There was a totally overlooked trial in @NEJM this week with jaw-dropping results. The question: how should we diagnose diabetes in pregnancy?

23,792 pregnant women randomized to receive either 1-step or 2-step screening for gestational diabetes.

nejm.org/doi/full/10.10…

/1
@NEJM There's no consensus on how to diagnose diabetes in pregnancy, which is VERY common and, if treated, can reduce risk of infant + maternal complications.

So the authors compared the more sensitive, single visit "one step" approach to a "two step" approach that can take 2 visits.
@NEJM There was a HUGE difference in diabetes diagnosis between the two groups:

One-step: 16.5% of women diagnosed with diabetes

Two-step: 8.5% diagnosed

This diagnosis comes with a lot of emotional and clinical baggage!!

…pregnancychildbirth.biomedcentral.com/articles/10.11…
@NEJM Was there a difference in outcomes between the two groups of women? 16.5% vs. 8.5%?

NOTHING

No difference in birth weight, pre-eclampsia, or C-section rates.

Oh, except babies in the one-step group were more likely to have hypoglycemia ... likely due to diabetes treatment
@NEJM I think this is a remarkable trial.

1) Demonstrates just how valuable RCTs are, especially for DIAGNOSIS, when you follow outcomes

2) Textbook example of how over-diagnosis happens and that over-diagnosis is REAL and HARMFUL
@NEJM Not measured: the enormous extra effort, $$ and stress suffered by women in the 2x diagnosis group

"Some women reported living in fear of risking the health of their baby and conducted extreme behaviours such as purging and starving themselves"

…pregnancychildbirth.biomedcentral.com/articles/10.11…
@NEJM Spread the word about this trial. Almost no one has tweeted about it and basically no media coverage.

nejm.org/doi/full/10.10…
@NEJM cc various folks who care about pregnancy + overdiagnosis @smilleralert @LaurawherryR @neel_shah @katybkoz @VPrasadMDMPH @ShannonBrownlee @RosenthalHealth

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More from @ml_barnett

8 Dec 20
On Saturday, I went outside to clear the small hill of ice that snow plows helpfully deposit on our driveway when it snows.

I didn't see a slick patch of ice. My feet flew into the air and I went splat on my left shoulder.

I was in enormous pain and realized I needed help.
I went to a local ED with a shoulder dislocation. I had a totally normal experience - in fact, I think above average.

But this time, as a patient, I learned again how "totally normal" in our health system is frustrating, isolating and bewildering.
After I checked in and was sitting in the waiting room, the endorphins from my fall wore off and I realized that I was in terrible pain.

The triage nurse called me in. I told her I was in a lot of pain. She snapped at me: "Look, I'm doing my job and you have to wait your turn."
Read 19 tweets
3 Dec 20
You have probably seen the record-breaking, terrible COVID-19 stats for Dec 2nd in the US

Daily cases: 195,695
Currently hospitalized: 100,226
Daily deaths: 2,733

You need to understand these numbers in context

It makes them even more frightening

covidtracking.com/data/charts/us…

🧵
Let's start with hospitalizations: 100,226 total on 12/2/20.

On the average day in 2018, there were 612,000 hospitalized patients. Assume this is 620,000 in 2020 without Covid

So roughly **16%** or ONE in SIX hospitalized patients in the US has Covid.

guide.prod.iam.aha.org/stats/historic…
This is WAY higher than ANY OTHER reason for hospitalization, including childbirth.

Top 3 reasons for admission in US, 2017 (36.5 million annual admissions):
Childbirth - 10.1%
Sepsis (infection) - 5.7%
Arthritis (elective surgery mostly) - 3.4%

hcup-us.ahrq.gov/faststats/Nati…
Read 8 tweets
13 Nov 20
I spent the entire month of February 2020 in a state of silent panic.

Watching Europe + US outbreaks play out, I knew something terrible was coming. But few of my colleagues shared the depth of my fear.

It feels like this again. And I think the public still has no idea.

🧵
Just. look. at. this. graph.

Did late March feel terrible and apocalyptic? We are FAR past that point right now.

And guess what? We have not yet reached the BUSIEST HOLIDAY TRAVEL WEEK OF THE YEAR

My patients are asking me about travel plans. They have no idea what is coming
And how can I blame them? Even *I* am uncertain about how to best counsel them.

Honestly guys ... as a PCP my best source of COVID-19 guidance is #epitwitter and #medtwitter.

If this is how I feel, as a PCP and a professor at @HarvardChanSPH then I fear for our country.
Read 9 tweets
10 Nov 20
New in @JAMA_current today on a new bundled payment model based in skilled nursing facilities (SNFs)!

Turns out that SNFs can save money too with bundled payments

W/ wonderful co-authors @kejoynt John Orav @DavidCGrabowski Arnie Epstein

brief thread

jamanetwork.com/journals/jama/… Image
@JAMA_current @kejoynt @DavidCGrabowski A little discussed bundled payment model run by CMMI from 2013-2018 was focused on nursing facilities as risk-bearing providers - so called "BPCI Model 3"

How did this program work for total joint replacement - the most common surgery in Medicare?

innovation.cms.gov/innovation-mod…
@JAMA_current @kejoynt @DavidCGrabowski We studied episodes at 448 SNFs from 2013-2017 and matched them to similar SNFs

Outcomes: spending, SNF days and admission/death

This was also my first chance to walk the walk of @laura_tastic @jamie_daw's excellent work on matching in diff-in-diff

Read 7 tweets
25 Aug 20
🚨 New in @JAMA_current 🚨

"Secret shopper" survey of 368 residential addiction programs for opioid use

TL;DR:

Fewer than 1/3rd offered maintenance treatment with buprenorphine while over 1 in 5 actively discouraged buprenorphine use

More below

jamanetwork.com/journals/jama/…
@JAMA_current Lots written about shoddy quality at residential addiction programs, but there is little hard data out there

We set out to get data on what programs offer to potential patients

Led by @tamarabeetham w/ coauthors @BrendanSaloner @DrSarahWakeman + Marema Gaye, Richard Frank
@JAMA_current @tamarabeetham @BrendanSaloner @DrSarahWakeman We called 368 residential programs as "secret shoppers" posing as individuals looking for opioid use disorder (OUD) treatment.

We asked what therapies do they offer, and do they nudge callers in any direction?
Read 9 tweets
23 Aug 20
It's been a depressing news week so is another thread of beautiful pictures from Google Earth to make you happy.

#1: Dramatic angles framing a river in Germany

Pics from Chrome extension: chrome.google.com/webstore/detai… Image
#2: An amazing city with respect for its neighbor forest in Ecuador Image
#3: One very scenic cloud in Vietnam Image
Read 9 tweets

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