Association of Neighborhood-Level Material Deprivation With Atrial Fibrillation Care in a Single-Payer Health Care System: A Population-Based Cohort Study.

BACKGROUND: There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care. METHODS: This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply. RESULTS: Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]). CONCLUSIONS: Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.

Post-acute health care burden after SARS-CoV-2 infection: a retrospective cohort study.

BACKGROUND: The post-acute burden of health care use after SARS-CoV-2 infection is unknown. We sought to quantify the post-acute burden of health care use after SARS-CoV-2 infection among community-dwelling adults in Ontario by comparing those with positive and negative polymerase chain reaction (PCR) test results for SARS-CoV-2 infection. METHODS: We conducted a retrospective cohort study involving community-dwelling adults in Ontario who had a PCR test between Jan. 1, 2020, and Mar. 31, 2021. Follow-up began 56 days after PCR testing. We matched people 1:1 on a comprehensive propensity score. We compared per-person-year rates for health care encounters at the mean and 99th percentiles, and compared counts using negative binomial models, stratified by sex. RESULTS: Among 531 702 matched people, mean age was 44 (standard deviation [SD] 17) years and 51% were female. Females who tested positive for SARS-CoV-2 had a mean of 1.98 (95% CI 1.63 to 2.29) more health care encounters overall per-person-year than those who had a negative test result, with 0.31 (95% CI 0.05 to 0.56) more home care encounters to 0.81 (95% CI 0.69 to 0.93) more long-term care days. At the 99th percentile per-person-year, females who tested positive had 6.48 more days of hospital admission and 28.37 more home care encounters. Males who tested positive for SARS-CoV-2 had 0.66 (95% CI 0.34 to 0.99) more overall health care encounters per-person-year than those who tested negative, with 0.14 (95% CI 0.06 to 0.21) more outpatient encounters and 0.48 (95% CI 0.36 to 0.60) long-term care days, and 0.43 (95% CI -0.67 to -0.21) fewer home care encounters. At the 99th percentile, they had 8.69 more days in hospital per-person-year, with fewer home care (-27.31) and outpatient (-0.87) encounters. INTERPRETATION: We found significantly higher rates of health care use after a positive SARS-CoV-2 PCR test in an analysis that matched test-positive with test-negative people. Stakeholders can use these findings to prepare for health care demand associated with post-COVID-19 condition (long COVID).

Implementation of Telehealth for Psychiatric Care in VA Emergency Departments and Urgent Care Clinics.

Objective: To conduct a mixed-methods evaluation of an emergency telehealth intervention in unscheduled settings (emergency department [ED] and urgent care clinic [UCC]) within the Veterans Health Administration (VHA). Materials and Methods: We used the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to conduct a mixed-methods evaluation of a novel telehealth program implemented in the VHA (Hospital System) in March 2020. We compared the 3 months preimplementation (December 1, 2019 through February 29, 2020) with the 3 months postimplementation (April 1, 2020 through June 30, 2020), then followed sustainability through January 31, 2021. Qualitative data were obtained from surveys and semistructured interviews of staff and providers and analyzed with thematic analysis. Results: Patient demographics and dispositions were similar pre- and postimplementation. The telemental health intervention was used in 319 (83%) unscheduled mental health consultations in the postimplementation phase. After implementation, we did not detect adverse trends in length of stay, 7-day revisits, or 30-day mortality. Use remained high with 82% (n = 1,010) of all unscheduled mental health consultations performed by telemental health in the sustainability phase. Staff and clinician interviews identified the following themes in the use of telemental health: (1) enhanced efficiency without compromising quality and safety, (2) initial apprehension, (3) the COVID-19 pandemic, and (4) sustainability after resolution of the COVID-19 pandemic. Conclusions: This mixed-methods evaluation of unscheduled telemental health implementation found that its use was feasible, did not impact the safety and efficacy of mental health consultations, and was highly acceptable and sustainable in unscheduled settings.

Inter-facility transfer for patients with acute large vessel occlusion stroke receiving mechanical thrombectomy.

BACKGROUND: Mechanical thrombectomy (MT) is the preferred treatment for large vessel occlusion (LVO) ischemic stroke, and neurological outcome improves with earlier treatment. Patients with LVO frequently require inter-facility transfer to access MT but delays at transferring EDs may worsen neurological outcomes. METHODS: We conducted a retrospective observational study to evaluate the association of time spent and transferring EDs with 90-day neurological outcomes among patients who were transferred from an outside ED to the Comprehensive Stroke Center and received MT. Time intervals at transferring EDs were examined descriptively, and multivariable logistic regression modeling was used to examine the association of time spent in the ED with 90-day neurologic outcome (modified Rankin Scale; good ≤2, poor ≥3). RESULTS: Among 111 patients transferred to a stroke center for MT between 2013 and 2017, the time between CT scan and the stroke center transfer request was 44 (IQR 27,65) minutes, or 47% of transferring ED total duration. Duration at the transferring ED was not significantly associated with 90-day outcome. Only NIH Stroke Scale at the time of arrival to the stroke center was associated with good 90-day neurological outcome (aOR 0.84, 95%CI 0.77, 0.92, p < 0.0001). CONCLUSIONS: Among LVO patients transferred for MT, the total time spent at transferring EDs was not associated with 90-day neurologic outcome in patients with LVO. As therapies and their associated effectiveness improves over time, future investigations should further characterize the time between CT and transfer request to identify targets for process improvement and clinical outcomes.

Comparing the Timeliness of Treatment in Younger vs. Older Patients with ST-Segment Elevation Myocardial Infarction: A Multi-Center Cohort Study.

BACKGROUND: ST-segment elevation myocardial infarction (STEMI) predominantly affects older adults. Lower incidence among younger patients may challenge diagnosis. OBJECTIVES: We hypothesize that among patients ≤ 50 years old, emergent percutaneous coronary intervention (PCI) for STEMI is delayed when compared with patients aged > 50 years. METHODS: This 3-year, 10-center retrospective cohort study included emergency department (ED) STEMI patients ≥ 18 years of age treated with emergent PCI. We excluded patients with an electrocardiogram (ECG) completed prior to ED arrival or a nondiagnostic initial ECG. Our primary outcome was door-to-balloon (D2B) time. We compared characteristics and outcomes among younger vs. older STEMI patients, and among age subgroups. RESULTS: There were 576 ED STEMI PCI patients, of whom 100 were ≤ 50 years old and 476 were > 50 years old. Median age was 44 years in the younger cohort (interquartile range [IQR] 41-47) vs. 62 years (IQR 57-70) among older patients. Median D2B time for the younger cohort was 76.5 min (IQR 67.5-102.5) vs. 81.0 min (IQR 65.0-105.5) in the older cohort (p = 0.91). This outcome did not change when ages 40 or 45 years were used to demarcate younger vs. older. The younger cohort had a higher prevalence of nonwhite races (38% vs. 21%; p < 0.001) and those currently smoking (36% vs. 23%; p = 0.005). The very young (≤30 years; 6/576) and very old (>80 years; 45/576) had 5.51 and 2.2 greater odds of delays. CONCLUSION: We found no statistically significant difference in D2B times between patients ≤ 50 years old and those > 50 years old. Nonwhite patients and those who smoke were disproportionately represented within the younger population. The very young and very old had higher odds of D2B times > 90 min.

Bioanalytical Assessment of Plasma Concentrations of Angiotensin-Converting Enzyme II Inhibitors and Angiotensin Receptor Blockers: A Pilot Study Among Patients Hospitalized With Acute Heart Failure.

BACKGROUND: Although angiotensin-converting enzyme II inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) improve chronic heart failure (HF) outcomes, their potential harms and benefits in acute HF (AHF) is less clear. STUDY QUESTION: We explored the relationship between ACEI or ARB plasma concentrations among patients with AHF with in-hospital change in estimated glomerular filtration rate (eGFR). DATA SOURCES AND STUDY DESIGN: From August 2016-June 2017, patients with AHF prescribed an outpatient ACEI or ARB were enrolled before AHF treatment. All patients were given twice their home dose of diuretic intravenously and received clinical care at the discretion of the medical team. Of 61 patients in the parent study, saved plasma from 34 who were prescribed an outpatient ACEI or ARB was included in this substudy. MEASURES AND OUTCOMES: Liquid chromatography-tandem mass spectrometry was performed to assess ACEI or ARB plasma concentrations before AHF treatment. Change in eGFR was computed using the Chronic Kidney Disease Epidemiology Collaboration equation, which adjusts for age, sex, and race; diuretic dose and enrollment eGFR were used to adjust for HF severity. Multiple linear regression adjusting for enrollment eGFR and diuretic dose was performed to examine the relationship between drug concentration (undetectable/low vs. in/above-range) and in-hospital change in eGFR. RESULTS: Of 34 patients with AHF, median age was 63 years (interquartile range, 58-78 years), 19 (55.9%) were women, median eGFR at enrollment was 55.6 mL/min (interquartile range, 35.2-75.3 mL/min), and for 11 (32.4%), no ACEI or ARB was detectable in plasma. Medication concentrations in- or above-reference range were associated with in-hospital decrease in eGFR of 8.3 mL/min (95% confidence interval, 15.3-1.3 mL/min decrease), after adjusting for enrollment eGFR and diuretic treatment. CONCLUSIONS: Bioanalytical assessment of medication levels may be useful to guide in-hospital ACEI and ARB therapy for patients with AHF.

Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study.

BACKGROUND: Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers. METHODS: This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility- and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence. RESULTS: Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%). CONCLUSIONS: VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.

Understanding the Information Needs and Context of Trauma Handoffs to Design Automated Sensing Clinical Documentation Technologies: Qualitative Mixed-Method Study of Military and Civilian Cases.

BACKGROUND: Current methods of communication between the point of injury and receiving medical facilities rely on verbal communication, supported by brief notes and the memory of the field medic. This communication can be made more complete and reliable with technologies that automatically document the actions of field medics. However, designing state-of-the-art technology for military field personnel and civilian first responders is challenging due to the barriers researchers face in accessing the environment and understanding situated actions and cognitive models employed in the field. OBJECTIVE: To identify design insights for an automated sensing clinical documentation (ASCD) system, we sought to understand what information is transferred in trauma cases between prehospital and hospital personnel, and what contextual factors influence the collection, management, and handover of information in trauma cases, in both military and civilian cases. METHODS: Using a multi-method approach including video review and focus groups, we developed an understanding of the information needs of trauma handoffs and the context of field documentation to inform the design of an automated sensing documentation system that uses wearables, cameras, and environmental sensors to passively infer clinical activity and automatically produce documentation. RESULTS: Comparing military and civilian trauma documentation and handoff, we found similarities in the types of data collected and the prioritization of information. We found that military environments involved many more contextual factors that have implications for design, such as the physical environment (eg, heat, lack of lighting, lack of power) and the potential for active combat and triage, creating additional complexity. CONCLUSIONS: An ineffectiveness of communication is evident in both the civilian and military worlds. We used multiple methods of inquiry to study the information needs of trauma care and handoff, and the context of medical work in the field. Our findings informed the design and evaluation of an automated documentation tool. The data illustrated the need for more accurate recordkeeping, specifically temporal aspects, during transportation, and characterized the environment in which field testing of the developed tool will take place. The employment of a systems perspective in this project produced design insights that our team would not have identified otherwise. These insights created exciting and interesting challenges for the technical team to resolve.

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients.

STUDY OBJECTIVE: Induction doses of etomidate during rapid sequence intubation cause transient adrenal dysfunction, but its clinical significance on trauma patients is uncertain. Ketamine has emerged as an alternative for rapid sequence intubation induction. Among adult trauma patients intubated in the emergency department, we compare clinical outcomes among those induced with etomidate and ketamine. METHODS: The study entailed a retrospective evaluation of a 4-year (January 2011 to December 2014) period spanning an institutional protocol switch from etomidate to ketamine as the standard induction agent for adult trauma patients undergoing rapid sequence intubation in the emergency department of an academic Level I trauma center. The primary outcome was hospital mortality evaluated with multivariable logistic regression, adjusted for age, vital signs, and injury severity and mechanism. Secondary outcomes included ICU-free days and ventilator-free days evaluated with multivariable ordered logistic regression using the same covariates. RESULTS: The analysis included 968 patients, including 526 with etomidate and 442 with ketamine. Hospital mortality was 20.4% among patients induced with ketamine compared with 17.3% among those induced with etomidate (adjusted odds ratio [OR] 1.41; 95% confidence interval [CI] 0.92 to 2.16). Patients induced with ketamine had ICU-free days (adjusted OR 0.80; 95% CI 0.63 to 1.00) and ventilator-free days (adjusted OR 0.96; 95% CI 0.76 to 1.20) similar to those of patients induced with etomidate. CONCLUSION: In this analysis spanning an institutional protocol switch from etomidate to ketamine as the standard rapid sequence intubation induction agent for adult trauma patients, patient-centered outcomes were similar for patients who received etomidate and ketamine.

Epidemiology and mapping of serious and fatal road traffic injuries in Guyana: results from a cross-sectional study.

OBJECTIVE: To describe the epidemiology of Guyana's road traffic injuries and perform the first geocoding of road traffic injuries in this setting. METHODS: This was a registry-based retrospective cross-sectional study investigating collisions resulting in serious and fatal injuries. Police reports from two police divisions were used to identify victim, second party (ie, non-victim) and collision characteristics of all serious and fatal collisions between January 2012 and June 2015. Collisions with available location data were geocoded using Geographic Information Systems. Distributions of characteristics were compared for urban and rural areas. Multivariable logistic regression was used to assess variables associated with fatal collisions. RESULTS: The study included 751 collisions, resulting in 1002 seriously or fatally injured victims. Fatally injured victims tended to be older, male and either pedestrians or cyclists. Fatal collisions tended to take place in rural areas, occur on weekends and involve speeding. Fifty-three per cent of fatalities occurred due to non-motorised road users being struck by motorised road users, and the most common fatal collision type was between pedestrians and motor vehicles (35%). The distribution of collisions was similar for urban (43.8%) and rural (56.2%) areas. Fatal collisions were more likely to occur in rural settings. CONCLUSIONS: Road traffic injuries pose a considerable public health burden in Guyana. These results suggest a pattern of high mortality in rural collisions and a disproportionate burden of injuries on vulnerable road users. The spatial distribution of collisions should be considered in order to target interventions and improve road traffic safety.

Risk-benefit analysis of lumbar puncture to evaluate for nontraumatic subarachnoid hemorrhage in adult ED patients.

OBJECTIVE: The objective of the study is to compare the risks and benefits of lumbar puncture (LP) to evaluate for subarachnoid hemorrhage (SAH) after a normal head computed tomographic (CT) scan. METHODS: This was an observational study of adult emergency department patients at a single hospital who presented with headache and underwent LP after a normal head CT to evaluate for SAH. Lumbar puncture results classified as indicating a SAH included xanthochromia in cerebrospinal fluid (CSF) or red blood cells in the final tube of CSF with an aneurysm or arteriovenous malformation on cerebral angiography. An LP-related complication was defined as hospitalization or a return visit due to symptoms attributed to the LP. Proportions of the study patients who had SAH diagnosed by LP and who experienced an LP-related complication were compared. RESULTS: The study included 302 patients, including 2 (0.66%) who were diagnosed with SAH based on LP (number needed to diagnose, 151); both of these patients had a known intracranial aneurysm. Eighteen (5.96%) patients experienced an LP-related complication (P < .01 compared with number with SAH diagnosed; number needed to harm, 17). Complications included 12 patients with low-pressure headaches, 4 with pain at the LP site, and 2 with contaminated CSF cultures. CONCLUSION: The yield of LP for diagnosing SAH in adults with nontraumatic headache after a normal head CT was very low. The severity of LP-related complications was low, but complications were more common than SAH diagnoses. Lumbar puncture may not be advisable after a normal head CT to evaluate for SAH, particularly in patients with low-risk clinical features for SAH.

Medication Nonadherence Before Hospitalization for Acute Cardiac Events.

Medication nonadherence increases the risk of hospitalization and poor outcomes, particularly among patients with cardiovascular disease. The purpose of this study was to examine characteristics associated with medication nonadherence among adults hospitalized for cardiovascular disease. Patients in the Vanderbilt Inpatient Cohort Study who were admitted for acute coronary syndrome or heart failure completed validated assessments of self-reported medication adherence (the Adherence to Refills and Medications Scale), demographic characteristics, health literacy, numeracy, social support, depressive symptoms, and health competence. We modeled the independent predictors of nonadherence before hospitalization, standardizing estimated effects by each predictor's interquartile range. Among 1,967 patients studied, 70.7% indicated at least some degree of medication nonadherence leading up to their hospitalization. Adherence was significantly lower among patients with lower health literacy (0.18-point change in adherence score per interquartile range change in health literacy), lower numeracy (0.28), lower health competence (0.30), and more depressive symptoms (0.52) and those of younger age, of non-White race, of male gender, or with less social support. Medication nonadherence in the period before hospitalization is more prevalent among patients with lower health literacy, numeracy, or other intervenable psychosocial factors. Addressing these factors in a coordinated care model may reduce hospitalization rates.

Association of health literacy with elevated blood pressure: a cohort study of hospitalized patients.

BACKGROUND: The clinical consequences of low health literacy are not fully understood. OBJECTIVES: We evaluated the relationship between low health literacy and elevated blood pressure (BP) at hospital presentation. RESEARCH DESIGN AND SUBJECTS: We conducted a cross-sectional evaluation of adult patients hospitalized at a university hospital between November 1, 2010 and April 30, 2012. MEASURES: Health literacy was assessed using the Brief Health Literacy Screen (BHLS). Low health literacy was defined as a BHLS score ≤9. BP was assessed using clinical measurements. The outcome was elevated BP (≥140/90 mm Hg; ≥130/80 mm Hg with diabetes or renal disease) or extremely elevated BP (>160/100 mm Hg) at hospital presentation. Multivariate logistic regression adjusted for age, sex, race, insurance, comorbidities, and antihypertensive medications; preplanned restricted analysis among patients with diagnosed hypertension was performed. RESULTS: Of 46,263 hospitalizations, 23% had low health literacy, which occurred more often among patients who were older (61 vs. 54 y), less educated (28.4% vs. 11.2% had not completed high school), and more often admitted through the emergency department (54.3% vs. 48.1%) than those with BHLS>9. Elevated BP was more frequent among those with low health literacy [40.0% vs. 35.5%; adjusted odds ratio (aOR) 1.06; 95% confidence interval (CI), 1.01-1.12]. Low health literacy was associated with extremely elevated BP (aOR 1.08; 95% CI, 1.01-1.16) and elevated BP among those without diagnosed hypertension (aOR 1.09; 95% CI, 1.02-1.16). CONCLUSIONS: More than ⅓ of patients had elevated BP at hospital presentation. Low health literacy was independently associated with elevated BP, particularly among patients without diagnosed hypertension.

Psychometric properties of the brief health literacy screen in clinical practice.

BACKGROUND: The three-item Brief Health Literacy Screen (BHLS) has been validated in research settings, but not in routine practice, administered by clinical personnel. OBJECTIVE: As part of the Health Literacy Screening (HEALS) study, we evaluated psychometric properties of the BHLS to validate its administration by clinical nurses in both clinic and hospital settings. PARTICIPANTS: Beginning in October 2010, nurses in clinics and the hospital at an academic medical center have administered the BHLS during patient intake and recorded responses in the electronic health record. MEASURES: Trained research assistants (RAs) administered the short Test of Functional Health Literacy in Adults (S-TOFHLA) and re-administered the BHLS to convenience samples of hospital and clinic patients. Analyses included tests of internal consistency reliability, inter-administrator reliability, and concurrent validity by comparing the nurse-administered versus RA-administered BHLS scores (BHLS-RN and BHLS-RA, respectively) to the S-TOFHLA. KEY RESULTS: Cronbach's alpha for the BHLS-RN was 0.80 among hospital patients (N = 498) and 0.76 among clinic patients (N = 295), indicating high internal consistency reliability. Intraclass correlation between the BHLS-RN and BHLS-RA among clinic patients was 0.77 (95 % CI 0.71-0.82) and 0.49 (95 % CI 0.40-0.58) among hospital patients. BHLS-RN scores correlated significantly with BHLS-RA scores (r = 0.33 among hospital patients; r = 0.62 among clinic patients), and with S-TOFHLA scores (r = 0.35 among both hospital and clinic patients), providing evidence of inter-administrator reliability and concurrent validity. In regression models, BHLS-RN scores were significant predictors of S-TOFHLA scores after adjustment for age, education, gender, and race. Area under the receiver operating characteristic curve for BHLS-RN to predict adequate health literacy on the S-TOFHLA was 0.71 in the hospital and 0.76 in the clinic. CONCLUSIONS: The BHLS, administered by nurses during routine clinical care, demonstrates adequate reliability and validity to be used as a health literacy measure.