Dos Santos L.G.,Collective Health
Journal of environmental science and health. Part. B, Pesticides, food contaminants, and agricultural wastes | Year: 2011
A method for determining atmospheric concentrations of eight pesticides applied to corn and soybean crops in Mato Grosso state, Brazil is presented. The method involved a XAD-2 resin cartridge coupled to a low volume air pump at 2 L min1 over 8 hours. Pesticides were recovered from the resin using sonication with n-hexane:ethyl acetate and determined by GC-MS. Good accuracy (76-128%) and precision (CV < 20%) were obtained for atrazine, chlorpyrifos, alpha- and beta-endosulfan, endosulfan sulfate, flutriafol, malathion, metolachlor and permethrin. Method detection ranged from 9.0 to 17.9 ng m3. This method was applied to 61 gas phase samples collected between December 2008 and June 2009. Atrazine and endosulfan were detected both in urban and rural areas indicating the importance of atmospheric dispersion of pesticides in tropical areas. The simple and efficient extraction method and sampling system employed was considered suitable for identifying pesticides in areas of intense agricultural production.
Walker M.L.,Collective Health
Minerva Chirurgica | Year: 2013
Small bowel and colon injury represents a significant portion of injuries sustained during penetrating trauma. These wounds may be tangential or through and through. Low velocity wounds are expected in the civilian setting, but high velocity wounds or shotgun injuries at close range can be seen as well. Most often these patients are explored and the injuries sustained can be managed effectively. Selective non-operative management for penetrating abdominal trauma is indicated only when there is no evidence of on-going hemorrhage or hollow viscus injury. The decision to abandon non-operative care must be made very early during the initial hospital course. In contrast bowel injury in blunt abdominal trauma may be difficult to detect. The clinical assessment and initial imaging will often define the extent of injury. However, patients with associated distracting injuries or subtle clinical signs will provide a greater challenge. This paper reviews the overall approach to patients with small bowel and colorectal trauma. It highlights published literature and makes recommendations regarding care based on injury assessment and the patients overall clinical condition. As surgeons we must use an evidenced based approach to undergird our clinical decision making. By doing so, we hope to bring improved outcomes and safer care to our patients.
Spatial distribution of suicide incidence rates in municipalities in the state of Espírito Santo (Brazil), 2003-2007: Spatial analysis to identify risk areas [Distribuição especial das taxas de incidência de suicídio nos municípios do Estado do Espírito Santo (Brasil), no período de 2003 a 2007]
Macente L.B.,Collective Health |
Zandonade E.,Federal University of Espirito Santo
Revista Brasileira de Psiquiatria | Year: 2012
Objective: To analyze the spatial distribution of suicide incidence rate in a residential municipality of the state of Espírito Santo (ES), Brazil, from 2003 to 2007. Methods: Ecologic study of the exploratory kind, based on secondary data. Deaths per suicide, which took place in each municipality of ES, were included in the data according to information provided by the Mortality Information System. For the spatial data analysis, a Bayesian approach was used (Global empirical and Local Bayesian ones) to correct epidemiological rates. Moran's I index was calculated to a worldwide spatial level dependence, and Local Moran (LISA) to a local spatial correlation. The following software applications were used: Excel; R 2.6.2; SPSS 11.5 and TerraView 3.3.1. Results: The geographical localization of the municipalities that showed an incidence rate characterized as the average for suicide after adjustment (EBest Global) forms a corridor in the countryside. Some common characteristics among these municipalities are: a) immigration (Italians, Pomeranians/ Germans); b) rural population (average of 53%); c) supporting economy (agriculture, husbandry and livestock). A global and local spatial correlation was found among the municipalities (p < 0.05). Conclusion: The study identified the spatial context where the greatest death incidence rate per suicide occurred in the state of ES, during the mentioned period. ©2012 Elsevier Editora Ltda. All rights reserved.
News Article | April 28, 2016
Ethan Weiss, a cardiologist at UC San Francisco, spends long hours at the hospital treating patients. But between shifts, he takes calls with health-technology entrepreneurs to offer them advice and feedback. As Weiss explains, it's not about the money. He does the majority of this advisory work for free or in exchange for a tiny chunk of equity. It's also not about prestige: He doesn't speak publicly about the startups he's consulting with. So why does he bother? For one thing, it makes for a stimulating break in the day. "I have an intense curiosity and I like novel things," says Weiss. It's a challenge to quantify the exact number of doctors moving into health tech; even if a large physicians' group like the American Medical Association (AMA) tried to keep track, it would need to determine whether to include doctors that advise startups but still practice one or two days a week, or just those who have left medicine altogether. I suspect that the former category is much larger. Suffice it to say, though, that Weiss is far from alone—the migration of doctors into the health tech space is noticeable. It is now fairly common for well-funded health-tech startups to have medical directors, physician founders, or chief medical/health officers on their team. Some high-profile examples include Collective Health, Sherpaa, Startup Health, Doximity, Aledade, and AthenaHealth. And the AMA tells me it is proactively forging partnerships in Silicon Valley and beyond to help doctors "work in tandem on the innovative tech solutions that promise to change health care." To understand why doctors are dabbling in startups or even changing careers, I recently polled MDs involved with startups (very informally) on Twitter to gauge whether they were motivated by money, prestige, fun, or altruism. Of 45 respondents, 44% were motivated by "fun." But it runs deeper than that. Weiss, for instance, has other motivations. He is concerned that much of the $4.5 billion in venture capital raised by digital health companies in 2015 will be spent on the next "Uber for health care," or the 10th next-generation stethoscope, rather than on solving patients' most pressing needs. "A lot of startups are peddling really cool technology in search of a problem," he told Fast Company. I recently spoke to a half dozen other physicians based in San Francisco, Boston, and other tech hubs to understand their motivations for working in the space. Here's what they said. New online communities have popped up to cater to doctors with an interest in health tech, and they shine a light on some of the problems in the medical field. A handful of California-based doctors started a private Facebook group called "dropout docs," which includes Rebecca Coelius, a UCSF medical school graduate who worked as a health director at Code for America; Amanda Angelotti, a fellow UCSF grad who works in clinical systems design at One Medical; Sean Duffy, a Harvard Medical School dropout who cofounded Omada Health; and Connie Chen, a practicing doctor who cofounded a chronic disease-management app called Vida. Much of the offline and online discussion is centered on the struggles of being a young doctor today, as well as the guilt associated with leaving medicine after years of education (and in many cases, a massive accumulation of student debt). Other groups, like U.K.-based Doctorpreneurs.com, The Modern MD, and the Society for Physician Entrepreneurs are also spreading the word about alternatives to clinical medicine via blog posts and job listings. "There is an increasing acceptance that doctors will leave clinical medicine and do something in the startup world," says Vishaal Virani, one of the founders of the Doctorpreneurs group. As Chen from the "dropout docs" group points out, some physicians don't see a clear path forward, career-wise, especially if they want to strike out on their own. As the industry consolidates—and small physician groups get gobbled up—it's harder than ever for doctors to start their own practices. That had traditionally been an entrepreneurial outlet for them. Other doctors are simply burned out after years of grappling with (often onerous) technology systems for documentation and billing, which hospitals have rapidly adopted in the past decade—a key reason that doctors today have less and less time to spend with patients (the average interaction these days is about 8 minutes). As one physician recently put it on the blog KevinMD.com: "The ratio of time spent on doctor-patient interactions compared to physician-computer ones appears so horribly skewed that it has reached the point of complete dysmorphia." "Doctor burnout and dissatisfaction is most definitely a factor [for why doctors are looking outside of clinical medicine]," says Daniel Kraft, a pediatrician, startup adviser, and the faculty chair for the medicine and Exponential Medicine program at Singularity University, a Silicon Valley think tank. "We see inefficiencies every day that are hurting patients." Some doctors are actively looking for ways to work hand in hand with entrepreneurs to fix these problems. They see problems with the industry, but they also see an opportunity to make a major impact. "Most physicians are desperate to help patients, especially when they keep seeing the same pain points," says Kraft. For Atul Butte, a doctor and researcher in biomedical informatics at UCSF, there's plenty to be excited about. Butte, who advises about 50 health tech startups, is optimistic about a range of new initiatives that offer ways to diagnose, treat, and care for patients. He is currently digging into the growing pool of open data from both failed and successful clinical trials, which he sees as vitally important for the development of new therapies. Most of the Bay Area doctors I spoke with had focused on one or two pet areas of health tech, ranging from mental health apps to sensor-based medical devices. And many of them, like Weiss, were working to divert the flow of money into health tech into the areas that would make a real impact. "I see a lot of companies that aren't picking the right problem," says Butte. Moreover, health tech also offers young and ambitious doctors an opportunity to make a name for themselves. "You talk at conferences, you are on panels, you do things that academic medicine would expect you to do when you have another couple of decades of experience," says Harvard Medical School-based physician Arshya Vahabzadeh, who is also a director at a neuroscience startup called BrainPower. Vahabzadeh believes that startups can help him make a more immediate impact. For entrepreneurs, physicians' growing interest in health tech is a huge boon for their businesses. Having a well-respected doctor on the team offers legitimacy (and a path to funding), and it is paving the way for them to tackle bigger and more complex problems. "I see too many entrepreneurs steering clear of the real medical challenges," says Weiss. "But I say now is the time. Don't think about the market in a year. Think about what can be accomplished in the next 10 years."
News Article | October 29, 2015
This is the second essay in a three-part series looking at problems and solutions in the health-care marketplace. Read part one, on the main issues with the existing insurance system, here. On the sixth floor of the historic Puck Building, in SoHo, are the headquarters of Oscar, a two-year-old startup that sells health insurance to individuals. The office, like the building’s Shakespearean namesake, has a certain playfulness: the walls double as chalkboards, kegs of beer round out the kitchen, and the names of the conference rooms refer to famous Oscars, including one called Bluth, after the “Arrested Development” character. “We want to introduce people to the idea of great health insurance,” announces a credo printed on one wall. “By being simple. By being thoughtful. By being friendly.” Oscar is one of several health-insurance companies to emerge in the past few years with the ambition of reinventing the industry. The Affordable Care Act, which was signed into law in 2010, created an unprecedented opportunity to change how Americans purchase and consume health care. The A.C.A. has made health insurance mandatory, creating a captive market. It has introduced the health-insurance exchanges, giving people who were previously uninsured an easier way to get coverage. It has accompanied a rise in the popularity of high-deductible plans, which charge lower annual fees but require greater out-of-pocket contributions, prompting consumers to be more judicious about how they seek care. And it has initiated a shift in reimbursement to health-care providers from rewarding volume to rewarding value, creating financial incentives for providers to reduce unnecessary spending. The question now, five years after the A.C.A. was passed, is how the health-insurance industry should evolve. In the past few years, two noteworthy approaches have emerged, addressing different aspects of the insurer-provider-patient triad. The first focusses on building a relationship between insurers and patients, capitalizing on the opportunity offered by the exchanges. The second attempts to forge financial alliances between insurers and providers. While both seek to improve the system, they reflect different strategic bets on where it is most amenable to innovation, and how insurers can have the greatest impact in the short-term. Oscar, which sells insurance on the individual exchanges, is one of the most visible examples of the direct-to-consumer approach. In September, Google’s growth-equity fund announced a $32.5-million investment in the company, bringing its total valuation to $1.75 billion. From Oscar’s sleek Web design to its colorful cartoon advertisements to its homepage U.R.L. (hioscar.com), the company’s clear hope is to attract customers by making something that is ordinarily unpleasant seem more palatable. It has amassed some forty thousand members in New York and New Jersey, where it currently operates, and plans to expand to Texas and California this November. Some critics have questioned whether Oscar’s clever marketing is simply a veneer for a traditional health-insurance plan. But Mario Schlosser, the C.E.O. of Oscar, told me that he sees the marketing as key to creating a different kind of insurance. “We have an asset, which is a membership base that is very engaged,” Schlosser said. That engagement allows the company to offer creative incentives to influence patient behavior in positive ways. Last year, for instance, Oscar began giving some members a monetary reward for getting a flu shot. Twice as many patients in that group signed up for the vaccine, as compared to Oscar patients who were not offered a reward. Oscar was also the first health-insurance company to offer members free unlimited access to telemedicine, a move Schlosser told me has minimized unnecessary office and emergency-room visits. An evaluation for abdominal pain would traditionally cost the company more than a thousand dollars; using telemedicine, it costs fifty-seven. And patients, who pay nothing at all, avoid considerable out-of-pocket costs. “It’s really being utilized by our members,” Schlosser told me. “Even though we pay for these visits, they over-all appear to be saving costs for the entire system, as opposed to costing more.” The direct-to-consumer strategy has its challenges, though. For one, prices have to be competitive for a company to win over market share—a strategy that can be difficult to sustain, particularly for startups that lack sufficient capital to buffer their losses. In hopes of promoting healthy competition, the government has sponsored a number of “consumer operated and oriented plans” (CO-OPs), non-profit organizations that, like Oscar, sell insurance on the exchanges. In September, regulators announced that they were shutting down Health Republic Insurance of New York, the largest of the CO-OPs. The company had lost more than fifty million dollars in the first half of this year. So far, eight CO-OPs across the country have closed their doors, and many more are dealing with financial losses and lower-than-expected enrollment. Another limitation of the direct-to-consumer approach is the size of the market. Last year, only seven million individuals bought coverage through an exchange, and the Congressional Budget Office projects that, over the next five years, enrollment will plateau below twenty-five million. By contrast, a hundred and fifty million people were insured through their workplace last year. It’s possible that this imbalance could shift—for example, if more employers were to adopt “private” employee-dedicated exchanges and give workers a fixed allowance to spend on a plan of their choice. A Kaiser Family Foundation report published this year indicated that while only two per cent of workers are currently enrolled in a private exchange, one in five employers are considering the model. By creating demand “from the ground up” among employees, Schlosser told me, Oscar hopes that eventually it, too, can expand into the employer market. While customer choice is typically considered a good thing, the direct-to-consumer market’s reliance on autonomy can also be a problem. When I became a doctor, I struggled to choose between just two plans that my employer had pre-selected for me, and research suggests that, in general, consumers make worse decisions when they are given too many options. “Throwing your employees to an exchange is not consumerism. That’s abdication,” Ali Diab, the co-founder of a company called Collective Health, which helps employers design and implement custom health plans, told me. “These are employees who you’re expecting to be engaged and productive at work, not benefits experts.” Perhaps the most serious criticism of the consumer-focussed strategy is that, no matter how well executed or widely adopted it is, it will do little to address the larger issue of rising health-care expenses. That’s because complex and chronic diseases drive the greatest share of costs, and providers still control most spending decisions where these illnesses are concerned. A 2013 survey on medical expenditures conducted by the Agency for Healthcare Research and Quality found that five per cent of the population accounted for nearly half of all health-care spending. Improving outcomes and decreasing costs for the sickest patients will take more than slick technology and a friendly interface—it will take close coördination with providers, adjustments to how they are compensated, and system-wide changes in clinical practice. Read part three, on new approaches to the relationship between providers and insurers, here.