Objectives: To determine whether providing physical therapy (PT) services in the emergency department (ED) improves outcomes for older adults who fall. Design: We used Medicare claims data to examine differences in recurrent fall‐related ED revisit rates of older adults who presented to the ED for a ground‐level fall and whether they received PT services in the ED. Our logistic regression model controlled for age, sex, Medicaid eligibility, acute injury, and certain known chronic comorbidities associated with risk of falling. Setting: We analyzed national 2012–13 Medicare claims data for individuals aged 65 and older. Participants: This was a claims‐based analysis. We defined an index visit as any ED claim that included an International Classification of Diseases, Ninth Revision, Clinical Modification E‐Code indicating a ground‐level fall. Visits resulting in admission were excluded, as were claims associated with an individual who died during follow‐up; 17,975 of the 560,277 claims for eligible outpatient index visits included revenue center codes for PT services. Measurements: We calculated the proportion of index visits associated with a fall‐related ED revisit within 30 and 60 days and assessed differences in these proportions between individuals who did and did not receive PT services in the ED. Results: Receiving PT services in the ED during an index visit for a ground‐level fall was associated with a significantly lower likelihood of a fall‐related ED revisit within 30 days (odds ratio (OR)=0.655, p<.001) and 60 days (OR=0.684, p<.001). Conclusion: Expanding PT services in the ED may reduce future fall‐related ED use of older adults. Additional analyses could assess characteristics of individuals receiving PT in the ED and follow‐up PT use after discharge. J Am Geriatr Soc 66:2205–2212, 2018.

The use of microbial larvicides, a form of larval source management, is a less commonly used malaria control intervention that nonetheless has significant potential as a component of an integrated vector management strategy. We evaluated community acceptability of larviciding in a rural district in east-central Tanzania using data from 962 household surveys, 12 focus group discussions, and 24 in-depth interviews. Most survey respondents trusted in the safety (73.1%) and efficacy of larviciding, both with regards to mosquito control (92.3%) and to reduce malaria infection risk (91.9%). Probing these perceptions using a Likert scale provides a more detailed picture. Focus group participants and key informants were also receptive to larviciding, but stressed the importance of sensitization before its implementation. Overall, 73.4% of survey respondents expressed a willingness to make a nominal household contribution to a larviciding program, a proportion which decreased as the proposed contribution increased. The lower-bound mean willingness to pay is estimated at 2,934 Tanzanian Shillings (approximately US$1.76) per three month period. We present a multivariate probit regression analysis examining factors associated with willingness to pay. Overall, our findings point to a receptive environment in a rural setting in Tanzania for the use of microbial larvicides in malaria control.

Background Delirium is common among seniors discharged from the emergency department (ED) and associated with increased risk of mortality. Prior research has addressed mortality associated with seniors discharged from the ED with delirium, however has generally relied on data from one or a small number of institutions and at single time points. Objectives Analyse mortality rates among seniors discharged from the ED with delirium up to 12 months at the national level. Design Retrospective cohort study. Setting Analysed data from the Centers for Medicare & Medicaid Services limited data sets for 2012–2013. Participants Medicare fee-for-service beneficiaries aged 65 years or older discharged from the ED. We focused on new incident cases of delirium, patients with any prior claims for delirium, hospice claims or end-stage renal disease were excluded. Sample size included 26 245 delirium claims, and a randomly selected sample of 262 450 controls. Outcome measures Mortality within 12 months after discharge from the ED, excluding patients transferred or admitted as inpatients. Results Among all beneficiaries, 46 508 (16.1%) died within 12 months, of which 39 404 (15.0%) were in the non-delirium (ie, control group) and 7104 (27.1%) were in the delirium cohort, respectively. Mortality was strongest at 30 days with an adjusted HR of 4.82 (95% CI 4.60 to 5.04). Over time, delirium was consistently associated with increased mortality risk compared with controls up to 12 months (HR 2.07; 95% CI 2.01 to 2.13). Covariates that affected mortality included older age, comorbidity and presence of dementia. Conclusions Our results demonstrate delirium is a significant marker of mortality among seniors in the ED, and mortality risk is most salient in the first 3 months following an ED visit. Given the significant clinical and financial implications, there is a need to increase delirium screening and management within the ED to help identify and treat this potentially fatal condition.

Objective: Microbial larviciding may be a potential supplement to conventional malaria vector control measures, but scant information on its relative implementation costs and effectiveness, especially in rural areas, is an impediment to expanding its uptake. We perform a costing analysis of a seasonal microbial larviciding programme in rural Tanzania.Methods: We evaluated the financial and economic costs from the perspective of the public provider of a 3‐month, community‐based larviciding intervention implemented in twelve villages in the Mvomero District of Tanzania in 2012–2013. Cost data were collected from financial reports and invoices and through discussion with programme administrators. Sensitivity analysis explored the robustness of our results to varying key parameters.Results: Over the 2‐year study period, approximately 6873 breeding sites were treated with larvicide. The average annual economic costs of the larviciding intervention in rural Tanzania are estimated at 2014US$ 1.44 per person protected per year (pppy),US$ 6.18 per household andUS$ 4481.88 per village, with the larvicide and staffing accounting for 14% and 58% of total costs, respectively.Conclusions: We found the costs pppy of implementing a seasonal larviciding programme in rural Tanzania to be comparable to the costs of other larviciding programmes in urban Tanzania and rural Kenya. Further research should evaluate the cost‐effectiveness of larviciding relative to, and in combination with, other vector control strategies in rural settings.

Policy decisions for malaria control are often difficult to make as decision-makers have to carefully consider an array of options and respond to the needs of a large number of stakeholders. This study assessed the factors and specific objectives that influence malaria control policy decisions, as a crucial first step towards developing an inclusive malaria decision analysis support tool (MDAST). Country-specific stakeholder engagement activities using structured questionnaires were carried out in Kenya, Uganda and Tanzania. The survey respondents were drawn from a non-random purposeful sample of stakeholders, targeting individuals in ministries and non-governmental organizations whose policy decisions and actions are likely to have an impact on the status of malaria. Summary statistics across the three countries are presented in aggregate. Important findings aggregated across countries included a belief that donor preferences and agendas were exerting too much influence on malaria policies in the countries. Respondents on average also thought that some relevant objectives such as engaging members of parliament by the agency responsible for malaria control in a particular country were not being given enough consideration in malaria decision-making. Factors found to influence decisions regarding specific malaria control strategies included donor agendas, costs, effectiveness of interventions, health and environmental impacts, compliance and/acceptance, financial sustainability, and vector resistance to insecticides. Malaria control decision-makers in Kenya, Uganda and Tanzania take into account health and environmental impacts as well as cost implications of different intervention strategies. Further engagement of government legislators and other policy makers is needed in order to increase funding from domestic sources, reduce donor dependence, sustain interventions and consolidate current gains in malaria.

Objectives Overdiagnosis of urinary tract infections (UTI) among people living with dementia is a nationally recognized problem associated with morbidity from antibiotics as well as multidrug‐resistant bacteria. However, whether this problem also exists in the emergency department (ED) is currently unknown. Methods To examine the association between dementia and UTI diagnosis in the ED we performed a retrospective analysis of Medicare beneficiaries older than 65 years old who presented to an ED in 2016. A diagnosis of UTI was present in 58,580 beneficiaries, and 321,479 beneficiaries without a diagnosis of UTI served as the comparison group. Our logistic regression model controlled for dementia, older age, female sex, Medicaid status, skilled nursing facility residence, history of prostate cancer, recent urinary catheter use, recurrent UTI, and multiple comorbidities. Results In our model, people living with dementia had over twice the odds (odds ratio = 2.27, 95% confidence interval = 2.21, 2.33) of being diagnosed with a UTI in the ED compared to those without dementia despite their lower prevalence of symptoms and signs localizing to the genitourinary tract (3.8% vs 8.9%, respectively). Conclusion This is the first study from a national database that examines the association of dementia with UTI diagnosis among older adults who visit the ED. Our study could not establish whether the UTI diagnoses in the ED were accurate but does imply a disproportionate burden of UTI diagnoses in people living with dementia despite their lower prevalence of clinical criterion. Antimicrobial stewardship in the ED should address the complexity of UTI diagnosis in dementia.