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General Medicine

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

Professionalism: Secondary Goals 
Professionalism: Definition and Qualities
Professionalism: Introduction
The Unfulfilled Promise of the Quality Movement
A Comparison Between Hospital Rankings and Outcomes Data
Profiles in Medical Courage: John Snow and the Courage of
   Conviction
Comparisons between Medicare Mortality, Readmission and 
   Complications
In Vitro Versus In Vivo Culture Sensitivities:
   An Unchecked Assumption?
Profiles in Medical Courage: Thomas Kummet and the Courage to
   Fight Bureaucracy
Profiles in Medical Courage: The Courage to Serve
   and Jamie Garcia
Profiles in Medical Courage: Women’s Rights and Sima Samar
Profiles in Medical Courage: Causation and Austin Bradford Hill
Profiles in Medical Courage: Evidence-Based 
   Medicine and Archie Cochrane
Profiles of Medical Courage: The Courage to Experiment and 
   Barry Marshall
Profiles in Medical Courage: Joseph Goldberger,
   the Sharecropper’s Plague, Science and Prejudice
Profiles in Medical Courage: Peter Wilmshurst,
    the Physician Fugitive
Correlation between Patient Outcomes and Clinical Costs
   in the VA Healthcare System
Profiles in Medical Courage: Of Mice, Maggots 
   and Steve Klotz
Profiles in Medical Courage: Michael Wilkins
   and the Willowbrook School
Relationship Between The Veterans Healthcare Administration
   Hospital Performance Measures And Outcomes 

 

Although the Southwest Journal of Pulmonary and Critical Care was started as a pulmonary/critical care/sleep journal, we have received and continue to receive submissions that are of general medical interest. For this reason, a new section entitled General Medicine was created on 3/14/12. Some articles were moved from pulmonary to this new section since it was felt they fit better into this category.

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Friday
Jun202014

Professionalism: Secondary Goals 

Robert A. Raschke, MD

Banner Good Samaritan Medical Center

Phoenix, AZ

Please recall my lengthy disclaimer from Part 1 of this series.

In part two, we reviewed the Oath of Maimonides. We considered our profession as a sacred vocation. We defined professionalism: A good doctor can be trusted to always place his/her individual patient’s best interest first, with ability, good judgment, and a caring attitude. We determined that we should be willing to make sacrifices in our commitment to our primary goal (as critical care physicians) – getting our patients and their families through their illness with as little disability and suffering as possible.

Now, my second disclaimer – I am going to express my opinions from atop my Ivory Tower – as I am not in private practice, and protected a bit from the harsh reality of the business world. I am going to express my possibly somewhat naive perspective on secondary goals related to our profession. These are not necessarily bad, but they may distract from our primary goal. I personally feel that I have to de-prioritize these goals in order to do what’s best for my patients.

It is not your primary goal to run your business.  I’m employed in a teaching hospital - so I can speak to this issue without having to "pay the overhead". However this was a personal choice I made early in my career, at a time when it was an unpopular and poorly-paid career path. I was able to afford it because my wife and I kept modest personal finances. The small home we raised our children in for 20 years cost less than twice my starting salary of $65,000. We have been blessed by not having to worry much about money along the way.  

The good salary we make as doctors ought to be used to achieve financial security in a modest lifestyle, so that we are less vulnerable to financial incentives. Remember, we did NOT go into medicine for the money. I’ve observed that some of my colleagues who spend a lot of money in their personal lives get caught-up in business practices that are not the best for their patients. I’ve also observed that some of the highest-earning physicians are most likely to suffer financial anxiety or even personal bankruptcy. Separate physician and business duties as much as possible .  Don’t hang out with or take gifts from medical salespeople that you would be at-all ashamed to tell your patients about. If you find your actions as a doctor are being unduly influenced by financial incentives, consider whether you can simplify your personal finances.

It is not your primary goal to have your patients or colleagues like you, as long as you are acting with good judgment and good attitude, in the patient’s best interest. One of my partners recently had a very frank discussion with a patient who was strongly suspected of Munchausen’s disease. Her self-destructive behavior had resulted in numerous ICU admissions and over 20 unnecessary endotracheal intubations. It was crucial to the care of this patient that this diagnosis was confronted, to avoid other unnecessary and dangerous interventions, and so that the underlying psychiatric disease could be treated. But this confrontation prompted an angry response. The patient filed an official complaint. This complaint came at a very bad time for my partner, and actually threatened costing him his job – although thankfully this did not come to pass. I hope he is able to do the right thing again next time, but it can be hard in a system where incentives for universal patient satisfaction are strong.

Another of my partners recently expressed exasperation with the more common difficulty of properly communicating poor prognosis to overly-optimistic family members who are praying for a miracle. We agreed that we have an obligation to express the truth – withholding poor prognostic information is essentially a lie of omission. Sometimes family members misinterpret this as a pessimistic attitude rather than plain old-fashioned honesty, no matter how much compassion we bring to the topic.    

I have injured my friendship and working relationship with several of my colleagues over the years because of disagreements over what was best for the patient. Conversely, some of my most shameful actions as a doctor were committed in an attempt “smooth things over” with colleagues that appeared to be trying to achieve the impossible, usually in relation to what I perceived to be futile care.

Several years ago, I was called to the bone marrow transplant unit to intubate a young woman with recurrent acute leukemia. She had previously failed two allogeneic bone marrow transplants, and had just failed an investigational chemotherapy protocol. She was in blast crisis, and rapidly developing multisystem organ failure. Worst of all, she had grade IV graft-vs-host disease and suffered florid gastrointestinal symptoms and was covered in skin lesions. She was non-communicative due to multifactorial delirium. Her family trusted the transplant hematologist, having known him for years, and they believed him when he told them that he could still save her.  

The transplant hematologist and I had had many disagreements in the past in situations in which I felt that patients and their families had been subjected to unnecessary suffering in futile situations, but up to this point, we had always been able to find at least an uneasy alliance. This time though, I flat out refused perform the requested intubation, and instead strongly recommended comfort care. I explained by rational to the patient’s family, who reacted with anger.  The transplant hematologist consulted a critical care physician from another group who came and inbutated the patient. The patient died several days later, during infusion of stem cells as part of a third transplant attempt.

This conflict damaged the working relationship between our groups, and hurt everyone’s job satisfaction, because we all enjoyed supporting the good work done in our bone marrow unit. It also hurt our group’s billings. But as best I can tell, my partners understood and supported my decision.   

It is not your primary goal to avoid a lawsuit. It is an incredible blessing not to get sued in the course of your career. Besides the obvious drawbacks, the stress of a lawsuit can seriously degrade your capacity to concentrate on taking care of patients, and even lead to physical illness. A lawsuit may even be career-ending – several very good clinicians that I know have made drastic career changes as a result of lawsuits. One perinatologist became an acupuncturist after a lawsuit involving an unpredictable complication of a blood transfusion. Others dropped out of critical care to practice office medicine or take administrative jobs.

But our primary goal takes precedence over medical-legal concerns. The practice of defensive medicine often leads patients to suffer complications of medically unnecessary procedures. Honesty in disclosure of errors is an ethical facet of our profession that often conflicts with the desire to avoid lawsuits. I once disclosed a major error in anticoagulation therapy that led to potentially disfiguring complications of cosmetic facial surgery to a young woman and her husband – this motivated them to send a letter to the CEO of our hospital at the time (the guy who signs my paycheck). Another time, I disclosed to a family that a patient’s previously unexplained in-hospital mortality had been determined to be caused by a transfusion-related West Nile Virus infection. I had exerted a major effort to make this obscure post-mortem diagnosis, the discovery and disclosure of which led to a request for records from a law-firm retained by the family.

I very much appreciate the help of the lawyers and paralegal staff of our risk management department, but I purposely avoid asking them for advice in situations when I already know the right thing to do for the patient. 

It is not your primary goal to achieve external measures of “quality” or utilization. Recently, the idea of physician “report cards” has been popularly embraced, and many employed physicians now have financial incentives based on surrogate measures of quality-of-care. Unfortunately many of the pooled outcomes used to define quality are difficult to interpret in the care of an individual patient. Recall the story of the liver transplant patient who received prolonged futile care (related in part 2 of this series). Note that the initial, poorly-focused care of this patient benefitted the 12-month mortality statistic for the transplant program, while appropriate comfort-focused care of the patient worsened the ICU mortality statistic. This example shows how statistics that sound like very valid measures of quality can be very misleading.  

Other surrogate markers of “quality” are initially supported by what seems like high-level experimental evidence, but are later found to lack benefit, or in some cases even cause harm. Recent examples in our specialty include early goal-directed therapy for severe sepsis, tight glucose control and the use of drotrecogan-alpha (Xigris®).

Even valid surrogate measures of quality are likely to greatly oversimplify what it means to be a good doctor, focusing excessively on a few particular elements of care, and distracting from aspects that might be more important to an individual patient.

I resist being incentivized to achieve any measure that may conflict with my primary goal, but also think we ought to analyze our “quality data” with open and self-critical minds. I do my best to use it to learn to how to make myself a better doctor, rather than concentrating solely on making my statistics improve. I think it is best to simply do the best job you can for each individual patient, prioritizing the things that are most important to that person, and let specific individual data points that others use to define quality fall where they may.

I don’t like being on committees, but I force myself to be involved in the process by which quality measures are chosen. I bring skepticism to the meetings, even in regards to practices that are currently “evidence-based” – because history proves that many of these will eventually be found to be erroneous. I try to champion quality improvement processes that make the most sense, such as hand-washing, and getting unnecessary invasive hardware (such as unneeded Foley catheters, and IV lines) out as soon as possible.

Unfortunately, the un-professional behavior of a few among us has damaged the trust that most people have for their doctors, providing a rationale for monitoring and incentivizing our behavior. But real professionals don’t need to be financially incentivized to do what’s right. It is my opinion that the people who most want to incentivize us (politicians and administrators) do not have the wisdom to pick the right actions to incentivize, and may not always have the individual patient’s best interests at heart.

Capacity: You have to be cognitively, psychologically and physically healthy to do your best work as a doctor. I studied medicine pretty hard during my training, but I am fundamentally intellectually (and all-around) lazy. Once I went into practice, I found I had trouble keeping current with medical literature, no longer having to worry about board exams. Trying to force myself to read worked about as well as most diets. Eventually the problem was solved when I started a monthly Critical Care journal club with our fellows. This forced me to review the current literature each month, and actually read the articles carefully. We each have our own ways to stay current, but having a teaching job is a big advantage. It justifies study as a job duty, and protects some time for you to work on it.

Happiness in your personal life will reflect on your ability to survive stress and maintain the right attitude at work. My wife Carolyn has been a wonderful blessing to me in this regard, and has helped me be a better doctor. Back in the days before we took night call, whenever my pager went off at night, it woke us both up. I would call in and try to figure out over the phone whether the patient was sick enough to warrant getting out of bed and driving in to the hospital in the middle of the night. It was pretty obvious to Carolyn that my ability to make good decisions when awoken from delta waves at 3 AM was questionable at best.  She suggested that I should just go in and see every ICU admit no matter how things sounded over the phone.  “You don’t do anything but toss and turn in bed anyway worrying that you should have gone in”.

This was a little extreme at the time for a teaching program, because we already had interns and residents in house all night. But it was endorsed by my wife, and it helped improve our patient care. The system was adopted by our entire group and practiced until we switched to 24-hour in-house coverage.  My happy marriage and supportive home life are an important counterbalance to the disappointments I often face in the ICU.      

Exercise regularly – you ought to be able to get some exercise even during your busiest work weeks. Whether you like running, yoga, weight-lifting or playing with your dog, your physical capacity and ability to concentrate will benefit from regular physical activity outside the hospital. I try to do some form of exercise at least twice a week, no matter how late I get home, even if it’s only for ten minutes.

Don’t take a job that will exceed your capacity to provide good care. I have seen hospitalists with a work list exceeding 50 patients for weekend rounds. No matter how efficient you are, no one can reliably do a good job with that magnitude of work load.

Feel free to comment if you disagree with part or all of the above. They are just the personal opinions of a confessed ex-altar-boy and boy scout!

END OF PART THREE  (next: part 4: “Attitude”)   

Reference as: Raschke RA. Professionalism: secondary goals. Southwest J Pulm Crit Care. 2014;8(6):349-53. doi: http://dx.doi.org/10.13175/swjpcc081-14 PDF

Thursday
May292014

Professionalism: Definition and Qualities

Robert A. Raschke, MD

Banner Good Samaritan Medical Center

Phoenix, AZ

 

[Please recall my lengthy disclaimer from Part 1 of this series.]

Moses Maimonides (1135-1206 AD) was a Jewish rabbi, philosopher and physician who studied and practiced in northern Africa. The Oath of Maimonides expresses his attitude towards our shared profession, that is still applicable to the bedside in a modern ICU:

"The eternal providence has appointed me to watch over the life and health of Thy creatures.

May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.

Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling."

I want to try to define professionalism, then call-out distinct qualities required to do the job right, as enumerated by Maimonides.

Definition of professionalism for a doctor: A good doctor can be trusted to always place his/her individual patient’s best interest first, with ability, good judgment, and a caring attitude.

Maimonides points out, first and last, that it is a privilege to be a doctor –not just a career (the word career implies that our main purpose is to make a living for ourselves).  Being a doctor is a sacred vocation. Our profession is first and foremost one of being a servant to others, not to ourselves. I personally can’t reliably maintain this attitude every minute of the day, but I try to remember it as often as I can. In addition to this proper attitude, Maimonides describes commitment, capacity, compassion and humility, which we will discuss shortly. But let’s start with “attitude” - just as Maimonides did.

I once very briefly took care of a 57 year old woman with a past medical history of short bowel syndrome, dependent on intravenous feeding. She had acutely developed Klebsiella pneumoniae sepsis of unclear origin and acute renal failure. She was receiving antibiotics, stress-dose steroids and dialysis. During her hospital course, she developed belly pain, and a CT showed pneumatosis intestinalis. The surgeon initially recommended conservative medical care, but after 72 hours, her condition deteriorated and he decided to operate. I saw her in the early afternoon on that day, just before the operating room technicians arrived to take her down to the OR. By this point, the proper course of action was already decided, and nothing I was likely to find on physical examination was likely to change it. So I looked her over briefly - put my stethoscope on her chest without listening very carefully - already thinking of the list of other patients I had left to see that afternoon. But as I straightened and prepared to leave her room, she told me that she was scared she was going to die.

Fortunately for me, I wasn’t terribly inpatient that day. My work list wasn’t too long.  I decided to mentally put my work aside*, and spend a little time with her [in retrospect, this thought that it was not “my work” to spend some time talking with this patient was obviously incorrect]. I brought a chair into the room and sat at her bedside. She told me some things about her life that I previously had no idea about – personal goals that her illness had prevented her from fulfilling. Now she felt she might never have another chance. I actually believed that she would come through the surgery OK.  I listened, and was able to comfort her a little. We ended up holding hands and saying a prayer together. The transport personal showed up to take her to the OR, interrupting us a little, but we had had a nice quiet moment together. I told her I would check in on her after her surgery. But she developed intraoperative complications and died in the OR, never again regaining consciousness.

This surprised and deflated me when I was notified shortly thereafter. Then it struck me more deeply that I was the last person on earth to talk with her before she died - perhaps with the exception of the anesthesiologist asking her to count backwards from 100. What would this patient’s sister, or best friend have given to trade places with me in that quiet moment we had together? The privilege that this represents is astounding. Whether you believe in God or providence, there was a reason that we are given such opportunities that goes way beyond simply making a living. The great opportunities we share demand our commitment.

Commitment: being willing to make sacrifices in an unswerving effort to achieve a single goal. Our primary goal, as taught to me by my friend and mentor, Tom Bajo, is to get the patient and their family through their illness with as little disability and suffering as possible. This sounds very straightforward on paper, but it can be hard to keep your eye on the ball in complicated clinical situations.

Consider the following story:

A 54-year-old patient who was admitted to the hospital with a chief complaint of “I feel terrible”. He underwent a liver transplant 12 months before, but was suffering transplant rejection despite treatment with tacrolimus and rapammune - drugs that had inflicted significant side effects. Over these past 2 months he suffered progressive severe liver failure, and had been turned-down for a salvage transplant. He had suffered recurrent episodes of acute renal failure, severe nosebleeds, unremitting diarrhea, encephalopathy, and depression.

In his admission history, his symptoms included nausea, anorexia, muscle pain, headaches, weakness, belly ache, recurrent nose bleeds, general debilitation and vomiting-up bile and all his medications. He had been admitted 3 times in the prior 2 months for similar complaints, only going home for a few days in between admissions.

At the time of his physical examination it was noted that he was cachectic, somnolent and deeply jaundiced. When the nurses tried to place a Foley catheter, the patient refused – the nurse quoted him in the chart as despairing: “I’ve been through so much.”

The patient expressed his wish to be made DNR to multiple physicians, and an order to that effect was written. But he was incredibly debilitated, and his ability to defend his decision was weak. A few hours later, a specialist spoke with him and rescinded the DNR order.

The primary managing physicians made the following assessment of the patient:

  1. pancytopenia secondary to liver failure
  2. volume depletion causing acute renal failure
  3. hypercalcemia partially related to immobility
  4. rhinorrhea, possibly secondary to CSF leak

(this later diagnosis seems odd, but was influenced by the patient’s complaint of a persistent runny nose after treatment of the patient by an ENT doc who was consulted to treat his nosebleeds – it was hypothesized that the treatment might have been complicated by a fracture of the patient’s cribiform plate, resulting in a cerebral spinal fluid leak)

I want to pause the story here for a moment to consider this assessment. It strikes me that it is almost unrecognizable in relation to the patient lying in the hospital bed. The assessment that lays more closely to the truth, and that would have better guided appropriate therapy is:

  1. the patient is dying.
  2. the patient is suffering.

The following management was ordered:

CT scan of brain and sinuses, spinal tap, neurosurgery consultation, ENT consultation, cefepime and vancomycin antibiotics, lab tests including TSH, free T4, iPTH, 1-25 vitamin D, 25-hydroxy vitamin D, SPEP, UPEP, Beta-2 transferrin of nasal secretions, Fe, TIBC, ferritin, methylmalonic acid level, homocystiene and fractionated bilirubin (looking for hemolysis).

I can’t say what thoughts were in other people’s minds, but their actions speak about the goals they were committed to achieving. Some appeared to be committed to merely keeping the patient alive. Some appeared to be committed to making obscure diagnoses that were highly unlikely to bring any relief to the patient. Some who privately felt the reversal of the DNR was wrong, seemed committed to preserving their working relationship with the specialist, who is a highly respected physician. Many doctors felt that what the patient really needed was comfort care, but nobody committed to that as their primary goal.

The patient suddenly lost consciousness, was found to have suffered a massive intracranial hemorrhage, and was transferred to the ICU – astoundingly for "a higher level of care”! By this, they meant more intervention – possibly endotracheal intubation. But now, my partner Jennie assumed authority for his care, and she immediately re-established DNR status and initiated comfort care.

If you are going to commit yourself to a single goal, pick the one that is achievable and most important to your patient, then chase it to the best of your ability with a caring attitude.

There are many false primary goals in medicine – not necessarily bad goals, but distractions from the best goal. We all need to de-prioritize these in order to be better doctors. In part 3 of this series, I will review some of these (likely getting myself in further trouble).

Reference as: Raschke RA. Professionalism: definition and qualities. Southwest J Pulm Crit Care. 2014;8(5):291-6. doi: http://dx.doi.org/10.13175/swjpcc071-14 PDF

Saturday
May242014

Professionalism: Introduction

Robert A. Raschke, MD

Banner Good Samaritan Medical Center

Phoenix, AZ

Editor's note: This is the first of a multi-part series on professionalism. The remaining parts will be posted over the next few weeks.

An important event in my career occurred about 20 years ago, late on a Friday afternoon. I was scheduled on call in the ICU for the entire 72-hour weekend, and even though I was just getting started, I was already tired and in a lousy mood. At 5 PM, I got a consult to see a patient in the neuro ICU. He was a 34-year-old man who had attempted suicide by drinking ethylene glycol antifreeze after an argument with his girlfriend. He had initially stabilized from a medical standpoint, but then developed delayed-onset cerebral edema. The team that was taking care of him had unsuccessfully pursued all treatment options. After 8 days of effort, he remained in a deep coma, near brain death. Now, with nothing left to try, and no hope left for a good outcome, they were dumping responsibility onto me just in time for the weekend.

I considered this unhappily as I began to page through his thick chart, trying to suppress my frustration so that I could concentrate, but I was interrupted by the patient's nurse – Terry - before I could get very far. She told me that the patient's mom had just stormed into the unit, and was demanding to talk with her son’s doctor - which as of the last 10 minutes was now me.  She warned me that the patient’s mother was inpatient, accusatory and totally unrealistic about her son's prognosis, but despite all this, Terry acted somewhat relieved that I was there. The impression that she was somehow happy about the situation made me even more angry than I already was. 

I had had enough. I really gave Terry an earful– outlining all my suspicions about the bad motivations of the referring team and concluding with my refusal to do their dirty work. Somehow, in my self-centeredness, I expected her to empathize with me. But she didn't. Instead, she appeared to be somewhat shocked and deflated. She listened silently to my rant, then turned and walked away without saying anything.

It took me a few minutes to realize that she had a higher opinion of me than I had of myself. She had thought I was a good doctor– strong enough to shoulder a tough situation– compassionate and empathic for a bereaved mother - ready to take on this challenge and make a bad situation a little better. I had proved her wrong.

I always thought of myself as a good doctor, but I realized then that I really wasn't all that good. I composed myself and tried to reset my thinking. I introduced myself to the patient’s mother briefly after explaining that I hadn't had time to review all the records– later, we would sit down and really talk. She actually wasn’t as unreasonable as I imagined she might be. It turned out I did have an important job to do in this case– to help a grieving mother come to terms with the death of her beloved son. The next day I apologized to Terry– this turned out to be a good long-term investment, since we continue to work together to this day.

This was an experience that got me thinking about how I could try to become a better doctor. Not by studying in order to get smarter, but by having the proper goals and attitude– the things this series is about.  Recounting this story also gives me the opportunity to admit that I claim no special personal legitimacy to write a series for SWJPCC on professionalism. I am pretty lazy at times. I have a temper when I’m under pressure. I can sometimes be hurtful to nurses and residents. There are even a few people who would consider it the height of hypocrisy for me to come off like I know anything about being good.  During the week in which I first began writing this section, I did a bunch of very unprofessional things– things I was ashamed of them even as I was proceeding forward with them:

  1. I got a page about a patient that was deteriorating just as I sat down to a very nice lunch. The patient was a young, otherwise– healthy alcoholic. I decided to relax and finish my lunch before heading up to see him. By time I finished dessert, he had deteriorated and was extremely unstable. 
  2. I had misgivings about a patient’s DNR status. I thought the family might rescind the DNR order if they fully understood the clinical situation. But I didn’t want them to rescind DNR status, so I purposely avoided talking to them. 
  3. I missed the essential (and not obscure) physical finding of abdominal pain in a patient with septic shock on steroids– a clinical mistake that I’ve repeatedly lectured others about during Mortality and Morbidity conference. This error delayed diagnosis of a life-threatening bowel perforation.
  4. I declined a personal invitation to attend the memorial service of a patient that I felt very close to– who had in fact asked me for a hug the last time I had seen her before she died. Instead, I sat at home and watched TV.

So no, I am not an expert at professionalism. But I do care about it. So I am not going to write about the doctor I am, but about the doctor I want to be. Please look at this series in that spirit and do not allow my personal shortcomings to undermine our consideration of this topic.

Why discuss professionalism in medicine? I've considered the possibility that the age of professionalism is over– that talking about it is like trying to get your kids interested in playing the board-game Monopoly. Technology is the thing nowadays. It’s incredibly satisfying to help save a patient’s life with ECMO in the ICU. Yet some technological advances increasingly distance us from our patients.     

I have heard that when Laennec invented the stethoscope in 1816, there was widespread concern about the negative effect it might have on the doctor-patient relationship. Prior to the invention of the stethoscope, doctors placed their ear directly upon the patient's chest to listen to the heart and lungs. At this point in history, the stethoscope actually came between the doctor and patient– a barrier to the intimacy of the physical examination.

In a modern ICU, all patients are under "standard precautions" for infectious disease control– this means doctors and nurses are supposed to wear gloves when we shake their hand. Other infection control precautions require that masks, eye-shields and gowns be worn inside patient rooms. When we employ a proning bed, the patient is totally cocooned– it’s is difficult to even see a patient inside a prone bed, much less touch them.

Telemedicine is increasingly incorporated into patient care– this allows a physician anywhere in the world to take care of patients in our hospital remotely, utilizing video cameras. Mobile devices– almost like robots– with a face display video screen for a head, can be wheeled into a patient’s room to facilitate electronic interactions between doctors and patients.

The advent of the hospitalist has all but destroyed the traditional continuity of the doctor patient relationship. Patients who are sick enough to land in the hospital are rarely seen by their family doctor. Within the hospital, many doctors (including myself) work shifts– taking care of individual patients only within the time slots of their work schedule. Technically, my responsibility for my patients ends at "quitting time”.

More physicians are employed by healthcare systems than ever before. The choices that patients and doctors once made together are thereby increasingly influenced by non-physician administrators. Politicians have increasingly attempted to create financial incentives for doctors to behave as they think we should behave. The very semantics of related constructs such as the “physician report card” diminishes us as a profession, turning us back to a time before we could be trusted to know and do what was best for our patients.

I think it's fair to say that the risk that might lose our professionalism, our humanism, has never been greater than it is at this point in the history of medicine. So there has probably never been a better time to reconsider professionalism as an essential part of being a doctor.

Many of us were taught in medical school about how to “act professional” – maintaining a detached demeanor, not allowing yourself to get emotionally-involved, appearing confident in all situations, etc. That’s not the kind of professionalism I’m going to talk about. Sir William Osler once said “the secret to the care of the patient is in caring for the patient” I think that’s a much better place to start our consideration of professionalism.

In the next installment we will consider the Oath of Maimonides and how it applies to the practice of medicine in a modern ICU:

"The eternal providence has appointed me to watch over the life and health of Thy creatures.

May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.

Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling."

Reference as: Raschke RA. Professionaism: introduction. Southwest J Pulm Crit Care. 2014;8(5):284-7. doi: http://dx.doi.org/10.13175/swjpcc067-14 PDF

Monday
Jan202014

The Unfulfilled Promise of the Quality Movement

Richard A. Robbins, MD

 

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ

 

Abstract

In the latter half of the 20th century efforts to improve medical care became known as the quality movement. Although these efforts were often touted as “evidence-based”, the evidence was often weak or nonexistent. We review the history of the quality movement. Although patient-centered outcomes were initially examined, these were replaced with surrogate markers. Many of the surrogate markers were weakly or non-evidence based interventions. Furthermore, the surrogate markers were often “bundled”, some evidence-based and some not. These guidelines, surrogate markers and bundles were rarely subjected to beta testing, and when carefully scrutinized, rarely correlated with improved patient-centered outcomes. Based on this lack of improvement in outcomes, the quality movement has not improved healthcare. Furthermore, the quality movement will not likely improve clinical performance until recommended or required interventions are tested using randomized trials.

Introduction

The quality movement has been touted as improving patient care at lower costs. However, there are very little data available that “clinically meaningful” outcomes have improved as a result of the quality movement. This manuscript will examine some of the major quality improvement efforts (Table 1).

Table 1. Major quality programs examined in this manuscript.

In addition, the manuscript will point out that some of the key issues with quality improvement measures particularly relevant to pulmonary/critical care physicians such as pneumococcal vaccination in adults, ventilator-associated pneumonia (VAP) and central line associated bloodstream infection (CLABSI) bundles.

Early History of the Quality Movement

Origins of the quality-of-care movement can be traced back to the nineteenth century. An early study assessing the efficacy of hospital care was the work of the British nurse, Florence Nightingale (1). She reported that the hospital in Scutari during the Crimean War had an exceedingly high mortality rate.

In 1910, Flexner issued a critical report of the U.S. medical educational system and called for major reforms. In addition to reforms in education, the report called for full time faculty who held appointments in a teaching hospital with adequate space and equipment (2). Shortly after the Flexner report, Codman developed the medical audit, a process for evaluating the overall practice of a physician including the outcomes of surgery (3).

A survey conducted by the American College of Surgeons of 700 hospitals in 1919 concluded that few were equipped to provide patients with even a minimal level of quality of care. The College went on to establish a program of minimum hospital standards (4). Later the program was transferred to the Joint Commission on Accreditation of Hospitals (now the JCAHO or Joint Commission). However, the Joint Commission was largely ineffective until 1965. At that time, the Joint Commission became one of the most powerful accrediting groups through its role in certifying eligibility for receipt of federal funds from Medicare and Medicaid.

As the role of government in paying for medical care has grown, so has the demand for assurance of the quality of the healthcare services. In the mid-1960s, utilization review activities were required to receive reimbursement for in-patient services from Medicare and Medicaid. Despite utilization review, increasing concern for accountability in healthcare arose from two sources. One was the consumer movement (5). This was fueled by continual reports of variation in services offered by different physicians and by different health care institutions. Usually the reports implied or stated that the care was substandard. The second was a dramatic increase in medical malpractice suits further eroding the public confidence in the medical profession.

The most common definition of quality of care used in the later twentieth century was authored by Donabedian in 1966 (6). He identified three major foci for the evaluation of quality of care­ outcome, process and structure. Outcome referred to the condition of the patient and the effectiveness of healthcare including traditional outcome measures such as morbidity, mortality, length of stay, readmission, etc. Process of care represented an alternative approach which examined the process of care itself rather than its outcomes. These processes are often referred to as surrogate markers. The structural approach involved examining the physical aspects of health care, including buildings, equipment, and supplies.

Joint Commission (JCAHO)

The structural approach was often emphasized in the Joint Commission surveys in the 1960’s and 70’s. Beginning in the 1970’s the Joint Commission began to address outcomes by requiring hospitals to perform medical audits. However, the Joint Commission soon realized that the audit was “tedious, costly and nonproductive” (7). Efforts to meet audit requirements were too frequently “a matter of paper compliance, with heavy emphasis on data collection and few results that can be used for follow-up activities. In the shuffle of paperwork, hospitals often lost sight of the purpose of the evaluation study and, most important, whether change or improvement occurred as a result of audit”. Furthermore, survey findings and research indicated that patient care and clinical performance had not improved (7).

In response to the ineffectiveness of the audit and the call to improve healthcare, the Joint Commission introduced a new quality assurance standard in 1980. The standard consisted of five elements:

  • The integration or coordination of all quality assurance activities into a comprehensive program;
  • A written plan for the program;
  • A problem-focused approach to review;
  • Annual reassessment of the program;
  • Measurable improvement in patient care or clinical performance.

Hospitals complied with most aspects of these five elements. Over 90% had a written plan, annual reassessment, and integration of the quality assurance activities under the hospital administration by mid-1982 (8). However, the other elements remained largely ignored. Physician involvement was often perfunctory either because of their reluctance to be involved or because of hospital administration reluctance to have them involved. Hospital boards and administrators had little idea of which problems were most important and little idea of how to proceed with evaluation and interpretation of the results. Given these limitations it is not surprising that data demonstrating measurable improvement in patient care was lacking.

A number of superficial name changes occurred over the next few years. These included quality improvement, total quality improvement, risk management, quality management and total quality improvement. Although each was touted as an improvement in quality assurance, none were fundamentally different than the original concept and none demonstrated a convincing improvement in any patient-centered outcomes.

Institute of Healthcare Improvement (IHI)

Recognizing weaknesses in the Joint Commission processes, private organizations attempted to develop programs that enhanced quality. One was the Institute for Healthcare Improvement (IHI). Founded by Donald Berwick in 1989, IHI was quite successful in attracting funding from a number of charitable organizations such as Kaiser Permanente Community Benefit, the Josiah Macy, Jr. Foundation, the Rx Foundation,​the MacArthur Foundation, the Robert Wood Johnson Foundation, the Bill & Melinda Gates Foundation, the Health Foundation, and the Izumi Foundation. Additional funding was obtained from insurance companies such as the Blue Cross and Blue Shield Association, the Cardinal Health Foundation, the Aetna Foundation, the Blue Shield of California Foundation. Some pharmaceutical funding was also obtained from​ Baxter International, Inc. and the Abbott Fund. In addition, through the IHI “Open School” many hospitals, both academic and private, supported IHI activities. These included the Mayo Clinic, Banner Good Samaritan Medical Center, St. Joseph's Hospital and Medical Center, the University of Arizona Medical Center, the University of Colorado at Denver, and University of New Mexico - Albuquerque (9).

Under Berwick’s leadership, IHI launched a number of proposals to improve healthcare. A noteworthy initiative from the IHI was the 18 month 100,000 Lives Campaign which began in January 2005. This campaign encouraged hospitals to adopt six best practices to reduce harm and deaths. The interventions included deployment of rapid response reams, a medication reconciliation process, interventions for acute myocardial infarction, a central line management process, administering antibiotics at a specific time to prevent surgical site infections, and using a ventilator protocol to minimize ventilator associated-pneumonia. Review of the evidence basis for at least 3 of these interventions reveals fundamental flaws. A large cluster-randomized, controlled trial demonstrated that medical response teams greatly increased medical response team calling, but did not substantially affect the incidence of cardiac arrest, unplanned ICU admissions, or unexpected death (10). Furthermore, the interventions to prevent central line infections and ventilator-associated pneumonia were either non- or weakly evidence-based and unlikely to improve patient outcomes (11,12)

Despite these limitations, IHI announced in June 2006 that the campaign prevented 122,300 avoidable deaths (13). Interestingly, the methodology and sloppy estimation of the number of lives saved were pointed out by Wachter and Pronovost (14), in the Joint Commission’s Journal of Quality and Safety. IHI failed to adjust their estimates of lives saved for case-mix which accounted for nearly three out of four "lives saved." The actual mortality data were supplied to the IHI by hospitals without audit, and 14% of the hospitals submitted no data at all. Moreover, the reports from even those hospitals that did submit data were usually incomplete. The most striking example of this is the fact that the IHI announcement of lives saved in 18 months was based on submissions through March, not June, 2006, accounting for only 15 months. The final three months were also extrapolated from hospitals’ previous submissions. Although not reported by IHI, it seems likely that there were even more missing data beyond that described above. One important confounder is the fact that the campaign took place against a background of declining inpatient mortality rates (14).

Whether this decline was a result of some of the quality improvement efforts promoted by IHI and others or other factors is unclear. Undeterred, the IHI proceeded with the 5,000,000 Lives Campaign claiming that over 80% of US hospitals were participants (15). However, this campaign ended in 2008 and was apparently not successful (16). Although IHI promised to publish results in major medical journals, a literature search revealed no published outcomes.

Department of Veterans Affairs (VA)

The Department of Veterans Affairs (VA) has played a pivotal role in the quality movement. Although VA hospitals have been required to be Joint Commission approved since the Regan Administration, the quality movement began with the appointment of Kenneth W. Kizer as the VA's undersecretary of health in 1994. An emergency room physician, Kizer was Director of California Emergency Medical Services, Chief of Public Health for California and Director of the California Department of Health Services before coming to the VA (18).

Kizer mandated several interventions. One was the installation and utilization of an electronic healthcare record. The second was a set of performance measures which became known as the chronic disease indicators (19). In order to encourage performance of these interventions, Kizer initiated pay-for-performance, not to the doctors and nurses doing the interventions, but to the top administration of the hospital. The focus changed from meeting the needs of the patient to meeting the performance measures so the administrators could receive their bonuses. From 1994 to 2000 nearly all the performance measures improved. Three improved dramatically-pneumococcal vaccination, annual measurement of hemoglobin A1C, and smoking cessation (19). However, the evidence basis that these interventions improved patient outcomes was questionable (20). Furthermore, there was no outcome data such as morbidity, mortality, admission rates, length of stay, etc. that supported the contention that the health of veterans improved.

Although politics forced Kizer’s resignation in 1999, he was followed by his deputy, Thomas L. Garthwaite and eventually by his Chief Quality and Performance Officer, Jonathan B. Perlin. Perlin realized that outcome data was needed and promised that this would be forthcoming. On August 11, 2003 at the First Annual VA Preventive Medicine Training Conference in Albuquerque, NM, Perlin claimed that the increase in pneumococcal vaccination saved 3914 lives between 1996 and 1998 (21) (For a copy of the slides used by Perlin click here). Furthermore, he claimed pneumococcal vaccination resulted in 8000 fewer admissions and 9500 fewer days of bed care between 1999 and 2001. However, this data was not measured but based on extrapolation from a single, non-randomized, observational study (22). Although no randomized study examining patient outcomes with the 23-polyvalent pneumococcal vaccine has been performed, other studies do not support the efficacy of the vaccine in adults (23-25). Furthermore, there was an overall downward trend in hospital admissions. The reduction in hospital admissions for pneumonia appeared to be nothing more than part of this trend since the number of outpatient visits for pneumonia increased (26).

Institute of Medicine (IOM)

The Institute of Medicine (IOM) is a non-profit, non-governmental organization founded in 1970, under the congressional charter of the National Academy of Sciences (27). Its purpose is to provide national advice on issues relating to biomedical science, medicine, and health, and its mission to serve as adviser to the nation to improve health.

The IOM attracted little attention until publication of “To Err is Human” in 1999 (28). This report was authored by the IOM’s committee on quality of health care in America whose members included Donald Berwick from the Institute of Healthcare Improvement and Mark Chassin, now president and chief executive officer of the Joint Commission. The report estimated that 44,000 to 98,000 deaths occur annually in the US due to medical errors. It was presented with drama and an assertion of lack of previous attention. This was followed by a plea to the medical profession to remember its promise to "do no harm" and that "at a very minimum, the health system needs to offer that assurance and security to the public." The clear implication was that doctors were killing their patients at a terrible rate and needed oversight and direction. The Clinton administration clearly heard this message and issued an executive order instructing government agencies that conduct or oversee health-care programs to implement proven techniques for reducing medical errors, and creating a task force to find new strategies for reducing errors. Congress soon launched a series of hearings on patient safety, and in December 2000 it appropriated $50 million to the Agency for Healthcare Research and Quality to support a variety of efforts targeted at reducing medical errors.

Examination of the two studies on which the IOM based their mortality estimates both came from the Harvard School of Public Health where Harvey Fineberg, president of the IOM, had been dean. The higher estimate was based on a 1991 study published in the New England Journal of Medicine (29). In this study, 30,121 medical records from 51 randomly selected acute care hospitals in New York State were reviewed. Population estimates of injuries were made. To do this the records were screened by trained nurses and medical-records analysts; if a record was screened as positive for a potentially adverse event, two physicians independently reviewed the record. The second study on which the lower mortality estimate was made was published in Medical Care in 2000 (30). The same group from the Harvard School of Public Health used a similar strategy and examined 15,000 records from acute care hospitals in Utah and Colorado from 1992.

Although examples were given of what constituted an adverse event and whether it was due to negligence, it is “difficult to judge whether a standard of care has been met” leading to a “relatively low level of reliability…” according to the first article.  In both articles, negligence remained undefined which ultimately means that the determination of negligence relied on judgment. Unexplained is why the second article showed deaths due to negligence in Utah and Colorado at half the rate of New York.

Hofer et al. (31) examined medical errors in large part as a response to “To Err is Human” and the Harvard School of Public Health studies on which the IOM based their mortality estimates. They made four principal observations. “First, errors have been defined in terms of failed processes without any link to subsequent harm. Second, only a few studies have actually measured errors, and these have not described the reliability of the measurement. Third, no studies directly examine the relationship between errors and adverse events. Fourth, the value of pursuing latent system errors (a concept pertaining to small, often trivial structure and process problems that interact in complex ways to produce catastrophe) using case studies or root cause analysis has not been demonstrated in either the medical or nonmedical literature”.

Patient Safety

The IOM report, “To Err is Human”, resulted in yet another name change for the quality movement, the patient safety movement. An article in JAMA by Leape, Berwick and Bates (32) in 2005 entitled “What Practices Will Most Improve Safety? Evidence-Based Medicine Meets Patient Safety” examined what the authors considered evidence-based practices that might improve patient safety. They examined patient safety targets and listed patient safety practices to reduce or eliminate any adverse outcomes. The evidence of each practice was graded greatest, high, medium, low and lowest. Unfortunately, mistakes were made and some would disagree with the strength of evidence. For example, the ventilator bundle from 2011 used by IHI lists 5 interventions:

  • Elevation of the Head of the Bed
  • Daily "Sedation Vacations" and Assessment of Readiness to Extubate
  • Peptic Ulcer Disease Prophylaxis
  • Deep Venous Thrombosis Prophylaxis
  • Daily Oral Care with Chlorhexidine

However, in their JAMA article the intervention with the greatest evidence for prevention of ventilator-associated pneumonia was continuous aspiration of subglottic secretions. Semirecumbent positioning and elective decontamination of the digestive tract were listed as having a high strength of evidence. Continuous oscillation was listed as medium strength evidence. Use of sucralfate was listed as lowest strength of evidence. Sedation vacations and oral care with chlorhexidine were not listed. Deep venous prophylaxis was listed as prevention of venous thromboembolism, which it clearly does but does not reduce mortality or prevent pneumonia (33). Peptic ulcer disease prophylaxis with H2 antagonists was listed as medium strength of evidence. The possibility that H2 antagonists might increase pneumonia rather than prevent it was not raised (34).

Similarly, practices listed in the 2005 JAMA article to prevent central line-associated bloodstream infection listed antibiotic-impregnated catheters (greatest strength of evidence); chlorhexidine, heparin and catheter tunneling (lower strength of evidence); and routine antibiotic prophylaxis and changing catheters routinely (lowest strength of evidence). However, the IHI central line bundle include:

  • Hand Hygiene
  • Maximal Barrier Precautions Upon Insertion
  • Chlorhexidine Skin Antisepsis
  • Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central Venous Access in Adult Patients
  • Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Although disagreement about the level of evidence may be appropriate, the IHI bundles are clearly discordant with the evidence basis of the interventions as listed in the JAMA article. Furthermore, IHI mixed practices with various levels of evidence into a single bundle and encouraged the performance of all in order to receive “credit” for compliance with the bundle.

Department of Health and Human Services (HHS)

When Berwick became director of HHS’ Center for Medicare and Medicaid Services (CMS) the IHI’s bundles moved with him. With the Agency for Healthcare Quality and Research (AHRQ), another division of HHS, CMS initiated a vigorous program to prevent hospital-acquired infections backed up with financial penalties for noncompliance. This included bundles mixing practices with various levels of evidence (or no evidence) and requiring compliance with all to receive “credit”, or in this case, avoid financial penalties for noncompliance. CMS referred to this as “value-based performance”.

In an increasingly familiar scenario, AHRQ issued a press release on September 20, 2012 touting the remarkable success of the program to reduce central line-associated bloodstream infections (CLABSIs) (35). The program “…reduced the rate [of CLABSI] … in intensive care units by 40 percent…saving more than 500 lives and avoiding more than $34 million in health care costs” (35). Although the methodology used to determine these numbers was not stated, it seems likely that it followed the model of IHI’s 100,000 Lives Campaign.  A program was initiated based on a dubious intervention(s)-in this case a 2 page checklist for central line insertion (36). Data on the incidence of infection was determined by billing, another form of self-reporting. The dollars and lives saved were then extrapolated from other publications.

There are several problems with this approach. First, Meddings et al. (37) determined that data on self reported urinary tract infections were “inaccurate” and “are not valid data sets for comparing hospital acquired catheter-associated urinary tract infection rates for the purpose of public reporting or imposing financial incentives or penalties”. The authors proposed that the nonpayment by Medicare for “reasonably preventable” hospital-acquired complications resulted in this discrepancy. There is no reason to assume that data reported for CLABSI is any more accurate. Further evidence comes from the observation that compliance with most of these bundles does not appear to correlate with outcomes such as mortality or readmission rates (38).

Second, choosing a single article which does not represent the overall body of evidence can be deceiving. In the pneumococcal vaccine example cited earlier, Perlin chose the only article to show a beneficial effect of the 23-polyvalent pneumococcal vaccine in adults (22). Most reviews and meta-analyses do not support the vaccine’s efficacy (23-25).

Third, many of the articles used for calculation of the mortality and cost savings are not risk adjusted. It may seem obvious, but saying that CLABSIs are associated with higher mortality and costs is not the same as saying the mortality and costs were caused by the CLABSI. Central lines are placed in sicker, more unstable patients and their underlying disease and not the CALBSI could account for the higher mortality and costs. These extrapolated conclusions are not the same as measurement of the mortality and costs in carefully planned and controlled randomized trials.

Discussion

Review of the quality movement reveals a dizzying array of pseudo-regulatory organizations and ever-changing programs and guidelines. The National Guidelines Clearinghouse lists in excess of 15,000 guidelines (39). This explosion of directives appears to undergo little to no oversight with no checks to ensure that these guidelines are evidence-based.

This manuscript reviewed some of the more prominent programs to improve healthcare and have found them sadly wanting (Table 1). Overall the science has been poor and evidence of improvement in patient outcomes lacking. It is unclear if the present programs have improved on the tedious, costly and nonproductive medical audits of the 1970’s (7). Like the audits, present quality programs appear to be more a matter of paper compliance. In the shuffle of paperwork, hospitals and regulatory agencies seem to have lost sight of that the purpose is to improve healthcare and not fulfill a political or financial goal.

As hospitals struggle to decrease complication rates in order to receive better reimbursement for “value-based performance” several likely strategies may evolve. One is to lie about the data. According to Meddings (37) this is apparently happening with urinary tract infections and clearly was happening with ventilator-associated pneumonia (12). The accuracy of the data submitted by a hospital’s quality manager, under intense scrutiny from the CEO or board to demonstrate the hospital’s success in quality improvement, is rarely questioned if it shows an improvement. This may be particularly true now that many CEOs and managers are operating under incentive systems that tie bonuses to quality performance (14). Tying hospital reimbursement may induce similar discrepancies. Another rather obvious strategy to increase reimbursement would be to prevent complications by not performing interventions such as urinary tract catheters or central lines. Whether this is happening is not clear but seems likely. It is also unclear whether this will be beneficial or harmful to patients.

It is difficult to argue that a complication might be good for a patient. However, some of the hospital-acquired infections and readmission rates correlate with improved mortality (38). The reason for this is not clear but could represent a minor complication of what are best practices that benefit the majority of patients.

According to Patrick Conway, CMS Chief Medical Officer and Deputy and Administrator for Innovation and Quality, CMS will be reorienting and aligning measures around patient-centered outcomes (40). Readmission rates for certain disorders are already part of CMS’ formula for reimbursement adjustments based on readmissions for COPD will begin in 2014. It is unclear at this juncture if other traditional outcome measures such as mortality, morbidiy, hospital length of stay and cost will also be considered. These would likely be an improvement over the “value-based performance” measures, many of which either do not or inversely correlate with outcomes.

The explosion in the number of groups attempting to improve quality and safety raises the question of how should target practices be selected. It is unclear if private organizations be setting a national agenda for change. The 100,000 Lives Campaign allowed IHI to receive credit for many things that would have happened anyway (14). The campaign created a landslide of “brand recognition” for IHI, and undoubtedly led to substantial new revenues and philanthropic dollars. A conflict (or, at very least, appearance of conflict) is unavoidable. A federal agency or regulator would not be vulnerable to such concerns.

Professional organizations need to do their part in improving the quality of medical care. Many, if not most, professional organizations have rushed to publish guidelines. Unfortunately, the evidence basis for these guidelines have been little better than the IHI, Joint Commission or IOM’s recommendations. Lee and Vielemeyer (41) 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 (42,43). It is doubtful that other medical societies are performing much better.

Medical journals also need to do their part. Reviewers and editors need to evaluate manuscripts regarding “quality medical care” with the same scientific skepticism applied to other articles. Randomized trials should not only be applied to diagnostic and therapeutic interventions but just as vigorously applied to formulation and implementation of guidelines and other interventions designed to improve medical care quality. Too often interventions based on either weak or no evidence become ingrained in medical practice when papers with questionable methods and/or outcomes are published. Journals should not allow authors to call an intervention as improving quality of medical care without definition of quality and without accompanying demonstration of an improvement in patient-centered outcomes.

Lastly, physicians need to do their part. Physicians should reevaluate their participation and financial support of medical societies that author or support non- or weakly evidenced guidelines. They should oppose quality programs introduced into medical practice that are not based on level I evidence (at least one randomized trial). That the IHI was able to introduce a program such as the 100,000 Lives Campaign into hospital practice based on weak or non-evidence based interventions such as rapid response teams, central-line insertions guidelines and ventilator-associated guidelines is disturbing. That the IHI was able to declare that implementation of their interventions saved 123,000 lives based on the sloppy collection of self-reported data is equally disturbing. That these interventions persist to this day is perhaps most disturbing of all. As taught by Flexner nearly a century ago, only through application of scientific principles and vigorous review of interventions will the quality of medical care improve.

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Reference as: Robbins RA. The unfulfilled promise of the quality movement. Southwest J Pulm Crit Care. 2014;8(1):50-63. doi: http://dx.doi.org/10.13175/swjpcc181-13 PDF

Monday
Sep232013

A Comparison Between Hospital Rankings and Outcomes Data

Richard A. Robbins, MD*

Richard D. Gerkin, MD  

 

*Phoenix Pulmonary and Critical Care Research and Education Foundation, Gilbert, AZ

Banner Good Samaritan Medical Center, Phoenix, AZ

 

Abstract

Hospital rankings have become common but the agreement between the rankings and correlation with patient-centered outcomes remains unknown. We examined the ratings of Joint Commission on Healthcare Organizations (JCAHO), Leapfrog, and US News and World Report (USNews), and outcomes from Centers for Medicare and Medicaid Hospital Compare (CMS) for agreement and correlation. There was some correlation among the three “best hospitals” ratings.  There was also some correlation between “best hospitals” and CMS outcomes, but often in a negative direction.  These data suggest that no one “best hospital” list identifies hospitals that consistently attain better outcomes.

Introduction

Hospital rankings are being published by a variety of organizations. These rankings are used by hospitals to market the quality of their services. Although all the rankings hope to identify “best” hospitals, they differ in methodology. Some emphasize surrogate markers; some emphasize safety, i.e., a lack of complications; some factor in the hospital’s reputation; some factor in patient-centered outcomes.  However, most do not emphasize traditional outcome measures such as mortality, mortality, length of stay and readmission rates. None factor cost or expenditures on patient care.

We examined three common hospital rankings and clinical outcomes. We reasoned that if the rankings are valid then better hospitals should be consistently on these best hospital lists. In addition, better hospitals should have better outcomes.

Methods

CMS

Outcomes data was obtained from the CMS Hospital Compare website from December 2012-January 2013 (1). The CMS website presents data on three diseases, myocardial infarction (MI), congestive heart failure (CHF) and pneumonia. We examined readmissions, complications and deaths for each of these diseases. We did not examine all process of care measures since many of the measures have not been shown to correlate with improved outcomes and patient satisfaction has been shown to correlate with higher admission rates to the hospital, higher overall health care expenditures, and increased mortality (2). In some instances actual data is not presented on the CMS website but only higher, lower or no different from the National average. In this case, scoring was done 2, 0 and 1 respectively with 2=higher, 0=lower and 1=no different.

Mortality is the 30-day estimates of deaths from any cause within 30 days of a hospital admission, for patients hospitalized with one of several primary diagnoses (MI, CHF, and pneumonia). Mortality was reported regardless of whether the patient died while still in the hospital or after discharge. Similarly, the readmission rates are 30-day estimates of readmission for any cause to any acute care hospital within 30 days of discharge. The mortality and readmission measures rates were adjusted for patient characteristics including the patient’s age, gender, past medical history, and other diseases or conditions (comorbidities) the patient had at hospital arrival that are known to increase the patient’s risk of dying or readmission.

The rates of a number of complications are also listed in the CMS data base (Table 1).

Table 1. Complications examined that are listed in CMS data base.

CMS calculates the rate for each serious complication by dividing the actual number of outcomes at each hospital by the number of eligible discharges for that measure at each hospital, multiplied by 1,000. The composite value reported on Hospital Compare is the weighted averages of the component indicators.  The measures of serious complications reported are risk adjusted to account for differences in hospital patients’ characteristics. In addition, the rates reported on Hospital Compare are “smoothed” to reflect the fact that measures for small hospitals are measured less accurately (i.e., are less reliable) than for larger hospitals.

Similar to serious infections, CMS calculates the hospital acquired infection data from the claims hospitals submitted to Medicare. The rate for each hospital acquired infection measure is calculated by dividing the number of infections that occur within any given eligible hospital by the number of eligible Medicare discharges, multiplied by 1,000. The hospital acquired infection rates were not risk adjusted.

JCAHO

The JCAHO list of Top Performers on Key Quality Measures™ was obtained from its 2012 list (3). The Top Performers are based on an aggregation of accountability measure data reported to The JCAHO during the previous calendar year.

Leapfrog

Leapfrog’s Hospital Safety Score were obtained from their website during December 2012-January 2013 (4). The score utilizes 26 National performance measures from the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS) to produce a single composite score that represents a hospital’s overall performance in keeping patients safe from preventable harm and medical errors. The measure set is divided into two domains: (1) Process/Structural Measures and (2) Outcome Measures. Many of the outcome measures are derived from the complications reported by CMS (Table 1). Each domain represents 50% of the Hospital Safety Score. The numerical safety score is then converted into one of five letter grades. "A" denotes the best hospital safety performance, followed in order by "B", "C", “D,” and “F.” For analysis, these letter grades were converted into numerical grades 1-5 corresponding to letter grades A-F.

US News and World Report

US News and World Report’s (USNews) 2012-3 listed 17 hospitals on their honor roll (5). The rankings are based largely on objective measures of hospital performance, such as patient survival rates, and structural resources, such as nurse staffing levels. Each hospital’s reputation, as determined by a survey of physician specialists, was also factored in the ranking methodology. The USNews top 50 cardiology and pulmonology hospitals were also examined.

Statistical Analysis

Categorical variables such as JCAHO and USNews best hospitals were compared with other data using chi-squared analysis. Spearman rank correlation was used to help determine the direction of the correlations (positive or negative). Significance was defined as p<0.05.

Results

Comparisons of Hospital Rankings between Organizations

A large database of nearly 3000 hospitals was compiled for each of the hospital ratings (Appendix 1). The “best hospitals” as rated by the JCAHO, Leapfrog and USNews were compared for correlation between the organizations (Table 2).

Table 2. Correlation of “best hospitals” between different organizations

There was significant correlation between the JCAHO and Leapfrog and Leapfrog and USNews but not between JCAHO and USNews.

JCAHO-Leapfrog Comparison

The Leapfrog grades were significantly better for JCAHO “Best Hospitals” compared to hospitals not listed as “Best Hospitals” (2.26 + 0.95  vs. 1.85 + 0.91, p<0.0001). However, there were multiple exceptions. For example, of the 358 JCAHO “Best Hospitals” with a Leapfrog grade, 84 were graded “C”, 11 were graded “D” and one was graded as “F”.

JCAHO-USNews Comparison

Of the JCAHO “Top Hospitals” only one was listed on the USNews “Honor Roll”. Of the cardiology and pulmonary “Top 50” hospitals only one and two hospitals, respectively, were listed on the JCAHO “Top Hospitals” list.

Leapfrog-USNews Comparison

The Leapfrog grades of the US News “Honor Roll” hospitals did not significantly differ compared to the those hospitals not listed on the “Honor Roll” (2.21 + 0.02 vs. 1.81 + 0.31, p>0.05). However, Leapfrog grades of the US News “Top 50 Cardiology” hospitals had better Leapfrog grades (2.21 +  0.02 vs. 1.92 + 0.14, p<0.05). Similarly, Leapfrog grades of the US News “Top 50 Pulmonary” hospitals had better Leapfrog grades (2.21 + 0.02 vs. 1.91 + 0.15, p<0.05).

“Best Hospital” Mortality, Readmission and Serious Complications

The data for the comparison between the hospital rankings and CMS’ readmission rates, mortality rates and serious complications for the JCAHO, Leapfrog, and USNews are shown in Appendix 2, Appendix 3, and Appendix 4 respectively. The results of the comparison of “best hospitals” compared to hospitals not listed as best hospitals are shown in Table 3.

Table 3. Results of “best hospitals” compared to other hospitals for mortality and readmission rates for myocardial infarction (MI), congestive heart failure (CHF) and pneumonia.

Red:  Relationship is concordant (better rankings associated with better outcomes)

Blue:  Relationship is discordant (better rankings associated with worse outcomes)

Note that of 21 total p values for relationships, 12 are non-significant, 6 are concordant and significant, and 6 are discordant and significant.  All 4 of the significant readmission relationships are discordant. All 5 of the significant mortality relationships are concordant. This underscores the disjunction of mortality and readmission. All 3 of the relationships with serious complications are significant, but one of these is discordant. Of the 3 ranking systems, Leapfrog has the least correlation with CMS outcomes (5/7 non-significant).  USNews has the best correlation with CMS outcomes (6/7 significant).  However, 3 of these 6 are discordant.

The USNews “Top 50” hospitals for cardiology and pulmonology were also compared to those hospitals not listed as “Top 50” hospitals for cardiology and pulmonology. Similar to the “Honor Roll” hospitals there was a significantly higher proportion of hospitals with better mortality rates for MI and CHF for the cardiology “Top 50” and for pneumonia for the pulmonary “Top 50”. Both the cardiology and pulmonary “Top 50” had better serious complication rates (p<0.05, both comparisons, data not shown).

Discussion

Lists of hospital rankings have become widespread but whether these rankings identify better hospitals is unclear. We reasoned that if the rankings were meaningful then there should be widespread agreement between the hospital lists. We did find a level of agreement but there were exceptions. Hospital rankings should correlate with patient-centered outcomes such as mortality and readmission rates. Overall that level of agreement was low.

One probable cause accounting for the differences in hospital rankings is the differing methodologies used in determined the rankings. For example, JCAHO uses an aggregation of accountability measures. Leapfrog emphasizes safety or a lack of complications. US News uses patient survival rates, structural resources, such as nurse staffing levels, and the hospital’s reputation. However, the exact methodolgical data used to formulate the rankings is often vague, especially for JCAHO and US News rankings. Therefore, it should not be surprising that the hospital rankings differ.

Another probable cause for the differing rankings is the use of selected complications in place of patient-centered outcome measures. Complications are most meaningful when they negatively affect ultimate patient outcomes. Some complications such as objects accidentally left in the body after surgery, air bubble in the bloodstream or mismatched blood types are undesirable but very infrequent. Whether a slight, but significant, increase in these complications would increase more global measures such as morality or readmission rates is unlikely. The overall poor correlation of these outcomes with deaths and readmissions in the CMS database is consistent with this concept.

Some of the surrogate complication rates are clearly evidence-based but some are clearly not. For example, many of the central-line associated infection and ventilator-associated pneumonia guidelines used are non-evidence based (6.7). Furthermore, overreaction to correct some of the complications such as “signs of uncontrolled blood sugar” may be potentially harmful. This complication could be interpreted as tight control of the blood sugar. Unfortunately, when rigorously studied, patients with tight glucose control actually had an increase in mortality (8).

In some instances a complication was associated with improved outcomes. Although the reason for this discordant correlation is unknown, it is possible that the complication may occur as a result of better care. For example, catherization of a central vein for rapid administration of fluids, drugs, blood products, etc. may result in better outcomes or quality but will increase the central line-associated bloodstream infection rate. In contrast, not inserting a catheter when appropriate might lead to worse outcomes or poorer quality but would improve the infection rate.

Many of the rankings are based, at least in part, on complication data self-reported by the hospitals to CMS. However, the accuracy of this data has been called into question (9,10). Meddings et al. (10) studied urinary tract infections which were self-reported by hospitals using claims data. According to Meddings (10), the data were “inaccurate” and not were “not valid data sets for comparing hospital acquired catheter-associated urinary tract infection rates for the purpose of public reporting or imposing financial incentives or penalties”. The authors proposed that the nonpayment by Medicare for “reasonably preventable” hospital-acquired complications resulted in this discrepancy. Inaccurate data may lead to the lack of correlation a complication and outcomes on the CMS database.

The sole source of mortality and readmission data in this study was CMS. This is limited to Medicare and Medicaid patients but is probably representative of the general population in an acute care hospital. However, also included on the CMS website is a dizzying array of measures. We did not analyze every measure but analyzed only those listed in Table 1. Whether examination of other measures would correlate with mortality and readmission rates is unclear.

There are several limitations to our data. First and foremost, the CMS data is self-reported by hospitals. The validity and accuracy of the data has been called into question. Second, data is missing in multiple instances. For example, much of the data from Maryland was not present. Also, there were multiple instances when the data was “unavailable” or the “number of cases are too small”.  Third, in some instances CMS did not report actual data but only higher, lower or no different from the National average. This loss of information may have led to inaccurate analyses. Fourth, much of the data are from surrogate markers, a fact which is important since surrogate markers have not been shown to predict outcomes. This is also puzzling since patient-centered outcomes are available.  Fifth, much of the outcomes data is derived from CMS which to a large extent eliminates Veterans Administration, pediatric, mental health and some other specialty facilities.

It is unclear if any of the hospital rankings should be used by patients or healthcare providers when choosing a hospital. At present it would appear that the rankings have an over reliance on surrogate markers, many of which are weakly evidence-based. Furthermore, categorizing the data as average, below or above average may lead to an inaccurate interpretation of the data. Lastly, the accuracy of the data is unclear. Finally, lack of data on length of stay and some major morbidities is a major weakness. We as physicians need to scrutinize these measurement systems and insist on greater methodological rigor and more relevant criteria to choose. Until these shortcomings are overcome, we cannot recommend the use of hospital rankings by patients or providers.

References

  1. http://www.medicare.gov/hospitalcompare/ (accessed 6/12/13).
  2. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405-11. [CrossRef] [PubMed]
  3. http://www.jointcommission.org/annualreport.aspx (accessed 6/12/13).
  4. http://www.hospitalsafetyscore.org (accessed 6/12/13).
  5. http://health.usnews.com/best-hospitals (accessed 6/12/13).
  6. 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.
  7. Hurley J, Garciaorr R, Luedy H, Jivcu C, Wissa E, Jewell J, Whiting T, Gerkin R, Singarajah CU, Robbins RA. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care. 2012;4:163-73.
  8. NICE-SUGAR Study Investigators. Intensive versus conventional insulin therapy in critically ill patients. N Engl J Med. 2009;360:1283-97. [CrossRef] [Pubmed]
  9. Robbins RA. The emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care. 2012;5:203-5.
  10. 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]

Reference as: Robbins RA, Gerkin RD. A comparison between hospital rankings and outcomes data. Southwest J Pulm Crit Care. 2013;7(3):196-203. doi: http://dx.doi.org/10.13175/swjpcc076-13 PDF