Technology & Policy

Updating the Toxic Substances Control Act to Protect Human Health

Updating the Toxic Substances Control Act to Protect Human Health

Leonardo Trasande
04/19/2016

Increasing evidence from laboratory and human studies shows that synthetic chemicals contribute to disease and dysfunction across the life course. Of particular emerging concern is the disruption of the hormonal process that has been found to be associated with increasing rates of obesity, diabetes, neurodevelopmental disabilities, infertility, and breast and prostate cancers.1 Given the magnitude of human and economic burden associated with these conditions, it might be expected that the passage of bipartisan legislation in both houses of Congress to update the Toxic Substances Control Act (TSCA) for the first time in 40 years would meet with widespread approval by the public health and medical community.

Mobility, Economic Opportunity and New York City Neighborhoods

Mobility, Economic Opportunity and New York City Neighborhoods
"Mobility, Economic Opportunity and New York City Neighborhoods," NYU Rudin Center for Transportation, November 2015.

Sarah M. Kaufman, Mitchell L. Moss, Jorge Hernandez and Justin Tyndall
01/04/2016

Although public transit provides access to jobs throughout the New York City region, there are actually substantial inequalities in mobility. By focusing on the neighborhood level, the NYU Rudin Center for Transportation has identified communities that are substantially underserved by the public transportation system. The Rudin Center ranked New York City’s 177 neighborhoods according to the number of jobs accessible from the neighborhoods by transit, within 60 minutes and completed by 9:00 a.m. on a Monday morning. This analysis reveals high variation in levels of transit access across New York affect residents’ employment levels, travel modes and incomes. This report seeks to affect the implementation of new policies and transit services to increase economic opportunity for New Yorkers, and ensure that the transportation system is fully leveraged to connect workers with jobs. These improvements will benefit all New Yorkers’ access to job opportunities and economic mobility.

Information Visibility in Humanitarian Operations: Current State-of-the-Art

Information Visibility in Humanitarian Operations: Current State-of-the-Art
In N. Atlay, M. Haselkorn, and C. Zobel (Eds.), Advances in Managing Humanitarian Operations. New York: Springer.

Privett, N.
04/18/2015

Purpose – Humanitarian operations can be greatly improved through increased supply chain visibility, that is, availability of information throughout the supply chain. This is broadly true for all types of humanitarian operations, whether disaster relief, global health efforts, or capacity building, or community development., and it is especially true for operations in developing or compromised country contexts.  This chapter establishes basic supply chain visibility needs in humanitarian contexts and explores current state-of-the-art technologies and applications employed to gain and improve visibility in humanitarian operations.  Conclusions are drawn regarding gaps in current visibility mechanisms as well as promising areas for further research and development.

                                                                       

Approach – Information regarding visibility needs, technologies, and projects was collected through 22 semi-structured interviews and a review of current literature from a variety of sources.  The state-of-the-art of visibility technology and applications are described by reviewing technologies, applications, and pilot projects in the humanitarian sector.  Conclusions are drawn comparing these technologies and addressing their weaknesses as well as remaining gaps in currently available solutions.

 

Findings – There is consensus among humanitarian researchers and practitioners that increased visibility has the potential to greatly improve humanitarian operations.  Firstly, though, any visibility mechanism must first be robust to potential humanitarian contextual challenges, including weak infrastructure (e.g., roads, electricity, internet and mobile networks), remoteness of operations, lack of human resources, and environmental conditions.  Identified visibility needs for humanitarian operations include tracking of location, tracking of inventory levels, temperature monitoring, tracing product information, information sharing, and decision making support.

This chapter demonstrates that current state-of-the-art technologies and applications aimed at increasing visibility in humanitarian operations are varied in approach and complexity; while  each tackle different needs, no one solution satisfies all. Reviewed technologies and applications are organized into the following categories: nontechnology-based applications, mature technologies, mobile phone applications and technologies, satellite-based technologies, temperature sensor and monitor technologies, and software technologies.  Indeed, each mechanism investigated (state-of-the-art technologies and applications) does improve visibility to some degree, but more complete visibility must be achieved through disconnected, patchwork solutions.  Thus, multifaceted and disjoined efforts must be employed to achieve even low levels of visibility today.

Over all of these technologies and applications, a set of key weaknesses has been identified.  While great advances and success has been achieved, unfeasible infrastructure dependency continues to be a weakness of existing technologies and applications. Such dependency includes reliance on electricity, computers, internet connectivity, cellular networks, and existing systems (e.g., RFID reader network). It is observed in this research, that as a solution moves away from being infrastructure dependent, it becomes more dependent on human resources.  As such, many of these solutions are labor intensive, dependent on reporting, and require extensive training.  However, human resources constraints and dependency themselves are serious issues facing humanitarian operations.  Furthermore, data collection is clearly limited and existing methods continue to be plagued by inaccuracy, deficient error checking provisions, and lack of back-up. Some data is still not real-time and delayed notification does not enable prevention. Affordability is another key weakness in the form of the devices, systems, and/or usage. 

Most importantly, for information visibility to be beneficial, (1) the information must be actionable and (2) the gained information and operational reaction systems must be synchronized for action, i.e., operations must be prepared and capable to respond to the information.  Thus, the greatest limitations are the lack of systems, procedures, and training that enable meaningful and appropriate reaction to the information provided. 

Contribution – This research assembles and evaluates current needs and efforts in humanitarian operations and supply chain visibility. Overall, this chapter informs current research and practice of ideal, necessary and realistically obtainable information in today’s humanitarian operations.  The benefits of this work extend broadly to operations and supply chain researchers and practitioners, including those engaged in humanitarian relief, global health supply chains, capacity building, and ongoing development campaigns.  Furthermore, the identification of gaps in current state-of-the-art technologies and applications directs future efforts of developers and users.

The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy

The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy
Medical Care, Vol. 53, no. 1, pp. 71-78. DOI: 10.1097/MLR.0000000000000259

Sivarajan, G., G.B. Taksler, D. Walter, C.P. Gross, R.E. Sosa,and D.V. Makarov
01/01/2015

Introduction: The rapid diffusion of the surgical robot has been controversial because of the technology’s high costs and its disputed marginal benefit. Some, however, have suggested that adoption of the robot may have improved care for patients with renal malignancy by facilitating partial nephrectomy, an underutilized, technically challenging procedure believed to be less morbid than radical nephrectomy. We sought to determine whether institutional acquisition of the robot was associated with increased utilization of partial nephrectomy.

Methods: We used all payer data from 7 states to identify 21,569 nephrectomies. These patient-level records were aggregated to the hospital-level then merged with the American Hospital Association Annual Survey and publicly available data on timing of robot acquisition. We used a multivariable difference-in-difference model to assess at the hospital-level whether robot acquisition was associated with an increase in the proportion of partial nephrectomy, adjusting for hospital nephrectomy volume, year of surgery, and several additional hospital-level factors.

Results: In the multivariable-adjusted differences-in-differences model, hospitals acquiring a robot between 2001 and 2004 performed a greater proportion of partial nephrectomy in both 2005 (29.9% increase) and 2008 (34.9% increase). Hospitals acquiring a robot between 2005 and 2008 also demonstrated a greater proportion of partial nephrectomy in 2008 (15.5% increase). In addition, hospital nephrectomy volume and urban location were also significantly associated with increased proportion of partial nephrectomy.

Conclusions: Hospital acquisition of the surgical robot is associated with greater proportion of partial nephrectomy, an underutilized, guideline-encouraged procedure. This is one of the few studies to suggest robot acquisition is associated with improvement in quality of patient care.

Application of global positioning system methods for the study of obesity and hypertension risk among low-income housing residents in New York City: a spatial feasibility study

Application of global positioning system methods for the study of obesity and hypertension risk among low-income housing residents in New York City: a spatial feasibility study
Geospatial Health, Vol. 9, no. 1, pp. 57-70. DOI: http://dx.doi.org/10.4081/gh.2014.6

Duncan, D.T., S.D. Regan, D. Shelley, K. Day, R.R. Ruff, M. Al-Bayan, and B. Elbel
09/01/2014

The purpose of this study was to evaluate the feasibility of using global positioning system (GPS) methods to understand the spatial context of obesity and hypertension risk among a sample of low-income housing residents in New York City (n = 120). GPS feasibility among participants was measured with a pre- and post-survey as well as adherence to a protocol which included returning the GPS device as well as objective data analysed from the GPS devices. We also conducted qualitative interviews with 21 of the participants. Most of the sample was overweight (26.7%) or obese (40.0%). Almost one-third (30.8%) was pre-hypertensive and 39.2% was hypertensive. Participants reported high ratings of GPS acceptability, ease of use and low levels of wear-related concerns in addition to few concerns related to safety, loss or appearance, which were maintained after the baseline GPS feasibility data collection. Results show that GPS feasibility increased over time. The overall GPS return rate was 95.6%. Out of the total of 114 participants with GPS, 112 (98.2%) delivered at least one hour of GPS data for one day and 84 (73.7%) delivered at least one hour on 7 or more days. The qualitative interviews indicated that overall, participants enjoyed wearing the GPS devices, that they were easy to use and charge and that they generally forgot about the GPS device when wearing it daily. Findings demonstrate that GPS devices may be used in spatial epidemiology research in low-income and potentially other key vulnerable populations to understand geospatial determinants of obesity, hypertension and other diseases that these populations disproportionately experience.

Are hospitals “keeping up with the Joneses”?: Assessing the spatial and temporal diffusion of the surgical robot

Are hospitals “keeping up with the Joneses”?: Assessing the spatial and temporal diffusion of the surgical robot
Healthcare : the Journal of Delivery Science & Innovation, Vol. 2, no. 2, pp. 152-157. DOI: 10.1016/j.hjdsi.2013.10.002

Li, H., M.H. Gail, B.R. Scott, H.T. Gold, D. Walter, D, M. Liu, C.P. Gross, and D.V. Makarov
07/01/2014

Background: The surgical robot has been widely adopted in the United States in spite of its high cost and controversy surrounding its benefit. Some have suggested that a “medical arms race” influences technology adoption. We wanted to determine whether a hospital would acquire a surgical robot if its nearest neighboring hospital already owned one.

Methods: We identified 554 hospitals performing radical prostatectomy from the Healthcare Cost and Utilization Project Statewide Inpatient Databases for seven states. We used publicly available data from the website of the surgical robot's sole manufacturer (Intuitive Surgical, Sunnyvale, CA) combined with data collected from the hospitals to ascertain the timing of robot acquisition during year 2001 to 2008. One hundred thirty four hospitals (24%) had acquired a surgical robot by the end of 2008. We geocoded the address of each hospital and determined a hospital's likelihood to acquire a surgical robot based on whether its nearest neighbor owned a surgical robot. We developed a Markov chain method to model the acquisition process spatially and temporally and quantified the “neighborhood effect” on the acquisition of the surgical robot while adjusting simultaneously for known confounders.

Results: After adjusting for hospital teaching status, surgical volume, urban status and number of hospital beds, the Markov chain analysis demonstrated that a hospital whose nearest neighbor had acquired a surgical robot had a higher likelihood itself acquiring a surgical robot (OR=1.71, 95% CI: 1.07–2.72, p=0.02).

Conclusion: There is a significant spatial and temporal association for hospitals acquiring surgical robots during the study period. Hospitals were more likely to acquire a surgical robot during the robot's early adoption phase if their nearest neighbor had already done so.

Test–retest reliability of a self-administered Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients

Test–retest reliability of a self-administered Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients
Journal of Substance Abuse Treatment, Vol. 47, no. 1, pp. 216-221. DOI: 10.1016/j.jsat.2014.01.007

McNeely, J., S.M. Strauss, S. Wright, J. Rotrosen, R. Khan, J.D. Lee, and M.N. Gourevitch
07/01/2014

The time required to conduct drug and alcohol screening has been a major barrier to its implementation in mainstream healthcare settings. Because patient self-administered tools are potentially more efficient, we translated the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) into an audio guided computer assisted self interview (ACASI) format. This study reports on the test–retest reliability of the ACASI ASSIST in an adult primary care population. Adult primary care patients completed the ACASI ASSIST, in English or Spanish, twice within a 1–4 week period. Among the 101 participants, there were no significant differences between test administrations in detecting moderate to high risk use for tobacco, alcohol, or any other drug class. Substance risk scores from the two administrations had excellent concordance (90–98%) and high correlation (ICC 0.90–0.97) for tobacco, alcohol, and drugs. The ACASI ASSIST has good test–retest reliability, and warrants additional study to evaluate its validity for detecting unhealthy substance use.

Twitter Response to the United States Preventive Services Task Force Recommendations against Screening with Prostate Specific Antigen

Twitter Response to the United States Preventive Services Task Force Recommendations against Screening with Prostate Specific Antigen
BJU International. DOI: 10.1111/bju.12748

Prabhu, V., T. Lee, S. Loeb, J.H. Holmes, H.T. Gold, H. Lepor, D.F. Penson, and D.V. Makarov
03/24/2014

Objective: To examine public and media response to the United States Preventive Services Task Force's (USPSTF) draft (October 2011) and finalized (May 2012) recommendations against prostate-specific antigen (PSA) testing using Twitter, a popular social network with over 200 million active users.

Materials and Methods: We used a mixed methods design to analyze posts on Twitter, called “tweets.” Using the search term “prostate cancer,” we archived tweets in the 24 hour periods following the release of the USPSTF draft and finalized recommendations. We recorded tweet rate per hour and developed a coding system to assess type of user and sentiment expressed in tweets and linked articles.

Results: After the draft and finalized recommendations, 2042 and 5357 tweets focused on the USPSTF report, respectively. Tweet rate nearly doubled within two hours of both announcements. Fewer than 10% of tweets expressed an opinion about screening, and the majority of these were pro-screening during both periods. In contrast, anti-screening articles were tweeted more frequently in both draft and finalized study periods. From the draft to the finalized recommendations, the proportion of anti-screening tweets and anti-screening article links increased (p= 0.03 and p<0.01, respectively).

Conclusions: There was increased Twitter activity surrounding the USPSTF draft and finalized recommendations. The percentage of anti-screening tweets and articles appeared to increase, perhaps due to the interval public comment period. Despite this, most tweets did not express an opinion, suggesting a missed opportunity in this important arena for advocacy.

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