Protocol of a monocentric, double-blind, randomized, superiority, controlled trial evaluating the effect of in-prison OROS-methylphenidate vs. placebo treatment in detained people with attention-deficit hyperactivity disorder (BATIR).

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is characterized by difficulty paying attention, poor impulse control, and hyperactive behavior. It is associated with several adverse health and social outcomes and leads to an increased risk of criminality and recidivism. Worldwide, ADHD is thus highly prevalent in prisons. However, ADHD treatment has been neglected in such environments. Stimulant medications such as osmotic-release oral system methylphenidate (OROS-MPH) are first-line treatments in the general population, but they are under-prescribed in prisons due to concerns about abuse, even though such claims are not empirically supported. This project aims to compare the efficacy of a 3-month in-prison OROS-MPH vs. placebo treatment on the severity of core ADHD symptoms and relevant in- and post-prison outcomes. METHODS: This study is a phase III, double-blinded, randomized, superiority, controlled trial of OROS-MPH vs. placebo. After randomization, the participants will receive 3 months of treatment with OROS-MPH or placebo (1:1 ratio) while incarcerated. Upon release, all participants will be offered the treatment (OROS-MPH) for 1 year but will remain blinded to their initial study group. The study will be conducted at the Division of Prison Health, Geneva, Switzerland, among incarcerated men (n = 150). Measures will include (1) investigator-rated ADHD symptoms, (2) acute events collected by the medical and prison teams, (3) assessment of the risk of recidivism, (4) medication side effects, (5) medication adherence, (6) study retention, (7) health care/prison costs, and (8) 1-year recidivism. Analyses will include bivariable and multivariable modeling (e.g., regression models, mixed-effects models, survival analyses) and an economic evaluation (cost-benefit analysis). DISCUSSION: We expect that early identification and treatment of ADHD in prison will be an important public health opportunity and a cost-effective approach that is likely to reduce the vulnerability of incarcerated individuals and promote pathways out of criminal involvement. The study will also promote standards of care for people with ADHD in prison and provide recommendations for continuity of care after release. TRIAL REGISTRATION: ClinicalTrials.gov NCT05842330 . Registered on June 5, 2023. Kofam.ch SNCTP000005388. Registered on July 17, 2023.

Evaluating the cost of simplicity in score building: An example from alcohol research.

Building a score from a questionnaire to predict a binary gold standard is a common research question in psychology and health sciences. When building this score, researchers may have to choose between statistical performance and simplicity. A practical question is to what extent it is worth sacrificing the former to improve the latter. We investigated this research question using real data, in which the aim was to predict an alcohol use disorder (AUD) diagnosis from 20 self-reported binary questions in young Swiss men (n = 233, mean age = 26). We compared the statistical performance using the area under the ROC curve (AUC) of (a) a "refined score" obtained by logistic regression and several simplified versions of it ("simple scores"): with (b) 3, (c) 2, and (d) 1 digit(s), and (e) a "sum score" that did not allow negative coefficients. We used four estimation methods: (a) maximum likelihood, (b) backward selection, (c) LASSO, and (d) ridge penalty. We also used bootstrap procedures to correct for optimism. Simple scores, especially sum scores, performed almost identically or even slightly better than the refined score (respective ranges of corrected AUCs for refined and sum scores: 0.828-0.848, 0.835-0.850), with the best performance been achieved by LASSO. Our example data demonstrated that simplifying a score to predict a binary outcome does not necessarily imply a major loss in statistical performance, while it may improve its implementation, interpretation, and acceptability. Our study thus provides further empirical evidence of the potential benefits of using sum scores in psychology and health sciences.

Thinking beyond cut-off scores in the assessment of potentially addictive behaviors: A brief illustration in the context of binge-watching.

While applying a diagnostic approach (i.e., comparing "clinical" cases with "healthy" controls) is part of our methodological habits as researchers and clinicians, this approach has been particularly criticized in the behavioral addictions research field, in which a lot of studies are conducted on "emerging" conditions. Here we exemplify the pitfalls of using a cut-off-based approach in the context of binge-watching (i.e., watching multiple episodes of series back-to-back) by demonstrating that no reliable cut-off scores could be determined with a widely used assessment instrument measuring binge-watching.

Changes in socioeconomic resources and mental health after the second COVID-19 wave (2020-2021): a longitudinal study in Switzerland.

BACKGROUND: During the 2020/2021 winter, the labour market was under the impact of the COVID-19 pandemic. Changes in socioeconomic resources during this period could have influenced individual mental health. This association may have been mitigated or exacerbated by subjective risk perceptions, such as perceived risk of getting infected with SARS-CoV-2 or perception of the national economic situation. Therefore, we aimed to determine if changes in financial resources and employment situation during and after the second COVID-19 wave were prospectively associated with depression, anxiety and stress, and whether perceptions of the national economic situation and of the risk of getting infected modified this association. METHODS: One thousand seven hundred fifty nine participants from a nation-wide population-based eCohort in Switzerland were followed between November 2020 and September 2021. Financial resources and employment status were assessed twice (Nov2020-Mar2021, May-Jul 2021). Mental health was assessed after the second measurement of financial resources and employment status, using the Depression, Anxiety and Stress Scale (DASS-21). We modelled DASS-21 scores with linear regression, adjusting for demographics, health status, social relationships and changes in workload, and tested interactions with subjective risk perceptions. RESULTS: We observed scores above thresholds for normal levels for 16% (95%CI = 15-18) of participants for depression, 8% (95%CI = 7-10) for anxiety, and 10% (95%CI = 9-12) for stress. Compared to continuously comfortable or sufficient financial resources, continuously precarious or insufficient resources were associated with worse scores for all outcomes. Increased financial resources were associated with higher anxiety. In the working-age group, shifting from full to part-time employment was associated with higher stress and anxiety. Perceiving the Swiss economic situation as worrisome was associated with higher anxiety in participants who lost financial resources or had continuously precarious or insufficient resources. CONCLUSION: This study confirms the association of economic stressors and mental health during the COVID-19 pandemic and highlights the exacerbating role of subjective risk perception on this association.

SARS-CoV-2 seroprevalence study after the first wave among persons living and working in an overcrowded Swiss prison.

PURPOSE: Prisons can be epicentres of infectious diseases. However, empirical evidence on the impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in prison is still scarce. This study aims to estimate the seroprevalence rates of anti-SARS-CoV-2 in the largest and most crowded Swiss prison and compare them with the seroprevalence rate in the general population. DESIGN/METHODOLOGY/APPROACH: A cross-sectional study was conducted in June 2020, one month after the first wave of SARS-CoV-2 in Switzerland. Groups included: people living in detention (PLDs) detained before the beginning of the pandemic (n = 116), PLDs incarcerated after the beginning of the pandemic (n = 61), prison staff and prison healthcare workers (n = 227) and a sample from the general population in the same time period (n = 3,404). The authors assessed anti-SARS-CoV-2 IgG antibodies. FINDINGS: PLDs who were incarcerated before the beginning of the pandemic had a significantly lower seroprevalence rate [0.9%, confidence interval (CI)95%: 0.1%-5.9%] compared to the general population (6.3%, CI 95%: 5.6-7.3%) (p = 0.041). The differences between PLDs who were incarcerated before and other groups were marginally significant (PLDs incarcerated after the beginning of the pandemic: 6.6%, CI 95%: 2.5%-16.6%, p = 0.063; prison staff CI 95%: 4.8%, 2.7%-8.6%, p = 0.093). The seroprevalence of prison staff was only slightly and non-significantly lower than that of the general population. ORIGINALITY/VALUE: During the first wave, despite overcrowding and interaction with the community, the prison was not a hotspot of SARS-CoV-2 infection. Preventive measures probably helped avoiding clusters of infection. The authors suggest that preventive measures that impact social welfare could be relaxed when overall circulation in the community is low to prevent the negative impact of isolation.

Equity in access to COVID-19 testing for undocumented migrants and homeless persons during the initial phase of the pandemic.

INTRODUCTION: The COVID-19 pandemic has excessively affected socially and economically deprived groups of population. There is a dearth of empirical evidence about the effect of policies regulating access to care for such groups. This study aims to document the impact of an equity-based strategy to facilitate access to COVID-19 testing during the initial phase of the pandemic. MATERIALS AND METHODS: This cross-sectional study included all outpatients presenting at the Geneva University Hospital for COVID-19 testing in March and April 2020. We compared the testing program uptake, and the proportions of positive tests and of complicated clinical course between undocumented migrants and homeless persons and the general population. RESULTS: Underserved patients represented 215 (6.5%) of the 3299 participants. There was no significant difference in the time-lag between the first COVID-19 evocative symptoms and the testing, the number of symptoms at presentation, and the participation to the program during its first month of implementation. The proportion of positive tests was significantly higher (32.1% vs. 23.6%, p=.005) among undeserved while the proportion of complicated clinical course was comparable. CONCLUSIONS: Equity-based policies can mitigate disparities in access to care during the pandemic and reduce the spread of COVID-19 in the community by early detection of infective cases. The high proportion of positive test in underserved patients highlight the need to include such groups into future COVID-19 immunization program. More globally, this study highlights the opportunity to reinforce healthcare systems to adapt to new threats and to contribute to a better protection of the whole of society.

Early experimental COVID-19 therapies: associations with length of hospital stay, mortality and related costs.

AIMS OF THE STUDY: Hydroxychloroquine and lopinavir/ritonavir have been used as experimental therapies to treat COVID-19 during the first wave of the pandemic. Randomised controlled trials have recently shown that there are no meaningful benefits of these two therapies in hospitalised patients. Uncertainty remains regarding the potential harmful impact of these therapies as very early treatments and their burden to the health care system. The present study investigated the length of hospital stay (LOS), mortality, and costs of hydroxychloroquine, lopinavir/ritonavir or their combination in comparison with standard of care among patients hospitalised for coronavirus disease 2019 (COVID-19). METHODS: This retrospective observational cohort study took place in the Geneva University Hospitals, Geneva, Switzerland (n = 840) between 26 February and 31 May 2020. Demographics, treatment regimens, comorbidities, the modified National Early Warning Score (mNEWS) on admission, and contraindications to COVID-19 treatment options were assessed. Outcomes included LOS, in-hospital mortality, and drug and LOS costs. RESULTS: After successful propensity score matching, patients treated with (1) hydroxychloroquine, (2) lopinavir/ritonavir or (3) their combination had on average 3.75 additional hospitalisation days (95% confidence interval [CI] 1.37–6.12, p = 0.002), 1.23 additional hospitalisation days (95% CI −1.24 – 3.51, p = 0.319), and 4.19 additional hospitalisation days (95% CI 1.52–5.31, p <0.001), respectively, compared with patients treated with the standard of care. Neither experimental therapy was significantly associated with mortality. These additional hospital days amounted to 1010.77 additional days for hydroxychloroquine and hydroxychloroquine combined with lopinavir/ritonavir, resulting in an additional cost of US$ 2,492,214 (95%CI US$ 916,839–3,450,619). CONCLUSIONS: Prescribing experimental therapies for COVID-19 was not associated with a reduced LOS and might have increased the pressure put on healthcare systems.

Identifying an accurate self-reported screening tool for alcohol use disorder: evidence from a Swiss, male population-based assessment.

BACKGROUND AND AIMS: Short screenings for alcohol use disorder (AUD) are crucial for public health purposes, but current self-reported measures have several pitfalls and may be unreliable. The main aim of our study was to provide empirical evidence on the psychometric performance of self-reports currently used. Our research questions were: compared with a gold standard clinical interview, how accurate are (1) self-reported AUD, (2) self-reported alcohol use over time and (3) biomarkers of alcohol use among Swiss men? Finally, we aimed to identify an alternative screening tool. DESIGN: A single-center study with a cross-sectional design and a stratified sample selection. SETTING: Lausanne University Hospital (Switzerland) from October 2017 to June 2018. PARTICIPANTS: We selected participants from the French-speaking participants of the ongoing Cohort Study on Substance Use and Risk Factors (n = 233). The sample included young men aged on average 27.0 years. MEASUREMENTS: We used the Diagnostic Interview for Genetic Studies as the gold standard for DSM-5 AUD. The self-reported measures included 11 criteria for AUD, nine alcohol-related consequences, and previous 12 months' alcohol use. We also assessed biomarkers of chronic excessive drinking (ethyl glucuronide and phosphatidylethanol). FINDINGS: None of the self-reported measures/biomarkers taken alone displayed both sensitivity and specificity close to 100% with respect to the gold standard (e.g. self-reported AUD: sensitivity = 92.3%, specificity = 45.8%). The best model combined eight self-reported criteria of AUD and four alcohol-related consequences. Using a cut-off of three, this screening tool yielded acceptable sensitivity (83.3%) and specificity (78.7%). CONCLUSIONS: Neither self-reported alcohol use disorder nor heavy alcohol use appear to be adequate to screen for alcohol use disorder among young men from the Swiss population. The best screening alternative for alcohol use disorder among young Swiss men appears to be a combination of eight symptoms of alcohol use disorder and four alcohol-related consequences.

Words matter: a call for humanizing and respectful language to describe people who experience incarceration.

BACKGROUND: Words matter when describing people involved in the criminal justice system because language can have a significant impact upon health, wellbeing, and access to health information and services. However, terminology used in policies, programs, and research publications is often derogatory, stigmatizing, and dehumanizing. DISCUSSION: In response, health experts from Europe, the United States, and Australia recommend that healthcare professionals, researchers, and policy makers working with people in detention follow key principles that foster constructive and humanizing language. These principles include: engage people and respect their preferences; use stigma-free and accurate language; prioritize individuals over their characteristics; and cultivate self-awareness. The article offers examples of problematic terms to be avoided because they do not convey respect for incarcerated people and propose preferred wording which requires contextualization to local language, culture, and environment. CONCLUSION: The use of respectful and appropriate language is a cornerstone of reducing harm and suffering when working with people involved in the criminal justice system; the use of stigmatizing and dehumanizing language must therefore come to an end.

Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health coverage.

OBJECTIVES: In countries with universal health coverage (UHC), national public health insurances cover 70% of health expenditures on average, but health care user fees and out-of-pocket expenditures have been neglected in empirical patient-centered health inequality research. This study is the first to investigate how health care-related factors are associated with health status among middle-aged and elderly people-vulnerable groups for the burden of illness-in countries with UHC. DESIGN: Longitudinal observational cohort study. SETTING: Population-based cohort Survey of Health, Ageing and Retirement in Europe (SHARE) in twelve countries with UHC. PARTICIPANTS: Non-institutionalized people aged 50 and older (n = 29,260). Two subsamples were also used: participants without global activity limitation at baseline (n = 16,879) and participants without depression at baseline (n = 21,178). MAIN OUTCOME MEASURES: Risk of death, risk of global activity limitations, and risk of depression. We used mixed-effects Cox proportional hazards regressions to estimate hazard ratios (HR) for all-cause mortality, physical limitations, and depression. RESULTS: Having a voluntary private insurance to cover health expenses not included in the public health care system (44.1% of the total sample) was a protective factor for all outcomes (HR≤0.91), controlling for a large range of socio-economic variables. On the contrary, having out-of-pocket expenditures (62.4%) was a risk factor (HR≥1.12). CONCLUSIONS: UHC systems are not free from health inequalities: there is a potential effect of lack of voluntary private insurance and out-of-pocket expenditures on mortality and health. Health care-related factors should be at focus in future researches designed to understand and address health inequalities. Reducing out-of-pocket expenditures and developing voluntary private insurance may protect against premature illness and death.

Health care costs of case management for frequent users of the emergency department: Hospital and insurance perspectives.

BACKGROUND: In most emergency departments (EDs), few patients account for a relatively high number of ED visits. To improve the management of these patients, the university hospital of Lausanne, Switzerland, implemented an interdisciplinary case management (CM) intervention. This study examined whether the CM intervention-compared with standard care (SC) in the ED-reduced costs generated by frequent ED users, not only from the hospital perspective, but also from the third-party payer perspective, that is, from a broader perspective that takes into account the costs of health care services used outside the hospital offering the intervention. METHODS: In this randomized controlled trial, 250 frequent ED users (>5 visits during the previous 12 months) were allocated to either the CM or the SC group and followed up for 12 months. Cost data were obtained from the hospital's analytical accounting system for the entire sample and from health insurance companies for a subgroup (n = 140). Descriptive statistics and multivariate regressions were used to make comparisons between groups and assess the contribution of patient characteristics to the main cost components. RESULTS: At the end of the 12-month follow-up, 115 patients were in the CM group and 115 in the SC group (20 had died). Despite differences in economic costs between patients in the CM intervention and the SC groups, our results do not show any statistically significant reduction in costs associated with the intervention, either for the hospital that housed the intervention or for the third-party payer. Frequent ED users were big users of health services provided by both the hospital and community-based services, with 40% of costs generated outside the hospital that housed the intervention. Higher age, Swiss citizenship, and having social difficulty increased costs significantly. CONCLUSIONS: As the role of the CM team is to guide patients through the entire care process, the intervention location is not limited to the hospital but often extends into the community.

Using case management in a universal health coverage system to improve quality of life of frequent Emergency Department users: a randomized controlled trial.

PURPOSE: Frequent Emergency Department users are likely to experience poor quality of life (QOL). Case management interventions are efficient in responding to the complex needs of this population, but their effects on QOL have not been tested yet. Therefore, the aim of our study was to examine to what extent a case management intervention improved frequent Emergency Department users' QOL in a universal health coverage system. METHODS: Data were part of a randomized controlled trial designed to improve frequent Emergency Department users' QOL at the Lausanne University Hospital, Switzerland. A total of 250 frequent Emergency Department users (≥ 5 attendances during the previous 12 months) were randomly assigned to the control (n = 125) or the intervention group (n = 125). The latter benefited from case management intervention. QOL was evaluated using the WHOQOL-BREF at baseline, two, five and a half, nine, and twelve months later. It included four dimensions: physical health, psychological health, social relationship, and environment. Linear mixed-effects models were used to analyze the change in the patients' QOL over time. RESULTS: Patients' QOL improved significantly (p < 0.001) in both groups for all dimensions after two months. However, environment QOL dimension improved significantly more in the intervention group after 12 months. CONCLUSIONS: Environment QOL dimension was the most responsive dimension for short-term interventions. This may have been due to case management's assistance in obtaining income entitlements, health insurance coverage, stable housing, or finding general health care practitioners. Case management in general should be developed to enhance frequent users' QOL. TRIAL REGISTRATION: http://www.clinicaltrials.gov , Unique identifier: NCT01934322.

Percepção da equipe de enfermagem sobre a utilização de dispensários eletrônicos / Perception of nursing staff on the use of automated dispensing cabinets

Introdução: O uso de dispensários eletrônicos em instituições de saúde tem sido associado à otimização do tempo da equipe de enfermagem e a redução de erros relacionados à medicamentos. Este estudo buscou avaliar a percepção da equipe de enfermagem sobre os dispensários eletrônicos. Métodos: Estudo exploratório utilizou a técnica de grupo focal e foi realizado com técnicos de enfermagem e enfermeiros de oito unidades de internação. Resultados: Para realização da técnica de grupo focal foi necessária a realização de nove encontros em 2015, com a participação de 27 profissionais de enfermagem. De forma geral, a equipe de enfermagem demonstrou estar satisfeita com o uso do equipamento, relatando a necessidade de adequações e melhorias no processo de trabalho associado ao dispensário. Os profissionais relataram que os sistemas de dispensários eletrônicos contribuem para a segurança do paciente. Conclusão: Os resultados possibilitam a elaboração de estratégias para melhorar o processo de trabalho que envolve o dispensário eletrônico, com foco contínuo na segurança do paciente. (AU)

Introduction: The use of automated dispensing cabinets in health care institutions has been associated with optimization of nursing staff's time and reduction in medication-related errors. This study aimed to evaluate the perception of a nursing team regarding automated dispensing cabinets. Methods: This exploratory study used a focal group technique and included nurses and practical nurses from eight admission units. Results: To conduct the focal group technique, nine meetings were held in 2015, with participation of 27 nursing professionals. In general, the nursing staff showed satisfaction with the use of the equipment, but reported a need for adjustments and improvements in the work process associated with the dispensing system. Professionals reported that automated dispensing systems contribute to patient safety. Conclusions: The results allow the formulation of strategies to improve the work process involving automated dispensing cabinets, with a continuous focus on patient safety. (AU)

Addictive behaviors and healthcare renunciation for economic reasons in a French population-based sample.

BACKGROUND: Healthcare renunciation for economic reasons is a major health concern, but it has been scarcely investigated among drug users, even if drug users constitute a vulnerable population in need of medical care. This study investigated associations of healthcare renunciation for economic reasons and addictive behaviors (alcohol, tobacco, cannabis, illicit drug use, and gambling) in a population-based sample of adults living in France, a country with universal health coverage. METHODS: Data were collected using the 2014 Health Barometer, a French cross-sectional survey conducted among a random representative sample of the general population aged 18-64 (n=12,852). Measures included healthcare renunciation, substance use (alcohol, tobacco, cannabis, and other illicit drugs) and gambling. Experimental/recreational and heavy/chronic use were assessed. Logistic regressions were used to test the relationship between healthcare renunciation and addictive behaviors, controlling for relevant covariates. RESULTS: A total of 25% of the participants had renounced care at least once in the previous twelve months. Most variables of drug use were significantly associated with increased healthcare renunciation. This was the case for heavy/hazardous use and experimental/recreational use. Regular gambling was not associated with healthcare renunciation, but disordered gambling was. CONCLUSION: This study showed that addictive behaviors, including substance use and gambling, were part of the burden of vulnerability of people who forgo care. Therefore, drug use and gambling patterns should be a focus in the development of policies to reduce health inequalities, not only for heavy and chronic drug users.

Healthcare renunciation among young adults in French higher education: A population-based study.

Healthcare renunciation has been a recent focus of the public health debate, but large-scale investigations of healthcare renunciation are scarce. The goal of this study was to examine healthcare renunciation among young adults at French universities. It investigated prevalence of and reasons for healthcare renunciation and identified subgroups of vulnerable youths. Data were collected in the 2013 triennial study conducted by the French National Observatory of Student Life. That study had a sample of 35,810 18- to 25-year-old participants. Measures included healthcare renunciation, reasons for healthcare renunciation, demographics, cultural and socioeconomic background, health and social outcomes, healthcare system-related variables, and markers of adulthood. The results showed that the prevalence of healthcare renunciation was 27.2%. The most common reasons for healthcare renunciation were refusal renunciation (self-care, 12.7%; wait for improvement, 15.5%) and barrier renunciation (financial reasons, 12.1%; lack of time, 10.2%). Therefore, healthcare renunciation is linked not only to financial constraints but also to individuals' subjective needs and ways of facing illness. Overall, disadvantaged youths and youths transitioning to adulthood were likelier to renounce care, especially for financial reasons. To conclude, there are social inequalities in the use of healthcare by emerging adults in higher education in France. Emerging adulthood appears to be a risky period in which people are likely to renounce healthcare for multiple reasons. Support should be provided for vulnerable youths to prevent them from becoming increasingly vulnerable.

Associations between perceived discrimination and health status among frequent Emergency Department users.

OBJECTIVE: Frequent Emergency Department (ED) users are vulnerable individuals and discrimination is usually associated with increased vulnerability. The aim of this study was to investigate frequent ED users' perceptions of discrimination and to test whether they were associated with increased vulnerability. METHODS: In total, 250 adult frequent ED users were interviewed in Lausanne University Hospital. From a previously published questionnaire, we assessed 15 dichotomous sources of perceived discrimination. Vulnerability was assessed using health status: objective health status (evaluation by a healthcare practitioner including somatic, mental health, behavioral, and social issues - dichotomous variables) and subjective health status [self-evaluation including health-related quality of life (WHOQOL) and quality of life (EUROQOL) - mean-scores]. We computed the prevalence rates of perceived discrimination and tested associations between perceived discrimination and health status (Fischer's exact tests, Mann-Whitney U-tests). RESULTS: A total of 35.2% of the frequent ED users surveyed reported at least one source of perceived discrimination. Objective health status was not significantly related to perceived discrimination. In contrast, experiencing perceived discrimination was associated with worse subjective health status (P<0.001). CONCLUSION: Frequent ED users are highly likely to report perceived discrimination during ED use, and this was linked to a decrease in their own rating of their health. Hence, discrimination should be taken into account when providing care to such users as it may constitute an additional risk factor for this vulnerable population. Perceived discrimination may also be of concern to professionals seeking to improve practices and provide optimal care to frequent ED users.

Case Management may Reduce Emergency Department Frequent use in a Universal Health Coverage System: a Randomized Controlled Trial.

BACKGROUND: Frequent emergency department (ED) users account for a disproportionately high number of ED visits. Studies on case management (CM) interventions to reduce frequent ED use have shown mixed results, and few studies have been conducted within a universal health coverage system. OBJECTIVE: To determine whether a CM intervention-compared to standard emergency care-reduces ED attendance. DESIGN: Randomized controlled trial. PARTICIPANTS: Two hundred fifty frequent ED users (5 or more visits in the prior 12 months) who visited a public urban ED at the Lausanne University Hospital between May 2012 and July 2013 were allocated to either an intervention (n = 125) or control (n = 125) group, and monitored for 12 months. INTERVENTIONS: An individualized CM intervention consisting of concrete assistance in obtaining income entitlements, referral to primary or specialty medical care, access to mental health care or substance abuse treatment, and counseling on at-risk behaviors and health care utilization (in addition to standard care) at baseline and 1, 3, and 5 months. MAIN MEASURES: We used a generalized linear model for count data (negative binomial distribution) to compare the number of ED visits during the 12-month follow-up between CM and usual care, from an intention-to-treat perspective. KEY RESULTS: At 12 months, there were 2.71 (±0.23) ED visits in the intervention group versus 3.35 (±0.32) visits among controls (ratio = 0.81, 95 % CI = 0.63; 1.02). In the multivariate model, the effect of the CM intervention on the number of ED visits approached statistical significance (b = -0.219, p = 0.075). The presence of poor social determinants of health was a significant predictor of ED use in the multivariate model (b = 0.280, p = 0.048). CONCLUSIONS: CM may reduce ED use by frequent users through an improved orientation to the health care system. Poor social determinants of health significantly increase use of the ED by frequent users.

Emerging Adulthood: A Time of Changes in Psychosocial Well-Being.

The principal aim of this study was to investigate the psychosocial well-being of emerging adults using psychological states associated with this transitional phase and classic measures of emerging adulthood. We expected psychological states to be more closely associated with psychological well-being than classic markers of achieved adulthood. Data were collected in the Cohort Study on Substance Use Risk Factors from 4,991 Swiss men aged 18-25 years. The assessment included the Short Form of the Inventory of Dimensions of Emerging Adulthood (IDEA-8), classic markers of achieved adulthood (e.g., financial independence, stable relationship), and psychosocial well-being. Structural equation models (SEMs) were conducted to test the association between measures of emerging adulthood and psychosocial well-being. Overall, the results highlighted contrasting associations of measures of emerging adulthood and psychosocial well-being. Youths facing negative psychological states (dimension "negativity") and exploring life without knowing how to define themselves (dimension "identity exploration") had a decreased psychosocial well-being. On the contrary, youths exploring many opportunities with an optimistic perspective (dimension "experimentation") had an increased psychosocial well-being. By contrast, classic markers of adulthood were less related to psychosocial well-being. The IDEA-8 Scale appeared to be a useful screening tool for identifying vulnerable youths, and emerging adulthood should be measured with a focus on the psychological states associated with this period. This information may be valuable for mental health systems that have not yet adapted to emerging adults' needs.

Risky substance use and peer pressure in Swiss young men: Test of moderation effects.

BACKGROUND: Peer pressure (PP) toward misconduct is a well-known risk factor for substance use. However, the way it interacts with social factors and the associations of the aspects of PP other than PP toward misconduct have been understudied. This study examined the associations of three aspects of PP with risky substance use and tested whether the associations of PP toward misconduct were moderated by social factors. METHOD: A representative sample of 5,680 young Swiss males completed a questionnaire assessing risky alcohol, cigarette, and cannabis use, PP toward misconduct, toward peer involvement, and toward peer conformity, as well as social support (SS) and neighbourhood cohesion. Multinomial logistic regression models were used. RESULTS: PP toward misconduct was positively associated with all substance use outcomes. The PP toward misconduct-risky alcohol use association was stronger in individuals reporting high than in those reporting low levels of PP toward peer involvement, SS, and neighbourhood cohesion. The PP toward misconduct-risky cannabis use association was stronger in individuals reporting high than in those reporting low levels of SS and neighbourhood cohesion. The PP toward misconduct-smoking association was stronger in individuals reporting high than in those reporting low levels of PP toward peer involvement. CONCLUSIONS: The risk for substance use associated with PP toward misconduct varies as a function of social factors. Being well connected with others (high level of PP toward peer involvement and SS), and living in a cohesive neighbourhood may amplify the risk for risky substance use associated with PP toward misconduct.

Characterizing the vulnerability of frequent emergency department users by applying a conceptual framework: a controlled, cross-sectional study.

BACKGROUND: Frequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability's different dimensions. This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability. METHODS: A controlled, cross-sectional study comparing frequent ED users to a control group of non-frequent users was conducted at the Lausanne University Hospital, Switzerland. Frequent users were defined as patients with five or more visits to the ED in the previous 12 months. The two groups were compared using validated scales for each one of the five dimensions of an innovative conceptual framework: socio-demographic characteristics; somatic, mental, and risk-behavior indicators; and use of health care services. Independent t-tests, Wilcoxon rank-sum tests, Pearson's Chi-squared test and Fisher's exact test were used for the comparison. To examine the -related to vulnerability- risk factors for being a frequent ED user, univariate and multivariate logistic regression models were used. RESULTS: We compared 226 frequent users and 173 controls. Frequent users had more vulnerabilities in all five dimensions of the conceptual framework. They were younger, and more often immigrants from low/middle-income countries or unemployed, had more somatic and psychiatric comorbidities, were more often tobacco users, and had more primary care physician (PCP) visits. The most significant frequent ED use risk factors were a history of more than three hospital admissions in the previous 12 months (adj OR:23.2, 95%CI = 9.1-59.2), the absence of a PCP (adj OR:8.4, 95%CI = 2.1-32.7), living less than 5 km from an ED (adj OR:4.4, 95%CI = 2.1-9.0), and household income lower than USD 2,800/month (adj OR:4.3, 95%CI = 2.0-9.2). CONCLUSIONS: Frequent ED users within a universal health coverage system form a highly vulnerable population, when taking into account all five dimensions of a conceptual framework of vulnerability. The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers. Application of the conceptual framework in future research is warranted.