Will Fewer Tests Improve Healthcare or Profits?

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

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

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

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

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

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

Richard A. Robbins, MD

Allen R. Thomas, MD

References

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

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

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

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

Identification of a Biomarker of Sleep Deficiency—Are We Tilting Windmills?

The amount of time spent asleep by adults in the United States and other developing countries is decreasing. It is estimated that over 40 years ago, adults slept in excess of 8 hours per night, but now sleep barely 7 hours per night (1) During this time frame, there has been a corresponding increase in obesity and diabetes mellitus which in part has been attributed to a reduction in time sleeping (2). In addition, sleep deficiency and other sleep disorders have been implicated as risk factors for hypertension, cardiovascular disease and cancer (3-5). Consequently, billions of excess health care dollars are spent on medical conditions associated with sleep deficiency or sleep disorders (6,7). Their impact also include substantial costs resulting from lost productivity as well as increased absenteeism, presenteeism and motor vehicle or industrial accidents (6,7).  Thus, sleep disorders and sleep deficiency are significant threats to public health and productivity in the United States and worldwide and no evidence of a decline is on the horizon. One barrier to reducing their impact is the difficulty in identifying on a societal and personal level the major consequence of sleep deficiency, sleepiness.

Despite the extraordinary progress made by sleep and circadian science in recent years, developing an accurate and easy to use biomarker for sleepiness and/or sleep deficiency has been elusive. Currently used objective assessments of sleepiness such as the multiple sleep latency test or the psychomotor vigilance test are either difficult to use outside the laboratory environment or do not evaluate all domains of sleep deficiency. Subjective assessments of sleepiness are unreliable because many individuals cannot recognize their impairment (8) and in some occupational scenarios (e.g., truck drivers, railroad engineers); there is personal incentive to deny its presence because of the fear of losing employment or income (9).

If developed, there would be several uses for a sleepiness or sleep deficiency biomarker. These include:

• Research: especially in field studies of the impact of sleep deficiency and/or sleepiness in both small and large size cohorts;
• Fitness for duty: in clinical and occupational settings (e.g., operating a motor vehicle, aircraft pilot) where objective assessment of sleepiness would be important in determining whether an individual could perform their job;
• Personal health: such testing might ultimately provide a means for an individual to determine his/her level of sleepiness and allow self adjustment of medication or positive airway pressure in the case of obstructive sleep apnea patients, analogous to currently used home glucose testing in persons with diabetes mellitus;
• Disease risk stratification: level of sleep deficiency might identify individuals with a greater likelihood of developing other medical conditions such as cardiovascular disease or diabetes.

In an attempt to “jumpstart” interest and research into developing a sleepiness or sleep deficiency biomarker, the Division of Sleep Medicine at Harvard Medical School hosted a conference on September 21-22, 2010 supported by the National Heart, Lung and Blood Institute and commercial entities entitled “Finding a Research Path for the Identification of Biomarkers of Sleepiness” (10). A number of prominent national and international speakers presented possible approaches to achieving this goal including behavioral, physiologic, genomic and proteomic solutions. This conference was followed by a panel discussion on this same topic at the annual Sleep 2011 international conference. Despite these high profile public discourses, there has been little progress in finding a sleepiness/sleep deficiency biomarker. A brief search of PubMed identified only one paper published since the conference directly relevant to this area (11).

Why has there been so little progress? I would propose the major reason is lack of a public “outcry”. Despite high profile incidences such as the crash of Colgan Air Flight #3407 (12) and the grounding of the Exxon Valdez (13), and a report from the Institute of Medicine (6) the general public has not adopted sleep issues as a major public health concern. In contrast, cancer, heart disease, obesity and diabetes, all of which may in part be consequences of sleep deficiency or a sleep disorder, are higher in the public consciousness. As a result, it is unlikely that funding initiatives such as a RFA on research into sleepiness or sleep deficiency biomarkers from the National Institutes of Health will be forthcoming.

What can be done? It should be the mission of all of us who are involved in sleep research and clinical Sleep Medicine to promote to the public the importance of sleep deficiency and sleep disorders in adversely impacting public health. Until there is a ground swell of public support, I fear attempts to identify biomarkers for sleepiness or sleep deficiency may be similar to “tilting at windmills.”

Stuart F. Quan, M.D.

Division of Sleep Medicine,

Brigham and Women’s Hospital and Harvard Medical School

401 Park Dr., 2^nd Floor East

Boston, MA 02215

Voice: 617-998-8842

Fax: 617-998-8823

Email: Stuart_Quan@hms.harvard.edu

References

1. McAllister EJ, Dhurandhar NV, Keith SW, et al. Ten putative contributors to the obesity epidemic. Crit Rev Food Sci Nutr 2009;49:868-913.
2. Spiegel K, Tasali E, Leproult R, Van Cauter E. Effects of poor and short sleep on glucose metabolism and obesity risk. Nat Rev Endocrinol 2009;5:253-261.
3. Budhiraja R, Sharief I, Quan SF. Sleep disordered breathing and hypertension. J Clin Sleep Med 2005; 1:401-4.
4. Kakizaki M, Kuriyama S, Sone T, et al. Sleep duration and the risk of breast cancer: the Ohsaki Cohort Study. Br J Cancer 2008; 99:1502-5.
5. Quan SF. Sleep Disturbances and their Relationship to Cardiovascular Disease. Am J Lifestyle Med 2009; 3:55s-59s.
6. Colten HR, Altevogt BM, Institute of Medicine. Committee on Sleep Medicine and Research. Sleep disorders and sleep deprivation: an unmet public health problem. Washington, DC: Institute of Medicine: National Academies Press, 2006; 404.
7. Anonymous. The Price of Fatigue: the surprising economic costs of unmanaged sleep apnea. 2010. https://sleep.med.harvard.edu/what-we-do/public-policy-research
8. Durmer JS, Dinges DF. Neurocognitive consequences of sleep deprivation. Semin Neurol 2005;25:117-129.
9. Smith B, Phillips BA. Truckers drive their own assessment for obstructive sleep apnea: a collaborative approach to online self-assessment for obstructive sleep apnea. J Clin Sleep Med 2011;7:241-245.
10. Anonymous. Harvard Biomarkers of Sleepiness Conference. 2011. https://sleep.med.harvard.edu/what-we-do/biomarkers-conference
11. Goel N, Banks S, Lin L, Mignot E, Dinges DF. Catechol-O-methyltransferase Val158Met polymorphism associates with individual differences in sleep physiologic responses to chronic sleep loss. PLoS One 2011;6:e29283.
12. Anonymous. Colgan Air Flight 3407. 2012. http://en.wikipedia.org/wiki/Colgan_Air_Flight_3407#cite_note-ntsb.2Faar-10.2F01-20
13. Anonymous. Details about the Accident SPILL: The wreck of the Exxon Valdez Final Report, Alaska Oil Spill Commission. 1990. http://www.evostc.state.ak.us/facts/details.cfm

Reference as: Quan SF. Identification of a biomarker of sleep deficiency-Are we tilting windmills? Southwest J Pulm Crit Care 2012;4:58-60. (Click here for a PDF version of the editorial) 

Competition or Cooperation?

One of our local institutions, the Mayo Clinic Arizona, was mentioned in a recent op-ed in the New York Times. The editorial entitled, “It Costs More, but Is It Worth More?” by Ezekiel J. Emanuel and Steven D. Pearson (1), criticizes the Mayo Clinic in Rochester and Arizona for building two new proton beam treatment facilities at a cost of more than $180 million dollars each.  It accuses the Mayo Clinic of participating in “…a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives”. The editorial states that except for a handful of rare pediatric cancers, the evidence is lacking for treatment of other types of cancer such as lung, esophageal, breast, head and neck, and prostate cancers.

John Noseworthy MD, President and Chief Executive of the Mayo Clinic, replied that the Mayo Clinic “will carefully study proton therapy and other new therapies, compare clinical outcomes and offer high-quality, cost-effective, proven and safer treatments for patients”. In another letter to the Minneapolis StarTribune, Nosewothy goes on to say, “Mayo Clinic takes serious issue with the authors' use of Mayo Clinic and its programs in this manner. As a not-for-profit institution, we are motivated by the best interests of our patients, not ‘profit’ or competitiveness. With the facility costs, start-up expenses and the extensive training required to offer this therapy, we do not expect to break even, much less earn a ‘profit,’ on our proton therapy program for years”.

I am not an expert in either cancer treatment or proton beam therapy, but a weekend search of the medical literature largely confirms that the therapy is unproven for most cancers, although there was no evidence that proton beam is inferior to more traditional means of delivering radiation therapy. Second, the cost of proton beam therapy is high. Costs are about $55,000 plus $15,000 in physician fees per patient for the therapy alone, twice as much as a linear accelerator. This sounds like a lot of money but you still need an estimated volume of about 2,000-3,500 patients per year to cover an investment of over $180 million investment.

So why are the Mayo Clinic and others constructing these centers since they are expensive; mostly of unproven superiority over existing therapies; and reimbursement, although generous, may not cover the cost of the facility? The answer is likely competition. Competition for patients largely drives tertiary referral centers. Locally, there is a small war going on between the Mayo Clinic Arizona and the new Banner MD Anderson Cancer Center. Mayo Clinic is concerned about MD Anderson having greater name recognition and losing its patients to the new center. Banner in partnership with MD Anderson sees an opportunity to compete in a large metropolitan center without a strong university medical center. Mayo Clinic Arizona undoubtedly feels that new technologies such as proton beam are necessary to compete with MD Anderson, especially since MD Anderson has a proton beam therapy unit in Houston.  

All this is probably not good for patients and illustrates that competition in medicine does not necessarily lead to cheaper, more effective care. Patients will be easily persuaded to receive the latest and greatest therapy when their life is on the line, especially when the bulk of the cost is covered by a third party. Whether proton beam therapy is the latest and greatest is fairly difficult to determine at this time, given the absence of well designed, randomized studies. The Center for Medicare and Medicaid Services (CMS) process of determining reimbursement costs is largely a mystery but needs to show some restraint. Large reimbursements for unproven therapies such as proton beam while underfunding areas with well demonstrated benefits is not in the best public interest. Furthermore, instead of directly or indirectly encouraging competition, CMS needs to foster cooperation. Perhaps requiring hospitals to work together to study the effectiveness of proton beam to get reimbursed would be a good first step. As Franklin D. Roosevelt said, “Competition has been shown to be useful up to a certain point and no further, but cooperation, which is the thing we must strive for today, begins where competition leaves off” (5).

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Emanuel EJ, Pearson SD. It costs more, but is it worth it? New York Times. http://opinionator.blogs.nytimes.com/tag/proton-beam-therapy/ (accessed 1-23-12).
2. Noseworthy J. Mayo clinic’s investment. New York Times. http://www.nytimes.com/2012/01/06/opinion/mayo-clinics-investment.html (accessed 1-23-12).
3. Nosewothy J.  Mayo CEO defends use of proton beam therapy. Minneapolis StarTribune http://www.startribune.com/opinion/otherviews/136758278.html (accessed 1-23-12).
4. Clark C. What would super committee say about $430m proton beam center war? http://www.healthleadersmedia.com/page-1/QUA-272912/What-Would-Super-Committee-Say-About-430M-Proton-Beam-Center-War (accessed 1-23-12).
5. http://www.brainyquote.com/quotes/authors/f/franklin_d_roosevelt.html (accessed 1-23-12).

Reference as: Robbins RA. Competition or cooperation? Southwest J Pulm Crit Care 2012;4:30-1. (Click here for a PDF version of the editorial)

Follow the Money

Many years ago there was a Federal whistleblower, Deep Throat, who leaked confidential Government information about the Nixon White House to reporters from the Washington Post. Fans of the book and movie will remember that his famous line was, “Follow the money.” That line came to mind when an article appeared in Health Affairs summarizing the US health care expenditures for 2010 (1). The main gist of the article is that the rate of growth in health care expenditures had slowed to only 3.9% and approximated the slowed growth from 2009 which was 3.8%. Previously the growth had been much larger averaging 7.2% from 2000-8 (2). The article points out that during recession expenditures usually slow but the expected decline in healthcare expenditures usually occurs far after the beginning of the recession. The authors state that the “lagged slowdown in health spending growth from the recent recession occurred more quickly than was the case in previous recessions. This was the result of a combination of factors, including the highest unemployment rate in twenty-seven years, a substantial loss of private health insurance coverage, employers’ increased caution about hiring and investing during the recovery, and the lowest median inflation adjusted household income since 1996.”

Following Deep Throat’s suggestion to follow the money, healthcare expenditures are listed below in Table 1.  

Table 1. Cost, growth and increase of health care expenditures 2010 compared to 2009 arranged from greatest to least percent growth.

*Calculated as the product of cost X percent growth.

The categories accounting for the largest dollar increase in expenditures appear to be net cost of health insurance, hospital costs and physician and clinical services. Although the article in Health Affairs has a fairly comprehensive discussion of each expenditure, the exact definitions of these categories were unclear. A little searching revealed that net cost of health insurance is calculated as the difference between calendar-year incurred premiums earned and benefits paid for private health insurance (2). This includes expenses such as personnel, executive bonuses, marketing, advertising, etc., but also includes profit. Health insurers average about 20% of their premiums going for expenses and profit (3). It is estimated that about 1-10% of the health insurance premiums go to profit (3). This would translate to about 10-50% of the net cost of health insurance going for profit or about 1.2-6.1 billion in costs during 2010.

A second cost was hospital care costs which accounted for nearly 40% of the increase in expenditures. “Hospital care is a summation of incurred benefits for inpatient hospital care, outpatient hospital care, and hospital-based hospice, hospital-based nursing home care and hospital-based home health care. Also included in hospital care are estimated ’combined billing’ amounts for services of hospital-based physicians…” (2). Examining this definition, administrative costs are glaringly missing. In 1999, administrative costs accounted for 24.3% of hospital expenses and were increasing (4). Conservatively assuming that the same percentage of administrative costs account for the increase in expenditures, this 24.7% would translate to about 9.7 billion in 2010.

Physician and clinical services includes offices of physicians and outpatient care centers, plus the portion of medical and diagnostic laboratories services that are billed independently by laboratories. Physician services account for 81% of these expenditures, but this portion of the physician and clinical services grew only 1.8% in 2010. Recalculating using 81% of the 515.5 billion for physician and clinical services and a 1.8% increase, the increase in expenditures for physician services accounted for 7.5 billion. According to the article in Health Affairs, 2010 was a year when people decided to forgo care, slowing growth in elective hospital procedures, the number of prescriptions dispensed, and physician office visits (1). In other words, less healthcare led to a slowing of expenses.

The above data suggest that physicians account for only about 16% of the healthcare costs and their portion of the healthcare pie seems to be decreasing compared to other healthcare expenditures. To control healthcare costs but not decrease healthcare, policymakers need to focus on those areas of expenditures that account for much of the increase in cost, and especially those that provide no healthcare product. Cuts in the net cost of health insurance and hospital administrative costs would seem two areas where considerable cost savings could be achieved with little to no reduction in patient care.

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Martin AB, Lassman D, Washington B, Catlin A; the National Health Expenditure Accounts Team. Growth In US Health Spending Remained Slow In 2010; Health Share Of Gross Domestic Product Was Unchanged From 2009. Health Aff (Millwood) 2012;31:208-219.
2. https://www.cms.gov/NationalHealthExpendData/downloads/dsm-10.pdf (accessed 1-17-12).
3. http://thinkprogress.org/health/2009/08/05/170897/are-health-insurers-making-too-much-money/?mobile=nc (accessed 1-17-12).
4. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med 2003;349:768-75.

Reference as: Robbins RA. Follow the money. Southwest J Pulm Crit Care 2012;4:19-21. (Click here for a PDF version of the editorial)

Happy First Birthday SWJPCC!

With the end of 2011, the Southwest Journal of Pulmonary and Critical Care (SWJPCC) completed its first full year of operation. Planning for SWJPCC began in August, 2010 and our first manuscript was posted on November 11, 2010. This has been a year of growth. We posted 8 manuscripts our first year and 68 this year (Table 1).

Table 1. Postings by SWJPCC 2010 and 2011.

 

We had manuscripts submitted from each fellowship programs in the Southwest (Phoenix, Tucson, Albuquerque and Denver) but also received submissions from outside the Southwest including from foreign countries such as the UK, India and Boston (which views itself as a separate country). Our readership has also steadily grown from 30 unique IP addresses in November, 2010 to nearly 1000 during December, 2011 (Figure 1, Panel A). Accompanying this increase in uniques has been an increase in the number of page views (the number of files that are requested from a site, also known as “hits”, Figure 1, Panel B).

Figure 1. Panel A. Unique IP addresses accessing the SWJPCC site by month. Panel B. Page views accessing the SWJPCC site by month.

With the increase in manuscripts we have expanded the number of associate editors from the original 5 to 13 with representatives from each pulmonary fellowship in the Southwest. For a list of editors click here.

Overall, this has been a good start and many need to be thanked. First, thanks to our authors. You took a chance on a new journal and we appreciate the opportunity to publish your work. Second, thanks to our reviewers.  SWJPCC, like all journals, relies upon expert reviewers in order to publish the highest quality manuscripts. We thank the reviewers for their time and effort in the prompt submission of their reviews. A list of reviewers for 2011 is below.

• Owen Austrheim
• David Baratz
• Richard Gerkin
• Michael Gotway
• Manoj Mathew
• Vijaychandran Nair
• Jennie O'Hea
• Lilibeth Pineda
• Francisco Ramirez
• Robert Raschke
• Patricia Rocha
• John Roehrs
• Clement Singarajah
• Linda Snyder
• Gerald Swartzberg
• Allen Thomas
• Carolyn Welsh
• Lewis Wesselius

Several are deserving of special thanks. First, our gratitude goes to the Arizona Thoracic Society (AZTS). We are the only local thoracic society who publishes a journal and SWJPCC would have not been possible without the support of AZTS members and officers including Rick Helmers, George Parides and Mary Kurth. Second, thanks to Eric Reece, our webmaster, who set up the journal, registered the domain, etc. and who continues to serve as a consultant. Third, a personal note of appreciation to Stuart Quan whose experience as editor of Sleep has been invaluable in guiding us through the development of SWJPCC. Fourth, SWJPCC acknowledges the Phoenix Pulmonary and Critical Care Research and Education Foundation who has provided the monetary support for SWJPCC. Last, and most importantly, thanks to our readers. Please visit as often as you can and feel free to provide us with your input. The journal is for you and we will strive to do our best to fulfill your needs.

Richard A. Robbins MD, Editor, SWJPCC

Reference as: Robbins RA. Happy first birthday SWJPCC! Southwest J Pulm Crit Care 2012;4:1-3. (Click here for a PDF version)