Characteristics of California Emergency Departments in Centers for Disease Control and Prevention-Designated HIV Priority Counties.

BACKGROUND: Refocused national HIV testing initiatives include a geographic focus. OBJECTIVE: Using a geographic focus, we sought to identify which emergency departments (EDs) might be the most efficient targets for future HIV testing efforts, using California as an example. METHODS: Retrospective analysis of California EDs, emergency physicians, and patients served, along with county-level estimates of HIV prevalence and proportion of the population living in poverty. Emphasis was placed on characterizing EDs affiliated with teaching hospitals and those located in Centers for Disease Control (CDC) and Prevention HIV priority counties. RESULTS: Of the 320 EDs studied, 178 were in priority counties, 29 were affiliated with teaching hospitals, and 24 had both characteristics. Of the 12,869,889 ED visits included, 61.8% occurred in priority counties, 14.7% in EDs affiliated with teaching hospitals, and 12.0% in EDs with both characteristics. The subset of EDs in priority counties with teaching hospital affiliations (compared with priority and nonpriority county ED groups without a teaching hospital affiliation) had higher overall median visit volumes and higher proportions of visits by at-risk and CDC-targeted populations (e.g., individuals who were homeless, those who identified as Black or African American race, and those who identified as Hispanic or Latino ethnicity, all p < 0.01). CONCLUSIONS: EDs in priority counties affiliated with teaching hospitals are major sources of health care in California. These EDs more often serve populations disproportionately impacted by HIV. These departments are efficient targets to direct testing efforts. Increasing testing in these EDs could reduce the burden of undiagnosed HIV in California.

Examining Social Determinants of Health During a Pandemic: Clinical Application of Z Codes Before and During COVID-19.

Recognition of the impact of social determinants of health (SDoH) on healthcare outcomes, healthcare service utilization, and population health has prompted a global shift in focus to patient social needs and lived experiences in assessment and treatment. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) provides a list of non-billable "Z codes" specific to SDoH for use in electronic health records. Using population-level analysis, this study aims to examine clinical application of Z codes in South Carolina before and during the COVID-19 pandemic. The study population consists of South Carolina residents who had a healthcare visit and had their COVID-19 test result reported to the state's Department of Health and Environmental Control before January 14, 2021. Of the 1,190,531 individuals in the overall sample, Z codes were used only for 14,665 (1.23%) of the patients, including 2,536 (0.97%) COVID-positive patients and 12,129 (1.30%) COVID-negative patients. Compared with hospitals that did not use Z codes, those that did were significantly more likely to have higher bed capacity (p = 0.017) and to be teaching hospitals (p = 0.03), although this was significant only among COVID-19 positive individuals. Those at inpatient visits were most likely to receive Z codes (OR: 5.26; 95% CI: 5.14, 5.38; p < 0.0001) compared to those at outpatient visits (OR: 0.07; 95%CI: 0.06, 0.07; p < 0.0001). There was a slight increase of Z code use from 2019 to 2020 (OR: 1.33, 95% CI: 1.30, 1.36; p < 0.0001), which was still significant when stratified by facility type across time. As one of the first studies to examine Z code use among a large patient population, findings clearly indicate underutilization by providers. Additional study is needed to understand the potentially long-lasting health effects related to SDoH among underserved populations.

Estimating resource utilization for emergency department visits by patients' HIV seropositivity in the United States, 2009 to 2018.

INTRODUCTION: The Emergency Department (ED) plays a key role in linkage to and engagement in care for people with HIV (PWH) in the United States, particularly for individuals without a routine source or schedule for care. Assessing patterns of ED resource utilization by PWH can help elucidate the role of EDs across the HIV care continuum. The aim of this study was to use visit-level data to characterize resource utilization patterns for HIV-related ED visit diagnoses compared to those of other ED visit types. METHODS: HIV-related ED visits were identified as either having answered 'have HIV' in a survey question, been diagnosed with HIV, or had HIV noted as a reason for a visit. Weighted, pooled cross-sectional analyses were performed using the National Hospital Ambulatory Medical Care Survey (NHAMCS) for 2009-2018. ED visits were restricted to those aged 13 years and older. Both descriptive and multivariable regression analyses were performed using Stata 15.1 to measure differences in ED resource utilization. RESULTS: A weighted total of 6.10 million ED visits occurred among PWH, representing 5.5 visits per 1000 ED visits. The rates of HIV-related ED visits (per 1000 ED visits) were higher among patients aged 50-64 years (9.1), males (7.9), African Americans (11.1), Medicaid recipients (7.8), patients in the Northeast (6.8), and patients in metropolitan areas (MSA) (6.1). HIV-related ED visits reflected higher resource utilization: including higher utilization of the ambulance, diagnostic tests, blood tests, urinalysis, HIV tests, intravenous fluids, medications, consultants, critical care units, longer visits, and hospital admissions. Multivariable regression models revealed higher ED resource utilization and showed that patients making HIV-related visits were 57% more likely to result in hospital admission, spending 17% more time compared to patients making non-HIV-related visits. CONCLUSION: Hospitals should be prepared to meet the unique needs of PWH presenting for ED services. Continued surveillance of resource utilization patterns among PWH in EDs is important to plan successful HIV care engagement interventions in these settings.

Small area estimation of county-level U.S. HIV-prevalent cases.

PURPOSE: Recent trends of HIV in the United States have indicated that the epidemic is no longer an urban issue; however, HIV data in rural settings are incomplete. Our objective was to estimate HIV prevalence in U.S. counties using small area estimation techniques (SAE) to better assess the burden of HIV nationally. METHODS: We performed SAE modeling to predict the reported number of HIV cases across the continental United States, including unreported counties using source data from the CDC National HIV Surveillance System. Our model borrowed strength from auxiliary HIV risk-indicator data, including geospatial information. Cross-validation was conducted to identify and assess the precision of the estimates. RESULTS: Our findings showed that most of the 677 unreported counties had low HIV prevalence levels (quintiles 1-2). Estimates in the South had high levels of HIV (quintile 4-5). Cross-validation techniques indicated good precision of the estimates, as 42% of the residuals were within ±10 HIV cases. CONCLUSIONS: HIV was highest along the coastlines and in the U.S. South. Cross-validation techniques provided sufficient support of our model. Our study provides a more complete picture of the burden of HIV across the United States and identifies communities in need of future targeted interventions.

Not quite color blind: ethnic and gender differences in attitudes toward older people among college students.

Attitudes toward older people can influence how they are treated and their cognitive and physical health. The populations of the United States and many other countries have become more ethnically diverse, and are aging. Yet little research examines how ethnic diversity affects attitudes toward older people. Our study addresses this research gap. Using the Aging Semantic Differential, 592 university students expressed their attitudes toward older African-American, Hispanic, and White women and men. Repeated measures analysis of variance examined attitude differences by participant ethnicity and gender, and by the ethnicity and gender of evaluated individuals. Both African-American and White students had more positive attitudes toward older women and men of their own ethnic group. Participants had more positive attitudes toward older women than they did toward older men. Findings suggest in-group favoritism, and the usefulness of training those in service industries and public service to treat older individuals equitably.

Patterns of engagement in care by HIV-infected adults: South Carolina, 2004-2006.

OBJECTIVE: Identify factors associated with HIV care utilization in South Carolina. DESIGN: Cross-sectional analysis of South Carolina nonpregnant HIV-infected individuals (N = 13,042) for the period 1 January 2004 to 31 December 2006. METHODS: Reporting of HIV laboratory markers is legally mandated in South Carolina. Individuals with reported viral load tests or CD4 cell counts during a calendar year were defined as 'in HIV-medical care' that year. Care utilization categories were in care, care all 3 years; not-in-care (NIC), no care received; and transitional care, during some but not all years. Multinomial logistic regression using generalized logits was used to estimate relationships between care utilization and predictor variables. RESULTS: Five thousand, two hundred and seventeen (40.0%) of South Carolina HIV-infected adults were NIC and 3300 (25.3%) were in transitional care during 2004-2006. Although a larger number of black than white HIV-infected adults were NIC, adjusted odds for NIC status were lower among blacks than whites [adjusted odds ratio (AOR), 0.82; 95% confidence interval 0.74, 0.92)]. Women had lower odds of being NIC than men (AOR, 0.66; 95% confidence interval 0.58, 0.74). Compared with individuals 55 years or older, individuals who were 25-34 years old were most likely to demonstrate both the NIC (AOR, 1.85; 95% confidence interval 1.29, 2.65) and transitional (AOR, 1.85; 95% confidence interval 1.31, 2.62) care patterns. CONCLUSION: Large proportions of the South Carolina HIV-infected adult population are not consistently accessing HIV-medical care. Targeted programs are needed to improve engagement for HIV-infected adults most likely to transition or not be in care.