Barriers to Accessing Acute Care for Newly Arrived Refugees

Introduction: Over the past decade, the number of refugees arriving in the United States (U.S.) has increased dramatically. Refugees arrive with unmet health needs and may face barriers when seeking care. However, little is known about how refugees perceive and access care when acutely ill. The goal of this study was to understand barriers to access of acute care by newly arrived refugees, and identify potential improvements from refugees and resettlement agencies.Methods: This was an in-depth, qualitative interview study of refugees and employees from refugee resettlement and post-resettlement agencies in a city in the Northeast U.S. Interviews were audiotaped, transcribed, and coded independently by two investigators. Interviews were conducted until thematic saturation was reached. We analyzed transcripts using a modified grounded theory approach.Results: Interviews were completed with 16 refugees and 12 employees from refugee resettlement/post-resettlement agencies. Participants reported several barriers to accessing acute care including challenges understanding the U.S. healthcare system, difficulty scheduling timely outpatient acute care visits, significant language barriers in all acute care settings, and confusion over the intricacies of health insurance. The novelty and complexity of the U.S. healthcare system drives refugees to resettlement agencies for assistance. Resettlement agency employees express concern with directing refugees to appropriate levels of care and report challenges obtaining timely access to sick visits. While receiving emergency department (ED) care, refugees experience communication barriers due to limitations in consistent interpretation services.Conclusion: Refugees face multiple barriers when accessing acute care. Interventions in the ED, outpatient settings, and in resettlement agencies, have the potential to reduce barriers to care. Examples could include interpretation services that allow for clinic phone scheduling and easier access to interpreter services within the ED. Additionally, extending the Refugee Medical Assistance program may limit gaps in insurance coverage and avoid insurance-related barriers to seeking care

Emergency Department Clinicians’ Attitudes Toward Opioid Use Disorder and Emergency Department-initiated Buprenorphine Treatment: A Mixed-Methods Study

Introduction: Emergency department (ED) visits related to opioid use disorder (OUD) have increased nearly twofold over the last decade. Treatment with buprenorphine has been demonstrated to decrease opioid-related overdose deaths. In this study, we aimed to better understand ED clinicians’ attitudes toward the initiation of buprenorphine treatment in the ED.Methods: We performed a mixed-methods study consisting of a survey of 174 ED clinicians (attending physicians, residents, and physician assistants) and semi-structured interviews with 17 attending emergency physicians at a tertiary-care academic hospital.Results: A total of 93 ED clinicians (53% of those contacted) completed the survey. While 80% of respondents agreed that buprenorphine should be administered in the ED for patients requesting treatment, only 44% felt that they were prepared to discuss medication for addiction treatment. Compared to clinicians with fewer than five years of practice, those with greater experience were less likely to approve of ED-initiated buprenorphine. In our qualitative analysis, physicians had differing perspectives on the role that the ED should play in treating OUD. Most physicians felt that a buprenorphine-based intervention in the ED would be feasible with institutional support, including training opportunities, protocol support within the electronic health record, counseling and support staff, and a robust referral system for outpatient follow-up.Conclusion: ED clinicians’ perception of buprenorphine varied by years of practice and training level. Most ED clinicians did not feel prepared to initiate buprenorphine in the ED. Qualitative interviews identified several addressable barriers to ED-initiated buprenorphine

Development of a Patient-centered Outcome Measure for Emergency Department Asthma Patients

Background: Measuring outcomes of emergency care is of key importance, but current metrics, such as 72-hour return visit rates, are subject to ascertainment bias, incentivize overtesting and overtreatment at initial visit, and do not reflect the full burden of disease and morbidity experienced at home following ED care. There is increasing emphasis on including patient-reported outcomes, but the existing patient-reported measures have limited applicability to emergency care. Objective: The objective was to identify concepts for inclusion in a patient-reported outcome measure for ED care and assess differences in potential concepts by health literacy. Methods: A three-phase qualitative study was completed using freelisting and semistructured interviewing for concept identification, member checking for concept ranking, and cognitive interviewing for question development. Participants were drawn from three tertiary care EDs. Parents of patients (pediatric) or patients (adult) with asthma completed a demographic survey and an assessment of health literacy. Phase 1 participants also completed a freelisting exercise and qualitative interview regarding the definition of success following ED discharge. Phase 2 participants completed a member checking survey based on concepts identified in Phase 1. Phase 3 was a pilot of trial questions based on the highest-ranked concepts from Phase 2. Results: Phase 1 enrolled 22 adult patients and 37 parents of pediatric patients. Phase 2 enrolled 41 adult patients and 200 parents. Phase 3 involved 15 parents. Across all demographic/literacy groups, Phase 1 participants reported return to usual activity and lack of asthma symptoms as the most important markers of success. In Phase 2, symptom improvement, medication use and access, and asthma knowledge were identified as the most important components of the definition of post-ED discharge success. Phase 3 resulted in five questions for the proposed measure. Conclusions: A stepwise qualitative process can identify, rank, and formulate questions based on patient-identified concepts for inclusion in a patient-reported outcome measure for ED discharge. The four key concepts identified for inclusion: symptom improvement, medication access, correct medication use, and asthma knowledge are not measured by existing quality metrics

ATLANTIC DIP: The Impact of Obesity on Pregnancy Outcome in Glucose-Tolerant Women

OBJECTIVE - A prospective Study of the impact of obesity on pregnancy Outcome in glucose-tolerant women. RESEARCH DESIGN AND METHODS - The Irish Atlantic Diabetes in Pregnancy network advocates universal screening for gestational diabetes. Women with normoglycemia and a recorded booking BMI were included. Maternal and infant outcomes correlated with booking BMI are reported. RESULTS - A total of 2,329 women fulfilled the criteria. Caesarean deliveries increased in overweight (OW) (odds ratio 1.57 [95% Cl 1.24-1.98]) and obese (013) (2.65 [2.03-3.46]) women. Hypertensive disorders increased in OW (2.30 11.55-3.40]) and 013 (3.29 [2.14-5.05]) women. Reported miscarriages increased in 013 (1,4 [1.11-1.77]) women. Mean birth weight was 3.46 kg in normal BMI (NBMI), 3.54 kg in OW, and 3.62 kg in 013 (P < 0.01) Mothers. Macrosomia occurred in 15.5, 21.4, and 27.8% of babies of NBMI, OW, and 013 mothers, respectively (P < 0.01). Shoulder dystocia occur in 4% (>4 kg) compared with 0.2% (<4 kg) babies (P < 0.01). Congenital malformation risk increased for 013 (2.47 [1.09-5.60]) women. CONCLUSIONS - OW and OB glucose-tolerant women have greater adverse pregnancy outcomes

Pre-pregnancy predictors of hypertension in pregnancy among Aboriginal and Torres Strait Islander women in north Queensland, Australia; a prospective cohort study

BACKGROUND Compared to other Australian women, Indigenous women are frequently at greater risk for hypertensive disorders of pregnancy. We examined pre-pregnancy factors that may predict hypertension in pregnancy in a cohort of Aboriginal and Torres Strait Islander women in north Queensland. METHODS Data on a cohort of 1009 Indigenous women of childbearing age (15–44 years) who participated in a 1998–2000 health screening program in north Queensland were combined with 1998–2008 Queensland hospitalisations data using probabilistic data linkage. Data on the women in the cohort who were hospitalised for birth (n = 220) were further combined with Queensland perinatal data which identified those diagnosed with hypertension in pregnancy. RESULTS Of 220 women who gave birth, 22 had hypertension in the pregnancy after their health check. The mean age of women with and without hypertension was similar (23.7 years and 23.9 years respectively) however Aboriginal women were more affected compared to Torres Strait Islanders. Pre-pregnancy adiposity and elevated blood pressure at the health screening program were predictors of a pregnancy affected by hypertension. After adjusting for age and ethnicity, each 1 cm increase in waist circumference showed a 4% increased risk for hypertension in pregnancy (PR 1.04; 95% CI; 1.02-1.06); each 1 point increase in BMI showed a 9% adjusted increase in risk (1.09; 1.04-1.14). For each 1 mmHg increase in baseline systolic blood pressure there was an age and ethnicity adjusted 6% increase in risk and each 1 mmHg increase in diastolic blood pressure showed a 7% increase in risk (1.06; 1.03-1.09 and 1.07; 1.03-1.11 respectively). Among those free of diabetes at baseline, the presence of the metabolic syndrome (International Diabetes Federation criteria) predicted over a three-fold increase in age-ethnicity-adjusted risk (3.5; 1.50-8.17). CONCLUSIONS Pre-pregnancy adiposity and features of the metabolic syndrome among these young Aboriginal and Torres Strait Islander women track strongly to increased risk of hypertension in pregnancy with associated risks to the health of babies.Sandra K Campbell, John Lynch, Adrian Esterman and Robyn McDermot

The risk of adverse pregnancy outcomes in women who are overweight or obese

Extent: 8p.Background: The prevalence of obesity amongst women bearing children in Australia is rising and has important implications for obstetric care. The aim of this study was to assess the prevalence and impact of mothers being overweight and obese in early to mid-pregnancy on maternal, peripartum and neonatal outcomes. Methods: A secondary analysis was performed on data collected from nulliparous women with a singleton pregnancy enrolled in the Australian Collaborative Trial of Supplements with antioxidants Vitamin C and Vitamin E to pregnant women for the prevention of pre-eclampsia (ACTS). Women were categorized into three groups according to their body mass index (BMI): normal (BMI 18.5-24.9 kg/m2); overweight (BMI 25-29.9 kg/m2) and; obese (BMI 30-34.9 kg/m2). Obstetric and perinatal outcomes were compared by univariate and multivariate analyses. Results: Of the 1661 women included, 43% were overweight or obese. Obese women were at increased risk of pre-eclampsia (relative risk (RR) 2.99 [95% confidence intervals (CI) 1.88, 4.73], p < 0.0001) and gestational diabetes (RR 2.10 [95%CI 1.17, 3.79], p = 0.01) compared with women with a normal BMI. Obese and overweight women were more likely to be induced and require a caesarean section compared with women of normal BMI (induction - RR 1.33 [95%CI 1.13, 1.57], p = 0.001 and 1.78 [95%CI 1.51, 2.09], p < 0.0001, caesarean section - RR 1.42 [95%CI 1.18, 1.70], p = 0.0002 and 1.63 [95%CI 1.34, 1.99], p < 0.0001). Babies of women who were obese were more likely to be large for gestational age (LFGA) (RR 2.08 [95%CI 1.47, 2.93], p < 0.0001) and macrosomic (RR 4.54 [95%CI 2.01, 10.24], p = 0.0003) compared with those of women with a normal BMI. Conclusion: The rate of overweight and obesity is increasing amongst the Australian obstetric population. Women who are overweight and obese have an increased risk of adverse pregnancy outcomes. In particular, obese women are at increased risk of gestational diabetes, pregnancy induced hypertension and pre-eclampsia. Effective preventative strategies are urgently needed.Chaturica Athukorala, Alice R Rumbold, Kristyn J Willson and Caroline A Crowthe

Prepregnancy body mass index, hypertensive disorders of pregnancy, and long-term maternal mortality

Recent data have shown increased maternal mortality rates and cardiovascular disease after hypertensive disorders of pregnancy (HDP), but the reasons for this increase remain unclear. This study investigates the effects of a prepregnancy cardiovascular risk factor, namely body mass index (BMI), on the relationship between HDP and postpregnancy mortality. Data came from a 1975-1976 subset (n=13,722) of a population-based cohort of women. Multiple logistic regression was used to examine the risk of HDP by BMI by calculating odds ratios (OR) and 95% confidence intervals (CI). Age-adjusted Cox proportional hazards models were used to examine survival rates by calculation of the hazard ratios (HR) and 95% CIs. Normal weight was defined as BMI 18.5-24.9 kg/m2, overweight as BMI 25-29.9 kg/m2 and obesity as BMI ≥ 30 kg/m2. Women who entered their pregnancy overweight or obese had increased HDP [OR 2.82 (95% CI: 2.40, 3.31) and OR 5.51 (4.51, 7.31)] and decreased survival [HR 1.42 (1.10, 1.83) and HR 2.43 (1.61, 3.68)] when compared to normal weight women. HDP were associated with increased mortality in women who survived \u3e15 years [HR 1.94 (1.42, 2.67)] and that association remained significant, although attenuated, after adjustment for BMI [HR 1.65 (1.19, 2.79)]. The risk of death after HDP was increased in women who entered their pregnancy being overweight [HR 1.86 (1.07, 3.20)] or obese [HR 2.90 (1.28, 6.58)] as compared to the normal weight women [HR 1.26 (0.74, 2.14)]. Elevated prepregnancy BMI is associated with increased risk of HDP, which are known to be associated with an increased risk of maternal mortality. The association between HDP and mortality is increased in women entering pregnancy with elevated BMI. While obesity is a known cardiovascular risk factor, it does not fully explain the association between HDP and later life maternal disease. These data suggest that women with HDP should be followed after their pregnancy and appropriate interventions initiated to increase their long-term survival

Emergency Nurses’ Perceptions of Opioid Use Disorder and Its Treatment in the Emergency Department

Objectives: To describe the knowledge and attitudes of emergency nurses regarding caring for patients with opioid use disorder in the emergency department.Background: Many eligible patients with opioid use disorder do not receive available emergency department services for treatment and harm mitigation. While prior study examined contributing provider factors, little is known of nursing factors. This study describes knowledge and attitudes of emergency nurses regarding patients with opioid use disorder and their evidence-based treatment services in the emergency department setting.Methods: Anonymous email surveys with novel and previously validated questions based on The Theory of Planned Behavior Framework were distributed to emergency department nurses at a large, urban tertiary-care hospital. Chi-Square and independent samples t-tests were used in analyses.Results: More than one third of nurses completed the questionnaire (39%, 85/218). Most showed willingness and confidence screening for substance use disorder (95% and 88% respectively). Higher confidence providing buprenorphine and take-home naloxone was significantly associated with having worked fewer years (8.33 v. 15.62 , p=0.01 and 7.38 v. 12.03, p=0.03 respectively). Confidence administering buprenorphine was significantly associated with receiving in-service training (p=0.03). Staff with knowledge of take-home naloxone, positive attitudes toward syringe service programs, and a belief in a biopsychosocial basis of addiction were significantly younger and had worked significantly fewer years than those not indicating these beliefs. Specific educational gaps were identified.Conclusion: Emergency nurses display willingness to champion evidence-based care for patients with opioid use disorder. Younger age and having worked fewer years were significantly associated with positive attitudes towards recovery science, harm mitigation, and services knowledge. Having worked fewer years was significantly associated with greater confidence performing treatment and harm mitigation. In-service training was significantly associated with greater confidence administering buprenorphine. Further study should support generalizability and determine which staff development measures generate improved outcomes