The Hefty Price of Obstructive Sleep Apnea

Reference as: Budhiraja R. The hefty price of sleep apnea. Southwest J Pulm Crit Care 2011;3:169-71. (Click here for a PDF version)

Obesity is approaching an epidemic level in the United States. The association between obesity and obstructive sleep apnea (OSA) is quite strong and likely causal. Approximately half of obese individuals have OSA and the risk of OSA increases with increasing BMI. Conversely, majority of individuals with OSA are obese. However, whether this relationship is bidirectional and OSA can, in turn, contribute to obesity is unclear.

The study by Brown and colleagues in the Journal attempts to answer this question ¹. The authors analyzed prospectively obtained data from a large community-based cohort and found that the participants with more severe sleep disordered breathing at baseline demonstrated a modest increase in body mass index (BMI) over a 5 year follow up period.

What can these intriguing results be attributed to? Pathophysiology of obesity is a multifactorial and complex process and may include dietary, lifestyle and genetic components.  As the authors hypothesize, an alteration in leptin-ghrelin levels in OSA may contribute to obesity. However, independent effect of sleep apnea on these metabolic hormones is still not clear. Studies in OSA, in contrast to those with sleep deprivation, actually suggest increased daytime leptin levels, primarily explained by obesity ². Similarly, contradictory data exist regarding ghrelin levels in OSA. While some studies demonstrate an increase in ghrelin levels ^{3, 4}, others do not ^{5, 6}. A decrease in energy expenditure is a plausible mechanism whereby OSA may lead to further weight gain. It is easily fathomable that disturbed sleep in obese people may contribute to daytime fatigue and lethargy and promote a more sedentary lifestyle.  However, convincing data from large studies confirming such an association is again lacking. Finally, an altered feeding behavior with a preference for a weight-gain promoting diet may be seen in sleep disordered breathing and contribute to obesity ⁷.

The strengths of this study include a large sample size derived from community-based cohorts, prospective collection of data and objective documentation of sleep abnormalities. However, the readers should bear in mind that the adjusted increase in BMI was fairly modest- in order of 0.21 kg/m² in those with mild OSA and 0.51 kg/m² in moderate to severe OSA. Furthermore, the statistical models used in the study accounted for only 7% of the total variance, suggesting that the factors not included in analysis likely played a prominent role in the weight gain.

Nevertheless, this study adds to emerging literature suggesting SDB as a risk factor for weight gain ^{8, 9}. Ideally, these data suggest need for well conducted prospective studies looking at physical activity, diet and change in BMI in patients with SDB. However, in view of the now well recognized adverse effects of severe sleep apnea, it will not be feasible to conduct long-term studies in these patients without offering treatment.  The other line of evidence that would support the hypothesis that sleep apnea predisposes to weight gain, would be weight loss with adequate therapy. Indeed some studies have assessed this, but with variable results ^10-12. Some of the factors underlying such variability in results may include differences in dietary habits, physical exercise, age of the participants, sleep duration, use of medications and presence of additional comorbidities ¹³. Future studies, apart from controlling for these variables, should also consider evaluating changes in central obesity instead of, or in addition to BMI, as the former may be a better marker of adverse cardiovascular outcomes than BMI ¹⁴.

Finally, obesity is a risk factor for an array of cardiovascular and metabolic adverse outcomes. This study provides further rationale to add abnormal sleep to unhealthy diet and lack of exercise as crucial factors that need to be modified to curb the obesity epidemic. Further longitudinal and interventional studies are required to help confirm these observations and assess the impact of better sleep on health outcomes.

Rohit Budhiraja, M.D.^{1, 2, 3}

Associate Editor

Southwest Journal of Pulmonary and Critical Care 

¹ Department of Medicine, Southern Arizona Veterans Affairs Health Care System (SAVAHCS) , Tucson, AZ

² Arizona Respiratory Center, The University of Arizona, Tucson, AZ

³ Department of Medicine, University of Arizona College of Medicine, Tucson, AZ

Corresponding Author:

Rohit Budhiraja, MD

Southern Arizona VA HealthCare System,

3601 S 6^th Ave,

Tucson, Arizona 85723

rohit.budhiraja@va.gov

Phone: 520-331-2007

Fax: 520-629-4641

References

1. Brown MA, Goodwin JL, Silva GE et al. The Impact of Sleep-Disordered Breathing on Body Mass Index (BMI): The Sleep Heart Health Study (SHHS). Southwest J Pulm Crit Care 2011;3:159-68.
2. Sánchez-de-la-Torre M , Mediano O, Barceló A et al. The influence of obesity and obstructive sleep apnea on metabolic hormones. Sleep Breath 2011 Sep 13. [Epub ahead of print]
3. Harsch IA, Konturek PC, Koebnick C et al. Leptin and ghrelin levels in patients with obstructive sleep apnoea: effect of CPAP treatment. Eur Respir J. 2003;22:251–7.
4. Takahashi K, Chin K, Akamizu T et al. Acylated ghrelin level in patients with OSA before and after nasal CPAP treatment. Respirology 2008;13:810–6.
5. Ulukavak Ciftci T, Kokturk O, Bukan N et al. Leptin and ghrelin levels in patients with obstructive sleep apnea syndrome. Respiration 2005;72:395–401.
6. Papaioannou I, Patterson M, Twigg GL et al. Lack of association between impaired glucose tolerance and appetite regulating hormones in patients with obstructive sleep apnea. J Clin Sleep Med 2011; 7:486-92B.
7. Vasquez MM, Goodwin JL, Drescher AA, Smith TW, Quan SF. Associations of dietary intake and physical activity with sleep disordered breathing in the apnea positive pressure long-term efficacy study (APPLES). J Clin Sleep Med 2008; 4:411-8.
8. Traviss KA, Barr SI, Fleming JA, Ryan CF. Lifestyle-related weight gain in obese men with newly diagnosed obstructive sleep apnea. J Am Diet 2002;102:703-6.
9. Phillips BG, Hisel TM, Kato M et al. Recent weight gain in patients with newly diagnosed obstructive sleep apnea. J Hypertens 1999;17:1297-300.
10. Chin K, Shimizu K, Nakamura T et al. Changes in intra-abdominal visceral fat and serum leptin levels in patients with obstructive sleep apnea syndrome following nasal continuous positive airway pressure therapy. Circulation 1999;100:706–71.
11. Loube DI, Loube AA, Erman MK. Continuous positive airway pressure treatment results in weight loss in obese and overweight patients with obstructive sleep apnea. J Am Diet Assoc 1997; 97:896–7.
12. Redenius R, Murphy C, O'Neill EO, al-Hamwi M, Zallek SN. Does CPAP lead to BMI? J Clin Sleep Med 2008;4:205–9.
13. Quan SF, Budhiraja R, Parthasarathy S. Is There a Bidirectional Relationship Between Obesity and Sleep-Disordered Breathing? J Clin Sleep Med 2008;4: 210–211.
14. Lee CM, Huxley RR, Wildman RP, Woodward M. Indices of abdominal obesity are better discriminators of cardiovascular risk factors than BMI: a meta-analysis. Journal of Clinical Epidemiology 2008; 61: 646-653.

Mismanagement at the VA: Where’s the Problem?

Reference as: Robbins RA. Mismanagement at the VA: where's the problem? Southwest J Pulm Crit Care 2011;3:151-3. (Click here for a PDF version of the editorial)

At the time I retired from my last Veterans Administration (VA) position there was an ongoing investigation into alleged mismanagement of non-VA fee care funds at this hospital. The VA Office of Inspector General (VAOIG) report of this investigation was released on November 8, 2011 (1). The VAOIG report is reflective of a wide-ranging problem of administrators making what are fundamentally clinical decisions and not allowing clinicians to determine the best allocation of resources - issues that are not unique to the VA. 

The VAOIG’s report substantiated that the hospital experienced a budget shortfall of $11.4 million in 2010, 20 percent of the 2010 Non-VA Fee Care Program funds. According to the VAOIG report highlights, “The shortfall occurred because the hospital lacked effective pre-authorization procedures for Long Term Acute Hospital fee care. Additionally, staff did not monitor inpatient fee care patients to determine if the patients could receive services in a VA facility”. As someone who spent about 1 week a month in the intensive care unit and cared for several of the patients who ultimately were transferred to receive long term acute hospital fee care, these recommendations seem inconsistent with the facts.

The purpose of the Non-VA Fee Care Program is to assist Veterans who cannot easily receive care at a VA medical facility. This program pays the medical care costs of patients to non-VA providers when the VA is unable to provide specific treatments or provide treatment economically. To initiate non-VA care, clinicians sent a consult form to a physician designated by the chief of staff for review. Almost all of the fee care claims were approved. The single, approving physician received hundreds of requests per week and lacked both the expertise and time to perform a detailed review of the requests.

Among the problems singled out by the VAOIG’s report was the use of long term acute care for the purposes of ventilator weaning. The report suggests that there was no determination of whether the VA could provide these services. To my knowledge there was no VA facility that provided long term ventilator care within 100 miles of the hospital.

It is known that predicting the ability to wean a patient from long-term mechanical ventilation is imprecise (2). According to the VAOIG’s report “…30 days was a reasonable limit to attempt ventilator weaning. If the veteran had not weaned in that time, then the [hospital] needed to re-evaluate the appropriateness of continued weaning and consider alternative medical options.” Thirty days is considerably shorter than the 3 months recommended by a collective task force from the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine (2).

The VAOIG report estimated that overspending on long term acute care resulted in $4.5 million of the nearly 12 million dollar in over spending. Although it is not clear how this figure was calculated, it is almost certainly an over estimate of the potential cost savings since these patients require care whether in an acute care facility for weaning or a long-term care facility and is based on a 30 day period rather than a 90 day period of weaning

Later in the VAOIG report two additional problems are identified which more likely explain the overspending: inadequate budgeting and inadequate accounting. Not knowing how much is being spent from an inadequate budget is a problem, but there is also another, more fundamental problem not identified in the VAOIG’s report. Why was there no VA acute care or long term facility available to care for these patients? There is certainly sufficient medical expertise within the VA to perform these services. It seems likely that a comparatively small investment in an appropriate facility could have resulted in considerable savings.

There is no convincing evidence presented in the VAOIG’s report that the non-VA services requested were inappropriate. Yet, the VAOIG’s report suggests replacing the lone, over-worked, part-time clinician with inadequate expertise with a full-time person or committee. These approving official(s) will probably also lack the expertise necessary to make these clinical decisions and do little more than harass clinicians for paperwork and documentation while inadequately reviewing the charts and avoiding responsibility for any decisions.

In response to the discovery of the shortfall, the hospital initiated several interim approaches to save money including a hiring freeze. This seems reasonable, but in the middle of the hiring freeze, administration did hire an assistant director into a newly created position. However, clinical personnel who had left or retired were not replaced. Second, the chief of staff who oversaw this shortfall placed a measure on the clinicians’ performance plan that non-VA fee basis spending be reduced compared to the previous year. Yet, according to the VAOIG’s report, the problem appeared to be inadequate budgeting and accounting rather than overspending. Not surprisingly, morale suffered and was reflected in an employee survey which ranked in the bottom 10% of the VA in 5 of the 6 categories surveyed. In order to improve these scores, the chief of staff charged the chiefs of each service with improving morale when the problem appeared to lie a little closer to home. Lastly, the hospital determined that chronic ventilator patients be held in the ICU in order to save non-VA fee expenses. The cost of this decision is that when the ICU is full, that VA patients needing ICU care are transferred to another hospital, a cost paid by the VA. Whether this administrative decision will save money is unknown.

This VAOIG’s report fails to emphasize the major problems, i.e., failure of the administration to work with the clinicians, inadequate budgeting and inadequate accounting. Rather than suggesting reasonable solutions, the VAOIG’s report rewards these administrative blunders by offering increasing administrative control over clinicians and apparently increasing administrative personnel as solutions. These recommendations do nothing other than waste resources which could be used for care of Veteran patients.

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. http://www.va.gov/oig/pubs/VAOIG-11-02280-23.pdf (accessed 11/17/11).
2. MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, Hess D, Hubmayer RD, Scheinhorn DJ; American College of Chest Physicians; American Association for Respiratory Care; American College of Critical Care Medicine. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001;120:375S-95S.

Editor’s note: Since this budget shortfall came to light, the hospital director retired for medical reasons; the chief of staff was transferred to another VISN as VISN chief medical officer; and the associate director has left the hospital.

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.

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.

Changes in Medicine: Job Security

Reference as: Robbins RA. Changes in medicine: job security. Southwest J Pulm Crit Care 2011;3:72-4.  (Click here for a PDF version).

A Medscape article entitled the “Six Biggest Gripes of Employed Doctors” listed job security as a major concern of hospital employed physicians (1). When I left fellowship, most junior physicians joined an established, group practice either as a salaried associate or with a guaranteed income. Few ventured into solo practice, especially in pulmonary and critical care where night calls are frequent and days off are rare. Usually after a few years, the associate became a partner. Partners were entitled to share in profits that they generated, and usually profits of the group. Now that many physicians are employees of hospitals or corporations rather than physician-controlled practices, marked changes in physicians’ business hiring and business practices are occurring.

Some observers don't think job security is a problem for physicians. I would agree. Doctors are in demand and nearly every physician can find a job. Matt Robbins, Senior Director of Marketing for Delta Physician Placement in Dallas, points out that hospitals will hire more physicians as healthcare reform expands coverage and increases the emphasis on care coordination (1). However, the physicians of the future may question the cost of medical school, residency, and fellowship to enter into a “master-servant” relationship with an employer.

For example, a radiologist with a long term private practice relationship with a hospital for many years was told that the hospital was severing this relationship in order to form an all employee model. However, he and his private practice colleagues were given the opportunity of joining the new hospital radiology group. Now his income is dependent on his productivity. It is difficult for him to find time to teach, discuss cases with consultants, or participate in conferences without a financial penalty.

Several of the Phoenix pulmonary and critical care fellows were previously employed as hospitalists. One was jobless after the group that had provided hospital services for services for several years did not have their contract renewed. The hospital hired their own hospitalists, mostly young physicians just out of training. However, within a few months most had left because of dissatisfaction, especially with the workload.

Although lack of physician productivity, hospital financial losses or hospital mergers have been cited as reasons for terminating or modifying physician contracts, it would appear that maximizing profits is more likely. In the “master-servant” relationship inherent with a hospital-employed physician, the downside may be increasing workload, decreasing income and declining autonomy. Although some would argue that this increasing competition is good for the patient consumer, the rising healthcare costs with declining physician income argue against this.

However, if a physician is unhappy, he or she can always leave. After all the relationship is “master-servant” not “master-slave” and most contracts can be cancelled with a few months notice. However, more and more contracts have noncompete clauses, requiring a physician not to practice within a certain distance after leaving (1). With many hospitals or hospital corporations expanding, many physicians may have to move from their previous practice area, even from a large metropolitan area. There is also the possibility that if the separation is acrimonious, the quality assurance process can be used make a physician’s relocation even more difficult. While the hospital administrator has the option of complaining about a physician, the reverse is often not true. Hospital employed physicians are frequently required to sign contracts stating that they cannot discuss their employment.

The negative side of hospital employment should cause physicians to pause and carefully examine a contract. The negatives may outweigh the positives. Furthermore, with hospital mergers and administrators frequently changing, even the best situation could quickly deteriorate.

What is needed is increased oversight of the physician-hospital relationship. First and foremost, an administrator directing or pressuring physician employees to order certain tests, prescribe certain medications, etc. is an unlicensed practice of medicine by the administrator. It increases the cost of healthcare by the ordering of unnecessary testing, procedures, or therapy where profit margin is more a consideration than patient benefit. This should be reported to state licensing agencies. Second, it is questionable that hospitals should be allowed to hire physicians. California has a law prohibiting hospital or corporation ownership of physician’s practices (2) but the law is complicated and appears to be largely unenforced (3). As hospitals hire more physicians, laws to protect both patients and physicians from unscrupulous hospital administrators need to be both enacted and enforced. Third, physicians should be wary of noncompete and no discussion clauses in contracts. These are red flags that could signal potential dire professional and financial consequences to a physician who is in a difficult employment which they wish to leave.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Terry KJ. Six biggest gripes of employed doctors. Medscape Business of Medicine 2011. http://www.medscape.com/viewarticle/737543 (accessed 8-22-11).
2. http://www.mbc.ca.gov/licensee/corporate_practice.html (accessed 9-23-11).
3. Fichter AJ. Owning a piece of the doc: state law restraints on lay ownership of healthcare enterprises. Journal of Health Law 2006:39:1-76.

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.

Changes in Medicine: the Decline of Physician Autonomy

Reference as: Robbins RA. Changes in medicine: the decline of physician autonomy. Southwest J Pulm Crit Care 2011;3:49-51. (Click here for a PDF version)

Thirty years ago when I left fellowship, there were predominantly two career paths, private practice or academics. I had chosen academics by virtue of doing a fellowship at a heavily research-based program, the National Institutes of Health (NIH). However, even at the NIH many of my colleagues eventually ended up in private practice, which was more lucrative and much more common than the academic practice I chose. Now a third path has become more common, practice as a hospital employee. I became a hospital employee over 30 years ago when I became a part-time, and later, full-time physician at a Department of Veterans Affairs (VA) medical center affiliated with a university. Apparently I was ahead of my time. In an article entitled “Majority of New Physician Jobs Feature Hospital Employment” 56% of physician search assignments by the national physician search firm Merritt Hawkins in 2011 were for hospitals (1). This had increased from 51% in 2010 and 23% in 2006. In contrast, only 2% of the firm's 2011 search assignments featured openings for independent, solo practitioners, down from 17% in 2006. "The era of the independent physician who owns and runs his or her practice is fading," according to Travis Singleton, a senior vice-president at Merritt Hawkins.

The reason that hospitals want to employee physicians is obvious-money. By increasing market share and collecting professional fees, hospitals profit from physician employment. Physicians may be fearful of the cost of setting up a private practice with the increasing uncertainties of reimbursement, making a salaried hospital position attractive. This is especially true for a new physician not wishing to add to the debt incurred during training or seeking less than full-time employment for family or personal reasons (2).

Although quality or efficiency is often touted as a major reason for hospitals to employee physicians, recent research suggests that neither result. Kuo and Goodwin (3) reviewed over 50,000 Medicare admissions and found that hospital length of stay was 0.64 day less and costs $282 lower among patients receiving hospitalist care compared to primary care physician care. However, this reduction in inpatient costs under the care of hospitalists was more than offset by a $332 increase in charges after discharge.  Furthermore, patients cared for by hospitalists were less likely to be discharged to home; more likely to have emergency department visits; more likely to be readmitted to the hospital; less likely to have a follow up visit with their primary care physician; and more likely to be admitted to a nursing facility. As the authors point out this is nothing more than cost shifting, and hospitalists, who are typically hospital employees, may be more susceptible to behaviors that promote cost shifting. Consistent with this concept, O’Malley et al. (4) state that hospital employed physicians increase costs by higher hospital and physician commercial insurance payment rates and hospital pressure on employed physicians to order more expensive care.

Although the disadvantages of hospital employment are several, “Ultimately, the loss of control over their own professional lives is what irks employed doctors the most…” (5). As someone who worked as a hospital employee for the VA for over 30 years, I found an increasing “master-servant relationship” particularly annoying. Decisions were often based on financial or political considerations by nonphysicians or under-qualified clinicians. For example, some have recommended propofol as a standard in conscious sedation (6). It offers a number of advantages including ease of titration and short duration of action. Propofol has been used by our group for years in the ICU. Our group applied for “privileges” to use propofol for bronchoscopy which was endorsed by the pharmacy and therapeutics committee. Yet, the clinical executive board denied the application which our group found puzzling.  I was later told by a quality assurance nurse that the basis of this decision was that propofol is what killed Michael Jackson.  Hopefully medical decision making meets a higher standard than the singular example of what may have happened to a pop star.

Another example is the guidelines from groups like the Institute for Healthcare Improvement (IHI) that quickly becomes hospital mandates. Many of these guidelines are, at best, weakly evidence based (7). Furthermore, the guidelines are bundled, i.e., several guidelines are grouped together. Bundling makes it difficult, if not impossible, to determine which guidelines are effective. Most have probably had little impact on patient outcomes, but at least one proved to be catastrophic. Tight control of blood sugar in the intensive care unit was mandated and monitored by the VA based on IHI recommendations. However, as demonstrated in the NICE-SUGAR study, tight control actually resulted in a 14% increase in patient mortality (8). This increase in mortality would translate to 9503 excess deaths at all VA hospitals between 2002 and 2009 or about 1 death for every 84 patients treated with tight control of glucose. After publication of the NICE-SUGAR study the IHI dropped the issue from its web site and the VA switched to also monitoring hypoglycemia. One might think that a guideline which resulted in a 14% increase in ICU mortality would cause an outcry to punish those responsible, but instead resulted only in a deafening silence.

I am hopeful that we have trained our young physicians to practice for their patients’ benefit, rather than the financial or political well-being of the hospital. Yet, I fear that the financial pressures of beginning practice and protecting one’s reputation and livelihood may be too great a pressure to resist. Until physicians are not supervised by non- or under-trained administrators in a “master-servant” relationship, incidents such as the increase in ICU mortality secondary to tight control of glucose are bound to reoccur.

Richard A. Robbins MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Crane M. Majority of New Physician Jobs Feature Hospital Employment. Medscape 2011. http://www.medscape.com/viewarticle/744504?sssdmh=dm1.695421&src=nldne (accessed 8-22-11).
2. Robbins RA. Changes in medicine: medical school. Southwest J Pulm Crit Care 2011:3:5-7.
3. Kuo Y-F, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med 2011;155:152-9
4. O'Malley AS, Bond AM, Berenson RA. Rising hospital employment of physicians: better quality, higher costs? Center for Studying Health System Change (HSC) 2011. http://www.hschange.com/CONTENT/1230/#ib5 (accessed 8-23-11).
5. Terry KJ. Six biggest gripes of employed doctors. Medscape Business of Medicine 2011. http://www.medscape.com/viewarticle/737543 (accessed 8-22-11).
6. Eichhorn V, Henzler D, Murphy MF. Standardizing care and monitoring for anesthesia or procedural sedation delivered outside the operating room. Curr Opin Anaesthesiol 2010;23:494-9.
7. 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.
8. The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360:1283-97.

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.