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Editorials

Last 50 Editorials

(Click on title to be directed to editorial, most recent listed first)

Screening for Obstructive Sleep Apnea in the Transportation Industry—
   The Time is Now
Mitigating the “Life-Sucking” Power of the Electronic Health Record
Has the VA Become a White Elephant?
The Most Influential People in Healthcare
Remembering the 100,000 Lives Campaign
The Evil That Men Do-An Open Letter to President Obama
Using the EMR for Better Patient Care
State of the VA
Kaiser Plans to Open "New" Medical School
CMS Penalizes 758 Hospitals For Safety Incidents
Honoring Our Nation's Veterans
Capture Market Share, Raise Prices
Guns and Sleep
Is It Time for a National Tort Reform?
Time for the VA to Clean Up Its Act
Eliminating Mistakes In Managing Coccidioidomycosis
A Tale of Two News Reports
The Hands of a Healer
The Fabulous Fours! Annual Report from the Editor
A Veterans Day Editorial: Change at the VA?
A Failure of Oversight at the VA
IOM Releases Report on Graduate Medical Education
Mild Obstructive Sleep Apnea: Beyond the AHI
Multidisciplinary Discussion (MDD) in Interstitial Lung Disease; Some
   Reflections
VA Administrators Breathe a Sigh of Relief
VA Scandal Widens
Don’t Fire Sharon Helman-At Least Not Yet
Questioning the Inspectors
Qualitygate: The Quality Movement's First Scandal
What's Wrong with Expert Opinion?
The Tremendous Threes! Annual Report from the Editor
Obamacare and Computers-Who Is to Blame? 
HIPAA-Protecting Patient Confidentiality or Covering Something Else?
Are Medical Guidelines Better Than Flipping a Coin?
Who Will Benefit and Who Will Lose from Obamacare?
Smoking, Epidemiology and E-Cigarettes
Treatment after a COPD Exacerbation
Executive Pay and the High Cost of Healthcare
Choosing Wisely-Where Is the Choice?
The State of Pulmonary and Critical Care in the Southwest
Doxycycline and IL-8 Modulation in a Line of Human Alveolar 
Epithelium: More Evidence for the Anti-Inflammatory Function 
   of Some Antimicrobials
What to Expect from Obamacare
The Terrific Twos! Annual Report from the Editor
Maintaining Medical Competence
Interference with the Patient–Physician Relationship
Guidelines for Starting Today’s Private Practice
The Emperor Has No Clothes: The Accuracy of
   of Hospital Performance Data 
Getting the Best Care at the Lowest Price
A New Paradigm to Improve Patient Outcomes
A Little Knowledge is a Dangerous Thing

 

For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care publishes editorials related to manuscripts in the Journal as well as areas of interest to the pulmonary, critical care and sleep communities. In general, editorials are written by the editors or are invited. However, the Journal will consider editorials written by others. Before submitting, a potential author of the editorial should contact the editor.

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Friday
Dec022016

Screening for Obstructive Sleep Apnea in the Transportation Industry—The Time is Now

Stuart F. Quan, M.D.

 

Division of Sleep and Circadian Disorders

Brigham and Women’s Hospital

and

Division of Sleep Medicine

Harvard Medical School

Boston, MA USA

and

Asthma and Airway Disease Research Center

University of Arizona College of Medicine,

Tucson, AZ USA

 

On September 29, 2016, a New Jersey Transit train failed to slow down and stop at the station in Hoboken, New Jersey. The resulting crash injured a number of passengers and killed a young mother who happened to be near the crash site. Subsequently, it was learned that the train engineer who apparently had blacked out was diagnosed as having severe obstructive sleep apnea (OSA) (1). Unfortunately, this was not an isolated incident. Over the past few years, there have been several other well-documented incidents of train, truck and bus crashes resulting from their operators falling asleep from OSA. In 2013, a Metro-North commuter train derailed outside of New York City because of excessive speed approaching a curve, the train engineer reported being “dazed” and was subsequently found to have OSA (2). Four passengers were killed and numerous others were injured. In another well-documented accident in 2013, the driver of a Greyhound bus fell asleep. The bus ran off the road, rolled on its side and injured 35 passengers. The driver had been told to get tested for OSA, but did not have the study done. A subsequent court-ordered polysomnogram showed OSA (3). In another incident in 2009, a truck-tractor semitrailer operator failed to notice slowing and stopped cars in front of him and collided with a passenger vehicle. This led to a series of rear end vehicle collisions resulting in 10 fatalities. The cause of the accident was operator fatigue related in part to OSA (4). These well-publicized incidents are only a few of the sleepiness/fatigue related accidents caused by unrecognized OSA in the transportation industry.

One of the most common symptoms attributed to OSA is daytime sleepiness which can be uncontrollable and unpredictable. Numerous studies have demonstrated that persons with OSA have an increased rate of motor vehicle accidents with up to a 4.9 fold higher risk (5). Accidents involving only a single vehicle are particularly frequent suggesting that the crashes are caused by the operators having fallen asleep. Truck drivers are at even greater risk, most likely because they are disproportionately male, middle aged and overweight, all of which are risk factors for OSA. Over a ten year span from 2004 to 2013, it has been estimated that 3,133 to 8,952 deaths and 77,000 and 220,000 serious injuries have resulted from sleepy operators of commercial motor vehicles, many of whom most likely had undiagnosed and untreated OSA (6).

Given the severe consequences of unrecognized OSA on public safety and the high prevalence of unrecognized OSA among operators of trains, buses and commercial trucks, the imperative to screen and treat these persons for OSA is high. The advisory boards to the Federal Motor Carrier Safety Administration (FMCSA) have recommended that commercial truck drivers be screened for OSA if their body mass index is > 40 kg/m2, or >33 kg/m2 and have 3 or more conditions or findings associated with OSA, but adoption of these recommendations has not occurred (7). More recently, the Department of Transportation, Federal Railroad Administration and the FMCSA have taken the first steps to mandate screening and treatment of rail and commercial motor vehicle operators for OSA by soliciting public comment (8). Airline pilots are already screened. However, there is substantial opposition from the trucking industry and drivers themselves, the latter because of potential job loss. However, such a screening program in one large trucking company has demonstrated a 5 fold reduction in accident rates in drivers who were adherent to CPAP treatment for OSA (5).

With the development of relatively simple to use ambulatory devices that can identify most persons with OSA, screening for OSA can be done easily and cost-effectively. In the vast majority of cases, referral to a sleep lab is not necessary. Persons diagnosed with OSA can be treated with several different modalities and are able to return to work. Employers may actually experience a reduction in their costs related to fewer accidents and improved employee health. Thus, there is no reason to delay requiring OSA screening programs for all persons working in occupations where public safety is at risk. For regulators, policy makers, and the various industries affected, the time is now. Failure to act places the responsibilities for the ensuing economic costs, injuries and deaths on your shoulders.

References

  1. Marsh R, Shortell D. NJ. Train Engineer in Crash had Undiagnosed Sleep Apnea. CNN. October 17, 2016. Available at: http://www.cnn.com/2016/11/17/us/njt-engineer-sleep-apnea/ (accessed 12/2/16).
  2. National Transportation Safety Board. Metro-North Railroad Derailment. October 24, 2014. Available at: http://www.ntsb.gov/investigations/accidentreports/pages/RAB1412.aspx (accessed 12/2/16).
  3. Five Passengers hurt in 2013 Greyhound Bus Crash Win $6 Million Settlement Attorneys Say. WCPO Cincinnati. http://www.wcpo.com/news/local-news/hamilton-county/cincinnati/five-passengers-hurt-in-2013-greyhound-bus-crash-win-6-million-settlement-attorneys-say (accessed 12/2/16).
  4. National Transportation Safety Board. Truck-Tractor Semitrailer Rear-End Collision Into Passenger Vehicles on Interstate 44. September 28, 2010. http://www.ntsb.gov/investigations/AccidentReports/Pages/HAR1002.aspx (accessed 12/2/16).
  5. Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med. 2009;5 (6):573–81.[PubMed]
  6. Burks SV, Anderson JE, Bombyk M, et al. Nonadherence with Employer-Mandated Sleep Apnea Treatment and Increased Risk of Serious Truck Crashes. Sleep. 2016 May 1;39(5):967-75. [CrossRef] [PubMed]
  7. Miller E. FMCSA Medical Review Board Issues Sleep Apnea Guidelines. Transport Topics. August 24, 2016. Available at:  http://www.ttnews.com/articles/basetemplate.aspx?storyid=42963&page=1 (accessed 12/2/16).
  8. Federal Motor Carrier Safety Administration. U.S. DOT Seeks Input on Screening and Treating Commercial Motor Vehicle Drivers and Rail Workers with Obstructive Sleep Apnea. March 8, 2016. Available at: https://www.fmcsa.dot.gov/newsroom/us-dot-seeks-input-screening-and-treating-commercial-motor-vehicle-drivers-and-rail-workers (accessed 12/2/16).

Cite as: Quan SF. Screening for obstructive sleep apnea in the transportation industry—the time is now. Southwest J Pulm Crit Care. 2016;13(6):285-7. doi: https://doi.org/10.13175/swjpcc132-16 PDF

Monday
Nov282016

Mitigating the “Life-Sucking” Power of the Electronic Health Record

An article in PulmCCM discussed “life-sucking” electronic health care records (EHR) (1). It is in turn based on an article in the Annals of Internal Medicine on the work time spent by physicians (2). The latter, funded by the American Medical Association, observed 57 physicians in internal medicine, family medicine, cardiology, and orthopedics over hundreds of hours. The study revealed that physicians spend almost two hours working on their electronic health record for every one hour of face-to-face patient time. Interestingly, physicians who used a documentation assistant or dictation spent more time with patients (31 and 44%) compared to those with no documentation support (23%).

The PulmCCM goes on to list some of the reasons that the EHR requires so much time:

  • The best and brightest minds in software design don't go to work for Epic, Cerner, Allscripts, and whoever the other ones are.
  • There's a high barrier to entry for competition now that most major health systems have implemented the big-name systems.
  • The vendors can't easily improve the front-end design's user-friendliness (like web pages and consumer software have) because it rests on clunky, proprietary frameworks built in the 1990s and which can't be substantially changed for stability reasons. Think Microsoft Office, but way worse.
  • Software designers are congenitally incapable of accepting the reality that a user would be better off the less they use the product, and designing it that way. They think their EHR is super cool, and can't fathom that it actually sucks to use.

Let me add another possibility. Those who demand implementation of the EHR see documentation as being most important because of the bottom line. It if comes at the price of physician efficiency so be it-as long as it does not hurt payment. Physicians are not paid for the required increased documentation much of which is unnecessary, redundant and, in some cases, downright silly (3). Furthermore, the concept that this improves patient outcomes largely seems to be a myth (4). Those manuscripts that report improved “quality” of care usually have examined meaningless surrogate metrics that often have little or even inverse relationships with patient outcomes (3). For example, high patient satisfaction seems to come at the price of increased mortality (5).

What is the solution-charge for the time. As it now stands, there is no downside to demanding pointless documentation. Third party payers can deny payment when something like the rarely beneficial family history is omitted. There should be a charge for seeing and caring for the patient and another “documentation fee” that is based on time. That would mean that a 20 minute office call would not be billed at 20 minutes but at the 1 hour of physician time the visit really consumes. Those physicians who use a documentation assistant or dictation can pay for these services by seeing more patients. Only in this way can the trend of wasting physicians’ most precious resource, their time, be mitigated.

Richard A. Robbins, MD*

Editor, SWJPCC

References

  1. PulmCCM. Life-sucking power of electronic health records measured, reported, lamented. November 25, 2016. Available at: http://pulmccm.org/main/2016/outpatient-pulmonology-review/life-sucking-power-electronic-health-records-measured-reported-lamented/ (accessed 11/28/16).
  2. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016 Sep 6. [Epub ahead of print] [CrossRef] [PubMed]
  3. Robbins RA. Brief review: dangers of the electronic medical record. Southwest J Pulm Crit Care. 2015;10(4):184-9. [CrossRef]
  4. Yanamadala S, Morrison D, Curtin C, McDonald K, Hernandez-Boussard T. Electronic health records and quality of care: an observational study modeling impact on mortality, readmissions, and complications. Medicine (Baltimore). 2016 May;95(19):e3332. [CrossRef] [PubMed]
  5. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012;172:405-11. [CrossRef] [PubMed]

*The views expressed are those of the author and do not reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as: Robbins RA. Mitigating the “life-sucking” power of the electronic health record. Southwest J Pulm Crit Care. 2016;13(5):255-6. doi: https://doi.org/10.13175/swjpcc125-16 PDF

Friday
Nov112016

Has the VA Become a White Elephant?

As I write this Dennis Wagner is publishing a series of articles in the Arizona Republic describing his quest to find out if care at VA hospitals has improved over the last 2 years (1). To begin the article Wagner describes the fable of the King of Siam who presented albino pachyderms to his enemies knowing they would be bankrupted because the cost of food and care outweighed all usefulness. A modern expression derives from this parable: the white elephant.

The Department of Veterans Affairs (VA) has prided itself on being a leader in healthcare. It is the largest healthcare system in the US, implemented the first electronic medical record, and more than 70 percent of all US doctors have received training in the VA healthcare system (2). This year the VA is celebrating the 70th anniversary of its partnership with US medical schools. Beginning in 1946, the VA partnered with academic institutions to provide health care and to train physicians, nurses and other healthcare professionals. “We are extremely proud of the long-standing, close relationships built over the past 70 years among VA and academic institutions across the country” said VA Secretary Robert A. McDonald. “These partnerships strengthen VA’s healthcare system, and provide high quality training for the nation’s healthcare workforce. We cannot do what we do without them.” On this Veterans Day these appear to be empty words.

To understand the VA wait list scandal and why it will be difficult to fix, it is important to understand the history of the VA academic affiliations. The VA initially affiliated with medical schools in 1946 because it had trouble attracting enough quality physicians to staff its hospitals. These affiliations led to the formation of "dean's hospitals" (3). These were VA hospitals closely affiliated with medical schools and made the VA hospitals teaching hospitals. The medical school faculty was in charge of patient care and teaching and the dean's committee oversaw it all. Not surprisingly, these dean's committees were largely despised by the non-physician directors of the VA business offices. In the mid-1990's they persuaded Veterans Health Administration undersecretary, Kenneth W. Kizer, to place them in charge of the VA hospitals as hospital directors. The dean's committees were dissolved, freeing the directors from any real local oversight. This set the foundation for the VA to return to 1945 and a culture that makes it difficult to attract sufficient numbers of quality physicians.

The inability to attract physicians is largely responsible for the widely publicized VA wait time crisis. Although the VA blames their inability to recruit on pay below what the private sector pays, this is only part of the story. VA administrators have repeatedly attempted to direct patient care leading to physician job dissatisfaction and poor morale. Rather than quality healthcare, the VA developed a list of largely meaningless metrics that substituted for quality. These so called "performance-measurements" were favored by VA administration in no small part because of the bonuses they generated for the administrators. This created a cycle of increasing numbers of measurements to generate increasing bonuses. Physicians were often pressured to remind patients to wear seat belts, not keep guns in the home, etc. leaving insufficient time to deal with real and immediate healthcare problems. In retrospect, even Kizer himself called the expanding number of performance measurements "bloated and unfocused" (4).

At first VA administrators tried to deny the problem of delayed care due to insufficient staffing. Next VA Central Office tried to make all VA clinics walk-in clinics, essentially shifting the problem to the physicians. When caught in lies about short wait times, VA Secretary McDonald fired a few administrators in Phoenix and then tried to minimize the problem (5). When announcing their progress on the problem, the VA touts the number of people it has hired but usually does not specify the number of physicians or other healthcare providers. Now the VA has decided to let nurses and pharmacists pick up the slack. The VA has proposed removing physician supervision of nurse practitioners and has begun using pharmacists for primary care (6,7).

A number of medical groups have opposed the increased authority for nurses (8). Neither nurses nor pharmacists have the length of training of physicians (9).  However, objections by the AMA and other groups are likely to fall on deaf ears. Unless the VA can recruit physician which seems unlikely without reform, what other choice do they have? It is unclear if the VA and courts will hold these less experienced and lower skilled practitioners to the same high standards they have held physicians. However, given that the VA administrators are knowingly replacing physicians with less skilled practitioners, this would seem reasonable.

Wagner's series in the Arizona Republic seems to suggest that the VA's lack of transparency makes it difficult to determine if care at VA hospitals have improved over the last 2 years (9). The conclusion from the series appears to be that the VA has not. This is not surprising given that no real reform has taken place and McDonald appears not to be in control of the VA. For example, two short years ago McDonald was proposing to downsize the VA administration (10). Like so many reforms, this seems to have fallen by the wayside under opposition from VA administration. In fact, Wagner implies that VA administration may actually have grown beyond what was already a bloated bureaucracy (9).

President-elect Trump has been critical of the VA and McDonald. It seems likely he will be gone this January but the VA administrators will remain. Hopefully, McDonald's replacement will do better in reforming the VA. If not, it might be time to view the VA as what it has become, a white elephant whose cost outweighs all usefulness. Consideration should be given to replacing the VA with care in the private sector. Although care will be more expensive, it is better than no or poor care which is what the VA patients are receiving now.

Richard A. Robbins, MD*

Editor, SWJPCC

References

  1. Wagner D. Seven VA hospitals, one enduring mystery: What's really happening?. Available at: http://www.azcentral.com/story/news/local/arizona-investigations/2016/10/23/va-hospitals-veterans-health-care-quest-for-answers/90337096/ (accessed 10/27/16).
  2. Department of Veterans Affairs. VA celebrates 70 years of partnering with medical schools. Available at: http://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2747 (accessed 10/27/16).
  3. Department of Veterans Affairs. Still going strong - the history of VA academic affiliations. Available at: http://www.va.gov/OAA/videos/transcript_affiliation_history.asp (accessed 10/27/16).
  4. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014 Jul 24;371(4):295-7. [CrossRef] [PubMed]
  5. Rein L. VA chief compares waits for veteran care to Disneyland: They don’t measure and we shouldn’t either. Washington Post. May 23, 2016. Available at: https://www.washingtonpost.com/news/powerpost/wp/2016/05/23/va-chief-compares-waits-for-veteran-care-to-disneyland-they-dont-measure-and-we-shouldnt-either/ (accessed 10/27/16).
  6. Department of Veterans Affairs. VA Proposes to grant full practice authority to advanced practice registered nurses. May 29, 2016. Available at: http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2793 (accessed 10/27/16).
  7. Galewitz P. VA shifts to clinical pharmacists to help ease patients’ long waits. Kaiser Health News. October 25, 2016. Available at: http://khn.org/news/va-treats-patients-impatience-with-clinical-pharmacists/ (accessed 10/27/16).
  8. Rein L. To cut wait times, VA wants nurses to act like doctors. Doctors say veterans will be harmed. Washington Post. May 27, 2016. Available at: https://www.washingtonpost.com/news/powerpost/wp/2016/05/27/to-cut-wait-times-va-wants-nurses-to-act-like-doctors-doctors-say-veterans-will-be-harmed/ (accessed 10/27/16).
  9. Robbins RA. Nurse pactitioners' substitution for physicians. Southwest J Pulm Crit Care. 2016;12(2):64-71. [CrossRef]
  10. Krause J. MyVA re-org likely set to downsize VA workforce, a lot. DisabledVeterans.org. Jan 28, 2015. Available at: http://www.disabledveterans.org/2015/01/29/myva-reorganization-likely-set-downsize-va-workforce-lot/ (accessed 10/27/16).

*The views expressed are those of the author and do not reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as Robbins RA. Has the VA Become a White Elephant? Southwest J Pulm Crit Care. 2016;13(5):235-7. doi: https://doi.org/10.13175/swjpcc108-16 PDF 

Sunday
Sep042016

The Most Influential People in Healthcare

Recently Modern Healthcare released their annual 2016 listing of the most influential people in Healthcare (1). Leading the list is President Barack Obama for his Affordable Care Act. The list consists of a monotonous list of bureaucrats, politicians, large healthcare chain CEOs, insurance company CEOs, health interest organizations (American Hospital Association, America's Health Insurance Plans Healthcare, etc.), professional organizations (American Medical Association, American Nurses Association, etc.), nongovernmental healthcare interest organizations (Joint Commission,  National Quality Forum, etc.) and vendors (Epic, McKesson, etc.). From the Southwest the list includes at least 11 hospital chain CEOs including 1 from Arizona, 3 from Colorado and 7 from California.

Striking is the lack of influential healthcare professionals who made the list. Only two are leading academicians-Atul Gawande, a surgeon and author at Harvard, and Robert Wachter, an internist and pioneer in the hosptialist movement at University of California San Francisco. John Noseworthy (Mayo Clinic) and Ronald DePinho (MD Anderson) were noteworthy academicians prior to becoming hospital CEOs. Underrepresented are deans at major medical colleges (e.g., Talmadge King, Skip Garcia), influential researchers and clinicians (e.g., Marvin Schwarz, Stuart Quan), influential training organizations (e.g., American College of Graduate Medical Education, American Board of Internal Medicine), and even editors of prominent medical journals (e.g., Jeff Drazen at the New England Journal, Howard Bauchner at JAMA).

Every year I am offended by the domination of this list by bureaucrats, politicians and businessmen and the lack of true healthcare professionals. However, the list reflects the reality that political and business interests direct medicine. Everything from my interaction with a patient, documentation through in an electronic healthcare record, and diagnostic testing and prescribing based on the which tests and drugs are least expensive for a particular insurance plan are influenced by these non-medical interests. Unfortunately, what is lost is the interests of the patient and the role of doctors and nurses as patient advocates.

Medicine has too often become a series of meaningless metrics leading to expensive but poorer care because of these political and business interests. Furthermore, the practice of medicine is becoming increasingly unpleasant and unrewarding for the doctors and nurses. The domination of these non-medical interests has led to an explosion in non-professional administrators who consume 40% of the healthcare dollar and to a large extent annoy providers leading to their dissatisfaction with their professions (2). For example, Deputy Secretary of Veterans Affairs, Sloan Gibson, recently touted improvements made by the Phoenix VA (3). According to Gibson the Phoenix VA had a net increase of 758 employees in the past 2 years with an additional 23 doctors and 48 nurses. That calculates out to 91% of their hires being something other than physicians and nurses. It is unclear what these people do but hopefully something more than demand that providers fill out forms which they shuffle leading to ever larger administrative bonuses. Otherwise, those new hires will quickly leave and the shortage of providers that created the VA scandal in the first place will not improve. Incidentally, Gibson's boss, Robert McDonald was number 36 on the list.

What can we do? Unfortunately, there would appear to be no quick fixes. Most of us are just trying to get by caring for our patients and doing the best we can. It will take education of the public to what is going on and how their healthcare dollar is spent. Ultimately, it will be patients that can demand the changes that are needed. Although the solutions may be difficult, one way we might be able to detect improvement is when fewer bureaucrats, politicians and businessmen make Modern Healthcare's most influential list.

Richard A. Robbins, MD*

Editor, SWJPCC

References

  1. Modern Healthcare. 100 Most Influential People in Healthcare 2016. Available at: http://www.modernhealthcare.com/community/100-most-influential/2016/ (accessed 9/3/16).
  2. Robbins RA. National health expenditures: the past, present, future and solutions. Southwest J Pulm Crit Care. 2015;11(4):176-85. [CrossRef]
  3. Wagner D. Top VA brass says Phoenix hospital is off critical list, cites improvements. Arizona Republic. September 1, 2016. Available at: http://www.azcentral.com/story/news/local/arizona-investigations/2016/09/01/va-deputy-secretary-touts-phoenix-hospital-improvements/89666526/ (accessed 9/3/16).

*The opinions expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as: Robbins RA. The most influential people in healthcare. Southwest J Pulm Crit Care. 2016;13(3):123-4. doi: http://dx.doi.org/10.13175/swjpcc089-16 PDF

Saturday
Jun252016

Remembering the 100,000 Lives Campaign

Earlier this week the Institute for Healthcare Improvement (IHI) emailed its weekly bulletin celebrating that it has been ten years since the end of the 100,000 Lives Campaign (Appendix 1). This was the campaign, according to the bulletin, that put IHI on the map. The Campaign started at the IHI National Forum in December 2004, when IHI's president, Don Berwick, announced that IHI would work together with nearly three-quarters of the US hospitals to reduce needless deaths by 100,000 over 18 months. A phrase borrowed from political campaigns became IHI's cri de coeur: “Some is not a number. Soon is not a time.”

The Campaign relied on six key interventions:

  • Rapid Response Teams
  • Improved Care for Acute Myocardial Infarction
  • Medication Reconciliation
  • Preventing Central Line Infections
  • Preventing Surgical Site Infections
  • Preventing Ventilator-Associated Pnemonia [sic]

According to the bulletin, the Campaign’s impact rippled across the organization and the world. IHI listed some of the lasting impacts:

  • IHI followed with the 5 Million Lives Campaign – a campaign to avoid 5 million instances of harm.
  • Don Berwick and Joe McCannon brought lessons from leading the Campaigns to Centers for Medicare and Medicaid Services (CMS) and the Partnership for Patients.
  • Related campaigns were launched in Canada, Australia, Sweden, Denmark, UK, Japan, and elsewhere.

IHI's profile definitely grew. One indicator tracked by IHI was media impressions, which rose to 250 million in the final year of the Campaign. IHI even put a recreational vehicle on the streets to promote their Campaign (Appendix 1). Campaign Manager Joe McCannon was on CNN to discuss the results of the Campaign.

How did IHI achieve such remarkable results in saving patients' lives? The answer is they did not. Review of the evidence basis for at least 3 of these interventions revealed fundamental flaws (1). The largest trial of rapid response teams failed to result in any improvements and the interventions to prevent central line infections and ventilator-associated pneumonia were non- or weakly-evidenced based and unlikely to improve patient outcomes (2-4). The poor methodology and sloppy estimation of the number of lives saved were pointed out in the Joint Commission’s Journal of Quality and Safety by Wachter and Pronovost (5). IHI failed to adjust their estimates of lives saved for case-mix which accounted for nearly three out of four "lives saved." The actual mortality data were supplied to the IHI by hospitals without audit, and 14% of the hospitals submitted no data at all. Moreover, the reports from even those hospitals that did submit data were usually incomplete. The most striking example is that the IHI was so anxious to announce their success that the data was based on only 15 months of data. The final three months were extrapolated from hospitals’ previous submissions. Important confounders such as the background of declining inpatient mortality rates were ignored. Even if the Campaign "saved" lives, it would be unclear if the Campaign had anything to do with the reduction (5). Buoyed by their success, the IHI proceeded with the 5,000,000 Lives Campaign (6). However, this campaign ended in 2008 and was apparently not successful (7). Although IHI promised to publish results in major medical journals, to date no publication is evident.

A fundamental flaw in the logic behind the 100,000 Lives Campaign was that preventing a complication, for example an infection, results in a life saved. Many of our patients in the ICU have an infection as their life-ending event. However, the patients are often in the ICU because their underlying disease(s). In many instances their underlying disease(s) such as cancer, heart disease, or chronic obstructive pulmonary disease are so severe that survival is unlikely. It is akin to poisoning, stabbing, shooting and decapitating a hapless victim and saying that had the decapitation been prevented, survival was assured. IHI also assumed that the data was collected completely and honestly. However, the data was incomplete as pointed out above and the honesty of self-reported hospital data has also been called into question (8).

The bulletin correctly pointed out that Berwick did carry this political campaign with its sloppy science to Washington as CMS' administrator. Under Berwick's leadership, CMS would announce a campaign, have the hospitals collect the data, extrapolate the mortality or other benefit, and prepare a press release. This scheme continues until this day (9). CMS further confounded the data by providing financial incentives to hospitals, often resulting in bonuses to hospital executives, making the data further suspect. Certainly, CMS would not examine the hospital data with skepticism because the success of their campaign was in their own political best interest.

The 100,000 Lives Campaign also had one other outcome. It made many of us who believe in the power of evidence-based medicine to enrich patients' lives to be suspicious of these political maneuvers. To rephrase a well-known quote, "The first victim of politics is the truth". These campaigns certainly financially benefit hospitals and their administrators and politically benefit bureaucrats, but whether they benefit patients is questionable. The bulletin from IHI should be viewed for what it is, a political self-promotion to rewrite the failed history of the 100,000 Lives Campaign.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Robbins RA. The unfulfilled promise of the quality movement. Southwest J Pulm Crit Care. 2014;8(1):50-63. [CrossRef]
  2. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, Finfer S, Flabouris A; MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365(9477):2091-7. [CrossRef] [PubMed]
  3. Hurley J, Garciaorr R, Luedy H, Jivcu C, Wissa E, Jewell J, Whiting T, Gerkin R, Singarajah CU, Robbins RA. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care 2012;4:163-73.
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Cite as: Robbins RA. Remembering the 100,000 lives campaign. Southwest J Pulm Crit Care. 2016;12(6):255-7. doi: http://dx.doi.org/10.13175/swjpcc058-16 PDF