Driven by need, shaped by access: Heterogeneity in patient profiles and patterns of service utilization in patients with alcohol use disorders.

BACKGROUND: Patients with alcohol-use disorders (AUDs) are highly heterogenous and account for an increasing proportion of general medical hospital visits. However, many patients with AUDs do not present with severe medical or psychiatric needs requiring immediate attention. There may be a mismatch between some patients' needs and the available services, potentially driving re-admissions and re-encounters. The current study aims to identify subgroups of AUD patients and predict differences in patterns of healthcare service use (HSU) over time. METHODS: Latent class analysis (LCA) was conducted using hospital data incorporating sociodemographic, health behavior, clinical, and service use variables to identify subtypes of AUD patients, then class membership was used to predict patterns of HSU. RESULTS: Four classes were identified with the following characteristics: (1) Patients with acute medical injuries (30 %); (2) Patients with socioeconomic and psychiatric risk factors, (11 %); (3) Patients with chronic AUD with primarily non-psychiatric medical needs (18 %); and (4) Patients with primary AUDs with low medical-treatment complexity (40 %). Negative binomial models showed that Class 4 patients accounted for the highest frequency of service use, including significantly higher rates of emergency department reencounters at 30 days and 12 months. CONCLUSIONS: The profile and patterns of HSU exhibited by patients in class 4 suggest that these patients have needs which are not currently being addressed in the emergency department. These have implications for how resources are allocated to meet the needs of patients with AUDs, including those who make frequent visits to the emergency department without high acuity medical needs.

Development and preliminary validation of a scale to assess physicians' emotional distress intolerance in end-of-life care communication.

CONTEXT: End-of-life care (EOLC) communication is beneficial but underutilized, particularly in conditions with a variable course such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). Physicians' emotional distress intolerance has been identified as a barrier to EOLC communication. However, studies of emotional distress intolerance in EOLC have largely relied on anecdotal reports, qualitative data, or observational studies of physician-patient communication. A free-standing measure of multiple dimensions of distress tolerance is warranted to enable the identification of individuals experiencing distress intolerance and to facilitate the effective targeting of interventions to improve distress tolerance. OBJECTIVES: This study provides preliminary data on the reliability and validity of the Physician Distress Intolerance (PDI) scale. We examine potential subdimensions of emotional distress intolerance. METHOD: Family medicine and internal medicine physicians completed the PDI, read vignettes describing patients with COPD or CHF, and indicated whether they initiated or delayed EOLC communication with their patients with similar conditions. RESULTS: Exploratory and confirmatory factor analyses were performed on separate samples. Confirmatory factor analysis confirmed that a three-factor solution was superior to a two- or one-factor solution. Three subscales were created: Anticipating Negative Emotions, Intolerance of Uncertainty, and Iatrogenic Harm. The full scale and subscales had adequate internal consistency and demonstrated evidence of validity. Higher scores on the PDI, indicating greater distress intolerance, were negatively associated with initiation and positively associated with delay of EOLC communication. Subscales provided unique information. SIGNIFICANCE OF RESULTS: The PDI can contribute to research investigating and addressing emotional barriers to EOLC communication.

Racial/Ethnic Discrimination and Food Consumption: Examination in Diverse Samples.

BACKGROUND: Racial/ethnic discrimination has been linked to poor health outcomes. Effects of discrimination on health behaviors, including patterns of food consumption, may contribute to health outcomes. PURPOSE: We examined relations of discrimination to consumption of healthy and unhealthy foods in two diverse samples. Structural equation modeling was used to examine variations in associations of discrimination to consumption by the timing and type of discrimination, for healthy vs. unhealthy food, and by sample. METHODS: Study 1 included a racially and ethnically diverse sample of adults from New York City (NYC: N = 157); Study 2 included a sample of American Indian and Alaska Native (AI/AN) adults from the Denver metro area (N = 303), many of whom also identified with other racial/ethnic groups. Participants completed self-report measures of racial/ethnic discrimination, food consumption, life stressors, and sociodemographic variables. RESULTS: Structural equation models indicated discrimination was associated with food consumption. Tests of model invariance indicated that the model of discrimination to food consumption can be applied to both samples. Discrimination within the past-week was associated with more frequent consumption of both unhealthy and healthy foods, whereas lifetime discrimination was associated with more frequent consumption only of unhealthy foods. CONCLUSIONS: The data were limited to self-report measures and only the frequency of consumption was assessed. The findings suggest discrimination may contribute to health disparities through effects on food consumption. Differential effects for past-week and lifetime discrimination suggest that multiple mechanisms may be involved.

Experiencing racial discrimination may undermine health through effects on health behavior, including patterns of food consumption. In two studies, we tested whether racial discrimination was linked with food consumption, specifically the frequency with which people ate healthy and unhealthy foods. We investigated both lifetime exposure to discrimination as well as more recent (past-week) exposure as predictors of food consumption. Study 1 focused on racially and ethnically diverse adults from New York City (NYC); Study 2 focused on American Indian and Alaska Native (AI/AN) adults from the Denver metro area. Overall, we found that higher levels of discrimination were associated with more frequent consumption of both unhealthy and healthy food. The timing of discrimination mattered. Higher levels of discrimination within the past-week were associated with more frequent consumption of healthy and unhealthy foods. In contrast, higher levels of lifetime discrimination were associated only with more frequent consumption of unhealthy food. The links between discrimination and food consumption remained significant controlling for socioeconomic status. The relations of discrimination to food consumption were similar across the diverse sample from NYC and the AI/AN sample from Denver. These findings may help researchers understand how discrimination may contribute to health disparities.

Racial discrimination and core executive functions.

Researchers have theorized that exposure to racial discrimination may impair executive functioning. The limited existing data broadly support this notion and suggest that discrimination may exert acute and persistent effects on executive functioning, potentially because of the cognitive demands associated with responding to discrimination. However, it is unclear if discrimination is differentially associated with different core executive functions. Further, the effects may vary depending on the timing of exposure, as recent or acute exposure to discrimination may operate on executive functioning through different mechanisms than exposure across the lifetime. The current study evaluates the relations of both recent and lifetime exposure to racial discrimination to three core executive functions (i.e., cognitive flexibility, inhibitory control and working memory) using a racially and ethnically diverse sample (n = 319). In fully adjusted models, recent discrimination was negatively associated with cognitive flexibility and working memory but not with inhibitory control. These data are consistent with the broader literature on acute stress effects on core executive functions and may have implications for understanding the effects of discrimination on health. Further research is warranted to understand the course and mechanisms of effects of lifetime and recent discrimination on core executive functions.

Addressing the Long COVID Crisis: Integrative Health and Long COVID.

While COVID-19 has killed millions of people globally, its lasting effects on the health and well-being of entire populations are just becoming clear. As many as 30% of those diagnosed with COVID-19 report continuing health-related problems, regardless of the severity of the initial infection. Given the infection rate in the world, that translates to between 5.4 and 17.9 million globally; about 700 000 in the US. The syndrome goes by many names; here we call it "long COVID." Patients experience a wide range of symptoms, including serious organ system effects such as pulmonary fibrosis, myocarditis, new diabetes diagnoses, stroke, and other cerebrovascular events. They also experience ongoing pain, fatigue, and cognitive dysfunction. We suggest here that these patients require an integrative health approach, one that combines traditional medical management, non-pharmacological approaches, and behavior and lifestyle changes. Such an approach has been shown to be beneficial in other chronic illnesses such as fibromyalgia, chronic fatigue syndrome, and post-Lyme disease.

My Life, My Way: A Quality Improvement Program to Increase Advance Care Planning in a Racially and Ethnically Diverse Patient Population.

BACKGROUND: A multilevel quality improvement program was implemented at an urban community hospital, serving a racially and ethnically pluralistic patient population, to increase participation in advance care planning (ACP). MEASURES: Number of eligible patients who completed an ACP form. INTERVENTION: Projects were implemented over the course of two years that targeted patients, health care providers, the organization, and the community. OUTCOMES: The intervention resulted in increased completion of four unique ACP forms. Completion of the Living Will increased by 60%, Health Care Proxy increased by 9%, Medical Orders for Life-Sustaining Treatment increased by 5%, and Do-Not-Resuscitate/Do-Not-Intubate orders increased by 3%. CONCLUSION: Multilevel interventions can increase ACP participation in a racially and ethnically pluralistic patient population.

Introduction to Hospice and Palliative Care.

Palliative care is a field of medicine that delivers patient-centered care for individuals and their families suffering from serious illness at all stages of the disease trajectory. It addresses the major priorities of relieving suffering, establishing goals of care, and managing physical symptoms while integrating the psychosocial, cultural, spiritual, and existential complexities of coping with chronic illness. This article discusses the role of palliative care in the health care system. It reviews the importance of prognostication, disease trajectory, and communication. The role of the primary care physician as part of a multidisciplinary team member delivering primary palliative care is emphasized.