On the short-term impact of pollution: The effect of PM 2.5 on emergency room visits.

In this paper, we study the short-term effect of fine particulate matter (PM 2.5) exposure on respiratory emergency room (ER) visits in Chile, a middle-income country with high levels of air pollution. To instrument for PM 2.5, we use wind speed at different altitudes (pressure levels). Unlike previous papers, our data allow us to study the impact of high pollution levels across all age groups. We find that a 1 µg per cubic meter (µg/m3 ) increase in PM 2.5 exposure for 1 day increases ER visits for respiratory illness by 0.36%. The effect is positive and significant for all age groups. Furthermore, the coefficients on government environmental alerts suggest that avoidance behavior becomes increasingly significant across all age groups as restrictions become more severe.

Identifying the process and agency characteristics associated with poor utilization outcomes in home healthcare.

This study identified the process and agency characteristics associated with poor utilization outcomes - higher percentages of patients (i) admitted to an acute care organization and (ii) visited an emergency room (ER) unplanned without hospitalization - for home health agencies (HHAs) in the United States. We conducted a secondary analysis of data about HHAs' various characteristics, process adherence levels, and utilization outcomes collected from disparate public repositories for 2010-2022. We developed descriptive tree-based models using HHAs' hospital admission or ER visit percentages as response variables. Across the board, hospital admission percentages have steadily improved while ER percentages deteriorated for an extended period. Recently, checking for fall risks and depression was associated with improved outcomes for urban agencies. In general, rural HHAs had worse utilization outcomes than urban HHAs. Targeted investments and improvement initiatives can help rural HHAs close the urban-rural gap in the future.

Prediction of adverse health outcomes using an electronic frailty index among nonfrail and prefrail community elders.

BACKGROUND: Early recognition of older people at risk of undesirable clinical outcomes is vital in preventing future disabling conditions. Here, we report the prognostic performance of an electronic frailty index (eFI) in comparison with traditional tools among nonfrail and prefrail community-dwelling older adults. The study is to investigate the predictive utility of a deficit-accumulation eFI in community elders without overt frailty. METHODS: Participants aged 65-80 years with a Clinical Frailty Scale of 1-3 points were recruited and followed for 2 years. The eFI score and Fried's frailty scale were determined by using a semiautomated platform of self-reported questionnaires and objective measurements which yielded cumulative deficits and physical phenotypes from 80 items of risk variables. Kaplan-Meier method and Cox proportional hazards regression were used to analyze the severity of frailty in relation to adverse outcomes of falls, emergency room (ER) visits and hospitalizations during 2 years' follow-up. RESULTS: A total of 427 older adults were evaluated and dichotomized by the median FI score. Two hundred and sixty (60.9%) and 167 (39.1%) elders were stratified into the low- (eFI ≤ 0.075) and the high-risk (eFI > 0.075) groups, respectively. During the follow-up, 77 (47.0%) individuals developed adverse events in the high-risk group, compared with 79 (30.5%) in the low-risk group (x2, p = 0.0006). In multivariable models adjusted for age and sex, the increased risk of all three events combined in the high- vs. low-risk group remained significant (adjusted hazard ratio (aHR) = 3.08, 95% confidence interval (CI): 1.87-5.07). For individual adverse event, the aHRs were 2.20 (CI: 1.44-3.36) for falls; 1.67 (CI: 1.03-2.70) for ER visits; and 2.84 (CI: 1.73-4.67) for hospitalizations. Compared with the traditional tools, the eFI stratification (high- vs. low-risk) showed better predictive performance than either CFS rating (managing well vs. fit to very fit; not discriminative in hospitalizations) or Fried's scale (prefrail to frail vs. nonfrail; not discriminative in ER visits). CONCLUSION: The eFI system is a useful frailty tool which effectively predicts the risk of adverse healthcare outcomes in nonfrail and/or prefrail older adults over a period of 2 years.

Fibromyalgia Increases Post-operative Healthcare Utilization Following total Hip Arthroplasty.

BACKGROUND: Preoperative factors can complicate the postoperative course and increase health care utilization following total hip arthroplasty (THA). Fibromyalgia is not generally recognized as a modifiable risk factor prior to THA. The aim of this investigation was to assess the effect of fibromyalgia on postoperative health care utilization following THA. METHODS: Patients who underwent primary THA from 2018 to 2019 were identified from a large national database using Current Procedural Terminology and International Classification of Diseases, tenth revision (International Classification of Diseases-10) codes. Patient demographics, age, sex, and preoperative opioid use were collected. Analysis compared patients who did and did not have fibromyalgia for postoperative health care utilization metrics; lengths of stay (LOS), 90-day postoperative opioid usages, dislocations, and emergency room visits. Independent t-tests were used to compare LOS and rates of ongoing opioid use. Logistic regression analyses with adjusted odds ratios evaluated the risk of dislocation and emergency room visit after adjusting for demographic characteristics and comorbidities. RESULTS: Compared to those who did not have fibromyalgia, patients who had fibromyalgia experienced longer LOS (P < .0001), increased odds of opioid use 90 days postoperatively (P < .0001) as well as increased odds of hip dislocation (P < .0001) and presentation to the emergency room (P < .0001). Patients who had fibromyalgia were also more likely to be "frequent flyers" with ≥5 emergency room visits after THA (P < .0001). CONCLUSIONS: Fibromyalgia can complicate postoperative care following THA with increased LOS, higher rates of opioid use, and increased odds of dislocation and emergency room visits. As focus shifts to preoperative optimization and risk stratification, more attention should be placed on fibromyalgia prior to THA.

Psychiatric Emergencies in Los Angeles County During, and After, Initial COVID-19 Societal Restrictions: An Interrupted Time-Series Analysis.

Emergency department (ED) visits for psychiatric care in the US reportedly declined during the COVID-19 pandemic. This work, however, does not control for strong temporal patterning in visits before the pandemic and does not examine a potential "rebound" in demand for psychiatric care following the relaxation of initial societal restrictions. Here, we examine COVID-19-related perturbations in psychiatric care during and after the 1st stage of societal restrictions in the largest safety-net hospital in Los Angeles. We retrieved psychiatric ED visit data (98,888 total over 156 weeks, Jan 2018 to Dec 2020) from Los Angeles County + USC Medical Center. We applied interrupted time series methods to identify and control for autocorrelation in psychiatric ED visits before examining their relation with the 1st stage of societal restrictions (i.e., March 13 to May 8, 2020), as well as the subsequent "rebound" period of relaxed restrictions (i.e., after May 8, 2020). Psychiatric ED visits fell by 78.13 per week (i.e., 12%) during the 1st stage of societal restrictions (SD = 23.99, p < 0.01). Reductions in ED visits for alcohol use, substance use, and (to a lesser extent) anxiety disorders accounted for the overall decline. After the 1st stage of societal restrictions, however, we observe no "rebound" above expected values in psychiatric ED visits overall (coef = - 16.89, SD = 20.58, p = 0.41) or by diagnostic subtype. This pattern of results does not support speculation that, at the population level, foregoing ED care during initial societal restrictions subsequently induced a psychiatric "pandemic" of urgent visits.

Reductions in NO2 and emergency room visits associated with California's goods movement policies: A quasi-experimental study.

INTRODUCTION: This study examines whether the "Emission Reduction Plan for Ports and Goods Movement" in California reduced air pollution exposures and emergency room visits among California Medicaid enrollees with asthma and/or chronic obstructive pulmonary disease. METHOD: We created a retrospective cohort of 5608 Medicaid enrollees from ten counties in California with data from 2004 to 2010. We grouped the patients into two groups: those living within 500 m of goods movement corridors (ports and truck-permitted freeways), and control areas (away from the busy truck or car permitted highways). We created annual air pollution surfaces for nitrogen dioxide and assigned them to enrollees' home addresses. We used a quasi-experimental design with a difference-in-differences method to examine changes before and after the policy for cohort beneficiaries in the two groups. RESULTS: The reductions in nitrogen dioxide exposures and emergency room visits were greater for enrollees in goods movement corridors than those in control areas in post-policy years. We found that the goods movement actions were associated with 14.8% (95% CI, -24.0% to -4.4%; P = 0.006) and 11.8% (95% CI, -21.2% to -1.2%; P = 0.030) greater reduction in emergency room visits for the beneficiaries with asthma and chronic obstructive pulmonary disease, respectively, in the third year after California's emission reduction plan. CONCLUSION: These findings indicate remarkable health benefits via reduced emergency room visits from the significantly improved air quality due to public policy interventions for disadvantaged and susceptible populations.

Geographic information system-based mapping of air pollution & emergency room visits of patients for acute respiratory symptoms in Delhi, India (March 2018-February 2019).

Background & objectives: Studies assessing the spatial and temporal association of ambient air pollution with emergency room visits of patients having acute respiratory symptoms in Delhi are lacking. Therefore, the present study explored the relationship between spatio-temporal variation of particulate matter (PM)2.5 concentrations and air quality index (AQI) with emergency room (ER) visits of patients having acute respiratory symptoms in Delhi using the geographic information system (GIS) approach. Methods: The daily number of ER visits of patients having acute respiratory symptoms (less than or equal to two weeks) was recorded from the ER of four hospitals of Delhi from March 2018 to February 2019. Daily outdoor PM2.5 concentrations and air quality index (AQI) were obtained from the Delhi Pollution Control Committee. Spatial distribution of patients with acute respiratory symptoms visiting ER, PM2.5 concentrations and AQI were mapped for three seasons of Delhi using ArcGIS software. Results: Of the 70,594 patients screened from ER, 18,063 eligible patients were enrolled in the study. Winter days had poor AQI compared to moderate and satisfactory AQI during summer and monsoon days, respectively. None of the days reported good AQI (<50). During winters, an increase in acute respiratory ER visits of patients was associated with higher PM2.5 concentrations in the highly polluted northwest region of Delhi. In contrast, a lower number of acute respiratory ER visits of patients were seen from the 'moderately polluted' south-west region of Delhi with relatively lower PM2.5 concentrations. Interpretation & conclusions: Acute respiratory ER visits of patients were related to regional PM2.5 concentrations and AQI that differed during the three seasons of Delhi. The present study provides support for identifying the hotspots and implementation of focused, intensive decentralized strategies to control ambient air pollution in worst-affected areas, in addition to the general city-wise strategies.

Obstructive sleep apnea in diabetic patients is associated with higher healthcare utilization.

BACKGROUND: Obstructive sleep apnea (OSA) is a frequent comorbid condition in patients with type 2 diabetic (T2DM). Concomitant OSA is associated with a detrimental impact on metabolic control. Both OSA and T2DM independently lead to increased cardiovascular disease and mortality. The impact of OSA on the acceleration of organ dysfunction leading to increased healthcare utilization is unknown. METHODS: This is a retrospective case-control cohort study, a secondary analysis utilizing a nationwide dataset. Patients who underwent elective surgical procedures from 2009 to 2014 were identified. Among these patients, we compared patients with obstructive sleep apnea and those without obstructive sleep apnea. Exact 1:1 matching was performed based on similar characteristics such as age, sex, geographic location, surgical facility environment, performing surgeon, and severity of illness during hospitalization. The subgroup of patients with T2DM with or without OSA was analyzed for post-discharge hospital admissions, intensive care unit (ICU) admissions, emergency room (ER) visits, and outpatient visits. RESULTS: Among 47,719 matched patients of the initial study, this subgroup included 4,567 patients with diabetes and OSA and 3,842 patients with diabetes but no OSA. In the presence of comorbid OSA, patients with T2DM had higher odds of increased healthcare utilization among all the outcomes: inpatient visits increased with an odds ratio of 2.50 (confidence interval (CI) 2.28-2.74) and ICU admissions 1.96 (CI 1.73-2.25) ER 1.93 **(CI 1.75-2.12) and outpatient visits 2.18 (CI 2.00-2.38). Future healthcare utilization per 100 patient-years was also increased significantly among all outcomes (p < 0.0001). CONCLUSIONS: In patients with diabetes undergoing elective surgery, the presence of OSA was associated with higher future healthcare utilization.

Association and interaction of O3 and NO2 with emergency room visits for respiratory diseases in Beijing, China: a time-series study.

BACKGROUND: Ozone (O3) and nitrogen dioxide (NO2) are the two main gaseous pollutants in the atmosphere that act as oxidants. Their short-term effects and interaction on emergency room visits (ERVs) for respiratory diseases remain unclear. METHODS: We conducted a time-series study based on 144,326 ERVs for respiratory diseases of Peking University Third Hospital from 2014 to 2019 in Beijing, China. Generalized additive models with quasi-Poisson regression were performed to analyze the association of O3, NO2 and their composite indicators (Ox and Oxwt) with ERVs for respiratory diseases. An interaction model was further performed to evaluate the interaction between O3 and NO2. RESULTS: Exposure to O3, NO2, Ox and Oxwt was positively associated with ERVs for total respiratory diseases and acute upper respiratory infection (AURI). For instance, a 10 µg/m3 increase in O3 and NO2 were associated with 0.93% (95%CI: 0.05%, 1.81%) and 5.87% (95%CI: 3.92%, 7.85%) increase in AURI at lag0-5 days, respectively. Significant linear exposure-response relationships were observed in Ox and Oxwt over the entire concentration range. In stratification analysis, stronger associations were observed in the group aged < 18 years for both O3 and NO2, in the warm season for O3, but in the cold season for NO2. In interaction analysis, the effect of O3 on total respiratory emergency room visits and AURI visits was the strongest at high levels (> 75% quantile) of NO2 in the < 18 years group. CONCLUSIONS: Short-term exposure to O3 and NO2 was positively associated with ERVs for respiratory diseases, particularly in younger people (< 18 years). This study for the first time demonstrated the synergistic effect of O3 and NO2 on respiratory ERVs, and Ox and Oxwt may be potential proxies.

Relationships between enabling services use and access to care among adults with cardiometabolic risk factors: findings from the 2014 National Health Center Patient Survey.

BACKGROUND: Community health centers (CHCs) provide comprehensive primary and preventive care to medically underserved, low-income, and racially/ethnically diverse populations. CHCs also offer enabling services, non-clinical assistance to reduce barriers to healthcare due to unmet social and material needs, to improve access to healthcare and reduce health disparities. For patients with modifiable cardiometabolic risk factors, including obesity, hypertension, and diabetes, enabling services may provide additional support to improve disease management. However, little is known about the relationship between enabling services and healthcare accessibility and utilization among patients with cardiometabolic risk factors. METHODS: This study uses data from the 2014 Health Center Patient Survey to examine the relationship between enabling services use and delayed/foregone care, routine check-ups, and emergency room visits, among adult community health center patients in the United States with cardiometabolic risk factors (N = 2358). Outcomes of enabling services users were compared to nonusers using doubly robust propensity score matching methods and generalized linear regression models. RESULTS: Overall, enabling service users were 15.4 percentage points less likely to report delayed/foregone care and 29.4 percentage points more likely to report routine check-ups than nonusers. Enabling service users who lived in urban areas, younger and middle-aged adults, and those with two cardiometabolic risk factors were also less likely to report delayed/foregone care and/or more likely to report routine check-ups in comparison with nonusers. However, among adults with three or more cardiometabolic risk factors, enabling services use was associated with a 41.3 percentage point increase in emergency room visits and a 7.6 percentage point decrease in routine check-ups. CONCLUSIONS: The findings highlight the value in utilizing enabling services to improve timeliness and receipt of care among CHC patients with heightened cardiometabolic risk. There is a need for targeting high-risk populations with additional enabling services to support management of multiple chronic conditions.

Short-term effect of ambient ozone pollution on respiratory diseases in western China.

Ambient air pollution has been regarded as an important cause of the morbidity and mortality of respiratory diseases. In the current work, a total of 469,490 respiratory emergency room (ER) visits in Lanzhou, China from Jan 1, 2013 to Dec 31, 2016 were collected. A generalized additive model (GAM) was used to investigate the association between O3 and respiratory ER visits for the different gender and age subgroups. The results showed that: (a) with per inter-quartile range (IQR) (31 µg/m3) increase in O3, the greatest relative risk (RR) of respiratory ER visits for the total was 1.014 (95% CI 1.008-1.020) at lag 4 days. Females and 16-to-45-year-olds were relatively more sensitive to O3; (b) the significant lag effects were found in single-day lag models, with the highest RR values for different groups were observed at lag 3-lag 5 days. The multi-day cumulative lag effects were stronger for the total; (c) in the multiple-pollutant models, the effects of O3 were generally increased when introducing other pollutants (PM10, PM2.5, SO2 and NO2) for adjustment. This study demonstrated that short-term exposure to O3 increased the RR of respiratory ER visits in Lanzhou, China.

Reducing potentially preventable health events among patients with asthma through multi-state, multi-center quality improvement program.

INTRODUCTION: Enhancing Care for Patients with Asthma is a multi-state, multi-center quality improvement program developed to augment guideline-based practice among health care providers through Plan-Do-Study-Act cycle. This study examined the association between the implementation of the guideline-based quality improvement program and subsequent changes in asthma-related emergency room visits and hospitalizations. METHODS: This retrospective, interrupted time-series study used administrative claims data from a private insurer that provided coverage to patients receiving care from participating health centers (15 centers in New Mexico, Oklahoma, Texas, and Illinois). The 12-month implementation period started in January 2013 for centers in Cohort 1 and October 2013 for centers in Cohort 2. The claims of 1,828 patients with asthma from January 2012 to May 2015 were analyzed. The data included 12-month pre-program implementation, 12-month program implementation, and 5-month post-program completion periods. RESULTS: The average number of asthma-related emergency room visits and hospitalizations decreased from 2.22 to 1.38 and 1.97 to 1.04 per 100 patients per month, respectively, in the 12-month pre-implementation period as compared to 12-month implementation period. The results of three-level generalized linear mixed models found that during the 12-month implementation period, patients had 37.7% and 47.1% lower rates of emergency room visits and hospitalizations, respectively, compared to the 12-month pre-implementation period (p < 0.001 in both comparisons). CONCLUSIONS: Enhancing Care for Patients with Asthma is an effective quality improvement program that was successfully executed in diverse geographical states and associated with reductions in potentially preventable health events. The findings support the widespread use of the program in other settings.

Domestic violence and abuse related emergency room visits in Ontario, Canada.

BACKGROUND: Hospitals' emergency rooms (ERs) are generally the first point of contact of domestic violence and abuse (DVA) victims to the health care system. For efficient management and resource allocation for ERs to manage DVA-related emergencies in Canada, it is important to quantify and assess the pattern of these visits. METHODS: Aggregate DVA-related ER visits data, using relevant ICD-10-CA codes, from 2012 to 2016 were retrieved from IntelliHealth Ontario. The 2011 ON-Marg (Ontario Marginalization) indices were linked at the Dissemination Area level to ER data. Descriptive analyses including total number and rate of visits per 100,000 people were calculated, stratified by age and sex. The Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were also assessed. RESULTS: From 2012 to 2016, 10,935 (81.2% by females and 18.8% by males) DVA-related visits were made to ERs in Ontario. An annual average of 25.5 visits per 100,000 females and 6.1 visits per 100,000 males was observed. Residential instability and deprivation were significant predictors of DVA-related ER visits. No particular site of injury was indicated in 38.5% of visits, 24.7% presented with cranio-maxillofacial (CMF) trauma in isolation, 28.9% presented with non-CMF injuries, and 7.9% visits presented with both CMF and non-CMF injuries. CONCLUSION: This study identified that the burden of DVA-related ER visits is large enough to warrant timely public health interventions, and observed that certain populations in Ontario experience more DVA and/or are more prone to its impact. Our findings have important implications for various stakeholders involved in planning and implementing relevant policies and programs.

The receipt of information by family physicians about their patient's emergency department visits: a record linkage study of electronic medical records to health administrative data.

BACKGROUND: Canadians are known to be frequent users of emergency department (ED) care. However, the exchange of information from ED visits to family physicians (FPs) is not well known. Our objectives were to determine whether Canadian FPs received information about their patient's ED visit and the patient characteristics related to the receipt of ED information. METHODS: This study was a descriptive record linkage study of FP Electronic Medical Record (EMR) data linked to health administrative data. Our study cohort included patients who had at least one ED visit in 2010 or 2015 in Ontario, Canada. An ED visit could include a transfer to or from another ED. The receipt of information from an ED note was examined in relation to patient age, sex, neighbourhood income quintiles, rurality and comorbidity. RESULTS: There were 26,609 patients in 2010 and 50,541 patients in 2015 with at least one ED visit. In 2010, 53.3% of FPs received an ED note for patients having a single ED visit compared to 41.0% in 2015. For patients with multiple ED visits, 58.2% of FPs received an ED note in 2010 compared to 45.7% in 2015. FPs were more likely to receive an ED note for patients not living in low income neighbourhoods, older patients, patients living in small urban areas and for patients having moderate comorbidity. FPs were less likely to receive a note for patients living in rural areas. CONCLUSIONS: Community-based FPs are more likely to get information after an ED visit for their older and sicker patients. However, FPs do not receive any information from EDs for over half their patients. Electronic health record technologies and their adoption by ED providers need to improve the seamless transfer of information about the care provided in EDs to FPs in the community.

[Effect of Air Pollution on Emergency Room Visits for Respiratory Diseases in Lanzhou].

Objective To explore the effect of air pollution on the number of emergency room visits for respiratory diseases in residents at different ages and its seasonal changes in Lanzhou,so as to provide a scientific basis for the early prevention of respiratory diseases in Lanzhou. Methods The daily number of emergency room visits for respiratory diseases in three class A hospitals in Lanzhou from January 1,2013 to December 31,2017,as well as the air pollutants and meteorological data of Lanzhou in the same period,was collected.After controlling the confounding factors including long-term trend of time,meteorological factors and day-of-week effect using a generalized additive model,we analyzed the relationships between air pollutants and the daily number of emergency room visits for respiratory diseases,and explored whether there was a lag effect of air pollutants.Results From 2013 to 2017,the emergency room visits for respiratory diseases in Lanzhou had a total number of 124 871,with an average of 69(1-367)visits per day.The single pollutant model showed that among the six conventional air pollutants monitored in Lanzhou,PM 2.5,PM10,NO2,SO2 and O38h had a lag effect on the number of emergency room visits for respiratory diseases.For every 10 µg/m 3 increase in the concentration of PM2.5 (lag02:t=4.792, P=0.001), PM10 (lag2:t=3.421, P<0.001), NO2 (lag6:t=3.654, P=0.003), SO2(lag06:t=4.712, P<0.001)and O38h (lag07:t=3.021, P=0.012), the number of emergency room visits for respiratory diseases increased by 0.900%(95% CI:0.573%-1.249%), 0.083%(95% CI:0.012%-0.153%), 1.293%(95% CI:0.867%-1.720%), 3.851%(95% CI:2.675%-5.041%)and 0.737%(95% CI:0.129%-1.348%), respectively.For every 1 mg/m3 increase in the concentration of CO(lag0:t=3.564,P<0.001),the number of emergency room visits for respiratory diseases increased by 2.556% (95%CI: 1.493%-3.629%). In gender stratification, PM2.5(male:t=3.124, P=0.019;female:t=3.418, P=0.007), PM10(male:t=2.980, P=0.160;female:t=2.997, P=0.013)and CO(male:t=4.117, P=0.001;female:t=4.629, P<0.001)in winter had stronger effects on the emergency room visits for respiratory diseases in females than that in males, while the effects of NO2(male:t=3.020, P=0.107;female:t=3.006, P=0.128), SO2(male:t=4.101, P<0.001;female:t=3.820, P<0.001)and O38h(male:t=3.660, P=0.022;female:t=3.517, P=0.018)in winter showed an opposite trend.In age stratification, the increase in the daily average concentration of PM2.5(0-14 years old:t=3.520, P=0.008), PM10(0-14 years old:t=3.840, P<0.001), SO2(0-14 years old:t=4.570, P<0.001), CO(0-14 years old:t=4.102, P=0.002)in winter would increase the emergency visits for respiratory diseases in the 0-14-year-old population.The daily average concentration of O38h(0-14 years old:t=4.210, P<0.001;15-64 years old:t=3.807, P=0.001)in summer only affected the visits of the 0-14-year-old and the 15-64-year-old populations, and the air pollutants had no significant effect on the visits of those≥65 years old.The double pollutant model analysis revealed that after introducing 5 other pollutants respectively, PM2.5, PM10, NO2, SO2 and O38h significantly increased the emergency room visits for respiratory diseases, and CO had a more obvious effect than that predicted with the single pollutant model. Conclusion The rises in the concentrations of six air pollutants in Lanzhou will increase the emergency room visits for respiratory diseases, and the patterns vary with different genders, ages and seasons.

Factors associated with emergency room visits and hospitalisation amongst low-income public rental flat dwellers in Singapore.

BACKGROUND: In Singapore, a densely urbanised Asian society, more than 80% of the population stays in public housing estates and the majority (90%) own their own homes. For the needy who cannot afford home ownership, public rental flats are available. Staying in a public rental flat is associated with higher hospital readmission rates and poorer access to health services. We sought to examine sociodemographic factors associated with hospital admissions and emergency room visits amongst public rental flat residents. METHODS: We surveyed all residents aged ≥60 years in a public rental housing precinct in central Singapore in 2016. Residents self-reported their number of emergency room visits, as well as hospitalisations, in the past 6 months. We obtained information on residents' sociodemographic characteristics, medical, functional and social status via standardised questionnaires. We used chi-square to identify associations between emergency room visits/hospitalisations and sociodemographic characteristics, on univariate analysis; and logistic regression for multivariate analysis. RESULTS: Of 1324 contactable residents, 928 participated in the survey, with a response rate of 70.1%. A total of 928 residents participated in our study, of which 59.5% were male (553/928) and 51.2% (476/928) were ≥ 70 years old. Around 9% (83/928) of residents had visited the emergency room in the last 6 months; while 10.5% (100/928) had been admitted to hospital in the past 6 months. On multivariable analysis, being religious (aOR = 0.43, 95%CI = 0.24-0.76) and having seen a primary care practitioner in the last 6 months (aOR = 0.46, 95%CI = 0.27-0.80) were independently associated with lower odds of emergency room visits, whereas loneliness (aOR = 1.96, 95%CI = 1.13-3.43), poorer coping (aOR = 1.72, 95%CI = 1.01-3.03) and better adherence (aOR = 2.23, 95%CI = 1.29-3.83) were independently associated with higher odds of emergency room visits. For hospitalisations, similarly poorer coping (aOR = 1.85, 95%CI = 1.12-3.07), better adherence (aOR = 1.69, 95%CI = 1.04-2.75) and poorer functional status (aOR = 1.85, 95%CI = 1.15-2.98) were all independently associated with higher odds of hospitalisations, whereas those who were religious (aOR = 0.62, 95%CI = 0.37-0.99) and those who were currently employed (aOR = 0.46, 95%CI = 0.37-0.99) had lower odds of being hospitalised. CONCLUSION: In this public rental flat population, functional status, coping and adherence, and having a religion were independently associated with emergency room visits and hospitalisation. Residents who had seen a primary care practitioner in the last 6 months had lower odds of visiting the emergency room.

Effectiveness of a community care management program for multimorbid elderly patients with heart failure in the Veneto Region.

BACKGROUND: The rapidly growing population of elderly subjects with multimorbidity is at risk of receiving fragmented and uncoordinated care, and have frequent hospitalizations and emergency room (ER) visits. AIMS: The study aims to describe the impact of a care management program (CMP) developed in the Veneto region (Northeastern Italy) for patients affected by chronic heart failure (CHF) and multimorbidity. METHODS: The CMP was provided to 330 patients > 65 years suffering from CHF and multimorbidity. They were compared to a propensity score matched reference group who received usual care. The intervention was provided by care manager nurses and General Practitioners working in the community. The quality of care from the patients' perspective was assessed by means of the Patient Assessment of Chronic Illness Care (PACIC). The effectiveness of the CMP has been evaluated comparing time changes in hospital admissions in the medical area and ER visits between the intervention and the reference group. RESULTS: The median PACIC overall score was 4 out of 5. The intervention group showed a reduction over time by 39% in hospitalization rates and by 33% in ER visits. The recourse to hospital care and ER did not change in the reference group. DISCUSSION: The current results indicate that a CMP can reduce Emergency Room visits and hospital admissions for elderly patients with CHF and multimorbidity. CONCLUSIONS: The CMP by emphasizing prevention, self-management, continuity and coordination of care, is beneficial among older community-dwelling multimorbid persons as compared to usual care.

Impact of Medical Home on Health Care of Children With and Without Special Health Care Needs: Update from the 2016 National Survey of Children's Health.

Objective The medical home has been promoted as an optimal model of health care delivery for children. The purpose of this study was to examine the association between having access to a medical home and the health care experiences of children with and without special health care needs (SHCN) in the United States. Methods We analyzed data from the 2016 National Survey of Children's Health. We modeled logistic regressions to assess associations of having access to a medical home with health care experiences for 11,392 CSHCN and 38,820 non-CSHCN. Results We found that not having access to a medical home was negatively associated with preventive medical and dental care visits, greater unmet medical and dental needs, and hospital emergency room visits. Additionally, not having access to a medical home was negatively associated with the physical and oral health among CSHCN and oral health among non-CSHCN. However, we found no significant association between improved physical health status and having access to a medical home among non-CSHCN. Conclusions Results from our analysis suggest that having access to a medical home remains key determinant of improved health care experiences by CSHCN and non-CSHCN in the United States. Our findings underscore the need to develop policies and implement a more concerted program to increase access to health care delivered under the medical home model for CSHCN and non-CSHCN. Policymakers, health care administrators and physician groups can use these findings to inform future policy decisions and service delivery reforms.

Association of emergency room visits for respiratory diseases with sources of ambient PM2.5.

Previous studies have reported associations of short-term exposure to different sources of ambient fine particulate matter (PM2.5) and increased mortality or hospitalizations for respiratory diseases. Few studies, however, have focused on the short-term effects of source-specific PM2.5 on emergency room visits (ERVs) of respiratory diseases. Source apportionment for PM2.5 was performed with Positive Matrix Factorization (PMF) and generalized additive model was applied to estimate associations between source-specific PM2.5 and respiratory disease ERVs. The association of PM2.5 and total respiratory ERVs was found on lag4 (RR = 1.011, 95%CI: 1.002, 1.020) per interquartile range (76 µg/m3) increase. We found PM2.5 to be significantly associated with asthma, bronchitis and chronic obstructive pulmonary disease (COPD) ERVs, with the strongest effects on lag5 (RR = 1.072, 95%CI: 1.024, 1.119), lag4 (RR = 1.104, 95%CI: 1.032, 1.176) and lag3 (RR = 1.091, 95%CI: 1.047, 1.135), respectively. The estimated effects of PM2.5 changed little after adjusting for different air pollutants. Six primary PM2.5 sources were identified using PMF analysis, including dust/soil (6.7%), industry emission (4.5%), secondary aerosols (30.3%), metal processing (3.2%), coal combustion (37.5%) and traffic-related source (17.8%). Some of the sources were identified to have effects on ERVs of total respiratory diseases (dust/soil, secondary aerosols, metal processing, coal combustion and traffic-related source), bronchitis ERVs (dust/soil) and COPD ERVs (traffic-related source, industry emission and secondary aerosols). Different sources of PM2.5 contribute to increased risk of respiratory ERVs to different extents, which may provide potential implications for the decision making of air quality related policies, rational emission control and public health welfare.

Association between parental access to paid sick leave and children's access to and use of healthcare services.

BACKGROUND: We examined the association between parental access to paid sick leave (PPSL) and children's use of preventive care and reduced likelihood of delayed medical care and emergency room (ER) visits. METHODS: We used the child sample of the National Health Interview Survey data (linked to the adult and family samples) from 2011 through 2015 and logistic and negative binomial regression models. RESULTS: Controlling for covariates, the odds of children with PPSL receiving flu vaccination were 12.5% [95%CI: 1.06-1.19] higher and receiving annual medical checkups were 13.2% [95%CI: 1.04-1.23] higher than those of children without PPSL. With PPSL, the odds of children receiving delayed medical care because of time mismatch were 13.3% [95%CI: 0.76-0.98] lower, and being taken to ER were 53.6% [95%CI: 0.27-0.81] lower than those of children without PPSL. PPSL was associated with 11% [95%CI: 0.82-0.97] fewer ER visits per year. CONCLUSION: PPSL may improve children's access and use of healthcare services and reduce the number of ER visits. Am. J. Ind. Med. 60:276-284, 2017. © 2017 Wiley Periodicals, Inc.