Ram's Doctoral background and academic interests are in the computational modeling of complex decisions, algorithm design and implementation, and data driven decision making. Outside of clinical work, his main competencies in this regard are software development, algorithm design and implementation, cost-effectiveness analysis, and decision analysis through computational models. He has also collaborated with industry to create and deploy operation specific software involving statistical computing and reasoning under inference. He has been practicing clinical Emergency Medicine in both community and academic settings for over 20 years.
Clinical Associate Professor, Emergency Medicine
Ph.D., Stanford University, Computational Decision Modeling (2007)
MD, University of Michigan, Medicine (1996)
BS, Stanford University, Biology (1991)
BA, Stanford University, Political Economy (1991)
Child mask mandates for COVID-19: a systematic review.
Archives of disease in childhood
Mask mandates for children during the COVID-19 pandemic varied in different locations. A risk-benefit analysis of this intervention has not yet been performed. In this study, we performed a systematic review to assess research on the effectiveness of mask wearing in children.We performed database searches up to February 2023. The studies were screened by title and abstract, and included studies were further screened as full-text references. A risk-of-bias analysis was performed by two independent reviewers and adjudicated by a third reviewer.We screened 597 studies and included 22 in the final analysis. There were no randomised controlled trials in children assessing the benefits of mask wearing to reduce SARS-CoV-2 infection or transmission. The six observational studies reporting an association between child masking and lower infection rate or antibody seropositivity had critical (n=5) or serious (n=1) risk of bias; all six were potentially confounded by important differences between masked and unmasked groups and two were shown to have non-significant results when reanalysed. Sixteen other observational studies found no association between mask wearing and infection or transmission.Real-world effectiveness of child mask mandates against SARS-CoV-2 transmission or infection has not been demonstrated with high-quality evidence. The current body of scientific data does not support masking children for protection against COVID-19.
View details for DOI 10.1136/archdischild-2023-326215
View details for PubMedID 38050026
- Potential "Healthy Vaccinee Bias" in a Study of BNT162b2 Vaccine against Covid-19. The New England journal of medicine 2023; 389 (3): 284-285
Rejoinder 3: School closures: The trigger point in the decline in pediatric mental health outcomes during the COVID-19 pandemic.
Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l'Academie canadienne de psychiatrie de l'enfant et de l'adolescent
2023; 32 (2): 88-92
View details for PubMedID 37181439
Rejoinder 3: School closures: The trigger point in the decline in pediatric mental health outcomes during the COVID-19 pandemic
JOURNAL OF THE CANADIAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
2023; 32 (2): 88-92
View details for Web of Science ID 001048547400008
Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income
Western Journal of Emergency Medicine
In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities.We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019.Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased.Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.
View details for DOI 10.5811/westjem.2021.1.49279
Patient and Physician Willingness to Use Personal Health Records in the Emergency Department
WESTERN JOURNAL OF EMERGENCY MEDICINE
2012; 13 (2): 172–75
Patient care in the emergency department (ED) is often complicated by the inability to obtain an accurate prior history even when the patient is able to communicate with the ED staff. Personal health records (PHR) can mitigate the impact of such information gaps. This study assesses ED patients' willingness to adopt a PHR and the treating physicians' willingness to use that information.This cross-sectional study was answered by 184 patients from 219 (84%) surveys distributed in an academic ED. The patient surveys collected data about demographics, willingness and barriers to adopt a PHR, and the patient's perceived severity of disease on a 5-point scale. Each patient survey was linked to a treating physician survey of which 210 of 219 (96%) responded.Of 184 surveys completed, 78% of respondents wanted to have their PHR uploaded onto the Internet, and 83% of providers felt they would access it. Less than 10% wanted a software company, an insurance company, or the government to control their health information, while over 50% wanted a hospital to control that information. The patients for whom these providers would not have used a PHR had a statistically significant lower severity score of illness as determined by the treating physician from those that they would have used a PHR (1.5 vs 2.4, P < 0.01). Fifty-seven percent of physicians would only use a PHR if it took less than 5 minutes to access.The majority of patients and physicians in the ED are willing to adopt PHRs, especially if the hospital participates. ED physicians are more likely to check the PHRs of more severely ill patients. Speed of access is important to ED physicians.
View details for DOI 10.5811/westjem.2011.11.6844
View details for Web of Science ID 000422594200007
View details for PubMedID 22900108
View details for PubMedCentralID PMC3415806
Cost-Effectiveness of Strategies for Diagnosing Pulmonary Embolism Among Emergency Department Patients Presenting With Undifferentiated Symptoms
ANNALS OF EMERGENCY MEDICINE
2010; 56 (4): 321-332
Symptoms associated with pulmonary embolism can be nonspecific and similar to many competing diagnoses, leading to excessive costly testing and treatment, as well as missed diagnoses. Objective studies are essential for diagnosis. This study evaluates the cost-effectiveness of different diagnostic strategies in an emergency department (ED) for patients presenting with undifferentiated symptoms suggestive of pulmonary embolism.Using a probabilistic decision model, we evaluated the incremental costs and effectiveness (quality-adjusted life-years gained) of 60 testing strategies for 5 patient pretest categories (distinguished by Wells score [high, moderate, or low] and whether deep venous thrombosis is clinically suspected). We performed deterministic and probabilistic sensitivity analyses.In the base case, for all patient pretest categories, the most cost-effective diagnostic strategy is to use an initial enzyme-linked immunosorbent assay D-dimer test, followed by compression ultrasonography of the lower extremities if the D-dimer is above a specified cutoff. The level of the preferred cutoff varies with the Wells pretest category and whether a deep venous thrombosis is clinically suspected. D-dimer cutoffs higher than the current recommended cutoff were often preferred for patients with even moderate and high Wells categories. Compression ultrasonography accuracy had to decrease below commonly cited levels in the literature before it was not part of a preferred strategy.When pulmonary embolism is suspected in the ED, use of an enzyme-linked immunosorbent assay D-dimer assay, often at cutoffs higher than those currently in use (for patients in whom deep venous thrombosis is not clinically suspected), followed by compression ultrasonography as appropriate, can reduce costs and improve outcomes.
View details for DOI 10.1016/j.annemergmed.2010.03.029
View details for Web of Science ID 000282854500004
View details for PubMedID 20605261
- Musculoskeltal Emergencies A Practical Guide to Pediatric Emergency Medicine 2010; 1
- Gastrointestinal Emergencies A Practical Guide to Pediatric Emergency Medicine 2010; 1
- Using Influence Diagrams in Cost Effectiveness Analysis for Medical Decisions Optimization in Medicine and Biology 2008
Using Influence Diagrams in Cost-Effectiveness Analysis for Medical Decisions
OPTIMIZATION IN MEDICINE AND BIOLOGY
View details for Web of Science ID 000268012400002
Non-Bayesian Classification to Obtain High Quality Clinical Decisions
OPTIMIZATION IN MEDICINE AND BIOLOGY
View details for Web of Science ID 000268012400003
- Non-Bayesian Classification to Obtain High Quality Clinical Decisions Optimization in Medicine and Biology 2008
Value of quantitative D-dimer assays in identifying pulmonary embolism: Implications from a sequential decision model
ACADEMIC EMERGENCY MEDICINE
2006; 13 (7): 755-766
To examine the cost-effectiveness of a quantitative D-dimer assay for the evaluation of patients with suspected pulmonary embolism (PE) in an urban emergency department (ED).The authors analyzed different diagnostic strategies over pretest risk categories on the basis of Wells criteria by using the performance profile of the ELISA D-dimer assay (over five cutoff values) and imaging strategies used in the ED for PE: compression ultrasound (CUS), ventilation-perfusion (VQ) scan (over three cutoff values), CUS with VQ (over three cutoff values), computed tomography (CT) angiogram (CTA) with pulmonary portion (CTP) and lower-extremity venous portion, and CUS with CTP. Data used in the analysis were based on literature review. Incremental costs and quality-adjusted-life-years were the outcomes measured.Computed tomography angiogram with pulmonary portion and lower-extremity venous portion without D-dimer was the preferred strategy. CUS-VQ scanning always was dominated by CT-based strategies. When CTA was infeasible, the dominant strategy was D-dimer with CUS-VQ in moderate- and high-Wells patients and was D-dimer with CUS for low-Wells patients. When CTP specificity falls below 80%, or if its overall performance is markedly degraded, preferred strategies include D-dimer testing. Sensitivity analyses suggest that pessimistic assessments of CTP accuracy alter the results only at extremes of parameter settings.In patients in whom PE is suspected, when CTA is available, even the most sensitive quantitative D-dimer assay is not likely to be cost-effective. When CTA is not available or if its performance is markedly degraded, use of the D-dimer assay has value in combination with CUS and a pulmonary imaging study. These conclusions may not hold for the larger domain of patients presenting to the ED with chest pain or shortness of breath in whom PE is one of many competing diagnoses.
View details for DOI 10.1197/j.aem.2006.02.011
View details for Web of Science ID 000239051800008
View details for PubMedID 16723725