Joint letter to Senate Appropriations Committee Supporting Funding for AHRQ for FY2014 (17-Apr-2013)

Joint letter to House Appropriations Committee Supporting Funding for AHRQ for FY2014 (17-Apr-2013)

(FY) 2014 302(b) allocation to the Labor, HHS, Education and Related Agencies Appropriations Subcommittee

Final Rule Eliminating Physician Supervision of Nurse Anesthetists Under Medicare/Medicaid. Letter to Department of Health and Human Services.

Extension for Standard Transactions and Code Set Regulations. Joint Letter to Congress.

Evaluation and Management (E/M) Documentation Guidelines and Clinical Examples. Joint Letter to Center for Medicare and Medicaid Services Administrator, Thomas Scully

Emergency Medical Treatment and Active Labor Act (EMTALA). Letter to House Committee on Energy and Commerce.

Emergency Medical Treatment and Active Labor Act (EMTALA). Letter to House Committee on Energy and Commerce.

eHI Joint Letter Requesting Extension of Comment Period for CMS Reducing Physician Burden and Prior Authorization Proposed Regulation

E M Sign-on Letter

Pandemic Response Requires Research Samples: A U.S. Safety-Net Hospital's Experience and Call for National Action

Biorepositories provide a critical resource for gaining knowledge of emerging infectious diseases and offer a mechanism to rapidly respond to outbreaks; the emergence of the novel coronavirus, SARS-CoV-2, has proved their importance. During the COVID-19 pandemic, the absence of centralized, national biorepository efforts meant that the onus fell on individual institutions to establish sample repositories. As a safety-net hospital, Boston Medical Center (BMC) recognized the importance of creating a COVID-19 biorepository to both support critical science at BMC and ensure representation in research for its urban patient population, most of whom are from underserved communities. This article offers a realistic overview of the authors' experience in establishing this biorepository at the onset of the COVID-19 pandemic during the height of the first surge of cases in Boston, Massachusetts, with the hope that the challenges and solutions described are useful to other institutions. Going forward, funders, policymakers, and infectious disease and public health communities must support biorepository implementation as an essential element of future pandemic preparedness.

Accuracy of Ultrasound Jugular Venous Pressure Height in Predicting Central Venous Congestion

Background: Assessment of volume status through the estimation of central venous pressure (CVP) is integral in the care of heart failure (HF). Bedside assessment is limited by obesity, variation in physical examination skills, and expertise in ultrasonography. Objective: To validate the accuracy of quantitative and qualitative point-of-care ultrasonography assessment of jugular venous pressure (JVP) in predicting elevated CVP. Design: Prospective observational study using convenience sampling. Setting: 2 U.S. academic hospitals. Patients: Adult patients undergoing right heart catheterization between 5 February 2019 and 1 March 2021. Measurements: Estimation of the JVP height by handheld ultrasound device (uJVP), JVP by traditional physical examination, and qualitative presence of a distended uJVP in the upright position (upright-uJVP) was done before invasive measurements. Receiver-operating characteristic analysis of the uJVP was compared with invasive hemodynamics. Results: In 100 participants undergoing right heart catheterization for HF indications (mean age, 59.6 years; 44% with preserved ejection fraction), the uJVP in a reclined position accurately predicted elevated right atrial pressure (RAP) (>10 mm Hg), with an area under the curve of 0.84. A positive uJVP in the upright position was 94.6% specific for predicting elevated RAP. Limitation: Limited examiners, only 2 centers, and convenience sampling. Conclusion: Point-of-care ultrasonography assessment of the uJVP is feasible, reproducible, and accurately predictive of elevated CVPs in patients undergoing right heart catheterization. Further investigation of clinical application of ultrasound-measured JVP seems warranted. Primary Funding Source: None.

Current Insights Into Respiratory Virus Transmission and Potential Implications for Infection Control Programs: A Narrative Review: Annals of Internal Medicine: Vol 174, No 12

Policies to prevent respiratory virus transmission in health care settings have traditionally divided organisms into Droplet versus Airborne categories. Droplet organisms (for example, influenza) are said to be transmitted via large respiratory secretions that rapidly fall to the ground within 1 to 2 meters and are adequately blocked by surgical masks. Airborne pathogens (for example, measles), by contrast, are transmitted by aerosols that are small enough and light enough to carry beyond 2 meters and to penetrate the gaps between masks and faces; health care workers are advised to wear N95 respirators and to place these patients in negative-pressure rooms. Respirators and negative-pressure rooms are also recommended when caring for patients with influenza or SARS-CoV-2 who are undergoing “aerosol-generating procedures,” such as intubation. An increasing body of evidence, however, questions this framework. People routinely emit respiratory particles in a range of sizes, but most are aerosols, and most procedures do not generate meaningfully more aerosols than ordinary breathing, and far fewer than coughing, exercise, or labored breathing. Most transmission nonetheless occurs at close range because virus-laden aerosols are most concentrated at the source; they then diffuse and dilute with distance, making long-distance transmission rare in well-ventilated spaces. The primary risk factors for nosocomial transmission are community incidence rates, viral load, symptoms, proximity, duration of exposure, and poor ventilation. Failure to appreciate these factors may lead to underappreciation of some risks (for example, overestimation of the protection provided by medical masks, insufficient attention to ventilation) or misallocation of limited resources (for example, reserving N95 respirators and negative-pressure rooms only for aerosol-generating procedures or requiring negative-pressure rooms for all patients with SARS-CoV-2 infection regardless of stage of illness). Enhanced understanding of the factors governing respiratory pathogen transmission may inform the development of more effective policies to prevent nosocomial transmission of respiratory pathogens.

K Awards: The Journey of a Thousand Steps

One Small Step for Sickle Cell Disease: Many More to Go

Contribution of Individual- and Neighborhood-Level Social, Demographic, and Health Factors to COVID-19 Hospitalization Outcomes

Background: Although disparities in COVID-19 outcomes have been observed, factors contributing to these differences are not well understood. Objective: To determine whether COVID-19 hospitalization outcomes are related to neighborhood-level social vulnerability, independent of patient-level clinical factors. Design: Pooled cross-sectional study of prospectively collected data. Setting: 38 Michigan hospitals. Patients: Adults older than 18 years hospitalized for COVID-19 in a participating site between March and December 2020. Measurements: COVID-19 outcomes included acute organ dysfunction, organ failure, invasive mechanical ventilation, intensive care unit stay, death, and discharge disposition. Social vulnerability was measured by the social vulnerability index (SVI), a composite measure of social disadvantage. Results: Compared with patients in low-vulnerability ZIP codes, those living in high-vulnerability ZIP codes were more frequently treated in the intensive care unit (29.0% vs. 24.5%); more frequently received mechanical ventilation (19.3% vs. 14.2%); and experienced higher rates of organ dysfunction (51.9% vs. 48.6%), organ failure (54.7% vs. 51.6%), and in-hospital death (19.4% vs. 16.7%). In mixed-effects regression analyses accounting for age, sex, and comorbid conditions, an increase in a patient's neighborhood SVI by 0.25 (1 quartile) was associated with greater likelihood of mechanical ventilation (increase of 2.1 percentage points), acute organ dysfunction (increase of 2.8 percentage points), and acute organ failure (increase of 2.8 percentage points) but was not associated with intensive care unit stay, mortality, or discharge disposition. Limitation: Observational data focused on hospitalizations in a single state. Conclusion: Hospitalized patients with COVID-19 from socially vulnerable neighborhoods presented with greater illness severity and required more intensive treatment, but once hospitalized they did not experience differences in hospital mortality or discharge disposition. Policies that target socially vulnerable neighborhoods and access to COVID-19 care may help ameliorate health disparities. Primary Funding Source: Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships Program, the Michigan Public Health Institute, and the Michigan Department of Health & Human Services.

Bringing Teaching Back to the Bedside

Medical Violence

Thiamine Supplementation in Patients With Alcohol Use Disorder Presenting With Acute Critical Illness: A Nationwide Retrospective Observational Study: Annals of Internal Medicine: Vol 175, No 2

Background: Thiamine supplementation is recommended for patients with alcohol use disorder (AUD). The authors hypothesize that critically ill patients with AUD are commonly not given thiamine supplementation. Objective: To describe thiamine supplementation incidence in patients with AUD and various critical illnesses (alcohol withdrawal, septic shock, traumatic brain injury [TBI], and diabetic ketoacidosis [DKA]) in the United States. Design: Retrospective observational study. Setting: Cerner Health Facts database. Patients: Adult patients with a diagnosis of AUD who were admitted to the intensive care unit with alcohol withdrawal, septic shock, TBI, or DKA between 2010 and 2017. Measurements: Incidence and predicted probability of thiamine supplementation in alcohol withdrawal and other critical illnesses. Results: The study included 14 998 patients with AUD. Mean age was 52.2 years, 77% of participants were male, and in-hospital mortality was 9%. Overall, 7689 patients (51%) received thiamine supplementation. The incidence of thiamine supplementation was 59% for alcohol withdrawal, 26% for septic shock, 41% for TBI, and 24% for DKA. Most of those receiving thiamine (n = 3957 [52%]) received it within 12 hours of presentation in the emergency department. The predominant route of thiamine administration was enteral (n = 3119 [41%]). Limitation: Specific dosing and duration were not completely captured. Conclusion: Thiamine supplementation was not provided to almost half of all patients with AUD, raising a quality-of-care issue for this cohort. Supplementation was numerically less frequent in patients with septic shock, DKA, or TBI than in those with alcohol withdrawal. These data will be important for the design of quality improvement studies in critically ill patients with AUD. Primary Funding Source: National Institutes of Health.

Effectiveness of Belimumab After Rituximab in Systemic Lupus Erythematosus: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 174, No 12

Background: B-cell depletion with rituximab is commonly used for patients with systemic lupus erythematosus (SLE) that is refractory to conventional therapy, but it yields variable responses. We hypothesized that high B-cell activating factor (BAFF) levels after rituximab can cause disease flares, thereby limiting its effectiveness. Objective: To obtain preliminary evidence for efficacy of the anti-BAFF therapeutic belimumab after rituximab in SLE. Design: Phase 2, randomized, double-blind (patients, assessors, researchers, care providers), placebo-controlled, parallel-group, superiority trial. (ISRCTN: 47873003) Setting: England. Participants: Fifty-two patients who had SLE that was refractory to conventional treatment and whose physicians had recommended rituximab therapy were recruited between 2 February 2017 and 28 March 2019. Intervention: Participants were treated with rituximab and 4 to 8 weeks later were randomly assigned (1:1) to receive intravenous belimumab or placebo for 52 weeks. Measurements: The prespecified primary end point was serum IgG anti–double-stranded DNA (anti-dsDNA) antibody levels at 52 weeks. Secondary outcomes included incidence of disease flares and adverse events. Results: At 52 weeks, IgG anti-dsDNA antibody levels were lower in patients treated with belimumab compared with placebo (geometric mean, 47 [95% CI, 25 to 88] vs. 103 [CI, 49 to 213] IU/mL; 70% greater reduction from baseline [CI, 46% to 84%]; P < 0.001). Belimumab reduced risk for severe flare (BILAG-2004 grade A) compared with placebo (hazard ratio, 0.27 [CI, 0.07 to 0.98]; log-rank P = 0.033), with 10 severe flares in the placebo group and 3 in the belimumab group. Belimumab did not increase incidence of serious adverse events. Belimumab significantly suppressed B-cell repopulation compared with placebo (geometric mean, 0.012 [CI, 0.006 to 0.014] vs. 0.037 [CI, 0.021 to 0.081] × 109/L) at 52 weeks in a subset of patients (n = 25) with available data. Limitations: Small sample size; biomarker primary end point. Conclusion: Belimumab after rituximab significantly reduced serum IgG anti-dsDNA antibody levels and reduced risk for severe flare in patients with SLE that was refractory to conventional therapy. The results suggest that this combination could be developed as a therapeutic strategy. Primary Funding Source: Versus Arthritis.