Robert Lipton

Emergency department crowding and risk of preventable medical errors

The objective of the study is to determine the association between emergency department (ED) crowding and preventable medical errors (PME). This was a retrospective cohort study of 533 ED patients enrolled in the National ED Safety Study (NEDSS) in four Massachusetts EDs. Individual patients’ average exposure to ED crowding during their ED visit was compared with the occurrence of a PME (yes/no) for the three diagnostic categories in NEDSS: acute myocardial infarction, asthma exacerbation, and dislocation requiring procedural sedation. To accommodate site-to-site differences in available administrative data, ED crowding was measured using one of three previously validated crowding metrics (ED Work Index, ED Workscore, and ED Occupancy). At each site, the continuous measure was placed into site-specific quartiles, and these quartiles then were combined across sites. We found that 46 (8.6%; 95% confidence interval, 6.4–11.3%) of the 533 patients experienced a PME. For those seen during higher levels of ED crowding (quartile 4 vs. quartile 1), the occurrence of PMEs was more than twofold higher, both on unadjusted analysis and adjusting for two potential confounders (diagnosis, site). The association appeared non-linear, with most PMEs occurring at the highest crowding level. We identified a direct association between high levels of ED crowding and risk of preventable medical errors. Further study is needed to determine the generalizability of these results. Should such research confirm our findings, we would suggest that mitigating ED crowding may reduce the occurrence of preventable medical errors.

Moderate Alcohol Use and Depression in Young Adults: Findings From a National Longitudinal Study

OBJECTIVES We examined the association between moderate alcohol use and depressive mood among young adults before and after adjustment for demographic, health, and socioeconomic factors that may act as confounders. METHODS We analyzed 2 waves of interview data collected from 13892 young adults who participated in the National Longitudinal Study of Adolescent Health to compare frequency of depressive symptoms in moderate drinkers with frequency of symptoms in young adults in other alcohol use categories. RESULTS With adjustment for health and socioeconomic factors, frequency of depressive symptoms were similar among moderate drinkers, lifetime and long-term abstainers, and heavy/heavier moderate drinkers but remained significantly higher among heavy drinkers. CONCLUSIONS Moderate alcohol use may have no effect on depression in young adults relative to abstinence from alcohol use.

Changes in Body Mass Index Associated With Head Start Participation

OBJECTIVES: The goal of this study was to determine if Head Start participation is associated with healthy changes in BMI. METHODS: The sample included children participating in Head Start between 2005 and 2013 and children from 2 comparison groups drawn from a Michigan primary care health system: 5405 receiving Medicaid and 19 320 not receiving Medicaid. Change in BMI z score from the beginning to the end of each of 2 academic years and the intervening summer was compared between groups by using piecewise linear mixed models adjusted for age, gender, and race/ethnicity. RESULTS: The total sample included 43 748 children providing 83 239 anthropometric measures. The Head Start sample was 64.9% white, 10.8% black, and 14.4% Hispanic; 16.8% of the children were obese and 16.6% were overweight at the initial observation. Children who entered Head Start as obese exhibited a greater decline in the BMI z score during the first academic year versus the comparison groups (β = –0.70 [SE: 0.05] vs –0.07 [0.08] in the Medicaid group [P < .001] and –0.15 [SE: 0.05] in the Not Medicaid group [P < .001]); patterns were similar for overweight children. Head Start participants were less obese, less overweight, and less underweight at follow-up than children in the comparison groups. CONCLUSIONS: Preschool-aged children with an unhealthy weight status who participated in Head Start had a significantly healthier BMI by kindergarten entry age than comparison children in a primary care health system (both those receiving and those not receiving Medicaid).

The Geography of Violence, Alcohol Outlets, and Drug Arrests in Boston

OBJECTIVES We examined the relationship between alcohol outlets, drug markets (approximated by arrests for possession and trafficking), and violence in Boston, Massachusetts, in 2006. We analyzed geographic and environmental versus individual factors related to violence and identified areas high in violent crime. METHODS We used data from the Boston Police Department, US Census, and Massachusetts State Alcohol Beverage Control Commission. Spatial modeling was employed at the block group level, and violent crime, alcohol outlets, and drug markets were mapped. RESULTS Relative to other block groups, block groups in the highest decile of violent crime (n = 55) were found to be poorer (e.g., lower incomes, higher percentages of vacant homes), and they had greater numbers of alcohol outlets and higher drug arrest rates. Alcohol outlets and drug possession and trafficking arrests were predictive of violent crime. Also, spatial effects resulting from neighboring block groups were related to violent crime. Both alcohol outlet density and type were associated with violent crime in a differentiated and complex way. CONCLUSIONS With drug possession and trafficking arrests as a proxy for drug markets, spatial relationships between alcohol outlets and violence were found in addition to typical sociodemographic predictors.

Quality of publications in emergency medicine

OBJECTIVE The objective of this study is to describe emergency medicine (EM) publications in terms of methodology, approval by institutional review board, method of consent, external validity, and setting (eg, prehospital or emergency department). METHODS The 12 top-ranked emergency journals were selected. We manually reviewed the last 30 original articles in each EM journal, to represent more than 2 months of publications for all EM journals (range, 2-6 months). Only clinical original articles on human subjects were included. To ensure accurate data transcription, each article was read at least twice by 2 different reviewers and graded by written criteria using an extraction standard chart. RESULTS Over the articles reviewed, 330 were analyzed. One hundred eighty-nine (57.3%) were prospective studies; 29 (8.8%) were randomized studies. Two hundred twenty-six studies (68.5%) mentioned an institutional review board approval or a waiver of authorization, and an informed consent was not mentioned in 227 (68.8%) of studies. Fifty-nine (17.9%) were conducted in a prehospital setting. Two hundred thirty-eight (72.1%) of these studies were at single-center institutions; the Unite States contributed 158 (47.9%) of the total publications. CONCLUSION This study describes publications in the field of EM. Randomized studies represent 9% of publications, most studies are cross-sectional, and more than half have a retrospective design. We found that, in one-third of the studies, an institutional review board review was not mentioned and informed consent was not specified in two-thirds of the studies. Emergency medicine research volume, quality, and grants activity must increase in order for EM to progress within academic medicine.

The effect of neighborhood context on the relationship between substance misuse and weapons aggression in urban adolescents seeking ED care

Background: Frameworks for studying the ecology of human behavior suggest that multiple levels of the environment influence behavior and that these levels interact. Applied to studies of weapons aggression, this suggests proximal risk factor (e.g., substance use) effects may differ across neighborhoods. Objectives: To estimate how the association between weapons aggression and substance use varies as a function of several community-level variables. Methods: Individual-level measures (demographics, behavioral measures) were obtained from a survey of youth aged 14–24 years old seeking care at a Level-1 ED in Flint, Michigan. Community-level variables were obtained from public sources. Logistic generalized additive models were used to test whether community-level variables (crime rates, alcohol outlets, demographics) modify the link between individual-level substance use variables and the primary outcome measure: self-reported past 6-month weapon (firearm/knife) related aggression. Results: The effect of marijuana misuse on weapons aggression varied significantly as a function of five community-level variables: racial composition, vacant housing rates, female headed household rates, density of package alcohol outlets, and nearby drug crime rates. The effect of high-risk alcohol use did not depend on any of the eight community variables tested. Conclusions: The relationship between marijuana misuse and weapons aggression differed across neighborhoods with generally less association in more disadvantaged neighborhoods, while high-risk alcohol use showed a consistently high association with weapons aggression that did not vary across neighborhoods. The results aid in understanding the contributions of alcohol and marijuana use to the etiology of weapon-related aggression among urban youth, but further study in the general population is required.

Bioterrorism preparedness expenditures may compromise public health.

The exchange of letters in the March issue regarding Cohen and colleagues’ October 2004 article1 did not sufficiently quantify the national public health impact of misdirecting precious dollars to bioterrorism preparedness. For fiscal years 2002–2005 and 2006 (projected), the Centers for Disease Control and Prevention’s (CDC’s) terrorism preparedness funding has varied from

Patient- and community-level sociodemographic characteristics associated with emergency department visits for childhood injury.

1.4 billion to

Original ArticlePatient- and Community-Level Sociodemographic Characteristics Associated with Emergency Department Visits for Childhood Injury

1.7 billion, averaging 22% of the CDC’s entire annual budget.2,3 The anthrax incident of 2001, which caused 5 deaths, prompted an ill-conceived smallpox vaccination campaign that was implicated in the deaths of 3 health workers4 and cost an additional

A spatial analysis of heterogeneity in the link between alcohol outlets and assault victimization: differences across victim subpopulations

0.6 billion in 2002 and 2003.2 It is difficult to accept the efficacy of dual-use prevention given the tragic failures during Hurricane Katrina.5 Thousands of the most vulnerable and helpless were left to die in the streets from dehydration, exposure, and lack of medical attention.6 Still, for the sake of argument, suppose that dual use (which Cohen et al. strongly discount) might prevent all of the estimated 36000 influenza-related deaths that occur each year.7 Even in this most optimistic of scenarios, the expenditure per fatality prevented would amount to more than