Emergency care in Brazil: factors leading to clinically inappropriate use of emergency care among young adult users in the Brazilian context.

BACKGROUND: This study aims to investigate the prevalence and associated risk factors of inappropriate use of emergency services among young adults in Vitória, Brazil. METHODS: A cross-sectional study was conducted over 30 consecutive days in November and December 2019, involving systematic random sampling of young adults (aged 18-39) visiting the municipal emergency care unit. Data were collected through structured interviews, utilizing the Hospital Urgency Appropriateness Protocol (HUAP) to identify inappropriate use. Demographic characteristics, healthcare utilization patterns, and medical diagnoses were assessed. Poisson regression models were employed to explore associations between variables. RESULTS: Among the 631 young adults surveyed, 30.6% exhibited inappropriate use of the emergency care unit. Factors associated with higher rates of inappropriate use included not seeking previous care in other healthcare services; having specific medical diagnoses like diseases of the respiratory system (PR: 2.03), diseases of the skin (PR: 4.13), and diseases of the ear and mastoid (PR: 3.74). CONCLUSION: The study underscores the significance of addressing inappropriate use of emergency services among young adults. Though the prevalence of inappropriate use was not significantly different from other age groups, the demographic characteristics and healthcare utilization patterns of young adults contribute to their unique challenges. To mitigate inappropriate use, efforts should focus on improving access to primary healthcare services, enhancing continuity of care, and raising awareness about appropriate healthcare-seeking behaviors among young adults. Ultimately, these interventions can foster a more effective and sustainable healthcare system that better serves the needs of the community.

Geographical variation and predictors of zero utilization for a standard maternal continuum of care among women in Ethiopia: a spatial and geographically weighted regression analysis.

BACKGROUND: Maintaining and effectively utilizing maternal continuum of care could save an estimated 860,000 additional mothers and newborn lives each year. In Ethiopia, the number of maternal and neonatal deaths occurred during pregnancy, childbirth, and the postpartum period was very high. It is indisputable that area-based heterogeneity of zero utilization for a standard maternal continuum of care is critical to improve maternal and child health interventions. However, none of the previous studies explored the spatial distribution of zero utilization for maternal continuum of care. Hence, this study was aimed to explore geographical variation and predictors of zero utilization for a standard maternal continuum of care among women in Ethiopia. METHODS: A total of 4178 women who gave birth five years preceding the 2016 Ethiopian demographic and health survey were included. ArcGIS version 10.7, SaT Scan version 9.6, and GWR version 4.0 Software was used to handle mapping, hotspot, ordinary least square, Bernoulli model analysis, and to model spatial relationships. Finally, a statistical decision was made at a p-value< 0.05 and at 95% confidence interval. MAIN FINDINGS: The proportion of mothers who had zero utilization of a standard maternal continuum of care was 48.8% (95% CI: 47.3-50.4). Hot spot (high risk) regions for zero utilization of maternal continuum of care was detected in Afder, Warder, Korahe and Gode Zones of Somali region and West Arsi Zone of Oromia region. Respondents who had poor wealth index, uneducated mothers, and mothers who declared distance as a big problem could increase zero utilization of maternal continuum of care by 0.24, 0.27, and 0.1 times. CONCLUSION: Five women out of ten could not utilize any components of a standard maternal continuum of care. Hot spot (high risk) areas was detected in Afder, Warder, Korahe and Gode Zones of Somali region and West Arsi Zone of Oromia region. Poor wealth index, uneducated mothers, and mothers who declare distance as a big problem were factors significantly associated with zero utilization of maternal continuum of care. Thus, geographical based intervention could be held to curve the high prevalence of zero utilization of maternal continuum of care.

Treatment of post-prostatectomy urinary incontinence and erectile dysfunction: there is insufficient utilisation of care in German cancer survivors.

PURPOSE: Treatment of post-prostatectomy urinary incontinence (UI) and erectile dysfunction (ED) increases quality of life (QoL). Aim of our study was to evaluate the utilisation of care among patients with post-prostatectomy UI and ED in Germany. METHODS: The HAROW study documented treatment of patients with localised prostate cancer (≤ T2c) in Germany. 1260 patients underwent radical prostatectomy (RP). Patients answered validated questionnaires after a median follow-up of 6.3 years. Response rate was 76.8%. RESULTS: Median age at RP was 65 (IQR 60-69) years. 14% (134/936) used more than one pad per day for UI. 25% (26/104, 30 missing) of UI patients underwent surgery to improve continence. Of patients without surgery, 41% (31/75) reported a moderate-to-severe issue concerning their incontinence with worse mental health and QoL. 81% (755/936) patients were unable to have an erection firm enough for sexual intercourse. Of all ED patients, 40% (319/793) used ED treatment regularly or tried it at least once. 49% (243/499) of patients with interest in sex never tried ED treatment. In multivariate analysis, patients not using ED treatments were older (≥ 70 years OR 4.1), and more often had preoperative ED (OR 2.3) and less interest in sex (OR 2.2). Nevertheless, 30% (73/240) of these patients had moderate-to-severe issues with their ED reporting worse mental health and QoL. CONCLUSION: Almost half of the patients without post-prostatectomy UI and ED treatment reported moderate-to-severe issues with a significant decrease in QoL. This indicates an insufficient utilisation of care in Germany.

Underutilization of Operative Capacity at the District Hospital Level in a Resource-Limited Setting.

INTRODUCTION: Improving surgical care in a resource-limited setting requires the optimization of operative capacity, especially at the district hospital level. METHODS: We conducted an analysis of the acute care surgery registry at Salima District Hospital in Malawi from June 2018 to November 2019. We examined patient characteristics, interventions, and outcomes. Modified Poisson regression modeling was used to identify risk factors for transfer to a tertiary center and mortality of patients transferred to the tertiary center. RESULTS: Eight hundred eighty-eight patients were analyzed. The most common diagnosis was skin and soft tissue infection (SSTI) at 35.9%. 27.5% of patients were transferred to Salima District Hospital, primarily from health centers, with a third for a diagnosis of SSTI. Debridement of SSTI comprised 59% of performed procedures (n = 241). Of the patients that required exploratory laparotomy, only 11 laparotomies were performed, with 59 patients transferred to a tertiary hospital. The need for laparotomy conferred an adjusted risk ratio (RR) of 10.1 (95% confidence interval [CI] 7.1, 14.3) for transfer to the central hospital. At the central hospital, for patients who needed urgent abdominal exploration, surgery had a 0.16 RR of mortality (95% CI 0.05, 0.50) while time to evaluation greater than 48 h at the central hospital had a 2.81 RR of death (95% CI 1.19, 6.66). CONCLUSIONS: Despite available capacity, laparotomy was rarely performed at this district hospital, and delays in care led to a higher mortality. Optimization of the district and health center surgical ecosystems is imperative to improve surgical access in Malawi and improve patient outcomes.

Regional socio-environmental characteristics associated with inadequate prenatal care during pregnancy: an ecological study of 47 prefectures in Japan.

BACKGROUND: Prenatal care (PNC) is a crucial health service that reduces the potential risks of adverse pregnancy and childbirth outcomes. It is monitored as one of the indicators of Universal Health Coverage (UHC) under the United Nations' Sustainable Development Goals. However, there are still mothers who do not use PNC, even when UHC has been achieved. As there have been few reports on the impact of local socio-environmental characteristics within the country, this study aimed to examine the association between local socio-environmental factors and inadequate use of PNC in Japan. METHODS: We conducted an ecological analysis of 47 prefectures in Japan using public open data. The dependent variables were the inadequate use of PNC, which are the rates of pregnant women who missed visiting PNC until 28 weeks' gestational age (GA) or those who never attended PNC before childbirth, and the independent variables were prefectural data of socio-economic, educational, and healthcare workforce-related factors. Multiple logistic regression analysis was used to examine the associations. RESULTS: The rate of pregnant women with late PNC initiation and never attending PNC before childbirth was 3.00-11.24 and 0.23-8.06 per 1000 pregnant women, respectively. Population numbers and densities, divorce rates, percentages of non-Japanese nationalities, and low percentages of high school enrolment were positively associated with inadequate PNC use. There was no statistically significant association with healthcare workforce, such as the number of obstetricians and gynaecologists. CONCLUSIONS: This ecological study revealed that inadequate PNC use is more common in urban areas with more non-Japanese nationality and lower education enrolment. There may be a need to provide education for those who do not have access to reproductive health education, such as that offered in high schools. Further studies are required to examine factors that affect access to PNC in Japan.

Underuse of oral anticoagulants in privately insured patients with atrial fibrillation: A population being targeted by the IMplementation of a randomized controlled trial to imProve treatment with oral AntiCoagulanTs in patients with Atrial Fibrillation (IMPACT-AFib).

BACKGROUND: Many studies showing underuse of oral anticoagulants (OACs) in patients with atrial fibrillation (AF) predated the advent of the non-vitamin K antagonist OACs. We retrospectively examined use of OACs in a large commercially insured population. METHODS: Administrative claims data from 4 research partners participating in FDA-Catalyst, a program of the Sentinel Initiative, were queried in September 2017. Patients were included if they were ≥30 years old with ≥365 days of medical/pharmacy coverage, and had ≥2 diagnosis codes for AF, a CHA2DS2-VASc score ≥2, absence of contraindications to OAC use, and no evidence of OAC use in the 365 days before the index AF diagnosis. The main outcome measures of the current analysis were rates of OAC use in the prior 12 months of cohort identification and factors associated with non-use. RESULTS: A total of 197,806 AF patients met the eligibility criteria prior to assessment of OAC treatment. Of these, 179,580 (91%) patients were ≥65 years old and 73,286 (37%) patients were ≥80 years old. Half of the patients (98,903) were randomized to the early intervention arm in the IMPACT-AFib trial and constitute the cohort for this analysis. Of these, 32,295 (33%) had no evidence of OAC use in the prior 12 months. Compared with patients with evidence of OAC use in the prior 12 months, patients without OAC use were more likely to be ≥80 years old, women, and have a history of anemia (51% vs 47%) and less likely to have diabetes (41% vs 44%), history of stroke or TIA (15% vs 19%), and history of heart failure (39% vs 48%). CONCLUSIONS: Despite a high risk of stroke, one-third of privately insured patients with AF and no obvious contraindications to an OAC were not treated with an OAC. There is an unmet need for evidence-based interventions that could lead to greater use of OACs in patients with AF at risk for stroke.

Elderly Patients with Metastatic Neuroendocrine Tumors Are Undertreated and Have Shorter Survival: The LyREMeNET Study.

INTRODUCTION: The incidence of neuroendocrine tumors (NETs) is rising, especially in elderly patients. The elderly cancer population presents considerable challenges, yet little is known about the characteristics, treatment patterns, and outcomes of metastatic NET (mNET) patients. METHODS: The Lyon Real-life Evidence in Metastatic NeuroEndocrine Tumors study (LyREMeNET, NCT03863106) included consecutive mNET patients, diagnosed between January 1990 and December 2017. The exclusion criteria were nonmetastatic NET, poorly differentiated neuroendocrine carcinoma, and mixed neuroendocrine-nonneuroendocrine neoplasms. We aimed to compare patients ≥70 years old to patients <70 years old. RESULTS: A total of 866 patients were included, 198 (23%) were ≥70 years old. There was no significant difference in characteristics except that elderly patients had synchronous metastasis more frequently. Elderly patients received significantly fewer treatments (median of 2.0 vs. 3.0 lines, respectively, p < 0.0001), were significantly less frequently treated by chemotherapy (32 vs. 54%), targeted therapy (16 vs. 30%), peptide receptor radionuclide therapy (5 vs. 16%), and they underwent significantly less frequently locoregional intervention. Median overall survival was significantly shorter in elderly patients (5.2 vs. 9.6 years). The most frequent cause of death was related to disease progression (71%). Multivariate analysis found that, after adjustment for tumor location, tumor grade, and number of metastatic sites, age remained significantly associated with overall survival (HR 1.66, 95% CI 1.26-2.18), indicating a poorer survival in patients ≥70 years old in comparison with younger patients (p = 0.0003). CONCLUSION: Patients ≥70 years old have a worse survival, die frequently from their disease, and are undertreated compared to younger patients.

Organised and opportunistic prevention in primary health care: estimation of missed opportunities by population based health interview surveys in Hungary.

BACKGROUND: Improvement of preventive services for adults can be achieved by opportunistic or organised methods in primary care. The unexploited opportunities of these approaches were estimated by our investigation. METHODS: Data from the Hungarian implementation of European Health Interview Surveys in 2009 (N = 4709) and 2014 (N = 5352) were analysed. Proportion of subjects used interventions in target group (screening for hypertension and diabetes mellitus, and influenza vaccination) within a year were calculated. Taking into consideration recommendations for the frequency of intervention, numbers of missed interventions among patients visited a general practitioner in a year and among patients did not visit a general practitioner in a year were calculated in order to describe missed opportunities that could be utilised by opportunistic or organised approaches. Numbers of missed interventions were estimated for the entire population of the country and for an average-sized general medical practice. RESULTS: Implementation ratio were 66.8% for blood pressure measurement among subjects above 40 years and free of diagnosed hypertension; 63.5% for checking blood glucose among adults above 45 and overweighed and free of diagnosed diabetes mellitus; and 19.1% for vaccination against seasonal influenza. There were 4.1 million interventions implemented a year in Hungary, most of the (3.8 million) among adults visited general practitioner in a year. The number of missed interventions was 4.5 million a year; mostly (3.4 million) among persons visited general practitioner in a year. For Hungary, the opportunistic and organised missed opportunities were estimated to be 561,098, and 1,150,321 for hypertension screening; 363,270, and 227,543 for diabetes mellitus screening; 2,784,072, and 380,033 for influenza vaccination among the < 60 years old high risk subjects, and 3,029,700 and 494,150 for influenza vaccination among more than 60 years old adults, respectively. By implementing all missed services, the workload in an average-sized general medical practice would be increased by 12-13 opportunistic and 4-5 organised interventions a week. CONCLUSIONS: The studied interventions are much less used than recommended. The opportunistic missed opportunities is prevailing for influenza vaccination, and the organised one is for hypertension screening. The two approaches have similar significance for diabetes mellitus screening.

The impact of primary health care reform on hospital emergency department overcrowding: Evidence from the Portuguese reform.

CONTEXT: The reduction in inappropriate utilization of hospitals' emergency departments (EDs) is usually an important objective of primary health care (PHC) reforms. Existing literature provides mixed evidence on the effectiveness of PHC reforms in reducing inappropriate utilization of ED. We assess whether the specific PHC reforms ongoing in Portugal since 2005, and in particular the creation of family health units (FHUs), were successful in reducing inappropriate utilization of EDs and provide a contribution to the debate of which PHC models contribute to reduce overuse of EDs. METHODS: We use patient-level data of 117 391 ED visits from two nonurban hospitals in Portugal to estimate a multivariate logistic regression that assesses the impact of different PHC models on inappropriate ED visits. Patients in our sample had four different models of PHC provision: the new FHU type A or type B and the old personalized health care units (PHUs), with or without a specific family physician assigned. RESULTS: The percentage of episodes that correspond to appropriate visits to the ED is 2% higher for patients enrolled in an FHU type B and 0.8% higher for users of FHU type A, when compared with users enrolled in PHU. Having an assigned family physician increases appropriate use of the ED by 1%. CONCLUSION: Portugal's PHC reform was successful in reducing inappropriate utilization of EDs.

Underutilization of Pulmonary Function Testing in Veterans Hospitalized for Chronic Obstructive Pulmonary Disease Exacerbation: Who are We Missing?

Pulmonary function testing (PFT) is required to diagnose chronic obstructive pulmonary disease (COPD) but is completed for only 30-50% of patients with the disease. We determined patient factors associated with decreased likelihood for PFT acquisition (i.e. underutilization) in the United States Veterans Affairs (VA) health care system.We performed a retrospective analysis of Veterans who survived a VA-based COPD hospitalization between 2012 and 2015. COPD was identified using International Classification of Disease (ICD)-9 codes. Our primary outcome was PFT acquisition, using Current Procedural Terminology (CPT) codes any time prior to the index hospitalization. We compared patients with and without PFTs and used logistic regression to identify associations with PFT underutilization.Of the 48,888 Veterans included, 78% underwent PFTs prior to hospitalization. Patients without PFTs were younger and more likely to be: women (4.2% vs. 3.6%; p = 0.01), nonwhite (22% vs. 19%; p < 0.0001), and current smokers (66% vs 61%; p < 0.0001). PFT acquisition was less likely in Veterans with alcohol and drug use disorders. Using logistic regression, Veterans who were women (Odds Ratio (OR) = 1.17 [95% confidence limit 1.03-1.32]), nonwhite (OR 1.12 [1.06-1.20]), and with a history of alcohol (OR = 1.07 [1.00-1.14]) or drug use disorders (OR = 1.15 [1.06-1.24]) were less likely to undergo PFTs.Though most Veterans hospitalized for COPD had PFTs prior to admission, PFTs are underutilized in Veterans who are: women, younger, nonwhite, and have alcohol or drug use disorders. These groups may be "at-risk" for delayed diagnosis or substandard COPD quality care.

Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi.

Background and purpose - Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods - Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results - Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation - Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.

Non-surgical treatment before hip and knee arthroplasty remains underutilized with low satisfaction regarding performance of work, sports, and leisure activities.

Background and purpose - Guidelines for managing hip and knee osteoarthritis (OA) advise extensive non-surgical treatment prior to surgery. We evaluated what percentage of hip and knee OA patients received non-surgical treatment prior to arthroplasty, and assessed patient satisfaction regarding alleviation of symptoms and performance of activities. Patients and methods - A multi-center cross-sectional study was performed in 2018 among 186 patients who were listed for hip or knee arthroplasty or had undergone surgery within the previous 6 months in the Netherlands. Questions concerned non-surgical treatments received according to the Stepped Care Strategy and were compared with utilization in 2013. Additionally, satisfaction with treatment effects for pain, swelling, stiffness, and activities of daily life, work, and sports/leisure was questioned. Results - The questionnaire was completed by 175 patients, age 66 years (range 38-84), 57% female, BMI 29 (IQR 25-33). Step 1 treatments, such as acetaminophen and lifestyle advice, were received by 79% and 60% of patients. Step 2 treatments, like exercise-based therapy and diet therapy, were received by 66% and 19%. Step 3-intra-articular injection-was received by 47%. Non-surgical treatment utilization was lower than in 2013. Nearly all treatments showed more satisfied patients regarding pain relief and fewer regarding activities of work/sports/leisure. Hip and knee OA patients were mostly satisfied with NSAIDs for all outcomes, while exercise-based therapy was rated second best. Interpretation - Despite international guideline recommendations, non-surgical treatment for hip and knee OA remains underutilized in the Netherlands. Of the patients referred for arthroplasty, more were satisfied with the effect of non-surgical treatment on pain than on work/sports/leisure participation.

Predictors of Nonurgent Emergency Visits at a Midsize Community-Based Hospital System: Secondary Analysis of Administrative Health Care Data.

INTRODUCTION: Nonurgent visits to the emergency department compromise efficiency in treating patients with urgent conditions and inversely influence the satisfaction of patients and staff. There is inconclusive evidence of the factors associated with nonurgent ED visits. Therefore, the purpose of this study was to explore the independent factors associated with nonurgent ED visits in a midsize community-based Canadian hospital system. METHODS: This was a retrospective, secondary analysis of data from 2 community hospitals in southwestern Ontario, Canada. We included ED patients in the analysis if they were local residents from the city or the surrounding county. RESULTS: Nonurgent visits constituted approximately 27% of all ED visits and were more likely to be associated with patients with a primary care provider referral (odds ratio = 2.87; 95% confidence interval, 2.75-2.99) and with patients who had no primary care provider (odds ratio = 1.10; 95% confidence interval, 1.04-1.16). Other predictors included younger age, season, time of day, ED arrival mode, geographical proximity of residence to the emergency department, and case presentation. DISCUSSION: The findings of this study may assist health care providers and stakeholders in developing strategies to minimize nonurgent ED visits.

One Stop: Examining the Reasons Patients Use the Emergency Department for Nonurgent Care and the Barriers They Face.

INTRODUCTION: Despite the plethora of research on the use of emergency department services for nonurgent primary health care, the vast majority of this research is quantitative in nature. To date, there is little research that reports on the problem from the patients' perspective and/or lived experience, which compromises health care providers' understanding of the essence of the problem as described by the patients. Thus, this study will provide a qualitative description of nonurgent ED visits from the patients' perspective. Specifically, this study answers the following research questions: 1) What are the reasons for patients and/or caregivers visiting the emergency department for nonurgent health conditions? and 2) What are the barriers experienced by patients and/or caregivers when seeking access to health care? METHODS: A qualitative descriptive design with face-to-face interviews of 33 consenting participants was conducted at 4 emergency departments. All interviewed participants were triaged as nonurgent patients by the ED personnel. RESULTS: Three themes surfaced from the data regarding reasons for using the emergency department: 1) Practitioner referral; 2) Efficacy of care; and 3) Time saver. When describing barriers that participants experienced when seeking care outside of the emergency department for their nonurgent conditions, 3 themes that emerged are lack of primary care provider, financial difficulties, and lack of comprehensive care outside the emergency department. DISCUSSION: The results of the study can help inform patient-centered care and future policy initiatives that will address the practices and barriers contributing to nonurgent ED visits.

How much of US health care spending provides direct care or benefit to patients?

Plans to optimize health care in the United States highlight the high cost but rarely explore opportunities for redirecting resources within the existing system to increase access to care while lowering spending. This analysis indicates that, of the total national health care expenditures of $3.21 trillion in 2015, only $1.4 trillion to $2.86 trillion was used to provide care to patients. This range was reached by the subtraction of excess spending in 7 categories. Thus, many opportunities exist to repurpose wasted expenditures to increase access to health care without the need for additional funding.

Over- and under-treatment of TB patients in Eastern China: an analysis based on health insurance claims data.

OBJECTIVE: Poor compliance with existing guidelines for tuberculosis (TB) care and treatment is an issue of concern in China. We assessed health service use by TB patients over the entire treatment process and compared it to the recommended guidelines. METHODS: We collected insurance claims data in three counties of one province of Eastern China. Patient records with a diagnosis of 'pulmonary TB' in 2015 and 2016 were extracted. Treatment duration, number of outpatient (OP) visits and hospital admissions, as well as total cost, out-of-pocket (OOP) payments and effective reimbursement rates were analysed. RESULTS: A total of 1394 patients were included in the analysis. More than 48% received over the 8 months of treatment that TB guidelines recommend, and over 28% received less. 49% of Urban and Rural Resident Basic Medical Insurance (URRBMI) TB patients were hospitalised while 30% of those with Urban Employee Basic Medical Insurance (UEBMI) had at least one admission. Median total cost for patients with hospital admission was almost 10 times that of patients without. By comparison, the average OOP was 5 times higher. UEBMI patients had a shorter treatment period, more outpatient visits but considerably fewer hospital admissions than URRBMI patients. CONCLUSIONS: We found an alarming extent of TB over- and under-treatment in our study population. There is an urgent need to improve compliance with treatment guidelines in China and to better understand the drivers of divergence. Extending the coverage of health insurance schemes and increasing reimbursement rates for TB outpatient services would seem to be key factors in reducing both the overall cost and financial burden on patients.

OBJECTIF: Le mauvais respect des directives existantes en matière de soins et de traitement de la tuberculose (TB) est un sujet préoccupant en Chine. Nous avons évalué l'utilisation des services de santé par les patients TB tout au long du processus de traitement et l'avons comparée aux directives recommandées. MÉTHODES: Nous avons collecté des données sur les réclamations d'assurance dans trois comtés d'une province de l'est de la Chine. Les dossiers de patients avec un diagnostic de «TB pulmonaire¼ en 2015 et 2016 ont été extraits. La durée du traitement, le nombre de visites ambulatoires et d'hospitalisations, ainsi que le coût total, les paiements directs et les taux de remboursement effectifs ont été analysés. RÉSULTATS: 1.394 patients ont été inclus dans l'analyse. Plus de 48% ont reçu plus de 8 mois du traitement recommandé par les directives TB et plus de 28% en ont reçu moins. 49% des patients TB résidents urbains et ruraux de l'assurance médicale de base (URRBMI) ont été hospitalisés, tandis que 30% de ceux avec une assurance médicale de base des employés urbains (UEBMI) ont eu au moins une admission. Le coût total moyen pour les patients hospitalisés était près de 10 fois plus élevé que celui des patients non hospitalisés. En comparaison, le payement direct moyen était 5 fois plus élevé. Les patients UEBMI ont eu une période de traitement plus courte, plus de visites ambulatoires mais beaucoup moins d'hospitalisations que les patients URRBMI. CONCLUSIONS: Nous avons trouvé une étendue alarmante de sur- et sous-traitement de la TB dans notre population d'étude. Il est urgent d'améliorer le respect des directives de traitement en Chine et de mieux comprendre les facteurs de divergence. L'extension de la couverture des schémas d'assurance santé et l'augmentation des taux de remboursement des services ambulatoires pour la TB sembleraient être des facteurs essentiels pour réduire à la fois le coût global et la charge financière pour les patients.

Underutilization of HIV Testing Among Men with Incarceration Histories.

Annual HIV testing is recommended for individuals at high risk of infection, specifically incarcerated populations. Incarcerated men carry a higher lifetime risk of acquiring HIV than the general population, yet little is known about their HIV testing behaviors. We collected Audio Computer Assisted Self Interview data for 819 men entering a state prison in North Carolina. We assessed correlates of previous HIV testing, including stigmatizing attitudes and beliefs, and explored two outcomes: (1) ever HIV tested before current incarceration, and (2) recency of last HIV test. Eighty percent had been HIV tested before; of those, 36% reported testing within the last year. Being African American, having education beyond high school, prior incarceration, and higher HIV knowledge increased odds of ever having tested. Results of this study highlight the need to expand HIV testing and education specific to incarcerated populations. Additionally, efforts should be made to monitor and encourage repeat screening.

Expanding Health Information Exchange Improves Identification of Frequent Emergency Department Users.

STUDY OBJECTIVE: Frequent emergency department (ED) users are of interest to policymakers and hospitals. The objective of this study is to examine the effect of health information exchange size on the identification of frequent ED users. METHODS: We retrospectively analyzed data from Healthix, a health information exchange in New York that previously included 10 hospitals and then grew to 31 hospitals. We divided patients into 3 cohorts: high-frequency ED users with 4 or more visits in any 30-day period, medium-frequency ED users with 4 or more visits in any year, and infrequent ED users with fewer than 4 visits in any year. For both the smaller (10-hospital) and larger (31-hospital) health information exchanges, we compared the identification rate of frequent ED users that was based on hospital-specific data with the corresponding rates that were based on health information exchange data. RESULTS: The smaller health information exchange (n=1,696,279 unique ED patients) identified 11.4% more high-frequency users (33,467 versus 30,057) and 9.5% more medium-frequency users (109,497 versus 100,014) than the hospital-specific data. The larger health information exchange (n=3,684,999) identified 19.6% more high-frequency patients (52,727 versus 44,079) and 18.2% more medium-frequency patients (222,574 versus 192,541) than the hospital-specific data. Expanding from the smaller health information exchange to the larger one, we found an absolute increase of 8.2% and 8.7% identified high- and medium-frequency users, respectively. CONCLUSION: Increasing health information exchange size more accurately reflects how patients access EDs and ultimately improves not only the total number of identified frequent ED users but also their identification rate.

The underutilization of obliterative and constrictive surgery in the surgical treatment of pelvic organ prolapse.

Vaginal length and caliber are necessary for satisfactory vaginal coitus. Surgical treatment of pelvic organ prolapse (POP) can include preservation of vaginal length and caliber, or shortening and narrowing of the vagina (constrictive and obliterative surgery). The latter option is proven to have fewer complications and a lower risk of recurrence of POP. Women undergoing surgical intervention for POP who are not coitally active and choose not to be coitally active for the rest of their lives should be offered constrictive and obliterative surgery.

Non-urgent paediatric emergency department presentation: A systematic review.

There has been an increase in the use of the emergency department (ED) for non-urgent presentations. The aim of this systematic review was to identify the proportion, criteria and predictors of non-urgent ED presentations in paediatric populations. A search of multiple databases was conducted for articles published from inception of the databases to 20 August 2018, which reported the proportion, criteria and predictors of non-urgent ED presentation in paediatric populations. Thirty-one articles met the inclusion criteria. The mean proportion of non-urgent paediatric ED presentations was 41.06 ± 15.16%. There appears to be a weak association between predisposing, enabling and needs factors and non-urgent ED use in paediatric populations. The findings of this review suggest that non-urgent ED use in paediatric populations is high. However, non-urgent ED use and the reasons for the visits in paediatric populations remain understudied.