Evaluation of a national clinical programme for the management of self-harm in hospital emergency departments: impact on patient outcomes and the provision of care.

BACKGROUND: Emergency departments are important points of intervention, to reduce the risk of further self-harm and suicide. A national programme to standardise the management of people presenting to the emergency department with self-harm and suicidal ideation (NCPSHI) was introduced in Ireland in 2014. The aim of this study was to evaluate the impact of the NCPSHI on patient outcomes and provision of care. METHODS: Data on self-harm presentations were obtained from the National Self-Harm Registry Ireland from 2012 to 2017. The impacts of the NCPSHI on study outcomes (3-month self-harm repetition, biopsychosocial assessment provision, admission, post-discharge referral, and self-discharge) were examined at an individual and aggregate (hospital) level, using a before and after study design and interrupted time series analyses, respectively. The 15 hospitals that implemented the programme by January 2015 (of a total of 24 between 2015 and 2017) were included in the analyses. RESULTS: There were 31,970 self-harm presentations during the study period. In hospitals with no service for self-harm (n = 4), risk of patients not being assessed reduced from 31.8 to 24.7% following the introduction of the NCPSHI. Mental health referral in this hospital group increased from 42.2 to 59.0% and medical admission decreased from 27.5 to 24.3%. Signs of a reduction in self-harm repetition were observed for this hospital group, from 35.1 to 30.4% among individuals with a history of self-harm, but statistical evidence was weak. In hospitals with a pre-existing liaison psychiatry service (n = 7), risk of self-discharge was lower post-NCPSHI (17.8% vs. 14.8%). In hospitals with liaison nurse(s) pre-NCPSHI (n = 4), medical admission reduced (27.5% vs. 24.3%) and there was an increase in self-harm repetition (from 5.2 to 7.8%. for those without a self-harm history). CONCLUSION: The NCPSHI was associated with improvements in the provision of care across hospital groups, particularly those with no prior service for self-harm, highlighting the need to consider pre-existing context in implementation planning. Our evaluation emphasises the need for proper resourcing to support the implementation of clinical guidelines on the provision of care for people presenting to hospital with self-harm.

The Influence of Different Physical Activity Behaviours on the Gut Microbiota of Older Irish Adults.

OBJECTIVE: A 24-hour day is made up of time spent in a range of physical activity (PA) behaviours, including sleep, sedentary time, standing, light-intensity PA (LIPA) and moderate-to-vigorous PA (MVPA), all of which may have the potential to alter an individual's health through various different pathways and mechanisms. This study aimed to explore the relationship between PA behaviours and the gut microbiome in older adults. DESIGN: Cross-sectional study. SETTINGS AND PARTICIPANTS: Participants (n=100; age 69.0 [3.0] years; 44% female) from the Mitchelstown Cohort Rescreen (MCR) Study (2015-2017). METHODS: Participants provided measures of gut microbiome composition (profiled by sequencing 16S rRNA gene amplicons), and objective measures of PA behaviours (by a 7-day wear protocol using an activPAL3 Micro). RESULTS: Standing time was positively correlated with the abundance of butyrate-producing and anti-inflammatory bacteria, including Ruminococcaceae, Lachnospiraceae and Bifidobacterium, MVPA was positively associated with the abundance of Lachnospiraceae bacteria, while sedentary time was associated with lower abundance of Ruminococcaceae and higher abundance of Streptococcus spp. CONCLUSION: Physical activity behaviours appear to influence gut microbiota composition in older adults, with different PA behaviours having diverging effects on gut microbiota composition.

Associations between Hospital Quality Outcomes and Medicare Spending per Beneficiary in the USA.

The cost of healthcare in the United States has increased over time. However, patient health outcomes have not trended with spending. There is a need to better comprehend the association between healthcare costs in the United States and hospital quality outcomes. Medicare spending per beneficiary (MSPB), a homogeneous metric across providers, can be used to evaluate the association between episodic Medicare spending and quality of care. Fifteen inpatient outcome measures were selected from Hospital Compare data among all (n = 4758) facilities and transformed to quintiles to ensure comparability across measures and to reduce the influence of outliers on the analysis. Both univariate and multiresponse multinomial ordered probit regression models were utilized across outcome domains to quantify associations between outcomes and spending. We found that MSPB was not associated with quality of care in most cases, adding evidence of a lack of outcome accountability among Medicare-funded facilities. Furthermore, worse outcomes were found to be associated with increased spending for some metrics. Policies are needed to align quality of care outcomes with the increasing costs of U.S. healthcare.

Psychosocial, psychiatric and work-related risk factors associated with suicide in Ireland: optimised methodological approach of a case-control psychological autopsy study.

BACKGROUND: Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls. METHODS: The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners' registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners' records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources. CONCLUSIONS: The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

Functional Impairment Variability in Children With ADHD Due to Emotional Impulsivity.

OBJECTIVE: The present study utilized ecological momentary assessment (EMA) to examine the effects of emotional impulsivity on overall functional impairment and functional impairment variability (FIV) of children with and without ADHD. METHOD: Parents of 74 children, 8- to 12-year-olds (42 with ADHD, 32 without ADHD), completed EMA assessment protocol ratings of their child's mood (3 times daily) and functional impairment (1 time daily) over the course of 28 days. RESULTS: Hierarchical regression analyses supported the interaction of ADHD diagnostic status and greater EMA-derived emotional impulsivity in the estimation of total functional impairment (Total FI) and FIV. Thus, greater emotional impulsivity was found to be related to greater Total FI and FIV among children with ADHD but not among children without ADHD. CONCLUSION: This study suggests that children with ADHD and greater emotional impulsivity demonstrate greater overall levels of functional impairment, with the severity of their impairment varying significantly over time.

The lifetime costs of overweight and obesity in childhood and adolescence: a systematic review.

BACKGROUND: Research into lifetime costs of obesity in childhood is growing. This review synthesizes that knowledge. METHODOLOGY: A computerized search of the international literature since 2000 was conducted. Mean total lifetime healthcare and productivity costs were estimated and inflated to 2014 Irish euros. RESULTS: This resulted in 13 published articles. The methodology used in these studies varied widely, and only one study estimated both healthcare and productivity costs. Cognizant of this heterogeneity, the mean total lifetime cost of a child or adolescent with obesity was €149,206 (range, €129,410 to €178,933) for a boy and €148,196 (range, €136,576 to €173,842) for a girl. This was divided into an average of €16,229 (range, €6,580 to €35,810) in healthcare costs and €132,977 (range, €122,830 to €143,123) in productivity losses for boys and €19,636 (range, €8,016 to €45,283) and €128,560, respectively, for girls. Income penalty accounted for the greater part of productivity costs, amounting to €97,118 (range, €86,971 to €107,264) per male adolescent with obesity and €126,108 per female adolescent. CONCLUSIONS: Healthcare costs and income penalty appear greater in girls while costs because of workdays lost seem greater in boys. There is proportionality between body mass index and costs. Productivity costs are greater than healthcare costs.

Job characteristics and mental health for older workers.

BACKGROUND: Adverse job characteristics have been linked with increased incidence of depression and anxiety in working populations. However, the association between job characteristics and mental health, in an older working population while controlling for personality traits, is less well known. AIMS: To examine the association between job characteristics (job demands and job control) and mental health (depression and anxiety) for older workers while controlling for personality traits. METHODS: A sample of workers aged 50-69 years were recruited from a primary health care clinic in Southern Ireland. Job characteristics were measured using the Copenhagen Psychosocial Questionnaire; demands (quantitative and cognitive) and control (influence at work and possibilities for development). Personality traits were measured using the Ten-Item Personality Inventory, depression was measured using the Center for Epidemiological Studies-Depression Scale and anxiety was measured using the Hospital Anxiety and Depression Scale. Descriptive analysis, simple and multiple linear regression analyses were conducted. RESULTS: The final sample size was 1025 with an initial 67% response rate. Multiple linear regression analysis showed job characteristics (in particular, job demands) to be significant positive predictors of symptoms of depression and anxiety. The inverse was true for job control variables and symptoms of depression. Neither possibilities for development nor influence at work were associated with symptoms of anxiety. CONCLUSIONS: Our findings indicate that despite potential confounders, higher demands at work can impact the worker's mental health negatively. Reducing job demands and encouraging role development may benefit the mental health of older workers.

Barriers and facilitators to initial and continued attendance at community-based lifestyle programmes among families of overweight and obese children: a systematic review.

The success of childhood weight management programmes relies on family engagement. While attendance offers many benefits including the support to make positive lifestyle changes, the majority of families referred to treatment decline. Moreover, for those who do attend, benefits are often compromised by high programme attrition. This systematic review investigated factors influencing attendance at community-based lifestyle programmes among families of overweight or obese children. A narrative synthesis approach was used to allow for the inclusion of quantitative, qualitative and mixed-method study designs. Thirteen studies met the inclusion criteria. Results suggest that parents provided the impetus for programme initiation, and this was driven largely by a concern for their child's psychological health and wellbeing. More often than not, children went along without any real reason or interest in attending. Over the course of the programme, however, children's positive social experiences such as having fun and making friends fostered the desire to continue. The stigma surrounding excess weight and the denial of the issue amongst some parents presented barriers to enrolment and warrant further study. This study provides practical recommendations to guide future policy makers, programme delivery teams and researchers in developing strategies to boost recruitment and minimise attrition.

Variation between hospitals in inpatient admission practices for self-harm patients and its impact on repeat presentation.

PURPOSE: Self-harm patient management varies markedly between hospitals, with fourfold differences in the proportion of patients who are admitted to a medical or psychiatric inpatient bed. The current study aimed to investigate whether differences in admission practices are associated with patient outcomes (repeat self-harm) while accounting for differences in patient case mix. METHODS: Data came from the National Self-Harm Registry Ireland. A prospective cohort of 43,595 self-harm patients presenting to hospital between 2007 and 2012 were included. As well as conventional regression analysis, instrumental variable (IV) methods utilising between hospital differences in rates of hospital admission were used in an attempt to gain unbiased estimates of the association of admission with risk of repeat self-harm. RESULTS: The proportion of self-harm patients admitted to a medical bed varied from 10 to 74 % between hospitals. Conventional regression and IV analysis suggested medical admission was not associated with risk of repeat self-harm. Psychiatric inpatient admission was associated with an increased risk of repeat self-harm in both conventional and IV analyses. This increased risk persisted in analyses stratified by gender and when restricted to self-poisoning patients only. CONCLUSIONS: No strong evidence was found to suggest medical admission reduces the risk of repeat self-harm. Models of health service provision that encourage prompt mental health assessment in the emergency department and avoid unnecessary medical admission of self-harm patients appear warranted. Psychiatric inpatient admission may be associated with a heightened risk of repeat self-harm in some patients, but these findings could be biased by residual confounding and require replication.

The area level association between suicide, deprivation, social fragmentation and population density in the Republic of Ireland: a national study.

PURPOSE: Numerous studies have examined the ecological relationship between suicide and area level determinants such as deprivation and social fragmentation. In Ireland, there is considerable geographic variation in the rates of suicide. However, there is a dearth of Irish studies investigating the geographic variability of suicide. METHODS: The Irish Central Statistics Office (CSO) provided data relating to all deaths by suicide and deaths of undetermined intent that occurred from 2009 to 2011. Negative binomial regression was used to examine the relationship between area level suicide rates and measures of deprivation, social fragmentation and population density that were taken from the 2011 National Census. RESULTS: Overall deprivation had the strongest independent effect on small-area rates of suicide, with the most deprived areas showing the greatest risk of suicide (risk ratio = 2.1; 95 % CI 1.70-2.52). Low population density (rurality) was associated with an increased risk suicide in males across both age groups and among females in the older 40-64-year age group. Conversely, a weak association between high population density (urbanicity) and increased suicide risk was found among females in the 15-39-year age group. Associations with social fragmentation only became apparent in the sub group analysis. Social fragmentation was associated with an elevated risk of suicide in the older 40-64 age group, with this effect being most pronounced among females. CONCLUSION: The findings of this study demonstrate marked geographical inequalities in the distribution of suicide in Ireland and highlight the importance of targeting suicide prevention resources in the most deprived areas.

The Relation of Poor Emotional Awareness and Externalizing Behavior Among Children With ADHD.

OBJECTIVE: Children with ADHD often demonstrate poor emotional self-awareness and higher levels of externalizing behavior problems relative to unaffected children. This study examined the relation of deficient emotional self-awareness to externalizing behavior problems in children with ADHD, and the role of emotional reactivity in this relationship. METHOD: Fifty-one 8- to 12-year-old children with ADHD and their parents completed measures of the children's emotional and behavioral functioning, as well as a diagnostic structured interview. RESULTS: Logistic regression suggested that more impaired emotional self-awareness was strongly associated with the diagnosis of a comorbid externalizing disorder. Hierarchical regression analyses strongly supported the relation of poor emotional awareness to reactivity-driven externalizing behavior, but not to proactive externalizing behavior. These effects were evident across reporters. CONCLUSION: This study suggested that poor emotional self-awareness is significantly linked to externalizing problems in children with ADHD, and that dysregulated emotional reactivity plays an important role in this relationship.

Health workforce planning and service expansion during an economic crisis: A case study of the national breast screening programme in Ireland.

This article aims to estimate the workforce and resource implications of the proposed age extension of the national breast screening programme, under the economic constraints of reduced health budgets and staffing levels in the Irish health system. Using a mixed method design, a purposive sample of 20 participants were interviewed and data were analysed thematically (June-September 2012). Quantitative data (programme-level activity data, screening activity, staffing levels and screening plans) were used to model potential workload and resource requirements. The analysis indicates that over 90% operational efficiency was achieved throughout the first six months of 2012. Accounting for maternity leave (10%) and sick leave (3.5%), 16.1 additional radiographers (whole time equivalent) would be required for the workload created by the age extension of the screening programme, at 90% operational efficiency. The results suggest that service expansion is possible with relatively minimal additional radiography resources if the efficiency of the skill mix and the use of equipment are improved. Investing in the appropriate skill mix should not be limited to clinical groups but should also include administrative staff to manage and support the service. Workload modelling may contribute to improved health workforce planning and service efficiency.

Validation of diet and urinary excretion derived estimates of sodium excretion against 24-h urine excretion in a worksite sample.

BACKGROUND AND AIMS: To validate diet and urinary excretion derived estimates of sodium intake against those derived from 24-h urine collections in an Irish manufacturing workplace sample. METHODS AND RESULTS: We have compared daily sodium (Na) excretion from PABA validated 24-h urine collections with estimated daily sodium excretion derived from the following methods: a standard Food Frequency Questionnaire (FFQ), a modified 24-h dietary recall method, arithmetic extrapolations from morning and evening spot urine samples, predicted sodium excretion from morning and evening spot urine samples using Tanaka's, Kawasaki's and the INTERSALT formula. All were assessed using mean differences (SD), Bland-Altman plots, correlation coefficients and ROC Area under the Curve (AUC) for a cut off of ≥100 mmol of Na/day. The Food Choice at Work study recruited 802 participants aged 18-64 years, 50 of whom formed the validation sample. The mean measured 24-h urinary sodium (gold standard) was 138 mmol/day (8.1 g salt). At the group level, mean differences were small for both dietary methods and for the arithmetic extrapolations from morning urine samples. The Tanaka, Kawasaki and INTERSALT methods provided biased estimates of 24-h urinary sodium. R(2) values for all methods ranged from 0.1 to 0.48 and AUC findings from 0.57 to 0.76. CONCLUSION: Neither dietary nor spot urine sample methods provide adequate validity in the estimation of 24-h urinary sodium at the individual level. However, group mean errors from dietary methods are small and random and compare favourably with those from spot urine samples in this population.

The association of emotional lability and emotional and behavioral difficulties among children with and without ADHD.

Children with ADHD often demonstrate a pattern of emotional lability characterized by sudden and intense shifts in affect. Emotional lability has been linked to emotional and behavioral problems in children with and without ADHD, but few studies have examined emotional lability over time. This study examined the effects of emotional lability over time on the behavioral and emotional difficulties of children with and without ADHD using an ecological momentary assessment (EMA) methodology. One hundred and two children aged 8-12 years (56 with ADHD and 46 without ADHD) and their parents completed baseline measures of the children's behavioral and emotional difficulties. Parents then completed a 28-day 3-times daily EMA assessment protocol to rate their child's emotional lability. Results suggested that emotional lability was associated with internalizing and/or externalizing diagnoses independent of ADHD diagnostic status, but was not directly associated with ADHD. Hierarchical regression analyses supported ADHD diagnostic status as a moderator of the association of greater EMA-derived emotional lability with children's behavioral difficulties, such that greater emotional lability was associated with greater behavioral difficulties among children with ADHD but not among children without ADHD. Results indicated that greater emotional lability was directly linked with greater emotional difficulties and that this relation was not moderated by ADHD diagnostic status. Overall, this study suggested that emotional lability is related to emotional difficulties independent of ADHD, but is differentially related to behavioral difficulties among children with and without ADHD.

Chronic kidney disease and obesity in Ireland: comparison of self-reported coronary artery disease in population study with clinic attendees.

Obesity is a growing issue in Ireland. The link between obesity, CKD and CAD has not previously been described in the Irish population. The prevalence of obesity and CKD was compared across 3 groups: population based estimates with self-reported CAD, population based estimates without self-reported CAD (SLAN-07) and a random selection of cardiology outpatients with CAD. The SLAN-07 is a representative survey of 1207 randomly selected participants ≥ 45 years. Validated methods measured parameters including waist circumference, blood pressure and markers of renal function specifically glomerular filtration rate (eGFR) and albumin: creatinine ratio. The Cardiology clinic surveyed a random selection of 126 participants ≥ 45 years with CAD. Similar parameters were measured using the validated methods utilised in SLAN-07 study. Prevalence of obesity and renal disease was significantly higher in both CAD groups. At population level, risk factors were modelled using logistic regression to compare odds of participants with self-reported CAD with those without. Age, hypertension, obesity, elevated waist circumference, renal disease and diabetes are significantly associated with existing CAD. Obesity and CKD are more frequent in patients with CAD. Routine evaluation is essential to facilitate more intensive management of these risk factors.

Nutrition knowledge, diet quality and hypertension in a working population.

OBJECTIVE: To examine if employees with higher nutrition knowledge have better diet quality and lower prevalence of hypertension. METHOD: Cross-sectional baseline data were obtained from the complex workplace dietary intervention trial, the Food Choice at Work Study. Participants included 828 randomly selected employees (18-64 years) recruited from four multinational manufacturing workplaces in Ireland, 2013. A validated questionnaire assessed nutrition knowledge. Food Frequency Questionnaires (FFQ) measured diet quality from which a DASH (Dietary Approaches to Stop Hypertension) score was constructed. Standardised digital blood pressure monitors measured hypertension. RESULTS: Nutrition knowledge was positively associated with diet quality after adjustment for age, gender, health status, lifestyle and socio-demographic characteristics. The odds of having a high DASH score (better diet quality) were 6 times higher in the highest nutrition knowledge group compared to the lowest group (OR = 5.8, 95% CI 3.5 to 9.6). Employees in the highest nutrition knowledge group were 60% less likely to be hypertensive compared to the lowest group (OR = 0.4, 95% CI 0.2 to 0.87). However, multivariate analyses were not consistent with a mediation effect of the DASH score on the association between nutrition knowledge and blood pressure. CONCLUSION: Higher nutrition knowledge is associated with better diet quality and lower blood pressure but the inter-relationships between these variables are complex.

Emotional Impulsivity and Emotional and Behavioral Difficulties Among Children With ADHD: An Ecological Momentary Assessment Study.

OBJECTIVE: Children with ADHD often demonstrate impulsive shifts in emotion, characterized by sudden and intense shifts in affect. This study examined the effects of emotional impulsivity over time on the emotional and behavioral functioning of children with ADHD using ecological momentary assessment (EMA). METHOD: Twenty-seven 8- to 12-year-old children with ADHD, and their parents, completed baseline measures of the children's emotional and behavioral functioning. Parents and children then completed an EMA protocol, whereby they each rated the child's affect three times daily for 28 days. RESULTS: Hierarchical regression analyses strongly supported the relation of greater EMA-derived emotional impulsivity to children's increased emotional and behavioral difficulties. These effects were evident across reporters and were maintained after controlling for baseline emotion dysregulation. CONCLUSION: Overall, this study demonstrated the utility of EMA-based assessments and suggested that emotional impulsivity may play an important role in the emotional and behavioral functioning of children with ADHD.

Characteristics of small areas with high rates of hospital-treated self-harm: deprived, fragmented and urban or just close to hospital? A national registry study.

BACKGROUND: Previous research has shown an inconsistent relationship between the spatial distribution of hospital treated self-harm and area-level factors such as deprivation and social fragmentation. However, many of these studies have been confined to urban centres, with few focusing on rural settings and even fewer studies carried out at a national level. Furthermore, no previous research has investigated if travel time to hospital services can explain the area-level variation in the incidence of hospital treated self-harm. METHODS: From 2009 to 2011, the Irish National Registry of Deliberate Self Harm collected data on self-harm presentations to all hospital emergency departments in the country. The Registry uses standard methods of case ascertainment and also geocodes patient addresses to small area geographical level. Negative binomial regression was used to explore the ecological relationship between area-level self-harm rates and various area-level factors. RESULTS: Deprivation, social fragmentation and population density had a positive linear association with self-harm, with deprivation having the strongest independent effect. Furthermore, self-harm incidence was found to be elevated in areas that had shorter journey times to hospital. However, while this association became attenuated after controlling for other area-level factors it still remained statistically significant. A subgroup analysis examining the effect of travel time on specific methods of self-harm, found that this effect was most marked for self-harm acts involving minor self-cutting. CONCLUSIONS: Self-harm incidence was influenced by proximity to hospital services, population density and social fragmentation; however, the strongest area-level predictor of self-harm was deprivation.