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Editorials

Last 50 Editorials

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

Disclosures for All
Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to
   Require Sleep Apnea Testing in Commercial Transportation Operators
The Unspoken Challenges to the Profession of Medicine
EMR Fines Test Trump Administration’s Opposition to Bureaucracy
Breaking the Guidelines for Better Care
Worst Places to Practice Medicine
Pain Scales and the Opioid Crisis
In Defense of Eminence-Based Medicine
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

 

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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Saturday
Aug192017

Disclosures for All

The August 15 edition of the Annals of Internal Medicine published an article “Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination - Randomized Controlled Trial" (1). The study examined open book vs. closed book testing for the American Board of Internal Medicine (ABIM) examination and found no or minimal changes in the outcomes between the two testing conditions.

All in all, this is not very exciting. However, what is interesting is a blog on the article written by Westby G. Fisher, MD in his Dr. Wes blog (2). He examined the disclosures from the Annals editors of the article who claimed no financial relationships or interests to disclose. However, Fisher points out that on its last available Form 990, the publishers of the Annals of Internal Medicine, the American College of Physicians (ACP), earned over $24.6 million in a single year selling their Medical Knowledge Self-Assessment Program to US physicians to study for their board certification and recertification examinations (3). Furthermore, Fisher notes that an accompanying editorial written by ACP's former senior executive vice president, Steven E. Weinberger, MD, a pulmonologist and an employee of the ACP, also did not disclose any meaningful conflicts. However, with compensation of nearly $800,000 in 2014, Weinberger’s compensation was over 3 times the average compensation of pulmonolgists in the Middle Atlantic states of $226,000 (3,4). It seems unlikely that unless their financial status was healthy that the ACP could have afforded a luxury such as Dr. Weinberger.

Fisher notes that the study was conceived exclusively by the American Board of Internal Medicine and executed by their corporate partners at PearsonVue and Wolters Kluwer. However, PearsonVue had more than a minor role in the research and had access to the study registrants' names, addresses, and probably more (2). Each of the 825 physicians enrolled in the study received $250 from the ABIM Foundation. None of the participants were told about the financial benefits to the ABIM, PearsonVue, Wolters Kluwer, or their content creators for participation in this study.

The financial future of many of the 24 approved medical specialty boards of the American Board of Medical Specialties (ABMS) and the 18 approved medical specialty boards of the American Osteopathic Association (AOA) was in doubt until maintenance of certification (MOC) was conceived back in the 1980’s (2). Since then there have been multiple attempts to show MOC leads to better patient outcomes, but to my knowledge, no meaningful improvements have been shown (5-7). Furthermore, advertising for MOC programs with slogans such as “Is your doctor board-certified?” likely led to an erosion of faith in the medical profession. These MOC programs can largely be lumped with other money-making schemes such as continuing medical education and hospital recertification which are funded on the backs of physicians, are time-consuming and have not been shown to improve care.

According to Fisher (2), “conflicted research” as published in the Annals of Internal Medicine misleads the public and represents little more than a free advertising for the financial agendas of MOC organizations who benefit from the research. Furthermore, “…it sets and incredibly low (and untrustworthy) bar for all of academic publishing.”

Although this is strong language, Fisher is right. Disclosures need to be full and honest from all. Here are ours. The cost of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) is funded by the non-profit Phoenix Pulmonary and Critical Care Research and Education Foundation. None of the foundation board of directors, the editors, associate editors, staff, reviewers or authors receive any compensation. Our operating expenses are less than $5000/year and our income is dependent on donations to our foundation. We hope this reassures our readers that we have no hidden agenda and that what they read in the SWJPCC is honestly reviewed.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Lipner RS, Brossman BG, Samonte KM, Durning SJ. Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination: A Randomized Controlled Trial. Ann Intern Med. 2017 Aug 15 [Epub ahead of print]. [CrossRef] [PubMed]
  2. Fisher WG. Fake news: Annals of Internal Medicine's disclosures. Dr. Wes. August 16, 2017. Available at: http://drwes.blogspot.com/2017/08/fake-news-annals-of-internal-medicines.html (accessed 8/17/17).
  3. CitizenAudit.org. American College of Physicians Form 990. 2014. Available at: http://pdfs.citizenaudit.org/2015_05_EO/23-1520302_990_201406.pdf (accessed 8/17/17).
  4. Peckham C. Medscape pulmonologist compensation report 2014. Medscape. April 15, 2014. Available at: http://www.medscape.com/features/slideshow/compensation/2014/pulmonarymedicine (accessed 8/17/17).
  5. Buscemi D, Wang H, Phy M, Nugent K. Maintenance of certification in Internal Medicine: participation rates and patient outcomes. J Community Hosp Intern Med Perspect. 2013 Jan 7;2(4). [CrossRef] [PubMed]
  6. Hayes J, Jackson JL, McNutt GM, Hertz BJ, Ryan JJ, Pawlikowski SA.Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA. 2014 Dec 10;312(22):2358-63. [CrossRef] [PubMed] 
  7. Gray BM, Vandergrift JL, Johnston MM, Reschovsky JD, Lynn LA, Holmboe ES, McCullough JS, Lipner RS. Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA. 2014 Dec 10;312(22):2348-57. [CrossRef] [PubMed] 

Cite as: Robbins RA. Disclosures for all. Southwest J Pulm Crit Care. 2017;15(2):87-9. doi: https://doi.org/10.13175/swjpcc105-17 PDF 

Thursday
Aug172017

Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to Require Sleep Apnea Testing in Commercial Transportation Operators

In another move favoring business interests and against the common good, the Trump administration’s Department of Transportation announced recently that they are rescinding plans to require testing for obstructive sleep apnea (OSA) in train and commercial motor vehicle operators (1). As exemplified by its withdrawal from the Paris climate accords, this decision is another example of how the current administration disregards scientific findings and present-day events in establishing policy that will be detrimental to Americans.

Let us step back for a moment and briefly review the evidence that the Trump administration has ignored.

  • It is well established that obstructive sleep apnea (OSA) can result in daytime sleepiness (2) and that sleepiness is detrimental to safe operation of a train or motor vehicle.
  • Many studies have established that persons with OSA have an increased risk of motor vehicle crashes (3).
  • Studies in commercial truck drivers have observed that this population has a high prevalence of OSA (4).
  • It is estimated that OSA costs the American economy $150 billion annually (5).
  • There now are relatively easy and inexpensive protocols to screen high risk individuals for OSA (4).
  • Obstructive sleep apnea is a treatable condition, and treatment mitigates OSA impairment in sleepiness and reduces crash risk (6,7). In contrast, non-compliance with treatment is associated with a five-fold increase in crash risk (6).
  • The costs of diagnosis and treatment are much lower than the costs that ensue when OSA persists untreated (5). For example, significant healthcare savings result from successful treatment of truck drivers (8).
  • Failure to recognize and treat OSA has resulted in several high-profile transportation accidents. The following are some recent incidents:
    • September 2016: A commuter rail train slammed into the station at Hoboken, NJ killing a female bystander and leaving a child without a mother. The engineer had undiagnosed severe OSA (9).
    • December 2013: A Metro North commuter rail engineer fell asleep and his train sped around a curve resulting in a crash that killed 4 and injured 70 (10). The National Transportation Safety Board determined that undiagnosed severe OSA was the probable cause of the accident. The lack of a policy which required sleep disorder screening was further determined to be a contributing factor (11).
    • September 2013: A Greyhound bus overturned on Interstate 70 because the driver fell asleep resulting in multiple injuries. The driver was later found to have untreated OSA (12).
    • June 2009: A tractor-trailer traveling at a high speed did not see stopped cars ahead on Interstate 44 resulting in a crash that killed 10 and injured 6. It was later determined that the truck driver had mild OSA contributing to fatigue (13).

Despite the weight of the aforementioned evidence, the current administration has chosen to ignore it in favor of letting private industry regulate itself implying the current regulations are sufficient. As illustrated by the incidents cited above, recent events have proven them wrong. As Sir Winston Churchill once said “Those who fail to learn from history are doomed to repeat it”. Continuing with the current policy will inevitably result in further preventable disasters and more loss of life.

What can be done? At the federal level, one should consider advocating to your own congressional representatives for reconsideration of this poorly considered policy. On a personal level, federal policy is ultimately guided by the “ballot box”, which is something to consider for the next election. Finally, be aware that the next time you are driving down the interstate, the truck or bus driver approaching you from behind may have untreated OSA!

Stuart F. Quan, M.D.1,2, Laura K. Barger, Ph.D.1, Matthew D. Weaver, Ph.D.1, and Charles A. Czeisler, Ph.D., M.D.1

1Division of Sleep and Circadian Disorders

Brigham and Women’s Hospital

Harvard Medical School, Boston, MA USA

2Asthma and Airway Disease Research Center

University of Arizona College of Medicine

Tucson, AZ USA

References

  1. Federal Register. Evaluation of safety sensitive personnel for moderate-to-severe obstructive sleep apnea. Last updated: 2017. Available at: https://federalregister.gov/d/2017-16451 (Accessed: August 10, 2017)
  2. Committee on Sleep Medicine and Research Board on Health Sciences Policy. Sleep disorders and Sleep Deprivation--An Unmet Public Health Problem. Washington, D.C.: National Academies Press, 2006; 404.
  3. 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 Dec 15;5(6):573-81. [PubMed]
  4. Kales SN, Straubel MG.Obstructive sleep apnea in North American commercial drivers. Ind Health. 2014;52(1):13-24. [CrossRef] [PubMed]
  5. Anonymous. Hidden health crisis costing America billions. Underdiagnosing and undertreating obstructive sleep apnea draining healthcare system. Last updated: 2016. Available at: http://www.aasmnet.org/sleep-apnea-economic-impact.aspx (Accessed: August 15, 2017)
  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. Tregear S, Reston J, Schoelles K, Phillips B.Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep. 2010 Oct;33(10):1373-80. [CrossRef] [PubMed]
  8. Hoffman B, Wingenbach DD, Kagey AN, Schaneman JL, Kasper D. The long-term health plan and disability cost benefit of obstructive sleep apnea treatment in a commercial motor vehicle driver population. J Occup Environ Med. 2010 May;52(5):473-7. [CrossRef] [PubMed]
  9. Anonymous Hoboken train crash investigation hampered by heavy damage. CBS News. 2016; Available at: http://www.cbsnews.com/news/hoboken-train-crash-investigation-hampered-heavy-damage/ (Accessed: August 15, 2017)
  10. Anonymous. December 2013 Spuyten Duyvil derailment. Last updated: 2017. Available at: https://en.wikipedia.org/wiki/December_2013_Spuyten_Duyvil_derailment (Accessed: August 10 , 2017)
  11. National Transportation Safety Board. ​Metro-North Railroad Derailment. Last updated: 2014. Available at: https://www.ntsb.gov/investigations/AccidentReports/Pages/RAB1412.aspx (Accessed: August 15, 2017)
  12. Lee D.  Sleep Test Leads to $6M Greyhound Settlement. Last updated: 2016. Available at: http://oldarchives.courthousenews.com/2016/03/09/sleep-test-leads-to-6m-greyhound-settlement.htm (Accessed: March 9, 2017)
  13. National Transportation Safety Board. Highway Accident Report: Truck‐Tractor Semitrailer Rear‐End Collision Into Passenger Vehicles on Interstate 44 Near Miami, Oklahoma June 26, 2009. Last updated: 2010. Available at: https://www.ntsb.gov/investigations/AccidentReports/Reports/HAR1002.pdf (Accessed: August 10, 2017)

Cite as: Quan SF, Barger LK, Weaver MD, Czeisler CA. Saving lives or saving dollars: The Trump administration rescinds plans to require sleep apnea testing in commercial transportation operators. Southwest J Pulm Crit Care. 2017;15:84-6. doi: https://doi.org/10.13175/swjpcc102-17 PDF 

Disclosures 

Editor's note: In 2016 Dr. Quan authored an editorial titled "Screening for Obstructive Sleep Apnea in the Transportation Industry—The Time is Now" in SWJPCC. The editorial encouraged screeening of transportation workers for sleep apnea.

Friday
Jun302017

The Unspoken Challenges to the Profession of Medicine

More and more, we are practicing in a challenging environment. Job satisfaction for our profession is at an all-time low, burnout at an all-time high and there exists an alarming depression rate. As a profession, we face no shortage of problems. Our medical student graduates await many hurdles and need to be prepared to deal with increasing educational costs, ACGME duty hour changes, declining interest in primary care, health care reform, declining Medicare reimbursement, assaults to fee for service designs, bundled payments, care for the uninsured, medical malpractice, ABIM recertification, and MOC changes, the electronic health record, among many others.

If you are like most physicians, you have found yourself grappling with patients seeking a particular drug especially when that drug is a controlled substance or an antibiotic. You want your patient’s approval of your care and maybe even avoidance of their anger while providing the appropriate care that is based on your best judgment.  The accrediting bodies like American Board of Medical Specialties and ACGME in overall policies require that those seeking board certification have demonstrated “altruism, accountability, excellence, duty, service, honor, integrity and respect for others” (1). A reaction of anger or disapproval challenges our wish to strive toward achieving goals of being altruistic, knowledgeable, skillful, and dutiful. How does a patient review on various internet sites or hospital administrators’ perspectives address essential elements of medical professionalism? Most of us now work for large organizations (2). So we all have an interest in conforming to their wishes. In fact we do not have independent choice in what we do and probably very few docs practice with independent choice. Whether it be medication formularies, patient satisfaction scores or performance measures that seem geared more to justify institutional financial goals than to truly improve patient care. 

Uncertainty has long characterized the practice of medicine despite advances in technology or biomedical knowledge. Medical professionalism is defined by what we do and how we act, by demonstrating that we are worthy of the trust bestowed upon us by our patients and the public. My friend shared with me “I try to use independent judgment but always take into account how much or what to do for a patient, thinking what would seem acceptable to others at work if the patient went home and died, and my care got reviewed”. More and more we are judged by everyone, and not just our peers. The opinions of non-medical professionals who lack insight are taken into account and some of that has to do with the lack of solidarity to our peers in front of the public which diminishes confidence for the whole profession (3). 

Listening to our patients is the first key step in adding critical insight to our decisions. Long term we are expected to be providing fiscally prudent appropriate care to the public. In an era of ever increasing drug abuse we need to focus on making our decisions and behavior based on patient’s best interests and the publics good and not on current organizational financial goals, health trends or other distractions from our profession.  

Medical professionalism requires subordinating your own interest to the interest of the patient’s and public’s health. We have a duty to do right and to avoid doing wrong in principles of beneficence and nonmaleficence. As an example, our profession has been criticized for both under and over prescribing pain medications and antibiotics. Resisting the current trends or an individual’s unsupported drug request in favor of patient and public’s good is what we need to exercise. We need to exercise accountability not just for ourselves but for our colleagues, including intervening and not abrogating our responsibility early in the slippery slope of such behaviors as being chronically late for over commitments for monetary gain, derogatory comments about institution/hospital that degrade trust in our profession to the public, outbursts of anger and inappropriate work place sexual harassment or alternatively false allegations of such type of behavior (4). The Public trust demands that we make appropriate decisions in face of complex environments and often unscientific pressures for the overall care of patient and public if we are to do our part in maintaining a profession (5). We need to continue to strive toward benefiting our patients and subordinating our interests to best meet the needs of our patients and we should stand our ground to pillars of our profession, otherwise maybe we should amend our thinking to accept the fact that we have become corporate or political factotums and not here for a higher calling. Our voices should be united, altruistic and with medical professionalism to maintain public’s trust. Create goals that will prevent burnout and focus lifestyle expectations that realistic and fulfilling in order to avoid the need to rush through the long queues of patients in the waiting room and its associated dissatisfaction (6).  

 

F. Brian Boudi, MD

Phoenix Veterans Administration Health Care System

University of Arizona College of Medicine

Phoenix, Arizona

 

Connie S. Chan, MD

Phoenix Veterans Administration Health Care System

Phoenix, Arizona 

References

  1. American Board of Internal Medicine. Project Professionalism. 2013. Available at:  https://medicinainternaucv.files.wordpress.com/2013/02/project-professionalism.pdf (accessed 6/29/17).
  2. G Hamel, Zanini M.  More of us are working in big bureaucratic organizations than ever before. Harvard Business Review. July 5, 2016. Available at: https://hbr.org/2016/07/more-of-us-are-working-in-big-bureaucratic-organizations-than-ever-before (accessed 6/29/17). 
  3. Pardes H. The future of medical schools and teaching hospitals in the era of managed care. Acad Med. 1997 Feb;72(2):97-102. [CrossRef] [PubMed]
  4. Scott KM, Berlec Š, Nash L, Hooker C, Dwyer P, Macneill P, River J, Ivory K. Grace Under Pressure: a drama-based approach to tackling mistreatment of medical students. Med Humanit. 2017 Mar;43(1):68-70. [CrossRef] [PubMed]
  5. Relman AS. Education to defend professional values in the new corporate age. Acad Med. 1998 Dec;73(12):1229-33. [CrossRef] [PubMed]
  6. Barkil-Oteo A. Have physicians finally joined the working class? KevinMD.com. November 3, 2016. Available at: http://www.kevinmd.com/blog/2016/11/physicians-finally-joined-working-class.html (accessed 6/29/16).

Cite as: Boudi FB, Chan CS. The unspoken challenges to the profession of medicine. Southwest J Pulm Crit Care. 2017;14(6):222-4. doi: https://doi.org/10.13175/swjpcc085-17 PDF 

Saturday
Jun172017

EMR Fines Test Trump Administration’s Opposition to Bureaucracy

Earlier this week the Health and Human Services Office of Inspector General (OIG) released an audit report on $6.1 billion paid to 250,000 clinicians in the incentive program for meaningful use of electronic medical records (EMRs) (1). A random sample of 100 clinicians who had received at least one incentive payment revealed that 14 of them who had had not met all meaningful use requirements as they had attested (Table 1) (1,2).

Table 1. Meaningful use deficiencies identified in 14 of 100 clinicians.

  • Six clinicians couldn't provide a mandatory analysis of security risks;
  • Four clinicians couldn't prove that they had generated at least one list of patients-another requirement -who had the same condition;
  • Three clinicians could not provide patient encounter data to document that they had met various meaningful use measures;
  • One clinician had 90-days' worth of patient encounter data when a year's worth was needed;
  • One clinician did not use certified EHR technology as much as required.

The OIG recommended that the Center for Medicare and Medicaid Services recover the $291,222 paid to the clinicians in the sample group and extrapolated the recovery to $729 million from the remaining clinicians based on this random sample. This is about 13% of the incentives paid to clinicians for the CMS EMR program. The decision to carry out the recommendation will ultimately fall to a US Department of Health and Human Services (HHS) secretary, Tom Price MD, who has opposed government programs that created regulatory hassles for physicians.

"We would protest if they went through with this," said Robert Tennant, director of health information technology policy at the Medical Group Management Association (MGMA). "Going after folks who tried to meet arbitrary government requirements, who made a good faith effort, isn't fair” (2). Tennant said that this complexity, made worse by evolving requirements, helps explain the deficiencies listed in the OIG audit. "I'm not surprised some providers found it daunting to keep up with the changes," he said. The requirement for a security risk analysis is a problem, Tennant noted, because CMS hasn't given clinicians sufficient guidance on how to meet the requirements. "This is a real stumbling block for smaller practices," he said. "They're not security experts, they're clinicians" (2). American College of Physicians Vice President of Governmental Affairs and Medical Practice Shari Erickson said that clinicians who originally attested to meaningful use lacked clear, specific guidance on what documentation they needed for each requirement (2).

CMS incentivized using EMRs because many clinicians were reluctant to initiate EMRs in their practices because of cost and efficiency considerations. Average costs to initiate an EMR were $163r,765 for a single practitioner and $233,298 for a practice with five physicians (3). Reimbursement under the EMR program was about $65,000 per provider (4). Furthermore, there was an 8% decrease in productivity after EMR initiation (3). In other words, if physicians wanted to see Medicare/Medicaid patients they were asked to use EMRs that cost them money and made them work harder.

The violations identified in the OIG audit seem fairly minor and are the type of trivial violations that the lawyers and bureaucrats seem to delight in identifying and excessively penalizing clinicians. In contrast, large health care organizations seem to go unpunished for more egregious violations. Witness the lack of action against Banner Healthcare for compromising 3.7 million medical records in 2016 (5). The average cost of data breach has been estimated at $398 per compromised record (2). Extrapolating, Banner should be fined nearly $1.5 billion.

Medicine is likely the most regulated industry in the US. Several of my colleagues have complained that the regulation seems more directed at them and not at the hospitals and insurance companies that seem to create most of the increase in cost and the violations. Some of the more paranoid clinicians viewed the EMR as nothing more than a tactic to gain further control of their practice and viewed Hillary Clinton as someone who would continue the onslaught on clinicians. These fines for EMR noncompliance are the first true test for the Trump administration in the area of healthcare regulation. Many of my colleagues are watching Trump and Price to see if their opposition to bureaucracy was merely lip service or has some backbone. 

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Levinson DR. Medicare paid hundreds of millions in electronic health record incentive payments that did not comply with federal requirements. Department of Health and Human Services. Office of the Inspector General. June 2017. Available at: https://oig.hhs.gov/oas/reports/region5/51400047.pdf (accessed 6/15/17).
  2. Lowes R. Proposal to take back EHR bonuses galls med societies. Medscape. June 13, 2017. Available at: http://www.medscape.com/viewarticle/881563?nlid=115819_4502&src=wnl_dne_170615_mscpedit&uac=9273DT&impID=1368453&faf=1 (accessed 6/15/17). 6
  3. Fleming NS, Aponte P, Ballard DJ, Becker E, Collinsworth A, Culler S, Kudyakov R, McCorkle R, Chang D. Exploring financial and non-financial costs and benefits of health information technology: the impact of an ambulatory electronic health record on financial and workflow in primary care practices and costs of implementation. The Agency for Healthcare Research and Quality (AHRQ). 2011. Available at: https://healthit.ahrq.gov/sites/default/files/docs/publication/R03HS018220-01Flemingfinalreport2011.pdf (accessed 6/15/17).
  4. Hayes TO. Are electronic medical records worth the costs of implementation?American Action Forum. August 6, 2015. Available at: https://www.americanactionforum.org/research/are-electronic-medical-records-worth-the-costs-of-implementation/ (accessed 6/15/17).
  5. Robbins RA. Banner hacked-3.7 million at risk. Southwest J Pulm Crit Care. 2016;13(2):80-1. [CrossRef]

Cite as: Robbins RA. EMR fines test Trump administration's opposition to bureaucracy. Southwest J Pulm Crit Care. 2017;14(6):312-4. doi: https://doi.org/10.13175/swjpcc079-17 PDF

Saturday
Jun102017

Breaking the Guidelines for Better Care

Two events happened this past week that inspired this editorial. First, on Wednesday morning I read the editorial titled “Breaking the Rules for Better Care” by Don Berwick et al. in JAMA (1). Berwick reports a survey of about 40 hospitals done by The Institute of Healthcare Improvement (IHI). The survey asked the question “If you could break or change any rule in service of a better care experience for patients or staff, what would it be?”. The answers were not surprising. Most centered on annoying hospital rules such as visiting hours, not waking patients, correct HIPPA interpretation, and eliminating the 3-day rule. Although these are correct, in the whole they have minimal effect on healthcare. Other suggestions more likely to improve patient care included improving access, reducing wait times and earlier patient mobility. From the suggestions, it seems likely that most were from administrators. In the editorial Berwick decried “Habits embedded in organizational behaviors, based on misinterpretations and with little to no actual foundation in legal, regulatory, or administrative requirements”. He goes on to say, “Health care leaders may be well advised to ask their clinicians, staffs, and patients which habits and rules appear to be harming care without commensurate benefits and, with prudence and circumspection, to change them.” As a clinician, I thoroughly agree with both of Berwick’s points.

Later that afternoon, I listened to a lecture by Clement Singarajah on sepsis guidelines. He reviewed the severe sepsis bundles promoted by the Surviving Sepsis Campaign and IHI, the latter being Berwick’s organization who wrote the editorial noted above (Table 1) (2,3).

Table 1.  Severe Sepsis Bundles.

The Severe Sepsis 3-Hour Resuscitation Bundle contains the following elements, to be completed within 3 hours of the time of presentation with severe sepsis:

  • Measure Lactate Level
  • Obtain Blood Cultures Prior to Administration of Antibiotics
  • Administer Broad Spectrum Antibiotics
  • Administer 30 mL/kg Crystalloid for Hypotension or Lactate ≥4 mmol/L

The 6-Hour Septic Shock Bundle contains the following elements, to be completed within 6 hours of the time of presentation with severe sepsis:

  • Apply Vasopressors (for Hypotension That Does Not Respond to Initial Fluid Resuscitation to Maintain a Mean Arterial Pressure (MAP) ≥65 mm Hg)
  • In the Event of Persistent Arterial Hypotension Despite Volume Resuscitation (Septic Shock) or Initial Lactate ≥4 mmol/L (36 mg/dL):
    • Measure Central Venous Pressure (CVP)
    • Measure Central Venous Oxygen Saturation (ScvO2)
  • Remeasure Lactate If Initial Lactate Was Elevated

We carefully reviewed each of the metrics, and concluded most were non-evidence based, outdated, or contradicted by more recent and better trials. The only exception was early antibiotic administration. Most of us reaffirmed our belief in the germ theory and felt that early administration of the correct antibiotics was probably mostly evidence-based and reasonable (4).

Is it possible that most of the metrics in the bundle are merely a waste of time as we concluded or could some be harmful? First, a recent meta-analysis examined a conservative fluid strategy in sepsis compared with a liberal strategy (the goal-directed therapy as advocated by the sepsis bundles) (5). Although there was no change in mortality, a conservative strategy resulted in increased ventilator-free days and reduced length of ICU stay. The meta-analysis concluded that the studies were underpowered to show a mortality benefit. Second, most of us had experienced delays in initiating antibiotics, the only guideline that makes a difference, while waiting for blood cultures to be drawn. None of us knew data that drawing blood cultures makes a difference in patient outcomes.

Berwick recommended asking clinicians which rules may be harming care. Rather than chiding others to do something, a good place to start might be IHI’s sepsis guidelines. The issue of continued support for non-evidence based or outdated guidelines points out the rigid dichotomy between self-delusional beliefs and science. Many (some would say most) guidelines are based on opinions and not science (6). Healthcare would be better if groups such as the Surviving Sepsis Campaign, IHI and the Centers for Medicare and Medicaid Services would follow their own advice and not burden healthcare providers with non-evidence based guidelines. Instead, they should only issue guidelines after carefully conducted, randomized, controlled trials establish a guideline rather than mandating the self-delusional beliefs of a few.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Berwick DM, Loehrer S, Gunther-Murphy C. Breaking the rules for better care. JAMA. 2017 Jun 6;317(21):2161-2. [CrossRef] [PubMed]
  2. Surviving Sepsis Campaign. Updated bundles in response to new evidence. Available at: http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf (accessed 6/9/17).
  3. Institute for Healthcare Improvement. Severe sepsis bundles. Available at: http://www.ihi.org/resources/Pages/Tools/SevereSepsisBundles.aspx (accessed 6/9/17).
  4. Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017 Jun 8;376(23):2235-44. [CrossRef] [PubMed]
  5. Silversides JA, Major E, Ferguson AJ, et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med. 2017 Feb;43(2):155-170. [CrossRef] [PubMed]
  6. Lee DH, Vielemeyer O. Analysis of overall level of evidence behind Infectious Diseases Society of America practice guidelines. Arch Intern Med. 2011;171:18-22. [CrossRef] [PubMed] 

Cite as: Robbins RA. Breaking the guidelines for better care. Southwest J Pulm Crit Care. 2017;14(6): 285-7. doi: https://doi.org/10.13175/swjpcc072-17 PDF