Stephen C. Dorner

Testing the effectiveness of two improved cookstove interventions in the Santiago de Chuco Province of Peru.

90% of people residing in rural areas of less-developed countries rely on coal and biomass fuels for heating and cooking, leading to high exposures to the products of incomplete combustion. Three Andean communities within the Santiago de Chuco province of Peru received two different models of improved cookstoves. The impact of these stoves in reducing personal exposures and kitchen concentrations of fine particulate matter (PM(2.5)) and carbon monoxide (CO) was evaluated separately in 64 homes (32 with each stove model) using air monitoring equipment. In the community receiving stove 1, baseline aggregate 48-h personal exposure (n=27) and kitchen concentrations (n=26) of PM(2.5) were 116.4 and 207.3μg/m(3), respectively, and 48-h personal (n=25) and kitchen (n=25) CO levels were 1.2 and 3.6ppm. After introducing the new stove to this community, those exposures reduced to 68.4 and 84.7μg/m(3), and 0.4 and 0.8ppm, representing reductions of 41.3%, 59.2%, 69.6% and 77.7% respectively. In the two communities receiving stove 2, corresponding levels were 126.3μg/m(3) (n=18), 173.4μg/m(3) (n=19), 0.9ppm (n=19), and 2.6ppm (n=17) before the installation of the stoves, and they reduced to 58.3, 51.1μg/m(3) and 0.6, 1.0ppm. Overall, homes receiving stove 2 saw reductions of 53.8, 70.5, 25.8 and 63.6%. All values are statistically significant (p<0.05) with the exception of personal CO reductions in the stove 2 group. Both stoves markedly reduce both kitchen and personal levels of wood smoke exposure, which we believe has the potential to improve health and quality of life.

Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act

Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act Nearly 12 million individuals have enrolled in coverage through the Affordable Care Act’s insurance marketplaces.1 The US Department of Health and Human Services regulates plans, applying a “reasonable access” standard to ensure access to “a sufficient number and type of providers.”2 Nonetheless, concerns remain about network adequacy.3 We assessed access to outpatient specialists in federal marketplace plans.

Community Paramedicine — Addressing Questions as Programs Expand

Various initiatives are using emergency medical service personnel to address critical problems in local U.S. delivery systems, such as insufficient primary and chronic care resources, overburdened EDs, and costly, fragmented emergency and urgent care networks.

Using exhaled carbon monoxide and carboxy-hemoglobin to evaluate the effectiveness of a chimney stove model in Peru

Abstract Background: Measurement of biological indicators of physiological change may be useful in evaluating the effectiveness of stove models, which are intended to reduce indoor smoke exposure and potential health effects. Objectives: We examined changes in exhaled carbon monoxide (CO), percentage carboxy-hemoglobin, and total hemoglobin in response to the installation of a chimney stove model by the Juntos National Program in Huayatan, Peru in 2008. Methods: Biomarkers were measured in a convenience sample comprising 35 women who met requirements for participation, and were measured before and three weeks after installation of a chimney stove. The relationships between exposure to indoor smoke and biomarker measurements were also analyzed using simple linear regression models. Results: Exhaled CO reduced from 6·71 ppm (95% CI 5·84–7·71) to 3·14 ppm (95% CI 2·77–3·66) three weeks after stove installation (P < 0·001) while % COHb reduced from 1·76% (95% CI 1·62–1·91) to 1·18% (95% CI 1·12–1·25; P < 0·001). Changes in exhaled CO and % COHb from pre- to post-chimney stove installation were not correlated with corresponding changes in exposure to CO and PM2·5 even though the exposures also reduced after stove installation. Conclusion: Exhaled CO and % COHb both showed improvement with reduction in concentration after the installation of the chimney cook stoves, indicating a positive physiological response subsequent to the intervention.

Attending documentation contribution to billing at an academic emergency department with an electronic health record

Introduction: In emergency medicine (EM), patient care documentation serves many functions, including supporting reimbursement. In addition, many electronic health record systems facilitate automatically populating certain data fields. As a result, in the academic model, the attendings note may now more often recapitulate many of the same elements found in the residents or physician assistants (PA) note. We sought to determine the value of additional attending documentation, and how often the attending documentation prevented a downcoding event. Methods: This retrospective, cross‐sectional study was exempted by the Institutional Review Board. We randomly reviewed 10 charts for each attending physician during the study period. Outcome measures included the frequency of prevented downcoding events, and the difference in this incidence between residents and PAs. Results: 530 charts were identified, but 6 were excluded as these patients left without being seen. 524 charts remained, of which 286 (45%) notes were written by residents and 238 (55%) notes were written by PAs. Attending documentation prevented 16 (3%) downcoding events, of which 11 were in patient encounters documented by residents and 5 were in encounters documented by PAs (p = 0.057). Conclusions: In this study of an academic medical center documentation model with an EHR, EM attending documentation of the history of present illness, review of systems, physical exam, and medical decision making portions prevented downcoding in a small number of cases. In addition, there was no significant difference in the incidence of prevented downcoding events between residents and PAs.

Measuring outcome differences associated with STEMI screening and diagnostic performance: a multicentred retrospective cohort study protocol

Introduction Advances in ST-segment elevation myocardial infarction (STEMI) management have involved improving the clinical processes connecting patients with timely emergency cardiovascular care. Screening upon emergency department (ED) arrival for an early ECG to diagnose STEMI, however, is not optimal for all patients. In addition, the degree to which timely screening and diagnosis are associated with improved time to intervention and postpercutaneous coronary intervention outcomes, under more contemporary practice conditions, is not known. Methods We present the methods for a retrospective multicentre cohort study anticipated to include 1220 patients across seven EDs to (1) evaluate the relationship between timely screening and diagnosis with treatment and postintervention clinical outcomes; (2) introduce novel measures for cross-facility performance comparisons of screening and diagnostic care team performance including: door-to-screening, door-to-diagnosis and door-to-catheterisation laboratory arrival times and (3) describe the use of electronic health record data in tandem with an existing disease registry. Ethics and dissemination The completion of this study will provide critical feedback on the quality of screening and diagnostic performance within the contemporary STEMI care pathway that can be used to (1) improve emergency care delivery for patients with STEMI presenting to the ED, (2) present novel metrics for the comparison of screening and diagnostic care and (3) inform the development of screening and diagnostic support tools that could be translated to other care environments. We will disseminate our results via publication and quality performance data sharing with each site. Institutional ethics review approval was received prior to study initiation.

Coerced Contracting is Not a Reasonable Solution to Balance Billing Letter With Response

Regarding the article on access to in-network emergency physicians, the authors conclude that a solution to the lack of access to in-network emergency physicians at many hospitals may be to require plans to contract with these physicians at hospitals that are in-network with the plan (if I understand their approach correctly). Though this mandate might be helpful in some cases, it is just as likely to increase the incidence of coercive contracting, where the plan puts pressure on a hospital in their network to force the emergency physician group at the hospital to accept deeply discounted rates from the plan, or be replaced by another group that will. A better solution would be for plans to be required to pay out-of-network emergency physicians (and on-call specialists) based on a benefit for out-of-network services that is a commercial market-based representation of the reasonable value of these services. Some percentile of usual and customary charges, using a database like the one established by FAIR Health, would provide such a reasonable value standard, while limiting outlier charges that are excessive and unreasonable. This approach is predicated on the idea that most physicians’ charges are reasonable, are designed to address practice costs and overhead, allow these physicians to meet their EMTALA mission to provide care to all, regardless of insurance status or ability to pay, and are subject to the pressures of the market for these services. This in turn would encourage plans to negotiate fairly with emergency physician groups, and not just take advantage of the EMTALA obligation or coercive contracting. It would also eliminate the need for so-called surprise balance billing.