Risk Of Emergency Room Visits Research Articles

Emergency room visits (ERVs) among occupational groups associated with ambient conditions in Taiwan.

This population-based study explored emergency room visits (ERVs) from all-causes, circulatory and respiratory diseases among different occupational groups in Taiwan associated with ambient average temperature. Daily area-age-sex specific ERVs records were obtained from the Taiwan's Ministry of Health and Welfare from 2009 to 2018. Distributed lag-nonlinear model (DLNM) was used to estimate the exposure-response relationships between daily average temperature and ERVs for all-causes, circulatory and respiratory diseases by occupational groups. Random-effects meta-analysis was used to pool the overall cumulative relative risk (RR) and 95% confidence interval (CI). The exposure-response curves showed ERVs of all-cause and respiratory diseases increased with rising temperature across all occupational groups. These effects were consistently stronger among younger (20-64 years old) and outdoor workers. In contrast, ERVs risk from circulatory diseases increased significantly during cold snaps, with a substantially higher risk for female workers. Interestingly, female workers, regardless of indoor or outdoor work, consistently showed a higher risk of respiratory ERVs during hot weather compared to males. Younger workers (20-64 years old) exhibited a higher risk of ERVs, likely due to job profiles with greater exposure to extreme temperatures. Notably, the highest risk of all-causes ERVs was observed in outdoor male laborers (union members), followed by farmers and private employees, with the lowest risk among indoor workers. Conversely, female indoor workers and female farmers faced the highest risk of respiratory ERVs. Again, female farmers with consistent outdoor exposure had the highest risk of circulatory ERVs during cold conditions. Our findings highlighted the complexity of temperature-related health risks associated with different occupational contexts. The population-level insights into vulnerable occupational groups could provide valuable comprehension for policymakers and healthcare practitioners.

Estimation of optimal adherence threshold for tumor necrosis factor inhibitors in rheumatoid arthritis

IntroductionOptimal adherence thresholds can vary across medications and disease states. The objective of the study was to determine the optimal threshold of the proportion of days covered (PDC) for tumor necrosis factor (TNF) inhibitors in patients with rheumatoid arthritis (RA).MethodsPatients with RA initiating self-administered TNF inhibitors were identified using 2012–18 Medicare fee-for-service claims. Time-varying PDC was calculated every day for the preceding 90 days during follow-up. Oral and injected glucocorticoid use, hospitalizations, emergency room (ER) visits, serious infections, and a composite of these were measured as outcomes. Time to first occurrence of each outcome as a function of time-varying PDC for TNF inhibitors was evaluated using Cox regression. Incident/dynamic time-dependent receiver operating characteristic curves and Youden’s J index were used to obtain the optimal PDC threshold for outcomes at 365 days.ResultsOf the 1190 patients who met the study inclusion criteria, almost 75% (865 patients) experienced at least one of the outcomes. Increasing PDC by 10% was significantly associated with decreased risks of the composite outcome (HR 0.98, 95% CI 0.96–1.00), oral glucocorticoid use (HR 0.93, 95% CI 0.91–0.96), and hospitalization (HR 0.96, 95% CI 0.94–0.99) but an increased risk of ER visits (HR 1.04, 95% 1.01–1.07). Optimal PDC thresholds for the composite outcome, oral glucocorticoid use, and hospitalization were 0.64, 0.59, and 0.56, respectively.ConclusionsIncreased PDC was associated with a decreased risk of adverse outcomes, except ER visits. The optimal PDC for TNF inhibitors in Medicare patients with RA based on clinical outcomes was about 60%.Key Points• The optimal proportion of days covered threshold for tumor necrosis factor inhibitors at 365 days based on clinical outcomes was found to be about 60%, which is lower than the traditional 80% used to define adherence.• Increased adherence was associated with decreased risks of oral glucocorticoid use, hospitalization, and the composite outcome. However, it was also associated with an increased risk of emergency room visits.• The mean time-varying 90-day proportion of days covered decreased throughout the study starting 92% at day 1 of follow-up to 62% at day 365.

Identifying Early-Phase Clinical Trial Participants at Risk for Experiencing Worse Clinical Outcomes.

To identify early-phase clinical trial (EP-CT) participants at risk for experiencing worse clinical outcomes and describe receipt of supportive care services. A retrospective review of the electronic health records of consecutive patients enrolled in EP-CTs from 2017 to 2019 examined baseline characteristics, clinical outcomes, and receipt of supportive care services. The validated Royal Marsden Hospital (RMH) prognosis score was calculated using data at the time of EP-CT enrollment (scores range from 0 to 3; scores ≥ 2 indicate poor prognosis). Differences in patient characteristics, clinical outcomes, and receipt of supportive care services were compared on the basis of RMH scores. Among 350 patients (median age = 63.2 years [range, 23.0-84.3 years], 57.1% female, 98.0% metastatic cancer), 31.7% had an RMH score indicating a poor prognosis. Those with poor prognosis RMH scores had worse overall survival (hazard ratio [HR], 2.00; P < .001), shorter time on trial (HR, 1.53; P < .001), and lower likelihood of completing the dose-limiting toxicity period (odds ratio, 0.42; P = .006) versus those with good prognosis scores. Patients with poor prognosis scores had greater risk of emergency room visits (HR, 1.66; P = .037) and hospitalizations (HR, 1.69; P = .016) while on trial, and earlier hospice enrollment (HR, 2.22; P = .006). Patients with poor prognosis scores were significantly more likely to receive palliative care consultation (46.8% v 27.6%; P < .001), but not other supportive care services. This study found that RMH prognosis score could identify patients at risk for decreased survival, shorter time on trial, and greater use of health care services. The findings underscore the need to develop supportive care interventions targeting EP-CT participants' distinct needs.

Payor Type is Associated With Increased Rates of Reoperation and Health-care Utilization Following Unicompartmental Knee Arthroplasty: A National Database Study.

Unicompartmental knee arthroplasty (UKA) is a common orthopedic procedure with overall good clinical outcomes; however, more recent literature has identified disparities in treatment access and outcomes based on sociodemographic factors. There is a paucity of literature examining whether payor type, including Medicare, Medicaid, and commercial insurance types, impacts early medical complications and rates of reoperation following a UKA. Patients with Medicare, Medicaid, or commercial payor type who underwent primary medial or lateral UKA between 2010 and 2019 were identified using a large national database. Ninety-day incidence of emergency department visit and 1-year incidence of revision, revision to arthroplasty, reimbursement, and cost of care were evaluated. Propensity score matching was used to control for patient demographic factors and comorbidities as covariates. Medicaid insurance was associated with an increased risk of emergency room visit (odds ratio [OR] 2.77; P < .001), revision surgery (OR 1.85; P < .001), and conversion to total knee arthroplasty (OR 1.50; P= .0292) compared to commercially insured patients. Medicaid insurance was associated with an increased risk of emergency room visit (OR 3.58; P < .001), revision surgery (OR 1.97; P < .001), and conversion to total knee arthroplasty (OR 1.80; P= .003). Medicaid patients were associated with a higher overall cost of care and lower reimbursement than commercial and Medicare patients (P < .001 and P < .001, respectively). These findings demonstrate that payor type is associated with increased rates of reoperation and health-care utilization following UKA despite controlling for covariates. Additional work is required to understand the complex relationship between socioeconomic status and outcomes to ensure appropriate health-care access for all patients and pursue appropriate risk stratification. III, retrospective chart review.

Impact of 3-Monthly Long-Acting Injectable Paliperidone Palmitate in Schizophrenia: A Retrospective, Real-World Analysis of Population-Based Health Records in Spain.

BackgroundTreatment of schizophrenia requires long-term medication to prevent relapse. Treatment nonadherence may increase the risk of relapse, leading to increased hospitalizations and emergency room (ER) visits. Long-acting injectables (LAIs) such as paliperidone palmitate have improved treatment adherence and therefore symptoms. However, real-world studies comparing 3-monthly LAI formulations with other LAIs and oral antipsychotics (OAs) are scarce.ObjectiveThe objective of this study was to investigate and evaluate the clinical effectiveness of paliperidone palmitate LAI monthly (PP1M; Xeplion®) and 3-monthly (PP3M; Trevicta®) formulations compared with the monthly LAI aripiprazole (AM; Abilify Maintena®) and OAs in Spain.MethodsThis was a retrospective, observational study including 2275 adult patients with schizophrenia in a Spanish population. Data from hospital, primary care, and pharmacy dispensation electronic medical records were obtained between January 2017 and February 2018. The main outcomes included psychiatric hospitalizations and ER visit rates, days on treatment, and treatment persistence.ResultsPatients receiving PP3M had a significantly lower mean hospitalization rate (0.00046 ± standard deviation [SD] 0.00181; p < 0.0001) than other treatment groups. Kaplan–Meier curves revealed that 92.0 and 88.4% of patients receiving PP3M remained hospitalization free by 12 and 18 months, respectively. All treatment groups had at least a twofold significantly higher risk of psychiatric hospitalizations compared with those receiving PP3M or OAs, and the hospitalization risk among the PP3M group was significantly lower (hazard ratio [HR] 0.46; 95% confidence interval [CI] 0.31–0.67). The risk of ER visits was significantly lower with both PP3M and PP1M than with OAs, and lowest with PP3M (HR 0.462 [95% CI 0.29–0.62] and HR 0.833 [95% CI 0.59–0.97], respectively). Time until treatment switch with PP3M was high, with more than 86.5% of patients remaining on treatment at 18 months.ConclusionsPP3M was more effective than OAs and monthly LAIs in improving clinical outcomes for patients with schizophrenia in a real-world setting in Spain.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40263-022-00917-1.

Effect of Air Quality on the Risk of Emergency Room Visits in Patients With Atrial Fibrillation.

Background: We investigated the effect of particulate matter with aerodynamic diameter <2.5 μm (PM2.5) and meteorological conditions on the risk of emergency room visits in patients with atrial fibrillation (AF) in Beijing, which is considered as a monsoon climate region.Methods: In this case-crossover design study, medical records from patients with AF who visited the Critical Care Center in the Emergency Department of Anzhen Hospital from January 2011 through December 2014 and air quality and meteorological data of Beijing during the same period were collected and analyzed using Cox regression and time-series autocorrelation analyses.Results: A total of 8,241 patients were included. When the average PM2.5 concentration was >430 μg/m3, the risk of emergency room visits for patients with uncomplicated AF, AF combined with cardiac insufficiency, and AF combined with rheumatic heart disease increased by 12, 12, and 40%, respectively. When the average PM2.5 concentration was >420 μg/m3, patients with AF combined with diabetes mellitus had a 75% increased risk of emergency room visits, which was the largest increase in risk among all types of patients with AF. When the average PM2.5 concentration was >390 μg/m3, patients with AF combined with acute coronary syndrome had an approximately 30% increased risk of emergency room visits, which was the highest and fastest increase in risk among all types of patients with AF. The risk of emergency room visits for patients with AF was positively correlated with air quality as the time lag proceeded, with an autocorrelation coefficient of 0.223 between the risk of emergency room visits and air quality in patients with AF on day 6 of the time lag.Conclusion: Exposure to certain concentrations of PM2.5 in a monsoon climate region significantly increased the risk of emergency room visits in patients with AF.

NONINVASIVE VENTILATION AT HOME REDUCES MORTALITY AND HEALTHCARE UTILIZATION IN COPD WITH CHRONIC RESPIRATORY FAILURE IN MEDICARE BENEFICIARIES

SESSION TITLE: New Insights into COPD and Its Complications SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Chronic respiratory failure due to Chronic Obstructive Pulmonary Disease (COPD-CRF) is associated with higher mortality risk and increased healthcare utilization. In recent years, non-invasive home ventilation (NIVH) has become increasingly used in patients with COPD-CRF. This study aims to investigate the association of NIVH with risk of death, hospitalizations, and emergency room (ER) visits in COPD-CRF Medicare beneficiaries in the US. METHODS: A time-to-event analysis was conducted using claims data from the Medicare Limited Data Set between 2012 and 2018. The study sample included COPD-CRF Medicare beneficiaries who received NIVH within two months post CRF diagnosis (treatment group), and patients with COPD-CRF not receiving NIVH during the study period (control group). The study outcomes of interest were overall survival, time to first hospitalization, and time to first ER visit post CRF diagnosis. To minimize confounding, propensity score methods with 1:1 nearest neighbor matching were used to match the treatment and control group. Cox proportional hazards regression models with bootstrapped standard errors were used to estimate the treatment on the treated effect of NIVH on risk of mortality, hospitalization and ER visits. Adjusted Hazards Ratio (aHR) and corresponding 95% Confidence Intervals (CIs) were reported. The risk difference (RD), relative risk reduction (RRR), and number needed to treat (NNT) at one-year post CRF diagnosis were also estimated. RESULTS: After matching, 517 patients with COPD-CRF receiving NIVH (treatment group; mean age 70.6, 44% male, and 86% white) and 511 patients with COPD-CRF who did not receive NIVH (control group) were included. NIVH significantly reduced the risk of death by 50% (aHR: 0.50; 95%CI: 0.36-0.65), the risk of hospitalization by 28% (aHR: 0.72; 95%CI: 0.52-0.93), and the risk of ER visit by 52% (aHR: 0.48; 95% CI: 0.38-0.58) (p<0.01). The treatment benefit remained constant for hospitalizations over the entire study period, but decreased for both death and ER visits. One-year post CRF diagnosis, a RD of 18.0%, with a RRR of 39.3% was observed for survival, a RD of 11.3%, with a RRR of 17.0% for hospitalizations, and a RD of 20.2%, with a RRR of 22.0% for ER visits. The NNT were 5.5, 8.8, 4.9 to prevent a death, hospitalization, and ER visit within the first year post CRF diagnosis, respectively. CONCLUSIONS: NIVH treatment was found to reduce the risk of death, hospitalizations, and ER visits significantly among Medicare beneficiaries with COPD-CRF. The study findings highlight the potential incremental value of NIVH over current medical treatment in reducing the healthcare burden among patients with CRF due to COPD. CLINICAL IMPLICATIONS: NIVH may currently be underutilized and should be considered in all patients with COPD-CRF. DISCLOSURES: Board Member relationship with Viemed Please note: $20001 - $100000 Added 06/01/2020 by William Frazier, source=Web Response, value=Restriced Stock Units Employee relationship with Viemed Please note: >$100000 Added 06/01/2020 by William Frazier, source=Web Response, value=Salary no disclosure on file for Richard Murphy; Employee relationship with PRECISIONheor Please note: $20001 - $100000 Added 05/31/2020 by Emma van Eijndhoven, source=Web Response, value=Salary

Patient and provider perceptions of emergency room visits during chemotherapy.

183 Background: Emergency room (ER) visits during chemotherapy are costly. To identify potential causes of ER visits, we interviewed oncology patients and providers about symptoms and other factors related to ER visits. Methods: People with cancer (n = 19) and oncology physicians and nurses (n = 11) were interviewed using a semi-structured protocol. Interviews were transcribed. The study team developed a codebook and interviews were coded deductively. Four of the interviews were double coded. Results: Patients reported communicating with their physicians mostly by telephone. Patients reported a variety of distressing symptoms from chemotherapy including infection, mouth sores, distress, fatigue, neuropathy, gastrointestinal (GI) effects. Pain, fever, neuropathy, and dizziness were symptoms that motivated ER visits. Patients reported that contact with their care team and having a specific plan for symptoms helped prevent ER visits. Patients also reported that going through chemotherapy the first time was harder because they did not know what to expect and the patient education can be overwhelming. Providers did not always have formal protocols for proactively contacting patients but those that did contacted patients early in treatment. Providers reported GI symptoms, pain, shortness of breath, dizziness, and infection as causes of ER visits. They reported difficulties assessing symptoms due to reporting inaccuracies and reticence to share details. Providers cited financial insecurity, remote living, and lack of social support as factors increasing risk of ER visits. Providers reported some patients would not call frequently enough while a smaller subset called more frequently than providers perceived as needed. Conclusions: Results suggest contact with the care team is crucial for preventing ER visits during chemotherapy. Symptoms causing ER visits were consistent with previous literature

Narcotic Use and Total Knee Arthroplasty

BackgroundAlthough the United States is in the midst of a narcotic epidemic, risk factors for use and the impact of perioperative narcotic use on total knee arthroplasty (TKA) outcomes is ill-defined. MethodsA national database was queried for patients who underwent primary TKA from 2007 to 2015. Patients taking narcotics in the preoperative, and for a prolonged period of time postoperatively, were identified. The risk factors for prolonged narcotic use were analyzed with a regression analysis, in addition to evaluating preoperative and prolonged postoperative use as independent risk factors for short-term and long-term complications. ResultsIn total, 113,337 patients met inclusion criteria, of which 31,733 patients were prescribed narcotics preoperatively and 35,770 patients were prescribed narcotics more than 3 months postoperatively. There are several independent risk factors for prolonged narcotic use postoperatively, the most significant being the number of narcotic prescriptions prescribed preoperatively. Preoperative narcotic use was independently associated with an increased risk of emergency room visits, readmission, infection, stiffness, and aseptic revision. Prolonged postoperative use was also associated with significantly increased rates of infection, stiffness, and aseptic revision. ConclusionPreoperative and prolonged narcotic use following TKA was associated with an increased risk of short-term and long-term complications following TKA. The liberal use of narcotics in the perioperative period should be considered a modifiable risk factor when considering elective TKA.

Association of time-serial changes in ambient particulate matters (PMs) with respiratory emergency cases in Taipei's Wenshan District.

Ambient air pollution poses a significant risk for a group of common and often debilitating respiratory diseases, but its direct impact on cause-specific respiratory diseases using emergency room visit (ERV) as an indicator remains to be fully explored. In this study, we conducted a time-series study of ambient PM2.5, NO2, SO2 and their association with ERV for asthma, COPD and pneumonia in a four-year time span. Relative risks for ERV as per log increase in the level of ambient pollutants with time lags of up to 10 days were calculated, using a generalized additive model of Poisson regression. Daily 24-h average concentrations of PM2.5 and pollutant gases were obtained from a local Gutting air quality monitoring station. Results showed that the ERVs for pneumonia and asthma were associated with the level of PM2.5. The effects of PM2.5 on the risk of ERV for asthma were found to be significant at lag days 1 and 2 with increasing risk of 4.34% [RR: 1.091; CI: 1.020–1.166 (95%)] and 3.58% [RR: 1.074; CI: 1.007–1.146 (95%)], respectively. The ERV for pneumonia was associated with the level of PM2.5 at lag days 5, 6 and 7, with increasing risk of 1.92% [RR: 1.039; CI: 1.009–1.070 (95%)], 2.03% [RR: 1.041; CI: 1.009–1.075 (95%)], and 1.82% [RR: 1.037; CI: 1.001–1.075 (95%)], respectively. Further, PM2.5, but not NO2 and SO2, posed a significant risk of ERV for asthma during spring at lag days 0, 1 and 2 (17.12%, RR: 1.408, CI: 1.075–1.238; 15.30%, RR: 1.358 CI: 1.158–1.166; 11.94%, RR: 1.165, CI: 1.004–1.121), which was particularly evident for those who were younger than 75 years of age. In contrast, only PM2.5 was a significant risk of ERV for COPD, which was primarily for those who were younger than 75 years of age during summer season at lag days 3, 4 and 5. (26.66%, RR: 1.704, CI: 1.104–2.632; 26.99%; RR: 1.716, CI: 1.151–2.557; 24.09%; RR: 1.619, CI: 1.111–2.360). Collectively, these results suggested significant seasonal variation and differential time lag effects of PM2.5 on ERV for asthma, COPD and pneumonia.

Emergency room visits associated with particulate concentration and Asian dust storms in metropolitan Taipei.

This study evaluated risks of emergency room visits (ERV) for all causes, circulatory diseases, and respiratory diseases associated with concentrations of particulate matter (PM10 and PM2.5) and Asian dust storms (ADS) from 2000 to 2008 in metropolitan Taipei. Cumulative 4-day (lag 0-3) relative risks (RR) and confidence intervals (CI) of cause-specific ERV associated with daily concentrations of PM10 or PM2.5 and ADS based on study period (ADS frequently inflicted period: 2000-2004 and less-inflicted period: 2005-2008) were estimated using a distributed lag non-linear model with Poisson distribution. Risks associated with ADS-inflicted season (winter and spring), strength (ratio of stations with Pollutant Standard Index above 100 is < 0.5 or ≥ 0.5), and duration (ADS lasting for 1-3 days or ≥ 4 days) were especially evaluated. In non-linear models, an increase in PM10 from 10 μg/m(3) to 50 μg/m(3) was associated with increased risk of ERV for all causes and respiratory disease with cumulative 4- day RR of 1.18 (95% CI: 1.13, 1.24) and 1.37 (95% CI: 1.23, 1.54), respectively. From 2005 to 2008, the cumulative 4-day RR for an ERV related to an increase in PM2.5 from 5 μg/m(3) to 30 μg/m(3) is 1.21 (95% CI: 1.03, 1.41) for respiratory diseases, and 1.15 (95% CI: 1.08, 1.22) for all causes. In comparison with normal days, elevated ERV of all causes and respiratory diseases was also associated with winter ADS (with corresponding RRs of 1.10 (95% CI: 1.07, 1.13) and 1.14 (95% CI: 1.08, 1.21)) and shorter and less area-affected ADS (with corresponding RRs of 1.07 (95% CI: 1.01, 1.10) and 1.09 (95% CI: 1.03, 1.14)) from 2000 to 2004. Results of this study demonstrate that population health risk varies not only with PM concentration, but also with the ADS characteristics.

Health Care Utilization and Costs of Idiopathic Pulmonary Fibrosis in U.S. Medicare Beneficiaries Aged 65 Years and Older

Management of idiopathic pulmonary fibrosis (IPF) is resource-intensive. Because an increasing prevalence of IPF was found among the elderly in the United States, it is important to understand the economic burden associated with the disease in this population. To compare health care resource utilization and costs between patients with IPF and matched control subjects without IPF in Medicare, the largest U.S. payer covering the elderly. Administrative claims from a 5% random sample of Medicare beneficiaries (aged 65+) from years 2000 to 2011 were analyzed. Incident patients with IPF were identified on the basis of International Classification of Diseases, ninth revision, Clinical Modification diagnosis codes, with at least 1 year of enrollment before (preindex) and after (postindex) the first diagnosis (index date). Up to five beneficiaries without IPF were matched to each patient with IPF, based on age, sex, race, and region. Annual health care resource utilization and medical costs (excluding outpatient drug costs) during the preindex and postindex periods were compared between patients with IPF and matched control subjects. A total of 7,855 patients with IPF were matched to 38,856 control subjects. Compared with matched control subjects during the preindex period, patients with IPF had an 82% higher risk of hospitalization (28.8 vs. 15.8%), and 72% higher total medical costs ($10,124 vs. $5,888). Compared with matched control subjects during the postindex period, patients with IPF had a 134% higher risk of hospitalization (48.7 vs. 20.8%), similar increased risk of emergency room visits (39.6 vs. 17.5%), and 134% higher total medical costs ($20,887 vs. $8,932). In the U.S. Medicare population, patients with IPF incurred substantial health care resource utilization. The annual IPF-attributable medical cost to the U.S. health care system, excluding medication costs, is estimated at close to $2 billion.

Disability is associated with emergency room visits in the elderly: a population-based study.

Emergency room (ER) visits and hospitalizations of elderly subjects with chronic comorbidities, often disabled, are increasing. The aim of the present study was to assess whether among older subjects functional disability is associated with increased ER visits and hospitalization rates. We assessed the association of functional ability with 1-year ER visits and hospitalization rates in all 342 subjects aged 75+ living in Tuscania (Italy) in 2004. Functional ability was estimated using the Katz' activities of daily living (ADLs), and the Lawton and Brody scale for the instrumental activities of daily living (IADLs). Functional disability was defined as the dependence for two or more ADLs or IADLs. According to Cox regression, disability in ADLs was associated with increased risk of ER visits (RR 2.12; 95% CI 1.11-4.08; P=.023) but not of hospital admission (RR 1.50; 95% CI .80-2.80; P=.208). Also, in Poisson regression, ADLs disability predicted the number of ER visits (IRR 2.56; 95% CI 1.48-4.40; P=.001). Disability is associated with increased risk of ER visits, but not of subsequent hospitalization in community-dwelling elderly, independent of clinical conditions. Dedicated studies are needed to evaluate the impact of social interventions for disabled elderly on ER access rates. Emergency Departments should implement innovative triage procedures to identify older patients with disability who gain access to ER, to recognize and classify any unmet social needs.

Impact of initiation timing of SSRI or SNRI on depressed adolescent healthcare utilization and costs

Background:Adolescents with newly diagnosed depression may not receive timely antidepressant therapy. Clinical and economic effects of early versus late treatment initiation are unclear.Objective:To compare effects of early versus late initiation of second-generation (SSRI/SNRI) antidepressants on emergency room (ER) visits, hospitalizations and healthcare costs in adolescents with depression.Methods:Patients aged 12–17 with a diagnosis of depression were identified in a claims database (1999–2007). Patients initiating antidepressants within 1 month of initial diagnosis were considered early initiators; patients initiating within 2–12 months were late initiators. Clinical resource use and healthcare costs were measured during the 6-month pre-index and 12-month post-index (study) periods and compared descriptively between groups. Logistic regression compared healthcare services utilization; a generalized linear model compared costs. All models were adjusted for baseline characteristics, including demographics, comorbidities, and healthcare services utilization.Results:A total of 7344 adolescents met study criteria. 4415 (60%) initiated antidepressant treatment within 1 month of diagnosis. At baseline, early initiators had more all-cause inpatient visits (14 vs. 7%) and all-cause ER visits than late initiators (25 vs. 21%, both p < 0.01). They had higher medical ($1434 vs. $1160) and total costs ($1565 vs. $1290) (both p < 0.01). In the study period, late initiators had higher risk of ER visits (OR = 1.13, p = 0.03). They incurred higher medical costs ($5415 vs. $4061) and higher total healthcare costs ($6001 vs. $4907), but lower adjusted drug costs ($767 vs. $888) (all p < 0.01).Limitations:Clinical data are scarce in the claims database, and the ability to observe disease severity and reasons for delayed treatment is limited. The definition of early and late initiation was based on empirical analysis, and no clear cutoff was identified beyond what was observed in the data.Conclusions:Adolescents who initiated SSRI/SNRI therapy earlier experienced lower risk of ER visits and had lower total costs compared to late initiators.

Air pollution and emergency room visits for cardiac arrhythmia in a subtropical city: Taipei, Taiwan

This study was undertaken to determine whether there was an association between air pollutant levels and emergency room (ER) visits for cardiac arrhythmia in Taipei, Taiwan. ER visits for cardiac arrhythmia and ambient air pollution data for Taipei were obtained for the period 2000–2006. The relative risk of ER visits was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant model, on warm days (≥23°C), statistically significant positive associations were found for all pollutants except SO2. On cool days (<23°C), all pollutants were also significantly associated with the number of ER visits for cardiac arrhythmia, except SO2. For the two-pollutant model, results for O3 and NO2 remained statistically significant on both warm and cool days. This study provides evidence that higher levels of ambient air pollutants increase the risk of ER visits for cardiac arrhythmia.

Air Pollution and Emergency Room Visits for Arrhythmias: Are There Potentially Sensitive Groups?

Recent studies showed that air pollution is a risk factor for hospitalization for arrhythmias. However, there is limited evidence to suggest which subpopulations are at higher risk for arrhythmia development due to increased air pollutant exposure. This study was undertaken to examine the modifying effect of specific secondary diagnosis (including hypertension, diabetes, and congestive heart failure) on the relationship between frequency of emergency room (ER) visits for arrhythmias and ambient air pollutants concentrations. ER visits for arrhythmias and ambient air pollution data for Taipei were obtained for the period 2000–2006. The relative risk of ER visits was estimated using a case-crossover approach. Data showed an increased risk of ER visits for arrhythmias in relation to increased O3 levels among individuals with a secondary diagnosis of hypertension and congestive heart failure.

Assessing the Association of Walking with Health Services Use and Costs among Socioeconomically Disadvantaged Older Adults

Background. The costs of physical inactivity are beginning to be recognized. Research to pinpoint these costs will provide needed information for researchers and policy-makers to develop cost-effective physical activity promotion programs. We present the association of walking with health services use and costs within a sample of 695 older, urban primary care patients.Methods. A survey provided most data, but utilization and cost data were obtained from a medical records system. Multivariate models were developed to assess the association of walking with health services use and costs, adjusting for sociodemographic characteristics, chronic disease, health status, and previous utilization.Results. Thirty-eight percent of respondents reported walking 0 minutes per week, 49% walked 1 to 119 minutes, and 13% walked 120 minutes or more. In the multivariate analyses, a report of walking 120 or more minutes was associated with a lower risk of emergency room visit and hospital stay in the subsequent year. No association was found between walking and primary care visits and total cost.Conclusion. These analyses suggest an association of walking 120 minutes or more with decreased emergency room visits (OR = 0.5, P = 0.046) and hospital stays (OR = 0.6, P = 0.034). This suggests that physical activity promotion among socioeconomically disadvantaged older adults has the potential to provide cost savings. This will not be known, however, until physical activity can be promoted and maintained among these adults.