Category Archives: Emergency Medicine

News about emergency services and medicine.

The latest in medical convenience: ER appointments

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 This story also ran in .

Scott Paul knew he needed to head to the emergency room on a recent Sunday after his foot became so painful he couldn’t walk.

The one thing that gave him pause was the thought of having to wait several hours next to a bunch of sick people.

But his wife, Jeannette, remembered she’d seen Dignity Health television commercials featuring a woman sitting in a hospital waiting room and then cutting to the same woman sitting on her living room couch as words come up on the screen: “Wait for the ER from home.”

“I’ve been in emergency rooms before, so I thought I’d see if this worked out,” she said, and went online to book an appointment for her husband at Dignity’s St. Mary’s Medical Center in San Francisco. Continue reading

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King County claims highest cardiac arrest survival rate

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Someone who has a cardiac arrest in King County has a greater chance of survival than anyone else in the world, according an analysis by county officials.

The survival rate for cardiac arrest in King County hit an all-time high of 62 percent in 2013, the analysis found.

By comparison, the cardiac survival rates in New York City, Chicago, and other urban areas have been recorded in the single digits.

According to the analysis, the cardiac survival rate in King County has risen over the past decade or so, from an above-average 27 percent in 2002 to 62 percent in 2013.

Cardiac Arrest

Strategies that have contributed to the rise include: Continue reading

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Why hospitals are failing civilians who get PTSD

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Gunby Lois Beckett
ProPublica, March 4, 2014

More than 20 percent of civilians with traumatic injuries may develop PTSD. Trauma surgeons explain why many hospitals aren’t doing anything about it.

Undiagnosed post-traumatic stress disorder is having a major impact on injured civilians, particularly those with violent injuries, as Propublica detailed last month.

One national study of patients with traumatic injuries found that more than 20 percent of them developed PTSD.

But many hospitals still have no systematic approach to identifying patients with PTSD or helping them get treatment.

We surveyed 21 top-level trauma centers in cities with high rates of violence. The results show that trauma surgeons across the country see PTSD as a serious problem.  Continue reading

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ER docs give Washington a D+

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The American College of Emergency Physicians has given Washington state a “near failing D+” in the its annual state-by-state report card assessing the nation’s emergency services.

Overall the state ranked 35th in the nation, down from its ranking of 19 in the College’s 2009 report, which that year gave Washington a C.

Screen Shot 2014-01-16 at 15.21.58 Continue reading

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Sign for an emergency room.

App tells how long you’re likely to wait in a hospital’s ER

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Sign for an emergency room.by Lena Groeger
ProPublica

Some medical conditions require and receive immediate care. People who are having heart attacks or who have suffered life-threatening injuries are typically seen by doctors as soon as they arrive at the hospital.

But in less urgent cases, patients arriving at the emergency room can wait for hours before seeing a doctor, receiving pain medication, having tests, or being admitted to the hospital.

And unless you had the foresight to call ahead, there is little way to know how long your visit will take.

Today ProPublica launching an interactive news application called ER Wait Watcher, which gives you a little more information to work with.

The app, which uses nationwide data recently released by the federal government, shows you how long it takes, on average, to see a doctor or other licensed professional at hospitals near you, plus the time it takes to drive there.

In many cases, the hospital closest to you may not be your best bet, because of long waiting times. Traveling farther may get you in front of a doctor sooner.

If you think you’re having a heart attack, or if you’ve suffered a serious injury, you should not use ER Wait Watcher. Please call 911. The ambulance will take you to the closest hospital, and won’t be as affected by traffic because it can speed and run red lights.

The app uses data from the Centers for Medicare and Medicaid Services on measures of “Timely and Effective Care.” These measures are based on a year’s worth of data that CMS updates quarterly (the last update was Dec. 12, 2013).

It includes averages for:

  • How long patients tend to wait before seeing a doctor,
  • how long they spend in the emergency department before being sent home or admitted to the hospital,
  • and how many leave without being seen at all.

All data is reported voluntarily by hospitals, which have a financial incentive to participate.

ER Wait Watcher also estimates in real time how long it would take to drive to nearby hospitals based on current traffic conditions. It fetches this data directly from Google, so travel times will change throughout the day.

While minutes matter when you’re having a medical emergency, longer wait times are not always an indicator of worse care. For example, emergency rooms that see more patients with behavioral health problems like alcohol abuse may have much longer wait times; it may take hours for a patient to sober up enough to be safely discharged.

Screen Shot 2013-12-20 at 07.09.30

Virginia Mason Medical Center had the longest wait times in Seattle, but 81% of patients said they would “Definitely Recommend” Virginia Mason, higher than the state average of 73%.

And time is not the only important factor, of course, so the app also includes patient satisfaction scores and other hospital quality measures to help you make an informed decision about which emergency room to go to.

The federal data includes what researchers say are important quality metrics for the nation’s emergency departments. According to Dr. Jeremiah Schuur, an emergency physician at Brigham and Women’s Hospital in Boston, the most useful measure from a patient’s perspective is waiting time — the time from when a patient walks in the door to when he sees a doctor.

Other emergency room measures, such as total length of stay at the hospital, may vary more depending on condition (a head fracture may take longer than a dislocated elbow) or on other patients (some hospitals treat sicker patients).

But whether or not a patient is seen quickly is a measure that can be compared across hospitals, says Schuur.

CMS’s move to standardize how to measure the quality of emergency care is especially needed now. In the last two decades an increase in ER patients, many of them older and sicker, has led to overcrowding.

Nationwide, ambulances are now turned away once a minute from overcrowded ERs and hospitals have difficulties in finding specialists to take emergency calls.

Some patients leave in frustration without being seen at all, while others can wait many hours for a hospital bed to become available. This confluence of problems led the Institute of Medicine to warn that emergency rooms in the United States are “at a breaking point.”

Overcrowding is not just an annoyance, and doesn’t just affect the people who come in complaining of a headache. A study of almost a million admissions to 187 California hospitals found that patients who were admitted after going through a very crowded emergency room were at 5 percent greater odds of dying than those admitted after passing through a less-crowded emergency room.

To tackle the problem, some experts advocate more measurement. Publicly releasing quality metrics can drive meaningful improvements in emergency care, according to a recent article in Health Affairs, a health policy journal. And the strategy has had some success in the past.

In 2004 hospitals began to publicly report a quality measure called “door-to-balloon time.” It refers to the time between a heart attack patient’s arrival at the emergency room and the moment of surgical intervention (which can sometimes involve inflating a thin balloon inside a heart artery).

CMS used door-to-balloon time to determine a portion of a hospital’s Medicare payment. Since then, emergency departments have focused a great deal of effort and money on identifying patients with heart attacks by screening them at triage. This has led to improvements in care for heart attack patients.

But not all measurements have had the same success. In 2005, England tried implementing another measure — a “four-hour rule” for the length of time a patient could stay in the emergency room before being sent home or admitted to the hospital. The country’s health service mandated that hospitals reach this four-hour time limit for 98 percent of their patients.

While nearly all hospitals met the goal, many also found ways to game the system, for example transferring patients to another doctor right before the clock ran out.

Since 2010, England has relaxed this measure and introduced new ones such as time to triage and percentage of patients who left without being seen.

Some U.S. emergency departments advertise their own quality care metrics, for example by posting waiting times on their websites, on billboards or on smartphone apps.

For people with conditions that are not life-threatening, this information allows them to postpone their trip or avoid a busy hospital altogether.

Theoretically this could help distribute patients more effectively and avoid pockets of crowding, improve patient satisfaction and serve as an incentive for hospitals to speed up their services.

But that information may not be reliable, or useful for comparing hospitals. On their own websites, hospitals are free to advertise any definition of “waiting time” they choose.

While one hospital could choose to count the time from when a patient arrives to when she is evaluated by a doctor, another could decide it’s when a patient is seen by a triage nurse, or receives a welcome from the hospital greeter.

Physician and Nurse Pushing GurneyIn order to solve these discrepancies, CMS established standard definitions and a common metric with which to accurately compare different hospitals.

The agency defines its own “waiting time” measure as the time from when a patient walks in the door to when he is evaluated by a licensed provider (a doctor, physician assistant or nurse practitioner). CMS says its specifications state clearly who qualifies, to avoid confusion.

A caveat: Hospitals may record these times inaccurately. In most cases someone must manually write down the time a patient was seen, so the times are not always precise. To combat this, some emergency rooms outfit doctors and nurses with electronic badges that wirelessly record exact times.

According to CMS, hospitals have 30 days to review their data before submitting it to the government. The agency places most of the responsibility on hospitals for making sure their data is correct before doing so.

Instead of emphasizing timeliness, future measures could look at effectiveness of care or how well emergency departments utilize resources, according to Dr. Schuur. While the newly released data is extremely important to enable individual hospitals to improve their operations, he said, “consumers should be aware that there is much more to the quality of an emergency room than how quickly they see you.”

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King County heart attack survival rate hits 57 percent

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From Public Health – Seattle & King County

The survival rate from cardiac arrest in King County has reached an all-time high of 57 percent, according to a new report released today by King County Executive Dow Constantine. Most other parts of the nation have survival rates that hover around 10 percent.

Medic one chart

“People are alive today in King County who would not have survived in most other places in the country,” said Executive Constantine. “Our EMS/Medic One system delivers rapid, high-quality critical care wherever you are.”

The Emergency Medical Services (EMS)/Medic One 2013 Annual Report highlights this achievement and other activities that place this EMS/Medic One system among the world’s best. The Executive has sent the report to the Metropolitan King County Council.

In 2012, the EMS system in King County responded to 172,700 calls to 9-1-1, including 48,010 for Advanced Life Support (ALS), the most serious or life-threatening injuries and illnesses. The average medic unit response time stayed steady at 7.5 minutes.

“Survival from cardiac arrest is the signature of quality for any EMS/Medic One system, and we continue to set the standard,” said Dr. David Fleming, Director and Health Officer for Public Health – Seattle & King County.

King County’s cardiac survival rate has increased from an above-average 27 percent in 2002 to 57 percent today. (Note to editors: graphic showing increases in King County cardiac survival rates is attached.)

The King County EMS/Medic One system is managed by the Emergency Medical Services Division of Public Health – Seattle & King County, and relies on a close partnership of thousands of professionals with fire departments, paramedic agencies, EMS dispatch centers, and hospitals to provide emergency care and save lives.

The full EMS 2013 Annual Report is available at www.kingcounty.gov/health/ems.

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ER doctor turns to palliative care to help patients cope with pain and death

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Alaska Palliative 300

Dr. Linda Smith meets with patient Dawn Dillard at Anchorage’s Providence hospital. Smith’s specialty is palliative care, she helps patients live with terminal or life-altering illnesses (Photo by Annie Feidt/Alaska Public Media).

By Annie Feidt, Alaska Public Radio

Dr. Linda Smith walks into a room at Providence Alaska Medical Center, ready with a stethoscope and a huge grin.

She teases her patient, Dawn Dillard, saying that her spiky hair recently resembled a “faux hawk.”

Dillard found out she had uterine cancer a year ago. Her oncologist gave her a year to live. The 57-year-old has beaten those odds, but now her kidneys are failing.

After the laughs are over, Smith sits down on the edge of Dillard’s bed, leans in, and starts talking about a surgical procedure to help her kidneys.

Smith is a palliative care doctor, a specialty that is growing rapidly in the U.S. The idea is to help patients cope with a terminal or life-altering illness.

And unlike hospice care, it is not offered only in the final months of life. Smith works on pain management, coordinating care and even does some counseling. Dillard, who is now in chemotherapy again, really appreciates it.

“I can’t even say how much she’s helped me,” Dillard says. “Just little things. You know, showing me things like breathing techniques. Sort of like mediation, just ways to focus on things that are positive and happy rather than focusing on your sickness and how crappy you feel.”

Becoming A Better Listener

Dr. Linda Smith (Photo by Mark Meyer/For NPR).

Dr. Linda Smith (Photo by Mark Meyer/For NPR).

Two years ago, Linda Smith was a very different kind of doctor.

She worked in the emergency room at the busy Anchorage hospital, where the goal was to quickly stabilize a patient and move on.

But two decades into her career, she started to question how she was caring for patients at the very end of their lives.

She remembers putting patients on breathing tubes and hearing family members say things like, “I know Dad didn’t want this, but we’re just not ready to let him go.”

“I started to have a lot of regret about doing things to people that were painful and uncomfortable and were prolonging their suffering,” Smith says. She thought, “if I only had the time to sit down with the family, I probably wouldn’t be doing these things.”

In 2011, Smith enrolled in a one-year palliative care fellowship at Providence. She had a lot to learn. She found out she was a bad listener. And she was abrupt. As an ER doctor, sometimes she was so busy she didn’t even sit down to deliver devastating news.

“I can remember saying to families things like, ‘I’m sorry, there’s nothing more I can do.’ And I realize now that sounds like abandonment to many people when you say you can’t do anything more. And the reality is I may not be able to do anything more to the patient that will make them survive, but there’s a lot more that I can do. I always can do more.”

Treatment Tradeoffs

A lot of what Smith does is talk to people. She doesn’t advocate for or against treatment, but she wants patients and their families to understand their decisions.

If a doctor puts in a breathing tube, for example, that may extend a patient’s life, but they won’t be able to eat or talk. If they die with a tube in, the family will miss hearing their last words.

So now Smith sits down for hard conversations and looks patients and their family members right in the eye. Earlier this year, she was called in to consult with the wife of a patient who was dying.

“When I entered the room,” Smith says, “The wife said to me, ‘I know who you are.’ And I said, ‘Oh. OK.’ And she said, ‘I don’t want to talk with you and I don’t want to like you because you’re here to talk about death and dying, aren’t you?’”

Smith had a short conversation with the woman, and left her a book on difficult end of life choices. She went back to visit her the next day.

“And she said, ‘You know, I so tried not to like you. And what you had to say. And I really realize that we need to have this discussion now, don’t we?’

“And I said, ‘When you’re ready, we’re ready to have that discussion.’ And she said, ‘I’m ready now,’” Smith recalls.

There’s a shortage of doctors who provide palliative care, and the need is growing as baby boomers slide towards old age.

Smith was planning to go back to the emergency room. But interactions like that one persuaded her to stay in palliative care. Now she works more and makes less money. Some days, she wonders if she’s crazy.

But then she gets to visit a patient like Dawn Dillard.

Back in her hospital room, Dillard and Smith talk about having a second procedure. Smith leaves and calls Dillard’s other doctors. They end up agreeing that the second procedure isn’t really necessary after all. So instead of staying another night in the hospital, Dillard is back home by the end of the day.

This story is part of a reporting partnership that includes APRNNPR and Kaiser Health News.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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ER visits take toll on older patients

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Sign for an emergency room.By Kelsey Miller

The majority of older patients who go to emergency departments in several nations around the world are likely to start out with complex conditions that deteriorate after their visits, according to a study published in the June 25 issue of Annals of Emergency Medicine.

Researchers from the Centre for Research in Geriatric Medicine at the University of Queensland, Australia, studied patients 75 years or older in emergency departments around the world to paint a picture of the unique problems they face — and how ERs can change to better serve them.

Lead author Dr. Leonard C. Gray said older people who arrive at emergency departments are more likely to have “geriatric syndromes” such as immobility, confusion and incontinence. The findings also indicated that for many, functional and cognitive issues increased afterward.

“These problems increase the complexity of care, and require specific interventions to ensure the best results,” Gray said in an email.

Researchers studied 2,282 patients in 13 different emergency departments in seven countries including Australia, Belgium, Canada, Germany, Iceland, India and Sweden.

They looked at medical records, talked to hospital staff and interviewed the patients directly about their cognitive function, mood, comprehension and more. Researchers also tracked the patients’ progress for 28 days after their ER visit.

Before coming to the ER, 54 percent were independent and didn’t require help for daily activities. After, only 33 percent were still listed as ”completely independent.”

The number of patients studied who displayed symptoms of cognitive impairment rose 6 percent after their trips to the ER, and the number of those who could not walk without assistance rose 23 percent.

Though the study fails to look into specific reasons why these older patients were negatively affected by ER visits, researchers say the numbers should be a signal for hospitals.

“With population aging, and relative reductions in severe health problems among younger age groups, the proportion of patients in the [emergency department] who are older is likely to increase,” Gray said. “Therefore, the case for designing the [emergency department] to cater for the needs of older people will escalate continuously.”

Such steps could include simple changes in furniture or lighting or more complex changes such as staff training and risk minimization.

“It seems not a matter of ‘if,’ but rather ‘when’ adjustments should be made,” Gray said.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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EMT

Front-line heroes subject to budget cuts, pay disparity

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By Marsha Mercer, Special to Stateline

When bombs exploded in Boston and a monster tornado tore through Oklahoma, paramedics and emergency medical technicians ran toward danger. As first responders, they put their own lives at risk in order to save the lives of others.

Yet EMTs and paramedics are governed by a haphazard patchwork of rules that vary widely by city and state. And their wages differ widely as well (see infographic), from a high of $52,930 a year in Washington, D.C., to a low of $25,900 a year in Kansas.

EMT pay map

The national average wage was $34,370 in 2012, according to the Bureau of Labor Statistics. In smaller and rural communities, EMTs and paramedics are often volunteers.

EMT Legislation This Year
  • At least 10 states enacted 28 laws this year affecting EMTs and paramedics.
  • Indiana, Kansas and Oklahoma lawmakers made it easier for military-trained emergency medical providers and veterans to qualify for licenses or to obtain temporary practice permits while satisfying other state requirements.
  • Virginia will require applicants for volunteer or paid EMS agencies to submit fingerprints for a national background check.
Source: The National Conference of State Legislatures.

Accidents and violence-related injuries are the leading cause of death for Americans under age 44, but there is no federal agency responsible for coordinating or guiding emergency services that respond to these incidents. What federal funding is available drips from faucets in several different departments.

In tough economic times, emergency services often are on the chopping block.

survey of Emergency Medical Services leaders in the 200 largest cities found 44 percent had cut services last year, according to the Journal of Emergency Medical Services.

It found 28 percent of big-city EMS agencies had a hiring freeze or were not filling vacancies, some for the third consecutive year.Fifteen percent reported layoffs. Twenty-one percent had no cost-of-living or pay-for-performance increases, some for the fourth year, the journal said.

“Several states have made catastrophic cuts to state EMS offices over the last few years, causing reductions in staff,” said Dia Gainor, executive director of the National Association of State EMS Officials (NASEMSO). She singled out Alabama, New York and Iowa.

A recent investigation by the Des Moines Register found Iowa’s EMS system “broken.” Staff in Iowa’s EMS bureau has been cut 40 percent and its budget reduced by more than one-third since 2009, resulting in delayed inspections of EMS providers and less oversight, the paper reported.

Detroit’s EMS system has been “decimated” by layoffs, and other cities have had furloughs, layoffs and “rolling brownouts” in which a response office shuts down for a day, said Don Lundy, president of the National Association of Emergency Medical Technicians, a federal advocacy group.

Unlike public health, fire and police departments, emergency services are the new kids on the block. In the 1960s, a town’s mortician might respond to a car crash in a hearse. The federal government took a leadership role in the 1970s, developing the nationwide 911 phone system and establishing EMTs as a profession. But funding dropped dramatically in the early 1980s.

“Since then, the push to develop more organized systems of EMS delivery has diminished, and EMS systems have been left to develop haphazardly across the United States,” the Institute of Medicine reported in 2006.

The report, “Emergency Medical Services: At the Crossroads,” described the nation’s EMS system as one of “severe fragmentation, an absence of systemwide coordination and planning, and a lack of accountability.”

Bureaucratic Confusion

Even the number of EMTs and paramedics is uncertain.

The Bureau of Labor Statistics said there were 232,860 paid EMTs and paramedics in 2012, based on its survey of employers.

In a 2011 report, the National Highway Traffic Safety Administration (NHTSA) said there were 826,111 certified EMTs and paramedics, based on a survey of state EMS officials.

This number includes part-time, unpaid volunteers and those who receive stipends, as well as full-time paid staff. They work in a wide range of settings, including hospitals, clinics, law enforcement agencies, fire stations, oil rigs, Indian reservations, ambulances and air transport.

NHTSA also said the BLS doesn’t distinguish between EMTs and paramedics and doesn’t identify EMS cross-trained as firefighters.

States with the highest number of paid EMTs and paramedics are California, New York, Pennsylvania, Texas and Illinois, according to BLS.

The states with the highest concentration of paid emergency workers compared with the national average are Maine, Tennessee, Delaware, South Carolina and Kentucky.

BLS economists said smaller states depend more heavily on paid EMS workers because they have smaller pools of volunteers.

“For a long time, EMS has been on the short end of the straw,” said Lundy of the EMTs association. He’s director of Charleston County EMS in South Carolina and has been an EMT for 38 years. “A lot of communities don’t understand the true value the emergency medical service brings to the community.”

Until there’s a problem or crisis. Lundy cited Washington, D.C., which has been plagued with complaints about poor service and long wait times for ambulances.

The city’s fire chief recently told the city council only 58 of 111 ambulances were in service, the city had only 245 paramedics (well short of its goal of 300), and some paramedics have responsibilities other than field work or responding to calls.

A key problem, Lundy and others say, is the lack of dedicated federal EMS funding.

“As we stand here today, there’s no federal funding for EMTs, no grants for the local level. There are grants for fire services, and about 2 percent of that money may go for non-fire EMS grants,” he said.

“There are a lot of very dedicated volunteers who are funding their organizations through barbecue chicken dinners on Saturday nights,” Lundy said. “That’s very sad because they are on the front lines of the health care people get every day. If you opened a hospital and made the staff throw chicken dinners every week to pay the bills, people would think you were crazy.”

A dozen states don’t fund EMS at all, the National Conference of State Legislatures reported in a study last year. Federal grants are available for state trauma systems through the U.S. Department of Health and Human Services, the NHTSA and the Department of Homeland Security. Some of that money can be used for EMS.

In addition, charitable foundations and corporations have become a source of revenue. For example, the Duke Endowment poured $5.5 million into emergency medical services in the Carolinas between 2004 and 2007.

“It’s an amalgamation of sources,” said Hollie Hendrikson of NCSL, who wrote the report on state trauma services. “Every state does it a little differently.”

Since the 1970s, when deaths from car crashes were a major concern, the Department of Transportation has housed an EMS office in NHTSA. Emergency services advocates are pushing for a lead federal agency for EMS, a need endorsed by the Institute of Medicine in 2006.

U.S. Rep. Larry Bucshon, R-Ind., a physician, introduced a bill in February that would set up an EMS office in HHS and provide EMS education and training grants. So far, the bill has just six co-sponsors.

Lundy hopes high-profile events like the Boston Marathon bombings will wake people to EMS needs. BLS estimates the need for paid paramedics and EMTs will rise 33 percent from 2010 to 2020, much faster than other occupations.

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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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In case of tornado, electronic health records can be just the prescription

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Radar debris signature from the Moore tornado.

Radar debris signature from the Moore tornado – National Weather Service

By Jenny Gold

Everyone expects a hospital to be ready to jump into action when disaster strikes. But what about when the disaster devastates the hospital itself?

Turns out, it helps a lot to have an electronic medical record system in place.

At least that was the case at Moore Medical Center in Oklahoma, a small hospital right in thepath of the tornado that ripped through the suburbs of Oklahoma City on Monday.

Three-hundred people — staff, patients and community members — hunkered down in the cafeteria, stairwells and chapel as 200-miles-per-hour winds demolished the building around them.

One patient in labor stayed on the second floor with two nurses, where they could continue to monitor the fetal heartbeat.

Amazingly, everyone survived. Within an hour, 30 patients had been transferred to the two other hospitals that are part of the Norman Regional Health System. And every one of them arrived with their medical histories fully intact. The woman in labor even delivered a healthy baby later that evening.

“The transfer was totally seamless,” says John Meharg, director of health information technology at Norman, which has had an electronic health record system for the past five years. “We’re very fortunate that we’re a little ahead of the game,” he said.

If the hospital system had still been using paper, Norman explains, “the first thing we would have had to do was find their records. And with all of the hustle and bustle of a disaster, they can easily get lost.”

As for any records left behind in files, he continues, “if the tornado doesn’t get them, the subsequent rain would ruin them. The roof’s gone, the walls are gone, and the windows are gone.”

Instead, physicians at the two transfer hospitals were able to pick up care for the Moore patients where their home physicians left off.

Even if the patients had been taken to hospitals outside of the Norman system, their records would still have gone along with them.

That’s because Oklahoma City has a regional health information exchange that allows the various hospital systems in the area to access all patient records, says Meharg.

“I’m very happy,” he adds, breathing a sigh of relief. “The systems never missed a beat. It would really have been a mess if we weren’t electronic.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Road deaths climb in 2012, ending six-year slide

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Car crash wreckBy Daniel C. Vock
Stateline Staff Writer

The number of people who died in traffic accidents inched up last year, reversing a downward trend in road deaths that began in 2006, according to a federal report.

Road deaths increased 5.3 percent last year, up to a total of 34,080, according to early estimates  from the National Highway Traffic Safety Administration.

“It is too soon to speculate” on why the numbers climbed, the agency said. “It should be noted that the historic downward trend in traffic fatalities in the past several years means any comparison will be to an unprecedented low baseline figure,” it added.

Nearly half of the increase in deaths came in the first quarter of 2012, when the death toll was 12.6 percent higher than a year earlier. The rate of increases dropped every quarter and, by the final quarter, it was just 1.7 percent higher than a year before.

The New England region had the greatest rise in traffic deaths, with more than a15 percent increase. A tier of states mostly in the Southwest (but also including Hawaii, Louisiana and Mississippi) also saw significant increases. The preliminary report did not contain state-by-state figures.

Federal researchers estimated Americans drove 9.1 billion more miles last year than in 2011, but that is only an increase of 0.3 percent.
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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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Snohomish emergency preparedness event seeks to engage diverse communities

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Photo by Ada Be

Photo by Ada Be

Snohomish County will sponsor an emergency preparedness event next week that will focus on engaging the county’s diverse communities.

The EMPOWER emergency preparedness fair will seek to break down the barriers between emergency responders and minority communities through a day of presentations, information sharing, resource tables, and demonstrations, from 8 a.m. to 2 p.m., Sat., April 20 at Everett Station, 3201 Smith Ave., Everett.

The event is free and open to the public, and includes complimentary continental breakfast and lunch. Walk-ins are welcome or you can register at Brown Paper Tickets.

The day will have two educational tracks: One for community residents to learn more about being prepared for emergencies, and another for emergency responders to learn ways to respond more effectively to a diverse community.

“This fair is for people who want to learn more about getting prepared for earthquakes, storms, and other disasters,” said Therese Quinn, event organizer and Medical Reserve Corps coordinator. “It is also for emergency responders and planners who want to learn more about working with vulnerable populations.”

Morning presentations follow a welcome by Snohomish County Sheriff John Lovick.

The emergency responder track will hear a hands-on diversity panel discuss “What you need to know when you respond in my community.” Panelists will include individuals from the Iraqi and Latino communities, and lesbian, gay, bisexual, and transgender community.

The panel discussion will be followed by speaker Conrad Kuehn from the Northwest ADA Center, presenting “Disability Language and Etiquette.”

The community education track includes a presentation on how to prepare for an emergency and make an emergency kit. Following the kit demonstration, a panel will discuss the mission of emergency responders as public safety — and not immigration enforcement.

Panelists include Dave Alcorta, Red Cross; Sgt. Manny Garcia, Everett Police Department; and John Pennington, Snohomish County Department of Emergency Management.

The lunchtime keynote speaker will be National Fire Academy Instructor Leslie Olson, who will talk about the importance of cross-cultural communication.

All presentations and the lunch keynote speech will be interpreted into Spanish and translated by Communication Access Realtime Translation (CART) for the deaf and hard of hearing.

The event is the result of community partnership among Snohomish Health District, Tulalip Tribes, Fire District 1, Starbucks, Communities of Color Coalition, Snohomish County Emergency Management, Medical Reserve Corps, Puget Sound Energy, City of Everett, and South Everett

Photo courtesy Ada Be via Flickr

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Physician and Nurse Pushing Gurney

Death rates rise at small, remote hospitals

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By Jordan Rau
KHN Staff Writer

This KHN story was produced in collaboration with 

Physician and Nurse Pushing Gurney

For 15 years, Congress has bestowed special privileges to some small remote hospitals, usually in rural areas, to help them stay afloat.

Medicare pays them more than it pays most hospitals and exempts them from financial pressure to operate efficiently and requirements to reveal how their patients fare.

Nearly one in four hospitals qualifies for the program.

Despite these benefits, there’s new evidence that the quality of many of these hospitals may be deteriorating.

study published Tuesday found that during the past decade the death rates of patients at these critical access hospitals were growing while mortality rates at other hospitals were dropping.

“This carved-out group of hospitals seems to be falling further and further behind,” said the paper’s lead author, Dr. Karen Joynt of the Harvard School of Public Health.

The study, published in the Journal of the American Medical Association, found that in 2002, mortality rates at critical access hospitals for Medicare patients with heart attacks, heart failure and pneumonia were about the same as at other hospitals. But they have diverged since then.

“It’s hard to provide care for really, really sick patients in a resource-limited setting.”

While death rates at other hospitals dropped by 0.2 percent a year, reaching 11.4 percent in 2010, mortality rates at critical access hospital death rates rose about 0.1 percent each year, reaching 13.3 percent in 2010.

Critical access hospitals also did worse than other small, rural hospitals that were not in the program. The paper said all these results were statistically significant.

Joynt and her co-authors, John Orav and Dr. Ashish Jha, also of Harvard, suggested that the hospitals’ care may suffer because they don’t have the latest sophisticated technology or specialists to treat the increasingly elderly and frail rural populations.

A previous paper by the trio found that critical access hospitals were less likely to have the ability to perform cardiac catheterizations and to have intensive care units.

“As we have more advanced treatments, it’s harder for rural hospital to keep up,” Joynt said. “It’s hard to provide care for really, really sick patients in a resource-limited setting.”

She also suggested that the hospitals may have been victims of their lenient treatment by the government. Since hospital officials are not required to evaluate their performances to make reports to Medicare, the government may not realize that facilities could need additional assistance in caring for sicker patients.

“This is 1,000 hospitals, a quarter of the hospitals in the country, that are invisible,” she said. “We’ve created a completely separate system, and in this case it looks like that has not done patients in these hospitals any favors.”

Brock Slabach, an executive at the National Rural Health Association, cautioned against drawing sweeping conclusions from the report. “Mortality is just one small part of the picture of what qualities means,” he said.

He said the association’s own research has found that rural hospitals do better in patient satisfaction surveys than do urban hospitals, and that there’s no substantial difference in other measures such as readmissions.

Congress started the critical access program in 1997 to stave off hospital closures in places where patients had no good alterative because the next hospital was at least 35 miles away by regular roads or 15 miles by secondary roads.

Hospitals with 25 or fewer beds could qualify. Hospitals near competitors, in cities as well as rustic areas, also got into the program through a loophole that until 2006 allowed states to designate hospitals as “necessary providers.”

In 2011, 1,331 hospitals qualified for the program, which reimburses hospitals for all of the costs of caring for Medicare patients plus an extra 1 percent.

It’s a generous system compared to the way Medicare pays other hospitals. They are given set sums for each patient based on their illnesses, a method that does not always cover all the costs of treatment.

Medicare spends about $8 billion a year on critical access hospitals, amounting to 5 percent of the country’s inpatient and outpatient expenses, according to Congress’Medicare Payment Advisory Commission.

The states with the most critical access hospitals are Kansas, Iowa, Minnesota, Texas and Nebraska, all with between 65 and 83 such facilities, federal data show.

In 2011, only Connecticut, Delaware, the District of Columbia, Maryland, New Jersey, Rhode Island, Puerto Rico and the Virgin Islands lacked any critical access hospitals.

Tuesday’s study adds to previous research by the Harvard researchers. In 2011, the researchers found that critical access hospitals were less likely to have basic electronic health records.

They also first reported then that these hospitals had worse death rates. After that paper was published, Joynt said rural hospital officials complained that the researchers did not note the improvements the hospitals had made over time.

In the study released Tuesday, Joynt and her colleagues examined that objection, but they determined that although some critical access hospitals had improved, overall the group had done worse compared with others. Tuesday’s study is the result of that research.

LocalHealthGuide Note: To learn about Critical Access Hospital program in Washington state go here.

An accompanying editorial by Dr. John Ioannidis, a medical professor at Stanford, called the paper “the best study to date” on the issue, though he said the paper might not have captured all the potential reasons for the discrepancy in death rates.

He also questioned whether policymakers should enact broad changes on critical access hospitals.

“Trying to impose quality data collection and reporting in such hospitals that have already strained resources may actually do more harm than good,” Ioannidis wrote. “Even for non-CAHs, the evidence is tenuous that performance and quality initiatives do work.”

Joynt said that her research, while not conclusive, indicated that the hospitals might need additional help. For instance, she said, through telemedicine, larger hospitals could offer the advice of their specialists to rural hospitals confronting complex cases. In addition, there might be better ways to transfer those patients to more advanced hospitals, she said.

“I see this as more of a systems problem than just a hospital problem,” Joynt said. “I don’t think that there really exists the right sort of systems or incentives to make that happen.”

Contact: jrau@kff.org

This article was produced by Kaiser Health News with support from The SCAN Foundation.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Reviving research into US gun violence – BMJ feature

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This article by LocalHealthGuide editor Michael McCarthy, MD first appeared on the BMJ’s website and is republished here with the journal’s permission. 

Michael McCarthy looks at whether events at Sandy Hook Elementary School are paving the way to reopen research into guns

GunIn January, in response to the shooting at the Sandy Hook Elementary School in Newtown, Connecticut, that left 20 schoolchildren and six adults dead, US president Barack Obama issued 23 executive orders to deal with gun violence in America.1

Among those was an order directing the US Centers for Disease Control and Prevention (CDC) to research the causes and prevention of gun violence, an order directing the US Attorney General to issue a report on new gun safety technology, and an order clarifying that the Patient Protection and Affordable Care Act, the president’s 2010 health reform law, “does not prohibit doctors asking their patients about guns in their homes.”

That it was necessary for the president to issue executive orders directing actions in a country that sees more than 31 000 killed from gunshot wounds each year surprised many.

But for 17 years, legislation has been on the books banning or severely constraining government initiatives to reduce gun violence and gun related injuries.

In his statement announcing his executive actions, Obama denounced in particular efforts to deny federal funding for scientific and medical research into the causes of gun violence. “We don’t benefit from ignorance. We don’t benefit from not knowing the science of this epidemic of violence,” Obama said.

For much of the 20th century, gun violence in the US had been considered a law enforcement issue. But in the late 1970s and early 1980s, a series of reports and workshops started to recast the issue as a public health problem and calling for a far broader societal approach.

The 1979 US surgeon general report, Healthy People, identified homicide as a important health problem.2 The report noted that although many factors were involved in the nation’s high murder rate, including economic deprivation, family breakup, and the glamorization of violence in the media, “Easy access to firearms appears to be the one factor with a striking relationship to murder.” And in 1985 the Institute of Medicine issued an influential report, Injury in America, calling on, among other initiatives, research into the effectiveness of laws and “other measures to reduce firearm homicide.”3

As part of this shift to a public health approach to violence reduction, the CDC created a Division of Violence Prevention in 1991 and a year later raised the division to center status as the National Center for Injury Prevention and Control (NCIPC).

Gun rights advocates, however, denounced the research coming out of the center and other research groups looking in to gun related injuries, which they charged was merely anti-gun propaganda designed to demonize guns.

Research funded by the CDC that particularly angered gun rights groups were reported in two papers in the New England Journal of Medicine in 1992 and 1993.45

In those papers, Arthur Kellermann and colleagues found that keeping a gun in the home was associated with a 2.7-fold increase risk of homicide for members of the household and a 4.8-fold increase in risk of suicide.

“Despite the widely held belief that guns are effective for protection, our results suggest that they actually posed a substantial threat to members of the household,” they wrote.

In 1995, gun rights advocates, led by the National Rifle Association, enlisted their supporters in Congress to pass legislation that would have eliminated NCIPC completely.

When that effort failed, they instead successfully stripped the CDC of the $2.6m (£1.7m; €1.9m) of its budget slated for gun violence research and forbid the agency “to advocate or promote gun control.”

Similar language was put in legislation governing the National Institutes of Health’s budget, and federal funding for public health research into gun violence all but disappeared.

Gun rights advocates also moved to pass both state and federal laws seeking to prevent doctors from asking their patients about guns in their homes.

Several medical societies, including the American Academy of Pediatrics, the American College of Physicians, and the Academy of Family Physicians, have recommended that physicians counsel their patients about firearm injury prevention, such as the use of gun safes and trigger locks.

Florida passed a law that made it possible to sanction doctors who held such conversations and recorded information about gun ownership in a patient’s medical record.

During the battle over the health reform law, Senator Harry Reid, the Senate Majority Leader and a Democrat from the rural state of Nevada, inserted a provision mandating that the wellness and health promotion activities implemented by the law “may not require the disclosure or collection of any information relating to . . . the presence or storage of a lawfully possessed firearm or ammunition in the residence or on the property of an individual; or . . . the lawful use, possession, or storage of a firearm or ammunition by an individual.”

Michael Hammond, legal counsel for the Gun Owners of America, a gun rights advocacy group which pushed for the provision, said his organization had two main concerns. Firstly, that gun ownership documented in electronic medical records would turn into a “de facto national gun registry.” Such a registry is an anathema to gun rights advocates who see gun registration as a first step towards confiscation.

The second concern, Hammond said, was that the presence of a gun in the home would be used by insurance companies to raise insurance premiums to the point that gun ownership would become prohibitively expensive.

Just as cigarette taxes are being used to discourage smoking, Hammond said, the price of health insurance, which everyone must purchase under the new health reform law could be used to discourage gun ownership.

“You can say that’s a good thing in respect to cigarettes, but we didn’t want the same thing to happen with respect to guns,” Hammond said.

Therese Richmond, a professor of nursing at the University of Pennsylvania and co-founder of the university’s Firearm and Injury Center, said such concerns are misplaced.

Much can be done to reduce deaths and injury from firearms without confiscating guns by adopting the same public health approaches that dramatically reduced motor-vehicle deaths in the 1970s and 80s, she said.

“We didn’t say cars are killing people; we didn’t say get rid of cars,” Richmond said, instead, public health approaches were used to change social norms around drinking and driving and seat-belt use and to improve car and road design. “Have we totally wiped put injury and death in the form of car crashes. No, but we have made significant inroads. Why can’t we take that model and do that with gun violence?’

Despite the president’s executive orders, the future of research into gun violence and gun-related injury prevention remains uncertain, says Kellermann, the lead author of the New England Journal of Medicine papers who is now chair in policy analysis at the RAND Corporation. One concern is that there is no guarantee Congress will provide the funding for the research, he said. The other concern is whether there will be enough researchers willing to do the work that’s needed.

“There were never large numbers of researchers active on this issue. You could almost count the public health community working on this topic on both hands without having to go to your toes,” Kellermann said. “What we don’t know is are there young or early-career medical and public health researchers who will rise to this challenge and be willing to take on work that could easily disappear as quickly as it re-emerges, particularly if Congress chooses not to take action.”

Kellermann also believes that it is possible to take public health approaches to “lower burden of mortality and morbidity from gun violence without compromising the safe, reasonable ownership, use and enjoyment of firearms.”

“But to do that we have to set the politics aside, try to understand the phenomenon much better and make smart choices as individuals and society,” he said.

Notes

Cite this as: BMJ 2013;346:f980

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
  • Provenance and peer review: commissioned, not peer reviewed.
  • Editorial: Common sense gun policy reforms for the United States, doi:10.1136/bmj.e8672.
  • Blog: Get the gun out of the house, http://bit.ly/12k2V7U.
  • Blog: Krishna Chinthapalli on the questions around gun control in the US,http://bit.ly/Tv2i6I.

References

  1. Remarks by the President and Vice President on Gun Violence. January 16, 2013 www.whitehouse.gov/the-press-office/2013/01/16/remarks-president-and-vice-president-gun-violence.
  2. United States Public Health Service. Healthy people: the surgeon general’s report on health promotion and disease prevention. Publication no 79-55071. http://profiles.nlm.nih.gov/NN/B/B/G/K/.
  3. National Academy of Sciences. Injury in America: a continuing public health problem. Washington: National Academy Press; 1985. www.nap.edu/catalog.php?record_id=609.
  4. Kellermann AL, Rivara FP, Somes G, Reay DT, Francisco J, Banton JG, Prodzinski J, Fligner C, Hackman BB. Suicide in the home in relation to gun ownership. N Engl J Med1992;327:467-72. http://www.nejm.org/doi/full/10.1056/NEJM199208133270705.
  5. Kellermann AL, Rivara FP, Rushforth NB, Banton JG, Reay DT, Francisco JT, Locci AB, Prodzinski J, Hackman BB, Somes G. Gun ownership as a risk factor for homicide in the home. N Engl J Med1993;329:1084-91. http://www.nejm.org/doi/full/10.1056/NEJM199310073291506.
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Observation units can improve care but may be costly for patients

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Hospital Entrance SignBy Michelle Andrews

There’s a growing recognition by clinicians that some patients who arrive at the emergency department can benefit if they’re kept under observation for up to a day so that staff can run more tests and monitor their progress to see if their condition is improving or deteriorating.

Unfortunately, many hospitals and insurers haven’t set up their clinical and billing systems or insurance contracts with these patients’ needs in mind.

Not only does this result in a longer stay in some cases, but it also can cause confusion for patients and bigger patient bills. Many experts say that the problem is likely to get worse.

More than a third of hospitals report having an  observation unit today, double the 19 percent that reported having one in 2003.

Experts say that the most effective observation units have a dedicated staff that follows clearly defined protocols. Rather than send a patient home who is at high risk for a heart attack following an emergency department visit because of chest pain, for example, staff might refer him to an observation unit for repeat blood tests, EKGs and a stress test.

A patient with severe asthma who needs time and medication to get an attack under control might be sent to the observation unit for several hours.

By monitoring and treating patients intensively upfront, observation unit staff can forestall problems and help people get better faster. Patients typically stay less than a day, though some may remain longer.

“These are patients who fall between the cracks,” says Michael Ross, an emergency physician who is director of observational medicine at Emory University School of Medicine in Atlanta. “They need more than an emergency department visit, but if managed practically they often need less than 24 hours of care.”

Shorter hospital stays can result in lower hospital costs. But hospital savings don’t necessarily translate into lower costs for patients.

Shorter hospital stays can result in lower hospital costs. A study that Ross co-authored on emergency department patients who had had a transient ischemic attack – a temporary interruption of blood flow to the brain that causes stroke-like symptoms and is sometimes a harbinger of a true stroke — showed that those who were referred to an observation unit were discharged nearly 38 hours sooner than those who were admitted as inpatients. Observation unit patients also cost the hospital less: The median amount was $2,092 versus $4,922.

But hospital savings don’t necessarily translate into lower costs for patients. Insurers treat care provided in an observation unit as outpatient care. That often means patients pay a la carte for every X-ray, blood test or scan.

In contrast, if patients are admitted as inpatients, they may owe only a single co-payment, after which all or nearly all services are covered. And for Medicare patients, being assigned to observation care rather than inpatient care can bring higher drug bills and affect coverage of subsequent nursing home care.

Part of the problem is that many hospitals that place patients on observation status don’t necessarily have a designated unit where such patients are treated.

Instead, they may place emergency department patients on observation status and put them in a bed on one of the regular inpatient hospital floors.

Such patients frequently don’t receive the care based on clearly defined protocols shown to be successful in designated observation units, experts say.

Adding to the confusion, the patient may think he’s been admitted and not realize he’s going to be billed for outpatient rather than inpatient care.

“It’s a terribly inefficient way to provide observation services,” Christopher Baugh, medical director of the emergency department observation unit at Brigham and Women’s Hospital in Boston, says of care that isn’t provided in a separate unit. “It’s also difficult to communicate [the difference] to patients who are in an inpatient area and sharing a room with an inpatient and spending sometimes a long time there.”

But the arrangement can be attractive to hospitals. Placing patients on observation status and putting them in a bed somewhere in the hospital reduces crowding in the emergency department.

It may also reduce the number of admissions. The Centers for Medicare & Medicaid Services and private insurers are monitoring hospital admissions closely and have been retroactively denying payment if they determine an admission wasn’t warranted.

“We’re going to see an explosion in observation status,” says Arthur Kellermann, a physician and senior researcher at Rand, a public policy research organization. Under the Affordable Care Act, hospitals with high readmission rates for Medicare patients with pneumonia, heart attack or heart failure are financially penalized.

The health law could prompt hospitals to use the observation designation with more patients, even if they don’t receive special care, say experts.

Unfortunately, the “complexity of this fragmented, loophole-ridden payment system has taken one of the best ideas in medicine and made it confusing to patients and doctors,” Kellermann says. “It could undermine what is one of the best ideas in health care.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Please send comments or ideas for future topics for the Insuring Your Health column to:

questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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