ABSTRACT
BACKGROUND
Children and adolescents with autism spectrum disorder (ASD) have many well-known health concerns, yet health conditions in adults with ASD remain poorly defined.
OBJECTIVE
To ...examine health conditions and functional status in adults with ASD and identify factors associated with health and functional status across age cohorts.
DESIGN AND SUBJECTS
We collected cross-sectional data from 255 adult subjects aged 18 to 71 years with ASD using the Rochester Health Status Survey IV (RHSS-IV), a 58-item validated survey instrument. We used the National Health and Nutritional Examination Survey and National Health Interview Survey to provide comparative prevalence rates in the general population.
RESULTS
Compared to the general population, young adults aged 18–29 with ASD had a substantially higher prevalence of seizure disorder (11.2 % vs. 1.4 %;
p
= 0.002), depression (16.4 % vs. 6.4 %;
p
= 0.007), hypertension (12.9 % vs. 6.3 %;
p
= 0.05), and allergies (39.7 % vs. 8.4 %;
p
< 0.001). In contrast, young adults with ASD had considerably lower rates of sexually transmitted illness (STI) (0.9 % vs. 4.3 %;
p
= 0.03), tobacco use (5.2 % vs. 31.9 %;
p
< 0.001), and alcohol misuse (0.9 % vs. 11.9 %;
p
< 0.001). Adults 40 and over with ASD also had higher rates of seizure disorder (29.2 % vs. 1.7 %;
p
< 0.001), lower tobacco use (2.8 % vs. 24.5 %;
p
< 0.001), and lower alcohol misuse (1.4 % vs. 18.2 %;
p
< 0.001) compared to the general population. Amongst the 55 % of participants with a documented IQ score, 91 % had an intellectual disability (IQ < 70). Within the cohort aged 40 years old and older, only 54.2 % were independent with eating, 43.0 % independent with dressing, and 43.1 % independent with bathing. Lower IQ and depression were associated with lower functional status.
CONCLUSIONS
Adults with ASD have a high prevalence of seizure disorders and depression, but low rates of STIs, tobacco use, and alcohol misuse. Within our cohort, the majority of older adults with ASD required some assistance with activities of daily living.
The nonmedical use of prescription drugs by adolescents and young adults has surpassed all illicit drugs except marijuana, yet little is known about prescribing patterns. We examined the prescribing ...of controlled medications to adolescents aged 15 to 19 and young adults aged 20 to 29.
We used cross-sectional data from the National Ambulatory Medical Care Survey (N = 4304 physicians) and the National Hospital Ambulatory Medical Care Survey (N = 2805 clinics; N = 1051 emergency departments) between 2005 and 2007. We also used consecutive data from 1994 to describe trends.
A controlled medication was prescribed at 2.3 million visits by adolescents and 7.8 million visits by young adults in 2007. Between 1994 and 2007, controlled medications were prescribed at an increasing proportion of visits from adolescents (6.4%-11.2%) and young adults (8.3%-16.1%) (P < .001 for trend). This increase was seen among males and females, in ambulatory offices and emergency departments, and for injury-related and non-injury-related visits (all P < .001). A controlled medication was prescribed during 9.6% of all adolescent visits and 13.8% of young-adult visits for non-injury-related indications and at 14.5% of adolescent visits and 27.0% of young-adult visits for injury-related reasons. Controlled medications were prescribed at a substantial proportion of visits for common conditions, such as back pain, to both adolescents (23.4%) and young adults (36.9%).
Controlled medications are prescribed at a considerable proportion of visits from adolescents and young adults, and prescribing rates have nearly doubled since 1994. This trend and its relationship to misuse of medications warrants further study.
During the COVID-19 pandemic, concerns arose about disparate access to health care and laboratory testing. There is limited information about the pandemic's impact on the frequency of diabetic ...laboratory testing across demographic subgroups (e.g., sex, age over 65 y, and race).
This retrospective study examined outpatient hemoglobin A1c (HbA1c) testing in a large academic medical center in Upstate New York between March 2019 and March 2021. Multivariate Poisson regression models were used to evaluate the pandemic's effects on HbA1c utilization.
Over 190,000 HbA1c results from predominately white (76.1 %) and older (mean age, 60.6 y) outpatients were analyzed. Compared to pre-pandemic time period, the average number of HbA1c tests per patient during COVID time period experienced a small, though significant, drop (1.3 to 1.2; p < 0.001) on aggregate and in outpatients, males, females, and seniors. The modest reduction was not significant by race except for the white seniors (p < 0.001). However, the testing frequency remained within recommendations from the American Diabetes Association for monitoring prediabetic patients and patients with stable glycemic control.
Given the propensity for healthcare disruptions to widen disparities, it is reassuring that we did not observe a worsening of disparities in rates of HbA1c testing during the COVID-19 pandemic.
Health conditions in children with cerebral palsy (CP) are well described, yet health is less defined with advancing age. We examined health conditions, functional status and health care utilization ...in adults with CP across age groups.
We collected cross-sectional data on health conditions, functional status and utilization from the medical records of adults with CP across a large university-affiliated primary care network using the Rochester Health Status Survey IV (RHSS-IV), a 58-item validated survey. Data from the National Health and Nutrition Examination Survey and National Health Interview Survey provided prevalence estimates for the general population as comparison.
Compared to the general population, adults with CP had higher rates of seizure disorder, obesity and asthma across all ages. Adults with CP under 30 years of age had higher rates of hypertension (16.7 versus 5.6%; P = 0.04), urinary incontinence (41.7 versus 10.5%; P < 0.001) and depression (16.7 versus 6.9%; P = 0.07). Conversely, there were lower rates of alcohol misuse, tobacco/nicotine and sexually transmitted illnesses. Independence with all activities of daily living decreased from 37.5% at 18-29 years of age to 22.5% in those 60 and over. Seizure disorders, urinary incontinence and gastroesophageal reflux disease were all independently associated with lower functional status. As expected, health care utilization increased with advancing age.
Adults with CP should be monitored for conditions occurring at higher prevalence in CP, as well as common conditions occurring with advancing age. Age-related functional decline should be anticipated, especially with coexisting seizure disorders and urinary incontinence.
ABSTRACT
BACKGROUND
Racial and ethnic disparities in opioid prescribing in the emergency department (ED) are well described, yet the influence of socioeconomic status (SES) remains unclear.
...OBJECTIVES
(1) To examine the effect of neighborhood SES on the prescribing of opioids for moderate to severe pain; and (2) to determine if racial disparities in opioid prescribing persist after accounting for SES.
DESIGN
We used cross-sectional data from the National Hospital Ambulatory Medical Care Survey between 2006 and 2009 to examine the prescribing of opioids to patients presenting with moderate to severe pain (184 million visits). We used logistic regression to examine the association between the prescribing of opioids, SES, and race. Models were adjusted for age, sex, pain-level, injury-status, frequency of emergency visits, hospital type, and region.
MAIN MEASURES
Our primary outcome measure was whether an opioid was prescribed during a visit for moderate to severe pain. SES was determined based on income, percent poverty, and educational level within a patient’s zip code.
RESULTS
Opioids were prescribed more frequently at visits from patients of the highest SES quartile compared to patients in the lowest quartile, including percent poverty (49.0 % vs. 39.4 %,
P
< 0.001), household income (47.3 % vs. 40.7 %,
P
< 0.001), and educational level (46.3 % vs. 42.5 %,
P
= 0.01). Black patients were prescribed opioids less frequently than white patients across all measures of SES. In adjusted models, black patients (AOR 0.73; 95 % CI 0.66–0.81) and patients from poorer areas (AOR 0.76; 95 % CI 0.68–0.86) were less likely to receive opioids after accounting for pain-level, age, injury-status, and other covariates.
CONCLUSIONS
Patients presenting to emergency departments from lower SES regions were less likely to receive opioids for equivalent levels of pain than those from more affluent areas. Black and Hispanic patients were also less likely to receive opioids for equivalent levels of pain than whites, independent of SES.
Background
Community health centers (CHCs) are an integral part of the health care safety net. As health systems seek to improve value, it is important to understand the quality of care provided by ...CHCs.
Objective
To evaluate the performance of CHCs compared with private practices on a comprehensive set of high-value and low-value care measures.
Design
This cross-sectional study used data from the National Ambulatory Medical Care Survey from 2010 through 2012. We compared CHCs with private practices using logistic regression models that adjusted for age, sex, race/ethnicity, insurance, number of chronic illnesses, rural versus urban location, region of country, and survey year.
Setting/Participants
We included outpatient visits to generalist physicians at either CHCs or private practices by patients 18 years and older.
Main Measures
We examined 12 measures of high-value care and 7 measures of low-value care.
Results
A total of 29,155 physician visits, representing 584,208,173 weighted visits, from 2010 through 2012 were included. CHCs were more likely to provide high-value care by ordering beta-blockers in CHF (46.9% vs. 36.5%; aOR 2.56; 95%CI 1.18–5.56), statins in diabetes (37.0% vs 35.5%; aOR 1.35; 95%CI 1.02–1.79), and providing treatment for osteoporosis (35.7% vs 23.2%; aOR 1.77; 95%CI 1.05–3.00) compared with private practices. CHCs were more likely to avoid low-value screening EKGs (98.7% vs. 88.0%; aOR 11.03; 95%CI 2.67–45.52), CBCs (75.9% vs. 65.7%; aOR 1.72; 95%CI 1.18–2.53), or urinalyses (86.0% vs. 80.5%; aOR 1.87; 95%CI 1.11–3.14) during a general medical exam. CHCs were also less likely to prescribe antibiotics for a URI (48.3% vs. 63.1%; aOR 0.59; 95%CI 0.40–0.88).
Conclusions
On a number of high-value and low-value measures of care, CHCs performed similar to or better than private practices. As healthcare delivery reforms continue to progress, CHCs are well positioned to provide high-value healthcare.
Abstract
BACKGROUND
Medication adherence is crucial to effective chronic disease management, yet little is known about the influence of the patient–provider interaction on medication adherence to ...hypertensive regimens. We aimed to examine the association between the patient’s experience with care and medication adherence.
METHODS
We collected 2,128 surveys over 4 years from a convenience sample of hypertensive patients seeking care at three urban safety-net practices in upstate New York. The survey collected adherence measures using the Morisky Medication Adherence Scale (MMAS-8) and patient experience measures. We used regression models to adjust for age, gender, race/ethnicity, self-reported health status, and clustering by patients. The primary outcome was reporting of medium-to-high adherence (MMAS ≥ 6) vs. low adherence
RESULTS
A total of 62.5% of respondents reported medium-to-high medication adherence. The concern the provider demonstrated for patient questions or worries (adjusted odds ratio AOR 1.4; 95% confidence interval CI 1.1–1.7), provider efforts to include the patient in decisions (AOR 1.5; 95% CI 1.8–1.9), information given (AOR 1.3; 95% CI 1.0–1.6), and the overall rating of care received (AOR 1.4; 95% CI 1.1–1.8) were associated with higher medication adherence. The amount of time the provider spent was not associated with medication adherence (AOR 1.2; 95% CI 0.9–1.4). Medium-to-high medication adherence was in turn associated with increased hypertension control rates.
CONCLUSIONS
Overall, better experiences with care were associated with higher adherence to hypertension regimens. However, the amount of time the provider spent with the patient was not statistically associated with medication adherence, suggesting that the quality of communication may be more important than the absolute quantity of time.
Medications contribute to patients' out-of-pocket costs, yet most clinicians do not routinely screen for patients' cost-of-medication (COM) concerns.
To assess whether a single training session ...improves COM conversations.
Before-after cross-sectional surveys of patients and qualitative interviews with clinicians and staff.
7 primary care practices in 3 U.S. states.
In total, 700 patients were surveyed from May 2017 to January 2018: 50 patients per practice before the intervention and another 50 patients per practice after the intervention. Eligibility criteria included age 18 years or older and taking 1 or more long-term medications. Qualitative interviews with 45 staff members were conducted.
A single 60-minute training session for clinicians and staff from each practice on COM importance, team-based screening, and cost-saving strategies.
Patient data (demographics, number of long-term medications, total monthly out-of-pocket medication costs, and history of cost-related medication nonadherence) were obtained immediately before and 3 months after the intervention. Practice staff were interviewed 3 months after the intervention.
A total of 700 patient surveys were completed. Frequency of COM discussion improved in 6 of the 7 practices and remained unchanged in 1 practice. Overall, COM conversations with patients increased from 17% at baseline to 32% postintervention (P = 0.00). There was substantial heterogeneity among sites in before-after differences in patient-reported out-of-pocket COM. Qualitative analyses from key informant interviews showed wide variation in implementation of screening approaches, workflow, adoption of a team-based approach, and strategies for addressing COM.
It is not known whether improvements in COM conversations were sustained beyond 3 months.
A single team training to screen and address patients' medication cost concerns improved COM discussions over the short term. Further research is needed to assess sustained effects and impact on patient costs and medication adherence and to determine whether more intensive, scalable interventions are needed.
Robert Wood Johnson Foundation.
Young adults are the most likely age group to be uninsured and have the highest prevalence of substance abuse, motor vehicle accidents, and sexually transmitted diseases, yet little is known about ...their use of ambulatory care.
To characterize ambulatory care of young adults.
Cross-sectional data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.
Community and hospital-based clinics.
Nonpregnant young adults age 20 to 29 years.
Ambulatory care utilization, types of visits, and preventive care.
Insured young adults had more visits (2.16 95% CI, 2.14 to 2.19 annual visits per capita) than those without insurance (0.59 CI, 0.54 to 0.67 annual visits per capita). Young men utilized ambulatory medical care less than adolescents age 15 to 19 years or older adults age 30 to 39 years (1.10, 1.65, and 1.73 annual visits per capita, respectively) and had lower rates of utilization than young women (1.10 vs. 2.31 annual visits per capita). Young black and Hispanic men had considerably fewer annual visits per capita (0.75 and 0.65, respectively) than did young white men (1.21). Young men had nearly one half the preventive care visits compared with male adolescents or older men (0.11, 0.24, and 0.19 annual visits per capita, respectively) and less than one quarter the visits compared with young women (0.11 vs. 0.48 annual visits per capita). Only 30.6% of visits by young adults included any preventive counseling, and few encounters included counseling directed toward injury prevention (2.4%), mental health (4.1%), or sexually transmitted diseases (2.7%).
School-based clinics were not included, and counseling may be underreported.
Young adults use less ambulatory medical care relative to other groups and infrequently receive preventive care directed at the greatest threats to their health. Efforts to ensure appropriate preventive care are needed.
None.
ABSTRACT
BACKGROUND
Young adults have a high prevalence of many preventable diseases and frequently lack a usual source of ambulatory care, yet little is known about their use of the emergency ...department.
OBJECTIVE
To characterize care provided to young adults in the emergency department.
DESIGN, SETTING, AND PARTICIPANTS
Cross-sectional analysis of visits from young adults age 20 to 29 presenting to emergency departments (N = 17,048) and outpatient departments (N = 14,443) in the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey.
MAIN MEASURES
Visits to the emergency department compared to ambulatory offices.
RESULTS
Emergency department care accounts for 21.6% of all health care visits from young adults, more than children/adolescents (12.6%;
P
< 0.001) or patients 30 years and over (8.3%;
P
< 0.001). Visits from young adults were considerably more likely to occur in the emergency department for both injury-related and non-injury-related reasons compared to children/adolescents (
P
< 0.001) or older adults (
P
< 0.001). Visits from black young adults were more likely than whites to occur in the emergency department (36.2% vs.19.2%;
P
< 0.001) rather than outpatient offices. The proportion of care delivered to black young adults in the emergency department increased between 1996 and 2006 (25.9% to 38.5%;
P
= 0.001 for trend). In 2006, nearly half (48.5%) of all health care provided to young black men was delivered through emergency departments. The urgency of young adult emergency visits was less than other age groups and few (4.7%) resulted in hospital admission.
CONCLUSIONS
A considerable amount of care provided to young adults is delivered through emergency departments. Trends suggest that young adults are increasingly relying on emergency departments for health care, while being seen for less urgent indications.
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