The Relationship between Same-Day Access and Continuity in Primary Care and Emergency Department Visits

We examined how emergency department (ED) visits for potentially preventable, mental health, and other diagnoses were related to same-day access and provider continuity in primary care using administrative data from 71,296 patients in 22 VHA clinics over a three-year period. ED visits were categorized as non-emergent; primary care treatable; preventable; not preventable; or mental health-related. We conducted multi-level regression models adjusted for patient and clinic factors. More same-day access significantly predicted fewer non-emergent and primary care treatable ED visits while continuity was not significantly related to any type of ED visit. Neither measure was related to ED visits for mental health problems.     

Emergency Department Use by Released Prisoners with HIV: An Observational Longitudinal Study

Background

Many people living with HIV access healthcare systems through the emergency department (ED), and increased ED use may be indicative of disenfranchisement with primary HIV care, under-managed comorbid disease, or coincide with use of other healthcare resources. The goal of this study was to investigate ED use by HIV-infected prisoners transitioning to communities.

Methods

We evaluated ED use by 151 HIV-infected released prisoners who were enrolled in a randomized controlled trial of directly administered versus self-administered antiretroviral therapy in Connecticut. Primary outcomes were quantity and type of ED visits and correlates of ED use were evaluated with multivariate models by Poisson regression.

Results

In the 12 months post-release, there were 227 unique ED contacts made by 85/151 (56%) subjects. ED visits were primarily for acute febrile syndromes (32.6%) or pain (20.3%), followed by substance use issues (19.4%), trauma (18%), mental illness (11%), and social access issues (4.4%). Compared to those not utilizing the ED, users were more likely to be white, older, and unmarried, with less trust in their physician and poorer perceived physical health but greater social support. In multivariate models, ED use was correlated with moderate to severe depression (IRR = 1.80), being temporarily housed (IRR = 0.54), and alcohol addiction severity (IRR = 0.21) but not any surrogates of HIV severity.

Conclusions

EDs are frequent sources of care after prison-release with visits often reflective of social and psychiatric instability. Future interventions should attempt to fill resource gaps, engage released prisoners in continuous HIV care, and address these substantial needs.     

Potentially Inappropriate Medication Use in Older Patients in Swiss Managed Care Plans: Prevalence,Determinants and Association with Hospitalization

Objectives

To describe the prevalence and determinants of potentially inappropriate medication (PIM) use and association with hospitalizations in an elderly managed care population in Switzerland.

Methods

Using health care claims data of four health insurers for a sample of managed care patients 65 years of age and older to compare persons on PIM with persons not on PIM. Beers'' 2012 and PRISCUS criteria were used to determine the potential inappropriateness of prescribed medications. The sample included 16′490 elderly patients on PIM and 33′178 patients not on PIM in the time period of January 1, 2008 through December 31, 2012. Prevalence estimates are standardized to the population of Switzerland. Associations between PIM and hospitalizations were examined by multivariate Cox regression analyses controlling for possible confounding variables.

Results

The estimated prevalence of PIM use in our managed care sample was 22.5%. Logistic regression analysis showed that number of different medications used in the previous year, total costs in the previous year and hospitalization in the previous year all significantly increased the likelihood of receiving PIM. Multiple Cox regression analysis revealed that those on cumulative levels of PIM use acted significantly as a factor related to greater hospitalization rates: the adjusted HR was 1.13 (95% CI 1.07–1.19) for 1 PIM, 1.27 (95% CI 1.19–1.35) for 2 PIM, 1.35 (95% CI 1.22–1.50) for 3 PIM, and 1.63 (95% CI 1.40–1.90) for more than 3 PIM compared to no PIM use.

Conclusions

The prevalence of PIM in managed care health plans are widely found but seem to be much lower than rates of non-managed care plans. Furthermore, our study revealed a significant association with adverse outcomes in terms of hospitalizations. These findings stress the need for further development of interventions to decrease drug-related problems and manage patients with multiple chronic conditions.     

The Association between Continuity of Care and All-Cause Mortality in Patients with Newly Diagnosed Obstructive Pulmonary Disease: A Population-Based Retrospective Cohort Study, 2005-2012

BackgroundThe disease burden is increasing for chronic obstructive pulmonary disease (COPD) due to increasing of the growth rate of prevalence and mortality. But the empirical researches are a little for COPD that studied the association between continuity of care and death and about predictors effect on mortality.ObjectiveTo investigate the association between continuity of care (COC) and chronic obstructive pulmonary disease (COPD) mortality and to identify other mortality-related factors in COPD patients.MethodsWe conducted a longitudinal, population-based retrospective cohort study in adult patients with COPD from 2002 to 2012 using a nationwide health insurance claims database. The study sample included individuals aged 40 years and over who developed COPD in 2005 and survived until 2006. We performed a Cox proportional hazard regression analysis with COC analyzed as a time-dependent covariate.ResultsOf the 3,090 participants, 60.8% died before the end of study (N = 1,879). The median years of survival for individuals with high COC (COC index≥0.75) was 3.92, and that for patients with low COC (COC index<0.75) was 2.58 in a Kaplan Meier analysis. In a multivariate, time-dependent analysis, low COC was associated with a 22% increased risk of all-cause mortality (HR, 1.22; 95% CI, 1.09–1.36). Not receiving oxygen therapy at home was associated with a 23% increased risk of all-cause mortality (HR, 1.23; 95% CI, 1.01–1.49). Moreover, the risk of all-cause mortality for individuals who admitted one time increased 38% (HR, 1.38; 95% CI, 1.21–1.59), two times was 63% (HR, 1.63; 95% CI, 1.34–1.99) and 3+ times was 96% (HR, 1.96; 95% CI, 1.63–2.36) relative to the reference group (no admission).ConclusionsHigh COC was associated with a decreased risk of all-cause mortality. In addition, home oxygen therapy and number of hospital admissions may predict mortality in patients with COPD.     

Four Decades of Educational Inequalities in Hospitalization and Mortality among Older Swedes

Background

The inverse association between education and mortality has grown stronger the last decades in many countries. During the same period, gains in life expectancy have been concentrated to older ages; still, old-age mortality is seldom the focus of attention when analyzing trends in the education-mortality gradient. It is further unknown if increased educational inequalities in mortality are preceded by increased inequalities in morbidity of which hospitalization may be a proxy.

Methods

Using administrative population registers from 1971 and onwards, education-specific annual changes in the risk of death and hospital admission were estimated with complimentary log-log models. These risk changes were supplemented by estimations of the ages at which 25, 50, and 75% of the population had been hospitalized or died (after age 60).

Results

The mortality decline among older people increasingly benefitted the well-educated over the less well-educated. This inequality increase was larger for the younger old, and among men. Educational inequalities in the age of a first hospital admission generally followed the development of growing gaps, but at a slower pace than mortality and inequalities did not increase among the oldest individuals.

Conclusions

Education continues to be a significant predictor of health and longevity into old age. That the increase in educational inequalities is greater for mortality than for hospital admissions (our proxy of overall morbidity) may reflect that well-educated individuals gradually have obtained more possibilities or resources to survive a disease than less well-educated individuals have the last four decades.     

BMI,Physical Activity,and Health Care Utilization/Costs among Medicare Retirees

Objective: To examine the influence of physical activity (PA) and BMI on health care utilization and costs among Medicare retirees. Research Methods and Procedures: This cross‐sectional study was based on 42, 520 Medicare retirees in a U.S.‐wide manufacturing corporation who participated in indemnity/perferred provider and one health risk appraisal during the years 2001 and 2002. Participants were assigned into one of the three weight groups: normal weight, overweight, and obese. PA behavior was classified into three levels: sedentary (0 time/wk), moderately active (1 to 3 times/wk), and very active (4+ times/wk). Results: Generalized linear models revealed that the moderately active retirees had $1456, $1731, and $1177 lower total health care charges than their sedentary counterparts in the normal‐weight, overweight, and obese groups, respectively (p < 0.01). The very active retirees had $1823, $581, and $1379 lower costs than the moderately active retirees. Health care utilization and specific costs showed similar trends with PA levels for all BMI groups. The total health care charges were lower with higher PA level for all age groups (p < 0.01). Discussion: Regular PA has strong dose‐response effects on both health care utilization and costs for overweight/obese as well as normal‐weight people. Promoting active lifestyle in this Medicare population, especially overweight and obese groups, could potentially improve their well‐being and save a substantial amount of health care expenditures. Because those Medicare retirees are hard to reach in general, more creative approaches should be launched to address their needs and interests as well as help reduce the usage of health care system.     

Absolute Lymphocyte Count as a Predictor of Mortality in Emergency Department Patients with Paraquat Poisoning

Background

Paraquat (PQ) is a potent, highly toxic and widely used herbicide. The major medical problems associated with PQ are accidental or suicidal ingestion. There are several prognostic markers of PQ poisoning, with the serum PQ concentration considered to be the best indicator of outcome. However, the measurement of such markers is limited in many hospitals.

Objective

The present study was conducted to investigate the association of absolute lymphocyte count (ALC) and the 30-day mortality rate in patients with PQ poisoning.

Methods

We performed a retrospective analysis of patients admitted to the emergency department after paraquat poisoning between January 2010 and April 2013. Independent risk factors including ALC for 30-day mortality were determined. The ALC was categorized in quartiles as ≤1700, 1700 to 3200, 3200 to 5000, and >5000. Univariate and multivariate Cox proportional hazard analysis were performed to determine the independent risk factors for mortality.

Results

A total of 136 patients were included in the study, and the 30-day mortality was 73.5%. ALC was significantly higher in nonsurvivors than in survivors. The highest ALC quartile (ALC>5000; hazard ratio, 2.58; 95% CI, 1.08–6.21) was associated with increased mortality in multivariate analysis. In addition, old age, lower arterial PaCO₂, increased peripheral neutrophil count, and high serum levels of creatinine were associated with mortality.

Conclusion

The absolute lymphocyte count is associated with the 30-day mortality rate in patients with paraquat poisoning.     

Association of Urinary Cadmium with Mortality in Patients at a Coronary Care Unit

Background

Determine the effect of the day 1 urinary excretion of cadmium (D1-UE-Cd) on mortality of patients admitted to a coronary care unit (CCU).

Methods

A total of 323 patients were enrolled in this 6-month study. Urine and blood samples were taken within 24 h after CCU admission. Demographic data, clinical diagnoses, and hospital mortality were recorded. The scores of established systems for prediction of mortality in critically ill patients were calculated.

Results

Compared with survivors (n = 289), non-survivors (n = 34) had higher levels of D1-UE-Cd. Stepwise multiple linear regression analysis indicated that D1-UE-Cd was positively associated with pulse rate and level of aspartate aminotransferase, but negatively associated with serum albumin level. Multivariate Cox analysis, with adjustment for other significant variables and measurements from mortality scoring systems, indicated that respiratory rate and D1-UE-Cd were independent and significant predictors of mortality. For each 1 μg/day increase of D1-UE-Cd, the hazard ratio for CCU mortality was 3.160 (95% confidence interval: 1.944–5.136, p < 0.001). The chi-square value of Hosmer-Lemeshow goodness-of-fit test for D1-UE-Cd was 10.869 (p = 0.213). The area under the receiver operating characteristic curve for D1-UE-Cd was 0.87 (95% confidence interval: 0.81–0.93).

Conclusions

The D1-UE-Cd, an objective variable with no inter-observer variability, accurately predicted hospital mortality of CCU patients and outperformed other established scoring systems. Further studies are needed to determine the physiological mechanism of the effect of cadmium on mortality in CCU patients.     

Relationship between Longitudinal Continuity of Primary Care and Likelihood of Death: Analysis of National Insurance Data

Background

Continuity of care (COC) is a widely accepted core principle of primary care and has been associated with patient satisfaction, healthcare utilization and mortality in many, albeit small, studies.

Objective

To assess the relationship between longitudinal continuity with a primary care physician (PCP) and likelihood of death in the French general population.

Design

Observational study based on reimbursement claims from the French national health insurance (NHI) database for salaried workers (2007–2010).

Setting

Primary care.

Patients

We extracted data on the number and pattern of visits made to a PCP and excluded all patients who did not visit a PCP at least twice within 6 months. We recorded age, gender, comorbidities, social status, and deaths.

Main outcome measures

The primary endpoint was death by all causes. We measured longitudinal continuity of care (COC) with a PCP twice a year between 2007 and 2010, using the COC index developed by Bice and Boxerman. We introduced the COC index as time-dependent variables in a survival analysis after adjustment for age, gender and stratifying on comorbidities and social status.

Results

A total of 325 742 patients were included in the analysis. The average COC index ranged from 0.74 (SD: 0.35) to 0.76 (0.35) (where 1.0 is perfect continuity). Likelihood of death was lower in patients with higher continuity (hazard ratio for an increase in 0.1 of continuity, adjusted for age, sex, and stratified on comorbidities and social status: 0.96 [0.95–0.96]).

Conclusion

Higher longitudinal continuity was associated with a reduced likelihood of death.     

Nontraumatic Hypotension and Shock in the Emergency Department and the Prehospital setting,Prevalence, Etiology,and Mortality: A Systematic Review

Background

Acute patients presenting with hypotension in the prehospital or emergency department (ED) setting are in need of focused management and knowledge of the epidemiology characteristics might help the clinician. The aim of this review was to address prevalence, etiology and mortality of nontraumatic hypotension (SBP ≤ 90 mmHg) with or without the presence of shock in the prehospital and ED setting.

Methods

We performed a systematic literature search up to August 2013, using Medline, Embase, Cinahl, Dare and The Cochrane Library. The analysis and eligibility criteria were documented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-guidelines) and The Cochrane Collaboration. No restrictions on language, publication date, or status were imposed. We used the Newcastle-Ottawa quality assessment scale (NOS-scale) and the Strengthening the Reporting of Observational studies in Epidemiology (STROBE-statement) to assess the quality.

Results

Six observational studies were considered eligible for analysis based on the evaluation of 11,880 identified papers. Prehospital prevalence of hypotension was 19.5/1000 emergency medicine service (EMS) contacts, and the prevalence of hypotensive shock was 9.5-19/1000 EMS contacts with an inhospital mortality of shock between 33 to 52%. ED prevalence of hypotension was 4-13/1000 contacts with a mortality of 12%. Information on mortality, prevalence and etiology of shock in the ED was limited. A meta-analysis was not feasible due to substantial heterogeneity between studies.

Conclusion

There is inadequate evidence to establish concise estimates of the characteristics of nontraumatic hypotension and shock in the ED or in the prehospital setting. The available studies suggest that 2% of EMS contacts present with nontraumatic hypotension while 1-2% present with shock. The inhospital mortality of prehospital shock is 33-52%. Prevalence of hypotension in the ED is 1% with an inhospital mortality of 12%. Prevalence, etiology and mortality of shock in the ED are not well described.     

Complaints and Diagnoses of Emergency Department Patients in the Netherlands: A Comparative Study of Integrated Primary and Emergency Care

ObjectiveIn the Netherlands, an increasing number of emergency departments (EDs) and general practitioner cooperatives collaborate by creating one Emergency-Care-Access-Point (ECAP). This has resulted in fewer patients at ECAP EDs. The objective of this study was to explore differences in patient characteristics, presented complaints and ED discharge diagnoses between EDs with an ECAP and EDs without an ECAP.MethodsA retrospective observational study was performed with 1800 consecutive patient records sampled from six EDs spread over the Netherlands in 2013. We extracted data on time and date of presentation, sex, age, presenting complaint, discharge diagnosis, origin and follow up.ResultsAt ECAP EDs, the mean age was 47.8 years (95%CI 46.1-49.4) compared to 41.3 (95%CI 39.7-42.9). Compared to non-ECAP EDs, more patients were referred by medical professionals (74.7% versus 46.8%), more patients received hospital admission (45.2% versus 29.0%) and fewer patients received GP follow-up (4.1% versus 16.9%). There was no significant difference in presenting complaints between ECAP and non-ECAP EDs. Most prevalent complaints were trauma (25.7% versus 29.7%), abdominal pain (12.1% versus 10.9%) and general symptoms (7.8% versus 4.8%). The most prevalent ED diagnoses significantly differed with fractures and dislocations (10.8%), sprains and strains (10.4%) and respiratory infections (6.8%) at ECAP EDs versus fractures and dislocations (10.7%), wounds (9.3%) and sprains and strains (8.9%) at non-ECAP EDs.ConclusionCompared to non-ECAP EDs, patients at ECAP EDs were older, medical professionals referred more patients and more patients received a hospital admission. We found some small differences in discharge diagnoses between ECAP EDs compared to non-ECAP EDs, but no difference in presented complaints.     

Access and Use of Medical Care among Obese Persons

The prevalence of obesity and severe obesity is growing rapidly, along with obesity‐related comorbidities and mortality. Given the increased health risks associated with obesity, it is vital that obese persons have adequate access to, and make consistent use of, medical care services. Assuming obese persons have access to medical care that is comparable to non‐obese persons, one would expect to observe greater use of medical services among obese persons. In this article we briefly review empirical evidence of the access to and use of medical care among obese persons. Although certain subgroups that tend to have disproportionately high prevalences of obesity (i.e., low socioeconomic status, minority groups) have reduced access to care, no studies have specifically examined whether or not obese persons have the same access to health care as do their lean counterparts. With respect to use of health care services, however, obesity has been consistently linked with greater rates of utilization and increased health care expenditures. Both the increased use and cost appear to be largely a function of treating obesity‐associated comorbidities such as diabetes and hypertension. We conclude that, although it is clear that obesity is associated with both greater use and cost of medical care, the relationship between obesity and access to medical care has not been determined.     

Association of Primary Care Characteristics with Variations in Mortality Rates in England: An Observational Study

Background

Wide variations in mortality rates persist between different areas in England, despite an overall steady decline. To evaluate a conceptual model that might explain how population and service characteristics influence population mortality variations, an overall null hypothesis was tested: variations in primary healthcare service do not predict variations in mortality at population level, after adjusting for population characteristics.

Methodology/Principal Findings

In an observational study of all 152 English primary care trusts (geographical groupings of population and primary care services, total population 52 million), routinely available published data from 2008 and 2009 were modelled using negative binomial regression. Counts for all-cause, coronary heart disease, all cancers, stroke, and chronic obstructive pulmonary disease mortality were analyzed using explanatory variables of relevant population and service-related characteristics, including an age-correction factor. The main predictors of mortality variations were population characteristics, especially age and socio-economic deprivation. For the service characteristics, a 1% increase in the percentage of patients on a primary care hypertension register was associated with decreases in coronary heart disease mortality of 3% (95% CI 1–4%, p = 0.006) and in stroke mortality of 6% (CI 3–9%, p<0.0001); a 1% increase in the percentage of patients recalling being better able to see their preferred doctor was associated with decreases in chronic obstructive pulmonary disease mortality of 0.7% (CI 0.2–2.0%, p = 0.02) and in all cancer mortality of 0.3% (CI 0.1–0.5%, p = 0.009) (continuity of care). The study found no evidence of an association at primary care trust population level between variations in achievement of pay for performance and mortality.

Conclusions/Significance

Some primary healthcare service characteristics were also associated with variations in mortality at population level, supporting the conceptual model. Health care system reforms should strengthen these characteristics by delivering cost-effective evidence-based interventions to whole populations, and fostering sustained patient-provider partnerships.     

The Association of Serum Leptin with Mortality in Older Adults

Objective

Elevated levels of serum leptin are associated with increased adiposity and production of pro-inflammatory cytokines. Both cytokines and body adiposity have been shown to predict cardiovascular events and mortality. The primary objective of the present study is to explore the associations between serum leptin and all-cause mortality and mortality from cardiovascular disease (CVD) over a span of 10 years, controlling for body adiposity and proinflammatory cytokines.

Methods

The Health, Aging and Body Composition (Health ABC) study is a prospective cohort of 3,075 older adults aged 70 to 79 years. This analysis includes 2,919 men and women with complete serum leptin and vital status data. Data on all-cause mortality and incident cardiovascular events (including Coronary Heart Disease and Congestive Heart Failure) were collected over 10 years of follow-up (mean 8.4 years).

Results

Women with leptin in quartile 2 and 3 were at lower risk of all-cause mortality, and those with leptin in quartile 2 were at lower risk of mortality from CVD as compared to women with lowest leptin values when adjusted for age, race, site, years of education, alcohol use, smoking, and physical activity. When these associations were additionally adjusted for body fat, C-reactive protein and pro-inflammatory cytokines, women with leptin values in quartile 3 were at lower risk of all-cause mortality and women with leptin in quartile 2 and 3 were at lower risk of mortality from CVD than women with lowest leptin values. These associations were not significant among men after adjusting for body fat and cytokines.

Conclusions

The present study suggests that moderately elevated concentrations of serum leptin are independently associated with lower risk of all-cause mortality and CVD-related mortality among older women. Among men, serum leptin is not associated with reduced risk of all-cause and CVD mortality after controlling for body fat and cytokines.     

Burden of Diarrhea,Hospitalization and Mortality Due to Cryptosporidial Infections in Indian Children

Background

Cryptosporidium spp. is a common, but under-reported cause of childhood diarrhea throughout the world, especially in developing countries. A comprehensive estimate of the burden of cryptosporidiosis in resource-poor settings is not available.

Methodology/Principal Findings

We used published and unpublished studies to estimate the burden of diarrhea, hospitalization and mortality due to cryptosporidial infections in Indian children. Our estimates suggest that annually, one in every 6–11 children <2 years of age will have an episode of cryptosporidial diarrhea, 1 in every 169–633 children will be hospitalized and 1 in every 2890–7247 children will die due to cryptosporidiosis. Since there are approximately 42 million children <2 years of age in India, it is estimated that Cryptosporidium results in 3.9–7.1 million diarrheal episodes, 66.4–249.0 thousand hospitalizations, and 5.8–14.6 thousand deaths each year.

Conclusions/Significance

The findings of this study suggest a high burden of cryptosporidiosis among children <2 years of age in India and makes a compelling case for further research on transmission and prevention modalities of Cryptosporidium spp. in India and other developing countries.