Letters
Inequities in access to liver transplantation exist across the United States generally and are not limited to veterans specifically.4 Rather, the VHA minimizes barriers to access and provides continuity of care across great distances based on an integrated system of 150 acute care hospitals and more than 820 community-based outpatient clinics. Veterans requiring specialized services may receive travel benefits to assist with care before and after receiving the transplant, including lodging for the veteran and caregiver. Beginning in 2010, the VHA enhanced its electronic transplant referral system and expanded telehealth capabilities to expedite timely transplant services. William P. Gunnar, MD, JD Author Affiliation: Veterans Health Administration, Washington, DC. Corresponding Author: William P. Gunnar, MD, JD, Veterans Health Administration, 810 Vermont Ave NW, Washington, DC 20420 (william.gunnar @va.gov). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being the Veterans Health Administration national director of surgery. 1. Goldberg DS, French B, Forde KA, et al. Association of distance from a transplant center with access to waitlist placement, receipt of liver transplantation, and survival among US veterans. JAMA. 2014;311(12):1234-1243. 2. Scientific Registry of Transplant Recipients. US hospitals with liver transplant centers. http://www.srtr.org/csr/current/Centers/TransplantCenters.aspx ?organcode=LI. Accessed May 19, 2014. 3. Zorzi D, Rastellini C, Freeman DH, Elias G, Duchini A, Cicalese L. Increase in mortality rate of liver transplant candidates residing in specific geographic areas: analysis of UNOS data. Am J Transplant. 2012;12(8):2188-2197. 4. Axelrod DA, Guidinger MK, Finlayson S, et al. Rates of solid-organ wait-listing, transplantation, and survival among residents of rural and urban areas. JAMA. 2008;299(2):202-207.
In Reply We concur with Dr Gunnar that distance-related inequities in access to liver transplantation are not unique to the VHA. However, the absence of robust national databases precludes such evaluations in the non-VA population. The VHA’s integrated electronic medical record allowed us to use the VHA as a model of the effects of centralization and there was no intent to imply that these are VHA-specific disparities. Unlike private centers, the VHA attempts to minimize the additional burden of distance by providing travel assistance to veterans and caregivers; however, such support does not ameliorate the reduced access to transplantation for veterans living more than 100 miles from a VATC. We would like to respond to Gunnar’s statement that the disparity in access to transplantation was observed regardless of whether the veteran received care at a VATC or non-VATC. We included waitlisting at non-VATCs as an outcome to determine if access to local non-VATCs mitigated the relationship between waitlisting at a VATC and distance, and found this not to be the case. The absolute increase in the proportion of potentially transplant-eligible veterans who were waitlisted at a VATC compared with any transplant center (VATCs and non-VATCs) was similar for veterans living more or less than 100 miles from a VATC. Thus, access to non-VATCs for veterans with secondary non-VA
insurance did not ameliorate the disparities in access to transplantation as a function of distance, in large part because the majority of veterans potentially eligible for transplant included in this cohort lacked secondary insurance and did not have access to local non-VATCs. Furthermore, the transplant rates of the waitlisted veteran cohorts need to be taken in context of the small fraction of potentially eligible patients who were actually waitlisted. Distance in the VHA also affects the referral process in a different manner than the private sector, in which the process of referring a patient for transplant evaluation may only require a referring gastroenterologist to contact the transplant center and send medical records. By contrast, VHA clinicians (often nonexpert, primary care, or mid-level clinicians) at non-VATCs must shepherd patients through an exhaustive, time-consuming, and resource-intensive evaluation prior to referral without the benefit of transplantexperienced coordinators, social workers, and psychiatrists afforded to the VATCs. The degree to which local rather than central barriers to access explain disparities in transplant waitlisting rates requires investigation. Last, we acknowledge that the implementation of the electronic referral system in 2010 postdates the period for which data were analyzed in the study. With sufficient time under the new referral schema, the effect of this central process improvement can be measured using the methods we established. This change, and the addition of new VA transplant centers, will hopefully provide all veterans with equivalent access to the excellent transplant services the VA administers independent of residency. David E. Kaplan, MD, MSc David S. Goldberg, MD, MSCE Author Affiliations: Gastroenterology Section, Philadelphia VA Medical Center, Philadelphia, Pennsylvania (Kaplan); Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia (Goldberg). Corresponding Author: David S. Goldberg, MD, MSCE, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Goldberg reported receiving a grant from Bayer HealthCare. No other disclosures were reported.
Early Descriptions of Closed-Chest Cardiac Massage To the Editor In their recent Viewpoint, Dr Eisenberg and colleagues1 stated that “closed-chest cardiac massage for the treatment of cardiac arrest was first described in the medical literature in 1960.” There had been descriptions of closed-chest cardiac massage as well as cases of its application among human patients published more than 50 years prior to that date. The first accurate description of external cardiac compressions by sternal compression for resuscitation of cardiac arrest was by Hill in 1868: “The surgeon’s left hand was placed firmly across the front of the chest, the fingers resting over the fifth, sixth, and seventh cartilages on the right side, while the tip of the thumb lay on the second piece of the sternum and the muscular part of the hand on
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Copyright 2014 American Medical Association. All rights reserved.
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Letters
the corresponding cartilages on the left side. The right hand now crossed over the left and forcible pressure made; the hands then being suddenly removed, the chest was allowed to expand by its own elasticity.”2 Maass reported successful use of closed-chest massage in 1892 in Germany3; 11 years later in the United States, Crile reported on its application in 7 cases with some success.4 Although these reports were noted by the medical community, resuscitation efforts focused more on open cardiac massage until closed-chest compression was accidentally rediscovered by Kouwenhoven, Jude, and Knickerbocker while working on achieving closed-chest defibrillation; they fortuitously noted that when the heavy copper defibrillator pads were placed against the chest of a dog in ventricular fibrillation, a femoral pulse pressure was noted.5
series. It was a landmark study3 and in a very short time dramatically changed the management of cardiac arrest. Mickey S. Eisenberg, MD, PhD Bentley J. Bobrow, MD Tom Rea, MD, MPH Author Affiliations: Department of Medicine, University of Washington, Seattle (Eisenberg, Rea); Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System, Phoenix (Bobrow). Corresponding Author: Bentley J. Bobrow, MD, Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System, 150 N 18th Ave, Phoenix, AZ 85007 ([email protected]).
Joseph Shiber, MD
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Bobrow reported receiving a grant from the Medtronic Foundation. Dr Rea reported serving as medical director for the Association of Public Safety Communication Officials and receiving a grant from the Medtronic Foundation. No other disclosures were reported.
Author Affiliation: Department of Emergency Critical Care, University of Florida College of Medicine, Jacksonville.
1. Eisenberg MS. Part III: the search for artificial circulation. In: Live in the Balance: Emergency Medicine and the Quest to Reverse Sudden Death. New York, NY: Oxford University Press; 1997:109-129.
Corresponding Author: Joseph Shiber, MD, Departments of Emergency Medicine and Critical Care, University of Florida College of Medicine, 655 W Eighth St, Jacksonville, FL 32209 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
2. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960;173:1064-1067. 3. Sladen A. Landmark perspective: closed-chest massage, Kouwenhoven, Jude, Knickerbocker. JAMA. 1984;251(23):3137-3140.
1. Eisenberg MS, Bobrow BJ, Rea T. Fulfilling the promise of “anyone, anywhere” to perform CPR. JAMA. 2014;311(12):1197-1198. 2. Hill JD. Observations of some of the dangers of chloroform in surgical practice and a successful mode of treatment. Br J Dent Sci. 1868;11:355-358. 3. Maass F. Die Methode der wiederbelebung bei hertod nach chloroformeinathmung [in German]. Berlin Klin Wochenschr. 1892;29:265. 4. Crile GW. Blood Pressure in Surgery. Philadelphia, PA: Lippincott; 1903:294. 5. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960;173:1064-1067.
In Reply Dr Shiber references the early literature of cardiopulmonary resuscitation. There were indeed several descriptions of maneuvers that were similar to closed-chest compression as practiced today. Some of these early techniques were in fact designed to help ventilate the lungs rather than circulate blood.1 The 1960 article by Kouwenhoven et al2 was the first human clinical application based on animal experimentation with unequivocal utility in a prospectively observed case
438
Guidelines for Letters Letters discussing a recent JAMA article should be submitted within 4 weeks of the article's publication in print. Letters received after 4 weeks will rarely be considered. Letters should not exceed 400 words of text and 5 references and may have no more than 3 authors. Letters reporting original research should not exceed 600 words of text and 6 references and may have no more than 7 authors. They may include up to 2 tables or figures but online supplementary material is not allowed. All letters should include a word count. Letters must not duplicate other material published or submitted for publication. Letters not meeting these specifications are generally not considered. Letters being considered for publication ordinarily will be sent to the authors of the JAMA article, who will be given the opportunity to reply. Letters will be published at the discretion of the editors and are subject to abridgement and editing. Further instructions can be found at http: //jama.com/public/InstructionsForAuthors.aspx. A signed statement for authorship criteria and responsibility, financial disclosure, copyright transfer, and acknowledgment and the ICMJE Form for Disclosure of Potential Conflicts of Interest are required before publication. Letters should be submitted via the JAMA online submission and review system at http://manuscripts.jama.com. For technical assistance, please contact [email protected]. Section Editor: Jody W. Zylke, MD, Senior Editor.
JAMA July 23/30, 2014 Volume 312, Number 4
Copyright 2014 American Medical Association. All rights reserved.
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Inequities in access to liver transplantation exist across the United States generally and are not limited to veterans specifically.4 Rather, the VHA minimizes barriers to access and provides continuity of care across great distances based on an integrated system of 150 acute care hospitals and more than 820 community-based outpatient clinics. Veterans requiring specialized services may receive travel benefits to assist with care before and after receiving the transplant, including lodging for the veteran and caregiver. Beginning in 2010, the VHA enhanced its electronic transplant referral system and expanded telehealth capabilities to expedite timely transplant services. William P. Gunnar, MD, JD Author Affiliation: Veterans Health Administration, Washington, DC. Corresponding Author: William P. Gunnar, MD, JD, Veterans Health Administration, 810 Vermont Ave NW, Washington, DC 20420 (william.gunnar @va.gov). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being the Veterans Health Administration national director of surgery. 1. Goldberg DS, French B, Forde KA, et al. Association of distance from a transplant center with access to waitlist placement, receipt of liver transplantation, and survival among US veterans. JAMA. 2014;311(12):1234-1243. 2. Scientific Registry of Transplant Recipients. US hospitals with liver transplant centers. http://www.srtr.org/csr/current/Centers/TransplantCenters.aspx ?organcode=LI. Accessed May 19, 2014. 3. Zorzi D, Rastellini C, Freeman DH, Elias G, Duchini A, Cicalese L. Increase in mortality rate of liver transplant candidates residing in specific geographic areas: analysis of UNOS data. Am J Transplant. 2012;12(8):2188-2197. 4. Axelrod DA, Guidinger MK, Finlayson S, et al. Rates of solid-organ wait-listing, transplantation, and survival among residents of rural and urban areas. JAMA. 2008;299(2):202-207.
In Reply We concur with Dr Gunnar that distance-related inequities in access to liver transplantation are not unique to the VHA. However, the absence of robust national databases precludes such evaluations in the non-VA population. The VHA’s integrated electronic medical record allowed us to use the VHA as a model of the effects of centralization and there was no intent to imply that these are VHA-specific disparities. Unlike private centers, the VHA attempts to minimize the additional burden of distance by providing travel assistance to veterans and caregivers; however, such support does not ameliorate the reduced access to transplantation for veterans living more than 100 miles from a VATC. We would like to respond to Gunnar’s statement that the disparity in access to transplantation was observed regardless of whether the veteran received care at a VATC or non-VATC. We included waitlisting at non-VATCs as an outcome to determine if access to local non-VATCs mitigated the relationship between waitlisting at a VATC and distance, and found this not to be the case. The absolute increase in the proportion of potentially transplant-eligible veterans who were waitlisted at a VATC compared with any transplant center (VATCs and non-VATCs) was similar for veterans living more or less than 100 miles from a VATC. Thus, access to non-VATCs for veterans with secondary non-VA
insurance did not ameliorate the disparities in access to transplantation as a function of distance, in large part because the majority of veterans potentially eligible for transplant included in this cohort lacked secondary insurance and did not have access to local non-VATCs. Furthermore, the transplant rates of the waitlisted veteran cohorts need to be taken in context of the small fraction of potentially eligible patients who were actually waitlisted. Distance in the VHA also affects the referral process in a different manner than the private sector, in which the process of referring a patient for transplant evaluation may only require a referring gastroenterologist to contact the transplant center and send medical records. By contrast, VHA clinicians (often nonexpert, primary care, or mid-level clinicians) at non-VATCs must shepherd patients through an exhaustive, time-consuming, and resource-intensive evaluation prior to referral without the benefit of transplantexperienced coordinators, social workers, and psychiatrists afforded to the VATCs. The degree to which local rather than central barriers to access explain disparities in transplant waitlisting rates requires investigation. Last, we acknowledge that the implementation of the electronic referral system in 2010 postdates the period for which data were analyzed in the study. With sufficient time under the new referral schema, the effect of this central process improvement can be measured using the methods we established. This change, and the addition of new VA transplant centers, will hopefully provide all veterans with equivalent access to the excellent transplant services the VA administers independent of residency. David E. Kaplan, MD, MSc David S. Goldberg, MD, MSCE Author Affiliations: Gastroenterology Section, Philadelphia VA Medical Center, Philadelphia, Pennsylvania (Kaplan); Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia (Goldberg). Corresponding Author: David S. Goldberg, MD, MSCE, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Goldberg reported receiving a grant from Bayer HealthCare. No other disclosures were reported.
Early Descriptions of Closed-Chest Cardiac Massage To the Editor In their recent Viewpoint, Dr Eisenberg and colleagues1 stated that “closed-chest cardiac massage for the treatment of cardiac arrest was first described in the medical literature in 1960.” There had been descriptions of closed-chest cardiac massage as well as cases of its application among human patients published more than 50 years prior to that date. The first accurate description of external cardiac compressions by sternal compression for resuscitation of cardiac arrest was by Hill in 1868: “The surgeon’s left hand was placed firmly across the front of the chest, the fingers resting over the fifth, sixth, and seventh cartilages on the right side, while the tip of the thumb lay on the second piece of the sternum and the muscular part of the hand on
jama.com
JAMA July 23/30, 2014 Volume 312, Number 4
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Ndsu Library Periodicals User on 06/02/2015
437
Letters
the corresponding cartilages on the left side. The right hand now crossed over the left and forcible pressure made; the hands then being suddenly removed, the chest was allowed to expand by its own elasticity.”2 Maass reported successful use of closed-chest massage in 1892 in Germany3; 11 years later in the United States, Crile reported on its application in 7 cases with some success.4 Although these reports were noted by the medical community, resuscitation efforts focused more on open cardiac massage until closed-chest compression was accidentally rediscovered by Kouwenhoven, Jude, and Knickerbocker while working on achieving closed-chest defibrillation; they fortuitously noted that when the heavy copper defibrillator pads were placed against the chest of a dog in ventricular fibrillation, a femoral pulse pressure was noted.5
series. It was a landmark study3 and in a very short time dramatically changed the management of cardiac arrest. Mickey S. Eisenberg, MD, PhD Bentley J. Bobrow, MD Tom Rea, MD, MPH Author Affiliations: Department of Medicine, University of Washington, Seattle (Eisenberg, Rea); Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System, Phoenix (Bobrow). Corresponding Author: Bentley J. Bobrow, MD, Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System, 150 N 18th Ave, Phoenix, AZ 85007 ([email protected]).
Joseph Shiber, MD
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Bobrow reported receiving a grant from the Medtronic Foundation. Dr Rea reported serving as medical director for the Association of Public Safety Communication Officials and receiving a grant from the Medtronic Foundation. No other disclosures were reported.
Author Affiliation: Department of Emergency Critical Care, University of Florida College of Medicine, Jacksonville.
1. Eisenberg MS. Part III: the search for artificial circulation. In: Live in the Balance: Emergency Medicine and the Quest to Reverse Sudden Death. New York, NY: Oxford University Press; 1997:109-129.
Corresponding Author: Joseph Shiber, MD, Departments of Emergency Medicine and Critical Care, University of Florida College of Medicine, 655 W Eighth St, Jacksonville, FL 32209 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
2. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960;173:1064-1067. 3. Sladen A. Landmark perspective: closed-chest massage, Kouwenhoven, Jude, Knickerbocker. JAMA. 1984;251(23):3137-3140.
1. Eisenberg MS, Bobrow BJ, Rea T. Fulfilling the promise of “anyone, anywhere” to perform CPR. JAMA. 2014;311(12):1197-1198. 2. Hill JD. Observations of some of the dangers of chloroform in surgical practice and a successful mode of treatment. Br J Dent Sci. 1868;11:355-358. 3. Maass F. Die Methode der wiederbelebung bei hertod nach chloroformeinathmung [in German]. Berlin Klin Wochenschr. 1892;29:265. 4. Crile GW. Blood Pressure in Surgery. Philadelphia, PA: Lippincott; 1903:294. 5. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960;173:1064-1067.
In Reply Dr Shiber references the early literature of cardiopulmonary resuscitation. There were indeed several descriptions of maneuvers that were similar to closed-chest compression as practiced today. Some of these early techniques were in fact designed to help ventilate the lungs rather than circulate blood.1 The 1960 article by Kouwenhoven et al2 was the first human clinical application based on animal experimentation with unequivocal utility in a prospectively observed case
438
Guidelines for Letters Letters discussing a recent JAMA article should be submitted within 4 weeks of the article's publication in print. Letters received after 4 weeks will rarely be considered. Letters should not exceed 400 words of text and 5 references and may have no more than 3 authors. Letters reporting original research should not exceed 600 words of text and 6 references and may have no more than 7 authors. They may include up to 2 tables or figures but online supplementary material is not allowed. All letters should include a word count. Letters must not duplicate other material published or submitted for publication. Letters not meeting these specifications are generally not considered. Letters being considered for publication ordinarily will be sent to the authors of the JAMA article, who will be given the opportunity to reply. Letters will be published at the discretion of the editors and are subject to abridgement and editing. Further instructions can be found at http: //jama.com/public/InstructionsForAuthors.aspx. A signed statement for authorship criteria and responsibility, financial disclosure, copyright transfer, and acknowledgment and the ICMJE Form for Disclosure of Potential Conflicts of Interest are required before publication. Letters should be submitted via the JAMA online submission and review system at http://manuscripts.jama.com. For technical assistance, please contact [email protected]. Section Editor: Jody W. Zylke, MD, Senior Editor.
JAMA July 23/30, 2014 Volume 312, Number 4
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Ndsu Library Periodicals User on 06/02/2015
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