Multidisciplinary Discussion (MDD) in Interstitial Lung Disease; Some Reflections

Thomas V. Colby MD*

Michael B. Gotway MD^†

Lewis J. Wesselius MD^‡

Departments of Pathology*, Radiology^†, and Pulmonary Medicine^‡

Mayo Clinic Arizona

13400 E. Shea Blvd.

Scottsdale, AZ 85259

Multidisciplinary discussion (MDD) has been used in many disciplines in medicine, notably in thoracic oncology for some two decades (1).  MDD at a multidisciplinary conference (MDC) formalizes activities that have also gone under the label of case conferences, tumor boards, etc. and this practice is time- honored in medical practice.  In the setting of interstitial lung disease (ILD), especially the idiopathic interstitial pneumonias (IIPs) and IPF MDD conducted by a “multidisciplinary team” (MDT) and is now the “gold standard” for diagnosis in this clinical setting (2) and is recommended in the 2011 guidelines for IPF and the 2013 guidelines for IIPs (3, 4). 

Clinical-pathologic correlation, clinical-radiologic-pathologic correlation and clinical-radiologic correlation have been integral to the study of interstitial lung disease since early work of  Heitzman (5), Carrington and Gaensler (6) and many others. This represents the conceptual framework on which the Fleischner Society:  “…an international, multidisciplinary medical society for thoracic radiology, dedicated to the diagnosis and treatment of diseases of the chest” founded in 1969 (7).

The emphasis of MDD in the setting of ILD derives primarily from the study of Flaherty et al (8).  Flaherty et al studied the kappa statistic for intra-observer agreement among expert clinicians evaluating ILD and showed that the kappa significantly improved as more clinical, radiologic and pathologic information was added, suggesting that clinicians had become more confident of their diagnoses with this process. 

In theory, MDD results in a consensus diagnosis based on all the appropriate evidence discussed in a single setting allowing a dynamic intercourse and engagement among the physicians involved.  It allows the physicians to “look each other in the eye” and assess the confidence in the interpretations presented.  It also enables all participating physicians to reassess and change their opinions on the basis of new information and ongoing discussion.  Many of the positive aspects of MDD include the following:

• Dynamic interaction with exchange of ideas
• Engagement of the physicians involved; improved self-esteem
• Physicians can gauge the confidence of others’ opinions/diagnoses (e.g., the radiologic or pathologic diagnosis)
• Physicians can reassess and reinterpret their findings and change their diagnoses
• Educational value for involved physicians (for example, surgeons can appreciate the radiologic findings in terms of where to biopsy; pathologists can appreciate the pathologic findings relative to HRCT)
• Educational value for training fellows and junior staff
• Encourages evidence-based approach
• Increased homogeneity and consistency in managing ILD
• Development of a group ethos with associated improved morale
• Continuous feedback regarding diagnoses
• Forum for developing research ideas
• Forum for discussion and recruitment to clinical trials
• Pooled group clinical experience with broad perspective on ILD (for example, radiologic findings inform the pathologic findings and vice versa)
• An MDD diagnosis might be considered a more defensible diagnosis than individuals’ diagnoses
• The belief that collective thought is better than individuals’ diagnoses

As in any human interaction, theory does not always translate into practice and there are number of issues that  arise with MDD.  Negative and potentially negative aspects of MDD can summarized as follows:

• Physician and allied health staff time
• Physician and allied health staff cost
• Difficulty in coordinating schedules to attend an MDD
• Too many (unselected) cases for discussion
• Lack of a defined protocol and administrative structure for the MDD
• How individual findings should be weighted in terms of final diagnosis
• The effect on the group of individuals’ personalities and stature
• Discourages independence of thought and problem-solving strategies especially for trainees
• Lack of a clear trail as to exactly how a final diagnosis was reached (individual opinions may be lost)
• The “groupthink” phenomenon (to maintain harmony and conformity a group decision may in fact be dysfunctional)
• Over-confidence by the clinician in a diagnosis reached by MDD
• Lack of data on inter- and intra-observer correlation for MDT diagnoses
• When no consensus diagnosis is reached, who is the final arbitrator?
• The phenomenon of “diagnosis drift” (see below)
• The difficulty in validating MDD/MDT diagnoses
• MDD is a luxury of an academic practice and not practical in routine clinical practice
• Medico-legal liability of group members for a group decision

The MDD process for ILD has not been uniformly defined.  Should this be a free-for-all?  Should there be a defined protocol?  The algorithm for the diagnosis of IPF in the 2011 guidelines is a good guide (3).  To some extent, the observations/opinions presented in an MDD are subjective and thus an MDD diagnosis is simply a collection of subjective judgments.  MDD is influenced by individual personalities and there is no question that an “eminence factor” may be at play; a very eminent radiologist may intimidate a relatively inexperienced clinician and the result might be skewed toward the radiologic interpretation.  Cultural factors may also be at play since in some societies age and experience are venerated.  There are no guidelines if a consensus is not reached, and it would be folly to assume that consensus would be reached after every MDD session. When there is no consensus, who is the final arbiter?  We believe the clinician caring for the patient should be the final arbiter. 

Participation in an MDD may leads to something that can be called “diagnosis drift.”  An example of this follows.  The differential diagnosis for IPF includes chronic hypersensitivity pneumonitis, which may show certain radiologic features that suggest that diagnosis.  When such cases are discussed in an MDD, pathologists then become sensitive to similar findings histologically and over time, tend to raise the differential of chronic hypersensitivity pneumonitis more often in the absence any validated confirmation of this practice.

How can MDD be improved?  Given the time, expense, and logistical issues, we think it is unrealistic to expect a MDD for all ILD or IPF cases and that cases for MDD should selected, particularly those where there appears to be discrepancy between the clinical, radiologic and/or pathologic findings. The availability of an electronic medical record (EMR) allows ready access to medical information that may obviate need for MDD in individual cases, although the give and take of discussion is lost.

An attempt should be made to better define the process and the roles of the participants.  We suspect that in most MDDs there is a de facto definition of the process and the roles, but some attempt could be made to formalize this.  Some additional suggestions include:

• Be cognizant of the pros and cons discussed above
• Better defined process with roles and leader clarified
• Preselection of cases to improve efficiency; not all ILD cases need to be discussed
• Include only individuals necessary for a given case (efficient use of staff and their time)
• Consider MDD “overreading” by an experienced group since many community practices will not find MDD to be feasible
• Use of teleconferencing
• Record of the MMD process/decisions
• Continuous reassessment and improvement of the MDD process

And as a final thoughts…..remember that an experienced clinician effectively goes through the process of MDD in the clinical evaluation of an individual patient, appropriately consulting radiologists, pathologists, and other colleagues as needed to reach a management decision……but how is that experience gained…?...The educational value of MDD should not be forgotten.

References

1. Powell HA, Baldwin DR. Multidisciplinary team management in thoracic oncology: more than just a concept? Eur Respir J 2014;43(6):1776-1786. [CrossRef] [PubMed]
2. Wells AU. Histopathologic diagnosis in diffuse lung disease: an ailing gold standard. Am J Respir Crit Care Med 2004;170(8):828-829. [CrossRef] [PubMed] 
3. Raghu G, Collard HR, Egan JJ, Martinez FJ, Behr J, Brown KK et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med 2011;183(6):788-824. [CrossRef] [PubMed]
4. Travis WD, Costabel U, Hansell DM, King TE, Jr., Lynch DA, Nicholson AG et al. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med 2013;188(6):733-748. [CrossRef] [PubMed] 
5. Heitzman ER. The lung: Radiologic-pathologic correlations. Mosby, 1973.
6. Carrington CB, Gaensler EA. Clinical-pathologic approach to diffuse infiltrative lung disease. Monogr Pathol 1978;19:58-87. [PubMed] 
7. Fleischner Society Website. [cited 2014 Jul 1]; Available from: http://fleischner.org/
8. Flaherty KR, King TE, Jr., Raghu G, Lynch JP, 3rd, Colby TV, Travis WD et al. Idiopathic interstitial pneumonia: what is the effect of a multidisciplinary approach to diagnosis? Am J Respir Crit Care Med 2004;170(8):904-910. [CrossRef] [PubMed]

Acknowledgements

The authors thank the Fleischner Society members attending the 2014 Leuven meeting and the following physicians for thoughtful discussion and input:  Jeffrey Galvin, David Hansell, David Lynch, Mathias Prokop, Jay Ryu, and Johny Verschakelen.

Reference as: Colby TV, Gotway MB, Wesselius LJ. Multidisciplinary discussion (MDD) in interstitial lung disease; some reflections. Southwest J Pulm Crit Care. 2014;9(1):32-5. doi: http://dx.doi.org/10.13175/swjpcc097-14 PDF 

VA Administrators Breathe a Sigh of Relief

On May 30, Eric Shinseki, the Secretary for Veterans Affairs (VA), resigned under pressure amidst a growing scandal regarding falsification of patient wait times at nearly 40 VA medical centers. Before leaving office Shinseki fired Sharon Helman, the former hospital director at the Phoenix VA, where the story first broke, along with her deputy and another unnamed administrator. In addition, Susan Bowers, director of VA Veterans Integrated Service Network (VISN) 18 and Helman’s boss, resigned. Robert Petzel, undersecretary for the Veterans Health Administration (VHA, head of the VA hospitals and clinics), had resigned earlier. You could hear the sigh of relief from the VA administrators.

With their bosses resigning left and right, the VA leadership in shambles and the reputation of the VA  soiled for many years to come, why are the VA administrators relieved? The simple answer is that nothing has really changed. There for a moment it looked like real reform might happen. Even President Obama in announcing Shinseki's resignation said the "There is a need for a change in culture..." (1). Shinseki’s resignation would indicate that any action to change the culture is unlikely. Sure a few administrators, like Helman, will lose their jobs, perhaps a few patients will get outsourced to private practioners, but nothing is being done or proposed to change the VA culture. A new interim VA secretary was named and his tenure is likely to be lengthy since no confirmation appears to go unchallenged in the US Congress, and who would want the job?

I was at the VA, when then undersecretary for VHA, Kenneth Kizer, made the fundamental change that resulted in the present mess. Kizer had come to the VA with a program he called the “prescription for change” (2). Indeed, Kizer made several changes but the one that really counted was that the chiefs of staff, doctors who ran the medical services in VA hospitals, were replaced by the head of the Medical Administration Service, usually a business person. This made the VA director the monarch over their own little kingdom, and we all know “it’s good to be the king”. Furthermore, we all know that power corrupts and now with absolute power, the VA director was absolutely corrupted. The hospital directors eliminated any sources of potential opposition. Physicians who did not “play ball” could suddenly find themselves as a target of an investigation (3). After being found guilty by a kangaroo court, their names would be turned over to the National Practioner Databank as bad doctors making it difficult to find a job outside the VA. Those cooperative physicians were rewarded, often for limiting the care of patients. In other words, putting the VA administrators’ interests before the patients’ (4). Lastly, the long-standing relationship with the Nation’s medical schools was destroyed (remember VA dean’s hospitals?). It was argued that the medical schools used the VA to serve their needs. Although this had some truth, it is part of the two-way street that makes cooperation possible. No VA administrator wanted a bunch of doctors and academics telling them what to do.

After eliminating any possible oversight from the physicians or the medical schools, an insulating administrative layer had to be placed between the hospitals and VA central office. Therefore, the Veterans Integrated Service Networks or VISNs, were created. Although ostensibly to improve oversight and efficiency (2), only in Washington would they believe that another layer of bureaucracy would do either. As more and more patients were packed into the system, the numbers of physicians and nurses decreased (5). Not surprisingly, wait times became longer and there was no alternative but to hide the truth. The administrators, the VISNs and VA Central office were all complicit in these lies. Their bonuses depended on it and even when it was discovered by the VA Office of Inspector General (VAOIG) nothing was done.

Congress, who supposedly also provides oversight, was swift to propose action that does not change the VA culture and accomplish little. In this election year Congressional cries to throw those VA bums out have been consistent and loud. However, plenty of clues were available to know that the wait time data was false. First, the concept that you can cut the numbers of physicians and nurses and improve wait times defies common sense. Second, the VAOIG had repeatedly reported that wait times were being falsified. Helman had already been accused of this when she was the director at the Spokane VA (6). This week the Senate passed a bill allowing veterans to see private doctors outside the VA system if they experience long wait times or live more than 40 miles from a VA facility; make it easier to fire VA officials; construct 26 new VA medical facilities and use $500 million in unobligated VA funds to hire additional VA doctors and nurses (7). The VA already is able to do the first two, and as the present crisis illustrates, funds can be diverted away from healthcare. It seems likely this is exactly what will happen unless additional oversight is provided.

Kizer and Ashish Jha authored an editorial on this crisis in the New England Journal of Medicine this week (8). They made three recommendations:

1. The VA should refocus on fewer measures that directly address what is most important to veteran patients and clinicians-especially outcome measures.
2. Some of the resources supporting the central and network office bureaucracies could be redirected to bolster the number of caregivers.
3. The VA needs to engage more with health care organizations and the general public.

All these recommendations are reasonable. Outcome measures, not process of care, should be measured (9). Paying bonuses to administrators for clinicians completing these process of care measures should stop. Many of these measures serve mostly to increase administrative bonuses and not improve patient care. By giving administrators supervisory authority over physicians, healthcare providers were forced to complete a seemingly endless checklists rather than serve the patients' interests.

Bureaucracies should be reduced. VA's central-office staff has grown from about 800 in the late 1990s to nearly 11,000 in 2012 (8). VISN offices have reflected this growth with over 4500 employees in 2012 (10). This diversion of funds away from healthcare is the source of the present problem.

The VA needs to re-engage with the medical schools and with its patients. Reestablishment of the Dean's Committee or other similar system that provides oversight of the VA hospital directors and administrators may be one method of achieving this oversight. The association of the medical schools with the VA served the VA well from the Second World War until the 1990s (11).

Poor pay and micromanagement of physicians to perform meaningless metrics makes primary care onerous. Appropriating funds might improve the salary discrepancy between the VA and the private sector but will not fix the micromanagement problem. The VA may find it difficult to recruit the needed physicians and nurses unless a more friendly work environment is created. How do we know that any appropriated money will be spent on healthcare providers and infrastructure unless additional oversight is put in place? Without oversight the VA positions will become VA vacancies and the VA hospitals will become administrative palaces. Local oversight by VA physicians, nurses and patients is one method of ensuring that appropriated monies are actually spent on healthcare.

VA health care is at a crossroads. New leadership can help the VA succeed but only if the administrative structure is fixed changing the VA culture. Until this occurs the same administrative monarchs will continue to rule their realms and nothing will really change.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Cohen T, Griffin D, Bronstein S, Black N. Shinseki resigns, but will that improve things at VA hospitals? CNN. May 31, 2014. Available at: http://www.cnn.com/2014/05/30/politics/va-hospitals-shinseki/ (accessed 6/7/14).
2. Kizer KW. Prescription for change. March 1996. Available at: http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf (accessed 6/7/14). 
3. Wagner D. The doctor who launched the VA scandal. Arizona Republic. May 31, 2014. Available at: http://www.azcentral.com/longform/news/arizona/investigations/2014/05/31/va-scandal-whistleblower-sam-foote/9830057/ (accessed 6/7/14).
4. Hsieh P. Three factors that corrupted VA health care and threaten the rest of American medicine. Forbes. May 30, 2014. Available at: http://www.forbes.com/sites/paulhsieh/2014/05/30/three-factors-that-corrupted-va-health-care/ (accessed 6/7/14).
5. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54. Available at: http://www.swjpcc.com/editorial/2012/5/5/va-administrators-gaming-the-system.html (accessed 6/7/14).
6. Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9. Available at: http://www.swjpcc.com/editorial/2014/5/26/va-scandal-widens.html (accessed 6/7/14). 
7. O'Keefe E. Senators reach bipartisan deal on bill to fix VA. Washington Post. June 5, 2014. Available at: http://www.washingtonpost.com/blogs/post-politics/wp/2014/06/05/senators-reach-bipartisan-deal-on-bill-to-fix-va/ (accessed 6/7/14).
8. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014 Jun 4. [Epub ahead of print]. Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1406852 (accessed 6/7/14). [CrossRef]
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353(17):1860-1. [CrossRef]
10. VA Office of Inspector General. Audit of management control structures for veterans integrated service network offices. March 27, 2012. Available at: http://www.va.gov/oig/pubs/VAOIG-10-02888-129.pdf (accessed 6/7/14).
11. VA policy memorandum no. 2: policy in association of veterans' hospitals with medical schools. January 30, 1946. Available at: http://www.va.gov/oaa/Archive/PolicyMemo2.pdf (accessed 6/7/14).

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado, or California Thoracic Societies or the Mayo Clinic.

Refence as: Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. doi: http://dx.doi.org/10.13175/swjpcc077-14 PDF

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.