2021

The Federal Health Authority, a Federal Reserve System for Health Care COVID-19 Has Exposed a Need for Change

JAMA Health Forum

James N. Weinstein, William B. Weeks, Jonathan S. Skinner

In 1907, a financial collapse led to a major US national recession, a 17%decline in industrial output,1 and creation of the Federal Reserve system in 1913 to “provide a means by which periodic panics which shake the American Republic and do it enormous injury shall be stopped.”2 The current COVID-19 pandemic shares many of the same causes as the Panic of 1907: lack of a coordinated federal response, lax state-level regulations, and absence of clear strategies to respond and recover from the initial outbreak. Therefore, we propose a new entity paralleling the Federal Reserve —the Federal Health Authority (FHA)—to anticipate health shocks, coordinate future responses, and address longer-term problems in the nation’s health and health care. Just as the Federal Reserve is tasked with sustainably maximizing the nation’s financial health, the FHAwould be tasked with doing the same for the nation’s health.

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The Association Between Neurohormonal Therapy and Mortality in Older Adults with Heart Failure With Reduced Ejection Fraction

Journal of the American Geriatrics Society

Lauren Gilstrap, Andrea M. Austin, Barbara Gladders, Parag Goyal, A. James O’Malley, Amber Barnato, Anna N.A, Tosteson, Jonathan S. Skinner

Neurohormonal therapy, which includes beta-blockers and angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACEi/ARBs), is the cornerstone of heart failure with reduced ejection fraction (HFrEF) treatment. While neurohormonal therapies have demonstrated efficacy in randomized clinical trials, older patients, which now comprise the majority of HFrEF patients, were underrepresented in those original trials. This study aimed to determine the association between short- (30 day) and long-term (1 year) mortality and the use of neurohormonal therapy in HFrEF patients, across the age spectrum.

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Rising Geographic Disparities in US Mortality

Journal of Economic Perspectives

Benjamin K. Couillard, Christopher L. Foote, Kavish Gandhi, Ellen Meara, and Jonathan Skinner

The 21st century has been a period of rising inequality in both income and health. In this paper, we find that geographic inequality in mortality for midlife Americans increased by about 70 percent between 1992 and 2016. This was not solely because of the increasing importance of “deaths of despair,” or by rising spatial income inequality during the same period. Instead, we find evidence that high-income states in 1992 were better able to enact public health strategies and adopt behaviors that, over the next quarter-century, resulted in pronounced relative declines in mortality. The substantial longevity gains in high-income states led to greater cross-state inequality in mortality.

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The Impact Of The COVID-19 Pandemic On Hospital Admissions In The United States

Health Affairs (Millwood)

John D. Birkmeyer, Amber Barnato, Nancy Birkmeyer, Robert Kessler, Jonathan Skinner

Hospital admissions in the US fell dramatically with the onset of the coronavirus disease 2019 (COVID-19) pandemic. However, little is known about differences in admissions patterns among patient groups or the extent of the rebound. In this study of approximately one million medical admissions from a large, nationally representative hospitalist group, we found that declines in non-COVID-19 admissions from February to April 2020 were generally similar across patient demographic subgroups and exceeded 20 percent for all primary admission diagnoses. By late June/early July 2020, overall non-COVID-19 admissions had rebounded to 16 percent below prepandemic baseline volume (8 percent including COVID-19 admissions). Non-COVID-19 admissions were substantially lower for patients residing in majority-Hispanic neighborhoods (32 percent below baseline) and remained well below baseline for patients with pneumonia (−44 percent), chronic obstructive pulmonary disease/asthma (−40 percent), sepsis (−25 percent), urinary tract infection (−24 percent), and acute ST-elevation myocardial infarction (−22 percent). Health system leaders and public health authorities should focus on efforts to ensure that patients with acute medical illnesses can obtain hospital care as needed during the pandemic to avoid adverse outcomes.

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Hospital Advance Care Planning, Treatment Intensity, and Mortality for COVID-19 Patients With Dementia

American Geriatric Society

Amber E. Barnato, John D. Birkmeyer, Jonathan S. Skinner, A. James O’Malley, Nancy J. O. Birkmeyer

Background: We sought to determine whether dementia is associated with treatment intensity and

mortality in patients hospitalized with COVID-19.

Methods: Review of the medical records for patients > 60 years of age (n=5,394) hospitalized with

COVID-19 from 132 community hospitals between March and June, 2020. We examined the

relationships between dementia and treatment intensity (including intensive care unit admission (ICU)

and mechanical ventilation (MV) and care processes that may influence them, including advance care

planning (ACP) billing and do-not-resuscitate (DNR) orders) and in-hospital mortality adjusting for age,

sex, race/ethnicity, comorbidity, month of hospitalization, and clustering within hospital. We further

explored the effect of ACP conversations on the relationship between dementia and outcomes, both at

the individual patient level (effect of having ACP) and at the hospital level (effect of being treated at a

hospital with low: <10%, medium 10-20%, or high >20% ACP rates)…

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Comparing Health Outcomes of Privileged US Citizens With Those of Average Residents of Other Developed Countries

JAMA Internal Medicine

Ezekiel J. Emanuel, Emily Gudbranson, Jessica Van Parys, et al

Question Are the health outcomes of White US citizens living in the 1% and 5% richest counties better than the health outcomes of average residents in other developed countries?

Findings In this comparative effectiveness study of 6 health outcomes, White US citizens in the 1% and 5% highest-income counties obtained better health outcomes than average US citizens but had worse outcomes for infant and maternal mortality, colon cancer, childhood acute lymphocytic leukemia, and acute myocardial infarction compared with average citizens of other developed countries.

Meaning For 6 health outcomes, the health outcomes of White US citizens living in the 1% and 5% richest counties are better than those of average US citizens but are not consistently better than those of average residents in many other developed countries, suggesting that in the US, even if everyone achieved the health outcomes of White US citizens living in the 1% and 5% richest counties, health indicators would still lag behind those in many other countries.

Abstract

Importance The average health outcomes in the US are not as good as the average health outcomes in other developed countries. However, whether high-income US citizens have better health outcomes than average individuals in other developed countries is unknown….

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Elevated Risk of COVID-19 Infection for Hospital-Based Health Care Providers

Journal of General Internal Medicine

Olivia A Sacks, Amber E Barnato, Jonathan S Skinner, John D Birkmeyer, Annie Fowler, Nancy Birkmeyer

There have been numerous reports of SARS-CoV-2 infection among health care workers (HCWs) across the globe. However, data is lacking on risk of hospital vs. community COVID-19 exposure faced by US providers. We report COVID-19 infection rates for physicians (MDs) and advance practice providers (APPs) in hospital medicine and critical care at a national acute care medical practice between March and December 2020.

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Association Between Beta-Blockers and Mortality and Readmission in Older Patients with Heart Failure: an Instrumental Variable Analysis

Journal of General Internal Medicine

Lauren Gilstrap, Andrea M Austin, A James O’Malley, Barbara Gladders, Amber E Barnato, Anna Tosteson, Jonathan Skinner

Background

The demographics of heart failure are changing. The rate of growth of the “older” heart failure population, specifically those≥ 75, has outpaced that of any other age group. These older patients were underrepresented in the early beta-blocker trials. There are several reasons, including a decreased potential for mortality benefit and increased risk of side effects, why the risk/benefit tradeoff may be different in this population.

Objective

We aimed to determine the association between receipt of a beta-blocker after heart failure discharge and early mortality and readmission rates among patients with heart failure and reduced ejection fraction (HFrEF), specifically patients aged 75+.

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The Association Between Neurohormonal Therapy and Mortality in Older Adults With Heart Failure With Reduced Ejection Fraction

Journal of General Internal Medicine

Lauren Gilstrap, Andrea M Austin, Barbara Gladders, Parag Goyal, A James O'Malley, Amber Barnato, Anna NA Tosteson, Jonathan S Skinner

Background/Objectives

Neurohormonal therapy, which includes beta‐blockers and angiotensin‐converting enzyme inhibitor/angiotensin receptor blockers (ACEi/ARBs), is the cornerstone of heart failure with reduced ejection fraction (HFrEF) treatment. While neurohormonal therapies have demonstrated efficacy in randomized clinical trials, older patients, which now comprise the majority of HFrEF patients, were underrepresented in those original trials. This study aimed to determine the association between short‐ (30 day) and long‐term (1 year) mortality and the use of neurohormonal therapy in HFrEF patients, across the age spectrum.

Design/Setting/Participants

This is a population‐based, retrospective, cohort study between January 2008 and December 2015. We used 100% Medicare Parts A and B and a random 40% sample of Part D to create a cohort of 295,494 fee‐for‐service beneficiaries with at least …

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Geographic and Demographic Variability in Transcatheter Aortic Valve Replacement Dispersion in the United States

Journal of the American Heart Association

Michael N Young, Stephen Kearing, David Malenka, Philip P Goodney, Jonathan Skinner, Alexander Iribarne

Background

Transcatheter aortic valve replacement (TAVR) has transformed the management of aortic valve stenosis. However, little national data are available characterizing the geographic and demographic dispersion of this disruptive technology relative to surgical aortic valve replacement (SAVR).

Methods and Results

In this US claims‐based study, we analyzed a 100% sample of fee‐for‐service Medicare beneficiaries from 2012 to 2017 and examined national rates of TAVR versus SAVR. Procedure rates were compared across years as a function of age, sex, race, and geography for TAVR and SAVR beneficiaries. There was significant growth in TAVR from 15.4 beneficiaries/100 000 enrollees in 2012 to 90.6 in 2017 (P<0.001). SAVR rates declined from 92.8 beneficiaries/100 000 enrollees in 2012 to 63.5 in 2017 (P<0.001). The growth of TAVR varied as a function of age (P<0.0001). While TAVR was the …

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Anticoagulant Use for Atrial Fibrillation Among Persons With Advanced Dementia at the End of Life

JAMA Internal Medicine

Gregory M Ouellet, Terri R Fried, Lauren G Gilstrap, John R O’Leary, Andrea M Austin, Jonathan S Skinner, Andrew B Cohen

In this cross-sectional study, we used Medicare data to identify nursing home residents 65 years or older with advanced dementia and AF who had at least moderate stroke risk (CHA2DS2VASC score≥ 2), and who died between January 1, 2014, and December 31, 2017. Advanced dementia was defined as a diagnosis of Alzheimer disease or another dementia, Cognitive Performance Score of 5 or 6, 5 and dependence in all activities of daily living on 2 Minimum Data Set assessments within the last 6 months of life. We used Chronic Condition Warehouse flags to ascertain AF. We excluded residents not enrolled in fee-for-service Medicare and those with claims for venous thromboembolism and valvular heart disease (including mechanical valves) in the 2 years before death. This study was approved by the institutional review boards at Yale University and the VA Connecticut Healthcare System, which …

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The Federal Health Authority, a Federal Reserve System for Health Care COVID-19 Has Exposed a Need for Change

JAMA Health Forum

James N. Weinstein, William B. Weeks, Jonathan S. Skinner

In 1907, a financial collapse led to a major US national recession, a 17% decline in industrial output,1 and creation of the Federal Reserve system in 1913 to “provide a means by which periodic panics which shake the American Republic and do it enormous injury shall be stopped.”

The current COVID-19 pandemic shares many of the same causes as the Panic of 1907: lack of a coordinated federal response, lax state-level regulations, and absence of clear strategies to respond and recover from the initial outbreak. Therefore, we propose a new entity paralleling the Federal Reserve —the Federal Health Authority (FHA)—to anticipate health shocks, coordinate future responses, and address longer-term problems in the nation’s health and health care. Just as the Federal Reserve is tasked with sustainably maximizing the nation’s financial health, the FHA would be tasked with doing the same for the nation’s health.

READ MORE