Scoping review: Social support impacts hospital readmission rates.

AIMS AND OBJECTIVES: To review and synthesise the current literature on social support and hospital readmission rates. BACKGROUND: Hospital readmission rates have not declined significantly since 2010 despite efforts to identify and implement strategies to reduce readmissions. After discharge, patients often report the need for help at home with personal care, medical care and/or transportation. Social factors can positively or negatively affect the transition from hospital to home and the extended recovery period experienced by patients. METHODS: Published primary studies in peer-reviewed journals, written in English, assessing the adult medical/surgical population and discussing social support and hospital readmission rates were included. A Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was completed for this scoping review. RESULTS: The search resulted in 2919 articles. After removing duplicates and reviewing content for the inclusion and exclusion criteria, 23 articles were selected for review. Social support is provided by those within one's social circle. There are several types of social support and depending on the needs to the patient, the type of social required and provided is different. CONCLUSIONS: The most common form of social support needed at home for people recovering after a hospitalisation was instrumental support, tangible care in the form of assistance with daily personal and medical care, and transportation. Patients who lacked adequate social support after discharge were at an increased risk of hospital readmission. RELEVANCE TO CLINICAL PRACTICE: Identifying factors, such as social support, that may impact hospital readmission rates is important for quality hospital to home care transitions. Assessing patients' needs and available social support to meet those needs may be an essential part of the discharge planning process to decrease the risk of hospital readmission.

Association of Patient-Centered Medical Home designation and quality indicators within HRSA-funded community health center delivery sites.

BACKGROUND: Patient-Centered Medical Home (PCMH) adoption is an important strategy to help improve primary care quality within Health Resources and Service Administration (HRSA) community health centers (CHC), but evidence of its effect thus far remains mixed. A limitation of previous evaluations has been the inability to account for the proportion of CHC delivery sites that are designated medical homes. METHODS: Retrospective cross-sectional study using HRSA Uniform Data System (UDS) and certification files from the National Committee for Quality Assurance (NCQA) and the Joint Commission (JC). Datasets were linked through geocoding and an approximate string-matching algorithm. Predicted probability scores were regressed onto 11 clinical performance measures using 10% increments in site-level designation using beta logistic regression. RESULTS: The geocoding and approximate string-matching algorithm identified 2615 of the 6851 (41.8%) delivery sites included in the analyses as having been designated through the NCQA and/or JC. In total, 74.7% (n = 777) of the 1039 CHCs that met the inclusion criteria for the analysis managed at least one NCQA- and/or JC-designated site. A proportional increase in site-level designation showed a positive association with adherence scores for the majority of all indicators, but primarily among CHCs that designated at least 50% of its delivery sites. Once this threshold was achieved, there was a stepwise percentage point increase in adherence scores, ranging from 1.9 to 11.8% improvement, depending on the measure. CONCLUSION: Geocoding and approximate string-matching techniques offer a more reliable and nuanced approach for monitoring the association between site-level PCMH designation and clinical performance within HRSA's CHC delivery sites. Our findings suggest that transformation does in fact matter, but that it may not appear until half of the delivery sites become designated. There also appears to be a continued stepwise increase in adherence scores once this threshold is achieved.

Incidental Cancer Diagnoses in Trauma Patients: A Case-Control Study Evaluating Long-term Outcomes.

BACKGROUND: This study evaluates whether trauma patients who incidentally learned about a malignancy have similar long-term outcomes as patients who organically learned about their malignancy. MATERIALS AND METHODS: Incidental findings (IF) patients were matched to noninjured cancer controls on age group, sex, cancer site, stage, and year of diagnosis. Unadjusted covariates included race, insurance type, rural residence, and time from diagnosis to first cancer intervention. Cox proportional hazard regression models were used to measure adjusted all-cause and cancer-specific mortality risk. RESULTS: Adjusted long-term mortality risk among IF cases was 1.42 (95% confidence interval [1.11-1.81]) compared with noninjured cancer controls. There was no statistically significant difference in all-cause mortality among IF cases who survived at least 30 d (1.24 [0.88-1.74]). IF cases had no increased risk of cancer-related mortality compared with controls (1.26 [0.96-1.64]). CONCLUSIONS: Long-term mortality risks among trauma patients with incidental cancer diagnoses are no different than the cancer population as a whole among patients who survive at least 30 d after injury. IF trauma patients are not more susceptible to cancer-related causes of death as a result of a physiological stress response due to injury.

Precision of provider licensure data for mapping member accessibility to Medicaid managed care provider networks.

BACKGROUND: In July 2018, the Centers for Medicare and Medicaid Services (CMS) updated its Medicaid Managed Care (MMC) regulations that govern network and access standards for enrollees. There have been few published studies of whether there is accurate geographic information on primary care providers to monitor network adequacy. METHODS: We analyzed a sample of nurse practitioner (NP) and physician address data registered in the state labor, licensing, and regulation (LLR) boards and the National Provider Index (NPI) using employment location data contained in the patient-centered medical home (PCMH) data file. Our main outcome measures were address discordance (%) at the clinic-level, city, ZIP code, and county spatial extent and the distance, in miles, between employment location and the LLR/NPI address on file. RESULTS: Based on LLR records, address information provided by NPs corresponded to their place of employment in 5% of all cases. NP address information registered in the NPI corresponded to their place of employment in 64% of all cases. Among physicians, the address information provided in the LLR and NPI corresponded to the place of employment in 64 and 72% of all instances. For NPs, the average distance between the PCMH and the LLR address was 21.5 miles. Using the NPI, the distance decreased to 7.4 miles. For physicians, the average distance between the PCMH and the LLR and NPI addresses was 7.2 and 4.3 miles. CONCLUSIONS: Publicly available data to forecast state-wide distributions of the NP workforce for MMC members may not be reliable if done using state licensure board data. Meaningful improvements to correspond with MMC policy changes require collecting and releasing information on place of employment.

Geographic Variation in Outpatient Health Care Service Utilization After Spinal Cord Injury.

OBJECTIVE: To assess whether travel distances between patients and providers predict the frequency in which outpatient health care services are accessed after spinal cord injury (SCI). DESIGN: A retrospective cohort study was carried out in South Carolina among employee health plan and Medicaid insurance recipients. SETTING: Research center. PARTICIPANTS: Two years of outpatient claimant data were evaluated from patients (N=243) aged ≥18 years who were hospitalized between 2010 and 2012. INTERVENTIONS: Travel distances were estimated by geocoding provider and patient address information onto street network files. MAIN OUTCOME MEASURES: Variation in service utilization use was assessed using negative binomial regression. Outpatient visits for physical medicine and rehabilitation, physician and specialty clinic, radiology, internal medicine, behavioral mental health, and "other" were evaluated. RESULTS: Longer travel distances were statistically significant predictors of decreased physician/specialty clinic (relative risk [RR]=.87; 95% confidence interval [CI], .79-.96) and physiotherapy (RR=.57; 95% CI, .46-.71) utilization, with mixed findings for other providers. Secondary analyses in which differences in service use were analyzed using census-defined classifications of urban and rural status did not demonstrate any geographic pattern. CONCLUSIONS: There are significant geographic variations in the use of select outpatient services among SCI populations across the state that are related to longer travel distances. That these patterns were only visible when using travel distance models as opposed to census-based classifications of urban and rural status adds support to augmenting routine data collection and surveillance with spatial analytical models.

The reliability of the American Community Survey for injury surveillance.

BACKGROUND: To evaluate the reliability and predictability of 49 socioeconomic indicators constructed from the annual and multiyear American Community Survey (ACS) data cycles for monitoring injury inequalities across the USA. METHODS: Cross-sectional analysis of the 2006-2013 annual and multiyear county-level ACS data cycles. Indicator reliability was assessed using the margin of error and coefficient of variation (CV). Overlapping multiyear data cycles were assessed for statistical dependence in the estimates. Negative binomial regression models were constructed from a selection of the most reliable indicators over time and across all data cycles using all-cause unintentional and homicide-related mortality records from the National Center for Health Statistics (NCHS). RESULTS: Fewer than half of all indicators for each data cycle generated 'high reliability' CV estimates for at least 95% of all census counties. Indicator reliability did not linearly improve with increasing sample size afforded from the multiyear surveys. On average, changes in socioeconomic conditions for the same geographic areas were statistically significantly different (p<0.05) in 14% (rage 0-99%) to 16% (rage 0-93%) of all overlapping multiyear data cycles. ACS indicators that were among the most reliable across data cycles corroborated variable relationships derived using estimates from the 2000 decennial census and corresponding NCHS records for that year. CONCLUSIONS: Few of the socioeconomic indicators previously used to measure injury disparities are consistently reliable across all ACS data cycles. Researchers should be judicious when selecting consecutive multiyear data cycles to approximate changes in annual socioeconomic conditions. Among the indicators that are reliable, it is advisable to use estimates from the annual ACS data cycle as a crude barometer of injury inequalities and the multiyear files to confirm and add precedence to national trends every three and five years.

Variation in type and frequency of diagnostic imaging during trauma care across multiple time points by patient insurance type.

BACKGROUND: Research has shown that uninsured patients receive fewer radiographic studies during trauma care, but less is known as to whether differences in care are present among other insurance groups or across different time points during hospitalization. Our objective was to examine the number of radiographic studies administered to a cohort of trauma patients over the entire hospital stay as well as during the first 24-hours of care. METHODS: Patient data were obtained from an American College of Surgeons (ACS) verified Level I Trauma Center between January 1, 2011 and December 31, 2012. We used negative binomial regression to construct relative risk (RR) ratios for type and frequency of radiographic imaging received among persons with Medicare, Medicaid, no insurance, or government insurance plans in reference to those with commercial indemnity plans. The analysis was adjusted for patient age, sex, race/ethnicity, injury severity score, injury mechanism, comorbidities, complications, hospital length of stay, and Intensive Care Unit (ICU) admission. RESULTS: A total of 3621 records from surviving patients age > =18 years were assessed. After adjustment for potential confounders, the expected number of radiographic studies decreased by 15 % among Medicare recipients (RR 0.85, 95 % CI 0.78-0.93), 11 % among Medicaid recipients (0.89, 0.81-0.99), 10 % among the uninsured (0.90, 0.85-0.96) and 19 % among government insurance groups (0.81, 0.72-0.90), compared with the reference group. This disparity was observed during the first 24-hours of care among patients with Medicare (0.78, 0.71-0.86) and government insurance plans (0.83, 0.74-0.94). Overall, there were no differences in the number of radiographic studies among the uninsured or among Medicaid patients during the first 24-hours of care compared with the reference group, but differences were observed among the uninsured in a sub-analysis of severely injured patients (ISS > 15). CONCLUSIONS: Both uninsured and insured patients treated at a not-for-profit verified Level I Trauma Center receive fewer radiographic studies than patients with commercial indemnity plans, even after adjusting for clinical and demographic confounders. There is less disparity in care during the first 24-hours, which suggests that patient pathology is the determining factor for radiographic evaluation during the acute care phase. Results from this study offer initial evidence of disparity in diagnostic imaging across multiple insurance groups over different periods of trauma care.

Census-based socioeconomic indicators for monitoring injury causes in the USA: a review.

BACKGROUND: Unlike the UK or New Zealand, there is no standard set of census variables in the USA for characterising socioeconomic (SES, socioeconomic status) inequalities in health outcomes, including injury. We systematically reviewed existing US studies to identify conceptual and methodological strengths and limitations of current approaches to determine those most suitable for research and surveillance. METHODS: We searched seven electronic databases to identify census variables proposed in the peer-reviewed literature to monitor injury risk. Inclusion criteria were that numerator data were derived from hospital, trauma or vital statistics registries and that exposure variables included census SES constructs. RESULTS: From 33 eligible studies, we identified 70 different census constructs for monitoring injury risk. Of these, fewer than half were replicated by other studies or against other causes, making the majority of studies non-comparable. When evaluated for a statistically significant relationship with a cause of injury, 74% of all constructs were predictive of injury risk when assessed in pairwise comparisons, whereas 98% of all constructs were significant when aggregated into composite indices. Fewer than 30% of studies selected SES constructs based on known associations with injury risk. CONCLUSIONS: There is heterogeneity in the conceptual and methodological approaches for using census data for monitoring injury risk as well as in the recommendations as to how these constructs can be used for injury prevention. We recommend four priority areas for research to facilitate a more unified approach towards use of the census for monitoring socioeconomic inequalities in injury risk.

Quantitative pH assessment of small-volume samples using a universal pH indicator.

We developed a hue-based pH determination method to analyze digital images of samples in a 384-well plate after the addition of a universal pH indicator. The standard error of calibration for 69 pH standards was 0.078 pH units, and no sample gave an error greater than 0.23 units. We then used in-solution isoelectric focusing to determine the isoelectric point of Wnt3A protein in conditioned medium and after purification and applied the described method to assess the pH of these small-volume samples. End users may access our standard to assay the pH of their own samples with no additional calibration.

Classifying outcomes of care for injured patients.

Many trauma survivors face challenges of impaired functioning, limited activities and reduced participation. Recovery from injury after acute care, therefore, becomes an important public health issue. This commentary discusses a framework for evaluating outcomes of acute care.

Identifying drug targets for schizophrenia through gene prioritization.

Background: Schizophrenia genome-wide association studies (GWASes) have identified >250 significant loci and prioritized >100 disease-related genes. However, gene prioritization efforts have mostly been restricted to locus-based methods that ignore information from the rest of the genome. Methods: To more accurately characterize genes involved in schizophrenia etiology, we applied a combination of highly-predictive tools to a published GWAS of 67,390 schizophrenia cases and 94,015 controls. We combined both locus-based methods (fine-mapped coding variants, distance to GWAS signals) and genome-wide methods (PoPS, MAGMA, ultra-rare coding variant burden tests). To validate our findings, we compared them with previous prioritization efforts, known neurodevelopmental genes, and results from the PsyOPS tool. Results: We prioritized 62 schizophrenia genes, 41 of which were also highlighted by our validation methods. In addition to DRD2, the principal target of antipsychotics, we prioritized 9 genes that are targeted by approved or investigational drugs. These included drugs targeting glutamatergic receptors (GRIN2A and GRM3), calcium channels (CACNA1C and CACNB2), and GABAB receptor (GABBR2). These also included genes in loci that are shared with an addiction GWAS (e.g. PDE4B and VRK2). Conclusions: We curated a high-quality list of 62 genes that likely play a role in the development of schizophrenia. Developing or repurposing drugs that target these genes may lead to a new generation of schizophrenia therapies. Rodent models of addiction more closely resemble the human disorder than rodent models of schizophrenia. As such, genes prioritized for both disorders could be explored in rodent addiction models, potentially facilitating drug development.

Socioeconomic and geographic disparities in access to endovascular abdominal aortic aneurysm repair.

BACKGROUND: Within Southwestern Ontario, abdominal aortic aneurysm (AAA) surgery has been centralized to a single university-affiliated medical center. The referral area serves 1.9 million people and includes community hospitals with limited vascular surgery capabilities. We reviewed the role of patients' travel distance, geographic location, and socioeconomic status (SES) to determine if centralization of endovascular programs results in disparity in access to endovascular surgery. We hypothesized that patients would travel a longer distance to specifically seek elective endovascular surgery while having open and emergent surgery closer to home. METHODS: All patients who underwent AAA repair (July 2005-June 2010) at London Health Science Centre were identified from the vascular surgery database. Method of repair, clinical presentation, and in-hospital mortality were recorded. Travel distance from each patient's home to our hospital and rural versus urban status was determined for each patient. SES was determined by using a previously validated, locally developed deprivation index. RESULTS: During this 5-year period, 1,243 patients were included in our analysis; 46.8% (n=581) underwent endovascular repair (EVAR) and 53.2% (n=662) underwent open repair. For elective cases, the in-hospital mortality rate was 2.0% (n=11) for EVAR and 3.6% (n=20) for open repair (P=0.1). There was no difference in clinical presentation between SES groups, but open repair was more frequently used in patients of lower SES compared to higher SES (odds ratio=1.32; 95% confidence interval: 1.02-1.72). Travel distance and rural/urban status were not associated with increased odds of EVAR. When ruptured aneurysms were excluded, elective patients of lower SES continued to have a higher rate of open surgery. CONCLUSION: Despite the centralization of endovascular programs in Canada, patients do not appear to be traveling a longer distance for EVAR while having open repairs closer to home as we expected. We did note that higher SES was associated with increased odds of EVAR, which may suggest a health care access bias for EVAR for patients of higher SES. Larger, population-based studies at the provincial or national level could confirm these initial findings.

Changes in access to community health services among rural areas affected and unaffected by hospital closures between 2006 and 2018: A comparative interrupted time series study.

PURPOSE: Recent studies suggest that Federally Qualified Health Centers (FQHC) may be expanding their provision of primary care in rural communities that experience a hospital loss. Whether these trends are different from rural areas not being affected by rural hospital closures is unknown. METHODS: Data included Centers for Medicare and Medicaid Services Provider of Services files, the Cecil G. Sheps hospital closure database, and American Community Survey estimates. Changes in straight-line distances to the nearest FQHC and rural health clinic (RHC) were compared between areas affected and unaffected by a rural hospital closure in a matched case control study design using an interrupted time series model. FINDINGS: There was no instantaneous percentage point increase in FQHC (2.41, 95% CI -0.79 to 5.60, P .140) or RHC (3.27, 95% CI -1.12 to 7.67, P .144) access following hospital closures compared to changes in access occurring in other rural areas. On average, rural ZIP codes affected by hospital closures exhibited a 0.84 percentage point increase in FQHC access over time (95% CI 0.40-1.28, P .000), but similar trends were also found within unaffected ZIP codes classified as small rural areas. CONCLUSIONS: Rural areas impacted by hospital closures did not experience an increase in proximity to FQHCs or RHCs relative to changes in access occurring in other rural areas. Over time, most rural areas are seeing an increase in access to FQHCs and RHCs. Policies are needed to incentivize primary care providers to target geographic areas experiencing a hospital closure.

Broadband access within Medically Underserved Areas and its implication for telehealth utilization.

PURPOSE: There is little information as to how America's broadband infrastructure might impact recent efforts to expand access to virtual care for underserved communities. OBJECTIVE: To examine potential and realized access to broadband internet services within Medically Underserved Areas (MUAs) that rely on community health care service providers for primary care. METHODS: This cross-sectional study included 214,946 US Census Block Group estimates from the 2017 and 2019 American Community Survey and the corresponding Federal Communications Commission database. Changes in household broadband subscription rates and Healthy People 2020 access thresholds within MUAs were assessed. FINDINGS: In 2019, 24,304 MUA households (31.9%) met Healthy People 2020 targets for broadband subscription rates, compared to 64.4% of non-MUA households (n = 89,285). On average, 74.7% of MUA households had a broadband internet subscription compared to 85.2% of non-MUA households, whereas 61.1% (n = 46,635) of MUA households had access to broadband speeds of at least 25.0 Mbps, compared to 75.6% (n = 104,696) of non-MUA households. Within urban households, there was a 0.8 to 1.3 to 1.6 annual percentage point convergence in MUA versus non-MUA broadband disparities between across quintiles (P < .05). Rural MUA households showed little improvement in broadband access between 2017 and 2019. CONCLUSIONS: There has been an overall convergence of broadband access disparities between MUA and non-MUA households over time, but less improvements in access among the most rural households. Reimbursement for audio-only telehealth visits by state Medicaid agencies would help drive down barriers to virtual health care options for populations residing in MUAs.

Association of Hospital Incentive Care Management Partnerships for Uninsured Patients With Emergency Department Utilization.

Importance: The South Carolina (SC) Healthy Outcomes Plan (HOP) program aimed to expand access to health care to individuals without insurance; it remains unknown whether there is an association between the SC HOP program and emergency department (ED) use among patients with high health care costs and needs. Objectives: To determine whether participation in the SC HOP was associated with reduced ED utilization among uninsured participants. Design, Setting, and Participants: This retrospective cohort study included 11 684 HOP participants (ages 18-64 years) with at least 18 months of continuous enrollment. Generalized estimating equations and segmented regression of interrupted time-series analyses of ED visits and charges were conducted from October 1, 2012, to March 31, 2020. Exposures: Time intervals related to the HOP were 1 year before and 3 years after participation. Main Outcomes and Measures: ED visits per 100 participants per month and ED charges per participant per month overall and by subcategory. Results: The mean (SD) age of the 11 684 participants in the study was 45.2 (10.9) years; 6293 (54.5%) were women; 5028 (48.4%) were Black participants and 5189 (50.0%) were White participants. Over the study period, the mean (SE) number of ED visits decreased by 44.1%, from 48.1 (5.2) to 26.9 (2.8) per 100 participants per month. The mean (SE) ED charges were reduced to $858 ($46) per participant per month, a decrease from a mean (SE) of $1583 ($88) per participant per month 1 year before HOP implementation. There was an immediate level decrease of 40% (relative risk [RR], 0.61; 99.5% CI, 0.48-0.76; P < .001) from the preenrollment period, with a sustained reduction trend of 8% (RR 0.92; 99.5% CI, 0.89-0.95; P < .001) during the postenrollment period. A level change for ED charges was detected, at a decrease of 40% (RR 0.60; 99.5% CI, 0.47-0.77; P < .001) directly after HOP enrollment with a subsequent downward trend of 10% (RR 0.90; 99.5% CI, 0.86-0.93; P < .001) for the postenrollment period. Conclusions and Relevance: In this retrospective cohort study, proportions and charges of ED visits by uninsured patients saw immediate and sustained decreases after HOP enrollment. Reducing ED charges may have been driven by decreasing the ED as the primary point of patient care, especially for high-frequency users. These findings have implications for other nonexpansion states seeking to maximize uninsured compensation for low-income populations through improved outcomes.

Using medical expenditure panel survey data to explore the relationship between patient-centered medical homes and racial disparities in severe maternal morbidity outcomes.

BACKGROUND: There are persistent racial/ethnic disparities in the occurrence of severe maternal morbidity. Patient-centered medical home care has the potential to address disparities in maternal outcomes. OBJECTIVES: To examine (1) the association between receiving patient-centered medical home care and severe maternal morbidity outcomes and (2) the interaction of race/ethnicity on patient-centered medical home status and severe maternal morbidity. DESIGN/METHODS: Using 2007 to 2016 data from the Medical Expenditures Panel Survey, we conducted a cross-sectional study to estimate the association between receipt of care from a patient-centered medical home and the occurrence of severe maternal morbidity, and racial-specific (White, Black, Asian, Other) relative risks of severe maternal morbidity. Our study used race as a proxy measure for exposure racism. We identified mothers (⩾15 years) who gave birth during the study period. We identified patient-centered medical home qualities using 11 Medical Expenditures Panel Survey questions and severe maternal morbidities using medical claims, and calculated generalized estimating equation models to estimate odds ratios of severe maternal morbidity and 95% confidence intervals. RESULTS: Among all mothers who gave birth (N = 2801; representing 5,362,782 US lives), only 25% received some exposure patient-centered medical home care. Two percent experienced severe maternal morbidity, and this did not differ statistically (p = 0.11) by patient-centered medical home status. However, our findings suggest a 85% decrease in the risk of severe maternal morbidity among mothers who were defined as always attending a patient-centered medical home (odds ratios: 0.15; 95% confidence interval:0.01-1.87; p = 0.14) and no difference in the risk of severe maternal morbidity among mothers who were defined as sometimes attending a patient-centered medical home (odds ratios: 1.00; 95% confidence interval:0.16-6.42; p = 1.00). There was no overall interaction effect in the model between race and patient-centered medical home groups (p = 0.82), or ethnicity and patient-centered medical home groups (p = 0.62) on the severe maternal morbidity outcome. CONCLUSION: While the rate of severe maternal morbidity was similar to US rates, few mothers received care from a patient-centered medical home which may be due to underreporting. Future research should further investigate the potential for patient-centered medical home-based care to reduce odds of severe maternal morbidity across racial/ethnic groups.

Percutaneous Endoscopic Gastrostomy Placement in Trauma Patients: Early vs Delayed Initiation of Enteral Feeding.

In critically ill trauma patients, adequate nutrition is essential for the body's healing process. Currently, there is no clinical standard for initiating feeds after percutaneous endoscopic gastrostomy (PEG) tube placement. We aimed to demonstrate that early enteral nutrition (EN) is as safe as delayed EN in patients who have undergone PEG tube insertion. We conducted a multi-center, retrospective cohort study of 384 patients from the Prisma Health Trauma Registries who received PEGs. Feeding intolerance was defined as high gastric residuals, nausea, emesis, sustained diarrhea, or ileus. The probability that a patient would experience intolerance was 11.7% in those fed within 6 hours, 5.1% among patients fed between 6 and 12 hours, 6.0% among patients fed between 12 and 24 hours, and 7.6% among patients fed after 24 hours, for which no statistically significant difference was detected. These findings support that early EN after PEG placement is safe in critically ill, trauma patients.

A two-stage cluster sampling method using gridded population data, a GIS, and Google Earth(TM) imagery in a population-based mortality survey in Iraq.

BACKGROUND: Mortality estimates can measure and monitor the impacts of conflict on a population, guide humanitarian efforts, and help to better understand the public health impacts of conflict. Vital statistics registration and surveillance systems are rarely functional in conflict settings, posing a challenge of estimating mortality using retrospective population-based surveys. RESULTS: We present a two-stage cluster sampling method for application in population-based mortality surveys. The sampling method utilizes gridded population data and a geographic information system (GIS) to select clusters in the first sampling stage and Google Earth TM imagery and sampling grids to select households in the second sampling stage. The sampling method is implemented in a household mortality study in Iraq in 2011. Factors affecting feasibility and methodological quality are described. CONCLUSION: Sampling is a challenge in retrospective population-based mortality studies and alternatives that improve on the conventional approaches are needed. The sampling strategy presented here was designed to generate a representative sample of the Iraqi population while reducing the potential for bias and considering the context specific challenges of the study setting. This sampling strategy, or variations on it, are adaptable and should be considered and tested in other conflict settings.

Does direct transport to provincial burn centres improve outcomes? A spatial epidemiology of severe burn injury in British Columbia, 2001-2006.

BACKGROUND: In Canada and the United States, research has shown that injured patients initially treated at smaller emergency departments before transfer to larger regional facilities are more likely to require longer stays in hospital or suffer greater mortality. It remains unknown whether transport status is an independent predictor of adverse health events among persons requiring care from provincial burn centres. METHODS: We obtained case records from the British Columbia Trauma Registry for adult patients (age ≥ 18 yr) referred or transported directly to the Vancouver General Hospital and Royal Jubilee Hospital burn centres between Jan. 1, 2001, and Mar. 31, 2006. Prehospital and in-transit deaths and deaths in other facilities were identified using the provincial Coroner Service database. Place of injury was identified through data linkage with census records. We performed bivariate analysis for continuous and discrete variables. Relative risk (RR) of prehospital and in-hospital mortality and hospital stay by transport status were analyzed using a Poisson regression model. RESULTS: After controlling for patient and injury characteristics, indirect referral did not influence RR of in-facility death (RR 1.32, 95% confidence interval [CI] 0.54- 3.22) or hospital stay (RR 0.96, 95% CI 0.65-1.42). Rural populations experienced an increased risk of total mortality (RR 1.22, 95% CI 1.00-1.48). CONCLUSION: Transfer status is not a significant indicator of RR of death or hospital stay among patients who received care at primary care facilities before transport to regional burn centres. However, significant differences in prehospital mortality show that improvements in rural mortality can still be made.

Geographic, racial/ethnic, and socioeconomic inequities in broadband access.

INTRODUCTION: Broadband access is a "super determinant of health." Understanding the spatial distribution and predictors of access may help target government programs and telehealth applications. Our aim was to examine broadband access across geography and sociodemographic characteristics using American Community Survey (ACS) data. METHODS: We used 5-year ACS estimates from 2014 to 2018 to evaluate broadband access across contiguous US census tracts. Rural-Urban Commuting Area (RUCA) codes were categorized as metropolitan, micropolitan, small town, and isolated rural. We performed bivariate analyses to determine differences by RUCA categories and meeting the Healthy People 2020 (HP2020) objective (83.2% broadband access) or not. We conducted spatial statistics and spatial regression analyses to identify clusters of broadband access and sociodemographic factors associated with broadband access. RESULTS: No RUCA grouping met the HP2020 objective; 80.6% of households had broadband access, including 82.0% of metropolitan, 73.9% of micropolitan, 70.7% of small town, and 70.0% of isolated rural households. Areas with high percentages of Black residents had lower broadband access, particularly in isolated rural tracts (54.9%). Low access was spatially clustered in the Southeast, Southwest, and northern plains. In spatial regression models, poverty and education were most strongly associated with broadband access, while the proportion of American Indian/Alaska Native population was the strongest racial/ethnic factor. CONCLUSIONS: Rural areas had less broadband access with the greatest disparities experienced among geographically isolated areas with larger Black and American Indian/Alaska Native populations, more poverty, and lower educational attainment, following well-known social gradients in health. Resources and initiatives should target these areas of greatest need.