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Background: Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into seven models of primary care: Traditional, Corporate, Health Care Home, Māori, Pacific, Trusts / Non-governmental organisations (Trust/NGOs) and District Health Board / Primary Care Organisations (DHB/PHO). We describe nurse work in relation to these models of care, populations with high health need and patient health outcomes. Methods: We conducted a cross-sectional study (at 30 September 2018) of data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥ 65 years), glucose control testing in adults with diabetes, immunisations (at 6 months), ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics. Results: Nurse clinical time, and combined nurse, nurse practitioner and general practitioner clinical time, were substantially higher in Trust/NGO, Māori, and Pacific practices than in other models. Increased patient clinical complexity was associated with more clinical input and higher scores on all outcome measures. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, depression screening, glucose control testing) were in Māori, Trust/NGO and Pacific practices. There was an eightfold difference, across models of care, in percentage of depression screening undertaken by nurses and a fivefold difference in cervical screening and glucose control testing. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree. Conclusions: Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release general practitioner clinical time for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner clinical time is required, especially in practices with high volumes of complex patients. [ABSTRACT FROM AUTHOR]

Background: For more than a century, Māori have experienced poorer health than non-Māori. In 2019 an independent Tribunal found the Government had breached Te Tiriti o Waitangi by "failing to design and administer the current primary health care system to actively address persistent Māori health inequities". Many Māori (44%) have unmet needs for primary care. Seven models of primary care were identified by the funders and the research team, including Māori-owned practices. We hypothesised patient health outcomes for Māori would differ between models of care. Methods: Cross-sectional primary care data were analysed at 30 September 2018. National datasets were linked to general practices at patient level, to measure associations between practice characteristics and patient health outcomes. Primary outcomes: polypharmacy (≥ 55 years), HbA1c testing, child immunisations, ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Regressions include only Māori patients, across all models of care. Results: A total of 660,752 Māori patients were enrolled in 924 practices with 124,854 in 65 Māori-owned practices. Māori practices had: no significant association with HbA1c testing, ambulatory sensitive hospitalisations or ED attendances, and a significant association with lower polypharmacy (3.7% points) and lower childhood immunisations (13.4% points). Māori practices had higher rates of cervical smear and cardiovascular risk assessment, lower rates of HbA1c tests, and more nurse (46%) and doctor (8%) time (FTE) with patients. The average Māori practice had 52% Māori patients compared to 12% across all practices. Māori practices enrolled a higher percentage of children and young people, five times more patients in high deprivation areas, and patients with more multimorbidity. More Māori patients lived rurally (21.5% vs 15%), with a greater distance to the nearest ED. Māori patients were more likely to be dispensed antibiotics or tramadol. Conclusions: Māori practices are an expression of autonomy in the face of enduring health system failure. Apart from lower immunisation rates, health outcomes were not different from other models of care, despite patients having higher health risk profiles. Across all models, primary care need was unmet for many Māori, despite increased clinical input. Funding must support under-resourced Māori practices and ensure accountability for the health outcomes of Māori patients in all models of general practice. [ABSTRACT FROM AUTHOR]

Background: Primary care in Aotearoa New Zealand is largely delivered by general practices, heavily subsidised by government. Te Tiriti o Waitangi (1840) guarantees equal health outcomes for Māori and non-Māori, but differences are stark and longstanding. Seven models of primary care have evolved. We hypothesised that patient health outcomes would differ between models of care; and that Māori, Pacific peoples and those living in material deprivation would have poorer outcomes from primary care. Methods: We conducted a cross-sectional study of patient-level data from national datasets and practices, at 30 September 2018, using multilevel mixed effects regression analyses (patients clustered within practices). Primary outcomes, considered to be measures of unmet need for primary care, were polypharmacy (≥ 65 years), HbA1c testing in adults with diabetes, childhood immunisations (6 months), ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Explanatory variables adjusted for patient and practice characteristics. Equity, by model of care, ethnicity and deprivation, was assumed if they showed no significant association with patient outcomes. Patient characteristics included: age, ethnicity, deprivation, multi-morbidity, first specialist assessments and practice continuity. Practice characteristics included: size, funding and doctor continuity. Clinical input (consultations and time with nurses and doctors) was considered a measure of practice response. Results: The study included 924 general practices with 4,491,964 enrolled patients. Traditional practices enrolled 73% of the population, but, on average, the proportion of Māori, Pacific and people living with material deprivation was low in any one Traditional practice. Patients with high health needs disproportionately enrolled in Māori, Pacific and Trust/NGO practices. There were multiple associations between models of care and patient health outcomes in fully adjusted regressions. No one model of care out-performed others across all outcomes. Patients with higher health need received more clinical input but this was insufficient to achieve equity in all outcomes. Being a Māori or Pacific patient, or living in material deprivation, across models of care, remained associated with poorer outcomes. Conclusions: Model-level associations with poor patient outcomes suggest inequity in measures that might be used to target investment in primary care. [ABSTRACT FROM AUTHOR]

Abstract Background During the recent outbreak of COVID-19 (coronavirus disease 2019), Lombardy was the most affected region in Italy, with 87,000 patients and 15,876 deaths up to May 26, 2020. Since February 22, 2020, well before the Government declared a state of emergency, there was a huge reduction in the number of emergency surgeries performed at hospitals in Lombardy. A general decrease in attendance at emergency departments (EDs) was also observed. The aim of our study is to report the experience of the ED of a third-level hospital in downtown Milan, Lombardy, and provide possible explanations for the observed phenomena. Methods This retrospective, observational study assessed the volume of emergency surgeries and attendance at an ED during the course of the pandemic, i.e. immediately before, during and after a progressive community lockdown in response to the COVID-19 pandemic. These data were compared with data from the same time periods in 2019. The results are presented as means, standard error (SE), and 95% studentized confidence intervals (CI). The Wilcoxon rank signed test at a 0.05 significance level was used to assess differences in per-day ED access distributions. Results Compared to 2019, a significant overall drop in emergency surgeries (60%, p

During outbreaks such as severe acute respiratory syndrome and COVID 19, many Emergency Departments across the world had a reduction in the general attendance, including the attendance of more serious and critical diagnoses. Here, the author shares the numbers seen at Singapore General Hospital, the largest public hospital in Singapore during the period of February to June 2020. The reduction ranged from 13% to 28% compared to the same period in 2019, before the outbreak. Patient and healthcare system-related factors which may have caused these observations are discussed. The author also puts forth the Behavioral Immune System and Response mechanism as a possible explanation for patients staying away from the hospitals during the outbreak.

Global warming has contributed to more frequent and severe extreme weather events, which has led to increased research on the health impacts of extreme heat. However, research on heatwaves, air quality, and their spatial impact on health service demand is limited. This study used machine learning (ML) approaches to obtain the optimised model to predict health service demand associated with those risk factors for an all-age model and compared it with young children (0–4 years) model in Perth. Ten years’ data (2006–2015) on emergency department attendances (EDA), socioeconomic status (SES), heatwaves, landscape fires, and gaseous and particulate air pollutants were collected. ML approaches, including decision tree, random forest (RF), and geographical random forest (GRF) models, were used to compare and select the best model for predicting EDA and identify important risk factors. Five-hundred cross validations were performed using the testing data, and a construct validation was performed by comparing actual and predicted EDA data. The results showed that the RF model outperformed other models, and SES, air quality, and heatwaves were among the important risk factors to predict EDA. The GRF model was fitted well to the data (R ^2 = 0.975) and further showed that heatwaves had significant geographic variations and a joint effect with PM _2.5 in the southern suburbs of the study area for young children. The RF and GRF models have satisfactory performance in predicting the impact of heatwaves, air quality, and SES on EDA. Heatwaves and air quality have great spatial heterogeneity. Spatial interactions between heatwaves, SES, and air quality measures were the most important predictive risk factors of EDA for young children in the Perth southern suburbs. Future studies are warranted to confirm the findings from this study on a wider scale.

Background: During the recent outbreak of COVID-19 (coronavirus disease 2019), Lombardy was the most affected region in Italy, with 87,000 patients and 15,876 deaths up to May 26, 2020. Since February 22, 2020, well before the Government declared a state of emergency, there was a huge reduction in the number of emergency surgeries performed at hospitals in Lombardy. A general decrease in attendance at emergency departments (EDs) was also observed. The aim of our study is to report the experience of the ED of a third-level hospital in downtown Milan, Lombardy, and provide possible explanations for the observed phenomena.Methods: This retrospective, observational study assessed the volume of emergency surgeries and attendance at an ED during the course of the pandemic, i.e. immediately before, during and after a progressive community lockdown in response to the COVID-19 pandemic. These data were compared with data from the same time periods in 2019. The results are presented as means, standard error (SE), and 95% studentized confidence intervals (CI). The Wilcoxon rank signed test at a 0.05 significance level was used to assess differences in per-day ED access distributions.Results: Compared to 2019, a significant overall drop in emergency surgeries (60%, p < 0.002) and in ED admittance (66%, p ≅ 0) was observed in 2020. In particular, there were significant decreases in medical (40%), surgical (74%), specialist (ophthalmology, otolaryngology, traumatology, and urology) (92%), and psychiatric (60%) cases. ED admittance due to domestic violence (59%) and individuals who left the ED without being seen (76%) also decreased. Conversely, the number of deaths increased by 196%.Conclusions: During the COVID-19 outbreak the volume of urgent surgeries and patients accessing our ED dropped. Currently, it is not known if mortality of people who did not seek care increased during the pandemic. Further studies are needed to understand if such reductions during the COVID-19 pandemic will result in a rebound of patients left untreated or in unwanted consequences for population health. [ABSTRACT FROM AUTHOR]

During outbreaks such as severe acute respiratory syndrome and COVID 19, many Emergency Departments across the world had a reduction in the general attendance, including the attendance of more serious and critical diagnoses. Here, the author shares the numbers seen at Singapore General Hospital, the largest public hospital in Singapore during the period of February to June 2020. The reduction ranged from 13% to 28% compared to the same period in 2019, before the outbreak. Patient and healthcare system-related factors which may have caused these observations are discussed. The author also puts forth the Behavioral Immune System and Response mechanism as a possible explanation for patients staying away from the hospitals during the outbreak. [ABSTRACT FROM AUTHOR]

Background: In a remote region of Western Australia, Kimberley, residents have nearly twice the State average per capita consumption of alcohol, four and a half times the level of alcohol-related hospitalizations and nearly three times the level of alcohol-related deaths. This study aimed to evaluate the long term effects of alcohol sale restrictions on health service utilization in two remote towns in Kimberley.Methods: Sale of high strength packaged alcohol was restricted in Fitzroy Crossing and Halls Creek since October 2007 and May 2009, respectively. Alcohol-related Emergency Department (ED) attendances and hospitalizations utilized by local residents before and after the intervention between 2003 and 2013 was compared by using yearly rates (/1,000 person-years) and interrupted time series analysis with Autoregressive Integrated Moving Average (ARIMA) modeling. The Western Australia specific aetiological fractions (AAFs) were applied to hospital inpatient data for estimation of the proportion of hospital separations attributable to alcohol.Results: In Fitzroy Crossing, there was a significant reduction of over 40% on rates (/1,000 person-years) of alcohol-related acute hospitalizations (54.2 [95% CI: 53.8–54.7] vs. 31.7 [31.4–32.1]) and ED attendances (534.1[532.8–535.5] vs. 294.5 [293.5–295.4]). In Halls Creek, there was a significant reduction of over 50% on rates (/1,000 person-years) of alcohol- related acute hospitalizations (17.7 [17.6–17.8] vs. 8.0 [7.9–8.1]) and ED attendance (248.4 [247.9–248.9] vs. 111.1[110.8–111.5]). Domestic violence and injury related hospitalization rates were also reduced by over 20% in both towns.Conclusions: The total restriction of selling high strength alcohol through a community driven process has shown to be effective in reducing alcohol-related health service utilization in post-intervention period. Continue monitoring is required to address new emerging issues. Future research on health service utilization related to alcohol by using interrupted time series analysis incorporating ARIMA modeling and applying AAFs are recommended for evaluating alcohol-related interventions.

The health effects of vitamin D are well documented, with increasing evidence of its roles beyond bone. There is, however, little evidence of the effects of vitamin D on hospitalisation among older adults. This study aimed to prospectively determine the relationship of vitamin D status in older adults with hospital admission and emergency department (ED) attendance. Trinity University of Ulster Department of Agriculture (TUDA) is a large cross-sectional study of older adults with a community population from three disease-defined cohorts (cognitive dysfunction, hypertension, and osteoporosis). Participants included in this analysis were recruited between 2008 and 2012. ED and hospital admission data were gathered from the date of TUDA participation until June 2013, with a mean follow up of 3.6 years. Of the 3093 participants, 1577 (50.9%) attended the ED during the period of follow-up. Attendees had lower mean serum 25(OH)D concentrations than non-attendees (59.1 vs. 70.6 nmol/L). Fully adjusted models showed an inverse association between vitamin D and ED attendance (Hazard Ratio (HR) 0.996; 95% Confidence Interval (CI) 0.995–0.998; p < 0.001). A total of 1269 participants (41%) were admitted to hospital during the follow-up. Those admitted had lower mean vitamin D concentrations (58.4 vs. 69.3 nmol/L, p < 0.001). In fully adjusted models, higher vitamin D was inversely associated with hospital admission (HR 0.996; 95% CI 0.994–0.998; p < 0.001) and length of stay (LOS) (β = −0.95, p = 0.006). This study showed independent prospective associations between vitamin D deficiency and increased hospitalisation by older adults. The need for further evaluation of current recommendations in relation to vitamin D supplementation, with consideration beyond bone health, is warranted and should focus on randomised controlled trials.

As global warming and the frequency and intensity of heatwaves increases, health service utilization, including emergency department attendances (EDA) have correspondingly increased across the world. The impact of air quality on health adds to the complexity of the effects. Potential joint effects between heatwaves and air quality on EDA have been rarely reported in the literature, prompting this study. To investigate the potential joint effect of heatwaves and air quality on the EDA for vulnerable populations in the Perth metropolitan area, Western Australia. A time series design was used. Daily data on EDA, heatwaves (excess heat factor>0) and air pollutants (CO, SO 2 , NO 2 , O 3 , PM 10 and PM 2.5) were collected for Perth, Western Australia from 2006 to 2015. Poisson regression modelling was used to assess the associations between heatwaves, air quality, and EDA. Risk assessments on age, gender, Aboriginality, socio-economic status (SES), and joint effect between heatwaves and air quality on EDA were conducted. The EDA rate was higher in heatwave days (77.86/100,000/day) compared with non-heatwave days (73.90/100,000/day) with rate ratio of 1.053 (95% confidence interval 1.048, 1.058). The EDA rate was higher in males, people older than 60 years or younger than 15 years, Aboriginal people, and people with low SES. Exposure to CO, SO 2 , O 3 and PM 2.5 increased risk on EDA and exposure to PM 2.5 showed joint effect with heatwave and increased risk of EDA by 6.6% after adjustment of all other risk factors. EDA is an important indicator to evaluate heatwave related morbidity for emergency medical service as EDA rate increased during heatwaves with relative high concentrations of air pollutants. As all air pollutants measured in the study were lower than the Australian National Standards, the joint effect of heatwaves and air quality needs to be further examined when it exceeds the standards. • Emergency department attendances (EDA) rate was higher during heatwave days. • EDA rates were higher in males, aged ≥60 or <15 years, people with Aboriginal background. • EDA rate was higher in people with low socio-economic status. • Exposure to CO, SO 2 , O 3 , PM 2.5 increased risk on EDA. • PM 2.5 had joint effect with heatwave, increased risk on EDA. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Health and Wellbeing Connection (HWC) pilot study was undertaken by Richmond Services in partnership with Pegasus Health, Partnership Health and the Canterbury District Health Board. OBJECTIVE: To explore whether a brief intervention offered to frequent attenders to hospital emergency department (ED) was successful in reducing inappropriate attendance. METHODS: Administration of the Kessler Depression and Anxiety (K10) scale; the World Health Organization Quality of Life Measure (WHOQOL-BREF); extracted de-identified rates of attendance at an ED of a general hospital and general practice, and follow up telephone interviews with study participants were used. RESULTS: By the end of the project, a total of 53 participants had completed the programme. On average, these participants reduced their attendance at the ED significantly while demonstrating no change in their attendance rates at general practice. Additionally, they reported a decrease in psychological distress and a positive increase in their quality of life. CONCLUSIONS: Although the number of participants in this study does not allow for robust analysis of efficacy of the program offered, it does indicate that there is merit in continuing to develop brief intervention case management models to support behaviour change programmes in hospital EDs. [ABSTRACT FROM AUTHOR]

In February of 2012 deaths in England and Wales showed a semi-permanent and unexpected increase which endured to around mid-2013. This increase appears to be linked to an increase in A&E attendance and emergency medical admissions. In August of 2013 Public Health England published a report designed to assure everyone that the excess deaths were merely confined to a few weeks during the winter of 2012/2013. However, this report which relies on output from the EuroMOMO methodology and can be shown to contain methodological limitations. The case for a genuine infectious outbreak is investigated. [ABSTRACT FROM AUTHOR]

The health effects of vitamin D are well documented, with increasing evidence of its roles beyond bone. There is, however, little evidence of the effects of vitamin D on hospitalisation among older adults. This study aimed to prospectively determine the relationship of vitamin D status in older adults with hospital admission and emergency department (ED) attendance. Trinity University of Ulster Department of Agriculture (TUDA) is a large cross-sectional study of older adults with a community population from three disease-defined cohorts (cognitive dysfunction, hypertension, and osteoporosis). Participants included in this analysis were recruited between 2008 and 2012. ED and hospital admission data were gathered from the date of TUDA participation until June 2013, with a mean follow up of 3.6 years. Of the 3093 participants, 1577 (50.9%) attended the ED during the period of follow-up. Attendees had lower mean serum 25(OH)D concentrations than non-attendees (59.1 vs. 70.6 nmol/L). Fully adjusted models showed an inverse association between vitamin D and ED attendance (Hazard Ratio (HR) 0.996; 95% Confidence Interval (CI) 0.995–0.998; p < 0.001). A total of 1269 participants (41%) were admitted to hospital during the follow-up. Those admitted had lower mean vitamin D concentrations (58.4 vs. 69.3 nmol/L, p < 0.001). In fully adjusted models, higher vitamin D was inversely associated with hospital admission (HR 0.996; 95% CI 0.994–0.998; p < 0.001) and length of stay (LOS) (β = −0.95, p = 0.006). This study showed independent prospective associations between vitamin D deficiency and increased hospitalisation by older adults. The need for further evaluation of current recommendations in relation to vitamin D supplementation, with consideration beyond bone health, is warranted and should focus on randomised controlled trials. [ABSTRACT FROM AUTHOR]

Background: In a remote region of Western Australia, Kimberley, residents have nearly twice the State average per capita consumption of alcohol, four and a half times the level of alcohol-related hospitalizations and nearly three times the level of alcohol-related deaths. This study aimed to evaluate the long term effects of alcohol sale restrictions on health service utilization in two remote towns in Kimberley. Methods: Sale of high strength packaged alcohol was restricted in Fitzroy Crossing and Halls Creek since October 2007 and May 2009, respectively. Alcohol-related Emergency Department (ED) attendances and hospitalizations utilized by local residents before and after the intervention between 2003 and 2013 was compared by using yearly rates (/1,000 person-years) and interrupted time series analysis with Autoregressive Integrated Moving Average (ARIMA) modeling. The Western Australia specific aetiological fractions (AAFs) were applied to hospital inpatient data for estimation of the proportion of hospital separations attributable to alcohol. Results: In Fitzroy Crossing, there was a significant reduction of over 40% on rates (/1,000 person-years) of alcohol-related acute hospitalizations (54.2 [95% CI: 53.8-54.7] vs. 31.7 [31.4-32.1]) and ED attendances (534.1[532.8-535.5] vs. 294.5 [293.5-295.4]). In Halls Creek, there was a significant reduction of over 50% on rates (/1,000 person-years) of alcohol- related acute hospitalizations (17.7 [17.6-17.8] vs. 8.0 [7.9-8.1]) and ED attendance (248.4 [247.9-248.9] vs. 111.1[110.8-111.5]). Domestic violence and injury related hospitalization rates were also reduced by over 20% in both towns. Conclusions: The total restriction of selling high strength alcohol through a community driven process has shown to be effective in reducing alcohol-related health service utilization in post-intervention period. Continue monitoring is required to address new emerging issues. Future research on health service utilization related to alcohol by using interrupted time series analysis incorporating ARIMA modeling and applying AAFs are recommended for evaluating alcohol-related interventions.

Background: Recent violence reduction initiatives in Glasgow have led to a reduction in recorded levels of violent crime.(1) This study evaluates the impact of these initiatives on assault-related emergency department attendances and admissions., Methods: A retrospective observational study conducted in Glasgow Royal Infirmary's emergency department comparing assault-related emergency department attendances and hospital admissions over two 30-day study periods (April 2010 and April 2012). The primary outcome measure was the change in assault-related emergency department attendances. The secondary outcome measure was the impact on assault-related hospital and critical care admissions., Results: In April 2010, there were 6098 emergency department attendances, 301 (4.9%) were due to assault. In April 2012, there were 7236 emergency department attendances, 263 (3.6%) were due to assault, representing a significant reduction in assault-related attendances (p < 0.01). There were significant reductions in level 1 admissions 2010 n = 56 (19.2%), 2012 n = 36 (14.0%) p = 0.04 and critical care admissions, 2010 n = 5 (1.7%), 2012 n = 1 (0.4%) p = 0.04., Conclusions: Violence reduction initiatives in Glasgow have contributed to a reduction in assault-related emergency department attendance at Glasgow Royal Infirmary. The reduction in hospital admissions, in particular critical care admissions, suggests a reduction in morbidity and cost to the National Health Service., (© The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)