Development of a healthcare system COVID Hotspotting Score in California: an observational study with prospective validation.

OBJECTIVE: To examine the value of health systems data as indicators of emerging COVID-19 activity. DESIGN: Observational study of health system indicators for the COVID Hotspotting Score (CHOTS) with prospective validation. SETTING AND PARTICIPANTS: An integrated healthcare delivery system in Northern California including 21 hospitals and 4.5 million members. MAIN OUTCOME MEASURES: The CHOTS incorporated 10 variables including four major (cough/cold calls, emails, new positive COVID-19 tests, COVID-19 hospital census) and six minor (COVID-19 calls, respiratory infection and COVID-19 routine and urgent visits, and respiratory viral testing) indicators assessed with change point detection and slope metrics. We quantified cross-correlations lagged by 7-42 days between CHOTS and standardised COVID-19 hospital census using observational data from 1 April to 31 May 2020 and two waves of prospective data through 21 March 2021. RESULTS: Through 30 September 2020, peak cross-correlation between CHOTS and COVID-19 hospital census occurred with a 28-day lag at 0.78; at 42 days, the correlation was 0.69. Lagged correlation between medical centre CHOTS and their COVID-19 census was highest at 42 days for one facility (0.63), at 35 days for nine facilities (0.52-0.73), at 28 days for eight facilities (0.28-0.74) and at 14 days for two facilities (0.73-0.78). The strongest correlation for individual indicators was 0.94 (COVID-19 census) and 0.90 (new positive COVID-19 tests) lagged 1-14 days and 0.83 for COVID-19 calls and urgent clinic visits lagged 14-28 days. Cross-correlation was similar (0.73) with a 35-day lag using prospective validation from 1 October 2020 to 21 March 2021. CONCLUSIONS: Passively collected health system indicators were strongly correlated with forthcoming COVID-19 hospital census up to 6 weeks before three successive COVID-19 waves. These tools could inform communities, health systems and public health officials to identify, prepare for and mitigate emerging COVID-19 activity.

A successful program preventing nonventilator hospital-acquired pneumonia in a large hospital system.

OBJECTIVE: To develop and evaluate a program to presvent hospital-acquired pneumonia (HAP). DESIGN: Prospective, observational, surveillance program to identify HAP before and after 7 interventions. An order set automatically triggered in programmatically identified high-risk patients. SETTING: All 21 hospitals of an integrated healthcare system with 4.4 million members. PATIENTS: All hospitalized patients. INTERVENTIONS: Interventions for high-risk patients included mobilization, upright feeding, swallowing evaluation, sedation restrictions, elevated head of bed, oral care and tube care. RESULTS: HAP rates decreased between 2012 and 2018: from 5.92 to 1.79 per 1,000 admissions (P = .0031) and from 24.57 to 6.49 per 100,000 members (P = .0014). HAP mortality decreased from 1.05 to 0.34 per 1,000 admissions and from 4.37 to 1.24 per 100,000 members. Concomitant antibiotic utilization demonstrated reductions of broad-spectrum antibiotics. Antibiotic therapy per 100,000 members was measured as follows: carbapenem days (694 to 463; P = .0020), aminoglycoside days (154 to 61; P = .0165), vancomycin days (2,087 to 1,783; P = .002), and quinolone days (2,162 to 1,287; P < .0001). Only cephalosporin use increased, driven by ceftriaxone days (264 to 460; P = .0009). Benzodiazepine use decreased between 2014 to 2016: 10.4% to 8.8% of inpatient days. Mortality for patients with HAP was 18% in 2012% and 19% in 2016 (P = .439). CONCLUSION: HAP rates, mortality, and broad-spectrum antibiotic use were all reduced significantly following these interventions, despite the absence of strong supportive literature for guidance. Most interventions augmented basic nursing care. None had risks of adverse consequences. These results support the need to examine practices to improve care despite limited literature and the need to further study these difficult areas of care.

Enhanced Recovery After Surgery to Change Process Measures and Reduce Opioid Use After Cesarean Delivery: A Quality Improvement Initiative.

OBJECTIVE: To evaluate implementation of an enhanced recovery after surgery (ERAS) program for patients undergoing elective cesarean delivery by comparing opioid exposure, multimodal analgesia use, and other process and outcome measures before and after implementation. METHODS: An ERAS program was implemented among patients undergoing elective cesarean delivery in a large integrated health care delivery system. We conducted a pre-post study of ERAS implementation to compare changes in process and outcome measures during the 12 months before and 12 months after implementation. RESULTS: The study included 4,689 patients who underwent an elective cesarean delivery in the 12 months before (pilot sites: March 1, 2015-February 29, 2016, all other sites: October 1, 2015-September 30, 2016), and 4,624 patients in the 12 months after (pilot sites: April 1, 2016-March 31, 2017, all other sites: November 1, 2016-October 31, 2017) ERAS program implementation. After ERAS implementation mean inpatient opioid exposure (average daily morphine equivalents) decreased from 10.7 equivalents (95% CI 10.2-11.3) to 5.4 equivalents (95% CI 4.8-5.9) controlling for age, race-ethnicity, prepregnancy body mass index, patient reported pain score, and medical center. The use of multimodal analgesia (ie, acetaminophen and neuraxial anesthesia) increased from 9.7% to 88.8%, the adjusted risk ratio (RR) for meeting multimodal analgesic goals was 9.13 (RR comparing post-ERAS with pre-ERAS; 95% CI 8.35-10.0) and the proportion of time patients reported acceptable pain scores increased from 82.1% to 86.4% (P<.001). Outpatient opioids dispensed at hospital discharge decreased from 85.9% to 82.2% post-ERAS (P<.001) and the average number of dispensed pills decreased from 38 to 26 (P<.001). The hours to first postsurgical ambulation decreased by 2.7 hours (95% CI -3.1 to -2.4) and the hours to first postsurgical solid intake decreased by 11.1 hours (95% CI -11.5 to -10.7). There were no significant changes in hospital length of stay, surgical site infections, hospital readmissions, or breastfeeding rates. CONCLUSIONS: Implementation of an ERAS program in patients undergoing elective cesarean delivery was associated with a reduction in opioid inpatient and outpatient exposure and with changes in surgical process measures of care without worsened surgical outcomes.

Composition or Context: Using Transportability to Understand Drivers of Site Differences in a Large-scale Housing Experiment.

BACKGROUND: The Moving To Opportunity (MTO) experiment manipulated neighborhood context by randomly assigning housing vouchers to volunteers living in public housing to use to move to lower poverty neighborhoods in five US cities. This random assignment overcomes confounding limitations that challenge other neighborhood studies. However, differences in MTO's effects across the five cities have been largely ignored. Such differences could be due to population composition (e.g., differences in the racial/ethnic distribution) or to context (e.g., differences in the economy). METHODS: Using a nonparametric omnibus test and a multiply robust, semiparametric estimator for transportability, we assessed the extent to which differences in individual-level compositional characteristics that may act as effect modifiers can account for differences in MTO's effects across sites. We examined MTO's effects on marijuana use, behavioral problems, major depressive disorder, and generalized anxiety disorder among black and Latino adolescent males, where housing voucher receipt was harmful for health in some sites but beneficial in others. RESULTS: Comparing point estimates, differences in composition partially explained site differences in MTO effects on marijuana use and behavioral problems but did not explain site differences for major depressive disorder or generalized anxiety disorder. CONCLUSIONS: Our findings provide quantitative, rigorous evidence for the importance of context or unmeasured individual-level compositional variables in modifying MTO's effects.

In-State and Interstate Associations Between Gun Shows and Firearm Deaths and Injuries: A Quasi-experimental Study.

BACKGROUND: Gun shows are an important source of firearms, but no adequately powered studies have examined whether they are associated with increases in firearm injuries. OBJECTIVE: To determine whether gun shows are associated with short-term increases in local firearm injuries and whether this association differs by the state in which the gun show is held. DESIGN: Quasi-experimental. SETTING: California. PARTICIPANTS: Persons in California within driving distance of gun shows. MEASUREMENTS: Gun shows in California and Nevada between 2005 and 2013 (n = 915 shows) and rates of firearm-related deaths, emergency department visits, and inpatient hospitalizations in California. RESULTS: Compared with the 2 weeks before, postshow firearm injury rates remained stable in regions near California gun shows but increased from 0.67 injuries (95% CI, 0.55 to 0.80 injuries) to 1.14 injuries (CI, 0.97 to 1.30 injuries) per 100 000 persons in regions near Nevada shows. After adjustment for seasonality and clustering, California shows were not associated with increases in local firearm injuries (rate ratio [RR], 0.99 [CI, 0.97 to 1.02]) but Nevada shows were associated with increased injuries in California (RR, 1.69 [CI, 1.16 to 2.45]). The pre-post difference was significantly higher for Nevada shows than California shows (ratio of RRs, 1.70 [CI, 1.17 to 2.47]). The Nevada association was driven by significant increases in firearm injuries from interpersonal violence (RR, 2.23 [CI, 1.01 to 4.89]) but corresponded to a small increase in absolute numbers. Nonfirearm injuries served as a negative control and were not associated with California or Nevada gun shows. Results were robust to sensitivity analyses. LIMITATION: Firearm injuries were examined only in California, and gun show occurrence was not randomized. CONCLUSION: Gun shows in Nevada, but not California, were associated with local, short-term increases in firearm injuries in California. Differing associations for California versus Nevada gun shows may be due to California's stricter firearm regulations. PRIMARY FUNDING SOURCE: National Institutes of Health; University of California, Berkeley; and Heising-Simons Foundation.

Changing Patterns in Rates and Means of Suicide in California, 2005 to 2013.

OBJECTIVES: To describe recent trends in suicide throughout California and to compare rates and methods of suicide ("means") across demographic groups. METHODS: Data from statewide mortality records were used to estimate age-adjusted rates of suicide from 2005 to 2013, overall and by means, age, gender, race/ethnicity, urbanicity, and county. RESULTS: The suicide rate increased 12.6% between 2005 and 2013, from 11.2 to 12.6 per 100 000 population, but this overall trend masks substantial heterogeneity across subgroups. In particular, rapid increases were observed for individuals of multiple races/ethnicities. Means of suicide changed, trending away from firearms toward suffocation and drug poisoning. CONCLUSIONS: High-risk groups and means of suicide are changing rapidly in California, so appropriate public health programming should prioritize population-based strategies.

Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range.

BACKGROUND: During pregnancy, most women do not meet gestational weight gain (GWG) guidelines, potentially resulting in adverse maternal and infant health consequences. Social environment determinants of GWG have been identified, but evidence on the relationship between neighbourhood violence and GWG is scant. Our study aims to examine the relationship between neighbourhood violence and GWG outside the recommended range. METHODS: We used statewide vital statistics and health care utilization data from California for 2006-12 (n = 2 364 793) to examine the relationship of neighbourhood violence (quarters of zip-code rates of homicide and assault) in the first 37 weeks of pregnancy with GWG (categorized using the Institute of Medicine's pregnancy weight gain guidelines). We estimated risk ratios (RR) and marginal risk differences, and analyses were stratified by maternal race/ethnicity and prepregnancy body mass index. RESULTS: Residence in neighbourhoods with the highest quartile of violence was associated with more excessive GWG (adjusted RR 1.04, 95% confidence interval CI 1.03, 1.05), compared to the lowest quartile of violence; violence was not associated with inadequate GWG. On the difference scale, this association translates to 2.3% more women gaining weight excessively rather than adequately if all women were exposed to high violence compared to if all women were exposed to low violence. Additionally, associations between neighbourhood violence and excessive GWG were larger in non-white women than in white women. CONCLUSIONS: These findings support the hypothesis that violence can affect weight gain during pregnancy, emphasizing the importance of neighbourhood violence as a public health issue.

Spatial Proximity to Incidents of Community Violence Is Associated with Fewer Suicides in Urban California.

Suicide is a leading cause of premature mortality. Aspects of the social environment such as incidents of violence in the community may induce psychological distress and affect suicidality, but these determinants are not well understood. We conducted an ecological study using California vital statistics records, geocoded to address of the decedent, to examine whether proximity to homicide was associated with the occurrence of suicide in urban census tracts. For each urban tract (N = 7194) and each month in 2012, we assessed homicides in the tract or within buffer zones around the tract with a 1-month lag. We estimated two risk difference parameters that capture how suicide risk is related to differences in homicide exposure. Proximity to homicides was negatively associated with suicide occurrence after controlling for demographic factors, seasonality, and other confounders. Estimates suggest that the absence of homicides would be associated with a 4.2 % higher number of tract-months with one or more suicides (95 % confidence interval 2.2-6.0). This relationship was stronger in tracts that were wealthier, older, and less civically engaged. Results were robust to a wide variety of sensitivity tests. Contrary to expectations, we identified a consistent negative association of proximity to homicide with suicide occurrence. It may be that a homicide deters or distracts from suicidality or that aggression or hopelessness may be expressed as inward or outward directed violence in different settings. Further investigation is needed to identify the drivers of this association.