Development of indicators for avoidable emergency medical service calls by mapping paramedic clinical impression codes to ambulatory care sensitive conditions and mental health conditions in the UK and Canada.

OBJECTIVE: Paramedic assessment data have not been used for research on avoidable calls. Paramedic impression codes are designated by paramedics on responding to a 911/999 medical emergency after an assessment of the presenting condition. Ambulatory care sensitive conditions (ACSCs) are non-acute health conditions not needing hospital admission when properly managed. This study aimed to map the paramedic impression codes to ACSCs and mental health conditions for use in future research on avoidable 911/999 calls. DESIGN: Mapping paramedic impression codes to existing definitions of ACSCs and mental health conditions. SETTING: East Midlands Region, UK and Southern Ontario, Canada. PARTICIPANTS: Expert panel from the UK-Canada Emergency Calls Data analysis and GEospatial mapping (EDGE) Consortium. RESULTS: Mapping was iterative first identifying the common ACSCs shared between the two countries then identifying the respective clinical impression codes for each country that mapped to those shared ACSCs as well as to mental health conditions. Experts from the UK-Canada EDGE Consortium contributed to both phases and were able to independently match the codes and then compare results. Clinical impression codes for paramedics in the UK were more extensive than those in Ontario. The mapping revealed some interesting inconsistencies between paramedic impression codes but also demonstrated that it was possible. CONCLUSION: This is an important first step in determining the number of ASCSs and mental health conditions that paramedics attend to, and in examining the clinical pathways of these individuals across the health system. This work lays the foundation for international comparative health services research on integrated pathways in primary care and emergency medical services.

An early warning precision public health approach for assessing COVID-19 vulnerability in the UK: the Moore-Hill Vulnerability Index (MHVI).

BACKGROUND: Most COVID-19 vulnerability indices rely on measures that are biased by rates of exposure or are retrospective like mortality rates that offer little opportunity for intervention. The Moore-Hill Vulnerability Index (MHVI) is a precision public health early warning alternative to traditional infection fatality rates that presents avenues for mortality prevention. METHODS: We produced an infection-severity vulnerability index by calculating the proportion of all recorded positive cases that were severe and attended by ambulances at small area scale for the East Midlands of the UK between May 2020 and April 2022. We produced maps identifying regions with high and low vulnerability, investigated the accuracy of the index over shorter and longer time periods, and explored the utility of the MHVI compared to other common proxy measures and indices. Analysis included exploring the correlation between our novel index and the Index of Multiple Deprivation (IMD). RESULTS: The MHVI captures geospatial dynamics that single metrics alone often overlook, including the compound health challenges associated with disadvantaged and declining coastal towns inhabited by communities with post-industrial health legacies. A moderate negative correlation between MHVI and IMD reflects spatial analysis which suggests that high vulnerability occurs in affluent rural as well as deprived coastal and urban communities. Further, the MHVI estimates of severity rates are comparable to infection fatality rates for COVID-19. CONCLUSIONS: The MHVI identifies regions with known high rates of poor health outcomes prior to the pandemic that case rates or mortality rates alone fail to identify. Pre-hospital early warning measures could be utilised to prevent mortality during a novel pandemic.

Psychometric Properties of LUN-MS: A New Questionnaire to Identify the Unmet Needs of People With Multiple Sclerosis.

Background: We developed a 29-item Questionnaire, Long-term Unmet Needs in MS (LUN-MS) to identify the unmet needs of people with multiple sclerosis (pwMS). Objective: To assess acceptability, test-retest reliability, internal consistency, and validity of the LUN-MS. Methods: Participants completed the LUN-MS and MSIS-29 twice, four weeks apart. Acceptability was assessed by looking at the response rate in each time point. Reliability was calculated by comparing the response during the two time points using Cohen's weighted kappa. Using principal component analysis, the dimensionality of the questionnaire's items was reduced, to five domains and the internal consistency of each domain was assessed using Cronbach's alpha. Concurrent validity was tested by comparing the total LUN-MS score against MSIS-29 and EQ-5D-3L using Pearson's product-moment correlation coefficient. Results: Among 88 participants, rate of completion at time points-1 and 2 was 96 and 80% respectively. Test-retest reliability for individual items was between fair to near-perfect (weighted Cohen's kappa 0.39-0.81). The unmet needs could be divided into five internally consistent domains (Cronbach's alpha 0.83-0.74): neuropsychological, ambulation, physical, interpersonal relationship and informational. Concurrent validity with MSIS-29 (r = 0.705, P < .001) and EQ-5D-3L (r = 0.617, P < .001) were good. Conclusion: LUN-MS is a reliable, valid, and acceptable tool to identify the unmet needs of pwMS.

Mental health emergencies attended by ambulances in the United Kingdom and the implications for health service delivery: A cross-sectional study.

OBJECTIVE: In the context of increasing demand for ambulance services, emergency mental health cases are among the most difficult for ambulance clinicians to attend, partly because the cases often involve referring patients to other services. We describe the characteristics of mental health emergencies in the East Midlands region of the United Kingdom. We explore the association between 999 (i.e. emergency) call records, the clinical impressions of ambulance clinicians attending emergencies and the outcomes of ambulance attendance. We consider the implications of our results for optimizing patient care and ambulance service delivery. METHODS: We conducted a retrospective observational study of records of all patients experiencing mental health emergencies attended by ambulances between 1 January 2018 and 31 July 2020. The records comprised details of 103,801 '999' calls (Dispatch), the preliminary diagnoses by ambulance clinicians on-scene (Primary Clinical Impression) and the outcomes of ambulance attendance for patients (Outcome). RESULTS: A multinomial regression analysis found that model fit with Outcome data was improved with the addition of Dispatch and Primary Clinical Impression categories compared to the fit for the model containing only the intercept and Outcome categories (Chi-square = 18,357.56, df = 180, p < 0.01). Dispatch was a poor predictor of Primary Clinical impression. The most common predictors of Outcome care pathways other than 'Treated and transported' were records of respiratory conditions at Dispatch and anxiety reported by clinicians on-scene. CONCLUSIONS: Drawing on the expertise of mental health specialists may help '999' dispatchers distinguish between physical and mental health emergencies and refer patients to appropriate services earlier in the response cycle. Further investigation is needed to determine if training Dispatch operatives for early triage and referral can be appropriately managed without compromising patient safety.

Fatigue in multiple sclerosis: A UK MS-register based study.

BACKGROUND: Fatigue is a widely experienced, incapacitating symptom of MS. It hinders daily functioning and has deleterious effects on quality of life. The UK MS Register is an online registry of over 20,000 participants with MS. The aim of this study was to estimate the prevalence, predictors, and impact of fatigue on people with MS using data from the UKMS register. METHODS: All participants who completed the Fatigue Severity Scale (FSS), WebEDSS, Hospital Anxiety and Depression Scale (HADS) within 28 days of each other were selected from the UK MS Register. Data on age, gender, duration and type of MS, use of disease modifying drugs and comorbidities were obtained from the UKMS register. We categorised people with FSS score of 5 or more as with fatigue and those with scores of 4 or less as without fatigue. Descriptive statistics and logistical and multiple regressions were used to explore predictors of fatigue and the effect of fatigue on mobility (MS Walking Scale), physical and psychological aspects of life (MS Impact Scale) and quality of life (European Quality of Life 5D-3 L). RESULTS: Amongst the 20,946 participants of the UK MS registry, 4620 completed FSS. Out of these, 775 (mean age= 54.71 years, SD= 10.90; mean duration of MS diagnosis =13.21 years, SD=9.75) had completed the FSS, Web EDSS and Hospital Anxiety and Depression Scale within 28 days of each other. 427 (55.1%) of pwMS had a FSS score >5 consistent with clinical fatigue. Logistic regression analysis showed that depression (p=<0.001), duration of MS (p = 0.017), secondary progressive MS (p = 0.001) and EDSS (p=<0.001) predicted fatigue. FSS scores had a significant negative impact on both psychological (p > 0.001) and physical (p > 0.001) domains of the MS Impact scale, MS walking scale (p = 0.003) and EQoL (p = 0.005). CONCLUSIONS: Fatigue was a common symptom amongst people with MS. Depression, longer duration of MS, secondary progressive MS, and high EDSS predicted fatigue. Fatigue had an adverse effect on physical activities, mobility, psychological wellbeing, and quality of life of people with MS.

Characterizing Unusual Spatial Clusters of Male Mental Health Emergencies Occurring During the First National COVID-19 "Lockdown" in the East Midlands Region, UK: A Geospatial Analysis of Ambulance 999 Data.

The widespread psychological effects of contagion mitigation measures associated with the novel coronavirus disease 2019 (COVID-19) are well known. Phases of "lockdown" have increased levels of anxiety and depression globally. Most research uses methods such as self-reporting that highlight the greater impact of the pandemic on the mental health of females. Emergency medical data from ambulance services may be a better reflection of male mental health. We use ambulance data to identify unusual clusters of high rates of male mental health emergencies occurring in the East Midlands of the United Kingdom during the first national "lockdown" and to explore factors that may explain clusters. Analysis of more than 5,000 cases of male mental health emergencies revealed 19 unusual spatial clusters. Binary logistic regression analysis (χ2 = 787.22, df = 20, p ≤ .001) identified 16 factors that explained clusters, including proximity to "healthy" features of the physical landscape, urban and rural dynamics, and socioeconomic condition. Our findings suggest that the factors underlying vulnerability of males to severe mental health conditions during "lockdown" vary within and between rural and urban spaces, and that the wider "hinterland" surrounding clusters influences the social and physical access of males to services that facilitate mental health support. Limitations on social engagement to mitigate effects of the pandemic are likely to continue. Our approach could inform delivery of emergency services and the development of community-level services to support vulnerable males during periods of social isolation.

Exploring the Impact of the COVID-19 Pandemic on Male Mental Health Emergencies Attended by Ambulances During the First National "Lockdown" in the East Midlands of the United Kingdom.

The novel coronavirus disease 2019 (COVID-19) pandemic and associated mitigation strategies such as "lockdown" are having widespread adverse psychological effects, including increased levels of anxiety and depression. Most research using self-reported data highlights the pandemic's impact on the psychological well-being of females, whereas data for mental health emergency presentations may reflect the impact on male mental health more accurately. We analyzed records of male mental health emergencies occurring in the East Midlands of the United Kingdom during the first national "lockdown." We computed two binary logistic regression models to (a) compare male mental health emergencies occurring during "lockdown," 2020 (5,779) with those occurring in the same period in 2019 (N = 4,744) and (b) compare male (N = 5,779) and female (N = 7,695) mental health emergencies occurring during "lockdown." Comparisons considered the characteristics of mental health emergencies recorded by ambulance clinicians (Primary Impressions), and the socioeconomic characteristics of communities where emergencies use the Index of Multiple Deprivation. We found that during "lockdown," male emergencies were more likely to involve acute anxiety (odds ratio [OR]: 1.42) and less likely to involve intentional drug overdose (OR: 0.86) or attempted suicide (OR: 0.71) compared with 2019. Compared with females, male emergencies were more likely to involve acute behavioral disturbance (OR: 1.99) and less likely to involve anxiety (OR: 0.67), attempted suicide (OR: 0.83), or intentional drug overdose (OR: 0.76). Compared with 2019, and compared with females, males experiencing mental health emergencies during "lockdown" were more likely to present in areas of high deprivation. Understanding the presentation of male mental health emergencies could inform improved patient care pathways.

Rethinking the health implications of society-environment relationships in built areas: An assessment of the access to healthy and hazards index in the context of COVID-19.

Urban environments have been evolving to mitigate threats to the health and wellbeing of societies for thousands of years, including establishing open spaces to combat bubonic plague, improving waste management in the 20th century, and more recently retrofitting urban landscapes with green space to promote physical exercise. In the context of the current COVID-19 pandemic there is a need to rethink how societies interact with space in built environments to prevent contagion at the same time as facilitating health behaviours, such as exercise. Previously, we examined the spatial relationship between features of urban landscapes that are commonly considered to be 'hazardous' and 'healthy' and unusual clusters of COVID-19 cases in the East Midlands of the UK using ambulance data. Here, we consider the nature of social engagement that these features of urban landscapes facilitate and identify society-environment interactions that may increase risk of exposure to the virus. In some cases, spaces that are commonly thought to promote health behaviour may increase exposure. Contagion hot-spots occur at the nexus of exposure and underlying susceptibility. The viral-host dynamics of infectious disease are changing. Now, as in past eras, societies are required to evolve and adapt to the new challenges presented by emerging infectious diseases in the modern world.

An exploration of factors characterising unusual spatial clusters of COVID-19 cases in the East Midlands region, UK: A geospatial analysis of ambulance 999 data.

Complex interactions between physical landscapes and social factors increase vulnerability to emerging infections and their sequelae. Relative vulnerability to severe illness and/or death (VSID) depends on risk and extent of exposure to a virus and underlying health susceptibility. Identifying vulnerable communities and the regions they inhabit in real time is essential for effective rapid response to a new pandemic, such as COVID-19. In the period between first confirmed cases and the introduction of widespread community testing, ambulance records of suspected severe illness from COVID-19 could be used to identify vulnerable communities and regions and rapidly appraise factors that may explain VSID. We analyse the spatial distribution of more than 10,000 suspected severe COVID-19 cases using records of provisional diagnoses made by trained paramedics attending medical emergencies. We identify 13 clusters of severe illness likely related to COVID-19 occurring in the East Midlands of the UK and present an in-depth analysis of those clusters, including urban and rural dynamics, the physical characteristics of landscapes, and socio-economic conditions. Our findings suggest that the dynamics of VSID vary depending on wider geographic location. Vulnerable communities and regions occur in more deprived urban centres as well as more affluent peri-urban and rural areas. This methodology could contribute to the development of a rapid national response to support vulnerable communities during emerging pandemics in real time to save lives.

Mental health emergencies and COVID-19: the impact of 'lockdown' in the East Midlands of the UK.

BACKGROUND: The most immediate response of the research community to COVID-19 has been a focus on understanding the effects, treatment and prevention of infection. Of equal and ongoing importance is elucidating the impact of mitigation measures, such as lockdown, on the well-being of societies. Research about mental health and lockdown in the UK has predominately involved large surveys that are likely to encounter self-selection bias. Further, self-reporting does not constitute a clinical judgement. AIMS: To (a) compare the age, gender and ethnicity of patients experiencing mental health emergencies prior compared with during lockdown, (b) determine whether the nature of mental health emergencies has changed during compared with before lockdown, (c) explore the utility of emergency medical service data for identifying vulnerability to mental health emergencies in real time during a pandemic. METHOD: A total of 32 401 clinical records of ambulance paramedics attending mental health emergencies in the East Midlands of the UK between 23 March and 31 July 2020 and the same period in 2019 were analysed using binary logistic regression. RESULTS: People of younger age, male gender and South Asian and Black ethnicity are particularly vulnerable to acute mental health conditions during lockdown. Patients with acute cases of anxiety have increased during lockdown whereas suicide and intentional drug overdose have decreased. CONCLUSIONS: Self-reported data may underrepresent the true impact of lockdown on male mental health and ethnic minority groups. Emergency medical data can be used to identify vulnerable communities in the context of the extraordinary circumstances surrounding the current pandemic, as well as under more ordinary circumstances.

'Sub-Prime' Water, Low-Security Entitlements and Policy Challenges in Over-Allocated River Basins: the Case of the Murray-Darling Basin.

Environmental policy is often implemented using market instruments. In some cases, including carbon taxing, the links between financial products and the environmental objectives, are transparent. In other cases, including water markets, the links are less transparent. In Australia's Murray-Darling Basin (MDB), financial water products are known as 'entitlements', and are similar to traditional financial products, such as shares. The Australian water market includes 'Low Security' entitlements, which are similar to 'sub-prime' mortgage bonds because they are unlikely to yield an amount equal to their financial worth. Nearly half the water purchased under the Murray-Darling Basin Plan for environmental purposes is 'Low Security'. We suggest that the current portfolio of water held by the Australian Government for environmental purposes reflects the mortgage market in the lead-up to the global financial crisis. Banks assumed that the future value of the mortgage market would reflect past trends. Similarly, it is assumed that the future value of water products will reflect past trends, without considering climate change. Historic records of allocations to 'Low Security' entitlements in the MDB suggest that, in the context of climate change, the Basin Plan water portfolio may fall short of the target annual average yield of 2075 GL by 511 GL. We recommend adopting finance sector methods including 'hedging' 'Low Security' entitlements by purchasing an additional 322-2755 GL of 'Low Security', or 160-511 GL of 'High Security' entitlements. Securing reliable environmental water is a global problem. Finance economics present opportunities for increasing the reliability of environmental flows.

Using voluntary agreements to exclude stock from waterways: An evaluation of project success and persistence.

Agriculture is one of the major drivers of ecological degradation in river basins. Excluding stock (cows and sheep) from grazing riverbanks and accessing rivers is one of the most common river restoration activities. To be effective, stock exclusion must be maintained indefinitely. In Australia, and elsewhere, stock exclusion projects are most commonly implemented by establishing voluntary agreements between landholders and government agencies. This study examined the extent to which landholders in 3 catchment management authority (CMA) regions in southeast Australia maintain stock exclusion from waterways, whether vegetation on riverbanks recovered, and the effectiveness of assessment methods. It was found that nearly half of landholders continue to graze stock on the riverbank. There has been some success with improving the condition of riparian vegetation. Sites with full stock exclusion contain the pre-European abundance of juvenile trees, and sites with continued grazing contain significantly lower abundance of juvenile trees. Establishing the effectiveness of management was made more difficult by the inconsistent methods used by the different CMAs. Stock exclusion projects implemented with voluntary agreements have the potential to succeed if oversight is improved between government agencies and CMAs and between CMAs and landholders. Projects will be easier to assess if regional authorities use consistent methods of assessment. Voluntary agreements are only suitable for environmental management if projects are monitored, maintained, and assessed appropriately. Integr Environ Assess Manag 2019;15:237-247. © 2018 SETAC.

Designing Interventions that Last: A Classification of Environmental Behaviors in Relation to the Activities, Costs, and Effort Involved for Adoption and Maintenance.

Policy makers draw on behavioral research to design interventions that promote the voluntary adoption of environmental behavior in societies. Many environmental behaviors will only be effective if they are maintained over the long-term. In the context of climate change and concerns about future water security, behaviors that involve reducing energy consumption and improving water quality must be continued indefinitely to mitigate global warming and preserve scarce resources. Previous reviews of environmental behavior have focused exclusively on factors related to adoption. This review investigates the factors that influence both adoption and maintenance, and presents a classification of environmental behaviors in terms of the activities, costs, and effort required for both adoption and maintenance. Three categories of behavior are suggested. One-off behaviors involve performing an activity once, such as purchasing an energy efficient washing machine, or signing a petition. Continuous behaviors involve the performance of the same set of behaviors for adoption and for maintenance, such as curbside recycling. Dynamic behaviors involve the performance of different behaviors for adoption and maintenance, such as revegetation. Behaviors can also be classified into four categories related to cost and effort: those that involve little cost and effort for adoption and maintenance, those that involve moderate cost and effort for adoption and maintenance, those that involve a high cost or effort for adoption and less for maintenance, and those that involve less cost or effort for adoption and a higher amount for maintenance. In order to design interventions that last, policy makers should consider the factors that influence the maintenance as well as the adoption of environmental behaviors.