COPD, COOP and BREATH at the VA

Reference as: Robbins RA. COPD, COOP and BREATH at the VA. Southwest J Pulm Crit Care 2011;2:27-28. (Click here for PDF version)

The February 2011 Pulmonary Journal Club reviews a study by Rice and colleagues (1) of high-risk COPD patients (click here for Pulmonary Journal Club). This review was authored by Kevin Park who also authored an ACP Journal Club review (2). In Rice’s study a single educational session, an individualized care plan, and monthly case-manager telephone calls, resulted in a 41% decrease in hospitalizations and emergency room visits and a nonsignficant trend toward decreased mortality.

Rice’s study was supported and conducted in the Veterans Integrated Service Network (VISN) 23 (Minnesota, Iowa, Nebraska and the Dakotas). The COPD patients in this study were recruited and followed primarily using the VA computer system. The study represents a potential model of data-based management leading to improved patient outcomes. The authors; Robert Petzel MD, then VISN 23 Director (now Veterans Healthcare Administration Undersecretary); and Janet Murphy, then VISN Primary Care Service Line CEO (now VISN 23 Director) are to be congratulated for their insight into conducting and supporting this study. Unfortunately, many VA administrators are not as far-sighted and restrict or place unreasonable obstacles to investigators’ access to VA data. VA administrators at the National, VISN and local levels should be encouraged to follow Dr. Petzel’s and Ms. Murphy’s lead in utilizing the VA computer system to conduct studies such as Rice’s.

At the time this study was ongoing, a similar study was also being conducted through the VA Cooperative studies program known as Bronchitis and Emphysema Advice and Training to Reduce Hospitalization (BREATH) trial (3). Like Rice’s study, the BREATH study incorporated self-management education, an action plan, and case-management to decrease the risk of hospitalizations due to COPD. However, in contrast to Rice’s study, the patients in BREATH had all been hospitalized within the past year and likely had more severe underlying COPD. Although this multi-center, randomized study which was planned for 5 years was on target for recruitment (425 subjects), it was cancelled after about 2 years. The reasons for the cancellation were never shared with the site investigators (of which this editor was one). It seems unlikely that a behavior study such as BREATH would result in a significant medically adverse outcome to mandate study cancellation. However, if such an outcome occurred in BREATH, it would throw the largely positive results of Rice’s study into question.

Richard A. Robbins MD, Editor, SWJPCC

References

1. Rice KL, Dewan N, Bloomfield HE, Grill J, Schult TM, Nelson DB, Kumari S, Thomas M, Geist LJ, Beaner C, Caldwell M, Niewoehner DE. Disease Management Program for Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial. Am J Respir Crit Care Med 2010;182:890-6.

2. Park K, Robbins RA. ACP Journal Club: A COPD disease management program reduced a composite of hospitalizations or emergency department visits.  ACP Journal Club 2011;154:JC3-5.

3. http://clinicaltrials.gov/ct/show/NCT00395083?order=1. Accessed 2/9/2011.

SWJPCC: The first three months

Reference as: Robbins RA. SWJPCC: The first three months. Southwest J Pulm Crit Care 2011;2:1-2. (click here for PDF)

During the Arizona Thoracic Society meeting on 1-18-11 a report was given to our sponsoring organization regarding the progress of the SWJPCC. Below is a synopsis of the report along with a link to a PowerPoint slide presentation at the end.

Planning for the journal began in August, 2010 with discussions at the Arizona Thoracic Society.  Several decisions were made at that meeting: 1. To proceed with the creation of an on-line journal; 2. To adopt the name Southwest Journal of Pulmonary and Critical Care; 3. To emphasize clinical medicine; 4. To peer review all manuscripts; and 5. To accept no sponsorship from organizations with a potential conflicts of interest such as hospitals, pharmaceuticals companies, etc. unless it was clear that such sponsorship was unrestricted.  During September and October, 2010 a web site manager was hired, Eric Reece from Bethesda, MD; the domain registered; a website created; and editorial board established. The first posting was an editorial on October 16^th, 2010 and our first manuscript was submitted on November 7^th, 2010.  This manuscript was peer reviewed, revised, and posted on November 11^th 2010. During 2010 we posted 8 articles: 2 in Imaging; one in Proceedings of the Arizona Thoracic Society; one Pulmonary Journal Club; two Critical Care Journal Clubs; one Sleep Journal Club; and one Editorial.  At the suggestion of Stuart Quan, a member of the editorial board, volumes and page numbers were assigned to each publication for ease of reference and the reference is given under the title of each posting.

As of 1-24-11 we have had 1043 page views for an average of 35/day.  One hundred and forty-three unique visitors have visited the site for an average of 4 unique visitors/day.  Hopefully, this will continue to grow.

A special thanks to our authors and reviewers, the latter are listed below. Without their help SWJPCC could not function:  Mike Gotway, Manny Mathew, Vijay Nair, Allen Thomas, and Lew Wesselius.

For the future, we are planning a short synopsis of each Arizona Thoracic Society meeting which can be found in a new section titled "Arizona Thoracic Society Notes" under "Proceedings of the Arizona Thoracic Society" on the left hand portion of the home page. We hope to soon post material authored outside the Phoenix area and to proceed with full-length manuscript publications under the Pulmonary, Critical Care and Sleep headings at the top of the home page.

Richard A. Robbins, M.D. , Editor, SWJPCC

Powerpoint Slide Set

Why Start A New Pulmonary/Critical Care Journal?

Reference as: Robbins RA. Why start a new pulmonary/critical care journal? Southwest J Pulm Crit Care 2010:1:1-2. (Click here for PDF Version)

With apologies to Paul McCartney, “You'd think that people would have had enough of [pulmonary and critical care journals]. But I look around me and I see it isn't so” (1). With the inception of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) we have several goals, not adequately filled by the present pulmonary and critical care publications.

First, the primary goal of the SWJPCC is pulmonary and critical care medicine fellow education. The American College of Graduate Medical Education has placed increasing requirements for clinical education in post-graduate medical education while simultaneously increasing the requirements for scholarly activity for fellows and faculty, yet restricting fellow work hours (2). It seems that these conflicting goals are unrealistic, unless clinical scholarly activity can be incorporated into a training program. In starting the SWJPCC, we hope to fulfill the scholarly needs of both fellows and faculty while emphasizing clinical medicine through the publication of such time honored activities as case presentations and reviews of the literature.

Second, peer-reviewed journals send articles out for review. While we will do the same, we have certain expectations of our reviewers. Unfortunately, reviewers are not always carefully chosen.  Sometimes inexperienced reviewers, feeling the need to establish themselves, indulge their own sense of self-importance by becoming “nagging nabobs of negativism” (3) demanding the answer to “the ultimate question of life, the universe and everything” (4) before a manuscript will see the light of publication. While emphasizing the highest medical journal standards, we realize that fellow and faculty time is limited and we hope to be reasonable regarding expectations of our authors.

Third, there has been a trend in some journals towards publishing articles emphasizing the “short-comings” of physicians while emphasizing the virtues of identifying these “faults”. For example, the New England Journal of Medicine published an article from a health regulatory organization (the Joint Commission), touting improved healthcare through administration of the pneumococcal vaccine to adults (5). This article implied that physicians who did not provide this vaccination to their adult patients were delinquent, and the Joint Commission’s efforts “corrected” this deficiency. However, previous publications have shown that pneumococcal vaccination in older adults results in a slight increase in the risk for hospitalization, but does not decrease mortality nor the risk for pneumonia (6), findings largely confirmed by a recent meta-analysis (7). Publication of articles substituting politics or opinions (especially when they are self-serving) for evidence-based care is not part of the mission of the SWJPCC.

Last, the SWPCC aspires to be a resource for practicing physician education, emphasizing case presentations, clinical articles, review articles, imaging, and journal clubs. We hope this journal will be useful for busy clinicians, assisting them in better serving the needs of their patients while also providing insight regarding practice matters of interest to the pulmonary and critical care medicine community.

With that, we begin.

Richard A. Robbins, M.D. on behalf of the Editors

References

1. McCartney, Paul. “Silly Love Songs”. Wings at the Speed of Sound. Palorphone/EMI, 1976.
2. http://www.acgme.org/acWebsite/nav/Pages/navPDcoord.asp
3. Agnew, Spiro. San Diego, CA. 1970.
4. Adams, Douglas. Life, the Universe and Everything. ISBN 0-330-26738-8.
5. Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-74.
6. Jackson LA, Neuzil KM, Yu O, Benson P, Barlow WE, Adams AL, Hanson CA, Mahoney LD, Shay DK, Thompson WW; Vaccine Safety Datalink. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med. 2003;348:1747-55.
7. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ. 2009;180:48-58.