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Objective. Examine how behavioral health (BH) integration affects health care costs, emergency department (ED) visits, and inpatient admissions.Data Sources/Study Setting. Truven Health MarketScan Research Databases.Study Design. Social network analysis identified 'care communities' (providers sharing a high number of patients) and measured BH integration in terms of how connected, or central, BH providers were to other providers in their community. Multivariable generalized linear models adjusting for age, sex, number of prescriptions, and Charlson comorbidity score were used to estimate the relationship between the centrality of BH providers and health care utilization of BH patients.Data Collection/Extraction Methods. Used outpatient, inpatient, and pharmacy claims data from six Medicaid plans from 2011 to 2013 to identify study outcomes, comorbidities, providers, and health care encounters.Principal Findings. Behavioral health centrality ranged from 0 (no BH providers) to 0.49. Relative to communities at the median BH centrality (0.06), in 2012, BH patients in communities at the 75th percentile of BH centrality (0.31) had 0.2 fewer admissions, 2.1 fewer all-cause ED visits, and accrued $1,947 fewer costs, on average.Conclusions. Increased behavioral centrality was significantly associated with a reduced number of ED visits, less frequent inpatient admissions, and lower overall health care costs.Key Words. Social network analysis, integrated behavioral network, health care costs, emergency and hospital utilization, substance use disorder, mental health, The relationship between variation in health care and patient-level costs and outcomes has been actively investigated for decades. Integration and collaboration among providers of different specialties are considered an important [...]

Adolescence is a critical period of neurocognitive development and increased prevalence of mood pathology. In this cross-sectional study, we replicated developmental patterns of neurocognition and tested whether mood symptoms moderated developmental effects. Participants were 419 adolescents (n= 246 with current mood disorders) who completed reward-learning and executive-functioning tasks and reported on age, puberty, and mood symptoms. Structural equation modeling revealed a quadratic relationship between puberty and reward-learning performance that was moderated by symptom severity: In early puberty, adolescents reporting higher manic symptoms exhibited heightened reward-learning performance (better maximizing of rewards on learning tasks), whereas adolescents reporting elevated anhedonia showed blunted reward-learning performance. Models also showed a linear relationship between age and executive functioning that was moderated by manic symptoms: Adolescents reporting higher mania showed poorer executive functioning at older ages. Findings suggest neurocognitive development is altered in adolescents with mood pathology and suggest directions for longitudinal studies.

Abstract Eyewitness identification research has typically been focused either on isolated specific factors or on more broadly defined and more ecologically valid contexts that occur in more realistic but less-controlled [...]

ABSTRACTBackground:There is increased recognition that traumatic events are a common experience among college students, and such events have shown to be associated with negative mental health outcomes and poorer well-being among this population. Although some work has focused on the relation between trauma exposure and mental health among college students, little work has explored the role of individual difference in fatigue severity within this group.Purpose:Therefore, the current study sought to address this gap in the existing literature by examining the explanatory role of fatigue severity in terms of anxiety/depression and post-traumatic stress among trauma exposed college students. Further, the mechanistic role of emotion dysregulation was evaluated as a possible factor that may underlie the relation between fatigue severity and mental health.Method:Seven hundred and thirty trauma-exposed college students were included in the present study (78.6% female, Mage = 22.59 years, SD = 5.48; 55.3% racial minority).Results:Results revealed that individual differences in fatigue severity had a significant indirect effect on the studied internalizing symptoms through emotion dysregulation.Conclusion:These novel findings suggest future work should continue to explore emotion dysregulation in the association between fatigue severity and internalizing symptoms among trauma-exposed college students.

BackgroundOpioids kill more people than any other drug. Naloxone is an opioid antagonist which can be distributed in take-home ‘kits’ for peer administration (THN). We aimed to determine the feasibility of carrying out a definitive randomised trial of THN in emergency settings.MethodsWe carried out a randomised feasibility trial clustered by site, in paired ED and Ambulance Service (AS) catchment areas. Usual care was administration of naloxone by paramedics or ED staff. In addition to usual care at intervention sites THN was offered to adults in ED or by paramedics for a problem related to opioid use. We assessed feasibility of intervention and trial methods based upon predetermined progression criteria: site sign-up; training of staff; identification of eligible patients and the proportion given kits. We planned to retrieve anonymised outcomes for people identified as being at high risk of opioid-related death.ResultsFour sites participated in the trial and 278 clinical staff were trained (ED1: 107, ED2: 25, AS1: 100, AS2 46). Sixty THN kits were supplied to patients during the 1-year recruitment period (ED1: 36, ED2 16, AS1: 4, AS2: 4). Eligible patients were not offered THN kits 164 times (ED1: 159, AS1, 2, AS2: 3). Reasons included: ‘forgot’ (n=136); ‘too busy’ (n=15); suspected intentional overdose (n=3). 626 people were considered but recorded as ineligible (ED: 532, ED2:4, AS1: 49, AS2:41). Reasons included: uncooperative (n=55); lacked capacity (n=35); reduced consciousness (n=41); in custody (n=21); absconded (n=161).ConclusionsThis study did not meet progression criteria for intervention feasibility, so outcomes were not followed up and a fully powered trial is not planned. The emergency setting was a challenging environment in which to provide THN kits, although it may be possible to design a less restrictive protocol, for instance to allow administration to people accompanying patients during emergencies.

The article discusses issues related to contingent risk insurance. Contingent risk insurance offers protection from identified legal risks, allowing concerned ones better manage risk associated with the uncertainties of high stakes litigation. It is stated that the impact of contingent risk insurance can be profound and certain key considerations during the underwriting process help insurers issue policies designed to provide value to both insurers and insureds.

BackgroundThe increasing burden of injury is further exacerbated by the presence of ethnic disparities in emergency healthcare settings. This review aimed to describe the published literature reporting comparative mortality by ethnicity of adults presenting with injury to emergency healthcare in developed countries.MethodsFive electronic databases (CINAHL, MEDLINE, Cochrane, Scopus and PsycINFO) were searched for peer-reviewed papers published from January 2010 to May 2022. Studies reporting adult mortality compared by race and or ethnicity conducted in emergency healthcare settings (pre-hospital and or ambulance setting, trauma centre and hospital emergency department) in developed countries were included in this review.Results1172 articles were retrieved from database searches and after removing 234 duplicates, 938 unique articles were screened for eligibility and finally 31 articles were included in the review.The most common type of injury presentations reported were blunt or nonpenetrating injuries followed by penetrating injuries and other non-specified injuries. Furthermore, three papers reported that people belonging to ethnic majority backgrounds experienced blunt or nonpenetrating trauma more than others (p<0.001).Increased risk of mortality among people from ethnic minority backgrounds was observed in 80.6% (n=25) of the included papers. The adjusted risk of mortality following an injury in people belonging to ethnic minority backgrounds ranged from odds ratio (OR): 1.05; 95% Confidence Interval (CI): 0.84 - 1.31 to OR: 1.58; 95% CI: 1.28 –1.97.ConclusionsTo our knowledge, this review provides the first insight into the mortality disparities faced by adults from ethnic minority backgrounds in developed nations, when they use emergency healthcare services for injuries. The data suggest that people from ethnic minorities have different patterns of injury and a higher risk of death. Further research is required to explain these differences and identify potential solutions.

BackgroundNIHR funding is provided to studies which will produce evidence to inform policy and practice in healthcare. Exploratory or feasibility work can be difficult to find funding for. We present the timeline and steps in the process from first having an idea for research through to gaining funding for a definitive trial.ObjectiveTo determine costs and effects of Fascia Iliaca Compartment Block delivered by paramedics at the scene of injury for suspected hip fracture.MethodsLiterature reviewDevelopment and testing of tool to support identification of hip fracture by paramedicsFeasibility trial (RAPID 1)Proposal for definitive trial (RAPID 2)ResultsFunding was gained from local NHS ‘Pathway to Portfolio’ resources to carry out the first stages of the programme; then a grant was won through the Welsh ‘Research for Patient and Public Benefit’ scheme to undertake a feasibility study. Finally, NIHR HTA funding was awarded to carry out a definitive trial, in five ambulance services.2015 – 16: A systematic review of the literature found that the effectiveness of FICB carried out by paramedics at the scene of injury is unknown, although nurse practitioners have been found to deliver this intervention safely in the Emergency Department.2015 – 16: A tool for identifying hip fracture at the scene of injury was developed by orthopaedic clinicians and tested by ambulance service staff. Sensitivity and positive predictive value were high.2015 – 18: Feasibility trial progression criteria related to methods and intervention safety and acceptability were met.2019 – 20: A full trial proposal was submitted, shortlisted, rejected, amended, resubmitted and funded.2020 – 2025: The RAPID 2 trial is now underway, with paramedic training and patient recruitment due to start in June 2021.ConclusionsResearch funding systems can work to help to progress from idea to full trial, although timescales can be lengthy.

BackgroundDrug poisoning deaths in England and Wales have increased by 52% since 2011 with over half involving opioids. Deaths are preventable if naloxone is administered in time. Take Home Naloxone (THN) kits have been distributed through drug services; however, uptake is low and effectiveness unproven. The TIME trial tests the feasibility of conducting a full randomised controlled trial of providing THN administration and basic life support training to high-risk opioid-users in emergency care settings.MethodsA multi-site feasibility trial commenced in June 2019 with two hospitals and their surrounding ambulance services (Bristol Royal Infirmary (BRI) with South Western Ambulance NHS Foundation Trust (SWASFT) and Hull Royal Infirmary with Yorkshire Ambulance Service) randomly allocated to intervention arms; and sites in Wrexham and Sheffield allocated as ‘usual care’ controls. SWASFT began recruiting in October 2019 with the aim of recruiting and training 50% (n=111) of paramedics working within the BRI’s catchment area, to supply THN to at least 100 eligible patients during a 12-month period.ResultsThe trial was suspended between 17.03.2020-06.08.2020 and extended to 01.03.2021 (COVID-19). Despite this, 121 SWASFT paramedics undertook TIME training. TIME trained paramedics attended 30% (n=57) of the n=190 opioid-related emergency calls requiring naloxone administration during the study period. A total of n=29 potentially eligible patients were identified before and n=28 after the COVID-19 suspension. Two patients were supplied with THN during each period. During the COVID-19 suspension, twenty-two potentially eligible patients were missed. The majority of eligible patients presented with a reduced consciousness level, preventing recruitment (73%; n=42/48). These patients were transported to hospital for further treatment (n=39) or died on scene following advanced life support (n=3).ConclusionsThe lowered consciousness levels of prehospital emergency ambulance patients who present with opioid poisoning, often prevent the delivery of training required to enable the supply of THN.

Objectives:We sought to explore the sociodemographics and primary care service utilization among people who died from opioid overdose and to assess the possibility of using this information to identify those at high risk of opioid overdose using routine linked data. Methods:Data related to decedents of opioid overdose between January 1, 2012 and December 31, 2015 were linked with general practitioner (GP) records over a period of 36 months prior to death. Results:Of n = 312 decedents of opioid overdose, 73% were male (n = 228). Average age at death was 40.72 (SD 11.92) years. A total of 63.8% of the decedents were living in the 2 most deprived quintiles according to the Welsh Index of Multiple Deprivation. Over 80% (n = 258) of the decedents were recorded as having at least 1 GP episode during the 36-month observation period prior to death. The median number of episodes per decedent was 75 [38-118]. Overall, 31.8% (n = 82) of decedents with at least 1 GP episode received a prescription for a proton pump inhibitor and 31% (n = 80) were prescribed a broad-spectrum antibiotic. According to their GP records, less than 10% were referred to or receiving specialist drug treatment (n = 24, 9.3%); or were known to be drug dependent (n = 21, 8.14%), or a drug user (n = 5, 1.94%). In all, 81% were recorded as smokers (n = 209) and 10.5% as ex-smokers (n = 27). Conclusions:The majority of decedents of opioid overdose were in contact with GP services prior to death. GPs are either often unaware of high-risk opioid use, or rarely record details of opioid use in patient notes. It is possible that GP awareness of high-risk opioid use could be increased. For example, awareness of the risks associated with opioid use, and the relationship between the sociodemographic and clinical characteristics of opioid overdose decedents could be raised using educational materials prominently displayed in waiting areas. Clinicians in primary care may be in an excellent position to intervene in problematic opioid use.

BackgroundIn response to rising healthcare demand and shortages of general practitioners (GPs), policy across the UK supports paramedics joining the clinical team in primary care. Numbers of paramedics in primary care (PPC) are increasing in England and Wales through a range of local initiatives. As the first stage in the ARRIVE feasibility study evaluating PPC, we conducted preliminary qualitative research to:Understand the key components of the PPC intervention and its potential impactsIdentify sites with PPC and describe the range of existing interventionsDevelop a logic model to describe PPC.MethodsWe interviewed a total of 19 stakeholders from across Wales, including Health Board managers, GPs, practice managers and paramedics. Interviews were recorded and transcribed in full, then analysed thematically. We held a stakeholder event, bringing together 21 people involved in commissioning, planning and delivering PPC to discuss the key components of a logic model, including outcome measures for evaluation.ResultsWe developed a logic model describing how paramedics provide direct clinical contact with patients in a primary care setting. Potential positive impacts include better patient experience, reductions in emergency admissions through better proactive care, increased sustainability of primary care, and increased levels of clinical skills and satisfaction for paramedics. Components of the intervention which varied across sites included type of patient contact (home visit or surgery); approaches to patient selection and triage; employment model; training and induction; and clinical supervision and support from GPs.ImplicationsPPC is a rapidly developing area of provision in primary care, but there is great variation in the nature of models which have been implemented, and there is still uncertainty about the risks and benefits of PPC, and about how best to deliver it. Our logic model underpins the ARRIVE feasibility study, which will help to build the evidence base urgently needed on the PPC innovation.

Background: Fatal opioid overdose is a significant public health problem with increasing incidence in developed countries. This study aimed to describe demographic and service user characteristics of decedents of opioid overdose in Wales to identify possible targets for behaviour modification and life-saving interventions., Methods: A retrospective cross-sectional analysis was conducted of a census sample of opioid overdose-related deaths recorded between January 01, 2012, and October 11, 2018, in Wales. UK Office for National Statistics, Welsh Demographic Service, and National Health Service datasets were linked deterministically. Decedents' circumstances of death, demographic characteristics, residency, and health service use were characterized over 3 years prior to fatal overdose using descriptive statistics., Results: In total, 638 people died of opioid overdose in Wales between January 01, 2012, and October 11, 2018, with an incidence rate of 3.04 per 100,000 people per year. Decedents were predominantly male (73%) and middle aged (median age 50 years). Fatal overdoses predominantly occurred in the community (93%) secondary to heroin (30%) or oxycodone derivative use (34%). In the 3 years prior to death, decedents changed address frequently (53%) but rarely moved far geographically. The majority of decedents had recently visited the emergency department (83%) or were admitted to the hospital (64%) prior to death. Only a minority had visited specialist drug services (32%)., Conclusions: Deaths from opioid overdose typically occur in middle-aged men living peripatetic lifestyles. Victims infrequently visit specialist drug services but often attend emergency medical services. Emergency department-based interventions may therefore be important in prevention of opioid overdose fatalities in the community., (The Author(s). Published by S. Karger AG, Basel.)