1
|
Moon KJ, Linton SL, Mojtabai R. Medical Debt and the Mental Health Treatment Gap Among US Adults. JAMA Psychiatry 2024; 81:985-992. [PMID: 39018037 PMCID: PMC11255967 DOI: 10.1001/jamapsychiatry.2024.1861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/25/2024] [Indexed: 07/18/2024]
Abstract
Importance Medical debt is common in the US and may hinder timely access to care for mental disorders. Objective To estimate the prevalence of medical debt among US adults with depression and anxiety and its association with delayed and forgone mental health care. Design, Setting, and Participants Cross-sectional, nationally representative survey study of US adult participants in the 2022 National Health Interview Survey who had current or lifetime diagnoses of depression or anxiety. Exposures Self-reported lifetime clinical diagnoses of depression and anxiety; moderate to severe symptoms of current depression (Patient Health Questionnaire-8 score ≥10) and anxiety (Generalized Anxiety Disorder-7 score ≥10) irrespective of lifetime diagnoses; and past-year medical debt. Main Outcomes and Measures Self-reported delaying and forgoing mental health care because of cost in the past year. Results Among 27 651 adults (15 050 [54.4%] female; mean [SD] age, 52.9 [18.4] years), 5186 (18.2%) reported lifetime depression, 1948 (7.3%) reported current depression, 4834 (17.7%) reported lifetime anxiety, and 1689 (6.6%) reported current anxiety. Medical debt was more common among adults with lifetime depression (19.9% vs 8.6%; adjusted prevalence ratio [aPR], 1.97; 95% CI, 1.96-1.98), lifetime anxiety (19.4% vs 8.8%; aPR, 1.91; 95% CI, 1.91-1.92), current depression (27.3% vs 9.4%; aPR, 2.34; 95% CI, 2.34-2.36), and current anxiety (26.2% vs 9.6%; aPR, 2.24; 95% CI, 2.24-2.26) compared with adults without the respective mental disorders. Medical debt was associated with delayed health care among adults with lifetime depression (29.0% vs 11.6%; aPR, 2.68; 95% CI, 2.62-2.74), lifetime anxiety (28.0% vs 11.5%; aPR, 2.45; 95% CI, 2.40-2.50), current depression (36.9% vs 17.4%; aPR, 2.25; 95% CI, 2.13-2.38), and current anxiety (38.4% vs 16.9%; aPR, 2.48; 95% CI, 2.35-2.66) compared with those without these diagnoses. Medical debt was associated with forgone health care among adults with lifetime depression (29.4% vs 10.6%; aPR, 2.66; 95% CI, 2.61-2.71), lifetime anxiety (28.2% vs 10.7%; aPR, 2.63; 95% CI, 2.57-2.68), current depression (38.0% vs 17.2%; aPR, 2.35; 95% CI, 2.23-2.48), and current anxiety (40.8% vs 17.1%; aPR, 2.57; 95% CI, 2.43-2.75) compared with those without the diagnoses. Conclusions and Relevance Medical debt is prevalent among adults with depression and anxiety and may contribute to the mental health treatment gap. In the absence of structural reform, new policies are warranted to protect against this financial barrier to mental health care.
Collapse
Affiliation(s)
- Kyle J. Moon
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sabriya L. Linton
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ramin Mojtabai
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
2
|
Shah MP, Douglas AG, Sauer BM, Richie MB, Douglas VC, Josephson SA, Guterman EL. Differences in Interfacility Transfer from Emergency Department and Inpatient Services for Inpatient Neurologic Care. Neurohospitalist 2024; 14:406-412. [PMID: 39308471 PMCID: PMC11412452 DOI: 10.1177/19418744241273205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024] Open
Abstract
Introduction Interhospital transfer is an important mechanism for improving access to specialized neurologic care but there are large gaps in our understanding of interhospital transfer for the management of non-stroke-related neurologic disease. Methods This observational study included consecutive patients admitted to an adult academic general neurology service via interhospital transfer from July 1, 2015 to July 1, 2017. Characteristics of the referring hospital and transferred patients were obtained through the American Hospital Association Directory, a hospital transfer database maintained by the accepting hospital, and the electronic medical record. The analyses used descriptive statistics to examine the cohort overall and compare characteristics of patients transferred from an emergency department and inpatient service. Results 504 patients were admitted via interhospital transfer during the study period. Of these, 395 patients (78.4%) were transferred because the referring hospital lacked capability, and 139 patients (27.6%) were transferred from an emergency department as opposed to inpatient service. Seizures was the most common diagnosis (23.8%). Patients who were transferred from an emergency department had a higher proportion covered by Medicaid (44.6%) than those transferred from an inpatient service (28.8%) and had a shorter median length of stay (3 days; IQR 2-7 vs 7 days; IQR 4-12). Conclusions The majority of observed interhospital non-stroke neurologic transfers occurred to improve access to specialized neurological care for patients, though patients transferred from the ED, as opposed to an inpatient service, had lower health care utilization, and this will be important to consider when developing systems of care and in future research.
Collapse
Affiliation(s)
- Maulik P. Shah
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Anne G. Douglas
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Brian M. Sauer
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Megan B. Richie
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Vanja C. Douglas
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - S. Andrew Josephson
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Elan L. Guterman
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| |
Collapse
|
3
|
Knowlton LM, Arnow K, Trickey AW, Tran LD, Harris AH, Morris AM, Wagner TH. Hospital Presumptive Eligibility Emergency Medicaid Programs: An Opportunity for Continuous Insurance Coverage? Med Care 2024; 62:567-574. [PMID: 38986116 PMCID: PMC11315624 DOI: 10.1097/mlr.0000000000002026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND Lack of health insurance is a public health crisis, leading to foregone care and financial strain. Hospital Presumptive Eligibility (HPE) is a hospital-based emergency Medicaid program that provides temporary (up to 60 d) coverage, with the goal that hospitals will assist patients in applying for ongoing Medicaid coverage. It is unclear whether HPE is associated with successful longer-term Medicaid enrollment. OBJECTIVE To characterize Medicaid enrollment 6 months after initiation of HPE and determine sociodemographic, clinical, and geographic factors associated with Medicaid enrollment. DESIGN This was a cohort study of all HPE approved inpatients in California, using claims data from the California Department of Healthcare Services. SETTING The study was conducted across all HPE-participating hospitals within California between January 1, 2016 and December 31, 2017. PARTICIPANTS We studied California adult hospitalized inpatients, who were uninsured at the time of hospitalization and approved for HPE emergency Medicaid. Using multivariable logistic regression models, we compared HPE-approved patients who enrolled in Medicaid by 6 months versus those who did not. EXPOSURES HPE emergency Medicaid approval at the time of hospitalization. MAIN OUTCOMES AND MEASURES The primary outcome was full-scope Medicaid enrollment by 6 months after the hospital's presumptive eligibility approval. RESULTS Among 71,335 inpatient HPE recipients, a total of 45,817 (64.2%) enrolled in Medicaid by 6 months. There was variability in Medicaid enrollment across counties in California (33%-100%). In adjusted analyses, Spanish-preferred-language patients were less likely to enroll in Medicaid (aOR 0.77, P <0.001). Surgical intervention (aOR 1.10, P <0.001) and discharge to another inpatient facility or a long-term care facility increased the odds of Medicaid enrollment (vs. routine discharge home: aOR 2.24 and aOR 1.96, P <0.001). CONCLUSION California patients who enroll in HPE often enroll in Medicaid coverage by 6 months, particularly among patients requiring surgical intervention, repeated health care visits, and ongoing access to care. Future opportunities include prospective evaluation of HPE recipients to understand the impact that Medicaid enrollment has on health care utilization and financial solvency.
Collapse
Affiliation(s)
- Lisa Marie Knowlton
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA
| | - Katherine Arnow
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA
| | - Linda D. Tran
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA
| | - Alex H.S. Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA
| | - Arden M. Morris
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA
| | - Todd H. Wagner
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA
| |
Collapse
|
4
|
Moura L, Karakis I, Howard D. Emergency department utilization among adults with epilepsy: A multi-state cross-sectional analysis, 2010-2019. Epilepsy Res 2024; 205:107427. [PMID: 39116513 DOI: 10.1016/j.eplepsyres.2024.107427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 07/08/2024] [Accepted: 08/05/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE We described patterns and trends in ED use among adults with epilepsy in the United States. METHODS Utilizing inpatient and ED discharge data from seven states, we conducted a cross-sectional analysis to identify adult ED visits diagnosed with epilepsy or seizures from 2010 to 2019. Using ED visit counts and estimates of state-level epilepsy prevalence, we calculated ED visit rates overall and by payer, condition, and year. RESULTS Our data captured 304,935 ED visits with epilepsy as a primary or secondary diagnosis in 2019. Across the seven states, visit rates ranged between 366 and 726 per 1000 and were higher than rates for adults without epilepsy in all states but one. ED visit rates were highest among Medicare and Medicaid beneficiaries (vs commercial or self-pay). Adults with epilepsy were more likely to be admitted as inpatients. Visits for nervous system disorders were 6.3-8.2 times higher among people with epilepsy, and visits for mental health conditions were 1.2-2.6 times higher. Increases in ED visit rates from 2010 to 2019 among people with epilepsy exceeded increases among adults without by 6.0-27.3 percentage points. CONCLUSION Adults with epilepsy visit the ED frequently and visit rates have been increasing over time. These results underscore the importance of identifying factors contributing to ED use and designing tailored interventions to improve ambulatory care quality.
Collapse
Affiliation(s)
- Lidia Moura
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, Harvard Medical School, Boston, MA, USA.
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; University of Crete School of Medicine, Heraklion, Greece
| | - David Howard
- Department of Health Policy, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
5
|
Milando CW, Sun Y, Romitti Y, Nori-Sarma A, Gause EL, Spangler KR, Sue Wing I, Wellenius GA. Generalizability of heat-related health risk associations observed in a large healthcare claims database of patients with commercial health insurance. Epidemiology 2024:00001648-990000000-00285. [PMID: 39120949 PMCID: PMC7616519 DOI: 10.1097/ede.0000000000001781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2024]
Abstract
BACKGROUND Extreme ambient heat is unambiguously associated with higher risk of illness and death. The Optum Labs Data Warehouse (OLDW), a database of medical claims from US-based patients with commercial or Medicare Advantage health insurance, has been used to quantify heat-related health impacts. Whether results for the insured sub-population are generalizable to the broader population has to our knowledge not been documented. We sought to address this question, for the US population in California from 2012 to 2019. METHODS We examined changes in daily rates of emergency department (ED) encounters and in-patient hospitalization encounters for all-causes, heat-related outcomes, renal disease, mental/behavioral disorders, cardiovascular disease, and respiratory disease. OLDW was the source for health data for insured individuals in California, and health data for the broader population were gathered from the California Department of Health Care Access and Information (HCAI). We defined extreme heat exposure as any day in a group of 2 or more days with maximum temperatures exceeding the county-specific 97.5 th percentile and used a space-time-stratified case-crossover design to assess and compare the impacts of heat on health. RESULTS Average incidence rates of medical encounters differed by dataset. However, rate ratios for ED encounters were similar across datasets for all causes (ratio of incidence rate ratios (rIRR) = 0.989; 95% confidence interval (CI) = 0.973, 1.011), heat-related causes (rIRR = 1.080; 95% CI = 0.999, 1.168), renal disease (rIRR = 0.963; 95% CI = 0.718, 1.292), and mental health disorders (rIRR = 1.098; 95% CI = 1.004, 1.201). Rate ratios for inpatient encounters were also similar. CONCLUSIONS This work presents evidence that OLDW can continue to be a resource for estimating the health impacts of extreme heat.
Collapse
Affiliation(s)
| | - Yuantong Sun
- Department of Environmental Health, Boston University
| | | | | | - Emma L Gause
- Department of Environmental Health, Boston University
- Center for Climate and Health, Boston University School of Public Health
| | | | - Ian Sue Wing
- Department of Earth and Environment, Boston University
| | - Gregory A Wellenius
- Department of Environmental Health, Boston University
- Center for Climate and Health, Boston University School of Public Health
| |
Collapse
|
6
|
Gaffney A, McCormick D, Himmelstein G, Woolhandler S, Himmelstein DU. Demand and Supply Drivers of Medicare and Non-Medicare Health Spending: An Analysis of U.S. States, 1991-2019. INTERNATIONAL JOURNAL OF SOCIAL DETERMINANTS OF HEALTH AND HEALTH SERVICES 2024:27551938241258399. [PMID: 39053017 DOI: 10.1177/27551938241258399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
For the last four decades, policymakers have attempted to control the United States's high health care costs by reducing patients' demand for care (e.g., by imposing managed-care restrictions or high costs on patients at the time of use). Yet studies based mostly on data from the public Medicare program, which covers mostly elderly Americans, suggest that supply (e.g., number of physicians or hospital beds) rather than demand drives aggregate service use and, hence, costs. Using variation between U.S. states in per enrollee Medicare spending versus per capita spending of all other (non-Medicare) individuals, we find that greater supply boosts costs for the entire population. Furthermore, we find that factors that suppress demand in the non-Medicare population do reduce non-Medicare health care spending, but simultaneously increase Medicare spending. This suggests that for a given supply of medical resources, suppressing demand for one group of patients may produce a compensatory increase in provision of care to those whose demand has not been suppressed. Health planning to assure adequate medical resources where they are needed while preventing excess supply where it is duplicative and wasteful is likely a more effective cost control strategy than the imposition of managed-care restrictions or imposing higher costs onto patients seeking care.
Collapse
Affiliation(s)
- Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Gracie Himmelstein
- Office of Population Research, Princeton University, Princeton, NJ, USA
- Department of Medicine, University of California Los Angeles Health, Los Angeles, USA
| | - Steffie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Hunter College, City University of New York, New York, USA
- Public Citizen Health Research Group, Washington, DC, USA
| | - David U Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Hunter College, City University of New York, New York, USA
- Public Citizen Health Research Group, Washington, DC, USA
| |
Collapse
|
7
|
Jung D, Song S, Ma C. Where Patients Live Matter in Emergency Department Visits in Home Health Care: Rural/Urban Status and Neighborhood Socioeconomic Status. J Appl Gerontol 2024; 43:933-944. [PMID: 37991851 DOI: 10.1177/07334648231216644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Abstract
An increasing body of evidence highlights the importance of an individual's place of residence on their health and functional outcomes. This study is based on Outcome and Assessment Information Set data to assess the differences in emergency department visits among Medicare home health care patients by patients' residence location (rural/urban status and neighborhood socioeconomic status). Compared to urban patients, a disproportionately higher proportion of rural patients lived in more or most disadvantaged neighborhoods (83.9% vs. 41.3%). Using linear probability regression models, patients in rural areas (coefficient = .02, p < .001) and disadvantaged neighborhoods (less disadvantaged: coefficient = .02, p < .001; more disadvantaged: coefficient = .034, p < .001; most disadvantaged: coefficient = .042, p < .001) were more likely to experience emergency department visits. Policymakers should consider utilizing area-based target interventions to mitigate gaps in home health care. Also, given that the majority of rural patients reside in disadvantaged neighborhoods, neighborhood characteristics should be considered in addressing rural-urban disparities and improving home health care.
Collapse
Affiliation(s)
- Daniel Jung
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
| | - Suhang Song
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
| | - Chenjuan Ma
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| |
Collapse
|
8
|
Hansen RM, Agana-Norman DFG, Hufton A, Hansen MA. Submersion Injuries and the Cost of Injury Associated with Drowning Events in the United States, 2006-2015. J Community Health 2024; 49:549-558. [PMID: 38145432 DOI: 10.1007/s10900-023-01323-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION The World Health Organization has reported submersion injuries as the third most common cause of death due to unintentional injury in the world. Greater detail in the rates, risk factors, and healthcare associated costs of submersion injuries could be instrumental in demonstrating the need for further funding and intervention. METHODS The study was a cross-sectional analysis of a nationally representative dataset of inpatient and emergency department (ED) encounters between 2006 and 2015 in the United States (US). Healthcare utilization costs were provided within the datasets and adjusted to reflect actual charges and provider fees. Lastly, the final cost values were adjusted to the 2020 US dollar (USD) and summarized using a log adjusted mean. RESULTS On average, there were 11,873 submersion injuries per year that presented to the ED in the US. Resulting in a rate where approximately 9 out of every 100,000 ED visits were associated with a submersion injury. Slightly more than 6% died in the ED, 24.2% were admitted, and 69.3% were discharged from the ED. In total, annual cost of submersion injuries in the US for ED care is approximately $12.5 million, inpatient care is approximately $27.5 million, and total annual healthcare cost exceeds $40 million. DISCUSSION While these results only represent a fraction of the total cost associated with submersion injuries, it remains substantial and unchanged over the 10-year study period. Certain demographic groups showed higher rates of injury and disease burden, thus bearing a greater amount of the cost.
Collapse
Affiliation(s)
- Regina M Hansen
- Epidemiology, Human Genetics & Environmental Sciences, University of Texas Health Science Center, Houston, TX, USA
| | - Denny Fe G Agana-Norman
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Amie Hufton
- Department of Liberal Studies, Texas A&M University at Galveston, Galveston, TX, USA
| | - Michael A Hansen
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|
9
|
Walter LA, Prados M, Lloyd A, Sontheimer S, Heimann M, Rodgers JB, Hand DT, Franco R. Birth cohort-specific consideration in an Emergency Department Hepatitis C Testing Programme: A description of age-related characteristics and outcomes. J Viral Hepat 2024; 31:233-239. [PMID: 38366787 DOI: 10.1111/jvh.13930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/15/2024] [Accepted: 02/10/2024] [Indexed: 02/18/2024]
Abstract
The emergency department (ED) has increasingly become an important public health partner in non-targeted hepatitis C virus (HCV) testing and referral to care efforts. HCV has traditionally been an infection associated with the Baby Boomer generation; however, recent exacerbation of the opioid epidemic has resulted in a growing number of younger cohorts, namely Millennials, also impacted by HCV. Examination of this age-related demographic shift, including subsequent linkage success and linkage barriers, from the perspective of an ED-based testing and linkage programme may have implications for future population and health systems interventions. A retrospective descriptive chart review was performed, inclusive of data from August 2015 through December 2020. We compared the quantity of positive HCV screening antibody (Ab) and confirmatory (RNA) tests and further considered linkage rates and correlative demographics (e.g. gender, race). Patient barriers to HCV care linkage (e.g. substance misuse, lack of health insurance, homelessness) were also evaluated. The data set was disaggregated by birth cohort to include Silent Generation (SG) (1928-45), Baby Boomer (BB) (1946-64), Generation X (Gen X) (1965-80), Millennial (1981-96) and Generation Z (1997-2012). Descriptive statistics and chi-square analysis were performed. Overall, 83,817 patients were tested for HCV (50.6% of eligible); 6187 (7.4%) were HCV Ab positive, and 2665 were HCV RNA positive (3.2%). RNA-positive individuals were more likely to be white (70.4%) and male (67.7%); generational distribution was similar (BB 33.3%, Gen X 32.0% and Millennials 32.7%). Amongst Ab-positive patients, white (45.5%), male (47.2%) and Millennial (49.7%) individuals were most likely to be RNA-positive. Overall, 28.1% of the RNA-positive cohort successfully linked to care; linkage to care rates were significantly higher in older generations (38.1% in BB vs. 17.8% in Millennials) (p < .00001). Over 90% were identified as having at least one linkage to care barrier. Younger generations (Gen X and Millennials) were disproportionately impacted by linkage barriers, including incarceration, lack of health insurance, history of mental health and substance use disorders, as well as history of or active injection drug use (IDU) (p < .00001). Older generations (SG and BB) were more likely to be impacted by competing medical comorbidities (p < .00001). The ED population represents a particularly vulnerable, at-risk cohort with a high prevalence of HCV and linkage to care barriers. While past HCV-specific recommendations and interventions have focused on Baby Boomers, this data suggests that younger generations, including Gen X and Millennials, are increasingly affected by HCV and face disparate social risk and social need factors which impede definitive care linkage and treatment.
Collapse
Affiliation(s)
- Lauren A Walter
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Myles Prados
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Audrey Lloyd
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sylvie Sontheimer
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Matthew Heimann
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joel B Rodgers
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Delissa T Hand
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ricardo Franco
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
10
|
Huguet N, Chen J, Parikh RB, Marino M, Flocke SA, Likumahuwa-Ackman S, Bekelman J, DeVoe JE. Applying Machine Learning Techniques to Implementation Science. Online J Public Health Inform 2024; 16:e50201. [PMID: 38648094 DOI: 10.2196/50201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/15/2023] [Accepted: 03/14/2024] [Indexed: 04/25/2024] Open
Abstract
Machine learning (ML) approaches could expand the usefulness and application of implementation science methods in clinical medicine and public health settings. The aim of this viewpoint is to introduce a roadmap for applying ML techniques to address implementation science questions, such as predicting what will work best, for whom, under what circumstances, and with what predicted level of support, and what and when adaptation or deimplementation are needed. We describe how ML approaches could be used and discuss challenges that implementation scientists and methodologists will need to consider when using ML throughout the stages of implementation.
Collapse
Affiliation(s)
- Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
- BRIDGE-C2 Implementation Science Center for Cancer Control, Oregon Health & Science University, Portland, OR, United States
| | - Jinying Chen
- Section of Preventive Medicine and Epidemiology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- Data Science Core, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- iDAPT Implementation Science Center for Cancer Control, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Ravi B Parikh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
- BRIDGE-C2 Implementation Science Center for Cancer Control, Oregon Health & Science University, Portland, OR, United States
| | - Susan A Flocke
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
- BRIDGE-C2 Implementation Science Center for Cancer Control, Oregon Health & Science University, Portland, OR, United States
| | - Sonja Likumahuwa-Ackman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
- BRIDGE-C2 Implementation Science Center for Cancer Control, Oregon Health & Science University, Portland, OR, United States
| | - Justin Bekelman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, United States
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
- BRIDGE-C2 Implementation Science Center for Cancer Control, Oregon Health & Science University, Portland, OR, United States
| |
Collapse
|
11
|
Khairat S, John R, Pillai M, McDaniel P, Edson B. Patient Characteristics Associated With Phone and Video Visits at a Tele-Urgent Care Center During the Initial COVID-19 Response: Cross-Sectional Study. Online J Public Health Inform 2024; 16:e50962. [PMID: 38241073 PMCID: PMC10802832 DOI: 10.2196/50962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/04/2023] [Accepted: 11/16/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Health systems rapidly adopted telemedicine as an alternative health care delivery modality in response to the COVID-19 pandemic. Demographic factors, such as age and gender, may play a role in patients' choice of a phone or video visit. However, it is unknown whether there are differences in utilization between phone and video visits. OBJECTIVE This study aimed to investigate patients' characteristics, patient utilization, and service characteristics of a tele-urgent care clinic during the initial response to the pandemic. METHODS We conducted a cross-sectional study of urgent care patients using a statewide, on-demand telemedicine clinic with board-certified physicians during the initial phases of the pandemic. The study data were collected from March 3, 2020, through May 3, 2020. RESULTS Of 1803 telemedicine visits, 1278 (70.9%) patients were women, 730 (40.5%) were aged 18 to 34 years, and 1423 (78.9%) were uninsured. There were significant differences between telemedicine modalities and gender (P<.001), age (P<.001), insurance status (P<.001), prescriptions given (P<.001), and wait times (P<.001). Phone visits provided significantly more access to rural areas than video visits (P<.001). CONCLUSIONS Our findings suggest that offering patients a combination of phone and video options provided additional flexibility for various patient subgroups, particularly patients living in rural regions with limited internet bandwidth. Differences in utilization were significant based on patient gender, age, and insurance status. We also found differences in prescription administration between phone and video visits that require additional investigation.
Collapse
Affiliation(s)
- Saif Khairat
- Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Cecil G Sheps Center for Health Services Research, Chapel Hill, NC, United States
- School of Nursing, University North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Roshan John
- Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Malvika Pillai
- Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Philip McDaniel
- Digital Research Services Department, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | |
Collapse
|
12
|
Aguirre AO, Lim J, Kuo CC, Ruggiero N, Siddiqi M, Monteiro A, Baig AA, Housley SB, Recker MJ, Li V, Reynolds RM. Social Determinants of Health and Associations With Outcomes in Pediatric Patients With Brain Tumors. Neurosurgery 2024; 94:108-116. [PMID: 37526439 DOI: 10.1227/neu.0000000000002624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/25/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Social determinants of health (SDOH) are nonmedical factors that affect health outcomes. Limited investigation has been completed on the potential association of these factors to adverse outcomes in pediatric populations. In this study, the authors aimed to analyze the effects of SDOH disparities and their relationship with outcomes after brain tumor resection or biopsy in children. METHODS The authors retrospectively reviewed the records of their center's pediatric patients with brain tumor. Black race, public insurance, median household income, and distance to hospital were the investigated SDOH factors. Univariate analysis was completed between number of SDOH factors and patient demographics. Multivariate linear regression models were created to identify coassociated determinants and outcomes. RESULTS A total of 272 patients were identified and included in the final analysis. Among these patients, 81 (29.8%) had no SDOH disparities, 103 (37.9%) had 1, 71 (26.1%) had 2, and 17 (6.2%) had 3. An increased number of SDOH disparities was associated with increased percentage of missed appointments ( P = .002) and emergency room visits ( P = .004). Univariate analysis demonstrated increased missed appointments ( P = .01), number of postoperative imaging ( P = .005), and number of emergency room visits ( P = .003). In multivariate analysis, decreased median household income was independently associated with increased length of hospital stay ( P = .02). CONCLUSION The SDOH disparities are prevalent and impactful in this vulnerable population. This study demonstrates the need for a shift in research focus toward identifying the full extent of the impact of these factors on postoperative outcomes in pediatric patients with brain tumor.
Collapse
Affiliation(s)
- Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Nicco Ruggiero
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Manhal Siddiqi
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
| | - Steven B Housley
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
| | - Matthew J Recker
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
| | - Veetai Li
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Pediatric Neurosurgery, John R. Oishei Children's Hospital, Buffalo , New York , USA
| | - Renée M Reynolds
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Pediatric Neurosurgery, John R. Oishei Children's Hospital, Buffalo , New York , USA
| |
Collapse
|
13
|
Fleszar-Pavlovic SE, Natori A, Moreno PI, Medina HN, Sookdeo V, MacIntyre J, Penedo FJ. Associations between age and patient-reported outcomes, emergency department visits, and hospitalizations among lung cancer patients receiving immune checkpoint inhibitors. Psychooncology 2024; 33:e6293. [PMID: 38282219 PMCID: PMC10926986 DOI: 10.1002/pon.6293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/06/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) for lung cancer (LC) treatment have a more favorable safety profile and improved patient reported outcomes (PROs) compared to chemotherapy, suggesting that ICIs are advantageous for older populations. The impact of ICIs on PROs, clinical outcomes, and age in LC patients remains to be established. We examined associations between age and PROs, emergency department (ED) visits, and hospitalizations in LC patients receiving ICIs. METHODS We performed retrospective analyses via My Wellness Check (MWC), an assessment and triage electronic medical record (EMR) integrated platform in LC patients receiving ICIs. Demographics, clinical characteristics, ED visits, and hospitalizations were extracted via EMR. Patient reported outcomes (PROMIS® anxiety, depression, fatigue, pain, physical function), and health-related quality of life (HRQOL; FACT-G7), were collected via MWC. We classified age into three categories (<65, 65-74, ≥75). Multiple regressions examined associations between PROs and age. Cox proportional hazards regressions assessed cumulative ED visits and hospitalizations. RESULTS Among LC patients (N = 190) receiving ICIs, patients ≥75 had lower depression (β = -5.80, p = 0.01) and higher HRQOL (β = 2.47, p = 0.05) compared with patients <65. Relative to patients <65, patients 65-74 had lower anxiety (β = -3.31, p = 0.05) and pain (β = -4.18, p = 0.03). Patients 65-74 and ≥ 75 had lower risk of an ED visit (adjusted hazards ratio [aHR] = 0.45, p = 0.05 and aHR = 0.21, p = 0.05, respectively) and patients 65-74 had lower risk of hospitalization (aHR = 0.36, p = 0.02) relative to patients <65. CONCLUSIONS Older LC patients (65-74; ≥75) have more favorable PROs and lower risk for negative clinical outcomes than younger (<65) patients.
Collapse
Affiliation(s)
| | - Akina Natori
- Division of Medical Oncology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Patricia I Moreno
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Heidy N Medina
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Vandana Sookdeo
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Jessica MacIntyre
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Frank J Penedo
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Psychology and Medicine, University of Miami, Miami, Florida, USA
| |
Collapse
|
14
|
Singh P, Nawaz S, Seiber EE, Bryant I, Moon K, Wastler H, Breitborde NJ. ED Visits for Schizophrenia Spectrum Disorders During the COVID-19 Pandemic at 5 Campus Health Systems. JAMA Netw Open 2023; 6:e2349305. [PMID: 38150255 PMCID: PMC10753394 DOI: 10.1001/jamanetworkopen.2023.49305] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/10/2023] [Indexed: 12/28/2023] Open
Abstract
Importance Although substantial research has reported grave population-level psychiatric sequelae of the COVID-19 pandemic, evidence pertaining to temporal changes in schizophrenia spectrum disorders in the US following the pandemic remains limited. Objective To examine the monthly patterns of emergency department (ED) visits for schizophrenia spectrum disorders after the onset of the COVID-19 pandemic. Design, Setting, and Participants This observational cohort study used time-series analyses to examine whether monthly counts of ED visits for schizophrenia spectrum disorders across 5 University of California (UC) campus health systems increased beyond expected levels during the COVID-19 pandemic. Data included ED visits reported by the 5 UC campuses from 2016 to 2021. Participants included persons who accessed UC Health System EDs had a diagnosis of a psychiatric condition. Data analysis was performed from March to June 2023. Exposures The exposures were binary indicators of initial (March to May 2020) and extended (March to December 2020) phases of the COVID-19 pandemic. Main Outcomes and Measures The primary outcome was monthly counts of ED visits for schizophrenia spectrum disorders. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes, categorized within Clinical Classification Software groups, were used to identify ED visits for schizophrenia spectrum disorders and all other psychiatric ED visits, from the University of California Health Data Warehouse database, from January 2016 to December 2021. Time-series analyses controlled for autocorrelation, seasonality, and concurrent trends in ED visits for all other psychiatric conditions. Results The study data comprised a total of 377 872 psychiatric ED visits, with 37 815 visits for schizophrenia spectrum disorders. The prepandemic monthly mean (SD) number of ED visits for schizophrenia spectrum disorders was 519.9 (38.1), which increased to 558.4 (47.6) following the onset of the COVID-19 pandemic. Results from time series analyses, controlling for monthly counts of ED visits for all other psychiatric conditions, indicated 70.5 additional ED visits (95% CI, 11.7-129.3 additional visits; P = .02) for schizophrenia spectrum disorders at 1 month and 74.9 additional visits (95% CI, 24.0-126.0 visits; P = .005) at 3 months following the initial phase of the COVID-19 pandemic in California. Conclusions and Relevance This study found a 15% increase in ED visits for schizophrenia spectrum disorders within 3 months after the initial phase of the pandemic in California across 5 UC campus health systems, underscoring the importance of social policies related to future emergency preparedness and the need to strengthen mental health care systems.
Collapse
Affiliation(s)
- Parvati Singh
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus
| | - Saira Nawaz
- Center for Health Outcomes and Policy Evaluation Studies, College of Public Health, The Ohio State University, Columbus
| | - Eric E Seiber
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus
| | - Ian Bryant
- Department of Economics, University of Cincinnati, Cincinnati, Ohio
| | - Kyle Moon
- Center for Health Outcomes and Policy Evaluation Studies, College of Public Health, The Ohio State University, Columbus
| | - Heather Wastler
- Early Psychosis Intervention Center, Department of Psychiatry and Behavioral Health, College of Medicine, The Ohio State University, Columbus
| | - Nicholas J Breitborde
- Early Psychosis Intervention Center, Department of Psychiatry and Behavioral Health, College of Medicine, The Ohio State University, Columbus
| |
Collapse
|
15
|
Armoon B, Griffiths MD, Mohammadi R, Ahounbar E, Fleury MJ. Acute care utilization and its associated determinants among patients with substance-related disorders: A worldwide systematic review and meta-analysis. J Psychiatr Ment Health Nurs 2023; 30:1096-1113. [PMID: 37211655 DOI: 10.1111/jpm.12936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/03/2023] [Accepted: 05/07/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Identifying determinants of emergency department (ED) use and hospitalization among patients with substance-related disorders (SRDs) can improve health services to address unmet health needs. AIM The present study aimed to identify the prevalence rates of ED use and hospitalization, and their associated determinants among patients with SRDs. METHODS Studies in English published from January 1, 1995, to December 1, 2022, were searched on PubMed, Scopus, Cochrane Library, and Web of Science to identify primary studies. RESULTS The pooled prevalence rates of ED use and hospitalization among patients with SRDs were 36% and 41%, respectively. Patients with SRDs who were the most at risk of being both ED users and hospitalized were those (i) having medical insurance, (ii) having other drug and alcohol use disorders, (iii) having mental health disorders, and (iv) having chronic physical illnesses. A lower level of education increased the risk of ED use only. DISCUSSION To decrease ED use and hospitalization, more comprehensive services may be offered to these vulnerable patients with diversified needs. IMPLICATIONS FOR PRACTICE Chronic care integrating outreach interventions could be more provided for patients with SRDs after discharge from acute care units or hospitals.
Collapse
Affiliation(s)
- Bahram Armoon
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Mark D Griffiths
- International Gaming Research Unit, Psychology Department, Nottingham Trent University, Nottingham, UK
| | - Rasool Mohammadi
- Social Determinants of Health Research Center, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
- Department of Biostatistics and Epidemiology, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Elaheh Ahounbar
- Orygen, The National Center of Excellence in Youth Mental Health, University of Melbourne, Parkville, Victoria, Australia
- Center for Youth Mental Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Marie-Josée Fleury
- Douglas Hospital Research Centre, Montreal, Quebec, Canada
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
16
|
Ukert B, Giannouchos TV. Association of the affordable care act with racial and ethnic disparities in uninsured emergency department utilization. BMC Health Serv Res 2023; 23:1302. [PMID: 38007468 PMCID: PMC10676572 DOI: 10.1186/s12913-023-10168-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 10/17/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Disparities in uninsured emergency department (ED) use are well documented. However, a comprehensive analysis evaluating how the Affordable Care Act (ACA) may have reduced racial and ethnic disparities is lacking. The goal was to assess the association of the ACA with racial and ethnic disparities in uninsured ED use. METHODS This study used data from the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) for Georgia, Florida, Massachusetts, and New York from 2011 to 2017. Participants include non-elderly adults between 18 and 64 years old. Outcomes include uninsured rates of ED visits by racial and ethnic groups and stratified by medical urgency using the New York University ED algorithm. Visits were aggregated to year-quarter ED visits per 100,000 population and stratified for non-Hispanic White, non-Hispanic Black, and Hispanic non-elderly adults. Quasi-experimental difference-in-differences and triple differences regression analyses to identify the effect of the ACA and the separate effect of the Medicaid expansion were used comparing uninsured ED visits by race and ethnicity groups pre-post ACA. RESULTS The ACA was associated with a 14% reduction in the rate of uninsured ED visits per 100,000 population (from 10,258 pre-ACA to 8,877 ED visits per 100,000 population post-ACA) overall. The non-Hispanic Black compared to non-Hispanic White disparity decreased by 12.4% (-275.1 ED visits per 100,000) post-ACA. About 60% of the decline in the Black-White disparity was attributed to disproportionate declines in ED visit rates for conditions classified as not-emergent (-93.2 ED visits per 100,000), and primary care treatable/preventable (-64.1 ED visits per 100,000), while the disparity in ED visit rates for injuries and not preventable conditions also declined (-106.57 ED visits per 100,000). All reductions in disparities were driven by the Medicaid expansion. No significant decrease in Hispanic-White disparity was observed. CONCLUSIONS The ACA was associated with fewer uninsured ED visits and reduced the Black-White ED disparity, driven mostly by a reduction in less emergent ED visits after the ACA in Medicaid expansion states. Disparities between Hispanic and non-Hispanic White adults did not decline after the ACA. Despite the positive momentum of declining disparities in uninsured ED visits, disparities, especially among Black people, remain.
Collapse
Affiliation(s)
- Benjamin Ukert
- Department of Health Policy and Management, Texas A&M University, 212 Adriance Lab Road, 1266 TAMU, College Station, 77843-1266, USA.
| | - Theodoros V Giannouchos
- Department of Health Policy and Organization, The University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL, 35233, USA.
| |
Collapse
|
17
|
Palte NK, Adler LSF, Ady JW, Truong H, Rahimi SA, Beckerman WE. Area Deprivation Index is not predictive of worse outcomes after open lower extremity revascularization. J Vasc Surg 2023; 78:1030-1040.e2. [PMID: 37318431 DOI: 10.1016/j.jvs.2023.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Prior research has shown that socioeconomic status (SES) is associated with higher rates of diabetes, peripheral vascular disease, and amputation. We sought to determine whether SES or insurance type increases the risk of mortality, major adverse limb events (MALE), or hospital length of stay (LOS) after open lower extremity revascularization. METHODS We conducted a retrospective analysis of patients who underwent open lower extremity revascularization at a single tertiary care center from January 2011 to March 2017 (n = 542). SES was determined using state Area Deprivation Index (ADI), a validated metric determined by income, education, employment, and housing quality by census block group. Patients undergoing amputation in this same time period (n = 243) were included to compare rates of revascularization to amputation by ADI and insurance status. For patients undergoing revascularization or amputation procedures on both limbs, each limb was treated individually for this analysis. We performed a multivariate analysis of the association between ADI and insurance type with mortality, MALE, and LOS using Cox proportional hazard models, including confounding variables such as age, gender, smoking status, body mass index, hyperlipidemia, hypertension, and diabetes. The cohort with an ADI quintile of 1, meaning least deprived, and the Medicare cohort were used for reference. P values of <.05 were considered statistically significant. RESULTS We included 246 patients undergoing open lower extremity revascularization and 168 patients undergoing amputation. Controlling for age, gender, smoking status, body mass index, hyperlipidemia, hypertension, and diabetes, ADI was not an independent predictor of mortality (P = .838), MALE (P = .094), or hospital LOS (P = .912). Controlling for the same confounders, uninsured status was independently predictive of mortality (P = .033), but not MALE (P = .088) or hospital LOS (P = .125). There was no difference in the distribution of revascularizations or amputations by ADI (P = .628), but there was higher proportion of uninsured patients undergoing amputation compared with revascularization (P < .001). CONCLUSIONS This study suggests that ADI is not associated with an increased risk of mortality or MALE in patients undergoing open lower extremity revascularization, but that uninsured patients are at higher risk of mortality after revascularization. These findings indicate that individuals undergoing open lower extremity revascularization at this single tertiary care teaching hospital received similar care, regardless of their ADI. Further study is warranted to understand the specific barriers that uninsured patients face.
Collapse
Affiliation(s)
- Nadia K Palte
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ
| | - Lily S F Adler
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ
| | - Justin W Ady
- Department of Surgery, Division of Vascular and Endovascular Therapy, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Huong Truong
- Department of Surgery, Division of Vascular and Endovascular Therapy, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Saum A Rahimi
- Department of Surgery, Division of Vascular and Endovascular Therapy, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - William E Beckerman
- Department of Surgery, Division of Vascular and Endovascular Therapy, Robert Wood Johnson Medical School, New Brunswick, NJ.
| |
Collapse
|
18
|
Lett E, Tran NK, Nweke N, Nguyen M, Kim JG, Holmboe E, McDade W, Boatright D. Intersectional Disparities in Emergency Medicine Residents' Performance Assessments by Race, Ethnicity, and Sex. JAMA Netw Open 2023; 6:e2330847. [PMID: 37733347 PMCID: PMC10514741 DOI: 10.1001/jamanetworkopen.2023.30847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 07/19/2023] [Indexed: 09/22/2023] Open
Abstract
Importance Previous studies have demonstrated sex-specific disparities in performance assessments among emergency medicine (EM) residents. However, less work has focused on intersectional disparities by ethnoracial identity and sex in resident performance assessments. Objective To estimate intersectional sex-specific ethnoracial disparities in standardized EM resident assessments. Design, Setting, and Participants This retrospective cohort study used data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education Milestones (Milestones) assessments to evaluate ratings for EM residents at 128 EM training programs in the US. Statistical analyses were conducted in June 2020 to January 2023. Exposure Training and assessment environments in EM residency programs across comparison groups defined by ethnoracial identity (Asian, White, or groups underrepresented in medicine [URM], ie, African American/Black, American Indian/Alaska Native, Hispanic/Latine, and Native Hawaiian/Other Pacific Islander) and sex (female/male). Main Outcomes and Measures Mean Milestone scores (scale, 0-9) across 6 core competency domains: interpersonal and communications skills, medical knowledge, patient care, practice-based learning and improvement, professionalism, and system-based practice. Overall assessment scores were calculated as the mean of the 6 competency scores. Results The study sample comprised 128 ACGME-accredited programs and 16 634 assessments for 2708 EM residents of which 1913 (70.6%) were in 3-year and 795 (29.4%) in 4-year programs. Most of the residents were White (n = 2012; 74.3%), followed by Asian (n = 477; 17.6%), Hispanic or Latine (n = 213; 7.9%), African American or Black (n = 160; 5.9%), American Indian or Alaska Native (n = 24; 0.9%), and Native Hawaiian or Other Pacific Islander (n = 4; 0.1%). Approximately 14.3% (n = 386) and 34.6% (n = 936) were of URM groups and female, respectively. Compared with White male residents, URM female residents in 3-year programs were rated increasingly lower in the medical knowledge (URM female score, -0.47; 95% CI, -0.77 to -0.17), patient care (-0.18; 95% CI, -0.35 to -0.01), and practice-based learning and improvement (-0.37; 95% CI, -0.65 to -0.09) domains by postgraduate year 3 year-end assessment; URM female residents in 4-year programs were also rated lower in all 6 competencies over the assessment period. Conclusions and Relevance This retrospective cohort study found that URM female residents were consistently rated lower than White male residents on Milestone assessments, findings that may reflect intersectional discrimination in physician competency evaluation. Eliminating sex-specific ethnoracial disparities in resident assessments may contribute to equitable health care by removing barriers to retention and promotion of underrepresented and minoritized trainees and facilitating diversity and representation among the emergency physician workforce.
Collapse
Affiliation(s)
- Elle Lett
- Health Systems and Population Health, University of Washington School of Public Health, Seattle
- Center for Anti-Racism and Community Health, University of Washington School of Public Health, Seattle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nguyen Khai Tran
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Palo Alto, California
| | - Nkemjika Nweke
- St George’s University School of Medicine, St George, Grenada
| | | | - Jung G. Kim
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Eric Holmboe
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - William McDade
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Dowin Boatright
- Ronald O. Perelman Department of Emergency Medicine, New York University, New York
| |
Collapse
|
19
|
Steinman L, Xing J, Court B, Coe NB, Yip A, Hill C, Rector B, Baquero B, Weiner BJ, Snowden M. Can a Home-Based Collaborative Care Model Reduce Health Services Utilization for Older Medicaid Beneficiaries Living with Depression and Co-occurring Chronic Conditions? A Quasi-experimental Study. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:712-724. [PMID: 37233831 DOI: 10.1007/s10488-023-01271-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/27/2023]
Abstract
Depression remains a major public health issue for older adults, increasing risk of costly health services utilization. While home-based collaborative care models (CCM) like PEARLS have been shown to effectively treat depression in low-income older adults living with multiple chronic conditions, their economic impact is unclear. We conducted a quasi-experimental study to estimate PEARLS effect on health service utilization among low-income older adults. Our secondary data analysis merged de-identified PEARLS program data (N = 1106), home and community-based services (HCBS) administrative data (N = 16,096), and Medicaid claims and encounters data (N = 164) from 2011 to 2016 in Washington State. We used nearest neighbor propensity matching to create a comparison group of social service recipients similar to PEARLS participants on key determinants of utilization guided by Andersen's Model. Primary outcomes were inpatient hospitalizations, emergency room (ER) visits, and nursing home days; secondary outcomes were long-term supports and services (LTSS), mortality, depression and health. We used an event study difference-in-difference (DID) approach to compare outcomes. Our final dataset included 164 older adults (74% female, 39% people of color, mean PHQ-9 12.2). One-year post-enrollment, PEARLS participants had statistically significant improvements in inpatient hospitalizations (69 fewer hospitalizations per 1000 member months, p = 0.02) and 37 fewer nursing home days (p < 0.01) than comparison group participants; there were no significant improvements in ER visits. PEARLS participants also experienced lower mortality. This study shows the potential value of home-based CCM for participants, organizations and policymakers. Future research is needed to examine potential cost savings.
Collapse
Affiliation(s)
- Lesley Steinman
- Health Promotion Research Center, Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, USA.
- Hans Rosling Center, University of Washington, 3980 15th Avenue NE, UW Mailbox 351621, Seattle, WA, 98195, USA.
| | - Jingping Xing
- Research and Data Analysis Division, Washington State Department of Social and Health Services, Olympia, USA
| | - Beverly Court
- Research and Data Analysis Division, Washington State Department of Social and Health Services, Olympia, USA
| | - Norma B Coe
- Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, USA
| | - Andrea Yip
- Seattle-King County Aging and Disability Services, Seattle, USA
| | - Clara Hill
- Department of Human Development, Washington State University, Pullman, USA
| | - Bea Rector
- Washington State Department of Social and Health Services, Aging and Long-Term Support Administration, Lacey, USA
| | - Barbara Baquero
- Health Promotion Research Center, Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington Schools of Medicine and Public Health, Seattle, USA
| | - Mark Snowden
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
| |
Collapse
|
20
|
Peck GL, Kuo YH, Hudson SV, Gracias VH, Roy JA, Strom BL. Decreased Emergency Cholecystectomy and Case Fatality Rate, Not Explained by Expansion of Medicaid. J Surg Res 2023; 288:350-361. [PMID: 37060861 PMCID: PMC10192015 DOI: 10.1016/j.jss.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 12/21/2022] [Accepted: 03/08/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION Population data on longitudinal trends for cholecystectomies and their outcomes are scarce. We evaluated the incidence and case fatality rate of emergency and ambulatory cholecystectomies in New Jersey (NJ) and whether the Medicaid expansion changed trends. MATERIALS AND METHODS A retrospective population cohort design was used to study the incidence of cholecystectomies and their case fatality rate from 2009 to 2018. Using linear and logistic regression we explored the trends of incidence and the odds of case fatality after versus before the January 1, 2014 Medicaid expansion. RESULTS Overall, 93,423 emergency cholecystectomies were performed, with 644 fatalities; 87,239 ambulatory cholecystectomies were performed, with fewer than 10 fatalities. The 2009 to 2018 annual incidence of emergency cholecystectomies dropped markedly from 114.8 to 77.5 per 100,000 NJ population (P < 0.0001); ambulatory cholecystectomies increased from 93.5 to 95.6 per 100,000 (P = 0.053). The incidence of emergency cholecystectomies dropped more after than before Medicaid expansion (P < 0.0001). The odds ratio for case fatality among those undergoing emergency cholecystectomies after versus before expansion was 0.85 (95% CI, 0.72-0.99). This decrease in case fatality, apparent only in those over age 65, was not explained by the addition of Medicaid. CONCLUSIONS A marked decrease in the incidence of emergency cholecystectomies occurred after Medicaid expansion, which was not accounted for by a minimal increase in the incidence of ambulatory cholecystectomies. Case fatality from emergency cholecystectomy decreased over time due to factors other than Medicaid. Further work is needed to reconcile these findings with the previously reported lack of decrease in overall gallstone disease mortality in NJ.
Collapse
Affiliation(s)
- Gregory L Peck
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey; New Jersey Alliance for Clinical and Translational Science, New Brunswick, New Jersey.
| | - Yen-Hong Kuo
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Shawna V Hudson
- New Jersey Alliance for Clinical and Translational Science, New Brunswick, New Jersey; Department of Family Practice, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey; Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Vicente H Gracias
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jason A Roy
- New Jersey Alliance for Clinical and Translational Science, New Brunswick, New Jersey; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Brian L Strom
- Rutgers Biomedical and Health Sciences, Newark, New Jersey
| |
Collapse
|
21
|
Forster BL, Thomas F, Arnold SR, Snider MA. Early Intravenous Magnesium Sulfate Administration in the Emergency Department for Severe Asthma Exacerbations. Pediatr Emerg Care 2023; 39:524-529. [PMID: 36728409 DOI: 10.1097/pec.0000000000002890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Severe asthma exacerbations in pediatric patients occur frequently and can require pediatric intensive care unit (PICU) admission. OBJECTIVE To determine if early administration of intravenous magnesium sulfate (IVMg) to pediatric patients experiencing severe asthma exacerbations, defined as a respiratory clinical score (RCS) of 9 to 12, resulted in fewer PICU admissions. METHODS Retrospective chart review of pediatric patients aged from 2 to 17 years presenting with a severe asthma exacerbation to a single tertiary care pediatric emergency department. Univariable and multivariable logistic regression analyses were used to determine if admission to the PICU was associated with early IVMg treatment, within 60 minutes of registration. RESULTS A total of 1911 patients were included in the study, of which 1541 received IVMg. The average time to IVMg was 79 minutes, with 35% of the patients receiving it within 60 minutes of arrival. Two hundred forty-eight (13%) were admitted to the PICU, 641 (34%) were admitted to the general inpatient floor, and 1022 (53%) were discharged home. Factors associated with increased odds ratio (OR) of PICU admission were: early IVMg (OR, 1.63; 95% CI: 1.16-2.28), arrival mode to the emergency department via ambulance (OR, 2.23; 95% CI: 1.45-3.43), history of PICU admission for asthma (OR, 1.73; 95% CI: 1.22-2.44), and diagnosis of status asthmaticus (OR, 8.88; 95% CI: 3.49-30.07). Calculated OR of PICU admission subcategorized by RCS for early IVMg patients, after controlling for PICU risk factors, are as follows: RCS 9 (reference), RCS 10 (OR, 2.52; 95% CI: 0.89-2.23), RCS 11 (OR, 2.19; 95% CI: 1.3-3.70), and RCS 12 (OR, 4.12; 95% CI: 2.13-7.95). CONCLUSIONS Early administration of IVMg to pediatric patients experiencing severe asthma exacerbations does not result in fewer PICU admissions.
Collapse
Affiliation(s)
- Brian L Forster
- From the Division of Emergency Services, Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventative Medicine, The University of Tennessee Health Science Center
| | - Sandra R Arnold
- Division of Infectious Diseases, Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN
| | - Mark A Snider
- From the Division of Emergency Services, Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital
| |
Collapse
|
22
|
Evaluation of the association between health insurance status and healthcare utilization and expenditures among adult cancer survivors in the United States. Res Social Adm Pharm 2023; 19:821-829. [PMID: 36842898 DOI: 10.1016/j.sapharm.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/03/2022] [Accepted: 02/15/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Health care expenditures for cancer care has increased significantly over the past decade and is further projected to rise. This study examined the associations between health insurance status and total direct health care expenditures and health care utilization among cancer survivors living in the United States. METHODS A cross-sectional study of cancer survivors aged ≥18 years, identified from the Medical Expenditures Panel Survey (MEPS) during 2017 using International Classification of Diseases, Tenth Revision codes specific for cancer. Health insurance was categorized into Private, Medicare, Medicaid, and uninsured. Multivariable ordinary least squares regression was used to examine the association between log expenditures and health insurance. Negative binomial regression with log link was used to obtain adjusted incident rate ratios (AIRR) for health care utilization. Survey weights were used to produce nationally representative estimates of the US population. RESULTS A total of 1140 (weighted = 13.9 million) cancer survivors were identified. Compared to the adjusted mean annual health care expenditures for the private group ($14,265; 95% confidence interval (CI): $12,645 to $16,092), the adjusted mean annual health care expenditures for the Medicare group were higher ($15,112; 95%CI: $13,361 to $17,092). As compared to the private group, the average annual expenditures for uninsured cancer survivors ($2315; 95%CI:1038 to $3501) was significantly lower and so was their health care utilization. Adjusted rates of ER visits for Medicaid were twice (AIRR:2.04; SE:0.28; p = 0.001) as compared to privately insured. CONCLUSIONS A difference in the average total direct expenditures between uninsured and privately insured patients was found. Uninsured had the lowest health care utilization while Medicaid reported significantly higher number of ER visits. Despite differences in program structures, health care expenditures across insurance types were similar. Lower utilization of health care services among uninsured suggests cost maybe a barrier to accessing care.
Collapse
|
23
|
Patel K, Diaz MJ, Taneja K, Batchu S, Zhang A, Mohamed A, Wolfe J, Patel UK. Predictors of inpatient admission likelihood and prolonged length of stay among cerebrovascular disease patients: A nationwide emergency department sample analysis. J Stroke Cerebrovasc Dis 2023; 32:106983. [PMID: 36641949 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/20/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To examine the hospital- and patient-related factors associated with increased likelihood of inpatient admission and extended hospitalization. METHODS We applied multivariate logistic regression to a subset of ED hospital and patient characteristics linearly extrapolated from the 2019 National Emergency Department Sample database (n=626,508). Patient characteristics with 10 or fewer ED visits after national extrapolation were not reported in the current study to maintain patient confidentiality, in accordance with the HCUP Data Use Agreement. All selected ED visits represented a primary diagnosis of CVD (ICD-10 codes 160-168). All reported hospital and patient characteristics were subject to adjustment for covariates. P-values < 0.05 were considered statistically significant. MAIN FINDINGS Medicare beneficiaries report higher inpatient admission rates than uninsured OR 0.81 (0.73-0.91) and privately insured OR 0.86 (0.79-0.94) individuals. Black and Native-American patients were 37% and 55% more likely to be hospitalized long (>75th percentile) (OR 1.37 [1.25-1.50], OR 1.55 [1.14-2.10]). Northeast emergency departments reported an increased odds of admission compared to the Midwest OR (0.40-0.62), South OR 0.79 (0.63-0.98) and West OR 0.52 (0.39-0.69). Patients with multiple comorbidities (mCCI = 3+) were 226% more likely to have a longer stay OR 3.26 (3.09-3.45) than patients presenting with zero or few comorbidities. Level I, II, and III trauma centers report distinctly high odds of inpatient admission (OR 3.54 [2.84-4.42], OR 2.68 [2.14-3.35], OR 1.51 [1.25-1.84]). PRINCIPAL CONCLUSIONS Likelihoods of inpatient admission and long hospital stays were observably stratified through multiple, independently acting hospital and patient characteristics. Significant associations were stratified by race/ethnicity, location, and clinical presentation, among others. Attention to the factors reported here may serve well to mitigate emergency department crowding and its sobering impact on United States healthcare systems and patients.
Collapse
Affiliation(s)
- Karan Patel
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States.
| | | | - Kamil Taneja
- Renaissance School of Medicine at Stony Brook University, 100 Nicolls Rd, Stony Brook, NY, 11794, United States
| | | | - Alex Zhang
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States
| | - Aleem Mohamed
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States
| | - Jared Wolfe
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States
| | - Urvish K Patel
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, United States
| |
Collapse
|
24
|
Rigney GH, Ghoshal S, Mercaldo S, Cheng D, Parks JJ, Velmahos GC, Lev MH, Raja AS, Flores EJ, Succi MD. Assessing the Relationship Between Race, Language, and Surgical Admissions in the Emergency Department. West J Emerg Med 2023; 24:141-148. [PMID: 36976591 PMCID: PMC10047742 DOI: 10.5811/westjem.2022.10.57276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 10/13/2022] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION English proficiency and race are both independently known to affect surgical access and quality, but relatively little is known about the impact of race and limited English proficiency (LEP) on admission for emergency surgery from the emergency department (ED). Our objective was to examine the influence of race and English proficiency on admission for emergency surgery from the ED. METHODS We conducted a retrospective observational cohort study from January 1-December 31, 2019 at a large, quaternary-care urban, academic medical center with a 66-bed ED Level I trauma and burn center. We included ED patients of all self-reported races reporting a preferred language other than English and requiring an interpreter or declaring English as their preferred language (control group). A multivariable logistic regression was fit to assess the association of LEP status, race, age, gender, method of arrival to the ED, insurance status, and the interaction between LEP status and race with admission for surgery from the ED. RESULTS A total of 85,899 patients (48.1% female) were included in this analysis, of whom 3,179 (3.7%) were admitted for emergent surgery. Regardless of LEP status, patients identifying as Black (odds ratio [OR] 0.456, 95% CI 0.388-0.533; P<0.005), Asian [OR 0.759, 95% CI 0.612-0.929]; P=0.009), or female [OR 0.926, 95% CI 0.862-0.996]; P=0.04) had significantly lower odds for admission for surgery from the ED compared to White patients. Compared to individuals on Medicare, those with private insurance [OR 1.25, 95% CI 1.13-1.39; P <0.005) were significantly more likely to be admitted for emergent surgery, whereas those without insurance [OR 0.581, 95% CI 0.323-0.958; P=0.05) were significantly less likely to be admitted for emergent surgery. There was no significant difference in odds of admission for surgery between LEP vs non-LEP patients. CONCLUSION Individuals without health insurance and those identifying as female, Black, or Asian had significantly lower odds of admission for surgery from the ED compared to those with health insurance, males, and those self-identifying as White, respectively. Future studies should assess the reasons underpinning this finding to elucidate impact on patient outcomes.
Collapse
Affiliation(s)
- Grant H Rigney
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Boston, Massachusetts
| | - Soham Ghoshal
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Boston, Massachusetts
| | - Sarah Mercaldo
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Debby Cheng
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Boston, Massachusetts
| | - Jonathan J Parks
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Department of Surgery, Boston, Massachusetts
| | - George C Velmahos
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Department of Surgery, Boston, Massachusetts
| | - Michael H Lev
- Massachusetts General Hospital, Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Boston, Massachusetts
| | - Ali S Raja
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Boston, Massachusetts
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Efren J Flores
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Marc D Succi
- Massachusetts General Hospital, Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Boston, Massachusetts
| |
Collapse
|
25
|
Lee J. Delayed or Forgone Care and Virtual Care in a Public Health Crisis Using Nationally Representative Population Data. Telemed J E Health 2023; 29:222-234. [PMID: 35671515 DOI: 10.1089/tmj.2022.0138] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Aim: To investigate factors influencing delayed or forgone care due to the coronavirus pandemic and examine patterns in overall virtual care use and virtual care related to the coronavirus pandemic. Methods: The cross-sectional study used the 2020 National Center for Health Statistics, National Health Interview Survey. Individuals (17,586) who responded to delayed or forgone care questions were included. A generalized linear model estimated prevalence ratios (PRs) for delayed care, forgone care, and virtual care. Results: Approximately 26.5% of participants reported either having delayed (23.6%) or forgone care (15.7%). Females showed 1.29 (95% confidence interval [CI] 1.20-1.38; p ≤ 0.000) and 1.29 (95% CI 1.17-1.48; p ≤ 0.000) times greater risk of delayed and forgone care than males, respectively. Being insured and having chronic conditions were associated with more delayed and forgone care. About 32.5% of adults reported 1 year of virtual care, and of these, 83.6% were related to the coronavirus pandemic. Patterns of virtual care use of 1 year and the one related to the coronavirus pandemic varied. In the coronavirus pandemic-related virtual care, adults of 85 years old or above had a lower likelihood (PR 0.87, 95% CI 0.77-1.00; p = 0.043) of receiving virtual care. Low education attainment and nonmetro areas showed less virtual care usage. Conclusions: The coronavirus pandemic greatly affected health care. While virtual care significantly increased, historically underserved populations, such as older adults, rural residents, and those with low education attainment, experienced disparities in virtual care use. The findings provide important implications for sustained health care in a rapidly changing public health landscape.
Collapse
Affiliation(s)
- Jusung Lee
- Department of Public Health, University of Texas at San Antonio, San Antonio, Texas, USA
| |
Collapse
|
26
|
Younger Age and Longer Case Times Associated With Emergency Department Visits After Cataract Surgery. Am J Ophthalmol 2023; 245:1-7. [PMID: 36029826 DOI: 10.1016/j.ajo.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE To characterize the frequency, reasons, hospital costs, and risk factors for emergency department (ED) visits within 30 days of cataract surgery. DESIGN Retrospective cohort study. METHODS A retrospective review of all cataract surgeries at Duke Health between 2013 and 2021 was conducted. Demographics, case characteristics (length, complexity by billing codes, anesthesia type), ED visit findings, and hospital costs were collected. Logistic regression models were used to determine the odds of ED visits based on several risk factors. RESULTS Of 34 246 patients (57 656 eyes) undergoing cataract surgery at Duke Health from 2013 to 2021, a total of 607 patients (1.77%) had 680 ED visits within 30 days of surgery. The most common ED diagnosis was cardiovascular (24.4%), whereas ocular complaints constituted 15.4% of visits. The most common ocular diagnoses were high intraocular pressure, rebound iritis, and posterior vitreous detachment. Hospital costs were lowest for ocular diagnoses (mean $467.72) and highest for trauma diagnoses (mean $4660.55). Risk factors for ED visits included case lengths greater than 30 minutes (OR 2.1, 95% CI 1.56-2.83, P < .001), the combination of Monitored Anesthesia Care (MAC) and retrobulbar anesthesia or general anesthesia (OR 2.98, 95% CI 1.73-5.12, P < .001), and age less than 70 years (OR 1.39, 95% CI 1.16-1.65, P < .001). CONCLUSIONS ED visits within 30 days of cataract surgery are uncommon. Longer case lengths, anesthesia other than MAC alone, and younger age are associated with higher odds of ED visits.
Collapse
|
27
|
Abstract
While most children with coronavirus 2019 (COVID-19) experience mild illness, some are vulnerable to severe disease and develop long-term complications. Children with disabilities, those from lower-income homes, and those from racial and ethnic minority groups are more likely to be hospitalized and to have poor outcomes following an infection. For many of these same children, a wide range of social, economic, and environmental disadvantages have made it more difficult for them to access COVID-19 vaccines. Ensuring vaccine equity in children and decreasing health disparities promotes the common good and serves society as a whole. In this article, we discuss how the pandemic has exposed long-standing injustices in historically marginalized groups and provide a summary of the research describing the disparities associated with COVID-19 infection, severity, and vaccine uptake. Last, we outline several strategies for addressing some of the issues that can give rise to vaccine inequity in the pediatric population.
Collapse
Affiliation(s)
- Carlos R Oliveira
- Corresponding Author: Carlos R. Oliveira, M.D., Ph.D., 15 York Street, PO Box 208064, New Haven, CT 06520-8064, USA. E-mail:
| | - Kristen A Feemster
- Vaccine Education Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Division of Infectious Disease, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Erlinda R Ulloa
- Department of Pediatrics, University of California Irvine School of Medicine, Irvine, CA 92697, USA
- Division of Infectious Diseases, Children’s Health of Orange County, Orange, CA 92868, USA
| |
Collapse
|
28
|
Sokol RL, Sethuraman U, Oag K, Vitale L, Donoghue L, Kannikeswaran N. Social Determinants of Severe Injury Among Pediatric Patients During the COVID-19 Pandemic: An Exploratory Study. J Pediatr Health Care 2022; 36:549-559. [PMID: 35738995 PMCID: PMC9156953 DOI: 10.1016/j.pedhc.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/27/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION This study sought to identify social determinants of health (SDH) patterns associated with severe pediatric injuries. METHOD We used cross-sectional data from children (≤18 years) admitted to a pediatric trauma center between March and November 2021 (n = 360). We used association rule mining (ARM) to explore SDH patterns associated with severe injury. We then used ARM-identified SDH patterns in multivariable logistic regressions of severe injury, controlling for patient and caregiver demographics. Finally, we compared results to naive hierarchical logistic regressions that considered SDH types as primary exposures rather than SDH patterns. RESULTS We identified three SDH patterns associated with severe injury: (1) having child care needs in combination with neighborhood violence, (2) caregiver lacking health insurance, and (3) caregiver lacking social support. In the ARM-informed logistic regression models, the presence of a child care need in combination with neighborhood violence was associated with an increased odds of severe injury (aOR, 2.77; 95% CI, 1.01-7.62), as was caregiver lacking health insurance (aOR, 2.29; 95% CI, 1.02-5.16). In the naive hierarchical logistic regressions, no SDH type in isolation was associated with severe injury. DISCUSSION Our exploratory analyses suggest that considering the co-occurrence of negative SDH that families experience rather than isolated SDH may provide greater insights into prevention strategies for severe pediatric injury.
Collapse
Affiliation(s)
| | - Usha Sethuraman
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Katherine Oag
- Division of Surgery, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Lisa Vitale
- Division of Surgery, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Lydia Donoghue
- Division of Surgery, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| |
Collapse
|
29
|
Markowitz W, Kausar K, Coffield E. Relationship between Patient Experience Scores and Health Insurance. Healthcare (Basel) 2022; 10:2128. [PMID: 36360469 PMCID: PMC9690600 DOI: 10.3390/healthcare10112128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/01/2022] [Accepted: 10/12/2022] [Indexed: 12/04/2022] Open
Abstract
(1) Background: the patient experience may be a performance indicator in value-based reimbursement. Accordingly, providers have an incentive to understand factors that affect their patients’ experiences. This study evaluated the relationship between health insurance type and patient experience ratings. (2) Methods: individual-level demographic, health/healthcare, and patient experience data were extracted from the Full-Year Consolidated Data File of the 2019 Medical Expenditure Panel Surveys. A logistic regression was used to evaluate whether how persons—included in this study’s analytic sample (aged 18 and over with complete covariate information)—rated the healthcare they received from all their providers was associated with their health insurance types controlling for covariates. (3) Results: relative to people 18−64 years of age with private health insurance, people 18−64 years of age without health insurance were less likely to rank their healthcare as a 9 or 10—where a 10 indicates the best possible care—(OR: 0.69; p = 0.015) while people aged 65 years or over with Medicare (OR: 1.34; p = 0.002) or with Medicare/private health insurance (OR: 1.48; p < 0.001) were more likely to rank their healthcare as a 9 or 10. (4) Conclusions: Select health insurance types were associated with how patients rate their healthcare. Stakeholders could use this information to create programs aimed to improve patient experience.
Collapse
Affiliation(s)
- Walter Markowitz
- Department of Population Health, Hofstra University, Hempstead, NY 11549, USA
| | | | - Edward Coffield
- Department of Population Health, Hofstra University, Hempstead, NY 11549, USA
| |
Collapse
|
30
|
Smith PD, Groves AK, Langellier BA, Keene DE, Rosenberg A, Blankenship KM. Eviction, post-traumatic stress, and emergency department use among low-income individuals in New Haven, CT. Prev Med Rep 2022; 29:101956. [PMID: 36161139 PMCID: PMC9502672 DOI: 10.1016/j.pmedr.2022.101956] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/05/2022] [Accepted: 08/14/2022] [Indexed: 11/22/2022] Open
Abstract
We sought to examine whether and how landlord-related forced moves (inclusive of, but not limited to, legal eviction) were associated with emergency department (ED) use over time. We used survey data collected between 2017 and 2019 among 283 low-income participants in New Haven, CT to examine whether experiencing a legal eviction or other landlord-related forced move (T0) was associated with increased odds of ED use 6 months (T1) and 12 months (T2) later. We conducted bootstrapped mediation analyses to examine indirect effects of post-traumatic stress symptoms. One-fifth of participants (n = 61) reported a recent forced move at baseline (T0); half of these were legally evicted. Landlord-related forced moves were associated with ED use at T1 (AOR = 2.06, 95 % CI: 1.04-4.06) and T2 (AOR = 3.05, 95 % CI: 1.59-5.88). After adjustment for sociodemographic factors and other health-related confounders, legal eviction was not significantly associated with ED use at T1 (AOR = 1.61, 95 % CI: 0.68-3.81), but was significantly associated with ED use at T2 (AOR = 3.58, 95 % CI: 1.58-8.10). Post-traumatic stress symptoms accounted for 15.1% of forced moves' association with ED use (p <.05). Landlord-related forced moves are positively associated with subsequent ED use, and post-traumatic stress symptoms are one factor that may help explain this association. Structural interventions that promote housing stability are needed to advance health equity, and they may also help to reduce preventable ED use. Such interventions are imperative in the context of the COVID-19 pandemic, which has strained health system capacity and exacerbated housing instability for many low-income renters. Results underscore the relevance of trauma-informed care and integrated care management to clinical practice in emergency settings.
Collapse
Affiliation(s)
- Patrick D. Smith
- Drexel University Dornsife School of Public Health, Department of Community Health and Prevention, Nesbitt Hall, 3215 Market Street, Philadelphia, PA 19104, USA
- Corresponding author at: Drexel University Dornsife School of Public Health, 3215 Market St, Office 718, Philadelphia, PA 19104, USA.
| | - Allison K. Groves
- Drexel University Dornsife School of Public Health, Department of Community Health and Prevention, Nesbitt Hall, 3215 Market Street, Philadelphia, PA 19104, USA
| | - Brent A. Langellier
- Drexel University Dornsife School of Public Health, Department of Health Management and Policy, Nesbitt Hall, 3215 Market Street, Philadelphia, PA 19104, USA
| | - Danya E. Keene
- Yale University School of Public Health, Department of Social and Behavioral Sciences, 60 College Street, New Haven, CT 06510, USA
| | - Alana Rosenberg
- Yale University School of Public Health, Department of Social and Behavioral Sciences, 60 College Street, New Haven, CT 06510, USA
| | - Kim M. Blankenship
- American University, Department of Sociology, 4400 Massachusetts Avenue, Washington, DC 20016, USA
| |
Collapse
|
31
|
Insaf TZ, Adeyeye T, Adler C, Wagner V, Proj A, McCauley S, Matson J. Road traffic density and recurrent asthma emergency department visits among Medicaid enrollees in New York State 2005-2015. Environ Health 2022; 21:73. [PMID: 35896993 PMCID: PMC9331590 DOI: 10.1186/s12940-022-00885-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Environmental exposures such as traffic may contribute to asthma morbidity including recurrent emergency department (ED) visits. However, these associations are often confounded by socioeconomic status and health care access. OBJECTIVE This study aims to assess the association between traffic density and recurrence of asthma ED visits in the primarily low income Medicaid population in New York State (NYS) between 2005 and 2015. METHODS The primary outcome of interest was a recurrent asthma ED visit within 1-year of index visit. Traffic densities (weighted for truck traffic) were spatially linked based on home addresses. Bivariate and multivariate logistic regression analyses were conducted to identify factors predicting recurrent asthma ED visits. RESULTS In a multivariate model, Medicaid recipients living within 300-m of a high traffic density area were at a statistically significant risk of a recurrent asthma ED visit compared to those in a low traffic density area (OR = 1.31; 95% CI:1.24,1.38). Additionally, we evaluated effect measure modification for risk of recurrent asthma visits associated with traffic exposure by socio-demographic factors. The highest risk was found for those exposed to high traffic and being male (OR = 1.87; 95% CI:1.46,2.39), receiving cash assistance (OR = 2.11; 95% CI:1.65,2.72), receiving supplemental security income (OR = 2.21; 95% CI:1.66,2.96) and being in the 18.44 age group (OR = 1.59;95% CI 1.48,1.70) was associated with the highest risk of recurrent asthma ED visit. Black non-Hispanics (OR = 2.35; 95% CI:1.70,3.24), Hispanics (OR = 2.13; 95% CI:1.49,3.04) and those with race listed as "Other" (OR = 1.89 95% CI:1.13,3.16) in high traffic areas had higher risk of recurrent asthma ED visits as compared to White non-Hispanics in low traffic areas. CONCLUSION We observed significant persistent disparities in asthma morbidity related to traffic exposure and race/ethnicity in a low-income population. Our findings suggest that even within a primarily low-income study population, socioeconomic differences persist. These differences in susceptibility in the extremely low-income group may not be apparent in health studies that use Medicaid enrollment as a proxy for low SES.
Collapse
Affiliation(s)
- Tabassum Zarina Insaf
- Bureau of Environmental and Occupational Epidemiology, New York State Department of Health, 1203 Corning Tower, Empire State Plaza, Albany, NY, USA.
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, NY, Rensselaer, USA.
| | - Temilayo Adeyeye
- Bureau of Environmental and Occupational Epidemiology, New York State Department of Health, 1203 Corning Tower, Empire State Plaza, Albany, NY, USA
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, NY, Rensselaer, USA
- Department of Environmental Health Sciences, University at Albany School of Public Health, Rensselaer, NY, USA
| | - Catherine Adler
- Bureau of Environmental and Occupational Epidemiology, New York State Department of Health, 1203 Corning Tower, Empire State Plaza, Albany, NY, USA
| | - Victoria Wagner
- Office of Quality and Patient Safety, New York State Department of Health, Albany, NY, USA
| | - Anisa Proj
- Office of Quality and Patient Safety, New York State Department of Health, Albany, NY, USA
| | - Susan McCauley
- Office of Quality and Patient Safety, New York State Department of Health, Albany, NY, USA
| | - Jacqueline Matson
- Office of Quality and Patient Safety, New York State Department of Health, Albany, NY, USA
| |
Collapse
|
32
|
Salhi BA, Zeidan A, Stehman CR, Kleinschmidt S, Liu EL, Bascombe K, Preston‐Suni K, White MH, Druck J, Lopez BL, Samuels‐Kalow ME. Structural competency in emergency medical education: A scoping review and operational framework. AEM EDUCATION AND TRAINING 2022; 6:S13-S22. [PMID: 35783075 PMCID: PMC9222890 DOI: 10.1002/aet2.10754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/10/2021] [Accepted: 12/11/2021] [Indexed: 06/15/2023]
Abstract
Objectives Existing curricula and recommendations on the incorporation of structural competency and vulnerability into medical education have not provided clear guidance on how best to do so within emergency medicine (EM). The goal of this scoping review and consensus building process was to provide a comprehensive overview of structural competency, link structural competency to educational and patient care outcomes, and identify existing gaps in the literature to inform curricular implementation and future research in EM. Methods A scoping review focused on structural competency and vulnerability following Arksey and O'Malley's six-step framework was performed in concurrence with a multistep consensus process culminating in the 2021 SAEM Consensus Conference. Feedback was incorporated in developing a framework for a national structural competency curriculum in EM. Results A literature search identified 291 articles that underwent initial screening. Of these, 51 were determined to be relevant to EM education. The papers consistently conceptualized structural competency as an interdisciplinary framework that requires learners and educators to consider historical power and privilege to develop a professional commitment to justice. However, the papers varied in their operationalization, and no consensus existed on how to observe or measure the effects of structural competency on learners or patients. None of the studies examined the structural constraints of the learners studied. Conclusions Findings emphasize the need for training structurally competent physicians via national structural competency curricula focusing on standardized core competency proficiencies. Moreover, the findings highlight the need to assess the impact of such curricula on patient outcomes and learners' knowledge, attitudes, and clinical care delivery. The framework aims to standardize EM education while highlighting the need for further research in how structural competency interventions would translate to an ED setting and affect patient outcomes and experiences.
Collapse
Affiliation(s)
- Bisan A. Salhi
- Department of Emergency MedicineEmory UniversityAtlantaGeorgiaUSA
- Department of AnthropologyEmory UniversityAtlantaGeorgiaUSA
| | - Amy Zeidan
- Department of Emergency MedicineEmory UniversityAtlantaGeorgiaUSA
| | - Christine R. Stehman
- Department of Emergency MedicineUniversity of Illinois College of MedicinePeoriaIllinoisUSA
| | - Sarah Kleinschmidt
- Department of Emergency MedicineUniversity of Massachusetts Medical School—BaystateSpringfieldMassachusettsUSA
| | - E. Liang Liu
- Department of Emergency MedicineEmory UniversityAtlantaGeorgiaUSA
| | - Kristen Bascombe
- Department of Emergency MedicineEmory UniversityAtlantaGeorgiaUSA
| | - Kian Preston‐Suni
- Department of Emergency MedicineVA Greater Los Angeles Healthcare SystemUniversity of California at Los AngelesLos AngelesCaliforniaUSA
| | - Melissa H. White
- Department of Emergency MedicineEmory UniversityAtlantaGeorgiaUSA
| | - Jeff Druck
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Bernard L. Lopez
- Department of Emergency MedicineSidney Kimmel Medical CollegePhiladelphiaPennsylvaniaUSA
| | | |
Collapse
|
33
|
Olfson M, Mauro C, Wall MM, Choi CJ, Barry CL, Mojtabai R. Healthcare coverage and service access for low-income adults with substance use disorders. J Subst Abuse Treat 2022; 137:108710. [PMID: 34998642 PMCID: PMC9086121 DOI: 10.1016/j.jsat.2021.108710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Although health coverage facilitates service access to adults in the general population, uncertainty exists over the extent to which this relationship extends to low-income adults with substance use disorders. METHODS The health status and service use patterns of low-income adults with substance use disorders who had continuous, discontinuous, and no past year health coverage were compared using data from the 2015-2019 National Survey on Drug Use and Health (NSDUH). The NSDUH is a nationally representative survey of the civilian non-institutionalized population. RESULTS In the weighted sample (unweighted n = 9243), approximately 65.66% of low-income adults with substance use disorders had continuous coverage, 17.03% had discontinuous coverage, and 17.31% had no insurance coverage during the past year. Although few group differences were observed in self-reported health status, the uninsured group compared to the discontinously and continuously covered groups, respectively, was less likely to report a past year substance use treatment visit (11.03% vs. 14.83% vs. 15.61%), an outpatient care visit (53.39% vs. 71.27% vs. 79.04%), an emergency department visit (33.33% vs. 45.76% vs. 45.57%), or an inpatient admission (9.24% vs. 15.11% vs. 15.58%). CONCLUSIONS Although the cross sectional design limits causal inferences, the correlations between lacking health insurance and low rates of substance use treatment and healthcare use raise the possibility that increasing healthcare coverage might increase access to substance use treatment and other needed healthcare services for low-income adults with substance use disorders.
Collapse
Affiliation(s)
- Mark Olfson
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States of America; Mailman School of Public Health, Columbia University, New York, NY, United States of America.
| | - Christine Mauro
- Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Melanie M Wall
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States of America; Mailman School of Public Health, Columbia University, New York, NY, United States of America; Division of Mental Health Data Science, New York State Psychiatric Institute, New York, NY, United States of America
| | - C Jean Choi
- Division of Mental Health Data Science, New York State Psychiatric Institute, New York, NY, United States of America
| | | | - Ramin Mojtabai
- Department of Health Policy and Management, Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America; Department of Mental Health, Bloomberg School of Public Health, Department of Psychiatry, Johns Hopkins University, Baltimore, MD, United States of America
| |
Collapse
|
34
|
Sabbatini AK, Dugan J. Medicaid Expansion and Avoidable Emergency Department Use-Implications for US National and State Government Spending. JAMA Netw Open 2022; 5:e2216917. [PMID: 35699963 DOI: 10.1001/jamanetworkopen.2022.16917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Amber K Sabbatini
- School of Medicine, Department of Emergency Medicine, University of Washington, Seattle
- School of Public Health, Department of Health Systems and Population Health, University of Washington, Seattle
| | - Jerome Dugan
- School of Public Health, Department of Health Systems and Population Health, University of Washington, Seattle
- Evans School of Public Policy & Governance, University of Washington, Seattle
| |
Collapse
|
35
|
Scott KW, Scott JW, Sabbatini AK, Chen C, Liu A, Dieleman JL, Duber HC. Assessing Catastrophic Health Expenditures Among Uninsured People Who Seek Care in US Hospital-Based Emergency Departments. JAMA HEALTH FORUM 2021; 2:e214359. [PMID: 35977304 PMCID: PMC8796980 DOI: 10.1001/jamahealthforum.2021.4359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/31/2021] [Indexed: 11/14/2022] Open
Abstract
Question What is the risk of a single treat-and-release emergency department (ED) visit contributing to a catastrophic health expenditure (CHE; health care costs exceeding 40% of post-subsistence income) among uninsured people? Findings In this cross-sectional study of 41.7 million ED visits from 2006 to 2017, nearly 1 in 5 (18%) uninsured treat-and-release ED patient encounters were at risk of CHE. This risk has grown over time and disproportionately burdens those with low incomes. Meaning Policies such as broadening financial risk protection for unscheduled care may help to mitigate CHE risk among uninsured people, who have few alternatives for care outside of the ED. Importance Uninsured people uniquely rely on the emergency department (ED) for care as they are less likely to have access to lower-cost alternatives. Prior work has demonstrated that most uninsured patients are at risk of catastrophic health expenditure (CHE) after being hospitalized for life-saving care. The risk of CHE for a single treat-and-release ED visit that does not result in a hospitalization among uninsured patient encounters is currently unknown. Objective To estimate the overall national risk of CHE among uninsured patients after a single treat-and-release ED visit from 2006 through 2017, and to characterize this risk across key traits. Design, Setting, and Population This cross-sectional study is based on a nationally representative sample of hospital-based ED visits between 2006 and 2017 in the United States (US) from the Nationwide Emergency Department Sample (NEDS). It examined outpatient ED visits among uninsured patients. Main Outcomes and Measures Risk of CHE for ED care defined as an ED charge that exceeds 40% of one’s estimated annual post-subsistence income. Results From 2006 to 2017, there were 41.7 million NEDS encounters that met inclusion criteria for this analysis, equating to a nationally weighted estimate of 184.6 million uninsured treat-and-release ED encounters over this period. The median ED charge for a single treat-and-release encounter grew from $842 in 2006 to $2033 by 2017. Approximately 1 in 5 uninsured patients (18% [95% CI, 18.0%-18.0%]) were at risk of CHE for a single treat-and-release ED visit over the study period. This estimated CHE risk increased from 13.6% (95% CI, 13.6%-13.6%) in 2006 to 22.6% (95% CI, 22.6%-22.7%) in 2017. Those living in the lowest income quartile faced a disproportionate share of this risk, with nearly 1 in 3 (28.5% [95% CI, 28.5%-28.6%]) facing CHE risk in 2017. In 2017, an estimated 3.2 million patient encounters nationally were at risk of CHE after a single treat-and-release ED visit. Conclusions and Relevance This cross-sectional analysis from 2006 to 2017 of 184.6 million uninsured treat-and-release visits found that 1 in 5 uninsured patient encounters are at risk for CHE. This risk has grown over time. Future policies designed to improve access for unscheduled care must consider the unique role of the ED as the de facto safety net and ensure that uninsured patients are not at undue risk of financial harm for seeking care.
Collapse
Affiliation(s)
- Kirstin Woody Scott
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - John W. Scott
- Department of Surgery, University of Michigan, Ann Arbor
| | | | - Carina Chen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Angela Liu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joseph L. Dieleman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Herbert C. Duber
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
- Department of Emergency Medicine, University of Washington, Seattle
| |
Collapse
|
36
|
James TG, Varnes JR, Sullivan MK, Cheong J, Pearson TA, Yurasek AM, Miller MD, McKee MM. Conceptual Model of Emergency Department Utilization among Deaf and Hard-of-Hearing Patients: A Critical Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182412901. [PMID: 34948509 PMCID: PMC8701061 DOI: 10.3390/ijerph182412901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/16/2022]
Abstract
Deaf and hard-of-hearing (DHH) populations are understudied in health services research and underserved in healthcare systems. Existing data indicate that adult DHH patients are more likely to use the emergency department (ED) for less emergent conditions than non-DHH patients. However, the lack of research focused on this population’s ED utilization impedes the development of health promotion and quality improvement interventions to improve patient health and quality outcomes. The purpose of this study was to develop a conceptual model describing patient and non-patient (e.g., community, health system, provider) factors influencing ED utilization and ED care processes among DHH people. We conducted a critical review and used Andersen’s Behavioral Model of Health Services Use and the PRECEDE-PROCEED Model to classify factors based on their theoretical and/or empirically described role. The resulting Conceptual Model of Emergency Department Utilization Among Deaf and Hard-of-Hearing Patients provides predisposing, enabling, and reinforcing factors influencing DHH patient ED care seeking and ED care processes. The model highlights the abundance of DHH patient and non-DHH patient enabling factors. This model may be used in quality improvement interventions, health services research, or in organizational planning and policymaking to improve health outcomes for DHH patients.
Collapse
Affiliation(s)
- Tyler G. James
- Department of Family Medicine, School of Medicine, University of Michigan, 1018 Fuller St., Ann Arbor, MI 48104, USA;
- Department of Health Education and Behavior, University of Florida, Florida Gym Room 5, P.O. Box 118210, Gainesville, FL 32611, USA; (J.C.); (A.M.Y.)
- Correspondence:
| | - Julia R. Varnes
- Department of Health Services Research, Management, and Policy, University of Florida, P.O. Box 100185, Gainesville, FL 32610, USA;
| | | | - JeeWon Cheong
- Department of Health Education and Behavior, University of Florida, Florida Gym Room 5, P.O. Box 118210, Gainesville, FL 32611, USA; (J.C.); (A.M.Y.)
| | - Thomas A. Pearson
- Department of Epidemiology, University of Florida, P.O. Box 100231, Gainesville, FL 32610, USA;
| | - Ali M. Yurasek
- Department of Health Education and Behavior, University of Florida, Florida Gym Room 5, P.O. Box 118210, Gainesville, FL 32611, USA; (J.C.); (A.M.Y.)
| | - M. David Miller
- School of Human Development and Organizational Studies in Education, University of Florida, P.O. Box 117047, Gainesville, FL 32611, USA;
| | - Michael M. McKee
- Department of Family Medicine, School of Medicine, University of Michigan, 1018 Fuller St., Ann Arbor, MI 48104, USA;
| |
Collapse
|
37
|
Wallace AS, Luther BL, Sisler SM, Wong B, Guo JW. Integrating social determinants of health screening and referral during routine emergency department care: evaluation of reach and implementation challenges. Implement Sci Commun 2021; 2:114. [PMID: 34620248 PMCID: PMC8499465 DOI: 10.1186/s43058-021-00212-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/06/2021] [Indexed: 12/29/2022] Open
Abstract
Background Despite the importance of social determinants in health outcomes, little is known about the best practices for screening and referral during clinical encounters. This study aimed to implement universal social needs screening and community service referrals in an academic emergency department (ED), evaluating for feasibility, reach, and stakeholder perspectives. Methods Between January 2019 and February 2020, ED registration staff screened patients for social needs using a 10-item, low-literacy, English-Spanish screener on touchscreens that generated automatic referrals to community service outreach specialists and data linkages. The RE-AIM framework, specifically the constructs of reach and adoption, guided the evaluation. Reach was estimated through a number of approaches, completed screenings, and receipt of community service referrals. Adoption was addressed qualitatively via content analysis and qualitative coding techniques from (1) meetings, clinical interactions, and semi-structured interviews with ED staff and (2) an iterative “engagement studio” with an advisory group composed of ED patients representing diverse communities. Results Overall, 4608 participants were approached, and 61% completed the screener. The most common reason for non-completion was patient refusal (43%). Forty-seven percent of patients with completed screeners communicated one or more needs, 34% of whom agreed to follow-up by resource specialists. Of the 482 participants referred, 20% were reached by outreach specialists and referred to community agencies. Only 7% of patients completed the full process from screening to community service referral; older, male, non-White, and Hispanic patients were more likely to complete the referral process. Iterative staff (n = 8) observations and interviews demonstrated that, despite instruction for universal screening, patient presentation (e.g., appearance, insurance status) drove screening decisions. The staff communicated discomfort with, and questioned the usefulness of, screening. Patients (n = 10) communicated a desire for improved understanding of their unmet needs, but had concerns about stigmatization and privacy, and communicated how receptivity of screenings and outreach are influenced by the perceived sincerity of screening staff. Conclusions Despite the limited time and technical barriers, few patients with social needs ultimately received service referrals. Perspectives of staff and patients suggest that social needs screening during clinical encounters should incorporate structure for facilitating patient-staff relatedness and competence, and address patient vulnerability by ensuring universal, private screenings with clear intent. Trial registration ClinicalTrials.gov, NCT04630041. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00212-y.
Collapse
Affiliation(s)
- Andrea S Wallace
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112-5880, USA. .,Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, USA.
| | - Brenda L Luther
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112-5880, USA
| | - Shawna M Sisler
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112-5880, USA
| | - Bob Wong
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112-5880, USA
| | - Jia-Wen Guo
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112-5880, USA
| |
Collapse
|
38
|
Russell ER, Tripathi R, Carroll BT. Emergency department utilization for impetigo among the pediatric population: A retrospective study of the national emergency department sample 2013-2015. Pediatr Dermatol 2021; 38:1111-1117. [PMID: 34338362 DOI: 10.1111/pde.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite the large burden of impetigo in childhood and high frequency of pediatric emergency department (ED) visits for skin conditions, limited information exists on the use of EDs for impetigo among US children. OBJECTIVE Our study aimed to generate national estimates of ED utilization and to identify sociodemographic predictors of impetigo-related ED visits. METHODS This was a retrospective, cross-sectional study of children ages 1-17 presenting to EDs with a primary diagnosis of impetigo using years 2013-2015 of the Nationwide Emergency Department Sample. RESULTS Impetigo accounted for 163 909 of the 71 488, 511 pediatric ED visits and was the fourth most common presenting skin diagnosis. Controlling for sociodemographic factors, patients presenting to the ED with impetigo were most likely to be 6-11 years old, male, and from lower-income quartiles. Patients were most likely to be uninsured and most likely to present on weekends in the summer. CONCLUSION This study provided national-level estimates of ED use for impetigo among US children. Ultimately, the identification of factors associated with increased ED utilization may help in developing targeted interventions to reduce the use of emergency care for impetigo.
Collapse
Affiliation(s)
- Emma R Russell
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Raghav Tripathi
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Bryan T Carroll
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center Department of Dermatology, Cleveland, OH, USA
| |
Collapse
|
39
|
Albright BB, Chino F, Chino JP, Havrilesky LJ, Aviki EM, Moss HA. Medicaid Expansion Reduced Uninsured Surgical Hospitalizations And Associated Catastrophic Financial Burden. Health Aff (Millwood) 2021; 40:1294-1303. [PMID: 34339246 PMCID: PMC10077516 DOI: 10.1377/hlthaff.2020.02496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An important function of health insurance is protecting enrollees from excessively burdensome charges for unanticipated medical events. Unexpected surgery can be financially catastrophic for uninsured people. By targeting the low-income uninsured population, Medicaid expansion had the potential to reduce the financial risks associated with these events. We used two data sources (state-level data for forty-four states and patient-level data for four states) to estimate the association of Medicaid expansion with uninsured surgical hospitalizations among nonelderly adults. Uninsured surgery cases were typically admitted through the emergency department-often for common emergency procedures-and 99 percent of them were estimated to be associated with financially catastrophic visit charges. We found that Medicaid expansion was associated with reductions in both the share (6.20 percent) and the population rate (7.85 per 10,000) of uninsured surgical discharges in expansion versus nonexpansion states. Our estimates suggest that in 2019 alone, adoption of Medicaid expansion in nonexpansion states could have prevented more than 50,000 incidences of catastrophic financial burden resulting from uninsured surgery.
Collapse
Affiliation(s)
- Benjamin B Albright
- Benjamin B. Albright is a gynecologic oncology fellow in the Department of Obstetrics and Gynecology, Duke University Medical Center, in Durham, North Carolina
| | - Fumiko Chino
- Fumiko Chino is an assistant attending in the Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, in New York, New York
| | - Junzo P Chino
- Junzo P. Chino is an associate professor in the Department of Radiation Oncology, Duke University Medical Center
| | - Laura J Havrilesky
- Laura J. Havrilesky is a professor in the Department of Obstetrics and Gynecology, Duke University Medical Center
| | - Emeline M Aviki
- Emeline M. Aviki is an assistant attending in the Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Haley A Moss
- Haley A. Moss is an assistant professor in the Department of Obstetrics and Gynecology, Duke University Medical Center
| |
Collapse
|
40
|
Nshakira-Rukundo E, Mussa EC, Nshakira N, Gerber N, von Braun J. Impact of community-based health insurance on utilisation of preventive health services in rural Uganda: a propensity score matching approach. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2021; 21:203-227. [PMID: 33566252 PMCID: PMC8192361 DOI: 10.1007/s10754-021-09294-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 01/25/2021] [Indexed: 06/12/2023]
Abstract
The effect of voluntary health insurance on preventive health has received limited research attention in developing countries, even when they suffer immensely from easily preventable illnesses. This paper surveys households in rural south-western Uganda, which are geographically serviced by a voluntary Community-based health insurance scheme, and applied propensity score matching to assess the effect of enrolment on using mosquito nets and deworming under-five children. We find that enrolment in the scheme increased the probability of using a mosquito net by 26% and deworming by 18%. We postulate that these findings are partly mediated by information diffusion and social networks, financial protection, which gives households the capacity to save and use service more, especially curative services that are delivered alongside preventive services. This paper provides more insight into the broader effects of health insurance in developing countries, beyond financial protection and utilisation of hospital-based services.
Collapse
Affiliation(s)
- Emmanuel Nshakira-Rukundo
- Center for Development Research (ZEF), University of Bonn, Genscherallee 3, 53117, Bonn, Germany.
- Institute for Food and Resource Economics, University of Bonn, Nussallee 19, 53115, Bonn, Germany.
| | - Essa Chanie Mussa
- Department of Agriculture Economics, University of Gondar, Gondar, Ethiopia
| | | | - Nicolas Gerber
- Center for Development Research (ZEF), University of Bonn, Genscherallee 3, 53117, Bonn, Germany
| | - Joachim von Braun
- Center for Development Research (ZEF), University of Bonn, Genscherallee 3, 53117, Bonn, Germany
| |
Collapse
|
41
|
Spycher J, Dusheiko M, Beaupère P, Gravier B, Moschetti K. Healthcare in a pure gatekeeping system: utilization of primary, mental and emergency care in the prison population over time. HEALTH & JUSTICE 2021; 9:11. [PMID: 33987749 PMCID: PMC8120814 DOI: 10.1186/s40352-021-00136-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/13/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND This study investigates the prisoner and prison-level factors associated with healthcare utilization (HCU) and the dynamic effects of previous HCU and health events. We analyze administrative data collected on annual adult prisoner-stay HCU (n = 10,136) including physical and mental chronic disease diagnoses, acute health events, penal circumstances and prison-level factors between 2013 and 2017 in 4 prisons of Canton of Vaud, Switzerland. Utilization of four types of health services: primary, nursing, mental and emergency care; are assessed using multivariate and multi-level negative binomial regressions with fixed/random effects and dynamic models conditional on prior HCU and lagged health events. RESULTS In a prison setting with health screening on detention, removal of financial barriers to care and a nurse-led gatekeeping system, we find that health status, socio-demographic characteristics, penal history, and the prison environment are associated with HCU overtime. After controlling for chronic and past acute illnesses, female prisoners have higher HCU, younger adults more emergencies, and prisoners from Africa, Eastern Europe, and the Americas lower HCU. New prisoners, pretrial detainees or repeat offenders utilize more all types of care. Overcrowding increases primary care but reduces utilization of mental and emergency services. Higher expenditure on medical staff resources is associated with more primary care visits and less emergency visits. The dynamics of HCU across types of care shows persistence over time related to emergency use, previous somatic acute illnesses, and acting out events. There is also evidence of substitution between psychiatric and primary care. CONCLUSIONS The prison healthcare system provides an opportunity to diagnose and treat unmet health needs for a marginalized population. Access to psychiatric and chronic disease management during incarceration and prevention of emergency or acute events can reduce future demand for care. Prioritization of high-risk patients and continuity of care inside and outside of prisons may reduce public health pressures in the criminal system. The prison environment and prisoners' penal circumstances impacts healthcare utilization, suggesting better coordination between the criminal justice and prison health systems is required.
Collapse
Affiliation(s)
- Jacques Spycher
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | | | - Pascale Beaupère
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- Service of Correctional Medicine and Psychiatry (SMPP), University hospital of Lausanne (CHUV), Lausanne, Switzerland
| | | | - Karine Moschetti
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- Technology Assessment Unit (UET), University hospital of Lausanne (CHUV), Lausanne, Switzerland
| |
Collapse
|
42
|
Wiley Z, Ross-Driscoll K, Wang Z, Smothers L, Mehta AK, Patzer RE. Racial and Ethnic Differences and Clinical Outcomes of COVID-19 Patients Presenting to the Emergency Department. Clin Infect Dis 2021; 74:387-394. [PMID: 33822023 PMCID: PMC8083480 DOI: 10.1093/cid/ciab290] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Since the introduction of remdesivir and dexamethasone for severe COVID-19 treatment, few large multi-hospital system US studies have described clinical characteristics and outcomes of minority COVID-19 patients who present to the emergency department (ED). METHODS This cohort study from the Cerner Real World Database (87 US health systems) from December 1, 2019 to September 30, 2020 included PCR-confirmed COVID-19 patients who self-identified as non-Hispanic Black (Black), Hispanic White (Hispanic), or non-Hispanic White (White). The main outcome was hospitalization among ED patients. Secondary outcomes included mechanical ventilation, intensive care unit care, and in-hospital mortality. Descriptive statistics and Poisson regression compared sociodemographics, comorbidities, receipt of remdesivir, receipt of dexamethasone, and outcomes by racial/ethnic groups and geographic region. RESULTS 94,683 COVID-19 patients presented to the ED. Blacks comprised 26.7% and Hispanics 33.6%. Nearly half (45.1%) of ED patients presented to hospitals in the South. 31.4% (n=29,687) were hospitalized. Lower proportions of Blacks were prescribed dexamethasone (29.4%; n=7,426) compared to Hispanics (40.9%; n=13,021) and Whites (37.5%; n=14,088). Hospitalization risks, compared to Whites, were similar in Blacks (Risk Ratio (RR)=0.94; 95% CI:0.82, 1.08; p=0.4)) and Hispanics RR=0.99 (95% CI:0.81, 1.21; p=0.91), but risk of in-hospital mortality was higher in Blacks, RR=1.18 (95% CI:1.06, 1.31; p=0.002) and Hispanics, RR=1.28 (95% CI: 1.13, 1.44; p < 0.001). CONCLUSIONS Minority patients were overrepresented among COVID-19 ED patients, and while they had similar risks of hospitalization as Whites, in-hospital mortality risk was higher. Interventions targeting upstream social determinants of health are needed to reduce racial/ethnic disparities in COVID-19.
Collapse
Affiliation(s)
- Zanthia Wiley
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Katie Ross-Driscoll
- Health Services Research Center, Emory University School of Medicine, Department of Medicine, Department of Surgery, Emory University School of Medicine, and Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Zhensheng Wang
- Health Services Research Center, Emory University School of Medicine, Department of Medicine, Department of Surgery, Emory University School of Medicine, and Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Laken Smothers
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA, Health Services Research Center, Emory University School of Medicine, Department of Medicine, Atlanta, Georgia, United States of America
| | - Aneesh K Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Rachel E Patzer
- Health Services Research Center, Emory University School of Medicine, Department of Medicine, Department of Surgery, Emory University School of Medicine, and Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia, United States of America
| |
Collapse
|
43
|
Sewell J, McDaniel CC, Harris SM, Chou C. Implementation of a pharmacist-led transitions of care program in an indigent care clinic: A randomized controlled trial. J Am Pharm Assoc (2003) 2021; 61:276-283.e1. [PMID: 33536154 DOI: 10.1016/j.japh.2021.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/25/2020] [Accepted: 01/07/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Pharmacists' involvement in the transitions of care has shown the potential to decrease readmissions and increase access to care in many populations; however, the uninsured patient populations have not been studied. The evidence for the feasibility of implementing transitions of care services in indigent care clinics with limited resources also remains limited. The objectives were to implement a pharmacist-led transitions of care program in an indigent care clinic, to demonstrate the feasibility of its implementation, and to evaluate its impact on readmissions and emergency department (ED) visit rates among an uninsured population. METHODS The study was a single-blind, parallel, randomized controlled trial implemented in an indigent care clinic in the Southeast region of the United States from October 2018 to July 2019. Eligible patients were those older than 18 years, uninsured, English-speaking, diagnosed with any condition, and recently discharged from a local community hospital within the past 16 days. The primary outcome was the hospital readmission rate at 30 days after discharge. The secondary outcomes included 60- and 90-day readmission rates in addition to 30-, 60-, and 90-day ED visit rates. RESULTS A total of 88 participants were recruited. The intervention was successfully implemented in the clinic, but patient-level barriers to follow-ups included transportation, accessibility, financial burdens, inconsistent telephone communication, and a lack of knowledge about the importance of follow-ups. At 30 days postdischarge, 13.64% of the patients in the usual care group experienced readmissions compared with 9.30% of the patients in the intervention group. The relative change in the 30-day readmission rates between the usual care and the intervention groups was 1.7 (rate ratio [RR] 1.69 [95% CI 0.47-6.08]). The RRs were insignificant for the 30-, 60-, and 90-day readmission and ED visit rates. CONCLUSION This study demonstrated the feasibility of implementing transitions of care services in a clinic with limited resources by pharmacists. The intervention showed promising results by reducing readmission rates.
Collapse
|
44
|
Crocker CE, Carter AJE, Emsley JG, Magee K, Atkinson P, Tibbo PG. When Cannabis Use Goes Wrong: Mental Health Side Effects of Cannabis Use That Present to Emergency Services. Front Psychiatry 2021; 12:640222. [PMID: 33658953 PMCID: PMC7917124 DOI: 10.3389/fpsyt.2021.640222] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 01/19/2021] [Indexed: 12/25/2022] Open
Abstract
Cannabis use is a modifiable risk factor for the development and exacerbation of mental illness. The strongest evidence of risk is for the development of a psychotic disorder, associated with early and consistent use in youth and young adults. Cannabis-related mental health adverse events precipitating Emergency Department (ED) or Emergency Medical Services presentations can include anxiety, suicidal thoughts, psychotic or attenuated psychotic symptoms, and can account for 25-30% of cannabis-related ED visits. Up to 50% of patients with cannabis-related psychotic symptoms presenting to the ED requiring hospitalization will go on to develop schizophrenia. With the legalization of cannabis in various jurisdiction and the subsequent emerging focus of research in this area, our understanding of who (e.g., age groups and risk factors) are presenting with cannabis-related adverse mental health events in an emergency situation is starting to become clearer. However, for years we have heard in popular culture that cannabis use is less harmful or no more harmful than alcohol use; however, this does not appear to be the case for everyone. It is evident that these ED presentations should be considered another aspect of potentially harmful outcomes that need to be included in knowledge mobilization. In the absence of a clear understanding of the risk factors for mental health adverse events with cannabis use it can be instructive to examine what characteristics are seen with new presentations of mental illness both in emergency departments (ED) and early intervention services for mental illness. In this narrative review, we will discuss what is currently known about cannabis-related mental illness presentations to the ED, discussing risk variables and outcomes both prior to and after legalization, including our experiences following cannabis legalization in Canada. We will also discuss what is known about cannabis-related ED adverse events based on gender or biological sex. We also touch on the differences in magnitude between the impact of alcohol and cannabis on emergency mental health services to fairly present the differences in service demand with the understanding that these two recreational substances may impact different populations of individuals at risk for adverse events.
Collapse
Affiliation(s)
- Candice E Crocker
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada.,Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada
| | - Alix J E Carter
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada.,Emergency Health Services, Halifax, NS, Canada
| | - Jason G Emsley
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kirk Magee
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Paul Atkinson
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada.,Horizon Health Network, Saint John, NB, Canada
| | - Philip G Tibbo
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| |
Collapse
|
45
|
Colorafi K, Thomas A, Wilson M, Corbett CF. Perspectives of Aging Adults Who Frequently Seek Emergency Department Care. Pain Manag Nurs 2020; 22:184-190. [PMID: 33317936 DOI: 10.1016/j.pmn.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/14/2020] [Accepted: 10/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The number of people managing chronic conditions is growing with the rapidly aging population. Visits to the emergency department are steadily rising, but little is known about the rationale of those seeking emergent care. AIMS The goal of this study was to better understand, from the patients' perspective, the reasons for seeking care in an emergency department setting. DESIGN A qualitative descriptive design was used to interview aging adults with at least two chronic conditions who made three or more visits to the emergency department within a year. PARTICIPANTS/SUBJECTS The eight-person sample was 88% female and 75% white, with an average age of 54 years. METHODS Participant interviews were conducted with a semistructured interview guide. Conventional content analysis was used to examine words and phrases in professionally transcribed documents. Qualitative methods for testing and confirming conclusions were performed. RESULTS We discovered that aging adults visit the emergency department to seek relief from unrelenting pain and to overcome barriers to receiving treatment for pain in ambulatory settings. Participants reported feeling judged when seeking emergency department care for pain management. CONCLUSIONS Participants described emergency department care as the only option in response to several barriers to healthcare access. Most commonly, emergency department care was sought when relief from persistent or acute pain was required. One way to reduce strain on EDs from pain-related visits is to manage patients with persistent pain more proactively in their community environment.
Collapse
Affiliation(s)
- Karen Colorafi
- School of Nursing and Human Physiology, Gonzaga University, Spokane, Washington; College of Nursing, Washington State University, Spokane, Washington.
| | - Amy Thomas
- College of Nursing, Washington State University, Spokane, Washington
| | - Marian Wilson
- College of Nursing, Washington State University, Spokane, Washington
| | - Cynthia F Corbett
- College of Nursing, Washington State University, Spokane, Washington; College of Nursing, University of South Carolina, Columbia, South Carolina
| |
Collapse
|
46
|
Czeisler MÉ, Marynak K, Clarke KE, Salah Z, Shakya I, Thierry JM, Ali N, McMillan H, Wiley JF, Weaver MD, Czeisler CA, Rajaratnam SM, Howard ME. Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns - United States, June 2020. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2020; 69:1250-1257. [PMID: 32915166 PMCID: PMC7499838 DOI: 10.15585/mmwr.mm6936a4] [Citation(s) in RCA: 948] [Impact Index Per Article: 237.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
47
|
Czeisler MÉ, Marynak K, Clarke KE, Salah Z, Shakya I, Thierry JM, Ali N, McMillan H, Wiley JF, Weaver MD, Czeisler CA, Rajaratnam SM, Howard ME. Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2020. [DOI: 10.15585/mmwr.mm6935e3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
48
|
Gaffney A, Woolhandler S, Himmelstein D. The Effect of Large-scale Health Coverage Expansions in Wealthy Nations on Society-Wide Healthcare Utilization. J Gen Intern Med 2020; 35:2406-2417. [PMID: 31745857 PMCID: PMC7403378 DOI: 10.1007/s11606-019-05529-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/25/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
Most analysts project that a reform like Medicare-for-All that lowers financial barriers to care would cause a surge in the utilization of services, raising costs despite stable or even reduced prices. However, the finite supply of physicians and hospital beds could constrain such utilization increases. We reviewed the effects of 13 universal coverage expansions in capitalist nations on physician and hospital utilization, beginning with New Zealand's 1938 Social Security Act up through the 2010 Affordable Care Act in the USA. Almost all coverage expansions had either a small (i.e., < 10%) or no effect on society-wide utilization. However, coverage expansions often redistributed care-increasing use among newly covered groups while producing small, offsetting reductions among those already covered. We conclude that in wealthy nations, large-scale coverage expansions need not cause overall utilization to surge if provider supply is controlled. However, such reforms could redirect care towards patients who most need it.
Collapse
Affiliation(s)
- Adam Gaffney
- Harvard Medical School, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02138 USA
| | - Steffie Woolhandler
- Harvard Medical School, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02138 USA
- City University of New York at Hunter College, New York, USA
| | - David Himmelstein
- Harvard Medical School, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02138 USA
- City University of New York at Hunter College, New York, USA
| |
Collapse
|
49
|
Hauser BM, Gupta S, Xu E, Wu K, Bernstock JD, Chua M, Khawaja AM, Smith TR, Dunn IF, Bergmark RW, Bi WL. Impact of insurance on hospital course and readmission after resection of benign meningioma. J Neurooncol 2020; 149:131-140. [PMID: 32654076 DOI: 10.1007/s11060-020-03581-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/02/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Surgical outcomes and healthcare utilization have been shown to vary based on patient insurance status. We analyzed whether patients' insurance affects case urgency for and readmission after craniotomy for meningioma resection, using benign meningioma as a model system to minimize confounding from the disease-related characteristics of other neurosurgical pathologies. METHODS We analyzed 90-day readmission for patients who underwent resection of a benign meningioma in the Nationwide Readmission Database from 2014-2015. RESULTS A total of 9783 meningioma patients with private insurance (46%), Medicare (39%), Medicaid (10%), self-pay (2%), or another scheme (3%) were analyzed. 72% of all cases were elective; with 78% of cases in privately insured patients being elective compared to 71% of Medicare (p > 0.05), 59% of Medicaid patients (OR 2.3, p < 0.001), and 49% of self-pay patients (OR 3.4, p < 0.001). Medicare (OR 1.5, p = 0.002) and Medicaid (OR 1.4, p = 0.035) were both associated with higher likelihood of 90-day readmission compared to private insurance. In comparison, 30-day analyses did not unveil this discrepancy between Medicaid and privately insured, highlighting the merit for longer-term outcomes analyses in value-based care. Patients readmitted within 30 days versus those with later readmissions possessed different characteristics. CONCLUSIONS Compared to patients with private insurance coverage, Medicaid and self-pay patients were significantly more likely to undergo non-elective resection of benign meningioma. Medicaid and Medicare insurance were associated with a higher likelihood of 90-day readmission; only Medicare was significant at 30 days. Both 30 and 90-day outcomes merit consideration given differences in readmitted populations.
Collapse
Affiliation(s)
| | - Saksham Gupta
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.,Computational Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Edward Xu
- Computational Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Kyle Wu
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Joshua D Bernstock
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Melissa Chua
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Ayaz M Khawaja
- Computational Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Timothy R Smith
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.,Computational Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Ian F Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Regan W Bergmark
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Wenya Linda Bi
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.
| |
Collapse
|
50
|
Unmet Healthcare Needs and Healthcare Access Gaps Among Uninsured U.S. Adults Aged 50-64. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17082711. [PMID: 32326420 PMCID: PMC7215278 DOI: 10.3390/ijerph17082711] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/11/2020] [Accepted: 04/14/2020] [Indexed: 11/18/2022]
Abstract
Lack of health insurance (HI) is a particular problem for near-older Americans aged 50–64 because they tend to have more chronic health conditions than younger age groups and are at increased risk of disability; however, little recent research has focused on HI coverage and healthcare access among this age group. Using the U.S. National Health Interview Survey data for the years 2013 to 2018, we compared HI coverage and healthcare access between the 50–64 and 65+ age groups. Using logistic regression analysis, we then examined the sociodemographic and health characteristics of past-year healthcare access of near-older Americans without HI to those with private HI or public HI (Medicare without Medicaid, Medicaid without Medicare, Medicare and Medicaid, and VA/military HI). We estimated the odds of healthcare access among those without HI compared to those with private or public HI. Near-older Americans without HI were at least seven times more likely to have postponed or foregone needed healthcare due to costs, and only 15% to 23% as likely to have had contact with any healthcare professional in the preceding 12 months. Expanding HI to near-older adults would increase healthcare access and likely result in reduced morbidity and mortality and higher quality of life for them.
Collapse
|