Projected Changes in Temperature-related Morbidity and Mortality in Southern New England.

BACKGROUND: Climate change is expected to result in more heat-related, but potentially fewer cold-related, emergency department visits and deaths. The net effect of projected changes in temperature on morbidity and mortality remains incompletely understood. We estimated the change in temperature-related morbidity and mortality at two sites in southern New England, United States, through the end of the 21st century. METHODS: We used distributed lag Poisson regression models to estimate the present-day associations between daily mean temperature and all-cause emergency department visits and deaths in Rhode Island and in Boston, Massachusetts. We estimated the change in temperature-related visits and deaths in 2045-2054 and 2085-2094 (relative to 2001-2010) under two greenhouse gas emissions scenarios (RCP4.5 and RCP8.5) using downscaled projections from an ensemble of over 40 climate models, assuming all other factors remain constant. RESULTS: We observed U-shaped relationships between temperature and morbidity and mortality in Rhode Island, with minima at 10.9°C and 22.5°C, respectively. We estimated that, if this population were exposed to the future temperatures projected under RCP8.5 for 2085-2094, there would be 5,976 (95% eCI = 1,630, 11,379) more emergency department visits but 218 (95% eCI = -551, 43) fewer deaths annually. Results were similar in Boston and similar but less pronounced in the 2050s and under RCP4.5. CONCLUSIONS: We estimated that in the absence of further adaptation, if the current southern New England population were exposed to the higher temperatures projected for future decades, temperature-related emergency department visits would increase but temperature-related deaths would not.

Heat-related morbidity and mortality in New England: Evidence for local policy.

BACKGROUND: Heat-related morbidity and mortality is a recognized public health concern. However, public health officials need to base policy decisions on local evidence, which is often lacking for smaller communities. OBJECTIVES: To evaluate the association between maximum daily heat index (HI) and morbidity and mortality in 15 New England communities (combined population: 2.7 million) in order to provide actionable evidence for local officials. METHODS: We applied overdispersed Poisson nonlinear distributed lag models to evaluate the association between HI and daily (May-September) emergency department (ED) admissions and deaths in each of 15 study sites in New Hampshire, Maine, and Rhode Island, controlling for time trends, day of week, and federal holidays. Site-specific estimates were meta-analyzed to provide regional estimates. RESULTS: Associations (sometimes non-linear) were observed between HI and each health outcome. For example, a day with a HI of 95°F vs. 75°F was associated with a cumulative 7.5% (95% confidence interval [CI]: 6.5%, 8.5%) and 5.1% (95% CI: 0.2%, 10.3%) higher rate of all-cause ED visits and deaths, respectively, with some evidence of regional heterogeneity. We estimate that in the study area, days with a HI≥95°F were associated with an annual average of 784 (95% CI: 658, 908) excess ED visits and 22 (95% CI: 3, 39) excess deaths. CONCLUSIONS: Our results suggest the presence of adverse health impacts associated with HI below the current local guideline criteria of HI≥100°F used to issue heat advisories. We hypothesize that lowering this threshold may lead to substantially reduced heat-related morbidity and mortality in the study area.

Randomized Trial of Communication Facilitators to Reduce Family Distress and Intensity of End-of-Life Care.

RATIONALE: Communication with family of critically ill patients is often poor and associated with family distress. OBJECTIVES: To determine if an intensive care unit (ICU) communication facilitator reduces family distress and intensity of end-of-life care. METHODS: We conducted a randomized trial at two hospitals. Eligible patients had a predicted mortality greater than or equal to 30% and a surrogate decision maker. Facilitators supported communication between clinicians and families, adapted communication to family needs, and mediated conflict. MEASUREMENTS AND MAIN RESULTS: Outcomes included depression, anxiety, and post-traumatic stress disorder (PTSD) among family 3 and 6 months after ICU and resource use. We identified 488 eligible patients and randomized 168. Of 352 eligible family members, 268 participated (76%). Family follow-up at 3 and 6 months ranged from 42 to 47%. The intervention was associated with decreased depressive symptoms at 6 months (P = 0.017), but there were no significant differences in psychological symptoms at 3 months or anxiety or PTSD at 6 months. The intervention was not associated with ICU mortality (25% control vs. 21% intervention; P = 0.615) but decreased ICU costs among all patients (per patient: $75,850 control, $51,060 intervention; P = 0.042) and particularly among decedents ($98,220 control, $22,690 intervention; P = 0.028). Among decedents, the intervention reduced ICU and hospital length of stay (28.5 vs. 7.7 d and 31.8 vs. 8.0 d, respectively; P < 0.001). CONCLUSIONS: Communication facilitators may be associated with decreased family depressive symptoms at 6 months, but we found no significant difference at 3 months or in anxiety or PTSD. The intervention reduced costs and length of stay, especially among decedents. This is the first study to find a reduction in intensity of end-of-life care with similar or improved family distress. Clinical trial registered with www.clinicaltrials.gov (NCT 00720200).

Enhancing resiliency for elderly populations : Shelter-in-place planning and training at facilities serving elderly populations through the Rhode Island Senior Resiliency Project.

Elderly populations are disproportionately affected by disasters. In part, this is true because for many older adults, special assistance is needed to mitigate the consequences of disasters on their health and wellbeing. In addition, many older adults may reside in diverse living complexes such as long-term care facilities, assisted living facilities and independent-living senior housing complexes. Planning for each type of facility is different and the unique features of these facilities must be considered to develop readiness to deal with disasters. Based on this, the Rhode Island Department of Health established the Senior Resiliency Project to bolster the level of resiliency for the types of living facilities housing older adults. The project involves performing onsite assessments of energy resources, developing site-specific sheltering-inplace and energy resiliency plans, and educating and training facility employees and residents on these plans and steps they can take to be better prepared. Based on the feasibility of conducting these activities within a variety of facilities housing older adults, the project is segmented into three phases. This paper describes survey findings, outcomes of interventions, challenges and recommendations for bridging gaps observed in phases 1 and 2 of the project.

Current and Projected Heat-Related Morbidity and Mortality in Rhode Island.

BACKGROUND: Climate change is expected to cause increases in heat-related mortality, especially among the elderly and very young. However, additional studies are needed to clarify the effects of heat on morbidity across all age groups and across a wider range of temperatures. OBJECTIVES: We aimed to estimate the impact of current and projected future temperatures on morbidity and mortality in Rhode Island. METHODS: We used Poisson regression models to estimate the association between daily maximum temperature and rates of all-cause and heat-related emergency department (ED) admissions and all-cause mortality. We then used downscaled Coupled Model Intercomparison Project Phase 5 (CMIP5; a standardized set of climate change model simulations) projections to estimate the excess morbidity and mortality that would be observed if this population were exposed to the temperatures projected for 2046-2053 and 2092-2099 under two representative concentration pathways (RCP): RCP 8.5 and 4.5. RESULTS: Between 2005 and 2012, an increase in maximum daily temperature from 75 to 85°F was associated with 1.3% and 23.9% higher rates of all-cause and heat-related ED visits, respectively. The corresponding effect estimate for all-cause mortality from 1999 through 2011 was 4.0%. The association with all-cause ED admissions was strongest for those < 18 or ≥ 65 years of age, whereas the association with heat-related ED admissions was most pronounced among 18- to 64-year-olds. If this Rhode Island population were exposed to temperatures projected under RCP 8.5 for 2092-2099, we estimate that there would be 1.2% (range, 0.6-1.6%) and 24.4% (range, 6.9-41.8%) more all-cause and heat-related ED admissions, respectively, and 1.6% (range, 0.8-2.1%) more deaths annually between April and October. CONCLUSIONS: With all other factors held constant, our findings suggest that the current population of Rhode Island would experience substantially higher morbidity and mortality if maximum daily temperatures increase further as projected. CITATION: Kingsley SL, Eliot MN, Gold J, Vanderslice RR, Wellenius GA. 2016. Current and projected heat-related morbidity and mortality in Rhode Island. Environ Health Perspect 124:460-467; http://dx.doi.org/10.1289/ehp.1408826.

Primary care residents want to learn about the patient-centered medical home.

BACKGROUND AND OBJECTIVES: The patient-centered medical home (PCMH) is an important model of primary care with a promise of improving quality, reducing costs, and improving patient satisfaction. Many primary care residency programs have PCMH initiatives, but it is unclear if residents are interested in learning more about the PCMH. Our objective was to examine primary care residents' attitudes and knowledge about the PCMH model and how it relates to them. METHODS: A total of 82 first- through third-year family medicine and internal medicine residents participated in a survey with 25 questions. Descriptive statistics were performed to describe the responses. RESULTS: The survey response rate was 91%. Sixty-one percent of residents thought they had "poor" or "fair" knowledge of the PCMH, and 84% thought it was important to be knowledgeable about the PCMH. Thirty-four percent rated their ability to describe the PCMH as "well" or "very well." Eighty-six percent thought they learned "too little" or "way too little" about the PCMH during medical school. The majority (88%) of residents were interested in learning more about the PCMH. CONCLUSIONS: Family and internal medicine residents are interested in learning more about the PCMH during residency. Residents may benefit from experiential learning that focuses on the PCMH.

Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU.

The intensive care unit (ICU), where death is common and even survivors of an ICU stay face the risk of long-term morbidity and re-admissions to the ICU, represents an important setting for improving communication about palliative and end-of-life care. Communication about the goals of care in this setting should be a high priority since studies suggest that the current quality of ICU communication is often poor and is associated with psychological distress among family members of critically ill patients. This paper describes the development and evaluation of an intervention designed to improve the quality of care in the ICU by improving communication among the ICU team and with family members of critically ill patients. We developed a multi-faceted, interprofessional intervention based on self-efficacy theory. The intervention involves a "communication facilitator" - a nurse or social worker - trained to facilitate communication among the interprofessional ICU team and with the critically ill patient's family. The facilitators are trained using three specific content areas: a) evidence-based approaches to improving clinician-family communication in the ICU, b) attachment theory allowing clinicians to adapt communication to meet individual family member's communication needs, and c) mediation to facilitate identification and resolution of conflict including clinician-family, clinician-clinician, and intra-family conflict. The outcomes assessed in this randomized trial focus on psychological distress among family members including anxiety, depression, and post-traumatic stress disorder at 3 and 6 months after the ICU stay. This manuscript also reports some of the lessons that we have learned early in this study.