Archive for August, 2012

Patient Safety_Growing Pains

August 25, 2012

The subject of patient safety and medical errors in the U.S. has received great attention due to the magnitude of the medical errors and adverse events in the healthcare system.

Research on patient safety and medical errors has revealed that medical errors and adverse events are a consequence of flaws in the healthcare system, and they occur at several points in the healthcare system. These points are supposed to act as defense layers to prevent the medical errors from occurring. Solutions are therefore needed at all levels in the healthcare delivery process.

Identifying viable solutions requires identification of the vulnerabilities that exist within the organization’s health care delivery process. This provides the organization with better insight into the nature of medical errors and adverse events that plaque their system and helps to prevent future injuries.

Voluntary error reporting systems are tools that have been developed to assist healthcare organizations identify and analyze medical errors, adverse events and sentinel events that occur within their organization. These systems also capture ‘near misses’ which are events that could have, but did not result in a medical error or adverse event. Many healthcare organizations have adopted voluntary error reporting systems in order to encourage reporting of these errors and events. However 6 out of 7 hospital based errors, accidents and other adverse events still go unreported.

Voluntary error reporting systems are powerful tools for the improvement of patient safety within an organization. Successful reporting systems are non-punitive, confidential, systems-oriented and independent amongst other factors. They also address barriers to reporting by expounding on key questions like: what should be reported; who should report; and what is the most appropriate time frame for reporting.

Additional resources and funding are needed to promote and advocate for greater adoption and successful utilization of voluntary error reporting systems in healthcare organizations.


Access to Health Care in the United States of America – Forever A Market Commodity or a Respected Human Right?

August 24, 2012

The United States of America is one of the few high-income nations on earth that does not guarantee access to health care for its population. In 2010, 49.9 million Americans remained uninsured and without access to health care. Disparities in access to health care are also pronounced among poor people of color, specifically African-American, Native Americans and Hispanics. The US ranked third last for health care for women, after Mexico and Hungary (OECD, 2006). Limiting access to health care services is detrimental to both individuals and society. This may inhibit a person’s ability to reach their full potential and may negatively impact on their quality of life. Preventing access to appropriate health services, in fact, has resulted in thousands of preventable deaths. Dr. Andrew Wilper et al. in a 2009 report from Harvard published in the American Journal of Public Health found that 44 800 preventable deaths occurred annually due to lack of access to health care in the United States. This is close to 15 times the number of lives lost in 9/11 – every year.

This is ironic as the United States easily outspends all other high-income countries in terms of percentage of Gross Domestic Product (GDP) devoted to health care. The amount of money spent in private expenditures on health care is also the highest in the world. According to the World Health Organization (WHO), the United States spends more on health care per capita and more on health care as a percentage of GDP than any other nation on earth. Despite this, the infant mortality rate of the US is the highest of all high-income countries while the life expectancy is lower than that of low and middle-income countries such as Cuba and Chile. Again, the WHO ranked the US in 2000, as having the highest in cost, 37th in overall performance, and 72nd by overall level of health. Thirty percent of health care spending is waste, including fraud (Berwick, 2011). From the individual perspective of health care users, medical debt accounted for 62.1% of all bankruptcies in 2007 (Himmelstein et al., 2009). Most medical debtors were well-educated and from the middle-class. Three quarters of these individuals also had health insurance. The share of bankruptcies attributable to medical problems rose by 50% between 2001 and 2007. The United States pays (and may waste) more on health care in the private sector, with worse health care outcomes while still not providing adequate coverage for all Americans, many of whom are forced into bankruptcy to cover costs of medical care.

It is a minority of health care that is funded through public mechanisms in the United States. The majority of Americans are covered through private insurance companies with health care packages purchased through a variety of market-driven economic models. Some states, such as Massachusetts, are providing a universal model of health care, but again with a substantial subsidy to private insurance corporations. The concept of universal, government-run or a single-payer health care system is foreign to many Americans. However, this idea indeed is gaining momentum given the growing 31% of health care dollars that go to administrative costs and not towards health care. While health care reform is currently being debated, the discussion surrounding access to health care must be broadened to include perspectives shared by many Americans and citizens of the world. Health care, and access thereof, has long been deemed a basic human right, as enshrined in the United Nations’ Declaration of Human Rights. As Americans, we are starting to understand that.

Which is more dangerous……vaccines or the anti-vaccine movement?

August 24, 2012

Source: CalWatchdog

Global efforts to increase immunization rates have seen major accomplishments in the past few years.  The Centers for Disease Control (CDC) created a massive measles initiative that is credited with measles elimination in the Americas. And, just this year, India was declared polio-free after a focus on increased mass immunization efforts.  While global efforts to improve vaccination rates and improve child health are seeing some significant successes, the United States seems to be falling in a different direction. 

Source: Caifornia Department of Public Health

California, in particular, has seen recent outbreaks in vaccine-preventable diseases including measles and pertussis.  These diseases are highly contagious and have very serious, sometimes deadly health consequences. 

Why are these outbreaks occurring?

More and more parents in California are choosing NOT to vaccinate their children. 

Many parents cite the association between vaccines and autism, brain damage, or developmental problems as a reason for refusing vaccines.  While no doctor can claim that vaccines are 100% safe, the highly publicized information linking vaccines to autism has been scientifically discredited.  This anti-vaccine movement in California is strong, but those who are most vocal in opposing vaccinations are often using non-scientific, out-dated, or discredited information that is scaring parents.  The American Academy of Physicians,  National Association of School Nurses, California Department of Public ,and CDC are reputable organizations, all of whom urge parents to comply with timely vaccinations for healthy children.  Yet, parents are often confused by conflicting messages between medical organizations and the anti-vaccine groups.  As a result of choosing not to vaccinate their own children, these parents are placing their own and other children at risk for very serious diseases. 

A new bill AB2109was proposed in California that would require parents who choose to not vaccinate their children to have a physician’s note on file before their children could attend public school.  The physicians note would testify that the health benefits and risks of immunizations were discussed in detail with the parent who refused the vaccinations.  This proposed bill would allow parents freedom in refusing vaccinations, but would increase parent education and limit false information from interfering with a parent’s decision.   This change in policy, if adopted and implemented, could be the beginning of a reverse in this trend of preventable childhood infectious disease outbreaks in California.

Weighing in on childhood obesity in Montgomery County, Maryland

August 24, 2012

The United States has the recent distinction of having the highest obesity rate in the developed world.

According to the 2007 Maryland BRFSS (Behavioral Risk Factor Surveillance System), about 17% of adults in Montgomery County, Maryland were obese.   However, it is difficult to draw conclusions about the childhood obesity rate in Montgomery County, since there is no systematic collection of BMI data in the school system.    How can you measure success in reducing childhood obesity without a  baseline or a way to measure progress?  How can you decide whether certain areas or school clusters need more allocation of resources?

The Montgomery County Commission on Health, an advisory body to the Montgomery County Council, has advocated for BMI collection in Montgomery County public schools (MCPS), with privacy protections, in order to analyze aggregated data by cluster and develop targeted strategies for obesity reduction and prevention.    MCPS does not formally collect BMI results.  I have–informally–heard two reasons: 1. privacy protection; and 2. lack of  resources.

Other Maryland counties, such as Harford county, where the public schools have been collecting BMI data since 2010, do not seem to have these issues.   Montgomery County parents can be a vocal and political powerhouse when it comes to funding and AP programs; but the Montgomery County Council of Parent Teacher Associations, while promoting nutritional school lunches, has been silent regarding BMI collection in the schools.

It’s a Mad Mad World…

August 24, 2012


The U.S. Department of Agriculture (USDA) has taken measures to prevent the introduction and potential spread of bovine spongiform encephalopathy (BSE), or Mad Cow Disease, into the cattle population of the US. As a prion disease, it is spread between certain species by feed that includes exposure to neural tissue, and when consumed by humans forms a terminal disease called Variant Creutzfeld-Jacob Disease, or vCJD.The fear of an outbreak – such as experienced in 1990s UK – lead to the authorization of policies to control for meat processing, feed and import restrictions, etc. USDA’s Animal and Plant Health Inspection Service (APHIS) has conducted surveillance for the disease since 1990 by targeting cattle populations where the disease is most likely to be found. The level of surveillance increased steadily from 1990 and jumped significantly in 2004 to nearly 1% of the cattle population following the detection of BSE from an imported cow. These policies have prevented BSE from entering the human foodsource in the US, and until recently the last cow that tested positive for BSE was in 2006.

Gradual fiscal cutbacks, however, have resulted in the current/ongoing BSE surveillance program, where the policy is to test 40,000 of the nearly 40 million US cattle each year. At 0.001%, some advocacy groups are claiming this is not adequate surveillance. The recent discovery of a BSE cow in California (the fourth ever detected in the US) has fueled the debate, in addition to recent scientific discovery of different prion variants and possible increased infectious qualities. Simply put, the current surveillance program is not comprehensive enough to protect the public. It is necessary for the current cattle feed and processing policies to continue, as well as an increase in BSE surveillance of the cattle population.



Passing the “Soda Tax” in Richmond, California

August 24, 2012



Thirty-five percent of adults and 17% of children are obese in the United States compared to 15% and 6.5% in 1980 2, 3.  Added sugar in food and beverages is documented as a large contributor to this increase in the national waistline.  This added sugar comes at the expense of calories with no nutritional benefit.4  Interestingly, liquids appear to affect the body in a different way than food as research shows that the body appears to incorporate fluids quickly leading to hunger pangs despite recent intake of many calories.  Those who drink sugary beverages are also at a much higher risk of obesity and diabetes which not only affects an individual but also increases overall healthcare costs.5  Given this data, it comes as little surprise that the CDC recognized reducing consumption of sugary drinks as a chief obesity prevention strategy 6

Scientific studies estimate that a one cent tax per ounce on sugar-sweetened beverages in the United States will decrease consumption by 15 percent in adults preventing roughly 2.4 million diabetes person-years, 95,000 heart attacks, 8,000 strokes, 26,000 premature deaths and prevent 17 billion dollars in medical costs.  This same tax would generate 13 billion in tax revenue. 6  While the tax in Richmond would produce smaller scale results, this law passing in one city is an important first step toward a nationwide beverage tax.  Several other locations had similar legislation fail in large part due to fierce, expensive counter campaigns by the beverage industry. 7  A tax increase on sugar-sweetened beverages has the potential to decrease obesity, decrease healthcare costs, and increase revenue in this country.  Passing the “soda tax” in Richmond, California, could set the stage for similar policies in other cities, states, and the nation in order to help derail our looming obese future.


Impaired decision making: Why good census data matters for decision makers

August 24, 2012

Two years ago, the Canadian federal government made a unilateral decision to scrap the mandatory long-form questionnaire of the Canadian census, in favor of a voluntary survey sent to a sample of 4.5 million households.  This decision was met with considerable backlash from the academic, government, and economic community, including the resignation of the Chief Statistician of Statistics Canada (the federal agency that administers the census) in protest.

In the census year 2011, the long-form was replaced with the National Household Survey, which was completed by individuals on a voluntary basis.  The voluntary aspect of this survey was the driving force behind the flurry of protests in Canada, with those opposed to scrapping the long-form questionnaire citing low response rates and non-response bias associated with voluntary surveys.  In contrast, those who supported the change have cited privacy concerns and intrusion of individual liberties.

The fires have yet to cool from this heated debate.  This year marks the first release of data from the revised 2011 census, with topics on families, dwellings, marital status, and languages to be released in the coming months.  But what will this data tell us and why has the change from a mandatory to voluntary survey caused such an uproar across the country?

U.S. Census Bureau. Washington, DC: 2012.

Historically, the Canadian census has contained two components: a short-form, completed by 80% of households; and a long-form, completed by the remaining 20%.  The short-form contains 8 questions on demographics, and is used by government agencies to allocate resources across the country.  The long-form contains 53 additional questions on education, ethnicity, mobility, income, employment, and dwelling characteristics; and is used by an array of decision makers, market research groups, and private corporations to plan community services, allocate health resources, and decide where to locate new shopping centres.

Although the detailed questions on sociodemographic data will be replicated in the NHS, the switch to a voluntary survey may compromise the underlying reliability of the data and negate any comparisons with historical census data.  Survey researchers, for example, have long battled with low response rates and biases due to differential response among certain segments of the population (e.g., lower income groups, or ethnic minorities).

As with the majority of policy decisions, these tend to have an impact on the most vulnerable populations in society.  A report from the House of Commons, for example, called for the reinstatement of the mandatory long-form, citing substantial impact on gender equality and women’s rights.

You can see why academics, private corporations, and community groups are fighting hard to preserve every ounce of reliable data.  Data users from across the health, economic, and development spectrum have voiced concerns over the utility of the new census data, with fears that the biased data will negatively impact policy and decision making.

Privacy concerns are valid, especially in middle- and high-income countries with electronic records and detailed administrative databases.  However, census data often pales in comparison to the data collected by retail corporations or social networking sites.  Moreover, the data is anonymized and confidential, meaning that users of the census data cannot identify individual survey respondents.  And perhaps most importantly, one cannot ignore the public good that arises from the use of the data, such as equitable resource allocation and health research.

Of course, there are other sources of data that can be used for health and development research.  In Scandinavian countries, for example, a system of government administrative databases are used to track detailed data on individuals; whereas in North America, population-based data repositories (here and here) have been used extensively to conduct health services research and evaluation.

Nevertheless, more detailed data is often necessary for health and development studies, above that which can be provided by administrative data.  Any researcher worth their salt would be well aware of the social and behavioral determinants of health that exert their influence across the life course.  Take just one look at the census survey contents and you’ll see how these can fit into multiple levels of the ecological framework for injury and illness prevention.  This is why reliable, population-based data is necessary for decision makers, and why our society needs to fight tooth and nail to preserve our decision making capacity — so that we are not making decisions in the dark.  The call for reinstatement of the mandatory long-form census remains loud and clear.

Financing the Success of Health Focused Sustainable Development

August 24, 2012

Charcoal cookstove in a Haitian orphanage

Unrefined energy sources such as charcoal and wood are utilized in much of the underdeveloped world as the main source of energy for cooking and heating.  From collecting to burning this biomass for fuel, women and children bear the burden of health issues including pneumonia, asthma, COPD, burns, and cancer from open fires with poor ventilation.  2.7 billion people worldwide use biomass as their energy source for cooking and heating. According to studies by the World Health Organization (WHO), 1.45 million people died in 2008 from using biomass as an energy source accounting for more premature deaths than caused by malaria, vector-borne illness or tuberculosis during this time frame. The global population and those using biomass as their primary energy source is projected to increase well into 2030.

In many countries, more than 10% (often as much as 25%)of household income is required to heat a household. Death rates may increase by 18% in colder climates due to lack of adequate heat. 1.45 billon people worldwide do not have electricity. Across Asia, India, Sub-Saharan Africa, Latin Americas, The Caribbean, and Europe, safe affordable energy sources have yet to be attained for everyone.

The human and economic burden of disease from the lack of affordable clean energy is a vital concern that has only recently been recognized as a global issue. Governments and private sectors dedicated to developing new energy sources have selectively viewed the environmental and financial impact of creating new policy or technological advancement for energy sources without considering the health implications of such innovations. Health assessment has not been a priority of the economic evaluation when developing goals for affordable sustainable energy models.

This past June 2012, the United Nations Rio+20 Summit on Sustainable Development, that brought together national, private sector, academic and scientific communities declared that health impact assessment is an essential criterion for sustainable development. The United Nations (UN) has created a Health Impact Assessment (HIA) bureau to develop awareness, policy and tools to evaluate the health impact of energy policy and development at the population level.

While this declaration and focus is to be hailed as an essential achievement in recognizing our human condition, it is by no means time to clap our hands in success.  As the less than consistent accomplishments to date of the Millennium Development Goals (MDGs) set a decade ago for 2015 demonstrate, our global record of success to meet lofty goals for ending poverty has much to be desired and still to be accomplished.

The UN Secretary General Ban Ki –moon declared that a global partnership is necessary for sustainable development and reaching all MDGs by 2015. Coming full circle, this partnership requires parallel policy by governments and the private sector not only to create energy sources that assess health impact before implementation, but allow them to be financially achievable and sustainable.

The Organization of Economic Co-Operation and Development (OECD) demonstrated that since 2008 health care spending in OECD countries has come to grinding halt.  How then will health assessment occur if healthcare in general is not being financed? Further, the economic security of affordable energy that is clean and sustainable, not only requires financing the initial investment but also financing the annual expense to maintain sustainability of the innovation.

The concept of healthy clean affordable and sustainable energy sources may appear overwhelming, but it is not an insurmountable goal. As an example, one solution for resolving the use of biomass as an energy source for cooking and heating is to support the development and use of clean cook stoves.  These are portable fuel-efficient appliances that as one study in India demonstrated would cost a household $10 annually to buy and then maintain.  On a global basis this amounts to 4.5 billion dollars annually.  Staggering number?  Not really.  The world spends more on malaria, and tuberculosis annually than this.  The reduction in healthcare spending on respiratory and cardiovascular diseases, the projected reduction in premature deaths, and reduction in disability adjusted life years, translates into tens of billions of dollars saved annually.

In the next several years, the World Health Organization and the United Nations must develop policies and partnerships that while commendably addressing the health impact of affordable energy and sustainable development will conjointly finance these healthy choices so that we may accomplish our Millennium Development Goals.

A Pill a Day to Prevent HIV Infection

August 24, 2012

On July 16, 2012, the Food and Drug Administration approved the first drug to reduce the risk of HIV infection for uninfected individuals at high risk of contracting HIV. Truvada (emtricitabine/tenofovir disoproxil fumarate), in combination with safer sex practices, was approved for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV. Approval was based on data from 2 clinical trials involving over 7,200 individuals; Partners Prep and IPREX. These studies demonstrated a substantial reduction in acquisition of HIV with consistent oral use of Truvada.

Cree Gordon, Test Positive Awareness Network

On August 9, 2012, the Centers for Disease Control and Prevention (CDC) released an interim guidance for clinicians considering use of PrEP for prevention of HIV infection in heterosexually active adults. Previous CDC guidance focused on reduction of risk of HIV acquisition among men who have sex with men.

(Credit: Justin Sullivan/Getty Images)

This controversial decision provides additional options for persons at risk of acquiring HIV, such as uninfected individuals in relationships with HIV infected individuals, or high risk individuals such as sex workers who may not be able to navigate protection. Opponents (The AIDS Healthcare Foundation) of this decision believe there is not enough safety and efficacy data to support an indication in women, and are concerned about development of resistance if Truvada is not taken regularly.

We believe this landmark decision is critical in the fight against HIV. Combined with safer sex practices, Truvada is an important addition to the toolkit of HIV prevention technologies. We also support expanded research on how Truvada will be used in real-world settings.

An unprecedented move to tackle obesity in New York

August 24, 2012

Recently New York City Mayor Michael Bloomberg proposed a ban on sales of sugary drinks larger than 16 ounces in restaurants, delis, sports arenas, and movie theaters in New York. His proposal has no precedent; New York is the first city in U.S. to directly attempts to limit sugary-drink’s portion. At a public hearing about this proposal the health experts, politicians and soda supporters squared off.

American beverage association, their advocacy group: New Yorkers for beverage choices, local council men and some consumers strongly object the idea. Aside from the obvious reason that it will reduce profit, the soda companies claim it will limit people’s choice which is a violation of civil right.

On the other hand, groups like Center for science in public interest (CSPI) said, in the wake of obesity epidemic it is about time to address the issue of increasing portion size of sweetened beverage which has increased many folds over the last fifty years. Besides, Dr. Walter Willett, chairman of epidemiology and nutrition of Harvard Medical School, pointed out that sugary drinks are now the single greatest source of added sugar in American diet. Therefore he supports the idea of attacking the number one target in the fight against obesity.

Although anybody can easily circumvent this ban that is if someone wants to drink 32 ounces of soda he or she can just buy two 16 ounce sodas.  But there is a behavioral economics called “default bias” behind this proposal which is: If a choice is offered where one option is seen as a default, most people will go for that default option.  For example, in countries where people have to choose to be an organ donor, most people aren’t donors; whereas in countries where people by default are organ donors unless they actively choose not to be, most people are donors.  The soda ban makes size 16 ounce or less the default option for the consumers. If they want more they will have to make an extra effort for that.

Researchers have shown that people does not have a fixed perception about portion size, they tend to consume food in the size a bag, box or bottle it comes with, a phenomenon known as “unit bias”. In 1974, the biggest container size for soda was 21 ounces in McDonalds and today the biggest one is 32 ounces. Therefore, the fact that now the largest soda in McDonalds is 32 ounces makes a 21 ounce soda feel sensible. The proposed ban is designed to flip this effect in people’s mind; if the largest soda people can buy is 16 ounce, a 12 ounce soda may start to seem normal.   

Although public opinion polls show a majority of American oppose this plan, the doctors treating the casualties of the obesity epidemic say even this unpopular proposal to soda portion should be just the beginning of stricter regulation of unhealthy foods in the country. Therefore, this proposal is the first bold step to fight against the big and powerful beverage companies who are spending billions of dollars marketing these large sugary drinks which are directly related to obesity. For the past forty years people have been the subject of social-science experiments, conducted by beverage and fast-food companies which only made these companies richer. And now they will again be the subject of such an experiment, conduct by the Department of health and Hygiene of New York City. But this time it will be for their benefit that is to reduce obesity epidemic in New York.  Plus there is good chance that this unprecedented experiment will be successful.