Association Between the Affordable Care Act and Emergency Department Visits for Psychiatric Disease.

INTRODUCTION: Emergency department (ED) utilization for psychiatric disease is increasing, and a lack of health insurance has been identified as a potential cause of preventable or avoidable ED use. Through the Affordable Care Act (ACA), more uninsured individuals gained health insurance; however, the effects of increased health insurance coverage on ED utilization for psychiatric disease have not been examined. METHODS: We performed a longitudinal, cross-sectional analysis of data from the Nationwide Emergency Department Sample, the largest all-payer ED database in the US, which contains data on over 25 million ED visits each year. We examined ED utilization for psychiatric disease as the primary reason for visit among adults aged 18-64. We compared the proportion of ED visits with a psychiatric diagnosis during post-ACA years (2011-2016) to pre-ACA (2009) using logistic regression adjusted for age, gender, payer, and hospital region. RESULTS: The proportion of ED visits with psychiatric diagnosis increased from pre-ACA (4.9%) to post-ACA years (ranging from 5.0-5.5%). There was a significant difference in the proportion of ED visits with a psychiatric diagnosis when comparing each post-ACA year with pre-ACA, with adjusted odds ratios ranging from 1.01-1.09. Among ED visits with a psychiatric diagnosis, the most common age group was 26-49 years, and patients were more likely to be male than female and to have visited urban rather than rural hospitals. During post-ACA years (2014-2016), private and uninsured payers decreased, Medicaid payers increased, and Medicare payers increased in 2014 and decreased in 2015-2016 compared to pre-ACA. CONCLUSION: With the ACA more people gained health insurance, yet ED visits for psychiatric disease continued to increase. These results suggest that increasing access to health insurance alone is not sufficient to reduce ED utilization for patients with a psychiatric disease.

The Association between Having a Preterm Birth and Later Maternal Mental Health: An Analysis of U.S. Pregnancy Risk Assessment Monitoring System Data.

INTRODUCTION: Although previous studies have found a relationship between having a preterm birth and maternal depression, methodologic issues may have limited the generalizability of results. Thus, the purpose of this study was to evaluate the relationship between having a preterm birth and postpartum depressive symptoms using a large, population-based sample of U.S. women. METHODS: This secondary data analysis used 2012-2014 U.S. Pregnancy Risk Assessment Monitoring System data (N = 89,366). Data on the exposure, preterm birth, were obtained from birth certificates. Infants born at 32 to less than 37 weeks' gestation were considered moderate to late preterm, infants born at 28 to less than 32 full weeks' gestation were considered very preterm, and infant born at less than 28 full weeks' gestation were considered extremely preterm. To assess the outcome, two Pregnancy Risk Assessment Monitoring System questions measuring postpartum depressive symptoms were used. Logistic regression was used to calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence interval (CIs). RESULTS: After adjustment for confounders, the relationship between having a preterm birth and maternal hopelessness was statistically significant for those who had very preterm and extremely preterm births (moderate to late preterm OR, 1.19; 95% CI, 1.00-1.42; very preterm OR, 1.28; 95% CI, 1.04-1.58; extremely preterm OR, 1.81; 95% CI, 1.31-2.49). In addition, after adjustment, findings indicated no association between preterm birth and maternal loss of interest (extremely preterm OR, 0.85 95% CI, 0.60-1.19; very preterm OR, 1.04; 95% CI, 0.86-1.26; preterm OR, 0.95; 95% CI, 0.82-1.10). CONCLUSIONS: Given the statistically significant increased association between having a preterm birth and postpartum depressive symptoms, health professionals may consider implementing comprehensive screening for depression and other mental illnesses among women who give birth prematurely. Findings may also inform future interventions to emphasize the importance of postpartum care among women who have experienced preterm birth.

Factors associated with health facility delivery in West and Central Africa: A multilevel analysis of seven countries.

We examined associations between individual and community socioeconomic status (SES) and childbirth in a health facility in West and Central Africa using data from the 2009-2011 United Nations Children's Fund (UNICEF) Multiple Indicator Cluster Survey for women in seven countries (n = 34,487). Individual SES measures were education and wealth; community SES was low or high poverty index. In adjusted results, women residing in communities with high poverty had significantly lower odds of facility delivery than those who lived in more affluent communities in five countries (all p < 0.001). Reducing out-of-pocket healthcare costs may improve women's access to delivery in health facilities.

Burnout and the Nurse Anesthetist: An Integrative Review.

The rapid changes in the US healthcare system have resulted in collateral damage to many healthcare providers. Many of these changes have increased demands placed on providers, resulting in high prevalence rates of burnout throughout various healthcare specialties. One healthcare specialty that has reported a recent surge in burnout in the United States is the Certified Registered Nurse Anesthetist (CRNA). Despite these concerns, most of the burnout research on anesthesia providers has focused on anesthesiologists and CRNA-equivalent anesthesia providers from other countries. This is particularly concerning given CRNAs' critical role in the future of US healthcare delivery. The purpose of this integrated review was to examine, discuss, and synthesize the burnout construct related to CRNAs practicing in the United States.

Associations between women's perceptions of domestic violence and contraceptive use in seven countries in West and Central Africa.

OBJECTIVES: This study examined associations of women's attitudes toward domestic violence (DV) and contraceptive use in West and Central Africa. STUDY DESIGN: We used data from the Multiple Indicator Cluster Surveys for women in seven countries in West and Central Africa (2009-2011, n=80,055). MAIN OUTCOME MEASURE: We measured contraceptive use as none, traditional, or modern contraceptives. DV approval was measured as no, low, or high tolerance of wife beating. Multinomial logistic regression estimated odds of using traditional or modern methods versus none, adjusting for age, education, wealth, residence, parity, marital structure, spousal age-difference, and religion. RESULTS: Many women had no or low DV tolerance (41%, 44%, respectively); most used no contraception (81%). In adjusted results, women with low DV tolerance had lower odds of using traditional contraceptive methods (odds ratio, OR=0.87; 95% confidence interval, CI: 0.78-0.98) or modern methods (OR=0.86; 95% CI: 0.78-0.95) compared to women with no tolerance. Women with high DV tolerance had 28% lower odds of traditional contraceptive use (95% CI: 0.60-0.90), and 38% lower odds of modern contraceptive use (95% CI: 0.59-0.88) compared to women with no tolerance. CONCLUSION: The high prevalence of DV approval may threaten the success of programs aimed at improving women's reproductive health, including contraceptive use.

Health disparities and social determinants of health among African-American women undergoing percutaneous coronary interventions (PCI).

This review of minority health describes the existing health disparities, the barriers to healthcare access and utilization, the role of three social determinants of health [i.e., (1) socioeconomic status, (2) education, and (3) stress and/or depression], the existing public-policies; and a health literacy strategy addressing social determinants of health to reduce disparities and improve outcomes in African-American women undergoing Percutaneous Coronary Intervention (PCI). Insurance, geography, facility-types, physician referral-bias, and cultural-differences pose as potential significant barriers to healthcare access and utilization. Likewise, lower socioeconomic-status, lack of education, and higher stress and/or depression is associated with adverse health-outcomes for this population. Although the elimination of health disparities is a national priority, comprehensive educational approaches focusing on cross-cultural communication, language barriers, cultural-sensitivity, and cultural-competence are needed.

Youth therapeutic alliance in intensive treatment settings.

Therapeutic alliance (TA), the helping relationship that develops between a client and clinician, has received little attention in child treatment studies until recently, though it is the factor found to be most predictive of clinical outcomes. Furthermore, TA is cited as one of the most important components to effective therapy according to practicing clinicians. This study examines the TA that develops between teacher/counselors and children in 2 settings, a partial hospital/day school and a wilderness camp. An important finding in this study is the lack of relationship between the teacher/counselor's view of TA and the youth's view. Moreover, this correlation does not improve according to how long the counselors have known or have treated the youth. The implications of this and other findings are discussed.