What They Don’t See

The author is currently living with a chronic autoimmune disease known as Hashimoto’s Thyroiditis, which caused his hypothyroidism. Although this disease is most common in middle-aged women, he was diagnosed at age 23. This disease is unique, because it is not entirely visible to others. In this piece, he presents a personal narrative of his diagnosis process and utilizes poetic inquiry to demonstrate to readers what “they,” meaning individuals without an invisible chronic autoimmune disease, don’t see.     

Differentiating ZIP Codes in Syndromic Data; What Can They Tell Us?

Objective

To classify visits to NYC emergency departments (ED) into NYC residential, NYC PO Box or commercial building, commuters to NYC, and out-of-town visitors. To describe patterns in each group, to evaluate how they differ, and to consider how the differences can affect syndromic surveillance analyses and results.

Introduction

The NYC Department of Health and Mental Hygiene (DOHMH) ED syndromic surveillance system receives data from 95% of all ED visits in NYC totaling 4 million visits each year. The data include residential ZIP code as reported by the patient. ZIP code information has been used by the DOHMH to separate visits into NYC and non-NYC for analysis; and, a closer examination of non-NYC visits may further inform disease surveillance.

Methods

Visits were initially differentiated into six home ZIP code types. NYC residential ZIP codes, PO Boxes and commercial buildings were identified with 2010 US Census and data from the SAS institute (SAS Institute Inc., Cary, NC, USA). Commuter visits to the EDs were classified as any ZIP codes from the NYC Core Based Statistical Area (CBSA; United States Office of Management and Budget). Out of town visits were identified using with the 2010 US Census. Unknown ZIP codes included all of those ZIP codes that were not identified by any of the previous methods, and missing ZIP codes were those that were blank. ZIP codes were verified with the United States Postal Service website (www.usps.com).Once ZIP codes were categorized, spatial and temporal trends in total ED visits by home ZIP code type were analyzed.

Results

Of the approximately 4 million ED visits in NYC during 2011, the number of visits by commuters and out-of-town visitors were 125,236 (3.1%) and 45,158 (1.1%) respectively (Figure 1). There were 4,676 (0.1%) visits with a NYC PO Box or building ZIP codes and 48,077 (1.2%) visits with a missing or non-interpretable ZIP codes. The majority of commuter and out-of-town ED visits occur at a smaller set of hospitals. Out-of town visitors mostly visited hospitals in Manhattan rather than hospitals in the outer boroughs. While the seasonal trends and day-of-week patterns for the NYC residents and the commuters appear to be fairly similar, this is not the case for out-of-town visitors. For example, total ED visit trends correlated well for NYC residents and commuters (r=0.77), but there was no correlation between NYC residents and out-of-town visitors (r=−0.18) over time. The number of ED visits among out-of-town visitors was higher during summer months and the winter holiday season, and this trend may have reflected the larger number of visitors during these periods. Day-of-week patterns were similar for NYC residents and commuters with weekdays associated with larger numbers of visits compared to weekends. However, the opposite was found true for out-of-town visitors with larger number of visits occurring over the weekends compared to weekdays.Open in a separate windowFigure 1:Total ED visits from the NYC Core Based Statistical Area (CBSA) and the surrounding region.

Conclusions

Considerable differences in temporal trends were found among out-of-town visitors, NYC residents, and commuters to NYC. Out-of-town visitors also tend to visit EDs located in Manhattan rather than in the outer boroughs. These results suggest that out-of-town visitors represent a unique population ED visitors. Analyzing NYC residents, commuters, and out-of-town visitors separately may provide additional information that could prove useful to daily syndromic surveillance activities.     

Who Are the Medical Travelers and What Do They Want?: A Qualitative Study

The ongoing debate on U.S. healthcare reform fueled by increasing cost and poor access to quality healthcare is spurring interest in medical travel. The topic of medical travel—going abroad to seek medical care—has been widely reported in various news outlets. This issue even resulted in a Senate Hearing before the Special Committee on Aging. Despite this popularity, very little empirical research has been conducted to describe and understand medical travelers. To fill this gap, the present study involves in-depth interviews of medical travel facilitators with extensive exposure to and communication with medical travelers. This article has multiple objectives. It aims to develop a demographic and psychographic profile of medical travelers and identify their underlying motives to seek medical care overseas. Based on these insights, it presents a list of propositions to be tested in further research. Finally, it offers practical implications for the healthcare industry.     

The Meaningful Use Regulations in Information Technology: What Do They Mean for Quality Improvement in Hospitals?

If provider organizations are serious about improving quality and efficiency, they must advance their electronic health record capabilities far beyond just meeting the U.S. federal regulations.     

Truly Enthralling: Epileptiform Events In Film and On Television—Why They Persist and What We Can Do About Them

ABSTRACT

Seizures and epilepsy have been portrayed in film since 1900 and on television since the 1950s, but unlike many other conditions, their depictions have not improved with increased scientific understanding. At this time, most individuals who are under 45 years of age will never witness a seizure. Thus, their information about what seizures are comes from depictions in film and on television. Because especially on television these fictive and often erroneous images are increasing, many think of them as accurate. The research addresses three questions in relation to these images: How do directors use the images? Why do uses of seizures in visual media not reflect contemporary scientific knowledge? Why have they persisted and increased in use? Data consist of material from 242 films and television episodes. The general category of seizures includes seizures in characters said to have epilepsy or some other condition, seizures related to alcohol/drug use, feigned or pseudoseizures, and a “throwaway” category. The research demonstrates how epileptiform events drive the narrative, support the genre, evoke emotional reactions, highlight traits of characters with seizures, accentuate traits of other characters through their responses, act as catalysts for action, and enhance voyeuristic experience. Through connecting categories, we explain a basic social process (Glaser, 2007 Glaser, B. 2007. The Grounded Theory Seminar Reader, Mill Valley, CA: Sociology Press.  [Google Scholar]). The conclusion is that these images are so enthralling that their use is likely to persist. The authors suggest that advocates acknowledge this and then find ways to have more continuing characters with correctly depicted epilepsy be part of television series as a way of exploring the truly enthralling dimensions of the condition.     

Nutrition Facts Panels: Who Uses Them,What Do They Use,and How Does Use Relate to Dietary Intake?

Background

Nutrition labels are a low-cost tool with the potential to encourage healthy eating habits.

The Value of Federated Data Networks in Oncology: What Research Questions Do They Answer? Outcomes From a Systematic Literature Review

ObjectivesReal-world evidence (RWE) plays an important role in addressing key research questions of interest to healthcare decision makers. Federated data networks (FDNs) apply novel technology to enable the conduct of RWE studies with multiple partners, without the need to share the individual partner’s data set. A systematic review of the published literature was performed to determine which types of research questions can best be addressed through FDNs, specifically in the field of oncology.MethodsSystematic searches of MEDLINE and Embase were undertaken to identify the types of research questions that had been addressed in studies using FDNs. Additional information was retrieved about study characteristics, statistical methods, and the FDN itself.ResultsIn total, 40 publications were included where research questions on the following had been addressed (multiple categories possible): disease natural history (58%), safety surveillance (18%), treatment pathways (15%), comparative effectiveness (10%), and cost/resource use studies (3%)—13% of studies had to be left uncategorized. A total of 50% of the studies were run with data partners in networks of ≤5. The size of the networks ranged from 227 patients to >5 million patients. Statistical methods used included distributed learning and distributed regression methods.ConclusionsFurther work is needed to raise awareness of the important role that FDNs can play in leveraging readily available RWE to address key research questions of interest in cancer and the benefits to the research community in engaging in federated data initiatives with a long-term perspective.     

Dairy Foods: Are They Politically Correct?

This article considers the scientific evidence on the prevalence and management of verified lactose intolerance and the growing misperception that dairy foods should be avoided because ethnic populations cannot tolerate them. Healthcare professionals, in particular, must understand why eliminating dairy foods is rarely necessary and is generally undesirable. The genetically programmed ability to digest the milk sugar lactose normally declines throughout childhood in all ethnic groups. Only rarely does lactase nonpersistence result in verifiable lactose intolerance. The intolerance-gastrointestinal symptoms, such as diarrhea, bloating, and abdominal cramping-is easily managed when it occurs and is not a barrier to the consumption of 2 to 3 servings of calcium-rich dairy foods, as encouraged by the Dietary Guidelines for Americans.     

Would They Follow What has been Laid Down? Cancer Patients' and Healthy Controls' Views on Adherence to Advance Directives Compared to Medical Staff

Advance directives are propagated as instruments to maintain patients’ autonomy in case they can no longer decide for themselves. It has been never been examined whether patients’ and healthy persons themselves are inclined to adhere to these documents. Patients’ and healthy persons’ views on whether instructions laid down in advance directives should be followed because that is (or is not) “the right thing to do”, not because one is legally obliged to do so, were studied and compared with that of medical staff. Method: Vignette study presenting five cases. Cancer patients, healthy persons, nursing staff and physicians (n = 100 in each group) were interviewed. An adherence score was calculated (maximum value 5). The adherence score is found to be low in all groups, yet lowest in patients (1.55; standard deviation 1.13) and healthy controls (1.60; 1.37). The scores are significantly different between nursing staff on the one hand and patients and healthy controls on the other (p < 0.005 and p < 0.05, respectively), and between doctors and patients (p < 0.05). Interviewees who want these documents to be followed tend to live alone and to have already written an advance directive. Conclusions: Cancer patients and healthy persons widely disregard instructions laid down in advance directives and consider them less binding than physicians and nursing staff do. Only a minority tends to adhere more to advance directives. To improve decision-making at the end of life when patients are no longer able to decide for themselves alternative concepts, such as advanced care planning, should be considered.     

“Yes They are Listening but Do They Hear Us?” Reflections on the Journey of the Barnardo's Participation Project

The Barnardo's Participation Project, previously known as the Disabled Children and Young People's Participation Project, was established by Barnardo's (Northern Ireland) in 2002. The aim of the Project was to develop ways of involving children and young people with disabilities in decision-making in relation to health and social care and children's services planning processes. Since its inception, hundreds of children and young people, with a range of physical and learning disabilities, sensory impairments and autism as well as life-limiting conditions, have participated in the Project. This paper describes how the Project has evolved over the years in response to emerging issues identified by the members as well as the demands of changing organisational and political contexts. Reflecting on the journey of the Project, the paper identifies the factors that contribute to successful participation practice and the challenges to participatory practice in recent years. As the title of this article suggests, the Project has found that children and young people with disabilities are skilled in recognising the difference between tokenistic consultation and meaningful participation. Within policy there is a strong emphasis on service user involvement; however, the principles of good participation practice require specific knowledge and attention. Good participation practice requires policy-makers and professionals to realign themselves with the rights of children and young people to have their say. The value of true, meaningful participation is evidenced by seeking and acting on their views about issues that affect their lives.     

Variation in Hospital Length of Stay: Do Physicians Adapt Their Length of Stay Decisions to What Is Usual in the Hospital Where They Work?

OBJECTIVE: To test the hypothesis that physicians who work in different hospitals adapt their length of stay decisions to what is usual in the hospital under consideration. DATA SOURCES: Secondary data were used, originating from the Statewide Planning and Research Cooperative System (SPARCS). SPARCS is a major management tool for assisting hospitals, agencies, and health care organizations with decision making in relation to financial planning and monitoring of inpatient and ambulatory surgery services and costs in New York state. STUDY DESIGN: Data on length of stay for surgical interventions and medical conditions (a total of seven diagnosis-related groups [DRGs]) were studied, to find out whether there is more variation between than within hospitals. Data (1999, 2000, and 2001) from all hospitals in New York state were used. The study examined physicians practicing in one hospital and physicians practicing in more than one hospital, to determine whether average length of stay differs according to the hospital of practice. Multilevel models were used to determine variation between and within hospitals. A t-test was used to test whether length of stay for patients of each multihospital physician differed from the average length of stay in each of the two hospitals. PRINCIPAL FINDINGS: There is significantly (p<.05) more variation between than within hospitals in most of the study populations. Physicians working in two hospitals had patient lengths of stay comparable with the usual practice in the hospital where the procedure was performed. The proportion of physicians working in one hospital did not have a consistent effect for all DRGs on the variation within hospitals. CONCLUSION: Physicians adapt to their colleagues or to the managerial demands of the particular hospital in which they work. The hospital and broader work environment should be taken into account when developing effective interventions to reduce variation in medical practice.     

Pregnancy Intention and Pregnancy Happiness: Are They Different?

Objectives: This study examines the relationship among pregnancy intention and attitudes, inconsistent contraceptive use, and plans for potential pregnancy among 311 women who presented at local health departments to seek a pregnancy test and for whom a pregnancy would be unintended. Methods: Women were surveyed prior to receiving pregnancy tests. Pregnancy intention was measured using traditional classifications of mistimed and unwanted pregnancies. Frequency distributions and chi-square tests were computed to examine and compare rates of happiness about the pregnancy among women with mistimed or unwanted pregnancy and to compare rates of inconsistent contraceptive use and plans for the pregnancy by intention and level of happiness. Results: Although all of the women selected for our sample stated that their pregnancies would be unintended, almost half (46%) were inconsistent contraceptive users. Further, 48% reported that they would be somewhat or very happy about a pregnancy. The proportion of women who were uncertain about the future of a pregnancy and who considered adoption or abortion was highest among those for whom a potential pregnancy was mistimed and who were unhappy about the pregnancy. Conclusions: Differentiating between pregnancy intention and happiness has practice implications for family planning and prenatal providers. Additional research should further elaborate these distinctions.     

Peer Passengers: How Do They Affect Teen Crashes?

PurposeThe specific mechanisms by which peer passengers increase teen drivers' crash risk are not completely understood. We aimed to provide insight on the two primary hypothesized mechanisms, distraction and promotion of risk-taking behavior, for male and female teen drivers and further for select driver–passenger gender combinations.MethodsFrom the National Motor Vehicle Crash Causation Survey (2005–2007), we analyzed a nationally representative sample of 677 drivers aged 16–18 years (weighted n = 277,484) involved in serious crashes, to compare the risk of specific distraction-related and risk-taking–related precrash factors (documented via on-scene crash investigation) for teens driving with peer passengers and teens driving alone.ResultsCompared with males driving alone, those with peer passengers were more likely to perform an aggressive act (risk ratio, RR [95% confidence interval] = 2.36 [1.29–4.32]) and perform an illegal maneuver (RR = 5.88 [1.81–19.10]) just before crashing; risk taking increased regardless of passenger gender. Crash-involved males with passengers were also more likely to be distracted by an exterior factor (RR = 1.70 [1.15–2.51]). Conversely, females with passengers were more often engaged in at least one interior nondriving activity (other than conversing with passengers) (RR = 3.87 [1.36–11.06]), particularly when driving with opposite-gender passengers. Female drivers, both with and without passengers, rarely drove aggressively or performed an illegal maneuver before crashing.ConclusionsPassengers may affect male teen driver crashes through both distraction and risk-promoting pathways, and female involvement primarily through internal distraction. Results of this and future studies investigating peer–driver interactions may guide development of passenger-related crash prevention efforts to complement already existing Graduated Driver Licensing passenger restrictions.