Geographic Distribution of Disaster-Specific Emergency Department Use After Hurricane Sandy in New York City

Socioeconomic vulnerability and differential impact of severe weather-induced power outages

In response to concerns about increasingly intense Atlantic hurricanes, new federal climate and environmental justice policies aim to mitigate the unequal impact of environmental disasters on economically and socially vulnerable communities. Recent research emphasizes that standard procedures for restoring power following extreme weather could be one significant contributor to these divergent outcomes. Our paper evaluates the hypothesis that more economically and socially vulnerable communities experience longer-duration power outages following hurricanes than less vulnerable communities do, conditional on the severity of the impact of the storm itself. Using data from eight major Atlantic hurricanes that made landfall between January 2017 and October 2020 and induced power outages for over 15 million customers in 588 counties in the Southeast, we demonstrate a significant relationship between socioeconomic vulnerability and the duration of time that elapses before power is restored for 95% of customers in a county. Specifically, a one-decile change in the socioeconomic status theme in the Social Vulnerability Index, a measure of vulnerability produced by the Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry, produces a 6.1% change in expected outage duration in a focal county. This is equivalent to a 170-min average change in the period of time prior to power restoration.

The relationship between exposure to Hurricane Harvey and mortality among nursing home residents

BACKGROUND

Nursing home (NH) residents are vulnerable to mortality after natural disasters. We examined NH residents' excess all-cause mortality associated with Hurricane Harvey, a unique disaster with long-lasting flooding effects. We also explored how mortality differed between short-stay and long-stay residents and by chronic conditions.

METHODS

We conducted a retrospective observational study of Texas NH residents, comparing 30- and 90-day mortality among residents exposed to Hurricane Harvey in August 2017 to residents not exposed in the same location and time period during the previous 2 years. Data came from the Minimum Data Set Assessments and the Medicare Beneficiary Summary File. We used linear probability models to examine the association between hurricane exposure and mortality, adjusting for resident demographics, clinical acuity, and NH fixed effects. Models were stratified by short-stay and long-stay status. We also described differences in mortality by residents' chronic conditions.

RESULTS

In 2017, 18,479 Texas NH residents were exposed to Hurricane Harvey. Exposure to Hurricane Harvey was not significantly associated with 30-day mortality. However, 7.6% (95% CI: 7.2, 7.9) of long-stay residents died 90 days after exposure to Harvey, compared to 6.3% (95% CI: 6.0, 6.7) during 2015. Apparently, this effect was driven by chronic obstructive pulmonary disease (COPD) as approximately 9.2% of these residents died within 90 days after Harvey landing compared to 7.2% in 2015 (p < 0.01).

CONCLUSIONS

Hurricane exposure appears to have significant consequences for mortality among long-stay NH residents, which appear to materialize over the long-term (90 days post-hurricane in our study) and may not be apparent immediately (30 days post-hurricane in our study). NH residents with COPD may be particularly vulnerable to increased mortality risk following hurricane exposure. The results highlight the need to pay special attention to mortality risk in NH residents, particularly those with COPD, following hurricane exposure.

Longitudinal Associations Between Disaster Damage and Falls/Fear of Falling in Older Adults: 9-Year Follow-Up of Survivors of the 2011 Great East Japan Earthquake and Tsunami

Background and Objectives

Fear of falling and falls are common in older adults. However, their associations with natural disaster exposures remain poorly understood. This study aims to examine longitudinal associations between disaster damage with fear of falling/falls among older disaster survivors.

Research Design and Methods

In this natural experiment study, the baseline survey (4,957 valid responses) took place 7 months before the 2011 Great East Japan Earthquake and Tsunami, and 3 follow-ups were conducted in 2013, 2016, and 2020. Exposures were different types of disaster damage and community social capital. Outcomes were fear of falling and falls (including incident and recurrent falls). We used lagged outcomes in logistic models adjusting for covariates and further examined instrumental activities of daily living (IADLs) as a mediator.

Results

The baseline sample had a mean (standard deviation) age of 74.8 (7.1) years; 56.4% were female. Financial hardship was associated with fear of falling (odds ratio (OR), 1.75; 95% confidence interval (CI) [1.33, 2.28]) and falls (OR, 1.29; 95% CI [1.05, 1.58]), especially recurrent falls (OR, 3.53; 95% CI [1.90, 6.57]). Relocation was inversely linked with fear of falling (OR, 0.57; 95% CI [0.34, 0.94]). Social cohesion was protectively associated with fear of falling (OR, 0.82; 95% CI [0.71, 0.95]) and falls (OR, 0.88; 95% CI [0.78, 0.98]) whereas social participation increased the risk of these issues. IADL partially mediated observed associations between disaster damage and fear of falling/falls.

Discussion and Implications

Experiences of material damage rather than psychological trauma were associated with falls and fear of falling, and the increased risk of recurrent falls revealed a process of cumulative disadvantage. Findings could inform targeted strategies for protecting older disaster survivors.

Hurricanes and Mortality among Patients Receiving Dialysis

BACKGROUND

Hurricanes are severe weather events that can disrupt power, water, and transportation systems. These disruptions may be deadly for patients requiring maintenance dialysis. We hypothesized that the mortality risk among patients requiring maintenance dialysis would be increased in the 30 days after a hurricane.

METHODS

Patients registered as requiring maintenance dialysis in the United States Renal Data System who initiated treatment between January 1, 1997 and December 31, 2017 in one of 108 hurricane-afflicted counties were followed from dialysis initiation until transplantation, dialysis discontinuation, a move to a nonafflicted county, or death. Hurricane exposure was determined as a tropical cyclone event with peak local wind speeds ≥64 knots in the county of a patient's residence. The risk of death after the hurricane was estimated using time-varying Cox proportional hazards models.

RESULTS

The median age of the 187,388 patients was 65 years (IQR, 53-75) and 43.7% were female. There were 27 hurricanes and 105,398 deaths in 529,339 person-years of follow-up on dialysis. In total, 29,849 patients were exposed to at least one hurricane. Hurricane exposure was associated with a significantly higher mortality after adjusting for demographic and socioeconomic covariates (hazard ratio, 1.13; 95% confidence interval, 1.05 to 1.22). The association persisted when adjusting for seasonality.

CONCLUSIONS

Patients requiring maintenance dialysis have a higher mortality risk in the 30 days after a hurricane.

Powerless in the Virgin Islands: Emergency Department and Wound Care Clinic Utilization Following the 2017 Hurricanes Irma and Maria on St. Thomas, U.S. Virgin Islands

OBJECTIVE

The main objective of this work was to characterize the prevalence of acute medical needs by examining emergency department (ED) and outpatient wound care clinic (WCC) visits before, during, and after the 2017 Hurricanes Irma and Maria, in St. Thomas, United States (U.S.) Virgin Islands.

METHODS

Descriptive statistics and logistic regression were used to assess associations between the occurrence of the storms and visits due to injuries and chronic conditions presented to the ED and WCC from September 1, 2016 to May 31, 2018.

RESULTS

ED visits increased and the rate of injury care was higher during the storms (12 patient visits per day) than before or after the storms (9 patient visits per day). WCC visits increased during (12%) and after the storms (45%), and were associated with patients 60 years and older. The odds of ED and WCC visits due to injury during the storms were significantly higher (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.17, 1.40) than prior to the storms. The odds for visits due to injuries were 1.19 (95% CI: 1.12, 1.28) times higher after the storms.

CONCLUSIONS

Increases occurred in ED and WCC visits for injury care during the storms and in WCC visits after the storms. Public health preparedness mandates understanding how major hurricanes impact the prevalence of acute medical needs, and the factors that influence decisions to seek medical care, in their wake.

Association Between Hurricane Sandy and Emergency Department Visits in New York City by Age and Cause

The magnitude, timing, and etiology of morbidity associated with tropical cyclones remains incompletely quantified. We examined the relative change in cause-specific emergency department (ED) visits among residents of New York City during and after Hurricane Sandy, a tropical cyclone that affected the northeastern United States in October 2012. We used quasi-Poisson constrained distributed lag models to compare the number of ED visits on and after Hurricane Sandy with all other days, 2005-2014, adjusting for temporal trends. Among residents aged ≥65 years, Hurricane Sandy was associated with a higher rate of ED visits due to injuries and poisoning (relative risk (RR) = 1.19, 95% confidence interval (CI): 1.10, 1.28), respiratory disease (RR = 1.35, 95% CI: 1.21, 1.49), cardiovascular disease (RR = 1.10, 95% CI: 1.02, 1.19), renal disease (RR = 1.44, 95% CI: 1.22, 1.72), and skin and soft tissue infections (RR = 1.20, 95% CI: 1.03, 1.39) in the first week following the storm. Among adults aged 18-64 years, Hurricane Sandy was associated with a higher rate of ED visits for renal disease (RR = 2.15, 95% CI: 1.79, 2.59). Among those aged 0-17 years, the storm was associated with lower rates of ED visits for up to 3 weeks. These results suggest that tropical cyclones might result in increased health-care utilization due to a wide range of causes, particularly among older adults.

Association Between Hurricane Sandy and Emergency Department Visits in New York City by Age and Cause

The magnitude, timing, and etiology of morbidity associated with tropical cyclones remains incompletely quantified. We examined the relative change in cause-specific emergency department (ED) visits among residents of New York City during and after Hurricane Sandy, a tropical cyclone that affected the northeastern United States in October 2012. We used quasi-Poisson constrained distributed lag models to compare the number of ED visits on and after Hurricane Sandy with all other days, 2005-2014, adjusting for temporal trends. Among residents aged ≥65 years, Hurricane Sandy was associated with a higher rate of ED visits due to injuries and poisoning (relative risk (RR) = 1.19, 95% confidence interval (CI): 1.10, 1.28), respiratory disease (RR = 1.35, 95% CI: 1.21, 1.49), cardiovascular disease (RR = 1.10, 95% CI: 1.02, 1.19), renal disease (RR = 1.44, 95% CI: 1.22, 1.72), and skin and soft tissue infections (RR = 1.20, 95% CI: 1.03, 1.39) in the first week following the storm. Among adults aged 18-64 years, Hurricane Sandy was associated with a higher rate of ED visits for renal disease (RR = 2.15, 95% CI: 1.79, 2.59). Among those aged 0-17 years, the storm was associated with lower rates of ED visits for up to 3 weeks. These results suggest that tropical cyclones might result in increased health-care utilization due to a wide range of causes, particularly among older adults.

Emergency department visits associated with satellite observed flooding during and following Hurricane Harvey

BACKGROUND

Flooding following heavy rains precipitated by hurricanes has been shown to impact the health of people. Earth observations can be used to identify inundation extents for subsequent analysis of health risks associated with flooding at a fine spatio-temporal scale.

OBJECTIVE

To evaluate emergency department (ED) visits before, during, and following flooding caused by Hurricane Harvey in 2017 in Texas.

METHODS

A controlled before and after design was employed using 2016-2018 ED visits from flooded and non-flooded census tracts. ED visits between landfall of the hurricane and receding of flood waters were considered within the flood period and post-flood periods extending up to 4 months were also evaluated. Modified Poisson regression models were used to estimate adjusted rate ratios for total and cause specific ED visits.

RESULTS

Flooding was associated with increased ED visits for carbon monoxide poisoning, insect bite, dehydration, hypothermia, intestinal infectious diseases, and pregnancy complications. During the month following the flood period, the risk for pregnancy complications and insect bite was still elevated in the flooded tracts.

SIGNIFICANCE

Earth observations coupled with ED visits increase our understanding of the short-term health risks during and following flooding, which can be used to inform preparedness measures to mitigate adverse health outcomes and identify localities with increased health risks during and following flooding events.

Global Climate Implications for Homelessness: A Scoping Review

Homelessness is a persistent global challenge with significant health impacts on those affected. Homeless people are by definition the most exposed to weather conditions and the social and economic problems caused by extreme weather and climate change and variability. This systematic review was designed to synthesize the academic literature that addresses the health and social implications of global climate change for homelessness. The question examined in this systematic scoping review is the following: What is the current state of knowledge in the scientific literature on the health and social implications of global climate change for homelessness? A systematic scoping review method was used to identify and synthesize the peer-reviewed literature relevant to this question. The databases searched were PsycINFO, Medline, Scopus, and Google Scholar. Of the 26 papers identified in this review, 20 employed original data analyses with conclusions largely inferred from cross-sectional associations. Themes included the potential influence of climate change on homelessness prevalence, climate impacts that exacerbate specific vulnerabilities of homeless populations (e.g., chronic illness, exposure, stigmatization), and health and social outcomes. Service use and design implications were also addressed. Given the scale of the impacts of climate change on homelessness, the literature on this topic poses promising directions but is under-developed in its current state to adequately inform risk mitigation and response planning. A systems framework is proposed here to inform future research and service design.

Emergency Department Use Among Assisted Living Residents After Hurricane Irma

OBJECTIVES

Nursing home residents are especially vulnerable to adverse outcomes after a hurricane. Prior research suggests that emergency department (ED) visits increase among community-residing older adults after natural disasters. However, little is known about the impact of hurricanes on the large population of older adults residing in assisted living (AL) settings, particularly the influence of storms on the rates and causes of ED visits. We examined whether rates of ED use for injuries and other medical reasons increased after Hurricane Irma in 2017 among AL residents in Florida.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Samples of 30,358 Medicare fee-for-service beneficiaries in 2016 and 28,922 beneficiaries in 2017 who resided in Florida AL communities.

MEASURES

The number of injury-related and other medical visits per 1,000 person-days within 30 and 90 days of September 1 in 2016 and 2017. We adjusted for age, race, sex, and chronic conditions using linear regression with AL fixed effects. We compared the top 10 primary diagnoses resulting in an ED visit between 2016 and 2017.

RESULTS

Adjusted rates of injury-related visits were 12.5% higher at 30 days but did not differ at 90 days. Other medical visits were 12% higher at 30 days in 2017 than in 2016 and 7.7% higher at 90 days. Heart failure was a leading cause of ED visits within 90 days of September 1 in 2017, unlike in 2016.

CONCLUSIONS AND IMPLICATIONS

Increased attention should be paid to AL communities in disaster preparedness and response efforts given the increased likelihood of ED visits following a hurricane.

Wind disasters adaptation in cities in a changing climate: A systematic review

Wind-related disasters will bring more devastating consequences to cities in the future with a changing climate, but relevant studies have so far provided insufficient information to guide adaptation actions. This study aims to provide an in-depth elaboration of the contents discussed in open access literature regarding wind disaster adaptation in cities. We used the Latent Dirichlet Allocation (LDA) to refine topics and main contents based on 232 publications (1900 to 2019) extracted from Web of Science and Scopus. We conducted a full-text analysis to filter out focal cities along with their adaptation measures. The results show that wind disaster adaptation research in cities has formed a systematic framework in four aspects: 1) vulnerability and resilience of cities, 2) damage evaluation, 3) response and recovery, and 4) health impacts of wind disaster. Climate change is the background for many articles discussing vulnerability and adaptation in coastal areas. It is also embedded in damage evaluation since it has the potential to exacerbate disaster consequences. The literature is strongly inclined towards more developed cities such as New York City and New Orleans, among which New York City associated with Hurricane Sandy ranks first (38/232). Studies on New York City cover all the aspects, including the health impacts of wind disasters which are significantly less studied now. Distinct differences do exist in the number of measures regarding the adaptation categories and their subcategories. We also find that hard adaptation measures (i.e., structural and physical measures) are far more popular than soft adaptation measures (i.e., social and institutional measures). Our findings suggest that policymakers should pay more attention to cities that have experienced major wind disasters other than New York. They should embrace the up-to-date climate change study to defend short-term disasters and take precautions against long-term changes. They should also develop hard-soft hybrid adaptation measures, with special attention on the soft side, and enhance the health impact study of wind-related disasters.

Perspectives on the Health Effects of Hurricanes: A Review and Challenges

Hurricanes are devastating natural disasters which dramatically modify the physical landscape and alter the socio-physical and biochemical characteristics of the environment, thus exposing the affected communities to new environmental stressors, which persist for weeks to months after the hurricane. This paper has three aims. First, it conceptualizes potential direct and indirect health effects of hurricanes and provides an overview of factors that exacerbate the health effects of hurricanes. Second, it summarizes the literature on the health impact of hurricanes. Finally, it examines the time lag between the hurricane (landfall) and the occurrence of diseases. Two major findings emerge from this paper. Hurricanes are shown to cause and exacerbate multiple diseases, and most adverse health impacts peak within six months following hurricanes. However, chronic diseases, including cardiovascular disease and mental disorders, continue to occur for years following the hurricane impact.

Development of a Mobile Hospital for Disaster Relief

Mobile supplemental hospitals were an important asset to community response in preparing for the recent pandemic. MED-1 is a Mobile Emergency Department that has adapted and evolved to the changing needs of communities in times of disaster and nondisaster. An overview of the asset (MED-1), the operations, and use is provided to demonstrate how mobile supplemental hospitals can effectively meet a range of healthcare needs. Innovative utilization of MED-1 has secured its future as an effective resource averaging 100 days of deployment per year.

Effects of Hurricanes on Emergency Department Utilization: An Analysis Across 7 US Storms

OBJECTIVE

Emergency departments (EDs) are critical sources of care after natural disasters such as hurricanes. Understanding the impact on ED utilization by subpopulation and proximity to the hurricane's path can inform emergency preparedness planning. This study examines changes in ED utilization for residents of 344 counties after the occurrence of 7 US hurricanes between 2005 and 2016.

METHODS

This retrospective observational study used ED data from the Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases. ED utilization rates for weeks during and after hurricanes were compared with pre-hurricane rates, stratified by the proximity of the patient county to the hurricane path, age, and disease category.

RESULTS

The overall population rate of weekly ED visits changed little post-hurricane, but rates by disease categories and age demonstrated varying results. Utilization rates for respiratory disorders exhibited the largest post-hurricane increase, particularly 2-3 weeks following the hurricane. The change in population rates by disease categories and age tended to be larger for people residing in counties closer to the hurricane path.

CONCLUSIONS

Changes in ED utilization following hurricanes depend on disease categories, age, and proximity to the hurricane path. Emergency managers could incorporate these factors into their planning processes.

Health Outcomes After Disaster for Older Adults With Chronic Disease: A Systematic Review

BACKGROUND AND OBJECTIVES

This review synthesizes the current literature surrounding chronic disease outcomes after weather- and climate-related disasters among older adults. The associations between exposure of older adults to weather- and climate-related disasters and the primary outcomes of diabetes, end-stage renal disease (ESRD), congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) were examined.

RESEARCH DESIGN AND METHODS

A systematic review of studies reporting on clinical outcomes of four chronic diseases after disaster exposure was performed. Under the direction of an informationist, the databases PubMed, Scopus, EMBASE, and Web of Science (Science and Social Science Citation Index) were searched from inception to July 2019.

RESULTS

Of 5,229 citations identified, 17 articles met the study criteria. Included articles were retrospective observational in nature and focused on earthquakes (24%, n = 4), hurricane (41%, n = 7), and wildfire (35%, n = 6) disasters. Outcome data by disease process included COPD (35%, n = 6), ESRD (41%, n = 7), CHF (24%, n = 4), and diabetes (29%, n = 5). Three main categories were identified: access to health care, postdisaster health care utilization, and study rigor. The age-stratified analyses reported in this review found multiple instances where disasters have limited or insignificant effects on older adults relative to younger populations.

DISCUSSION AND IMPLICATIONS

Disaster research faces unique methodological challenges, and there remains a need for data-driven conclusions on how best to care for older adults before, during, and after disasters. To encourage consistent dialogue among studies, we advocate for the use of rigorous and standardized scientific methodology to examine the health impacts of disasters on adults with chronic disease.

Access to Care for VA Dialysis Patients During Superstorm Sandy

Introduction: This study examines the use of dialysis services by end-stage renal disease (ESRD) patients following the Superstorm Sandy-related, months-long closure of the New York campus of the US Department of Veterans Affairs (VA) New York Harbor VA Healthcare System (NYHHS, Manhattan VAMC). Methods: Outpatient visits, dialysis care, emergency department visits, and hospitalizations at VA and non-VA facilities for 47 Manhattan VAMC ESRD patients were examined 12 months pre- and post-Sandy using VA administrative and clinical data. Results: The Brooklyn campus of NYHHS, which is within ten miles of Manhattan VAMC, experienced the largest increase in the number of dialysis encounters after the closure. Dialysis encounters for VA patients also increased at non-VA facilities, rising on average, to 106 per month. For the James J Peters Bronx VAMC, the number of total dialysis encounters for Manhattan VAMC patients fluctuated between 39 and 43 per month, dropping to less than 30 after the Manhattan VAMC dialysis unit reopened. Conclusion: Manhattan VAMC ESRD patients used nearby alternate VA sites and non-VA clinics for their care during the closure of the Manhattan VAMC dialysis unit. The VA electronic health records played an important role in ensuring continuity of care for patients who exclusively used VAMC facilities post-Sandy because patient information was immediately accessible at other VA facilities. The events related to Superstorm Sandy highlight the need for dialysis providers to have a comprehensive disaster plan, including nearby alternate care sites that can increase service capacity when a dialysis facility is closed because of a disaster.

Natural Disasters in the Americas, Dialysis Patients, and Implications for Emergency Planning: A Systematic Review

Introduction

Natural hazards are elements of the physical environment caused by forces extraneous to human intervention and may be harmful to human beings. Natural hazards, such as weather events, can lead to natural disasters, which are serious societal disruptions that can disrupt dialysis provision, a life-threatening event for dialysis-dependent people. The adverse outcomes associated with missed dialysis sessions are likely exacerbated in island settings, where health care resources and emergency procedures are limited. The effect of natural disasters on dialysis patients living in geographically vulnerable areas such as the Cayman Islands is largely understudied. To inform predisaster interventions, we systematically reviewed studies examining the effects of disasters on dialysis patients and discussed the implications for emergency preparedness in the Cayman Islands.

Methods

Two reviewers independently screened 434 titles and abstracts from PubMed, Scopus, CINAHL, and Cochrane Library. We included studies if they were original research articles published in English from 2009 to 2019 and conducted in the Americas.

Results

Our search yielded 15 relevant articles, which we included in the final analysis. Results showed that disasters have both direct and indirect effects on dialysis patients. Lack of electricity, clean water, and transportation, and closure of dialysis centers can disrupt dialysis care, lead to missed dialysis sessions, and increase the number of hospitalizations and use of the emergency department. Additionally, disasters can exacerbate depression and lead to posttraumatic stress disorder among dialysis patients.

Conclusion

To our knowledge, this systematic review is the first study that presents a synthesis of the scientific literature on the effects of disasters on dialysis populations. The indirect and direct effects of disasters on dialysis patients highlight the need for predisaster interventions at the patient and health care system levels. Particularly, educating patients about an emergency renal diet and offering early dialysis can help to mitigate the negative effects of disasters.

Long-term Effects of Disasters on Seniors With Diabetes: Evidence From Hurricanes Katrina and Rita

OBJECTIVE

To estimate the long-run mortality effects of Hurricanes Katrina and Rita on seniors with diabetes.

RESEARCH DESIGN AND METHODS

We performed a retrospective cohort analysis of Medicare enrollment and claims data covering four states and ∼10 years. Affected individuals were identified by whether they lived in a county that suffered a high impact and were stratified by whether they moved to a different county following the storms. Propensity scores matched affected and comparison subjects based on demographic and socioeconomic characteristics and the presence of chronic conditions. Our sample consisted of 170,328 matched affected subjects.

RESULTS

The affected subjects had a nearly 40% higher all-cause mortality risk in the 1st month after the storms, but the difference fell to <6% by the end of the full observation period. The mortality risks of heart disease and nephritis also exhibited the largest differences immediately following the storms. Among the affected subjects, the all-cause mortality risk was higher for those who moved to a different county, with an especially large difference among those who moved to an affected county.

CONCLUSIONS

The propensity matching procedure resulted in the comparison and affected groups having similar observable characteristics. However, we only examined the extreme outcome of mortality, our definition of affected was somewhat crude, and our sample did not include individuals enrolled in Medicare Advantage. Our findings highlight the importance of the immediate response to disasters, yet also demonstrate the long-lasting impact disasters can have.

Examining Associations Between Hurricane Sandy Exposure and Posttraumatic Stress Disorder by Community of Residence

Exposure to 2012's Hurricane Sandy differed by community across New York City and nearby Long Island, and the differential impact of exposure on mental health concerns must be studied to enhance resilience in vulnerable communities. We assessed the association between self-reported Hurricane Sandy exposure and subsequent posttraumatic stress disorder (PTSD) symptoms, obtained through validated questionnaires completed by residents of lower Manhattan (n = 1,134), Queens/Long Island (LI)/Staten Island (SI; n = 622), and the Rockaways (n = 1,011); mean assessment times were 7, 14, and 32 months post-Sandy, respectively. The median number of hurricane exposures was similar for all communities; however, Rockaways residents had a higher proportion of likely PTSD symptoms (18.8%) compared to lower Manhattan (8.0%) and Queens/LI/SI residents (5.8%). Regarding likely PTSD, there was significant interaction between total hurricane exposure and community, p = .002, and flooding and community, p = .040. Number of hurricane exposures was associated with higher odds of likely PTSD in Queens/LI/SI, AOR = 1.61, 95% CI [1.34, 1.94]; lower Manhattan, AOR = 1.43, 95% CI [1.28, 1.59]; and the Rockaways, AOR = 1.25, 95% CI [1.16, 1.35]. Flooding was associated with increased odds of likely PTSD in the Rockaways, AOR = 1.65, 95% CI [1.01, 2.69]; and Queens/LI/SI, AOR = 3.29, 95% CI [1.08, 10.00]. This study emphasizes the differential impact of hurricane exposure on subsequent PTSD symptoms in three communities affected by Hurricane Sandy. Future preparedness and recovery efforts must understand community correlates of mental health concerns to promote resilience in vulnerable communities.

Emergency Department Visits by and Hospitalizations of Senior Diabetics in the Three Years Following Hurricanes Katrina and Rita

While prior studies have investigated health care utilization immediately following disasters, few have examined utilization beyond that period. We use individual-level U.S. Medicare claims data for three years prior to (2002-2004) and after (2006-2008) Hurricanes Katrina and Rita to investigate whether senior diabetics affected by the storms had a greater number of emergency department visits and days hospitalized in the three years following the storms. An event study was conducted using regression analysis that controlled for all fixed individual characteristics. While the 2006 and 2007 rates of increase in utilization were relatively similar across the control group and the two affected groups, in 2008 the affected groups exhibited substantially greater increases in both emergency department visits and days hospitalized. The differences correspond to an additional 380,907 days hospitalized and 21,583 emergency department visits in 2008. The results indicate that, in addition to short term effects previously estimated, disasters may have longer term effects on utilization of healthcare services. These potential effects suggest that improved post-disaster care may significantly reduce the healthcare costs of disasters.

Power Outage Preparedness and Concern among Vulnerable New York City Residents

Power outages can impact health, and certain populations may be more at risk. Personal preparedness may reduce impacts, but information on power outage preparedness and risk perception among vulnerable populations is limited. We examined power outage preparedness and concern among New York City residents, including vulnerable populations defined as older adults (≥ 65 years), and respondents with household members who require assistance with daily activities or depend on electric medical devices. A random sample telephone survey was conducted during November-December 2016. Preparedness was defined as having a three-day supply of drinking water, non-perishable food, and a working flashlight. Among all respondents (n = 887), 58% were prepared and 46% expressed concern about health. Respondents with electric-dependent household members (9% of all respondents) tended to have higher preparedness (70 vs. 56% of respondents without electric-dependent household members). Among this group, only 40% reported being registered with a utility company to receive early notification of outages. While the subgroup sample was small, respondents with registered electric-dependent household members had lower preparedness than those with non-registered users (59 vs. 76%). Respondents with household members who needed assistance had comparable levels of preparedness to respondents without someone who needed assistance (59 vs. 57%). Older adults had greater preparedness than younger adults (65 vs. 56%). Health concerns were greater among all vulnerable groups than the general population. Levels of preparedness varied among vulnerable respondents, and awareness of power outage notification programs was low. Our findings highlight the need to increase awareness and preparedness among at-risk people.

Health Impacts of Citywide and Localized Power Outages in New York City

BACKGROUND

Previous studies investigated potential health effects of large-scale power outages, including the massive power failure that affected the northeastern United States and Ontario, Canada, in August 2003, and outages associated with major storms. However, information on localized outages is limited.

OBJECTIVE

The study sought to examine potential health impacts of citywide and localized outages in New York City (NYC).

METHODS

Along with the citywide 2003 outage, localized outages in July 1999 and July 2006 were identified. We additionally investigated localized, warm- and cold-weather outages that occurred in any of 66 NYC electric-grid networks during 2002–2014 using New York State Public Service Commission data. Mortality and hospitalizations were geocoded and linked to the networks. Associations were estimated using Poisson time-series regression, including examining distributed lags and adjusting for temperature and temporal trends. Network-specific estimates were pooled by season.

RESULTS

Respiratory disease hospitalizations were associated with the 2006 localized outage [cumulative relative risk [CRR] over 0–1 lag day, lag₀₁=2.26 (95% confidence interval [CI]: 1.08, 4.74)] and the 2003 citywide outage, but not with other localized, warm-weather outages. Renal disease hospitalizations were associated with the 2003 citywide outage, and with localized, warm-weather outages, pooled across networks [RR at lag₃=1.16 (95% CI: 1.00, 1.34)], but not the 2006 localized outage. All-cause mortality was positively associated with the 1999, 2003, and 2006 outages (significant for the 2003 outage only), but not with other localized, warm-weather outages. Localized, cold-weather outages were associated with all-cause mortality [lag₀₁ CRR=1.06 (95% CI: 1.01, 1.12)] and cardiovascular disease hospitalizations [lag₀₁ CRR=1.14 (95% CI: 1.03, 1.26)], and fewer respiratory disease hospitalizations [lag₀₃ CRR=0.77 (95% CI: 0.61, 0.97)].

CONCLUSIONS

Localized outages may affect health. This information can inform preparedness efforts and underscores the public health importance of ensuring electric grid resiliency to climate change. https://doi.org/10.1289/EHP2154.

Homelessness and Emergency Medicine: A Review of the Literature

OBJECTIVES

We aimed to synthesize the available evidence on the demographics, prevalence, clinical characteristics, and evidence-based management of homeless persons in the emergency department (ED). Where appropriate, we highlight knowledge gaps and suggest directions for future research.

METHODS

We conducted a systematic literature search following databases: PubMed, Ovid, and Google Scholar for articles published between January 1, 1990, and December 31, 2016. We supplemented this search by cross-referencing bibliographies of the retrieved publications. Peer-reviewed studies written in English and conducted in the United States that examined homelessness within the ED setting were included. We used a qualitative approach to synthesize the existing literature.

RESULTS

Twenty-eight studies were identified that met the inclusion criteria. Based on our study objectives and the available literature, we grouped articles examining homeless populations in the ED into four broad categories: 1) prevalence and sociodemographic characteristics of homeless ED visits, 2) ED utilization by homeless adults, 3) clinical characteristics of homeless ED visits, and 4) medical education and evidence-based management of homeless ED patients.

CONCLUSION

Homelessness may be underrecognized in the ED setting. Homeless ED patients have distinct care needs and patterns of ED utilization that are unmet by the current disease-oriented and episodic models of emergency medicine. More research is needed to determine the prevalence and characteristics of homelessness in the ED and to develop evidence-based treatment strategies in caring for this vulnerable population.

Burden and Risk Factors for Cold-Related Illness and Death in New York City

Exposure to cold weather can cause cold-related illness and death, which are preventable. To understand the current burden, risk factors, and circumstances of exposure for illness and death directly attributed to cold, we examined hospital discharge, death certificate, and medical examiner data during the cold season from 2005 to 2014 in New York City (NYC), the largest city in the United States. On average each year, there were 180 treat-and-release emergency department visits (average annual rate of 21.6 per million) and 240 hospital admissions (29.6 per million) for cold-related illness, and 15 cold-related deaths (1.8 per million). Seventy-five percent of decedents were exposed outdoors. About half of those exposed outdoors were homeless or suspected to be homeless. Of the 25% of decedents exposed indoors, none had home heat and nearly all were living in single-family or row homes. The majority of deaths and illnesses occurred outside of periods of extreme cold. Unsheltered homeless individuals, people who use substances and become incapacitated outdoors, and older adults with medical and psychiatric conditions without home heat are most at risk. This information can inform public health prevention strategies and interventions.

Access to Care for Homeless Veterans During Disasters

Introduction: Since 1970, natural disasters have led to both temporary and permanent closures of multiple medical centers and outpatient clinics at the US Department of Veterans Affairs (VA) nationwide. Access to care during such events is critical for vulnerable populations, especially homeless veterans. As such, facility closures may disproportionately affect homeless veteran patients who are both more likely to experience adverse effects from disasters and face multiple barriers to care. Methods: A cross-sectional survey was administered to a probability sample of 2000 homeless VA patients living in and receiving VA health care in the Northeast United States. The survey was completed by 383 respondents (20% adjusted response rate). This pilot study examines predictors of difficulty accessing care in the event that the VA facility that homeless VA patients routinely use is forced to close because of a natural disaster. Results: In a multivariate logistic regression, homeless VA patients who had Medicaid were less likely (OR 0.38; 95% CI: 0.18-0.78; P < .01) to report that they would have difficulty obtaining care elsewhere if their normal VA facility was closed in a future natural disaster. Conclusions: Findings suggest that Medicaid coverage has the potential to facilitate access to care for homeless veteran VA patients during disasters. Policy changes that decrease Medicaid coverage could limit access to care for homeless veterans during closures of VA medical facilities.

A Community Checklist for Health Sector Resilience Informed by Hurricane Sandy

This is a checklist of actions for healthcare, public health, nongovernmental organizations, and private entities to use to strengthen the resilience of their community's health sector to disasters. It is informed by the experience of Hurricane Sandy in New York and New Jersey and analyzed in the context of findings from other recent natural disasters in the United States. The health sector is defined very broadly, including-in addition to hospitals, emergency medical services (EMS), and public health agencies-healthcare providers, outpatient clinics, long-term care facilities, home health providers, behavioral health providers, and correctional health services. It also includes community-based organizations that support these entities and represent patients. We define health sector resilience very broadly, including all factors that preserve public health and healthcare delivery under extreme stress and contribute to the rapid restoration of normal or improved health sector functioning after a disaster. We present the key findings organized into 8 themes. We then describe a conceptual map of health sector resilience that ties these themes together. Lastly, we provide a series of recommended actions for improving health sector resilience at the local level. The recommended actions emphasize those items that individuals who experienced Hurricane Sandy deemed to be most important. The recommendations are presented as a checklist that can be used by a variety of interested parties who have some role to play in disaster preparedness, response, and recovery in their own communities. Following a general checklist are supplemental checklists that apply to specific parts of the larger health sector.

Vulnerability of Older Adults in Disasters: Emergency Department Utilization by Geriatric Patients After Hurricane Sandy

Objective

Older adults are a potentially medically vulnerable population with increased mortality rates during and after disasters. To evaluate the impact of a natural disaster on this population, we performed a temporal and geospatial analysis of emergency department (ED) use by adults aged 65 years and older in New York City (NYC) following Hurricane Sandy’s landfall.

Methods

We used an all-payer claims database to analyze demographics, insurance status, geographic distribution, and health conditions for post-disaster ED visits among older adults. We compared ED patterns of use in the weeks before and after Hurricane Sandy throughout NYC and the most afflicted evacuation zones.

Results

We found significant increases in ED utilization by older adults (and disproportionately higher in those aged ≥85 years) in the 3 weeks after Hurricane Sandy, especially in NYC evacuation zone one. Primary diagnoses with notable increases included dialysis, electrolyte disorders, and prescription refills. Secondary diagnoses highlighted homelessness and care access issues.

Conclusions

Older adults display heightened risk for worse health outcomes with increased ED visits after a disaster. Our findings suggest the need for dedicated resources and planning for older adults following a natural disaster by ensuring access to medical facilities, prescriptions, dialysis, and safe housing and by optimizing health care delivery needs to reduce the burden of chronic disease. (Disaster Med Public Health Preparedness. 2018;12:184–193)

Index to Predict In-hospital Mortality in Older Adults after Non-traumatic Emergency Department Intubations

INTRODUCTION

Our goal was to develop and validate an index to predict in-hospital mortality in older adults after non-traumatic emergency department (ED) intubations.

METHODS

We used Vizient administrative data from hospitalizations of 22,374 adults ≥75 years who underwent non-traumatic ED intubation from 2008-2015 at nearly 300 U.S. hospitals to develop and validate an index to predict in-hospital mortality. We randomly selected one half of participants for the development cohort and one half for the validation cohort. Considering 25 potential predictors, we developed a multivariable logistic regression model using least absolute shrinkage and selection operator method to determine factors associated with in-hospital mortality. We calculated risk scores using points derived from the final model's beta coefficients. To evaluate calibration and discrimination of the final model, we used Hosmer-Lemeshow chi-square test and receiver-operating characteristic analysis and compared mortality by risk groups in the development and validation cohorts.

RESULTS

Death during the index hospitalization occurred in 40% of cases. The final model included six variables: history of myocardial infarction, history of cerebrovascular disease, history of metastatic cancer, age, admission diagnosis of sepsis, and admission diagnosis of stroke/ intracranial hemorrhage. Those with low-risk scores (<6) had 31% risk of in-hospital mortality while those with high-risk scores (>10) had 58% risk of in-hospital mortality. The Hosmer-Lemeshow chi-square of the model was 6.47 (p=0.09), and the c-statistic was 0.62 in the validation cohort.

CONCLUSION

The model may be useful in identifying older adults at high risk of death after ED intubation.

Emergency Department Visits for Homelessness or Inadequate Housing in New York City before and after Hurricane Sandy

Hurricane Sandy struck New York City on October 29, 2012, causing not only a large amount of physical damage, but also straining people's health and disrupting health care services throughout the city. In prior research, we determined that emergency department (ED) visits from the most vulnerable hurricane evacuation flood zones in New York City increased after Hurricane Sandy for several medical diagnoses, but also for the diagnosis of homelessness. In the current study, we aimed to further explore this increase in ED visits for homelessness after Hurricane Sandy's landfall. We performed an observational before-and-after study using an all-payer claims database of ED visits in New York City to compare the demographic characteristics, insurance status, geographic distribution, and health conditions of ED patients with a primary or secondary ICD-9 diagnosis of homelessness or inadequate housing in the first week after Hurricane Sandy's landfall versus the baseline weekly average in 2012 prior to Hurricane Sandy. We found statistically significant increases in ED visits for diagnosis codes of homelessness or inadequate housing in the week after Hurricane Sandy's landfall. Those accessing the ED for homelessness or inadequate housing were more often elderly and insured by Medicare after versus before the hurricane. Secondary diagnoses among those with a primary ED diagnosis of homelessness or inadequate housing also differed after versus before Hurricane Sandy. These observed differences in the demographic, insurance, and co-existing diagnosis profiles of those with an ED diagnosis of homelessness or inadequate housing before and after Hurricane Sandy suggest that a new population cohort-potentially including those who had lost their homes as a result of storm damage-was accessing the ED for homelessness or other housing issues after the hurricane. Emergency departments may serve important public health and disaster response roles after a hurricane, particularly for people who are homeless or lack adequate housing. Further, tracking ED visits for homelessness may represent a novel surveillance mechanism to assess post-disaster infrastructure impact and to prepare for future disasters.

Acute post-disaster medical needs of patients with diabetes: emergency department use in New York City by diabetic adults after Hurricane Sandy

OBJECTIVE

To evaluate the acute impact of disasters on diabetic patients, we performed a geospatial analysis of emergency department (ED) use by New York City diabetic adults in the week after Hurricane Sandy.

RESEARCH DESIGN AND METHODS

Using an all-payer claims database, we retrospectively analyzed the demographics, insurance status, and medical comorbidities of post-disaster ED patients with diabetes who lived in the most geographically vulnerable areas. We compared the patterns of ED use among diabetic adults in the first week after Hurricane Sandy's landfall to utilization before the disaster in 2012.

RESULTS

In the highest level evacuation zone in New York City, postdisaster increases in ED visits for a primary or secondary diagnosis of diabetes were attributable to a significantly higher proportion of Medicare patients. Emergency visits for a primary diagnosis of diabetes had an increased frequency of certain comorbidities, including hypertension, recent procedure, and chronic skin ulcers. Patients with a history of diabetes visited EDs in increased numbers after Hurricane Sandy for a primary diagnosis of myocardial infarction, prescription refills, drug dependence, dialysis, among other conditions.

CONCLUSIONS

We found that diabetic adults aged 65 years and older are especially at risk for requiring postdisaster emergency care compared to other vulnerable populations. Our findings also suggest that there is a need to support diabetic adults particularly in the week after a disaster by ensuring access to medications, aftercare for patients who had a recent procedure, and optimize their cardiovascular health to reduce the risk of heart attacks.