All posts by Mike Schadone

Technology

Making the Strange Familiar – A Cultural Identity

Scouring the literature in an attempt to define indigenous identity as it relates to me has been futile. Weaver (2001) describes the difficulty of obtaining a consensus on the definition of indigenous identity and how to apply the term. She continues to outline her frustration and finally gives in to using less exact terms. Corntassel (2003) shows how a multitude of definitions has arisen that are both incomplete and politicized. Neither Weaver nor Corntassel nor any of the other scholars that I have read in the past two weeks would agree, based on their writings, that I would have some indigenous identity. It seems that this would otherwise offend them. It is obvious, however, that I have a cultural identity as do all people, but I fail to see myself as indigenous, so I will concentrate on this cultural identity using the fieldwork methods outlined by Omohundro (2008).

My cultural identity is, in part, related to my ancestry, or genealogy. As far as I can tell, my ancestry is a combination of Italian, French, English, German, Irish, Scottish, and Portuguese, though living New England, specifically around Boston, Providence, and New York, I have more of an affinity to my Irish and Italian heritage. However, it does appear that I share my English heritage with nobility of Queen Catherine’s privy court, Sir John Alexander Webb, and William Shakespeare.

Developing as a child in my household, I have learned a few ideals that have more import and others: loyalty, character, and resolution. Honesty, temperance, and justice I have learned on my own, or more evidently from my environment growing up. Much of this wisdom of our forefathers is still evident in and around Rhode Island, thankfully. Understanding why my ancestors migrated as they did certainly underscores the importance of freedom, liberty, and tolerance.

The ethnosemantics of Rhode Islanders can be quite intriguing to outsiders. I am not sure that I have ever met anyone who enjoyed the dandle as much as my cousins and I. Others, though, would have used a see-saw or teeter-totter. Likewise, I remember looking forward to enjoying a cabinet on a hot summer day with my grinder. Others might have enjoyed a milkshake with their submarine sandwich, hoagie, or hero. It seems that we stole the terms bubbler and soda from Wisconsinites as they moved to the area as my ancestors did. A bubbler being a water fountain and soda refers to any carbonated beverage.

Even more interesting than our vocabulary, though, is our pronunciation. Traveling around the country, I have noticed that when residents of other States hear an accent, they usually just comment on it. For the typical Rhode Islander, we are made to repeat ourselves often. Sometimes people truly do not understand our vernacular, but mostly it is for the novelty of it all. Rhode Islanders seem to remove the letter ‘r’ from words and place them in words that do not have any. Additionally, we run many words together unnecessarily. For example, “A Rhod’aylindah would flip a breakah if the lights’n out an’ say suntin’ like ‘I’ve an idear… let’s getindacah’n go fe’ bananar splits wit vanillar ice cream,’” or my favorite, “Immunna gessin gaggahs, djeetjet?” This question would usually be replied with, “No, joo?” More obvious, the first set of statements refers to resetting a circuit breaker after losing power then taking a ride in the car to get a banana split. The second, more cryptic, phrasing simply translates, “I am going to get some gaggers (or, hot weiners; see also http://www.olneyvillenewyorksystem.com), did you eat yet?” The reply being, “No, did you?” We tend to ask even if we know the answer.

As our strange vocabulary and pronunciation are very colloquial, I think I might understand how it has developed. Rhode Island has always been known for tolerance, both religious and political; therefore, the heritage has always been a rich mixture of various cultures attempting to flee from various types of oppression. My assumption is that much of the dialect and vocabulary is simply based on misunderstanding and ethnosemantic distortions of the multiple cultures residing at any given time in Rhode Island, a pidgin. I may be mistaken, but the thesis seems viable.

Understanding my cultural identity allows me to view the world and other cultures with temperance and acceptance. My heritage is rich with both culture and despotism. Likely, many other people have a similar story. Most important in understanding cultural identity is the ability to benchmark one’s self against society. Doing so allows me the ability to focus on the moral strengths that I have learned while attempting to temper the weaknesses. With a more complete understanding, I am able to justify the life lessons that I might pass on to others.

References

Corntassel, J. J. (2003). Who is indigenous? ‘Peoplehood’ and ethnonationalist approaches to rearticulating indigenous identity. Nationalism and Ethnic Politics, 9(1), 75-100. doi:10.1080/13537110412331301365

Omohundro, J. T. (2008). Thinking like an anthropologist: A practical introduction to cultural anthropology. New York, NY: McGraw Hill.

Weaver, H. N. (2001). Indigenous identity: What is it and who really has it? The American Indian Quarterly, 25(2), 240-255. doi:10.1353/aiq.2001.0030

Politics, Technology

Indigenous People

In order to define a term, such as “indigenous peoples”, one must examine the words that make up the phrase. “Peoples” are collections of societies, and “indigenous” implies nativity or autochthony. I have always considered “indigenous peoples” to be those societies that have an intrinsic relationship to the land inhabited. Ergo, when a society is provided for by the land, the act of habitation changes the land, and that land changes the society in a fundamental way. Whenever this is true and can be applied to a society, then it is a society of indigenous people.

The largest difficulty in defining or categorizing human beings is the resultant scale upon which they are measured as a group. I do not hold such inclinations as to group and sort people based on ethnicity, societal values, economics, or any other humanly devised subjective measures. The United Nations (2008) requires a society to be impoverished or suffer some other gross inequality in order to claim indigeny. I feel that this approach only serves to feed ideologic notions by marginalization and deprives the society from a rightful claim. By attempting to create a system to help indigenous peoples from inequality, the United Nations has sought to identify these peoples and have instead cast a definition upon them. Certainly, this is a problem.

References

Secretariat of the United Nations Permanent Forum on Indigenous Issues, Division for Social Policy and Development, Department of Economic and Social Affairs. (2008). Resource kit on indigenous peoples’ issues. New York, NY: United Nations. Retrieved from http://www.un.org/esa/socdev/unpfii/documents/resource_kit_indigenous_2008.pdf

Health Care, Politics, Public Health, Society

Reducing Philanthropy to Political Commentary

In searching the typical news outlets for stories related to health care reform, be it local or national, I cannot help but notice that health care reform is the news. The factions are split, and the bias is evident. As the news outlets lean more to the left of the political spectrum than ever before, it is almost impossible to research the real issues at hand. Wading through the political views to glimpse a meaningful patient-focused agenda is quite difficult lately.

An article written by Randall Beach (2009) of the New Haven Register focuses on a group of doctors that rely on charity to provide health care to a select adult population who do not qualify for Medicaid and make less than $20,000 per year. Unfortunately, this article, like so many others, reduces philanthropy to political commentary.

Our current health care system is fragmented, and many people believe health care reform is needed (“54% Say Major Changes Needed”, 2009). As Dr. Peter Ellis is quoted, “Our motto is: ‘Health care reform starts at home'” (Beach, 2009, p. 3). It does not make sense, however, to provide Universal Health Care at the cost of our failing economy. Dr. Ellis’ group, Project Access, has secured funding from private sources, including the Hospital of St. Raphael and Yale-New Haven Hospital staff, the Aetna Group, the Community Foundation for Greater New Haven, and the New Haven County Medical Association Foundation. Additionally, 350 local care providers are associated with the project. This is a grassroots effort at helping to care for our neighbors, and as far as I have read, it seems to be a reasonable and responsible attempt to mend some of the local disparities to health care access.

Though I commend Mr. Beach for covering such a newsworthy story, it serves no one to inflame the current health care debates with political posturing by the media. I believe that the recent passing of health care reform will do nothing but create more clutter and complication for us to untangle when we finally have the financial stability to address the issue responsibly and realistically. In the meantime, I, like Project Access, will continue to volunteer my time and medical services to my community.

References

Beach, R. (2009, December 28). Doctors giving health care reform a head start. New Haven Register. Retrieved from http://www.nhregister.com/articles/2009/12/28/news/new_haven/a1_mon_nedoctors_art.prt

54% Say Major Changes Needed in Health Care System, 45% Disagree. (2009, October 2). Rasmussen Reports. Retrieved from http://www.rasmussenreports.com/public_content/politics/current_events/healthcare/october_2009/54_say_major_changes_needed_in_health_care_system_45_disagree

Academia, Health Care, Politics, Public Health, Society

Health Care Reform

In beginning this endeavor, I found it initially difficult to find anything related to health care legislation that I would be inclined to support or oppose in a letter to my Congressman. I tend to rely on the elections in order to convey my political positions. After studying some of the recent legislation, I found that the only premise that interested me was the adoption of The Patient Protection and Affordable Care Act of 2010 and the related Health Care and Education Reconciliation Act of 2010. Unfortunately, attempting to find credible dialogue on the internet regarding these laws is both impractical and near impossible. The special interest groups are leaning to their respective extremes. With commentary not proving trustworthy for factual insight, I relied on the Congressional Budget Office and the full text of the laws to cement my position. Using the aforementioned information in conjunction with Senator Lieberman’s contact information from the U. S. Senate website (http://www.senate.gov), I formulated a letter to him outlining my economic concerns (see Appendix).

I understand the grandeur of the idea of universal health care. I applaud the debates of how best to offer affordable or free health care to ever citizen of the United States. Unfortunately, as a nation, we are not fit in our financial means to proffer such an expensive entitlement. As Goodson (2010) reports, many of the initiatives outlined within the law are not guaranteed to be successful. This at an increased cost of $390 billion over the first 10 years (Elmendorf, 2010).

To ensure that my points were valid, I researched the approval ratings of these laws. According to WashingtonWatch.com (2010), approximately 80% of respondants do not favor the passing of these laws. More scientifically, however, a consistent range of 54 – 58% of Americans favor repeal of the laws, while 63% of senior citizens agree (Rasmussen Reports, 2010).

References

Elmendorf, D. W. (2010, March 20). Manager’s amendment to reconciliation proposal [Letter to the Honorable Nancy Pelosi]. U. S. Congress, Washington, D. C. Retrieved from the Congressional Budget Office website: http://www.cbo.gov/ftpdocs/113xx/doc11379/ Manager%27sAmendmenttoReconciliationProposal.pdf

Goodson, J. D. (2010). Patient Protection and Affordable Care Act: Promise and peril for primary care. Annals of Internal Medicine. Advance online publication. Retrieved from http://www.annals.org/content/early/2010/04/15/0003-4819-152-11-201006010-00249.full

Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152 (2010).

Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148 (2010).

Rasmussen Reports. (2010, May 17). Health care law: 56% Still Want to Repeal Health Care Law, Political Class Disagrees. Retrieved on May 22, 2010, from http://www.rasmussenreports.com/public_content/politics/current_events/healthcare/march_2010/health_care_law

WashingtonWatch.com. (2010). P.L. 111-148, The Patient Protection and Affordable Care Act. Retrieved on May, 22, 2010 from http://www.washingtonwatch.com/bills/show/111_PL_111-148.html

Appendix

Michael F. Schadone
[REDACTED] Woodstock, CT 06282

The Honorable Joseph I. Lieberman
706 Hart Office Building
United States Senate
Washington, DC 20510

May 22, 2010

Re: The Patient Protection and Affordable Care Act of 2010

 Dear Senator:

 My name is Michael Schadone and I am a nationally registered critical care paramedic working in Northeast Connecticut. I am writing you today because I do not support the recent legislation referred to as The Patient Protection and Affordable Care Act of 2010. I urge you and your colleagues in Congress to repeal this law. I believe that our efforts aimed at improving the economy will, in itself, dramatically reduce the disparities in access to health care.

Under the auspices of a progressive government, our country has seen many times of woe. Bigger government and higher rates of spending have driven our economy into the ground. It was only the idea of smaller government and trust in the American entrepreneur that ever caused unemployment rates to drop to less than five percent. More people gainfully employed means more people with access to affordable health care. Is this not our goal? In Europe, economic systems are collapsing. Many of the countries with universal health care have tax rates approaching 70 percent (including ‘value-added tax’). It is commonly held that suppressing the spending power of the citizenry will surely lead to a collapse of the free market, the basis of our economy. I certainly do not want the United States of America to resemble Greece, Portugal, Spain, or Cuba. We are the Great Experiment, and so far, it is working. I fear, though, not for much longer.

I favor universal health care just as I favor universal education and other entitlements but not at the expense of our country. Improvements to the economy will put us in a position to gain strength and enable us to afford such a sweeping paradigm shift in health care. More importantly, a better economy will allow us to do it properly. I urge you to focus on the economy and repeal this dangerous law.

 Sincerely,

Michael F. Schadone

Academia, Clinical, Emergency Medical Services, Health Care

Flawed Conclusions in Literature Review

For this week’s discussion, I have chosen to analyze an article (Sakr et al., 2006) that attempts to outline the efficacy and potential dangers of certain drugs used to treat shock. As a critical care paramedic, the discussion surrounding this article can provide insight to choosing alternative therapies when caring for my patients, but it is important for me to understand the potential biases and limitations of such a study that could lead to flawed conclusions (Gluud, 2006).

Sakr et al. (2006) collected data on ICU admissions over a two week period to further understand how dopamine effects mortality and morbidity when administered in response to hemodynamic compromise. Also, other administered vasoactive drugs were included in the analysis whether administered concomitantly with dopamine or instead of dopamine. The researchers did not distinguish between etiologies except to delineate between septic shock and non-septic shock. Patients who presented with shock or suffered a shock state within the first 24 hours of admission were included in the analysis. Patients admitted to the ICU mainly for 24 hour surgical observation where not included.

Shock is defined as “a state of inadequate cellular sustenance associated with inadequate or inappropriate tissue perfusion resulting in abnormal cellular metabolism” (Hillman & Bishop, 2004, p. 121). There are many etiologies of shock, including sepsis, anaphylactic, neurogenic, hypovolemic, cardiogenic, and others, which respond differently to various therapies. This confounder creates an information bias, as this variable is not identified in the data collection and cannot be scrutinized. Simply identifying the etiology of each shock state would limit this bias. The researchers, however, acknowledge this limitation and others.

Another confounding variables is the time constraint of the data. In regards to septic shock, this variable becomes evident. Many pathogens spread predictively during certain times of the year. The concomitant treatment of these infections could predispose patients to suffer a prolonged state of shock (in cases where the pathogen might not be immediately recognized) or provide for an ideal treatment pathway when the pathogen and the antibiotic regimen are fully understood and effective. This selection bias could be controlled by choosing patients who present throughout the year.

As Gluud (2006) points out:

When intervention effects are moderate or small, the human processing of data, unsystematic data collection, and the human capacity to overcome illnesses spontaneously limit the value of uncontrolled observations. Experimental models are essential for estimation of toxicity and pathophysiology.
(p. 494)

References

Gluud, L. L. (2006). Bias in Clinical Intervention Research. American Journal of Epidemiology, 163(6), 493–501. doi:10.1093/aje/kwj069

Hillman, K. & Bishop, G. (2004). Clinical Intensive Care and Acute Medicine. West Nyack, N.Y.: Cambridge University Press.

Sakr, Y., Reinhart, K., Vincent, J., Sprung, C. L., Moreno, R., Ranieri, V. M., De Backer, D., & Payen, D. (2006). Does Dopamine Administration in Shock Influence Outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Critical Care Medicine, 34(3), 589-597. doi:10.1097/01.CCM.0000201896.45809.E3

Academia, Clinical, Culture, Emergency Management, Emergency Medical Services, Health Care, Public Health, Technology

Patient Safety Considerations for EMS

 In the out-of-hospital emergency care setting, patient safety is paramount. Initially, victims of trauma or illness are already suffering in an uncontrolled environment. It is this same environment where first responders, emergency medical technicians, and paramedics must operate to stabilize and transport the victim to the hospital, a more controlled environment. Unfortunately, there is little research in the area of patient safety in this setting (Meisel, Hargarten, & Vernick, 2008; Paris & O’Conner, 2008).

Importance

Focusing on patient safety and developing processes to ensure optimal safety would allow the study of inherently dangerous, yet potentially beneficial therapies, such as rapid sequence intubation where the clinician uses a series of medications to rapidly sedate and paralyze a critical patient for ease of inserting a breathing tube. Focusing on safety, an EMS department in Maryland successfully instituted such a program (Sullivan, King, Rosenbaum, & Smith, 2010).

With more research in this area, the Emergency Medical Services (EMS) can improve the care they seek to deliver to their patients.

Challenges

There are many challenges facing EMS as they seek to deliver safe and effective care to their patients. Motor vehicle accidents (including air transportation accidents), dropped patients, medication and dosage errors, other inappropriate care, and assessment errors all contribute to the number of adverse events in the EMS out-of-hospital care setting (Meisel et al., 2008). Unfortunately, it has proved difficult to identify both the existence and the cause of each event (Meisel et al., 2008; Paris et al., 2008). Additionally, there are adverse events that are impossible to track, such as the iatrogenic exposure to a pathogen. It would be very difficult to distinguish how and when a patient was first exposed to the infecting pathogen without considering community-acquired infections and hospital-acquired infections, which are both equally difficult to ascertain (Taigman, 2007).

Strategies for improvement

As EMS seeks to increase the professionalism among its ranks, the stakeholders must acknowledge responsibility for providing evidence-based processes to ensure patient safety.

References

Meisel, Z. F., Hargarten, S., & Vernick, J. (2008, October). Addressing prehospital patient safety using the science of injury prevention and control.Prehospital Emergency Care, 12(4), 4-14.

Paris, P. M. & O’Connor, R. E. (2008, January). A national center for EMS provider and patient safety: helping EMS providers help us. Prehospital Emergency Care, 12(1), 92-94.

Sullivan, R. J., King, B. D., Rosenbaum, R. A., & Shiuh, T. (2010, January). RSI: the first two years. One agency’s experience implementing an RSI protocol. EMS Magazine, 39(1), 34-51.

Taigman, M. (2007, July). We don’t mean to hurt patients. EMS Magazine, 52(4), 36-42.

Academia, Health Care, Politics, Public Health, Society

Freedom vs. Health Care Reform

In the United States, we believe in individual rights, some of which are enumerated in the U. S. Constitution. The right to health care is not one of these. As our country prospers or declines, we may amend our Constitution to ensure more rights or take them away. The question, now, is can we afford health care for all? At this moment, I believe we cannot. Other countries have attempted to provide health care for all of its citizens but are facing economic troubles in spite of 70% tax rates (Clark & Dilnot, 2002). I believe that high tax rates are dangerous to the economy because the people and the government compete in mobilizing the economy; whereas with lower tax rates, the small businesses can drive the economy (U.S. Small Business Administration, Office of Advocacy, 2006).

It is my experience that those who overutilize health care are those who are under-insured (e.g. Medicare and Medicaid) and uneducated about the health care system. Further, it seems that the underpayment of costs by the Medicare and Medicaid programs are driving up the recoverable costs to other payors (Brennan & Mello, 2009). This is why I believe that our health care system is as expensive and inefficient as it is. “The U.S. health care system also spends more on administrative or overhead costs related to health care,” says Garber and Skinner (2008, p. 32), but they attribute this to administrative waste where I conclude that the over-administration is needed to meet the demands of an over-regulated and inefficient payment system.

In conclusion, our health care system is linked to our economy, and improving the economy is the only way to ensure that our health care system improves. By adding entitlements, we are forcing the American people to minimize their financial growth and, thereby, their financial freedom to choose affordable health care.

References

Brennan, T. A. & Mello, M. M. (2009). Incremental health care reform. Journal of the American Medical Association, 301(17), 1814-1816. doi:10.1001/jama.2009.610

Clark, T. & Dilnot, A. (2002). Long-term trends in British taxation and spending (IFS Briefing Note No. 25). London, UK: The Institute for Fiscal Studies. Retrieved from http://www.ifs.org.uk/bns/bn25.pdf

Garber, A. M. & Skinner, J. (2008). Is American health care uniquely inefficient? Journal of Economic Perspective, 22(4), 27–50. doi:10.1257/jep.22.4.27.

U.S. Small Business Administration, Office of Advocacy. (2006, September 28). Small business drives the U.S. economy — represent 99.7 percent of all businesses, employ 57.4 million (SBA No. 06-17 ADVO). Retrieved from http://www.sba.gov/advo/press/06-17.html

Academia, Clinical, Emergency Medical Services, Health Care, Politics, Public Health, Society

Pay-for-performance in EMS?

There has been much discussion regarding reimbursement models for health services, and two main themes have emerged, the historical fee-for-service model and a quality-driven pay-for-performance model (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While many providers argue that the reimbursement level is currently too low to sustain operations (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007), patient advocates cite an overwhelming number of medical mistakes allowing providers to benefit from poorer outcomes leading to increased needs of critical care services which lengthen hospital stays dramatically (Committee on Quality of Health Care in America & Institute of Medicine Staff, 2001; Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While considering more effective designs within our health care system, treatment efficacy, reimbursement paradigms, and patient safety could possibly be used as a foundation upon which to rebuild our health care infrastructure. The Committee on Quality of Health Care in American and the Institute of Medicine Staff (2001) offer “six aims [safe, effective, patient-centered, timely, efficient, and equitable] for improvement that can raise the quality of care to unprecedented levels” (p. 5).

Fee-for-service models, the traditional norm in health care reimbursement, seek to itemize care expenditures based on particular procedures or services rendered to the patient. Though fee-for-service models reward providers for timely, and possibly effective and efficient, delivery of care, it does little to address safe, patient-centered, and equitable considerations.

Financial barriers embodied in current payment methods can create significant obstacles to higher-quality health care. Even among health professionals motivated to provide the best care possible, the structure of payment incentives may not facilitate the actions needed to systematically improve the quality of care, and may even prevent such actions.
(Committee on Quality of Health Care in America et al., 2001, p. 181)

As a paramedic, I am bound to a Medicare reimbursement model that focuses solely on the transportation of the patient and not on the care rendered. For a patient experiencing cardiac chest pain, merely placing them on a continuous ECG monitor and providing transportation to the hospital allows my employer to be paid the same as if I initiated an intravenous line, administered oxygen, aspirin, nitroglycerin, and morphine, and performed serial diagnostic 15-lead ECG readings during the transport. In any case, though, payment is withheld if the patient is not transported. I have to assume that this inequitable reimbursement scheme is replicated across the health care spectrum.

Pay-for-performance models, however, seek to reward the provider for improving the quality of care delivered and “represents an attempt to align incentives in the payment system so that rewards are given to providers who foster the six quality aims set forth in the Quality Chasm report” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 36; Committee on Quality of Health Care in America et al., 2001). Some detractors of pay-for-performance worry that providers serving poor and ethnic communities that have typically poor health and preventative compliance will not benefit from such performance measures. The worry is that the numbers of providers will be lacking in these communities, worsening the communities health outcomes (Nafziger, 2010). Though, “pay for performance is not simply a mechanism to reward those who perform well; rather, its purpose is to encourage redesign and transformation of the health care system to ensure high-quality care for all” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 44). Pay-for-performance focuses on safety, and a search of the literature does not reveal any complicating risk to patients under a pay-for-performance system so long as the system is patient-centric, taking into account the patient population serviced by each provider.

For instance, regarding a certain type of heart attack called a “STEMI”, or ST-segment elevation myocardial infarction, it is beneficial for the paramedic ambulance to bypass the local community hospital and transport the patient to a primary coronary intervention (PCI) facility for a cardiac catheterization. In this instance, the local community hospital is losing potential revenue. Perhaps if the reimbursement model reflected this evidence-based and patient-centered decision and provided a small monetary reward to the local community hospital for allowing the directed care at the PCI center, then mortality and morbidity from STEMI in the community would be reduced and the local hospital would be rewarded for their involvement in the process even if they did not provide any direct care. This is just one instance in the realm of emergency care where pay-for-performance can help to ensure safe, effective, patient-centered, timely, efficient, and equitable delivery of care to the patient.

As both a health care provider and consumer, I would prefer the pay-for-performance model of reimbursement. As a provider, I am a patient advocate, and as a patient, I will, of course, advocate for myself. Pay-for-performance enables provider growth, evidence-based practice, better patient safety mechanisms, and an overall efficient and a more complete and holistic delivery of care.

References

Committee on Quality of Health Care in America (Author), & Institute of Medicine Staff (Author). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff (Author). (2007). Rewarding provider performance: Aligning incentives in Medicare. Washington, DC: National Academies Press.

Nafziger, B. (2010, May 6). Pay for performance could hurt docs who serve poor, blacks and hispanics. DOTMed News. Retrieved from http://www.dotmed.com/fr/news/story/12570/

Academia, Clinical, Emergency Management, Emergency Medical Services, Health Care, Public Health

Botulism: A Measurement of Occurrence

 Botulism, caused by the Clostridium botulinum bacterium, is typically caused by poorly prepared, home-canned foods and can cause symptoms as simple as blurred or double vision to full body paralysis, sometimes causing death (Centers for Disease Control and Prevention [CDC], 1996). The incidence of botulism is said to be extremely low with only 126 reported cases in the United States in 2003; with only eight attributable to foodborne vectors, the predominant cause is accidental contamination (CDC, 2004).

One of the concerns regarding botulism is its toxicity. Botulinum toxin is the most potent toxin known to man (CDC, 2006). This potency lends to botulinum’s ability to be used as an agent of bioterrorism, though most of the known cases have been shown to be accidental in nature (CDC, 1996; CDC, 2006). Another concern is the accidental or negligent contamination of any food prepared for wide distribution, such as canned vegetables from a large manufacturer.

Surveillance is important to identify each and every case in order to have the most accuracy possible when considering increasing or decreasing trends of incidence and prevalence of the disease. The cause of any increase or decrease in incidence of botulism should always be investigated.

Any increase of incidence could identify a possible problem while a decreased incidence could foretell efficacy in the efforts of mitigation. More appropriately, though, as Friis and Sellers (2009) show, further identification should be made in order to focus on specific descriptive factors, such as affected populations, the geography of these populations, known vectors, and factors of time. This process will ensure that more accurate trends are observed.

For instance, the CDC (2004) has stated that in a typical year, such as 2004, the incidence of botulism is less than 200. With incidence reporting covering the entire United States, increases or decreases in this crude number serve only to identify general changes in frequency; whereas, further identification of certain characteristics of the disease pattern will help to further isolate affected individuals and etiologies (Friis et al., 2009). Within the CDC’s (2004) data, infant occurrence of botulism is identified as the major contributor to incidence, thereby isolating the remaining occurrences to adults. The CDC has gone further to separate the incidences of botulism into three groups, infant occurrence, foodborne infection, and wound infection. A separate group is reserved for other occurrences relating to the use of pharmacological botulin.

Using descriptive factoring of the 2003 CDC data (2004), further geographic isolation of occurrences show that infant occurring botulism is fairly wide-spread with a small number of incidences in each of twenty-two States, though California and Pennsylvania account for about half of the reported infant occurrences. Foodborne and wound occurrences of botulism were isolated to Alaska, California, Colorado, Oregon, Utah, and Washington. Texas had the only two reportable cases classified as “Other”. Theoretical assumptions can now be used to show that the problem in Texas is resolved but should continue to be monitored, and food safety education projects should focus on home-canning in the western regions of the United States.

In conclusion, epidemiology is an important means of understanding and identifying causation and etiology, as well as preparing for mitigation and outbreak response. In this example of botulism, I have identified localization of the disease, common pathways of infection, or vectors, and means of helping to mitigate future occurrences of the disease. Botulism numbers are quite low, but dealing with other diseases of larger scale, grouping the data into useful subsets will assist in following the progression of the disease from outbreak to outbreak and in consideration of mitigation techniques employed.

References

Centers for Disease Control and Prevention, U. S. Department of Health and Human Services. (1996). Botulism (Clostridium botulinum): 1996 case definition [CSTE Position Statement No. 09-ID-29]. Retrieved from http://www.cdc.gov/ncphi/disss/nndss/casedef/botulism_current.htm

Centers for Disease Control and Prevention, U. S. Department of Health and Human Services. (2004). Surveillance for Outbreaks of Botulism [Summary of 2003 Data]. Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/Botulism_CSTE_2003.pdf

Centers for Disease Control and Prevention, U. S. Department of Health and Human Services. (2006). History of Bioterrorism: Botulism. CDC Emergency Preparedness and You [Podcast]. Washington, DC: CDC Bioterrorism Preparedness and Response Program.

Friis, R. H., & Sellers, T. A. (2009). Epidemiology for public health practice (4th ed.). Sudbury, MA: Jones & Bartlett.

Academia, Health Care, Public Health, Society

The Socio-economics and Certain Illnesses or Injuries

Kovner and Knickman (2008) describe health disparities as health problems common to specific populations, and they differentiate health care disparities as a “[reflection of] the interaction of health care access and utilization with broader societal issues related to racial and ethnic, socioeconomic, and gender differences” (p. 421). Many social groups take part in risky behaviors. If these social groups are drawn along certain socio-economic lines, then it would appear that there is a causal relationship between socio-economics and certain illnesses or injuries when the correlation is truly the risk-taking behavior. Blacks having a ten-fold incidence of AIDS over whites may be related to preliminary health education with no causal relationship to the access of health care (Kovner et al., 2008). Additionally, Kovner et al. point out a higher incidence of Blacks leaving emergency departments before being cared for. Could this be a result of Blacks seeking emergent care for non-emergent problems? Certainly, there are health problems and health care problems common to specific populations.

Initially, when considering racial and ethnic differences, my views revolve around socioeconomic determinants where causal relationships are not what many would consider. Most, I imagine, would consider the cause of poor care to be uncaring health care professionals, but I would venture that the attitudes of some health professionals are the end-result that correlates to poor care. If a health care provider treats patients who continually dismiss their poor health or take part in risky health behavior without considering the long-term effects, the health care professional becomes dispassionate and disconnected, mistrusting patients, and delivering care that is substandard, but presumed to be aligned with the responsibilities taken by the patients, generally speaking. Ergo, if they don’t care, why should I? This generalization creates a common distrust between patient and provider. Aside from the patient-provider relationship, there seems to be a more daunting issue of access to health insurance, which obviates the correlation to a lack of health care access. What are the causes of these disparities?

How do we address the disparities in health care? First, we need to identify if there are truly disparities, what they are exactly, and what is causing them. Recent research suggests a need to find the methods most appropriate to tackle these questions (Kirby, Taliaferro, & Zuvekas, 2006; Lê Cook, McGuire, Meara, & Zaslavsky, 2009; Lê Cook, McGuire, & Zuvekas, 2009). Do we need to understand the problem? Educating both the providers and patients effectively in how to approach each other as well as instituting quality improvement strategies within each health care practice should assure, at least retrospectively, that all patients within a practice would get the same care as any other patient treated by that practice. Additionally, providing patient education about how to access health care appropriately and effectively would help to avoid some of the pitfalls common in our health care system. Some of which may be attributable causes to many of the health care disparities of today.

In conclusion, I feel that many of the health care disparities are not caused by the health care system, though the relationship is noticeable. There are many other factors that need to be considered, and as Kirby et al. point out, “Researchers and policymakers may need to broaden the scope of factors they consider as barriers to access if the goal of eliminating disparities in health care is to be achieved” (p. I64).

References

Kirby, J. B., Taliaferro, G., & Zuvekas, S. H. (2006) Explaining racial and ethnic disparities in health care. Official Journal of Medical Care, 44(5), I64-I72. doi:10.1097/01.mlr.0000208195.83749.c3

Kovner, A. R., Knickman, J. R., & Jonas, S. (Eds.). (2008). Jonas & Kovner’s health care delivery in the United States (9th ed.). New York, NY: Springer.

Lê Cook, B., McGuire, T. G., Meara, E., & Zaslavsky, A. M. (2009). Adjusting for Health Status in Non-Linear Models of Health Care Disparities [Manuscript]. Health Service Outcomes Research Methodologies, 9(1), 1–21. doi:10.1007/s10742-008-0039-6

Lê Cook, B., McGuire, T. G., & Zuvekas, S. H. (2009). Measuring Trends in Racial/Ethnic Health Care Disparities [Manuscript]. Medical Care Research Review, 66(1), 23-48. doi:10.1177/1077558708323607