Disparities in COVID-19 testing and outcomes among Asian American and Pacific Islanders: an observational study in a large health care system.

BACKGROUND: The COVID-19 pandemic has disproportionately impacted racial and ethnic minorities in the United States, including Asian Americans, Native Hawaiians and Pacific Islanders (Asian Americans and NH/PIs). However, few studies have highlighted nor disaggregated these disparities by Asian Americans and NH/PIs ethnic subgroups. METHODS: This retrospective, cross-sectional observational study aimed to assess variation of Asian Americans and NH/PIs COVID-19 testing and outcomes compared to non-Hispanic Whites (NHW). The study utilized data from the electronic health records (EHR) and the COVID-19 Universal Registry for Vital Evaluations (CURVE) from all patients tested for SARS-CoV-2 (n = 556,690) at a large, health system in Northern and Central California between February 20, 2020 and March 31, 2021. Chi-square tests were used for testing differences in the severity of COVID-19 (hospitalization, ICU admission, death) and patient demographic and clinical characteristics across the Asian Americans and NH/PIs subgroups and NHW. Unadjusted and adjusted Odds Ratios (ORs) were estimated for measuring effect of race ethnicity on severity of COVID-19 using multivariable logistic regression. RESULTS: Of the entire tested population, 70,564/556,690 (12.7%) tested positive for SARS-CoV-2. SARS-CoV-2 positivity of Asian subgroups varied from 4% in the Chinese and Korean populations, to 11.2%, 13.5%, and 12.5% for Asian Indian, Filipino, and "other Asian" populations respectively. Pacific Islanders had the greatest subgroup test positivity at 20.1%. Among Asian Americans and NH/PIs patients with COVID-19 disease, Vietnamese (OR = 2.06, 95% CI = 1.30-3.25), "Other Asian" (OR = 2.13, 95% CI = 1.79-2.54), Filipino (OR = 1.78, 95% CI = 1.34-2.23), Japanese (OR = 1.78, 95% CI = 1.10-2.88), and Chinese (OR = 1.73, 95% CI = 1.34-2.23) subgroups had almost double the odds of hospitalization compared to NHW. Pacific Islander (OR = 1.58, 95% CI = 1.19-2.10) and mixed race subgroups (OR = 1.55, 95% CI = 1.10-2.20) had more than one and a half times odds of hospitalization compared to NHW. Adjusted odds of ICU admission or death among hospitalized patients by different Asian subgroups varied but were not statistically significant. CONCLUSIONS: Variation of COVID-19 testing and hospitalization by Asian subgroups was striking in our study. A focus on the Asian Americans and NH/PIs population with disaggregation of subgroups is crucial to understand nuances of health access, utilization, and outcomes among subgroups to create health equity for these underrepresented populations.

"Could we have predicted this?" The association of a future mental health need in young people with a non-specific complaint and frequent emergency department visits.

OBJECTIVE: Mental health emergencies among young people are increasing. There is growing pressure for emergency departments to screen patients for mental health needs even when it is not their chief complaint. We hypothesized that young people with an initial non-specific condition and emergency department (ED) revisits have increased mental health needs. METHODS: Retrospective, observational study of the California Office of Statewide Health Planning and Development Emergency Department Discharge Dataset (2010-2014) of young people (11-24 years) with an index visit for International Classification of Diseases, Ninth Revision diagnostic codes of "Symptoms, signs, and ill-defined conditions" (Non-Specific); "Diseases of the respiratory system" (Respiratory) and "Unintentional injury" (Trauma) who were discharged from a California ED. Patients were excluded if they had a prior mental health visit, chronic disease, or were pregnant. ED visit frequency was counted over 12 months. Regression models were created to analyze characteristics associated with a mental health visit. RESULTS: Patients in the Non-Specific category compared to the Respiratory category had 1.2 times the odds of a future mental health visit (OR 1.20; 95% CI 1.17-1.24). Patients with ≥1 ED revisit, regardless of diagnostic category, had 1.3 times the odds of a future mental health visit. Patients with both a Non-Specific index visit and 1, 2, and 3 or more revisits with non-specific diagnoses had increasing odds of a mental health visit (OR 1.38; 95% CI 1.29-1.47; OR 1.70; 95% CI 1.46-1.98; OR 2.20; 95% CI 1.70-2.87, respectively.). CONCLUSIONS: Young people who go to the ED for non-specific conditions and revisits may benefit from targeted ED mental health screening.

Increasing ambulatory treatment of pediatric minor burns-The emerging paradigm for burn care in children.

INTRODUCTION: Innovations in topical burn treatment along with a drive toward value-based care are steering burn care to the outpatient setting. Little is known regarding what characteristics predict outpatient treatment of pediatric minor burns and whether there is a temporal trend toward this treatment paradigm. METHODS: A retrospective cohort study was performed using California's Office of Statewide Health Planning and Development linked emergency department and inpatient database (2005-2013). All patients under 18years of age with a primary burn diagnosis were extracted. Using patient and facility level variables, we used regression modeling to evaluate predictors of outpatient burn treatment and temporal trends. RESULTS: There were 16,480 pediatric minor burn encounters during the period. 56.4% were male, 85.3% had <10% total body surface area (TBSA), 76.3% were scald or contact, and 77.3% were at deepest depth 2nd degree. Multiple variables predicted an increased likelihood of discharge home including older age(p<0.001), smaller TBSA(p<0.001), and superficial/partial thickness burns(< 0.001). Children of Hispanic and Black race were less likely to be discharged home compared to White and Asian peers(p=<0.001). On Poisson modeling, the incidence rate ratio over the 9-year period for home discharge was 1.004 (95% CI 1.001-1.008, p=0.032). CONCLUSION: Older patients and those with more superficial burns were more likely to be treated as outpatients. Black and non-white Hispanic race was associated with inpatient admission. There is a growing trend toward ambulatory treatment of minor burns in the pediatric population. Further research is needed to assess whether outpatient treatment of pediatric minor burns results in greater readmissions.

Nationwide Assessment of Factors Associated with Nonoperative Management of Pediatric Splenic Injury.

To evaluate variation in care nationwide for children with splenic injuries at pediatric trauma, adult trauma, and nontrauma centers. We used the National Inpatient Sample from 2001 to 2010 to identify pediatric patients with splenic injury. We analyzed demographic, clinical, and hospital status characteristics. The primary objective was comparison of splenectomy rates at pediatric, adult, and nontrauma centers. We identified 34,599 patients with splenic injury. Throughout the study, 3,979 (11.5%) patients underwent splenectomy: 8.2 per cent of patients at pediatric trauma, 17.6 per cent at adult trauma, and 14.5 per cent at nontrauma centers. Multivariate regression analysis demonstrated patients had decreased odds of splenectomy at pediatric trauma centers compared with adult and nontrauma centers (OR = 0.42, P < 0.001). In addition, children aged 14 to 17 years (OR = 2.5) with injury severity score > 14 (OR = 5.8) had increased odds of undergoing splenectomy. In this nationwide sample, children with splenic injury treated at adult trauma and nontrauma centers had significantly higher rates of splenectomy compared with children treated at pediatric trauma centers. We highlight the need for interventions that ensure all injured children receive appropriate and high quality trauma care.

Predictors of Nondiagnostic Ultrasound for Appendicitis.

BACKGROUND: Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US. OBJECTIVES: We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies. METHODS: A prospective cohort study of consecutive patients 4 to 30 years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI >85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed. RESULTS: Over 3 months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p < 0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients. CONCLUSION: Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding imaging options for children with acute abdominal pain.

Emergency department-based health insurance enrollment for children: does linkage lead to insurance retention and utilization?

OBJECTIVES: Although 40% of emergency departments (EDs) report having an insurance linkage program, no studies have evaluated the long-term success of these programs. This study aimed to examine insurance retention and utilization by children initially referred to insurance by our ED insurance linkage program. METHODS: We retrospectively examined insurance records of all uninsured children successfully enrolled in public insurance by the insurance linkage program established in our suburban academic ED between 2004 and 2009. Emergency department-enrolled children were matched by age, sex, program, and year of enrollment to a control group of children from the same county who were enrolled in non-ED settings. Wilcoxon signed rank and χ tests were used to compare enrollment and claims variables. RESULTS: Emergency department-enrolled children retained insurance for longer, had a higher reenrollment rate, and were higher users of insurance. The average length of enrollment for ED children was 734 days versus 597 days in the control group. Eighty percent of the ED cohort reenrolled in insurance after initial eligibility expiration versus 64% of the control group. Children enrolled via the ED averaged 26 claims (vs 12 claims) and $20,087 (vs $5216) in hospital charges per year of enrollment. This higher utilization was reflected in increased primary care, specialty care, ED visits, inpatient, and mental health claims in the ED group. CONCLUSIONS: Emergency department-based insurance enrollment programs have the potential to improve access to health care for children. Policies aimed at expanding insurance enrollment among the uninsured population, including the Affordable Care Act, may consider the ED's potential as an effective enrollment site.

Improved management of acute asthma among pregnant women presenting to the ED.

BACKGROUND: A multicenter study in the late 1990s demonstrated suboptimal emergency asthma care for pregnant women in US EDs. After a decade, follow-up data are lacking. We aimed to examine changes in emergency asthma care of pregnant women since the 1990s. METHODS: We combined data from four multicenter observational studies of ED patients with acute asthma performed in 1996 to 2001 (three studies) and 2011 to 2012 (one study). We restricted the data so that comparisons were based on the same 48 EDs in both time periods. We identified all pregnant patients aged 18 to 44 years with acute asthma. Primary outcomes were treatment with systemic corticosteroids in the ED and, among those sent home, at ED discharge. RESULTS: Of 4,895 ED patients with acute asthma, the analytic cohort comprised 125 pregnant women. Between the two time periods, there were no significant changes in patient demographics, chronic asthma severity, or initial peak expiratory flow. In contrast, ED systemic corticosteroid treatment increased significantly from 51% to 78% across the time periods (OR, 3.11; 95% CI, 1.27-7.60; P = .01); systemic corticosteroids at discharge increased from 42% to 63% (OR, 2.49; 95% CI, 0.97-6.37; P = .054). In the adjusted analyses, pregnant women in recent years were more likely to receive systemic corticosteroids, both in the ED (OR, 4.76; 95% CI, 1.63-13.9; P = .004) and at discharge (OR, 3.18; 95% CI, 1.05-9.61; P = .04). CONCLUSIONS: Between the two time periods, emergency asthma care in pregnant women significantly improved. However, with one in three pregnant women being discharged home without systemic corticosteroids, further improvement is warranted.

Survival of a patient with tetanus in Bhutan using a magnesium infusion managed only by clinical signs.

Tetanus is a life-threatening disease that continues to have a high prevalence in developing countries. Severe muscle spasms often require patients to receive tracheostomy, high-dose sedatives, and sometimes prolonged neuromuscular blockade. Magnesium sulfate (MgSO4) infusion has great promise as an adjunct treatment for severe tetanus, as it may allow clinicians to decrease the dose of other sedative medications. Although the mechanism of action of MgSO4 is not well understood, it appears to attenuate both the muscle spasms and autonomic instability associated with severe tetanus infections. However, MgSO4 infusions are often managed based on serial measurements of serum magnesium levels and other laboratory tests such as arterial blood gases, which can be difficult to obtain in resource-poor settings. We describe a case of severe tetanus in Bhutan managed through the use of magnesium infusion titrated solely to physical examination findings.

Djenkolism: case report and literature review.

Djenkolism is an uncommon but important cause of acute kidney injury. It sporadically occurs after an ingestion of the djenkol bean (Archidendron pauciflorum), which is native to Southeast Asia. The clinical features defining djenkolism include: spasmodic suprapubic and/or flank pain; urinary obstruction; and acute kidney injury. The precise pathogenesis of acute kidney injury following djenkol ingestion remains unknown. However, it is proposed that an interaction between the characteristics of the ingested beans and the host factors causes hypersaturation of djenkolic acid crystals within the urinary system, resulting in subsequent obstructive nephropathy with sludge, stones, or possible spasms. We report a case of djenkolism from our rural clinic in Borneo, Indonesia. Our systematic literature review identified 96 reported cases of djenkolism. The majority of patients recovered with hydration, bicarbonate therapy, and pain medication. Three patients required surgical intervention; one patient required ureteral stenting for the obstructing djenkolic acid stones. Four of the 96 reported patients died from acute kidney failure. We stress the importance of awareness of djenkolism to guide medical practitioners in the treatment of this rare disease in resource-poor areas in Southeast Asia.

Clinical correlation needed: what do emergency physicians do after an equivocal ultrasound for pediatric acute appendicitis?

BACKGROUND: Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT. METHODS: Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1-18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT. RESULTS: Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age >11 years, leukocytosis >15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT. CONCLUSIONS: We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT.

Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm.

OBJECTIVE: Patients receiving interfacility transfer to a higher level of medical care for ruptured abdominal aortic aneurysms (rAAAs) are an important minority that are not well characterized and are typically omitted from outcomes and quality indicator studies. Our objective was to compare patients transferred for treatment of rAAAs with those treated without transfer, with particular emphasis on mortality and resource utilization. METHODS: We linked longitudinal data from 2005 to 2010 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and Emergency Department Databases from California, Florida, and New York. Patients were identified using International Classification of Diseases-Ninth Revision-Clinical Modification codes. Our main outcome variables were mortality, length of stay, and cost. Data included discharge information on the transfer-out and transfer-in hospital. We used univariate and multivariate analysis to identify variables independently associated with transfer and in-hospital mortality. RESULTS: Of 4439 rAAA patients identified with intent to treat, 847 (19.1%) were transferred before receiving operative repair. Of those transferred, 141 (17%) died without undergoing AAA repair. By multivariate analysis, increasing age in years (odds ratio [OR] 0.98; 95% confidence interval [CI], 0.97-0.99; P < .001), private insurance vs Medicare (OR, 0.62; 95% CI, 0.47-0.80; P < .001), and increasing comorbidities as measured by the Elixhauser Comorbidity Index (OR, 0.90; 95% CI, 0.86-0.95; P < .001) were negatively associated with transfer. Weekend presentation (OR, 1.23; 95% CI, 1.02-1.47; P = .03) was positively associated with transfer. Transfer was associated with a lower operative mortality (adjusted OR, 0.81; 95% CI, 0.68-0.97; P < .02) but an increased overall mortality when including transferred patients who died without surgery (OR, 1.30; 95% CI, 1.05-1.60; P = .01). Among the transferred patients, there was no significant difference in travel distance between those who survived and those who died (median, 28.7 vs 25.8 miles; P = .07). Length of stay (median, 10 vs 9 days; P = .008), and hospital costs ($161,000 vs $146,000; P = .02) were higher for those transferred. CONCLUSIONS: The survival advantage for patients transferred who received treatment was eclipsed by increased mortality of the transfer process. Including 17% of transferred patients who died without receiving definitive repair, mortality was increased for patients transferred for rAAA repair compared with those not transferred after adjusting for demographic, clinical, and hospital factors. Transferred patients used significantly more hospital resources. Improving systems and guidelines for interfacility transfer may further improve the outcomes for these patients and decrease associated hospital resource utilization.

The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011.

BACKGROUND: Trauma centers (TCs) have been shown to decrease mortality in adults, but this has not been demonstrated at a population level in all children. We hypothesized that seriously injured children would have increased survival in a TC versus nontrauma center (nTC), but there would be no increased benefit from pediatric-designated versus adult TC care. METHODS: This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999-2011). DRG International Classification of Diseases-9th Rev. (ICD-9) diagnostic codes indicating trauma were identified for children (0-18 years), and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death and which appeared at both TCs and nTCs. Instrumental variable (IV) analysis using differential distance between the child's residence to a TC and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. Instrumental variable regression models analyzed the association between mortality and TC versus nTC care as well as for pediatric versus adult TC designations, adjusting for demographic and clinical variables. RESULTS: Unadjusted mortality for the entire population of children with nontrivial trauma (n = 445,236) was 1.2%. In the final study population (n = 77,874), mortality was 5.3%, 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% confidence interval, -0.80 to -0.30; p = 0.044) decrease in mortality for children cared for in TC versus nTC. No decrease in mortality was demonstrated for children cared for in pediatric versus adult TCs. CONCLUSION: Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA.

PURPOSE: To evaluate the effectiveness of a staged ultrasonography (US) and computed tomography (CT) imaging protocol for the accurate diagnosis of suspected appendicitis in children and the opportunity for reducing the number of CT examinations and associated radiation exposure. MATERIALS AND METHODS: This retrospective study was compliant with HIPAA, and a waiver of informed consent was approved by the institutional review board. This study is a review of all imaging studies obtained in children suspected of having appendicitis between 2003 and 2008 at a suburban pediatric emergency department. A multidisciplinary staged US and CT imaging protocol for the diagnosis of appendicitis was implemented in 2003. In the staged protocol, US was performed first in patients suspected of having appendicitis; follow-up CT was recommended when US findings were equivocal. Of 1228 pediatric patients who presented to the emergency department for suspected appendicitis, 631 (287 boys, 344 girls; age range, 2 months to 18 years; median age, 10 years) were compliant with the imaging pathway. The sensitivity, specificity, negative appendectomy rate (number of appendectomies with normal pathologic findings divided by the number of surgeries performed for suspected appendicitis), missed appendicitis rate, and number of CT examinations avoided by using the staged protocol were analyzed. RESULTS: The sensitivity and specificity of the staged protocol were 98.6% and 90.6%, respectively. The negative appendectomy rate was 8.1% (19 of 235 patients), and the missed appendicitis rate was less than 0.5% (one of 631 patients). CT was avoided in 333 of the 631 patients (53%) in whom the protocol was followed and in whom the US findings were definitive. CONCLUSION: A staged US and CT imaging protocol in which US is performed first in children suspected of having acute appendicitis is highly accurate and offers the opportunity to substantially reduce radiation.