Distances to emergency departments and non-urgent utilization of medical services: a systematic review.

BACKGROUND: The use of Emergency Departments (EDs) for non-urgent medical conditions is a global public health concern. OBJECTIVES: A systematic review, guided by a registered protocol (PROSPERO: CRD42023398674), was conducted to interpret the association between distance as a measure of healthcare access and the utilization of EDs for non-urgent care in high- and middle-income countries. METHODS: The search was conducted on 22 August 2023 across five databases using controlled vocabulary and natural language keywords. Eligibility criteria included studies that examined non-urgent care, and featured concepts of emergency departments, non-urgent health services and distance, reported in English. Articles and abstracts where patients were transported by ambulance/paramedic services, referred/transferred from another hospital to an ED, or those that measured distance to an ED from another health facility were excluded. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework informed the quality of evidence. RESULTS: Fifteen articles met the inclusion criteria. All studies demonstrated satisfactory quality with regard to study design, conduct, analysis and presentation of results. Eight (53.3%) of the studies (1 paediatric, 4 all ages/adult, 3 ecological) found a moderate level of evidence of an inverse association between distance and ED visit volume or utilization for non-urgent medical conditions, while the remaining studies reported very low or low evidence. CONCLUSIONS: Half of the studies reported non-urgent ED use to be associated with shortest distance traveled or transportation time. This finding bears implications for healthcare policies aiming to reduce ED use for non-urgent care.

Main findings: Using the systematic review methodology, a qualitative synthesis of the prior literature showed moderate evidence of the negative role of distance on emergency departments use across middle- and high-income countries.Added knowledge: This systematic review adds to the literature by providing evidence that clarifies prior inconsistent findings on the association between distance, a measure of healthcare access, and non-urgent emergency department utilization.Global health impact for policy and action: Based on the main finding of negative role of distance, a three-tiered policy recommendation to reduce non-urgent use of emergency departments is provided that include: 1) public health systems reforms, 2) patient education, and 3) improved access to primary care providers.

Treatment for Insomnia Symptoms is Associated with Reduced Depression Among Older Adults: A Propensity Score Matching Approach.

OBJECTIVES: The study aimed to investigate the effect of utilization of treatment for insomnia symptoms on the prevalence of major depressive disorder among older adults in India. METHODS: We used the data from the Longitudinal Ageing Study in India (LASI), 2017-18. The sample included 10,911 older individuals who reported insomnia symptoms. The propensity score matching (PSM) approach was used to compare the depressive disorder among those who received vs. not received treatment. RESULTS: Only 5.7% of older adults reporting insomnia symptoms received treatment. On average, prevalence of depressive disorder among men and women who received treatment for insomnia symptoms was lesser by 0.79 and 0.33 points, respectively, than those who did not receive treatment. In the matched sample, treatment for insomnia symptoms was significantly associated with lesser prevalence of depression for both older men (ß= -0.68, p < .001) and older women (ß= -0.62, p < .001). CONCLUSIONS: The current findings suggest that treatment for insomnia symptoms can reduce the risk of depressive disorder among older adults and the effects are higher among older men than women.

Older Adult Falls in the Community: Does Unsafe Home Environment Have a Risk Role Through the Mediating Effect of Functional Limitations?

BACKGROUND AND OBJECTIVES: Fall incidents from unsafe home environments are frequent in older-adult homes but the literature is ambiguous whether it is the presence/absence, or the interplay of such conditions and physical functioning that is of salience. We therefore estimated whether unsafe home environment is adversely associated with subsequent falls among older adults and what proportion of this association was mediated through limitations in daily and instrumental activities of daily living (ADL/IADL). RESEARCH DESIGN AND METHODS: Using a nationally representative sample of community-dwelling Medicare beneficiaries (≥65 years) in the 2018-2019 National Health and Aging Trends Study (n = 2,599), we conducted bivariate and multivariable analyses. We examined baseline conditions of home disorders, unsafe bathroom settings, unsafe house/building features, and house disrepairs in 2018 and their relation with subsequent falls in 2019, after controlling for covariates. To assess whether ADL/IADL limitations mediated this relationship, we employed the Karlson-Holm-Breen methodology. RESULTS: In 2019, the self-reported prevalence of falls among older adults was estimated at 34.68%. Although baseline home disorders had both a direct (adjusted odds ratio [aOR]: 1.14, 95% confidence interval [CI]:1.03,1.26) and an indirect effect through limitations in ADL and IADL (aOR: 1.01; 95% CI: 1.00,1.03), the relation between unsafe bathroom settings and subsequent falls was unclear. Unsafe house/building features and house disrepairs were not statistically significantly related either directly or indirectly with subsequent falls. DISCUSSION AND IMPLICATIONS: Addressing home disorders through policy and housing assessments to highlight home environmental safety would be essential to address falls among older adults.

Mediation of pain in the association of sleep problems with falls among older adults in India.

Body pain, sleep problems and falls are commonly reported among the elderly population. This study aimed to explore the mediating role of pain in the association of sleep problems with fall-outcomes (falls, fall-injury, and multiple falls) among older adults. Cross-sectional data from the baseline survey of Longitudinal Aging Study in India (LASI), 2017-18 were used. The total sample size for the study was 28,285 older adults aged 60 years and above. Falls and fall-related injuries among older adults in the last two years were self-reported. The Jenkins Sleep Scale (JSS-4) was used to assess sleep problems while pain was assessed using questions on whether respondents reported that they were troubled by pain and they required some form of medication or treatment for the relief of pain. Multivariable logistic regression and mediation analyses were conducted to fulfill the study objectives. While 13% older adults suffered from sleep problems, 38.83% were troubled with pain. Additionally, 12.63%, 5.64% and 5.76% older adults reported falls, fall-injury and multiple falls respectively. Older adults who suffered from sleep problems had higher odds of falls [adjusted odds ratio (aOR): 1.43, confidence interval (CI): 1.30-1.58], fall-injuries, [aOR:1.50,CI:1.30-1.73] and multiple falls [aOR:1.41,CI:1.24-1.62]. Similarly, older adults who were troubled with pain were more likely to report falls [aOR:1.80, CI:1.67-1.95], fall-injuries [aOR:1.66, CI:1.48-1.87] and multiple falls [aOR:1.90,CI:1.69-2.12]. The percent of the mediated effect of pain when examining the association between sleep problems and fall outcomes were reported to be 17.10%, 13.56% and 18.78% in case of falls, fall-injuries and multiple falls respectively. The current study finds evidence that pain mediates the association of sleep problems and falls, fall-injuries, and multiple falls among older Indian adults. Both sleep problems and pain are modifiable risk factors that need attention for fall prevention strategies.

Interpreting COVID-19 deaths among nursing home residents in the US: The changing role of facility quality over time.

A report published last year by the Centers for Medicare & Medicaid Services (CMS) highlighted that COVID-19 case counts are more likely to be high in lower quality nursing homes than in higher quality ones. Since then, multiple studies have examined this association with a handful also exploring the role of facility quality in explaining resident deaths from the virus. Despite this wide interest, no previous study has investigated how the relation between quality and COVID-19 mortality among nursing home residents may have changed, if at all, over the progression of the pandemic. This understanding is indeed lacking given that prior studies are either cross-sectional or are analyses limited to one specific state or region of the country. To address this gap, we analyzed changes in nursing home resident deaths across the US between June 1, 2020 and January 31, 2021 (n = 12,415 nursing homes X 8 months) using both descriptive and multivariable statistics. We merged publicly available data from multiple federal agencies with mortality rate (per 100,000 residents) as the outcome and CMS 5-star quality rating as the primary explanatory variable of interest. Covariates, based on the prior literature, consisted of both facility- and community-level characteristics. Findings from our secondary analysis provide robust evidence of the association between nursing home quality and resident deaths due to the virus diminishing over time. In connection, we discuss plausible reasons, especially duration of staff shortages, that over time might have played a critical role in driving the quality-mortality convergence across nursing homes in the US.

Opioid and Nonopioid Analgesic Prescriptions for Dental Visits in the Emergency Department, 2015-2017 National Hospital Ambulatory Medical Care Survey.

INTRODUCTION: Prescription and nonprescription opioid misuse and the rising number of dental visits in emergency departments (EDs) are growing public health concerns in the US. Our study objective was to examine the relationship between prescription analgesics (opioids and nonopioids) and the type of ED visits (dental and nondental) at the national level. METHODS: We used data from the 2015-2017 National Hospital Ambulatory Medical Care Survey to examine the association between opioid, nonopioid, and combination of opioid and nonopioid analgesic prescriptions and dental and nondental visits in the ED. Covariates included socioeconomic variables, time of visit, provider type, triage level, hospital location (urban vs rural), and pain level. We conducted descriptive, bivariate, and multivariable analyses using weighted estimates. RESULTS: The final study sample included 57,098 ED visits from approximately 6 million dental and 414 million nondental visits to EDs during 2015-2017 nationally. Among dental visits, 20.8% received nonopioid analgesics (vs 23.4% among nondental visits), 36.6% received opioid analgesics (vs 14.0% among nondental visits), and 17.7% received both opioids and nonopioid analgesics (vs 8.7% among nondental visits). Adjusted multinomial logistic regression model indicated that, compared with nondental visits, dental visits had 4.8, 1.9, and 3.4 times higher likelihood of receipt of an opioid, nonopioid, or both opioid and nonopioid analgesic prescription, respectively, in the ED than no analgesic prescriptions. CONCLUSION: Dental visits resulted in receipt of a significantly higher proportion of opioid prescriptions compared with nondental visits during 2015-2017. The study findings highlight the need for developing interventions to reduce opioid prescriptions in the ED, especially for dental visits.

Emergency department use for nontraumatic dental conditions among children and adolescents: NEDS 2014-2015.

OBJECTIVES: Despite great efforts to improve paediatric dental care access in the last two decades, the use of emergency departments (ED) for dental conditions among children that are more appropriately addressed in dental offices remains a public health concern in the United States. We examined factors associated with ED visits for nontraumatic dental conditions or NTDCs and ED visits for any other reason among children and adolescents. METHODS: A retrospective secondary data analysis of ED visits was conducted using the 2014-2015 Nationwide Emergency Department Sample (NEDS) data. NTDCs were further categorized as diseases of hard tissue (eg dental caries), pulp/periapical (eg root canal infections), gingival/periodontal (eg conditions that affect the supporting tissues) and other. We included patient/socioeconomic characteristics, disposition, time of visit, and the Grouped Charlson Comorbidity Index (GRPCI) in our analysis. Bivariate associations were tested using chi-squared test (α = 0.05). RESULTS: There were 70 616 194 ED visits in 2014-15, with 465 353 (0.7%) visits for NTDCs. Statistically significant differences were observed for all patient characteristics tested, except for gender when comparing children visiting the ED for NTDCs and children visiting for any other reason. Medicaid was the expected payer for nearly 60% of all ED visits, and the uninsured shared a larger proportion of NTDC visits (19.4%) than other visits (8.8%). Late adolescents (aged 18-21) accounted for over 50% of NTDC visits but only one-fifth of all other types of ED visits. Late adolescents (18-21 years old) who were uninsured had a significantly higher proportion of NTDC visits. Of all NTDC visits, 19.1% were related to hard tissue disease, 25.3% pulp/periapical, 7.9% periodontal disease, and the remaining were grouped as other dental diseases. CONCLUSIONS: The ED use for NTDCs is more common among late adolescents, Medicaid and uninsured groups. Examining and implementing new approaches that improve access to routine dental care for these groups may help in reducing inefficient ED use related to NTDCs.

Risk Factors of Fall-Related Emergency Department Visits by Fall Location of Older Adults in the US.

INTRODUCTION: Prior evidence indicates that predictors of older adult falls vary by indoor-outdoor location of the falls. While a subset of United States' studies reports this finding using primary data from a single geographic area, other secondary analyses of falls across the country do not distinguish between the two fall locations. Consequently, evidence at the national level on risk factors specific to indoor vs outdoor falls is lacking. METHODS: Using the 2017 Nationwide Emergency Department Sample (NEDS) data, we conducted a multivariable analysis of fall-related emergency department (ED) visits disaggregated by indoor vs outdoor fall locations of adults 65 years and older (N = 6,720,937) in the US. RESULTS: Results are compatible with findings from previous primary studies. While women (relative risk [RR] = 1.43, 95% confidence interval [CI], 1.42-1.44) were more likely to report indoor falls, men were more likely to present with an outdoor fall. Visits for indoor falls were highest among those 85 years and older (RR = 2.35, 95% CI, 2.33-2.37) with outdoor fall visits highest among those 84 years and younger. Additionally, the probabilities associated with an indoor fall in the presence of chronic conditions were consistently much higher when compared to an outdoor fall. We also found that residence in metropolitan areas increased the likelihood of an indoor elderly fall compared to higher outdoor fall visits from seniors in non-core rural areas, but both indoor and outdoor fall visits were higher among older adults in higher income ZIP codes. CONCLUSION: Our findings highlight the contrasting risk profile for elderly ED patients who report indoor vs outdoor falls when compared to the elderly reporting no falls. In conjunction, we highlight implications from three perspectives: a population health standpoint for EDs working with their primary care and community care colleagues; an ED administrative vantage point; and from an individual emergency clinician's point of view.

Associations between living alone, depression, and falls among community-dwelling older adults in the US.

Social isolation is closely linked to depression and falls in late life and are common among seniors. Although the literature has highlighted age-related variations in these three geriatric conditions, evidence on heterogeneities across older adult age categories is lacking. To address this gap, we present cross-sectional analyses using indicators of social isolation, depression, and falls of older adults constructed from the most recent Behavioral Risk Factor Surveillance System (BRFSS) data. An age-based understanding is critical to improve health interventions since health changes occur at a faster rate among seniors than in any other population subgroup. We included all adults 60 years and older (n = 113,233) in the 2018 BRFSS landline dataset and used the status of living alone, depressive disorder diagnosis, and fall incidences reported by these seniors to respectively create the social isolation, depression, and fall indicators. We conducted multivariable logistic regressions to compare findings on these indicators across the three age categories of 60-69, 70-79, and 80 and above after adjusting for a common set of covariates. Results indicate that the likelihood of seniors living alone and reporting depression is the highest among those 80 years and above. Conversely, the odds of depressed seniors reporting falls is the greatest among the 60-69 year olds. Accordingly, we highlight key implications for targeted health promotion and care delivery to seniors.

Opioid prescriptions in emergency departments: Findings from the 2016 National Hospital Ambulatory Medical Care Survey.

In the past decade, there has been a rising trend in the emergency department (ED) visits in the US and these visits carry a significant burden of prescription opioids. This study utilized the latest available data from the 2016 National Hospital Ambulatory Medical Care Survey (NHAMCS) and examined the factors associated with opioid prescriptions in the ED. The outcome variable was receipt of opioid prescription, and the primary variable of interest was the type of visit (dental/non-dental). Other variables included age, gender, race/ethnicity, region, payer, day of the visit, and pain level. Descriptive and multivariate analyses were conducted and predicted marginal probabilities were determined. P ≤ 0.05 was considered statistically significant. In 2016, 22.5% of visits in ER received opioid prescriptions. In the unadjusted analysis, opioid prescriptions were associated with all correlates except day of the visit. In the adjusted model, odds of receiving opioid prescription were 3.5 times more among dental visits compared to non-dental visits (95% Confidence Interval [CI] = 2.4-5.1) and 9.4 times more among visits with severe pain compared to visits with mild pain (95% CI = 7.7-11.4). Opioid prescriptions among 45-64 years old were 7.1 times (95% CI = 5.5-9.1] more likely compared to those among under 18 age-group. Opioid prescriptions in ED differed significantly by the type of visit and pain level. Given the higher likelihood of opioid prescriptions among dental visits, it is imperative to develop better prescription guidelines for dental visits in ED.

Dental visits and associated emergency department-charges in the United States: Nationwide Emergency Department Sample, 2014.

BACKGROUND: Use of hospital emergency department (ED) for dental care is on the rise. This study estimates the total ED dental visits and determines mean charges by the type of disease and other patient characteristics. METHODS: Using the first-listed diagnosis from the 2014 National Emergency Department Sample, the number and types of dental visits in the ED were identified and descriptive statistics were summarized. Using bivariate analyses, we determined the mean ED charges for adults and children by the type of dental disease and other sociodemographic correlates, comorbidity index, income, disposition, and payer. RESULTS: There were 2.43 million dental-related ED visits in 2014 with average charge of $992: $994 for adults and $971 for children under age 18. Bivariate analyses suggested that ED visits were higher among adults aged 19 through 45, those from urban areas, low-income neighborhoods, with higher comorbidity index, or those uninsured/Medicaid. A P-value of ≤ .05 was considered significant. CONCLUSIONS: High number of ED visits result due to dental problems. Our results provide most current estimates of volume and charges of dental-related ED visits. PRACTICAL IMPLICATIONS: Dental treatment in emergency room is costly. Collaborative care approaches need to be identified and tested to provide effective care for dental patients in the ED.

Hours Lost to Planned and Unplanned Dental Visits Among US Adults.

INTRODUCTION: Poor oral health is associated with lost hours at work or school, which may affect a person's productivity. The objective of our study was to estimate work or school hours lost to dental visits among adults aged 18 and older by the types of visits (emergency or unplanned; routine, planned, or orthodontic; or cosmetic) and to determine the factors associated with hours lost. METHODS: We used the most recent Oral Health Supplement data, from the 2008 National Health Interview Survey (NHIS), to estimate the total hours lost at work or school for dental visits among adults in the United States. The associations of the hours lost in unplanned and planned dental visits with socioeconomic characteristics, oral health status, and affordability were calculated. We used χ2 tests and logistic regression to determine associations at P < .05. RESULTS: An average of 320.8 million work or school hours were lost annually for dental care in the United States, of which 92.4 million hours were for emergency (unplanned) care (0.99 h/adult), 159.8 million for routine (planned) care or orthodontic care (1.71 h/adult), and 68.6 million for cosmetic care (0.73 h/adult). Adults with poor oral health were more likely to lose one or more hours in unplanned dental visits (OR = 5.60; 95% confidence interval [CI], 3.25-9.63) than those who reported very good oral health. Not being able to afford dental care was positively associated with more work hours lost in unplanned care (odds ratio [OR] = 2.56; 95% CI, 1.76-3.73). Compared with Hispanic adults, non-Hispanic white adults (OR = 2.09; 95% CI, 1.40-3.11) and non-Hispanic Asian adults and adults of other races/ethnicities (OR =1.91; 95% CI, 1.06-3.47) were more likely to lose any hours for planned care. Consistently, those with more than a high school education were more likely to lose any hours in planned care (OR = 1.39; 95% CI, 1.06-1.83) than those with a high school education or less. CONCLUSIONS: Dental problems result in hours lost from work and may adversely affect a person's productivity. There is disparity in lost hours at work by race/ethnicity and dental care affordability.

Evidence of horizontal and vertical interactions in health care spending in the Philippines.

This article examines whether within a decentralized system of health care spending, local government units in developing countries have any incentive to compete with one another. The existence of spatial competition, whether horizontal or vertical, is tested in the case of Philippines using local government health expenditures data. Results indicate that health spending is characterized by a strong positive interaction between municipalities, consistent with the existence of a horizontal fiscal interaction. However, the results provide less support for the existence of vertical externalities, with the interaction of municipalities with provinces being positive and marginally significant.

Fiscal competition in health spending among local governments in the Philippines.

The Philippines is one of several Asian countries that has decentralized the provision of health care to its local governments in recent decades. In the context of decentralization, a few studies have previously examined the issue of fiscal competition among local governments in the developing world. This report presents a summary of a published study that examined the existence of inter-jurisdictional competition in health-care spending in the Philippines. The results indicate the presence of positive fiscal "spillovers" in health spending, consistent with municipalities/cities competing to outspend their neighbours. Several potential explanations forthis finding are discussed.