Evaluation of an EMS-Based Community Paramedic Pilot Program to Reduce Frequency of 9-1-1 Calls among High Utilizers.

BACKGROUND: Many community paramedic interventions aim to reduce unnecessary emergency department visits among high utilizers of acute care, but fewer focus specifically on reducing summons for emergency medical services (EMS). We implemented an EMS-based pilot program that identified high utilizers of 9-1-1 and facilitated community paramedic outreach encounters to understand and address potentially unnecessary 9-1-1 calls. This study compares the pre- and post-intervention incidence rate of 9-1-1 calls among program participants. METHODS: This retrospective evaluation was conducted using pilot data from a single U.S. EMS agency that responds to approximately 100,000 9-1-1 calls annually. High utilizers, defined as individuals with ≥3 9-1-1 calls in 90 days, were identified for recruitment between February 1, 2019 and December 31, 2019. Community paramedics recruited participants via phone and then conducted home visits to assist them with navigation away from unnecessary 9-1-1 use. Dispatch data from September 1, 2018 to December 31, 2019 were used to compute the incidence rate of 9-1-1 calls per 30 person-days of observation before and after the initial home visits. RESULTS: Data from 108 program participants were analyzed. The majority were over the age of 50 (79%), and 33% completed more than one visit. Median person-days of observation before and after the initial home visit were 354 days and 132 days, respectively. Participants called 9-1-1 an average of 0.68 times per 30 person-days prior to the community paramedic intervention, and 0.51 times per 30 person-days after the intervention, which represents an overall mean decrease in 9-1-1 utilization of 25% (p < 0.001). Although a decrease in 9-1-1 utilization was observed in the majority of participants, the 9-1-1 call rate increased in 29% of participants. No statistically significant changes in 9-1-1 use were observed in participants who received more than one home visit or who were in the highest quartile of 9-1-1 use prior to the intervention. CONCLUSION: This pilot work demonstrates the feasibility of an EMS-based, community paramedic-only intervention to reduce unnecessary 9-1-1 calls and suggests that some modest reductions in EMS use may be achievable by dispatching community paramedics to conduct home visits with frequent users of 9-1-1.

A Retrospective, Single-Agency Analysis of Ambulance Crashes during a 3-Year Period: Association with EMS Driver Characteristics and a Telematics-Measured Safe Driving Score.

BACKGROUND: Driver demographics and aggressive driving behavior are established risk factors for traffic accidents, yet their role in ambulance crashes remains poorly studied. We reviewed all ambulance crashes that occurred in our emergency medical services (EMS) agency during a 3-year period, and examined incidence rates (IR) by driver characteristics and telematics-measured driver behavior. METHODS: This retrospective study was conducted in a U.S. EMS agency that operates 75 Type III ambulances and requires personnel to document all ambulance collisions, regardless of severity. Crashes reported between September 2017 and August 2020 were reviewed, and established criteria were used to classify injury and vehicle damage severity. Serious crashes were defined as events with any injury and/or functional or disabling damage. A vehicle telematics system installed fleet-wide in 2017 continuously captures driver-specific data, including miles driven and indicators related to speeding, harsh cornering and braking, and seatbelt use. A composite score characterizes compliance with safe driving behaviors (1 = low compliance to 5 = high compliance). Crash IR per 100,000 miles, IR ratios (IRR), and Poisson regression were used in analysis. Driver sex, age, agency tenure, miles driven, and safe driving score were examined. RESULTS: Clinicians reported 214 crashes and the IR of any crash and serious crash were 2.1 and 0.63 per 100,000 miles, respectively. Injuries occurred in 8% of crashes and were all of low acuity. About one third of crashes produced functional (21%) or disabling (8%) vehicle damage, and the ambulance required towing in 10%. In a multivariate model, female sex (IRR = 1.50, 95%CI = 1.13-1.97), age 18-24 (IRR = 1.67, 95%CI = 1.06-2.66), and being in the lowest quartile of safe driving score (IRR = 1.51, 95%CI = 1.14-2.02) were EMS driver factors independently associated with an increased risk of any collision. CONCLUSION: Most ambulance crashes are minor events, but the proportion that result in injury and/or functional or disabling vehicle damage may be as high as one-third. Poor driver compliance with objectively measured safe driving behaviors may increase risk for collisions independent of driver sex and age. The EMS industry would benefit from additional studies that examine the full spectrum of ambulance crashes and expand understanding of EMS driver-related risk factors.

Content Analysis: First-Time Patient User Challenges with Top-Rated Commercial Diabetes Apps.

Background/Introduction: Using a mobile application (app) may improve diabetes self-management. However, the use of diabetes apps is low, possibly due to design and usability issues. The purpose of this study was to identify barriers to app use among adult patients with diabetes who were testing diabetes apps for the first time. Materials and Methods: We conducted a content analysis of observation notes and patient comments collected during the testing of two top commercially available diabetes apps as part of a crossover randomized trial. Participants were adult patients with type 1 or type 2 diabetes on insulin therapy. We analyzed field notes and transcriptions of audio recordings. Open coding derived categories of usability issues, which then were grouped into themes and subthemes on usability problem types. Results: A total of 92 adult Android smartphone users were recruited online (e.g., Facebook) and in-person postings. Three major themes described problems with data input, app report display and presentation, and self-learning options. Data entry modes were problematic because of overcrowded app screens, complicated "save data" steps, and a lack of data entry confirmation. The app icons, wording, entry headings, and analysis reports were not intuitive to understand. Participants wanted self-learning options (e.g., pop-up messages) during app use. Conclusions: Patient testing of top commercially available diabetes apps revealed key usability design issues in data entry, app report, and self-help learning options. Good app training for patients is necessary for both initial use and long-term use of diabetes apps to support self-management.

Risk factors associated with the surgical management of craniopharyngiomas in pediatric patients: analysis of 1961 patients from a national registry database.

OBJECTIVE Patient demographic characteristics, hospital volume, and admission status have been shown to impact surgical outcomes of sellar region tumors in adults; however, the data available following the resection of craniopharyngiomas in the pediatric population remain limited. The authors sought to identify potential risk factors associated with outcomes following surgical management of pediatric craniopharyngiomas. METHODS The Nationwide Inpatient Sample database and Kids' Inpatient Database were analyzed to include admissions for pediatric patients (≤ 18 years) who underwent a transcranial or transsphenoidal craniotomy for resection of a craniopharyngioma. Patient-level factors, including age, race, comorbidities, and insurance type, as well as hospital factors were collected. Outcomes analyzed included mortality rate, endocrine and nonendocrine complications, hospital charges, and length of stay. A multivariate model controlling for variables analyzed was constructed to examine significant independent risk factors. RESULTS Between 2000 and 2011, 1961 pediatric patients were identified who underwent a transcranial (71.2%) or a transsphenoidal (28.8%) craniotomy for resection of a craniopharyngioma. A major predilection for age was observed with the selection of a transcranial (23.4% in < 7-year-olds, 28.1% in 7- to 12-year-olds, and 19.7% in 13- to 18-year-olds) versus transphenoidal (2.9% in < 7-year-olds, 7.4% in 7- to 12-year-olds, and 18.4% in 13- to 18-year-olds) approach. No significant outcomes were associated with a particular surgical approach, except that 7- to 12-year-old patients had a higher risk of nonendocrine complications (relative risk [RR] 2.42, 95% CI 1.04-5.65, p = 0.04) with the transsphenoidal approach when compared with 13- to 18-year-old patients. The overall inpatient mortality rate was 0.5% and the most common postoperative complication was diabetes insipidus (64.2%). There were no independent factors associated with inpatient mortality rates and no significant differences in outcomes among groups based on sex and race. The average length of stay was 11.8 days, and the mean hospital charge was $116,5 22. Hospitals with medium and large bed capacity were protective against nonendocrine complications (RR 0.53, 95% CI 0.3-0.93, p = 0.03 [medium]; RR 0.45, 95% CI 0.25-0.8, p < 0.01 [large]) and total complications (RR 0.73, 95% CI 0.55-0.97, p = 0.03 [medium]; RR 0.68, 95% CI 0.51-0.9, p < 0.01 [large]) when compared with hospitals with small bed capacity (< 200 beds). Patients admitted to rural hospitals had an increased risk for nonendocrine complications (RR 2.56, 95% CI 1.11-5.9, p = 0.03). The presence of one or more medical comorbidities increased the risk of higher total complications (RR 1.38, 95% CI 1.14-1.68), p < 0.01 [1 comorbidity]; RR 2.37, 95% CI 1.98-2.84, p < 0.01 [≥ 2 comorbidities]) and higher total hospital charges (RR 2.9, 95% CI 1.08-7.81, p = 0.04 [1 comorbidity]; RR 9.1, 95% CI 3.74-22.12, p < 0.01 [≥ 2 comorbidities]). CONCLUSIONS This analysis identified patient age, comorbidities, insurance type, hospital bed capacity, and rural or nonteaching hospital status as independent risk factors for postoperative complications and/or increased hospital charges in pediatric patients with craniopharyngioma. Transsphenoidal surgery in younger patients with craniopharyngioma was a risk factor for nonendocrine complications.

Demographic factors, outcomes, and patient access to transsphenoidal surgery for Cushing's disease: analysis of the Nationwide Inpatient Sample from 2002 to 2010.

OBJECT Cushing's disease (CD) is a potentially lethal neuroendocrinopathy that often requires specialized multidisciplinary treatment to achieve optimized outcomes. The authors analyzed data pertaining to patient, hospital, and admission characteristics as they relate to outcomes following transsphenoidal surgery (TSS) in more than 5500 patients treated for CD. METHODS The Nationwide Inpatient Sample (NIS) database was used to identify all patients admitted with CD between 2002 and 2010. A variety of patient demographic data (e.g., age, sex, race, payer status), hospital variables (e.g., bed size, TSS volume, teaching status), and admission subtypes (e.g., elective, emergency) were tested for association with postoperative endocrine and nonendocrine complications, mortality, nonroutine discharge, length of stay, and total hospital charges. All tests were performed using univariate analysis followed by multivariate analysis, with 4 models tested via an additive methodology. Statistical significance was defined as a p value < 0.05 for all analyses. RESULTS From 2002 to 2010, 5527 individuals who were admitted for TSS (54 biopsies, 4254 partial resections, and 1271 total resections; 5579 total TSS procedures) were identified as patients with CD. There were 25 deaths following TSS, resulting in a mortality incidence rate of 0.45%. Nonendocrine and endocrine complications were reported in 22.4% and 11.1% of patients, respectively. The most common nonendocrine complications were postoperative neurological complications (6.98%) and mechanical ventilation (1.71%). Diabetes insipidus was reported in 14.79% of patients. In a multivariate analysis, patients with Medicare were at increased risk of nonendocrine complications (relative risk [RR] 2.24, 95% CI 1.15-4.38; p = 0.02). Patients with Medicare had increased risk of higher charges (RR 1.89, 95% CI 1.04-3.45; p = 0.04), as did those with Medicaid (RR 1.93, 95% CI 1.10-3.41; p = 0.02). Additionally, as compared with white patients, Hispanic patients had an increased rate of higher charges (RR 1.86, 95% CI 1.12-3.10; p = 0.02). Patients whose age was less than 40 years had a higher risk of developing diabetes insipidus (RR 1.39, 95% CI 1.0-1.93; p = 0.05). When compared with those in northeast hospitals, patients in western hospitals were more likely to experience nonendocrine complications (RR 1.85, 95% CI 0.99-3.46; p = 0.05) and endocrine complications (RR 1.98, 95% CI 1.28-3.07; p < 0.01). Patients treated in teaching hospitals were at significantly lower risk of incurring higher hospital charges (RR 0.49, 95% CI 0.28-0.85; p = 0.01). Patients with emergency admissions had a risk of higher hospital charges (RR 3.06, 95% CI 1.26-7.46; p = 0.01) and nonendocrine complications (RR 3.18, 95% CI 1.22-8.28; p = 0.02). CONCLUSIONS This review of NIS data in more than 5500 patients treated surgically for CD pointed to major outcome disparities predicted primarily by payer status, admission type, and hospital region. Identification and targeting of such barriers to quality health care in patients with CD may help optimize patient outcomes on a national level and present an opportunity to improve access of high-risk patient subgroups to specialty centers of excellence.

Trends in fall-related encounters and predictors of non-transport at a US Emergency Medical Services Agency.

Non-transport to a hospital after emergency medical services (EMS) encounters for falls is common. However, incident factors associated with non-transport have not been well studied, especially beyond older adults. The objectives of this study are to (1) describe trends in fall-related EMS utilisation among adult patients from 2010 to 2018; (2) describe incident characteristics by age; and (3) identify incident factors associated with non-transport following a fall. This retrospective observational study includes prehospital clinical records data on falls from a large ambulance service in Minnesota, USA. Multivariable logistic regression was used to assess the independent association between non-transport and the following factors: sex, age, race, previous fall-related EMS encounter, incident location and primary impression. Of 62,835 fall-related encounters studied, 14.7% (9,245) did not result in transport by EMS. Fall calls were less common among younger people and the location and medical conditions primarily treated by an EMS provider during a 9-1-1 call differed greatly from those occurring among patients 65 and older. Factors most strongly associated with an increased risk of non-transport in the multivariable model were a primary impression of 'No apparent illness/injury' (OR = 34.5, 95% CI = 30.7-38.7), falling in a public location (OR = 2.09, CI = 1.96-2.22) and having had a fall-related EMS encounter during the prior year (OR = 1.15, CI = 1.1-1.2). Falls that occur in public locations, in patients with a previous fall, or result in no clinical detection of apparent illness or injury have a significantly increased odds of non-transport. Non-transport fall incidents in the United States require significant agency resources. Knowledge about the incident factors associated with non-transport calls is informative for development of alternative models for prehospital care delivery and initiatives to better serve patients.

Trends in hospitalization of preterm infants with intraventricular hemorrhage and hydrocephalus in the United States, 2000-2010.

OBJECT Even with improved prenatal and neonatal care, intraventricular hemorrhage (IVH) occurs in approximately 25%-30% of preterm infants, with a subset of these patients developing hydrocephalus. This study was undertaken to describe current trends in hospitalization of preterm infants with posthemorrhagic hydrocephalus (PHH) using the Nationwide Inpatient Sample (NIS) and the Kids' Inpatient Database (KID). METHODS The KID and NIS were combined to generate data for the years 2000-2010. All neonatal discharges with ICD-9-CM codes for preterm birth with IVH alone or with IVH and hydrocephalus were included. RESULTS There were 147,823 preterm neonates with IVH, and 9% of this group developed hydrocephalus during the same admission. Of patients with Grade 3 and 4 IVH, 25% and 28%, respectively, developed hydrocephalus in comparison with 1% and 4% of patients with Grade 1 and 2 IVH, respectively. Thirty-eight percent of patients with PHH had permanent ventricular shunts inserted. Mortality rates were 4%, 10%, 18%, and 40%, respectively, for Grade 1, 2, 3, and 4 IVH during initial hospitalization. Length of stay has been trending upward for both groups of IVH (49 days in 2000, 56 days in 2010) and PHH (59 days in 2000, 70 days in 2010). The average hospital cost per patient (adjusted for inflation) has also increased, from $201,578 to $353,554 (for IVH) and $260,077 to $495,697 (for PHH) over 11 years. CONCLUSIONS The number of neonates admitted with IVH has increased despite a decrease in the number of preterm births. Rates of hydrocephalus and mortality correlated closely with IVH grade. The incidence of hydrocephalus in preterm infants with IVH remained stable between 8% and 10%. Over an 11-year period, there was a progressive increase in hospital cost and length of stay for preterm neonates with IVH and PHH that may be explained by a concurrent increase in the proportion of patients with congenital cardiac anomalies.

Cross-Sectional Analysis on Racial and Economic Disparities Affecting Mortality in Preterm Infants with Posthemorrhagic Hydrocephalus.

BACKGROUND: Despite major advances in medicine, racial and socioeconomic disparities continue to affect health care outcomes. Higher overall infant mortality has been reported for black neonates compared with their Hispanic and white counterparts. The underlying basis for these differences remains unclear. A potential influencing factor is the management of premature neurologic complications in this disadvantaged group. This study examines racial and socioeconomic disparities on mortality in preterm infants with posthemorrhagic hydrocephalus (PHH). METHODS: Data from the Nationwide Inpatient Sample and Kids Inpatient Database were combined from 2000 to 2010. Discharges with International Classification of Diseases, Ninth Revision, Clinical Modification codes for preterm births with intraventricular hemorrhage and PHH were included. Relative risk (RR) ratios for mortality, complications, length of stay, and hospital costs were obtained with multivariate analysis after controlling for patient-level, hospital-level, and admission-level factors. RESULTS: When controlling for patient and hospital factors, black neonates had increased mortality compared with whites and Hispanics (RR = 1.47; P < 0.01). This association existed despite lower rates of congenital cardiac defects (RR = 0.84; P < 0.01), gastrointestinal complications (RR = 0.84; P < 0.01), and general complications of prematurity (RR = 0.95; P = 0.04) in the black cohort. Preterm infants insured by Medicaid had increased mortality compared with those with private insurance (RR = 1.2; P = 0.04) after adjusting for patient and hospital factors. CONCLUSIONS: Among preterm infants with intraventricular hemorrhage and resultant PHH, black infants and those insured by Medicaid have significantly increased mortality but these 2 effects are independent. Further studies are needed to fully understand the factors affecting these racial and socioeconomic disparities.

Exposure to Bovine Leukemia Virus Is Associated with Breast Cancer: A Case-Control Study.

BACKGROUND: Age, reproductive history, hormones, genetics, and lifestyle are known risk factors for breast cancer, but the agents that initiate cellular changes from normal to malignant are not understood. We previously detected bovine leukemia virus (BLV), a common oncogenic virus of cattle, in the breast epithelium of humans. The objective of this study was to determine whether the presence of BLV DNA in human mammary epithelium is associated with breast cancer. METHODS: This was a case-control study of archival formalin fixed paraffin embedded breast tissues from 239 donors, received 2002-2008 from the Cooperative Human Tissue Network. Case definition as breast cancer versus normal (women with no history of breast cancer) was established through medical records and examination of tissues by an anatomical pathologist. Breast exposure to BLV was determined by in situ-PCR detection of a biomarker, BLV DNA, localized within mammary epithelium. RESULTS: The frequency of BLV DNA in mammary epithelium from women with breast cancer (59%) was significantly higher than in normal controls (29%) (multiply- adjusted odds ratio = 3.07, confidence interval = 1.66-5.69, p = .0004, attributable risk = 37%). In women with premalignant breast changes the frequency of BLV DNA was intermediate (38%) between that of women with breast cancer and normal controls (p for trend < .001). CONCLUSIONS: Among the specimens in this study, the presence of amplified BLV DNA was significantly associated with breast cancer. The odds ratio magnitude was comparable to those of well-established breast cancer risk factors related to reproductive history, hormones, and lifestyle and was exceeded only by risk factors related to genetics (familial breast cancer), high dose ionizing radiation, and age. These findings have the potential for primary and secondary prevention of breast cancer.

A conserved role for atlastin GTPases in regulating lipid droplet size.

Lipid droplets (LDs) are the major fat storage organelles in eukaryotic cells, but how their size is regulated is unknown. Using genetic screens in C. elegans for LD morphology defects in intestinal cells, we found that mutations in atlastin, a GTPase required for homotypic fusion of endoplasmic reticulum (ER) membranes, cause not only ER morphology defects, but also a reduction in LD size. Similar results were obtained after depletion of atlastin or expression of a dominant-negative mutant, whereas overexpression of atlastin had the opposite effect. Atlastin depletion in Drosophila fat bodies also reduced LD size and decreased triglycerides in whole animals, sensitizing them to starvation. In mammalian cells, co-overexpression of atlastin-1 and REEP1, a paralog of the ER tubule-shaping protein DP1/REEP5, generates large LDs. The effect of atlastin-1 on LD size correlates with its activity to promote membrane fusion in vitro. Our results indicate that atlastin-mediated fusion of ER membranes is important for LD size regulation.