Fake News in Healthcare

An article in the National Review by Pascal-Emmanuel Gobry points out that there is considerable waste in healthcare spending (1). He blames much of this on two entitlements-Medicare and employer-sponsored health insurance. He also lays much of the blame on doctors. “Doctors are the biggest villains in American health care. ... As with public-school teachers, we should be able to recognize that a profession as a whole can be pathological even as many individual members are perfectly good actors, and even if many of them are heroes. And just like public-school teachers, the medical profession as a whole puts its own interests ahead of those of the citizens it claims to be dedicated to serve.”

Who is Pascal-Emmanuel Gobry and how could he say something so nasty about teachers and my profession? A quick internet search revealed that Mr. Gobry is a fellow at the Ethics & Public Policy Center, a conservative Washington, D.C.-based think tank and advocacy group (2). According to his biography, Gobry writes about religion, culture, politics, economics, business, and technology, but not health care. He is a columnist at The Week, a contributor at Forbes, a blogger at the Patheos Catholic and his writing has appeared in the Wall Street Journal, The Atlantic, and The Daily Beast amongst others. He holds a Master of Science in management from HEC Paris (Hautes études commerciales de Paris, a quite prestigious business school) and lives in Paris.

To make his point on waste, Mr. Gobry comments on Atul Gawande’s 2007 New Yorker “exposé on the Herculean efforts by a handful of scientists to get intensive-care physicians to implement a basic hygiene measures checklist so as to stop hospital-borne diseases” (3). He goes on to quote the Centers for Disease Control that hospital-borne diseases kill about 100,000 people per year, that the checklist was of no cost to the doctors, and its scientific rationale was unquestionable. “Doctors still resisted it with all their might because they found it mildly inconvenient; perhaps they found it even less acceptable that anybody might tell them how to do their jobs”. I showed this article to one of my former pulmonary/critical care fellows who has been in practice about 10 years. He commented, “Another guy who doesn’t practice medicine or know what he’s talking about.”

Gobry is referring to the Institute of Healthcare Improvement (IHI) central line associated blood stream infection (CLABSI) guidelines. These include hand washing, sterile gloves, sterile gown, wearing of a cap, full body drape, chlorhexidine, and not using femoral sites for insertion. In our intensive care units only chlorhexidine usage was associated with a decline in CLABSI (4). Every ICU I have practiced in has emphasized handwashing and demanded use of sterile gloves, gowns and drapes. The remaining guidelines are not supported by good evidence.

Gobry also claims that a computer is better at diagnosis than most physicians. He claims that the evidence is “pretty robust at this point, and the profession resists it tooth and nail. In a few years, we’ll be able to know how many unnecessary deaths this led to, but the number will have lots of zeroes”. However, in the only direct comparison of diagnostic accuracy, physicians vastly outperformed computer algorithms (84.3% vs. 51.2%) (5).

Journalists like Gobry are writing melodramatic articles about medicine and often getting it wrong. In this case he sensationalized Gawande’s article and misquoted the evidence for both the IHI guidelines and computer diagnosis.

There’s a TV commercial about an actor playing a doctor. Gobry is a business journalist attempting to play a doctor at the National Review. My former fellow is right. Gobry is a guy who does not know what he is talking about. Unfortunately, his writings can affect public policy and influence politicians who know even less. As President Trump said, “Nobody knew that health care could be so complicated” (6).

I am a doctor playing a journalist at the Southwest Journal of Pulmonary and Critical Care. Our articles may not be as sensational as Gobry’s, but we stick to what we know-pulmonary, critical care and sleep medicine. I think we usually get it right. President Trump has railed against “fake news”, most recently on Lou Dobbs Tonight (7). Journalists like Gobry contribute to fake news by being deliberately obtuse, appealing to emotions, name-calling, and omitting or distorting facts. As physicians, we have been denigrated by journalists like Gobry and others who make outrageous claims for their own purposes. It is the responsibility of physicians to challenge those like Gobry who get it wrong.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Gobry P-E. The most wasteful health spending is also the most popular. National Review. October 25, 2017. Available at: http://www.nationalreview.com/article/453088/health-care-spending-wasteful-popular (accessed 10/25/17).
2. Ethics & Public Policy Center. Pascal-Emmanuel Gobry. https://eppc.org/author/pascal-emmanuel-gobry/ (accessed 10/25/17).
3. Gawande A. The Checklist. The New Yorker. December 10, 2007. Available at: https://www.newyorker.com/magazine/2007/12/10/the-checklist (accessed 10/25/17).
4. Hurley J, Garciaorr R, Luedy H, et al. 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. Available at: http://www.swjpcc.com/critical-care/2012/5/10/correlation-of-compliance-with-central-line-associated-blood.html. 
5. Semigran HL, Levine DM, Nundy S, Mehrotra A. Comparison of Physician and Computer Diagnostic Accuracy. JAMA Intern Med. 2016 Dec 1;176(12):1860-1861. [CrossRef] [PubMed]
6. Howell T Jr. Trump: 'Nobody Knew That Health Care Could Be So Complicated'. Fox News. February 27, 2017. Available at: http://nation.foxnews.com/2017/02/27/trump-nobody-knew-health-care-could-be-so-complicated (accessed 10/25/17).
7. Trump DJ. Lou Dobbs Tonight. October 25, 2017. Available at: http://video.foxbusiness.com/v/5624925494001/?#sp=show-clips (accessed 10/26/17).

Cite as: Robbins RA. Fake news in healthcare. Southwest J Pulm Crit Care. 2017;15(4):171-3. doi: https://doi.org/10.13175/swjpcc132-17 PDF 

The Emperor Has No Clothes: The Accuracy of Hospital Performance Data

Several studies were announced within the past month dealing with performance measurement. One was the Joint Commission on the Accreditation of Healthcare Organizations (Joint Commission, JCAHO) 2012 annual report on Quality and Safety (1). This includes the JCAHO’s “best” hospital list. Ten hospitals from Arizona and New Mexico made the 2012 list (Table 1).

Table 1. JCAHO list of “best” hospitals in Arizona and New Mexico for 2011 and 2012.

This compares to 2011 when only six hospitals from Arizona and New Mexico were listed. Notably underrepresented are the large urban and academic medical centers. A quick perusal of the entire list reveals that this is true for most of the US, despite larger and academic medical centers generally having better outcomes (2,3).

This raises the question of what criteria are used to measure quality. The JCAHO criteria are listed in Appendix 2 at the end of their report. The JCAHO criteria are not outcome based but a series of surrogate markers. The Joint Commission calls their criteria “evidence-based” and indeed some are, but some are not (2). Furthermore, many of the Joint Commission’s criteria are bundled. In other words, failure to comply with one criterion is the same as failing to comply with them all. They are also not weighted, i.e., each criterion is judged to be as important as the other. An example where this might have an important effect on outcomes might be pneumonia. Administering an appropriate antibiotic to a patient with pneumonia is clearly evidence-based. However, administering the 23-polyvalent pneumococcal vaccine in adults is not effective (4-6). By the Joint Commission’s criteria administering pneumococcal vaccine is just as important as choosing the right antibiotic and failure to do either results in their judgment of noncompliance.

Previous studies have not shown that compliance with the JCAHO criteria improves outcomes (2,3). Examination of the US Health & Human Services Hospital Compare website is consistent with these results. None of the “best” hospitals in Arizona or New Mexico were better than the US average in readmissions, complications, or deaths (7).

A second announcement was the success of the Agency for Healthcare Quality and Research’s (AHRQ) program on central line associated bloodstream infections (CLABSI) (8). According to the press release the AHRQ program has prevented more than 2,000 CLABSIs, saving more than 500 lives and avoiding more than $34 million in health care costs. This is surprising since with the possible exception of using chlorhexidine instead of betadine, the bundled criteria are not evidence-based and have not correlated with outcomes (9). Examination of the press release reveals the reduction in mortality and the savings in healthcare costs were estimated from the hospital self-reported reduction in CLABSI.

A clue to the potential source of these discrepancies came from an article published in the Annals of Internal Medicine by Meddings and colleagues (10). These authors studied urinary tract infections which were self-reported by hospitals using claims data. According to Meddings, the data 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 propose 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 or ventilator associated pneumonia (VAP) is any more accurate.

These and other healthcare data seem to follow a trend of bundling weakly evidence-based, non-patient centered surrogate markers with legitimate performance measures. Under threat of financial penalty the hospitals are required to improve these surrogate markers, and not surprisingly, they do. The organization mandating compliance with their outcomes joyfully reports how they have improved healthcare saving both lives and money. These reports are often accompanied by estimates, but not measurement, of patient centered outcomes such as mortality, morbidity, length of stay, readmission or cost. The result is that there is no real effect on healthcare other than an increase in costs. Furthermore, there would seem to be little incentive to question the validity of the data. The organization that mandates the program would be politically embarrassed by an ineffective program and the hospital would be financially penalized for honest reporting.

Improvement begins with the establishment of guidelines that are truly evidence-based and have a reasonable expectation of improving patient centered outcomes. Surrogate markers should be replaced by patient-centered outcomes such as mortality, morbidity, length of stay, readmission, and/or cost. The recent "pay-for-performance" ACA provision on hospital readmissions that went into effect October 1 is a step in the right direction. The guidelines should not be bundled but weighted to their importance. Lastly, the validity of the data needs to be independently confirmed and penalties for systematically reporting fraudulent data should be severe. This approach is much more likely to result in improved, evidence-based healthcare rather than the present self-serving and inaccurate programs without any benefit to patients.

Richard A. Robbins, MD*

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Available at: http://www.jointcommission.org/assets/1/18/TJC_Annual_Report_2012.pdf (accessed 9/22/12).
2. 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.
3. Rosenthal GE, Harper DL, Quinn LM. Severity-adjusted mortality and length of stay in teaching and nonteaching hospitals. JAMA 1997;278:485-90.
4. Fine MJ, Smith MA, Carson CA, Meffe F, Sankey SS, Weissfeld LA, Detsky AS, Kapoor WN. Efficacy of pneumococcal vaccination in adults. A meta-analysis of randomized controlled trials. Arch Int Med 1994;154:2666-77.
5. Dear K, Holden J, Andrews R, Tatham D. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Sys Rev 2003:CD000422.
6. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ 2009;180:48-58.
7. http://www.hospitalcompare.hhs.gov/ (accessed 9/22/12).
8. http://www.ahrq.gov/news/press/pr2012/pspclabsipr.htm (accessed 9/22/12).
9. 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.
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.

*The views expressed are those of the author and do not necessarily represent the views of the Arizona or New Mexico Thoracic Societies.

Reference as: Robbins RA. The emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care 2012;5:203-5. PDF