Competition or Cooperation?

One of our local institutions, the Mayo Clinic Arizona, was mentioned in a recent op-ed in the New York Times. The editorial entitled, “It Costs More, but Is It Worth More?” by Ezekiel J. Emanuel and Steven D. Pearson (1), criticizes the Mayo Clinic in Rochester and Arizona for building two new proton beam treatment facilities at a cost of more than $180 million dollars each.  It accuses the Mayo Clinic of participating in “…a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives”. The editorial states that except for a handful of rare pediatric cancers, the evidence is lacking for treatment of other types of cancer such as lung, esophageal, breast, head and neck, and prostate cancers.

John Noseworthy MD, President and Chief Executive of the Mayo Clinic, replied that the Mayo Clinic “will carefully study proton therapy and other new therapies, compare clinical outcomes and offer high-quality, cost-effective, proven and safer treatments for patients”. In another letter to the Minneapolis StarTribune, Nosewothy goes on to say, “Mayo Clinic takes serious issue with the authors' use of Mayo Clinic and its programs in this manner. As a not-for-profit institution, we are motivated by the best interests of our patients, not ‘profit’ or competitiveness. With the facility costs, start-up expenses and the extensive training required to offer this therapy, we do not expect to break even, much less earn a ‘profit,’ on our proton therapy program for years”.

I am not an expert in either cancer treatment or proton beam therapy, but a weekend search of the medical literature largely confirms that the therapy is unproven for most cancers, although there was no evidence that proton beam is inferior to more traditional means of delivering radiation therapy. Second, the cost of proton beam therapy is high. Costs are about $55,000 plus $15,000 in physician fees per patient for the therapy alone, twice as much as a linear accelerator. This sounds like a lot of money but you still need an estimated volume of about 2,000-3,500 patients per year to cover an investment of over $180 million investment.

So why are the Mayo Clinic and others constructing these centers since they are expensive; mostly of unproven superiority over existing therapies; and reimbursement, although generous, may not cover the cost of the facility? The answer is likely competition. Competition for patients largely drives tertiary referral centers. Locally, there is a small war going on between the Mayo Clinic Arizona and the new Banner MD Anderson Cancer Center. Mayo Clinic is concerned about MD Anderson having greater name recognition and losing its patients to the new center. Banner in partnership with MD Anderson sees an opportunity to compete in a large metropolitan center without a strong university medical center. Mayo Clinic Arizona undoubtedly feels that new technologies such as proton beam are necessary to compete with MD Anderson, especially since MD Anderson has a proton beam therapy unit in Houston.  

All this is probably not good for patients and illustrates that competition in medicine does not necessarily lead to cheaper, more effective care. Patients will be easily persuaded to receive the latest and greatest therapy when their life is on the line, especially when the bulk of the cost is covered by a third party. Whether proton beam therapy is the latest and greatest is fairly difficult to determine at this time, given the absence of well designed, randomized studies. The Center for Medicare and Medicaid Services (CMS) process of determining reimbursement costs is largely a mystery but needs to show some restraint. Large reimbursements for unproven therapies such as proton beam while underfunding areas with well demonstrated benefits is not in the best public interest. Furthermore, instead of directly or indirectly encouraging competition, CMS needs to foster cooperation. Perhaps requiring hospitals to work together to study the effectiveness of proton beam to get reimbursed would be a good first step. As Franklin D. Roosevelt said, “Competition has been shown to be useful up to a certain point and no further, but cooperation, which is the thing we must strive for today, begins where competition leaves off” (5).

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Emanuel EJ, Pearson SD. It costs more, but is it worth it? New York Times. http://opinionator.blogs.nytimes.com/tag/proton-beam-therapy/ (accessed 1-23-12).
2. Noseworthy J. Mayo clinic’s investment. New York Times. http://www.nytimes.com/2012/01/06/opinion/mayo-clinics-investment.html (accessed 1-23-12).
3. Nosewothy J.  Mayo CEO defends use of proton beam therapy. Minneapolis StarTribune http://www.startribune.com/opinion/otherviews/136758278.html (accessed 1-23-12).
4. Clark C. What would super committee say about $430m proton beam center war? http://www.healthleadersmedia.com/page-1/QUA-272912/What-Would-Super-Committee-Say-About-430M-Proton-Beam-Center-War (accessed 1-23-12).
5. http://www.brainyquote.com/quotes/authors/f/franklin_d_roosevelt.html (accessed 1-23-12).

Reference as: Robbins RA. Competition or cooperation? Southwest J Pulm Crit Care 2012;4:30-1. (Click here for a PDF version of the editorial)

Follow the Money

Many years ago there was a Federal whistleblower, Deep Throat, who leaked confidential Government information about the Nixon White House to reporters from the Washington Post. Fans of the book and movie will remember that his famous line was, “Follow the money.” That line came to mind when an article appeared in Health Affairs summarizing the US health care expenditures for 2010 (1). The main gist of the article is that the rate of growth in health care expenditures had slowed to only 3.9% and approximated the slowed growth from 2009 which was 3.8%. Previously the growth had been much larger averaging 7.2% from 2000-8 (2). The article points out that during recession expenditures usually slow but the expected decline in healthcare expenditures usually occurs far after the beginning of the recession. The authors state that the “lagged slowdown in health spending growth from the recent recession occurred more quickly than was the case in previous recessions. This was the result of a combination of factors, including the highest unemployment rate in twenty-seven years, a substantial loss of private health insurance coverage, employers’ increased caution about hiring and investing during the recovery, and the lowest median inflation adjusted household income since 1996.”

Following Deep Throat’s suggestion to follow the money, healthcare expenditures are listed below in Table 1.  

Table 1. Cost, growth and increase of health care expenditures 2010 compared to 2009 arranged from greatest to least percent growth.

*Calculated as the product of cost X percent growth.

The categories accounting for the largest dollar increase in expenditures appear to be net cost of health insurance, hospital costs and physician and clinical services. Although the article in Health Affairs has a fairly comprehensive discussion of each expenditure, the exact definitions of these categories were unclear. A little searching revealed that net cost of health insurance is calculated as the difference between calendar-year incurred premiums earned and benefits paid for private health insurance (2). This includes expenses such as personnel, executive bonuses, marketing, advertising, etc., but also includes profit. Health insurers average about 20% of their premiums going for expenses and profit (3). It is estimated that about 1-10% of the health insurance premiums go to profit (3). This would translate to about 10-50% of the net cost of health insurance going for profit or about 1.2-6.1 billion in costs during 2010.

A second cost was hospital care costs which accounted for nearly 40% of the increase in expenditures. “Hospital care is a summation of incurred benefits for inpatient hospital care, outpatient hospital care, and hospital-based hospice, hospital-based nursing home care and hospital-based home health care. Also included in hospital care are estimated ’combined billing’ amounts for services of hospital-based physicians…” (2). Examining this definition, administrative costs are glaringly missing. In 1999, administrative costs accounted for 24.3% of hospital expenses and were increasing (4). Conservatively assuming that the same percentage of administrative costs account for the increase in expenditures, this 24.7% would translate to about 9.7 billion in 2010.

Physician and clinical services includes offices of physicians and outpatient care centers, plus the portion of medical and diagnostic laboratories services that are billed independently by laboratories. Physician services account for 81% of these expenditures, but this portion of the physician and clinical services grew only 1.8% in 2010. Recalculating using 81% of the 515.5 billion for physician and clinical services and a 1.8% increase, the increase in expenditures for physician services accounted for 7.5 billion. According to the article in Health Affairs, 2010 was a year when people decided to forgo care, slowing growth in elective hospital procedures, the number of prescriptions dispensed, and physician office visits (1). In other words, less healthcare led to a slowing of expenses.

The above data suggest that physicians account for only about 16% of the healthcare costs and their portion of the healthcare pie seems to be decreasing compared to other healthcare expenditures. To control healthcare costs but not decrease healthcare, policymakers need to focus on those areas of expenditures that account for much of the increase in cost, and especially those that provide no healthcare product. Cuts in the net cost of health insurance and hospital administrative costs would seem two areas where considerable cost savings could be achieved with little to no reduction in patient care.

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Martin AB, Lassman D, Washington B, Catlin A; the National Health Expenditure Accounts Team. Growth In US Health Spending Remained Slow In 2010; Health Share Of Gross Domestic Product Was Unchanged From 2009. Health Aff (Millwood) 2012;31:208-219.
2. https://www.cms.gov/NationalHealthExpendData/downloads/dsm-10.pdf (accessed 1-17-12).
3. http://thinkprogress.org/health/2009/08/05/170897/are-health-insurers-making-too-much-money/?mobile=nc (accessed 1-17-12).
4. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med 2003;349:768-75.

Reference as: Robbins RA. Follow the money. Southwest J Pulm Crit Care 2012;4:19-21. (Click here for a PDF version of the editorial)

Happy First Birthday SWJPCC!

With the end of 2011, the Southwest Journal of Pulmonary and Critical Care (SWJPCC) completed its first full year of operation. Planning for SWJPCC began in August, 2010 and our first manuscript was posted on November 11, 2010. This has been a year of growth. We posted 8 manuscripts our first year and 68 this year (Table 1).

Table 1. Postings by SWJPCC 2010 and 2011.

 

We had manuscripts submitted from each fellowship programs in the Southwest (Phoenix, Tucson, Albuquerque and Denver) but also received submissions from outside the Southwest including from foreign countries such as the UK, India and Boston (which views itself as a separate country). Our readership has also steadily grown from 30 unique IP addresses in November, 2010 to nearly 1000 during December, 2011 (Figure 1, Panel A). Accompanying this increase in uniques has been an increase in the number of page views (the number of files that are requested from a site, also known as “hits”, Figure 1, Panel B).

Figure 1. Panel A. Unique IP addresses accessing the SWJPCC site by month. Panel B. Page views accessing the SWJPCC site by month.

With the increase in manuscripts we have expanded the number of associate editors from the original 5 to 13 with representatives from each pulmonary fellowship in the Southwest. For a list of editors click here.

Overall, this has been a good start and many need to be thanked. First, thanks to our authors. You took a chance on a new journal and we appreciate the opportunity to publish your work. Second, thanks to our reviewers.  SWJPCC, like all journals, relies upon expert reviewers in order to publish the highest quality manuscripts. We thank the reviewers for their time and effort in the prompt submission of their reviews. A list of reviewers for 2011 is below.

• Owen Austrheim
• David Baratz
• Richard Gerkin
• Michael Gotway
• Manoj Mathew
• Vijaychandran Nair
• Jennie O'Hea
• Lilibeth Pineda
• Francisco Ramirez
• Robert Raschke
• Patricia Rocha
• John Roehrs
• Clement Singarajah
• Linda Snyder
• Gerald Swartzberg
• Allen Thomas
• Carolyn Welsh
• Lewis Wesselius

Several are deserving of special thanks. First, our gratitude goes to the Arizona Thoracic Society (AZTS). We are the only local thoracic society who publishes a journal and SWJPCC would have not been possible without the support of AZTS members and officers including Rick Helmers, George Parides and Mary Kurth. Second, thanks to Eric Reece, our webmaster, who set up the journal, registered the domain, etc. and who continues to serve as a consultant. Third, a personal note of appreciation to Stuart Quan whose experience as editor of Sleep has been invaluable in guiding us through the development of SWJPCC. Fourth, SWJPCC acknowledges the Phoenix Pulmonary and Critical Care Research and Education Foundation who has provided the monetary support for SWJPCC. Last, and most importantly, thanks to our readers. Please visit as often as you can and feel free to provide us with your input. The journal is for you and we will strive to do our best to fulfill your needs.

Richard A. Robbins MD, Editor, SWJPCC

Reference as: Robbins RA. Happy first birthday SWJPCC! Southwest J Pulm Crit Care 2012;4:1-3. (Click here for a PDF version) 

The Hefty Price of Obstructive Sleep Apnea

Reference as: Budhiraja R. The hefty price of sleep apnea. Southwest J Pulm Crit Care 2011;3:169-71. (Click here for a PDF version)

Obesity is approaching an epidemic level in the United States. The association between obesity and obstructive sleep apnea (OSA) is quite strong and likely causal. Approximately half of obese individuals have OSA and the risk of OSA increases with increasing BMI. Conversely, majority of individuals with OSA are obese. However, whether this relationship is bidirectional and OSA can, in turn, contribute to obesity is unclear.

The study by Brown and colleagues in the Journal attempts to answer this question ¹. The authors analyzed prospectively obtained data from a large community-based cohort and found that the participants with more severe sleep disordered breathing at baseline demonstrated a modest increase in body mass index (BMI) over a 5 year follow up period.

What can these intriguing results be attributed to? Pathophysiology of obesity is a multifactorial and complex process and may include dietary, lifestyle and genetic components.  As the authors hypothesize, an alteration in leptin-ghrelin levels in OSA may contribute to obesity. However, independent effect of sleep apnea on these metabolic hormones is still not clear. Studies in OSA, in contrast to those with sleep deprivation, actually suggest increased daytime leptin levels, primarily explained by obesity ². Similarly, contradictory data exist regarding ghrelin levels in OSA. While some studies demonstrate an increase in ghrelin levels ^{3, 4}, others do not ^{5, 6}. A decrease in energy expenditure is a plausible mechanism whereby OSA may lead to further weight gain. It is easily fathomable that disturbed sleep in obese people may contribute to daytime fatigue and lethargy and promote a more sedentary lifestyle.  However, convincing data from large studies confirming such an association is again lacking. Finally, an altered feeding behavior with a preference for a weight-gain promoting diet may be seen in sleep disordered breathing and contribute to obesity ⁷.

The strengths of this study include a large sample size derived from community-based cohorts, prospective collection of data and objective documentation of sleep abnormalities. However, the readers should bear in mind that the adjusted increase in BMI was fairly modest- in order of 0.21 kg/m² in those with mild OSA and 0.51 kg/m² in moderate to severe OSA. Furthermore, the statistical models used in the study accounted for only 7% of the total variance, suggesting that the factors not included in analysis likely played a prominent role in the weight gain.

Nevertheless, this study adds to emerging literature suggesting SDB as a risk factor for weight gain ^{8, 9}. Ideally, these data suggest need for well conducted prospective studies looking at physical activity, diet and change in BMI in patients with SDB. However, in view of the now well recognized adverse effects of severe sleep apnea, it will not be feasible to conduct long-term studies in these patients without offering treatment.  The other line of evidence that would support the hypothesis that sleep apnea predisposes to weight gain, would be weight loss with adequate therapy. Indeed some studies have assessed this, but with variable results ^10-12. Some of the factors underlying such variability in results may include differences in dietary habits, physical exercise, age of the participants, sleep duration, use of medications and presence of additional comorbidities ¹³. Future studies, apart from controlling for these variables, should also consider evaluating changes in central obesity instead of, or in addition to BMI, as the former may be a better marker of adverse cardiovascular outcomes than BMI ¹⁴.

Finally, obesity is a risk factor for an array of cardiovascular and metabolic adverse outcomes. This study provides further rationale to add abnormal sleep to unhealthy diet and lack of exercise as crucial factors that need to be modified to curb the obesity epidemic. Further longitudinal and interventional studies are required to help confirm these observations and assess the impact of better sleep on health outcomes.

Rohit Budhiraja, M.D.^{1, 2, 3}

Associate Editor

Southwest Journal of Pulmonary and Critical Care 

¹ Department of Medicine, Southern Arizona Veterans Affairs Health Care System (SAVAHCS) , Tucson, AZ

² Arizona Respiratory Center, The University of Arizona, Tucson, AZ

³ Department of Medicine, University of Arizona College of Medicine, Tucson, AZ

Corresponding Author:

Rohit Budhiraja, MD

Southern Arizona VA HealthCare System,

3601 S 6^th Ave,

Tucson, Arizona 85723

rohit.budhiraja@va.gov

Phone: 520-331-2007

Fax: 520-629-4641

References

1. Brown MA, Goodwin JL, Silva GE et al. The Impact of Sleep-Disordered Breathing on Body Mass Index (BMI): The Sleep Heart Health Study (SHHS). Southwest J Pulm Crit Care 2011;3:159-68.
2. Sánchez-de-la-Torre M , Mediano O, Barceló A et al. The influence of obesity and obstructive sleep apnea on metabolic hormones. Sleep Breath 2011 Sep 13. [Epub ahead of print]
3. Harsch IA, Konturek PC, Koebnick C et al. Leptin and ghrelin levels in patients with obstructive sleep apnoea: effect of CPAP treatment. Eur Respir J. 2003;22:251–7.
4. Takahashi K, Chin K, Akamizu T et al. Acylated ghrelin level in patients with OSA before and after nasal CPAP treatment. Respirology 2008;13:810–6.
5. Ulukavak Ciftci T, Kokturk O, Bukan N et al. Leptin and ghrelin levels in patients with obstructive sleep apnea syndrome. Respiration 2005;72:395–401.
6. Papaioannou I, Patterson M, Twigg GL et al. Lack of association between impaired glucose tolerance and appetite regulating hormones in patients with obstructive sleep apnea. J Clin Sleep Med 2011; 7:486-92B.
7. Vasquez MM, Goodwin JL, Drescher AA, Smith TW, Quan SF. Associations of dietary intake and physical activity with sleep disordered breathing in the apnea positive pressure long-term efficacy study (APPLES). J Clin Sleep Med 2008; 4:411-8.
8. Traviss KA, Barr SI, Fleming JA, Ryan CF. Lifestyle-related weight gain in obese men with newly diagnosed obstructive sleep apnea. J Am Diet 2002;102:703-6.
9. Phillips BG, Hisel TM, Kato M et al. Recent weight gain in patients with newly diagnosed obstructive sleep apnea. J Hypertens 1999;17:1297-300.
10. Chin K, Shimizu K, Nakamura T et al. Changes in intra-abdominal visceral fat and serum leptin levels in patients with obstructive sleep apnea syndrome following nasal continuous positive airway pressure therapy. Circulation 1999;100:706–71.
11. Loube DI, Loube AA, Erman MK. Continuous positive airway pressure treatment results in weight loss in obese and overweight patients with obstructive sleep apnea. J Am Diet Assoc 1997; 97:896–7.
12. Redenius R, Murphy C, O'Neill EO, al-Hamwi M, Zallek SN. Does CPAP lead to BMI? J Clin Sleep Med 2008;4:205–9.
13. Quan SF, Budhiraja R, Parthasarathy S. Is There a Bidirectional Relationship Between Obesity and Sleep-Disordered Breathing? J Clin Sleep Med 2008;4: 210–211.
14. Lee CM, Huxley RR, Wildman RP, Woodward M. Indices of abdominal obesity are better discriminators of cardiovascular risk factors than BMI: a meta-analysis. Journal of Clinical Epidemiology 2008; 61: 646-653.

Mismanagement at the VA: Where’s the Problem?

Reference as: Robbins RA. Mismanagement at the VA: where's the problem? Southwest J Pulm Crit Care 2011;3:151-3. (Click here for a PDF version of the editorial)

At the time I retired from my last Veterans Administration (VA) position there was an ongoing investigation into alleged mismanagement of non-VA fee care funds at this hospital. The VA Office of Inspector General (VAOIG) report of this investigation was released on November 8, 2011 (1). The VAOIG report is reflective of a wide-ranging problem of administrators making what are fundamentally clinical decisions and not allowing clinicians to determine the best allocation of resources - issues that are not unique to the VA. 

The VAOIG’s report substantiated that the hospital experienced a budget shortfall of $11.4 million in 2010, 20 percent of the 2010 Non-VA Fee Care Program funds. According to the VAOIG report highlights, “The shortfall occurred because the hospital lacked effective pre-authorization procedures for Long Term Acute Hospital fee care. Additionally, staff did not monitor inpatient fee care patients to determine if the patients could receive services in a VA facility”. As someone who spent about 1 week a month in the intensive care unit and cared for several of the patients who ultimately were transferred to receive long term acute hospital fee care, these recommendations seem inconsistent with the facts.

The purpose of the Non-VA Fee Care Program is to assist Veterans who cannot easily receive care at a VA medical facility. This program pays the medical care costs of patients to non-VA providers when the VA is unable to provide specific treatments or provide treatment economically. To initiate non-VA care, clinicians sent a consult form to a physician designated by the chief of staff for review. Almost all of the fee care claims were approved. The single, approving physician received hundreds of requests per week and lacked both the expertise and time to perform a detailed review of the requests.

Among the problems singled out by the VAOIG’s report was the use of long term acute care for the purposes of ventilator weaning. The report suggests that there was no determination of whether the VA could provide these services. To my knowledge there was no VA facility that provided long term ventilator care within 100 miles of the hospital.

It is known that predicting the ability to wean a patient from long-term mechanical ventilation is imprecise (2). According to the VAOIG’s report “…30 days was a reasonable limit to attempt ventilator weaning. If the veteran had not weaned in that time, then the [hospital] needed to re-evaluate the appropriateness of continued weaning and consider alternative medical options.” Thirty days is considerably shorter than the 3 months recommended by a collective task force from the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine (2).

The VAOIG report estimated that overspending on long term acute care resulted in $4.5 million of the nearly 12 million dollar in over spending. Although it is not clear how this figure was calculated, it is almost certainly an over estimate of the potential cost savings since these patients require care whether in an acute care facility for weaning or a long-term care facility and is based on a 30 day period rather than a 90 day period of weaning

Later in the VAOIG report two additional problems are identified which more likely explain the overspending: inadequate budgeting and inadequate accounting. Not knowing how much is being spent from an inadequate budget is a problem, but there is also another, more fundamental problem not identified in the VAOIG’s report. Why was there no VA acute care or long term facility available to care for these patients? There is certainly sufficient medical expertise within the VA to perform these services. It seems likely that a comparatively small investment in an appropriate facility could have resulted in considerable savings.

There is no convincing evidence presented in the VAOIG’s report that the non-VA services requested were inappropriate. Yet, the VAOIG’s report suggests replacing the lone, over-worked, part-time clinician with inadequate expertise with a full-time person or committee. These approving official(s) will probably also lack the expertise necessary to make these clinical decisions and do little more than harass clinicians for paperwork and documentation while inadequately reviewing the charts and avoiding responsibility for any decisions.

In response to the discovery of the shortfall, the hospital initiated several interim approaches to save money including a hiring freeze. This seems reasonable, but in the middle of the hiring freeze, administration did hire an assistant director into a newly created position. However, clinical personnel who had left or retired were not replaced. Second, the chief of staff who oversaw this shortfall placed a measure on the clinicians’ performance plan that non-VA fee basis spending be reduced compared to the previous year. Yet, according to the VAOIG’s report, the problem appeared to be inadequate budgeting and accounting rather than overspending. Not surprisingly, morale suffered and was reflected in an employee survey which ranked in the bottom 10% of the VA in 5 of the 6 categories surveyed. In order to improve these scores, the chief of staff charged the chiefs of each service with improving morale when the problem appeared to lie a little closer to home. Lastly, the hospital determined that chronic ventilator patients be held in the ICU in order to save non-VA fee expenses. The cost of this decision is that when the ICU is full, that VA patients needing ICU care are transferred to another hospital, a cost paid by the VA. Whether this administrative decision will save money is unknown.

This VAOIG’s report fails to emphasize the major problems, i.e., failure of the administration to work with the clinicians, inadequate budgeting and inadequate accounting. Rather than suggesting reasonable solutions, the VAOIG’s report rewards these administrative blunders by offering increasing administrative control over clinicians and apparently increasing administrative personnel as solutions. These recommendations do nothing other than waste resources which could be used for care of Veteran patients.

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. http://www.va.gov/oig/pubs/VAOIG-11-02280-23.pdf (accessed 11/17/11).
2. MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, Hess D, Hubmayer RD, Scheinhorn DJ; American College of Chest Physicians; American Association for Respiratory Care; American College of Critical Care Medicine. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001;120:375S-95S.

Editor’s note: Since this budget shortfall came to light, the hospital director retired for medical reasons; the chief of staff was transferred to another VISN as VISN chief medical officer; and the associate director has left the hospital.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.