New @NEJM out today!!

After a high risk OUD event (OD or detox)
- White patients get buprenorphine 80% more often than Black pts
- This is not due to diffs in methadone or frequency of health care access
- Rates of rx opioids/benzos are HIGHER than bupe

nejm.org/doi/full/10.10… @NEJM Before I dive in, this was a joint effort of @HarvardHPM @HMSHCP @DartmouthInst w/ Nancy Morden, @ermeara @Ateevm @DrLewinson and many others

We focused on disabled Medicare enrollees from 2016-2019 with an OUD "index event" like OD, IV drug related infection or detox/rehab.

Excited to share a new paper today with @McGarryBE and @ashdgandhi published today in @NEJM

TL;DR Nursing homes with higher use of COVID-19 tests for staff had 30% fewer resident cases and 26% fewer deaths than low testing facilities. That's a LOT.

/1

nejm.org/doi/full/10.10… @McGarryBE @ashdgandhi @NEJM Why does this matter? In the early pandemic, we had no vaccines, no Paxlovid. Top priority - keeping COVID out of nursing homes by testing staff frequently. But a lot of nursing homes didn't.

We need to understand what this policy failure cost us.

/2

washingtonpost.com/health/2020/09…

It's that time again - my list of 10 of the most thought-provoking, surprising, and rigorous studies in health care in 2022!

Themes this year:
1) Care delivery changes that work (and don't)
2) Race and health care
3) Natural experiments in the ED
+ a few misc. cool papers Before we dive in - this list is
A) not comprehensive
B) not presented in any particular order
(I’m also focusing on papers written by folks outside my circle of colleagues/collaborators)

First up is a set of 4 studies on changes to care delivery or coverage.

New work in @JAMA_current today - who has been getting those precious monoclonal antibody infusions for COVID-19 in the US?

It's not pretty ...

Work led by @CarolineLBehr with @kejoynt @ermeara Arnie Epstein and John Orav.

jamanetwork.com/journals/jama/… @JAMA_current @CarolineLBehr @kejoynt @ermeara We identified 1.9 million cases of COVID-19 in Medicare claims without hospitalization/death in the first week.

In nearly every case, those at higher risk of dying from COVID-19 were LESS likely to get monoclonal antibodies (mAbs).

jamanetwork.com/journals/jama/…

Here's my list of 12 papers in 2021 at the intersection of health care, medicine, economics and policy that surprised me, made me think, or were just damn clever.

I'm just going to focus on non-COVID-19 papers - we have enough of that other stuff in our feeds.

Off we go!

/1 Before we dive in - this is
A) definitely not comprehensive
B) definitely not in order of awesomeness

I’m also focusing on papers written by folks outside my direct circle of collaborators (w/ a couple of non-Harvard exceptions I can’t resist).

Sorry @AnupamBJena

/2

New analysis in @NEJM today with coauthors @McGarryBE @ashdgandhi @DavidCGrabowski

Vaccine mandates continue to be controversial, including in nursing homes. What are the stakes exactly?

The results are sobering, to say the least ...

nejm.org/doi/full/10.10… @NEJM @McGarryBE @ashdgandhi @DavidCGrabowski From June-Aug 2021, we compared resident and staff infection + mortality rates between 12,000 homes with the lowest staff vaccination rates (~30%) vs. highest (~80%).

In the least vaccinated homes:
+132% COVID cases in residents
+58% staff cases
+195% resident mortality

yikes

Extremely provocative French study out in @JAMAInternalMed this morning on persistent COVID symptoms.

What is the association between persistent symptoms and COVID-19 serology vs. patient belief that they had COVID?

jamanetwork.com/journals/jamai… @JAMAInternalMed The authors took a cross sectional cohort of >26,000 French survey respondents and compared their reports of persistent symptoms in early 2021 with:

1) COVID-19 serology collected May-Nov 2020
2) Self-reported belief about prior COVID-19 infection

2x2 table of pt chars below

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.

Brief primary care rant.

It's 2021. We have developed an effective vaccine for a novel virus in months and we can land a probe on a comet.

There is major cognitive dissonance with our potential as a society vs. the every day struggle to provide basic care for common conditions Let me give a few examples.

Take hypertension. 1 in 3 Americans has it. It causes millions of years of life lost.

What is the process to diagnose and treat it? I have to beg my patient to buy a $40 cuff at a pharmacy, measure their BP, then call or send the numbers to me.

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.

https://twitter.com/ml_barnett/status/1335983958761361408

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.

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…

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

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/… @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…

🚨 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

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… #2: An amazing city with respect for its neighbor forest in Ecuador

New paper out today in @Health_Affairs on shortages of PPE and staff in nursing homes nationally.

We did an in-depth analysis of shortages reported in @CMSGov's COVID-19 nursing home survey (98% of facilities in the US)

healthaffairs.org/doi/abs/10.137…

with @McGarryBE @DavidCGrabowski @Health_Affairs @CMSGov @McGarryBE @DavidCGrabowski Nursing homes have been devastated by COVID-19 - only 1.3 million older adults in the US but >40% of ALL COVID-19 deaths in the US.

Part of the challenge has been persistent PPE and staff shortages. These are widely reported but there hasn't been much data on what is happening.

Two important studies today in @JAMAInternalMed on digital access among older Americans.

They are framed as relevant to telemedicine access but really this is about accessing almost ANY service in the Covid-19 era

Brief thread

jamanetwork.com/journals/jamai…

jamanetwork.com/journals/jamai… @JAMAInternalMed The first study by @eric_t_roberts @Ateevm uses Census data from 2018 to ask how many Medicare enrollees have access to:
1) any computer with high speed internet
2) smartphone with data
3) any digital access

And over 1 in 4 lack ANY digital access as above

Tweet thread of my favorite Google Earth photos from lord know how many tabs I have opened in the past two months.

I love the flowing green tendrils in this one. Very dramatic. Wiggly islands in Kazakhstan

I cannot recommend @JMichaelMcW’s new @nejmcatalyst article more highly.

It is an eloquent and deeply reasoned critique of quality measurement and the payment models based on them.

Brief thread to entice you to read. Long but worth every minute.

catalyst.nejm.org/doi/full/10.10… @JMichaelMcW @nejmcatalyst He writes that the pandemic has revealed the core strength of US health care: the professionalism of its workforce.

They "not only exhausted & imperiled themselves but they also rapidly absorbed ever-changing information about an emerging disease and implemented new practices."

The problems of post-COVID-19 syndrome are not getting enough attention. I am seeing patients every single session with persistent fatigue, generalized weakness and other weird symptoms like partial anosmia.

There's nothing to offer them, even the barest thread of information The implications of a prolonged post-COVID-19 syndrome are really staggering.

There are 3.9 million confirmed Covid cases in the US - and we know that is only a fraction of total cases. Let's say we have 6 million total cases.

Hot off the presses - new data on telehealth use in 2020 in Medicare!

From no less authoritative a source than @SeemaCMS herself in @Health_Affairs blog.

There are a lot of interesting details in here, let's do a brief /thread

healthaffairs.org/do/10.1377/hbl… @SeemaCMS @Health_Affairs First off - telehealth expansion, as predicted, was HUGE

From 13,000 beneficiaries a week pre-COVID (once upon a time that felt like a lot to me) to 1.7 MILLION a week by the end of April.

With 60 million people on Medicare that's nearly 3% with a telehealth visit every week!