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1.
Ann Emerg Med ; 2021 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-34922776

RESUMO

STUDY OBJECTIVE: There is strong evidence supporting emergency department (ED)-initiated buprenorphine for opioid use disorder, but less is known about how to implement this practice. Our aim was to describe implementation, maintenance, and provider adoption of a multicomponent strategy for opioid use disorder treatment in 3 urban, academic EDs. METHODS: We conducted a retrospective analysis of electronic health record data for adult patients with opioid use disorder-related visits before (March 2017 to November 2018) and after (December 2018 to July 2020) implementation. We describe patient characteristics, clinical treatment, and process measures over time and conducted an interrupted time series analysis using a patient-level multivariable logistic regression model to assess the association of the interventions with buprenorphine use and other outcomes. Finally, we report provider-level variation in prescribing after implementation. RESULTS: There were 2,665 opioid use disorder-related visits during the study period: 28% for overdose, 8% for withdrawal, and 64% for other conditions. Thirteen percent of patients received medications for opioid use disorder during or after their ED visit overall. Following intervention implementation, there were sustained increases in treatment and process measures, with a net increase in total buprenorphine of 20% in the postperiod (95% confidence interval 16% to 23%). In the adjusted patient-level model, there was an immediate increase in the probability of buprenorphine treatment of 24.5% (95% confidence interval 12.1% to 37.0%) with intervention implementation. Seventy percent of providers wrote at least 1 buprenorphine prescription, but provider-level buprenorphine prescribing ranged from 0% to 61% of opioid use disorder-related encounters. CONCLUSION: A combination of strategies to increase ED-initiated opioid use disorder treatment was associated with sustained increases in treatment and process measures. However, adoption varied widely among providers, suggesting that additional strategies are needed for broader uptake.

2.
Am J Emerg Med ; 51: 331-337, 2021 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-34800906

RESUMO

STUDY OBJECTIVE: Emergency departments (ED) are critical touchpoints for encounters among patients with opioid use disorder (OUD), but implementation of ED initiated treatment and harm reduction programs has lagged. We describe national patient, visit and hospital-level characteristics of ED OUD visits and characterize EDs with high rates of OUD visits in order to inform policies to optimize ED OUD care. METHODS: We conducted a descriptive, cross-sectional study with the 2017 Nationwide Emergency Department Sample (NEDS) from the Healthcare Cost and Utilization Project, using diagnostic and mechanism of injury codes from ICD-10 to identify OUD related visits. NEDS weights were applied to generate national estimates. We evaluated ED visit and clinical characteristics of all OUD encounters. We categorized hospitals into quartiles by rate of visits for OUD per 1000 ED visits and described the visit, clinical, and hospital characteristics across the four quartiles. RESULTS: In 2017, the weighted national estimate for OUD visits was 1,507,550. Overdoses accounted for 295,954. (19.6%) of visits. OUD visit rates were over 8× times higher among EDs in the highest quartile of OUD visit rate (22.9 per 1000 total ED visits) compared with EDs in the lowest quartile of OUD visit rate (2.7 per 1000 ED visits). Over three fifths (64.2%) of all OUD visits nationwide were seen by the hospitals in the highest quartile of OUD visit rate. These hospitals were predominantly in metropolitan areas (86.2%), over half were teaching hospitals (51.7%), and less than a quarter (23.3%) were Level 1 or Level 2 trauma centers. CONCLUSION: Targeting initial efforts of OUD care programs to high OUD visit rate EDs could improve care for a large portion of OUD patients utilizing emergency care.

3.
Ann Intern Med ; 2021 Nov 16.
Artigo em Inglês | MEDLINE | ID: mdl-34781715

RESUMO

BACKGROUND: Although most patients with SARS-CoV-2 infection can be safely managed at home, the need for hospitalization can arise suddenly. OBJECTIVE: To determine whether enrollment in an automated remote monitoring service for community-dwelling adults with COVID-19 at home ("COVID Watch") was associated with improved mortality. DESIGN: Retrospective cohort analysis. SETTING: Mid-Atlantic academic health system in the United States. PARTICIPANTS: Outpatients who tested positive for SARS-CoV-2 between 23 March and 30 November 2020. INTERVENTION: The COVID Watch service consists of twice-daily, automated text message check-ins with an option to report worsening symptoms at any time. All escalations were managed 24 hours a day, 7 days a week by dedicated telemedicine clinicians. MEASUREMENTS: Thirty- and 60-day outcomes of patients enrolled in COVID Watch were compared with those of patients who were eligible to enroll but received usual care. The primary outcome was death at 30 days. Secondary outcomes included emergency department (ED) visits and hospitalizations. Treatment effects were estimated with propensity score-weighted risk adjustment models. RESULTS: A total of 3488 patients enrolled in COVID Watch and 4377 usual care control participants were compared with propensity score weighted models. At 30 days, COVID Watch patients had an odds ratio for death of 0.32 (95% CI, 0.12 to 0.72), with 1.8 fewer deaths per 1000 patients (CI, 0.5 to 3.1) (P = 0.005); at 60 days, the difference was 2.5 fewer deaths per 1000 patients (CI, 0.9 to 4.0) (P = 0.002). Patients in COVID Watch had more telemedicine encounters, ED visits, and hospitalizations and presented to the ED sooner (mean, 1.9 days sooner [CI, 0.9 to 2.9 days]; all P < 0.001). LIMITATION: Observational study with the potential for unobserved confounding. CONCLUSION: Enrollment of outpatients with COVID-19 in an automated remote monitoring service was associated with reduced mortality, potentially explained by more frequent telemedicine encounters and more frequent and earlier presentation to the ED. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

4.
Artigo em Inglês | MEDLINE | ID: mdl-34818130

RESUMO

RATIONALE: Many decisions to admit patients to the ICU are not grounded in evidence regarding who benefits from such triage, straining ICU capacity and limiting its cost-effectiveness. OBJECTIVES: To measure the benefits of ICU admission for patients with sepsis or acute respiratory failure. METHODS: At 27 U.S. hospitals across two health systems from 2013 to 2018, we performed a retrospective cohort study using two-stage instrumental variable quantile regression with a strong instrument (hospital capacity strain) governing ICU vs. ward admission among high-acuity patients (i.e., Laboratory-based Acute Physiology Score v2 ≥ 100) with sepsis and/or acute respiratory failure who did not require mechanical ventilation or vasopressors in the emergency department (ED). MEASUREMENTS AND MAIN RESULTS: Among sepsis patients (n = 90,150), admission to the ICU was associated with a 1.32-day longer hospital length of stay (95% confidence interval 1.01-1.63, p < 0.001) (when treating deaths as equivalent to long lengths of stay) and higher in-hospital mortality (odds ratio 1.48, 95% CI 1.13-1.88, p = 0.004). Among respiratory failure patients (n = 45,339), admission to the ICU was associated with a 0.82-day shorter hospital length of stay (95% confidence interval -1.17--0.46, p < 0.001) and reduced in-hospital mortality (odds ratio 0.75, 95% CI 0.57-0.96, p = 0.04). In sensitivity analyses of LOS excluding, ignoring, or censoring death, results were similar in sepsis but not in respiratory failure. In subgroup analyses, harms of ICU admission for sepsis patients were concentrated among older patients and those with fewer comorbidities, and benefits of ICU admission for respiratory failure patients were concentrated among older patients, highest-acuity patients, and those with more comorbidities. CONCLUSIONS: Among high-acuity patients with sepsis who did not require life support in the ED, initial admission to the ward, compared to the ICU, was associated with shorter LOS and improved survival, whereas among acute respiratory failure patients, triage to the ICU, compared to the ward, was associated with improved survival.

5.
Resuscitation ; 167: 233-241, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34087419

RESUMO

BACKGROUND: Several prospective studies have demonstrated that the echocardiographic detection of any myocardial activity during PEA is strongly associated with higher rates of return of spontaneous circulation (ROSC). We hypothesized that PEA represents a spectrum of disease in which not only the presence of myocardial activity, but more specifically that the degree of left ventricular (LV) function would be a predictor of outcomes. The purpose of this study was to retrospectively assess the association between LV function and outcomes in patients with OHCA. MATERIALS AND METHODS: Using prospectively obtained data from an observational cohort of patients receiving focused echocardiography during cardiopulmonary resuscitation (CPR) in the Emergency Department (ED) setting, we analyzed 312 consecutive subjects with available echocardiography images with initial rhythm of PEA. We used left ventricular systolic fractional shortening (LVFS), a unidimensional echocardiographic parameter to perform the quantification of LV function during PEA. Regression analyses were performed independently to evaluate for relationships between LVFS and a primary outcome of ROSC and secondary outcome of survival to hospital admission. We analyzed LVFS both as a continuous variable and as a categorial variable using the quartiles and the median to perform multiple different comparisons and to illustrate the relationship of LVFS and outcomes of interest. We performed survival analysis using Cox proportional hazards model to evaluate the hazard corresponding to length of resuscitation. RESULTS: We found a positive association between LVFS and the primary outcome of ROSC (OR 1.04, 95%CI 1.01-1.08), but not with the secondary outcome of survival to hospital admission (OR 1.02, 95%CI 0.96-1.08). Given that the relationship was not linear and that we observed a threshold effect in the relationship between LVFS and outcomes, we performed an analysis using quartiles of LVFS. The predicted probability of ROSC was 75% for LVFS between 23.4-96% (fourth quartile) compared to 47% for LVFS between 0-4.7% (first quartile). The hazard of not achieving ROSC was significantly greater for subjects with LVFS below the median (13.1%) compared to the subgroup with LVFS greater than 13.1% (p < 0.05), with the separation of the survival curves occurring at approximately 40 min of resuscitation duration. CONCLUSIONS: Left ventricular function measured by LVFS is positively correlated with higher probability of ROSC and may be associated with higher chances of survival in patients with PEA arrest.


Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca Extra-Hospitalar , Ecocardiografia , Humanos , Parada Cardíaca Extra-Hospitalar/diagnóstico por imagem , Parada Cardíaca Extra-Hospitalar/terapia , Estudos Prospectivos , Estudos Retrospectivos , Função Ventricular Esquerda
6.
J Child Psychol Psychiatry ; 62(5): 580-583, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33817792

RESUMO

Youth firearm injury is a worsening public health crisis, and the risks are not distributed evenly. Bottiani et al. skillfully explicated those health disparities, described sociological factors underlying them, and explored avenues for prevention. We supplement their analysis by detailing problems and solutions related to a critical barrier to firearm violence prevention - the nonexistence both of reliable 'gold standard' nonfatal firearm injury surveillance data, and systems for near real-time surveillance of firearm injuries at granular spatial scales that would enable to optimization of rapid response protocols and neighborhood-based prevention programs. We conclude with a discussion of modern, scalable, behavioral intervention approaches that could be leveraged to fill the largely absent evidence base resulting from the documented underfunding of youth firearm violence prevention research.


Assuntos
Armas de Fogo , Ferimentos por Arma de Fogo , Adolescente , Humanos , Vigilância da População , Características de Residência , Violência/prevenção & controle
7.
Am J Emerg Med ; 47: 154-157, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33812332

RESUMO

OBJECTIVE: To determine the rate at which commercially-insured patients fill prescriptions for naloxone after an opioid-related ED encounter as well as patient characteristics associated with obtaining naloxone. METHODS: This is a retrospective cohort study of adult patients discharged from the ED following treatment for an opioid-related condition from 2016 to 2018 using a commercial insurance claims database (Optum Clinformatics® Data Mart). The primary outcome was a pharmacy claim for naloxone in the 30 days following the ED encounter. A multivariable logistic regression model examined the association of patient characteristics with filled naloxone prescriptions, and predictive margins were used to report adjusted probabilities with 95% confidence intervals. RESULTS: 21,700 patients had opioid-related ED encounters during the study period, of which 1743 (8.0%) had encounters for heroin overdose, 8825 (40.7%) for overdose due to other opioids, 5400 (24.9%) for withdrawal, and 5732 (26.4%) for other opioid use disorder conditions. 230 patients (1.1%) filled a prescription for naloxone within 30 days. Patients with heroin overdose (2.6%; 95%CI 1.7 to 3.4), recent prescriptions for opioid analgesics (1.4%; 95%CI 1.1 to 1.7), recent prescriptions for buprenorphine (1.9%; 95%CI 1.0 to 2.9), and naloxone prescriptions in the prior year (3.3%; 95%CI 1.8 to 4.8) were more likely to obtain naloxone. The rate was significantly higher in 2018 [1.9% (95%CI 1.5 to 2.2)] as compared to 0.4% (95%CI 0.3 to 0.6) in 2016. CONCLUSIONS: Few patients use insurance to obtain naloxone by prescription following opioid-related ED encounters. Clinical and policy interventions should expand distribution of this life-saving medication in the ED.


Assuntos
Overdose de Drogas/epidemiologia , Prescrições de Medicamentos/estatística & dados numéricos , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Síndrome de Abstinência a Substâncias/epidemiologia , Adulto , Bases de Dados Factuais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
8.
JAMA Netw Open ; 4(3): e213243, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33764425

RESUMO

Importance: Surgeons must balance management of acute postoperative pain with opioid stewardship. Patient-centered methods that immediately evaluate pain and opioid consumption can be used to guide prescribing and shared decision-making. Objective: To assess the difference between the number of opioid tablets prescribed and the self-reported number of tablets taken as well as self-reported pain intensity and ability to manage pain after orthopedic and urologic procedures with use of an automated text messaging system. Design, Setting, and Participants: This quality improvement study was conducted at a large, urban academic health care system in Pennsylvania. Adult patients (aged ≥18 years) who underwent orthopedic and urologic procedures and received postoperative prescriptions for opioids were included. Data were collected prospectively using automated text messaging until postoperative day 28, from May 1 to December 31, 2019. Main Outcomes and Measures: The primary outcome was the difference between the number of opioid tablets prescribed and the patient-reported number of tablets taken (in oxycodone 5-mg tablet equivalents). Secondary outcomes were self-reported pain intensity (on a scale of 0-10, with 10 being the highest level of pain) and ability to manage pain (on a scale of 0-10, with 10 representing very able to control pain) after orthopedic and urologic procedures. Results: Of the 919 study participants, 742 (80.7%) underwent orthopedic procedures and 177 (19.2%) underwent urologic procedures. Among those who underwent orthopedic procedures, 384 (51.8%) were women, 491 (66.7%) were White, and the median age was 48 years (interquartile range [IQR], 32-61 years); 514 (69.8%) had an outpatient procedure. Among those who underwent urologic procedures, 145 (84.8%) were men, 138 (80.7%) were White, and the median age was 56 years (IQR, 40-67 years); 106 (62%) had an outpatient procedure. The mean (SD) pain score on day 4 after orthopedic procedures was 4.72 (2.54), with a mean (SD) change by day 21 of -0.40 (1.91). The mean (SD) ability to manage pain score on day 4 was 7.32 (2.59), with a mean (SD) change of -0.80 (2.72) by day 21. The mean (SD) pain score on day 4 after urologic procedures was 3.48 (2.43), with a mean (SD) change by day 21 of -1.50 (2.12). The mean (SD) ability to manage pain score on day 4 was 7.34 (2.81), with a mean (SD) change of 0.80 (1.75) by day 14. The median quantity of opioids prescribed for patients who underwent orthopedic procedures was high compared with self-reported consumption (20 tablets [IQR, 15-30 tablets] vs 6 tablets used [IQR, 0-14 tablets]), similar to findings for patients who underwent urologic procedures (7 tablets [IQR, 5-10 tablets] vs 1 tablet used [IQR, 0-4 tablets]). Over the study period, 9452 of 15 581 total tablets prescribed (60.7%) were unused. A total of 589 patients (64.1%) used less than half of the amount prescribed, and 256 patients (27.8%) did not use any opioids (179 [24.1%] who underwent orthopedic procedures and 77 [43.5%] who underwent urologic procedures). Conclusions and Relevance: In this quality improvement study of adult patients reporting use of opioids after common orthopedic and urologic surgical procedures through a text messaging system, the quantities of opioids prescribed and the quantity consumed differed. Patient-reported data collected through text messaging may support clinicians in tailoring prescriptions and guide shared decision-making to limit excess quantities of prescribed opioids.


Assuntos
Analgésicos Opioides/farmacologia , Procedimentos Ortopédicos/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Medidas de Resultados Relatados pelo Paciente , Melhoria de Qualidade , Envio de Mensagens de Texto , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
9.
JAMA Intern Med ; 181(8): 1133-1134, 2021 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-33779696
11.
JAMA Intern Med ; 181(2): 237-244, 2021 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-33284327

RESUMO

Importance: Firearm injury research in the US has focused on fatal injuries. The incidence and epidemiologic factors associated with nonfatal firearm injuries are less understood. Objective: To evaluate estimates of incidence and trends over time of fatal and nonfatal firearm injuries. Design, Setting, and Participants: A cross-sectional, ecologic study was conducted using data throughout the US from 2009 to 2017. Data on fatal injuries from the Centers for Disease Control and Prevention were combined with national data on emergency department visits for nonfatal firearm injury from the Nationwide Emergency Department (ED) sample. Data analysis was conducted from August 2019 to September 2020. Exposures: Firearm injuries identified with International Classification of Diseases external cause of injury codes and categorized by intent of injury, age group, and urban-rural location. Main Outcomes and Measures: Incidence, case fatality rate, and trends over time of firearm injury according to intent, age group, and urban-rural location. Results: From 2009 to 2017, there was a mean of 85 694 ED visits for nonfatal firearm injury and 34 538 deaths each year. An annual mean of 26 445 deaths (76.6%) occurred outside of the hospital. Assault was the most common overall mechanism (38.9%), followed by unintentional injuries (36.9%) and intentional self-harm (19.6%). Self-harm, which accounted for 21 128 deaths (61.2%), had the highest case fatality rate (89.4%; 95% CI, 88.5%-90.4%), followed by assault (25.9%; 95% CI, 23.7%-28.6%) and legal intervention (23.4%; 95% CI, 21.6%-25.5%). Unintentional injuries were the most common nonfatal injuries (43 729 [51.0%]) and had the lowest case fatality rate (1.2%; 95% CI, 1.1%-1.3%). Self-harm deaths, 87.8% of which occurred outside the hospital, increased in all age groups in both rural and urban areas during the study period and were most common among people aged 55 years and older. The rate of fatal assault injuries was higher in urban than in rural areas (16.6 vs 9.0 per 100 000 per year) and highest among people aged 15 to 34 years (38.6 per 100 000 per year). Rates of unintentional injury were higher in rural than in urban areas (18.5 per 100 000 vs 12.4 per 100 000). Conclusions and Relevance: In this cross-sectional study, suicide appears to be the most common cause of firearm injury death in the US, and most people who die from suicide never reach the hospital. These findings suggest that assaults and unintentional injuries account for most nonfatal and overall firearm injuries and for most of the injuries that are treated in hospitals.

13.
Ann Am Thorac Soc ; 17(12): 1599-1609, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32697602

RESUMO

Rationale: A small but growing number of hospitals are experimenting with emergency department-embedded critical care units (CCUs) in an effort to improve the quality of care for critically ill patients with sepsis and acute respiratory failure (ARF).Objectives: To evaluate the potential impact of an emergency department-embedded CCU at the Hospital of the University of Pennsylvania among patients with sepsis and ARF admitted from the emergency department to a medical ward or intensive care unit (ICU) from January 2016 to December 2017.Methods: The exposure was eligibility for admission to the emergency department-embedded CCU, which was defined as meeting a clinical definition for sepsis or ARF and admission to the emergency department during the intervention period on a weekday. The primary outcome was hospital length of stay (LOS); secondary outcomes included total emergency department plus ICU LOS, hospital survival, direct admission to the ICU, and unplanned ICU admission. Primary interrupted time series analyses were performed using ordinary least squares regression comparing monthly means. Secondary retrospective cohort and before-after analyses used multivariable Cox proportional hazard and logistic regression.Results: In the baseline and intervention periods, 3,897 patients met the inclusion criteria for sepsis and 1,865 patients met the criteria for ARF. Among patients admitted with sepsis, opening of the emergency department-embedded CCU was not associated with hospital LOS (ß = -1.82 d; 95% confidence interval [CI], -4.50 to 0.87; P = 0.17 for the first month after emergency department-embedded CCU opening compared with baseline; ß = -0.26 d; 95% CI, -0.58 to 0.06; P = 0.10 for subsequent months). Among patients admitted with ARF, the emergency department-embedded CCU was not associated with a significant change in hospital LOS for the first month after emergency department-embedded CCU opening (ß = -3.25 d; 95% CI, -7.86 to 1.36; P = 0.15) but was associated with a 0.64 d/mo shorter hospital LOS for subsequent months (ß = -0.64 d; 95% CI, -1.12 to -0.17; P = 0.01). This result persisted among higher acuity patients requiring ventilatory support but was not supported by alternative analytic approaches. Among patients admitted with sepsis who did not require mechanical ventilation or vasopressors in the emergency department, the emergency department-embedded CCU was associated with an initial 9.9% reduction in direct ICU admissions in the first month (ß = -0.099; 95% CI, -0.153 to -0.044; P = 0.002), followed by a 1.1% per month increase back toward baseline in subsequent months (ß = 0.011; 95% CI, 0.003-0.019; P = 0.009). This relationship was supported by alternative analytic approaches and was not seen in ARF. No associations with emergency department plus ICU LOS, hospital survival, or unplanned ICU admission were observed among patients with sepsis or ARF.Conclusions: The emergency department-embedded CCU was not associated with clinical outcomes among patients admitted with sepsis or ARF. Among less sick patients with sepsis, the emergency department-embedded CCU was initially associated with reduced rates of direct ICU admission from the emergency department. Additional research is necessary to further evaluate the impact and utility of the emergency department-embedded CCU model.


Assuntos
Serviço Hospitalar de Emergência , Unidades de Terapia Intensiva , Cuidados Críticos , Mortalidade Hospitalar , Hospitais , Humanos , Tempo de Internação , Estudos Retrospectivos
14.
Ann Am Thorac Soc ; 17(11): 1440-1447, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32521176

RESUMO

Rationale: Prior approaches to measuring healthcare capacity strain have been constrained by using individual care units, limited metrics of strain, or general, rather than disease-specific, populations.Objectives: We sought to develop a novel composite strain index and measure its association with intensive care unit (ICU) admission decisions and hospital outcomes.Methods: Using more than 9.2 million acute care encounters from 27 Kaiser Permanente Northern California and Penn Medicine hospitals from 2013 to 2018, we deployed multivariable ridge logistic regression to develop a composite strain index based on hourly measurements of 22 capacity-strain metrics across emergency departments, wards, step-down units, and ICUs. We measured the association of this strain index with ICU admission and clinical outcomes using multivariable logistic and quantile regression.Results: Among high-acuity patients with sepsis (n = 90,150) and acute respiratory failure (ARF; n = 45,339) not requiring mechanical ventilation or vasopressors, strain at the time of emergency department disposition decision was inversely associated with the probability of ICU admission (sepsis: adjusted probability ranging from 29.0% [95% confidence interval, 28.0-30.0%] at the lowest strain index decile to 9.3% [8.7-9.9%] at the highest strain index decile; ARF: adjusted probability ranging from 47.2% [45.6-48.9%] at the lowest strain index decile to 12.1% [11.0-13.2%] at the highest strain index decile; P < 0.001 at all deciles). Among subgroups of patients who almost always or never went to the ICU, strain was not associated with hospital length of stay, mortality, or discharge disposition (all P ≥ 0.13). Strain was also not meaningfully associated with patient characteristics.Conclusions: Hospital strain, measured by a novel composite strain index, is strongly associated with ICU admission among patients with sepsis and/or ARF. This strain index fulfills the assumptions of a strong within-hospital instrumental variable for quantifying the net benefit of admission to the ICU for patients with sepsis and/or ARF.


Assuntos
Hospitalização , Unidades de Terapia Intensiva , Serviço Hospitalar de Emergência , Mortalidade Hospitalar , Hospitais , Humanos , Estudos Retrospectivos
16.
JAMA Netw Open ; 3(5): e205852, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32459355

RESUMO

Importance: Timely initiation and referral to treatment for patients with opioid use disorder seen in the emergency department is associated with reduced mortality. It is not known how often commercially insured adults obtain follow-up treatment after nonfatal opioid overdose. Objective: To investigate the incidence of follow-up treatment following emergency department discharge after nonfatal opioid overdose and patient characteristics associated with receipt of follow-up treatment. Design, Setting, and Participants: A retrospective cohort study was conducted using an administrative claims database for a large US commercial insurer, from October 1, 2011, to September 30, 2016. Data analysis was performed from May 1, 2019, to September 26, 2019. Adult patients discharged from the emergency department after an index opioid overdose (no overdose in the preceding 90 days) were included. Patients with cancer and without continuous insurance enrollment were excluded. Main Outcomes and Measures: The primary outcome was follow-up treatment in the 90 days following overdose, defined as a combined outcome of claims for treatment encounters or medications for opioid use disorder (buprenorphine and naltrexone). Analysis was stratified by whether patients received treatment for opioid use disorder in the 90 days before the overdose. Logistic regression models were used to identify patient characteristics associated with receipt of follow-up treatment. Marginal effects were used to report the average adjusted probability and absolute risk differences (ARDs) in follow-up for different patient characteristics. Results: A total of 6451 patients were identified with nonfatal opioid overdose; the mean (SD) age was 45.0 (19.3) years, 3267 were women (50.6%), and 4676 patients (72.5%) reported their race as non-Hispanic white. A total of 1069 patients (16.6%; 95% CI, 15.7%-17.5%) obtained follow-up treatment within 90 days after the overdose. In adjusted analysis of patients who did not receive treatment before the overdose, black patients were half as likely to obtain follow-up compared with non-Hispanic white patients (ARD, -5.9%; 95% CI, -8.6% to -3.6%). Women (ARD, -1.7%; 95% CI, -3.3% to -0.5%) and Hispanic patients (ARD, -3.5%; 95% CI, -6.1% to -0.9%) were also less likely to obtain follow-up. For each additional year of age, patients were 0.2% less likely to obtain follow-up (95% CI, -0.3% to -0.1%). Conclusions and Relevance: Efforts to improve the low rate of timely follow-up treatment following opioid overdose may seek to address sex, race/ethnicity, and age disparities.


Assuntos
Assistência ao Convalescente/estatística & dados numéricos , Analgésicos Opioides/envenenamento , Overdose de Drogas/epidemiologia , Seguro Saúde/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/terapia , Adulto , Overdose de Drogas/terapia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia
18.
J Gen Intern Med ; 35(6): 1783-1788, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31898130

RESUMO

BACKGROUND: Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA. OBJECTIVE: To determine the effect of the ACA's young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose. DESIGN: Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011-2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses. PARTICIPANTS: Adults aged 23-25 years old and 27-29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose. MAIN MEASURES: Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults. KEY RESULTS: There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI - 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI - 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI - 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13-3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI - 0.80 to 1.78]). CONCLUSIONS: Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.


Assuntos
Overdose de Drogas , Overdose de Opiáceos , Adulto , Analgésicos Opioides , Overdose de Drogas/epidemiologia , Heroína , Humanos , Patient Protection and Affordable Care Act , Estados Unidos/epidemiologia , Adulto Jovem
19.
J Gen Intern Med ; 35(3): 662-671, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31602561

RESUMO

BACKGROUND: Prescribing limits are one policy strategy to reduce short-term opioid prescribing, but there is limited evidence of their impact. OBJECTIVE: Evaluate implementation of a state prescribing limit law and health system electronic medical record (EMR) alert on characteristics of new opioid prescriptions, refill rates, and clinical encounters. DESIGN: Difference-in-differences study comparing new opioid prescriptions from ambulatory practices in New Jersey (NJ) to controls in Pennsylvania (PA) from 1 year prior to the implementation of a NJ state prescribing limit (May 2016-May 2017) to 10 months after (May 2017-March 2018). PARTICIPANTS: Adults with new opioid prescriptions in an academic health system with practices in PA and NJ. INTERVENTIONS: State 5-day opioid prescribing limit plus health system and health system EMR alert. MAIN MEASURES: Changes in morphine milligram equivalents (MME) and tablet quantity per prescription, refills, and encounters, adjusted for patient and prescriber characteristics. KEY RESULTS: There were a total of 678 new prescriptions in NJ and 4638 in PA. Prior to the intervention, median MME/prescription was 225 mg in NJ and 150 mg in PA, and median quantity was 30 tablets in both. After implementation, median MME/prescription was 150 mg in both states, and median quantity was 20 in NJ and 30 in PA. In the adjusted model, there was a greater decrease in mean MME and tablet quantity in NJ relative to PA after implementation of the policy plus alert (- 82.99 MME/prescription, 95% CI - 148.15 to - 17.84 and - 10.41 tabs/prescription, 95% CI - 19.70 to - 1.13). There were no significant differences in rates of refills or encounters at 30 days based on exposure to the interventions. CONCLUSIONS: Implementation of a prescribing limit and EMR alert was associated with an approximately 22% greater decrease in opioid dose per new prescription in NJ compared with controls in PA. The combination of prescribing limits and alerts may be an effective strategy to influence prescriber behavior.


Assuntos
Analgésicos Opioides , Registros Eletrônicos de Saúde , Padrões de Prática Médica , Adulto , Idoso , Feminino , Humanos , Masculino , Medicare , New Jersey , Pennsylvania/epidemiologia , Prescrições , Estados Unidos
20.
J Trauma Acute Care Surg ; 88(1): 42-50, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31524837

RESUMO

BACKGROUND: Many injured patients presenting to Level III/IV trauma centers will be transferred to Level I/II centers, but how these transfers influence benchmarking at Level III/IV centers has not been described. We hypothesized that the apparent observed to expected (O:E) mortality ratios at Level III/IV centers are influenced by the location at which mortality is measured in transferred patients. METHODS: We conducted a retrospective study of adult patients presenting to Level III/IV trauma centers in Pennsylvania from 2008 to 2017. We used probabilistic matching to match patients transferred between centers. We used a risk-adjusted mortality model to estimate predicted mortality, which we compared with observed mortality at discharge from the Level III/IV center (O) or observed mortality at discharge from the Level III/IV center for nontransferred patients and at discharge from the Level I/II center for transferred patients (O). RESULTS: In total, 9,477 patients presented to 11 Level III/IV trauma centers over the study period (90% white; 49% female; 97% blunt mechanism; median Injury Severity Score, 8; interquartile range, 4-10). Of these, 4,238 (44%) were transferred to Level I/II centers, of which 3,586 (85%) were able to be matched. Expected mortality in the overall cohort was 332 (3.8%). A total of 332 (3.8%) patients died, of which 177 (53%) died at the initial Level III/IV centers (O). Including posttransfer mortality for transferred patients in addition to observed mortality in nontransferred patients (O) resulted in worse apparent O:E ratios for all centers and significant differences in O:E ratios for the overall cohort (O:E, 0.53; 95% confidence interval, 0.45-0.61 vs. O:E, 1.00, 95% confidence interval, 0.92-1.11; p < 0.001). CONCLUSION: Apparent O:E mortality ratios at Level III/IV centers are influenced by the timing of measurement. To provide fair and accurate benchmarking and identify opportunities across the continuum of the trauma system, a system of shared attribution for outcomes of transferred patients should be devised.


Assuntos
Benchmarking/métodos , Transferência de Pacientes/estatística & dados numéricos , Centros de Traumatologia/organização & administração , Ferimentos e Lesões/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Benchmarking/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/cirurgia
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