Brendan G Carr

University of Pennsylvania, Filadelfia, Pennsylvania, United States

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Publications (98)356.81 Total impact

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    ABSTRACT: Sudden hospital closures displace patients from usual sources of care and force them to access facilities that lack their prior medical records. For patients with complex needs and for nearby hospitals already strained by high volume, disaster-related hospital closures induce a public health emergency. Our objective was to analyze responses of patients from public versus private emergency departments after closure of their usual hospital after Hurricane Sandy. Using a statewide database of emergency visits, we followed patients with an established pattern of accessing 1 of 2 hospitals that closed after Hurricane Sandy: Bellevue Hospital Center and NYU Langone Medical Center. We determined how these patients redistributed for emergency care after the storm. We found that proximity strongly predicted patient redistribution to nearby open hospitals. However, for patients from the closed public hospital, this redistribution was also influenced by hospital ownership, because patients redistributed to other public hospitals at rates higher than expected by proximity alone. This differential response to hospital closures demonstrates significant differences in how public and private patients respond to changes in health care access during disasters. Public health response must consider these differences to meet the needs of all patients affected by disasters and other public health emergencies. (Disaster Med Public Health Preparedness. 2015;00:1-9).
    Disaster Medicine and Public Health Preparedness 03/2015; DOI:10.1017/dmp.2015.11 · 1.14 Impact Factor
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    ABSTRACT: The location of comprehensive stroke centers (CSCs) is critical to ensuring rapid access to acute stroke therapies; we conducted a population-level virtual trial simulating change in access to CSCs using optimization modeling to selectively convert primary stroke centers (PSCs) to CSCs. Up to 20 certified PSCs per state were selected for conversion to maximize the population with 60-minute CSC access by ground and air. Access was compared across states based on region and the presence of state-level emergency medical service policies preferentially routing patients to stroke centers. In 2010, there were 811 Joint Commission PSCs and 0 CSCs in the United States. Of the US population, 65.8% had 60-minute ground access to PSCs. After adding up to 20 optimally located CSCs per state, 63.1% of the US population had 60-minute ground access and 86.0% had 60-minute ground/air access to a CSC. Across states, median CSC access was 55.7% by ground (interquartile range 35.7%-71.5%) and 85.3% by ground/air (interquartile range 59.8%-92.1%). Ground access was lower in Stroke Belt states compared with non-Stroke Belt states (32.0% vs 58.6%, p = 0.02) and lower in states without emergency medical service routing policies (52.7% vs 68.3%, p = 0.04). Optimal system simulation can be used to develop efficient care systems that maximize accessibility. Under optimal conditions, a large proportion of the US population will be unable to access a CSC within 60 minutes. © 2015 American Academy of Neurology.
    Neurology 03/2015; DOI:10.1212/WNL.0000000000001390 · 8.30 Impact Factor
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    ABSTRACT: Emergency visits are rising nationally, whereas the number of emergency departments is shrinking. However, volume has not increased uniformly at all emergency departments. It is unclear what factors account for this variability in emergency volume growth rates. The objective of this study was to test the association of hospital and population characteristics and the effect of hospital closures with increases in emergency department volume. The study team analyzed emergency department volume at New York State hospitals from 2004 to 2010 using data from cost reports and administrative databases. Multivariate regression was used to evaluate characteristics associated with emergency volume growth. Spatial analytics and distances between hospitals were used in calculating the predicted impact of hospital closures on emergency department use. Among the 192 New York hospitals open from 2004 to 2010, the mean annual increase in emergency department visits was 2.7%, but the range was wide (-5.5% to 11.3%). Emergency volume increased nearly twice as fast at tertiary referral centers (4.8%) and nonurban hospitals (3.7% versus urban at 2.1%) after adjusting for other characteristics. The effect of hospital closures also strongly predicted variation in growth. Emergency volume is increasing faster at specific hospitals: tertiary referral centers, nonurban hospitals, and those near hospital closures. This study provides an understanding of how emergency volume varies among hospitals and predicts the effect of hospital closures in a statewide region. Understanding the impact of these factors on emergency department use is essential to ensure that these populations have access to critical emergency services. (Population Health Management 2015;xx:xxx-xxx).
    Population Health Management 02/2015; DOI:10.1089/pop.2014.0123 · 1.18 Impact Factor
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    ABSTRACT: To complete a 30-year interrupted time-series analysis of the impact of austerity-related and prosperity-related events on the occurrence of suicide across Greece. Greece from 1 January 1983 to 31 December 2012. A total of 11 505 suicides, 9079 by men and 2426 by women, occurring in Greece over the study period. National data from the Hellenic Statistical Authority assembled as 360 monthly counts of: all suicides, male suicides, female suicides and all suicides plus potentially misclassified suicides. In 30 years, the highest months of suicide in Greece occurred in 2012. The passage of new austerity measures in June 2011 marked the beginning of significant, abrupt and sustained increases in total suicides (+35.7%, p<0.001) and male suicides (+18.5%, p<0.01). Sensitivity analyses that figured in undercounting of suicides also found a significant, abrupt and sustained increase in June 2011 (+20.5%, p<0.001). Suicides by men in Greece also underwent a significant, abrupt and sustained increase in October 2008 when the Greek recession began (+13.1%, p<0.01), and an abrupt but temporary increase in April 2012 following a public suicide committed in response to austerity conditions (+29.7%, p<0.05). Suicides by women in Greece also underwent an abrupt and sustained increase in May 2011 following austerity-related events (+35.8%, p<0.05). One prosperity-related event, the January 2002 launch of the Euro in Greece, marked an abrupt but temporary decrease in male suicides (-27.1%, p<0.05). This is the first multidecade, national analysis of suicide in Greece using monthly data. Select austerity-related events in Greece corresponded to statistically significant increases for suicides overall, as well as for suicides among men and women. The consideration of future austerity measures should give greater weight to the unintended mental health consequences that may follow and the public messaging of these policies and related events. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    BMJ Open 01/2015; 5(1). DOI:10.1136/bmjopen-2014-005619 · 2.06 Impact Factor
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    ABSTRACT: As emergency care becomes increasingly regionalized, systems planners must determine how system expansion impacts existing system assets. We hypothesized that accrediting new Level II and III trauma centers impacted the trauma patient census and severity at a nearby Level I trauma center and estimated the magnitude of the impact. We conducted an interrupted time series analysis using monthly patient counts during the past 10 years for five trauma centers located near one another in Pennsylvania. The Level I center (TC-A) operated for the entire period. A Level II center 39 miles away was accredited after 70 months (TC-B), one Level III center 46 miles away was accredited after 95 months but lost accreditation after 11 months (TC-C), and two other Level III centers 40 miles and 45 miles away were accredited after 107 months (TC-D and TC-E). Monthly patient volume at the Level I center, which increased gradually over the study and summed to 25,120 patients, decreased by 10.8% (p < 0.05) when TC-B was accredited and decreased by an additional 12.9% (p < 0.05) when TC-D and TC-E were accredited simultaneously. No change stemmed from temporarily accrediting TC-C. Ultimately, the Level I center treated 1,903 fewer patients than expected over 51 months, an 11.9% volume reduction, and patient severity remained consistent but mortality decreased. Accrediting Level II and Level III trauma centers reduced patient volume and reduced overall mortality at a nearby Level I center. Strategic planning of statewide trauma systems can help balance rapid access to care with maintenance of adequate annual patient volumes of critically injured patients. Epidemiologic study, Level IV.
    Journal of Trauma and Acute Care Surgery 11/2014; 77(5):764-768. DOI:10.1097/TA.0000000000000430 · 2.50 Impact Factor
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    ABSTRACT: Time to achieve target temperature varies substantially for patients who undergo targeted temperature management (TTM) after cardiac arrest. The association between arrival at target temperature and neurologic outcome is poorly understood. We hypothesized that shorter time from initiation of cooling to target temperature (“induction”) will be associated with worse neurologic outcome, reflecting more profound underlying brain injury and impaired thermoregulatory control.
    Resuscitation 10/2014; 88. DOI:10.1016/j.resuscitation.2014.10.018 · 3.96 Impact Factor
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    ABSTRACT: Background and Purpose We examine whether the proportion of the US population with 60 minute access to Primary Stroke Centers (PSCs) varies based on geographic and demographic factors. Methods Population level access to PSCs within 60 minutes was estimated using validated models of prehospital time accounting for critical prehospital time intervals and existing road networks. We examined the association between geographic factors, demographic factors, and access to care. Multivariable models quantified the association between demographics and PSC access for the entire United States and then stratified by urbanicity. Results Of the 309 million people in the United States, 65.8% had 60 minute PSC access by ground ambulance (87% major cities, 59% minor cities, 9% suburbs, and 1% rural). PSC access was lower in stroke belt states (44% versus 69%). Non-whites were more likely to have access than whites (77% versus 62%), and Hispanics were more likely to have access than non-Hispanics (78% versus 64%). Demographics were not meaningfully associated with access in major cities or suburbs. In smaller cities, there was less access in areas with lower income, less education, more uninsured, more Medicare and Medicaid eligibles, lower healthcare utilization, and healthcare resources. Conclusions There are significant geographic disparities in access to PSCs. Access is limited in nonurban areas. Despite the higher burden of cerebrovascular disease in stroke belt states, access to care is lower in these areas. Selecting demographic and healthcare factors is strongly associated with access to care in smaller cities, but not in other areas, including major cities.
    Stroke 10/2014; 45(11). DOI:10.1161/STROKEAHA.114.006021 · 6.02 Impact Factor
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    ABSTRACT: Study aims: To assess whether increased use of targeted temperature management (If M) within an integrated healthcare delivery system resulted in improved rates of good neurologic outcome at hospital discharge (Cerebral Performance Category score of 1 or 2). Methods: Retrospective cohort study of patients with OHCA admitted to 21 medical centers between January 2007 and December 2012. A standardized TTM protocol and educational program were introduced throughout the system in early 2009. Comatose patients eligible for treatment with TTM were included. Adjusted odds of good neurologic outcome at hospital discharge and survival to hospital discharge were assessed using multivariate logistic regression. Results: A total of 1119 patients were admitted post-OHCA with coma, 59.1% (661 of 1119) of which were eligible for If M. The percentage of patients treated with TTM markedly increased during the study period: 10.5% in the years preceding( 2007-2008) vs. 85.1% in the years following (2011-2012) implementation of the practice improvement initiative. However, unadjusted in-hospital survival (37.3% vs. 39.0%, p = 0.77) and good neurologic outcome at hospital discharge (26.3% vs. 26.6%, p = 1.0) did not change. The adjusted odds of survival to hospital discharge (AOR 1.0, 95% CI 0.85-1.17) or a good neurologic outcome (AOR 0.94,95% CI 0.79-1.11) were likewise non-significant. Interpretation: Despite a marked increase in TTM rates across hospitals in an integrated delivery system, there was no appreciable change in the crude or adjusted odds of in-hospital survival or good neurologic outcomes at hospital discharge among eligible post-arrest patients.
    Resuscitation 08/2014; 85(11). DOI:10.1016/j.resuscitation.2014.08.014 · 3.96 Impact Factor
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    ABSTRACT: Background and Purpose-Only 3% to 5% of patients with acute ischemic stroke receive intravenous recombinant tissue-type plasminogen activator (r-tPA) and <1% receive endovascular therapy. We describe access of the US population to all facilities that actually provide intravenous r-tPA or endovascular therapy for acute ischemic stroke. Methods-We used US demographic data and intravenous r-tPA and endovascular therapy rates in the 2011 US Medicare Provider and Analysis Review data set. International Classification of Diseases-Ninth Revision codes 433. xx, 434. xx and 436 identified acute ischemic stroke cases. International Classification of Diseases-Ninth Revision code 99.10 defined intravenous r-tPA treatment and International Classification of Diseases-Ninth Revision code 39.74 defined endovascular therapy. We estimated ambulance response times using arc-Geographic Information System's network analyst and helicopter transport times using validated models. Population access to care was determined by summing the population contained within travel sheds that could reach capable hospitals within 60 and 120 minutes. Results-Of 370 351 acute ischemic stroke primary diagnosis discharges, 14 926 (4%) received intravenous r-tPA and 1889 (0.5%) had endovascular therapy. By ground, 81% of the US population had access to intravenous-capable hospitals within 60 minutes and 56% had access to endovascular-capable hospitals. By air, 97% had access to intravenous-capable hospitals within 60 minutes and 85% had access to endovascular hospitals. Within 120 minutes, 99% of the population had access to both intravenous and endovascular hospitals. Conclusions-More than half of the US population has geographic access to hospitals that actually deliver acute stroke care but treatment rates remain low. These data provide a national perspective on acute stroke care and should inform the planning and optimization of stroke systems in the United States.
    Stroke 08/2014; 45(10). DOI:10.1161/STROKEAHA.114.006293 · 6.02 Impact Factor
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    ABSTRACT: Rationale: Severe sepsis is increasing in incidence and has a high rate of in-patient mortality. Hospitals that treat a larger number of patients with severe sepsis may offer a survival advantage. Objectives: We sought to assess the effect of severe sepsis case volume on mortality, hypothesizing that higher volume centers would have lower rates of inpatient death. Methods: We performed a retrospective cohort study over a 7-year period (2004-2010), utilizing a nationally representative sample of hospital admissions, examining the relation between volume, urban location, organ dysfunction and survival. Measurements: To identify potential differences in outcomes, hospitals were divided into 5 categories (<50, 50-99, 100-249, 250-499, 500+ annual cases) and adjusted mortality was compared by volume. Results: A total of 914,200 patients with severe sepsis were identified over a 7-year period (2004-2010). Overall in-hospital mortality was 28.1%. In a fully adjusted model, there was an inverse relationship between severe sepsis case volume and in-patient mortality. Hospitals in the highest volume category had substantially improved survival compared to hospitals with the lowest case volume [adjusted OR 0.64 (95% CI 0.60 - 0.69)]. In cases of severe sepsis with one reported organ dysfunction, a mortality of 18.9% was found in hospitals with < 50 annual cases compared to 10.4% in hospitals treating 500+ cases [adjusted OR 0.54 (95% CI 0.49-0.59)]. Similar differences were found in patients with up to three total organ dysfunctions. Conclusions: Patients with severe sepsis treated in hospitals with higher case volumes had improved adjusted outcomes.
    American Journal of Respiratory and Critical Care Medicine 08/2014; 190(6). DOI:10.1164/rccm.201402-0289OC · 11.04 Impact Factor
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    ABSTRACT: Study objective Reasons for recurrent emergency department (ED) visits have been examined primarily through administrative data review. Inclusion of patients’ perspectives of reasons for ED return may help inform future initiatives aimed at reducing recurrent utilization. The objective of this study is to describe the personal experiences and challenges faced by patients transitioning home after an ED discharge. Methods We performed semistructured qualitative interviews of adult patients with an unscheduled return to the ED within 9 days of an index ED discharge. Questions focused on problems with the initial discharge process, medications, outpatient care access, social support, and health care decisionmaking. Themes were identified with a modified grounded theory approach. Results Sixty interviews were performed. Most patients were satisfied with the discharge process at the index discharge, but many had complaints about the clinical care delivered, including insufficient evaluation and treatment. The primary reason for returning to the ED was fear or uncertainty about their condition. Most patients had a primary care physician, but they rarely visited a physician before returning to the ED. Patients cited convenience and more expedited evaluations as primary reasons for seeking care in the ED versus the clinic. Conclusion Postdischarge factors, including perceived inability to access timely follow-up care and uncertainty and fear about disease progression, are primary motivators for return to the ED. Many patients prefer hospital-based care because of increased convenience and timely results. Further work is needed to develop alternative pathways for patients to ask questions and seek guidance when and where they want.
    Annals of Emergency Medicine 08/2014; DOI:10.1016/j.annemergmed.2014.07.015 · 4.33 Impact Factor
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    ABSTRACT: Objectives Although 72-hour emergency department (ED) revisits are increasingly used as a hospital metric, there is no known empirical basis for this 72-hour threshold. The objective of this study was to determine the timing of ED revisits for adult patients within 30days of ED discharge. Methods This was a retrospective cohort study of all nonfederal ED discharges in Florida and Nebraska from April 1, 2010, to March 31, 2011, using data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP). ED discharges were followed forward to identify ED revisits occurring at any hospital within the same state within 30days. The cumulative hazard of an ED revisit was plotted. Parametric and nonparametric modeling was performed to characterize the rate of ED revisits. Results There were 4,782,045 ED discharges, with 7.5% (95% confidence interval [CI]=7.4% to 7.5%) associated with 3-day revisits, and 22.4% (95% CI=22.3% to 22.4%) associated with 30-day revisits, inclusive of the 3-day revisits. A double-exponential model fit the data best (p<0.0001), and a single hinge point at 9days (multivariate adaptive regression splines [MARS] model) yielded the best linear fit to the data, suggesting 9days as the most reasonable cutoff for identification of acute ED revisits. Multiple stratified and subgroup analyses produced similar results. Future work should focus on identifying primary reasons for potentially avoidable return ED visits instead of on the revisit occurrence itself, thus more directly measuring potential lapses in delivery of high-quality care. Conclusions Almost one-quarter of ED discharges are linked to 30-day ED revisits, and the current 72-hour ED metric misses close to 70% of these patients. Our findings support 9days as a more inclusive cutoff for studies of ED revisits.
    Academic Emergency Medicine 08/2014; 21(8). DOI:10.1111/acem.12442 · 2.20 Impact Factor
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    ABSTRACT: To examine the impact of telemedicine on access to acute stroke care and expertise in the state of Texas. Texas hospitals were surveyed using a standard questionnaire and categorized as: (1) stand-alone Primary Stroke Centers not using telemedicine for acute stroke care, (2) Primary Stroke Centers using telemedicine for acute stroke care, (3) non-Primary Stroke Center hospitals using telemedicine for acute stroke care, or (4) non-Primary Stroke Center hospitals not using telemedicine for acute stroke care. Population data were obtained from the US Census Bureau and the Neilson Claritas Demographic Estimation Program. Access within 60 minutes to a designated facility was calculated at the block group level. Over 75% of Texans had 60-minute access to a stand-alone Primary Stroke Center. Including Primary Stroke Centers using telemedicine increased access by 6.5%. Adding non- Primary Stroke Centers that use telemedicine for acute stroke care provided 60-minute access for an additional 2% of Texans, leaving 16% of Texans without 60-minute access to acute stroke care. Approximately 62% of Texans had 60-minute access to more than one type of facility that provided acute stroke care. The use of telemedicine in the state of Texas brought 60-minute access to >2 million Texans who otherwise would not have had access to acute stroke expertise. Our findings demonstrate that using telemedicine for acute stroke has the ability to provide neurologically underserved areas access to acute stroke care.
    06/2014; 1(1):27-33. DOI:10.1002/acn3.20
  • Academic Emergency Medicine 05/2014; 21(5). DOI:10.1111/acem.12381 · 2.20 Impact Factor
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    ABSTRACT: Optimal care of adults with severe acute respiratory failure requires specific resources and expertise. We sought to measure geographic access to these centers in the United States. Cross-sectional analysis of geographic access to high capability severe acute respiratory failure centers in the United States. We defined high capability centers using two criteria: (1) provision of adult extracorporeal membrane oxygenation (ECMO), based on either 2008-2013 Extracorporeal Life Support Organization reporting or provision of ECMO to 2010 Medicare beneficiaries; or (2) high annual hospital mechanical ventilation volume, based 2010 Medicare claims. Nonfederal acute care hospitals in the United States. We defined geographic access as the percentage of the state, region and national population with either direct or hospital-transferred access within one or two hours by air or ground transport. Of 4,822 acute care hospitals, 148 hospitals met our ECMO criteria and 447 hospitals met our mechanical ventilation criteria. Geographic access varied substantially across states and regions in the United States, depending on center criteria. Without interhospital transfer, an estimated 58.5% of the national adult population had geographic access to hospitals performing ECMO and 79.0% had geographic access to hospitals performing a high annual volume of mechanical ventilation. With interhospital transfer and under ideal circumstances, an estimated 96.4% of the national adult population had geographic access to hospitals performing ECMO and 98.6% had geographic access to hospitals performing a high annual volume of mechanical ventilation. However, this degree of geographic access required substantial interhospital transfer of patients, including up to two hours by air. Geographic access to high capability severe acute respiratory failure centers varies widely across states and regions in the United States. Adequate referral center access in the case of disasters and pandemics will depend highly on local and regional care coordination across political boundaries.
    PLoS ONE 04/2014; 9(4):e94057. DOI:10.1371/journal.pone.0094057 · 3.53 Impact Factor
  • Brendan G Carr, Zachary F Meisel
    Academic Emergency Medicine 01/2014; DOI:10.1111/acem.12295 · 2.20 Impact Factor
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    ABSTRACT: Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia. This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index. Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police. We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care.
    Annals of emergency medicine 12/2013; 63(5). DOI:10.1016/j.annemergmed.2013.11.008 · 4.33 Impact Factor
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    ABSTRACT: Collective knowledge and coordination of vital interventions for time-sensitive conditions (ST-segment elevation myocardial infarction [STEMI], stroke, cardiac arrest, and septic shock) could contribute to a comprehensive statewide emergency care system, but little is known about population access to the resources required. We seek to describe existing clinical management strategies for time-sensitive conditions in Pennsylvania hospitals. All Pennsylvania emergency departments (EDs) open in 2009 were surveyed about resource availability and practice patterns for time-sensitive conditions. The frequency with which EDs provided essential clinical bundles for each condition was assessed. Penalized maximum likelihood regressions were used to evaluate associations between ED characteristics and the presence of the 4 clinical bundles of care. We used geographic information science to calculate 60-minute ambulance access to the nearest facility with these clinical bundles. The percentage of EDs providing each of the 4 clinical bundles in 2009 ranged from 20% to 57% (stroke 20%, STEMI 32%, cardiac arrest 34%, sepsis 57%). For STEMI and stroke, presence of a board-certified/board-eligible emergency physician was significantly associated with presence of a clinical bundle. Only 8% of hospitals provided all 4 care bundles. However, 53% of the population was able to reach this minority of hospitals within 60 minutes. Reliably matching patient needs to ED resources in time-dependent illness is a critical component of a coordinated emergency care system. Population access to critical interventions for the time-dependent diseases discussed here is limited. A population-based planning approach and improved coordination of care could improve access to interventions for patients with time-sensitive conditions.
    Annals of emergency medicine 12/2013; 63(5). DOI:10.1016/j.annemergmed.2013.11.018 · 4.33 Impact Factor
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    ABSTRACT: To use the natural experiment of health insurance reform in Massachusetts to study the impact of increased insurance coverage on ICU utilization and mortality. Population-based cohort study. Massachusetts and four states (New York, Washington, Nebraska, and North Carolina) that did not enact reform. All nonpregnant nonelderly adults (age 18-64 yr) admitted to nonfederal acute care hospitals in one of the five states of interest were eligible, excluding patients who were not residents of a respective state at the time of admission. We used a difference-in-differences approach to compare trends in ICU admissions and outcomes of in-hospital mortality and discharge destination for ICU patients. Healthcare reform in Massachusetts was associated with a decrease in ICU patients without insurance from 9.3% to 5.1%. There were no significant changes in adjusted ICU admission rates, mortality, or discharge destination. In a sensitivity analysis excluding a state that enacted Medicaid reform prior to the study period, our difference-in-differences analysis demonstrated a significant increase in mortality of 0.38% per year (95% CI, 0.12-0.64%) in Massachusetts, attributable to a greater per-year decrease in mortality postreform in comparison states (-0.37%; 95% CI, -0.52% to -0.21%) compared with Massachusetts (0.01%; 95% CI, -0.20% to 0.11%). Massachusetts healthcare reform increased the number of ICU patients with insurance but was not associated with significant changes in ICU use or discharge destination among ICU patients. Reform was also not associated with changed in-hospital mortality for ICU patients; however, this association was dependent on the comparison states chosen in the analysis.
    Critical care medicine 11/2013; 42(4). DOI:10.1097/CCM.0000000000000044 · 6.15 Impact Factor
  • Annals of Emergency Medicine 10/2013; 62(4):S142-S143. DOI:10.1016/j.annemergmed.2013.07.222 · 4.33 Impact Factor

Publication Stats

1k Citations
356.81 Total Impact Points

Institutions

  • 2009–2015
    • University of Pennsylvania
      • • Center for Clinical Epidemiology and Biostatistics
      • • Department of Emergency Medicine
      Filadelfia, Pennsylvania, United States
  • 2007–2015
    • Thomas Jefferson University
      Filadelfia, Pennsylvania, United States
  • 2006–2014
    • William Penn University
      Filadelfia, Pennsylvania, United States
  • 2009–2013
    • The Children's Hospital of Philadelphia
      Philadelphia, Pennsylvania, United States
  • 2007–2011
    • Hospital of the University of Pennsylvania
      • Department of Emergency Medicine
      Philadelphia, Pennsylvania, United States
  • 2010
    • Mayo Clinic - Rochester
      • Department of Emergency Medicine
      Рочестер, Minnesota, United States
    • Emory University
      • Department of Emergency Medicine
      Atlanta, Georgia, United States
  • 2008
    • Robert Wood Johnson Foundation
      Princeton, New Jersey, United States
  • 2007–2008
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States