Emergency department utilization and disposition outcomes by pediatric patients with cancer in Maryland and New York from 2013 to 2017.

BACKGROUND: Pediatric patients with cancer commonly seek emergency department (ED) care, yet there is limited evidence on ED utilization patterns and disposition outcomes among these patients. METHODS: Retrospective analysis of the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases for Maryland and New York from 2013 to 2017. We compared ED visits and disposition outcomes for 5.8 million pediatric patients (<18 years old) with and without cancer, and used multivariable regressions to estimate associations between the number of ED visits, hospital (inpatient) admissions through the ED, and ED or inpatient mortality and sociodemographic and clinical factors within the cancer cohort. RESULTS: Pediatric patients with cancer had more ED visits per year on average (2.4 vs. 1.5, p < .001), higher shares of admissions (56.8% vs. 6.6%, p < .001) and mortality (1.2% vs. 0.1%, p < .001) compared to those without cancer. Among patients with cancer, uninsured pediatric patients had fewer ED visits and lower risk of admission to a hospital through the ED compared to those with Medicaid coverage (total visits: incidence rate ratio [IRR]: 0.82, 95% confidence intervals [CI]: 0.75-0.90; admission: IRR: 0.75, 95% CI: 0.65-0.86). Mortality risks were higher for pediatric patients with cancer residing in areas with the lowest median household income, and with no health insurance coverage (IRR: 2.81, 95% CI: 1.21-6.51) compared to Medicaid. CONCLUSIONS: Our findings emphasize the importance of enhancing health insurance coverage policies and social services for pediatric patients with cancer and their families to address clinical and nonclinical needs.

Association of the affordable care act with racial and ethnic disparities in uninsured emergency department utilization.

BACKGROUND: Disparities in uninsured emergency department (ED) use are well documented. However, a comprehensive analysis evaluating how the Affordable Care Act (ACA) may have reduced racial and ethnic disparities is lacking. The goal was to assess the association of the ACA with racial and ethnic disparities in uninsured ED use. METHODS: This study used data from the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) for Georgia, Florida, Massachusetts, and New York from 2011 to 2017. Participants include non-elderly adults between 18 and 64 years old. Outcomes include uninsured rates of ED visits by racial and ethnic groups and stratified by medical urgency using the New York University ED algorithm. Visits were aggregated to year-quarter ED visits per 100,000 population and stratified for non-Hispanic White, non-Hispanic Black, and Hispanic non-elderly adults. Quasi-experimental difference-in-differences and triple differences regression analyses to identify the effect of the ACA and the separate effect of the Medicaid expansion were used comparing uninsured ED visits by race and ethnicity groups pre-post ACA. RESULTS: The ACA was associated with a 14% reduction in the rate of uninsured ED visits per 100,000 population (from 10,258 pre-ACA to 8,877 ED visits per 100,000 population post-ACA) overall. The non-Hispanic Black compared to non-Hispanic White disparity decreased by 12.4% (-275.1 ED visits per 100,000) post-ACA. About 60% of the decline in the Black-White disparity was attributed to disproportionate declines in ED visit rates for conditions classified as not-emergent (-93.2 ED visits per 100,000), and primary care treatable/preventable (-64.1 ED visits per 100,000), while the disparity in ED visit rates for injuries and not preventable conditions also declined (-106.57 ED visits per 100,000). All reductions in disparities were driven by the Medicaid expansion. No significant decrease in Hispanic-White disparity was observed. CONCLUSIONS: The ACA was associated with fewer uninsured ED visits and reduced the Black-White ED disparity, driven mostly by a reduction in less emergent ED visits after the ACA in Medicaid expansion states. Disparities between Hispanic and non-Hispanic White adults did not decline after the ACA. Despite the positive momentum of declining disparities in uninsured ED visits, disparities, especially among Black people, remain.

Association of Medicaid expansion with dental emergency department visits overall and by states' Medicaid dental benefits provision.

BACKGROUND: Evidence on the association of Medicaid expansion with dental emergency department (ED) utilization is limited, while even less is known on policy-related changes in dental ED visits by Medicaid programs' dental benefits generosity. The objective of this study was to estimate the association of Medicaid expansion with changes in dental ED visits overall and by states' benefits generosity. METHODS: We used the Healthcare Cost and Utilization Project's Fast Stats Database from 2010 to 2015 for non-elderly adults (19 to 64 years of age) across 23 States, 11 of which expanded Medicaid in January 2014 while 12 did not. Difference-in-differences regression models were used to estimate changes in dental-related ED visits overall and further stratified by states' dental benefit coverage in Medicaid between expansion and non-expansion States. RESULTS: After 2014, dental ED visits declined by 10.9 [95% confidence intervals (CI): -18.5 to -3.4] visits per 100,000 population quarterly in states that expanded Medicaid compared to non-expansion states. However, the overall decline was concentrated in Medicaid expansion states with dental benefits. In particular, among expansion states, dental ED visits per 100,000 population declined by 11.4 visits (95% CI: -17.9 to -4.9) quarterly in states with dental benefits in Medicaid compared to states with emergency-only or no dental benefits. Significant differences between non-expansion states by Medicaid's dental benefits generosity were not observed [6.3 visits (95% CI: -22.3 to 34.9)]. CONCLUSIONS: Our findings suggest the need to strengthen public health insurance programs with more generous dental benefits to curtail costly dental ED visits.

Rural-Urban Disparities in Hospital Admissions and Mortality Among Patients with COVID-19: Evidence from South Carolina from 2021 to 2022.

Although rural communities have been hard-hit by the COVID-19 pandemic, there is limited evidence on COVID-19 outcomes in rural America using up-to-date data. This study aimed to estimate the associations between hospital admissions and mortality and rurality among COVID-19 positive patients who sought hospital care in South Carolina. We used all-payer hospital claims, COVID-19 testing, and vaccination history data from January 2021 to January 2022 in South Carolina. We included 75,545 hospital encounters within 14 days after positive and confirmatory COVID-19 testing. Associations between hospital admissions and mortality and rurality were estimated using multivariable logistic regressions. About 42% of all encounters resulted in an inpatient hospital admission, while hospital-level mortality was 6.3%. Rural residents accounted for 31.0% of all encounters for COVID-19. After controlling for patient-level, hospital, and regional characteristics, rural residents had higher odds of overall hospital mortality (Adjusted Odds Ratio - AOR = 1.19, 95% Confidence Intervals - CI = 1.04-1.37), both as inpatients (AOR = 1.18, 95% CI = 1.05-1.34) and as outpatients (AOR = 1.63, 95% CI = 1.03-2.59). Sensitivity analyses using encounters with COVID-like illness as the primary diagnosis only and encounters from September 2021 and beyond - a period when the Delta variant was dominant and booster vaccination was available - yielded similar estimates. No significant differences were observed in inpatient hospitalizations (AOR = 1.00, 95% CI = 0.75-1.33) between rural and urban residents. Policymakers should consider community-based public health approaches to mitigate geographic disparities in health outcomes among disadvantaged population subgroups.

Racial, Ethnic, and Rural/Urban Disparities in HIV and Sexually Transmitted Infections in South Carolina.

Examining the current incidence rates of HIV and STIs among racial and ethnic minority and rural residents is crucial to inform and expand initiatives and outreach efforts to address disparities and minimize the health impact of these diseases. A retrospective, cross-sectional study was conducted using Medicaid administrative claims data over a 2-year period (July 2019-June 2021) in South Carolina. Our main outcomes of interest were claims for chlamydia, gonorrhea, syphilis, and HIV. Any beneficiary with at least one claim for a relevant diagnosis throughout the study period was considered to have one of these diseases. Descriptive analyses and multivariable regression models were used to estimate the association between STIs, HIV, race and ethnicity, and rurality. Overall, 158,731 Medicaid beneficiaries had at least one medical claim during the study period. Most were female (86.6%), resided in urban areas (66.6%), and were of non-Hispanic Black race/ethnicity (42.6%). In total, 6.3% of beneficiaries had at least one encounter for chlamydia, 3.2% for gonorrhea, 0.5% for syphilis, and 0.8% for HIV. In multivariable models, chlamydia, gonorrhea, and HIV claims were significantly associated with non-Hispanic Black or other minority race/ethnicity compared to non-Hispanic white race/ethnicity. Rural residents were more likely to have a claim associated with chlamydia and gonorrhea compared to urban residents. The opposite was observed for syphilis and HIV. Providing updated evidence on disparities in STIs and HIV among racial/ethnic minority and rural populations in a southern state is essential for shaping state Medicaid policies to address health disparities.

Child and Adolescent Anxiety and Depression Prior to and During the COVID-19 Pandemic in the United States.

Childhood anxiety and depression have been increasing for years, and evidence suggests the COVID-19 pandemic has exacerbated this trend. However, research has examined anxiety and depression primarily as exclusive conditions, overlooking comorbidity. This study examined relationships between the COVID-19 pandemic and anxiety and depression to clarify risk factors for singular and comorbid anxiety and depression in children. Using 2018-2019 and 2020-2021 samples from the National Survey of Children's Health, a nationally representative survey of children aged 0-17 in the United States, associations between the COVID-19 pandemic and child anxiety and depression were examined via survey-weights' adjusted bivariate and multiple regression analyses, controlling for demographic characteristics. The COVID-19 pandemic was associated with higher odds of having comorbid anxiety and depression but not singular anxiety or depression. Female sex, older age, having special healthcare needs, more frequent inability to cover basic needs on family income, and poorer caregiver mental health were associated with having been diagnosed with singular and comorbid anxiety and depression. Children that witnessed or were victims of violence in the neighborhood were also more likely to have comorbid anxiety and depression. Implications for prevention, intervention, and policy are discussed.

Assessing forgetfulness and polypharmacy and their impact on health-related quality of life among patients with hypertension and dyslipidemia in Greece during the COVID-19 pandemic.

PURPOSE: We estimate the association between forgetfulness to take medications as prescribed and polypharmacy and health-related quality of life (HRQoL) among a cohort of patients with hypertension, dyslipidemia or both in Greece during the COVID-19 pandemic. METHODS: A telephone survey of 1018 randomly selected adults was conducted in Greece in June 2020. Participants were included in the survey, if they (a) had a diagnosis of hypertension, dyslipidemia or both and (b) were on prescription treatment for these conditions. HRQoL was calculated using the short form (SF) -12 Patient Questionnaire. A multivariable generalized linear regression model (GLM) was used to estimate the association between forgetfulness and polypharmacy and HRQoL, controlling for sociodemographic and health-related covariates. RESULTS: Overall, 351 respondents met the inclusion criteria, of whom 28 did not fully complete the questionnaire (response rate: 92%, n = 323). Of those, 37% were diagnosed with hypertension only, 28% with dyslipidemia only, and 35% with both. Most reported good to average physical (64.1%) and mental health (48.6%). Overall, 25% indicated that they sometimes forget to take their prescribed medications, and 12% took two or more pills multiple times daily. Total HRQoL score was 68.9% (s.d. = 18.0%). About 10% of participants reported paying less attention to their healthcare condition during the pandemic. Estimates of multivariable analyses indicated a negative association between forgetfulness (- 9%, adjusted ß: - 0.047, 95% confidence interval - 0.089 to - 0.005, p = 0.029), taking two or more pills multiple times daily compared to one pill once a day (- 16%, adjusted ß: - 0.068, 95% confidence interval - 0.129 to - 0.008, p = 0.028) and total HRQoL. CONCLUSION: Our results suggest that among adult patients with hypertension, dyslipidemia or both in Greece, those who forget to take their medications and those with more complex treatment regimens had lower HRQoL. Such patients merit special attention and require targeted approaches by healthcare providers to improve treatment compliance and health outcomes.

Risk of tizanidine-induced adverse events after concomitant exposure to ciprofloxacin: A cohort study in the U.S.

BACKGROUND: Tizanidine's potent muscle relaxant properties and short onset of action makes it desirable for pain management. However, concomitant use of tizanidine with ciprofloxacin, a strong inhibitor of the P450-CYP1A2 cytochrome metabolic pathway of tizanidine, can result in increased tizanidine plasma levels and associated adverse outcomes, particularly hypotension. The aim of this study was to assess the risk of hypotension with coadministration of tizanidine and ciprofloxacin. METHODS: An observational nested cohort study of patients 18 years or older on tizanidine was conducted using data from electronic health records from 2000 to 2018 in the US. We estimated the prevalence and risk of hypotension associated with the DDI between tizanidine and ciprofloxacin using multivariable logistic regression models. RESULTS: Our analysis included 70,110 encounters of patients on tizanidine across 221 hospitals. Most encounters included females (65.7%), whites (82.4%), with an average age of 56 years (SD 14.9) and an Elixhauser comorbidity index mean of 1.6 (SD 2.3). Ciprofloxacin was co-administered with tizanidine in 2487 encounters (3.6%). Compared to patients who did not receive ciprofloxacin, co-administration of tizanidine and ciprofloxacin was associated with an increased likelihood of hypotension (adjusted odds ratio: 1.43, 95% Confidence Intervals:1.25-1.63, p-value<0.001). CONCLUSIONS: Our findings suggest that the concomitant use of tizanidine and ciprofloxacin is associated with an elevated risk of hypotension. The prevalence of co-administration of drugs with a documented interaction highlights the need for continuous education across providers to avoid the incidence of DDI related adverse events and further complications and to improve patient outcomes.

Emergency Department Utilization by Adolescents Experiencing Homelessness in Massachusetts.

BACKGROUND: Adolescents who experience homelessness rely heavily on emergency departments (EDs) for their health care. OBJECTIVES: This study estimates the relationship between homelessness and ED use and identifies the sociodemographic, clinical, visit-level, and contextual factors associated with multiple ED visits among adolescents experiencing homelessness in Massachusetts. RESEARCH DESIGN: We used the Healthcare Cost and Utilization Project State Emergency Department Databases on all outpatient ED visits in Massachusetts from 2011 to 2016. We included all adolescents who were 11-21 years old. We estimated the association between homelessness and ED utilization and investigated predictors of multiple ED visits among adolescents who experience homelessness using multivariate logistic and negative binomial regressions. RESULTS: Our study included 1,196,036 adolescents, of whom about 0.8% experienced homelessness and this subset of adolescents accounted for 2.2% of all ED visits. Compared with those with stable housing, adolescents who were homeless were mostly covered through Medicaid (P<0.001), diagnosed with 1 or more comorbidities (P<0.001), and visited the ED at least once for reasons related to mental health; substance and alcohol use; pregnancy; respiratory distress; urinary and sexually transmitted infections; and skin and subcutaneous tissue diseases (P<0.001). Homeless experience was associated with multiple ED visits (incidence rate ratio=1.18; 95% confidence intervals, 1.16-1.19) and frequent ED use (4 or more ED visits) (adjusted odds ratio=2.21; 95% confidence interval, 2.06-2.37). Factors related to clinical complexity and Medicaid compared with lack of coverage were also significant predictors of elevated ED utilization within the cohort experiencing homelessness. CONCLUSIONS: Adolescents who experience homelessness exhibit higher ED use compared with those with stable housing, particularly those with aggravated comorbidities and chronic conditions. Health policy interventions to integrate health care, housing, and social services are essential to transition adolescents experiencing homelessness to more appropriate community-based care.

Trends in outpatient emergency department visits during the COVID-19 pandemic at a large, urban, academic hospital system.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has critically affected healthcare delivery in the United States. Little is known on its impact on the utilization of emergency department (ED) services, particularly for conditions that might be medically urgent. The objective of this study was to explore trends in the number of outpatient (treat and release) ED visits during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, retrospective study of outpatient emergency department visits from January 1, 2019 to August 31, 2020 using data from a large, urban, academic hospital system in Utah. Using weekly counts and trend analyses, we explored changes in overall ED visits, by patients' area of residence, by medical urgency, and by specific medical conditions. RESULTS: While outpatient ED visits were higher (+6.0%) in the first trimester of 2020 relative to the same period in 2019, the overall volume between January and August of 2020 was lower (-8.1%) than in 2019. The largest decrease occurred in April 2020 (-30.4%), followed by the May to August period (-12.8%). The largest declines were observed for visits by out-of-state residents, visits classified as non-emergent, primary care treatable or preventable, and for patients diagnosed with hypertension, diabetes, headaches and migraines, mood and personality disorders, fluid and electrolyte disorders, and abdominal pain. Outpatient ED visits for emergent conditions, such as palpitations and tachycardia, open wounds, syncope and collapse remained relatively unchanged, while lower respiratory disease-related visits were 67.5% higher in 2020 relative to 2019, particularly from March to April 2020. However, almost all types of outpatient ED visits bounced back after May 2020. CONCLUSIONS: Overall outpatient ED visits declined from mid-March to August 2020, particularly for non-medically urgent conditions which can be treated in other more appropriate care settings. Our findings also have implications for insurers, policymakers, and other stakeholders seeking to assist patients in choosing more appropriate setting for their care during and after the pandemic.

The effect of expanded insurance coverage under the Affordable Care Act on emergency department utilization in New York.

BACKGROUND: One of the proposed benefits of expanding insurance coverage under the Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for non-urgent visits related to lack of health insurance coverage and access to primary care providers. The objective of this study was to estimate the effect of the 2014 ACA implementation on ED use in New York. METHODS: We used the Healthcare Cost and Utilization Project State Emergency Department and State Inpatient Databases for all outpatient and all inpatient visits for patients admitted through an ED from 2011 to 2016. We focused on in-state residents aged 18 to 64, who were covered under Medicaid, private insurance, or were uninsured prior to the 2014 expansion. We estimated the effect of the expanded insurance coverage on average monthly ED visits volumes and visits per 1000 residents (rates) using interrupted time-series regression analyses. RESULTS: After ACA implementation, overall average monthly ED visits increased by around 3.0%, both in volume (9362; 95% Confidence Intervals [CI]: 1681-17,522) and in rates (0.80, 95% CI:0.12-1.49). Medicaid covered ED visits volume increased by 23,972 visits (95% CI: 16,240 -31,704) while ED visits by the uninsured declined by 13,297 (95% CI:-15,856 - -10,737), and by 1453 (95% CI:-4027-1121) for the privately insured. Medicaid ED visits rates per 1000 residents increased by 0.77 (95% CI:-1.96-3.51) and by 2.18 (95% CI:-0.55-4.92) for those remaining uninsured, while private insurance visits rates decreased by 0.48 (95% CI:-0.79 - -0.18). We observed increases in primary-care treatable ED visits and in visits related to mental health and alcohol disorders, substance use, diabetes, and hypertension. All estimated changes in monthly ED visits after the expansion were statistically significant, except for ED visit rates among Medicaid beneficiaries. CONCLUSION: Net ED visits by adults 18 to 64 years of age increased in New York after the implementation of the ACA. Large increases in ED use by Medicaid beneficiaries were partially offset by reductions among the uninsured and those with private coverage. Our results suggest that efforts to expand health insurance coverage only will be unlikely to reverse the increase in ED use.

The Effect of the Medicaid Expansion on Frequent Emergency Department Use in New York.

BACKGROUND: There is limited evidence on the effect of the Affordable Care Act (ACA) on frequent emergency department (ED) use. OBJECTIVES: To estimate the effect of the ACA Medicaid expansion on frequent ED use in New York. METHODS: We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases from 2011 to 2016. A consistent and unique patient identifier enabled us to identify ED visits by the same patient across different facilities within the state for each calendar year. Multivariate logistic regressions were used to quantify the policy's effect on frequent ED use (≥ 4 ED visits/year). We included in-state residents 18 to 64 years of age who were covered by Medicaid, private insurance, or were uninsured. Sensitivity analyses were conducted using alternative definitions of frequent use. To validate the findings, a falsification analysis was also conducted using only the 3 pre-expansion years. RESULTS: Our study included 14.3 million ED patients with 23.8 million ED visits from 2011 to 2016. Frequent users (7.2%) accounted for 26.6% of all ED visits. The likelihood of frequent ED use declined by 4% among Medicaid beneficiaries (adjusted odds ratio [AOR] 0.96, 95% confidence intervals (CI) 0.95-0.97) and by 12% for the uninsured (AOR 0.88, 95% CI 0.86-0.89) in the post-expansion period, compared with the pre-expansion period. Private insurance enrollees were 9% more likely to exhibit frequent use in the post-expansion period (AOR 1.09, 95% CI 1.08-1.11). The sensitivity analyses yielded results similar to those of the main model. The falsification analyses revealed small and insignificant year-to-year changes in the 3 pre-expansion years. CONCLUSION: The likelihood of frequent ED use decreased 3 years after New York implemented the ACA Medicaid expansion, particularly for Medicaid beneficiaries and the uninsured, highlighting the importance of expanding health insurance and provisions tailored at high-need populations.

Predictors of Multiple Emergency Department Utilization Among Frequent Emergency Department Users in 3 States.

BACKGROUND: Research on frequent emergency department (ED) use shows that a subgroup of patients visits multiple EDs. This study characterizes these individuals. OBJECTIVE: The objective of this study was to determine how many frequent ED users seek care at multiple EDs and to identify sociodemographic, clinical, and contextual factors associated with such behavior. RESEARCH DESIGN: We used the 2011-2014 Healthcare Cost and Utilization Project State Emergency Department Databases data on all outpatient ED visits in New York, Massachusetts, and Florida. We studied all adult ED users with ≥5 visits in a year and defined multisite use as visits to ≥3 different sites. We estimated predictors of multisite use with multivariate logistic regressions. RESULTS: Across all 3 states, 1,033,626 frequent users accounted for 7,613,077 ED visits. Of frequent users, 25% were multisite users, accounting for 30% of the visits studied. Frequent users with at least 1 visit for mental health or substance use-related diagnosis were more likely to use multiple sites. Uninsured frequent users and those with public insurance were associated with less use of multiple EDs than those with private coverage while lacking consistent coverage by the same insurance within each year were associated with using multiple sites. CONCLUSIONS: Health policy interventions to reduce duplicative or unnecessary ED use should apply a population health perspective and engage multiple hospitals. Community-level preventive approaches and a stronger infrastructure for mental health and substance use are essential to mitigate multisite ED use.

Concordance in Medical Urgency Classification of Discharge Diagnoses and Reasons for Visit.

Importance: Current policies to divert emergency department (ED) visits for less medically urgent conditions to more cost-effective settings rely on retrospective adjudication of discharge diagnoses. However, patients present to the ED with concerns, making it challenging for clinicians. Objective: To characterize ED visits based on the medical urgency of the presenting reasons for visit and to explore the concordance between discharge diagnoses and reasons for visit. Design, Setting, and Participants: In this retrospective, cross-sectional study, a nationwide sample of ED visits by adults (aged ≥18 years) in the US from the 2018 and 2019 calendar years' ED data of the National Hospital Ambulatory Medical Care Survey was used. An algorithm to probabilistically assign ED visits into medical urgency categories based on the presenting reason for visit was developed. A 3-step, look-back method was applied using an updated version of the New York University ED algorithm, and a map of all possible discharge diagnoses to the same reasons for visit was developed. Analyses were conducted in July and August 2023. Main Outcomes and Measures: The main outcome was probabilistic medical urgency classification of reasons for visits and discharge diagnoses and their concordance. Results: We analyzed 27 068 ED visits (mean age, 48.2% years [95% CI, 47.5%-48.9% years]) representing 190.7 million visits nationwide. Women (mean, 57.0% [95% CI, 55.9%-58.1%]) and patients with public health insurance coverage, including Medicare (mean, 24.9% [95% CI, 21.9%-28.0%]) and Medicaid (mean, 25.1% [95% CI, 21.0%-29.2%]), accounted for the largest share of ED visits, and a mean of 13.2% (95% CI, 11.4%-15.0%) of all visits resulted in a hospital admission. Overall, about 38.5% and 53.9% of all ED visits were classified with 100% and 75% probabilities, respectively, as injury related, emergency care needed, emergent but primary care treatable, nonemergent, or mental health or substance use disorders related based on discharge diagnosis compared with 0.4% and 12.4%, respectively, of all encounters based on patients' reason for visit. Among discharge diagnoses assigned with high certainty to only 1 urgency category using the New York University ED algorithm, between 38.0% (95% CI, 36.3%-39.6%) and 57.4% (95% CI, 56.0%-58.8%) aligned with the probabilistic categorical assignments of their corresponding reasons for visit. Conclusions and Relevance: In this cross-sectional study of 190.7 million ED visits among adults aged 18 years or older, a smaller percentage of reasons for visit could be prospectively categorized with high accuracy to a specific medical urgency category compared with all visits based on discharge diagnoses, and a limited concordance between reasons for visit and discharge diagnoses was found. Alternative methods are needed to identify the medical necessity of ED encounters more accurately.

Waning effectiveness of mRNA COVID-19 vaccines against inpatient and emergency department encounters.

In the United States, most real-world estimates of COVID-19 vaccine effectiveness are based on data drawn from large health systems or sentinel populations. More data is needed to understand how the benefits of vaccination may vary across US populations with disparate risk profiles and policy contexts. We aimed to provide estimates of mRNA COVID-19 vaccine effectiveness against moderate and severe outcomes of COVID-19 based on state population-level data sources. Using statewide integrated administrative and clinical data and a test-negative case-control study design, we assessed mRNA COVID-19 vaccine effectiveness against SARS-CoV-2-related hospitalizations and emergency department visits among adults in South Carolina. We presented estimates of vaccine effectiveness at discrete time intervals for adults who received one, two or three doses of mRNA COVID-19 vaccine compared to adults who were unvaccinated. We also evaluated changes in vaccine effectiveness over time (waning) for the overall sample and in subgroups defined by age. We showed that while two doses of mRNA COVID-19 vaccine were initially highly effective, vaccine effectiveness waned as time elapsed since the second dose. Compared to protection against hospitalizations, protection against emergency department visits was found to wane more sharply. In all cases, a third dose of mRNA COVID-19 vaccine conferred significant gains in protection relative to waning protection after two doses. Further, over more than 120 days of follow-up, the data revealed relatively limited waning of vaccine effectiveness after a third dose of mRNA COVID-19 vaccine.

Determinants of Persistent, Multi-Year, Frequent Emergency Department Use Among Children and Young Adults in Three US States.

OBJECTIVE: This study examines the factors associated with persistent, multi-year, and frequent emergency department (ED) use among children and young adults. METHODS: We conducted a retrospective secondary analysis using the 2012-2017 Healthcare Cost and Utilization Project State Emergency Department Databases for children and young adults aged 0-19 who visited any ED in Florida, Massachusetts, and New York. We estimated the association between persistent frequent ED use and individuals' characteristics using multivariable logistic regression models. RESULTS: Among 1.3 million patients with 1.8 million ED visits in 2012, 2.9% (37,558) exhibited frequent ED use (≥4 visits in 2012) and accounted for 10.2% (181,138) of all ED visits. Longitudinal follow-up of frequent ED users indicated that 15.4% (5770) remained frequent users periodically over the next 1 or 2 years, while 2.2% (831) exhibited persistent frequent use over the next 3-5 years. Over the 6-year study period, persistent frequent users had 31,551 ED visits at an average of 38.0 (standard deviation = 16.2) visits. Persistent frequent ED use was associated with higher intensity of ED use in 2012, public health insurance coverage, inconsistent health insurance coverage over time, residence in non-metropolitan and lower-income areas, multimorbidity, and more ED visits for less medically urgent conditions. CONCLUSIONS: Clinicians and policymakers should consider the diverse characteristics and needs of pediatric persistent frequent ED users compared to broader definitions of frequent users when designing and implementing interventions to improve health outcomes and contain ED visit costs.

Effectiveness of COVID-19 vaccination against school absenteeism in children and adolescents hospitalized with COVID-19.

BACKGROUND: COVID-19 vaccination has been recommended for children to protect them and to enable in-person educational and social activities. METHODS: We estimated COVID-19 vaccination effectiveness (VE) against school absenteeism in children 5-17 years old hospitalized from September 1, 2021 through May 31, 2023. Full vaccination was defined as two vaccine doses. RESULTS: We studied 231 children admitted to hospital with COVID-19, including 206 (89.2 %) unvaccinated/partially vaccinated and 25 (10.8 %) fully vaccinated. Unvaccinated/partially vaccinated children were absent from school for longer periods compared to fully vaccinated children (median absence: 14 versus 10 days; p-value = 0.05). Multivariable regression showed that full COVID-19 vaccination was associated with fewer days of absence compared to no/partial vaccination on average (adjusted relative risk: 0.77; 95 % CI: 0.61 to 0.98). COVID-19 VE was 50.7 % (95 % CI: -11.3 % to 78.2 %) for school absenteeism above the median duration of absenteeism. CONCLUSIONS: Full COVID-19 vaccination conferred protection against school absenteeism in hospitalized school-aged children with COVID-19.

Comparison of morbidity and absenteeism due to COVID-19 and seasonal influenza in a large cohort of health care personnel in the 2022 to 2023 season.

BACKGROUND: To compare the morbidity and work absenteeism associated with coronavirus disease 2019 (COVID-19) and influenza among health care personnel (HCP) in 2022 to 2023. METHODS: We followed 5,752 hospital-based HCP in Greece from November 14, 2022 through May 28, 2023. Symptomatic HCP was tested for SARS-CoV-2 and influenza by real-time polymerase chain reaction and/or rapid antigen detection test. The association between the duration of absenteeism and the type of disease was estimated by multivariable regression models. RESULTS: A total of 734 COVID-19 cases and 93 influenza cases were studied. The mean duration of absence per COVID-19 case was 5.8days compared with a mean of absence of 3.6days per influenza case (P value <.001). Overall, COVID-19 accounted for 4,245days missed during the study period compared with 333days missed due to influenza. Multivariable regression estimates indicated that HCP with COVID-19 had 1.91 more days of absenteeism (95% confidence interval 1.67-2.15) compared with those with influenza, on average. CONCLUSIONS: As SARS-CoV-2 becomes endemic, COVID-19 remains the prevalent cause of morbidity and absenteeism among HCP, accounting for considerably more workdays missed compared with influenza. HCP should be up-to-date with COVID-19 booster vaccinations and annual influenza vaccination in order to protect them as well as health care systems from HCP absenteeism.