1/ read this @adamcancryn @tylerpager piece, and let's discuss some of the points raised

‘There is a palpable concern’: Biden presses advisers over 100 million Covid shot goal politi.co/2XHhk1f
2/ first, I am so glad @JoeBiden *is* putting a hard to reach goal out there

When @matkendall and I set our first public targets
@ONC_HealthIT a longtime fed told us "never give them a date AND a number"

It's risky, it's gutsy, and it's the right thing to do for the country.
3/ It will be very hard to hit 100M in 100 days

But the very fact that this article was written EVEN BEFORE THEY START points to the intense focus it brings.

The new admin may miss their first big test, but vaccinate tens of millions more than if they shunned responsibility

4/ I'm also really happy to hear that @JoeBiden is "urging advisers to avoid generalities and drill down on the particulars"

The details are everything in a job like this. It's not enough to say, breezily, we give it to the states, then it's their problem.

That approach failed
5/ "Pushing on details" <> "don't trust the team"

“He wants to know about the practical details. I think that’s a good thing because that makes sure the plans are grounded in reality, but I don’t take from those conversations that he doesn’t believe in his team.”

6/ and what is going to change, to make 10M a reality?

These strategies are good, but there's one big piece of advice I would have for @JeffZients @NQuillian @choucair

In a public health emergency, take advantage of the systems we use during peacetime

primary care practices
7/ Yes, we do need to give state and local public health officials more resources, but also more guidance and more tools.

For all the parlor generals out there- read this searing interview w a Florida county manager- would you do better? are you sure?

8/ Yes, we need feds to not abdicate their role and engage directly (c/f testing debacle)

Setting up field centers to cover high volume urban centers as well as underserved rural areas makes sense.

But we also need to open the CDC's (non-state) pipeline beyond CVS/Walgreens
9/ This is the system CDC has established to take orders for the vaccine supply purchased by the feds and to get them shipped (by McKesson) to the recipients.

Right now, the only "provider organizations" getting vaccine from CDC (vs states) are the pharmacies

Expand this pipe
10/ Yes, pushing out more vaccine doses so they are not sitting in federal warehouses is good.

But we have a huge "last mile" problem.

Feds -> State -> Hospitals -> ? -> High risk elderly

Trickle down from hospitals with excess doses before they spoil is not a good plan.
11/ Non-hospital physician practices can't even figure out how to get their own staff vaccinated.

12/ We need willing arms as well as vaccine supply- that's why a large portion of annual vaccines are given by community PCPs

Given vaccine resistance in many, it will be critical to have trusted practices *proactively reach out* to high risk patients

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More from @Farzad_MD

30 Dec 20
1/ People are hardwired to get infuriated when they see injustice.

But I fear that applying this lens to covid vaccine distribution will lead to more deaths not fewer.

Stanford has screwed up, again. Some people who shouldn't have gotten it, did.
2/ What's the natural response then, from those all the way down the distribution chain, from state administrators to hospital execs worried about "wrong people" getting vaccinated first?

You spend more time collecting data, parsing into finer and finer gradations

You slow down
3/ Hospitals and nursing homes don't release more to staff until every i has been dotted.

States don't release more to hospitals and nursing homes until they've used up allotment

feds don't release more to states

Amidst a vaccine shortage, available supply sits in warehouses.
Read 8 tweets
29 Nov 20
1/ Opening schools in the midst of a COVID surge is a hard problem with unavoidable tradeoffs.

There are absolutist statements on either side of the debate, so I expect passionate rebuttals, but let me lay out a decision-making framework, from an epidemiologists' perspective
2/ First off, we have to make sure that the schools have the resources and space to implement the 5 key mitigation
strategies correctly and consistently.

Not a given.

*Social distancing
*Contact tracing
*Hand hygiene
*Cleaning and disinfection

first 2 >> last 2
3/ Let's say we have some resources for testing, how does that contribute?

What we are trying to achieve?

Do you think the goal is Screening (identify asymptomatic infectious cases before they can expose others) or Surveillance (understand incidence to inform policy)?
Read 22 tweets
15 Nov 20
1/ It's indescribable seeing results from NYC EMS ambulance runs showing how cardiac arrests skyrocketed during COVID

(I started a program to monitor these symptoms in real time--among the very first application of syndromic surveillance in public health, 2 decades ago)
2/ Every day, crews from @FDNY are called to 20 to 30 patients who have collapsed, and attempt resuscitation. Can you imagine?

It's never like the movies. Most patients die, ribs cracked. 75% of the time you never get a heart rate back.

On April 6, there were 305.

3/ In the dry language of medical research the researchers describe the horrible statistics.

During the peak, most patients had nonshockable presenting rhythms of asystole and pulseless electrical activity. 92.2% of the time they called off the resuscitation without a pulse.
Read 7 tweets
11 Nov 20
1/ I've been feeling more and more disengaged from COVID work, disillusioned with the growing realization that all the smart research and policy doesn't make a damn bit of difference

Not for the 1st time, I've seen that what I thought was an information problem is something else
2/ I so admire those public health Cassandras who've been unrelenting, continuing to beat the drum of science and policy for the past 9 months

repeating over and over again what must be done, as the cases and deaths mount, with no strategy in sight

tweets, interviews, articles
3/ It's perhaps no accident that they (and I) are "formers"

People who ran the agencies, who know the pain of the experts and scientists working inside, and are free to speak

CDC @DrTomFrieden
FDA @ScottGottliebMD
CMS @ASlavitt
FDA/CMS @DukeMargolis McClellan
WH @ZekeEmanuel
Read 10 tweets
10 Oct 20
1/ Policy makers: Wait, Isn’t quality of care better at large expensive health systems c/w independent practices?

Previous Research: Ummm no. But we can keep looking

@AHRQNews What if we look at high needs patients?

@RANDCorporation It’s ... worse?

2/ To test hypothesis that health systems provide better care to patients w high needs, diff in quality b/w system‐affiliated & nonaffiliated physicians

ED visits were significantly *different* in system‐affiliated (117.5 per 100) & nonaffiliated POs (106.8 per 100, P < .0001).
3/ I love how delicately the RAND researchers approach this in their conclusion: “Health systems may not confer hypothesized quality advantages to patients with high needs.”

(Then why do they get paid so much more?)
Read 4 tweets
23 Sep 20
1/ How can we reduce Medicare spending without harming patients?

What we do @AledadeACO is transformative, but hard.

There are some low hanging fruit. This was one of them

Prior auth for repetitive, scheduled non-emergency ambulance transportation

2/ When CMS first released their public use files, I ran some analyses looking for aberrations-

One thing that jumped right out was...Repetitive non-emergency ambulance runs- often for the same person going back and forth to dialysis 3 times a week.

3/ In my blog @BrookingsInst back in 2014 I wrote:

"Medicare and law enforcement officials will need to create new processes for dealing with a potential flood of outlier reports from amateur sleuths like me."

But prevention >> fraud enforcement

Read 12 tweets

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