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Cited by 3Indigenous Health, Education, and RightsHomelessness and Social IssuesIndigenous Health and Education

Health care utilisation changes among Alaska Native adults after participation in an indigenous community programme to address adverse life experiences: a propensity score-matched analysis

Open access
Ray, Lily, Outten, Bobbi, Gottlieb, Katherine·2020·International Journal of Circumpolar Health
DOI 10.1080/22423982.2019.1705048PMC PMC6968385
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Abstract

The aim of this study was to investigate whether participation in Family Wellness Warriors Initiative (FWWI), an Alaska Native program that addresses adverse life experiences, is associated with changes in health care utilisation. The study method was a propensity score-matched cohort analysis using retrospective electronic health record data from Southcentral Foundation, a tribal health care system, from 2012 to 2017. Ninety p\articipants in FWWI trainings were identified as the intervention cohort and were propensity matched with 90 people who participated in other emotional wellness-related interventions. The primary outcome was the number of total health system visits. Secondary outcomes included emergency department (ED) visits, substance-use visits and visits with somatisation potential. After adjustment for covariates, FWWI participants showed a 36% reduction in total system visits (incidence rate ratio 0.64, 95% CI 0.49-0.84) and a 70% reduction in substance use visits (incidence rate ratio 0.30, 95% CI 0.10-0.93) when compared to the control. FWWI participants showed a 40% reduction in ED visits (incidence rate ratio 0.60, 95%CI 0.35-1.02) when compared to the control that was borderline significant. No significant differences were found for visits with somatisation potential (incidence rate ratio 1.25, 95% CI 0.79-1.99).

AI snapshot

Written from the paper’s full text.

TL;DR

In a propensity score-matched cohort of Alaska Native adults at Southcentral Foundation, participation in the Family Wellness Warriors Initiative (FWWI) was associated with lower total health system visits and substance use visits compared with other emotional wellness interventions. Emergency department visits showed a borderline reduction, while visits with somatisation potential did not differ significantly.

Key findings

  • FWWI participants had 36% fewer total system visits (incidence rate ratio 0.64, 95% CI 0.49–0.84) and 70% fewer substance use visits (incidence rate ratio 0.30, 95% CI 0.10–0.93) than matched comparison participants.
  • Emergency department visits were 40% lower among FWWI participants (incidence rate ratio 0.60, 95% CI 0.35–1.02), described as borderline significant.
  • No significant difference was found for visits with somatisation potential; the abstract and Table 1 report an incidence rate ratio of 1.25 (95% CI 0.79–1.99), while the Results text reports 1.09 (95% CI 0.72–1.64).
  • FWWI participants reported an average of 4.5 adverse life experiences; matched comparison participants reported an average of 4.6.

Methods

  • Propensity score-matched cohort analysis using retrospective electronic health record data from Southcentral Foundation, a tribal health care system, from 2012 to 2017; 90 FWWI participants were matched 1:1 with 90 people who participated in non-FWWI emotional wellness-related interventions requiring a health care referral.
  • Primary outcome was total health system visits; secondary outcomes were substance use visits, emergency department visits, and visits with somatisation potential, measured in the 6-month post-period after a 3-month transition period.
  • MatchIt was used for optimal 1:1 propensity matching; balance was assessed with standardised differences; outcomes were modelled with GEE-based negative binomial regression with exchangeable correlation and empirical standard errors, double-adjusted for covariates including demographics, Charlson score, behavioural health diagnoses, prior utilisation, adverse experiences, and anxiety/trauma/depression scores.

Limitations

  • Stated: the observational design may leave unidentified confounders; the somatisation diagnosis taxonomy may have been overly broad and may not have captured changes in medically unexplained symptoms; the substance use taxonomy may have missed some substance use visits.
  • Stated: FWWI is community-based and attracts participants who may prefer a non-medical approach, while the comparison pool participated in emotional wellness programs requiring a health care referral; the full comparison pool differed from the treatment group, though matching selected similar members, and generalisability to all SCF behavioural health users is unclear.
  • Evident in the text: the somatisation-potential incidence rate ratio is reported inconsistently across the abstract/Table 1 and the Results text.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1080/22423982.2019.1705048

Cites

74 of 74 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

10 of 55 cited sources checked · 3 supported · 0 flagged · accuracy not yet measured

  • Interpretationcitation

    The mechanism through which FWWI reduces emergency department utilisation may be increased self-efficacy and reduced anxiety, depression, and trauma symptomology.

    “As internal FWWI evaluations show increased self-efficacy and reduced anxiety, depression and trauma symptomology among participants, this may be the mechanism through which the training reduces ED utilisation.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [19] Ray L, 2019, Journal of Health Disparities Research and Practice

      The Discussion reports FWWI evaluation results showing decreased depression, anxiety, and trauma symptomology among participants. The paper discusses building self-efficacy, but the reported quantitative increases concern self-esteem and other protective factors, not self-efficacy; it also does not link these changes to emergency department use. The proposed mechanism is therefore not established by this source. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
  • Premisecitation

    Most studies of trauma-focused psychotherapies have focused on behavioural health outcomes such as PTSD symptomology, depression or anxiety.

    “most studies of trauma-focused psychotherapies have focused on behavioural health outcomes such as PTSD symptomology, depression or anxiety [26,27].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [26] source
    • cites [27] source

      The Methods sections on Eligibility Criteria and Outcomes (page numbers unavailable) describe CBT-based studies of chronic pain in older adults and include depression and anxiety among the outcomes assessed. Our copy does not address trauma-focused psychotherapy, PTSD outcomes, or whether most studies in that field focus on behavioural health outcomes (searched: trauma-focused psychotherapy and posttraumatic stress disorder). (LLM, conf=0.76)

      Experimental — accuracy not yet measured
  • Premisecitation

    For those with trauma symptomology, reducing PTSD symptoms is more effective than health education in treating substance use.

    “Programs that do treat both have found that for those with trauma symptomology, reducing PTSD symptoms is more effective than health education in treating substance use [63].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [63] source

      The Discussion reports that PTSD-targeted treatment was more effective than the comparison treatment at improving substance use, but only among participants with heavy substance use at baseline who achieved significant PTSD reductions. The study involved women with co-occurring PTSD and substance use disorders, so the citing sentence overgeneralizes the finding to people with trauma symptoms broadly. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Findingown data

    After adjustment for covariates, FWWI participants had a 36% reduction in total system visits compared with matched comparison participants (incidence rate ratio 0.64, 95% CI 0.49-0.84).

    “After adjustment for covariates, FWWI participants showed a 36% reduction in total system visits (incidence rate ratio 0.64, 95% CI 0.49–0.84)”
    • Also stated in: § Results · plain
      “The post-training incidence rate ratio for total system visits was 0.64 (95% CI 0.49–0.84), which is the equivalent of 36% fewer total system visits among FWWI participants when compared to control participants.”
    Quote in the paperSubstantial claim
  • Findingown data

    FWWI participants had a 40% reduction in emergency department visits compared with matched comparison participants (incidence rate ratio 0.60, 95% CI 0.35-1.02), which was borderline significant.

    “FWWI participants showed a 40% reduction in ED visits (incidence rate ratio 0.60, 95%CI 0.35–1.02) when compared to the control that was borderline significant.”
    • Also stated in: § Results · plain
      “The post-training incidence rate ratio for ED visits was 0.60 (95% CI 0.35–1.02), which is the equivalent of 40% fewer ED visits among the FWWI participants when compared to the control participants.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 20
  • May combine two claims. 16

  • Classified as probably not a substantial claim.

    Premisecitation

    Adverse childhood experiences are associated with many negative adult health and health care utilisation outcomes, including cardiovascular illness, depression, suicide attempts, unhealthy substance use, obesity, lung disease, liver disease, cancer and medically unexplained symptoms such as pain or gastrointestinal problems.

    “Adverse childhood experiences are associated with many negative adult health and health care utilisation outcomes, including cardiovascular illness, depression, suicide attempts, unhealthy substance use, obesity, lung disease, liver disease, cancer and medically unexplained symptoms such as pain or gastrointestinal problems[1–6].”
    Quote in the paperSubstantial claim1 of 6 sources checked
    • cites [1] source
    • cites [2] source
    • cites [3] source

      The Abstract and the sections on health risk factors and disease conditions report associations between adverse childhood experiences and the listed behaviors and diseases, including depressed mood, suicide attempts, severe obesity, heart disease, cancer, and lung and liver disease (page numbers unavailable in our copy). The Abstract identifies health care utilization as an outcome the broader study is assessing, but this initial paper does not report an association with it. It also does not report findings on medically unexplained pain or gastrointestinal symptoms. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
    • cites [4] Hamby, S. L. The spectrum of victimization and the implications for health. In K. A. Kendall-Tackett editor, Application and practice in health psychology. Health consequences of abuse in the family: A clinical guide for evidence-based practice (p. 7–27). American Psychological Association, Washington, DC; 2004. source
    • cites [5] source
    • cites [6] source

  • May combine two claims.

    Premisecitation

    FWWI focus group participants described a reduction in anxiety and distress as a result of processing their trauma and understanding it was not their fault, and an increased sense of control over their lives.

    “FWWI focus group participants described a reduction in anxiety and distress as a result of processing their trauma and understanding it was not their fault, and an increased sense of control over their lives as a result of better understanding their emotions, seeing others with similar experiences making positive changes and building coping skills during trainings [19].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [19] Ray L, 2019, Journal of Health Disparities Research and Practice

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Recommended treatments for adverse life experiences are generally trauma-focused psychotherapies that reduce PTSD symptomology, improve self-esteem and build healthy emotional responses and interpersonal skills.

    “Recommended treatments for ALEs are generally trauma-focused psychotherapies that reduce PTSD symptomology, improve self-esteem and build healthy emotional responses and interpersonal skills [16–19].”
    Quote in the paperNot a substantial claim2 of 4 sources checked
    • cites [16] source
    • cites [17] source

      The ‘Key Differences Among Treatment Models for Co-Occurring PTSD and SUD’ section says PTSD therapies aim to develop self-worth and healthy relationships, and that interventions include affect-regulation and social problem-solving skills. The ‘Psychotherapy Approaches for PTSD and Addiction’ section reports evidence for CBT in treating PTSD. The paper addresses PTSD, particularly alongside substance-use disorder, but does not establish that trauma-focused psychotherapy is generally recommended for all adverse life experiences or that such treatments reliably produce all the listed improvements. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [18] source
    • cites [19] Ray L, 2019, Journal of Health Disparities Research and Practice

      The Discussion (Tables 5a–5b; page unavailable) describes trauma-focused CBT and other trauma treatments that address symptoms, emotional responses, and interpersonal skills. The Results and the 'Reject shame and false beliefs' section report improved self-esteem among FWWI participants. The paper does not establish that trauma-focused psychotherapies are generally the recommended treatments for adverse life experiences or that those psychotherapies generally improve self-esteem. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The relationship between adverse life experiences and substance use is well documented and has been explained through the self-medication model, which posits that persons experiencing PTSD attempt to cope with their distress by taking substances such as alcohol or drugs.

    “The relationship between adverse life experiences and substance use is well documented and has been explained through the self-medication model, which posits that persons experiencing PTSD attempt to cope with their distress by taking substances such as alcohol or drugs [55,59–61].”
    Quote in the paperSubstantial claim1 of 4 sources checked
    • cites [55] Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders, and sexual behavior: implications for healthcare. In Lanius, Ruth A., Eric Vermetten, and Clare Pain, editors. The impact of early life trauma on health and disease: The hidden epidemic. Cambridge (UK): Cambridge UP; 2010. p. 77–87. source
    • cites [59] source
    • cites [60] source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [61] source

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    There is recognised need for more trauma-informed approaches to substance use treatment.

    “As such, there is recognised need for more trauma-informed approaches to substance use treatment [62–64].”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [62] source
    • cites [63] source
    • cites [64] source

  • May combine two claims.

    Interpretationcitation

    The mechanism for reduced total system visits is likely a reduction in anxiety, depression, and trauma symptomology, and an increase in self-efficacy.

    “The potential mechanism is likely the same as proposed for ED visits: a reduction in anxiety, depression, and trauma symptomology, and an increase in self-efficacy, as shown by FWWI evaluations [19].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [19] Ray L, 2019, Journal of Health Disparities Research and Practice

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    FWWI participants reported an average of 4.5 adverse life experiences as measured by the Alaska screening tool.

    “FWWI participants reported an average of 4.5 ALEs as measured by the Alaska screening tool [30].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] DHSS A (2011). Alaska screening tool. Available from: http://dhss.alaska.gov/dbh/Documents/Resources/pdf/AST_2011.pdf

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Matched comparison group participants reported an average of 4.6 adverse experiences as measured by the Alaska screening tool.

    “Matched comparison group participants reported an average of 4.6 adverse experiences as measured by the Alaska screening tool [30].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] DHSS A (2011). Alaska screening tool. Available from: http://dhss.alaska.gov/dbh/Documents/Resources/pdf/AST_2011.pdf

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Coping skills can be learned and functioning improved using similar group exercises.

    “coping skills can be learned and functioning improved using similar group exercises [16,18]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [16] source
    • cites [18] source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Adverse experiences in adulthood can negatively affect physical and mental health, and the effect of traumatic events throughout the lifetime can be cumulative and substantial.

    “Adverse experiences in adulthood can also negatively affect physical and mental health, and the effect of traumatic events throughout the lifetime can be cumulative and substantial [7–9].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [7] source
    • cites [8] source
    • cites [9] source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    A person must process traumatic memories and build a coherent narrative in order to replace harmful thought patterns and contain experiences.

    “a person must process traumatic memories and build a coherent narrative in order to replace harmful thought patterns and contain experiences [51,52]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [51] source
    • cites [52] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Many programs to reduce emergency department utilisation focus on primary care access, case management support and chronic conditions self-management education.

    “A brief review of the literature indicates that many programs to reduce ED utilisation focus on primary care access, case management support and chronic conditions self-management education [45,48,54].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [45] source
    • cites [48] source
    • cites [54] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Non-stigmatising screening for adverse childhood experiences was associated with fewer emergency department visits the following year.

    “Felitti and colleagues found that non-stigmatising screening for ACEs was associated with fewer ED visits the following year [55].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [55] Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders, and sexual behavior: implications for healthcare. In Lanius, Ruth A., Eric Vermetten, and Clare Pain, editors. The impact of early life trauma on health and disease: The hidden epidemic. Cambridge (UK): Cambridge UP; 2010. p. 77–87. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Connecting with others can normalise experiences and reduce distress.

    “connecting with others can normalise experiences and reduce distress [16,53]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [16] source
    • cites [53] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Reducing unnecessary emergency department visits is recognised as an important policy goal due to the potential for significant cost savings.

    “Reducing unnecessary ED visits is recognised as an important policy goal due to the potential for significant cost savings [54].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [54] source

  • May combine two claims.

    Interpretationown data

    Participation in FWWI is associated with significantly fewer total health system visits and substance use visits among Alaska Native adults in the Southcentral Foundation system.

    “We found that after completing the FWWI program, participants had significantly fewer total and substance use visits when compared to comparison group participants.”
    • Also stated in: § Conclusion · plain
      “Our study, conducted in a closed health care system, shows that an Alaska Native program that helps adults heal from past adverse experiences can significantly reduce total health system visits and substance use visits.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    This study's results may not apply to all those utilising SCF's various behavioural health programs, especially those with more behavioural health diagnoses.

    “While it is not clear if this study’s results would apply to all those utilising SCF’s various behavioural health programs (especially those with more behavioural health diagnoses), there are many people with multiple ALEs who prefer community-based programming and do not seek formal behavioural health services.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premiseown data

    In internal focus groups, multiple FWWI participants described previous substance use driven by ALE-related distress, and then noted that through FWWI they were able to resolve much of that distress, as well as develop healthy coping skills that replaced substance use.

    “In internal focus groups, multiple FWWI participants described previous substance use driven by ALE-related distress, and then noted that through FWWI they were able to resolve much of that distress, as well as develop healthy coping skills that replaced substance use.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    FWWI is a community-based program that does not require a referral through a healthcare system, whereas the comparison pool participated in emotional wellness programs that require a health care referral.

    “FWWI is a community-based program that does not require a referral through a healthcare system. FWWI often attracts participants who prefer a non-medical approach to emotional wellness. The comparison pool participated in emotional wellness programs that require a health care referral, such as counselling, group therapy or other behavioural health programs.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Study design and conductnone given

    The diagnosis taxonomy for visits with somatisation potential may have been overly broad and not captured change in visits with medically unexplained symptoms.

    “The diagnosis taxonomy for visits with somatisation potential may have been overly broad and not captured change in visits with medically unexplained symptoms.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    SCF primary care providers noted using diagnoses related to stress or pain for some somatic visits, but because these diagnoses are not included in the Smith classifier, any changes in stress or pain-related visits would not have been captured in this study.

    “Finally, SCF primary care providers noted using diagnoses related to stress or pain for some somatic visits but because these diagnoses are not included in the Smith classifier any changes in stress or pain-related visits would not have been captured in this study.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Higher overall health care utilisation is associated with histories of trauma and abuse.

    “Multiple studies have shown associations between higher overall health care utilisation and histories of trauma and abuse [56,57].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [56] source
    • cites [57] source

  • May combine two claims.

    Study design and conductcitation

    The somatisation potential classifier was developed on persons with higher utilisation levels, whereas this study's cohort included persons with normal utilisation levels.

    “Additionally, the classifier was developed on persons with higher utilisation levels, and our cohort included persons with normal utilisation levels.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32] source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Visits driven by somatic or medically unexplained symptoms are known to drive a high proportion of primary care visits, to be difficult to treat biomedically and to frequently be associated with a history of abuse or trauma.

    “Visits driven by somatic or medically unexplained symptoms are known to drive a high proportion of primary care visits, to be difficult to treat biomedically and to frequently be associated with a history of abuse or trauma [2,65,66].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [2] source
    • cites [65] Katon WJ, 1998, J Clin Psychiatry
    • cites [66] source

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Many substance use treatment programs do not directly address trauma histories, and participants suffering from PTSD often have worse treatment outcomes.

    “Yet, many substance use treatment programs do not directly address trauma histories, and participants suffering from PTSD often have worse treatment outcomes [62].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [62] source

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Study design and conductnone given

    The diagnosis taxonomy for substance use visits is a widely used measurement system and is likely more accurate, but it is possible some substance use visits were missed.

    “The diagnosis taxonomy for substance use visits is a widely used measurement system and is likely more accurate, but it is possible some substance use visits were missed.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Given the study's observational design, there may be unidentified confounders that were not adjusted for in the model.

    “Given the study’s observational design, there may be unidentified confounders that were not adjusted for in the model.”
    Quote in the paperNot a substantial claim
27 of 27

  • The authors state this as an assumption.

    No prior propensity-score matched study has examined the health care utilisation effects of a psychosocial intervention to address adverse lifetime experiences.

    “To our knowledge, this is the first propensity-score matched study of the health care utilisation effects of a psychosocial intervention to address adverse lifetime experiences.”

  • The authors state this as an assumption.

    No prior work on adverse experiences, trauma or PTSD cited emergency department visit count changes as an outcome, or studies on reducing emergency department visits that focused on helping people heal from adverse experiences.

    “Otherwise, we could not find work on adverse experiences, trauma or PTSD that cited ED visit count changes as an outcome, or studies on reducing ED visits that focused on helping people to heal from adverse experiences.”

  • The paper relies on this without support.

    Both groups’ participants showed the desire to make a change in their life by seeking out and participating in an emotional wellness program.

    “Most importantly, both groups’ participants showed the desire to make a change in their life by seeking out and participating in an emotional wellness program.”

  • The authors state this as an assumption.

    Healing from adverse life experiences is an essential step that must occur for participants to build resilience, self-efficacy and healthy relationships.

    “FWWI provides intensive 5-day trainings which are grounded in Alaska Native values and methodologies and based on the theory that healing from ALEs is an essential step that must occur in order for participants to build resilience, self-efficacy and healthy relationships (Figure 1).”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Conflicting results for visits with somatisation potential

    Major

    The Results text reports an incidence rate ratio of 1.09 (95% CI 0.72-1.64), while Table 1 reports 1.25 (95% CI 0.79-1.99) for the same outcome.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. Ray L, 2019, Journal of Health Disparities Research and Practice, 12, 40
  2. Stuart EA, 2011, J Stat Softw, 42
  3. Katon WJ, 1998, J Clin Psychiatry

Cited by

Sorted by citations

Related

Authors
Ray, L., Outten, B., & Gottlieb, K.
Affiliations
Southcentral Foundation (US)
Corresponding author
Outten, Bobbi
ORCID
Ray, Lily
Venue
International Journal of Circumpolar Health
Publisher
Informa UK Limited
Published
2019-12-20
Volume
79
Issue
1
Pages
1705048-1705048
ISSN
  • 1239-9736 (ISSN-L)
  • 2242-3982
DOI
10.1080/22423982.2019.1705048
PMC
PMC6968385
OpenAlex
W2995120273
Cited by
3
References
70
Citations by year
2024: 1 · 2022: 2
FWCI
0.49
Type
journal article
Language
en
Open access
Licence
Locations
  • International Journal of Circumpolar Health (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
Topics
  • Social Sciences › Health › Indigenous Health, Education, and Rights
  • Health Sciences › Health Professions › General Health Professions › Homelessness and Social Issues
  • Health Sciences › Health Professions › General Health Professions › Indigenous Health and Education
Keywords
health care utilization, life events, emergency department visits, tribal health services
MeSH terms
Alaska Natives, Alaskan Natives, Adult, Community Health Services, Female, Health Promotion, Humans, Male, Patient Acceptance of Health Care, Retrospective Studies, United States, Case-Control Studies, United States Indian Health Service, Patient Satisfaction, Propensity Score

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