Emergency Department Utilization: A Qualitative Analysis of Illinois Medical Home Network Patients.

Background Inappropriate emergency department (ED) use continues to plague healthcare in terms of disease management and costs. In 2012, the State of Illinois implemented Medical Home Network (MHN) where Medicaid recipients were assigned to primary care providers to, in part, reduce overreliance on EDs. However, MHN patients have continued to use EDs. Objective The purpose of this study is to provide a qualitative analysis of Medicaid patient-identified barriers to primary care, facilitators of emergency use, and related mental health and psychosocial factors. Methods Patients who presented themselves at the ED located at an urban, academic medical center participated in one-time, individual interviews. Participants arrived with non-urgent, minor, or moderate acuity. Interviews were digitally audiorecorded and transcribed for data analysis. Researchers analyzed data using the Grounded Theory approach. Results Four themes were identified: 1) barriers related to visiting a primary care provider (not having an appointment and scheduling issues), 2) elements of ED use (the experience of physical pain), 3) mental health and stress (a lack of willingness to discuss mental health issues), and 4) varying perceptions of primary care and the ED (the ED provides care that is fast, solution-oriented, team-based, and patient-centered within an environment containing necessary equipment). Conclusions Findings may inform interventions such as the use of community health workers as liaisons between MHN, the ED, primary care, and patients. Addressing patient perceptions regarding the role of primary care and stigma surrounding mental health can lead to decreasing ED use and increasing continuous primary care use for vulnerable patients

Evaluating Strategies For Reducing Health Disparities By Addressing The Social Determinants Of Health

Research reveals that the opportunities for healthy choices in homes, neighborhoods, schools, and workplaces can have decisive impacts on health. This article reviews scientific evidence from promising interventions focused on the social determinants of health, and describes ways in which they can improve population health and reduce health disparities. We show that there is sufficient evidence to support policy interventions targeted at education and early childhood; urban planning and community development; housing; income enhancements and supplements; and employment. When available, cost-effectiveness evaluations show that these interventions lead to long-term societal savings; however, more routine attention to cost considerations is needed for these interventions. We also discuss challenges to implementation, including the need for long-term financing in order to scale-up effective interventions for implementation at the local, state, or national level. Although we know enough to act, questions remain about how to optimally scale-up these interventions and maximize their benefits for the most vulnerable populations

Challenges and Considerations Related to Studying Dementia in Blacks/African Americans

Blacks/African Americans have been reported to be ~2–4 times more likely to develop clinical Alzheimer’s disease (AD) compared to Whites. Unfortunately, study design challenges (e.g., recruitment bias), racism, mistrust of healthcare providers and biomedical researchers, confounders related to socioeconomic status, and other sources of bias are often ignored when interpreting differences in human subjects categorized by race. Failure to account for these factors can lead to misinterpretation of results, reification of race as biology, discrimination, and missed or delayed diagnoses. Here we provide a selected historical background, discuss challenges, present opportunities, and suggest considerations for studying health outcomes among racial/ethnic groups. We encourage neuroscientists to consider shifting away from using biologic determination to interpret data, and work instead toward a paradigm of incorporating both biological and socio-environmental factors known to affect health outcomes with the goal of understanding and improving dementia treatments for Blacks/African Americans and other underserved populations

Susceptibility to Scams in Older Black and White Adults

Previous reports on racial differences in scam susceptibility have yielded mixed findings, and few studies have examined reasons for any observed race differences. Older Black and White participants without dementia (N = 592) from the Minority Aging Research Study and the Rush Memory and Aging Project who completed a susceptibility to scam questionnaire and other measures were matched according to age, education, sex, and global cognition using Mahalanobis distance. In adjusted models, older Black adults were less susceptible to scams than older White adults (Beta = −0.2496, SE = 0.0649, p = 0.0001). Contextual factors did not mediate and affective factors did not moderate this association. Analyses of specific items revealed Black adults had greater knowledge of scam targeting of older adults and were less likely to pick up the phone for unidentified callers. Older Black adults are less susceptible to scams than demographically-matched older White adults, although the reasons remain unknown

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Regional differences in awareness and attitudes regarding genetic testing for disease risk and ancestry

Little is known about the lay public’s awareness and attitudes concerning genetic testing and what factors influence their perspectives. The existing literature focuses mainly on ethnic and socioeconomic differences; however, here we focus on how awareness and attitudes regarding genetic testing differ by geographical regions in the US. We compared awareness and attitudes concerning genetic testing for disease risk and ancestry among 452 adults (41% Black and 67% female) in four major US cities, Norman, OK; Cincinnati, OH; Harlem, NY; and Washington, DC; prior to their participation in genetic ancestry testing. The OK participants reported more detail about their personal ancestries (p = 0.02) and valued ancestry testing over disease testing more than all other sites (p < 0.01). The NY participants were more likely than other sites to seek genetic testing for disease (p = 0.01) and to see benefit in finding out more about one’s ancestry (p = 0.02), while the DC participants reported reading and hearing more about genetic testing for African ancestry than all other sites (p < 0.01). These site differences were not better accounted for by sex, age, education, self-reported ethnicity, religion, or previous experience with genetic testing/counseling. Regional differences in awareness and attitudes transcend traditional demographic predictors, such as ethnicity, age and education. Local sociocultural factors, more than ethnicity and socioeconomic status, may influence the public’s awareness and belief systems, particularly with respect to genetics

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

The Association of Late Life Cognitive Activity with Healthcare and Financial Decision Making in Community-Dwelling, Non-Demented Older Adults

Objective: The purpose of this study was to test the hypothesis that late life cognitive activity is associated with decision-making in older adults and to examine whether this association varies by level of cognitive function. Design: This study employed a cross-sectional design. Setting: All data were collected in participants' community-based residences. Participants: Participants were 1,084 older adults (mean age = 81.05 years, standard deviation = 7.53) without dementia (median Mini-Mental State Examination score = 29, interquartile range = 27.86-30.00). Measurements: Participants completed assessments of late life cognitive activity, cognitive function, and decision-making. We used linear regression models to examine the associations of late life cognitive activity and cognitive function with decision-making. Results: In a regression model adjusted for age, gender, and education, more frequent late life cognitive activity was associated with better decision-making, as was higher cognitive function. Furthermore, in an additional model that included the interaction of late life cognitive activity and cognitive function, the interaction was significant, such that late life cognitive activity was most strongly associated with decision-making among participants with lower levels of cognitive function. Conclusion: Frequent engagement in late life cognitive activity may help maintain decision-making among older persons, particularly among those with lower levels of cognitive function