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Editorials

Last 50 Editorials

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

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
Equitable Peer Review and the National Practitioner Data Bank 
Fake News in Healthcare 
Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad
   Leadership 
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 

 

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.

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Entries in pneumococcal vaccination (2)

Friday
Apr132012

Will Fewer Tests Improve Healthcare or Profits? 

Earlier this month, the American Board of Internal Medicine (ABIM) Foundation, in partnership with Consumer Reports, announced an educational initiative called Choosing Wisely (1). Nine medical organizations were asked to name five things physicians and patients should question. The initiative lists specific, evidence-based recommendations physicians and patients should discuss to make wise decisions on their individual situation. The list of tests and procedures Choosing Wisely advises against include common procedures and treatments such as EKGs done routinely during a physical examination, routine MRI’s for back pain, antibiotics for mild sinusitis, and routine EKG and chest X-rays preoperatively. Some experts estimate that up to one-third of the $2 trillion of annual health care costs in the United States each year is spent on unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life (2). We at the Southwest Journal of Pulmonary and Critical Care (SWJPCC) applaud the use of evidence-based medicine in determining testing and treatment. Any information that can inform medical decision making is welcome.

With most of the Choosing Wisely recommendations there is solid evidence that the procedures do not improve patient outcomes (1). Nevertheless several previous efforts to limit testing have failed and even provoked backlashes. For example, in November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment (2). An area of further concern is that the Choosing Wisely recommendations will be used not just to make informed decisions, but by payers to limit decisions that a patient and physician can make. This is especially true since the motivation for these recommendations may not be to improve care but to decrease expenses and increase profits by insurers and other payers.

Several of the quality improvement and training organizations affiliated with the ABIM have recommendations and guidelines that are either non- or weakly-evidence based and have not been shown to improve patient outcomes. Surely, these should also be questioned. These include most of the hospital performance measures for acute myocardial infarction, congestive heart failure, pneumonia and surgical process of care, the ventilator-associated pneumonia guidelines, and the central line associated bloodstream infection guidelines (3-5).  Furthermore, in examining the requirements for recertification by the ABIM, the parent organization that sponsored the Choosing Wisely initiative, the evidence basis for the ever increasing frequency of examinations for ever increasing fees and the quality improvement initiative in individual practices is unclear (6).

The recommendations number only 5 from each society (with several overlapping) and come from only 9 of the over 50 medical societies, organizations and boards affiliated with the ABIM. Why recommendations from other medical societies including pulmonary and critical care organizations such as the American Thoracic Society (ATS)* and the American College of Chest Physicians (ACCP) were not included was not stated. In order to help the ABIM, ATS and ACCP, we list some procedures and treatments below that pulmonary and critical care physicians might consider for inclusion in the Choosing Wisely recommendations:

  1. Pneumococcal vaccination with the 23 polyvalent vaccine in adults
  2. Chest X-ray after bronchoscopy or needle biopsy in the absence of symptoms
  3. Routine use of heparin for deep venous thrombosis prophylaxis 
  4. Routine chest X-ray in the absence of clinical suspicion of intrathoracic pathology
  5. Pulmonary consultation for bronchoscopy for nonobstructive atelectasis
  6. Ordering blood troponin levels in the absence of a clinical suspicion of myocardial infarction
  7. Admission of a patient to the ICU who has chosen not to be resuscitated (DNR) and without clear goals of what is be accomplished in the ICU
  8. Provision of powered mobility devices where there is not a clear medical necessity
  9. Diagnosis and management of  COPD without spirometry
  10. Developing and calling guidelines “evidence-based” when they are opinion or developed from nonrandomized trials.

Overall, the Choosing Wisely recommendations are a welcome start provided they are put to the use intended by the ABIM and contributing organizations. These should be expanded by contributions from other specialty groups and societies, but only if the evidence basis for each recommendation is clearly stated and based on adequate trials. Efforts to use these recommendations to control physician practice by proxy for financial gain are unethical and should be prominently noted and publicized if found to occur.

Richard A. Robbins, MD

Allen R. Thomas, MD

References

  1. http://choosingwisely.org/?page_id=13
  2. http://www.nytimes.com/2012/04/04/health/doctor-panels-urge-fewer-routine-tests.html?_r=1&permid=67
  3. Robbins RA, Gerkin R, Singarajah CU. Relationship between the Veterans Healthcare Administration hospital performance measures and outcomes. Southwest J Pulm Crit Care 2011;3:92-133.
  4. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
  5. Hurley J, Garciaorr R, Leudy H et al. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. (Submitted)
  6. http://www.abim.org/research/seminal-bibliography/certification.aspx

*The Southwest Journal of Pulmonary and Critical Care is the official publication of the Arizona Thoracic Society which is the Arizona state affiliate of the  American Thoracic Society.

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

Reference as: Robbins RA, Thomas AR. Will fewer tests improve healthcare or profits? Southwest J Pulm Crit Care 2012;4:111-3. (Click here for a PDF version of the editorial)

Saturday
Oct162010

Why Start A New Pulmonary/Critical Care Journal? 

Reference as: Robbins RA. Why start a new pulmonary/critical care journal? Southwest J Pulm Crit Care 2010:1:1-2. (Click here for PDF Version)

With apologies to Paul McCartney, “You'd think that people would have had enough of [pulmonary and critical care journals]. But I look around me and I see it isn't so” (1). With the inception of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) we have several goals, not adequately filled by the present pulmonary and critical care publications.

First, the primary goal of the SWJPCC is pulmonary and critical care medicine fellow education. The American College of Graduate Medical Education has placed increasing requirements for clinical education in post-graduate medical education while simultaneously increasing the requirements for scholarly activity for fellows and faculty, yet restricting fellow work hours (2). It seems that these conflicting goals are unrealistic, unless clinical scholarly activity can be incorporated into a training program. In starting the SWJPCC, we hope to fulfill the scholarly needs of both fellows and faculty while emphasizing clinical medicine through the publication of such time honored activities as case presentations and reviews of the literature.

Second, peer-reviewed journals send articles out for review. While we will do the same, we have certain expectations of our reviewers. Unfortunately, reviewers are not always carefully chosen.  Sometimes inexperienced reviewers, feeling the need to establish themselves, indulge their own sense of self-importance by becoming “nagging nabobs of negativism” (3) demanding the answer to “the ultimate question of life, the universe and everything” (4) before a manuscript will see the light of publication. While emphasizing the highest medical journal standards, we realize that fellow and faculty time is limited and we hope to be reasonable regarding expectations of our authors.

Third, there has been a trend in some journals towards publishing articles emphasizing the “short-comings” of physicians while emphasizing the virtues of identifying these “faults”. For example, the New England Journal of Medicine published an article from a health regulatory organization (the Joint Commission), touting improved healthcare through administration of the pneumococcal vaccine to adults (5). This article implied that physicians who did not provide this vaccination to their adult patients were delinquent, and the Joint Commission’s efforts “corrected” this deficiency. However, previous publications have shown that pneumococcal vaccination in older adults results in a slight increase in the risk for hospitalization, but does not decrease mortality nor the risk for pneumonia (6), findings largely confirmed by a recent meta-analysis (7). Publication of articles substituting politics or opinions (especially when they are self-serving) for evidence-based care is not part of the mission of the SWJPCC.

Last, the SWPCC aspires to be a resource for practicing physician education, emphasizing case presentations, clinical articles, review articles, imaging, and journal clubs. We hope this journal will be useful for busy clinicians, assisting them in better serving the needs of their patients while also providing insight regarding practice matters of interest to the pulmonary and critical care medicine community.

With that, we begin.

Richard A. Robbins, M.D. on behalf of the Editors

References

  1. McCartney, Paul. “Silly Love Songs”. Wings at the Speed of Sound. Palorphone/EMI, 1976.
  2. http://www.acgme.org/acWebsite/nav/Pages/navPDcoord.asp
  3. Agnew, Spiro. San Diego, CA. 1970.
  4. Adams, Douglas. Life, the Universe and Everything. ISBN 0-330-26738-8.
  5. Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-74.
  6. Jackson LA, Neuzil KM, Yu O, Benson P, Barlow WE, Adams AL, Hanson CA, Mahoney LD, Shay DK, Thompson WW; Vaccine Safety Datalink. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med. 2003;348:1747-55.
  7. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ. 2009;180:48-58.