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Clinically significant weight gain (CSWG) is associated with increased morbidity and mortality. This study describes CSWG and comorbidities observed in patients with bipolar I disorder (BD-I) and schizophrenia (SZ) after initiating select second-generation antipsychotics (SGAs).
Percent change in weight, CSWG (=7% weight increase), and incident comorbidities within 12 months of treatment were assessed among patients initiating oral SGAs of moderate-to-high weight gain risk using medical records/claims (OM1 Real-World Data Cloud; January 2013-February 2020). Oral SGAs included clozapine (SZ), iloperidone (SZ), paliperidone (SZ), olanzapine, olanzapine/fluoxetine (BD-I), quetiapine, and risperidone. Outcomes were stratified by baseline body mass index and reported descriptively.
Among patients with BD-I (N = 9142) and SZ (N = 8174), approximately three-quarters were overweight/obese at baseline. During treatment (mean duration = 30 weeks), average percent weight increase was 3.7% (BD-I) and 3.3% (SZ). Average percent weight increase was highest for underweight/normal weight patients (BD-I = 5.5%; SZ = 4.8%), followed by overweight (BD-I = 3.8%; SZ = 3.4%) and obese patients (BD-I = 2.7%; SZ = 2.3%). Within 3 months of treatment, 12% of all patients experienced CSWG. A total of 11.3% (BD-I) and 14.7% (SZ) of patients developed coronary artery disease, hypertension, dyslipidemia, or type 2 diabetes within 12 months of treatment; development of comorbidities was highest among overweight/obese patients and those with CSWG.
Patients who were underweight/normal weight at baseline had the greatest percent change in weight during treatment. Increased comorbidities were observed within 12 months of treatment, specifically among overweight/obese patients and those with CSWG. The magnitude of weight gain and development of comorbidities were similar for patients with BD-I and SZ.
Hospitalized patients undergoing evaluation for pulmonary tuberculosis (TB) require airborne isolation while testing for Mycobacterium tuberculosis (MTB) to reduce risk of nosocomial transmission. GeneXpert MTB/RIF (Xpert) is more rapid and accurate than sputum smear microscopy, but it is not routinely used to ‘rule out’ infectious pulmonary TB among hospitalized patients in the United States. We sought to evaluate the diagnostic performance and cost-effectiveness of Xpert-based TB evaluation.
We conducted a retrospective cohort study of hospitalized adults evaluated for pulmonary TB at a large academic medical center in New York from 2010 to 2017. Using propensity score matching, we compared hospital length-of-stay among patients undergoing conventional smear-based TB evaluation to a control group with non-TB pneumonia. We performed a probabilistic cost-effectiveness analysis to compare Xpert-based versus conventional TB evaluation.
In total 1,421 patients were evaluated for TB with airborne isolation and sputum testing; mycobacterial culture was positive for MTB in 49 (3.4%). Conventional TB evaluation was associated with an increase of 4.4 hospital days compared to propensity-matched controls. Xpert-based testing strategies dominated conventional TB evaluation with a cost savings of $5,947 (95% CI, $1,156–$12,540) and $4,445 (95% CI, $696–$9,526) per patient depending on the number of Xpert tests performed (1 vs 2, respectively) and assumptions about the reduction of length of stay achieved.
In the evaluation of hospitalized patients for pulmonary TB, Xpert-based testing has superior diagnostic performance and is likely cost-effective compared to smear microscopy due to reduced hospital length-of-stay associated with more rapid test results.
Among patients with schizophrenia (SZ) and bipolar I disorder (BD-I) treated with second-generation antipsychotics (SGAs), clinically-significant weight gain (CSWG) and treatment interruptions (TIs) are challenges that may result in morbidity/mortality.
CSWG and TIs were assessed among patients who initiated oral SGAs of moderate-to-high weight gain risk (no exposure to index SGAs/first-generation antipsychotics for =12 months) using medical records/claims (OM1 Data Cloud; January 2013-February 2020). Outcomes included CSWG (=7% increase in baseline weight) and TIs (switches [to SGAs of low weight gain risk/long-acting injectables] or discontinuations [no SGAs for >30 days]). Descriptive analyses included proportions of patients with CSWG and TIs, and median time to these outcomes.
Approximately three-quarters of patients were overweight/obese at baseline (SZ: N=8,174; BD-I: N=9,142). Within 3 months of SGA initiation, 12% of all patients experienced CSWG. For patients on treatment with index SGAs for >6 months (SZ: 29%; BD-I: 27%), 28% (SZ) and 30% (BD-I) experienced CSWG during follow-up. Median time to CSWG was 14 weeks. CSWG results were numerically similar among patients with SZ and BD-I.
Over 96% of patients had TIs during follow-up (median time of 12 [SZ] and 13 [BD-I] weeks). Among patients with CSWG and subsequent TIs and weight measurements, 74% did not return to baseline weight after interrupting treatment; the remainder returned to baseline weight with median times of 38 (SZ) and 39 (BD-I) weeks. Results suggest that most patients with CSWG do not return to baseline weight after stopping treatment with oral SGAs of moderate-to-high weight gain risk.
This study tested whether the association between interparental conflict and adolescent externalizing symptoms was moderated by a polygenic composite indexing low dopamine activity (i.e., 7-repeat allele of DRD4; Val alleles of COMT; 10-repeat variants of DAT1) in a sample of seventh-grade adolescents (Mean age = 13.0 years) and their parents. Using a longitudinal, autoregressive design, observational assessments of interparental conflict at Wave 1 predicted increases in a multi-informant measurement of youth externalizing symptoms 2 years later at Wave 3 only for children who were high on the hypodopaminergic composite. Moderation was expressed in a “for better” or “for worse” form hypothesized by differential susceptibility theory. Thus, children high on the dopaminergic composite experienced more externalizing problems than their peers when faced with more destructive conflicts but also fewer externalizing problems when exposed to more constructive interparental conflicts. Mediated moderation findings indicated that adolescent reports of their emotional insecurity in the interparental relationship partially explained the greater genetic susceptibility experienced by these children. More specifically, the dopamine composite moderated the association between Wave 1 interparental conflict and emotional insecurity 1 year later at Wave 2 in the same “for better” or “for worse” pattern as externalizing symptoms. Adolescent insecurity at Wave 2, in turn, predicted their greater externalizing symptoms 1 year later at Wave 3. Post hoc analyses further revealed that the 7-repeat allele of the dopamine receptor D4 (DRD4) gene was the primary source of plasticity in the polygenic composite. Results are discussed as to how they advance process-oriented Gene x Environment models of emotion regulation.
Mixing matrices quantify how people with similar or different characteristics make contact with each other, creating potential for disease transmission. Little empirical data on mixing patterns among persons who inject drugs (PWID) are available to inform models of blood-borne disease such as HIV and hepatitis C virus. Egocentric drug network data provided by PWID in Baltimore, Maryland between 2005 and 2007 were used to characterise drug equipment-sharing patterns according to age, race and gender. Black PWID and PWID who were single (i.e. no stable sexual partner) self-reported larger equipment-sharing networks than their white and non-single counterparts. We also found evidence of assortative mixing according to age, gender and race, though to a slightly lesser degree in the case of gender. Highly assortative mixing according to race and gender highlights the existence of demographically isolated clusters, for whom generalised treatment interventions may have limited benefits unless targeted directly. These findings provide novel insights into mixing patterns of PWID for which little empirical data are available. The age-specific assortativity we observed is also significant in light of its role as a key driver of transmission for other pathogens such as influenza and tuberculosis.
Introduction: Continued smoking by cancer patients causes adverse cancer treatment outcomes, but few patients receive evidence-based smoking cessation as a standard of care.
Aim: To evaluate practical strategies to promote wide-scale dissemination and implementation of evidence-based tobacco cessation services within state cancer centers.
Methods: A Collaborative Learning Model (CLM) for Quality Improvement was evaluated with three community oncology practices to identify barriers and facilitate practice change to deliver evidence-based smoking cessation treatments to cancer patients using standardized assessments and referrals to statewide smoking cessation resources. Patients were enrolled and tracked through an automated data system and received follow-up cessation support post-enrollment. Monthly quantitative reports and qualitative data gathered through interviews and collaborative learning sessions were used to evaluate meaningful quality improvement changes in each cancer center.
Results: Baseline practice evaluation for the CLM identified the lack of tobacco use documentation, awareness of cessation guidelines, and awareness of services for patients as common barriers. Implementation of a structured assessment and referral process demonstrated that of 1,632 newly registered cancer patients,1,581 (97%) were screened for tobacco use. Among those screened, 283 (18%) were found to be tobacco users. Of identified tobacco users, 207 (73%) were advised to quit. Referral of new patients who reported using tobacco to an evidence-based cessation program increased from 0% at baseline across all three cancer centers to 64% (range = 30%–89%) during the project period.
Conclusions: Implementation of quality improvement learning collaborative models can dramatically improve delivery of guideline-based tobacco cessation treatments to cancer patients.
Human movement contributes to the probability that pathogens will be introduced to new geographic locations. Here we investigate the impact of human movement on the spatial spread of Chikungunya virus (CHIKV) in Southern Thailand during a recent re-emergence. We hypothesised that human movement, population density, the presence of habitat conducive to vectors, rainfall and temperature affect the transmission of CHIKV and the spatiotemporal pattern of cases seen during the emergence. We fit metapopulation transmission models to CHIKV incidence data. The dates at which incidence in each of 151 districts in Southern Thailand exceeded specified thresholds were the target of model fits. We confronted multiple alternative models to determine which factors were most influential in the spatial spread. We considered multiple measures of spatial distance between districts and adjacency networks and also looked for evidence of long-distance translocation (LDT) events. The best fit model included driving-distance between districts, human movement, rubber plantation area and three LDT events. This work has important implications for predicting the spatial spread and targeting resources for control in future CHIKV emergences. Our modelling framework could also be adapted to other disease systems where population mobility may drive the spatial advance of outbreaks.
The revised Dietary Guideline Index (DGI-2013) scores individuals’ diets according to their compliance with the Australian Dietary Guideline (ADG). This cross-sectional study assesses the diet quality of 794 community-dwelling men aged 74 years and older, living in Sydney, Australia participating in the Concord Health and Ageing in Men Project; it also examines sociodemographic and lifestyle factors associated with DGI-2013 scores; it studies associations between DGI-2103 scores and the following measures: homoeostasis model assessment – insulin resistance, LDL-cholesterol, HDL-cholesterol, TAG, blood pressure, waist:hip ratio, BMI, number of co-morbidities and medications and frailty status while also accounting for the effect of ethnicity in these relationships. Median DGI-2013 score was 93·7 (54·4, 121·2); most individuals failed to meet recommendations for vegetables, dairy products and alternatives, added sugar, unsaturated fat and SFA, fluid and discretionary foods. Lower education, income, physical activity levels and smoking were associated with low scores. After adjustments for confounders, high DGI-2013 scores were associated with lower HDL-cholesterol, lower waist:hip ratios and lower probability of being frail. Proxies of good health (fewer co-morbidities and medications) were not associated with better compliance to the ADG. However, in participants with a Mediterranean background, low DGI-2013 scores were not generally associated with poorer health. Older men demonstrated poor diet quality as assessed by the DGI-2013, and the association between dietary guidelines and health measures and indices may be influenced by ethnic background.
Introduction: We characterised tobacco use, cessation patterns, and patient satisfaction with a cessation support program at an NCI Designated Comprehensive Cancer Center following a mandatory tobacco assessment and automatic referral.
Methods: A 3-month follow-up survey (via web, paper, or telephone) was administered between March 2013 and November 2013 for all patients referred to and contacted by a cessation support service, and who consented to participation three months prior to administration. Patients were asked about their perceived importance and self-efficacy to quit smoking, quit attempts, and satisfaction with the cessation service.
Results: Fifty-two percent (257/499) of patients who participated in the cessation support service, and consented to be contacted again, completed a follow-up survey. Of those who participated, 9.7% were referred to the service as having recently quit tobacco (in the past 30 days) and 23.6% reported having quit at the time of first contact. At the 3-month follow-up, 48.1% reported being smoke-free for the previous seven days. When patients were asked about their experience with the cessation service, 86.4% reported being very or mostly satisfied with the service, and 64.3% reported that their experience with the service increased their satisfaction with the care received at the cancer centre.
Conclusions: Our findings suggest that recently diagnosed cancer patients are aware that quitting tobacco is important, are making attempts to quit, and are amenable to an opt-out automatic referral cessation support service as part of their cancer care.
Introduction: Patients with mild traumatic brain injury (mTBI) frequently present to the emergency department (ED); however, wide variation in diagnosis and management has been demonstrated in this setting. Sub-optimal mTBI management can contribute to post-concussion syndrome (PCS), affecting vocational outcomes like return to work. This study documented the work-related events, ED management, discharge advice, and outcomes for employed patients presenting to the ED with mTBI. Methods: Adult (>17 years) patients presenting to one of three urban EDs in Edmonton, Alberta with Glasgow coma scale score ≥13 within 72 hours of a concussive event were recruited by on-site research assistants. Follow-up calls ascertained outcomes, including symptoms and their severity, advice received in the ED, and adherence to discharge instructions, at 30 and 90 days after ED discharge. Dichotomous variables were analyzed using chi-square testing; continuous variables were compared using t-tests or Mann-Whitney tests, as appropriate. Work-related injury and return to work outcomes were modelled using logistic or linear regression, as appropriate. Results: Overall, 250 patents were enrolled; 172 (69%) were employed at the time of their injury and completed at least one follow-up. The median age was 37 years (interquartile range [IQR]: 24, 49.5), both sexes were equally represented (48% male), and work-related concussions were uncommon (16%). Work-related concussion was related to manual labor jobs and self-reported history of attention deficit disorder. Patients often received advice to avoid sports (81%) and/or work (71%); however, the duration of recommended time off varied. Most employed patients (80%) missed at least one day of work (median=7 days; IQR: 3, 14); 91% of employees returned to work by 90 days, despite 41% reporting persistent symptoms. Increased days of missed work were linked to divorce, history of sleep disorder, and physician’s advice to avoid work. Conclusion: While work-related concussions are uncommon, most employees who sustain a mTBI at any time miss some work. Many patients experience mTBI symptoms past 90 days, which has serious implications for workers’ abilities to fulfill their work duties and risk of subsequent injury. Workers, employers, and the workers compensation system should take the necessary precautions to ensure that workers return to work safely and successfully following a concussion.
Introduction: When patients transition from long term care (LTC) to emergency departments (ED), communication among clinicians in different settings is often poor. We pilot tested a transfer form to facilitate communications of handover information among LTCs, emergency medical services (EMS), and EDs regarding LTC residents transitioning to and from the ED. We interpret implementation challenges in light of the “theoretical domains” implementation framework in order to produce lessons for future healthcare communication interventions. Methods: We provided setting specific training and a user guide to 13 participating sites, collected 90 forms to assess completion rates, and assessed perspectives on the form from 266 surveys of healthcare providers. Throughout the study, staff kept detailed notes on implementation of the form. We retrospectively categorized implementation challenges reported by survey respondents, and/or recorded in staff implementation notes, according to the theoretical domains framework. Results: The LTC patient transfer forms were used in 36.4% of transitions (90/247), and were completed most often by staff in the LTC (57/90, 63%). Survey results indicated that ED and EMS staff felt the information on the form was useful to them, although they rarely completed their sections of the form. Implementation challenges included low awareness/recognition of the form among healthcare providers, belief that the form distracted from patient care, lack of time for form completion, negative reinforcement for LTC staff (who saw little return for the time they invested in completing the form), and mistrust among clinicians who work in different settings. Conclusion: Future efforts to improve healthcare communications must be acceptable for all clinicians. Innovation should balance the workload required among sites/clinicians and the benefits that the intervention offers to sites/clinicians should be explicitly tracked and reported. For this intervention, more effort should be made to inform LTC sites that the transfer information they provide is useful for EMS and ED clinicians. Moreover, gaps in perspectives and lack of trust among clinicians who work in different settings must be recognized and addressed in any multi-site communication intervention.
Introduction: Patients with mild traumatic brain injury (mTBI) often present to the emergency department (ED). Incorrect diagnosis may delay appropriate treatment and recommendations for these patients, prolonging recovery. Notable proportions of missed mTBI diagnosis have been documented in children and athletes, while diagnosis of mTBI has not been examined in the general adult population. Methods: A prospective cohort study was conducted in one academic (site 1) and two non-academic (sites 2 and 3) EDs in Edmonton, Canada. On-site research assistants enrolled adult (>17 years) patients presenting within 72 hours of the injury event with clinical signs of mTBI and Glasgow comma scale score ≥13. Patient demographics, injury characteristics, and ED flow information were collected by chart review. Physician-administered questionnaires and patient interviews documented the recommendations given by emergency physicians at discharge. Bi-variable comparisons are reported using Pearson’s chi-square tests, Student’s t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. Results: Overall, 130/250 enrolled patients were female, and the median age was 35. Proportions of successfully diagnosed mTBI varied significantly across study sites (Site 1: 89%; Site 2: 73%, Site 3: 53%; p>0.001). Patients without a diagnosis were less likely to receive a recommendation to follow-up with their family physician (OR=0.08; 95% CI: 0.03, 0.21) or advice about return to work (OR=0.17; 95% CI: 0.08, 0.04) or physical activity (OR=0.08; 95% CI: 0.04, 0.17). Patients with missed diagnoses had longer ED stays (median=5.0 hours; IQR: 3.8, 7.0) compared with diagnosed mTBI patients (median=3.9 hours; IQR: 3.0, 5.3). In the adjusted model, patients presenting to non-academic centers had reduced likelihood of mTBI diagnosis (Site 2: OR=0.21; 95% CI: 0.08, 0.58; Site 3: OR=0.07; 95% CI: 0.02, 0.24). Conclusion: The diagnostic accuracy of physicians assessing patients presenting with symptoms of mTBIs to these three EDs is suboptimal. The rates of missed diagnosis vary among EDs and were associated with length of ED stay. Closer examination of institutional factors, including diagnosis processes and personnel factors such as physician training, is needed to identify effective strategies to heighten the awareness of mTBI presentations.
The co-existence of stroke and HIV has increased in recent years, but the impact of HIV on post-stroke outcomes is poorly understood. We examined the impact of HIV on inpatient mortality, length of acute hospital stay and complications (pneumonia, respiratory failure, sepsis and convulsions), in hospitalized strokes in Thailand. All hospitalized strokes between 1 October 2004 and 31 January 2013 were included. Data were obtained from a National Insurance Database. Characteristics and outcomes for non-HIV and HIV patients were compared and multivariate logistic and linear regression models were constructed to assess the above outcomes. Of 610 688 patients (mean age 63·4 years, 45·4% female), 0·14% (866) had HIV infection. HIV patients were younger, a higher proportion were male and had higher prevalence of anaemia (P < 0·001) compared to non-HIV patients. Traditional cardiovascular risk factors, hypertension and diabetes, were more common in the non-HIV group (P < 0·001). After adjusting for age, sex, stroke type and co-morbidities, HIV infection was significantly associated with higher odds of sepsis [odds ratio (OR) 1·75, 95% confidence interval (CI) 1·29–2·4], and inpatient mortality (OR 2·15, 95% CI 1·8–2·56) compared to patients without HIV infection. The latter did not attenuate after controlling for complications (OR 2·20, 95% CI 1·83–2·64). HIV infection is associated with increased odds of sepsis and inpatient mortality after acute stroke.
An increasing number of researchers and policymakers have been moved to study and intervene in the lives of children affected by violent conflicts (Masten, 2014). According to a United Nations Children's Fund (2009) report, over 1 billion children under the age of 18 are growing up in regions where acts of political violence and armed conflict are, as Ladds and Cairns (1996, p. 15) put it, “a common occurrence—a fact of life.” In recent years, the United Nations Children's Fund, advocacy and human rights groups, journalists, and researchers have drawn public attention to the high rates of child casualties in these regions, and to the plights of those children still caught in the crossfire. It has thus become clear that both the challenges and the stakes are higher than ever to promote the safety and well-being of affected children around the world (Masten & Narayan, 2012; Tol, Jordans, Kohrt, Betancourt, & Komproe, 2012).
Over 1 billion children worldwide are exposed to political violence and armed conflict. The current conclusions are qualified by limited longitudinal research testing sophisticated process-oriented explanatory models for child adjustment outcomes. In this study, consistent with a developmental psychopathology perspective emphasizing the value of process-oriented longitudinal study of child adjustment in developmental and social–ecological contexts, we tested emotional insecurity about the community as a dynamic, within-person mediating process for relations between sectarian community violence and child adjustment. Specifically, this study explored children's emotional insecurity at a person-oriented level of analysis assessed over 5 consecutive years, with child gender examined as a moderator of indirect effects between sectarian community violence and child adjustment. In the context of a five-wave longitudinal research design, participants included 928 mother–child dyads in Belfast (453 boys, 475 girls) drawn from socially deprived, ethnically homogenous areas that had experienced political violence. Youth ranged in age from 10 to 20 years and were 13.24 (SD = 1.83) years old on average at the initial time point. Greater insecurity about the community measured over multiple time points mediated relations between sectarian community violence and youth's total adjustment problems. The pathway from sectarian community violence to emotional insecurity about the community was moderated by child gender, with relations to emotional insecurity about the community stronger for girls than for boys. The results suggest that ameliorating children's insecurity about community in contexts of political violence is an important goal toward improving adolescents' well-being and adjustment. These results are discussed in terms of their translational research implications, consistent with a developmental psychopathology model for the interface between basic and intervention research.
Introduction: The Medical University of South Carolina (MUSC) hospital implemented an inpatient opt-out smoking-cessation service where smokers received a mandatory smoking-cessation consult and phone follow-up within 1-month post-discharge.
Aim: To examine predictors of patients who opted-out of bedside counselling or follow-up phone calls.
Methods: Eligible adult cigarette smokers admitted to the MUSC hospital were enrolled in the programme. Opting-out of bedside consult or follow-up calls were assessed separately using log-linear modelling where predictors included patient demographics, length of hospitalisation, insurance type, smoking history, and motivation/confidence to quit.
Results: Of the 38,758 admitted patients (February 2014–May 2015), 6,684 reported currently smoking and were automatically referred to bedside-consult. Approximately 26% of smokers made contact with the counselor, most of whom (83%) accepted the consult. Amongst patients eligible for post-discharge follow-up (n = 3485), 49% responded to the calls. Those who opted-out of the bedside-consult were mostly males (RR = 1.29). Those who did not respond to follow-up calls were younger age (RR = 1.33), with Medicaid/no insurance (RR = 1.17), and had not received a bedside consult (RR = 1.32).
Conclusions: An opt-out smoking-cessation programme was feasible and acceptable to most patients and was able to reach 65% of eligible smokers; 17% opted-out of bedside counselling; <1% asked to be removed from further phone calls.
Introduction: Suboptimal use of nicotine replacement therapy (NRT) may pose a significant barrier to smokers attempting to quit. We examined NRT use as a predictor of smoking abstinence and heavy drinking in a randomised trial of hazardous drinkers who contacted the NY State Smokers’ quitline for smoking cessation assistance.
Methods: Participants (N = 1,948) received either Tobacco Only Counselling or Alcohol + Tobacco Counselling (ATC), both in addition to a 2-week supply of NRT. NRT use, smoking status, and heavy drinking days were assessed by self-report at the 7-month follow-up.
Results: Of those smokers who completed the 7-month follow-up (N = 843), 53.1% used all of the NRT and 40.6% used some. Those who used all of the NRT were more likely to be abstinent from smoking than those who used some, and more likely to report no heavy drinking days than those who used some or none.
Conclusions: Approximately half of the heavy drinking smokers calling the quitline are willing to use the 2-week supply of free NRT, and most will at least try it. Those who reported using all of the NRT were more likely to report smoking abstinence and no heavy drinking days at the 7-month follow-up.
Introduction: Some non-urgent/low-acuity Emergency Department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study surveyed patients who presented to the ED and explored their self-reported reasons and barriers for not being connected to a primary care provider (PCP). Methods: Patients aged 17 years and older were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada. Following initial triage, stabilization, and verbal informed consent, patients completed a 47-item questionnaire. Data from the survey were cross-referenced to a minimal patient dataset consisting of ED and demographic information. The questionnaire collected information on patient characteristics, their connection to a PCP, and patients' reasons for not having a PCP. Results: Of the 2144 eligible patients, 1408 (65.7%) surveys were returned and 1402 (65.4%) were completed. The majority of patients (74.4%) presenting to the ED reported having a family physician; however, the ‘closeness’ of the connection to their family physician varied greatly among ED patients with the most recent family physician visit ranging from 1 hour before ED presentation to 45 years prior. Approximately 25% of low acuity ED patients reported no connection with a family physician. Reasons for a lack of PCP connection included: prior physician retired, left, or died (19.8%), they had never tried to find one (19.2%), they had recently moved to Alberta (18.0%), and they were unable to find one (16.5%). Conclusion: A surprisingly high proportion of ED patients (25.6%) have no identified PCP. Patients had a variety of reasons for not having a family physician. These need to be understood and addressed in order for primary care access to successfully contribute to diverting non-urgent, low acuity presentations from the ED.
Introduction: Some low acuity Emergency Department (ED) presentations are considered non-urgent or convenience visits and potentially avoidable with improved access to primary care. This study explored self-reported reasons why non-urgent patients presented to the ED. Methods: Patients, 17 years and older, were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada during weekdays (0700 to 1900). A 47-item questionnaire was completed by each consenting patient, which included items on whether the patient believed the ED was their best care option and the rationale supporting their response. A thematic content analysis was performed on the responses, using previous experience and review of the literature to identify themes. Results: Of the 2144 eligible patients, 1408 (65.7%) questionnaires were returned, and 1402 (65.4%) were analyzed. For patients who felt the ED was their best option (n = 1234, 89.3%), rationales included: safety concerns (n = 309), effectiveness of ED care (n = 284), patient-centeredness of ED (n = 277), and access to health care professionals in the ED (n = 204). For patients who felt the ED was not their best care option (n = 148, 10.7%), rationales included a perception that: access to health professionals outside the ED was preferable (n = 39), patient-centeredness (particularly timeliness) was lacking in the ED (n = 26), and their health concern was not important enough to require ED care (n = 18). Conclusion: Even during times when alternative care options are available, the majority of non-urgent patients perceived the ED to be the most appropriate location for care. These results highlight that simple triage scores do not accurately reflect the appropriateness of care and that understanding the diverse and multi-faceted reasons for ED presentation are necessary to implement strategies to support non-urgent, low acuity care needs.
Theoretical and empirical evidence suggest that the way in which parents discuss everyday emotional experiences with their young children (i.e., elaborative reminiscing) has significant implications for child cognitive and socioemotional functioning, and that maltreating parents have a particularly difficult time in engaging in this type of dialogue. This dyadic interactional exchange, therefore, has the potential to be an important process variable linking child maltreatment to developmental outcomes at multiple levels of analysis. The current investigation evaluated the role of maternal elaborative reminiscing in associations between maltreatment and child cognitive, emotional, and physiological functioning. Participants included 43 maltreated and 49 nonmaltreated children (aged 3–6) and their mothers. Dyads participated in a joint reminiscing task about four past emotional events, and children participated in assessments of receptive language and emotion knowledge. Child salivary cortisol was also collected from children three times a day (waking, midday, and bedtime) on 2 consecutive days to assess daily levels and diurnal decline. Results indicated that maltreating mothers engaged in significantly less elaborative reminiscing than did nonmaltreating mothers. Maternal elaborative reminiscing mediated associations between child maltreatment and child receptive language and child emotion knowledge. In addition, there was support for an indirect pathway between child maltreatment and child cortisol diurnal decline through maternal elaborative reminiscing. Directions for future research are discussed, and potential clinical implications are addressed.