organic compounds in local point source air pollution pose distinctive elevated risks for respiratory disease-associated emergency room visits

Air pollution increases risk of respiratory disease but prior research has focused on particulate matter and criteria air pollutants, and there are few studies on respiratory effects of volatile organic compounds (VOC). We examined zip code level relationships between emergency room (ER) visits for respiratory illness and VOC pollution in New York State from 2010 to 2018. Detailed information on VOC pollution was derived from the National Emissions Inventory, which provides point source information on VOC emissions at the zip code level. We considered four respiratory diseases: asthma, acute upper respiratory infections, chronic obstructive pulmonary disease (COPD), and lower respiratory disease, using mixed effects regression with a random intercept to account for county level variability in single pollutant models, and Random Forest Regression (RFR) to assess relative importance of VOC exposures when considered together in multipollutant models.Single pollutant models show associations between respiratory-related ER visits with all pollutants of interest across all study years, even after adjusting for poverty and smoking by zip code. The largest relative single pollutant effect sizes considered included benzene, ethylbenzene, and total (summed) VOCs. Results from RFR including all VOC exposures indicate that ethylbenzene has the greatest variable importance for asthma, acute upper respiratory infections, and COPD, with toluene and benzene most important for lower respiratory ailments. RFR results also demonstrate presence of pairwise interactive effects between VOC pollutants. Our findings show that local VOC pollution may offer a significant contribution to the risk of respiratory disease-related ER visits, and that effects vary by illness and by VOC compound. ER visit rates for respiratory illness were elevated in high poverty zip codes, although this may be attributable to the fact that the poor lack basic access to health care and use ERs more frequently for routine care.

Adverse Consequences of Food Insecurity Among U.S. Adults Beyond Health Outcomes

Food insecurity is associated with poorer health, but the adverse consequences of food insecurity may extend beyond just health outcomes. Thus, this study examined the association between food insecurity and health insurance coverage, access to care, healthcare utilization, and financial hardships among U.S. adults. This study employed a retrospective longitudinal cohort study design using panel data from the 2016-2017 Medical Expenditure Panel Survey. Linear probability models were used to examine the association between food insecurity in 1 year and outcomes of interest (health insurance coverage, access to care, healthcare utilization, and financial hardships) in the subsequent year. Analysis was conducted in April 2023. Food insecurity was associated with higher uninsured rates and lower private coverage rates (3.5 [95% CI: 1.6-5.5] and -3.9 [95% CI: -6.2, -1.7] percentage points). Moreover, food insecurity was associated with lower access to care, including delay in receiving necessary medical care and delay in obtaining necessary prescription drugs (2.9 [95% CI: 1.0-4.8] and 4.1 [95% CI: 2.1-6.2]). Furthermore, food insecurity was associated with a higher rate of emergency room visits (2.8 [95% CI: 0.1-5.7]), whereas associations with inpatient, outpatient, and prescription drug use were not significant. Food insecurity was also associated with greater financial hardships, such as experiencing difficulties paying medical bills (9.6 [95% CI: 6.7-12.6]). These findings highlight the adverse consequences of food insecurity on access to and affordability of care for U.S. adults and families. Food insecurity can have far-reaching implications for the well-being of individuals and families.

Ambulatory Orbital Fracture Repair: An Analysis of ER Visits After Surgery From a Multistate Study.

To determine the 30-day postoperative emergency room (ER) visit rate following ambulatory orbital fracture repair with same-day discharge, and the causes and risk factors associated with ER visit. Database study. State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) for California, New York, and Florida for 2011. We identified orbital fracture repair procedures among adults from the SASD, which was linked to the SEDD to identify the incidence and causes of ER visits within 30 days. Univariate and multivariable logistic regression models were used to determine the factors associated with ER visit. Among 762 patients, the 30-day postoperative ER visit rate was 4.5%. Most ER visits (58.9%) occurred during the first week after surgery. The most common reasons for ER visits were related to pain, swelling, headache, dizziness, and fatigue (29.4%), followed by ophthalmologic etiologies including visual disturbances and infection of the eye (14.7%). There was no case of retrobulbar hematoma. In the multivariate analysis, patients living in Florida were at a significantly higher risk for ER visit compared to those in California (odds ratio: 4.48 [1.43-14.10], p = .010). Ambulatory orbital fracture repair appears to be safe. Common reasons for ER visit included pain, swelling, and ophthalmic symptoms. An increased risk for ER visit was seen with certain geographic regions but not with medical comorbidities or concurrent facial fractures or procedures.

Évaluation quantitative de l’effet sur le passage aux urgences et les hospitalisations d’un dispositif départemental innovant de prise en charge des situations de crise durant l’adolescence en Haute-Garonne, France

ObjectivesCrisis situations are common during adolescence. Current data show that adolescents in crisis are either directly referred to hospital psychiatric emergency rooms, or they make an appointment for a specialized consultation, in a medical-psychological center (CMP), in a medical-psychological-pedagogical center (CMPP), or with a private practitioner. The Departmental Reactive System for Adolescents was implemented in 2017 in the French department of Haute-Garonne to provide adolescents in crisis an immediate specialized psychiatric consultation including on-going support for three months. Our objective was to measure the effect of the implementation of this health system organization (HSO) on the evolution of the annual incidence of emergency room visits and hospitalizations of adolescents for psychiatric reasons at the Toulouse University Hospital, the sole facility for such care in Haute-Garonne. MethodsWe conducted a quasi-experimental study comparing the evolution, before and after the implementation of the DDRA31, the annual incidence rates of emergency room visits (pediatric and adult) and hospitalizations related to mental health at the Toulouse University Hospital for adolescents aged 12 to 17 years of age, residing in Haute-Garonne, from 2014 to 2019. Factors associated with the risk of hospitalization were analyzed using mixed-effects logistic regression to measure the effect of the system, over time, with the specific year as the primary explanatory variable, adjusted for sex and age. ResultsFrom 2014 to 2019, 6 686 emergency room visits by 4 245 adolescents took placefor psychiatric motives or diagnostics. The annual incidence rate of emergency department visits related to mental health was stable from 14.0 (95 % CI: 13.2–14.9), per 100 adolescents in 2014 to 13.9 (95 % CI: 13.2–14.7) in 2019, with a higher incidence rate for girls and adolescents aged from 15 to 17 years old. The main reasons for emergency room visits were behavioral problems or agitation, drug intoxications or suicide attempts, and drug or alcohol use or abuse. The annual incidence of hospitalizations decreased significantly since 2017, from 38.3 (95 % CI: 34.1–42.8) per 100 adolescents in 2014 to 24.2 (95 % CI: 21.2–27.4) per 100 adolescents in 2019. This decrease was shown for both males and females but only for adolescents aged from 15 to 17 years old, from 21.8 (CI 95 %: 17.9–26.1) in 2014 to 2.6 (CI 95 %: 1.5–4.1) in 2019. Modeling of the hospitalization risk showed a significant reduction from 2017 onward inclusive with an odds ratio ranging from 0.63 (95 % CI: 0.49–0.80) in 2017 to 0.52 (95 % CI: 0.41–0.67) in 2019. DiscussionThe fact that an impact of the HSO was found only for adolescents aged 15 to 17 years of age could indicate a selective effectiveness depending on age possibly caused by differences in physician attitudes depending on the age of the patient. The chronology of changes in hospitalization rates after a visit to the emergency room corresponded to the period when the HSO was implemented, whereas hospitalization rates were stable over the three years prior to its implementation. The main limitations of our study were the absence of data regarding emergency department diagnoses and discharge modes for the year 2019 and the lack of a temporal perspective. ConclusionOur study did not show any significant effect of the HSO on the annual incidence of emergency room visits related to mental health, but there was a possible effect on reducing the yearly incidence rate and the risk of hospitalization of adolescents in psychiatric services following an emergency room visit. The implementation of reactive ambulatory structures could therefore reduce the demand on hospitalization services that are under pressure.