A Profile of Indian Health Service Emergency Departments

Mixed-Method, Multilevel Clustered-Randomized Control Trial for Menstrual Health Disparities

Menstrual cycle characteristics are largely considered unmodifiable reproductive factors, a framing that prevents exploration of the ways structural factors interfere with menstrual health. Given the role of structural factors like healthy food and healthcare access on reproductive health and the grave need for structural interventions to known reproductive health disparities that disproportionately target cisgender women racialized as Black, it is imperative that science begin to examine how structural factors influence menstrual health. To explore such research, we employ critical race theory and intersectionality to illustrate what a structural intervention to improve menstrual cycle health could look like. Centering those with the greatest need, persons racialized as Black and/or LatinX living in food and healthcare deserts in Northern Manhattan, our illustrative sample includes four groups of persons who menstruate (e.g., cisgender girls and women) that are pre-menarche, pre-parous, postpartum, or perimenopausal. We describe a hypothetical, multilevel clustered-randomized control trial (cRCT) that provides psychoeducation on racism-related trauma and free delivered groceries to both treatment and control groups, while randomizing 30 clusters of housing associations to receive either sexual health clinics at their housing association or free vouchers for healthcare. We embed mixed methods (diaries, interviews, surveys, mobile apps, observation) into the design to evaluate the effectiveness of the 1-year intervention, in addition to determining the impact on participants through their perspectives. Through this illustration, we provide a novel example of how structural interventions can apply mixed methods to evaluate effectiveness while delivering services to populations impacted by multiple structural factors. We demonstrate how qualitative and quantitative approaches can be paired in clustered RCTs and how a living logic model can empirically incorporate the population perspective into more effective interventions. Lastly, we reveal how sensitive menstrual health is to structural factors and how upstream improvements will trickle down to potentially reduce health disparities in reproductive health.

Alcohol Use Disorder Visits and Suicide Ideation Diagnosis: Racial/Ethnic Differences at Emergency Departments

INTRODUCTION

Nationally, suicide ideation prevalence is comparable among White, American Indian/Alaska Native, Black, and Hispanic adults experiencing alcohol use disorder. This study examines whether such comparability extends to the probability of receiving a suicide ideation diagnosis when presenting with alcohol use disorder at emergency departments. The probability of hospitalization following such diagnosis is examined as well.

METHODS

National Emergency Department Sample (2019) data were used. Logistic and multilevel logistic regression analyses were performed in 2022-2023 with suicide ideation diagnosis and subsequent hospitalization as the outcome variables. Control variables included demographics, payor, alcohol use disorder level, comorbidities, and emergency department facility. Adjusted probabilities were computed.

RESULTS

Age-adjusted probabilities of suicide ideation diagnoses for American Indian/Alaska Native, Black, and Hispanic patients with alcohol use disorder were 5.4%, 6.7%, and 4.9% (95% CIs=3.7, 7.1; 6.0, 7.4; 4.4, 5.4), respectively; all less than that for White counterparts (8.7%; 95% CI=8.2, 9.2). Among patients with alcohol use disorder plus suicide ideation diagnoses, the age-adjusted probability of hospitalization for American Indians/Alaska Natives (32.4%; 95% CI=20.9, 44.0) was less than that for Whites, Blacks, and Hispanics (49.8%, 52.3%, and 49.9%; 95% CIs=46.7, 52.8; 47.1, 57.5; and 43.9, 55.8, respectively). In regressions with multiple control variables, the racial/ethnic differences remained statistically significant (p<0.05).

CONCLUSIONS

Diagnosis of suicide ideation, a key step in emergency department suicide prevention care, occurred significantly less often for patients of color with alcohol use disorder than for White counterparts. American Indians/Alaska Natives, the racial/ethnic group known to have the nation's highest suicide rate, had the lowest probability of being hospitalized after a diagnosis of alcohol use disorder plus suicide ideation.

People with Disabilities' Access to Medical Care During the COVID-19 Pandemic

Delaying and forgoing medical care intensifies the health disparities and unmet needs people with disabilities already face. While many people with disabilities were at high risk for COVID-19, less is known about their access to medical care during the pandemic. This study explored people with disabilities' access to medical care during the COVID-19 pandemic. We analyzed United States Census Bureau COVID-19 Household Pulse Survey data from the second year of the pandemic (April-July 2021) from people with (n = 38,512) and without (n = 296,260) disabilities. During the second year of the pandemic, 30.8% of people with disabilities delayed getting medical care and 28.9% forwent needed care. People with disabilities were also significantly more likely to delay and forgo medical care than people without disabilities. Attention must be drawn to the unmet needs of people with disabilities and efforts must be made to expand their access to health care.

Availability of Pediatric Emergency Care Coordinators in United States Emergency Departments

OBJECTIVE

To determine the availability of pediatric emergency care coordinators (PECCs) in US emergency departments (EDs) in 2015, and to determine the change in availability of PECCs in US EDs from 2015 to 2017.

STUDY DESIGN

As part of the National Emergency Department Inventory-USA, we administered a survey to all 5326 US EDs open in 2015; all 5431 in 2016; and all 5489 in 2017. Through these surveys, we assessed the availability of PECCs. Descriptive statistics characterized EDs with and without PECCs; multivariable logistic regressions identified characteristics independently associated with PECC availability.

RESULTS

Among the 4443 (83%) EDs with 2015 data, 763 (17.2%) reported the availability of at least 1 PECC. The states with the largest proportion of EDs with PECCs were Delaware (78%, 7/9 EDs) and Maryland (48%, 20/42 EDs), and no PECCs were reported in Mississippi, North Dakota, or Wyoming. Availability of a PECC was associated (P < .001) with larger annual total ED visit volume and a dedicated pediatric ED area. Compared with the 17.2% of EDs reporting a PECC in 2015, 833 (18.6%) reported 1 in 2016, and 917 (19.8%) reported 1 in 2017 (P < .001).

CONCLUSIONS

Availability of at least 1 PECC increased slightly (2.6%) between 2015 and 2017, but ∼80% of EDs continue without one.

American Indian Reservations and COVID-19: Correlates of Early Infection Rates in the Pandemic

OBJECTIVE

To determine the household and community characteristics most closely associated with variation in COVID-19 incidence on American Indian reservations in the lower 48 states.

DESIGN

Multivariate analysis with population weights.

SETTING

Two hundred eighty-seven American Indian Reservations and tribal homelands (in Oklahoma) and, as of April 10, 2020, 861 COVID-19 cases on these reservation lands.

MAIN OUTCOME MEASURES

The relationship between rate per 1000 individuals of publicly reported COVID-19 cases at the tribal reservation and/or community level and average household characteristics from the 2018 5-Year American Community Survey records.

RESULTS

By April 10, 2020, in regression analysis, COVID-19 cases were more likely by the proportion of homes lacking indoor plumbing (10.83, P = .001) and were less likely according to the percentage of reservation households that were English-only (-2.43, P = .03). Household overcrowding measures were not statistically significant in this analysis (-6.40, P = .326).

CONCLUSIONS

Failure to account for the lack of complete indoor plumbing and access to potable water in a pandemic may be an important determinant of the increased incidence of COVID-19 cases. Access to relevant information that is communicated in the language spoken by many reservation residents may play a key role in the spread of COVID-19 in some tribal communities. Household overcrowding does not appear to be associated with COVID-19 infections in our data at the current time. Previous studies have identified household plumbing and overcrowding, and language, as potential pandemic and disease infection risk factors. These risk factors persist. Funding investments in tribal public health and household infrastructure, as delineated in treaties and other agreements, are necessary to protect American Indian communities.

Closing the gap: Improving access to trauma care in New Mexico (2007-2017)

BACKGROUND

Trauma is a major cause of death and disability in the United States, and significant disparities exist in access to care, especially in non-urban settings. From 2007 to 2017 New Mexico expanded its trauma system by focusing on building capacity at the hospital level.

METHODS

We conducted a geospatial analysis at the census block level of access to a trauma center in New Mexico within 1 h by ground or air transportation for the years 2007 and 2017. We then examined the characteristics of the population with access to care. A multiple logistic regression model assessed for remaining disparities in access to trauma centers in 2017.

RESULTS

The proportion of the population in New Mexico with access to a trauma center within 1 h increased from 73.8% in 2007 to 94.8% in 2017. The largest increases in access to trauma care within 1 h were found among American Indian/Alaska Native populations (AI/AN) (35.2%) and people living in suburban areas (62.9%). In 2017, the most rural communities (aOR 58.0), communities on an AI/AN reservation (aOR 25.6), communities with a high proportion of Hispanic/Latino persons (aOR 8.4), and a high proportion of elderly persons (aOR 3.2) were more likely to lack access to a trauma center within 1 h.

CONCLUSION

The New Mexico trauma system expansion significantly increased access to trauma care within 1 h for most of New Mexico, but some notable disparities remain. Barriers persist for very rural parts of the state and for its sizable American Indian community.

Nontargeted Diabetes Screening in a Navajo Nation Emergency Department

We developed a nontargeted diabetes screening program in a rural Indian Health Service emergency department in Shiprock, New Mexico to measure the proportion of previously undiagnosed diabetes and prediabetes, and to assess glycemic control among patients with known disease. Of 924 patients screened in the emergency department between May and July 2017, 28.8% screened positive for previously undiagnosed diabetes or prediabetes; among patients with known disease, the median hemoglobin A1c was 8.2%. Of the newly identified patients, 54.9% attended follow-up.