Edward Mensah

Feasibility of a rapid diagnostic protocol for an emergency department chest pain unit.

STUDY OBJECTIVE To evaluate the applicability of a short-stay protocol for exclusion of acute ischemic heart disease without hospital admission and to analyze these results in the context of a conceptual model. METHODS An observational study of patients who presented with chest pain to the emergency department of an 886-bed inner-city municipal hospital and who needed hospital admission to rule out acute myocardial infarction (AMI). Patients were assessed by ED attending physicians to determine eligibility for an alternative, 12-hour protocol in an ED chest pain observation unit (CPOU) followed by immediate exercise testing. Outcome measures were proportion of patients eligible for the short-stay protocol, risk factor profile, and reasons for exclusion. RESULTS Of 500 patients screened, 446 had sufficient data points to determine protocol eligibility. Of these, 238 (53.3%; 95% confidence interval [CI], 48.7% to 57.9%) were found to have low probability for AMI. After study exclusion criteria were applied to the patient cohort, 63 patients (14.1%; 95% CI, 10.9% to 17.3%) were eligible for the protocol. The most common reasons for exclusion were history of coronary artery disease (46%) and inability to perform an interpretable exercise tolerance test (42%). CONCLUSION Although most admitted patients with chest pain (53%) were at low probability for AMI, only a minority (14%) were eligible for a short-stay protocol that required patients to be free of known coronary artery disease and able to perform an exercise tolerance test. Factors affecting the operations and efficiency of a CPOU include clinical characteristics of the target patient population, protocol tests used, and hospital occupancy and reimbursement patterns.

Introduction: Geographic Information Systems in Public Health and Medicine

Geographic information systems (GIS) are increasingly being used in public health and medicine. Advances in computer technology, the encouragement of its use by the federal government, and the wide availability of academic and commercial courses on GIS are responsible for its growth. Some view GIS as only a tool for spatial research and policy analysis, while others believe it is part of a larger emerging new science including geography, cartography, geodesy, and remote sensing. The specific advantages and problems of GIS are discussed. The greatest potential of GIS is its ability to clearly show the results of complex analyses through maps. Problems in using GIS include its costs, the need to adequately train staff, the use of appropriate spatial units, and the risk it poses to violating patient confidentiality. Lastly, the fourteen articles in this special issue devoted to GIS are introduced and briefly discussed.

Why do we need pharmacists in pharmacovigilance systems

Pharmacovigilance is the science and activity relating to the collection, detection, assessment, monitoring, and prevention of adverse effects with pharmaceutical products. Pharmacovigilance basically targets safety of medicine. Pharmacists have crucial role in health systems to maintain the rational and safe use of medicine for they are drug experts who are specifically trained in this field. Effective use of pharmacists’ workforce will improve the outcome of the pharmacotherapy as well as decrease global health costs. Given their advanced training, pharmacists can utilize pharmacovigilance systems interfaced with electronic health records to monitor the performance of the drugs they fill and also identify adverse drug reactions earlier than non-pharmacists, thereby reducing high healthcare costs.

Catalytic Hydrolysis of VIP in Pregnant Women with Asthma

Rationale: The neuropeptide vasoactive intestinal peptide (VIP) is one of the physiologic mediators of non-adrenergic, non-cholinergic smooth muscle relaxation of the airway and an important modulator of innate and adaptive immune responses. VIP catalytic autoantibodies are increased in asthma and serum VIP level is decreased during acute exacerbation of asthma. The effect of pregnancy on asthma is variable and depends in part on the severity of pre-existing asthma, along with other physiological and pathophysiological changes. We hypothesized that hydrolysis of VIP by circulating catalytic VIP antibodies will be increased in pregnancy in patients with asthma. Study objective: To determine the level of catalytic autoantibodies to VIP in pregnant asthmatics compared to non-pregnant asthmatics and control pregnant women without asthma. Methods: We prospectively enrolled eight pregnant asthmatics (age, 26.5 ± 2.6 years; mean ± SEM), nine pregnant women without asthma (32.0 ± 3.0 years), seven non-pregnant women with asthma (25.0 ±1.9 years), and seven non-pregnant women without asthma (34.4 ± 2 years) into the study. VIP hydrolysis was performed in all subjects. Results: Immunoglobulin G (IgG) autoantibodies that catalyze the hydrolysis of vasoactive intestinal peptide (VIP) were present at greater levels in the blood of pregnant women with asthma (7.6 ± 1.1 pM VIP/6 h) compared to pregnant women without asthma (4.0 ± 0.5; p < 0.001), non-pregnant asthmatics (4.9 ± 0.9; p < 0.05) or non-pregnant women without asthma (1.9 ± 0.7; p < 0.05). Conclusion: An increase in the VIP hydrolyzing activity of IgG is independently associated with asthma and pregnancy. The autoantibodies hold the potential of affecting the pathophysiology of the airways in pregnant asthmatics.

A Decision Support Tool for Using an ICD-10 Anatomographer to Address Admission Coding Inaccuracies: A Commentary

Abstract In the chaotic environment of an emergency department trauma unit, accuracy and timeliness in decision making are required to save a patient’s life. In a large urban city, where gun violence is high, emergency department physicians must have a wide array of tools in order to effectively and efficiently treat victims of gun violence and ensure that their diagnoses are properly coded. A disparity currently exists between the accuracy of ICD-9 admission coding and discharge coding with some error rates as much as seventy percent. [1,2,3,4] The elevated error rate is poised to increase even more, as the US transitions from ICD-9 to ICD-10 coding standard. The proposed decision support tool, the ICD-10 anatomographer, will have many advantages to medical professionals working in high-intensity settings. Emergency department physicians in busy trauma care units in large urban hospitals will be able to utilize this technology to find the accurate ICD-10 code in an efficient manner, thereby improving quality of care and saving lives. Keywords: decision support, ICD-9 to ICD-10 transition, anatomography

The performance of Medicare, Medicaid, and individual commercial products

EXECUTIVE SUMMARY Medicare, Medicaid, and individual nongovernmental insurance products are marketed by commercial health insurance companies. We propose that the product offerings be viewed as a group rather than as separate products competing for internal company resources. A study population consisting of 35 Aetna plans in 24 states, 124 Blue Cross Blue Shield plans (BCBS) in 45 states and the District of Columbia, 43 Cigna plans in 28 states, and 23 UnitedHealth plans in 22 states was examined on 29 variables, including financial, marketing, and medical management data. The findings revealed that Medicaid and individual nongovernmental products were terminated more often than other products across all ownership types. When BCBS plans were analyzed across for‐profit, nonprofit, and mutual ownership types, the companies had distinct preferences for product offerings. The study provided evidence that health plans will limit their exposure to Medicare, Medicaid, and individual nongovernmental products in preference to comprehensive/group products.

Data Sources and Data Tools

Data Sources and Data Tools offers an introduction to the basic concepts of strategically finding and evaluating publically available data for health analysis. Leading data providers and sources, at the local, state, and national levels, are introduced and reviewed as exemplars. In the evolving and dynamic universe of available health data, a variety of statistical tools and techniques as well as methods to organize complex work schemes are necessary for data acquisition, management, and interpretation.

Crowdinforming During Public Health Emergencies: A Commentary

During the recent 2009 Novel H1N1 influenza pandemic, public health safety efforts included prevention and mitigation actions such as mass vaccination programs, community education focused on infection control, social distancing and how to avoid contracting and spreading influenza.[1-3] There were also programs to rapidly deploy caches of ventilators, antivirals and personal protective equipment to treat and reduce transmission of influenza infection.[1,3,4] Despite these efforts, many became ill.[12] Where and when to seek medical care was part of the public health education message. The problem becomes continuing to meet concurrent public health prevention goals, plus ongoing medical obligations with existing staff and space.[4,6,7] The same medical staff members delivering antiviral medications to those exposed and running mass vaccination programs were also treating the ill. In addition, aggressive viral culture acquisition and special processing was instituted.[1,9] Screening for febrile employees and exposed personnel in high risk facilities was started so that antiviral prophylaxis could be rapidly administered. Alternate care sites were initiated to address the increased volumes and to sequester possibly infective patients. [1] Hospitals often make plans to delay routine care and redeploy the staff and treatment space if the influenza surge required this step.[6,7] In addition to all that new activity, some jurisdictions instituted new influenza-like-illness (ILI) reporting requirements for hospitals.[2] Even normal staffing levels may be insufficient to meet these new responsibilities and existing staff numbers may be further reduced due to illness during this pandemic.[10] Emergency departments (EDs) are a good place to begin addressing load distribution during patient surge events such as the 2009 novel H1N1 pandemic. They are open 24/7, serve all who present for treatment, and do not incur the scheduling delays associated with primary care or other office-based appointments. They are prepared to address the most severe acuity of illness and are in hospitals which are often centrally located and highly familiar to the local community. Indeed, unprecedented patient surges were reported during the 2009 influenza season. [1, 8] In OJPHI, Vol 2, No. 1, Bob McLeod introduced a novel combination of agent based modeling (ABM), electronic medical record dashboards to predict ED waiting room times, and Crowdinforming as a method to redistribute patients seeking ED care.[11] The purpose is to balance area hospital waiting room loads during pandemics surges. This is a very innovative idea with important applications in medicine and public health.

Determinants of Decision Making Under a Decentralized Regulatory Environment: A Case Study of the Asbestos Hazards Emergency Response Act (AHERA)

The Asbestos Hazards Emergency Response Act (AHERA), unlike previous environmental regulations such as the Clean Air and Clean Water Acts, does not specify a standardized ambient concentration of contaminant against which compliance could be measured. The law only requires that each local education agency inspect for asbestos and, depending on the condition of the material found (undamaged, potential for damage, damaged, significantly damaged), develop and implement a management plan in a timely fashion. The broad latitude given to local authorities regarding the specific level of environmental control adopted raises a new set of regulatory design issues that differ from those involved in regulations with specific compliance standards. This study employs a logit model to assess how local factors may affect the responses that school districts make regarding the level of compliance with the federal asbestos regulations. The results show that press coverage, the effects of more organized interest groups such as unions, and the role of the courts, contribute significantly to the school districts compliance with the regulations. According to the model, the probability of initiating inspections and developing management plans will be decreased by over 60 percent if the school district has a poorer population. The survey underscores the need for regulatory planners to assess the ways in which a variety of interest groups receive and process environmental regulations.

Asbestos Removal and Treatment Impacts on Housing and Urban Neighborhoods

Reducing the health hazard caused by the presence of asbestos in buildings is likely to give rise to costly adjustments in the nations stock of buildings. This article focuses on the residential building stocks, and estimates the effects of several regulatory scenarios on building values, building life and the decision to convert buildings to high-income uses. We find that the value of low-income buildings is seriously eroded by the abatement scenarios analyzed. Conversion of buildings by rehabilitation is discouraged because values inclusive of rehabilitation costs are seriously reduced, and incentives to delay are introduced. Effects on building values in high-income neighborhoods are relatively less severe. Asbestos has been present in buildings for many years and has been employed in a great variety of productive uses. The United States Environmental Protection Agency (EPA) has estimated that it is present in 55 percent of all residential buildings over ten units in size [1]. In recent years, however, its life-threatening properties have become widely recognized and demands for solutions to the health problem it poses have proliferated. To a growing extent, residential building owners, the focus of this article, must consider the demand for