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BACKGROUND: Identification of pulmonary embolism (PE) across a cohort currently requires burdensome manual review. Previous approaches to automate capture of PE diagnosis have either been too complex for widespread use or have lacked external validation. We sought to develop and validate the Regular Expression Aided Determination of PE (READ-PE) algorithm, which uses a portable text-matching approach to identify PE in reports from computed tomography with angiography (CTA). METHODS: We identified derivation and validation cohorts of final radiology reports for CTAs obtained on adults (≥ 18 years) at two independent, quaternary academic emergency departments (EDs) in the United States. All reports were in the English language. We manually reviewed CTA reports for PE as a reference standard. In the derivation cohort, we developed the READ-PE algorithm by iteratively combining regular expressions to identify PE. We validated the READ-PE algorithm in an independent cohort, and compared performance against three prior algorithms with sensitivity, specificity, positive-predictive-value (PPV), negative-predictive-value (NPV), and the F1 score. RESULTS: Among 2948 CTAs in the derivation cohort 10.8 % had PE and the READ-PE algorithm reached 93 % sensitivity, 99 % specificity, 94 % PPV, 99 % NPV, and 0.93 F1 score, compared to F1 scores ranging from 0.50 to 0.85 for three prior algorithms. Among 1206 CTAs in the validation cohort 9.2 % had PE and the algorithm had 98 % sensitivity, 98 % specificity, 85 % PPV, 100 % NPV, and 0.91 F1 score. CONCLUSIONS: The externally validated READ-PE algorithm identifies PE in English-language reports from CTAs obtained in the ED with high accuracy. This algorithm may be used in the electronic health record to accurately identify PE for research or surveillance. If implemented at other EDs, it should first undergo local validation and may require maintenance over time.
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Traumatic brain injury (TBIs) necessitates a rapid and comprehensive medical response to minimize secondary brain injury and reduce mortality. Emergency medical services (EMS) clinicians serve a critical role in the management of prehospital TBI, responding during an initial phase of care with significant impact on patient outcomes. We used versions two and three of the Brain Trauma Foundation (BTF) Prehospital Guidelines for the Management of Traumatic Brain Injury and the NASEMSO National Model Clinical Guidelines to determine key elements for a TBI prehospital protocol and included common factors across sources such as recommendations concerning patient monitoring, hypoxia, hypotension, hyperventilation, cerebral herniation, airway management, hyperosmolar therapy, and transport destination. We then conducted a cross-sectional evaluation of publicly available statewide EMS clinical protocols in the US to determine the degree of alignment with national guidelines. We calculated descriptive statistics for each factor in the state protocols. Despite adoption of some evidence-based recommendations for a standard approach to the prehospital management of patients with TBI, we found significant variability in statewide EMS treatment protocols for management of severe TBI, especially in the recommended frequency of patient reassessment and for the management of suspected herniation. Most statewide protocols provided guidance regarding oxygenation, ventilation, and blood pressure management that aligned with evidence-based guidelines. While most protocols did address management of oxygenation and ventilation, one in four protocols had no specific guidance for managing hypoxia and only 31% of protocols recommended avoiding hyperventilation. For the management of suspected cerebral herniation, over half of statewide protocols recommended hyperventilation, whereas only 31% explicitly advised against hyperventilation regardless of TBI severity. Interestingly, 94% of protocols do not mention the use of hyperosmolar therapy for TBI patients, neither recommending use or avoidance of hyperosmolar therapy. In conclusion, we found inconsistent adoption of national recommendations in available statewide protocols for prehospital TBI management. We identified significant gaps and variation in statewide protocols regarding patient monitoring and reassessment, as well as in several key areas of severe TBI management.
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Background/Objective: Asthma is a common chronic medical condition among children and the most common diagnosis associated with interfacility transports for pediatric patients. As many as 40% of pediatric transfers may be unnecessary, resulting in potential delays in care and unnecessary costs. Our objective was to identify the patient-related factors associated with potentially unnecessary transfers for pediatric patients with asthma. Methods: We used patient care data from the California Department of Health Care Access and Information patient discharge and emergency department (ED) datasets to capture ED visits where a pediatric patient (age 2-17 years) presented with asthma and was transferred to another ED or acute care hospital. The outcome of interest was a potentially unnecessary transfer, defined as a visit where length of stay after transfer was <24 hours and no advanced services were used, such as respiratory therapy or critical care. Patient-related characteristics were extracted, including age, gender, race/ethnicity, primary language, insurance status, and clinical characteristics. First, we used descriptive statistics to compare necessary vs unnecessary transfers. Second, we used generalized estimating equations accounting for clustering by ED to estimate odds ratios (OR) and identify factors associated with potentially unnecessary transfers. Results: A total of 4,233 pediatric ED patients were transferred with a diagnosis of asthma, including 461 (11%) transfers that met criteria as potentially unnecessary. Median age was 12 years (interquartile range 7-15), and 46% were female. Factors associated with increased odds of potentially unnecessary transfer while controlling for key factors included younger age (eg, 2-5 years, OR 2.0, 95% confidence interval [CI] 1.4-2.9), male gender (OR 1.4, 95% CI 1.1-1.7), and Hispanic ethnicity (OR 1.6, 95% CI 1.2-2.1), while multiple hospitalizations for asthma per year was associated with decreased odds (OR 0.2, 95% CI 0.1-0.4). Conclusion: Several patient-related factors were associated with increased or decreased odds of potentially unnecessary transfers among pediatric patients presenting to the ED with asthma. These factors can be considered in future work to better understand, predict, and reduce unnecessary transfers and their negative consequences.
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Asma , Servicio de Urgencia en Hospital , Transferencia de Pacientes , Humanos , Asma/terapia , Niño , Masculino , Femenino , Estudios Retrospectivos , Transferencia de Pacientes/estadística & datos numéricos , Adolescente , Servicio de Urgencia en Hospital/estadística & datos numéricos , California , Preescolar , Tiempo de Internación/estadística & datos numéricosRESUMEN
BACKGROUND: The prehospital care provided by emergency medical services (EMS) personnel is a critical component of the public health, public safety, and health care systems in the U.S.; however, the population-level value of EMS care is often overlooked. No studies have examined how the density of EMS personnel relates to population-level health outcomes. Our objectives were to examine the geographic distribution and density of EMS personnel in the U.S.; and quantify the association between EMS personnel density and population-level health outcomes. METHODS: We conducted a cross-sectional evaluation of county-level EMS personnel density using estimates from the National Registry of Emergency Medical Technicians in nine states that require continuous national certification (Alabama, Louisiana, Massachusetts, Minnesota, New Hampshire, North Dakota, South Carolina, Vermont, and Washington, D.C.). Outcomes of interest included life expectancy, all-cause mortality, and cardiac arrest mortality. We used quantile regression models to examine the association between a 10-person increase in EMS personnel density and each outcome at the 10th, 50th (median), and 90th percentiles, controlling for population characteristics and area health resources. RESULTS: There were 356 counties included, with a mean EMS density of 223 EMS personnel per 100,000 population. Density was higher in rural compared to urban counties (247 versus 186 per 100,000 population; p = 0.001). In unadjusted models, there was a significant association between increase in EMS personnel density and an increase in life expectancy at each examined percentile (e.g., 50th percentile, increase of 52.9 days; 95% CI 40.2, 65.5; p < 0.001), decrease in all-cause mortality at each examined percentile, and decrease in cardiac arrest mortality at the 50th and 90th percentiles. These associations were not statistically significant in the adjusted models. CONCLUSIONS: EMS personnel density differs between urban and rural areas, with higher density per population in rural areas. There were no statistically significant associations between EMS density and population-level health outcomes after controlling for population characteristics and other health resources. The best approach to quantifying the community-level value that EMS care may or may not provide remains unclear.
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Servicios Médicos de Urgencia , Paro Cardíaco , Salud Poblacional , Humanos , Estudios Transversales , Recursos HumanosRESUMEN
Background/Objective: Bronchospasm, caused by asthma and other related conditions, is a significant cause of morbidity and mortality commonly managed by emergency medical services (EMS). We aimed to evaluate the quality of prehospital management of bronchospasm by EMS in the US.Methods: The National EMS Information System Public Release Research dataset, a nationwide convenience sample of prehospital patient care report data from 2018 to 2019, was used to capture 9-1-1 activations where patients aged ≥2 years were treated and transported by EMS for suspected bronchospasm. First, we described the extent to which EMS care met eight quality measures identified from available statewide EMS protocols, existing quality measures, and national guidelines. Second, we quantified the extent of risk-standardized agency-level variation in administration of inhaled beta agonists and systemic corticosteroids using logistic regression models, accounting for patient characteristics, severity, and clustering by agencies. Third, we compared rates of completed prehospital interventions between pediatric (age <18 years) versus adult patients using two-sample t-tests.Results: A total of 1,336,988 EMS encounters for suspected bronchospasm met inclusion criteria. Median age of patients was 66 years, with only 4% pediatric; 55% were female. Advanced life support (ALS) units managed 94% of suspected bronchospasm. Respiratory rate (98%) and pulse oximetry (96%) were documented in nearly all cases. Supplemental oxygen was administered to hypoxic patients by 65% of basic life support (BLS) and 73% of ALS units. BLS administered inhaled beta-agonist therapy less than half the time (48%), compared to 77% by ALS. ALS administered inhaled anticholinergic therapy in 38% of cases, and systemic corticosteroids in 19% of cases. Pediatric patients were significantly less likely to receive supplemental oxygen when hypoxic, inhaled beta-agonists, inhaled anticholinergics, or systemic corticosteroids.Conclusions: We found important gaps in recent EMS practice for prehospital care of suspected bronchospasm. We highlight three targets for improvement: inhaled beta-agonist administration by BLS, systemic corticosteroid administration by ALS, and increased interventions for pediatric patients. These findings indicate important areas for research, protocol modification, and quality improvement efforts to improve EMS management of bronchospasm.
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Espasmo Bronquial , Servicios Médicos de Urgencia , Adulto , Anciano , Niño , Femenino , Humanos , Masculino , Corticoesteroides , Espasmo Bronquial/tratamiento farmacológico , Estudios Transversales , Oxígeno , Estados Unidos , Preescolar , Adolescente , Persona de Mediana EdadRESUMEN
Objective: We aimed to evaluate the differences in characteristics and illness/injury severity among patients who present to the emergency department (ED) via emergency medical services (EMS) compared to patients who present via other means. Methods: We analyzed a nationwide sample of ED visits from the 2015-2019 National Hospital Ambulatory Medical Care Survey. We excluded patients <18 or >92 years old, who eloped or left against medical advice, or who arrived via interfacility transport. Mode of presentation was dichotomized to those presenting to the ED via EMS versus any other mode of transportation. Using the appropriate survey sampling weights, we described patient characteristics and compared measures of illness/injury severity between groups using a multivariable logistic regression model. Results: An unweighted total of 73,397 ED visits, representing a weighted estimate of 528,083,416 ED visits in the United States during 2015-2019, included 18% arriving via EMS and 82% via other means. EMS patients were older, more often male, more often had multiple chronic medical conditions, and less often had private insurance. EMS patients had higher priority triage scores, consumed more resources in the ED, and had longer lengths of stay. Arrival by EMS was associated with higher odds of hospital admission (odds ratio [OR] 2.7, 95% confidence interval [CI] 2.4-2.9) and in-hospital mortality (OR 11.1, 95% CI 7.3-17.2). Conclusions: Patients presenting via EMS had significantly different characteristics and outcomes than those presenting via other means. These important differences should be considered when comparing studies of all ED patients versus those who present via EMS.
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STUDY OBJECTIVE: To describe the demographic, clinical, and emergency medical service (EMS) response characteristics associated with EMS activations for asthma and chronic obstructive pulmonary disease (COPD) exacerbations in the US. METHODS: Using a nationwide set of out-of-hospital patient care report data from 2018 to 2019, we analyzed 9-1-1 EMS activations where asthma/COPD exacerbation was indicated by symptom, impression, or treatment provided. We excluded patients with ages less than 2 years or unknown, nonemergency transports, and encounters with any indication of anaphylaxis. Demographic, clinical, and EMS response characteristics were described for pediatric and adult patients with asthma/COPD exacerbations. RESULTS: A total of 1,336,988 asthma/COPD exacerbations were included, comprising 5% of qualifying 9-1-1 scene activations from 2018 to 2019. Most patients were adults (96%). Most adult patients were female (55%), whereas most pediatric patients were male (58%). Most activations occurred in urban settings (82%), particularly in pediatric patients (90%). Most asthma/COPD exacerbations were managed by advanced life support units (94%). Inhaled bronchodilators and systemic corticosteroid therapy were administered to 75% and 14% of all patients, respectively. Adults more often had oxygen saturation <92% (43% vs 20% of pediatric patients) and were more often treated with assisted ventilation (9% vs 1%). CONCLUSION: In this large nationwide sample of 9-1-1 activations treated and transported by EMS, 5% were for asthma/COPD exacerbation. Future work should focus on evidence-based standardization of EMS protocols and practice for asthma/COPD exacerbations to improve the quality of EMS care.
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Asma , Enfermedad Pulmonar Obstructiva Crónica , Adulto , Humanos , Masculino , Femenino , Niño , Estados Unidos/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/terapia , Estudios Retrospectivos , Asma/diagnóstico , Asma/epidemiología , Asma/terapia , Broncodilatadores/uso terapéutico , Hospitales , Progresión de la EnfermedadRESUMEN
BACKGROUND: Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. This study aimed to describe treatment patterns and the odds of a favorable patient outcome (e.g., return of spontaneous circulation (ROSC) or being presumptively alive at the end of the incident) among rural OHCA patients in the U.S. METHODS: Using the 2018 National Emergency Medical Services Informational System (NEMSIS) dataset, we analyzed OHCA incidents where an emergency medical services (EMS) unit provided cardiopulmonary resuscitation (CPR) and either terminated the resuscitation or completed transport. We excluded traumatic injuries, pediatric patients, and incidents with response time >60 minutes. The primary outcome was ROSC at any time during the EMS incident. The secondary outcome was a binary end-of-event indicator previously described for use in NEMSIS to estimate longer-term outcomes. Multivariable logistic regression was performed for each outcome measure comparing rural, suburban, and urban settings while controlling for key factors. RESULTS: A total of 64,489 OHCA incidents were included, with 5,601 (8.9%) in rural settings. Among the full sample of OHCA incidents, ROSC was achieved in 20,578 (33.6%) cases, including 29.2% in rural settings and 34.1% in urban or suburban settings (p < 0.001). Advanced life support units responded to 95.3% of all calls, and a greater proportion of rural OHCA incidents were managed by basic life support units (7.4% vs. 4.2%, p < 0.001). Rural OHCA incidents had longer response times (7.5 vs. 5.9 minutes, p < 0.001), and rural patients were less likely to receive epinephrine (69.3% vs. 73.3%, p < 0.001). Further, EMS clinicians in rural areas were more likely to use mechanical CPR (29.5% vs. 27.6%, p < 0.01) and were less likely to perform advanced airway management (48.5% vs. 54.2%, p < 0.001). Rural patients had lower odds of achieving ROSC than urban patients after controlling for other factors (OR 0.81, 95% CI: 0.75-0.87). Rural patients also had lower odds of having a positive end-of-event outcome (i.e., presumptively alive) after controlling for other factors (OR 0.86, 95% CI: 0.79-0.93). CONCLUSION: In this national sample of EMS-treated OHCAs, rural patients had lower odds of a favorable outcome (e.g., ROSC or presumptively alive) compared to those in urban settings.
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Reanimación Cardiopulmonar , Servicios Médicos de Urgencia , Paro Cardíaco Extrahospitalario , Humanos , Niño , Paro Cardíaco Extrahospitalario/epidemiología , Paro Cardíaco Extrahospitalario/terapia , Factores de Tiempo , Población RuralRESUMEN
AIM: We describe emergency medical services (EMS) protocols and prehospital practice patterns related to traumatic cardiac arrest (TCA) management in the U.S. METHODS: We examined EMS management of TCA by 1) assessing variability in recommended treatments in state EMS protocols for TCA and 2) analyzing EMS care using a nationwide sample of EMS activations. We included EMS activations involving TCA in adult (≥18 years) patients where resuscitation was attempted by EMS. Descriptive statistics for recommended and actual treatments were calculated and compared between blunt and penetrating trauma using χ2 and independent 2-group Mann-Whitney U tests. RESULTS: There were 35 state EMS protocols publicly available for review, of which 16 (45.7%) had a specific TCA protocol and 17 (48.5%) had a specific termination of resuscitation protocol for TCA. Recommended treatments varied. We then analyzed 9,565 EMS activations involving TCA (79.1% blunt, 20.9% penetrating). Most activations (93%) were managed by advanced life support. Return of spontaneous circulation was achieved in 25.5% of activations, and resuscitation was terminated by EMS in 26.4% of activations. Median prehospital scene time was 16.4 minutes; scene time was shorter for penetrating mechanisms than blunt (12.0 vs 17.0 min, p < 0.001). Endotracheal intubation was performed in 32.0% of activations, vascular access obtained in 66.6%, crystalloid fluids administered in 28.8%, and adrenaline administered in 60.1%. CONCLUSION: Actual and recommended approaches to EMS treatment of TCA vary nationally. These variations in protocols and treatments highlight the need for a standardized approach to prehospital management of TCA in the U.S.
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Reanimación Cardiopulmonar , Servicios Médicos de Urgencia , Paro Cardíaco Extrahospitalario , Adulto , Estudios Transversales , Soluciones Cristaloides , Epinefrina , Humanos , Paro Cardíaco Extrahospitalario/etiología , Paro Cardíaco Extrahospitalario/terapiaRESUMEN
Background: Describing the US emergency medical services workforce is important to understand gaps in recruitment and retention and inform efforts to improve diversity. Our objective was to describe the characteristics and temporal trends of emergency medical technicians (EMTs) and paramedics in the United States. Methods: We performed a repeated cross-sectional evaluation of US Census Bureau's American Community Survey 1-year Public Use Microdata Sample data sets from 2011-2019. We included respondents working as an EMT or paramedic. Survey-weighted descriptive statistics of demographic and employment characteristics were calculated. Trend analysis was conducted using joinpoint regression to estimate slope and annual percent change (APC). Results: The total estimated number of EMTs and paramedics in the United States increased from 216,310 (95%CI 204,957-227,663) in 2011 to 289,830 (95%CI 276,918-302,743) in 2019 (APC 3.0%; 95%CI 1.4%, 4.7%). There was a slight increase in the proportion of females (2011, 31%; 2019, 35%). There was a significant decrease in proportion of non-Hispanic whites (2011, 80%; 2019, 72%; APC -1.5%; 95%CI -2.0%, -0.9%) with concurrent increases in other racial/ethnic groups (e.g., Hispanics, 2011, 10%; 2019, 13%). About half worked >40 hours per week, with little change over time. Between 15% and 18% lived and worked in different states, and about 40% traveled ≥30 minutes to their workplace. Conclusions: The number of EMTs and paramedics actively working in EMS as their primary paid occupation has increased over time. However, there have been only modest changes in their demographic diversity.
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BACKGROUND: Geriatric patients face disparities in prehospital trauma care. We hypothesized that geriatric trauma patients are more likely to experience prolonged prehospital scene time than younger adults. METHODS: Retrospective analysis of the 2017 National Emergency Medical Services Information System. Patients who met anatomic or physiologic trauma criteria based on national triage guidelines were included (n = 16,356). Geriatric patients (age≥65, n = 3594) were compared to younger adults (age 18-64). The primary outcome was prolonged scene time (>10 min). Multivariable logistic regression was performed, controlling for patient demographics, on-scene treatments, and injury severity. RESULTS: Geriatric patients were more likely to experience prolonged scene time than younger adults after controlling for other factors (OR 1.78, 95% CI 1.57-2.04, p < 0.001). The likelihood of prolonged scene time reached OR 2.29 (95% CI 1.85-2.84) for patients age 70-79 and OR 2.66 (95% CI 2.07-3.42) for patients age 80-89, relative to age 18-29. CONCLUSIONS: Geriatric trauma patients are more likely than younger adults to have prolonged prehospital scene time. This disparity may be caused by delayed recognition of injury severity or age-related cognitive biases.
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Servicios Médicos de Urgencia , Heridas y Lesiones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Humanos , Puntaje de Gravedad del Traumatismo , Persona de Mediana Edad , Pacientes , Estudios Retrospectivos , Centros Traumatológicos , Triaje , Heridas y Lesiones/terapia , Adulto JovenRESUMEN
BACKGROUND: The percentage of female dermatologists has increased from 6.9% in 1970 to 48.9% in 2017. Despite the changing gender composition of the dermatologist workforce, it is unknown whether there are gender-based differences in dermatology practice locations. OBJECTIVE: This study aimed to characterize gender-based differences in dermatology practice locations across the United States. METHODS: A cross-sectional study of all dermatologists in the 2020 Centers for Medicare and Medicaid Services Physician Compare Database was performed. The number of self-identified female dermatologists and total dermatologists in each county and state was tabulated, and Spearman's correlation coefficients between county-level demographic and socioeconomic characteristics and female practices were calculated. RESULTS: Among 11,911 dermatologists, 5945 (49.9%) self-identified as female and 5966 (50.1%) as male. Of the 1052 counties with a dermatologist, 291 (27.7%) had no female dermatologist and 149 (14.2%) had no male dermatologist. The percentage of female dermatologists in each state ranged from 18.4% to 62.2%. Female dermatologists practiced more in areas with a higher percentage of democratic voters (râ¯=â¯+0.22) and higher median household income (râ¯=â¯+0.18), and less in rural counties (râ¯=â¯-0.18) or counties with higher uninsured rates (râ¯=â¯-0.11). CONCLUSION: Female dermatologists remain significantly underrepresented in some regions in the United States, particularly in the Mountain states and rural counties. As women continue entering the dermatologist workforce, these results can inform workforce planning strategies to improve the distribution and accessibility of dermatologists across the United States.
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There are significant disparities in access to dermatologists in rural areas relative to urban areas. We examined the associations between demographic and medical school characteristics and entry into dermatology practice in urban versus rural counties. All dermatologists who graduated from U.S. allopathic or osteopathic medical schools in the 2020 Centers for Medicare & Medicaid Services Physician Compare Database were assessed. Dermatology practice locations were coded as metropolitan or non-metropolitan according to the Rural-Urban Continuum Codes. Of 10,076 dermatologists, 543 (5.4%) practiced in non-metropolitan counties. Male gender (odds ratio [OR] 1.48, 95% CI 1.23-1.77), public medical school attendance (OR 1.94, 95% CI 1.61-2.34), DO degree (OR 1.84, 95% CI 1.32-2.51), medical school location in a non-metropolitan county (OR 5.41, 95% CI 3.66-7.84), and medical school rural track program (OR 1.57, 95% CI 1.07-2.26) were associated with higher odds of non-metropolitan dermatology practice. Our findings highlight that male gender, graduation from a non-metropolitan or public medical school, DO degree, and rural tracks are associated with higher likelihood of non-metropolitan dermatology practice. These results can inform efforts within the field of dermatology to strengthen the rural dermatologist workforce and suggest that rural educational experiences during medical school may increase recruitment of rural dermatologists.
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Selección de Profesión , Dermatólogos/provisión & distribución , Accesibilidad a los Servicios de Salud , Servicios de Salud Rural/estadística & datos numéricos , Facultades de Medicina , Servicios Urbanos de Salud/estadística & datos numéricos , Estudios Transversales , Dermatología/estadística & datos numéricos , Femenino , Fuerza Laboral en Salud , Humanos , Masculino , Estados UnidosAsunto(s)
Biopsia/instrumentación , Procedimientos Quirúrgicos Dermatologicos/instrumentación , Países en Desarrollo , Accesibilidad a los Servicios de Salud/organización & administración , Equipo Quirúrgico/provisión & distribución , Biopsia/estadística & datos numéricos , Estudios Transversales , Procedimientos Quirúrgicos Dermatologicos/estadística & datos numéricos , Instituciones de Salud/provisión & distribución , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , HumanosRESUMEN
Importance: Emergency medical services (EMS) are an essential component of the health care system, but the effect of insurance expansion on EMS call volume remains unclear. Objective: This study investigated the association between health insurance expansion and EMS dispatches for asthma, an ambulatory care-sensitive condition. We hypothesized that insurance expansion under the Patient Protection and Affordable Care Act (ACA) would be associated with decreased EMS dispatches for asthma emergencies. Design, Setting, and Participants: This cohort study examined 14â¯865â¯267 ambulance calls dispatched within New York City from 2008 to 2018, including 217â¯303 calls for asthma-related emergencies, and used interrupted time series analysis to study the change in the annual incidence of EMS dispatches for asthma emergencies after implementation of the ACA. Multivariable linear regression examined the association between the uninsured rate and the incidence of asthma-related dispatches, controlling for population demographic characteristics and air quality index. Exposures: Implementation of ACA on January 1, 2014. Main Outcomes and Measures: Incidence of EMS dispatches for asthma emergencies per 100â¯000 population per year (ie, asthma EMS dispatch rate) as classified by the 911 call-taker. Results: In this study of 217â¯303 EMS dispatches for asthma-related emergencies, there was a decrease in the asthma EMS dispatch rate after implementation of the ACA, from a mean (SD) of 261 (24) dispatches per 100â¯000 population per year preintervention to 211 (47) postintervention (P = .047). This decrease in asthma EMS dispatch rate after ACA implementation was significant on interrupted time series analysis. Prior to 2014, the annual asthma EMS dispatch rate was increasing by 11.8 calls per 100â¯000 population per year (95% CI, 6.1 to 17.4). After ACA implementation, the asthma EMS dispatch rate decreased annually by 28.5 calls per 100â¯000 population per year (95% CI, -37.6 to -19.3), a significant change in slope from the preintervention period (P < .001). Multivariable linear regression, controlling for percentage of individuals younger than age 18 years, degree of racial/ethnic diversity, median household income, and air quality index, found that a 1% decrease in the citywide uninsured rate was associated with a decrease of 98.9 asthma dispatches per 100â¯000 population per year (95% CI, 5.72-192.10; P = .04). Conclusions and Relevance: Insurance expansion within New York City under the ACA was associated with a significant reduction in the asthma EMS dispatch rate. Insurance expansion may be a viable method to reduce EMS utilization for ambulatory care-sensitive conditions such as asthma.
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Ambulancias/estadística & datos numéricos , Asma , Servicios Médicos de Urgencia/tendencias , Seguro de Salud/tendencias , Pacientes no Asegurados/estadística & datos numéricos , Patient Protection and Affordable Care Act , Urgencias Médicas , Asesoramiento de Urgencias Médicas/tendencias , Humanos , Modelos Lineales , Análisis Multivariante , Ciudad de Nueva YorkRESUMEN
BACKGROUND /OBJECTIVES: Although 82% of pediatricians report that their patients have difficulty accessing pediatric dermatologists, the regions with greatest need for the specialty are not well-defined. We aimed to determine the geographic distribution of pediatric dermatologists relative to the number of children and pediatric generalists. METHODS: We performed a cross-sectional study of all US board-certified pediatric dermatologists, generalists (defined as pediatricians and family medicine physicians), and children in 2020. Data were obtained from the Society for Pediatric Dermatology, American Board of Pediatrics, Centers for Medicare and Medicaid, and US Census Bureau. Number of children, pediatric dermatologists, and pediatric generalists were tabulated in each county and state, and the distributions of pediatric dermatologists and generalists relative to the population of children were quantified with the Gini coefficient. RESULTS: Of 317 pediatric dermatologists, 243 (76.7%) were women and 311 (98.1%) worked in a metropolitan county. A pediatric dermatologist was present in 41/50 (82%) states and 142/3228 (4.4%) counties. Not a single pediatric dermatologist was found in 54/92 (58.7%) counties with 100 000-199 999 children, 15/53 (28.3%) counties with 200 000-499 999 children, and 4/13 (30.8%) counties with ≥500 000 children. The Gini coefficient for the state-level distribution of pediatric dermatologists relative to population of children was 0.488 compared to 0.132 for that of pediatric generalists. CONCLUSION: There is a maldistribution of pediatric dermatologists, resulting in children with unmet dermatologic needs in nine states and 96 heavily populated counties. These results can inform initiatives to recruit pediatric dermatologists and to expand telehealth access to specific high-density areas.
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Dermatología , Pediatría , Anciano , Niño , Estudios Transversales , Dermatólogos , Femenino , Humanos , Masculino , Medicare , Estados Unidos , Recursos HumanosAsunto(s)
Infecciones por Coronavirus/epidemiología , Países en Desarrollo , Recursos en Salud/provisión & distribución , Neumonía Viral/epidemiología , Betacoronavirus , COVID-19 , Infecciones por Coronavirus/economía , Humanos , Pandemias/economía , Equipo de Protección Personal/provisión & distribución , Neumonía Viral/economía , SARS-CoV-2 , Ventiladores Mecánicos/provisión & distribuciónRESUMEN
An essential step in the morphogenesis of tailed bacteriophages is the joining of heads and tails to form infectious virions. Our understanding of the maturation of complete virus particles remains incomplete. Through an unknown mechanism, phage T4 gene product 4 (gp4) plays an essential role in the head-tail joining step of T4-like phages. Alignment of T4 gp4 homologs identified a type II restriction endonuclease motif. Purified gp4 from both T4 and a marine T4-like bacteriophage, YC, have non-specific nuclease activity in vitro. Mutation of a single conserved amino acid residue in the endonuclease fold of T4 and YC gp4 abrogates nuclease activity. When expressed in trans, the wild type T4 gp4, but neither the mutated T4 protein nor the YC homolog, rescues a T4 gene 4 amber mutant phage. Thus the nuclease activity appears essential for morphogenesis, potentially by cleaving packaged DNA to enable the joining of heads to tails.