The effect of socioeconomic status on outcomes for seriously ill patients: a linked data cohort study

Socioeconomic Status and Dementia Risk Among Intensive Care Unit Survivors: Using National Health Insurance Cohort in Korea

BACKGROUND

In aging populations, more elderly patients are going to the intensive care unit (ICU) and surviving. However, the specific factors influencing the occurrence of post-intensive care syndrome in the elderly remain uncertain.

OBJECTIVE

To investigate the association between socioeconomic status (SES) and risk of developing dementia within two years following critical care.

METHODS

This study included participants from the Korean National Health Insurance Service Cohort Database who had not been diagnosed with dementia and had been hospitalized in the ICU from 2003 to 2019. Dementia was determined using specific diagnostic codes (G30, G31) and prescription of certain medications (rivastigmine, galantamine, memantine, or donepezil). SES was categorized into low (medical aid beneficiaries) and non-low (National Health Insurance) groups. Through a 1:3 propensity score matching based on sex, age, Charlson comorbidity index, and primary diagnosis, the study included 16,780 patients. We used Cox proportional hazard models to estimate adjusted hazard ratios (HR) of dementia.

RESULTS

Patients with low SES were higher risk of developing dementia within 2 years after receiving critical care than those who were in non-low SES (HR: 1.23, 95% CI: 1.04-1.46). Specifically, patients with low SES and those in the high-income group exhibited the highest incidence rates of developing dementia within two years after receiving critical care, with rates of 3.61 (95% CI: 3.13-4.17) for low SES and 2.58 (95% CI: 2.20-3.03) for high income, respectively.

CONCLUSIONS

After discharge from critical care, compared to the non-low SES group, the low SES group was associated with an increased risk of developing dementia.

Linking Sepsis with chronic arterial hypertension, diabetes mellitus, and socioeconomic factors in the United States: A scoping review

RATIONALE

Sepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host immune response to infection. Social risk factors including location and poverty are associated with sepsis-related disparities. Understanding the social and biological phenotypes linked with the incidence of sepsis is warranted to identify the most at-risk populations. We aim to examine how factors in disadvantage influence health disparities related to sepsis.

METHODS

A scoping review was performed for English-language articles published in the United States from 1990 to 2022 on PubMed, Web of Science, and Scopus. Of the 2064 articles found, 139 met eligibility criteria and were included for review.

RESULTS

There is consistency across the literature of disproportionately higher rates of sepsis incidence, mortality, readmissions, and associated complications, in neighborhoods with socioeconomic disadvantage and significant poverty. Chronic arterial hypertension and diabetes mellitus also occur more frequently in the same geographic distribution as sepsis, suggesting a potential shared pathophysiology.

CONCLUSIONS

The distribution of chronic arterial hypertension, diabetes mellitus, social risk factors associated with socioeconomic disadvantage, and sepsis incidence, are clustered in specific geographical areas and linked by endothelial dysfunction. Such population factors can be utilized to create equitable interventions aimed at mitigating sepsis incidence and sepsis-related disparities.

Association Between Socioeconomic Status and Outcomes in Critical Care: A Systematic Review and Meta-Analysis

OBJECTIVES

Socioeconomic status is well established as a key determinant of inequalities in health outcomes. Existing literature examining the impact of socioeconomic status on outcomes in critical care has produced inconsistent findings. Our objective was to synthesize the available evidence on the association between socioeconomic status and outcomes in critical care.

DATA SOURCES

A systematic search of CINAHL, Ovid MEDLINE, and EMBASE was undertaken on September 13, 2022.

STUDY SELECTION

Observational cohort studies of adults assessing the association between socioeconomic status and critical care outcomes including mortality, length of stay, and functional outcomes were included. Two independent reviewers assessed titles, abstracts, and full texts against eligibility and quality criteria.

DATA EXTRACTION

Details of study methodology, population, exposure measures, and outcomes were extracted.

DATA SYNTHESIS

Thirty-eight studies met eligibility criteria for systematic review. Twenty-three studies reporting mortality to less than or equal to 30 days following critical care admission, and eight reporting length of stay, were included in meta-analysis. Random-effects pooled analysis showed that lower socioeconomic status was associated with higher mortality at less than or equal to 30 days following critical care admission, with pooled odds ratio of 1.13 (95% CIs, 1.05-1.22). Meta-analysis of ICU length of stay demonstrated no significant difference between socioeconomic groups. Socioeconomic status may also be associated with functional status and discharge destination following ICU admission.

CONCLUSIONS

Lower socioeconomic status was associated with higher mortality following admission to critical care.

Screening for Social Risk Factors in the ICU During the Pandemic

Due to limitations in data collected through electronic health records, the social risk factors (SRFs) that predate severe illness and restrict access to critical care services are poorly understood.

OBJECTIVES

This study explored the feasibility and utility of directly eliciting SRFs in the ICU by implementing a screening program.

DESIGN SETTING AND PARTICIPANTS

Five hundred sixty-six critically ill patients at the medical ICU of Robert Wood Johnson University Hospital from July 1, 2019, to September 31, 2021, were interviewed for SRFs using an adapted version of the American Academy of Family Physicians' Social Needs Screening Tool.

MAIN OUTCOMES AND MEASURES

For each SRFs, we compared basic demographic factors, proxies of socioeconomic status, and severity score between those with and without the SRFs through chi-square tests and Wilcoxon rank-sum tests. Furthermore, we determined the prevalence of SRFs overall, before, and during the COVID-19 pandemic.

RESULTS

Of critically ill patients, 39.58% reported at least one SRF. Age, zip-code matched median household income, and insurance type differed depending on the SRFs. Notably, patients with SRFs were admitted with a lower average severity score, indicating reduced risk in mortality. Since March 2020, the prevalence of SRFs in the ICU overall fell from 54.47% to 35.44%. Conversely, the proportion of patients unable to afford healthcare increased statistically significantly from 7.32% to 18.06%.

CONCLUSIONS AND RELEVANCE

Screening for SRFs in the ICU detected the presence of disproportionally low-risk patients whose access to critical care services became restricted throughout the pandemic.

A Modified Physical Disability Screening Model after Treatment in the Intensive Care Unit: A Nationwide Derivation-Validation Study

Background: Many of the survivors of critical illnesses in the intensive care unit (ICU) suffer from physical disability for months after the treatment in the ICU. Identifying patients who are susceptible to disability is essential. The purpose of the study was to modify a model for early in-ICU prediction of the patient’s risk for physical disability two months after the treatment in the ICU. Methods: A prospective multicenter derivation–validation study was conducted from 1 July 2015, to 31 August 2016. We modified a model consisting of three risk factors in the derivation group and tested the modified model in the validation group. They were asked for their physical abilities before being admitted, two months after discharge from the ICU by a binary ADL staircases questionnaire. The univariate and multivariate logistic regression was used to modify physical disability components in the derivation data set. Receiver operating characteristic curves were used to determine the sensitivity and specificity of the threshold values in the validation group. Results: Five-hundred nineteen survivors were enrolled in the derivation group, and 271 in the validation. In multivariable analysis, the odds ratio (OR) of physical disability significantly increased with educational level ≤ elementary school (OR: 36.96, 95%CI: 18.14–75.29), inability to sit without support (OR: 15.16, 95%CI: 7.98–28.80), and having a fracture (OR: 12.74, 95%CI: 4.47–36.30). The multivariable validation model indicated that education level, inability to sit without support, and having a fracture simultaneously had sensitivity 71.3%, specificity 88.2%, LR+ 6.0, LR− 0.33, PPV 90.9, and NPV 64.9 to predict physical disability. Applying the coefficients derived from the multivariable logistic regression fitted on the derivation dataset in the validation dataset and computing diagnostic index sensitivity 100%, specificity 60.5%, LR+ 2.5, LR− 0.003, PPV 80.8, and NPV 100. The modified model had an excellent prediction ability for physical disability (AUC ± SE = 0.881 ± 0.016). Conclusions: Low education level, inability to sit without support, and having a fracture in a modified model were associated with the development of physical disability after discharge from ICU. Therefore, these clinical variables should be considered when organizing follow-up care for ICU survivors.

OUP accepted manuscript

Background

Somatic syndromes are present in 30 per cent of primary healthcare populations and are associated with increased health service use and health costs. Less is known about secondary care surgical inpatient populations.

Methods

This was a prospective longitudinal cohort study (n = 465) of consecutive adult admissions with an episode of non-traumatic abdominal pain, to the Acute General Surgical Unit at a tertiary hospital in New South Wales, Australia. Somatic symptom severity (SSS) was dichotomized using the Patient Health Questionnaire (PHQ)-15 with a cut-off point of 10 or higher (medium–high SSS) and compared pre-admission and during admission. Total healthcare utilization and direct costs were stratified by a PHQ-15 score of 10 or higher. Linear regression was used to examine differences in costs, and a multivariable linear regression was used to examine the relationship of PHQ-15 scores of 10 or higher to total costs, reported as mean total costs of care and percentage difference (95 per cent confidence intervals).

Results

Fifty-two per cent (n = 242) of participants had a medium–high SSS with greater pre-admission and admission interval health service costs. Mean total direct costs of care were 25 per cent (95 per cent c.i. 8 to 44 per cent) higher in the PHQ-15 score of 10 or higher group: mean difference €1401.93 (95 per cent c.i. €512.19 to €2273.67). The multivariable model showed a significant association of PHQ-15 scores of 10 or higher (2.1 per cent; 0.2–4.1 per cent greater for each one-point increase in score) with total hospital costs, although the strongest contributions to cost were older age, operative management, and lower socioeconomic level. There was a linear relationship between PHQ scores and total healthcare costs.

Conclusions

Medium to high levels of somatic symptoms are common in surgical inpatients with abdominal pain and are independently associated with greater healthcare utilization.

Neighborhood Socioeconomic Disadvantage and Disability After Critical Illness

OBJECTIVES

Factors common to socioeconomically disadvantaged neighborhoods, such as low availability of transportation, may limit access to restorative care services for critical illness survivors. Our primary objective was to evaluate whether neighborhood socioeconomic disadvantage was associated with an increased disability burden after critical illness. Our secondary objective was to determine if the effect differed for those discharged to the community compared with those discharged to a facility.

DESIGN

Longitudinal cohort study with linked Medicare claims data.

SETTING

United States.

PATIENTS

One hundred ninety-nine older adults, contributing to 239 ICU admissions, who underwent monthly assessments of disability for 12 months following hospital discharge in 13 different functional tasks from 1998 to 2017.

MEASUREMENTS AND MAIN RESULTS

Neighborhood disadvantage was assessed using the area deprivation index, a 1-100 ranking evaluating poverty, housing, and employment metrics. Those living in disadvantaged neighborhoods (top quartile of scores) were less likely to self-identify as non-Hispanic White compared with those in more advantaged neighborhoods. In adjusted models, older adults living in disadvantaged neighborhoods had a 9% higher disability burden over the 12 months following ICU discharge compared with those in more advantaged areas (rate ratio, 1.09; 95% Bayesian credible interval, 1.02-1.16). In the secondary analysis adjusting for discharge destination, neighborhood disadvantage was associated with a 14% increase in disability burden over 12 months of follow-up (rate ratio, 1.14; 95% credible interval, 1.07-1.21). Disability burden was 10% higher for those living in disadvantaged neighborhoods and discharged home as compared with those discharged to a facility, but this difference was not statistically significant (interaction rate ratio, 1.10; 95% credible interval, 0.98-1.25).

CONCLUSIONS

Neighborhood socioeconomic disadvantage is associated with a higher disability burden in the 12 months after a critical illness. Future studies should evaluate barriers to functional recovery for ICU survivors living in disadvantaged neighborhoods.

An Innovative Individual-Level Socioeconomic Measure Predicts Critical Care Outcomes in Older Adults: A Population-Based Study

BACKGROUND

Little is known about the impact of socioeconomic status (SES) as a key element of social determinants of health on intensive care unit (ICU) outcomes for adults.

OBJECTIVE

We assessed whether a validated individual SES index termed HOUSES (HOUsing-based SocioEconomic status index) derived from housing features was associated with short-term outcomes of critical illness including ICU mortality, ICU-free days, hospital-free days, and ICU readmission.

METHODS

We performed a population-based cohort study of adult patients living in Olmsted County, Minnesota, admitted to 7 intensive care units at Mayo Clinic from 2011 to 2014. We compared outcomes between the lowest SES group (HOUSES quartile 1 [Q1]) and the higher SES group (HOUSES Q2-4). We stratified the cohort based on age (<50 years old and ≥50 years old).

RESULTS

Among 4134 eligible patients, 3378 (82%) patients had SES successfully measured by the HOUSES index. Baseline characteristics, severity of illness, and reason for ICU admission were similar among the different SES groups as measured by HOUSES except for larger number of intoxications and overdoses in younger patients from the lowest SES. In all adult patients, there were no overall differences in mortality, ICU-free days, hospital-free days, or ICU readmissions in patients with higher SES compared to lower SES. Among older patients (>50 years), those with higher SES (HOUSES Q2-4) compared to those with lower SES (HOUSES Q1) had lower mortality rates (hazard ratio = 0.72; 95% CI: 0.56-0.93; adjusted P = .01), increased ICU-free days (mean 1.08 days; 95% CI: 0.34-1.84; adjusted P = .004), and increased hospital-free days (mean 1.20 days; 95% CI: 0.45-1.96; adjusted P = .002). There were no differences in ICU readmission rates (OR = 0.74; 95% CI: 0.55-1.00; P = .051).

CONCLUSION

Individual-level SES may be an important determinant or predictor of critical care outcomes in older adults. Housing-based socioeconomic status may be a useful tool for enhancing critical care research and practice.

Associations Between Socioeconomic Status, Patient Risk, and Short-Term Intensive Care Outcomes

OBJECTIVES

To investigate the association of socioeconomic status as measured by the average socioeconomic status of the area where a person resides on short-term mortality in adults admitted to an ICU in Queensland, Australia.

DESIGN

Secondary data analysis using de-identified data from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation linked to the publicly available area-level Index of Relative Socioeconomic Advantage and Disadvantage from the Australian Bureau of Statistics.

SETTING

Adult ICUs from 35 hospitals in Queensland, Australia, from 2006 to 2015.

PATIENTS

A total of 218,462 patient admissions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The outcome measure was inhospital mortality. The main study variable was decile of Index of Relative Socioeconomic Advantage and Disadvantage. The overall crude inhospital mortality was 7.8%; 9% in the most disadvantaged decile and 6.9% in the most advantaged decile (p < 0.001). Increasing socioeconomic disadvantage was associated with increasing severity of illness as measured by Acute Physiology and Chronic Health Evaluation III score, admission with a diagnosis of sepsis or trauma, cardiac, respiratory, renal, and hepatic comorbidities, and remote location. Increasing socioeconomic advantage was associated with elective surgical admission, hematological and oncology comorbidities, and admission to a private hospital (all p < 0.001). After excluding patients admitted after elective surgery, in the remaining 106,843 patients, the inhospital mortality was 13.6%, 13.3% in the most disadvantaged, and 14.1% in the most advantaged. There was no trend in mortality across deciles of socioeconomic status after excluding elective surgery patients. In the logistic regression model adjusting for severity of illness and diagnosis, there was no statistically significant difference in the odds ratio of inhospital mortality for the most disadvantaged decile compared with other deciles. This suggests variables used for risk adjustment may lie on the causal pathway between socioeconomic status and outcome in ICU patients.

CONCLUSIONS

Socioeconomic status as defined as Index of Relative Socioeconomic Advantage and Disadvantage of the area in which a patient lives was associated with ICU admission diagnosis, comorbidities, severity of illness, and crude inhospital mortality in this study. Socioeconomic status was not associated with inhospital mortality after excluding elective surgical patients or when adjusted for severity of illness and admission diagnosis. Commonly used measures for risk adjustment in intensive care improve understanding of the pathway between socioeconomic status and outcomes.

Socioeconomic Factors and Intensive Care Unit-Related Cognitive Impairment

OBJECTIVE

We aimed to identify socioeconomic and clinical risk factors for post-intensive care unit (ICU)-related long-term cognitive impairment (LTCI).

SUMMARY BACKGROUND DATA

After delirium during ICU stay, LTCI has been increasingly recognized, but without attention to socioeconomic factors.

METHODS

We enrolled a prospective, multicenter cohort of ICU survivors with shock or respiratory failure from surgical and medical ICUs across 5 civilian and Veteran Affairs (VA) hospitals from 2010 to 2016. Our primary outcome was LTCI at 3- and 12 months post-hospital discharge defined by the Repeatable Battery for Assessment of Neuropsychological Symptoms (RBANS) global score. Covariates adjusted using multivariable linear regression included age, sex, race, AHRQ socioeconomic index, Charlson comorbidity, Framingham stroke risk, Sequential Organ Failure Assessment, duration of coma, delirium, hypoxemia, sepsis, education level, hospital type, insurance status, discharge disposition, and ICU drug exposures.

RESULTS

Of 1040 patients, 71% experienced delirium, and 47% and 41% of survivors had RBANS scores >1 standard deviation below normal at 3- and 12 months, respectively. Adjusted analysis indicated that delirium, non-White race, lower education, and civilian hospitals (as opposed to VA), were associated with at least a half standard deviation lower RBANS scores at 3- and 12 months (P ≤ 0.03). Sex, AHRQ socioeconomic index, insurance status, and discharge disposition were not associated with RBANS scores.

CONCLUSIONS

Socioeconomic and clinical risk factors, such as race, education, hospital type, and delirium duration, were linked to worse PICS ICU-related, LTCI. Further efforts may focus on improved identification of higher-risk groups to promote survivorship through emerging improvements in cognitive rehabilitation.

Long term outcomes for Aboriginal and Torres Strait Islander Australians after hospital intensive care

OBJECTIVES

To assess long term outcomes for Aboriginal and Torres Strait Islander (Indigenous) Australians admitted non-electively to intensive care units (ICUs).

DESIGN

Data linkage cohort study; analysis of ICU patient data (Australian and New Zealand Intensive Care Society Adult Patient Database), prospectively collected during 2007-2016.

SETTING

All four university-affiliated level 3 ICUs in South Australia.

MAIN OUTCOMES

Mortality (in-hospital, and 12 months and 8 years after admission to ICU), by Indigenous status.

RESULTS

2035 of 39 784 non-elective index ICU admissions (5.1%) were of Indigenous Australians, including 1461 of 37 661 patients with South Australian residential postcodes. The median age of Indigenous patients (45 years; IQR, 34-57 years) was lower than for non-Indigenous ICU patients (64 years; IQR, 47-76 years). For patients with South Australian postcodes, unadjusted mortality at discharge and 12 months and 8 years after admission was lower for Indigenous patients; after adjusting for age, sex, diabetes, severity of illness, and diagnostic group, mortality was similar for both groups at discharge (adjusted odds ratio [aOR], 0.95; 95% CI, 0.81-1.10), but greater for Indigenous patients at 12 months (aOR, 1.14; 95% CI, 1.03-1.26) and 8 years (adjusted hazard ratio, 1.23; 95% CI, 1.13-1.35). The number of potential years of life lost was greater for Indigenous patients (median, 24.0; IQR, 15.8-31.8 v 12.5; IQR, 0-22.3), but, referenced to respective population life expectancies, relative survival at 8 years was similar (proportions: Indigenous, 0.78; 95% CI, 0.75-0.80; non-Indigenous, 0.77; 95% CI, 0.76-0.78).

CONCLUSIONS

Adjusted long term mortality and median number of potential life years lost are higher for Indigenous than non-Indigenous patients after intensive care in hospital. These differences reflect underlying population survival patterns rather than the effects of ICU admission.

Use of prehospital emergency medical services according to income of residential area

Background

The increasing usage of emergency medical services (EMS) missions is a challenge in modern practice. This study was designed to examine the association of the income level of residential areas on the rate of EMS missions and the frequency of EMS use in these areas.

Methods

All EMS missions for adult patients (>18 years) encountered by one rescue department in Northern Finland between June 2015 and May 2017 were analysed. The area served was categorised into four categories, according to the median annual income of the postal code areas. EMS missions per 1000 person-years, rate of non-transport missions and the number of dispatches to frequent (>4 EMS calls/year and highly frequent (>10 calls/year)EMS users per area were investigated.

Results

There were 62 759 EMS missions, 34.8% of which resulted in non-transport. The crude rate of EMS dispatches was higher in the low-income area compared with other income areas (133.3 vs 108.9 vs 111.3 vs 73.6/1000 person-years) as well as the rate of high-frequency user dispatches (21.5 vs 11.5 vs 7.2 vs 4.3/1000-person years). The rate of non-transports missions was higher also (69.4 vs 43.4 vs 42.5. vs 30.6/1000 person-years). The highest crude rate of EMS use was found in people older than 65 years living in the lowest income areas (294.8/1000 person-years). After age adjustment, the highest rate of EMS use was found in rural areas with the lowest income (146.3/1000 person-years).

Conclusions

The rate of the EMS missions and non-transport missions differs significantly among different income areas. Resource usage was significantly higher in the low income areas. This information can be used in planning allocation of EMS and preventive healthcare resources.

Impact of Socioeconomic Status on 30-Day and 1-Year Mortalities after Intensive Care Unit Admission in South Korea: A Retrospective Cohort Study

Background

Socioeconomic status (SES) is closely associated with health outcomes, including mortality in critically ill patients admitted to intensive care unit (ICU). However, research regarding this issue is lacking, especially in countries where the National Health Insurance System is mainly responsible for health care. This study aimed to investigate how the SES of ICU patients in South Korea is associated with mortality.

Methods

This was a retrospective observational study of adult patients aged ≥20 years admitted to ICU. Associations between SES-related factors recorded at the time of ICU admission and 30-day and 1-year mortalities were analyzed using univariable and multivariable Cox regression analyses.

Results

A total of 6,008 patients were included. Of these, 394 (6.6%) died within 30 days of ICU admission, and 1,125 (18.7%) died within 1 year. Multivariable Cox regression analysis found no significant associations between 30-day mortality after ICU admission and SES factors (P>0.05). However, occupation was significantly associated with 1-year mortality after ICU admission.

Conclusions

Our study shows that 30-day mortality after ICU admission is not associated with SES in the National Health Insurance coverage setting. However, occupation was associated with 1-year mortality after ICU admission.

Association of socioeconomic status with outcomes in older adult community-dwelling patients after visiting the emergency department: a retrospective cohort study

OBJECTIVES

Older adults frequently visit the emergency department (ED). Socioeconomic status (SES) has an important impact on health and ED utilisation; however, the association between SES and ED utilisation in elderly remains unclear. The aim of this study was to investigate the association between SES in older adult patients visiting the ED on outcomes.

DESIGN

A retrospective study.

PARTICIPANTS

Older adults (≥65 years) visiting the ED, in the Netherlands. SES was stratified into tertiles based on average household income at zip code level: low (<€1800/month), intermediate (€1800-€2300/month) and high (>€2300/month).

PRIMARY OUTCOMES

Hospitalisation, inhospital mortality and 30-day ED return visits. Effect of SES on outcomes for all groups were assessed by logistic regression and adjusted for confounders.

RESULTS

In total, 4828 older adults visited the ED during the study period. Low SES was associated with a higher risk of hospitalisation among community-dwelling patients compared with high SES (adjusted OR 1.3, 95% CI 1.1 to 1.7). This association was not present for intermediate SES (adjusted OR 1.1, 95% CI 0.95 to 1.4). Inhospital mortality was comparable between the low and high SES group, even after adjustment for age, comorbidity and triage level (low OR 1.4, 95% CI 0.8 to 2.6, intermediate OR 1.3, 95% CI 0.8 to 2.2). Thirty-day ED revisits among community-dwelling patients were also equal between the SES groups (low: adjusted OR 1.0, 95% CI 0.7 to 1.4, and intermediate: adjusted OR 0.8, 95% CI 0.6 to 1.1).

CONCLUSION

In older adult ED patients, low SES was associated with a higher risk of hospitalisation than high SES. However, SES had no impact on inhospital mortality and 30-day ED revisits after adjustment for confounders.

Has the income of the residential area impact on the use of intensive care?

BACKGROUND

The socioeconomic factors have an impact on case mix and outcome in critical illness, but how these factors affect the use of intensive care is not studied. The aim of this study was to evaluate the incidence of intensive care unit (ICU) admissions in patients from residential areas with different annual incomes.

METHODS

Single-center, retrospective study in Northern Finland. All the non-trauma-related emergency admissions from the hospital district area were included. The postal codes were used to categorize the residential areas according to each area's annual median income: the low-income area, €18,979 to €28,841 per year; the middle-income area, €28,879 to €33,856 per year; and the high-income area, €34,221 to €53,864 per year.

RESULTS

A total of 735 non-trauma-related admissions were included. The unemployment or retirement, psychiatric comorbidities and chronic alcohol abuse were common in this population. The highest incidence, 5.5 (4.6-6.7)/1000/year, was in population aged more than 65 years living in high-income areas. In working-aged population, the incidence was lowest in high-income areas (1.5 (1.3-1.8/1000/year) compared to middle-income areas (2.2 (1.9-2.6)/1000/year, P = 0.001) and low-income areas (2.0 (1.7-2.4)/1000/, P = 0.009). Poisonings were more common in low-income areas. There were no differences in outcome.

CONCLUSION

The incidence of ICU admission in working-aged population was 25% higher in those areas where the annual median income was below the median annual income of €38,775 per inhabitant per year in Finland.

Associations Between Economic Pressure and Diabetes Efficacy in Couples With Type 2 Diabetes

Objective

The purpose of this study was to explore dyadic associations between economic pressure and diabetes self-efficacy via emotional distress in patients with type 2 diabetes and their partners.

Background

Understanding how economic pressure is associated with successful diabetes management is an important area for research, as couples with type 2 diabetes can incur heavy economic pressures that could likely influence diabetes outcomes.

Method

Data from 117 married couples were used to test actor-partner associations using moderated mediation analyses in a structural equation modeling framework. Problem-solving communication was tested as a possible moderator of the economic pressure-emotional distress pathway.

Results

Results revealed that greater patient economic pressure was associated with lower patient and spouse confidence in the patient's diabetes management ability through higher levels of patient emotional distress. The deleterious association between economic pressure and emotional distress was less pronounced when spouses reported more effective problem-solving communication.

Conclusion

These results provide evidence that the economic pressure couples with type 2 diabetes face may reduce the patient and spouse's confidence in the patient's diabetes management ability.

Implications

This study demonstrates the importance of couple's relationship processes in buffering the impact of economic pressure on diabetes management, providing a clear target for intervention and education efforts.

Public versus Private Healthcare Systems following Discharge from the ICU: A Propensity Score-Matched Comparison of Outcomes

Purpose. The long-term outcomes of patients after discharge from tertiary ICUs as they relate to the public versus private healthcare systems in Brazil have not yet been evaluated. Materials and Methods. A multicenter prospective cohort study was conducted to compare the all-cause mortality and the physical functional status (PFS) 24 months after discharge from the ICU between adult patients treated in the public and private healthcare systems. A propensity score- (PS-) matched comparison of all causes of mortality and PFS 24 months after discharge from the ICU was performed. Results. In total, 928 patients were discharged from the ICU including 172 (18.6%) patients in the public and 756 (81.4%) patients in the private healthcare system. The results of the PS-matched comparison of all-cause mortality revealed higher mortality rates among the patients of the public healthcare system compared to those of the private healthcare system (47.3% versus 27.6%, P = 0.003). The comparison of the PS-matched Karnofsky performance and Lawton activities of daily living scores between the ICU survivors of the public and private healthcare systems revealed no significant differences. Conclusions. The patients of private healthcare system exhibited significantly greater survival rates than the patients of the public healthcare system with similar PFS following ICU discharge.

Characteristics and outcomes of critically ill Aboriginal and/or Torres Strait Islander patients in North Queensland

A retrospective cohort analysis of an admission database for the intensive care unit at The Townsville Hospital was undertaken to describe the characteristics and short-term outcomes of critically ill Aboriginal and Torres Strait Islander patients. The Townsville Hospital is the tertiary referral centre for Northern Queensland and services a region in which Aboriginal and Torres Strait Islander people constitute 9.6% of the population. Aboriginal and Torres Strait Islander patients were significantly younger and had higher rates of invasive mechanical ventilation, emergency admissions and transfers from another hospital. Despite these factors, intensive care mortality did not differ between groups (9.4% versus 7.7%, P=0.1). Higher Acute Physiology and Chronic Health Evaluation III-j scores were noted in the Aboriginal and Torres Strait Islander population requiring emergency admission (65 versus 60, P=0.022) but were lower for elective admission (38 versus 42, P <0.001). Despite higher predicted hospital mortality for Aboriginal and Torres Strait Islander patients requiring emergency admission, no significant difference was observed (20.1% versus 19.1%, P=0.656). In a severity adjusted model, Aboriginal and/or Torres Strait Islander status did not statistically significantly alter the risk of death (odds ratio 0.88, 95% confidence interval 0.65, 1.2, P=0.398). Though Aboriginal and Torres Strait Islander patients requiring intensive care differed in admission characteristics, mortality was comparable to other critically ill patients.

Health-related quality of life following pediatric critical illness

PURPOSE

The aims of this focused review of the literature on children surviving critical illness were to (1) determine whether health-related quality of life (HRQL) represents a clinically meaningful outcome measure for children surviving critical illness and (2) evaluate the HRQL measures implemented in pediatric critical care studies to date.

METHODS

This was a focused review of the literature from 1980 to 2015 based on a search of EMBASE/PubMed, MEDLINE and PsycInfo assessing trends and determinants of HRQL outcomes in children surviving critical illness. We also evaluated the psychometric properties of the HRQL instruments used in the studies identified by examining each measure's reported reliability, validity and sensitivity to clinical change.

RESULTS

The literature search identified 253 pediatric articles for potential inclusion in the review, among which data from 78 studies were ultimately selected for inclusion. Of the 22 measures utilized in the studies reviewed, only four demonstrated excellent psychometric properties for use in pediatric critical care trials. Trends in HRQL identified in the studies reviewed suggest significant ongoing morbidity for children surviving critical illness. Key determinants of poor HRQL outcomes include reason for PICU admission (sepsis, meningoencephalitis, trauma), antecedents (chronic comorbid conditions), treatments received (prolonged cardiopulmonary resuscitation, long-stay patients, invasive technology), psychological outcomes (post-traumatic stress disorder, parent anxiety/depression) and social and environmental characteristics (low socioeconomic status, parental education and functioning).

CONCLUSIONS

Validated pediatric HRQL instruments are now available. Significant impact on HRQL has been demonstrated in acute and acute on chronic critical illness. Future pediatric critical care interventional trials should include both mortality as well as long-term HRQL measurements to truly ascertain the full impact of critical illness in children.

Early prediction of new-onset physical disability after intensive care unit stay: a preliminary instrument

Introduction

Many intensive care unit (ICU) survivors suffer from physical disability for months after ICU stay. There is no structured method to identify patients at risk for such problems. The purpose of the study was to develop a method for early in-ICU prediction of the patient’s individual risk for new-onset physical disability two months after ICU stay.

Methods

In total, 23 potential predictors for physical disability were assessed before individual ICU discharge. Two months after ICU discharge, out of 232 eligible patients, 148 ICU survivors (64%) completed the activity of daily living (ADL) staircase questionnaire to determine new-onset physical disability.

Results

A total of 95% percent of patients had no ADL reduction prior to ICU admission. Forty-seven percent (n = 69) of questionnaire responders suffered from worsened ADL. We identified four independent predictors for new-onset physical disability: Low educational level (odds ratio (OR) = 6.8), impaired core stability (OR = 4.6), fractures (OR = 4.5) and ICU length of stay longer than two days (OR = 2.6). The predictors were included in a screening instrument. The regression coefficient of each predictor was transformed into a risk score. The sum of risk scores was related to a predicted probability for physical disability in the individual patient. The cross-validated area under receiver operating characteristics curve (AUC) for the screening instrument was 0.80.

Conclusions

Educational level is the single most important predictor for new-onset physical disability two months after ICU stay, followed by impaired core stability at ICU discharge, the presence of fractures and ICU stay longer than two days. A simple screening instrument based on these predictors can be used at ICU discharge to determine the risk for new-onset physical disability. This preliminary instrument may help clinicians to identify patients in need of support, but needs external validation prior to wider clinical use.

Electronic supplementary material

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Effect of an injury awareness education program on risk-taking behaviors and injuries in juvenile justice offenders: a retrospective cohort study

Background

Risk-taking behavior is a leading cause of injury and death amongst young people.

Methodology and Principal Findings

This was a retrospective cohort study on the effectiveness of a 1-day youth injury awareness education program (Prevent Alcohol and Risk-related Trauma in Youth, P.A.R.T.Y.) program in reducing risk taking behaviors and injuries of juvenille justice offenders in Western Australia. Of the 3659 juvenile justice offenders convicted by the court magistrates between 2006 and 2010, 225 were referred to the P.A.R.T.Y. education program. In a before and after survey of these 225 participants, a significant proportion of them stated that they were more receptive to modifying their risk-taking behavior (21% before vs. 57% after). Using data from the Western Australia Police and Department of Health, the incidence of subsequent offences and injuries of all juvenile justice offenders was assessed. The incidence of subsequent traffic or violence-related offences was significantly lower for those who had attended the program compared to those who did not (3.6% vs. 26.8%; absolute risk reduction [ARR] = 23.2%, 95% confidence interval [CI] 19.9%–25.8%; number needed to benefit = 4.3, 95%CI 3.9–5.1; p = 0.001), as were injuries leading to hospitalization (0% vs. 1.6% including 0.2% fatality; ARR = 1.6%, 95%CI 1.2%–2.1%) and alcohol or drug-related offences (0% vs. 2.4%; ARR 2.4%, 95%CI 1.9%–2.9%). In the multivariate analysis, only P.A.R.T.Y. education program attendance (odds ratio [OR] 0.10, 95%CI 0.05–0.21) and a higher socioeconomic background (OR 0.97 per decile increment in Index of Relative Socioeconomic Advantage and Disadvantage, 95%CI 0.93–0.99) were associated with a lower risk of subsequent traffic or violence-related offences.

Significance

Participation in an injury education program involving real-life trauma scenarios was associated with a reduced subsequent risk of committing violence- or traffic-related offences, injuries, and death for juvenille justice offenders.

Socioeconomic status, severity of disease and level of family members' care in adult surgical intensive care patients: the prospective ECSSTASI study

Background

Low socioeconomic status (SES) is associated with increased mortality from cardiovascular disease, cancer and trauma. However, individual-level prospective data on SES in relation to health outcomes among critically ill patients admitted to intensive care units (ICU) are unavailable.

Methods

In a cohort of 1,006 patients at a 24-bed surgical ICU of an academic tertiary care facility in Germany, we examined levels of SES in relation to disease severity at admission, time period of mechanical ventilation, length of stay and frequency of phone calls and visits by next-of-kin.

Findings

Patients with low SES had higher risk for Sequential Organ Failure Assessment (SOFA) score greater or equal to 5 [multivariate-adjusted odds ratio (OR) 1.49; 95% confidence interval (CI) 0.95–2.33; p = 0.029] and a trend for higher risk for Simplified Acute Physiology Score (SAPS II) greater or equal to 31 (OR 1.28; 95% CI 0.80–2.05; p = 0.086) at admission as compared with patients with high SES. When compared with men with high SES, those with low SES had greater risk for ICU treatment ≥5 days (multivariate-adjusted OR 1.99; 95% CI 1.06–3.74; p = 0.036) and showed a trend for a low number of visits from next-of-kin (<0.5 visits per day) (OR 1.85; 95% CI 0.79–4.30; p = 0.054). In women such associations could not be demonstrated.

Interpretation

Socioeconomic status is inversely related to severity of disease at admission and to length of stay in ICU, and positively associated with the level of care by next-of-kin. Whether relations differ by gender requires further examination.

Empirical aspects of linking intensive care registry data to hospital discharge data without the use of direct patient identifiers

In the field of intensive care, clinical data registries are commonly used to support clinical audit and develop evidence-based practice. However, they are often restricted to the intensive care unit episode only, limiting their ability to follow long-term patient outcomes and identify patient readmissions. Data linkage can be used to supplement existing data, but a lack of unique patient identifiers may compromise the accuracy of the linkage process. The aim of this study was to assess the quality of linking the Australia/New Zealand critical care registry to a state financial claims database using a method without direct patient identifiers and to identify possible sources of bias from this method. We used a linkage method relying on indirect patient identifiers and compared the accuracy of this method to one that also included the patient medical record number and date of birth. The overall linkage rate using the method with indirect identifiers was 92.3% compared to 94.5% using the method with direct identifiers. Factors most strongly associated with not being a correct link in the first method included patients at one study hospital, admissions in 2002 and 2003 and having a hospital length of stay of 20 days or more. Linking the Australia/New Zealand critical care without direct patient identifiers is a valid linkage method that will enable the measurement of long-term patient survival and readmissions. While some sources of bias have been identified, this method provides sufficient quality linkage that will support broad analyses designed to signal future in-depth research.

Neighborhood poverty rate and mortality in patients receiving critical care in the academic medical center setting

BACKGROUND

Poverty is associated with increased risk of chronic illness but its contribution to critical care outcome is not well defined.

METHODS

We performed a multicenter observational study of 38,917 patients, aged ≥ 18 years, who received critical care between 1997 and 2007. The patients were treated in two academic medical centers in Boston, Massachusetts. Data sources included 1990 US census and hospital administrative data. The exposure of interest was neighborhood poverty rate, categorized as < 5%, 5% to 10%, 10% to 20%, 20% to 40% and > 40%. Neighborhood poverty rate is the percentage of residents below the federal poverty line. Census tracts were used as the geographic units of analysis. Logistic regression examined death by days 30, 90, and 365 post-critical care initiation and in-hospital mortality. Adjusted ORs were estimated by multivariable logistic regression models. Sensitivity analysis was performed for 1-year postdischarge mortality among patients discharged to home.

RESULTS

Following multivariable adjustment, neighborhood poverty rate was not associated with all-cause 30-day mortality: 5% to 10% OR, 1.05 (95% CI, 0.98-1.14; P = .2); 10% to 20% OR, 0.96 (95% CI, 0.87-1.06; P = .5); 20% to 40% OR, 1.08 (95% CI, 0.96-1.22; P = .2); > 40% OR, 1.20 (95% CI, 0.90-1.60; P = .2); referent in each is < 5%. Similar nonsignificant associations were noted at 90-day and 365-day mortality post-critical care initiation and in-hospital mortality. Among patients discharged to home, neighborhood poverty rate was not associated with 1-year-postdischarge mortality.

CONCLUSIONS

Our study suggests that there is no relationship between the neighborhood poverty rate and mortality up to 1 year following critical care at academic medical centers.

General health care service utilisation: where, when and by whom in a socioeconomically disadvantaged population

This paper aimed to examine the utilisation of and preferences related to health care services by residents of a disadvantaged area and to identify factors associated with levels of current and future use. Data were collected from face-to-face structured interviews of randomly selected residents of a disadvantaged local government area in 2003-04. Information about respondents' health and socioeconomic status and patterns of use and preferred features of health care was analysed in PASW Statistic 17. Chi-square statistics were used to examine differences in utilisation by sex and simple logistic regression provided sex specific age-adjusted odds ratios about frequent visits. Most respondents (95%) attended a 'usual' general practitioner (GP) service and about two-fifths had obtained other health care in the last 12 months. The median number of visits was four and most providers offered bulk billing (83%). Less common were visits to the dentist (32%), emergency department (14%), specialists (29%) and the hospital (5%). Providers' skills and traits, physical access and bulk billing were key considerations for men and women when choosing a health care provider. Disadvantaged communities want skilled practitioners who reflect their demographic mix and are located at convenient and accessible clinics, which preferably bulk bill. Apart from GP visits, this group appears to make only moderate use of specialists and emergency departments, and little routine use of other primary health services.

Economic hardship associated with managing chronic illness: a qualitative inquiry

Background

Chronic illness and disability can have damaging, even catastrophic, socioeconomic effects on individuals and their households. We examined the experiences of people affected by chronic heart failure, complicated diabetes and chronic obstructive pulmonary disease to inform patient centred policy development. This paper provides a first level, qualitative understanding of the economic impact of chronic illness.

Methods

Interviews were conducted with patients aged between 45 and 85 years who had one or more of the index conditions and family carers from the Australian Capital Territory and Western Sydney, Australia (n = 66). Content analysis guided the interpretation of data.

Results

The affordability of medical treatments and care required to manage illness were identified as the key aspects of economic hardship, which compromised patients' capacity to proactively engage in self-management and risk reduction behaviours. Factors exacerbating hardship included ineligibility for government support, co-morbidity, health service flexibility, and health literacy. Participants who were on multiple medications, from culturally and linguistically diverse or Indigenous backgrounds, and/or not in paid employment, experienced economic hardship more harshly and their management of chronic illness was jeopardised as a consequence. Economic hardship was felt among not only those ineligible for government financial supports but also those receiving subsidies that were insufficient to meet the costs of managing long-term illness over and above necessary daily living expenses.

Conclusion

This research provides insights into the economic stressors associated with managing chronic illness, demonstrating that economic hardship requires households to make difficult decisions between care and basic living expenses. These decisions may cause less than optimal health outcomes and increased costs to the health system. The findings support the necessity of a critical analysis of health, social and welfare policies to identify cross-sectoral strategies to alleviate such hardship and improve the affordability of managing chronic conditions. In a climate of global economic instability, research into the economic impact of chronic illness on individuals' health and well-being and their disease management capacity, such as this study, provides timely evidence to inform policy development.