Environmental justice: frequency and severity of US chemical industry accidents and the socioeconomic status of surrounding communities

STUDY OBJECTIVES

The Clean Air Act Amendments of 1990 requires that chemical facilities in the US with specified quantities of certain toxic or flammable chemicals file a five year history of accidents. This study considers the relation between the reported accidents and surrounding community characteristics.

DESIGN

This study is a retrospective analysis of the association between the demographics of counties in which facilities are located and the risk of accidental chemical release and resulting injuries at those facilities. The "location risk" (the risk that a facility having large volumes of hazardous chemicals is located in a community) and "operations risk" (the risk of an accident itself) are investigated.

SETTING

1994-2000 accident history data from 15 083 US industrial facilities using one or more of 140 flammable or toxic substances above a threshold level. Demographic makeup of 2333 counties surrounding these facilities was determined from the 1990 US census.

MAIN RESULTS

Larger and more chemical intensive facilities tend to be located in counties with larger African-American populations and in counties with both higher median incomes and high levels of income inequality. Even after adjusting for location risk there is greater risk of accidents for facilities in heavily African-American counties (OR of accident = 1.9, 95% CI = 1.5 to 2.4).

CONCLUSIONS

Further research and policy interventions are required to reduce the probability of locating facilities in an inequitable fashion, as well as health surveillance, and regulatory monitoring and enforcement activities to ensure that hazardous facilities in minority communities prepare and prevent accidental chemical releases to the same standards as elsewhere.

Condensable composites: the next generation

The search for a tooth-colored restorative material with the physical and handling characteristics of amalgam has been ongoing for many years. The esthetic awareness of our patients is such that many insist on tooth-colored replacements when they need a dental restoration. The introduction of condensable composites is the latest step toward that goal. This article will discuss the evolution of this restorative option, the latest advancements in the technology, and describe in detail the techniques for placement and finishing of this material. The use of esthetic composite tints also will be discussed.

From being a radiologist to watching a radiologist: impact of filmless operation on the training of radiology residents

RATIONALE AND OBJECTIVES

The authors performed this study to investigate the impact of changing from a film-based image interpretation system to one using digital image workstations on the training of radiology residents in the interpretation of radiographs.

MATERIALS AND METHODS

Data were collected during a period when a conventional system of image interpretation with hard-copy images and multiviewers was used and during a period when digital image workstations were used. During each period, it was noted whether the first interpretation of the radiographs was performed by a radiology resident, by an attending radiologist, or as a group effort including both an attending radiologist and a radiology resident(s). In addition, it was noted whether a radiology resident or an attending radiologist dictated the report.

RESULTS

The proportion of images first interpreted by the radiology resident alone decreased from 38% (53 of 139) when using the conventional system to 17% (34 of 199) after the switch to interpreting images on the workstations (P = .001). During the film-based period, radiology residents dictated 45% of reports (141 of 312), but during the workstation period, radiology residents dictated only 4% of reports (24 of 667; P = .001).

CONCLUSION

The authors observed a decrease in autonomous participation by radiology residents in image interpretation and dictation of reports and an increase in "group reading" after the switch from a film-based system to a workstation system.

Using packable composites for direct posterior placement

BACKGROUND

Although dentists have been using resin-based composites successfully to restore posterior teeth in Class II situations for several years, creating a functional, anatomical proximal contact remains a clinical challenge for many clinicians.

OVERVIEW

This article presents a step by-step technique for creating a predictable proximal contact using a packable resin-based composite as the restorative material. Using a technique that is similar to that for amalgam will enable the dentist to make a successful transition to using composite as an alternative to amalgam in some posterior teeth.

PRACTICE IMPLICATIONS

More patients today are well-informed about dental care and are seeking tooth-colored restorative alternatives. Excellent materials and proven techniques are making the transition from traditional metallic restorations easier and more predictable. With this article, the authors aim to help dentists gain confidence in their technique and enable them to provide this service for their patients.

Does managed care gatekeeping affect African Americans' access to emergency care?

A number of national initiatives have focused attention on persistent racial and ethnic disparities in health and health care. The rising tide of improvements in health has not raised all boats; in some cases, the health gap between whites and minorities has widened. Although many social and economic forces contribute to this gap, inequitable access to health care also plays a part. This Issue Brief examines a common strategy that managed care organizations use to reduce emergency department visits--gatekeeping--and describes a study of the differential impact it may have on African Americans.

Effect of ethnicity on denial of authorization for emergency department care by managed care gatekeepers

OBJECTIVE

After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital.

METHODS

A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO.

RESULTS

African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94).

CONCLUSIONS

African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area.

Preventive care in the emergency department, Part I: Clinical preventive services--are they relevant to emergency medicine? Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group

In 1998 the Society for Academic Emergency Medicine's (SAEM's) Board of Directors asked the SAEM Public Health and Education Task Force to develop recommendations for prevention, screening, and counseling activities to be conducted in emergency departments (EDs). The Task Force's work was divided into two phases: 1) a discussion of the rationale for preventive services in the ED, along with generation of a preliminary list of prevention activities that could be studied for ED implementation; and 2) a formal evidence-based review of topics chosen from the preliminary list, along with recommendations for ED implementation and further study. This paper represents Phase I of the project. Phase II, the formal evidence-based review and recommendations, is published separately in this issue.

Treatment of osteoporosis: are physicians missing an opportunity?

BACKGROUND

Medical treatment of women with established osteoporosis may decrease the incidence of future fractures. Postmenopausal women who have sustained a distal radial fracture have decreased bone-mineral density and nearly twice the risk of a future hip fracture. The purpose of this study was to evaluate the adequacy of diagnosis and treatment of osteoporosis in postmenopausal women following an acute fracture of the distal part of the radius.

METHODS

A retrospective cohort study was performed with use of a claims database that includes more than three million patients, from thirty states, enrolled in multiple health plans. All women, fifty-five years of age or older, who sustained a distal radial fracture between July 1, 1994, and June 30, 1997, were identified in the database. Only patients with at least six months of continuous and complete medical and pharmaceutical health-care coverage from the date of the fracture were enrolled, to ensure that all health-care claims would be captured in the database. This cohort of patients was then evaluated to determine the proportion who had undergone either a diagnostic bone-density scan or treatment with any recommended medication for established osteoporosis (estrogen, a bisphosphonate, or calcitonin) within six months following the fracture.

RESULTS

A search of the database identified 1,162 women, fifty-five years of age or older, who had a distal radial fracture. Of these 1,162 patients, thirty-three (2.8 percent) underwent a bone-density scan and 266 (22.9 percent) were treated with at least one of the medications approved for treatment of established osteoporosis. Twenty women had both a bone-density scan and drug treatment. Therefore, only 279 (24.0 percent) of the 1,162 women who sustained a distal radial fracture underwent either diagnostic evaluation or treatment of osteoporosis. There was a significant decrease in the rate of treatment of osteoporosis with increasing patient age at the time of the fracture (p < 0.0001).

CONCLUSIONS

Current physician practice may be inadequate for the diagnosis and treatment of osteoporosis in postmenopausal women who have sustained a distal radial fracture.

Ventriculo-peritoneal shunt performance under hyperbaric conditions

A novice scuba diver with an implanted ventriculo-peritoneal (VP) shunt inquired about the performance characteristics of his shunt while diving. A literature search revealed no information regarding shunt performance under hyperbaric conditions. The manufacturer could not certify that the shunt would function under pressure. Therefore, four VP shunts were tested according to the manufacturer's testing protocol at 1 and 4 atm abs in a multiplace hyperbaric chamber. The pressure (in mm of H2O) required to establish flow through the shunts was recorded. Trials at 1 atm abs (n = 12) and 4 atm abs (n = 12) show that all shunts performed within the pressure range specified by the manufacturer.

Violent injuries among women in an urban area

The national statistics are familiar by now: each year, more than 2 million women are raped and/or physically assaulted; more than one-third of them are injured during their most recent assault. Annually, more than 500,000 women seek medical services as a result of violence-related injuries, often from hospital emergency departments. But national statistics cannot fully capture the extent of violence experienced by women in inner-city areas, nor do they point to modifiable risk factors at a community level. This Issue Brief highlights a new study that investigates the circumstances and correlates of violent injuries among women in one urban, low-income community.

Violent injuries among women in an urban area

BACKGROUND

Although the rate of death from injuries due to violent acts is much higher among black women than among white women in the United States, little is known about the nature and correlates of violent injuries among black women living in urban areas.

METHODS

In this case-control study conducted at three emergency departments in one inner-city community (in west Philadelphia), we studied 405 adolescent girls and women who had been intentionally injured and 520 adolescent girls and women (control subjects) who had health problems not related to violent injury. Data were collected by conducting standardized interviews with use of questionnaires and by screening urine for illicit drugs. Individual logistic-regression models were constructed to identify factors associated with violent injuries inflicted by partners and those inflicted by persons other than the partners of the victims.

RESULTS

The male partners of the injured women were much more likely than the male partners of control subjects to use cocaine (odds ratio, 4.4; 95 percent confidence interval, 2.3 to 8.4) and to have been arrested in the past (odds ratio, 3.1; 95 percent confidence interval, 1.8 to 5.2). Fifty-three percent of violent injuries to the women had been perpetrated by persons other than their partners. Women's use of illicit drugs and alcohol abuse were factors associated with both violence on the part of partners and violence on the part of other persons. Neighborhood characteristics, including low median income, a high rate of change of residence, and poor education, were independently associated with the risk of violent injuries among women.

CONCLUSIONS

Women in this urban, low-income community face violence from both partners and other persons. Substance abuse, particularly cocaine use, is a significant correlate of violent injuries. Standard Census data may help identify neighborhoods where women are at high risk for such violence and that would benefit from community-level interventions.

Adverse outcomes of managed care gatekeeping

OBJECTIVES

To determine whether telephone preauthorization for reimbursement of ED care (medical "gate-keeping") by managed care organizations (MCOs) is associated with adverse outcomes.

METHODS

A structured review was performed of case reports solicited during 1994 and 1995 with possible adverse outcomes related to managed care gatekeeping. Gatekeeping was defined as the requirement imposed by an MCO that ED staff contact on-call gatekeepers (i.e., clinical or nonclinical MCO personnel) to request preauthorization for ED treatment (a requirement that such MCOs enforce by refusing payment for the ED care unless preauthorization is obtained). Cases in which gatekeeper denial of preauthorization occurred were sought. Two physicians agreed on patient eligibility and classification criteria, then independently, retrospectively classified case reports identified as MCO ED payment denials into 1 of 4 categories: 1) adverse outcome; 2) patient placed at increased risk of death or disability; 3) "near miss" (emergency physicians prevented adverse outcome by caring for patient despite denial); and 4) none of the above.

RESULTS

Of the 143 cases reviewed, 29 reports represented MCO ED payment denial. Of these 29 eligible cases, there were 4 (14%) patients with adverse outcomes, 4 (14%) patients placed at increased risk, and 21 (72%) near misses. All of the 29 cases came from different EDs, representing 9 different states, with the majority from California. Adverse outcomes included respiratory failure from fulminant meningococcemia, hypovolemic syncope from ruptured ectopic pregnancy, hypovolemic arrest from vascular fibroid hemorrhage necessitating emergency hysterectomy, and prolonged postoperative course following ruptured duodenal ulcer. Patients placed at increased risk were diagnosed as having epiglottitis, myocardial infarction, ruptured ectopic pregnancy, and delayed treatment of hip septic arthritis. Near misses included diagnoses of ectopic pregnancy (n = 2), pneumothorax (n = 2), alcohol withdrawal seizures and pancreatitis necessitating intensive care unit admission, appendicitis, bacterial meningitis, cerebrovascular accident, cryptococal meningitis in immuno comprised host, endocarditis, incarerated inguinal hernia, meningocococemia, meninoccocal meningitis, peritonsillar abscess, pneumococcal meningitis, ruptured abdominal aortic aneurysm, shock from gastrointestinal bleeding, small bowel obstruction, schizophrenic crisis resulting in psychiatric hospitalization, suicidal depression resulting in psychiatric hospitalization, and unstable angina.

CONCLUSION

Adverse outcomes occur with MCO gatekeeping, Although the present study cannot ascertain whether this is a frequent event or a rare one, the safety of MCO gatekeeping deserves further study.

Successful management of the gingival tissues for aesthetic restorative procedures

A sage advisor once said, "Why is it that we (dentists) never seem to have the time to do all steps the first time around, but then find the time when something goes amiss?" Many of us are caught up in a prison called time that directly dictates our every move. We must be released from this mindset and rediscover the importance of patience and devotion to technique. That same wise man added, "The definition of a short cut is the longest distance between two points." The moral is time spent to gain tissue health will be returned a thousand fold. Cases will be completed with greater patient comfort and doctor satisfaction.

Judging who needs emergency department care: a prerequisite for policy-making

The debate regarding risks and benefits of triaging nonurgent patients away from emergency departments (EDs) stems from widely varying estimates as to what proportion of ED visits are inappropriate. A study was undertaken based on the hypothesis that these discrepant estimates might be due to differences in how "appropriateness" is defined. This cross-sectional study included 596 ED patients. Seven different indicators of "Inappropriate" ED visits were used. Two could be determined by the patient; two were based on the triage nurse's assessment; three were determined retrospectively, by chart review. All 21 possible pairs of indicators were compared for agreement using the kappa statistic. The proportion of ED visits classified as inappropriate by the different indicators ranged from 10% to 90%. Kappa values for agreement between indicators ranged from -0.04 to 0.31, indicating poor agreement beyond that expected due to chance alone. Decisions as to which ED visits are appropriate depend heavily on the criteria used. Limiting patients' access to EDs without the aid of a valid and reliable standard for what constitutes an appropriate ED visit could create harmful barriers to care.

Stenting in malignant obstruction of superior vena cava

The treatment of patients with malignant superior vena caval obstruction with minimal morbidity has been made possible by the recent introduction of expandable metal stents as the sole palliative treatment or as an adjunct to other treatment modalities. To alleviate the distressing symptoms of superior vena caval obstruction, self-expanding metal stents were used successfully in 12 (Wallstent device in 6 and Gianturco device in 6 patients) of 13 patients. The diagnoses were small cell carcinoma (n = 4), squamous cell carcinoma (n = 4), non-Hodgkin's lymphoma (n = 1), and mesothelioma (n = 1), and a diagnosis of malignancy was not confirmed (although strongly suspected) in the remaining three cases. Eleven patients had immediate relief of obstruction and there was no change in one patient. Mean follow-up was 3.7 months (range 1 to 10 months). Excellent palliation was obtained in all but one patient in whom recurrent superior vena caval obstruction developed 3 months after stenting. Mean survival was 4.8 months (range 1 to 10 months). The ease of insertion with the use of local anesthesia with radiologic control, the self-expanding nature of the stent, and the lack of major complications on follow-up of up to 10 months are particular advantages. The self-expanding superior vena caval stents are a useful addition to our armamentarium in the management of malignant superior vena caval obstruction.

The cost-effectiveness of voluntary counseling and testing of hospital inpatients for HIV infection

OBJECTIVE

To evaluate the cost-effectiveness of voluntary counseling and testing of US hospital inpatients for the human immunodeficiency virus (HIV).

DATA SOURCES

Data for entry into the model were derived from a review of the literature, consultation with experts, and consensus of the authors.

DATA EXTRACTION

We rated our confidence in these probabilities and costs by grading the data inputs using methods adapted from those of the US Preventive Services Task Force.

DATA SYNTHESIS

Decision analysis models were developed to evaluate two outcomes: (1) cost per health care worker (HCW) HIV infection averted if measures are taken by the HCW to reduce his or her risk of acquiring HIV; and (2) cost per inpatient HIV infection detected. Sensitivity analyses were also conducted. Using baseline input values, testing to avert HCW infection may prevent 3.6 HIV infections per year at a total program cost of $2.7 billion, or a cost of $753 million per infection averted. At baseline assumptions (seroprevalence = 1%), testing to detect inpatient HIV infection would cost $16,104 per year per infection detected. Cost-effectiveness at baseline drops to $8353 per HIV infection detected if the seroprevalence is 10%. If testing is limited to hospitals with inpatient seroprevalences of at least 1%, approximately 5400 persons per year will be falsely labeled HIV-positive.

CONCLUSIONS

This analysis provides no justification for testing inpatients to prevent HIV infection of HCWs. Screening inpatients to detect HIV infection may be justified at seroprevalences exceeding 1%, but issues of medical or social discrimination, false-positive results, informed consent, and logistics must be resolved first.

The cost-effectiveness of HIV testing of physicians and dentists in the United States

OBJECTIVE

To evaluate the cost-effectiveness of alternative policies for human immunodeficiency testing (HIV) testing of physicians and dentists.

METHODS

Decision analysis and cost-effectiveness analysis from a societal perspective were used. Data were derived from extensive literature review and consultation with experts. We conducted sensitivity analyses and also performed a cost-benefit analysis.

ANALYSES

We analyzed policies for mandatory or voluntary testing of all physicians, surgeons, and dentists; for those testing positive, we analyzed mandatory or voluntary exclusion from practice, restriction from performance of invasive procedures, or requirements to inform patients of serostatus.

MAIN OUTCOME MEASURE

Cost per patient infection averted.

RESULTS

Although one-time mandatory testing of surgeons and dentists with mandatory restriction of those found to be HIV-positive is more cost-effective than other policies, the cost-effectiveness varies tremendously under different scenarios. Results were highly sensitive to several data inputs, especially HIV seroprevalence of surgeons and dentists and transmission risk. For example, under a medium seroprevalence and transmission risk scenario, mandatory testing of all surgeons might avert 25 infections at a total cost of $27.9 million or $1,115,000 per infection averted and an incremental cost of $291,000 compared with current testing; however, the incremental cost-effectiveness per patient infection averted ranges from $29,807,000 under a low-risk scenario to a savings of $81,000 under a high-risk scenario.

CONCLUSION

Our analysis neither justifies nor precludes a mandatory testing policy. Further research on the key data inputs is needed. Given the ethical, social, and public health implications, mandatory testing policies should not be implemented without greater certainty as to their cost-effectiveness.

Refusing care to emergency department of patients: evaluation of published triage guidelines

STUDY OBJECTIVE

To determine whether a set of published triage guidelines identifies patients who can safely be refused emergency department care.

DESIGN

Historical cohort study.

SETTING

A public hospital ED.

TYPE OF PARTICIPANTS

All patients triaged during a one-week period who were not in the most acute triage category.

MEASUREMENTS

Two ED nurses, blinded to the study hypothesis, reviewed each triage sheet to determine whether the case met the published guidelines for refusing care. In addition, each ED record was reviewed for appropriateness; a visit was considered appropriate only if predetermined, explicit criteria were met and an emergency physician agreed that a 24-hour delay in care might have worsened the patient's outcome.

MAIN RESULTS

Of the 106 patients who would have been refused care according to the triage guidelines, 35 (33%) had appropriate visits. Four were hospitalized.

CONCLUSION

When tested in our patient population, the triage guidelines were not sufficiently sensitive to identify patients who needed ED care. Broad application of these guidelines may jeopardize the health of some patients.

Proposals for health care reform: how do we evaluate them?

The Society for Academic Emergency Medicine suggests a systematic approach to evaluating proposals for reform of the medical care system. Described are the three components of the problem--access, cost, and quality. Then, goals are proposed for health care reform. With this background, we describe the major questions that reform proposals must address and the potential impact of reform on emergency medicine. Emergency physicians must actively support health reform legislation that is in the over-all best interest or our patients and our specialty, and work with the new federal administration to evaluate proposed changes.

Case report: metastatic transitional cell carcinoma presenting in a urinoma

We describe a case of transitional cell carcinoma (TCC) metastasising into a urinoma cavity in a patient where the primary tumour arose at the ipsilateral ureterovesical junction. Seeding of transitional cell carcinoma into contiguous structures following surgical intervention has been reported, but to our knowledge, this is the first report of spread into a distant urinoma.

Wilderness emergency medical services: the experiences at Sequoia and Kings Canyon National Parks

This article describes the National Park Service wilderness emergency medical services (EMS) system, as implemented at Sequoia-Kings Canyon National Park. EMS records on all 434 patients in the period from August 1, 1986, to July 31, 1987, were reviewed. Most patients had minor problems. Overall, 77% of patients contacting the EMS system were released at the scene, and base hospital contact was made in only 28% of cases. However, there were three deaths, 44 (10%) patients who received advanced life support, and 292 (67%) patients who received basic life support. Seven patients who received advanced life support were released without transport. Decisions regarding scope of practice in a low-volume, wilderness EMS system are complicated by long transport times and problems with skills maintenance. Differences between the times and problems with skills maintenance. Differences between the patients treated by a wilderness system and those seen in most urban systems may make it appropriate to release a greater portion of patients without ambulance transport. In a system with long response and transport times, use of personnel with different training than in the urban setting becomes necessary.

Rational ordering of electrolytes in the emergency department

STUDY OBJECTIVE

To validate the predictive abilities of a retrospectively developed set of clinical criteria for detecting clinically significant electrolyte abnormalities, using a different patient population.

DESIGN

Cross-sectional study.

SETTING

The emergency department of a busy public hospital.

TYPE OF PARTICIPANTS

Nine hundred eighty-two patients on whom the emergency physician ordered serum electrolytes.

INTERVENTIONS

The predictive properties of ten clinical criteria were evaluated; these included poor oral intake, vomiting, chronic hypertension, taking a diuretic, recent seizure, muscle weakness, age of 65 years or more, alcoholism, abnormal mental status, and recent history of electrolyte abnormality.

MEASUREMENTS AND MAIN RESULTS

Seven hundred thirty patients (74.3%) had one or more electrolytes outside of the laboratory normal range, but only 143 (14.6%) had clinically significant electrolyte abnormalities. The clinical criteria predicted 135 of the clinically significant electrolyte abnormalities (sensitivity, 94.4%). When the eight "false-negative" cases were reviewed, none of the electrolyte abnormalities affected patient outcome. Implementation of the criteria would have avoided unnecessary testing in 233 patients (23.7%).

CONCLUSION

Although no set of clinical criteria can eliminate the need for clinical judgment, use of a set of clinical criteria could substantially decrease electrolyte ordering without compromising patient care.

Perimortem cesarean section

Perimortem cesarean section probably represents an underemphasized procedure on the skills list of the emergency physician. Although fraught with emotional and medicolegal overtones, the procedure can yield viable infants in at least 15% of cases and occasionally alters maternal hemodynamics so as to restore the pulse in a clinically dead woman. This article reviews the physiology and hemodynamics of the maternal-fetal unit and discusses prognostic factors for the survival of healthy mother and infant, leading to recommendations for when to perform a perimortem cesarean section. The article then describes the technical aspects of the procedure.

Approach to acute pharyngitis

The evaluation of the patient with a "sore throat" is deceptively complex. The clinician must first assess the potential for airway compromise. Specific risk factors, reviewed in this article, should be considered, including the presence of a pharyngeal membrane, immunocompromise, potential gonococcal exposure, and prior rheumatic fever.