Search Journal-type in search term and press enter
Announcements and Recruitment
Social Media-Follow Southwest Journal of Pulmonary and Critical Care on Facebook and Twitter

Editorials

Last 50 Editorials

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

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
VA Administrators Gaming the System
Will Fewer Tests Improve Healthcare or Profits?
Identification of a Biomarker of Sleep Deficiency—
   Are We Tilting Windmills?
Competition or Cooperation?
Follow the Money
Happy First Birthday SWJPCC! 
The Hefty Price of Obstructive Sleep Apnea 
Mismanagement at the VA: Where’s the Problem? 
Why Is It So Difficult to Get Rid of Bad Guidelines?
Changes In Medicine: Job Security 
Changes In Medicine: The Decline Of Physician Autonomy 
Changes in Medicine: Fellowship
Changes in Medicine: Residency
Changes in Medicine: Medical School
The Pain of The Timeout 
Guidelines, Recommendations and Improvement in Healthcare

 

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.

-------------------------------------------------------------------------------------

Monday
Nov102014

A Veterans Day Editorial: Change at the VA?

"Meet the new boss,

Same as the old boss.

Won't Get Fooled Again!"

            -Peter Townshend

Today we honor our veterans. A year ago VA patients languished on waiting lists waiting for healthcare. VA administrators hid the truth at over 100 VAs and took bonuses for meeting their wait time goals. Money has been poured into the VA, patients in rural areas are seen outside the VA, and it is now supposedly easier to fire other senior VA officials. Dennis Wagner authored an article in the Arizona Republic that claimed the VA has made some changes but more changes are needed (1). I agree with the need for change but would argue that there has been no real change at the VA.

Last week I saw a VA patient in my private practice. He was paying for tiotropium or Spiriva®, a long-acting anticholinergic used in chronic obstructive pulmonary disease, out of his pocket. He was under the impression that the VA did not "carry" tiotropium. I told him that this was not true and that he should go to the VA and ask to be seen in pulmonary clinic if his primary care physician could not prescribe tiotropium. He was sent to the pharmacy where the pharmacist wanted to know why I would prescribe this expensive drug. He was sent back to my office for a response. I xeroxed a copy of my notes and gave them to the patient. I do not know whether he got the tiotropium but my guess is that probably not without some hassle. This is unchanged from prior to the scandal when patient care was undermined by healthcare support staff. No real change there.

Last night, the new Secretary of the VA, Robert McDonald, was on "60 Minutes" (2). He announced that he is "reorganizing" the VA. Although details were not stated, this sounded mostly like a consolidation of websites, not a bad thing, but hardly a "reorganization". He also said how sorry he was for past mistakes and how the new VA was going to do better. I had déjà vu going back to the mid 90's with Ken Kaiser's "Prescription for Change" (3). Eric Shinseki, the VA secretary recently forced to resign, used similar rhetoric and was "mad as hell" at the falsified wait lists (4). No real change there.

McDonald used the term "customers" to refer to VA patients (2). This has occurred off and on since the mid 90's and is a term some healthcare providers find offensive. We do not flip burgers at McDonald's and find it inappropriate and offensive to equate healthcare professionals with businessmen selling Charmin, Luvs, Pampers, Gillette razors, Covergirl makeup, etc. No real change there.

Earlier this week, the VA named a new director at the Phoenix VA, ground zero of the VA scandal (5). He is the former director of the Milwaukee VA and director of the VA's Rocky Mountain regional network, apparently coaxed out of retirement to serve for about a year as director at the troubled medical center. He replaces two directors who served a matter of months. While director at the Rocky Mountain VA region he named Cynthia McCormack, former chief of nursing at the Phoenix VA, as director of the Cheyenne VA (6). Cheyenne was second only to Phoenix in having the widespread falsification of wait times discovered. Sharon Helman, the Phoenix VA director sits at home suspended while collecting a paycheck but McCormack appears to continue to direct the Cheyenne VA. No real change there.

Although a handful of administrators have been fired by the VA, the data falsification was rampant, with most VAs apparently falsifying their records (2). Yet these administrators retain their jobs and continue to rule their healthcare empires. McDonald claimed that names had been turned over to the Department of Justice (DOJ), but the DOJ declined to prosecute, and that administrative law judges were blocking the firing of administrators (2). No real change there.

The VA still functions with a lack of oversight. Congressmen make statements and issue press releases when politically convenient. The VA office of inspector general (VAOIG) still does investigations in response to whistle-blowers. After turning over their findings to VA central office to water down, the VAOIG usually makes some recommendations that are quickly accepted but not acted on by the VA (7). No real change there.

Lastly, there is the popular media. For years we heard about Ken Kizer's "Prescription for Change" and the miracle of the transformation to the VA (3,8). This infuriated many of us who knew it was not true (9). We wondered why the press was so accepting of the claims. They certainly are not on other political issues. However, in this case Dennis Wagner of the Arizona Republic, CNN and several other news sources stayed with the story and ferreted out the truth. Real change there. Hopefully, news media with continue their investigative reporting and question VA officials when they put forth self-serving data that is difficult to believe. This is my hope and may be the only result of the VA scandal that will force change. Hopefully the media "won't get fooled again".

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

  1. Wagner D. Much change in wake of VA scandal; more needed. Arizona Republic. November 8, 2014. Available at: http://www.azcentral.com/story/news/arizona/investigations/2014/11/08/phoenix-va-scandal-changes/18716281/.
  2. 60 Minutes. Robert McDonald: cleaning up the VA. Aired November 9, 2014. Available at: http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals/.
  3. Kizer KW. Prescription for change. March 22, 1995. Available at: http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf
  4. Cohen T, Frates C. Shinseki 'mad as hell' about VA allegations, but won't resign. CNN. May 23, 2014. Available at: http://www.cnn.com/2014/05/15/politics/va-scandal-eric-shinseki-preview/.
  5. Wagner D. VA names new director for Phoenix medical center. Arizona Republic. November 4, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/11/04/phoenix-veterans-affairs-medical-center-interim-director-brk/18467665/.
  6. Cheyenne VA Medical Center. Leadership team: Cynthia McCormack. Available at: http://www.cheyenne.va.gov/about/leadership.asp.
  7. Robbins RA. A failure of oversight at the VA. Southwest J Pulm Crit Care. 2014;9(3):179-82. [CrossRef]
  8. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348(22):2218-27. [CrossRef] [Pubmed]
  9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353(17):1860-1. [CrossRef] [PubMed] 

Reference as: Robbins RA. A veterans day editorial: change at the VA? Southwest J Pulm Crit Care. 2014;9(5):281-3. doi: http://dx.doi.org/10.13175/swjpcc150-14 PDF

Thursday
Sep112014

A Failure of Oversight at the VA

On September 8, 2014 the Washington Examiner reported that the Central Office of the VA was allowed to change language in the VA Office of Inspector General (VAOIG) report on delays in patient care at the Phoenix VA Medical Center (1). Crucial language that the VAOIG could not “conclusively” prove that delays in care caused patient deaths at a Phoenix hospital was added to its final report after a draft version was sent to agency administrators for comment. Rep. Jeff Miller, chairman of the House veterans' committee, said "there are significant differences between the final IG report and the draft version ...". The following day Richard Griffin, the acting VAOIG, vigorously defended the independence of his office and bristled at the allegations that the VA was allowed to alter his office's report. However, his denials and indignance seem disingenuous.

To understand why, we need to go back a few years. First, the Phoenix VA overspent its Fee Basis consult budget in 2010. This is the money budgeted to send patients outside the VA for care. To do this a request was filled out and reviewed. Although the Chief of Staff often reviews these requests, this responsibility was delegated to the associate chief of staff for ambulatory care, Keith Piatt. He nearly always approved these requests. Dr. Piatt had other duties including patient care and limited expertise in several of the areas he was requested to evaluate. Furthermore, poor accounting made if unclear if there was sufficient money to pay for these consults. However, rather than questioning why so many patients were outsourced, the VAOIG blamed the problem on the inadequacy of Dr. Piatt's reviews (2). Given this recent IG investigation, it is not surprising that the Phoenix VA administrators were reluctant to outsource patients.

Second, Sam Foote, the initial whistleblower at the Phoenix VA contacted VAOIG in October, 2013. However, according to Foote the VAOIG did not seem to take his allegations seriously, and did what appears to be a superficial investigation (1). So Foote went to the House Committee on Veterans Affairs this past February. Only after the scandal was made public did the VAOIG acknowledge the inadequate care at the Phoenix VA.

Third, the VA prematurely made press releases prior to the release of the VAOIG's final report attempting to exonerate their responsibility (1,3). The final VAOIG report, apparently altered by the VA, was "unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans.” Although this would hardly seem to be an exoneration, media outlets widely reported that whistle-blower allegations were exaggerated and that veterans were not severely affected by wrongdoing at the Phoenix VA medical center. However, in several instances it would seem likely that delayed care contributed to premature patient deaths and would was questioned in a Senate hearing on September 10, 2014 (3).

Fourth, VAOIG investigators corroborated virtually every major allegation of wrongdoing submitted by the first whistle-blower, Dr. Sam Foote (3). Nevertheless, the report and congressional briefing papers contain passages that appear to criticize Foote and his credibility, emphasizing that "the whistle-blower did not provide us with a list of 40 patient names" referring to VA patients Foote said died while awaiting care in Phoenix. This passage was apparently added by VA Central Office. Foote said the portion of the report about him is "false and misleading" because he and other whistle-blowers provided 24 names to inspectors and explained where to identify16 more. The VA report acknowledged that Foote had supplied at least 17 names and that others could not be traced because documentation had been destroyed by VA employees. Rather than defending their indefensible actions, VA Central Office has apparently resorted to denial, indignance, and blaming the whistleblower.

Fifth, the VA continues to obfuscate and obstruct investigations. According to the VAOIG, managers at 13 VA facilities lied to investigators about scheduling problems and other issues and officials at 42 of the 93 sites engaged in manipulation of scheduling, including 19 sites where appointments were cancelled and then rescheduled for the same day to meet on-time performance goals (4). However, it remains unclear whether officials at the Phoenix and Cheyenne VAs have been fired or even suspended. Citing privacy issues, the VA has refused to comment. However, in 2011, Jack Bagdade, a Phoenix VA physician, was fired for violation of the Hatch Act (5). His firing was widely publicized locally. Bagdade was lobbying Senator John McCain for a new research building at the Phoenix VA. Bagdade forwarded an e-mail from McCain's office entitled "Drink Beer for John McCain". If Bagdade's termination for forwarding an e-mail was appropriate punishment (and I am certainly not saying that it was), then what is appropriate punishment for VA administrators who knowingly manipulated patient appointments for their own personal gain, altered records and then lied to investigators?

Several of the VA administrators involved are also licensed physicians and nurses. However, both the Arizona Board of Medical Examiners and Arizona Board of Nursing have been strangely silent. Altering medical records and then lying about it would seem to be a clear violation of the Arizona statues.

Congress also has to accept some responsibility for their lack of oversight. The problem of inadequate numbers of physicians has been known for years (6). Recently appointed VA Secretary, Robert McDonald, pointed out that the Phoenix VA has now hired 53 additional full-time employees in recent months to help alleviate the appointment backlog (4). He did not mention how many of these employees are physicians nor did he mention how many of the patients were outsourced. However, it seems likely that the hires were merely new administrative personnel to outsource the care of patients. One senior VA official who asked not to be identified said that morale at the VA is poor and doubted that the VA will be able to fill the multiple physician vacancies commenting "Who would want to work here?".

Congress passing a bill to make it easier to fire senior VA administrators suggests they realize there is a problem. However, the legislation still leaves the control of the money up to the very people who misspent it bringing about the present crises. It is also unclear who will do the firing. To date no administrators have been fired despite the law supposedly making this easier. It seems unlikely that any VA administrators are going to fire their colleagues for doing what they are probably also doing or know about. "One of the chief lessons of the VA scandal is that we cannot rely on VA, alone, to effectively identify and correct problems plaguing the department," said Rep. Jeff Miller, chairman of the house veterans' committee. "Oversight and feedback from outside stakeholders is crucial to ensuring VA delivers the benefits and services our veterans have earned." (7). I agree. However, it is doubtful based on their lack of action that either the VAOIG or VA Central Office will take any substantive action to hold those accountable for this scandal and its cover-up.  A reasonable solution is to establish a system for local oversight by physicians, nurses and patients (8). Rep. Miller is right, we cannot rely on the VA to fix this problem and oversight is crucial.

Richard A. Robbins, MD*

Editor

References

  1. Taupin M. IG let veterans affairs officials alter report to absolve agency in phoenix deaths. Washington Examiner. September 8, 2014. Available at: http://washingtonexaminer.com/ig-let-veterans-affairs-officials-alter-report-to-absolve-agency-in-deaths/article/2553035 (accessed 9/10/14).
  2. VA Office of Inspector General. Review of Alleged Mismanagement of Non-VA Fee Care Funds at the Phoenix VA Health Care System. November 8, 2011. Available at: http://www.va.gov/oig/pubs/VAOIG-11-02280-23.pdf (accessed 9/10/14).
  3. Wagner D. Critics: VA influenced Inspector General to change Phoenix report for spin-control. Arizona Republic. September 10, 2014. Available at: http://www.azcentral.com/story/news/politics/investigations/2014/09/10/report-phoenix-va-deaths-raises-questions/15375005/ (accessed 9/10/14).
  4. Daly M. Watchdog: VA managers lied to investigators about delays. Associated Press. September 9, 2014. Available at: http://www.azcentral.com/story/news/nation/politics/2014/09/09/watchdog-va-managers-lied-delays/15334159/ (accessed 9/10/14).
  5. Kujz S. Valley doctor loses job over invitation to have beer with Arizona senator. ABC News. March 25, 2011. Available at: http://www.abc15.com/news/region-phoenix-metro/central-phoenix/valley-doctor-loses-job-over-invitation-to-have-beer-with-arizona-senator (accessed 9/10/14).
  6. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54. Available at: http://www.swjpcc.com/editorial/2012/5/5/va-administrators-gaming-the-system.html (accessed 9/10/14).
  7. Jordan B. Congressman takes va oversight on the road. Military.com news. August 12, 2014. Available at: http://www.military.com/daily-news/2014/08/12/congressman-takes-va-oversight-on-the-road.html (accessed 9/10/14).
  8. Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. [CrossRef] 

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

Reference as: Robbins RA. A failure of oversight at the VA. Southwest J Pulm Crit Care. 2014;9(3):179-82. doi: http://dx.doi.org/10.13175/swjpcc119-14 PDF

Tuesday
Aug122014

IOM Releases Report on Graduate Medical Education

On July 29 the Institute of Medicine (IOM) released a report on graduate medical education (GME) (1). This is the residency training that doctors complete after finishing medical school. This training is funded by about $15 billion annually from the Federal government with most of the monies coming from the Center for Medicare and Medicaid Services (CMS). The report calls for an end to providing the money directly to the teaching hospitals and to dramatically alter the way the funds are paid. Instead payments would be made to community clinics phased in over about 10 years. To administer the program, the report recommends the formation of two committees: 1. A GME Policy Council in the Office of the Secretary of the U.S. Department of Health; and 2. A GME Center within the Centers for Medicare & Medicaid Services to manage the operational aspects of GME CMS funding. The later committee would administer two funds: 1. A GME Operational Fund to distribute ongoing support for residency training positions that are currently approved and funded; and 2. A GME Transformation Fund to finance initiatives to develop and evaluate innovative GME programs, to determine and validate appropriate GME performance measures, to pilot alternative GME payment methods, and to award new Medicare-funded GME training positions in priority disciplines and geographic areas.

If adopted, the plan would end decades of attempts by CMS to coerce medical school graduates into primary care, especially in rural, underserved areas. By controlling funding for GME training, CMS would be able to dictate how physician training. Negative reaction was expected and swift from the American Hospital Association, the American Medical Association and the American Council on Graduate Medical Education, whose members would lose CMS money (2-4). Also expected, the proposal was supported by the American Academy of Family Physicians whose members who would gain under the proposal (5).

The IOM committee has a point. Despite a growing public investment in GME, there are persistent problems with uneven geographic distribution of physicians, too many specialists, not enough primary care providers, and a lack of cultural diversity in the physician workforce. Furthermore, according to the report "a variety of surveys indicate that recently trained physicians in some specialties cannot perform simple procedures often required in office-based practice.”

However, can a committee formed by CMS be expected to improve the health of America? Based on the composition of the committee and their past performance we think not. First, the committee was co-chaired by Don Berwick who was head of the Institute for Healthcare Improvement (IHI), CMS Administrator and presently a candidate for Massachusetts governor (6). During Berwick's tenure, the IHI proposed a number of non- or weakly evidence-based metrics. Many of these have been found to make no impact on patient-centered outcomes such as mortality, length of stay, readmission rates, morbidity, etc. (7). An example was the 18 month 100,000 Lives Campaign which according to Berwick prevented 122,300 avoidable deaths. However, the methodology, incomplete data and sloppy estimation of the number of deaths makes Berwick's claim dubious. Furthermore, when the campaign was expanded to the 5,000,000 Lives Campaign the "results" could not be reproduced. Also during Berwick's tenure, IHI prematurely championed tight control of blood sugar in the ICU, an intervention which resulted in a 14% increase in ICU mortality when properly studied (8). Undaunted, Berwick put many of these same meaningless metrics in place when he became administrator of CMS. One of these metrics, readmission rates, has been associated with a higher mortality (9). Now Berwick is running for Massachusetts governor. One wonders how politics might have affected the report.

Other members of the committee include the committee co-chair, Gail Wilensky, who was administrator of HCFA (the precursor of CMS), nurses, physician assistants, economists, a representative from industry and a number of academics. Missing were members of the large community of practicing physicians. It seems the IOM committee was assembled to produce a political rather than an evidence-based answer of how to solve patient care disparities. To paraphrase a well-known quote, the first casualty of politics is usually the truth. It seems likely that the proposed GME Center within CMS would have a similar composition to Berwick's present IOM committee and would likely offer political rhetoric rather than meaningful reform to GME. Similarly to those championed by Berwick at IHI and later CMS, we suspect that a series of meaningless metrics would be required that would do nothing other than add a paper burden to a medical system already drowning in paperwork. By removing local control, CMS will likely ignore local strengths. For example, the University of Colorado has an extremely strong pulmonary and critical care division. Although America needs this physician expertise, especially critical care, it seems likely that CMS might move these residency slots to family practice or general medicine. We believe that local control with appropriate incentives, is more likely to solve these problems than a centralized bureaucracy in Washington.

Lastly, a word about the report's claim graduates lack the skills to perform basic procedures. Our observations are similar and we are inclined to accept the claim. However, we point out that it was decisions of committees such as those proposed that required attending physicians to perform procedures in order to be reimbursed and that residents have fewer opportunities to perform procedures due to work hour restrictions. The committee's implication that somehow physician trainers are to blame seems quite disingenuous. Not identified in the report but crucial to physician development is developing skills to critically evaluate medical literature, rather than blindly follow the guidelines proposed by CMS, IHI or others of a similar ilk. 

The proposals in the IOM report are a bad idea from a committee whose head has been rife with bad ideas. The committee's report is not the "New Flexner Report" but will be the coffin nail in the death of quality, caring physicians if adopted.

Richard A. Robbins, MD

Clement U. Singarajah, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ

References

 

  1. Institute of Medicine. Graduate medical education that meets the nation's health needs. July 29, 2014. Available at: http://www.iom.edu/Reports/2014/Graduate-Medical-Education-That-Meets-the-Nations-Health-Needs.aspx (accessed 8/5/14).
  2. American Hospital Association. IOM panel recommends new financing system for physician training. July 29, 2014. Available at: http://www.ahanews.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_072914_IOM&domain=AHANEWS (accessed 8/5/14).
  3. Hoven AD. AMA urges continued support for adequate graduate medical education funding to meet future physician workforce needs. July 29, 2014. Available at: http://www.ama-assn.org/ama/pub/news/news/2014/2014-07-29-support-graduate-medical-education-funding.page (accessed 8/5/14).
  4. Kirch DG. IOM’s vision of GME will not meet real-world patient needs. July 29, 2014. Available at: https://www.aamc.org/newsroom/newsreleases/381882/07292014.html (accessed 8/5/14).
  5. Blackwelder R. Recommended GME overhaul will support a physician workforce to meet nation’s evolving health needs. July 29, 2014. Available at: http://www.aafp.org/media-center/releases-statements/all/2014/gme-physician-workforce.html (accessed 8/5/14).
  6. About Don. Available at: http://www.berwickforgovernor.com/about-don (accessed 8/5/14).
  7. Robbins RA. The unfulfilled promise of the quality movement. Southwest J Pulm Crit Care. 2014;8(1):50-63. [CrossRef]
  8. NICE-SUGAR Study Investigators. Intensive versus conventional insulin therapy in critically ill patients. N Engl J Med 2009;360:1283-97. [CrossRef] [PubMed]

Reference as: Robbins RA, Singarajah CU. IOM releases report on graduate medical education. Southwest J Pulm Crit Care. 2014;9(2):123-5. doi: http://dx.doi.org/10.13175/swjpcc107-14 PDF

 

Friday
Jul252014

Mild Obstructive Sleep Apnea: Beyond the AHI

Joyce Lee-Iannotti MD

James M Parish MD

Division of Pulmonary Medicine (Dr Parish) Center for Sleep Medicine Department of Neurology (Dr Lee-Iannotti), Center for Sleep Medicine

Mayo Clinic Arizona

Scottsdale, Arizona

A common conundrum faced by sleep medicine practitioners is how to manage the large group of patients with mild sleep apnea. Many patients are referred for sleep evaluation, with symptoms thought to be due to obstructive sleep apnea (OSA). Often polysomnography demonstrates only mild sleep apnea, and the clinician and patient are faced with the dilemma of whether to use continuous positive airway pressure (CPAP) therapy or an oral appliance. In making this important decision the clinician incorporates the commonly used definition of mild sleep apnea as an apnea-hypopnea index of between 5 and 14 apneas or hypopneas per hour of sleep.  Moderate sleep apnea is defined as 15-29 events per hour, and severe is 30 and above events per hour. These arbitrary thresholds originated in the early 1980s when knowledge of this condition was in its infancy and little was known about the long term health effects. The definition was based on the finding of apneas, defined by the complete cessation of airflow for at least 10 seconds. The concept of hypopnea and respiratory-effort related arousal (RERA) came later and with frequently changing definitions that have been the subject of significant controversy throughout the last 30 years.  Many sleep centers include these RERA’s in the definition of respiratory disturbance index, which is incorrectly used interchangeably with AHI. While the sleep literature has demonstrated the untoward effects of moderate to severe sleep apnea, there has been considerable debate about the clinical significance of mild sleep apnea, that is, an AHI between 5 and 15.

The current paper by Quan, et al (1) is a significant contribution to the literature in sleep medicine addressing this important clinical question. This paper reports data drawn from the APPLES study, a large multi-center, well-conducted study designed to determine if CPAP therapy improves sleepiness, mood disorder, or cognitive function in patients with OSA, that has subsequently produced several important publications (2-6). As part of the study, extensive data was obtained on each of these neurocognitive parameters including the Epworth Sleepiness Scale, Stanford Sleepiness Scale, Hamilton Rating Scale for Depression, Profile of Mood States, and Sleep Apnea Quality of Life Index, all validated questionnaires used frequently in the sleep literature. In this part of the study, 199 patients with an AHI>5 but <15 were compared to 40 patients enrolled in the study, but with and AHI<5. The mean AHI was 10 per hour in the mild OSA group, and was 3 per hour in the non-OSA group.  Size of the study was statistically large enough to determine significant differences. Remarkably, there was no significant difference in any rating of sleepiness, mood, or quality of life between the two groups. This study produces an important challenge to the traditional thresholds of disease severity, and raises the question of whether mild sleep apnea based on AHI alone is a disease, and whether it truly requires treatment. Since many patients seen at sleep medicine clinics fall into this category, this is an extremely important question to address.

Several previous studies have attempted to elucidate the issue of mild sleep apnea. Barnes, et al (7) in a randomized controlled trial of CPAP in mild OSA (defined in their study as an AHI 5-30 events per hour) reported that CPAP improved self-reported symptoms of snoring, restless sleep, daytime sleepiness, and irritability, but did not improve objective measure of sleepiness (multiple sleep latency test) or any test of neurobehavioral function, quality of life, mood scores, or 24-hour blood pressure. Weaver, et al (8) reported results from the CATNAP study, a randomized, sham-CPAP controlled study of self reported sleepy patients with mild OSA (defined as AHI 5-30 events per hour) that CPAP significantly improved scores on the Functional Outcomes of Sleep Questionnaire. Both of these trials differ from the current study by defining mild OSA as an AHI up to 30 per hour, whereas the major controversy involves those patients in the AHI 5-15 range. The CATNAP study also selected patients who complained of excessive sleepiness.

The findings from this study emphasize the need to differentiate “obstructive sleep apnea” from “obstructive sleep apnea syndrome.”  Obstructive sleep apnea has been traditionally defined solely by the AHI, whereas OSA syndrome incorporates the subjective and clinical components to the diagnosis (sleepiness, mood disturbance, fatigue, etc.) An abnormal AHI in the mild range without symptoms may not warrant  treatment with CPAP, whereas an excessively sleepy patient with an AHI of 7 would require at least a trial of CPAP with close monitoring. Fatigue, although traditionally associated with mood disorders, is a common symptom in sleep medicine and may be a manifestation of untreated sleep apnea. Future studies could incorporate a fatigue scale (e.g. Fatigue Severity Score) as an adjunct to the Epworth sleepiness score to assess the importance of fatigue as a symptom of OSA.

The current study has an important limitation in that subjects were enrolled based on a referral to a sleep center for some clinical indication related to OSA, and therefore do not represent the general population. It would be possible that individuals drawn randomly from the general population would have lower scores on these tests than a group of subjects referred to a sleep center, which would result in the mild OSA group having significantly different scores on these tests than the general population. In addition the no-OSA group in this study included only 40 patients, and it is possible that a larger group of true no-OSA patients without symptoms causing referral to a sleep center would yield a slightly different result. However, if the untoward effects of mild OSA are indeed significant, it should be relatively easy to find significant abnormalities in mood, sleepiness, and quality of life, and the inability to demonstrate differences in this study group leads one to conclude that the differences, if they exist, are likely to very small.

Besides the mood and quality of life effects of sleep apnea, cardiovascular disease is known to be a significant consequence of obstructive sleep apnea (9).  Stroke, heart failure, myocardial infarction, and atrial fibrillation are known to occur more commonly in untreated OSA than in normal individuals (10). There have been several studies on the cardiovascular effects of mild sleep apnea. The Sleep Heart Health study found a small but significant increase in cardiovascular disease in mild sleep apnea (11).  In another study, Buchner et al (12) found CPAP reduced the risk of subsequent cardiovascular events in patients with mild to moderate (AHI 5-30 per hour) OSA. Therefore, the clinician must look at not only at the AHI, but the larger picture inclusive of presenting symptoms and cardiovascular and cerebrovascular risk factors when deciding on treatment.

Ultimately, this paper challenges the sleep community to look beyond the AHI and improve management algorithms for patients with mild obstructive sleep apnea, with or without symptoms. We propose that an obstructive sleep apnea score be developed, similar to the CHADS-2 score used to determine the need for anticoagulation in patients with non-valvular atrial fibrillation as a means of secondary stroke prevention (13). The “OSA score” could incorporate the AHI, the Epworth sleepiness scale, a quality of life score, a fatigue severity scale, and known cardiovascular and cerebrovascular co-morbidities. A point system could be generated to determine the need for CPAP or alternative therapies.

Hence, this study is likely to be a sentinel study in the sleep medicine literature. Further research in how to “score” patients who need treatment is needed in order to provide best value in management of sleep apnea.

References

  1. Quan SF, Budhiraja R, Batool-Anwar S, Gottlieb DJ, Eichling P, Patel S, Wei Shen, Walsh JK, Kushida CA. Lack of impact of mild obstructive sleep apnea on sleepiness, mood and quality of life. Southwest J Pulm Crit Care. 2014;9(1):44-56. [CrossRef]
  2. Kushida CA, Nichols DA, Quan SF, et al. The Apnea Positive Pressure Long-term Efficacy Study (APPLES): rationale, design, methods, and procedures. J Clin Sleep Med 2006;2(3):288-300. [PubMed] 
  3. Quan SF, Chan CS, Dement WC, et al. The association between obstructive sleep apnea and neurocognitive performance--the Apnea Positive Pressure Long-term Efficacy Study (APPLES). Sleep 2011;34(3):303-14B. [PubMed]
  4. Kushida CA, Nichols DA, Holmes TH, et al. Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: The Apnea Positive Pressure Long-term Efficacy Study (APPLES). Sleep 2012;35(12):1593-602. [PubMed]
  5. Quan SF, Budhiraja R, Clarke DP, et al. Impact of treatment with continuous positive airway pressure (CPAP) on weight in obstructive sleep apnea. J Clin Sleep Med. 2013;9(10):989-93. [PubMed]
  6. Batool-Anwar S, Goodwin JL, Drescher AA, et al. Impact of CPAP on activity patterns and diet in patients with obstructive sleep apnea (OSA). J Clin Sleep Med. 2014;10(5):465-72. [PubMed] 
  7. Barnes M, Houston D, Worsnop CJ, et al. A randomized controlled trial of continuous positive airway pressure in mild obstructive sleep apnea. Am J Resp Crit Care Med. 2002;165(6):773-80. [CrossRef] [PubMed] 
  8. Weaver TE, Mancini C, Maislin G, et al. Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial. Am J Respir Crit Care Med 2012;186(7):677-83. [CrossRef] [PubMed]
  9. Newman AB, Nieto FJ, Guidry U, et al. Relation of sleep-disordered breathing to cardiovascular disease risk factors: the Sleep Heart Health Study. Am J Epidemiol. 2001;154(1):50-9. [CrossRef] [PubMed] 
  10. Somers VK, White DP, Amin R, et al. Sleep Apnea and Cardiovascular Disease: An American Heart Association/American College of Cardiology Foundation Scientific Statement From the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing In Collaboration With the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). J Am Coll Cardiol. 2008;52(8):686-717. [CrossRef] [PubMed] 
  11. Shahar E, Whitney C, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001;163:19-25. [CrossRef] [PubMed] 
  12. Buchner NJ, Sanner BM, Borgel J, Rump LC. Continuous Positive Airway Pressure Treatment of Mild to Moderate Obstructive Sleep Apnea Reduces Cardiovascular Risk. Am J Resp Crit Care Med. 2007;176(12):1274-80. [CrossRef] [PubMed] 
  13. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864-70. [CrossRef] [PubMed] 

Reference as: Lee-Iannotti J, Parish JM. Mild obstructive sleep apnea: beyond the AHI. Southwest J Pulm Crit Care. 2014;9(1):40-3. doi: http://dx.doi.org/10.13175/swjpcc099-14 PDF

Tuesday
Jul152014

Multidisciplinary Discussion (MDD) in Interstitial Lung Disease; Some Reflections

Thomas V. Colby MD*

Michael B. Gotway MD

Lewis J. Wesselius MD

 

Departments of Pathology*, Radiology, and Pulmonary Medicine

Mayo Clinic Arizona

13400 E. Shea Blvd.

Scottsdale, AZ 85259

 

Multidisciplinary discussion (MDD) has been used in many disciplines in medicine, notably in thoracic oncology for some two decades (1).  MDD at a multidisciplinary conference (MDC) formalizes activities that have also gone under the label of case conferences, tumor boards, etc. and this practice is time- honored in medical practice.  In the setting of interstitial lung disease (ILD), especially the idiopathic interstitial pneumonias (IIPs) and IPF MDD conducted by a “multidisciplinary team” (MDT) and is now the “gold standard” for diagnosis in this clinical setting (2) and is recommended in the 2011 guidelines for IPF and the 2013 guidelines for IIPs (3, 4). 

Clinical-pathologic correlation, clinical-radiologic-pathologic correlation and clinical-radiologic correlation have been integral to the study of interstitial lung disease since early work of  Heitzman (5), Carrington and Gaensler (6) and many others. This represents the conceptual framework on which the Fleischner Society:  “…an international, multidisciplinary medical society for thoracic radiology, dedicated to the diagnosis and treatment of diseases of the chest” founded in 1969 (7).

The emphasis of MDD in the setting of ILD derives primarily from the study of Flaherty et al (8).  Flaherty et al studied the kappa statistic for intra-observer agreement among expert clinicians evaluating ILD and showed that the kappa significantly improved as more clinical, radiologic and pathologic information was added, suggesting that clinicians had become more confident of their diagnoses with this process. 

In theory, MDD results in a consensus diagnosis based on all the appropriate evidence discussed in a single setting allowing a dynamic intercourse and engagement among the physicians involved.  It allows the physicians to “look each other in the eye” and assess the confidence in the interpretations presented.  It also enables all participating physicians to reassess and change their opinions on the basis of new information and ongoing discussion.  Many of the positive aspects of MDD include the following:

  • Dynamic interaction with exchange of ideas
  • Engagement of the physicians involved; improved self-esteem
  • Physicians can gauge the confidence of others’ opinions/diagnoses (e.g., the radiologic or pathologic diagnosis)
  • Physicians can reassess and reinterpret their findings and change their diagnoses
  • Educational value for involved physicians (for example, surgeons can appreciate the radiologic findings in terms of where to biopsy; pathologists can appreciate the pathologic findings relative to HRCT)
  • Educational value for training fellows and junior staff
  • Encourages evidence-based approach
  • Increased homogeneity and consistency in managing ILD
  • Development of a group ethos with associated improved morale
  • Continuous feedback regarding diagnoses
  • Forum for developing research ideas
  • Forum for discussion and recruitment to clinical trials
  • Pooled group clinical experience with broad perspective on ILD (for example, radiologic findings inform the pathologic findings and vice versa)
  • An MDD diagnosis might be considered a more defensible diagnosis than individuals’ diagnoses
  • The belief that collective thought is better than individuals’ diagnoses

As in any human interaction, theory does not always translate into practice and there are number of issues that  arise with MDD.  Negative and potentially negative aspects of MDD can summarized as follows:

  • Physician and allied health staff time
  • Physician and allied health staff cost
  • Difficulty in coordinating schedules to attend an MDD
  • Too many (unselected) cases for discussion
  • Lack of a defined protocol and administrative structure for the MDD
  • How individual findings should be weighted in terms of final diagnosis
  • The effect on the group of individuals’ personalities and stature
  • Discourages independence of thought and problem-solving strategies especially for trainees
  • Lack of a clear trail as to exactly how a final diagnosis was reached (individual opinions may be lost)
  • The “groupthink” phenomenon (to maintain harmony and conformity a group decision may in fact be dysfunctional)
  • Over-confidence by the clinician in a diagnosis reached by MDD
  • Lack of data on inter- and intra-observer correlation for MDT diagnoses
  • When no consensus diagnosis is reached, who is the final arbitrator?
  • The phenomenon of “diagnosis drift” (see below)
  • The difficulty in validating MDD/MDT diagnoses
  • MDD is a luxury of an academic practice and not practical in routine clinical practice
  • Medico-legal liability of group members for a group decision

The MDD process for ILD has not been uniformly defined.  Should this be a free-for-all?  Should there be a defined protocol?  The algorithm for the diagnosis of IPF in the 2011 guidelines is a good guide (3).  To some extent, the observations/opinions presented in an MDD are subjective and thus an MDD diagnosis is simply a collection of subjective judgments.  MDD is influenced by individual personalities and there is no question that an “eminence factor” may be at play; a very eminent radiologist may intimidate a relatively inexperienced clinician and the result might be skewed toward the radiologic interpretation.  Cultural factors may also be at play since in some societies age and experience are venerated.  There are no guidelines if a consensus is not reached, and it would be folly to assume that consensus would be reached after every MDD session. When there is no consensus, who is the final arbiter?  We believe the clinician caring for the patient should be the final arbiter. 

Participation in an MDD may leads to something that can be called “diagnosis drift.”  An example of this follows.  The differential diagnosis for IPF includes chronic hypersensitivity pneumonitis, which may show certain radiologic features that suggest that diagnosis.  When such cases are discussed in an MDD, pathologists then become sensitive to similar findings histologically and over time, tend to raise the differential of chronic hypersensitivity pneumonitis more often in the absence any validated confirmation of this practice.

How can MDD be improved?  Given the time, expense, and logistical issues, we think it is unrealistic to expect a MDD for all ILD or IPF cases and that cases for MDD should selected, particularly those where there appears to be discrepancy between the clinical, radiologic and/or pathologic findings. The availability of an electronic medical record (EMR) allows ready access to medical information that may obviate need for MDD in individual cases, although the give and take of discussion is lost.

An attempt should be made to better define the process and the roles of the participants.  We suspect that in most MDDs there is a de facto definition of the process and the roles, but some attempt could be made to formalize this.  Some additional suggestions include:

  • Be cognizant of the pros and cons discussed above
  • Better defined process with roles and leader clarified
  • Preselection of cases to improve efficiency; not all ILD cases need to be discussed
  • Include only individuals necessary for a given case (efficient use of staff and their time)
  • Consider MDD “overreading” by an experienced group since many community practices will not find MDD to be feasible
  • Use of teleconferencing
  • Record of the MMD process/decisions
  • Continuous reassessment and improvement of the MDD process

And as a final thoughts…..remember that an experienced clinician effectively goes through the process of MDD in the clinical evaluation of an individual patient, appropriately consulting radiologists, pathologists, and other colleagues as needed to reach a management decision……but how is that experience gained…?...The educational value of MDD should not be forgotten.

References

  1. Powell HA, Baldwin DR. Multidisciplinary team management in thoracic oncology: more than just a concept? Eur Respir J 2014;43(6):1776-1786. [CrossRef] [PubMed]
  2. Wells AU. Histopathologic diagnosis in diffuse lung disease: an ailing gold standard. Am J Respir Crit Care Med 2004;170(8):828-829. [CrossRef] [PubMed] 
  3. Raghu G, Collard HR, Egan JJ, Martinez FJ, Behr J, Brown KK et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med 2011;183(6):788-824. [CrossRef] [PubMed]
  4. Travis WD, Costabel U, Hansell DM, King TE, Jr., Lynch DA, Nicholson AG et al. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med 2013;188(6):733-748. [CrossRef] [PubMed] 
  5. Heitzman ER. The lung: Radiologic-pathologic correlations. Mosby, 1973.
  6. Carrington CB, Gaensler EA. Clinical-pathologic approach to diffuse infiltrative lung disease. Monogr Pathol 1978;19:58-87. [PubMed] 
  7. Fleischner Society Website. [cited 2014 Jul 1]; Available from: http://fleischner.org/
  8. Flaherty KR, King TE, Jr., Raghu G, Lynch JP, 3rd, Colby TV, Travis WD et al. Idiopathic interstitial pneumonia: what is the effect of a multidisciplinary approach to diagnosis? Am J Respir Crit Care Med 2004;170(8):904-910. [CrossRef] [PubMed]

Acknowledgements

The authors thank the Fleischner Society members attending the 2014 Leuven meeting and the following physicians for thoughtful discussion and input:  Jeffrey Galvin, David Hansell, David Lynch, Mathias Prokop, Jay Ryu, and Johny Verschakelen.

Reference as: Colby TV, Gotway MB, Wesselius LJ. Multidisciplinary discussion (MDD) in interstitial lung disease; some reflections. Southwest J Pulm Crit Care. 2014;9(1):32-5. doi: http://dx.doi.org/10.13175/swjpcc097-14 PDF