Abstract
Background:
Stimulants are becoming increasingly prevalent among overdoses, yet little is understood about how stimulant use impacts emergency department (ED) utilization.
Methods:
Using data from California’s Department of Healthcare Access and Information, we conducted a five-year trend analysis of stimulant-related ED visits from acute care hospitals in California from 2017 to 2021. For each year, we determined the stimulant-related ED visit rate per 100,000 ED visits for adults aged ≥18 utilizing ICD-10 diagnosis codes. We estimated the percent changes in overall stimulant-related visit rates during the study period and by subgroup, including by demographic characteristics, Charlson comorbidity index score (CCIS), and cardiovascular (CV) diagnoses. We used chi-squared analyses to examine changes in trends over time.
Results:
The rate of stimulant-related ED visits increased from 2064.4 per 100,000 ED visits in 2017 to 2586.1 per 100,000 ED visits in 2021, a 25.3 % increase (P < 0.001). By race/ethnicity, people identified as Native American/Alaska Natives had the highest ED visit rate in 2021 (4713.5 per 100,000 ED visits) and the largest increase of 60.8 % (P < 0.001). The proportion of stimulant-related ED visits with CV disease diagnoses increased from 13.8 % in 2017 to 18.0 % in 2021, a relative increase of 30.8 % (P < 0.001).
Conclusions:
Stimulant-related ED visits are increasing among adults in California, especially among non-white populations and those with higher comorbidity. This sharp rise highlights the critical need for targeted interventions and harm reduction strategies that consider the unique effects of stimulant use on ED rates and CV outcomes.
Keywords: Central nervous system stimulants, Cardiovascular diseases, Emergency medical services
1. Introduction
Nationally, substance use-related emergency department (ED) visits, where substance use is either the direct cause or a contributing reason for a visit, are increasing and pose a significant challenge to healthcare systems and public health [1–3]. Stimulant use is associated with increased mortality and morbidity, including psychiatric complications and exacerbation of chronic health conditions [4–6], which can lead to acute healthcare utilization. A previous study showed a rise in stimulant-related ED visits primarily driven by psychostimulants, with an absolute increase of 10.7 visits per 10,000 population between 2008 and 2018 [7]. Stimulant-related overdoses have also demonstrated a similar trend, with increases in both cocaine and psychostimulant-related overdoses [8]. In Florida, ED visits for stimulated-related overdoses continued to rise throughout the COVID-19 pandemic despite a decline in the number of all-cause ED visits [9]. Stimulant-related deaths have also risen since 2010, with the mortality rate for many stimulants doubling every four years between 2010 and 2017 [10]. These trends highlight the critical need for additional research to examine the impacts of stimulant use on healthcare systems and patient outcomes.
Stimulant use is strongly associated with acute and chronic cardiovascular (CV) complications. Stimulants such as cocaine and methamphetamines can result in electrical and structural remodeling of the heart, leading to conditions such as heart failure, hypertension, myocardial infarction (MI), acute coronary syndrome, arrhythmias, aortic dissection, and sudden cardiac death [6,11], and can exacerbate existing CV disease resulting in acute healthcare utilization. Stimulant-related ED visits are associated with an increasing rate of cardiopulmonary concerns [7]. Meanwhile, there have been sharp increases in stimulant-related heart failure hospitalizations in the United States (US), especially when compared to hospitalization trends from other cardiotoxic substances such as cocaine and alcohol [5,12,13]. Among all substances, stimulants were the fastest-growing category of combined substance use and CV mortality between 2010 and 2019 [14].
These studies highlight an increasing trend of stimulant-related acute healthcare visits in the US and associated CV outcomes, presenting an important public health issue that necessitates further study. Examining changes in stimulant-related ED visits could help policymakers allocate resources efficiently and improve patient outcomes [2]. The present study aims to identify key trends, demographic shifts, and CV disease diagnoses related to stimulant-related ED visits in California.
2. Methods
2.1. Study design and data source
We conducted a retrospective cohort study of adults aged ≥18 using visit-level data from 2017 through 2021 from all non-federal acute care hospitals in California using non-public data from the California Department of Healthcare Access and Information (HCAI) [15]. All licensed hospitals in California are subject to reporting utilization data in a standardized format to HCAI. Data presented in this study represent unique ED encounters from hospitals providing emergency medical services licensed by the State of California, available in two non-public HCAI research data sources: Patient Discharge Data (PDD) and Emergency Department and Ambulatory Surgery Data (EDAS). ED encounters resulting in admission to the same hospital are combined with the inpatient record and only reported in the PDD; all other ED encounters are reported in the EDAS. For this study, same-hospital ED admissions from the PDD were combined with ED encounters from the EDAS to construct a complete ED utilization database for analysis, including all non-duplicative encounters reported to HCAI.
2.2. Measures
Data consisted of hospital-collected demographic characteristics including age groups, race/ethnicity (Hispanic, Non-Hispanic White, non-Hispanic Black, non-Hispanic Asian/Pacific Islander, and non-Hispanic Other), sex (male and female), region, and payer/insurance (private, Medicare, Medi-Cal the state Medicaid program, self-pay). Using the primary diagnosis and up to 24 secondary diagnoses based on the International Classification of Disease (ICD) 10 Revision Clinical Modification diagnoses codes, we were able to classify stimulant-related ED visits based on the following categories: 1. abuse and unspecified use, 2. dependence, 3. poisoning, and 4. adverse effects (not including diagnoses in remission). Based on the literature, we selected substance use-related and CV diagnoses from ICD-10 diagnoses codes [5,12,13,14,16]. Supplemental Table 1 lists all ICD-10 codes used in this analysis. The Charlson comorbidity index score (CCIS) was calculated with the enhanced coding algorithm provided by Quan et al. for ICD-10 coding and stratified by the following scores: 0, 1, 2, and ≥ 3 [17].
2.3. Statistical analysis
For each year, we determined the number and rate per 100,000 ED visits for overall stimulant-related ED visits among adults aged ≥18 and estimated trends between 2017 and 2021. We stratified individual trends of stimulant-related ED visits per 100,000 ED visits by all the above measures. For substance use and CV diagnoses, we calculated the proportion of all stimulant-related ED visits with these diagnoses for each calendar year. Trends were calculated based on the five-year study period using chi-square to compare 2017 to 2021 for subgroups. Statistical significance was defined as a p-value <0.05. Statistical analyses were conducted with IBM SPSS Statistics (version 27.0; SPSS, Inc., Chicago, IL). Our Institutional Review Board approved this study.
3. Results
The number of stimulant-related ED visits significantly increased from 243,380 (2064.4 per 100,000 ED visits) in 2017 to 281,708 (2586.1 per 100,000 ED visits) in 2021, a 25.3% increase, P-value <0.001 (Table 1). There was, however, a drop from 2722.7 per 100,000 ED visits in 2020 to 2586.1 per 100,000 ED visits in 2021, but the overall number of stimulant-related ED visits increased from 277,465 to 281,708. Among age groups, individuals aged 75+ showed the sharpest increase, with an 84.1 % increase in ED visit rates per 100,000 (50.8 to 93.6), P < 0.001. Significant increases were observed in all racial/ethnic groups, with the Native American/Alaskan Native demographic showing an increase of 60.8 % and having the highest rate across all study years. Regarding comorbidity, patients with higher CCIS scores (1+) had higher rates and relative increases than patients with a score of 0. The highest rate in 2021 was observed in the San Diego/Imperial County region (3145.2 per 100,000 ED visits), while the largest relative increases were seen in the North Coast (50.8 % increase, P < 0.001) and the San Francisco Bay Area (30.6 % increase, P ≤0.001) regions.
Table 1.
Stimulant-related emergency department visit rates per 100,000 emergency department visits, 2017–2021.
| Emergency department visits per 100,000 | Change from 2017 to 2021 | |||||||
|---|---|---|---|---|---|---|---|---|
| 2017 | 2018 | 2019 | 2020 | 2021 | Absolute % Change | Relative % Change | p | |
| Overall | 2064.4 | 2202.5 | 2292.9 | 2722.7 | 2586.1 | 521.6 | 25.3 | <0.001 |
| Age (years) | ||||||||
| 18–24 | 1858.4 | 1865.0 | 1731.2 | 1920.9 | 1568.5 | −289.9 | −15.6 % | <0.001 |
| 25–34 | 2968.5 | 3176.7 | 3310.1 | 3959.3 | 3631.6 | 663.1 | 22.3 % | <0.001 |
| 35–44 | 3019.6 | 3331.8 | 3526.4 | 4224.9 | 4112.5 | 1092.9 | 36.2 % | <0.001 |
| 45–54 | 2994.7 | 3140.5 | 3283.4 | 3708.1 | 3584.4 | 589.7 | 19.7 % | <0.001 |
| 55–64 | 2124.0 | 2315.2 | 2553.6 | 2998.1 | 3028.5 | 904.5 | 42.6 % | < 0.001 |
| 65–74 | 599.5 | 704.2 | 785.9 | 976.0 | 1025.6 | 426.0 | 71.1 % | < 0.001 |
| 75+ | 50.8 | 52.2 | 59.8 | 79.2 | 93.6 | 42.8 | 84.1 % | <0.001 |
| Sex | ||||||||
| Male | 3138.8 | 3332.4 | 3472.5 | 4015.6 | 3883.2 | 744.4 | 23.7 % | <0.001 |
| Female | 1204.8 | 1290.1 | 1332.1 | 1570.2 | 1469.0 | 264.2 | 21.9 % | <0.001 |
| Race/Ethnicity | ||||||||
| Hispanic or Latino | 1756.1 | 1885.7 | 1964.8 | 2326.1 | 2237.8 | 481.8 | 27.4 % | <0.001 |
| Non-Hispanic White | 2213.7 | 2385.4 | 2457.1 | 2890.6 | 2726.3 | 512.6 | 23.2 % | <0.001 |
| Non-Hispanic Black | 3216.2 | 3395.4 | 3552.7 | 4350.6 | 4147.6 | 931.4 | 29.0 % | <0.001 |
| Non-Hispanic Asian/Pacific Islander | 679.1 | 738.1 | 803.5 | 978.3 | 906.8 | 227.7 | 33.5 % | <0.001 |
| Non-Hispanic Native American/Alaskan Native | 2931.5 | 3035.4 | 4498.5 | 4668.0 | 4713.5 | 1782.0 | 60.8 % | <0.001 |
| Non-Hispanic Other | 1783.0 | 1927.4 | 2209.1 | 2825.8 | 2703.4 | 920.4 | 51.6 % | <0.001 |
| Payer | ||||||||
| Private | 921.2 | 968.3 | 952.5 | 1028.0 | 935.0 | 13.8 | 1.5 % | 0.07 |
| Medicare | 979.0 | 1025.1 | 1074.4 | 1277.1 | 1239.8 | 260.8 | 26.6 % | <0.001 |
| Medi-Cal | 3534.5 | 3844.0 | 4074.3 | 4942.5 | 4666.3 | 1131.8 | 32.0 % | <0.001 |
| Self-Pay/No insurance | 2981.6 | 3133.7 | 3198.4 | 3691.3 | 3675.2 | 693.6 | 23.3 % | <0.001 |
| Charlson comorbidity index score [17] | ||||||||
| 0 | 1992.0 | 2133.2 | 2158.4 | 2606.5 | 2413.1 | 421.0 | 21.1 % | <0.001 |
| 1 | 2126.3 | 2270.3 | 2466.7 | 2890.4 | 2815.2 | 688.9 | 32.4 % | <0.001 |
| 2 | 2341.3 | 2470.1 | 2740.2 | 3123.6 | 3137.3 | 796.0 | 34.0 % | <0.001 |
| ≥3 | 2264.1 | 2362.5 | 2600.2 | 2912.9 | 2955.5 | 691.4 | 30.5 % | <0.001 |
| Region | ||||||||
| Central Coast | 1610.6 | 1698.1 | 1739.6 | 2144.8 | 2081.4 | 470.8 | 29.2 % | <0.001 |
| Inland Empire | 2061.2 | 2255.0 | 2449.2 | 2658.9 | 2561.9 | 500.7 | 24.3 % | <0.001 |
| Los Angeles County | 1947.7 | 2081.3 | 2148.5 | 2558.9 | 2494.9 | 547.2 | 28.1 % | <0.001 |
| North Coast | 1802.0 | 2007.3 | 2094.8 | 2857.1 | 2718.0 | 915.9 | 50.8 % | <0.001 |
| Northern San Joaquin Valley | 2061.9 | 2142.2 | 2239.7 | 2371.0 | 2240.0 | 178.1 | 8.6 % | < 0.001 |
| Orange County | 1678.3 | 1875.8 | 1845.7 | 2237.2 | 2119.2 | 440.9 | 26.3 % | <0.001 |
| San Diego/Imperial County | 2591.2 | 2619.1 | 2902.3 | 3452.9 | 3145.2 | 554.0 | 21.4% | < 0.001 |
| San Francisco Bay Area | 2141.7 | 2274.4 | 2365.7 | 3000.8 | 2796.7 | 654.9 | 30.6 % | <0.001 |
| Southern San Joaquin Valley | 2239.5 | 2395.4 | 2401.8 | 2828.8 | 2700.7 | 461.2 | 20.6 % | < 0.001 |
| Superior California | 2307.5 | 2474.5 | 2500.3 | 2919.2 | 2724.9 | 417.4 | 18.1 % | <0.001 |
The rate for cocaine-related diagnoses was 381.3 per 100,000 ED visits in 2021 (a 1.5 % decrease from 2017, P = 0.03), while the rate for other stimulant-related diagnoses was 2312.2 per 100,000 ED visits in 2021 (with a 30.1 % increase, P < 0.001) (Table 2). Caffeine, methylphenidate, and ecstasy combined made up <0.5 % of all other stimulant-related diagnoses. The proportion of stimulant-related ED visits with any additional substance use diagnosis was highest for cannabis (15.3 % in 2021) and alcohol (14.7 % in 2021), with both having a decline during the study period (Table 3). The proportion of stimulant-related ED visits with CV disease diagnoses increased from 13.8 % in 2017 to 18.0 % in 2021, an absolute increase of 4.2 % and a relative increase of 30.8 % (P < 0.001).
Table 2.
Trends in stimulant-related emergency department visits 2017–2021 per 100,000 emergency department by stimulant.
| Emergency department visits per 100,000 | Change from 2017 to 2021 | |||||||
|---|---|---|---|---|---|---|---|---|
| 2017 | 2018 | 2019 | 2020 | 2021 | Absolute % Change | Relative % Change | p | |
| Cocaine Related Diagnosis | ||||||||
| Cocaine Abuse and Unspecified Use | 356.0 | 360.8 | 347.9 | 378.5 | 345.3 | −10.8 | −3.0 % | <0.001 |
| Cocaine Dependence | 21.9 | 23.9 | 20.7 | 23.1 | 21.1 | −0.8 | −3.5 % | 0.22 |
| Cocaine Poisoning | 15.6 | 21.5 | 26.4 | 29.5 | 24.9 | 9.3 | 59.2 % | <0.001 |
| Cocaine Adverse Effects | 2.5 | 2.5 | 2.7 | 2.3 | 2.3 | −0.2 | −7.7 % | 0.36 |
| Any Cocaine-Related Diagnosis | 387.1 | 396.5 | 382.9 | 417.9 | 381.3 | −5.8 | −1.5% | 0.03 |
| Other Stimulant Related Diagnosis | ||||||||
| Other Stimulant Abuse / Unspecified Use | 1591.0 | 1701.4 | 1804.6 | 2167.9 | 2056.8 | 465.8 | 29.3 % | <0.001 |
| Other Stimulant Dependence | 140.6 | 155.9 | 153.2 | 190.2 | 192.9 | 52.3 | 37.2 % | <0.001 |
| Other Stimulant Poisoning | 64.1 | 77.7 | 88.1 | 110.4 | 106.1 | 42.1 | 65.7 % | <0.001 |
| Other Stimulant Adverse Effects | 19.9 | 21.7 | 22.2 | 24.0 | 21.7 | 1.8 | 9.0 % | 0.003 |
| Any Other Stimulant-Related Diagnosis | 1777.3 | 1909.4 | 2012.9 | 2421.7 | 2312.2 | 534.9 | 30.1 % | <0.001 |
Table 3.
Trends in stimulant-related emergency department visits 2017–2021 by proportion of substance-related diagnosis and cardiovascular conditions.
| Proportion of Stimulant-Related Emergency Department Visits | Change from 2017 to 2021 | |||||||
|---|---|---|---|---|---|---|---|---|
| 2017 | 2018 | 2019 | 2020 | 2021 | Absolute % Change | Relative % Change | p | |
| Substance-related Diagnosis | ||||||||
| Alcohol-related diagnosis | 15.6 % | 15.2 % | 15.1 % | 15.2 % | 14.7 % | −1.0 % | −6.1 % | < 0.001 |
| Cannabis-related diagnosis | 17.7 % | 17.2 % | 16.1 % | 15.9 % | 15.3 % | −2.4 % | −13.6 % | < 0.001 |
| Hallucinogen-related diagnosis | 0.7 % | 0.7 % | 0.8 % | 1.0 % | 1.1 % | 0.5 % | 70.3 % | < 0.001 |
| Inhalant-related diagnosis | <0.1 % | <0.1 % | <0.1 % | <0.1 % | <0.1 % | <0.1 % | −2.2 % | 0.88 |
| Opioid-related diagnosis | 9.2 % | 9.4 % | 9.7 % | 9.4 % | 9.0 % | −0.3 % | −2.8 % | 0.001 |
| Other/Poly substance diagnosis | 3.6 % | 3.5 % | 3.3 % | 3.5 % | 3.6 % | 0.0 % | −0.2 % | 0.90 |
| Sedative-related diagnosis | 1.2 % | 1.3 % | 1.1 % | 1.3 % | 1.3 % | 0.1 % | 5.3 % | 0.04 |
| Cardiovascular (CV) Conditions | ||||||||
| Aortic dissection | 0.1 % | 0.1 % | 0.1 % | 0.1 % | 0.1 % | 0.0 % | 25.2 % | 0.03 |
| Acute myocardial infarction | 1.3 % | 1.5 % | 1.7 % | 2.0 % | 2.3 % | 1.1 % | 86.1 % | < 0.001 |
| Acute ischemic heart disease | 0.1 % | 0.1 % | 0.1 % | 0.1 % | 0.1 % | 0.0 % | 8.3 % | 0.30 |
| Atrial fibrillation / flutter | 2.9 % | 3.2 % | 3.5 % | 3.6 % | 4.0 % | 1.1 % | 38.4 % | <0.001 |
| Cardiomyopathy | 4.6 % | 5.0 % | 5.3 % | 5.5 % | 5.9 % | 1.3 % | 28.0 % | < 0.001 |
| Heart Failure | 10.3 % | 11.0 % | 12.1 % | 12.5 % | 13.8 % | 3.5 % | 33.8 % | < 0.001 |
| Hypertensive crisis | 1.5 % | 1.7 % | 2.0 % | 2.0 % | 2.3 % | 0.8 % | 56.9 % | <0.001 |
| Hypertensive heart disease | 7.3 % | 8.6 % | 9.7 % | 9.8 % | 10.8 % | 3.4 % | 46.6 % | <0.001 |
| Myocarditis | <0.1 % | <0.1 % | <0.1 % | <0.1 % | <0.1 % | <0.1 % | 53.6 % | 0.14 |
| Paroxysmal tachycardia | 1.1 % | 1.2 % | 1.4% | 1.4% | 1.6 % | 0.4 % | 35.9 % | <0.001 |
| Pericarditis | 0.2 % | 0.2 % | 0.3 % | 0.3 % | 0.4 % | 0.1 % | 56.2 % | <0.001 |
| Valvular Heart Disease | 0.7 % | 0.8 % | 0.9 % | 1.0 % | 1.1 % | 0.5 % | 72.9 % | <0.001 |
| Ventricular Dysfunction | 2.8 % | 2.8 % | 3.0 % | 2.9 % | 3.1 % | 0.3 % | 10.8 % | <0.001 |
| Any of the above CV diagnoses | 13.8 % | 14.6 % | 16.0 % | 16.3 % | 18.0 % | 4.2 % | 30.8 % | <0.001 |
4. Discussion
In this large, population-based analysis of the state of California, our findings show an increase in stimulant-related ED visits from 2017 to 2021. Individuals identifying as Native American or Alaska Natives had both higher rates and larger increases in ED visits. This further highlights the need to recognize the unique risk factors, including historical trauma and structural racism, in addressing the harms related to stimulant use in this population with culturally integrative care [18,19]. Our study also reveals the significant impact of stimulant use on CV diagnoses. Similarly, individuals with higher comorbidity had higher ED visit rates and larger increases. This highlights the complex intersection between stimulant use and chronic diseases, especially its impact in exacerbating chronic diseases that could lead to acute healthcare utilization [5,12,13,14,16].
Our analysis shows that between 2019 and 2020, including the start of the COVID-19 pandemic, there was the sharpest increase in stimulant-related ED visits during the study period. These results are consistent with a previous study from Florida demonstrating a rise in stimulant overdoses despite a decrease in all-cause ED visits between 2019 and 2020 [9]. These findings also substantiate prior studies showing increased substance use patterns, including methamphetamines, during the start of the COVID-19 pandemic [20,21]. However, between 2020 and 2021, we observed a decrease in stimulant-related ED visit rate (although the overall numbers continued to increase). This may be because individuals may have been reluctant to seek medical care at hospitals due to fear of COVID-19 infection, leading to a temporary decline in overall ED visits in 2020 and, thus, a relatively sharp increase in stimulant-related ED rate for that year. However, the continued increase in the total number of stimulant-related ED visits within the study period warrants additional attention moving forward.
Regarding other substances, stimulant-related ED visits were most likely to present with additional alcohol or cannabis-related diagnoses, although these rates decreased during the study period. In 2021, our data showed a 9 % rate of concurrent opioid-related diagnosis during stimulant-related ED visits, which remained stable throughout the study period. This finding is surprising given the recent rise in incidence, overdoses, and deaths from concurrent use of stimulants and opioids [8,21–24]. This discrepancy may be due to regional variations affecting stimulant use patterns in California but is difficult to fully characterize without further investigation. Still, this emphasizes the need for comprehensive harm reduction strategies, including opioid overdose education, naloxone distribution programs, and the distribution of fentanyl test strips for all people who use stimulants [25,26]. Finally, prior studies have shown that while cocaine-related ED visits predominate in Southern regions of the US, other psychostimulant-related visits predominate in the western US [7]. Indeed, in our analysis, cocaine-related diagnoses represented only 14.7 % of stimulant-related ED visits in 2021 and decreased during our study period. In contrast, other stimulant-related diagnoses had a large relative increase of 30.1 % between 2017 and 2021, likely mainly representing methamphetamine-related ED visits. Continued monitoring and region-specific public health interventions are crucial for addressing the evolving landscape of substance use and its associated health outcomes, including acute healthcare utilization.
Our study also reveals the significant impact of stimulant use on CV diseases. Diagnosis of almost all CV conditions in our analysis of stimulant-related ED visits showed a significant increase over the study period. These findings are consistent with the known cardiotoxic properties of long-term stimulant use, including causing widespread CV dysfunction, including acute conditions such as arrhythmias and MI, to chronic conditions such as cardiomyopathy and pulmonary hypertension [6,11,27,28]. People who use stimulants who develop CV conditions are more likely to be younger and face worse prognoses compared to non-stimulant using patients, including a quickly rising mortality rate due to combined stimulant use and CV disease [5,14]. These findings point to a growing public health crisis and the need to not only address stimulant use but also incorporate CV health as a key component of substance use treatment and prevention. Furthermore, all patients with existing CV disease should be screened for stimulant use. Consideration should also be given to the expansion of evidence-based interventions for stimulant use disorder, such as contingency management [29].
This study has several important limitations. This study captured ED visits and not individuals. Further, there is heterogeneity in coding among clinicians, which is inherent in administrative data. This may also include a reporting bias, as clinicians may have been more aware of the possible role of stimulant use in ED presentations later in the study period. Also, relying on ED diagnosis codes may underestimate a patient’s medical conditions. Furthermore, given there are no specific ICD-10 codes for methamphetamine, we are unable to capture this fully, but it likely represents most visits. Additionally, due to limitations in ICD coding, we are unable to assess specific stimulants for most categories, and our analysis does include caffeine-related ED visits. However, known caffeine visits accounted for <0.5 % of all stimulant-related visits. Finally, our study is limited to the state of California and does not include Veterans Administration facilities, and results from this study are not generalizable nationally or to other states. However, this analysis of trends in the most populated state in the country can add insight into the trends of stimulant-related ED trends in the US.
5. Conclusion
The significant increase in stimulant use across California highlights the need for increased public health surveillance. Targeted campaigns must raise awareness among communities most affected by stimulant use and increase the public’s awareness of the dangers of stimulant use to reduce the harms associated with it, especially among people living with chronic diseases.
Supplementary Material
Funding statement
This study was funded by grants from the National Institute on Health: K23DA043651 (Han), R21DA058404 (Han), and T35AG026757 (Han, Chen, Lin). Work was also supported, in part, by UC San Diego Sam and Rose Stein Institute for Research on Aging.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ajem.2025.03.051.
Footnotes
Ethical approval and informed consent statements
This study was approved by the University of California San Diego’s Institutional Review Board.
Prior presentations
The results of this study were presented as an oral abstract at the 2023 AMERSA National Meeting in Washington, DC.
CRediT authorship contribution statement
Benjamin H. Han: Writing – review & editing, Writing – original draft, Supervision, Funding acquisition, Conceptualization. Jesse J. Brennan: Writing – review & editing, Formal analysis, Data curation. Wayne E. Kepner: Writing – review & editing. Steven Chen: Writing – review & editing. Sidney Lin: Writing – review & editing. Joseph A. Carley: Writing – review & editing. Julia Larson: Writing – review & editing. Edward M. Castillo: Project administration, Investigation, Formal analysis, Data curation.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Data availability
This data is available through the California Department of Healthcare Access and Information.
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Supplementary Materials
Data Availability Statement
This data is available through the California Department of Healthcare Access and Information.