One-year changes in methamphetamine use,dependence and remission in a community-recruited cohort

Aims: Investigate changes to a prospective cohort of methamphetamine users over 12 months, predictors of remission from methamphetamine dependence and past-month abstinence from methamphetamine use.

Method: Structured interviews were administered to 255 regular methamphetamine users at baseline (2010) and 12 months (2011). A multivariate generalised estimating equation (GEE) model identified adjusted associations with past-month abstinence at follow-up. A multivariate logistic regression analysis identified factors independently associated with remission from methamphetamine dependence.

Results: Most (60%) participants were methamphetamine-dependent at baseline. Remission from dependence (n?=?38) was independently associated with age (OR: 0.93; 95% CI: 0.88–1.00), maintaining/gaining employment since baseline (OR: 3.14; 95% CI: 1.21–8.14) and a greater increase in self-perceived social support (OR: 1.08; 95% CI: 1.01–1.16). Past-month abstinence at follow-up was independently associated with being female (OR: 1.94; 95% CI: 1.10–3.44), recent criminal behaviours (OR: 0.46; 95% CI: 0.26–0.82), recent ecstasy (OR: 0.30; 95% CI: 0.12–0.72) and benzodiazepine use (OR: 0.53; 95% CI: 0.29–0.96), and being less methamphetamine-dependent (OR: 0.79; 95% CI: 0.72–0.88). Drug treatment was not independently associated with either outcome at follow-up.

Conclusions: Our findings highlight the potential for natural remission from methamphetamine dependence; however, targeted interventions should be developed for individuals who are likely to maintain dependent/harmful use patterns.     

Predictors of duloxetine versus other treatments among veterans with diabetic peripheral neuropathic pain: a retrospective study

Objective: This study used medical and pharmacy records from the Veterans Affairs (VA) health system to explore the predictors of duloxetine versus other treatments for patients with diabetic peripheral neuropathic pain (DPNP). Methods: The electronic medical and pharmacy records from January 2004 to December 2008 were requested from the Veterans Integrated Service Network 16 data warehouse. All select patients received either duloxetine or other treatments [tricyclic antidepressants (TCAs), venlafaxine, gabapentin, and pregabalin] over the study period, with the first dispense date of the index agent as the index date. All patients must have 1⁺ prior DPNP diagnosis (ICD‐9‐CM: 250.6x or 357.2), but no diagnoses of prior depression (ICD‐9‐CM: 296.2, 296.3, 300.4, 309.1, or 311.0), fibromyalgia (ICD‐9‐CM: 729.1), or neuralgia (ICD‐9‐CM: 729.2). Logistic regression was used to examine the predictors of receiving duloxetine versus other treatments, controlling for demographics, comorbidities, prior pain level, prior use of other medications, and opioid use. Results: The analytical sample included 2,694 patients (duloxetine cohort, n = 216; other‐treatment cohort, n = 2,478). Prior uses of gabapentin (odds ratio [OR] = 13.66, 95% confidence interval [CI]: 9.70–19.24), TCAs (OR = 5.40, 95% CI: 3.73–7.82), or venlafaxine (OR = 3.67, 95% CI: 1.67–8.06) were strong predictors of duloxetine. Other comorbidities associated with duloxetine were anxiety (OR = 2.08, 95% CI: 1.40–3.08), cerebrovascular disease (OR = 1.44, 95% CI: 1.01–2.07), and substance abuse (OR = 2.11, 95% CI: 1.10–4.03). Prior opioid users were 1.47 (95% CI: 1.02–2.12) times as likely to receive duloxetine as those without prior opioid use. Patients with self‐reported severe pain were 1.66 (95% CI: 1.11–2.50) times as likely to receive duloxetine as those with no pain reported. Conclusion: DPNP patients in the VA healthcare system with prior other treatment use, select comorbid conditions, prior substance abuse, prior opioid use, and higher pain level were more likely to receive duloxetine.     

Prediction of failure to retain work 1 year after interdisciplinary functional restoration in occupational injuries

Brede E, Mayer TG, Gatchel RJ. Prediction of failure to retain work 1 year after interdisciplinary functional restoration in occupational injuries.ObjectiveTo identify risk factors for work retention (a patients' ability to both obtain and retain employment) at 1 year after treatment for a chronic disabling occupational musculoskeletal disorder (CDOMD).DesignProspective cohort study.SettingConsecutive patients undergoing interdisciplinary functional restoration treatment in a regional rehabilitation referral center.ParticipantsA sample of 1850 consecutive CDOMD patients, who were admitted to and completed a functional restoration program, were subsequently classified as work retention or nonwork retention at a 1-year posttreatment evaluation.InterventionsNot applicable.Main Outcome MeasuresMeasures, including medical evaluations, demographic and occupational data, psychosocial diagnostic evaluation, and validated measures of pain, disability, and depressive symptoms, were obtained at admission to, and discharge from, the program.ResultsUsing a multivariate logistic regression analysis, the following variables were found to be significant predictors of failure to retain work: older age (odds ratio [OR]=1.84; 95% confidence interval [CI], 1.33–2.54), female sex (OR=1.46; 95% CI, 1.09–1.94), nonworking status at discharge (OR=1.65; 95% CI, 1.11–2.45), extreme disability at admission (OR=1.46; 95% CI, 1.06–2.00), antisocial personality disorder (OR=2.11; 95% CI, 1.09–4.08), receipt of government disability benefits at admission (OR=2.28; 95% CI, 1.06–4.89), and dependence on opiate pain medications (OR=1.43; 95% CI, 1.02–2.00). The final model improved prediction by 75% over assigning all patients to the larger (work retention) group.ConclusionsThis study identified demographic, psychosocial, and occupational factors that were predictive of failure to retain work. These risk factors may be used to individualize treatment plans for CDOMD patients in order to provide optimal functional restoration.     

Predictors of Symptom Duration and Bacteriuria in Uncomplicated Urinary Tract Infection

Abstract

Objective: To identify baseline predictors of symptom duration after empirical treatment for uncomplicated urinary tract infection (UTI) and significant bacteriuria in a cohort of women treated for UTI.

Design: Prospective single-centre cohort study.

Setting: Outpatient clinic in Norway.

Patients: From September 2010 to November 2011, 441 women aged 16–55 years with symptoms of uncomplicated UTI were included.

Results: Dipstick findings of leukocyte esterase 1?+?(incidence rate ratio (IRR) 1.93, 95% confidence interval (CI) 1.23–3.01, p?<?0.01) and microbe resistant to mecillinam treatment (IRR 1.41, 95% CI 1.07–1.89, p?=?0.02) predicted longer symptom duration. More pronounced symptoms did not predict longer symptom duration (IRR 1.18, 95% CI 0.94–1.46, p?=?0.15) or significant bacteriuria (odds ratio [OR] 1.16, 95% CI 0.72–1.88, p?=?0.54). Leukocyte esterase 2?+?(OR 2.51, 95% CI 0.92–6.83, p?=?0.07) or 3?+?(OR 2.40, 95% CI 0.88–6.05, p?=?0.09) and nitrite positive urine dipstick test (OR 3.22, 95% CI 1.58–7.01, p?=?<0.01) were associated with bacteriuria.

Conclusion: More pronounced symptoms did not correlate with significant bacteriuria or symptom duration after empirical treatment for acute cystitis. One might reconsider the current practice of treating uncomplicated UTI based on symptoms alone.

• Key Points

• Treatment strategies for milder infectious diseases must consider ways of reducing antibiotic consumption to decelerate the increase in antibiotic resistance. Our findings suggest that more emphasis should be put on urine dipstick results and bacteriological findings in the clinical setting. One might reconsider the current practice of treating uncomplicated UTIs based on symptoms alone.

     

Analysis of ECOG performance status in head and neck squamous cell carcinoma patients: association with sociodemographical and clinical factors, and overall survival

Purpose

In the present study, we analyzed sociodemographical and clinical factors, and the Eastern Cooperative Oncology Group performance status (ECOG-PS) scale in head and neck squamous cell carcinoma (HNSCC) patients. We evaluated the impact of a range of variables on overall survival.

Methods

We investigated a sample of HNSCC patients (n?=?671), using sociodemographical and clinical information, and survival data collected from a review of epidemiological, clinical, and treatment reports. Statistical associations were analyzed by bivariate and multivariate statistical tests. Statistical significance was set at p?<?0.05.

Results

Of patients 85.4% recorded good ECOG-PS scores. Poor ECOG-PS scores were associated with the covariates indicative of dysphagia [odd ratios (OR)?=?2.660, CI 95%?=?1.661–4.260, p?=?0.000] and large-size malignant disease (T3–T4; OR?=?5.337, CI 95%?=?2.251–12.652, p?=?0.000). Overall survival analysis revealed that ECOG-PS scores (OR?=?1.879, CI 95%?=?1.162–3.038, p?=?0.010), tumor size (OR?=?1.665, CI 95%?=?1.035–2.680, p?=?0.036), and the presence of cervical metastasis (OR?=?3.145, CI 95%?=?2.008–4.926, p?=?0.000) were independent predictors.

Conclusion

Evaluation of physical consumption in head and neck cancer patients at diagnosis may indicate a more aggressive type of malignant disease. Thus, the ECOG-PS scale may help to identify HNSCC patients in need of rapid referral, who may benefit from specific therapeutic and rehabilitative interventions.     

Prognostic factors for self-rated function and perceived health in patient living at home three months after a hip fracture

Purpose: To explore the relationship between prefracture sociodemographic and health characteristics, basic activities of daily living, instrumental activities of daily living and perceived health 3 months after a hip fracture aged 65 or older.Methods: Age, sex, living alone or not, use of walking aids and whether they had experienced another fall during the previous 6 months, were recorded in hospital and at a three-month follow-up. A total of 277 patients were included. The Barthel Index, the Nottingham Extended ADL Index, the Short Form-12 questionnaire, and the Mini Mental State Examination were used.Results: Prefracture use of a walking aid outdoors was a predictor of postfracture dependency in basic activities of daily living: odds ratio (OR) 2.0, 95% confidence intervals (CI 1.1–3.6), reduced score in instrumental activities of daily living (OR 1.8; 95% CI 1.0–3.2) and reduced perceived physical health (p?=?0.04). Prefracture instrumental activity of daily living was a predictor for dependency in basic activities of daily living (OR 3.3; 95% CI 1.7–6.3). Cognitive dysfunction was a risk factor for dependency in basic activities of daily living (OR 0.1; 95% CI 0.01–0.7).Conclusions: Prefracture use of outdoor walking aids, perceived physical health, cognitive function, instrumental activity of daily living and female gender were all predictors explaining the three-month outcomes for basic activities of daily living and instrumental activity of daily living.

Implications for Rehabilitation

• The use of a walking aid before hip fracture may be a poor prognostic factor affecting 3-months rehabilitation outcome of hip-fractured patients.

• It is of importance to having knowledge of the patient’s prefracture status when planning rehabilitation.

     

Short-term outcome of take-home prescriptions for opioid dependence: a clinic-based study

Introduction & Aim: To evaluate in a real-world setting the short-term outcome among opioid-dependent patients receiving take-home medications.

Methods: A total of 102 opioid-dependent patients who formed part of this study received either naltrexone or buprenorphine as long-term treatment for relapse prevention. Following the initiation of treatment in a hospital-based setting, a family member supervised the treatment at home. Measurements included assessment of demographic and clinical variables, retention in treatment, drug use at baseline and follow-up.

Results: Majority of patients (69, 67.6%) were dependent on pharmaceutical opioids. Thirty-two (32%) received naltrexone and 70 (68%) were put on buprenorphine maintenance treatment. Follow-up information was available for 67.5% for 3 months, 63% for 6 months and 58% for 1 year. At the end of 6 months, 40% patients were abstinent. This rate decreased to 37.8% at the end of 1 year.

Discussion & Conclusions: Buprenorphine was found to be more effective with greater retention rates compared with naltrexone (68% vs. 42%). Buprenorphine maintenance was also found to be useful for patients with pharmaceutical opioid dependence.     

Do medical treatments increase the risk of substance abuse in older people with dementia

Abstract

The current study aims to determine the association between medical treatments and the risk of substance abuse in the elderly with dementia. The research was conducted on Malaysian elderly who were demented and non-institutionalized. The study was a national cross sectional survey that included 1210 non-institutionalized Malaysian elderly with dementia. The Multiple Logistic Regression Model was applied to predict the risk of substance abuse in respondents. The prevalence of substance abuse was approximately 57.9% among subjects. Furthermore, medical treatment (OR?=?1.88, 95% CI: 1.37–2.59), ethnic non-Malay (OR?=?1.44, 95% CI: 1.12–1.84) and male sex (OR?=?4.64; 95% CI: 3.42–6.29) significantly increased substance abuse after adjusting for socio-demographic factors. The results showed that age, marital status and educational level did not predict significantly the risk of substance abuse in samples (p?>?0.05). It was concluded that male sex, medical treatment and ethnic non-Malay can increase the risk of substance abuse in the older people with dementia.     

Has the Prevalence of Invalidating Musculoskeletal Pain Changed Over the Last 15 Years (1993–2006)? A Spanish Population-Based Survey

The aim of the current study was to estimate the prevalence and time trend of invalidating musculoskeletal pain in the Spanish population and its association with socio-demographic factors, lifestyle habits, self-reported health status, and comorbidity with other diseases analyzing data from 1993–2006 Spanish National Health Surveys (SNHS). We analyzed individualized data taken from the SNHS conducted in 1993 (n = 20,707), 2001 (n = 21,058), 2003 (n = 21,650) and 2006 (n = 29,478). Invalidating musculoskeletal pain was defined as pain suffered from the preceding 2 weeks that decreased main working activity or free-time activity by at least half a day. We analyzed socio-demographic characteristics, self-perceived health status, lifestyle habits, and comorbid conditions using multivariate logistic regression models. Overall, the prevalence of invalidating musculoskeletal pain in Spanish adults was 6.1% (95% CI, 5.7–6.4) in 1993, 7.3% (95% CI, 6.9–7.7) in 2001, 5.5% (95% CI, 5.1–5.9) in 2003 and 6.4% (95% CI 6–6.8) in 2006. The prevalence of invalidating musculoskeletal pain among women was almost twice that of men in every year (P < .05). The multivariate analysis showed that occupational status (unemployed), sleep <8 hours/day and having any accident in the preceding year were significantly associated in both gender with a higher likelihood of suffering from invalidating musculoskeletal pain among Spanish adults. Within men, other predictors of invalidating musculoskeletal pain were to be married and lower educational level, whereas in women were age of 45–64 years old (OR 1.89, 95% CI 1.32–2.7), obesity (OR 1.23, 95% CI 1.06–1.42), a sedentary lifestyle (OR 1.23, 95% CI 1.06–1.42), and presence of comorbid chronic diseases (OR 1.32, 95% CI 1.14–1.53). Further, worse self-reported health status was also related to a greater prevalence of invalidating musculoskeletal pain (OR 6.88, 95% 5.62–8.40 men, OR 7.24, 95% 6.11–8.57 women). Finally, we found that the prevalence of invalidating musculoskeletal pain increased from 1993 to 2001 for both men (OR 1.31, 95% 1.08–1.58) and women (OR 1.19, 95% 1.03–1.39) with no significant increase from the remaining surveys. Our results suggest that invalidating musculoskeletal pain deserves an increased awareness among health professionals. More educational programs which address postural hygiene, physical exercise, and how to prevent obesity and sedentary lifestyle habits should be provided by Public Health Services.PerspectiveThis population-based study indicates that invalidating musculoskeletal pain that reduces main working activity is a public health problem in Spain. The prevalence of invalidating musculoskeletal pain was higher in women than in men and associated to lower income, poor sleeping, worse self-reported health status, and other comorbid conditions. Further, the prevalence of invalidating musculoskeletal pain increased from 1993 to 2001, but remained stable from the last years (2001 to 2006).     

Risk of obstetric and thromboembolic complications in family members of women with previous adverse obstetric outcomes carrying common inherited thombophilias

Summary. Background: Factor (F)V Leiden and the prothrombin 20210A mutation (PTm) are associated with the occurrence of obstetric complications, including pregnancy‐related venous thromboembolism (VTE). It is not known whether family members of women with FV Leiden or PTm and previous obstetric complications have a higher risk of VTE or adverse obstetric outcomes. Methods: A retrospective family study including 563 relatives of 177 women with previous adverse outcomes carrying FV Leiden or PTm, referred between April 1993 and June 2010. A history of obstetric complications and VTE was obtained. Prevalence of VTE and obstetric complications in relatives with and without inherited thrombophilias was compared. Adjusted odd ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression models that controlled for predictors (age, FV Leiden and PTm). Results: Relatives carrying FV Leiden had a significant and independent risk for obstetric complications (OR: 1.98, 95% CI 1.03–3.83); this risk was not observed in the presence of PTm (OR: 1.03, 95% CI 0.46–2.32). The presence of FV Leiden or PTm in heterozygosis was significantly and independently associated with the occurrence of VTE (OR: 5.2, 95% CI: 1.70–15.91). Severe thrombophilias were strong risk factors for VTE (OR: 23.2, 95% CI: 6.0–89.85). Male gender was a significant and independent risk factor for VTE (OR: 3.49, 95% CI: 1.51–8.05). The risk did not change when relatives of women with a previous pregnancy‐related VTE were excluded (OR: 3.49, 95% CI: 1.51–8.05). Conclusions: Knowledge of thrombophilia status may help to better define the obstetric and thromboembolic risks in asymptomatic family members of women who suffered from obstetric complications.     

Predictors of femoral hematoma in patients undergoing elective coronary procedure: a trigonometric evaluation

Vascular complications in the femoral artery puncture site are the most common complications of the coronary angiography. Femoral hematoma is the leading participant of the vascular complications. We investigated the femoral hematoma predictive value of angle of sheath to trochanter major in patients undergoing elective coronary procedures. In this prospective analysis, we evaluated the femoral hematoma predictive value of angle of sheath to trochanter major on 246 patients undergoing elective coronary procedures. In this prospective analysis, we evaluated the femoral hematoma predictive value of angle of sheath to trochanter major on 246 patients undergoing elective coronary procedures. Patients were divided into two as femoral hematoma (n?=?23) and control (n?=?223) groups according to post-procedure femoral hematoma status. Other independent predictors of femoral hematoma were also evaluated. In-hospital multivariable analysis revealed higher rates of femoral hematoma for patients with chronic renal failure (OR 24.97, 95% CI 3.04–78.88, p?=?0.003), with higher diastolic blood pressure after the procedure (OR 1.08 95% CI 1.00–1.16, p?=?0.037), with femoral vein puncture during procedure (OR 17.74, 95% CI 2.67–54.74, p?=?0.003) and with higher angle of sheath to trochanter major (OR 1.52, 95% CI 1.13–2.05, p?=?0.005). The best cut-off value of the angle of sheath to trochanter major to predict femoral hematoma was 15.6° with 74% sensitivity and 70% specificity (AUC: 0.75; 95% CI 0.63–0.86; p?<?0.001). The angle of sheath to trochanter major provides an independent predictor of femoral hematoma in patients undergoing elective coronary procedures. Our data suggests the importance of fluoroscopic guidance during femoral artery access with the predictive role of the angle of sheath to trochanter major.     

The Association Between Opioid Use and Outcomes in Infants Undergoing Pyloromyotomy

PurposeThe purpose of this study was to describe the frequency and variation of opioid use across hospitals in infants undergoing pyloromyotomy and to determine the impact of opioid use on postoperative outcomes.MethodsA retrospective cohort study (2005–2015) was conducted by using the Pediatric Health Information System (PHIS) database, including infants (aged <6 months) with pyloric stenosis who underwent pyloromyotomy. Infants with significant comorbidities were excluded. Opioid use was classified as a patient receiving at least 1 opioid medication during his or her hospital stay and categorized as preoperative, day of surgery, or postoperative (≥1 day after surgery). Outcomes included prolonged hospital length of stay (LOS; ≥3 days) and readmission within 30 days.FindingsOverall, 25,724 infants who underwent pyloromyotomy were analyzed. Opioids were administered to 6865 (26.7%) infants, with 1385 (5.4%) receiving opioids postoperatively. In 2015, there was significant variation in frequency of opioid use by hospital, with 0%–81% of infants within an individual hospital receiving opioids (P < 0.001). Infants only receiving opioids on the day of surgery exhibited decreased odds of prolonged hospital LOS (odds ratio [OR], 0.85; 95% CI, 0.78–0.92). Infants who received an opioid on both the day of surgery and postoperatively exhibited increased odds of a prolonged hospital LOS (OR, 1.71; 95% CI, 1.33–2.20). Thirty-day readmission was not associated with opioid use (OR, 1.03; 95% CI, 0.93–1.14).ImplicationsThere is national variability in opioid use for infants undergoing pyloromyotomy, and postoperative opioid use is associated with prolonged hospital stay. Nonopioid analgesic protocols may warrant future investigation.     

Pattern and predictors of the initiation of biologic agents for the treatment of rheumatoid arthritis in the United States: An analysis using a large observational data bank

Objective: The aim of this study was to identify factors associated with the initiation of biologic agents for the treatment of rheumatoid arthritis (RA) in a large US observational cohort.Methods: Semiannual patient-reported data in the ARAMIS (Arthritis, Rheumatism and Aging Medical Information System) data bank from January 1998 to January 2006 were analyzed retrospectively using pooled logistic regression (with adjustment for center-level and temporal effects) to identify patient-, disease-, and treatment-related characteristics associated with the initiation of biologics for the treatment of RA.Results: The analysis included 1545 patients from 7 US centers. By 2006, 41.4% of 679 patients remaining in the sample had received biologics. Initiation of biologics was significantly associated with greater disability in the previous 6-month period (per 1-unit increase in Health Assessment Questionnaire score: odds ratio [OR] = 1.45; 95% CI, 1.22–1.72; P < 0.01) and treatment in the previous period with steroids (OR = 2.24; 95% CI, 1.76–2.85; P < 0.01) or nonbiologic disease-modifying antirheumatic drugs (OR = 2.43; 95% CI, 1.71–3.46; P < 0.01). Two sociodemographic factors were significant predictors of decreased use of biologics: older age (per 10 years: OR = 0.74; 95% CI, 0.660.82; P < 0.01) and lower annual income (per $10,000 reduction: OR = 0.95; 95% CI, 0.91–1.00; P = 0.04). There were no significant differences with respect to sex, race, employment status, comorbidity, previous NSAID use, or treatment center.Conclusions: Disease- and treatment-related factors were significant predictors of the initiation of biologics for RA. Independent of these factors, however, biologics were less often used in patients who were older and those with lower incomes. Use of biologics increased steadily over the period studied.     

Impact of microvascular obstruction and infarct size on left ventricular remodeling in reperfused myocardial infarction: a contrast-enhanced cardiac magnetic resonance imaging study

Infarct size (IS) and microvascular obstruction (MO) following ST-elevation myocardial infarction (STEMI) reperfusion may affect left ventricular (LV) remodeling. We evaluated the impact of extent and transmurality of IS and MO in LV remodeling using contrast-enhanced cardiac magnetic resonance imaging (MRI). Thirty-six consecutive patients presenting with a first STEMI and undergoing contrast-enhanced cardiac MRI within 5?days of successful primary percutaneous coronary intervention (PPCI) were enrolled. Gadolinium-enhanced MRI at first passage and in delayed imaging was performed to assess MO and IS. LV remodeling was evaluated by echocardiography at 6-month-follow-up and defined as a percent increase in the LV end-diastolic volume >20%. Thirteen patients (36%) developed LV remodeling. IS and MO extent score was associated with LV remodeling (OR 1.5, 95% CI 1.02–2.38, P?=?0.04, and OR 3.1, 95% CI 1.45–6.64, P?=?0.003, respectively), along with IS and MO trasmurality (OR 1.4, 95% CI 1.007–2.12, P?=?0.046, and OR 3.1, 95% CI 1.24–7.89, P?=?0.016, respectively). Importantly, IS and MO extent score combination gave an OR of 3.4 (95% CI 1.4–7.9, P?=?0.004) and the combination of IS and MO transmurality increased the OR to 4.8 (95% CI 1.5–15.2, P?=?0.007). Finally, when combining simultaneously IS and MO extent score and transmurality the OR reached 5.3 (95% CI 3.34–18.2, P?=?0.0008). The evaluation of both IS and MO extent and transmurality by MRI is of prognostic utility in patients undergoing PPCI. Importantly, IS and MO transmurality significantly increases the risk of adverse remodeling and should be routinely assessed in post-STEMI patients.     

Clinical and Economic Factors Associated with Ambulance Use to the Emergency Department

Background: Concern about ambulance diversion and emergency department (ED) overcrowding has increased scrutiny of ambulance use. Knowledge is limited, however, about clinical and economic factors associated with ambulance use compared to other arrival methods. Objectives: To compare clinical and economic factors associated with different arrival methods at a large, urban, academic hospital ED. Methods: This was a retrospective, cross‐sectional study of all patients seen during 2001 (N= 80,209) at an urban academic hospital ED. Data were obtained from hospital clinical and financial records. Outcomes included acuity and severity level, primary complaint, medical diagnosis, disposition, payment, length of stay, costs, and mode of arrival (bus, car, air‐medical transport, walk‐in, or ambulance). Multivariate logistic regression identified independent factors associated with ambulance use. Results: In multivariate analysis, factors associated with ambulance use included: triage acuity A (resuscitation) (adjusted odds ratio [OR], 51.3; 95% confidence interval [CI] = 33.1 to 79.6) or B (emergent) (OR, 9.2; 95% CI = 6.1 to 13.7), Diagnosis Related Group severity level 4 (most severe) (OR, 1.4; 95% CI = 1.2 to 1.8), died (OR, 3.8; 95% CI = 1.5 to 9.0), hospital intensive care unit/operating room admission (OR, 1.9; 95% CI = 1.6 to 2.1), motor vehicle crash (OR, 7.1; 95% CI = 6.4 to 7.9), gunshot/stab wound (OR, 2.1; 95% CI = 1.5 to 2.8), fell 0–10 ft (OR, 2.0; 95% CI = 1.8 to 2.3). Medicaid Traditional (OR, 2.0; 95% CI = 1.4 to 2.4), Medicare Traditional (OR, 1.8; 95% CI = 1.7 to 2.1), arrived weekday midnight–8 AM (OR, 2.0; 95% CI = 1.8 to 2.1), and age ≥65 years (OR, 1.3; 95% CI = 1.2 to 1.5). Conclusions: Ambulance use was related to severity of injury or illness, age, arrival time, and payer status. Patients arriving by ambulance were more likely to be acutely sick and severely injured and had longer ED length of stay and higher average costs, but they were less likely to have private managed care or to leave the ED against medical advice, compared to patients arriving by independent means.     

Racial and ethnic disparities in emergency department–initiated buprenorphine across five health care systems

Background

Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood.

Methods

This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity.

Results

Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45–0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48–0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56–1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09–1.83) and adjusted models (aOR 1.41, 95% CI 1.08–1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99–1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64).

Conclusions

Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.