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Goraya N, Madias NE, Simoni J, Kahlon M, Aksan N, Wesson DE. Kidney and Cardiovascular Protection Using Dietary Acid Reduction in Primary Hypertension: A Five-Year, Interventional, Randomized, Control Trial. Am J Med 2024:S0002-9343(24)00357-7. [PMID: 39107215 DOI: 10.1016/j.amjmed.2024.06.006] [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] [Received: 04/23/2024] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND High fruit and vegetable diets are associated with reduced chronic kidney disease and cardiovascular disease but are infrequently used in hypertension treatment. Low acid diets are also associated with reduced chronic kidney disease and cardiovascular disease, and fruits and vegetables or oral sodium bicarbonate (NaHCO3) lowers dietary acid. METHODS We randomized 153 hypertensive macroalbuminuric patients receiving pharmacologic chronic kidney disease and cardiovascular disease protection to get fruits and vegetables, oral NaHCO3, or Usual Care. We assessed the course of kidney disease progression and cardiovascular disease risk indices over five years. RESULTS Chronic kidney disease progression was slower in participants receiving fruits and vegetables or oral NaHCO3 than Usual Care [mean (SE)] [-1.08 (0.06) and -1.17 (0.07) vs. -1.94 (0.11) mL/min/1.73m2/ year, respectively, P's< .001). Yet, systolic blood pressure was lower, and cardiovascular disease risk indices improved more in participants receiving fruits and vegetables than in those receiving NaHCO3 or Usual Care. These cardiovascular benefits of fruits and vegetables were achieved despite lower doses of pharmacologic chronic kidney disease and cardiovascular disease protection. CONCLUSION The trial supports fruits and vegetables as foundational hypertension treatment to reduce chronic kidney disease progression and cardiovascular disease risk.
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Affiliation(s)
- Nimrit Goraya
- Department of Internal Medicine, Baylor Scott and White Health, Temple, Tex; Department of Internal Medicine, Texas A&M Health Sciences Center College of Medicine, Temple, Tex
| | - Nicolaos E Madias
- St. Elizabeth's Medical Center and Department of Medicine, Tufts University School of Medicine, Boston, Mass
| | - Jan Simoni
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock Tex
| | - Maninder Kahlon
- Department of Population Health, Dell Medical School-The University of Texas at Austin, Austin, Tex
| | - Nazan Aksan
- Department of Population Health, Dell Medical School-The University of Texas at Austin, Austin, Tex
| | - Donald E Wesson
- Department of Internal Medicine, Dell Medical School - The University of Texas at Austin, Austin, Tex.
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Strehlow M, Alvarez A, Blomkalns AL, Caretta-Wyer H, Gharahbaghian L, Imler D, Khan A, Lee M, Lobo V, Newberry JA, Riberia R, Sebok-Syer S, Shen S, Gisondi MA. Precision emergency medicine. Acad Emerg Med 2024. [PMID: 38940478 DOI: 10.1111/acem.14962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/13/2024] [Accepted: 05/23/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Precision health is a burgeoning scientific discipline that aims to incorporate individual variability in biological, behavioral, and social factors to develop personalized health solutions. To date, emergency medicine has not deeply engaged in the precision health movement. However, rapid advances in health technology, data science, and medical informatics offer new opportunities for emergency medicine to realize the promises of precision health. METHODS In this article, we conceptualize precision emergency medicine as an emerging paradigm and identify key drivers of its implementation into current and future clinical practice. We acknowledge important obstacles to the specialty-wide adoption of precision emergency medicine and offer solutions that conceive a successful path forward. RESULTS Precision emergency medicine is defined as the use of information and technology to deliver acute care effectively, efficiently, and authentically to individual patients and their communities. Key drivers and opportunities include leveraging human data, capitalizing on technology and digital tools, providing deliberate access to care, advancing population health, and reimagining provider education and roles. Overcoming challenges in equity, privacy, and cost is essential for success. We close with a call to action to proactively incorporate precision health into the clinical practice of emergency medicine, the training of future emergency physicians, and the research agenda of the specialty. CONCLUSIONS Precision emergency medicine leverages new technology and data-driven artificial intelligence to advance diagnostic testing, individualize patient care plans and therapeutics, and strategically refine the convergence of the health system and the community.
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Affiliation(s)
- Matthew Strehlow
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Al'ai Alvarez
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andra L Blomkalns
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Holly Caretta-Wyer
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Laleh Gharahbaghian
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Daniel Imler
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ayesha Khan
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Moon Lee
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Viveta Lobo
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer A Newberry
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ryan Riberia
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Stefanie Sebok-Syer
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Sam Shen
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Michael A Gisondi
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
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Kitzman H, Montgomery AH, Khan M, Mamun A, Tecson KM, Allison P, Simoni J, Wesson DE. The Fruit and Veggies for Kidney Health Study: A Prospective Randomized Trial. Kidney Med 2023; 5:100736. [PMID: 38046912 PMCID: PMC10692733 DOI: 10.1016/j.xkme.2023.100736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Rationale & Objective Providing fruits and vegetables (F&Vs) to health care system patients with elevated urine albumin-creatinine ratio (ACR) reduced ACR, slowed chronic kidney disease (CKD) progression and reduced cardiovascular disease (CVD) risk factors in previous studies. This study evaluated a community-based strategy in lower-income populations to identify African Americans with elevated ACR before health care system involvement and sustain them in a 6-month F&V protocol with (F&V + Cook) and without (F&V Only) cooking instructions, with the hypothesis that adjuvant cooking instructions with F&Vs would further reduce ACR. Study Design Prospective, randomized, parallel 2-arm design. Setting & Participants African American adults with ACR >10 mg/g creatinine randomized to 1 of 2 study arms. Interventions Two cups/day of F&Vs with or without cooking instructions in participants followed 6 months. Outcomes Participants sustaining the F&V protocol and between-group indicators of CVD risk, kidney injury, and dietary intake at 6 weeks and 6 months. Results A total of 142 African American adults (mean age, 57.0 years; ACR, 27.4 mg/g; body mass index, 34.4; 24.9% CKD 1; 24.8% CKD 2; 50.4% CKD 3; 55% female) randomized to F&V Only (n=72) or F&V + Cook (n=70), and 71% were retained at 6 months. Participants received 90% of available F&V pick-ups over 6 weeks and 69% over 6 months. In the adjusted model, 6-month ACR was 31% lower for F&V + Cook than F&V Only (P = 0.02). Net 6-week F&V intake significantly increased and biometric variables improved for participants combined into a single group. Limitations Small sample size, low-baseline ACR, and potential nonresponse bias for 24-hour dietary recall measure. Conclusions These data support the feasibility of identifying community-dwelling African Americans with ACR indicating elevated CVD and CKD risk and sustaining a F&V protocol shown to improve kidney outcomes and CVD risk factors and provides preliminary evidence that cooking instructions adjuvant to F&Vs are needed to lower ACR. Funding National Institute on Diabetes, Digestive, and Kidney Diseases grant "Reducing chronic kidney disease burden in an underserved population" (R21DK113440). Trial Registration NCT03832166. Plain-Language Summary African Americans, particularly those in low-income communities, have increased rates of chronic kidney disease (CKD) with worsening outcomes over time. Giving fruits and vegetables to individuals with CKD identified in health care systems was previously shown to reduce kidney damage, measured by urine protein albumin, and slow kidney function decline. We recruited African Americans in low-income communities with increased urine albumin levels. They received fruits and vegetables for 6 months, and we tested whether added cooking instructions further reduced urine albumin levels. Most participants continued to receive fruits and vegetables throughout the 6 months. Those given cooking instructions had lower urine albumin levels after 6 months, indicating decreased kidney damage. Providing cooking instructions with fruits and vegetables appears to lessen kidney damage more than just fruits and vegetables alone.
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Affiliation(s)
- Heather Kitzman
- Baylor Scott and White Health and Wellness Center, Dallas, TX
- Robbins Institute for Health Policy and Leadership, Baylor University, Waco, TX
- University of Texas Southwestern Medical Center, Peter O’Donnell Jr. School of Public Health, Dallas, TX
| | | | - Mahbuba Khan
- Baylor Scott and White Health and Wellness Center, Dallas, TX
| | - Abdullah Mamun
- Baylor Scott and White Health and Wellness Center, Dallas, TX
| | - Kristen M. Tecson
- Baylor Heart and Vascular Institute, Baylor Scott & White Research Institute, Dallas, TX
- Texas A&M Health Sciences Center College of Medicine Department of Internal Medicine, Dallas, TX
| | | | - Jan Simoni
- Texas Tech University Health Sciences Center Department of Surgery, Lubbock, TX
| | - Donald E. Wesson
- Dell Medical School – The University of Texas at Austin, Austin, TX
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Mayhew M, Denton A, Kenney A, Fairclough J, Ojha A, Bhoite P, Hey MT, Seetharamaiah R, Shaffiey S, Schneider GW. Social deprivation, the Area Deprivation Index, and emergency department utilization within a community-based primary and preventive care program at a Florida medical school. J Public Health (Oxf) 2023. [DOI: 10.1007/s10389-023-01871-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023] Open
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Kar Ray M, Theodoros T, Wyder M, Nghiem S, Chiu J, Morrison T, Steginga A, Sorrensen R, Kinsella K, Lombardo C. Proactive Detection (PROTECT) and Safety Planning to Shorten Emergency Department Stays for Psychiatric Patients. Psychiatr Serv 2023; 74:17-23. [PMID: 35795980 DOI: 10.1176/appi.ps.202100659] [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: 01/04/2023]
Abstract
OBJECTIVE A literature gap exists for interventions to decrease average length of stay (ALOS) for patients with psychiatric presentations at the emergency department (ED). Long ALOSs are often related to sequential assessments of patients with high suicide risk or patients awaiting an inpatient bed. Safety planning may provide opportunities for diverting patients to the community and for reducing ED ALOS. This study reports on the impact of a safety-planning approach based on the PROTECT (proactive detection) framework for suicide prevention. METHODS A complex intervention (comprising leadership, governance, and innovation) was instrumental in embedding a new clinical culture of proactive detection and positive risk management through safety planning at Princess Alexandra Hospital in Brisbane, Queensland, Australia. Practice as usual continued at a comparator nonintervention site (NIS). In total, 24,515 psychiatric presentations over 24 months were grouped into monthly averages for key outcomes, providing a sample size of 24 at each site. A difference-in-differences analysis across sites, preintervention (January-November 2019) and postimplementation (December 2019-December 2020), was used to estimate the intervention's impact. RESULTS ED ALOS for psychiatric presentations, patients with an ALOS >12 hours, patients with an ALOS >24 hours, and inpatient psychiatric admissions decreased significantly compared with NIS (p<0.01) pre- and postimplementation of the safety-planning intervention. CONCLUSIONS Embedding a recovery-oriented culture of safety significantly reduced ED ALOS for psychiatric evaluations. Leadership, governance, and innovative practices that shift the focus of assessment and care from a mindset of risk prediction to one of prevention through collaborative safety planning as outlined in the PROTECT framework may have far-reaching benefits for patient care.
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Affiliation(s)
- Manaan Kar Ray
- Addiction and Mental Health Services, Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Brisbane, Queensland, Australia (Kar Ray, Theodoros, Wyder, Morrison, Steginga, Sorrensen, Kinsella); Australian Institute for Suicide Research and Prevention (Kar Ray) and The Hopkins Centre (Wyder), Griffith University, Brisbane, Queensland, Australia; Princess Alexandra-Southside Clinical Unit, Princess Alexandra Hospital, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Theodoros); Department of Health Services, Research and Policy, Australian National University, Canberra, New South Wales, Australia (Nghiem); Toowoomba Base Hospital, Toowoomba, Queensland, Australia (Chiu); Research and Development, Mental Health Foundation, London, and Cambridge Public Health Interdisciplinary Research Centre, Department of Psychiatry, University of Cambridge, United Kingdom (Lombardo)
| | - Theo Theodoros
- Addiction and Mental Health Services, Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Brisbane, Queensland, Australia (Kar Ray, Theodoros, Wyder, Morrison, Steginga, Sorrensen, Kinsella); Australian Institute for Suicide Research and Prevention (Kar Ray) and The Hopkins Centre (Wyder), Griffith University, Brisbane, Queensland, Australia; Princess Alexandra-Southside Clinical Unit, Princess Alexandra Hospital, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Theodoros); Department of Health Services, Research and Policy, Australian National University, Canberra, New South Wales, Australia (Nghiem); Toowoomba Base Hospital, Toowoomba, Queensland, Australia (Chiu); Research and Development, Mental Health Foundation, London, and Cambridge Public Health Interdisciplinary Research Centre, Department of Psychiatry, University of Cambridge, United Kingdom (Lombardo)
| | - Marianne Wyder
- Addiction and Mental Health Services, Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Brisbane, Queensland, Australia (Kar Ray, Theodoros, Wyder, Morrison, Steginga, Sorrensen, Kinsella); Australian Institute for Suicide Research and Prevention (Kar Ray) and The Hopkins Centre (Wyder), Griffith University, Brisbane, Queensland, Australia; Princess Alexandra-Southside Clinical Unit, Princess Alexandra Hospital, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Theodoros); Department of Health Services, Research and Policy, Australian National University, Canberra, New South Wales, Australia (Nghiem); Toowoomba Base Hospital, Toowoomba, Queensland, Australia (Chiu); Research and Development, Mental Health Foundation, London, and Cambridge Public Health Interdisciplinary Research Centre, Department of Psychiatry, University of Cambridge, United Kingdom (Lombardo)
| | - Son Nghiem
- Addiction and Mental Health Services, Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Brisbane, Queensland, Australia (Kar Ray, Theodoros, Wyder, Morrison, Steginga, Sorrensen, Kinsella); Australian Institute for Suicide Research and Prevention (Kar Ray) and The Hopkins Centre (Wyder), Griffith University, Brisbane, Queensland, Australia; Princess Alexandra-Southside Clinical Unit, Princess Alexandra Hospital, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Theodoros); Department of Health Services, Research and Policy, Australian National University, Canberra, New South Wales, Australia (Nghiem); Toowoomba Base Hospital, Toowoomba, Queensland, Australia (Chiu); Research and Development, Mental Health Foundation, London, and Cambridge Public Health Interdisciplinary Research Centre, Department of Psychiatry, University of Cambridge, United Kingdom (Lombardo)
| | - Jacqui Chiu
- Addiction and Mental Health Services, Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Brisbane, Queensland, Australia (Kar Ray, Theodoros, Wyder, Morrison, Steginga, Sorrensen, Kinsella); Australian Institute for Suicide Research and Prevention (Kar Ray) and The Hopkins Centre (Wyder), Griffith University, Brisbane, Queensland, Australia; Princess Alexandra-Southside Clinical Unit, Princess Alexandra Hospital, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Theodoros); Department of Health Services, Research and Policy, Australian National University, Canberra, New South Wales, Australia (Nghiem); Toowoomba Base Hospital, Toowoomba, Queensland, Australia (Chiu); Research and Development, Mental Health Foundation, London, and Cambridge Public Health Interdisciplinary Research Centre, Department of Psychiatry, University of Cambridge, United Kingdom (Lombardo)
| | - Thomas Morrison
- Addiction and Mental Health Services, Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Brisbane, Queensland, Australia (Kar Ray, Theodoros, Wyder, Morrison, Steginga, Sorrensen, Kinsella); Australian Institute for Suicide Research and Prevention (Kar Ray) and The Hopkins Centre (Wyder), Griffith University, Brisbane, Queensland, Australia; Princess Alexandra-Southside Clinical Unit, Princess Alexandra Hospital, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Theodoros); Department of Health Services, Research and Policy, Australian National University, Canberra, New South Wales, Australia (Nghiem); Toowoomba Base Hospital, Toowoomba, Queensland, Australia (Chiu); Research and Development, Mental Health Foundation, London, and Cambridge Public Health Interdisciplinary Research Centre, Department of Psychiatry, University of Cambridge, United Kingdom (Lombardo)
| | - Anne Steginga
- Addiction and Mental Health Services, Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Brisbane, Queensland, Australia (Kar Ray, Theodoros, Wyder, Morrison, Steginga, Sorrensen, Kinsella); Australian Institute for Suicide Research and Prevention (Kar Ray) and The Hopkins Centre (Wyder), Griffith University, Brisbane, Queensland, Australia; Princess Alexandra-Southside Clinical Unit, Princess Alexandra Hospital, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Theodoros); Department of Health Services, Research and Policy, Australian National University, Canberra, New South Wales, Australia (Nghiem); Toowoomba Base Hospital, Toowoomba, Queensland, Australia (Chiu); Research and Development, Mental Health Foundation, London, and Cambridge Public Health Interdisciplinary Research Centre, Department of Psychiatry, University of Cambridge, United Kingdom (Lombardo)
| | - Rosemary Sorrensen
- Addiction and Mental Health Services, Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Brisbane, Queensland, Australia (Kar Ray, Theodoros, Wyder, Morrison, Steginga, Sorrensen, Kinsella); Australian Institute for Suicide Research and Prevention (Kar Ray) and The Hopkins Centre (Wyder), Griffith University, Brisbane, Queensland, Australia; Princess Alexandra-Southside Clinical Unit, Princess Alexandra Hospital, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Theodoros); Department of Health Services, Research and Policy, Australian National University, Canberra, New South Wales, Australia (Nghiem); Toowoomba Base Hospital, Toowoomba, Queensland, Australia (Chiu); Research and Development, Mental Health Foundation, London, and Cambridge Public Health Interdisciplinary Research Centre, Department of Psychiatry, University of Cambridge, United Kingdom (Lombardo)
| | - Kieran Kinsella
- Addiction and Mental Health Services, Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Brisbane, Queensland, Australia (Kar Ray, Theodoros, Wyder, Morrison, Steginga, Sorrensen, Kinsella); Australian Institute for Suicide Research and Prevention (Kar Ray) and The Hopkins Centre (Wyder), Griffith University, Brisbane, Queensland, Australia; Princess Alexandra-Southside Clinical Unit, Princess Alexandra Hospital, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Theodoros); Department of Health Services, Research and Policy, Australian National University, Canberra, New South Wales, Australia (Nghiem); Toowoomba Base Hospital, Toowoomba, Queensland, Australia (Chiu); Research and Development, Mental Health Foundation, London, and Cambridge Public Health Interdisciplinary Research Centre, Department of Psychiatry, University of Cambridge, United Kingdom (Lombardo)
| | - Chiara Lombardo
- Addiction and Mental Health Services, Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Brisbane, Queensland, Australia (Kar Ray, Theodoros, Wyder, Morrison, Steginga, Sorrensen, Kinsella); Australian Institute for Suicide Research and Prevention (Kar Ray) and The Hopkins Centre (Wyder), Griffith University, Brisbane, Queensland, Australia; Princess Alexandra-Southside Clinical Unit, Princess Alexandra Hospital, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Theodoros); Department of Health Services, Research and Policy, Australian National University, Canberra, New South Wales, Australia (Nghiem); Toowoomba Base Hospital, Toowoomba, Queensland, Australia (Chiu); Research and Development, Mental Health Foundation, London, and Cambridge Public Health Interdisciplinary Research Centre, Department of Psychiatry, University of Cambridge, United Kingdom (Lombardo)
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Abstract
OBJECTIVES Adverse childhood experiences (ACEs) including physical, emotional, or sexual abuse; neglect; and/or exposure to household instability have been associated with adult emergency department utilization, but the impact of parental ACEs on pediatric emergency department (PED) utilization has not been studied. The primary aim was to determine if parental ACEs impact resource utilization as measured by (1) frequency of PED utilization, (2) acuity of PED visits, and (3) 72-hour PED return rates. The secondary aim was to determine if resilience interacts with the impact of parental ACEs on PED utilization. METHODS This study is a cross-sectional survey using previously validated measures of ACEs, resiliency, and social determinants of health screening. Surveys were administered from October 17, 2019, to November 27, 2019, via iPad by research assistants in our institution's PEDs. Survey responses were linked to data abstracted from the electronic health record. Descriptive statistics were used to characterize our study population. Pearson correlation was used to identify correlation between ACEs, social determinants of health, and PED utilization measures. RESULTS A total of 251 parents had complete data. Parental ACEs were positively associated with frequency of PED visits (incidence rate ratio, 1.013). In addition, high levels of parental resilience attenuated the association between parental ACEs and the number of severe acuity visits and were associated with fewer 72-hour return visits (incidence rate ratio, 0.49). CONCLUSIONS Parental ACEs appear to be positively associated with frequency of PED utilization and inversely associated with higher-acuity PED visits and parental resiliency.
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Wesson DE, Mathur V, Tangri N, Hamlett S, Bushinsky DA, Boulware LE. Primary Medical Care Integrated with Healthy Eating and Healthy Moving is Essential to Reduce Chronic Kidney Disease Progression. Am J Med 2022; 135:1051-1058. [PMID: 35576995 DOI: 10.1016/j.amjmed.2022.04.015] [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] [Received: 03/29/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 11/27/2022]
Abstract
Increasing adverse outcomes in patients with chronic kidney disease reflect growth of patients with early-stage chronic kidney disease and their increasing per population rates of these outcomes. Progression of chronic kidney disease, more than current level of kidney function, is the primary driver of adverse chronic kidney disease-related outcomes. Racial/ethnic minorities progress faster to end-stage kidney disease with greater risk for adverse outcomes. Diabetes and hypertension cause two-thirds of end-stage kidney disease, for which primary medical care integrated with healthy eating and increased physical activity (healthy moving) slows chronic kidney disease progression. Patients with early-stage chronic kidney disease are appropriately managed by primary care practices but most lack infrastructure to facilitate this integration that reduces adverse chronic kidney disease-related outcomes. Individuals of low socioeconomic status are at greater chronic kidney disease risk, and flexible regulatory options in Medicaid can fund infrastructure to facilitate healthy eating and healthy moving integration with primary medical care. This integration promises to reduce chronic kidney disease-related adverse outcomes, disproportionately in racial/ethnic minorities, and thereby reduce chronic kidney disease-related health disparities.
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Affiliation(s)
- Donald E Wesson
- Dell Medical School - The University of Texas at Austin; Donald E Wesson Consulting, LLC, Dallas, Texas.
| | | | - Navdeep Tangri
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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Kitzman H, Tecson K, Mamun A, da Graca B, Yeramaneni S, Halloran K, Wesson D. Integrating Population Health Strategies into Primary Care: Impact on Outcomes and Hospital Use for Low-Income Adults. Ethn Dis 2022; 32:91-100. [PMID: 35497399 DOI: 10.18865/ed.32.2.91] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective Our objectives were two-fold: 1) To evaluate the benefits of population health strategies focused on social determinants of health and integrated into the primary care medical home (PCMH) and 2) to determine how these strategies impact diabetes and cardiovascular disease outcomes among a low-income, primarily minority community. We also investigated associations between these outcomes and emergency department (ED) and inpatient (IP) use and costs. Design Retrospective cohort. Setting Community-based PCMH: Baylor Scott & White Health and Wellness Center (BSW HWC). Patients/Participants All patients who attended at least two primary care visits at BSW HWC within a 12-month time span from 2011-2015. Methods Outcomes for patients participating in PCMH only (PCMH) as compared to PCMH plus population health services (PCMH+PoPH) were compared using electronic health record data. Main Outcomes Diastolic and systolic blood pressure, hemoglobin A1c, ED visits and costs, and IP hospitalizations and costs were examined. Results From 2011-2015, 445 patients (age=46±12 years, 63% African American, 61% female, 69.5% uninsured) were included. Adjusted regression analyses indicated PCMH+PoPH had greater improvement in diabetes outcomes (prediabetes HbA1c= -.65[SE=.32], P=.04; diabetes HbA1c= -.74 [SE=.37], P<.05) and 37% lower ED costs than the PCMH group (P=.01). Worsening chronic disease risk factors was associated with 39% higher expected ED visits (P<.01), whereas improved chronic disease risk was associated with 32% fewer ED visits (P=.04). Conclusions Integrating population health services into the PCMH can improve chronic disease outcomes, and impact hospital utilization and cost in un- or under-insured populations.
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Affiliation(s)
- Heather Kitzman
- Baylor Scott & White Health and Wellness Center, Baylor Scott & White Health, Dallas, TX; Robbins Institute for Health Policy & Leadership, Baylor University, Waco, TX
| | - Kristen Tecson
- Baylor Scott & White Heart and Vascular Institute, Baylor Scott & White Health, Dallas, TX
| | - Abdullah Mamun
- Baylor Scott & White Health and Wellness Center, Baylor Scott & White Health, Dallas, TX; Robbins Institute for Health Policy & Leadership, Baylor University, Waco, TX
| | | | | | - Kenneth Halloran
- Baylor Scott & White Health and Wellness Center, Baylor Scott & White Health, Dallas, TX; Robbins Institute for Health Policy & Leadership, Baylor University, Waco, TX
| | - Donald Wesson
- Baylor Scott & White Health and Wellness Center, Baylor Scott & White Health, Dallas, TX; Robbins Institute for Health Policy & Leadership, Baylor University, Waco, TX
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Jordan EJ, Young SJ, Menachemi N. Expanding the Curriculum in a School of Public Health. Front Public Health 2021; 9:700638. [PMID: 34490185 PMCID: PMC8418086 DOI: 10.3389/fpubh.2021.700638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/12/2021] [Indexed: 11/23/2022] Open
Abstract
Public health education has long been concentrated in a core set of public health disciplines such as epidemiology, biostatistics, and environmental health. Despite leaps forward in our understanding of the myriad influences on public health, little has changed in the organization of our educational systems. One issue brought to the forefront of public consciousness by the COVID-19 pandemic is the importance of leisure experiences, such as nature walks, to mental and physical well-being. In this descriptive best practice article, we discuss our approach to expanding the notion of a school of public health and provide examples of how disciplines and subjects outside of the “norms” of public health education, including leisure studies, can help better prepare students for their future in the field. Leisure studies is just one of many subject areas that can add value to public health pedagogy, and we envision many other subject areas and departments integrating into schools of public health in the future.
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Affiliation(s)
- Evan J Jordan
- Department of Health and Wellness Design, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Sarah J Young
- Department of Health and Wellness Design, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Nir Menachemi
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University Purdue University, Indianapolis, IN, United States
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Lindau ST, Makelarski JA, Abramsohn EM, Beiser DG, Boyd K, Huang ES, Paradise K, Tung EL. Sharing information about h
ealth‐related
resources: Observations from a community resource referral intervention trial in a predominantly African American/Black community. J Assoc Inf Sci Technol 2021. [DOI: 10.1002/asi.24560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Stacy Tessler Lindau
- Department of Obstetrics and Gynecology The University of Chicago Chicago Illinois USA
- Department of Medicine – Geriatrics The University of Chicago Chicago Illinois USA
| | | | - Emily M. Abramsohn
- Department of Obstetrics and Gynecology The University of Chicago Chicago Illinois USA
| | - David G. Beiser
- Section of Emergency Medicine, Department of Medicine The University of Chicago Chicago Illinois USA
| | - Kelly Boyd
- Department of Obstetrics and Gynecology The University of Chicago Chicago Illinois USA
| | - Elbert S. Huang
- Section of General Internal Medicine, Department of Medicine The University of Chicago Chicago Illinois USA
| | - Kelsey Paradise
- Department of Obstetrics and Gynecology The University of Chicago Chicago Illinois USA
| | - Elizabeth L. Tung
- Section of General Internal Medicine, Department of Medicine The University of Chicago Chicago Illinois USA
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11
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Kitzman H, DaGraca B, Mamun A, Collinsworth A, Halloran K, Masica A. Embedded Health Systems Science as a driver of care improvement within an integrated delivery organization. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 8 Suppl 1:100497. [PMID: 34175103 DOI: 10.1016/j.hjdsi.2020.100497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 10/23/2020] [Accepted: 11/03/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Embedded Health Systems Science (HSS) has the potential to reduce gaps between research and delivery of evidence-based medicine. Models are needed to guide the development of embedded HSS in health care delivery organizations particularly with the rise of value-based care. METHODS The development of HSS infrastructure at a large nonprofit health care delivery organization is described, along with an embedded HSS diabetes study to illustrate the integration of program specific data, electronic health records, and health care system data infrastructure. To compare diabetes outcomes across four evidenced-based programs, a control group was developed from EHR data using propensity score matching. Mixed effect adjusted models were used to estimate reductions in hemoglobin A1c (HbA1c) and body weight. RESULTS Adjusted analyses using an EHR derived comparison group demonstrated significantly different findings than unadjusted pre to post analyses. The embedded HSS study indicates that appropriate statistical methods, staff with required expertise, and integration with health system data infrastructure are needed to develop timely and rigorous HSS outcomes that effectively improve patient care. CONCLUSIONS Embedded HSS has the potential to inform value-based care models and contribute to evidence-based medicine approaches that improve patient care. Although developing system wide integrated data structures and staff with the appropriate skills requires substantial effort, the outcome is more reliable evaluations that lead to higher quality and higher value care. IMPLICATIONS Health care delivery organizations can improve patient care by dedicating resources to embed HSS into its routine operations.
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Affiliation(s)
- Heather Kitzman
- Baylor Scott and White Health and Wellness Center, Baylor Scott and White Health, Dallas, TX, USA.
| | - Briget DaGraca
- Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas, TX, USA
| | - Abdullah Mamun
- Baylor Scott and White Health and Wellness Center, Baylor Scott and White Health, Dallas, TX, USA
| | - Ashley Collinsworth
- Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas, TX, USA
| | - Kenneth Halloran
- Baylor Scott and White Health and Wellness Center, Baylor Scott and White Health, Dallas, TX, USA
| | - Andrew Masica
- Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas, TX, USA; Texas Health Resources, Arlington, TX, USA
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12
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Spencer-Brown LEK, Brophy JE, Panzer PE, Hayes MA, Blitstein JL. Evaluation of an Electronic Health Record Referral Process to Enhance Participation in Evidence-Based Arthritis Interventions. Prev Chronic Dis 2021; 18:E46. [PMID: 33988498 PMCID: PMC8139456 DOI: 10.5888/pcd18.200484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE AND OBJECTIVES Effective community-based programs to manage arthritis exist, but many adults with arthritis are unaware that these programs are available in their communities. An electronic health record (EHR) referral intervention was designed to strengthen health care and community-based partnerships and increase participation in these arthritis programs. The intervention was developed in response to a national effort that aimed to enhance the health, wellness, and quality of life for people with arthritis by increasing the awareness and availability of, and participation in arthritis-appropriate evidence-based interventions. INTERVENTION APPROACH The National Recreation and Park Association recruited 4 park and recreation agencies and their health care partners to implement an EHR-based retrospective and point-of-care referral intervention. Eligible for referral were adults aged 45 or older with an arthritis condition who were seen by a physician within the past 18 months, and were living within the park and recreation service area. After health care organizations identified eligible adults, they either mailed communication packages describing the availability and benefits of the intervention and conducted phone calls to encourage arthritis-appropriate intervention participation or counseled and referred patients during an office visit. EVALUATION METHODS The pilot was assessed by using semi-structured interviews with key intervention staff members and the Consolidated Framework for Implementation Research. RESULTS Our approach resulted in referrals for 3,660 people, 1,063 (29%) of whom participated in an intervention. Analysis of key informant interviews also highlighted the specific contextual factors, facilitators, and barriers that influenced the adaptation and overall implementation of the referral intervention. IMPLICATIONS FOR PUBLIC HEALTH Our pilot demonstrates that successful coordination between health care organizations and community-based organizations can promote awareness of and participation in community-based programs. An understanding of the contextual factors and lessons learned can be used to inform processes that can lead to more effective and sustainable health care and community-based partnerships.
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Affiliation(s)
- Lesha E K Spencer-Brown
- National Recreation and Park Association, Programs and Partnerships, Ashburn, Virginia.,Now with Administration for Community Living, Department of Health and Human Services, Washington, District of Columbia.,Administration on Aging, Administration for Community Living, US Department of Health and Human Services, 330 C Street SW, Washington, DC 20201.
| | - Jenna E Brophy
- RTI International, Food, Nutrition and Obesity Policy Research, Research Triangle Park, North Carolina
| | | | - Michael A Hayes
- RTI International, Food, Nutrition and Obesity Policy Research, Research Triangle Park, North Carolina
| | - Jonathan L Blitstein
- RTI International, Public Health Research Division, Research Triangle Park, North Carolina.,Now with Insight Policy Research, Arlington, Virginia
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13
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Simon M, Baur C, Guastello S, Ramiah K, Tufte J, Wisdom K, Johnston-Fleece M, Cupito A, Anise A. Patient and Family Engaged Care: An Essential Element of Health Equity. NAM Perspect 2020; 2020:202007a. [PMID: 35291751 DOI: 10.31478/202007a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In this paper, we emphasize and explore health equity as an integral component of a culture of patient and family engaged care (PFEC), rather than an isolated or peripheral outcome. To examine the role of PFEC in addressing health inequities, we build on the 2017 NAM Perspectives discussion paper "Harnessing Evidence and Experience to Change Culture: A Guiding Framework for Patient and Family Engaged Care." Informed by both scientific evidence and the lived experience of patients, their care partners, practitioners, and health system leaders, the paper by Frampton et al. introduced a novel Guiding Framework that delineates critical elements that work together to co-create a culture of PFEC, while also depicting a logical sequencing for implementation that facilitates progressive change and improvement toward the Quadruple Aim outcomes of better culture, better care, better health, and lower costs. In this paper, the authors highlight the need to integrate addressing health and health care disparities and improving health equity as core components of the framework to ensure the culture and policy changes necessary to meaningfully engage patients, health system staff, families, and communities.
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14
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Duru OK, Harwood J, Moin T, Jackson N, Ettner S, Vasilyev A, Mosley DG, O’Shea DL, Ho S, Mangione CM. Evaluation of a National Care Coordination Program to Reduce Utilization Among High-cost, High-need Medicaid Beneficiaries With Diabetes. Med Care 2020; 58 Suppl 6 Suppl 1:S14-S21. [PMID: 32412949 PMCID: PMC10653047 DOI: 10.1097/mlr.0000000000001315] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Medical, behavioral, and social determinants of health are each associated with high levels of emergency department (ED) visits and hospitalizations. OBJECTIVE The objective of this study was to evaluate a care coordination program designed to provide combined "whole-person care," integrating medical, behavioral, and social support for high-cost, high-need Medicaid beneficiaries by targeting access barriers and social determinants. RESEARCH DESIGN Individual-level interrupted time series with a comparator group, using person-month as the unit of analysis. SUBJECTS A total of 42,214 UnitedHealthcare Medicaid beneficiaries (194,834 person-months) age 21 years or above with diabetes, with Temporary Assistance to Needy Families, Medicaid expansion, Supplemental Security Income without Medicare, or dual Medicaid/Medicare. MEASURES Our outcome measures were any hospitalizations and any ED visits in a given month. Covariates of interest included an indicator for intervention versus comparator group and indicator and spline variables measuring changes in an outcome's time trend after program enrollment. RESULTS Overall, 6 of the 8 examined comparisons were not statistically significant. Among Supplemental Security Income beneficiaries, we observed a larger projected decrease in ED visit risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -6.6%; 95% confidence interval: -11.2%, -2.1%). Among expansion beneficiaries, we observed a greater decrease in hospitalization risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -5.8%; 95% confidence interval: -11.4%, -0.2%). CONCLUSION A care coordination program designed to reduce utilization among high-cost, high-need Medicaid beneficiaries was associated with fewer ED visits and hospitalizations for patients with diabetes in selected Medicaid programs but not others.
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Affiliation(s)
- O. Kenrik Duru
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
| | - Jessica Harwood
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
| | - Tannaz Moin
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
- VA Greater Los Angeles Healthcare System,11301 Wilshire Boulevard Los Angeles, CA 90073-1003
| | - Nick Jackson
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
| | - Susan Ettner
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
- UCLA Fielding School of Public Health, 650 Charles E. Young Dr. South, Los Angeles, CA 90095
| | - Arseniy Vasilyev
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
| | | | | | - Sam Ho
- UnitedHealthcare, Minnetonka, MN 55343
| | - Carol M. Mangione
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
- UCLA Fielding School of Public Health, 650 Charles E. Young Dr. South, Los Angeles, CA 90095
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15
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Carlson LC, Kim J, Samuels-Kalow ME, Yun BJ, Terry DF, Weilburg JB, Lee J. Comparing neighborhood-based indices of socioeconomic risk factors and potentially preventable emergency department utilization. Am J Emerg Med 2020; 44:213-219. [PMID: 32291162 DOI: 10.1016/j.ajem.2020.03.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/21/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Neighborhood stress score (NSS) and area deprivation index (ADI) are two neighborhood-based composite measures used to quantify an individual's socioeconomic risk based on home location. In this analysis, we compare the relationships between an individual's socioeconomic risk, based on each of these measures, and potentially preventable acute care utilization. METHODS Using emergency department (ED) visit data from two academic medical centers in Boston, Massachusetts, we conducted adjusted Poisson regressions of ADI decile and NSS decile with counts of low acuity ED visits, admissions for ambulatory care sensitive conditions (ACSCs), and patients with high frequency ED utilization at the census block group (CBG) level within the greater Boston area. RESULTS Both NSS and ADI decile were associated with elevated rates of utilization, although the associated incidence rate ratios (IRRs) for NSS were higher than those for ADI across all three measures. NSS decile was associated with IRRs of 1.11 [95% CI: 1.10-1.12], 1.16 [1.14-1.17], and 1.22 [1.19-1.25] for ACSC admissions, low acuity ED visits, and patients with high frequency ED utilization, respectively; compared with 1.04 [1.04-1.05], 1.11 [1.10-1.11], and 1.10 [1.08-1.12] for ADI decile. CONCLUSION ADI and NSS both represent effective tools to assess the potential impact of geographically-linked socioeconomic drivers of health on potentially preventable acute care utilization. NSS decile was associated with a greater effect size for each measure of utilization suggesting that this may be a stronger predictor, however, additional research is necessary to evaluate these findings in other contexts.
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Affiliation(s)
- Lucas C Carlson
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA; Population Health Management, Partners HealthCare, Boston, MA, USA.
| | - Jungyeon Kim
- Department of Population Health, Harvard School of Public Health, Boston, MA, USA
| | - Margaret E Samuels-Kalow
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Brian J Yun
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Dellara F Terry
- Population Health Management, Partners HealthCare, Boston, MA, USA
| | - Jeffrey B Weilburg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jarone Lee
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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16
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Characteristics of Non-Emergent Visits in Emergency Departments: Profiles and Longitudinal Pattern Changes in Taiwan, 2000-2010. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16111999. [PMID: 31195627 PMCID: PMC6603954 DOI: 10.3390/ijerph16111999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/26/2019] [Accepted: 06/04/2019] [Indexed: 11/17/2022]
Abstract
An increasing number of emergency department (ED) visits have posed a challenge to health systems in many countries, but an understanding of non-emergent ED visits has remained limited and contentious. This retrospective study analyzed ED visits using three representative cohorts from routine data to explore the profiles and longitudinal pattern changes of non-emergent ED visits in Taiwan. Systematic-, personal-, and ED visit-level data were analyzed using a logistic regression model. Average marginal effects were calculated to compare the effects of each factor. The annual ED visit rate increased up to 261.3 per 1000 population in 2010, and a significant one-third of visits were considered as non-emergent. The rapidly growing utilization of ED visits underwent a watershed change after cost-sharing payments between patients and medical institutions were increased in 2005. In addition to cohort effects resulting from cost-sharing payment changes, all factors were significantly associated with non-emergent ED visits with different levels of impact. We concluded that non-emergent ED visits were associated with multifaceted factors, but the change to cost-sharing payment, being female, younger age, and geographical residence were the most predictive factors. This information would enhance the implementation of evidence-based strategies to optimize ED use.
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