Background In 2009, the Strategy for the Control of Antimicrobial Resistance in Ireland (SARI) Hospital Antimicrobial Stewardship (AMS) Working Group published guidance on antimicrobial stewardship in hospitals.These were the first guidelines outlining the rationale for AMS in Irish hospitals and healthcare institutions.The aim of this scoping review is to evaluate the progress of AMS implementation in Ireland and align the findings with the 2009 SARI Hospital AMS Working Group guidance recommendations. Methods Systematic searches were conducted in four electronic databases (PubMed, CINAHL, Embase, Web of Science) and five targeted websites for grey literature.Titles and abstracts were screened independently by two reviewers and all authors reviewed full-text publications. Studies were mapped into at least one of four predefined recommendations, (A) Structure and Organisation of Antimicrobial Stewardship, (B) Roles and Responsibilities for Prescribers, (C) Antimicrobial Stewardship Interventions and (D) Recommendations for non-acute Residential Healthcare Institutions. These recommendations will be used as a framework for the outcome of interest in this scoping review. Results The search yielded 544 peer reviewed papers, of which 29 were included and 327 grey reports, of which 24 were included. Most articles (n=46) were mapped to categories A and C. Findings in category A highlight inadequate staffing and the need for greater investment in Information Technology (IT) to support AMS and infection prevention and control. Category C findings emphasise implementation challenges, including the need for hospital leadership to commit to improved availability of relevant resources, improving diagnostic capacity, and provision of education for prescribers, pharmacists, nurses, and patients. Conclusions AMS implementation in Ireland has progressed over the past two decades, but significant challenges remain. Addressing resources including recruitment of staff and a defined budget, development of a structured national implementation plan with agreed annual targets, investing in IT and strengthening leadership commitment for all healthcare settings will be essential for future improvements.

Background Antimicrobial stewardship programmes (ASP) are essential in promoting responsible antimicrobial use, reducing antimicrobial resistance (AMR) and health care-associated infections. In 2009 the Strategy for the Control of Antimicrobial Resistance in Ireland (SARI), Hospital Antimicrobial Stewardship Working Group published guidance on antimicrobial stewardship (AMS) in hospitals. This paper presents a protocol for a scoping review which aims to examine the current literature to evaluate progress related to the implementation of the SARI (2009) guidance on antimicrobial stewardship in hospitals in Ireland. Methods This scoping review will be conducted in line with the five-stage methodological framework by Arksey & O’Mally 2005. We will search the following databases (PubMed, CINAHL, Embase, Web of Science) and targeted websites for articles and reports for possible inclusion in our review. Studies pertaining to AMS undertaken or related to the Republic of Ireland from January 2010 until December 2021 will be included. We will include all study designs. We will map all selected publications to the recommendations of the SARI (2009) guidance document. The protocol follows the guidance of Peters et al., 2022. Two reviewers will independently screen studies and reports to assess eligibility with any discrepancies resolved by consensus discussion with a third reviewer. Results These will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR)and this checklist will be included when the scoping review is published. Conclusion This scoping review will map studies and reports to evaluate AMS in relation to national guidelines without restriction on study design or outcomes in the Republic of Ireland. This information has the potential to provide a valuable resource for the implementation of future AMS research and interventions.

BackgroundThis study aimed to assess the prevalence and persistence of key maternal morbidities - urinary incontinence, faecal incontinence, pelvic girdle pain, sexual health problems, depression, and anxiety - after the births of a first and second baby. Its longitudinal design distinguishes it from previous research by examining a range of morbidities over two childbirths and stratifying results based on women's prior health history.Methods and findingsA prospective cohort of 3,047 nulliparous women completed surveys in early pregnancy and at 3, 6, 9, and 12-months postpartum after their first birth. Of these, 254 women who had a second baby and consented to follow-up completed additional surveys at 6-months and/or 12-months postpartum after their second baby's birth. Prevalence of each morbidity was reported at each time point, 3, 6, 9, 12-months after the first birth; and 6 and/or 12-months after the second birth. Persistence was defined as reporting the morbidity at 6 and/or 12-months after the first birth and again at 6 and/or 12-months after the second birth. Among 91 women reporting urinary incontinence after their first baby's birth, persistence was 100% (n = 5/5) for those who experienced it in the 12-months prior to their first pregnancy and 39.5% (n = 34/86) for those without (RR 2.53, 95% CI (1.95-3.29)). For pelvic girdle pain (n = 86), persistence was 98.1% (n = 52/53) who experienced it in the 12-months prior to their first pregnancy and 97.0% (n = 32/33) for those without (RR 1.01, 95% CI (0.94-1.09)). Sexual health problems persisted in 100% (n = 76/76) of those who experienced it in the 12-months prior to their first pregnancy versus 89.6% (n = 43/48) without (RR 1.12, 95% CI (1.02-1.23)). Depression persisted in 50% (n = 4/8) of those who experienced it in the 12 months prior to their first pregnancy versus 19.0% (n = 15/79) without (RR 2.63, 95% CI (1.15-6.03)); and anxiety persisted in 100% (n = 1/1) of those who experienced it in the 12-months prior to their first pregnancy versus 13.5% (n = 12/89) without anxiety (RR 7.42, 95% CI (4.38-12.55)).ConclusionsThese findings underscore the need for early identification and intervention to mitigate long-term health issues, highlighting the importance of targeted pregnancy and postpartum care for women with prior maternal morbidities.

ABSTRACTBackgroundCardiovascular diseases (CVD) are the leading cause of mortality and disability globally. An ongoing reform of the Irish healthcare system is underway with a focus on preventing avoidable CVD and lessening its burden to society. However, the high rates of healthcare service use attributable to CVD and the associated costs have not been adequately quantified in Ireland. We examined the difference in health service utilisation and costs for populations with and without CVD in Ireland for the period preceding the reform.MethodsSecondary data analysis of the first wave (2009-2011) of The Irish Longitudinal Study on Ageing (TILDA), a nationally representative study of community-dwelling adults in Ireland aged 50+. CVD was defined as having a self-reported doctor’s diagnosis of myocardial infarction, angina, heart failure, stroke, atrial fibrillation or transient ischaemic attack. Participants self-reported the utilization of healthcare services over the 12 months preceding the interview. Negative binomial regression with average marginal effects (AME) was used to model the effect of CVD on healthcare service utilisation. We estimated the incremental number of general practitioner (GP) and outpatient department (OPD) visits, accident and emergency department (A&E) attendances and hospitalisations in population with CVD relative to population without CVD and calculated the associated costs. Analyses were adjusted for socio-demographic confounders and other chronic conditions. Using census 2022 data on the total number of people aged 50+ living in Ireland, we estimated the total incremental costs attributable to CVD at the population level.ResultsAmong 8113 participants, the prevalence of CVD was 18.2% (95% confidence interval (CI): 17.3, 19.0). Participants with CVD reported higher utilization of all healthcare services. In adjusted models, having CVD was associated with incremental 1.19 (95% CI: 0.99, 1.39) GP and 0.79 (95% CI: 0.65, 0.93) OPD visits over the past year. There were twice as many incremental hospitalisations in males with CVD compared to females with CVD (AME: 0.20 (95% CI: 0.16, 0.23) for males vs AME: 0.10 (95% CI: 0.07, 0.14) for females), but no difference was observed with respect to the incremental use of other healthcare services by gender or age groups. The incremental cost of healthcare service use in this population relative to the population without CVD were an estimated €352.2 million (95% CI: €272.8, €431.7), 93% of which was due to use of secondary care services.ConclusionThere are substantial use of healthcare services and costs associated with CVD in Ireland, with hospital admissions being the biggest contributor to costs. While a shift towards the management of uncomplicated CVD cases in primary care is currently being implemented in Ireland, continued efforts aimed at CVD primary prevention and management are required to contain healthcare service costs. Further research on gender-disparities in the use of healthcare services attributable to CVD is warranted.

Background Antimicrobial stewardship programmes (ASP) are essential in promoting responsible antimicrobial use, reducing antimicrobial resistance (AMR) and health care-associated infections. In 2009 the Strategy for the Control of Antimicrobial Resistance in Ireland (SARI), Hospital Antimicrobial Stewardship Working Group published guidance on antimicrobial stewardship (AMS) in hospitals. This paper presents a protocol for a scoping review which aims to examine the current literature to evaluate progress related to the implementation of the SARI (2009) guidance on antimicrobial stewardship in hospitals in Ireland. Methods This scoping review will be conducted in line with the five-stage methodological framework by Arksey & O’Mally 2005. We will search the following databases (PubMed, CINAHL, Embase, Web of Science) and targeted websites for articles and reports for possible inclusion in our review. Studies pertaining to AMS undertaken or related to the Republic of Ireland from January 2010 until December 2021 will be included. We will include all study designs. We will map all selected publications to the recommendations of the SARI (2009) guidance document. The protocol follows the guidance of Peters et al., 2022. Two reviewers will independently screen studies and reports to assess eligibility with any discrepancies resolved by consensus discussion with a third reviewer. Results These will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR)and this checklist will be included when the scoping review is published. Conclusion This scoping review will map studies and reports to evaluate AMS in relation to national guidelines without restriction on study design or outcomes in the Republic of Ireland. This information has the potential to provide a valuable resource for the implementation of future AMS research and interventions.

Background: As part of Ireland’s response to the COVID-19 pandemic, travellers to Ireland were required to restrict movements on arrival. Worldwide compliance with measures such as quarantine and testing vary and are influenced by factors including an individual’s knowledge of trust in, and attitudes towards these measures. The aim of this study was to explore student experiences of restricted movements after entering Ireland from abroad and to assess the acceptability and feasibility of self-administered SARS-CoV-2 tests. Methods: The Incoming Student Wellbeing and the Acceptability and Benefits of serial COVID-19 testing (ISWAB) study recruited university students who travelled into Ireland and were required by national public health guidance to restrict their movements. As part of the study, students were provided with SARS-CoV-2 self-test kits. This qualitative study explored the students’ attitudes to self-testing and restricted movements using focus groups and interviews. Ethical approval was obtained. Interviews were conducted until data saturation was reached. Interview transcripts were thematically analysed. Results: Of 41 ISWAB participants, 32 agreed to participate in a follow-up qualitative study providing written consent. One focus group, two group interviews and three individual interviews were conducted in August 2021, on Microsoft Teams. Among the 11 (seven male, four female) students interviewed, self-testing was considered feasible and acceptable. Facilitators of adherence to restrictions included: support with grocery shopping and study periods coinciding with quarantine. Barriers to well-being included: living alone, being an individual who leads a social lifestyle, and the number of days of quarantine completed. Conclusions: This qualitative study demonstrated high levels of compliance with restriction of movement guidelines and self-testing, with limited impact on general well-being. Self-testing for SARS-CoV-2 was found to be practical and achievable for at home use by participants in this study. The findings of this study may inform future self-testing initiatives.

Background: As part of Ireland’s response to the COVID-19 pandemic, travellers to Ireland were required to restrict movements on arrival. Worldwide compliance with measures such as quarantine and testing vary and are influenced by factors including an individual’s knowledge of trust in, and attitudes towards these measures. The aim of this study was to explore student experiences of restricted movements after entering Ireland from abroad and to assess the acceptability and feasibility of self-administered SARS-CoV-2 tests. Methods: The Incoming Student Wellbeing and the Acceptability and

Objectives To explore trends in pharmaceutical expenditure on diabetes between 2011 and 2015, describing trends in expenditure on blood glucose-lowering medications and estimating the effect of cost-containment measures implemented during this time. Design Repeated cross-sectional study of national pharmacy claims data in Ireland. Participants Patients’ dispensed items used in the treatment or management of diabetes. Primary and secondary outcomes Total expenditure associated with diabetes was calculated by extracting data on all diabetes-related items dispensed to eligible patients. Costs were categorised into two groups. Diabetes-specific items include items used directly in diabetes treatment (WHO-Anatomical Therapeutic Chemical (ATC): A10, V07, V04) and diabetes-related include all other condition-related items (WHO-ATC: B01, C, H04, N03, N06). The impacts of two specific cost-containment measures, co-payments and reference pricing, were assessed using segmented linear regression analyses of interrupted time-series. Results Total expenditure varied over the study period, peaking at €216 994 441 in 2012. Expenditure on diabetes-specific items increased steadily by 18% reaching €153 621 477 in 2015, with blood glucose-lowering medications accounting for 73% of this increase. During the same period, expenditure on diabetes-related items decreased by 32% to €50 835 856. The introduction of reference pricing for atorvastatin in November 2013 resulted in immediate costs savings of €2.4 million per yearly quarter (level-change p<0.001). Conclusions The increasing expenditure on blood glucose-lowering medications negates the effect of recent cost-containment measures, presenting a significant challenge for the provision of diabetes care. Innovative policies are required to ensure high-quality diabetes care can be provided at an equitable, affordable and sustainable rate.

Background:Healthcare-associated infection compromises patient safety. Compliance with hand hygiene (HH) guidelines has been shown to be an effective method of reducing infection; however, it remains suboptimal and poorer among doctors compared to other healthcare workers. The aim of this study is to determine the relationship between an individualised observational hand hygiene audit (OHHA) and feedback intervention with observed HH compliance.Methods:We used a retrospective interrupted time series design using OHHA data from a five-year period, 2011–2015. OHHA indicated poorer HH compliance among doctors than other healthcare workers in a 345-bed acute private hospital. An increase in orthopaedic surgical site infection prompted additional auditing of the orthopaedic unit further identifying substandard HH compliance among orthopaedic surgeons. In addition to ongoing HH interventions, an individualised hand hygiene audit and feedback intervention focusing on consultant orthopaedic surgeons was implemented. Observed HH compliance improved. The intervention was then extended to include all consultant doctors at the study site. Audit was implemented by trained clinical nurse managers during clinical rounds. Written audit feedback was provided by the infection prevention and control team.Results:HH compliance increased significantly among both orthopaedic surgeons and other consultant doctors, P < 0.05.Conclusion:An individualised audit and feedback intervention was effective in improving compliance. Incorporation of OHHA with individualised feedback into routine daily practice needs to be considered as a quality improvement opportunity. This study has the potential to inform other audit and feedback interventions to maximise effectiveness and ensure implementation.

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BACKGROUND:Implementation science experts recommend that theory-based strategies, developed in collaboration with healthcare professionals, have greater chance of success.AIM:This study evaluated the impact of a theory-based strategy for optimising the use of serum immunoglobulin testing in primary care.DESIGN AND SETTING:An interrupted time series with segmented regression analysis in the Cork-Kerry region, Ireland. An intervention was devised comprising a guideline and educational messages-based strategy targeting previously identified GP concerns relevant to testing for serum immunoglobulins.METHOD:Interrupted time series with segmented regression analysis was conducted to evaluate the intervention, using routine laboratory data from January 2012 to October 2016. Data were organised into fortnightly segments (96 time points pre-intervention and 26 post-intervention) and analysed using incidence rate ratios with their corresponding 95% confidence intervals.RESULTS:In the most parsimonious model, the change in trend before and after the introduction of the intervention was statistically significant. In the 1-year period following the implementation of the strategy, test orders were falling at a rate of 0.42% per fortnight (P<0.001), with an absolute reduction of 0.59% per fortnight, corresponding to a reduction of 14.5% over the 12-month study period.CONCLUSION:The authors' tailored guideline combined with educational messages reduced serum immunoglobulin test ordering in primary care over a 1-year period. Given the rarity of the conditions for which the test is utilised and the fact that the researchers had only population-level data, further investigation is required to examine the clinical implications of this change in test-ordering patterns.

Objectives To understand the impact of emergency department (ED) reconfiguration on the number of patients waiting for hospital beds on trolleys in the remaining EDs in four geographical regions in Ireland using time-series analysis. Setting EDs in four Irish regions; the West, North-East, South and Mid-West from 2005 to 2015. Participants All patients counted as waiting on trolleys in an ED for a hospital bed in the study hospitals from 2005 to 2015. Intervention The system intervention was the reconfiguration of ED services, as determined by the Department of Health and Health Service Executive. The timing of these interventions varied depending on the hospital and region in question. Results Three of the four regions studied experienced a significant change in ED trolley numbers in the 12-month post-ED reconfiguration. The trend ratio before and after the intervention for these regions was as follows: North-East incidence rate ratio (IRR) 2.85 (95% CI 2.04 to 3.99, p<0.001), South IRR 0.68 (95% CI 0.51 to 0.89, p=0.006) and the Mid-West IRR 0.03 (95% 1.03 to 2.03, p=0.03). Two of these regions, the South and the Mid-West, displayed a convergence between the observed and expected trolley numbers in the 12-month post-reconfiguration. The North-East showed a much steeper increase, one that extended beyond the 12-month period post-ED reconfiguration. Conclusions Findings suggest that the impacts of ED reconfiguration on regional level ED trolley trends were either non-significant or caused a short-term shock which converged on the pre-reconfiguration trend over the following 12 months. However, the North-East is identified as an exception due to increased pressures in one regional hospital, which caused a change in trend beyond the 12-month post reconfiguration.

Purpose: We simulate population shifts in the distribution of sugar-sweetened beverage (SSB) consumption and address previous methodological limitations to provide valid and reliable estimates of the potential impact of public health interventions on type II diabetes incidence in Ireland. Methods: A comparative risk assessment was conducted, using distribution shift calculations to estimate potential impact fractions (PIFs) for percentage reductions in SSB consumption. Data from the Survey of Lifestyle, Attitudes and Nutrition was analyzed. Individual risk of developing type H diabetes was estimated using a risk prediction algorithm. PIFs were calculated using risk estimates, changes in SSB consumption, and an appropriately specified relative risk. The impact of a 20% levy on SSB5 was explored. Monte-Carlo simulation with 150,000 iterations estimated uncertainty intervals (UIs). PIFs were applied to 2016 census data, estimating the absolute incident cases that may potentially be avoided through reduced SSB consumption. Results: Of the 7272 Survey of Lifestyle, Attitudes and Nutrition participants, 53.3% consumed SSBs. The 10-year rate of type II diabetes was estimated at 4.3% (95% confidence interval: 4.2%, 4.4%). Simulating a 100% reduction in SSB consumption, the population attributable fraction was 1.8% (95%UI: 0.1%, 3.3%). Population shifts in consumption after a 20% levy results in a PIF of 0.37% (95%UI: 0.02%, 0.7%). We estimate 135,850 incident type II diabetes cases over a 10-year period. Of these, 2446 (95% UI: 136, 4483) cases may be attributable to SSB consumption. Conclusions: Overcoming previous methodological limitations, unbiased estimates demonstrate that a population shift in SSB consumption can potentially play a role in the primary prevention of type II diabetes. (C) 2019 Elsevier Inc. All rights reserved.

Objectives Parents of children with cystic fibrosis (CF) are at risk of depression and anxiety symptoms, yet, they are an under-researched group. This national cross-sectional study investigated the prevalence of anxiety and depression in parents of children with CF, and examined the associations between these symptoms and their child's physical health and quality of life. Methods A total of 203 parents of children attending nine paediatric CF clinics across Ireland filled out a questionnaire pack containing: a background information questionnaire; the Hospital Anxiety and Depression Scale (HADS); the Centre for Epidemiological Studies Depression Scale (CES-D); and, the Cystic Fibrosis Quality of Life Scale-Revised Edition (CFQ-R). Results According to the HADS, 38% of parents had elevated anxiety and 12% had elevated depression symptoms. Just over a fifth (20.7%) had elevated depression symptoms on the CES-D. Mothers had significantly higher levels of anxiety than fathers. There were statistically significant negative linear correlations between parents' HADS anxiety and depression scores and their child's pulmonary function, and between parents' HADS anxiety and depression scores and their child's quality of life. Conclusions These results indicate that parents are at risk of depression and anxiety symptoms, and that these are associated with the physical health and quality of life of their child with CF. The findings support the need for parents to have mental health screening annually in CF services, as recommended in international guidelines. There is also a need to integrate a family-centred approach into CF services with appropriate supports and mental health referral pathways for parents.

Childhood obesity is an important public health issue. We aimed to systematically review studies that used group-based trajectory modelling approaches to investigate body mass index (BMI) trajectories in early childhood, explore associated determinants, and the association with body composition outcomes. Five databases were searched systematically for studies using group-based trajectory modelling approaches to track BMI trajectories from birth. Fourteen studies using latent class growth analysis or growth mixture modelling to track BMI trajectories were identified. Three or four trajectories were identified in most studies. High maternal pre-pregnancy BMI was the most frequently identified risk factor for membership of a rapid gain trajectory. Significant associations between rapid weight gain and stable high trajectories and body measures at follow-up were identified by several studies. Relatively similar trajectories were identified across studies. Trajectories characterized by rapid weight gain were associated with several predictors, as well as body measures at follow-up, however not with great consistency. Similar associations with body measure outcomes were found for stable high and rapid gain trajectories, suggesting that long-term outcomes do not differ greatly between children with consistently high BMI and children with rapid increases in BMI. As the shape and timing of the trajectories differed between studies, it is difficult to draw conclusions.

To estimate the 10-year risk of fatal cardiovascular disease (CVD) in the 40 to 69 year old general population in Germany stratified by sex and to analyze differences between socio-economic status (SES), region and community size in individuals without CVD. The analysis is based on the newly recalibrated SCORE Deutschland risk charts and considered other comorbidities for the classification of the high CVD risk group according to the guidelines of the European Society of Cardiology.In 3,498 participants (40-69 years) from the German Health Examination Survey for Adults 2008-2011 (DEGS1) without a history of CVD (myocardial infarction, coronary heart disease, heart failure, stroke) we estimated the proportion with a low (SCORE <1%), moderate (SCORE 1-<5%) and high 10-year CVD mortality risk (SCORE ≥5% or diabetes, renal insufficiency, SBP/DPB ≥180/110 mmHg or cholesterol >8 mmol/l). The prevalence of low, moderate and high risk was 42.8%, 38.5% and 18.8% in men and 73.7%, 18.1% and 8.2% in women. The prevalence of high risk was significantly lower in women with a high compared to a low SES (3.3% vs. 11.2%) and in communities with ≥100.000 inhabitants compared to <20.000 inhabitants (5.4% vs.10.9%). There were no significant associations between predicted CVD mortality risk and SES or community size in men and regions in men and women. Among the high risk group, 58.2% of men and 9.8% of women had SCORE ≥5%, leaving the majority of women (60.1%) classified as high risks due to diabetes and SCORE <5%.Our results suggest the persistence of socioeconomic disparities in predicted cardiovascular mortality in women and support the need of large-scale prevention efforts beyond individual lifestyle modification or treatment. Furthermore, the importance of additional comorbidities for the high risk group classification is highlighted.

BACKGROUND: People with cystic fibrosis face substantial physical, psychological, and social challenges as they move into adolescence and adulthood, which are likely to impact on their health-related quality of life. This study sought to examine the relative importance of physical and mental health variables associated with health-related quality of life in this group. METHODS: Adults and adolescents (N = 174; ≥14 y old) from across 11 adult or pediatric cystic fibrosis clinics in the Republic of Ireland, completed a background questionnaire that contained self-reported physical health variables, pulmonary function (ie, FEV1%) and body mass index. Questionnaire packs also contained the Hospital Anxiety and Depression Scale (HADS) and the Cystic Fibrosis Questionnaire-Revised, which has been specifically designed to assess health-related quality of life in patients with cystic fibrosis. RESULTS: HADS depression and/or anxiety scores were negatively associated with 11 of the 12 Cystic Fibrosis Questionnaire-Revised domain scores. FEV1% was positively associated with 8 domains when controlling for HADS anxiety but only 4 domains when controlling for HADS depression. HADS anxiety and depression scores demonstrated larger effect sizes and explained a greater proportion of the variance than pulmonary function in 8 of the 12 Cystic Fibrosis Questionnaire-Revised domain scores. CONCLUSIONS: Mental health variables, depression and anxiety, were strongly associated with health-related quality of life in subjects with cystic fibrosis and demonstrated greater effect sizes and explained a higher proportion of the variance overall than the physical health indicators, FEV1% and body mass index, which highlighted the importance of screening for, and treating, depression and anxiety symptoms.

BackgroundMany emergency admissions are deemed to be potentially avoidable in a well-performing health system.ObjectiveTo measure the impact of population and health system factors on county-level variation in potentially avoidable emergency admissions in Ireland over the period 2014–2016.MethodsAdmissions data were used to calculate 2014–2016 age-adjusted emergency admission rates for selected conditions by county of residence. Negative binomial regression was used to identify which a priori factors were significantly associated with emergency admissions for these conditions and whether these factors were also associated with total/other emergency admissions. Standardised incidence rate ratios (IRRs) associated with a 1 SD change in risk factors were reported.ResultsNationally, potentially avoidable emergency admissions for the period 2014–2016 (266 395) accounted for 22% of all emergency admissions. Of the population factors, a 1 SD change in the county-level unemployment rate was associated with a 24% higher rate of potentially avoidable emergency admissions (IRR: 1.24; 95% CI 1.04 to 1.41). Significant health system factors included emergency admissions with length of stay equal to 1 day (IRR: 1.20; 95% CI 1.11 to 1.30) and private health insurance coverage (IRR: 0.92; 95% CI 0.89 to 0.96). The full model accounted for 50% of unexplained variation in potentially avoidable emergency admissions in each county. Similar results were found across total/other emergency admissions.ConclusionThe results suggest potentially avoidable emergency admissions and total/other emergency admissions are primarily driven by socioeconomic conditions, hospital admission policy and private health insurance coverage. The distinction between potentially avoidable and all other emergency admissions may not be as useful as previously believed when attempting to identify the causes of regional variation in emergency admission rates.

Background: A number of observational and intervention studies have investigated the relationship between physical activity and mental health; however, few studies evaluate the association between physical activity and depression in a population sample by using minute by minute data over one week from accelerometer. The purpose of this study is to explore the different physical activity patterns and the relationships between these patterns and depression symptoms based on minute by minute accelerometer assessed data. Methods: Data from the Mitchelstown cohort study were used. Taking consider of non-wear time and background information missing, 375 participants were included in this study. They all completed questionnaires and wore accelerometers for seven consecutive days. Questionnaire provided background information and Center for Epidemiological Studies Depression Scale (CES-D) score measurements, accelerometer output provided minute by minute physical activity data. Bivariate smoothing method was used to explore the interaction effect of depression score and other continuous background covariates to CES-D, multiple regression analysis was used to get the relationship between CES-D score and physical activity level. Results: Within Day Physical activity profile analysis showed that after 11:00 pm and before around 7:00 am, participants in moderate and moderate to severe depression groups are much active than the other two groups, but during the other day time, moderate to severe group is less active than the others. There were strong contrasts between depression groups regarding time-of day of peak per minute activity. Daily activity gets progressively lower for moderate to severe group since between 7 am and 8 am, and the cumulative activity is the lowest among these four groups. Bivariate relationship analysis also showed there were difference between male and female, different depression groups participants.