Southwest Ballot Measures Affecting Healthcare

Modern Healthcare (1) has published an article summarizing ballot measures affecting healthcare. Those from the Southwest are listed below:

States

Arizona

1. Recreational marijuana. Proposition 205: Legalizes recreational marijuana use for people 21 and older. Opponents of the measure include the Arizona Health and Hospital Association and Insys Therapeutics, a company that makes a cannabis-based pain medication.

California 

1. Medi-Cal hospital fee program. Proposition 52: Requires the legislature to get voter approval to use fee revenue for purposes other than generating federal matching funds and funding enhanced Medicaid payments and grants for hospitals. The initiative, which was written by the California Hospital Association and is supported by most state lawmakers, would also make the program permanent, requiring a supermajority in the legislature to end it.
2. Tobacco tax. Proposition 56: Increases the state's cigarette tax by $2 a pack and impose an "equivalent increase on other tobacco products and electronic cigarettes containing nicotine." The revenue primarily would support healthcare programs.
3. Prescription drug price regulations. Proposition 61: Ties the prices California state agencies pay for prescription drugs to the discounts negotiated by the U.S. Veterans Affairs Department. The initiative, backed by the AIDS Healthcare Foundation, has drawn more than $100 million in spending from opponents, most of it from the pharmaceutical industry.
4. Legalization of recreational marijuana. Proposition 64: Legalizes recreational marijuana use for people 21 and older and creates taxes on the cultivation and retail sale of the drug.

Colorado

1. ColoradoCare, a single-payer health system. Amendment 69: Amends the state's constitution to establish a universal healthcare system financed by payroll taxes and governed by an elected 21-member board of trustees. The plan is opposed by Colorado Hospital Association.
2. Cigarette tax. Amendment 72: Amends the state's constitution to increase the cigarette tax from 84 cents a pack to $2.59 a pack. Most of the revenue would fund health-related programs, research into tobacco-related health issues and education and prevention. E-cigarettes are exempt.
3. Physician-assisted suicide. Proposition 106: The End of Life Options Act allows physicians to prescribe a lethal drug to their terminally ill patients and allows terminally ill patients to be prescribed lethal drugs to end their life.

Nevada

1. Recreational marijuana. Question 2: Legalizes recreational marijuana use for people 21 and older.  
2. Medical equipment tax. Question 4: Exempts medical equipment like oxygen machines and hospital beds from the state sales tax.

Cities

1. Albany, CA. Soda tax: A 1 cent per ounce tax on sugary beverages.
2. San Francisco, CA. Soda tax: A 1 cent per ounce tax on sugary beverages.
3. Oakland, CA. Soda tax: A 1 cent per ounce tax on sugary beverages.
4. Boulder, CO. Soda tax: Imposes a 2 cent per ounce tax on sugary beverages.

Richard A. Robbins, MD

Editor, SWJPCC

Reference

1. Modern Healthcare. How the Nov. 8 state elections will affect healthcare. November 5, 2016. Available at: http://www.modernhealthcare.com/article/20161105/NEWS/161109991 (accessed 11/7/16).

Cite as: Robbins RA. Southwest ballot measures affecting healthcare. Southwest J Pulm Crit Care. 2016;13(5):218-9. doi: http://dx.doi.org/10.13175/swjpcc114-16 PDF 

ACGME Proposes Dropping the 16 Hour Resident Shift Limit

The Accreditation Council for Graduate Medical Education (ACGME) is proposing that first-year residents would no longer be limited to 16-hour shifts during the 2017-2018 academic year under a controversial proposal released today (1). Instead, individual residency programs could assign first-year trainees to shifts as long as 28 hours, the current limit for all other residents. The 28-hour maximum includes 4 transitional hours that's designed in part to help residents improve continuity of care. The plan to revise training requirements does not change other rules designed to protect all residents from overwork. including the maximum80 hours per week.

The ACGME capped the shifts of first-year residents at 16 hours in 2011 as a part of an ongoing effort to make trainee schedules more humane and avoid clinical errors caused by sleep deprivation. ACGME CEO Thomas Nasca, MD, told Medscape Medical News that the problem arises largely from first-year residents not being on the same schedule as supervising residents and others on their "home" educational team (2). On a 16-hour clock, first-year residents can end up working under relative strangers, said Dr Nasca. "The lack of synchronization is very disruptive." The solution, he said, is putting everyone on the same clock.

The ACGME touts a study published in the New England Journal of Medicine in February showing that longer shifts and less rest in between for surgical residents did not affect the rate of serious complications or surgical fatalities (3). A review in 2014 suggested that patient outcomes might be worse with the restrictions (4).

Both the American Medical Student Association, the Committee of Interns and Residents, and Public Citizen oppose the move. The ACGME proposal will go to the group's board of directors for a final decision after a 45-day comment period. More information on the proposal is available for download at https://www.acgme.org/. Comments can be submitted to cprrevision@acgme.org.

References

1. ACGME. ACGME task force presents new residency training requirements for public comment. November 4, 2016. Available at: https://www.acgme.org/Portals/0/PDFs/CPRNewsRelease_Fall2016_FINAL.pdf (accessed 11/4/16).
2. Lowes R. Let first-year residents work longer shifts, ACGME proposes. Medscape. November 4, 2016. Available at: http://www.medscape.com/viewarticle/871432?nlid=110468_3901&src=wnl_newsalrt_161104_MSCPEDIT&uac=9273DT&impID=1228495&faf=1 (accessed 11/4/16).
3. Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016 Feb 25;374(8):713-27. TU[CrossRef]UTH HTU[PubMed]UT
4. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014 Jun;259(6):1041-53. HTU[CrossRef]UTH HTU[PubMed]UT 

Cite as: Robbins RA. ACGME proposes dropping the 16 hour resident shift limit. Southwest J Pulm Crit Care. 2016;13(5):216-7. doi: http://dx.doi.org/10.13175/swjpcc113-16 PDF

Non-Small Cell Lung Cancer: RT Out, Pembrolizumab In, and Vaccine Hope or Hype

Three articles on non-small cell lung cancer (NSCLC) recently appeared which were of interest and might alter therapy. The first on whole brain radiation therapy (WBRT) was presented at the at the European Respiratory Society (ERS) International Congress 2016 and simultaneously published online in the Lancet (1). WBRT and dexamethasone have been the standard of care for patients with NSCLC brain metastases. However, the study of 538 randomized patients concludes that WBRT provides "little additional clinically significant benefit" with brain metastases. Notably, all the patients were unsuitable for surgical resection or stereotactic radiotherapy, owing to widespread metastases. However, patients younger than 60 years did seem to have a survival advantage and might represent an exception.

The second study presented at the European Society for Medical Oncology (ESMO) 2016 Congress reports that the addition of pembrolizumab to first-line treatment with pemetrexed and carboplatin significantly improved objective response rate and progression-free survival in NSCLC (2). The study included 123 treatment-naive NSCLC patients whose tumors did not harbor EGFR or ALK aberrations. Participants were randomly assigned to receive pemetrexed plus carboplatin with or without pembrolizumab. At a median follow-up of 10.6 months, results showed that objective response rate was 55% with pembrolizumab vs 29% with chemotherapy alone (treatment difference, 26%; 95% CI, 9-42; P = .0016). All responses were partial.

Pembrolizumab is a humanized IgG4 monoclonal antibody (mouse antibody grafted to human immunoglublin) which destroys a protective mechanism on cancer cells, allowing the immune system to destroy those cancer cells. It targets the programmed cell death 1 (PD-1) receptor. The drug was initially used in treating metastatic melanoma but is a promising new therapy for advanced cancers, now including lung cancer. Brighton et al. (3) recently reported in the SWJPCC that pembrolizumab can result in drug-induced pneumonitis.

Earlier this spring a Fox News report in Phoenix made some spectacular claims about a Cuban lung cancer vaccine concluding that it “could literally save millions of live” (4-includes a video of the original broadcast). Dr. Santosh Rao from Banner MD Anderson Cancer Center in Phoenix, who apparently has seen studies on the vaccine says that the vaccine does something, and that it extends life. However, he added that "the question will always come up, is it better than some of the new therapies that we have that also help the immune system function better". Banner MD Anderson Cancer Center has been promoting the coverage on social media adding that the vaccine is “potentially groundbreaking". Dr. Doug Campos-Outcalt, Chair of New Department of Family, Community and Preventive Medicine, commented that he was as baffled by the coverage. “Why MD Anderson would hype this alleged breakthrough before it has undergone controlled clinical trials is beyond my understanding,” said Campos-Outcalt. The drug has not been used in the United States but Roswell Park Institute in Buffalo, NY, has applied to do a clinical trial on the vaccine called CIMAVax. If approved, the trial will probably not begin until 2017 and will likely take several years.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Mulvenna P, Nankivell M, Barton R, et al. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet. 2016 Oct 22;388(10055):2004-14. [CrossRef] [PubMed]
2. Hoffman J. Adding pembrolizumab to chemo improves efficacy in metastatic NSCLC. Cancer Therapy Advisor. November 1, 2016. Available at: http://www.cancertherapyadvisor.com/lung-cancer/lung-cancer-nsclc-pembrolizumab-chemotherapy-improved-efficacy/article/569669/ (accessed 11/2/16).
3. Brighton AM, Jain T, Bryce AH, Sista RR, Viggiano RW, Wesselius LJ. November 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016:13(5):191-5. [CrossRef]
4. Lomangino K. FOX, Banner MD Anderson hype Cuba cancer “breakthrough”. Health News Review. March 7, 2016. Available at: http://www.healthnewsreview.org/2016/03/fox-md-anderson-hype-cuba-cancer-breakthrough-rumors/ (accessed 11/2/16).

Cite as: Robbins RA. Non-small cell lung cancer: RT out, pembrolizumab in, and vaccine hope or hype. Southwest J Pulm Crit Care. 2016;13(5):205-6. doi: http://dx.doi.org/10.13175/swjpcc107-16 PDF

Dental Visits May Prevent Pneumonia

Several sources are reporting on a paper presented at IDWeek that showed people with a regular dental checkup had half the incidence of bacterial pneumonia (1). Michelle Doll and colleagues used the Medical Expenditure Panel Survey (MEPS) data from 2013. The researchers were able to assess participants' access to dental care and used ICD-9 codes to look for bacterial pneumonia in the previous year. The survey had data on 26,687 people, including 441 who had an episode of bacterial pneumonia. Thirty-four percent of those who developed pneumonia reported having at least two dental checkups a year, compared with 46% of those who did not. It is important to point out that this is an observational study and there were significant differences between those who developed and did not develop bacterial pneumonia. Those who got pneumonia were: more likely to be white and older, with an average age of 47 versus 40; more likely to have comorbidities and cognitive limitations; and less likely to have dental insurance.

Nevertheless, the data is consistent with the hypothesis that microaspiration is a frequent cause of bacterial pneumonia. Previous data has shown oral chlorhexidine reduces ventilator-associated pneumonia in the ICU (2). Although a large randomized study is needed, the data suggests that dental care may be another community-acquired pneumonia preventative in addition to conjugated pneumococcal vaccine (3).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Smith M. Regular checkups linked to protection against bacterial disease. Medscape. October 28, 2016. Available at: http://www.medpagetoday.com/MeetingCoverage/IDWeek/61071 (accessed 10/28/16). 
2. Hua F, Xie H, Worthington HV, Furness S, Zhang Q, Li C. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2016 Oct 25;10:CD008367. [CrossRef] [PubMed]
3. Bonten MJ, Huijts SM, Bolkenbaas M, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med. 2015 Mar 19;372(12):1114-25. [CrossRef] [PubMed]

Cite as: Robbins RA. Dental visits may prevent penumonia. Southwest J Pulm Crit Care. 2016;13(4):186. doi: http://dx.doi.org/10.13175/swjpcc105-16 PDF

Hospital Employment of Physicians Does Not Improve Quality

The Annals of Internal Medicine posted a manuscript on-line today reporting that the growing trend of physician employment by hospitals does not improve quality (1). In 2003, approximately 29% of hospitals employed members of their physician workforce, a number that rose to 42% by 2012. The authors conducted a retrospective cohort study of U.S. acute care hospitals between 2003 and 2012 and examined mortality rates, 30-day readmission rates, length of stay, and patient satisfaction scores for common medical conditions for 803 hospitals that switched to the employment model compared with 2085 control hospitals that did not switch. Switching hospitals were more likely to be large (11.6% vs. 7.1%) or major teaching hospitals (7.5% vs. 4.5%) and less likely to be for-profit institutions (8.8% vs. 19.9%) (all p values <0.001).

The authors used Medicare Provider Analysis and Review File (MedPAR) from 2002 to 2013 to calculate hospital-level risk-adjusted performance on mortality, readmissions, and length of stay for acute myocardial infarction, congestive heart failure, and pneumonia. Hospital Compare data from 2007 to 2013 was used to assess overall patient satisfaction. After conversion to a physician employed model, no difference was found in any of 4 primary composite quality metrics with the single exception of readmission rates for pneumonia. That decline was modest (19.3% vs. 19.1% readmissions) and judged not likely to be clinically significant by the authors.

Recently, Baker and colleagues found that hospital employment of  physicians is associated with higher spending and prices (2). This data combined with the data from the present study suggest that the trend is for higher healthcare costs without an improvement in quality. Commenting in Medscape Richard Gunderman, a well-known healthcare delivery researcher from the University of Indiana, said that those who think quality comes from increasingly larger organizations with more advanced information technology and greater standardization across the system will see these results as surprising and disappointing (3). Pointing to high levels of burnout and widespread complaints of lack of time with patients, Gunderman said less physician control over individual patient care has taken a toll. "There's no doubt that a demoralized workforce will tend to drive quality down," he said. "Many hospitals and health systems around the country are grappling with poor and, in some cases, dismal engagement scores. I think that's an indication that a lot of physicians feel that the changes taking place across healthcare are problematic."

Funding for the study was provided by the Agency for Healthcare Research and Quality. Limitations of the study was that the patients were primarily Medicare beneficiaries aged 65 years and older. Therefore, the applicability of the findings to a younger population is unknown, however, the authors doubted that after switching to an employment model, hospitals would improve care for one group and not another.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Scott KW, Orav EJ, Cutler KM, Jha AK. Changes in hospital–physician affiliations in U.S. hospitals and their effect on quality of care. Ann Intern Med. 2016. Available at: http://annals.org/article.aspx?articleid=2552987 (accessed 9/20/16). [CrossRef]
2. Baker LC, Bundorf MK, Kessler DP. Vertical integration: hospital ownership of physician practices is associated with higher prices and spending. Health Aff (Millwood). 2014 May;33(5):756-63. [CrossRef] [PubMed]
3. Frellick M. Physician employment by hospitals does not improve quality Medscape. September 19, 2016. Available at: http://www.medscape.com/viewarticle/868978?nlid=109338_2863&src=wnl_dne_160920_mscpedit&uac=9273DT&impID=1200121&faf=1#vp_2 (accessed 9/20/16). 

Cite as: Robbins RA. Hospital employment of physicians does not improve quality. Southwest J Pulm Crit Care. 2016;13(3):133-4. doi: http://dx.doi.org/10.13175/swjpcc099-16 PDF