Kaiser Permanente: Helping the People Without a Country

Kaiser Permanente physicians May Alhariri and Michael Drusano see the needs of Syrians in teeming tent cities as a long-term commitment — with no end in sight.

Physicians Michael Drusano, MD, and May Alhariri, MD, pictured with a refugee family in Greece.

(Originally published on Kaiser Permanente — Share)


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For Mayssoun Alhariri, MD, the Syrian refugees she thinks about most are the children.

"One girl was about 7 years old, yet she was carrying her baby brother on her shoulders, trying to calm him down. The look in her eyes really struck me; she was no longer a child. A 10-year-old boy was in charge of making sure his disabled father was taking his medications."

Dr. Alhariri saw this and much more when she went on medical missions with the Syrian American Medical Society to Turkey in 2014 and to Jordan in 2015. SAMS is a nonpolitical, nonprofit medical relief organization saving lives and alleviating suffering of Syrians in their homeland and in neighboring countries.

A Kaiser Permanente Santa Clara internal medicine physician, Dr. Alhariri is native to Syria. She received her medical education in Damascus and joined SAMS in 2011, even bringing her two teen daughters on one medical mission.

"I am surprised by how resilient the people are," she said of the refugees. "They can't wait to go back to their homeland despite losing everything. But they can't go back until it is safe. And it is not safe. Now they are in camps where in winter there are puddles up to their knees."

Civil war and suffering

Syria's conflict started as an uprising for human rights in March 2011, then turned into civil before becoming a "proxy war" involving other countries and factions. The United Nations estimates that 400,000 people have been killed during the conflict. Among the pre-war population of around 22 million, up to 13.5 million Syrians have required humanitarian assistance and around 5 million are now refugees.

Early on, SAMS physicians served on missions inside conflict-torn regions in Syria. But now the country is so unsafe that Dr. Alhariri and other physicians are deployed by SAMS to neighboring countries, including Greece. That's where Michael Drusano, MD, a Kaiser Permanente Richmond adult and family medicine physician, volunteered for two weeks last winter.

"I saw a lot of chronic untreated conditions we normally see in primary care as well as outbreaks of vaccine-preventable illnesses due to the collapse of the health system," said Dr. Drusano. "Additionally, due to the very cold winter, there were respiratory infections and complaints such as body aches."

Dr. Alhariri, who was in camps earlier in the conflict, saw up to 50 patients a day, with conditions ranging from migraines to malnutrition.

Each physician encountered many refugees with acute stress, including depression and anxiety brought on from leaving one country and being in limbo in another.

"Sometimes you would meet a child who had lost both parents or a mother who had lost all her children," Dr. Alhariri said of the trauma of loss.

Children play in a Syrian refugee camp in Turkey.

Bearing witness

As part of the U.N. resettlement, refugees are given a list of countries to choose from, Dr. Drusano explained. While they may rank their top 3, there is no guarantee where they will go; they may end up living anywhere from the U.K. to Estonia.

Dr. Drusano has been volunteering on missions since medical school. He said that while refugee camps are known for hardship, even a few creature comforts make an enormous difference.

Children play in a Syrian refugee camp in Turkey.For the Syrians, children have missed entire school years and adults have been unable to work. "One camp had a falafel café, a library and a weight room for exercise. The mood seemed lighter at that camp."

SAMS and its volunteers are now focusing on hiring local physicians to help the refugees and people inside, as well as building hospitals in some areas inside Syria.

"The intensity of the situation makes you realize what we take for granted and how difficult life can be for some," said Dr. Alhariri, now a SAMS board member. "But you can still offer help, even with limited resources. I can't see ever stopping this work."

"We provided medical care, but we also bore witness to what the Syrian refugees are going through," said Dr. Drusano. "And through that we learned how to provide better care for all displaced people."

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Kaiser Permanente Researchers Develop New Models for Predicting Suicide Risk

Approach may offer value to health systems and clinicians in targeting interventions to prevent suicide

Originally Published by Kaiser Permanente.

Combining data from electronic health records with results from standardized depression questionnaires better predicts suicide risk in the 90 days following either mental health specialty or primary care outpatient visits, reports a team from the Mental Health Research Network, led by Kaiser Permanente research scientists.

The study, "Predicting Suicide Attempts and Suicide Death Following Outpatient Visits Using Electronic Health Records," conducted in five Kaiser Permanente regions (Colorado, Hawaii, Oregon, California and Washington), the Henry Ford Health System in Detroit, and the HealthPartners Institute in Minneapolis, was published today in the American Journal of Psychiatry.

Combining a variety of information from the past five years of people's electronic health records and answers to questionnaires, the new models predicted suicide risk more accurately than before, according to the authors. The strongest predictors include prior suicide attempts, mental health and substance use diagnoses, medical diagnoses, psychiatric medications dispensed, inpatient or emergency room care, and scores on a standardized depression questionnaire.

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"We demonstrated that we can use electronic health record data in combination with other tools to accurately identify people at high risk for suicide attempt or suicide death," said first author Gregory E. Simon, MD, MPH, a Kaiser Permanente psychiatrist in Washington and a senior investigator at Kaiser Permanente Washington Health Research Institute.

In the 90 days following an office visit:

  • Suicide attempts and deaths among patients whose visits were in the highest 1 percent of predicted risk were 200 times more common than among those in the bottom half of predicted risk.
  • Patients with mental health specialty visits who had risk scores in the top 5 percent accounted for 43 percent of suicide attempts and 48 percent of suicide deaths.
  • Patients with primary care visits who had scores in the top 5 percent accounted for 48 percent of suicide attempts and 43 percent of suicide deaths.

This study builds on previous models in other health systems that used fewer potential predictors from patients' records. Using those models, people in the top 5 percent of risk accounted for only a quarter to a third of subsequent suicide attempts and deaths. More traditional suicide risk assessment, which relies on questionnaires or clinical interviews only, is even less accurate.

The new study involved seven large health systems serving a combined population of 8 million people in nine states. The research team examined almost 20 million visits by nearly 3 million people age 13 or older, including about 10.3 million mental health specialty visits and about 9.7 million primary care visits with mental health diagnoses. The researchers deleted information that could help identify individuals.

"It would be fair to say that the health systems in the Mental Health Research Network, which integrate care and coverage, are the best in the country for implementing suicide prevention programs," Dr. Simon said. "But we know we could do better. So several of our health systems, including Kaiser Permanente, are working to integrate prediction models into our existing processes for identifying and addressing suicide risk."

Suicide rates are increasing, with suicide accounting for nearly 45,000 deaths in the United States in 2016; 25 percent more than in 2000, according to the National Center for Health Statistics.

Other health systems can replicate this approach to risk stratification, according to Dr. Simon. Better prediction of suicide risk can inform decisions by health care providers and health systems. Such decisions include how often to follow up with patients, refer them for intensive treatment, reach out to them after missed or canceled appointments — and whether to help them create a personal safety plan and counsel them about reducing access to means of self-harm.