Impacts of Hurricane Matthew Exposure on Infections and Antimicrobial Prescribing in North Carolina Veterans.

The impact of hurricane-related flooding on infectious diseases in the US is not well understood. Using geocoded electronic health records for 62,762 veterans living in North Carolina counties impacted by Hurricane Matthew coupled with flood maps, we explore the impact of hurricane and flood exposure on infectious outcomes in outpatient settings and emergency departments as well as antimicrobial prescribing. Declines in outpatient visits and antimicrobial prescribing are observed in weeks 0-2 following the hurricane as compared with the baseline period and the year prior, while increases in antimicrobial prescribing are observed 3+ weeks following the hurricane. Taken together, hurricane and flood exposure appear to have had minor impacts on infectious outcomes in North Carolina veterans, not resulting in large increases in infections or antimicrobial prescribing.

Impact of a Community-Based Weight Management Program in a North Carolina Health Care System.

BACKGROUND AND OBJECTIVES:  Current strategies for obesity management in primary care leave many patients inadequately treated or unable to access treatment entirely. We aimed to evaluate a comprehensive, primary care clinic-based weight management program's clinical effectiveness in a community practice setting.  Methods:  This was an 18-month pre/postintervention study. We collected demographic and anthropometric data on patients enrolled in a primary care-based weight management program. The primary outcomes were percent weight loss postintervention and the proportion of patients who achieved a clinically significant total body weight loss (TBWL) of 5% or greater.  Results:  Our program served 550 patients over 1,952 visits from March 2019 through October 2020. A total of 209 patients had adequate program exposure, defined as four or more completed visits. Among these, all received targeted lifestyle counseling and 78% received antiobesity medication. Patients who attended at least four visits had an average TBWL of 5.7% compared to an average gain of 1.5% total body weight for those with only one visit. Fifty-three percent of patients (n=111) achieved greater than 5% TBWL, and 20% (n=43) achieved greater than 10% TBWL. CONCLUSION:  We demonstrated that a community-based weight management program delivered by obesity medicine-trained primary care providers effectively produces clinically significant weight loss. Future work will include wider implementation of this model to increase patient access to evidence-based obesity treatments in their communities.

Injury severity analysis of time-of-day fluctuations and temporal volatility in reverse sideswipe collisions: A random parameter model with heterogeneous means and heteroscedastic variances.

PROBLEM: Sideswipe collisions in the opposite direction often result in more severe injuries than the typical same-direction crashes, especially when light trucks are involved. This study investigates the time-of-day fluctuations and temporal volatility of potential factors that affect the injury severity of reverse sideswipe collisions. METHODS: A series of random parameters logit models with heterogeneous means and heteroscedastic variances are developed and utilized to explore unobserved heterogeneity inherent in variables and preclude biased parameter estimation. The segmentation of estimated results is also examined through temporal instability tests. RESULTS: Based on crash data in North Carolina, a number of contributing factors are identified that have profound associations with obvious and moderate injuries. Meanwhile, significant temporal volatility is observed in the marginal effects of several factors such as driver restraint, alcohol or drugs impact, Sport Utility Vehicle (SUV) at fault, and adverse road surface across three different periods. Fluctuations in the time of day indicate that restraint with belts is more effective in mitigating the obvious injury in the nighttime, and high-class roadway sustains a higher probability of resulting in more serious injury compared to the daytime. PRACTICAL APPLICATIONS: The findings of this study could help further guide the implementation of safety countermeasures related to atypical sideswipe collisions.

Frequency and types of alternative breeding strategies employed by nesting American black ducks in North Carolina.

Although most birds are considered to be at least partially monogamous, molecular evidence continues to uncover that many species can have multiple sexual mates. Many species of Waterfowl (Order Anseriformes) consistently deploy alternative breeding strategies, and although cavity nesting species have been well studied, few attempts to understand rates of alternative breeding strategies exist in the Anatini tribe. Here, we assay mitochondrial DNA and thousands of nuclear markers across 20 broods of American black ducks (Anas rubripes; "black duck") that included 19 females and 172 offspring to study population structure as well as types and rates of secondary breeding strategies in coastal North Carolina. First, we report high levels of relatedness among nesting black ducks and offspring and while 17 (of 19) females were of pure black duck descent, three were found to be black duck x mallard (A. platyrhynchos) hybrids. Next, we evaluated for mismatched mitochondrial DNA and paternity identities across each female's clutch to determine types and frequency of alternative or secondary breeding strategies. Although we report that nest parasitism occurred in two nests, 37% (7 of 19) of the sampled nests were multi-paternal as a result of extra-pair copulation. In addition to being part of a mix of strategies used to increase fecundity by successfully breeding females, we posit nest densities providing easier alternative mate access for males also explains high rates of extra-pair copulation among our sampled black ducks. Ultimately, however, while some proportion of females of many species engage in forms of secondary breeding strategies, we conclude that the decision to do so appears to be seasonally flexible for each individual.

Hurricane Florence and suicide mortality in North Carolina: a controlled interrupted time-series analysis.

BACKGROUND: Natural disasters are associated with increased mental health disorders and suicidal ideation; however, associations with suicide deaths are not well understood. We explored how Hurricane Florence, which made landfall in September 2018, may have impacted suicide deaths in North Carolina (NC). METHODS: We used publicly available NC death records data to estimate associations between Hurricane Florence and monthly suicide death rates using a controlled, interrupted time series analysis. Hurricane exposure was determined by using county-level support designations from the Federal Emergency Management Agency. We examined effect modification by sex, age group, and race/ethnicity. RESULTS: 8363 suicide deaths occurred between January 2014 and December 2019. The overall suicide death rate in NC between 2014 and 2019 was 15.53 per 100 000 person-years (95% CI 15.20 to 15.87). Post-Hurricane, there was a small, immediate increase in the suicide death rate among exposed counties (0.89/100 000 PY; 95% CI -2.69 to 4.48). Comparing exposed and unexposed counties, there was no sustained post-Hurricane Florence change in suicide death rate trends (0.02/100 000 PY per month; 95% CI -0.33 to 0.38). Relative to 2018, NC experienced a statewide decline in suicides in 2019. An immediate increase in suicide deaths in Hurricane-affected counties versus Hurricane-unaffected counties was observed among women, people under age 65 and non-Hispanic black individuals, but there was no sustained change in the months after Hurricane Florence. CONCLUSIONS: Although results did not indicate a strong post-Hurricane Florence impact on suicide rates, subgroup analysis suggests differential impacts of Hurricane Florence on several groups, warranting future follow-up.

Race, geography, and risk of breast cancer treatment delays: A population-based study 2004-2015.

BACKGROUND: Treatment delays affect breast cancer survival and constitute poor-quality care. Black patients experience more treatment delay, but the relationship of geography to these disparities is poorly understood. METHODS: We studied a population-based, retrospective, observational cohort of patients with breast cancer in North Carolina between 2004 and 2017 from the Cancer Information and Population Health Resource, which links cancer registry and sociodemographic data to multipayer insurance claims. We included patients >18 years with Stage I-III breast cancer who received surgery or chemotherapy as their first treatment. Delay was defined as >60 days from diagnosis to first treatment. Counties were aggregated into nine Area Health Education Center regions. Race was dichotomized as Black versus non-Black. RESULTS: Among 32,626 patients, 6190 (19.0%) were Black. Black patients were more likely to experience treatment delay >60 days (15.0% of Black vs. 8.0% of non-Black). Using race-stratified modified Poisson regression, age-adjusted relative risk of delay in the highest risk region was approximately twice that in the lowest risk region among Black (relative risk, 2.1; 95% CI, 1.6-2.6) and non-Black patients (relative risk, 1.9; 95% CI, 1.5-2.3). Adjustment for clinical and sociodemographic features only slightly attenuated interregion differences. The magnitude of the racial gap in treatment delay varied by region, from 0.0% to 9.4%. CONCLUSIONS: Geographic region was significantly associated with risk of treatment delays for both Black and non-Black patients. The magnitude of racial disparities in treatment delay varied markedly between regions. Future studies should consider both high-risk geographic regions and high-risk patient groups for intervention to prevent delays.

SARS-CoV-2 Antibody Prevalence among Industrial Livestock Operation Workers and Nearby Community Residents, North Carolina, 2021 to 2022.

Industrial livestock operations (ILOs), particularly processing facilities, emerged as centers of coronavirus disease 2019 (COVID-19) outbreaks in spring 2020. Confirmed cases of COVID-19 underestimate true prevalence. To investigate the prevalence of antibodies against SARS-CoV-2, we enrolled 279 participants in North Carolina from February 2021 to July 2022: 90 from households with at least one ILO worker (ILO), 97 from high-ILO intensity areas (ILO neighbors [ILON]), and 92 from metropolitan areas (metro). More metro (55.4%) compared to ILO (51.6%) and ILON participants (48.4%) completed the COVID-19 primary vaccination series; the median completion date was more than 4 months later for ILO compared to ILON and metro participants, although neither difference was statistically significant. Participants provided a saliva swab we analyzed for SARS-CoV-2 IgG using a multiplex immunoassay. The prevalence of infection-induced IgG (positive for nucleocapsid and receptor binding domain) was higher among ILO (63%) than ILON (42.9%) and metro (48.7%) participants (prevalence ratio [PR], 1.38; 95% confidence interval [CI], 1.06 to 1.80; reference category ILON and metro combined). The prevalence of infection-induced IgG was also higher among ILO participants than among an Atlanta health care worker cohort (PR, 2.45; 95% CI, 1.80 to 3.33) and a general population cohort in North Carolina (PRs, 6.37 to 10.67). The infection-induced IgG prevalence increased over the study period. Participants reporting not masking in public in the past 2 weeks had higher infection-induced IgG prevalence (78.6%) than participants reporting masking (49.3%) (PR, 1.59; 95% CI, 1.19 to 2.13). Lower education, more people per bedroom, Hispanic/Latino ethnicity, and more contact with people outside the home were also associated with higher infection-induced IgG prevalence. IMPORTANCE Few studies have measured COVID-19 seroprevalence in North Carolina, especially among rural, Black, and Hispanic/Latino communities that have been heavily affected. Antibody results show high rates of COVID-19 among industrial livestock operation workers and their household members. Antibody results add to evidence of health disparities related to COVID-19 by socioeconomic status and ethnicity. Associations between masking and physical distancing with antibody results also add to evidence of the effectiveness of these prevention strategies. Delays in the timing of receipt of COVID-19 vaccination reinforce the importance of dismantling vaccination barriers, especially for industrial livestock operation workers and their household members.

Investigation of a Symptomatic Tick Bite Patient Confirms Borrelia burgdorferi in Ixodes scapularis and White-Footed Mice in Ashe County, North Carolina.

In June 2021, a traveler to Ashe County, North Carolina, was bitten by an Ixodes scapularis tick. The patient experienced axillary lymphadenopathy and an erythematous rash near the bite site. We confirmed Borrelia burgdorferi sensu stricto through PCR testing and DNA sequencing in the attached tick and later from mice trapped inside the cabin where the patient stayed.

Trends in fatal occupational injury rates among older workers before and after the Great Recession of 2008.

BACKGROUND: Older workers experience higher rates of fatal occupational injury than younger workers worldwide. In North Carolina, the population of older workers more than doubled between 2000 and 2017. In 2008, the Great Recession changed occupational patterns among all age groups. We examined annual rates and distribution of fatal occupational injuries experienced by older workers, comparing the pre-recession period (2000-2007) to the post-recession period (2009-2017). METHODS: Detailed information on all fatal occupational injuries during the period between 1 January 2000 and 31 December 2017 were abstracted from the records of the North Carolina Office of the Chief Medical Examiner and the office of vital records. The decennial Census and American Community Survey were used to estimate the population at risk and derive annual rates of fatal occupational injury. RESULTS: During the study period, 537 occupational fatalities occurred among workers 55+ years of age. The rate of fatal occupational injury among older workers declined 2.8% per year, with a 7.7% yearly decline in the pre-recession period compared with a 1.4% increase per year in the post-recession period. Workers 65+ years of age experienced rate increases in both periods. The highest rates of unintentional fatal occupational injury (injuries that were not purposefully inflicted) were observed in forestry, fishing hunting and trapping, and wood building manufacturing. Intentional fatal occupational injury rates (homicide, suicide) were highest in transportation, gas/service stations and grocery/food stores. CONCLUSIONS: Older workers have persistently high rates of fatal occupational injury in North Carolina before and after the Great Recession.

North Carolina pharmacists' willingness to sell fentanyl test strips: a survey study.

BACKGROUND: Although fentanyl test strips (FTS) can accurately determine the presence of fentanyl in unregulated substances, access to FTS remains limited. This study aimed to examine North Carolina community pharmacists' attitudes and willingness to engage in various behaviors related to FTS sales and distribution. METHODS: A convenience sample of community pharmacists completed an online survey that assessed: (1) comfort initiating an FTS conversation; (2) willingness to sell FTS, distribute FTS instructions, counsel on FTS, refer patients to harm reduction organizations, and advertise FTS; (3) perceived barriers and benefits of selling FTS; and (4) interest in FTS training. Data were collected from March to May 2022. Descriptive statistics were calculated. RESULTS: Of the 592 pharmacists who participated, most were somewhat or very willing to refer patients to harm reduction organizations for FTS (514, 86.9%), counsel on FTS (485, 81.9%), distribute FTS instructions (475, 80.2%), sell FTS (470, 79.3%), and advertise FTS for sale (372, 62.9%). The most commonly reported benefits of selling FTS were reducing overdose deaths in the community (n = 482, 81.4%) and participating in community harm reduction efforts (n = 455; 76.9%). Barriers commonly reported to selling FTS were: not knowing where to order FTS (n = 295, 49.8%) and discomfort initiating a conversation about FTS (n = 266, 44.9%). Most respondents (88.3%) were interested in FTS training. CONCLUSION: North Carolina community pharmacists are willing to engage in various behaviors related to FTS sales and distribution. Most pharmacists were interested in receiving FTS training, which should be created to address pharmacist-reported barriers to FTS sales. Pharmacist distribution of FTS could increase access to FTS at the community level and has the potential to change drug use behavior and reduce overdose deaths.

The association between information technology sophistication and patient portal use: A cross sectional study in Eastern North Carolina.

Even with the extolled benefits of patient portals, there has been some challenges to ensuring patient portal use. This study examines if a patient's level of information technology (IT) sophistication, defined as the degree of use of diverse information technologies by an individual, is associated with their use of a patient portal. Patients previous experience and exposure to other similar technologies like desktop computer, laptop, internet, smart phone, or social media explains their willingness to use information technology for their health. Data on a cross-sectional survey of 565 individuals in Eastern NC was available for analysis. Multinomial regression analyses revealed that IT sophistication is important in determining whether patients will use a patient portal. It specifies that patients with low IT sophistication compared to those with high IT sophistication were more likely to have never activated their patient portals (RRR = 2.2155, p < 0.009), or to have activated but never used a patient portal (RRR = 3.5869, p < 0.010). The findings of this study should aid healthcare leaders as they strive to improve patient engagement. They should continue to promote the benefits of the patient portal and consider offering personalized support programs for patients with low IT sophistication.

COVID-19 Symptoms by Variant Period in the North Carolina COVID-19 Community Research Partnership, North Carolina, USA.

In North Carolina, USA, the SARS-CoV-2 Omicron variant was associated with changing symptomology in daily surveys, including increasing rates of self-reported cough and sore throat and decreased rates of loss of taste and smell. Compared with the pre-Delta period, Delta and Omicron (pre-BA.4/BA.5) variant periods were associated with shorter symptom duration.

Community socioeconomic and urban-rural differences in emergency medical services times for suspected stroke in North Carolina.

OBJECTIVE: Our objectives were to describe time intervals of EMS encounters for suspected stroke patients in North Carolina (NC) and evaluate differences in EMS time intervals by community socioeconomic status (SES) and rurality. METHODS: This cross-sectional study used statewide data on EMS encounters of suspected stroke in NC in 2019. Eligible patients were adults requiring EMS transport to a hospital following a 9-1-1 call for stroke-like symptoms. Incident street addresses were geocoded to census tracts and linked to American Community Survey SES data and to rural-urban commuting area (RUCA) codes. Community SES was defined as high, medium, or low based on tertiles of an SES index. Urban, suburban, and rural tracts were defined by RUCA codes 1, 2-6, and 7-10, respectively. Multivariable quantile regression was used to estimate how the median and 90th percentile of EMS time intervals varied by community SES and rurality, adjusting for each other; patient age, gender, and race/ethnicity; and incident characteristics. RESULTS: We identified 17,117 eligible EMS encounters of suspected stroke from 2028 census tracts. The population was 65% 65+ years old; 55% female; and 69% Non-Hispanic White. Median response, scene, and transport times were 8 (interquartile range, IQR 6-11) min, 16 (IQR 12-20) min, and 14 (IQR 9-22) minutes, respectively. In quantile regression adjusted for patient demographics, minimal differences were observed for median response and scene times by community SES and rurality. The largest median differences were observed for transport times in rural (6.7 min, 95% CI 5.8, 7.6) and suburban (4.7 min, 95% CI 4.2, 5.1) tracts compared to urban tracts. Adjusted rural-urban differences in 90th percentile transport times were substantially greater (16.0 min, 95% CI 14.5, 17.5). Low SES was modesty associated with shorter median (-3.3 min, 95% CI -3.8, -2.9) and 90th percentile (-3.0 min, 95% CI -4.0, -2.0) transport times compared to high SES tracts. CONCLUSIONS: While community-level factors were not strongly associated with EMS response and scene times for stroke, transport times were significantly longer rural tracts and modestly shorter in low SES tracts, accounting for patient demographics. Further research is needed on the role of community socioeconomic deprivation and rurality in contributing to delays in prehospital stroke care.

Prostate cancer aggressiveness and financial toxicity among prostate cancer patients.

INTRODUCTION: Financial toxicity (FT) is a growing concern among cancer survivors that adversely affects the quality of life and survival. Individuals diagnosed with aggressive cancers are often at a greater risk of experiencing FT. The objectives of this study were to estimate FT among prostate cancer (PCa) survivors after 10-15 years of diagnosis, assess the relationship between PCa aggressiveness at diagnosis and FT, and examine whether current cancer treatment status mediates the relationship between PCa aggressiveness and FT. METHODS: PCa patients enrolled in the North Carolina-Louisiana Prostate Cancer Project (PCaP) were recontacted for long-term follow-up. The prevalence of FT in the PCaP cohort was estimated. FT was estimated using the COmprehensive Score for Financial Toxicity, a validated measure of FT. The direct effect of PCa aggressiveness and an indirect effect through current cancer treatment on FT was examined using causal mediation analysis. RESULTS: More than one-third of PCa patients reported experiencing FT. PCa aggressiveness was significantly independently associated with high FT; high aggressive PCa at diagnosis had more than twice the risk of experiencing FT than those with low or intermediate aggressive PCa (adjusted odds ratio [aOR] = 2.13, 95% CI = 1.14-3.96). The proportion of the effect of PCa aggressiveness on FT, mediated by treatment status, was 10%, however, the adjusted odds ratio did not indicate significant evidence of mediation by treatment status (aOR = 1.05, 95% CI = 0.95-1.20). CONCLUSIONS: Aggressive PCa was associated with high FT. Future studies should collect more information about the characteristics of men with high FT and identify additional risk factors of FT.

Experiences with small and large numbers of protesters at abortion clinics in North Carolina.

OBJECTIVES: To analyze the association between number of antiabortion protesters and patients' and their companions' experiences accessing abortion clinics in North Carolina. STUDY DESIGN: In this concurrent mixed-methods study conducted in 2018-2019 at two independent abortion clinics in North Carolina, the author triangulated the methods of participant observation, descriptive statistical analysis of survey data, and thematic content analysis of open-ended responses to compare experiences of respondents who observed larger (>10) versus smaller (1-10) numbers of protesters at their clinic visit. The analytic sample contained experiences of patients and companions who saw protesters during the study period. RESULTS: Of 1530 people approached for the survey, 886 (58%) completed the questionnaire. Overall, 655 respondents were included in the analysis. Most respondents (n = 546, 83%) saw 1 to 10 protesters, versus those who saw >10 protesters (n = 109, 17%). Respondents who saw 1 to 10 protesters had their cars stopped at higher rates (53%) than those who saw >10 protesters (40%) but reported being physically approached at similar rates (22% vs. 23%). Respondents who saw >10 protesters indicated that it was more dangerous to drive into the clinic (44% vs. 23%) and more difficult to access the clinic (65% vs. 39%), when compared with people who saw 1 to 10 protesters. Respondents who saw >10 protesters also reported that they thought about leaving more frequently (21% vs. 12%), that the protesters made them feel unsafe (44% vs. 23%), made their visit more stressful (71% vs. 59%), and protesters negatively impacted their clinic experience at higher rates (47% vs. 31%). CONCLUSIONS: Respondents experienced logistical barriers to clinic access regardless of the number of protesters, though these worsened with larger numbers of protesters. Respondents perceived larger numbers of protesters as more intimidating and felt less safe navigating into the clinic. While all respondents made it to their appointments, these perceptions about larger numbers show how clinic protesting is an intimidating force that interferes with clinic access. IMPLICATIONS: Showing the ways that the number of protesters relates to logistical and emotional barriers can help clinics in planning mitigation measures to address issues of clinic access for their patients and their companions.

Lead Levels in Spices From Market Basket and Home Lead Investigation Samples in North Carolina.

OBJECTIVES: Lead investigators in North Carolina found evidence that contaminated spices may contribute to children's elevated blood lead levels. We compared lead levels in samples of spices and other consumable products by country of purchase to inform consumer safety interventions and regulations. METHODS: From February 1, 2011, through October 22, 2020, North Carolina lead investigators sampled spices and other consumable products from 103 homes of children with confirmed elevated blood lead levels. In 2017, the study team purchased 50 products frequently sampled during lead investigations, as a "market basket" sample, from local stores in or near Raleigh, North Carolina. The State Laboratory of Public Health analyzed 423 product samples using mass spectrometry. We extracted environmental sample results from lead investigations from the North Carolina Electronic Lead Surveillance System. RESULTS: The median market basket lead result was 0.07 mg/kg (SD = 0.17); the maximum lead result was 0.88 mg/kg. The median home lead investigation sample result was 0.26 mg/kg (SD = 489.44); the maximum lead result was 6504.00 mg/kg in turmeric purchased in India. Among all samples, products purchased in India had more than triple the median lead levels (0.71 mg/kg) of those purchased in the United States (0.19 mg/kg). CONCLUSIONS: Purchasing spices in the United States is an action that consumers can take that may reduce their lead poisoning risk. Regulatory agencies should consider a lead limit of <1 mg/kg as attainable for spices sold in US stores and for ingredients of any foods that may be consumed by children.

Appendectomy by Pediatric Surgeons in North Carolina is Associated With Higher Charge Than General Surgeons.

INTRODUCTION: The delivery of pediatric surgical care for acute appendicitis involves general surgeons (GS) and pediatric surgeons (PS), but the differences in clinical practice are primarily undescribed. We examined charge differences between GS and PS for the treatment of pediatric acute appendicitis. METHODS: We performed a retrospective review of the North Carolina hospital discharge database (2013-2017) in pediatric patients (≤18 y) who had surgery for appendiceal pathology (acute or chronic appendicitis and other appendiceal pathology). We performed a bivariate analysis of surgical charges over the type of surgical providers (GS, PS, other specialty, and unassigned surgeons). RESULTS: Over the study period, 21,049 patients had appendicitis or other diseases of the appendix, and 15,230 (72.4%) underwent appendectomy. Patients who were operated on by PS were younger (10 y, interquartile range (IQR): 6-13 versus 13 y, IQR: 9-16, P < 0.001). Acute appendicitis was diagnosed in 2860 (44.3%) and 3173 (49.2%) of the PS and GS cohorts, respectively, P = 0.008. PS compared to GS performed a higher percentage of laparoscopic (n = 2,697, 89.4% versus n = 2,178, 65.5%) than open appendectomies (n = 280, 9.3% versus n = 1,118, 33.6%), P < 0.001. The overall hospital charges were $28,081 (IQR: $21,706-$37,431) and $24,322 (IQR: $17,906-$32,226) for PS and GS, respectively, P < 0.001. Surgical charges where higher for PS than GS, $12,566 (IQR: $9802-$17,462) and $8051 (IQR: $5872-$2331), respectively. When controlling for diagnosis, surgical approach, emergent status, age, and surgical cost of appendiceal surgery, and hospital charges following appendiceal surgery were $4280 higher for PS than GS (95% CI: 3874-4687). CONCLUSIONS: The total charge for operations for appendiceal disease is significantly higher for PS compared to GS. Pediatric surgeons had increased surgical charges compared to GS but decreased radiology charges. The specific reasons for these differences are not clearly delineated in this data set and persist after controlling for relevant covariates. However, these data demonstrate that increasing value in pediatric appendicitis may require specialty-based targets.

The effect of increased emergency department demand on throughput times and disposition status for pediatric psychiatric patients.

OBJECTIVES: Emergency department (ED) crowding has been shown to increase throughput measures of length of stay (LOS), wait time, and boarding time. Psychiatric utilization of the ED has increased, particularly among younger patients. This investigation quantifies the effect of ED demand on throughput times and discharge disposition for pediatric psychiatric patients in the ED. METHODS: Using electronic medical record data from 1,151,396 ED visits in eight North Carolina EDs from January 1, 2018, through December 31, 2020, we identified 14,092 pediatric psychiatric visits. Measures of ED daily demand rates included overall occupancy as well as daily proportion of non-psychiatric pediatric patients, adult psychiatric patients, and pediatric psychiatric patients. Controlling for patient-level factors such as age, sex, race, insurance, and triage acuity, we used linear regression to predict throughput times and logistic regression to predict disposition status. We estimated effects of ED demand by academic versus community hospital status due to ED and inpatient resource differences. RESULTS: Most ED demand measures had insignificant or only very small associations with throughput measures for pediatric psychiatric patients. Notable exceptions were that a one percentage point increase in the proportion of non-psychiatric pediatric ED visits increased boarding times at community sites by 1.06 hours (95% CI: 0.20-1.92), while a one percentage point increase in the proportion of pediatric psychiatric ED visits increased LOS by 3.64 hours (95% CI: 2.04-5.23) at the academic site. We found that ED demand had a minimal effect on disposition status, with small increases in demand rates favoring <1 percentage point increases in the likelihood of discharge. Instead, patient-level factors played a much stronger role in predicting discharge disposition. CONCLUSIONS: ED demand has a meaningful effect on throughput times, but a minimal effect on disposition status. Further research is needed to validate these findings across other state and healthcare systems.

COVID-19 Symptoms by Variant Period in the North Carolina COVID-19 Community Research Partnership, North Carolina, USA.

In North Carolina, USA, the SARS-CoV-2 Omicron variant was associated with changing symptomology in daily surveys, including increasing rates of self-reported cough and sore throat and decreased rates of loss of taste and smell. Compared with the pre-Delta period, Delta and Omicron (pre-BA.4/BA.5) variant periods were associated with shorter symptom duration.

Association of prenatal stress with distance to delivery for pregnant women in Western North Carolina.

PURPOSE: Rural areas throughout the US continue to see closures of maternity wards and decreasing access to prenatal and intrapartum care. Studies examining closure's impacts have demonstrated both positive and negative effects on maternal and neonatal outcomes of mortality and morbidity. Our study aims to build on growing evidence from Canada and Scandinavia that suggests increased travel time to give birth is associated with increased emotional and financial stress for rural pregnant women. METHODS: Pregnant patients at 7 clinic sites in western North Carolina were invited to complete the Rural Pregnancy Experience Scale (RPES) while waiting for their prenatal appointments. Results were analyzed using adjusted linear regressions to examine the correlation between RPES scores and self-reported distance to anticipated birth location as well as RPES scores with recent local labor and delivery closure. FINDINGS: A total of 174 participants completed the survey and met inclusion criteria. For every 10 min increase in travel distance to the patient's anticipated place of delivery, RPES scores increased by an average of 0.72 points. Participants who reported a recent labor and delivery unit closure near them saw average increases of 2.52 on the RPES. CONCLUSIONS: Our findings are consistent with the growing body of literature internationally that demonstrates the distance required to travel to delivery location is associated with increased stress among rural pregnant women.