Brendan G Carr

University of Pennsylvania, Filadelfia, Pennsylvania, United States

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Publications (130)496.54 Total impact

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    ABSTRACT: Objective: We aimed to characterize the geographic distribution of post-Hurricane Sandy emergency department use in administrative flood evacuation zones of New York City. Methods: Using emergency claims data, we identified significant deviations in emergency department use after Hurricane Sandy. Using time-series analysis, we analyzed the frequency of visits for specific conditions and comorbidities to identify medically vulnerable populations who developed acute postdisaster medical needs. Results: We found statistically significant decreases in overall post-Sandy emergency department use in New York City but increased utilization in the most vulnerable evacuation zone. In addition to dialysis- and ventilator-dependent patients, we identified that patients who were elderly or homeless or who had diabetes, dementia, cardiac conditions, limitations in mobility, or drug dependence were more likely to visit emergency departments after Hurricane Sandy. Furthermore, patients were more likely to develop drug-resistant infections, require isolation, and present for hypothermia, environmental exposures, or administrative reasons. Conclusions: Our study identified high-risk populations who developed acute medical and social needs in specific geographic areas after Hurricane Sandy. Our findings can inform coherent and targeted responses to disasters. Early identification of medically vulnerable populations can help to map "hot spots" requiring additional medical and social attention and prioritize resources for areas most impacted by disasters. (Disaster Med Public Health Preparedness. 2016;page 1 of 11).
    No preview · Article · Feb 2016 · Disaster Medicine and Public Health Preparedness
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    ABSTRACT: Total population health is a key tenet of health care reform efforts, evident in initiatives such as the National Quality Strategy, shifts toward population-based payments, and community benefit requirements for tax-exempt hospitals. Representing total population health in a way that guides best practices and establishes shared accountability for geographic communities, however, remains a challenge in part because of differences in how stakeholders define populations. To better understand the landscape of potential denominators for population health, this study examined a selection of relevant geographic units. The approach included a comprehensive review of health services and public health research literature as well as recent pertinent health policy documents. Units were characterized based on whether they: exhibit "breadth" of coverage across the whole US population; are "accurate" or grounded in health care utilization patterns; are "actionable" with mechanisms for implementing funding and regulation; and promote "synergism" or effective coordination of public health and health care activities. Although other key components of a total population health unit may exist and no single identified unit possesses all of the aforementioned features, several promising candidates were identified. Specifically, healthcare coalitions link health care and public health domains to care for a geographic community, but their connection to utilization is not empiric and limited funding exists at the coalition level. Although Accountable Care Organizations do not uniformly incorporate public health or facilitate coordination across all payers or providers, they represent an effective mechanism to increase collaboration within health care systems and represent a potential building block to influence total population health. (Population Health Management XXXX;XX:XXX-XXX).
    Full-text · Article · Jan 2016 · Population Health Management
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    ABSTRACT: Background: -Therapeutic hypothermia (TH) attenuates reperfusion injury in comatose survivors of cardiac arrest. The utility of TH in patients with non-shockable initial rhythms has not been widely accepted. We sought to determine whether TH improved neurologic outcome and survival in post-arrest patients with non-shockable rhythms. Methods and results: -We identified 519 patients after in- and out-of-hospital cardiac arrest with non-shockable initial rhythms from the Penn Alliance for Therapeutic Hypothermia (PATH) registry between 2000-2013. Propensity score matching was used. Patient and arrest characteristics used to estimate the propensity to receive TH were age, sex, location of arrest, witnessed arrest, and duration of arrest. To determine the association between TH and outcomes, we created two multivariable logistic models controlling for confounders. Of 201 propensity score matched pairs, mean age was 63±17 years; 51% were male; and 60% had an initial rhythm of pulseless electrical activity. Survival to hospital discharge was greater in patients who received TH (17.6% vs. 28.9%; p<0.01), as was discharge CPC of 1-2 (13.7% vs 21.4%; p= 0.04). In adjusted analyses, patients who received TH were more likely to survive (OR 2.8, 95% CI: 1.6-4.7) and have better neurologic outcome (OR 3.5, 95% CI: 1.8-6.6) than those that did not receive TH. Conclusions: -Using propensity score matching, we found patients with non-shockable initial rhythms treated with TH had better survival and neurologic outcome at hospital discharge than those who did not receive TH. Our findings further support the use of TH in patients with initial non-shockable arrest rhythms.
    Preview · Article · Nov 2015 · Circulation
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    ABSTRACT: Administrative data are critical to describing patterns of use, cost, and appropriateness of imaging in emergency care. These data encompass a range of source materials that have been collected primarily for a nonresearch use: documenting clinical care (e.g., medical records), administering care (e.g., picture archiving and communication systems), or financial transactions (e.g., insurance claims). These data have served as the foundation for large, descriptive studies that have documented the rise and expanded role of diagnostic imaging in the emergency department (ED). This article summarizes the discussions of the breakout session on the use of administrative data for emergency imaging research at the May 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The authors describe the areas where administrative data have been applied to research evaluating the use of diagnostic imaging in the ED, the common sources for these data, and the strengths and limitations of administrative data. Next, the future role of administrative data is examined for answering key research questions in an evolving health system increasingly focused on measuring appropriateness, ensuring quality, and improving value for health spending. This article specifically focuses on four thematic areas: data quality, appropriateness and value, special populations, and policy interventions.
    No preview · Article · Nov 2015 · Academic Emergency Medicine
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    ABSTRACT: . Ischemic stroke is a time sensitive disease with the effectiveness of treatment decreasing over time. Treatment is more likely to occur at Primary Stroke Centers (PSC); thus rapid access to acute stroke care through stand-alone PSCs or telemedicine (TM) is vital for all Americans. The objective of this study is to determine if disparities exist in access to PSCs or the extended access to acute stroke care provided by TM. Methods . Data from the US Census Bureau and the 2010 Neilson Claritas Demographic Estimation Program, American Hospital Association annual survey, and The Joint Commission list of PSCs and survey response data for all hospitals in the state of Texas were used. Results . Over 64% of block groups had 60-minute ground access to acute stroke care. The odds of a block group having 60-minute access to acute stroke care decreased with age, despite adjustment for sex, race, ethnicity, socioeconomic status, urbanization, and total population. Conclusion . Our survey of Texas hospitals found that as the median age of a block group increased, the odds of having access to acute stroke care decreased.
    Full-text · Article · Nov 2015 · Stroke Research and Treatment
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    ABSTRACT: Purpose: Age is a risk factor for death, adverse outcomes, and health care use following trauma. The American College of Surgeons' Trauma Quality Improvement Program (TQIP) has published "best practices" of geriatric trauma care; adoption of these guidelines is unknown. We sought to determine which evidence-based geriatric protocols, including TQIP guidelines, were correlated with decreased mortality in Pennsylvania's trauma centers. Methods: PA's level I and II trauma centers self-reported adoption of geriatric protocols. Survey data were merged with risk-adjusted mortality data for patients ≥65 from a statewide database, the Pennsylvania Trauma Systems Foundation (PTSF), to compare mortality outlier status and processes of care. Exposures of interest were center-specific processes of care; outcome of interest was PTSF mortality outlier status. Results: 26 of 27 eligible trauma centers participated. There was wide variation in care processes. Four trauma centers were low outliers; three centers were high outliers for risk-adjusted mortality rates in adults ≥65. Results remained consistent when accounting for center volume. The only process associated with mortality outlier status was age-specific solid organ injury protocols (p = 0.04). There was no cumulative effect of multiple evidence-based processes on mortality rate (p = 0.50). Conclusions: We did not see a link between adoption of geriatric best-practices trauma guidelines and reduced mortality at PA trauma centers. The increased susceptibility of elderly to adverse consequences of injury, combined with the rapid growth rate of this demographic, emphasizes the importance of identifying interventions tailored to this population. Level of evidence: III. Study type: Descriptive.
    No preview · Article · Oct 2015 · European Journal of Trauma and Emergency Surgery
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    ABSTRACT: Background-Primary stroke centers (PSCs) utilize more recombinant tissue plasminogen activator (rt-PA) than non-PSCs. The impact of PSCs on racial disparities in rt-PA use is unknown. Methods and Results-We used data from the Nationwide Inpatient Sample from 2004 to 2010, limited to states that publicly reported hospital identity and race. Hospitals certified as PSCs by The Joint Commission were identified. Adults with a diagnosis of ischemic stroke were analyzed. Rt-PA use was defined by the International Classification of Diseases, 9th Revision procedure code 99.10. Discharges (304 152 patients) from 26 states met eligibility criteria, and of these 71.5% were white, 15.0% black, 7.9% Hispanic, and 5.6% other. Overall, 24.7% of white, 27.4% of black, 16.2% of Hispanic, and 29.8% of other patients presented to PSCs. A higher proportion received rt-PA at PSCs than non-PSCs in all race/ethnic groups (white 7.6% versus 2.6%, black 4.8% versus 2.0%, Hispanic 7.1% versus 2.4%, other 7.2% versus 2.5%, all P<0.001). In a multivariable model adjusting for year, age, sex, insurance, medical comorbidities, a diagnosis-related group-based mortality risk indicator, ZIP code median income, and hospital characteristics, blacks were less likely to receive rt-PA than whites at non-PSCs (odds ratio=0.58, 95% CI 0.50 to 0.67) and PSCs (odds ratio=0.63, 95% CI 0.54 to 0.74) and Hispanics were less likely than whites to receive rt-PA at PSCs (odds ratio=0.77, 95% CI: 0.63 to 0.95). In the fully adjusted model, interaction between race and presentation to a PSC for likelihood of receiving rt-PA did not reach significance (P=0.98). Conclusions-Racial disparities in intravenous rt-PA use were not reduced by presentation to PSCs. Black patients were less likely to receive thrombolytic treatment than white patients at both non-PSCs and PSCs. Hispanic patients were less likely to be seen at PSCs relative to white patients and were less likely to receive intravenous rt-PA in the fully adjusted model.
    No preview · Article · Oct 2015 · Journal of the American Heart Association

  • No preview · Article · Oct 2015

  • No preview · Article · Oct 2015
  • K.L. Rising · J.E. Hollander · B.G. Carr

    No preview · Article · Oct 2015

  • No preview · Article · Oct 2015
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    ABSTRACT: The failure to rescue (FTR) rate is the probability of death after a major complication and was defined in elective surgical cohorts. In elective surgery, the precedence rate (proportion of deaths preceded by major complications) approaches 100%, but recent studies in trauma report rates of only 20–25%. We hypothesised that use of high quality data would result precedence rates in higher than those derived from national datasets, and we further sought to characterise the nature of those deaths not preceded by major complications.
    Preview · Article · Oct 2015 · Injury
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    ABSTRACT: We sought to improve public health surveillance by using a geographic analysis of emergency department (ED) visits to determine local chronic disease prevalence. Using an all-payer administrative database, we determined the proportion of unique ED patients with diabetes, hypertension, or asthma. We compared these rates to those determined by the New York City Community Health Survey. For diabetes prevalence, we also analyzed the fidelity of longitudinal estimates using logistic regression and determined disease burden within census tracts using geocoded addresses. We identified 4.4 million unique New York City adults visiting an ED between 2009 and 2012. When we compared our emergency sample to survey data, rates of neighborhood diabetes, hypertension, and asthma prevalence were similar (correlation coefficient = 0.86, 0.88, and 0.77, respectively). In addition, our method demonstrated less year-to-year scatter and identified significant variation of disease burden within neighborhoods among census tracts. Our method for determining chronic disease prevalence correlates with a validated health survey and may have higher reliability over time and greater granularity at a local level. Our findings can improve public health surveillance by identifying local variation of disease prevalence. (Am J Public Health. Published online ahead of print July 16, 2015: e1-e8. doi:10.2105/AJPH.2015.302679).
    Full-text · Article · Jul 2015 · American Journal of Public Health
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    ABSTRACT: International Classification of Disease, Ninth Revision (ICD-9) diagnosis codes have not been validated for identifying cases of missed abortion where a pregnancy is no longer viable but the cervical os remains closed. Our goal was to assess whether ICD-9 code "632" for missed abortion has high sensitivity and positive predictive value (PPV) in identifying patients in the emergency department (ED) with cases of stable early pregnancy failure (EPF). We studied females ages 13-50 years presenting to the ED of an urban academic medical center. We approached our analysis from two perspectives, evaluating both the sensitivity and PPV of ICD-9 code "632" in identifying patients with stable EPF. All patients with chief complaints "pregnant and bleeding" or "pregnant and cramping" over a 12-month period were identified. We randomly reviewed two months of patient visits and calculated the sensitivity of ICD-9 code "632" for true cases of stable miscarriage. To establish the PPV of ICD-9 code "632" for capturing missed abortions, we identified patients whose visits from the same time period were assigned ICD-9 code "632," and identified those with actual cases of stable EPF. We reviewed 310 patient records (17.6% of 1,762 sampled). Thirteen of 31 patient records assigned ICD-9 code for missed abortion correctly identified cases of stable EPF (sensitivity=41.9%), and 140 of the 142 patients without EPF were not assigned the ICD-9 code "632"(specificity=98.6%). Of the 52 eligible patients identified by ICD-9 code "632," 39 cases met the criteria for stable EPF (PPV=75.0%). ICD-9 code "632" has low sensitivity for identifying stable EPF, but its high specificity and moderately high PPV are valuable for studying cases of stable EPF in epidemiologic studies using administrative data.
    Preview · Article · Jul 2015 · The western journal of emergency medicine
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    ABSTRACT: Racial and ethnic disparities have been previously reported in acute stroke care. We sought to determine the effect of telemedicine (TM) on access to acute stroke care for racial and ethnic minorities in the state of Texas. Data were collected from the US Census Bureau, The Joint Commission and the American Hospital Association. Access for racial and ethnic minorities was determined by summing the population that could reach a primary stroke centre (PSC) or telemedicine spoke within specified time intervals using validated models. TM extended access to stroke expertise by 1.5 million residents. The odds of providing 60-minute access via TM were similar in Blacks and Whites (prevalence odds ratios (POR) 1.000, 95% CI 1.000-1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000-1.001). The odds of providing access via TM were also similar for Hispanics and non-Hispanics (POR 1.000, 95% CI 1.000-1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000-1.000). We found that telemedicine increased access to acute stroke care for 1.5 million Texans. While racial and ethnic disparities exist in other components of stroke care, we did not find evidence of disparities in access to the acute stroke expertise afforded by telemedicine. © The Author(s) 2015.
    No preview · Article · Jun 2015 · Journal of Telemedicine and Telecare
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    ABSTRACT: Background: Geographic variation in healthcare has been traditionally studied in large areas such as hospital referral regions or service areas. These analyses are limited by variation that exists within local communities. Materials and methods: Using a New York claims database, we analyzed variation in emergency department use using 35 million visits from 2008 to 2012 among 4797 Census tracts, a smaller unit than usually studied. Using multivariate analysis, we studied associations between population characteristics and proximity to healthcare with rates of emergency department use. We analyzed how factors associated with emergency department utilization differed among urban, suburban, and rural regions. Results: We found significant geographic variation in emergency department use among Census tracts. Public insurance and uninsurance were correlated with high emergency department utilization across all types of regions. We found that race, ethnicity, and poverty were only associated with high emergency department use in urban regions. In suburban and rural regions, a lower proportion of elderly residents and shorter distances to the nearest ED were correlated with high emergency department use. Conclusions: Significant variation in emergency department use exists locally when studied within small geographic areas. Insurance type is significantly associated with variation in emergency department use across urban, suburban, and rural regions, whereas the significance of other factors depended on urbanicity. Implications: Studying geographic variation at a more granular level can lead to better understanding of local population health, drivers of healthcare utilization, and inform targeted interventions. Given heterogeneity in emergency department use by Census tract, policies directed at shaping acute care utilization must consider these local geographic differences.
    No preview · Article · Jun 2015

  • No preview · Article · May 2015 · Journal of the American Academy of Dermatology
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    ABSTRACT: We examine differences in inpatient mortality and hospitalization costs at trauma and nontrauma centers for injuries of minor and moderate severity. Inpatient data sets from the California Office of Statewide Health Planning and Development were analyzed for 2009 to 2011. The study population included patients younger than 85 years and admitted to general, acute care hospitals with a primary diagnosis of a minor or moderate injury. Minor injuries were defined as having a New Injury Severity Score less than 5 and moderate injuries as having a score of 5 to 15. Multivariate logistic regression and generalized linear model with log-link and γ distribution were used to estimate differences in adjusted inpatient mortality and costs. A total of 126,103 admissions with minor or moderate injury were included in the study population. The unadjusted mortality rate was 6.4 per 1,000 admissions (95% confidence interval [CI] 5.9 to 6.8). There was no significant difference found in mortality between trauma and nontrauma centers in unadjusted (odds ratio 1.2; 95% CI 0.97 to 1.48) or adjusted models (odds ratio 1.1; 95% CI 0.79 to 1.57). The average cost of a hospitalization was $13,465 (95% CI $12,733 to $14,198) and, after adjustment, was 33.1% higher at trauma centers compared with nontrauma centers (95% CI 16.9% to 51.6%). For patients admitted to hospitals for minor and moderate injuries, hospitalization costs in this study population were higher at trauma centers than nontrauma centers, after adjustments for patient clinical-, demographic-, and hospital-level characteristics. Mortality was a rare event in the study population and did not significantly differ between trauma and nontrauma centers. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · May 2015 · Annals of emergency medicine
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    ABSTRACT: Objectives This study explored what smartphone health applications (apps) are used by patients, how they learn about health apps, and how information about health apps is shared.Methods Patients seeking care in an academic ED were surveyed about the following regarding their health apps: use, knowledge, sharing, and desired app features. Demographics and health information were characterized by summary statistics.ResultsOf 300 participants, 212 (71%) owned smartphones, 201 (95%) had apps, and 94 (44%) had health apps. The most frequently downloaded health apps categories were exercise 46 (49%), brain teasers 30 (32%), and diet 23 (24%). The frequency of use of apps varied as six (6%) of health apps were downloaded but never used, 37 (39%) apps were used only a few times, and 40 (43%) health apps were used once per month. Only five apps (2%) were suggested to participants by health care providers, and many participants used health apps intermittently (55% of apps ≤ once a month). Participants indicated sharing information from 64 (59%) health apps, mostly within social networks (27 apps, 29%) and less often with health care providers (16 apps, 17%).Conclusions While mobile health has experienced tremendous growth over the past few years, use of health apps among our sample was low. The most commonly used apps were those that had broad functionality, while the most frequently used health apps encompassed the topics of exercise, diet, and brain teasers. While participants most often shared information about health apps within their social networks, information was less frequently shared with providers, and physician recommendation played a small role in influencing patient use of health apps.
    No preview · Article · May 2015 · Academic Emergency Medicine
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    ABSTRACT: Effective measurement of health care quality, access, and cost for populations requires an accountable geographic unit. Although Hospital Service Areas (HSAs) and Hospital Referral Regions (HRRs) have been extensively used in health services research, it is unknown whether these units accurately describe patterns of hospital use for patients living within them. To evaluate the ability of HSAs, HRRs, and counties to define discrete health care populations. Cross-sectional geographic analysis of hospital admissions. All hospital admissions during the year 2011 in Washington, Arizona, and Florida. The main outcomes of interest were 3 metrics that describe patient movement across HSA, HRR, and county boundaries: localization index, market share index, and net patient flow. Regression models tested the association of these metrics with different HSA characteristics. For 45% of HSAs, fewer than half of the patients were admitted to hospitals located in their HSA of residence. For 16% of HSAs, more than half of the treated patients lived elsewhere. There was an equivalent degree of movement across county boundaries but less movement across HRR boundaries. Patients living in populous, urban HSAs with multiple, large, and teaching hospitals tended to remain for inpatient care. Patients admitted through the emergency department tended to receive care at local hospitals relative to other patients. HSAs and HRRs are geographic units commonly used in health services research yet vary in their ability to describe where patients receive hospital care. Geographic models may need to account for differences between emergent and nonemergent care.
    No preview · Article · Apr 2015 · Medical care

Publication Stats

2k Citations
496.54 Total Impact Points

Institutions

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