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Southwest Pulmonary and Critical Care Fellowships
In Memoriam

 Editorials

Last 50 Editorials

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

Hospitals, Aviation and Business
Healthcare Labor Unions-Has the Time Come?
Who Should Control Healthcare? 
Book Review: One Hundred Prayers: God's answer to prayer in a COVID
   ICU
One Example of Healthcare Misinformation
Doctor and Nurse Replacement
Combating Physician Moral Injury Requires a Change in Healthcare
   Governance
How Much Should Healthcare CEO’s, Physicians and Nurses Be Paid?
Improving Quality in Healthcare 
Not All Dying Patients Are the Same
Medical School Faculty Have Been Propping Up Academic Medical
Centers, But Now Its Squeezing Their Education and Research
   Bottom Lines
Deciding the Future of Healthcare Leadership: A Call for Undergraduate
and Graduate Healthcare Administration Education
Time for a Change in Hospital Governance
Refunds If a Drug Doesn’t Work
Arizona Thoracic Society Supports Mandatory Vaccination of Healthcare
   Workers
Combating Morale Injury Caused by the COVID-19 Pandemic
The Best Laid Plans of Mice and Men
Clinical Care of COVID-19 Patients in a Front-line ICU
Why My Experience as a Patient Led Me to Join Osler’s Alliance
Correct Scoring of Hypopneas in Obstructive Sleep Apnea Reduces
   Cardiovascular Morbidity
Trump’s COVID-19 Case Exposes Inequalities in the Healthcare System
Lack of Natural Scientific Ability
What the COVID-19 Pandemic Should Teach Us
Improving Testing for COVID-19 for the Rural Southwestern American Indian
   Tribes
Does the BCG Vaccine Offer Any Protection Against Coronavirus Disease
   2019?
2020 International Year of the Nurse and Midwife and International Nurses’
   Day
Who Should be Leading Healthcare for the COVID-19 Pandemic?
Why Complexity Persists in Medicine
Fatiga de enfermeras, el sueño y la salud, y garantizar la seguridad del
   paciente y del publico: Unir dos idiomas (Also in English)
CMS Rule Would Kick “Problematic” Doctors Out of Medicare/Medicaid
Not-For-Profit Price Gouging
Some Clinics Are More Equal than Others
Blue Shield of California Announces Help for Independent Doctors-A
   Warning
Medicare for All-Good Idea or Political Death?
What Will Happen with the Generic Drug Companies’ Lawsuit: Lessons from
   the Tobacco Settlement
The Implications of Increasing Physician Hospital Employment
More Medical Science and Less Advertising
The Need for Improved ICU Severity Scoring
A Labor Day Warning
Keep Your Politics Out of My Practice
The Highest Paid Clerk
The VA Mission Act: Funding to Fail?
What the Supreme Court Ruling on Binding Arbitration May Mean to
   Healthcare 
Kiss Up, Kick Down in Medicine 
What Does Shulkin’s Firing Mean for the VA? 
Guns, Suicide, COPD and Sleep
The Dangerous Airway: Reframing Airway Management in the Critically Ill 
Linking Performance Incentives to Ethical Practice 
Brenda Fitzgerald, Conflict of Interest and Physician Leadership 
Seven Words You Can Never Say at HHS

 

 

For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care welcomes submission of editorials on journal content or issues relevant to the pulmonary, critical care or sleep medicine. Authors are urged to contact the editor before submission.

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Friday
Sep132013

Are Medical Guidelines Better Than Flipping a Coin? 

A recent article by Prasad et al. (1) in the Mayo Clinic Proceedings reviewed all original articles published over 10 years (2001-2010) in the New England Journal of Medicine (NEJM). Articles were classified on the basis of whether they addressed a medical practice, whether they tested a new or existing therapy, and whether results were positive or negative. Most striking was that of the 363 articles examining standards of care, 146 (40.2%) reversed that practice, whereas 138 (38.0%) reaffirmed it. The remaining percentage remained inconclusive.

As pointed out in an accompanying editorial, the NEJM is widely read, has high visibility and has a large influence on the mass media and medical practitioners (2). However, the effect of articles published in the NEJM, Lancet and JAMA, the top 3 general medical journals in terms of impact factor, are markedly inflated (3,4). Presumably, a randomized trial published in these journals must be true because these are the “best” medical journals. 

Prasad’s conclusions that the NEJM reversed accept medical practice about half the time would be consistent with the Cochrane Review of Clinical Trials.  El Dib et al. (5) concluded in 2004 that there is insufficient evidence to endorse the examined interventions 47.8% of the time. A repeat evaluation in 2011 showed that the percentage of insufficient evidence remained about the same (6).

Now before anyone gets too upset, I happen to agree that NEJM, Lancet and JAMA are probably the best and most influential medical journals. Authors send their best work to these journals because they are widely read. The editors choose articles based on their importance and whether the work is new, innovative, or contradicts accepted medical practice. All of this makes these journals the most influential.

Not surprisingly, authors of guidelines give more credibility to these higher impact journals. In other words, a randomized trial done in the NEJM is more likely to influence a guideline writing committee that a trial from the Southwest Journal of Pulmonary and Critical Care. Looking at Bob Raschke’s recent journal club reviewing 6 landmark randomized controlled trials that were eventually reversed, 5 were from the NEJM or JAMA (7). Several of the outcomes from these studies were the basis for guidelines.

Guideline writing committees really cannot do better than the medical literature.  However, if half the established standards of care are wrong as Prasad suggests, half the guidelines based on these standards of care are also wrong. Should we require higher levels of evidence before practice guidelines are recommended-perhaps at least two, or in cases of marginal effects, even more trials. To me the overwhelming answer has to be yes.

Lee and Vielemeyer (8) found that only 14% of the Infectious Disease Society of America (IDSA) guidelines are based on level I evidence (data from >1 properly randomized controlled trial). Much of this 14% and the 86% that are below level I evidence will eventually be proven wrong. I doubt that other medical societies are performing much better. Serving on a guideline writing committee is a compliment paid by professional colleagues. However, as Lee and Vielemeyer point out, the guidelines tend to be more opinion than science. This is especially true when the data supporting standards of care is weak, nonexistent or conflicting. Experts often rationalize that an answer is needed, even when the correct response might be “I don’t know”.

All this points out that reading and interpreting medical literature is difficult. It takes knowledge, experience and a healthy dose of skepticism.  Experts relying on the best evidence frequently get it wrong. Improvement lies in the intellectual honesty of the guidelines committees and research. Well designed clinical trials are usually expensive and time-consuming, not what health care administrators want to hear in a time of restricted budgets. However, can we afford not to invest in getting it right?

Richard A. Robbins, MD*

References

  1. Prasad V, Vandross A, Toomey C, et al. A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clin Proc. 2013;88(8):790-8. [CrossRef] [PubMed] 
  2. Ioannidis JP. How many contemporary medical practices are worse than doing nothing or doing less? Mayo Clin Proc. 2013;88(8):779-81. [CrossRef] [PubMed] 
  3. ISI Web of Science. Journal Citation Reports. Available at: http://thomsonreuters.com/journal-citation-reports.  Accessed August 7, 2013.
  4. Siontis KC, Evangelou E, Ioannidis JP. Magnitude of effects in clinical trials published in high-impact general medical journals. Int J Epidemiol. 2011;40(5):1280-91. [CrossRef] [PubMed] 
  5. El Dib RP, Atallah AN, Andriolo RB. Mapping the Cochrane evidence for decision making in health care. J Eval Clin Pract. 2007;13(4):689-692. [CrossRef] [PubMed] 
  6. Villas Boas PJ, Spagnuolo RS, Kamegasawa A, et al. Systematic reviews showed insufficient evidence for clinical practice in 2004: what about in 2011? The next appeal for the evidence-based medicine age. J Eval Clin Pract. 2013;19(4):633-7. [CrossRef] [PubMed] 
  7. Raschke RA. August 2013 critical care journal club: less is more. Southwest J Pulm Crit Care. 2013;7(3):162-4. [CrossRef]
  8. 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] 

*The opinions expressed are those of the author and do not necessarily reflect the opinion or policies of the Arizona, New Mexico, or Colorado Thoracic Societies, the Mayo Clinic, or most guideline writing committees.

Reference as: Robbins RA. Are medical guidelines better than flipping a coin? Southwest J Pulm Crit Care. 2013;7(3):181-3. doi: http://dx.doi.org/10.13175/swjpcc124-13 PDF

Friday
Aug162013

Who Will Benefit and Who Will Lose from Obamacare? 

The debate continues over the Patient Protection and Affordable Care Act (ACA, Obamacare) (1). One the one hand the White House and their Democratic supporters say the law will: 1. Expand coverage to the poor; 2. Control costs; and 3. Improve care. On the other hand, opponents say the law is a job killer. Employers will be forced to eliminate positions, or reduce staffers to part-time hours to save costs. A recent article stated that Obamacare is certain to create a number of new positions but that seemed to be only part of the story (2). Below we offer our short lists of who will benefit and who will lose under Obamacare.

Who Will Benefit

  1. Uninsured patients. Many patients who are uninsured or underinsured will benefit because their lack of health insurance results in delays in diagnosis and treatment. Uninsured patients often seek care in the hospital emergency department. Included in the uninsured are the poor and those with preexisting conditions.
  2. Hospitals. Most hospitals are not-for-profit and as part of their community service provide free or undercompensated care to patients without health insurance. However, under Obamacare, hospitals will now receive payment improving profitability (3). However, the Center for Medicare and Medicaid Services (CMS) has shown a tendency to punish hospitals that underperform on certain performance measures such as 30 day readmission rate. It is possible that the initial increase in payments may be eventually be offset by reduction in payments for noncompliance.
  3. Insurance Companies. Everyone will be required to purchase health insurance and that is great for the insurance business. Because there is some uncertainty regarding the eventual costs, insurance companies will generously estimate any increase in costs and pass this along to the consumer. Overall premiums will likely increase.
  4. Lawyers. Obamacare rules and regulations are highly detailed, complex, confusing and changing. This will require increased numbers of lawyers to interpret the law and decide how it should be followed. It has been estimated that companies will spend $6 billion on legal services relating to government regulations this year, up 5% from 2012 (2). This will likely continue to increase under Obamacare.
  5. Administrators and Bureaucrats.
    • The complicated rules and regulations of Obamacare will be policed at several levels. This will require increased manpower to maintain compliance from the hospital quality assurance department to the state and Federal government.
    • Payroll employees will need to increase. Obamacare requires employers to offer insurance to employees who work an average of 30 hours a week or more, at a cost for workers of not more than 9.5% of their annual salary. The responsibility of tracking work hours and health spending will fall to payroll departments.
    • Under Obamacare, doctors and hospitals must use electronic medical records, replacing paper systems with digital records and billing. According to the Bureau of Labor Statistics (BLS) the number of medical records and health information technicians employed in the U.S. has grown 7% to more than 182,000 since 2009, before Obamacare was enacted (4). Employers will also have to build new electronic systems to report the costs of their employees’ health coverage to the government, although they will have more time to do it, since the 2014 deadline has been extended.
    • Medical billing coders to submit the new electronic payments will be needed. The estimated 25-30 million new patients will bring many new bills. This will include coders not only for physician offices and hospitals, but also coding jobs for insurance companies. 
    • Navigating Obamacare will likely require a huge increase customer support staff known as “navigators”. The Centers for Medicare and Medicaid Services recently announced it would provide $54 million to fund the positions, and virtually any individual or entity could apply to serve as navigators.
    • Consultants will be needed to advise administrators how to reduce costs and increase profits. These consultants will cost money.
    • Administrators will likely seize the opportunity to increase their control over medical practice and increase their pay by claiming increased responsibilities supervising more employees. Over the past 20 years there has been a decrease in administrative efficiency and an accompanying increase in administrators and administrative costs (5). Obamacare will likely continue this trend.
  6. Fitness Clubs & Health Education Providers. The law pressures employers to reduce their health spending by making workers healthier. Companies will likely hire health education providers to help employees design personalized nutrition and fitness programs, and offer workers incentives to participate. The field will grow 24% to over 300,000 positions by 2020, according to the BLS (6).
  7. Nurse Practitioners and Physician Assistants. The increase numbers of people with health coverage through Obamacare is expected to increase the demand for physician services by at least 2% to 3% (2). Because Obamacare emphasizes preventive care, the increase will be especially high for primary care for services such as regular checkups and other preventive medicine. However, the relatively sudden increase in patients will not be matched by a sudden increase in physicians. Doctors, especially primary care physicians, are already in short supply and take years to educate before entering the workforce (1). The physician workforce cannot possibly be expected to expand sufficiently to handle the increase in patients. Rather, physician assistants and nurse practitioners will be needed to perform many of the same services. BLS forecasts PA jobs will grow 30% to more than 108,000 from 2010 to 2020 (7); registered nurses will increase 26% to more than 3 million (8).
  8. Occupational therapists. Under Obamacare, patients with disabilities can no longer be denied health insurance. This will likely increase the demand for occupational therapists, which help optimize disabled people’s homes and workplaces to meet their mobility needs. However, like physicians, this profession is already in short supply with an unemployment rate of just 1% and a forecast for 43% growth in jobs by 2020 (9).

But what about the losers? Here’s our short list of losers under Obamacare.

Who Will Lose

  1. Unemployed and small business. Small business owners' fear of the effect of the new health-care reform law on their bottom line is prompting many to hold off on hiring and even to shed jobs in some cases, a recent Gallup poll found (10). Forty-one percent of the businesses surveyed have frozen hiring because of Obamacare. Nineteen percent answered "yes" when asked if they had "reduced the number of employees you have in your business as a specific result of the Affordable Care Act” (10).
  2. Physicians. Increased demand for physician services, which are already in short supply, should increase physician reimbursement. However, it has been clear for some time that the law of supply and demand does not apply to healthcare. Instead, Obamacare will further reduce fees to health care providers, by $415 billion over 2013-2022 (11). As these reductions go into effect, more and more physicians are certain to stop taking new patients whose insurance offers low reimbursement. This is already happening with Medicare and Medicaid patients. This may lead to poorer health outcomes especially in the poor, the very people Obamacare was intended to help the most (11).
  3. The Poor in Some States. The poor should finally have access to affordable insurance under Obamacare, but millions will most likely remain uninsured (12). Low-income adults in the 21 states that aren't expanding Medicaid will not be eligible. Some 4.9 million people will not be covered in 2016 if these states don't expand, according to the Urban Institute. Another 1.5 million uninsured are in six states that are considering expansion, but have yet to approve it. The three states in the Southwest, Arizona, New Mexico and Colorado are all expanding.
  4. Safety-Net Hospitals. Hospitals that serve the most vulnerable patients, so called safety-net hospitals, may be hurt by Obamacare (13). These hospitals receive “disproportionate share payments” through the Medicare and Medicaid programs, money to cover high levels of uninsured patients. These payments will be cut by more than $30 billion over the next decade. Under Obamacare, the safety-net hospitals will gain a new source of revenue when millions of the uninsured gain coverage but the law’s spending cuts could result in a net decrease in reimbursement. This may be especially true in those states that are not expanding Medicaid. Safety-net hospitals in these states may end up with the same number of uninsured patients but with less reimbursement.
  5. Lightly-Regulated States. Some states allow insurers to sell bare-bones plans excluding the sick, which keeps costs down (14). Under Obamacare, insurers must offer a package of essential benefits -- including maternity, mental health and medications -- and must cover all who apply. States including Indiana, Ohio, Florida and South Carolina, have recently released preliminary rate information highlighting steep price increases. In contrast, states such as California and New York will likely see price reductions since they already require insurers to provide comprehensive coverage. Rates there could fall by half since the pool will expand to include many younger, healthier residents under Obamacare.
  6. Young Men. Obamacare requires that women pay the same amount as men. Furthermore, Obamacare does not allow insurers to charge older participants more than three times the young. One analysis found that 21-year-old men will pay more, but older women and men will pay less (14). A young man's increase would be 63% while older men and women will pay about 6-7% less.
  7. Healthy Patients. Healthy patients will likely pay more for less care. One example is healthy young men (see above), but also included are people who do not need many of the preventative services offered such as smoking cessation, weight reduction, etc.

Obamacare promises improved, cheaper healthcare. The logic is that costs would be reduced and healthcare would be improved by paying only for value- and evidence-based care. However, this approach has been in place for some time at CMS and has yet to reduce costs or improve care. For example, President Obama promised that electronic healthcare records would “…cut waste, eliminate red tape and reduce the need to repeat expensive medical tests”. However, rather than reduce costs, the opposite happened. With better documentation, physicians billed at higher levels actually increasing costs (15). Response blaming physicians was swift implying physician malfeasance rather than administrative mismanagement (16). To date no evidence of widespread fraud has been produced. Even CMS’ highly touted hospital infection reduction program fails to pass muster on close inspection. The incidence of hospital infection relies on hospitals self-reported data. Faced with a financial penalty, many hospitals have chosen to be less than truthful about their infection rates rather than accept a reduction in payments (17).

Most of the deficiencies of Obamacare can be corrected. Correction can only occur when programs are tested and then observationally evaluated to identify problems that may arise. Elements of programs that are beneficial should be continued and improved. Bad ones should be dropped. The political game of continuing costly programs that do not improve healthcare and spinning the results will jeopardize everyone’s future. Even with the most perfect programs (and Obamacare is far from that), Obamacare insures 30 million additional people and that costs more. The money to pay for it will have to come from healthy workers. There is no such thing as a free lunch.

Richard A. Robbins, MD*

Manoj Mathew, MD*

References

  1. Kaiser Family Foundation. Summary of the affordable healthcare act. Available at: http://kff.org/health-reform/fact-sheet/summary-of-new-health-reform-law/ (accessed 8/12/13).
  2. Wieczner J. 10 Careers Boosted by Obamacare. Available at: http://finance.yahoo.com/news/10-careers-boosted-obamacare-150410654.html?page=2. (accessed 8/12/13). 
  3. Patton W. Obamacare, part III: who will benefit the most? Forbes. Available at: http://www.forbes.com/sites/mikepatton/2012/11/30/obamacare-part-iii-who-will-benefit-the-most/ (accessed 8/12/13).
  4. Bureau of Labor Statistics. Occupational outlook handbook: medical records and health information technicians. Available at: http://www.bls.gov/ooh/Healthcare/Medical-records-and-health-information-technicians.htm (accessed 8/12/13).
  5. Woolhandler S, Campbell T, Himmelstein DU. Health care administration in the United States and Canada: micromanagement, macro costs. Int J Health Serv. 2004;34(1):65-78. [CrossRef] [PubMed]
  6. Bureau of Labor Statistics. Occupational outlook handbook: fitness trainers and instructors. Available at: http://www.bls.gov/ooh/personal-care-and-service/fitness-trainers-and-instructors.htm (accessed 8/12/13).
  7. Bureau of Labor Statistics. Occupational outlook handbook: physician assistants. Available at: http://www.bls.gov/ooh/Healthcare/Physician-assistants.htm (accessed 8/12/13).
  8. Bureau of Labor Statistics. Occupational employment statistics: occupational employment and wages, May 2012, 29-1171 nurse practitioners. Available at: http://www.bls.gov/oes/current/oes291171.htm (accessed 8/12/13).
  9. Bureau of Labor Statistics. Occupational outlook handbook: occupational therapists. Available at: http://www.bls.gov/ooh/healthcare/occupational-therapists.htm (accessed 8/12/13).
  10. Mangan D. Will Obamacare hurt jobs? it's already happening, poll finds. CNBC. Available at: http://www.cnbc.com/id/100825782 (accessed 8/12/13).
  11. Robbins RA. What to expect from Obamacare. Southwest J Pulm Crit Care. 2013;6(1):23-8.
  12. Luhby T. Who loses out under Obamacare? CNNMoney. Available at: http://money.cnn.com/2013/07/25/news/economy/obamacare-medicaid/index.html (accessed 8/12/13).
  13. Kliff S. Hospitals serving the uninsured face challenge under Obamacare. Washington Post. Available at: http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/16/hospitals-serving-the-uninsured-face-challenge-under-obamacare/ (accessed 8/12/13).
  14. Luhby T. Where Obamacare premiums will soar. CNNMoney. Available at: http://money.cnn.com/2013/08/06/news/economy/obamacare-premiums/index.html?iid=obinsite (accessed 8/12/13).
  15. Haig S. Electronic medical records: will they really cut costs? Time 2009. Available at: http://www.time.com/time/health/article/0,8599,1883002,00.html#ixzz2FF0XBf5d (accessed 8/12/13).
  16. Carlson J. HHS inspector general's office quizzes providers about EHR use. Modern Healthcare 2012. Available at: http://www.modernhealthcare.com/article/20121023/NEWS/310239946  (accessed 8/12/13).
  17. Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med 2012;157:305-12. [CrossRef] [PubMed]

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

Reference as: Robbins RA, Mathew M. Who will benefit and who will lose from Obamacare? Southwest J Pulm Crit Care. 2013;7(2):103-8. doi: http://dx.doi.org/10.13175/swjpcc106-13 PDF

Saturday
Jul202013

Smoking, Epidemiology and E-Cigarettes

"The true face of smoking is disease, death and horror - not the glamour and sophistication the pushers in the tobacco industry try to portray." - David Byrne

In our fellows’ conference we recently reviewed the evolution of the science of clinical epidemiology as it relates to the association of smoking and lung cancer and the concurrent history of tobacco marketing in the United States. 

This story begins in 1950, when Richard Doll and Austin Bradford Hill published their landmark case control study demonstrating the association between smoking and lung cancer (1). This study was performed with methodological standards that have rarely been matched in the 63 years since.  Exhaustive analysis of possible confounders, a multi-stage evaluation of study blinding, determination of dose-effect, and the use of multiple analyses to establish consistency are among many examples of superb attention to detail exercised by Doll and Hill in this study.  The results showed that patients with lung cancer were about 15 times more likely than matched control patients to have smoked tobacco (Odds ratio 15).  The p-value was 0.00000064  - indicating that the probability of calculating such a result by chance alone is less than one-in-a-million.  In comparison, many modern case control trials are characterized by weak associations (odds ratios of 1-3) with p-values that are barely significant.  Yet the phenomenal and nearly unparalleled results of this study had practically no discernable effect on the increasing rate of smoking in the following decade.

Many factors opposed the conclusions of Doll and Hill.  Atmospheric pollution – perhaps emanating from motor car exhaust or asphalt tarmac – was felt to be the leading suspect in the increasing incidence of lung cancer.  At the time, it seemed inconceivable to most people that smoking could cause cancer.  Two thirds of British men smoked.  Smoking was widely endorsed by the medical profession – Doll and Hill themselves had both previously been smokers.  The British Department of Health did not endorse their findings, amid worries that the study might start a panic.  Several prominent statisticians, including Sir Ronald Fisher, publicly criticized their study design and conclusions.  Fisher was a polymath – a genius with significant accomplishments in multiple disciplines, widely recognized as the founder of modern statistics, having invented Fisher’s exact test, and ANOVA and having collaborated in the development of the Student’s T test.  Fisher was also an avid smoker.  It was later disclosed that Fisher had lucrative financial ties to the tobacco industry, raising questions whether Fisher’s criticisms of Doll and Hill were bought and paid for.

Doll and Hill followed up with a stronger study design – performing one of the finest cohort studies ever – the British Physician’s study.  They enrolled over 40,000 British Physicians – almost 70% of all registered in Britain.  Outcomes in this cohort were eventually evaluated over 50 years, and contributed to our knowledge in many areas of medicine.  But the results in regards to the relationship between smoking and lung cancer were objectively convincing within the first decade of follow-up.  In an interim analysis in 1961 (2), the relative risk for lung cancer in smokers was found to be increased 18 times – consistent with the findings of their case control trial.  Fisher’s exact test was incalculable in 1961 since it required the quantization of enormous factorials, but I calculated a p-value of 0.0000000000000001 (one in 100-quadrillion) using their data and an on-line Microsoft statistics program.  It’s satisfying to find that Fisher’s namesake statistic so convincingly validates the conclusions that he personally refuted.  Sir Austin Bradford Hill is famous for his contention that we often over-focus on achieving a p-value < 0.05 in modern medical research – the incomparable statistical significance of this study illustrates his point.  

Despite increasing scientific evidence against smoking, cigarette consumption in the U.S. continued to rise, and did not fall below pre-1950 levels until the early eighties.  A further generation of young men took on the habit, many of which were introduced to smoking in the armed services - cigarettes having been routinely included in C-rations of US soldiers who fought in WWII, Korea and Viet Nam.  Cigarette smoking was endorsed by everyone from movie stars, to sports stars to doctors – Bob Hope, Mickey Mantle and Ronald Reagan among them.  Santa Claus appeared in multiple ads with a cigarette in one hand, and his red toy bag in the other – fecklessly endorsing multiple different brands including Lucky Strikes and Pall Malls. 

Several tobacco advertisement campaigns were particularly influential.  Philip Morris introduced the “Marlboro Man”, considered one of the most brilliant ad campaigns in history, in 1954.  Marlboro cigarettes were filtered.  The implied (but factitious) protective benefits of the filter were not explicitly marketed, but filtered cigarettes were considered “feminine” at the time.  The use of real rodeo cowboys in the Marlboro ads dramatically changed that impression – particularly in the minds of post adolescent boys.  One indication of the success of the Marlboro Man is that Philip Morris is said to have spent $300 million dollars finding a replacement when Darrell Winfield, the most famous of the Marlboro men, retired.

In the late sixties, Philip Morris also marketed smoking to young women with a brand designed specifically for women called Virginia Slims.  Riding the wave of women’s liberation, the slogan “You’ve come a long way baby” promoted smoking as a way to express emancipation and empowerment.   RJ Reynolds introduced the “Joe Camel” ad campaign in 1987, allegedly targeting children with a cool-looking cartoon of an anthropomorphic camel.  Sounds silly, I know, but it worked.  In 5 short years after starting this campaign, the annual sales of Camel cigarettes to teenagers rose from 6 million to 470 million dollars.  At its peak, it was shown that six-year-old children could associate the character of “Joe Camel” with Camel cigarettes about as frequently as they could associate Mickey Mouse with Disney.  A study published in JAMA concluded that tobacco experimentation by 700,000 adolescents per year could be attributed to targeted advertising (3). 

Although public education had already made great inroads in reducing smoking in the US by the 80’s, legal and governmental anti-smoking pressure began to build thereafter.  In 1988, Rose Cipollone  posthumously won the first successful wrongful harm lawsuit of a smoker against a tobacco manufacturer.  Mangini sued RJ Reynolds on behalf of children in regards to the Joe Camel ad campaign.  In the 1988 Report of the Surgeon General, C Everett Koop concluded that nicotine has an addictiveness similar to that of heroin.  C Everett Koop’s continuing efforts to raise public awareness initiated some of the first public discourse in regards to the dangers of second-hand smoke (subsequently found to cause 50,000 deaths per year in the U.S.).  Smoking rates in the United States declined from 38% to 27% during his tenure.

In the 1990s, the tobacco lobby engaged in a comprehensive and aggressive political effort to neutralize clean indoor air legislation, minimize tobacco tax increases, and preserve the industry's marketing strategies.  However the famous Waxman congressional hearings intervened in 1997.  In sworn testimony before congress, the CEOs of seven major tobacco companies famously asserted that smoking tobacco was not addictive, contrary to incontrovertible scientific evidence.  Two sources revealed their insincerity.  The first was testimony of previous employees of the tobacco industry, such as Jeffrey Wigman and Victor DeNoble, who testified that the addictive and carcinogenic properties of cigarette tobacco had been artificially manipulated by the industry.   The second was the discovery of internal tobacco industry memos, which revealed that the addictive properties of tobacco were well recognized within the industry as early as 1960s.  A few excerpts follow:

“… nicotine is addictive. We are, then, in the business of selling nicotine, an addictive drug” July 17, 1963 report by then Brown & Williamson general counsel/vice president Addison Yeaman.

 “The cigarette should be conceived not as a product but as a package. The product is nicotine. …Think of a cigarette as a dispenser for a dose unit of nicotine…”  1972 William Dunn, Jr., of the Philip Morris Research Center, “Motives and Incentives in Cigarette Smoking.”

“Within 10 seconds of starting to smoke, nicotine is available in the brain. . . giving an instantaneous catch or hit . . . Other “drugs” such as marijuana, amphetamines, and alcohol are slower”  Circa 1980  C.C. Greig in a BAT R&D memo

The Waxman hearings resulted in a $368 billion dollar assessment against the tobacco industry, and increased restrictions on advertising and lobbying.  Shortly thereafter, the Joe Camel and Marlboro Man ad campaigns were terminated.  With the public revelation that three previous Marlboro Men had died from lung cancer, that ad campaign had lost its appeal.  

In the late 90s/early 2000s, the nicotine content of all major brands of cigarettes was progressively increased on average by 1.8% per year.  This might theoretically make it harder for smokers to kick the habit.  Sales promotions totaling about $400 per year per smoker were directed at loyal smokers.  Despite restrictions, the tobacco industry continued to invest $25 million dollars per year in lobbying.  Upon further negotiation, the tobacco master settlement was reduced to 200 billion – only 12.7 billion to be paid up front.  The full details of this settlement have become increasingly legally obfuscated over time in my opinion; some states are actually selling tobacco settlement bonds now to protect themselves against loss of future return from the settlement.   

Although US cigarette consumption has dramatically fallen, worldwide sales are peaking, and the international rates of women smokers are still on the rise.  Philips Morris restructured and rebranded their corporation as Altria (sounds like the word “altruistic”).  They subsumed Kraft and Nabisco foods, but the majority of their >100,000 million dollars in annual revenue are derived from tobacco sales, about two-thirds of which are international. 

Many US tobacco firms are rapidly investing in production and marketing of electronic cigarettes that vaporize nicotine for inhalation.  It is likely that inhaling vaporized nicotine is less dangerous than smoking tobacco.  However, the health effects of inhaling vaporized nicotine are not well studied yet.  The purported benefits of vaping over smoking have already been publicly aired as an argument to turn back current restrictions on public smoking.  Electronic cigarettes are being advertised as glamorous again in advertisements reminiscent of tobacco ads seen in the 1970s.  E-cigs in which nicotine is flavored with chocolate, or various fruit flavors, seem to once-again target children.  The promotion of a highly addictive drug to children and young adults cannot be beneficial to society in the long term, even if vaping doesn’t lead to lung cancer.  But the rapid increase in vaping promises that another round in the societal struggle against nicotine addiction is about to begin again.

Doll and Hill’s work played a tremendous beneficial role in this story.  Their case control and cohort studies set the methodological standard by which all subsequent observational trials should be measured – although our experience in journal club is that modern observational trials don’t even come close.  Furthermore, their work became the basis for the subsequent formulation of the “Bradford Hill Criteria” for establishing causation, which still plays a dominant role in medical and medicolegal reasoning.   

Robert A. Raschke, MD

Associate Editor 

References

  1. Doll R, Hill AB. Smoking and carcinoma of the lung; preliminary report. Br Med J. 1950;2(4682):739-48. [CrossRef]
  2. Doll R, Hill AB. The mortality of doctors in relation to their smoking habits; a preliminary report. Br Med J. 1954;1(4877):1451-5. [CrossRef]
  3. Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Berry CC. Tobacco industry promotion of cigarettes and adolescent smoking. JAMA. 1998;279(7):511-5. [CrossRef] [PubMed]   

Reference as: Raschke RA. Smoking, epidemiology and e-cigarettes. Southwest J Pulm Crit Care. 2013;7(1):41-5. doi: http://dx.doi.org/10.13175/swjpcc092-13 PDF

Thursday
Jul112013

Treatment after a COPD Exacerbation

A couple of years ago I was consulted about a patient at the Phoenix VA who had been admitted for the third time for a COPD exacerbation in two months. Each time the patient was treated with inhaled short-acting bronchodilators, corticosteroids and an antibiotic; rapidly improved; and was discharged after only one or two days in the hospital.  The discharge medications were albuterol, ipratropium, and rapidly tapering doses of prednisone. Apparently, no consideration was given to adding long-acting beta agonists (LABA), long-acting muscarinic antagonists (LAMA), and/or inhaled corticosteroids (ICS). These later medications have been shown to reduce exacerbations in most studies (1,2).

I was reminded of this incident by a recent article published by Melzer et al. in the Journal of Internal Medicine (3). The authors examined 2760 patients with exacerbations of COPD admitted to hospitals in the VA Northwest Health Network (VISN 20) to determine if a LABA and/or glucocorticoid were prescribed at discharge. These medications reduce exacerbations and the best predictor of a future exacerbation is a history of exacerbations (1,2,4). Of the 2760 patients 93% were not receiving a LABA or an ICS at the time of their exacerbation. Of this 93%, two-thirds of the patients had no change in therapy after their exacerbation. The authors state that “among patients treated for COPD exacerbations, there were missed opportunities to potentially reduce subsequent exacerbations by adding treatments known to modify exacerbation risk”. The authors go on to suggest that the VA could develop a Quality Enhancement Research Initiative (QUERI) program to improve delivery of care for some chronic conditions.

So why did the patient at the Phoenix VA and 2/3 of the patients in VISN 20 not receive a LABA, LAMA and/or inhaled corticosteroid after their exacerbations as recommended by the GOLD and ATS guidelines? Are the doctors in the Pacific Northwest and Phoenix unaware of the guidelines as the article and its accompanying editorial imply (5)? The answer probably lies elsewhere. First, the VA does not use the GOLD or ATS guidelines but has developed their own guidelines (6). These guidelines specifically mention consideration of the addition of inhaled corticosteroids and a LAMA but make no mention of a LABA. Rather than encouraging use of these medications, programs were created at the Phoenix VA which restricted Veterans’ access to these more expensive medications. The VA administration empowered the pharmacy to make unilateral decisions based on fiscal considerations with inadequate expert clinician input. These include a requirement to refer all patients for pulmonary consultation for long-acting bronchodilator therapy. This overloaded the pulmonary clinics with patients that did not necessarily need to be seen. In addition, there was a requirement for a trial of ipratropium before beginning tiotropium which took multiple visits further overloading the clinics.

This is another example of administrators meddling in clinical care only to have it blow up in their face and cause something else to go awry wasting money. In this case, the low use of long-acting bronchodilators likely led to an increase in admissions for exacerbation of COPD which are a major determinant of the costs of COPD care (7). Ignorance of the providers is blamed and another program to correct the harm caused by the initial blunder is created. Another example is the control of blood sugar in the ICU. After pushing for tight control of blood sugar for several years, the VA Inpatient Evaluation Center (IPEC) seamlessly converted their program to one examining hypoglycemia when tight control resulting in hypoglycemia was found to be harmful with the publication of the NICE-SUGAR study (8,9).

A QUERI program examining whether a LABA and/or corticosteroid was prescribed at discharge for a COPD patient does not need to be created. What needs to be done is to allow the physicians in the Pacific Northwest and Phoenix to use their best skills and judgment in caring for the patients without interference. If something must be measured, readmissions for exacerbation of COPD could be considered but should be part of a comprehensive program that measures outcomes such as mortality, length of stay, and morbidity. Otherwise, administrative blunders to correct past mistakes will continue.

Richard A. Robbins, M.D.*

References

  1. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010. Available at: http://www.goldcopd.org/Guidelines/guidelines-resources.html  (accessed 7/7/13)
  2. Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, Criner G, van der Molen T, Marciniuk DD, Denberg T, Schünemann H, Wedzicha W, MacDonald R, Shekelle P; American College of Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155(3):179-91. [CrossRef] [PubMed]
  3. Melzer AC, Feemster LM, Uman JE, Ramenofsky DH, Au DH. Missing potential opportunities to reduce repeat COPD exacerbations. J Gen Intern Med. 2013;28(5):652-9. [CrossRef] [PubMed]
  4. Hurst JR, Vestbo J, Anzueto A, Locantore N, Müllerova H, Tal-Singer R, Miller B, Lomas DA, Agusti A, Macnee W, Calverley P, Rennard S, Wouters EF, Wedzicha JA; Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Investigators. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med 2010;363:1128-38. [CrossRef] [PubMed]
  5. Jubelt LE. Capsule Commentary on Melzer et.al., Missing Potential Opportunities to Reduce Repeat COPD Exacerbations. J Gen Intern Med. 2013;28(5):708. [CrossRef] [PubMed]
  6. The Management of COPD Working Group. VA/DOD clinical practice guideline for management of outpatient chronic obstructive pulmonary disease. Available at: http://www.healthquality.va.gov/copd/copd_20.pdf (accessed 7/7/13)
  7. Hilleman DE, Dewan N, Malesker M, Friedman M. Pharmacoeconomic evaluation of COPD. Chest. 2000;118(5):1278-85. [PubMed] [PubMed]
  8. Falciglia M, Freyberg RW, Almenoff PL, D'Alessio DA, Render ML. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med. 2009;37(12):3001-9. [CrossRef] [PubMed]
  9. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-97. [CrossRef] [PubMed]

*The opinions expressed are those of the author and not necessarily the Southwest Journal of Pulmonary and Critical Care or the Arizona, New Mexico or Colorado Thoracic Societies.  

Reference as: Robbins RA. Treatment after a COPD exacerbation. Southwest J Pulm Crit Care. 2013;7(1):28-30. doi: http://dx.doi.org/10.13175/swjpcc089-13 PDF

Thursday
Jun202013

Executive Pay and the High Cost of Healthcare 

Two recent articles examined hospital executive pay. One was “Bitter Pill: Why Medical Bills Are Killing Us” from Time magazine (1). We reviewed this article in our “March 2013 Critical Care Journal Club” (2). The other is a more recent article from Kaiser Health News (3). The later is particularly intriguing since it discusses healthcare executive compensation. We thought it might be of interest to examine executive compensation from selected nonprofit hospital tax returns from Arizona, New Mexico and Arizona. (Table 1). [Editor's note: It may be necessary to enlarge the view on your browswer to adquately visualize the tables.]

Table 1. Financial information from Southwest hospitals latest year tax return as listed by GuideStar (4).

*Includes Scottsdale Healthcare Corporation

These Southwest hospitals appear to be doing quite well. Overall they had combined incomes of $19,831,088,546, assets of $ 10,228,640,923 and profits of $1,145,888,944. None lost money. Although the data from organizations such as Dignity, Banner, Scottsdale Healthcare, Exempla, and Presbyterian Healthcare include several hospitals, they are doing well, especially for “nonprofit” hospitals.

The CEOs were also doing well (Table 2).

Table 2. CEO and executive compensation from Southwest hospitals latest year tax return as listed by GuideStar (4).

*Includes employees listed on Form 990.

**Includes Scottsdale Healthcare Corporation

The CEOs were paid an average of $1,718,484 and the average executive made $591,618. Not bad for being paid by a “nonprofit” organization. The CEO pay is nearly 8 times and the executive pay is nearly 3 times the slightly over $200,000 average Southwest pulmonary and critical care physician received in 2011 (5).

The Kaiser Healthcare News article went on to point out that boards at nonprofit hospitals are often paying hospital administrators much more for boosting volume than delivering healthcare value (3). Hospital administrators agreed but were quick to point out that compensation is increasingly being determined by healthcare performance incentives. However, James Guthrie, a hospital compensation consultant for Integrated Healthcare Strategies stated about administrative compensation, "What you're seeing is incentive plans that look pretty similar to what they looked like five years ago or ten years ago…they're changing, but they're changing fairly slowly."

Two of the local executives mentioned in the Kaiser Healthcare News article were Lloyd Dean and Peter Fine, heads of Dignity Health and Banner Health respectively. Incentive goals for Dean included unspecified "annual and long-term financial performance” (4). Dean's bonus for 2011 was $2.1 million. Fine speaks of "an unwavering commitment to improve clinical quality and efficiency" but Fine's long-term incentive goals included profits and revenue growth (4).

"Boards of trustees in health care are oriented around top-line, revenue goals," said Dr. Donald Berwick, who was CEO of the Institute of Healthcare Improvement (IHI) and later the Administrator for the Centers for Medicare and Medicaid Services (CMS) (Figure 1).

Figure 1. Dr. Donald Berwick

"They celebrate the CEO when the hospital is full instead of rewarding business models that improve patients' care." Such deals undermine measures in the 2010 health law that aim to cut unnecessary treatment and control costs, say economists and policy authorities (3).

An explosion of medical regulatory groups have arisen to improve quality, including Berwick’s IHI. These regulatory groups have often produced guidelines embraced by hospital administrators as improving healthcare. However, the administrators are often self-servingly paid bonuses for guideline compliance. Because nearly all the regulatory organizations are “nonprofit” like the hospitals, surely they would have more modest profits (Table 3).

Table 3. Financial information of healthcare regulatory organizations from latest year tax return as listed by GuideStar (4).

We are happy to report that the regulatory organizations had much more humble finances compared to the Southwest hospitals. Overall the four we examined totaled incomes of $589,724,293, assets of $563,032,211 and profits of $30,489,739. Only the American Board of Internal Medicine lost money with a loss of $-1,733,146 on income of nearly $50 million. For comparison, we added the Phoenix Pulmonary and Critical Care Research and Education Foundation to Table 3. It is the financial source behind the Southwest Journal of Pulmonary and Critical Care.

Executive pay was also more modest than Southwest hospital administrators (Table 4).

Table 4. CEO and executive compensation from healthcare regulatory organizations latest year tax return as listed by GuideStar (4).

*Includes employees listed on Form 990.

The CEOs were paid an average of $885,938 and the average executive made $382,009. Although much lower than the average $1,718,484 and the $591,618 paid to Southwest hospital CEO and executives, these salaries are still not bad for a “nonprofit” organization.

The only regulatory organization to lose money was the American Board of Internal Medicine. Either an increase or revenue or a decrease in expenses will eventually be necessary. The major source of income for the American Board is test revenue and increasing the fee for certification or the frequency and/or fees for maintenance of certification may be necessary. Alternatively, they could pay their CEO less than $786,751, eliminate the CEO’s spousal travel benefits, or lower the compensation for general internists such as Eric Holmboe from $417,945 to be more in line with the $161,000 average income of general internists in the mid-Atlantic region (4,5).

Donald Berwick has a good point and is correct. Hospital administrators need to be rewarded more for improving healthcare and less for keeping the hospital full and profits high. However, in 2009 while CEO at IHI Berwick was compensated $920,952 (4). This is almost 7 times the compensation of the average pediatrician in New England (5). Included were $88,200 in bonuses. It is unclear from the tax return what justified these bonuses (4).

Executive pay for both hospital and regulatory administrators is too high and contributes to the high cost of healthcare. We find no evidence that either type of administrator contributes much to improved patient-centered outcomes. Quality care continues to rely on an adequate number of good doctors, nurses and other healthcare providers. If anyone should be paid bonuses for healthcare, it is those providing care, not administrators.

Present bonus systems for healthcare administrators are perverse. As noted above these include bonuses for keeping the hospital full and profits high, neither consistent with what should be the goals of a nonprofit organization. Furthermore, increasing pay for supervising an increased number of administrative personnel will only add to the increasing costs. If administrators must be paid a bonus let them be paid for performance directly under their control. This could include ensuring that adequate numbers of good doctors and nurses are caring for the patients and improving administrative efficiency. These should result in better care but lower numbers of administrators consuming fewer healthcare dollars.

Last Friday, June 14, the Medicare Payment Advisory Commission, or MedPAC released their recommendations to Congress (8). These include recommendations that may be relative to hospital administrative pay. One is for “site-neutral payment”. Currently Medicare pays hospitals more than private physician offices for many services. MedPAC recommended that Congress “move immediately to cut payments to hospitals for many services that can be provided at much lower cost in doctors’ offices.” The commission said that “current payment disparities had created incentives for hospitals to buy physician practices, driving up costs...” This will increase the hospital’s bottom line, and therefore, the administrators’ bonuses. We agree with MedPAC’s recommendation.

MedPAC also told Congress that “the financial penalties that Medicare imposes on hospitals with high rates of patient readmissions are too harsh for hospitals serving the poor and should be changed.” Based on this and data that higher mortality is associated with lower readmission rates, we agree (9). Rewarding hospitals for potentially harmful patient practices that increase the hospital’s bottom line are not appropriate. Financial incentives for reducing readmissions should only be part of a more global assessment of patient outcomes including mortality, length of stay and morbidity. Regulatory administrators need to become more focused on patients and less on an endless array of surrogate markers that have little to do with quality of care.

Richard A. Robbins, M.D.*

Clement U. Singarajah, M.D.*

References

  1. Brill S. Bitter Pill: Why Medical Bills Are Killing Us. Time. February 20, 2013. PDF available at: http://livingwithmcl.com/BitterPill.pdf (accessed 6/17/13).
  2. Stander P. March 2013 critical care journal club. Southwest J Pulm Crit Care. 2013;6(4):168-9. Available at: http://www.swjpcc.com/critical-care-journal-club/2013/4/2/march-2013-critical-care-journal-club.html (accessed 6-17-13).
  3. Hancock J. Hospital CEO Bonuses Reward Volume And Growth. Kaiser Health News. June 16, 2013. Available at: http://www.kaiserhealthnews.org/Stories/2013/June/06/hospital-ceo-compensation-mainbar.aspx (accessed 6-17-13).
  4. http://www.guidestar.org/ (accessed 6-17-13).
  5. http://www.medscape.com/sites/public/physician-comp/2012 (accessed 6-17-13).
  6. Robbins RA, Thomas AR, Raschke RA. Guidelines, recommendations and improvement in healthcare. Southwest J Pulm Crit Care 2011;2:34-37. Available at: http://www.swjpcc.com/editorial/2011/2/25/guidelines-recommendations-and-improvement-in-healthcare.html
  7. Robbins RA. Why is it so difficult to get rid of bad guidelines? Southwest J Pulm Crit Care 2011;3:141-3. Available at: http://www.swjpcc.com/editorial/2011/11/1/why-is-it-so-difficult-to-get-rid-of-bad-guidelines.html
  8. http://www.medpac.gov/documents/Jun13_EntireReport.pdf (accessed 6-17-13).
  9. Robbins RA, Gerkin RD. Comparisons between Medicare mortality, morbidity, readmission and complications. Southwest J Pulm Crit Care. 2013;6(6):278-86. Available at: http://www.swjpcc.com/general-medicine/2013/6/13/comparisons-between-medicare-mortality-readmission-and-compl.html

*The opinions expressed are those of the authors and not necessarily the Southwest Journal of Pulmonary and Critical Care or the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA, Singarajah CU. Executive pay and the high cost of healthcare. Southwest J Pulm Crit Care. 2013;6(6):299-304. doi: http://dx.doi.org/10.13175/swjpcc080-13 PDF