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Challenges of a Supplemental Private Option Under National Health Insurance—Observations From Australia
Bruce E. Landon, MD, MBA; Shaun Larkin, HlthScD, MBA; Adam G. Elshaug, PhD
doi : 10.1001/jamainternmed.2020.8435
JAMA Intern Med. 2021;181(4):421-422
As the US debates possible policy paths to achieve affordable and sustainable universal health insurance coverage, there has been support for maintaining private choice in the market. Although private insurance is currently central to the US health care system, its potential role, if any, under alternative approaches to coverage expansion, such as Medicare for All, is less clear. Many countries with universal coverage maintain private insurance for services that are not covered. However, Australia is one of the few countries with universal government-sponsored insurance that actively promotes the use of parallel private insurance to supplement public coverage for services that are covered. Currently, about 44% of Australians have some form of private hospital insurance.1 In this article, we discuss the role of private hospital insurance in Australia, some of the benefits and drawbacks, and how the Australian example might inform US policy.
Authorized Generics and Their Evolving Role in Prescription Drug Pricing and Access
Stacie B. Dusetzina, PhD; Nancy L. Keating, MD, MPH; Haiden A. Huskamp, PhD
doi : 10.1001/jamainternmed.2020.8450
JAMA Intern Med. 2021;181(4):423-424
In recent years, amid public outcry over high prices, several large pharmaceutical companies have launched “authorized generic” versions of their brand-name products at steeply reduced list prices, including for epinephrine injectors (EpiPen), insulin (Humalog and NovoLog), and hepatitis C treatments (Harvoni and Epclusa). In each case, the manufacturers garnered positive media attention1,2 when announcing their authorized generic products and the potential savings for patients, even while their brand-name counterparts remained under patent protection for years to come. These examples raise important questions about the incentives for manufacturers of brand-name medicines to introduce authorized generics and whether their availability benefits consumers. In this Viewpoint, we explain what authorized generics are, describe 3 ways that they are used, and consider whether they improve access to prescription drugs or lower out-of-pocket spending for patients.
Testimony of the Beirut Explosion—A White Coat Soaked in Blood and Tears
Bachar El-Baba
doi : 10.1001/jamainternmed.2020.8720
JAMA Intern Med. 2021;181(4):425-426
My name is Bachar El-Baba. I am a Lebanese medical student in my last year of training at the University of Balamand, rotating at Saint George Hospital University Medical Center in Achrafieh-Beirut, Lebanon. I am writing this testimony to document what happened on Tuesday, August 4, 2020, from the perspective of a first-line responder.
Efficacy of a Combination of Conservative Therapies vs an Education Comparator on Clinical Outcomes in Thumb Base OsteoarthritisA Randomized Clinical Trial
Leticia A. Deveza, MD, PhD; Sarah R. Robbins, PhD; Vicky Duong, BSc (Hons); et al.
doi : 10.1001/jamainternmed.2020.7101
JAMA Intern Med. 2021;181(4):429-438
Importance A combination of conservative treatments is commonly used in clinical practice for thumb base osteoarthritis despite limited evidence for this approach.
Risk Factors Associated With All-Cause 30-Day Mortality in Nursing Home Residents With COVID-19
Orestis A. Panagiotou, MD, PhD; Cyrus M. Kosar, MA; Elizabeth M. White, PhD, APRN; et al.
doi : 10.1001/jamainternmed.2020.7968
JAMA Intern Med. 2021;181(4):439-448
Importance The coronavirus disease 2019 (COVID-19) pandemic has severely affected nursing homes. Vulnerable nursing home residents are at high risk for adverse outcomes, but improved understanding is needed to identify risk factors for mortality among nursing home residents.
Estimated SARS-CoV-2 Seroprevalence in the US as of September 2020
Kristina L. Bajema, MD, MSc; Ryan E. Wiegand, MS; Kendra Cuffe, MPH; et al.
doi : 10.1001/jamainternmed.2020.7976
JAMA Intern Med. 2021;181(4):450-460
Importance Case-based surveillance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection likely underestimates the true prevalence of infections. Large-scale seroprevalence surveys can better estimate infection across many geographic regions.
Evaluation of Cloth Masks and Modified Procedure Masks as Personal Protective Equipment for the Public During the COVID-19 Pandemic
Phillip W. Clapp, PhD; Emily E. Sickbert-Bennett, PhD, MS; James M. Samet, PhD, MPH; et al.
doi : 10.1001/jamainternmed.2020.8168
JAMA Intern Med. 2021;181(4):463-469
Importance During the coronavirus disease 2019 (COVID-19) pandemic, the general public has been advised to wear masks or improvised face coverings to limit transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, there has been considerable confusion and disagreement regarding the degree to which masks protect the wearer from airborne particles.
Variation in US Hospital Mortality Rates for Patients Admitted With COVID-19 During the First 6 Months of the Pandemic
David A. Asch, MD, MBA; Natalie E. Sheils, PhD; Md Nazmul Islam, PhD, MBA; et al.
doi : 10.1001/jamainternmed.2020.8193
JAMA Intern Med. 2021;181(4):471-478
Importance It is unknown how much the mortality of patients with coronavirus disease 2019 (COVID-19) depends on the hospital that cares for them, and whether COVID-19 hospital mortality rates are improving.
Association of the Intensity of Diagnostic Evaluation With Outcomes in Incidentally Detected Lung Nodules
Farhood Farjah, MD, MPH; Sarah E. Monsell, MS; Michael K. Gould, MD, MS; et al.
doi : 10.1001/jamainternmed.2020.8250
JAMA Intern Med. 2021;181(4):480-489
Importance Whether guideline-concordant lung nodule evaluations lead to better outcomes remains unknown.
Assessment of Coverage in England of Cancer Drugs Qualifying for US Food and Drug Administration Accelerated Approval
Avi Cherla, MSc; Huseyin Naci, MHS, PhD; Aaron S. Kesselheim, MD, JD, MPH; et al.
doi : 10.1001/jamainternmed.2020.8441
JAMA Intern Med. 2021;181(4):490-498
Importance Numerous cancer drugs have received accelerated approval from the US Food and Drug Administration (FDA) based on clinical trial outcomes that are otherwise not acceptable for traditional FDA approval; the accelerated approval process allows outcomes based on surrogate measures that are only reasonably likely to estimate clinical benefits. In England, the National Institute for Health and Care Excellence (NICE) evaluates the clinical benefits and cost-effectiveness of drugs after they have received regulatory approval and issues recommendations regarding their coverage in the National Health Service (NHS). However, the level of concordance between European and FDA decision-making in the context of drugs qualifying for FDA accelerated approval is unknown.
Evaluation of the Clinical Benefit of Cancer Drugs Submitted for Reimbursement Recommendation Decisions in Canada
Daniel E. Meyers, MD, MSc; Kristina Jenei, BSN; Timothy M. Chisamore, MSc; et al.
doi : 10.1001/jamainternmed.2020.8588
JAMA Intern Med. 2021;181(4):499-508
Importance Cancer drugs approved by the US Food and Drug Administration have come under scrutiny for marginal clinical benefits; however, the clinical benefits of cancer drugs recommended for reimbursement in Canada have not been adequately studied.
Risk of Progression to Diabetes Among Older Adults With Prediabetes
Mary R. Rooney, PhD, MPH; Andreea M. Rawlings, PhD; James S. Pankow, PhD, MPH; et al.
doi : 10.1001/jamainternmed.2020.8774
JAMA Intern Med. 2021;181(4):511-519
Importance The term prediabetes is used to identify individuals at increased risk for diabetes. However, the natural history of prediabetes in older age is not well characterized.
Contents of US Food and Drug Administration Refuse-to-File Letters for New Drug Applications and Efficacy Supplements and Their Public Disclosure by Applicants
Harinder Singh Chahal, PharmD, MSc; Sanjana Mukherjee, PhD, MSc; Daniel W. Sigelman, JD; et al.
doi : 10.1001/jamainternmed.2020.8866
JAMA Intern Med. 2021;181(4):522-529
Importance Before reviewing drug applications, the US Food and Drug Administration (FDA) conducts “filing reviews” to assess whether they are complete enough for full review. If the applications are incomplete, the FDA issues refuse-to-file (RTF) letters identifying deficiencies. The FDA does not make these RTF letters public at the time of issuance. Why the FDA issues RTF letters and how often the letters and their contents are made publicly available are unknown.
Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis PainA Randomized Clinical Trial
Susan M. McCurry, PhD; Weiwei Zhu, MS; Michael Von Korff, ScD; et al.
doi : 10.1001/jamainternmed.2020.9049
JAMA Intern Med. 2021;181(4):530-538
Importance Scalable delivery models of cognitive behavioral therapy for insomnia (CBT-I), an effective treatment, are needed for widespread implementation, particularly in rural and underserved populations lacking ready access to insomnia treatment.
Antibiotic Treatment for Inpatient Asthma ExacerbationsWhat Have We Learned?
Thomas B. Newman, MD, MPH
doi : 10.1001/jamainternmed.2020.7229
JAMA Intern Med. 2021;181(4):427-428
An extensively revised, retracted, and replaced article by Stefan et al1 in this issue of JAMA Internal Medicine assesses outcomes associated with antibiotic treatment in adults hospitalized for asthma exacerbations. About half of such patients are treated with antibiotics (primarily macrolides and quinolones) without a clear clinical indication. Stefan et al1 found that while treatment with antibiotics on day 1 of hospitalization was associated with slightly increased length of stay and costs, it was associated with a statistically significant 1.1% (95% CI, 0.2% to 1.9%) absolute reduction in the risk of treatment failure (7.1% vs 8.2%), defined as initiation of mechanical ventilation, transfer to the intensive care unit after hospital day 1, in-hospital mortality, or readmission for asthma exacerbation within 30 days of discharge. They conclude that their results “highlight the need to perform randomized clinical trials to determine the role of antibiotic prescribing among patients hospitalized for asthma exacerbation.”1
Beyond Age—Improvement of Prognostication Through Physical and Cognitive Functioning for Nursing Home Residents With COVID-19
M?rlon Juliano Romero Aliberti, MD, PhD; Thiago Junqueira Avelino-Silva, MD, PhD
doi : 10.1001/jamainternmed.2020.8190
JAMA Intern Med. 2021;181(4):448-449
the rapid spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has imposed multilevel challenges on societies everywhere, from abrupt changes in our day-to-day lives to overwhelming new pressures on health systems worldwide.1 Although there are many devastating effects of coronavirus disease 2019 (COVID-19), few compare with the pandemic’s terrible burden on nursing home residents, their families, and their health care clinicians.2
Antibodies, Immunity, and COVID-19
Brad Spellberg, MD; Travis B. Nielsen, PhD; Arturo Casadevall, MD, PhD
doi : 10.1001/jamainternmed.2020.7986
JAMA Intern Med. 2021;181(4):460-462
widespread availability of commercial assays that detect anti–severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies has enabled researchers to examine naturally acquired immunity to coronavirus disease 2019 (COVID-19) at the population level. Several studies have found that the SARS-CoV-2 seroprevalence (the percentage of the population with serum containing antibodies that recognize the virus) has remained below 20% even in the most adversely affected areas globally, such as Spain and Italy.1-3 In this issue of JAMA Internal Medicine, Bajema et al4 contribute new information on the shifting nature of SARS-CoV-2 seroprevalence in the US. The study uses national data to expand on an earlier US Centers for Disease Control and Prevention study of seroprevalence of antibodies to SARS-CoV-2 in 10 US sites.3
Decreased COVID-19 Mortality—A Cause for Optimism
Leon Boudourakis, MD, MHS; Amit Uppal, MD
doi : 10.1001/jamainternmed.2020.8438
JAMA Intern Med. 2021;181(4):478-479
after a hard year, good news related to coronavirus disease 2019 (COVID-19) is welcome. In this issue of JAMA Internal Medicine, Asch and colleagues1 provide a reason for optimism that our health care system has improved in our ability to care for persons with COVID-19. The authors performed a national analysis of COVID-19–associated mortality that spanned 955 US hospitals, representing nearly 40?000 patients. Using administrative claims data from a large national health insurer, they found that a hospital’s risk-standardized event rate (a composite of hospital mortality or referral to hospice) because of COVID-19 had significantly decreased. Specifically, the risk-adjusted mortality decreased from 16.56% to 9.29% in the early period of this study (January through April 2020) compared with the later period (May through June 2020).
Approval and Coverage of Cancer Drugs in England, Canada, and the US
Vinay Prasad, MD, MPH; Myung S. Kim, MD
doi : 10.1001/jamainternmed.2020.8587
JAMA Intern Med. 2021;181(4):509-510
For approval of cancer drugs, the US Food and Drug Administration (FDA) is tolerant of uncertainty and prioritizes speed over other factors.1 Most drug approvals are based on surrogate markers, such as tumor shrinkage in a fraction of patients (response rate) or delayed tumor growth (progression-free survival). These surrogates use arbitrary percentage cutoffs and are not optimized to ensure that a drug can improve the length or quality of life.2
Prediabetes—A Risk Factor Twice Removed
Kenneth Lam, MD; Sei J. Lee, MD, MAS
doi : 10.1001/jamainternmed.2020.8773
JAMA Intern Med. 2021;181(4):520-521
The concept of prediabetes (and similar concepts of impaired fasting glucose and impaired glucose tolerance) formally emerged in the 1990s to better characterize the incremental pathophysiology leading to the eventual development of diabetes.1 It is defined by ranges of disordered glucose values between normal and diabetes (eg, hemoglobin A1c levels, 5.7%-6.4% [to convert to the proportion of total hemoglobin, multiply by 0.01]). We treat it as a risk factor for diabetes; in midlife, those with a hemoglobin A1c level of 6.0% to 6.5% have 20 times the risk of developing diabetes compared with those with a hemoglobin A1c level of 5.0%.2
Filtration Efficiency of Face Masks Used by the Public During the COVID-19 Pandemic
Robert Steinbrook, MD
doi : 10.1001/jamainternmed.2020.8234
JAMA Intern Med. 2021;181(4):470
in November 2020, the US was averaging more than 1 million new coronavirus disease 2019 (COVID-19) cases per week, an astounding number. To make progress against the pandemic, routine and universal use of face masks throughout society is essential.
Another Reason for Greater Transparency at the US Food and Drug Administration
Robert Steinbrook, MD
doi : 10.1001/jamainternmed.2020.8841
JAMA Intern Med. 2021;181(4):529
In 2010, a transparency task force at the US Food and Drug Administration (FDA) recommended that the agency disclose more information about marketing applications for medical products.1 An important goal was to increase the completeness and accuracy of the public information about drugs and other products, including the reasons that some applications are not approved.
Screening for Lipoprotein(a) Levels in Persons at Low Risk for Cardiovascular DiseaseA Teachable Moment
Ludovico Furlan, MD; Patrick Azcarate, MD; Rita F. Redberg, MD, MSc
doi : 10.1001/jamainternmed.2020.8367
JAMA Intern Med. 2021;181(4):539
A 64-year-old woman with a history of breast cancer and paroxysmal atrial fibrillation was referred by her primary care physician to our cardiology clinic for cardiac risk assessment. She had no cardiovascular risk factors or family history of cardiovascular disease (CVD) and reported having a healthy diet and regular exercise.
The Toxic Effects of an Incomplete Medication HistoryA Teachable Moment
Mei-Ni Belzile, MD, MSc; Kiran Battu, RPh, PharmD, BScPhm; Peter E. Wu, MD, MSc
doi : 10.1001/jamainternmed.2020.8863
JAMA Intern Med. 2021;181(4):540-541
A woman in her 40s presented to the emergency department with a 3-week history of severe abdominal pain, nausea, vomiting, and rebound tenderness on examination. This was her third hospital presentation, as the pain persisted with no diagnosis despite multiple investigations, including normal results of abdominal imaging (ultrasonography and 2 computed tomography scans), a general surgery consultation, and an internal medicine consultation. Her medical history included anxiety, depression, and rheumatoid arthritis, for which she was prescribed etanercept, 50 mg subcutaneously, every Sunday; methotrexate, 20 mg subcutaneously, every Sunday; and folic acid supplementation Monday to Saturday.
Evaluation of Progress Toward Gender Equity Among Departmental Chairs in Academic Medicine
Bismarck C. Odei, MD; Phylicia Gawu, MD, MS; Sonu Bae, BS; et al.
doi : 10.1001/jamainternmed.2020.6267
JAMA Intern Med. 2021;181(4):548-550
Although the gender gap in medical school matriculation has closed,1 the representation of women in leadership roles in academic medicine has been reported to be low, particularly among departmental chairs.2 This study evaluates the extent of progress in female representation among program directors (PDs), chairs, and deans to provide a valuable benchmark by which to evaluate future progress.
Prevalence of Personal Attacks and Sexual Harassment of Physicians on Social Media
Tricia R. Pendergrast, BA; Shikha Jain, MD; N. Seth Trueger, MD, MPH; et al.
doi : 10.1001/jamainternmed.2020.7235
JAMA Intern Med. 2021;181(4):550-552
Women are more likely than men to report being harassed online and are more than twice as likely to experience online sexual harassment.1,2 Despite broad adoption of social media by medical professionals, there is limited information about physicians’ experiences with harassment on social media. We report on a case series of physicians invited to describe their experiences of harassment on social media.
Association of Diet and Lifestyle With the Risk of Gastroesophageal Reflux Disease Symptoms in US Women
Raaj S. Mehta, MD; Long H. Nguyen, MD, MS; Wenjie Ma, MBBS, ScD; et al.
doi : 10.1001/jamainternmed.2020.7238
JAMA Intern Med. 2021;181(4):552-554
Gastroesophageal reflux disease (GERD) affects nearly 30% of the US population.1 Clinicians recommend dietary and lifestyle modifications to prevent GERD symptoms, but no prospective data are available to inform these recommendations. We evaluated the joint association of dietary and lifestyle factors with the risk of GERD symptoms.
Health Needs and Functional Disability Among Mail-Order Pharmacy Users in the US
Adam W. Gaffney, MD, MPH; Steffie Woolhandler, MD, MPH; David Himmelstein, MD
doi : 10.1001/jamainternmed.2020.7254
JAMA Intern Med. 2021;181(4):554-556
Widening deficits for the US Postal Service have led to operational changes that have delayed deliveries.1 Many Americans, particularly elderly individuals,2 rely on mail-delivered medications, raising concerns that delays could have medical repercussions.
COVID-19 Test Result Turnaround Time for Residents and Staff in US Nursing Homes
Brian E. McGarry, PT, PhD; Gillian K. SteelFisher, PhD; David C. Grabowski, PhD; et al.
doi : 10.1001/jamainternmed.2020.7330
JAMA Intern Med. 2021;181(4):556-559
Skilled nursing facility (SNF) residents comprise over 40% of coronavirus disease 2019 (COVID-19) deaths nationally.1 Surveillance testing is critical for controlling asymptomatic and presymptomatic viral transmission in these high-risk settings.2 For surveillance testing in SNFs to effectively guide infection control, results need to be obtained in less than 1 day.3 To facilitate such rapid testing,4 Medicare began distributing point-of-care severe acute respiratory syndrome coronavirus 2 antigen test instruments in July 2020, focused on SNFs in COVID-19 hot spot counties.5 Little is known about the adequacy of test result turnaround in SNFs.
Speed, Evidence, and Safety Characteristics of Vaccine Approvals by the US Food and Drug Administration
Jeremy Puthumana, MD, MS; Alexander C. Egilman, BA; Audrey D. Zhang, MD; et al.
doi : 10.1001/jamainternmed.2020.7472
JAMA Intern Med. 2021;181(4):559-560
There is an urgent need to develop a safe and effective vaccine to prevent coronavirus disease 2019 (COVID-19). However, recent surveys suggest that more than half of Americans are hesitant about receiving a potential COVID-19 vaccine, owing to concerns about adverse effects or lack of effectiveness.1 There is also concern that the US Food and Drug Administration (FDA) might authorize a vaccine prematurely.2 To understand the usual approval process followed by the FDA, we systematically evaluated all novel vaccines approved by the FDA over the last decade, characterizing the premarket development and regulatory review times, the clinical evidence on which approval was based, and the size and follow-up duration of the prelicensure safety database.
Engagement in Meaningful Activities Among Older Adults With Disability, Dementia, and Depression
Anna Oh, PhD, MPH, RN; Siqi Gan, MPH; W. John Boscardin, PhD; et al.
doi : 10.1001/jamainternmed.2020.7492
JAMA Intern Med. 2021;181(4):560-562
Participation and active engagement in meaningful activities is beneficial to the emotional and physical well-being of older adults.1,2 Meaningful activities are enjoyable activities that are associated with personal interests.2,3 Functional limitations, cognitive impairment, and depression may diminish the ability to participate and engage in meaningful activities and place older adults at higher risk of loss of identity and well-being.3 This study explored the association between disability, dementia, and depression and engagement in meaningful activities in a nationally representative sample of community-dwelling adults 65 years and older.
Assessment of Filled Buprenorphine Prescriptions for Opioid Use Disorder During the Coronavirus Disease 2019 Pandemic
Thuy D. Nguyen, PhD; Sumedha Gupta, PhD; Engy Ziedan, PhD; et al.
doi : 10.1001/jamainternmed.2020.7497
JAMA Intern Med. 2021;181(4):562-565
The coronavirus disease 2019 (COVID-19) pandemic has profoundly disrupted health care delivery in the US.1 The Centers for Disease Control and Prevention noted a 9.1% increase in reported 12-month counts of drug overdose deaths from March 2019 to March 2020, from 67?726 to 73?860.2 On March 13, 2020, a COVID-19 national emergency was declared. To diminish potential barriers to treatment access, 3 days later, federal guidelines on telemedicine use were released, providing authorized practitioners increased flexibility to prescribe buprenorphine to patients with opioid use disorder (OUD) during this public health emergency.3 Other local, state, and federal policy initiatives have also attempted to preserve access to medication treatment for OUD, yet the cumulative outcome of these undertakings is not clear.
Unusual Cause of Cardiac Arrest
Takahiro Tsushima, MD; Toral R. Patel, MD; Jayakumar Sahadevan, MD
doi : 10.1001/jamainternmed.2020.8370
JAMA Intern Med. 2021;181(4):542-543
A patient in their 40s with a history of remote coronary artery bypass grafting, heart failure with reduced ejection fraction, and poorly controlled insulin-dependent diabetes was admitted to the cardiac intensive care unit with acute decompensated heart failure. The patient’s baseline electrocardiogram (ECG) demonstrated normal sinus rhythm, with normal PR and QRS intervals at 132 and 82 milliseconds, respectively. With poor response to intravenous (IV) diuretics, the patient underwent right heart cardiac catheterization, which demonstrated a low cardiac index, high left ventricular filling pressure, and elevated systemic vascular resistance. The patient’s outpatient use of metoprolol was discontinued, and IV dobutamine (5.0 µg/kg/min) was initiated with continuing aggressive IV diuresis. While defecating on the bedside commode, the patient became lightheaded and unresponsive. The patient’s pulse was barely palpable, and the ECG rhythm showed bradycardia (Figure).
Atrioventricular Dissociation in a Heart Transplant Recipient
Joel Morillo, MD; Eusebio Garc?a-Izquierdo Jaén, MD; Ignacio Fern?ndez Lozano, PhD
doi : 10.1001/jamainternmed.2020.8889
JAMA Intern Med. 2021;181(4):544-545
A patient in their mid-50s with a recent heart transplant (HTx) presented to the emergency department after syncope at rest. The patient had a history of former smoking and dilated ischemic cardiomyopathy. During admission, the patient experienced another transient loss of consciousness, coinciding with asystole that persisted for up to 8 seconds. P waves could not be clearly identified because of artifacts on the baseline electrocardiogram (ECG).
An Unusual Case of Chest Pain With Wide Complex Arrhythmia—No Stents Needed
Usman A. Hasnie, MD; Haren Patel, MD; Harish Doppalapudi, MD
doi : 10.1001/jamainternmed.2020.8999
JAMA Intern Med. 2021;181(4):546-547
A current smoker in their 50s with uncontrolled hypertension presented with acute substernal chest pain and shortness of breath. On presentation, their blood pressure was 206/97 mm Hg, heart rate was 106 beats per minute, and they had an elevated high-sensitivity troponin level of 125 ng/L (upper level of normal, 15 ng/L). The presenting electrocardiogram (ECG) is shown (Figure). The chest pain continued despite treatment with intravenous nitroglycerine. Results of an echocardiogram revealed hypokinesis of the distal septum with a mildly reduced left ventricular ejection fraction of 40% to 50%.
What to Do With Sideline Guilt
Calvin S. Bruce, MD
doi : 10.1001/jamainternmed.2020.6523
JAMA Intern Med. 2021;181(4):565
To the Editor The Physician Perspective by Reuben1 on sideline guilt should strike a deep chord for many of us. I am a family physician, 72 years old, 6 years retired after an episode of ill health from which I have recovered. So I have my health, food in the refrigerator, enough money in the bank, and a spouse who still puts up with me. The only hardship we face is that coronavirus disease 2019 (COVID-19) has kept us from seeing our far-flung children and grandchildren and forced us to socialize distantly with our friends. Many of my pre-pandemic activities—working as a nursing home ombudsman, teaching medical students, serving on hospital committees—have been curtailed completely or relegated to virtual visits. That I, as a noncritical care specialist, could meaningfully replace a frontline worker is a dubious proposition at best. As Reuben1 points out, staying away from hospitals may be the most constructive thing some of us can do. But beyond the world of medicine, there is so much more to feel guilty about. The COVID-19 pandemic and current events have brought into sharp focus the long-standing racial and class inequities from which I and so many who might read this have undoubtedly benefited in one way or another. I would add 2 suggestions to those Reuben1 has proposed. First, allow yourself to experience gratitude if you float in the same guilty boat as I do: gratitude that you have the boat. Second, get angry about the state of the world and get motivated. The Viewpoint by Berwick2 on the moral determinants of health is a good place to start. There is much that those of us who are blessed not to be suffering in these difficult times can do to help make sure the new normal will better than the old.
What to Do With Sideline Guilt
Henry S. Kahn, MD
doi : 10.1001/jamainternmed.2020.6529
JAMA Intern Med. 2021;181(4):565
To the Editor As the coronavirus disease 2019 (COVID-19) pandemic charges ahead, I too have felt the sideline guilt that David Reuben1 described in his recent Physician Perspective. I retired from active patient care several years ago. Truth be told, it has been decades since I had acute-care skills that might be useful in today’s intensive care units. Nevertheless, as a retiree, I am tormented by the undeniable horrors of the pandemic.
What to Do With Sideline Guilt—Reply
David B. Reuben, MD
doi : 10.1001/jamainternmed.2020.6526
JAMA Intern Med. 2021;181(4):565-566
In Reply I would like to thank Kahn and Bruce as well as other retired physicians who contacted me directly for their reflections on sideline guilt.1 While acknowledging the guilt emotion described in the article, they seem less disturbed about not being on the front lines of the battle. Perhaps that is because this is no longer a possibility, as they stepped down from direct patient care roles before the pandemic. Yet these physicians remain engaged and remarkably energetic, channeling this energy into advocacy for health care financing reform (Kahn) and for a broader set of societal issues (Bruce). I am also struck by the expressions of how thankful they are for personally being spared infection by the virus. For them, gratitude rather than guilt is a more prominent emotion.
Negative Conversion Rate of SARS-CoV-2 Infection
Ruiyuan Zhang, MM; Huiying Liang, PhD; Jinling Tang, PhD
doi : 10.1001/jamainternmed.2020.7201
JAMA Intern Med. 2021;181(4):566
To the Editor By September 11, 2020, there were more than 28 million people infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worldwide (https://coronavirus.jhu.edu/). In a recent issue of JAMA Internal Medicine, an Original Investigation by Lee et al1 found that the negative conversion rate in asymptomatic cases was higher than that in symptomatic cases, although to a statistically insignificant degree (Figure 11). However, the negative conversion rate and its comparison between symptomatic and asymptomatic cases may be biased for the following reasons.
Negative Conversion Rate of SARS-CoV-2 Infection—Reply
Seungjae Lee, MD; Tark Kim, MD, PhD; Eunjung Lee, MD, PhD
doi : 10.1001/jamainternmed.2020.7204
JAMA Intern Med. 2021;181(4):566-567
In Reply We wish to thank Zhang et al for their comments on our Original Investigation.1 They considered the overestimation of the negative conversion rate owing to the use of a single negative result to define negative conversion. During the study, the Korean Center for Disease Control and Prevention also recommended that quarantined individuals should be released after 2 consecutive negative polymerase chain reaction results from the upper respiratory tract in a 24-hour interval,2 similar to the guidelines from the China National Health Commission.3 We defined the first negative conversion as the first negative result for both upper and lower respiratory tract specimens. In Kaplan-Meier curves of 2 consecutive negative conversion proportions of specimens from the upper and lower respiratory tract, we confirmed that negative conversion rates are not statistically different between symptomatic and asymptomatic patients in either upper respiratory or lower respiratory specimens.1
Substitution of Generic Drugs and Biosimilars
Sang Kyu Cho, PharmD, MPH, PhD; Hankyung Jun, MA, MPA
doi : 10.1001/jamainternmed.2020.8561
JAMA Intern Med. 2021;181(4):567-568
To the Editor In a recent issue of JAMA Internal Medicine, Sacks and colleagues1 examined the variation in state regulations regarding how pharmacists can substitute prescriptions for brand-name drugs with generic drugs and biosimilars. The authors found substantial variation in state regulations, suggesting a need to optimize state drug product selection laws to promote bioequivalent generic drug and biosimilar substitution.
Substitution of Generic Drugs and Biosimilars—Reply
Ameet Sarpatwari, PhD, JD; Aaron S. Kesselheim, MD, JD, MPH; Chana A. Sacks, MD, MPH
doi : 10.1001/jamainternmed.2020.8564
JAMA Intern Med. 2021;181(4):568
In Reply In their response to our Original Investigation,1 Cho and Jun raise interesting points about the reach and limitations of state drug product selection laws. While many biologic medications bypass pharmacist dispensing and are administered by physicians in an outpatient setting, many that account for substantial spending do not. The 2 examples that Cho and Jun mention, adalimumab and etanercept, accounted for approximately $3.2 billion and $1.9 billion in reported Medicare Part D spending, respectively, in 2018.2 Several other top-selling biologics, such as the interleukin (IL)-12/IL-23 antagonist ustekinumab, the IL-17 inhibitor secukinumab, and insulin products—which were reclassified as biologics in March 20203 and alone account for many billions of dollars in annual expenditures in the US—are also primarily pharmacy dispensed. Therefore, meaningful health system savings can result from optimizing state drug product selection laws to facilitate interchangeable biosimilar use.
Possible Immortal Time Bias in Study of Antibiotic Treatment and Outcomes in Patients Hospitalized for Asthma
Thomas B. Newman, MD, MPH
doi : 10.1001/jamainternmed.2020.7602
JAMA Intern Med. 2021;181(4):568-569
To the Editor In their Original Investigation published in the March 2019 issue of JAMA Internal Medicine, Stefan et al1 reported a 1-day higher median length of stay among patients admitted for acute asthma who were treated with antibiotics for at least 2 days starting in the first 2 days of their hospitalization, compared with propensity score–matched controls not so treated. The authors should clarify how the timing of antibiotic exposure and length of stay were determined because it seems like the study might be susceptible to immortal time bias,2 in which there is a period in the exposed group during which they are not at risk of the outcome (which in this case is discharge from the hospital).
Notice of Retraction and Replacement. Stefan et al. Association of antibiotic treatment with outcomes in patients hospitalized for an asthma exacerbation treated with systemic corticosteroids. JAMA Intern Med. 2019;179(3):333-340
Mihaela S. Stefan, MD, PhD; Penelope S. Pekow, PhD; Peter K. Lindenauer, MD, MSc
doi : 10.1001/jamainternmed.2020.7599
JAMA Intern Med. 2021;181(4):569-570
In Reply On behalf of our coauthors, we thank Dr Newman1 for raising concern that our study reported in the article, “Association of Antibiotic Treatment With Outcomes in Patients Hospitalized for an Asthma Exacerbation Treated With Systemic Corticosteroids,” published in the March 2019 issue of JAMA Internal Medicine,2 was susceptible to immortal time bias because of how we had determined the timing of antibiotic exposure and length of stay in our original analysis.
Error in Quiz Answer Option
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doi : 10.1001/jamainternmed.2020.8212
JAMA Intern Med. 2021;181(4):570
in the CME Online Quiz Questions1 for the Original Investigation titled “Association of Antibiotic Treatment With Outcomes in Patients Hospitalized for an Asthma Exacerbation Treated With Systemic Corticosteroids,”2 published online in the March 2019 issue of JAMA Internal Medicine, a quiz answer option has been updated. In Question 4, option C has been changed to “Lower risk of treatment failure.” The quiz has been updated online.
Incorrect Answer in CME Online Quiz Questions
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doi : 10.1001/jamainternmed.2020.8943
JAMA Intern Med. 2021;181(4):570
in the CME Online Quiz Questions1 for the Original Investigation titled “Effects of Time-Restricted Eating on Weight Loss and Other Metabolic Parameters in Women and Men With Overweight and Obesity: The TREAT Randomized Clinical Trial”2 published in the November 2020 issue, there was an omission in an answer choice for question 1. The correct text is “C. Noncaloric beverages (only water and black coffee or tea) were permitted outside of the eating widow for the TRE group.” This quiz was corrected online.
Errors in Degree Symbols and Descriptors
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doi : 10.1001/jamainternmed.2020.8975
JAMA Intern Med. 2021;181(4):570
in the Original Investigation entitled “Evaluation of Cloth Masks and Modified Procedure Masks as Personal Protective Equipment for the Public During the COVID-19 Pandemic,”1 some of the masks used were incorrectly described as “woven,” and a temperature was recorded as “85.1 °C” that should have been “85.1 °F.” This article was corrected online.
Error in Author Surname
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doi : 10.1001/jamainternmed.2020.8976
JAMA Intern Med. 2021;181(4):570
in the Editor’s Note entitled “Filtration Efficiency of Face Masks Used by the Public During the COVID-19 Pandemic,”1 Dr Steinbrook’s surname was incorrectly written as “Steinbeck.” This article was corrected online.
Replacement of Nonauthor Collaborator Names
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doi : 10.1001/jamainternmed.2021.0139
JAMA Intern Med. 2021;181(4):570
in the Original Investigation titled “Association Between Early Treatment With Tocilizumab and Mortality Among Critically Ill Patients With COVID-19”1 that printed on January 4, 2021, the nonauthor collaborator names were omitted from the PubMed listing. The article has been corrected by adding Supplement 3 containing all names.
Errors in Data Presentation in Text, Table, and Supplement
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doi : 10.1001/jamainternmed.2021.1321
JAMA Intern Med. 2021;181(4):570
in the article by Rooney et al titled “Risk of Progression to Diabetes Among Older Adults With Prediabetes,” published online February 8, 2021, and also in the April 2021 print issue of JAMA Internal Medicine,1 because of a calculation error, the incidence rates in Results, Table 2, and eTable 3 in the Supplement were incorrectly reported and have been replaced with corrected values. In addition, text was omitted from the first sentence in the findings portion of the Key Points. The corrected sentence now reads, “In this cohort study of 3412 older adults, the prevalence of prediabetes (mean [SD] age, 75.6 [5.2] years) was high and differed substantially depending on the definition used, with estimates ranging from 29% for glycated hemoglobin levels of 5.7% to 6.4% and fasting glucose levels of 100 to 125 mg/dL to 73% for either glycated hemoglobin levels of 5.7% to 6.4% or fasting glucose levels of 100 to 125 mg/dL.” The overall interpretation and implications of the study still stand.
