Ram S Duriseti

All Publications

• School Mask Mandates and COVID-19: The Challenge of Using Difference-in-Differences Analysis of Observational Data to Estimate the Effectiveness of a Public Health Intervention. Annals of internal medicine Chandra, A., Hoeg, T. B., Ladhani, S., Prasad, V., Duriseti, R. 2024

  Abstract

  BACKGROUND: There are considerable challenges when using difference-in-differences (DiD) analysis of ecological data to estimate the effectiveness of public health interventions in rapidly changing situations.OBJECTIVE: To discuss the shortcomings of DiD methodology for the estimation of the effects of public health interventions using ecological data.DESIGN: As an example, the authors consider an analysis that used DiD methodology and reported a causal reduction in COVID-19 cases due to the maintenance of school mask mandates. They did alternate analyses using various control groups to assess the robustness of the prior analysis.SETTING: School districts in the greater Boston area and Massachusetts during the 2021-to-2022 academic year.PARTICIPANTS: Students and school staff.MEASUREMENTS: Changes in COVID-19 case rates in districts that did and did not lift mask mandates.RESULTS: Important potential confounders rendered DiD methodology inappropriate for causal inference, including prior immunity, temporal variation in rates of infection, and changes in testing practices. The racial composition and income of intervention and control groups also differed substantially. Compared with maintaining the mask requirement, dropping the requirement was associated with anywhere from an increase of 5.64 cases (95% CI, 3.00 to 8.29 cases) per 1000 persons to a decrease of 2.74 cases (CI, 0.63 to 4.85 cases) per 1000 persons, depending on choice of control group and whether students or staff were examined.LIMITATION: Ecological data were used; detailed data on all potential confounders were unavailable.CONCLUSION: Alternate analyses yielded estimates consistent with a wide range of both negative and positive associations in COVID-19 case rates after removal of mask mandates. The findings highlight the challenges of using DiD analysis of ecological data to estimate the effectiveness of interventions in divergent intervention and control groups during rapidly changing circumstances.PRIMARY FUNDING SOURCE: None.

  View details for DOI 10.7326/M23-2907

  View details for PubMedID 39374524

• Face masks and protection against COVID-19 and other viral respiratory infections: Assessment of benefits and harms in children. Paediatric respiratory reviews Sandlund, J., Duriseti, R., Ladhani, S. N., Stuart, K., Noble, J., Beth Hoeg, T. 2024

  Abstract

  Mask mandates for children were implemented at schools and childcare centers during the COVID-19 pandemic, and the US continues to recommend masking down to the age of two in certain settings. Medical interventions should be informed by high-quality evidence and consider the possibility of harm (i.e., include harm-benefit analyses). In this review, we weigh the existing evidence for the effectiveness of mask mandates to protect against COVID-19 and other viral respiratory infections and the harms associated with face mask wearing in children. There is a lack of robust evidence of benefit from masking children to reduce transmission of SARS-CoV-2 or other respiratory viruses. The highest quality evidence available for masking children for COVID-19 or other viral respiratory infections has failed to find a beneficial impact against transmission. Mechanistic studies showing reduced viral transmission from use of face masks and respirators have not translated to real world effectiveness. Identified harms of masking include negative effects on communication and components of speech and language, ability to learn and comprehend, emotional and trust development, physical discomfort, and reduction in time and intensity of exercise. Effectiveness of child masking has not been demonstrated, while documented harms of masking in children are diverse and non-negligible and should prompt careful reflection. Recommendations for masking children fail basic harm-benefit analyses.

  View details for DOI 10.1016/j.prrv.2024.08.003

  View details for PubMedID 39306529

• Child mask mandates for COVID-19: a systematic review. Archives of disease in childhood Sandlund, J., Duriseti, R., Ladhani, S. N., Stuart, K., Noble, J., Høeg, T. B. 2023

  Abstract

  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 Hoeg, T. B., Duriseti, R., Prasad, V. 2023; 389 (3): 284-285

  View details for DOI 10.1056/NEJMc2306683

  View details for PubMedID 37470285

• 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 Vidal, C., Holland, E. T., Duriseti, R. S. 2023; 32 (2): 88-92

  View details for Web of Science ID 001048547400008

• 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 Vidal, C., Holland, E. T., Duriseti, R. S. 2023; 32 (2): 88-92

  View details for PubMedID 37181439

• Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income Western Journal of Emergency Medicine Lowe, J., Brown, I., Duriseti, R., et al 2021: 552-560

  Abstract

  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 Menon, A. S., Greenwald, S., Ma, T. J., Kooshesh, S., Duriseti, R. 2012; 13 (2): 172–75

  Abstract

  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 Duriseti, R. S., Brandeau, M. L. 2010; 56 (4): 321-332

  Abstract

  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 Ram Duriseti 2010; 1
• Gastrointestinal Emergencies A Practical Guide to Pediatric Emergency Medicine Ram Duriseti 2010; 1
• Using Influence Diagrams in Cost Effectiveness Analysis for Medical Decisions Optimization in Medicine and Biology Ram Duriseti 2008
• Using Influence Diagrams in Cost-Effectiveness Analysis for Medical Decisions OPTIMIZATION IN MEDICINE AND BIOLOGY Duriseti, R. S., Lim, G. J., Lee, E. K. 2008: 61–94

  View details for Web of Science ID 000268012400002

• Non-Bayesian Classification to Obtain High Quality Clinical Decisions OPTIMIZATION IN MEDICINE AND BIOLOGY Duriseti, R. S., Lim, G. J., Lee, E. K. 2008: 95–115

  View details for Web of Science ID 000268012400003

• Non-Bayesian Classification to Obtain High Quality Clinical Decisions Optimization in Medicine and Biology Ram Duriseti 2008
• Value of quantitative D-dimer assays in identifying pulmonary embolism: Implications from a sequential decision model ACADEMIC EMERGENCY MEDICINE Duriseti, R. S., Shachter, R. D., Brandeau, M. L. 2006; 13 (7): 755-766

  Abstract

  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