A New Paradigm to Improve Patient Outcomes

A Tongue-in-Cheek Look at the Cost of Patient Satisfaction

A landmark article entitled “The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality” was recently published in the Archives of Internal Medicine by Fenton et al. (1). The authors conducted a prospective cohort study of adult respondents (n=51,946) to the 2000 through 2007 national Medical Expenditure Panel Survey. The results showed higher patient satisfaction was associated with higher admission rates to the hospital, higher overall health care expenditures, and increased mortality.

The higher costs are probably not surprising to many health care administrators. Programs to improve patient satisfaction such as advertising, valet parking, gourmet meals for patients and visitors, massages, never-ending patient and family satisfaction surveys, etc. are expensive and would be expected to increase costs. Some would argue that these costs are simply the price of competing for patients in the present health care environment. Although the outcomes are poorer, substituting patient satisfaction as a surrogate marker for quality of care is probably still valid as a business goal (2). Furthermore, administrators and some healthcare providers are paid bonuses based on patient satisfaction. These bonuses are necessary to maintain salaries at a level to attract the best and brightest.

Although it seems logical that most ill patients wish to live and get well as quickly and cheaply as possible, the Archives article demonstrates that this is a fallacy. Otherwise, higher patient satisfaction would clearly correlate with lower mortality, admission rates and expenses. Since the hospitals and other health care organizations are here to serve the public, some would argue that giving the patients what they want is more important that boring outcomes such as hospital admission rates, costs and mortality.

The contention of this study – that dissatisfaction might improve patient survival – may have biological plausibility.  Irritation with the healthcare process might induce adrenal activation, with resulting increases in beneficial endogenous catecholamines and cortisol.  The resulting increase in global oxygen delivery might reduce organ failure.  Furthermore, the irritated patient is less likely to consent to unnecessary medical procedures and is therefore protected from ensuing complications.  An angry patient is likely to have less contact with healthcare providers who are colonized with potentially dangerous multi-drug resistant bacteria.

Specific bedside practices can be implemented in order to increase patient dissatisfaction, and thereby benefit mortality.   Nurses can concentrate on techniques of sleep deprivation such as waking the patient to ask if they want a sleeping pill.  Third year medical students can be employed to start all IVs and perform all lumbar punctures.  Attending physicians can do their part by being aloof and standoffish.  For instance, a patient suffering an acute myocardial infarction might particularly benefit from hearing about the minor inconveniences the attending suffered aboard a recent south Pacific cruise ship – “I ordered red caviar, and they brought black!”  During the medical interview, non-pregnant women should always be asked “when is the baby due?”  Repeatedly confusing the patient’s name, or calling them by multiple erroneous names on purpose, can heighten their sense of insecurity.  Simply making quotation signs with your fingers whenever the physician refers to themselves as their “doctor” can be quite off-putting. 

Simple props can be useful.  Wads of high-denomination cash, conspicuously bulging from all pockets of the attending’s white coat, can promote a sense of moral outrage.  Conspicuously placing a clothespin on your nose upon entering the patient’s room can be quite effective.  Simply placing your stethoscope in ice water for a few minutes before applying it to the patient’s bare chest can make a difference   

Other more innovative techniques might arise.  Charging the patient in cash for each individual medical intervention might be quite useful, emphasizing the magnitude of overcharging.  This would be made apparent to the patient who for instance might be asked to pay $40 cash on the barrelhead for a single aspirin pill.

Often the little things make a big difference – dropping a pile of aluminum food trays on the floor at 4 AM, clamping the Foley tube, purposely ignoring requests for a bedpan, or making the patient NPO for extended periods for no apparent reason can be quite effective. 

However, we fear that health care professionals may have difficulty overcoming their training to be responsive to patients. Therefore, we suggest a different strategy to National health care planners seeking to reduce costs and improve patient mortality, what we term the designated institutional offender (DIO). A DIO program where an employee is hired to offend patients would likely be quite cost effective. The DIO would not need expensive equipment or other resources. The DIO role is best suited for someone with minimal education and a provocative attitude. Only the most deficient and densest (as opposed to the best and brightest) should be hired.

Clearly, an authoritative group must be formed to establish guidelines and bundles for both the DIO and healthcare providers. We suggest formation of the Institute of Healthcare Irritation, or IHI.  They could certify DIOs to insure that the 7 habits of highly offensive people are used (3).  IHI can also establish clinical practice bundles like the rudeness bundle, the physical discomfort bundle, the moral outrage bundle, etc.

We suggest the following as an example to muster compliance with the physical discomfort bundle. The patient must be documented to be experiencing:

• Hunger
• Thirst
• Too cold (or too hot)
• Sleep deprivation
• Drug-related constipation
• And the inability to evacuate their bladder

Patient satisfaction with even a single component indicates failure of bundle compliance. Of course a cadre of personnel will need to be hired to ensure compliance with the bundles.

Based on the evidence from the Archives article, there was a 9.1% cost differential between the highest and the lowest satisfaction quartile. Shifting patients to lower satisfaction quartiles could result in huge cost savings. If the DIO and IHI strategies to offend are particularly effective, many patients will not return for health care at all, resulting in further savings. Targeting those who are the largest consumers of care could result in even larger savings.

The DIO and IHI would also save lives. Those patients in the highest satisfaction quartile had a 26% higher mortality rate than the lowest quartile. If patients who have poor self-related health and > 3 chronic diseases are excluded, the mortality rate is 44% higher in the highest satisfaction quartile.

Administrators could now be paid bonuses for not only compliance with the IHI bundles, but also lower patient satisfaction scores, since they can argue that lower satisfaction is actually good for patients. Furthermore, the administrators should receive higher compensation since the DIO and the personnel hired to ensure compliance with the IHI guidelines would be additional employees in their administrative chain of command and administrative salaries are often based on the number of employees they supervise.   

Richard A. Robbins, MD

Robert A. Raschke, MD

References

1. 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;172:405-11.
2. Browne K, Roseman D, Shaller D, Edgman-Levitan S. Analysis & commentary. Measuring patient experience as a strategy for improving primary care. Health Aff (Millwood). 2010 May;29(5):921-5
3. Bing S. The seven habits of highly offensive people. Fortune magazine available at http://money.cnn.com/magazines/fortune/fortune_archive/1995/11/27/208025/index.htm (accessed 7-7-12).

Reference as: Robbins RA, Raschke RA. A new paradigm to improve patient outcomes: a tongue-in-cheek look at the cost of patient satisfaction. Southwest J Pulm Crit Care 2012;5:33-5. (Click here for a PDF version of the editorial) 

A Little Knowledge is a Dangerous Thing

An article entitled “A Comprehensive Care Management Program to Prevent Chronic Obstructive Pulmonary Disease Hospitalizations: A Randomized, Controlled Trial” from the VA cooperative studies program was recently published in the Annals of Internal Medicine (1).  This article describes the BREATH trial mentioned in a previous editorial (2). BREATH was a randomized, controlled, multi-center trial performed at 20 VA medical centers comparing an educational comprehensive care management program to guideline-based usual care for patients with chronic obstructive pulmonary disease (COPD). The intervention included COPD education during 4 individual and 1 group sessions, an action plan for identification and treatment of exacerbations, and scheduled proactive telephone calls for case management. After enrolling 426 (44%) of the planned total of 960 the trial was stopped because there were 28 deaths from all causes in the intervention group versus 10 in the usual care group (hazard ratio, 3.00; 95% CI, 1.46 to 6.17; p = 0.002). Deaths due to COPD accounted for the largest difference (10 deaths in the intervention group versus 3 in usual care; hazard ratio, 3.60; 95% CI, 0.99 to 13.08). This trial led us to perform a meta-analysis of educational interventions in COPD (3). In this meta-analysis of 2476 subjects we found no difference in mortality between intervention and usual care groups and that the recent Annals study was heterogenous compared to the other studies.

Should the recent VA study have been stopped early? Several reports demonstrate that studies stopped early usually overestimate treatment effects (4-7). Some have even suggested that stopping trials early is unethical (7). A number of articles suggest that trials should only be stopped if predetermined statistical parameters are exceeded, with the p value for stopping set at a very low level (4-7).  There was no planned interim analysis for any outcome in the recent VA trial. The rationale for stopping a study for an adverse effect when there is no a priori reasonable link between the intervention and the adverse effect is missing in this instance.  It seems unlikely that education would actually lead to increased deaths in COPD patients.  Any effect should logically have impacted the COPD related mortality, yet there was no significant increase for COPD related deaths in the intervention group. An accompanying editorial by Stuart Pocock makes most of these points and suggests that chance was the most likely cause of the excess deaths (8).

The VA Coop Trials coordinating center told the investigators that the reason for stopping the trial was that there were “significant adverse events” in the intervention group. Inquires regarding what adverse events went unanswered. This would seem to be a breakdown in VA research oversight. The information provided to both investigators and research subjects was incomplete and would seem to be a violation of the informed consent, which states the subject would be notified of any new information that significantly altered their risk.

Lastly, investigators were repeatedly warned by the VA coordinating center that “all communications with the media should occur through your facility Public Affairs office”. It seems very unlikely that personnel in any public affairs office have sufficient research training to answer any medical, statistical or ethical inquiries into the conduct of this study.

In our meta-analysis we have shown that self-management education is associated with a reduction in hospital admissions with no indication for detrimental effects in other outcome parameters. This would seem sufficient to justify a recommendation of self-management education in COPD. However, due to variability in interventions, study populations, follow-up time, and outcome measures, data are still insufficient to formulate clear recommendations regarding the form and content of self-management education programs in COPD.

Richard A. Robbins, M.D.*

Editor, Southwest Journal of Pulmonary

   and Critical Care

References

1. Fan VS, Gaziano JM, Lew R, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med 2012;156:673-683.
2. Robbins RA. COPD, COOP and BREATH at the VA. Southwest J Pulm Crit Care 2011;2:27-28.
3. Hurley J, Gerkin R, Fahy B, Robbins RA. Meta-analysis of self-management education for patients with chronic obstructive pulmonary disease. Southwest J Pulm Crit Care 2012;4:?-?.
4. Pocock SJ, Hughes MD. Practical problems in interim analyses, with particular regard to estimation.Control Clin Trials 1989;10:209S-221S.
5. Montori VM, Devereaux PJ, Adhikari NK, et al. Randomized trials stopped early for benefit: a systematic review. JAMA 2005;294:2203-9.
6. Bassler D, Briel M, Montori VM, et al. Stopping randomized trials early for benefit and estimation of treatment effects: systematic review and meta-regression analysis. JAMA 2010;303:1180-7.
7. Mueller PS, Montori VM, Bassler D, Koenig BA, Guyatt GH. Ethical issues in stopping randomized trials early because of apparent benefit. Ann Intern Med. 2007;146:878-81.
8. Pocock SJ. Ethical dilemmas and malfunctions in clinical trials research. Ann Intern Med 2012;156:746-747.

*Dr. Robbins was an investigator and one of the co-authors of the Annals of Internal Medicine manuscript (reference #1).

Reference as: Robbins RA. A little knowledge is a dangerous thing. Southwest J Pulm Crit Care 2012;4:203-4. (Click here for a PDF version of the editorial) 

Why Is It So Difficult to Get Rid of Bad Guidelines?

Reference as: Robbins RA. Why is it so difficult to get rid of bad guidelines? Southwest J Pulm Crit Care 2011;3:141-3. (Click here for a PDF version of the editorial)

My colleagues and I recently published a manuscript in the Southwest Journal of Pulmonary and Critical Care examining compliance with the Joint Commission of Healthcare Organization (Joint Commission, JCAHO) guidelines (1). Compliance with the Joint Commission’s acute myocardial infarction, congestive heart failure, pneumonia and surgical process of care measures had no correlation with traditional outcome measures including mortality rates, morbidity rates, length of stay and readmission rates. In other words, increased compliance with the guidelines was ineffectual at improving patient centered outcomes. Most would agree that ineffectual outcomes are bad. The data was obtained from the Veterans Healthcare Administration Quality and Safety Report and included 485,774 acute medical/surgical discharges in 2009 (2). This data is similar to the Joint Commission’s own data published in 2005 which showed no correlation between guideline compliance and hospital mortality and a number of other publications which have failed to show a correlation with the Joint Commission’s guidelines and patient centered outcomes (3-8). As we pointed out in 2005, the lack of correlation is not surprising since several of the guidelines are not evidence based and improvement in performance has usually been because of increased compliance with these non-evidence based guidelines (1,9).

The above raises the question that if some of the guidelines are not evidence based, and do not seem to have any benefit for patients, why do they persist? We believe that many of the guidelines were formulated with the concept of being easy and cheap to measure and implement, and perhaps more importantly, easy to demonstrate an improvement in compliance. In other words, the guidelines are initiated more to create the perception of an improvement in healthcare, rather than an actual improvement. For example in the pneumonia guidelines, one of the performance measures which have markedly improved is administration of pneumococcal vaccine. Pneumococcal vaccine is easy and cheap to administer once every 5 years to adult patients, despite the evidence that it is ineffective (10). In contrast, it is probably not cheap and certainly not easy to improve pneumonia mortality rates, morbidity rates, length of stay and readmission rates.

To understand why these ineffectual guidelines persist, one needs to understand who benefits from guideline implementation and compliance. First, organizations which formulate the guidelines, such as the Joint Commission, benefit. Implementing a program that the Joint Commission can claim shows an improvement in healthcare is self-serving, but implementing a program which provides no benefit would be politically devastating. At a time when some hospitals are opting out of Joint Commission certification, and when the Joint Commission is under pressure from competing regulatory organizations, the Joint Commission needs to show their programs produce positive results.

Second, programs to ensure compliance with the guidelines directly employ an increasingly large number of personnel within a hospital. At the last VA hospital where I was employed, 26 full time personnel were employed in quality assurance. Since compliance with guidelines to a large extent accounts for their employment, the quality assurance nurses would seem to have little incentive to question whether these guidelines really result in improved healthcare. Rather, their job is to ensure guideline compliance from both hospital employees and nonemployees who practice within the hospital.

Lastly, the administrators within a hospital have several incentives to preserve the guideline status quo. Administrators are often paid bonuses for ensuring guideline compliance. In addition to this direct financial incentive, administrators can often lobby for increases in pay since with the increase number of personnel employed to ensure guideline compliance, the administrators now supervise more employees, an important factor in determining their salary. Furthermore, success in improving compliance, allows administrators to advertise both themselves and their hospital as “outstanding”.

In addition, guidelines allow administrative personnel to direct patient care and indirectly control clinical personnel. Many clinical personnel feel uneasy when confronted with "evidence-based" protocols and guidelines when they are clearly not “evidence-based”. Such discomfort is likely to be more intense when the goals are not simply to recommend a particular approach but to judge failure to comply as evidence of substandard or unsafe care. Reporting a physician or a nurse for substandard care to a licensing board or on a performance evaluation may have devastating consequences.

There appears to be a discrepancy between an “outstanding” hospital as determined by the Joint Commission guidelines and other organizations. Many hospitals which were recognized as top hospitals by US News & World Report, HealthGrades Top 50 Hospitals, or Thomson Reuters Top Cardiovascular Hospitals were not included in the Joint Commission list. Absent are the Mayo Clinic, the Cleveland Clinic, Johns Hopkins University, Stanford University Medical Center, and Massachusetts General.  Academic medical centers, for the most part, were noticeably absent. There were no hospitals listed in New York City, none in Baltimore and only one in Chicago. Small community hospitals were overrepresented and large academic medical centers were underrepresented in the report. However, consistent with previous reports, we found that larger predominately urban, academic hospitals had better all cause mortality, surgical mortality and surgical morbidity compared to small, rural hospitals (1).

Despite the above, I support both guidelines and performance measures, but only if they clearly result in improved patient centered outcomes. Formulating guidelines where the only measure of success is compliance with the guideline should be discouraged. We find it particularly disturbing that we can easily find a hospital’s compliance with a Joint Commission guideline but have difficulty finding the hospital’s standardized mortality rates, morbidity rates, length of stay and readmission rates, measures which are meaningful to most patients. The Joint Commission needs to develop better measures to determine hospital performance. Until that time occurs, the “quality” measures need to be viewed as what they are-meaningless measures which do not serve patients but serve those who benefit from their implementation and compliance.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. 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.
2. Available at: http://www.va.gov/health/docs/HospitalReportCard2010.pdf (accessed 9-28-11).
3. Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. N Engl J Med. 2005;353:255-64.
4. Werner RM, Bradlow ET. Relationship between Medicare's hospital compare performance measures and mortality rates. JAMA 2006;296:2694-702.
5. Peterson ED, Roe MT, Mulgund J, DeLong ER, Lytle BL, Brindis RG, Smith SC Jr, Pollack CV Jr, Newby LK, Harrington RA, Gibler WB, Ohman EM. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA 2006;295:1912-20.
6. Fonarow GC, Yancy CW, Heywood JT; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry. Arch Int Med 2005;165:1469-77.
7. Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med 2008;149:29-32.
8. Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM.  Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA. 2010;303:2479-85.
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353:1860-1.
10. 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.

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

Guidelines, Recommendations and Improvement in Healthcare

“You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing.”-Thomas Sowell

Reference as: Robbins RA, Thomas AR, Raschke RA. Guidelines, recommendations and improvement in healthcare. Southwest J Pulm Crit Care 2011;2:34-37. (Click here for PDF version)

In the February, 2011 Critical Care Journal Club two articles were reviewed that dealt with Infectious Disease Society of America (IDSA) guidelines (click here for Critical Care Journal Club). The first by Lee and Vielemeyer (1) reviewed the evidence basis for the 4218 IDSA recommendations and found that only 14% were based on Level 1 evidence (data from >1 properly randomized controlled trial). The graph summarizing the data in Figure 1 of the manuscript is exemplary in its capacity to communicate the weak evidence basis for many of the IDSA recommendations.

A second study by Kett et al. (2) examined the outcomes when the American Thoracic Society (ATS)/IDSA therapeutic guidelines for management of possible multidrug-resistant pneumonia were followed. The authors found a 14% difference in survival when the guidelines were followed, but surprisingly, the survival was better if the guidelines were not followed. Dr. Kett and colleagues are to be congratulated for their candor in reporting their retrospective analysis of empirical antibiotic regimens for patients at risk for multidrug-resistant pathogens. The ATS/IDSA guidelines (3) state that “combination therapy should be used if patients are likely to be infected with MDR pathogens (Level II or moderate evidence that comes from well designed, controlled trials without randomization…”. However, the ATS/IDSA guidelines go on to state, “No data have documented the superiority of this approach compared with monotherapy, except to enhance the likelihood of initially appropriate empiric therapy (Level I evidence…from well conducted, randomized controlled trials)” (4).

The problem comes with the interpretation and implementation of these and other guidelines. Some, usually inexperienced clinicians or nonclinicians, seem to believe that following any set of guidelines will enhance the “quality” of patient care. Not all guidelines or studies are created equally. Some are evidence-based, important, correct and likely to make a real difference. These usually come from professional societies and are authored by well-respected, experts in the field whose goal is improve patient outcomes. As suggested by Kett’s article even these guidelines may not be infallible. Other guidelines are not evidence-based, unimportant, incorrect and can border on the trivial. These are often authored by nonprofessional, nonexperts to create a “political statistic” (5) rather than improve patient care.

If some guidelines are bad, how can those be separated from the good? We suggest 5 traits of quality guidelines: 

1. The guideline’s authors are identified and are well-respected, experts in the field appropriate to the guideline.
2. The authors identify potential conflicts of interest.
3. The evidence is graded and supported by references to relevant scientific literature.
4. The guidelines state how they selected and reviewed the references on which the guidelines are based.
5. After completion, the guidelines are reviewed by a group of reasonably knowledgeable individuals (for example the IDSA Board of Directors) that can be identified and are willing to risk the reputation of themselves and their organization on the guidelines.

Even with the above safeguards guidelines may be non-evidence-based, unimportant, incorrect or trivial, and if so, implementation may be at best a waste of resources, or at worst harmful to patient care. We ask that guideline writing committees show restraint in authoring documents which are little more than their opinions. Not every medical question, especially the trivial and the unimportant, needs a guideline. Furthermore, we would ask an endorsement from professional organizations that only guidelines based on randomized clinical trials be given a strong recommendation. As pointed out by Lee and Vielemeyer (1) only 23% of the IDSA guidelines were supported by randomized trials while 37% of strong recommendations were supported only by opinion or descriptive studies.

IDSA states on their guidelines website, “It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to the guidelines listed below to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances” (6). Despite this and other disclaimers, guidelines often take on a life onto themselves, frequently carrying the weight of law, regardless of the supporting evidence. We call for professional societies to end the practice of strongly recommending those guidelines based on opinion. Such practices have led and will continue to lead to systematic patient harm. Only those guidelines based on strong evidence should be given a strong recommendation. If the professional societies believe an opinion on a particular issue is appropriate despite a lack of evidence, a different designation such as recommendation or suggestion should be used to clearly separate it from a guideline.  The term guideline should be reserved for those statements that are evidence-based, important, and almost certainly correct and can make a real difference to patients.

Richard A Robbins MD, Allen R Thomas MD, and Robert A Raschke MD

References

1. Lee DH, Vielemeyer O. Analysis of overall level of evidence behind infectious diseases society of America practice guidelines. Arch Intern Med. 2011;171:18-22.
2. Kett DH, Cano E, Quartin AA, Mangino JE, Zervos MJ, Peyrani P, Cely CM, For KD, Scerpella EG, Ramirez JA. Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study.  Lancet Infect Dis 2011 Jan 19. [Epub ahead of print].
3. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416.
4. Paul M, Benuri-Silbiger I, Soares-Weiser K, Liebovici L. Beta-Lactam monotherapy versus beta-lactam–aminoglycoside combination therapy for sepsis in immunocompetent patients: systematic review and metaanalysis of randomised trials. BMJ, doi:10.1136/bmj.38028.520995.63 (published March 2, 2004). Available at URL http://bmj.bmjjournals.com/cgi/reprint/bmj.38028.520995.63v1.pdf?ck_nck (accessed February 11, 2011).
5. Churchill, Winston. London, UK. 1945. as cited in The Life of Politics, 1968,  Henry Fairlie, Methuen, pp. 203-204.
6. Infectious Disease Society of American. Standards, Practice Guidelines, and Statements Developed and/or Endorsed by IDSA. Available at URL http://www.idsociety.org/content.aspx?id=9088 (accessed February 12, 2011).