Publications

Objective This study investigated patient- and area-level characteristics associated with adolescent emergency department (ED) patients risk of subsequent ED visits for self-harm. Method Retrospective analysis of adolescent patients presenting to a California ED in 2010 (n = 480,706) was conducted using statewide, all-payer, individually linkable administrative data. We examined associations between multiple predictors of interest (patient sociodemographic factors, prior ED utilization, and residential mobility; and area-level characteristics) and odds of a self-harm ED visit in 2010. Patients with any self-harm in 2010 were followed up over several years to assess predictors of recurrent self-harm. Results Self-harm patients (n = 5539) were significantly more likely than control patients (n = 16,617) to have prior histories of ED utilization, particularly for mental health problems, substance abuse, and injuries. Residential mobility also increased risk of self-harm, but racial/ethnic minority status and residence in a disadvantaged zipcode decreased risk. Five-year cumulative incidence of recurrent self-harm was 19.3%. Admission as an inpatient at index visit, Medicaid insurance, and prior ED utilization for psychiatric problems or injury all increased recurrent self-harm risk. Conclusions A range of patient- and area-level characteristics observable in ED settings are associated with risk for subsequent self-harm among adolescents, suggesting new targets for intervention in this clinical context.

Introduction: We sought to understand the association between youthful self-harm and sub- sequent chronic disease-related healthcare utilization and whether self-harm reflects unique vulnerability in comparison with severe psychiatric disorders. Methods: We used a retrospective matched cohort design with statewide, all-payer, individually linked emergency department (ED) data from California, USA. Risk of future ED visits for common chronic conditions in adolescence (headaches, asthma, epilepsy, diabetes, and gastro- intestinal disorders, assessed using ICD-9 diagnoses) were compared between three adolescent study groups presenting to an ED in 2010: self-harm patients (n=5,484), patients with psy- chiatric complaints but no self-harm (n=14,235), and patients with other complaints (n=16,452). Cohort follow-up ended on Sept. 30, 2015. Analyses were adjusted for patients prior histories of ED utilization for chronic conditions as well as patient- and area-level socio- demographic characteristics. Results: Risk of subsequent ED visits was higher among self-harm patients compared to non- psychiatric control patients for subsequent epilepsy- (aRR=1.77, 95% CI [1.42, 2.21]). Risk of subsequent ED visits was higher among psychiatric patients compared to non-psychiatric control patients for subsequent headache- (aRR=1.31, 95% CI [1.21, 1.42]), and epilepsy-related problems (aRR=1.85, 95% CI [1.55, 2.21]). Self-harm patients were at higher risk than psy- chiatric patients for subsequent gastrointestinal disorder (aRR=1.76, 95% CI [1.03, 3.01]). Conclusions: Findings suggest that self-harm behavior and psychiatric disorders are associated with increased ED utilization for subsequent chronic disease-related ED utilization. Chronic disease among adolescent psychiatric patients should be attended to, potentially involving new models of clinical follow-up care.

Objective: Suicide mortality rates in rural areas of the United States are twice that of rates in urban areas, and identifying which factors—eg, higher rates of suicidal distress, lower rates of help-seeking behaviors, or greater access to firearms—contribute to this rural/urban disparity could help target interven- tions. Method: Using 2015-2016 data on adult respondents to the California Health Interview Survey (n = 40,041), we examined associations between residence in a rural (vs nonrural) census tract and nonfatal suicidal ideation and attempt. Results: We found that living in a rural area was not associated with nonfatal suicidal behavior (OR for past-year suicidal ideation = 0.87, 95% CI: 0.63-1.20; OR for past-year suicide attempt = 0.55, CI: 0.20-1.48). Women living in rural areas had higher odds of lifetime suicidal ideation compared to women living in nonrural areas, but this difference was not significant (OR = 1.17, CI: 0.94- 1.44). We also found that, among individuals reporting suicidal behavior, there were few rural/nonrural differences in perceived need for treatment, such as seeing a physician or taking a prescription for mental health problems. Conclusions: Our results do not suggest higher suicidal distress or lower treatment-seeking behaviors as explanations for the rural/urban disparity in suicide mortality rates. Further attention is needed to the unique risk factors driving suicidality in rural areas, as well as exploring heterogeneity in these factors across different rural contexts.

Background Reducing maternal mortality is a priority in the United States and worldwide. Drug-related deaths and suicide may account for a substantial and growing portion of maternal deaths, yet information on the incidence of and sociodemographic variation in these deaths is scarce. Objective We sought to examine incidence of drug-related and suicide deaths in the 12 months after delivery, including heterogeneity by sociodemographic factors. We also explored maternal decedents health care utilization prior to death. Study Design This retrospective, population-based cohort study followed up 1,059,713 women who delivered a live-born infant in California hospitals during 2010–2012 to ascertain maternal death. Analyses were conducted using statewide, all-payer, longitudinally-linked hospital and death data. Results A total of 300 women died during follow-up, a rate of 28.33 deaths per 100,000 person-years. The leading cause of death was obstetric-related problems (6.52 per 100,000 person-years). Drug-related deaths were the second leading cause of death (3.68 per 100,000 person-years), and suicide was the seventh leading cause (1.42 per 100,000 person-years); together these deaths comprised 18% of all maternal deaths. Non-Hispanic white women, Medicaid-insured women, and women residing in micropolitan areas were especially likely to die from drugs/suicide. Two thirds of women who died, including 74% of those who died by drugs/suicide, made ≥1 emergency department or hospital visit between their delivery and death. Conclusion Deaths caused by drugs and suicide are a major contributor to mortality in the postpartum period and warrant increased clinical attention, including recognition by physicians and Maternal Mortality Review Committees as a medical cause of death. Importantly, emergency department and inpatient hospital visits may serve as a point of identification of, and eventually prevention for, women at risk for these deaths.

Anxiety-inducing life events increase the risk of motor vehicle crashes. We test the hypothesis that earthquakes, known to increase anxiety in the population, also increase the incidence of motor vehicle crashes. Our study took place in Oklahoma, USA where wastewater injection resulted in increased induced seismicity between 2010 and 2016. We identified dates of earthquakes ≥ magnitude 4 (a level felt by most people) with data from the U.S. Geologic Survey. The Oklahoma Highway Safety Office provided county-level monthly vehicle crash counts. We defined high, medium, and low earthquake exposure counties based on the location of earthquake epicenters. Using time-series analyses, we evaluated the association between monthly counts of ≥magnitude 4 earthquakes and motor vehicle crashes by exposure group. Earthquakes ≥ magnitude 4 took place in 38 of 84 study months, and a monthly average of 5813 (SD = 384) crashes occurred between 2010 and 2016. In high-exposure counties, we observed an additional 39.2 motor vehicle crashes per each additional ≥ magnitude 4 earthquake in the prior month (SE = 11.5). We found no association between the timing of ≥magnitude 4 earthquakes and motor vehicle crashes in the medium or low exposure counties. With a binary earthquake exposure variable, we found a 4.6% (SE = 1.4%) increase in motor vehicle crashes in the high exposure counties in the month following 1 or more ≥magnitude 4 earthquakes. Consistent with our hypothesis, there was no association between earthquakes of magnitude ≤ 2.5 and motor vehicle crashes in the high-exposure counties. This novel evidence of an association between induced earthquakes in Oklahoma and motor vehicle crashes warrants future research given the high economic and social costs of such vehicle crashes.

Objective. Adolescent self-harm rates have risen substantially in the U.S., yet health and social outcomes among contemporary self-harming youths are infrequently tracked and remain poorly understood. This study investigated long-term health service utilization (emergency department [ED] visits and inpatient admissions) and inpatient costs among a recent cohort of adolescent deliberate self-harm patients. Methods. This retrospective cohort study used statewide, all-payer, longitudinally-linked patient discharge data from California, USA. All CA residents aged 10-19 years presenting to EDs in 2010 with deliberate self-harm (n=5,396) were compared with two control groups: A random sample of adolescent patients with other complaints, matched on sex, age, residential ZIP code, and month of index visit (general control patients; n=14,921), and matched patients with psychiatric complaints but no self-harm (psychiatric controls; n=15,835). Study outcomes included five-year rates of subsequent ED visits, inpatient admissions, and inpatient costs, both overall and for psychiatric and non-psychiatric complaints separately. Results. Self-harm patients rates of ED utilization, inpatient admissions, and inpatient costs were significantly higher than those of general control patients (by 39%, 81%, and 21%, respectively), controlling for confounding demographic and utilization characteristics. Associations mostly persisted, though smaller in magnitude, in comparisons with psychiatric control patients. Both psychiatric and non-psychiatric complaints contributed to self-harming adolescents excess health service utilization and costs. Conclusion. Adolescent deliberate self-harm is associated with long-lasting and costly patterns of health service utilization, often but not exclusively for psychiatric complaints. Future research should investigate the pathways underlying these associations, and incorporate service utilization as a key patient outcome.

Background: Violent injuries are a leading cause of morbidity and mortality among youths. Little is known about adolescents patterns of and risk factors for repeat assault injuries, yet understanding who is at risk for repeated assaults is important for intervention and prevention efforts. Investigating these questions in population-based adolescent samples is particularly critical. Objective: Our aim was to estimate the 5-year cumulative incidence of and risk factors for repeat emergency department (ED) visits for assault injury among adolescents experiencing an index assault visit, and compare the method of injury for adolescents first and second visits. Methods: Statewide, longitudinal data from California were used to follow 17,845 adolescents who reported to an ED with assault-related injuries in 2010. Incidence rate ratios were estimated to examine risk factors for repeat assault injury within 1 year and 5 years following the index visit. Results: A total of 3273 (18.3%) assaulted adolescents experienced one or more additional assault injury ED visits during the full follow-up period. Only 37.3% of these repeat assaults occurred within the first year following the index assault. Of adolescents with a repeat assault injury, the method of injury often changed and followed no clear pattern. Sociodemographic characteristics (e.g., older age, black race) and history of prior ED visits for assault and mental health problems predicted increased risk of repeat assault. Conclusions: Previous work may underestimate the rate of repeated assault among adolescents. Adolescents with a history of violence involvement and mental health problems are at elevated risk for repeated assault, and should be targeted for intervention.

Importance: Emergency departments (EDs) have the potential to play a pivotal role in suicide risk detection and prevention, yet little is known about the profile of risk of suicide after ED visits in the United States. Objectives: To examine 1-year incidence of suicide and other mortality among ED patients who presented with nonfatal deliberate self-harm, suicidal ideation, or any other chief concern, and to examine sociodemographic and clinical factors associated with suicide mortality risk. Design, Setting, and Participants: This retrospective cohort study included statewide, all-payer, longitudinally linked ED patient records and mortality data from all California residents who presented to a California-licensed ED at least 1 time from January 1, 2009, to December 31, 2011, with deliberate self-harm, suicidal ideation but not self-harm, or neither (a 5% random sample). Age-, sex-, and race/ethnicity-adjusted standardized mortality ratios (SMRs) for suicide and other manners or causes of death were determined for each patient group using statewide mortality data. Data were analyzed from January 10 to July 18, 2019. Main Outcomes and Measures: Suicide and other manners or causes of death were ascertained using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Suicide rate and all mortality rates were measured per 100 000 person-years. Results: Among 648 646 individuals (mean [SD] age, 43.8 [20.6] years; 350 687 [54.1%] women) who visited an ED in California from 2009 to 2011, the rates of suicide deaths per 100 000 person-years in the year after index ED presentation were 693.4 deaths among 83 507 individuals presenting with deliberate self-harm (SMR, 56.8; 95% CI, 52.1-61.4), 384.5 deaths among 67 379 individuals presenting with suicidal ideation but not self-harm (SMR, 31.4; 95% CI, 27.5-35.2), and 23.4 deaths among 497 760 reference patients (SMR, 1.9; 95% CI, 1.6-2.3). Compared with the demographically matched general population, the rates of nonsuicide external-cause mortality were also increased among patients with self-harm (SMR, 14.2; 95% CI, 12.9-15.5), patients with suicidal ideation (SMR, 11.8; 95% CI, 10.6-13.0), and reference patients (SMR, 2.2; 95% CI, 2.0-2.3). In all 3 groups, the rates of suicide mortality per 100 000 person-years were higher among men (deliberate self-harm: 1011.1 deaths; suicidal ideation: 539.8 deaths; reference: 36.6 deaths), people 65 years or older (deliberate self-harm: 1919.5 deaths; suicidal ideation: 691.2 deaths; reference: 28.6 deaths), and non-Hispanic white patients (deliberate self-harm: 914.1 deaths; suicidal ideation: 511.6 deaths; reference: 33.8 deaths) than among their respective referent groups. Other sociodemographic factors and clinical diagnoses were associated with striking differences in suicide rates, but these patterns were heterogeneous across patient groups. Conclusions and Relevance: These findings suggest that ED patients with deliberate self-harm or suicidal ideation are associated with substantially increased risk of suicide and other mortality during the year after ED presentation. The process of planning for ED discharge may present opportunities to help ensure safe transitions to continuing outpatient mental health care and to consider broader risk for unintentional injury and other causes of premature mortality.

Objective: This study evaluated whether emergency de- partment (ED) patient presentations for problems related to mental and substance use disorders could be validly moni- tored by a syndromic surveillance system that uses chief complaints to identify mental disorders. Methods: The study used syndromic surveillance data on 146,315 ED visits to participating Fresno County, California, hospitals between January 1 and December 31, 2013. Free- text patient chief complaints are automatically classified into syndromes based on the developer s algorithms. Agreement was assessed between the algorithm s syndrome classifica- tion of mental health and substance abuse (MHSA) disorders and ICD-9-CM discharge diagnostic codes. Diagnosis and ED utilization patterns among patients with at least one visit with an MHSA syndrome classification were also examined. Results: Approximately 8% of ED visits during the study period received an MHSA syndrome classification. Overall agreement between MHSA syndrome classification and psychiatric- or substance use–related ICD-9 discharge diagnoses was high (k=.92, 95% confidence interval= .91–.92). Sensitivity (100%) and specificity (98.6%) of the MHSA syndrome classification were also very high. MHSA syndrome–classified patients exhibited high levels of health care andmorbidity burden compared with other patients. Conclusions: ED chief complaints can be utilized to reliably and validly ascertain the incidence of patient presentations for mental and substance use disorders in contexts in which discharge diagnoses are not routinely available. Wider adoption of MHSA-related syndrome algorithms by syn- dromic surveillance systems could be valuable for public mental health surveillance, service delivery, and resource planning efforts.

© 2017 Objective To describe the planning, development, pilot testing, fielding, and outcomes of a community health survey in a rural California county pursuing public health accreditation. Design Community partners helped the local health department develop the community health survey. Extensive English- and Spanish-language pilot testing was conducted over a period of four months. Final survey fielding was conducted online and at 20 community sites. Results 2189 completed surveys were collected. Total costs for developing and fielding the survey were approximately $25,000. Survey results indicated that alcoholism/drug abuse, breathing problems, and obesity were the primary health concerns of county residents. Benefits of conducting the community survey included strengthening inter-organizational partnerships between community partners, engaging a large and diverse respondent sample, and gathering information on a nuanced set of health indicators. Challenges included an unexpectedly high number of respondents and managing the needs of respondents with disabilities or poor literacy. Conclusion The information gathered from the community health survey was used in the implementation of a county-wide multi-agency strategic plan to address health priorities identified in the CHA. Engaging a broad set of community partners throughout the survey process was critical for ensuring the project s relevance and long-term regional impact.