More Medical Science and Less Advertising

A recent article appeared in JAMA Open Access reporting that wait times to see a provider in the Department of Veterans Affairs (VA) have improved (1). You might remember that in the not so distant past the VA was embroiled in a controversy for reporting falsely short wait times (2). The widely publicized scandal was centered in Phoenix and led to the firing, resignation or retirement of a number of administrators in VA Central Office, the Southwest Veterans Integrated Service Network (VISN) and the Phoenix VA. What was not as well publicized, but perhaps even more disturbing, was that up to 70% of VA facilities also were reporting deceptively shortened wait times (3). Congress appropriated additional money for the VA to fix the wait times but it is unclear how the money was spent (2).

Now the VA reports that the wait times have shortened and compares favorably to the private sector. The VA’s history has to lead to some skepticism about the data. Is it true? Is it accurate? The short answer is that we do not know because the VA data is largely self-reported. The VA used a different method, the secret shopper approach, for the private sector assessment. In this method a caller requests a routine appointment with a randomly selected care physician in a given health care market. The reported VA data may not be representative of the VA as a whole. Only some metropolitan areas were selected and did not include non-metropolitan facilities and no facilities from the Southwest VISN where there was a known problem. Furthermore, the data is only for new patients requesting a primary care, dermatology, cardiology, or orthopedic appointment. Data for wait times to see other specialties is not reported.

An accompanying editorial by two VA investigators does a good job in explaining the nuances of the study (4). Editorials in response to a specific article are often authored by the reviewers. If these editorial authors were also the article’s reviewers, they can hardly be blamed for saying nice things about the manuscript since “biting the hand that feeds you” is usually a dangerous practice. However, why JAMA published the article in the first place is puzzling. Certainly, lack of timely access to healthcare is very important and lack of access has been associated with higher costs and worse outcomes (4,5). However, this article reports nothing about how the VA achieved this improvement in access. Was it by hiring additional physicians to see the patients or by hiring additional scheduling clerks or additional practice extenders such as physician assistants or nurse practitioners?

The VA data could be easily manipulated. If access by a limited number of new patients is all that is being reported, there may be a tendency to underfund other areas. What about other specialty areas such as oncology, nephrology, pulmonary, neurology, general surgery, ENT, audiology, and ophthalmology to name just a few? What about established patients? What about financial incentives? Were the administrators given bonuses for improving access in these highly selected areas but none or less in others? This is the system the VA used during the wait times scandal and likely contributed to the falsification of data (6).

As it now stands the manuscript represents more advertising than medical science. Medical journals owe their readers better. Hopefully, we at the Southwest Journal are doing a better job of publishing articles that allows the practitioners to better care for their patients and not administrators make their bonus.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Penn M, Bhatnagar S, Kuy S, Lieberman S, Elnahal S, Clancy C, Shulkin D. Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers. JAMA Netw Open. 2019 Jan 4;2(1):e187096. [CrossRef] [PubMed]
2. Wagner D. Seven VA hospitals, one enduring mystery: What's really happening? The Arizona Republic. October 23, 2016. Available at: https://www.azcentral.com/story/news/local/arizona-investigations/2016/10/23/va-hospitals-veterans-health-care-quest-for-answers/90337096/ (accessed 1/25/19).
3. 60 Minutes. Robert McDonald: cleaning up the VA. Aired November 9, 2014. Available at: http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals/ (accessed 1/25/19).
4. Kaboli PJ, Fihn SD. Waiting for Care in Veterans Affairs Health Care Facilities and Elsewhere. JAMA Netw Open. 2019 Jan 4;2(1):e187079. [CrossRef] [PubMed]
5. Roemer MI, Hopkins CE, Carr L, Gartside F. Copayments for ambulatory care: penny-wise and pound-foolish. Med Care. 1975 Jun;13(6):457-66. [CrossRef] [PubMed]
6. Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9.

Cite as: Robbins RA. More medical science and less advertising. Southwest J Pulm Crit Care. 2019;18(1):29-30. doi: https://doi.org/10.13175/swjpcc005-19 PDF 

Cite as: Robbins RA

Pain Scales and the Opioid Crisis

In the last year, physicians and nurses have increasingly voiced their dissatisfaction with pain as the fifth vital sign. In June 2016, the American Medical Association recommended that pain scales be removed in professional medical standards (1). In September 2016, the American Academy of Family Physicians did the same (2). A recent Medscape survey reported that over half of surveyed doctors and nurses supported removal of pain assessment as a routine vital sign (3).

In the 1990’s there was a widespread impression that pain was undertreated. Whether this was true or an impression created by a few practitioners and undertreated patients with the support of the pharmaceutical industry is unclear. Nevertheless, the prevailing thought became that identifying and quantifying pain would lead to more appropriate pain therapy. The American Society of Anesthesiologists and the American Pain Society issued practice guidelines for pain management (4,5). Subsequently, both the Department of Veterans Affairs and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandated a pain scale as the fifth vital sign (6-9). Most commonly these scales ask patients to rate their pain on a scale of 1-10. The JCAHO mandated that "Pain is assessed in all patients” and would give hospitals "requirements for Improvement" if they failed to meet this standard (9). The JCAHO also published a book in 2000 for purchase as part of required continuing education seminars (9). The book cited studies that claimed "there is no evidence that addiction is a significant issue when persons are given opioids for pain control." It also called doctors' concerns about addiction side effects "inaccurate and exaggerated." The book was sponsored by Purdue Pharma makers of oxycodone.

Almost as soon as the standards were initiated, suggestions emerged that pain treatment was becoming overzealous. In 2003 a survey of 250 adults who had undergone surgical procedures reported that almost 90% were satisfied with their pain medications. Nevertheless, the authors concluded that “many patients continue to experience intense pain after surgery … additional efforts are required to improve patients’ postoperative pain experience” (8). Concerns about overaggressive treatment for pain increased after Vila et al. (10) reported in 2005 that the incidence of opioid oversedation increased from 11.0 to 24.5 per 100 000 inpatient hospital days after the hospitals implemented a numerical pain treatment algorithm. As early as 2002 the Institute for Safe Medication Practices linked overaggressive pain management to a substantial increase in oversedation and fatal respiratory depression events (11). Articles appeared questioning the wisdom of asking every patient to rate their pain noting that implementation of the scale did not appear to improve pain management (12). The JCAHO removed its standard to assess pain in all patients but not until 2009.

The US has seen a dramatic increase in the incidence of opioid deaths (13). It is unclear if adoption of the pain scale and its widespread application to all patients contributed to the increase although the time frame and the data from Vila et al. (10) suggest that this is likely.

There have been other factors that may have also contributed to the increase in opioid deaths. The Medscape survey mentioned above asked participants how often they feel pressure to prescribe pain medication in order to keep patient satisfaction levels high (3). Specifically mentioned was the Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS. HCAHPS is a patient satisfaction survey required for all hospitals in the US. About two thirds of doctors and nurses felt there was pressure (3). The survey also asked respondents about the influence of patient reviews on opioid prescribing. Forty-six percent of doctors said the reviews were more than slightly influential. The surveys seemed to carry more weight with nurses. Seventy-three percent said the reviews were influential. Others have blamed pharmaceutical company marketing opioids as a way of reducing pain and increasing patient satisfaction (14). Clearly, there has been a dramatic increase in narcotic prescriptions. Not surprisingly, pharmaceutical companies have done little to curb the use of their products.

Earlier this year, former CDC Director Tom Frieden said "The prescription overdose epidemic is doctor-driven…It can be reversed in part by doctors' actions” (15). Some physicians have taken this as blame for the entire opioid crisis, including deaths from heroin and illegal fentanyl. There may be some validity in this belief since abuse of illegal narcotics sometimes evolves out of abuse of prescribed narcotics. However, the actions of the health regulatory agencies that mandated pain scales and created guidelines for pain management were not mentioned by Dr. Frieden. Also, not mentioned are the patient satisfaction surveys. 

About a year ago the CDC issued guidelines for prescribing opioids for chronic pain (15). These guidelines were developed in collaboration with a number of federal agencies including the Department of Veterans Affairs which was one of the first to mandate pain scales and the Centers for Medicare and Medicaid Services (CMS) which mandated HCAHPS. Pain is a subjective symptom and quantification and treatment are imprecise. The goal cannot be to deliver perfect pain management but to reduce the incidence of under- and overtreatment as much as possible. Someone needs to assess patients’ pain complaints and prescribe opioids appropriately. No one is better qualified and prepared than the clinician at the bedside.

No one condones the unethical practice of widespread prescription of opioids without sufficient medical oversight. However, meddling by unqualified bureaucrats, administrators and politicians emphasizes guidelines over appropriate care. As detailed above, the present opioid crisis may be an unattended consequence of the pain scale and opioid prescribing guidelines. Further intrusion by the same groups who created the crisis is unlikely to solve the problem but is likely to create additional problems such as the undertreatment of patients with severe pain. As I write this on the ides of March it may be appropriate to paraphrase a line from Julius Cesar, “The fault lies not in our doctors but in our regulators”.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Anson P. AMA drops pain as vital sign. Pain News Network. June 16, 2016. Available at: https://www.painnewsnetwork.org/stories/2016/6/16/ama-drops-pain-as-vital-sign (accessed 3/2/17).
2. Lowes R. Drop pain as the fifth vital sign, AAFP says. Medscape Medical News. September 22, 2016. Available at: http://www.medscape.com/viewarticle/869169 (accessed 3/2/17).
3. Ault A. Many physicians, nurses want pain removed as fifth vital sign. Medscape Medical News. Medscape Medical News. February 21, 2017. Available at: http://www.medscape.com/viewarticle/875980?nlid=113119_3464&src=WNL_mdplsfeat_170228_mscpedit_ccmd&uac=9273DT&spon=32&impID=1299168&faf=1 (accessed 3/2/17).
4. Practice guidelines for acute pain management in the perioperative setting. A report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology. 1995 Apr;82(4):1071-81. [CrossRef] [PubMed]
5. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, Lipman AG, Bookbinder M, Sanders SH, Turk DC, Carr DB. American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med. 2005 Jul 25;165(14):1574-80. [CrossRef] [PubMed]
6. National Pain Management Coordinating Committee. Pain as the 5Th vital sign toolkit. Department of Veterans Affairs. October 2000. Available at: https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf (accessed 3/2/17).
7. Baker DW. History of The Joint Commission's Pain Standards: Lessons for Today's Prescription Opioid Epidemic. JAMA. 2017 Mar 21;317(11):1117-8. [CrossRef] [PubMed]
8. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-540. [CrossRef] [PubMed]
9. Moghe S. Opioid history: From 'wonder drug' to abuse epidemic. CNN. October 14, 2016. Available at: http://www.cnn.com/2016/05/12/health/opioid-addiction-history/ (accessed 3/2/17).
10. Vila H Jr, Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesth Analg. 2005;101(2):474-480. [CrossRef] [PubMed]
11. Institute for Safe Medication Practices. Pain scales don’t weigh every risk. July 24, 2002. Available at: https://www.ismp.org/newsletters/acutecare/articles/20020724.asp (accessed 3/2/17).
12. Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006 Jun;21(6):607-12. [CrossRef] [PubMed] 
13. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016 Dec 16;65. Published on-line. [CrossRef] [PubMed]
14. Cha AE. The drug industry’s answer to opioid addiction: More pills. Washington Post. October 16, 2016. Available at: https://www.washingtonpost.com/national/the-drug-industrys-answer-to-opioid-addiction-more-pills/2016/10/15/181a529c-8ae4-11e6-bff0-d53f592f176e_story.html?utm_term=.36c5992fa62f (accessed 3/2/17).
15. Lowes R. CDC issues opioid guidelines for 'doctor-driven' epidemic. Medscape. March 15, 2016. Available at: http://www.medscape.com/viewarticle/860452 (accessed 3/2/17).

Cite as: Robbins RA. Pain scales and the opioid crisis. Southwest J Pulm Crit Care. 2017;14(3):119-22. doi: https://doi.org/10.13175/swjpcc033-17 PDF 

The Evil That Men Do-An Open Letter to President Obama

"The evil that men do lives after them; the good is oft interred with their bones". William Shakespeare, Julius Caesar, Act 3, Scene 2

Dear President Obama:

Late in a second term, a President's attention often turns to framing their legacy. I suspect you are no exception and have given this considerable thought. You might wish to be remembered for the Affordable Care Act, even called Obamacare, which brought the US closer to universal healthcare coverage. However, I recall the end of President Clinton's second term a short 16 years ago. During that administration the Federal coffers were full; an unprecedented business boom occurred; and foreign entanglements that might have led to war were avoided. However, most of us do not remember those positives, but recall a White House intern and a certain blue dress. As pointed out by Shakespeare over 400 years ago powerful men are remembered not so much for the good they do but the bad.

Robert McDonald, your Secretary of Veterans Affairs (VA), was brought on board two years ago to deal with concerns about long waiting times for Veterans Administration medical services-concerns and the subsequent lies that were told to cover it up that led you to fire his predecessor, Eric Shinseki. McDonald was talking to reporters in the week leading up to Memorial Day, when attention always turns not just to honoring America's war dead but to whether the government is delivering services it promised living Veterans. The reporters asked McDonald why the VA doesn't publicly report the date when veterans first ask for medical care so as to better measure waiting times (1). His reply:

"The days to an appointment is really not what we should be measuring. What we should be measuring is the veteran's satisfaction. What really counts is: How does the veteran feel about their encounter with the VA? When you go to Disney, do they measure the hours you wait in line?"

Although McDonald later apologized for his remarks, they were offensive to me as a physician who worked in the VA, and I might point out wrong on several fronts. First, Disney does track its wait times. Second, the remark shows a fundamental disconnect between upper echelon management and healthcare. As we pointed out several years ago, satisfaction with healthcare does not mean better healthcare, in fact, it may mean worse care, perhaps because the focus is more on satisfaction than good care (2). Third, McDonald's remark was truly disingenuous. McDonald is concerned about wait times which led you to fire his predecessor. Otherwise, why would the VA lift the supervision requirement for nurse practioners which they did later in the week (3)?

The prolonged wait times occurred because an insufferable VA administration created a hostile work environment for physicians. Many left and the VA was unable to replace them. Although salary is part of this, it is less of a problem than those inside the Beltway believe. The VA abandoned its academic affiliations and created a work environment where physicians seeing patients is largely put in the same category as janitors waxing a floor. Middle level administrators who know nothing about healthcare are now directing physicians on what they should do. The goal has become less about healthcare than the administrators being in charge. The replacement of physicians by nurse practioners is in line with this concept. The goal will not be as much to deliver quality healthcare, a concept that is often nebulous and hard to define, but rather to redefine quality. For example, replacing timely and good care with a measure such as making sure that on each visit the Veteran is reminded to fasten their safety belt (a current requirement), is certainly measurable, cheap and does not require a physician. In most businessmen's minds it matters little whether it does any good or not. It is a measure of someone's concept of quality and the VA will deliver quality as long as it does not cost too much and an administrator can receive a bonus for it. Based on the VA, many physicians are suspicious that this is the long term goal of Obamacare.

So on this Memorial Day, let us remember our Veterans, Mr. President, and consider your legacy. My view is that unless changes are made, your misdirection of healthcare both at the VA and nationally through Obamacare, could be your White House intern in a blue dress.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Capital Gazette editorial board. Our say: McDonald gaffe points to a deeper problem. Capital Gazette. May 30, 2016. Available at: HTUhttp://www.capitalgazette.com/opinion/our_say/ph-ac-ce-our-say-0529-20160529-story.htmlUTH (accessed 5/30/16).
2. Robbins RA, Rashke RA. A new paradigm to improve patient outcomes: a tongue-in-cheek look at the cost of patient satisfaction. Southwest J Pulm Crit Care 2012;5:33-5. Available at: HTU/editorial/2012/7/17/a-new-paradigm-to-improve-patient-outcomes.htmlUTH (accessed 5/30/16).
3. Japsen B. VA would join 21 states already lifting nurse practitioner hurdles. Forbes. May 26,2016. Available at: HTUhttp://www.forbes.com/sites/brucejapsen/2016/05/26/va-would-join-21-states-lifting-nurse-practitioner-hurdles/#2d4e391e9f2cUTH (accessed 5/30/16).

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

Cite as: Robbins RA. The evil that men do-an open letter to President Obama. Southwest J Pulm Crit Care. 2016 May;12(5):201-2. doi: http://dx.doi.org/10.13175/swjpcc048-16 PDF

State of the VA

Earlier this week, President Obama gave his last State of the Union Address. Although this usually is a speech giving the President the opportunity of flaunt his accomplishments, no mention was made of the VA (1). Given the troubles at the VA, there seems little to tout.

Over 70% of the VA medical centers were discovered to have falsified wait times (2). Because of the wait scandal, VA Secretary Eric Shinseki resigned and VA undersecretary, Robert Petzel MD, retired under pressure. Ironically, Shinseki, a retired Army general and member of the Joint Chiefs of Staff, was viewed in a favorable light by the current administration because of a spat with the Bush administration's Secretary of Defense, Donald Rumsfeld, over the number of troops needed to secure Iran and Afghanistan (3). However, during Shinseki's tenure the number of VA "medical troops", doctors and nurses, was insufficient to care for the number of veterans. It is unclear if the new secretary, Bob McDonald, has done much to correct the problem.

Locally, the director of the Phoenix VA regional office, Susan Bowers, retired under pressure and former Phoenix VA Director Sharon Helman was fired (4). However, Helman was allowed to keep her bonus for the falsely reported shorter wait times and is appealing her firing. Her deputies, Lance Robinson and Brad Curry, were placed on administrative leave, but after over a year and a half have recently returned to work in the Phoenix VA regional office. Darren Deering DO, the Phoenix chief of staff, underwent a VA internal investigation because of retaliating against one of the Phoenix VA whistleblowers, Katherine Mitchell MD. Disciplinary action was recommended but no action was taken. In October 2015, the IG released a new report citing critical staffing shortages at the Phoenix VA.

Earlier this week the Senate Veterans Affairs Committee approved the nomination of Washington lawyer Michael Missal as the new permanent Department of Veterans Affairs inspector general (VAIG) (5). Lawmakers from both parties have sought a permanent VAIG for over 2 years. The chairman of the Senate veterans panel, Republican Sen. Johnny Isakson of Georgia, says the top priority of the inspector general must be to "hold bad actors at the VA accountable" for chronic delays for veterans seeking medical care and other problems at the agency.

If confirmed by the full Senate which is expected, Missal might be busy. Whether Isakson is serious or this is more political posturing is unclear. Rather than a few “bad actors” the wait scandal suggests that fraud, waste and abuse are common, perhaps even rampant, within the VA. Rather than being held “accountable”, the bad actors are more often protected and even rewarded by VA Central Office. Although Veterans and the public might be optimistic, it is likely that they will be disappointed by Missal, as they have by VAIGs and others charged with VA oversight in the past.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Graf N. Veterans' affairs left out of State of the Union; Phoenix VA whistleblower disappointed in speech. ABC15 Arizona. January 13, 2016. Available at: http://www.abc15.com/news/region-phoenix-metro/central-phoenix/veterans-affairs-left-out-of-state-of-the-union-phoenix-va-whistleblower-disappointed-in-speech (accessed 1/15/16).
2. Klimas J. Huge backlog: 70 percent of VA facilities used alternative waitlists. Washington Times. June 9, 2014. Available at: http://www.washingtontimes.com/news/2014/jun/9/audit-more-57000-await-initial-va-visits/?page=all (accessed 1/15/16).
3. DeFrank T. How Donald Rumsfeld complicated Eric Shinseki’s last administration exit. National Journal. May 31, 2014. Available at: http://www.nationaljournal.com/white-house/2014/05/31/how-donald-rumsfeld-complicated-eric-shinsekis-last-administration-exit (accessed 1/15/16).
4. Arizona Republic. VA in crisis: the Republic investigation. Available at: http://www.azcentral.com/investigations/vahealthsystem/ (accessed 1/15/16).
5. Daly M. Senate panel backs lawyer Missal as VA watchdog. Washington Post. January 12, 2016. Available at: https://www.washingtonpost.com/politics/whitehouse/senate-panel-backs-lawyer-missal-as-va-watchdog/2016/01/12/d13db550-b96d-11e5-85cd-5ad59bc19432_story.html (accessed 1/15/16).

*The opinions expressed are those of the author and not necessarily the opinions of the Arizona, New Mexico, Colorado or California Thoracic Socities or the Mayo Clinic.

Cite as: Robbins RA. State of the VA. Southwest J Pulm Crit Care. 2016;12(1):28-9. doi: http://dx.doi.org/10.13175/swjpcc008-16 PDF

Honoring Our Nation's Veterans

Today is Armistice Day, renamed Veterans Day in 1954, to honor our Nation's Veterans. In Washington the rhetoric from both the political right and left supports our Veterans. My cynical side reminds me that this might have something to do with Veterans voting in a higher percentage than the population as a whole, but let me give the politicians this one. Serving our Country in the military is something that deserves to be honored. I was proud to serve our Veterans over 30 years at four Department of Veterans Affairs (VA) hospitals.

However, the VA has had a very bad year. First, in Washington there were the resignations of the Secretary of Veterans Affairs, Eric Shinseki; the undersecretary for the Veterans Health Administration, Robert Petzel; and the undersecretary for the Veterans Benefits Administration, Allison Hickey. Locally, in the light of the VA wait scandal there were the firing of the Phoenix VA Medical Centers director, Sharon Helman, and her deputies along with the retirement of her boss, Susan Bowers. Furthermore, there seem to be a never-ending string of scandals ranging from the mundane of greed-driven fraud to the more exotic of accusing a VA whistleblower of engaging in sexual threesomes. Despite a healthy increase in funding, there was the threat by VA administrators of closing VA hospitals to meet a VA budget shortfall. This resulted in Congress knuckling under to allow the use of emergency funds. Veterans groups are using billboards to accuse the VA of lying (Figure 1).

Figure 1. Billboard across from the VA October 12, 2015.

I could go on and on. However, the real question is not so much of what dirty deeds are being done, but how the VA administrators get away with it.

There has been both a lack of oversight and lack of accountability. Robert McDonald, who replaced Shinseki, has promised to punish the evil doers but has replaced action with the mantra "all is well" and has done nothing. In several instances wrong-doing has apparently been rewarded, such as Bowers replacement having lied to Congress (1). If the VA cannot police itself-and it apparently cannot-there are a multitude of regulatory agencies that have shirked their oversight responsibilities. I thought it was time to mention a few.

First, there are both the Veterans Integrated Service Networks, the regional VA offices, and VA Central Office itself in Washington. Both these organizations have been caught in the scandals and have done nothing. Second, there is Congress. The House Veterans Affairs Committee has seemed to make a sincere effort to identify some of the problems but Secretary McDonald and his cadre of 11,000 in Central Office has repeatedly stone-walled any investigation and Congress has done nothing. Third, there is the White House. The Obama Administration has seemed more interested in declaring the problem fixed than actually fixing the problem and has done nothing.

Those are the obvious but there are some less obvious regulatory failures. First, there are the multiple hospital inspectors. Within the VA is the Office of Inspector General (IG) who is charged with investigating wrong-doing within the VA. Locally they had been called to Phoenix multiple times including for the wait time scandal but have done nothing. The poor performance resulted in the resignation of the acting VA IG, Richard Griffin, under pressure. Second, there is the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO). The Phoenix VA Medical Center managed to go from a "top performer" in 2011 to noncompliant "with U.S. standards for safety, patient care and management" in 2014. Only the naive would believe that a hospital can transition that much in 3 years. There is also the Arizona Board of Medical Examiners and Nursing. Both doctors and nurses were involved in the cover-up of the wait scandal but these boards have done nothing. The VA is the largest system for training future physicians and nurses, and it seems that the future doctors and nurses might not be learning the highest professional and ethical standards. Nonetheless, the Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing have done nothing.

However, my personal disgust is highest for the Department of Justice (DOJ). It is known that seventy percent of the hospitals were fudging their wait data. The administrators, not the doctors or nurses, received bonuses for short wait times. None of the administrators have gone to jail or even been charged with fraud. None have even had to repay their bonuses. The DOJ has done nothing. If 70% of the doctors were caught faking data to received bonuses, I have every confidence that the legal eagles at DOJ would gleefully put each and every one on trial.

So what can be done? There appears to be no oversight. This was clearly illustrated in the report from the recent Human Resources (HR) team from Central Office sent to Phoenix to help with what can be kindly described as a dysfunctional department. They were essentially shown the door by the acting director, Glen Grippen, saying that he "calls the shots" (2).

The solution is that Mr. Grippen and others of his ilk should no longer call the shots. They have shown a consistent arrogance and disregard for our Nation's Veterans and those that serve them. He and others need oversight, not by a far-off committee in Washington as President Obama has proposed which will likely fare no better than Congress. Oversight could be best provided by local physicians and nurses who have interest in Veteran care but are not employed by the VA. This used to occur in many VA hospitals and was called the Dean's Committee. The dean of the local medical school along with the chairman of the departments of medicine, surgery, pathology, radiology, and others formed a committee that oversaw care at the VA. The committee had interests in the patient care of Veterans but also in the physicians who were faculty at the local medical school and the medical students, residents and fellows who were under their supervision. This committee was a victim of Ken Kizer's "prescription for change" in the 1990s. Now, this old system might be an antidote for Kizer's prescription which has seemed to turn poison.

The VA is pushing to hire more personnel to deal with wait times and lack of patient care. However, it is unclear how many of the new hires are doctors and nurses contributing to patient care and how many are administrators and bureaucrats.  My experiences and conversations with my colleagues convinces me that not all hospitals are as badly managed as those in the Southwest. Those considering a career at the VA need to carefully investigate each hospital to see if it is the type of place that the leadership will provide the resources to care for the Veterans, which is after all, the definition of leadership.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Wagner D. Department of Veterans Affairs names new regional health director. Arizona Republic. October 15, 2015. Available at: http://www.azcentral.com/story/news/arizona/politics/2015/10/15/department-veterans-affairs-names-new-regional-health-director/73900478/
2. Wagner D. VA team blasts Phoenix personnel office. Arizona Republic. November 2, 2015. Available at: http://www.azcentral.com/story/news/arizona/investigations/2015/11/02/va-team-blasts-phoenix-personnel-office/74763366/

Cite as: Robbins RA. Honoring our Nation's Veterans. Southwest J Pulm Crit Care. 2015;11(5):228-30. doi: http://dx.doi.org/10.13175/swjpcc141-15 PDF

Time for the VA to Clean Up Its Act

One year after a Veterans Affairs (VA) scandal was ignited here in Phoenix, the number of veterans on wait lists is 50 percent higher than at the same time last year, according to VA data (1). The VA is also facing a nearly $3 billion budget shortfall. VA Secretary Bob McDonald has asked for “flexibility” to reallocate billions of dollars in clinical funds to cover the shortfall.

Since the scandal broke last year, VA providers have increased their workloads, adding 2.7 million more appointments than the previous year. However, the VA has played "games" with patient eligibility for years. When money was plentiful VA administrators would open the doors to patients since the following years' budgets were based on the number of patients seen. However, when money was tight, the doors would be slammed shut leaving many patients in the lurch scrambling to obtain health care elsewhere. Now it appears that patients might be returning to the VA.

“Something has to give,” the department’s deputy secretary, Sloan D. Gibson, said in an interview. “We can’t leave this as the status quo. We are not meeting the needs of veterans, and veterans are signaling that to us by coming in for additional care, and we can’t deliver it as timely as we want to.” Now the VA is asking Congress' permission to use clinical funds to pay for the budgetary shortfall.

The VA has threatened furloughs and hiring freezes to reduce spending. This seems to be quite sensible. However, in the past, the VA has cut clinical positions which undoubtedly contributed to longer wait times. For example, when I was chief of pulmonary at the Phoenix VA, one of my physicians retired, giving 6 month notice. However, we were not allowed to replace the physician because of a "hiring freeze". This apparently only applied to clinicians since a new associate director was hired.

As we predicted over a year ago, the VA would continue to be troubled due to lack of reform and oversight (2).  The present VA secretary, Robert McDonald, is still relatively new on the job and inexperienced in both healthcare and government service. His inaction suggests that he may be confused, or worse, listening to long-entrenched central office bureaucrats. Below are some suggestions which could result in substantial savings and would have little impact on patient care.

Furlough the staffs of the Veterans Integrated Service Networks (VISNs), the 21 VA regional offices which are scheduled to be downsized. The VISNs provide no healthcare and the savings in salaries from the nearly 5000 employees would be substantial (2). Similarly, VA central office which grew from 800 employees to 11,000 in less than 15 years could probably do with a few less administrators (3).

Local VA bureaucracies reflect the growth of central office and VISN bureaucracies. It is unclear what many of the hospital associate and assistant directors do other than sit in meetings. Most hospitals could do without them for a while. Similarly, compliance officers and patient "advocates" really serve no purpose. Despite multiple patient complaints about wait times, the lack of action that led to the VA scandal demonstrates that they are not effective. There are also some physicians and nurses who do not see patients. For example, most VA Chiefs of Staff do not see patients. Nursing administration is bloated with "clip board" nurses who do little than attend meetings and create an ever increasing, and seemingly never ending, stream of paperwork for nurses who are already overworked. Surely, we could do without some of these people. 

It seems unlikely that VA officials will implement any meaningful cost savings. Instead they will try to preserve the status quo by petitioning Congress to allow them to shift clinical funds depriving veterans of healthcare. That includes using funds from a new program that was a priority for congressional Republicans called the “Choice Card”. This program allows certain veterans to obtain taxpayer-funded care from private doctors. VA administrators have blamed the budget shortfall on this program along with a new treatment for hepatitis C (1). The VA has been accused of dragging its feet on the Choice program and once again appears to be trying to sabotage the program and keep the funds. Gibson said in the interview that in future years more money will also be needed. He said he intended to tell lawmakers, “Veterans are going to respond with increased demand, so get your checkbooks out.”

VA administrators appear more concerned with keeping money inside their dysfunctional agency than caring for vets. Based on past history, Congress will probably let the VA shift the money and none of the recommendations above will happen. If furloughs occur, they will be lower level employees and result in little financial saving. Of course, administrative bonuses will be hefty this year because in their eyes, the administrators have successfully averted a financial crisis. Unless there are some fundamental changes made at the VA, the trend of the last 20 years of bloating the bureaucracy at the expense of healthcare will continue.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Oppel, RA Jr. Wait lists grow as many more veterans seek care and funding falls far short. New York Times, June 20, 2015. Available at: http://www.nytimes.com/2015/06/21/us/wait-lists-grow-as-many-more-veterans-seek-care-and-funding-falls-far-short.html (accessed 6/24/15).
2. Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. [CrossRef]
3. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med 2014;371:295-7. [CrossRef] [PubMed] 

Reference as: Robbins RA. Time for the VA to clean up its act. Southwest J Pulm Crit Care. 2015;10(6):350-1. doi: http://dx.doi.org/10.13175/swjpcc088-15 PDF

A Tale of Two News Reports

On Wednesday, February 25, 2015 two new stories aired, one on National Public Radio (NPR) that I heard riding home that afternoon and the other later in the evening on the CBS Evening News with Scott Pelley. Both stories were on the Department of Veterans Affairs (VA) but I was struck by the contrasting style of the two reports.

The first story was an NPR report on back injuries in nurses (1). According to the report nurses suffer more back injuries than almost any other occupation — and they get those injuries mainly from doing the everyday tasks of lifting and moving patients. The report stated that the VA has invested over $200 million in protecting nurses predominately by providing lifts and other devices for moving patients. VA hospitals across the country have reduced nursing injuries from moving patients by an average of 40 percent since the program started. The reduction at the Loma Linda hospital where the report was focused was closer to 30 percent — but the injuries that employees suffered were less serious than they used to be. Loma Linda spent almost $1 million during a recent four-year period just to hire replacements for employees who got hurt so badly they had to go home. However, this past year they spent nothing because according to the report nobody got hurt badly enough to miss work.

The VA's reputation for accurate information has been called into question. The Phoenix VA was the ground zero of an investigation which eventually discovered that about 70% of VA hospitals were falsifying patient waiting reports (2). Perhaps everything in this NPR report is true, however, the NPR report reminded me of so many I heard over the past two decades where any medical report was accepted by the media at face value. Many of the reports I knew were not true because I worked at the VA. There are several reasons to be skeptical. First, it is from the VA. Second, the director of the Loma Linda VA was Donald F. Moore until late 2012. Prior to that position Moore had been the director of the Phoenix VA. Third, the reported drop in injuries borders on the unbelievable. Nursing supervisors likely need to get approval to replace injured nurses.  Perhaps a directive either not to report any back injuries or that approval of replacement nurses would not be granted was issued. There are many ways to falsify the data, but NPR was nonquestioning in their report.

Later that evening CBS Evening News correspondent Wyatt Andrews reported that he found widespread mismanagement of VA claims. The mismanagement resulted in veterans being denied the benefits they earned, and many even dying before they get an answer from the VA (3). Five whistleblowers at the Oakland, California, Veterans Benefits office told CBS News that more than 13,000 claims filed between 1996 and 2009 ended up stashed in a file cabinet and ignored until 2012. VA supervisors in Oakland ordered marking the claims "no action necessary" and to toss them aside. Whistleblowers said that was illegal. Last week, the VA inspector general confirmed that because of, "poor record keeping" In Oakland, "veterans did not receive... benefits to which they may have been entitled." How many veterans is not known, because thousands of records were missing when inspectors arrived. In the last year, the inspector general has found serious issues in at least six VA benefits offices, including unprocessed claims in Philadelphia, 9,500 records sitting on employees' desks in Baltimore and computer manipulation in Houston to make claims look completed when they were not. VA Central Office said in a statement, "..electronic claims processing [has] transformed mail management for compensation claims ... greatly minimizing any risk of delays due to lost or misplaced mail...For any deficiencies identified, steps are taken to appropriately process the documents and correct any deficiencies." Much of this sounded very familiar and similar to the patient wait times the VA falsified last year.

The CBS report closed with a statement from the Veterans service organization Veteran Warriors, which advocates for veterans who are having difficulty with their claims. The Veteran Warriors said in a statement: "Too many cases have come to light, wherein the VA leaders have destroyed, deleted, hidden and manipulated veterans claims - their very access to benefits and services - and NOT ONE OF THEM has been criminally charged. It is time for our nations' leaders to stop listening to the endless "lip service" of accountability and demand answers. If they do not get them, it is time for repercussions to be felt by those who obviously believe they are above the law and insulated from prosecution." It was clear that the Veteran Warriors did not believe the VA and also clear that neither did CBS News.

The weak reporting on medical issues has been apparent to me for some time. The CBS report suggests that this may be changing. The VA scandal may point out that medical reports need to questioned just like other news stories. Truthfulness does matter and the VA continually blaming clerks and other lower level employees for administrative inadequacies or attacking the whistleblower has become tedious. Even the present inspector general's report blamed the closing of the Veterans claims on "poor record keeping". In this instance CBS news was doing their job questioning the VA but NPR was not.

Richard A. Robbins, MD

Editor

SWJPCC

References

1. Zwerdling D. At VA hospitals, training and technology reduce nurses' injuries. NPR. February 25, 2015. Available at: http://www.npr.org/2015/02/25/387298633/at-va-hospitals-training-and-technology-reduce-nurses-injuries (accessed 3/7/15).
2. Robbins RA. A veterans day editorial: change at the VA? Southwest J Pulm Crit Care. 2014;9(5):281-3. [CrossRef]
3. CBS News. Whistleblowers: Veterans cheated out of benefits. February 25, 2015. Available at: http://www.cbsnews.com/news/veteran-benefits-administration-mismanagement-uncovered-in-investigation/ (accessed 3/7/15).

Reference as: Robbins RA. A tale of two news reports. Southwest J Pulm Crit Care. 2015;10(3):143-4. doi: http://dx.doi.org/10.13175/swjpcc038-15 PDF

A Veterans Day Editorial: Change at the VA?

"Meet the new boss,

Same as the old boss.

Won't Get Fooled Again!"

            -Peter Townshend

Today we honor our veterans. A year ago VA patients languished on waiting lists waiting for healthcare. VA administrators hid the truth at over 100 VAs and took bonuses for meeting their wait time goals. Money has been poured into the VA, patients in rural areas are seen outside the VA, and it is now supposedly easier to fire other senior VA officials. Dennis Wagner authored an article in the Arizona Republic that claimed the VA has made some changes but more changes are needed (1). I agree with the need for change but would argue that there has been no real change at the VA.

Last week I saw a VA patient in my private practice. He was paying for tiotropium or Spiriva®, a long-acting anticholinergic used in chronic obstructive pulmonary disease, out of his pocket. He was under the impression that the VA did not "carry" tiotropium. I told him that this was not true and that he should go to the VA and ask to be seen in pulmonary clinic if his primary care physician could not prescribe tiotropium. He was sent to the pharmacy where the pharmacist wanted to know why I would prescribe this expensive drug. He was sent back to my office for a response. I xeroxed a copy of my notes and gave them to the patient. I do not know whether he got the tiotropium but my guess is that probably not without some hassle. This is unchanged from prior to the scandal when patient care was undermined by healthcare support staff. No real change there.

Last night, the new Secretary of the VA, Robert McDonald, was on "60 Minutes" (2). He announced that he is "reorganizing" the VA. Although details were not stated, this sounded mostly like a consolidation of websites, not a bad thing, but hardly a "reorganization". He also said how sorry he was for past mistakes and how the new VA was going to do better. I had déjà vu going back to the mid 90's with Ken Kaiser's "Prescription for Change" (3). Eric Shinseki, the VA secretary recently forced to resign, used similar rhetoric and was "mad as hell" at the falsified wait lists (4). No real change there.

McDonald used the term "customers" to refer to VA patients (2). This has occurred off and on since the mid 90's and is a term some healthcare providers find offensive. We do not flip burgers at McDonald's and find it inappropriate and offensive to equate healthcare professionals with businessmen selling Charmin, Luvs, Pampers, Gillette razors, Covergirl makeup, etc. No real change there.

Earlier this week, the VA named a new director at the Phoenix VA, ground zero of the VA scandal (5). He is the former director of the Milwaukee VA and director of the VA's Rocky Mountain regional network, apparently coaxed out of retirement to serve for about a year as director at the troubled medical center. He replaces two directors who served a matter of months. While director at the Rocky Mountain VA region he named Cynthia McCormack, former chief of nursing at the Phoenix VA, as director of the Cheyenne VA (6). Cheyenne was second only to Phoenix in having the widespread falsification of wait times discovered. Sharon Helman, the Phoenix VA director sits at home suspended while collecting a paycheck but McCormack appears to continue to direct the Cheyenne VA. No real change there.

Although a handful of administrators have been fired by the VA, the data falsification was rampant, with most VAs apparently falsifying their records (2). Yet these administrators retain their jobs and continue to rule their healthcare empires. McDonald claimed that names had been turned over to the Department of Justice (DOJ), but the DOJ declined to prosecute, and that administrative law judges were blocking the firing of administrators (2). No real change there.

The VA still functions with a lack of oversight. Congressmen make statements and issue press releases when politically convenient. The VA office of inspector general (VAOIG) still does investigations in response to whistle-blowers. After turning over their findings to VA central office to water down, the VAOIG usually makes some recommendations that are quickly accepted but not acted on by the VA (7). No real change there.

Lastly, there is the popular media. For years we heard about Ken Kizer's "Prescription for Change" and the miracle of the transformation to the VA (3,8). This infuriated many of us who knew it was not true (9). We wondered why the press was so accepting of the claims. They certainly are not on other political issues. However, in this case Dennis Wagner of the Arizona Republic, CNN and several other news sources stayed with the story and ferreted out the truth. Real change there. Hopefully, news media with continue their investigative reporting and question VA officials when they put forth self-serving data that is difficult to believe. This is my hope and may be the only result of the VA scandal that will force change. Hopefully the media "won't get fooled again".

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. Much change in wake of VA scandal; more needed. Arizona Republic. November 8, 2014. Available at: http://www.azcentral.com/story/news/arizona/investigations/2014/11/08/phoenix-va-scandal-changes/18716281/.
2. 60 Minutes. Robert McDonald: cleaning up the VA. Aired November 9, 2014. Available at: http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals/.
3. Kizer KW. Prescription for change. March 22, 1995. Available at: http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf
4. Cohen T, Frates C. Shinseki 'mad as hell' about VA allegations, but won't resign. CNN. May 23, 2014. Available at: http://www.cnn.com/2014/05/15/politics/va-scandal-eric-shinseki-preview/.
5. Wagner D. VA names new director for Phoenix medical center. Arizona Republic. November 4, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/11/04/phoenix-veterans-affairs-medical-center-interim-director-brk/18467665/.
6. Cheyenne VA Medical Center. Leadership team: Cynthia McCormack. Available at: http://www.cheyenne.va.gov/about/leadership.asp.
7. Robbins RA. A failure of oversight at the VA. Southwest J Pulm Crit Care. 2014;9(3):179-82. [CrossRef]
8. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348(22):2218-27. [CrossRef] [Pubmed]
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353(17):1860-1. [CrossRef] [PubMed] 

Reference as: Robbins RA. A veterans day editorial: change at the VA? Southwest J Pulm Crit Care. 2014;9(5):281-3. doi: http://dx.doi.org/10.13175/swjpcc150-14 PDF

Questioning the Inspectors

In the early twentieth century hospitals were unregulated and care was arbitrary, nonscientific and often poor. The Flexner report of 1910 and the establishment of hospital standards by the American College of Surgeons in 1918 began the process of hospital inspection and improvement (1). The later program eventually evolved into what we know today as the Joint Commission. Veterans Administration (VA) hospitals have been inspected and accredited by the Joint Commission since the Reagan administration.

The VA hospitals often share reports regarding recent Joint Commission inspections and disseminate the reports as a "briefing". One of these briefings from a recent  Amarillo VA inspection was widely distributed as an email attachment and forwarded to me (for a copy of the briefing click here). There were several items in the briefing that are noteworthy. One was on the first page (highlighted in the attachment) where the briefing stated, "Surveyor recommended teaching people how to smoke with oxygen, not just discuss smoking cessation". However, patients requiring oxygen should not smoke with oxygen flowing (2,3).  It is not that oxygen is explosive but a patient lighting a cigarette in a high oxygen environment can ignite their oxygen tubing resulting in a facial burn (2,3). A very rare but more serious situation can occur when a home fire results from ignition of clothing, bedding, etc. (3).

A quick Google search revealed no data for any program teaching patients to smoke on oxygen. It is possible that the author of the "briefing" misunderstood the Joint Commission surveyor. However, the lack of physician, nurse and respiratory therapist autonomy makes it easy to envision administrative demands for a program to "teach people how to smoke on oxygen" wasting clinician and technician time to do something that is potentially harmful.

Although this is an extreme and absurd example of healthcare directed by bureaucrats, review of the remainder of the "briefing" is only slightly less disappointing. Most of the Joint Commission's recommendations for Amarillo would not be expected to improve healthcare and even fewer have an evidence basis. The Joint Commission focus should be on those standards demonstrated to improve patient outcomes rather than a series of arbitrary meaningless metrics. For example, a Joint Commission inspection should include an assessment of the adequacy of nurse staffing, are the major medical specialties and subspecialties readily accessible, is sufficient equipment and space provided to care for the patients, etc. (4-5).  By ignoring the important and focusing on the insignificant, the Joint Commission is pushing hospitals towards arbitrary and nonscientific care reminiscent of the last century. These poor hospital inspections will undoubtedly eventually lead to poorer patient outcomes.

Richard A. Robbins, MD*

Editor

References

1. Borus ME, Buntz CG, Tash WR. Evaluating the Impact of Health Programs: A Primer. 1982. Cambridge, MA: MIT Press.
2. Robb BW, Hungness ES, Hershko DD, Warden GD, Kagan RJ. Home oxygen therapy: adjunct or risk factor? J Burn Care Rehabil. 2003;24(6):403-6. [CrossRef] [PubMed]
3. Ahrens M. Fires And Burns Involving Home Medical Oxygen. National Fire Protection. Association. Available at: http://www.nfpa.org/safety-information/for-consumers/causes/medical-oxygen (accessed 3/12/14).
4. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002 Oct 23-30;288(16):1987-93. [CrossRef] [PubMed]
5. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14(8):499-511. [CrossRef] [PubMed]

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

Reference as: Robbins RA. Questioning the inspectors. Southwest J Pulm Crit Care. 2014;8(3):188-9. doi: http://dx.doi.org/10.13175/swjpcc032-14 PDF

HIPAA-Protecting Patient Confidentiality or Covering Something Else?

A case of a physician fired from the Veterans Administration (VA) for violation of the Health Care Portability and Accountability Act of 1996 (HIPAA) illustrates a problem with both the law and the VA. Anil Parikh, a VA physician at the Jesse Brown VA in Chicago, was dismissed on a charge of making unauthorized disclosures of confidential patient information on October 19, 2007.  On January 3, 2011 the Merit Systems Protection Board (MSPB) reversed Dr. Parikh’s removal.

Dr. Parikh's initially made disclosures to the VA Office of Inspector General and to Senator Barack Obama and Congressman Luis Gutierrez, in whose district the Jesse Brown VA lies.  Dr. Parikh alleged that there were systematic problems within the Jesse Brown VA that resulted in untimely and inadequate patient care. The confidential patient information Parikh disclosed included examples of the misdiagnoses and misdirection of patients within the hospital. Specifically, Dr. Parikh alleged that a physician failed to diagnose a patient’s rectal abscess and sent him home rather than refer him for proper surgical treatment. Two patients who should have been accepted in the emergency room were improperly directed to the urgent care area. One of these patients who should have been admitted to the intensive care unit was improperly placed on the general medical floor, resulting in the eventual deterioration of his condition to the point where he required intubation. Parikh later testified that he made these disclosures out of concern for patient health and safety.

The IG referred the matter to Mr. James Jones, director of the Jesse Brown VA for investigation. Mr. Jones assigned Dr. Jeffrey Ryan, Associate Chief of Staff, to investigate the allegations. Dr. Ryan concluded that there was no evidence of mismanagement or misdiagnosis and the IG closed their case. Dr. Parikh then disclosed the information to Denise Mercherson, his own attorney; Dr. Fred Zar, the director of the internal medicine residency program at Loyola, the American College of Graduate and Medical Education (ACGME) and other members of Congress serving on Congressional VA oversight committees. After these disclosures, Parikh was fired by Mr. Jones.

After exhausting his appeals to be reinstated with the VA Office of Special Counsel, Parikh filed an individual right of action (IRA) with the MSPB contending that his disclosures were protected under the Whistleblower Protection Act (WPA), and that the VA removed him based on those protected disclosures. The administrative judge hearing the case found that Parikh failed to establish MSPB jurisdiction over his appeal because “he failed to make a nonfrivolous allegation that any of his disclosures were protected under the WPA”.  Parikh then filed a petition for review by the full board, and the MSPB reversed the initial decision.  The issue for MSPB was whether Parikh's disclosures were protected under the WPA. Although the administrative judge initially hearing the case found that Parikh failed to establish that he reasonably believed these disclosures were evidence of a substantial and specific danger to public health or safety, the full MSPB disagreed. They found that the nature of the harm that could result from patient care and management issues that Parikh disclosed was "severe” that could result in patient death.

The VA argued that Parikh's disclosures were prohibited under HIPPA. According to Lisa Yee and Timothy Morgan, lawyers for the Chicago VA General Counsel, Parikh's disclosures were not covered by the WPA because the WPA and the Privacy Act of 1974 excludes disclosures prohibited by law. The VA also argued that Dr. Parikh's disclosures were prohibited by HIPAA. The MSPB had little trouble rejecting both these arguments, finding that one of the exceptions is a disclosure to a Congressional committee. The VA lastly argued that Dr. Parikh's disclosures were prohibited by VA policy since the VA had not approved disclosure of the information. However, the MSPB found that the VA's policy in question was not a "substantive" rule, but merely a reference to the HIPPA and the Privacy Act. The MSPB found that the disclosures were a factor to his removal and ordered him reinstated with back pay.

Physicians considering a career with the VA should carefully examine this case. The MSPB concluded that the VA retaliated against Dr. Parikh, not for disclosing confidential patient information, but whistleblowing. After over 3 years, Dr. Parikh has his job back but his work situation is probably not “friendly”. And what has become of the VA administrators and their lawyers who violated WPA by retaliating against Dr. Parikh-to my knowledge, nothing.

The adversarial relationship between the VA administrators and physicians appears to be a one-way street. A physician can have their career destroyed by the VA, but if the accusations are unjustified, there are no consequences to the accusers. On the other hand, physicians that voice concerns for patient care and safety can have their professional reputation ruined by the VA. Particularly concerning is the misuse of HIPAA by VA attorneys as a weapon against physicians.

Dr. Parikh’s case would not appear to be an isolated event. A quick review of the news reveals a VA nurse in Albuquerque was charged with sedition for criticism of the Bush administration’s handling of hurricane Katrina and Iraq (2).  In Phoenix a VA physician was fired after forwarding an e-mail from a Senator John McCain staffer suggesting physicians go to a McCain political rally and lobby for a new VA research building (3). The Phoenix VA chief of hematology/oncology resigned after his name was placed in the National Practioner Databank; an action he felt was unjustified (4). Most recently the Phoenix VA public relations director was demoted after giving unfavorable testimony about VA administrators (5). If the VA is having trouble recruiting as their recent TV advertising suggests, they might consider a different approach. A good start would be the use of HIPAA to protect patient confidentiality rather than cover something else.

Richard A. Robbins, MD

Editor

References

1. US Merit System Protection Board. 2011 MSPB 1. Docket No. CH-1221-08-0352-B-2. Available at: http://www.mspb.gov/. Accessed 9/10/13. 
2. Dees DE. VA nurse in New Mexico accused of sedition. Mother Jones. 2006. Available at: http://www.motherjones.com/mojo/2006/02/va-nurse-new-mexico-accused-sedition. Accessed 9/10/13. 
3. Franklin RE. VA doc fired for political email. Arizona Star. 2011. Available at: http://azstarnet.com/news/local/va-doc-fired-for-political-email/article_3e353bbf-b04a-52ff-8a9c-6cb49e78a47a.html. Accessed  9/10/13.
4. Robbins RA. Profiles in medical courage: Thomas Kummet and the courage to fight burearcracy. Southwest J Pulm Crit Care. 2013;6(1):29-35.
5. Wagner D. VA official in Arizona demoted after her testimony. Arizona Republic. Available at http://www.azcentral.com/news/arizona/articles/20130314va-official-arizona-pedene-demoted-after-testimony.html  accessed 9/10/13.

Reference as: Robbins RA. HIPAA-protecting patient confidentiality or covering something else? Southwest J Pulm Crit Care. 2013;7(4):236-8. doi: http://dx.doi.org/10.13175/swjpcc128-13 PDF

Treatment after a COPD Exacerbation

A couple of years ago I was consulted about a patient at the Phoenix VA who had been admitted for the third time for a COPD exacerbation in two months. Each time the patient was treated with inhaled short-acting bronchodilators, corticosteroids and an antibiotic; rapidly improved; and was discharged after only one or two days in the hospital.  The discharge medications were albuterol, ipratropium, and rapidly tapering doses of prednisone. Apparently, no consideration was given to adding long-acting beta agonists (LABA), long-acting muscarinic antagonists (LAMA), and/or inhaled corticosteroids (ICS). These later medications have been shown to reduce exacerbations in most studies (1,2).

I was reminded of this incident by a recent article published by Melzer et al. in the Journal of Internal Medicine (3). The authors examined 2760 patients with exacerbations of COPD admitted to hospitals in the VA Northwest Health Network (VISN 20) to determine if a LABA and/or glucocorticoid were prescribed at discharge. These medications reduce exacerbations and the best predictor of a future exacerbation is a history of exacerbations (1,2,4). Of the 2760 patients 93% were not receiving a LABA or an ICS at the time of their exacerbation. Of this 93%, two-thirds of the patients had no change in therapy after their exacerbation. The authors state that “among patients treated for COPD exacerbations, there were missed opportunities to potentially reduce subsequent exacerbations by adding treatments known to modify exacerbation risk”. The authors go on to suggest that the VA could develop a Quality Enhancement Research Initiative (QUERI) program to improve delivery of care for some chronic conditions.

So why did the patient at the Phoenix VA and 2/3 of the patients in VISN 20 not receive a LABA, LAMA and/or inhaled corticosteroid after their exacerbations as recommended by the GOLD and ATS guidelines? Are the doctors in the Pacific Northwest and Phoenix unaware of the guidelines as the article and its accompanying editorial imply (5)? The answer probably lies elsewhere. First, the VA does not use the GOLD or ATS guidelines but has developed their own guidelines (6). These guidelines specifically mention consideration of the addition of inhaled corticosteroids and a LAMA but make no mention of a LABA. Rather than encouraging use of these medications, programs were created at the Phoenix VA which restricted Veterans’ access to these more expensive medications. The VA administration empowered the pharmacy to make unilateral decisions based on fiscal considerations with inadequate expert clinician input. These include a requirement to refer all patients for pulmonary consultation for long-acting bronchodilator therapy. This overloaded the pulmonary clinics with patients that did not necessarily need to be seen. In addition, there was a requirement for a trial of ipratropium before beginning tiotropium which took multiple visits further overloading the clinics.

This is another example of administrators meddling in clinical care only to have it blow up in their face and cause something else to go awry wasting money. In this case, the low use of long-acting bronchodilators likely led to an increase in admissions for exacerbation of COPD which are a major determinant of the costs of COPD care (7). Ignorance of the providers is blamed and another program to correct the harm caused by the initial blunder is created. Another example is the control of blood sugar in the ICU. After pushing for tight control of blood sugar for several years, the VA Inpatient Evaluation Center (IPEC) seamlessly converted their program to one examining hypoglycemia when tight control resulting in hypoglycemia was found to be harmful with the publication of the NICE-SUGAR study (8,9).

A QUERI program examining whether a LABA and/or corticosteroid was prescribed at discharge for a COPD patient does not need to be created. What needs to be done is to allow the physicians in the Pacific Northwest and Phoenix to use their best skills and judgment in caring for the patients without interference. If something must be measured, readmissions for exacerbation of COPD could be considered but should be part of a comprehensive program that measures outcomes such as mortality, length of stay, and morbidity. Otherwise, administrative blunders to correct past mistakes will continue.

Richard A. Robbins, M.D.*

References

1. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010. Available at: http://www.goldcopd.org/Guidelines/guidelines-resources.html  (accessed 7/7/13)
2. Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, Criner G, van der Molen T, Marciniuk DD, Denberg T, Schünemann H, Wedzicha W, MacDonald R, Shekelle P; American College of Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155(3):179-91. [CrossRef] [PubMed]
3. Melzer AC, Feemster LM, Uman JE, Ramenofsky DH, Au DH. Missing potential opportunities to reduce repeat COPD exacerbations. J Gen Intern Med. 2013;28(5):652-9. [CrossRef] [PubMed]
4. Hurst JR, Vestbo J, Anzueto A, Locantore N, Müllerova H, Tal-Singer R, Miller B, Lomas DA, Agusti A, Macnee W, Calverley P, Rennard S, Wouters EF, Wedzicha JA; Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Investigators. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med 2010;363:1128-38. [CrossRef] [PubMed]
5. Jubelt LE. Capsule Commentary on Melzer et.al., Missing Potential Opportunities to Reduce Repeat COPD Exacerbations. J Gen Intern Med. 2013;28(5):708. [CrossRef] [PubMed]
6. The Management of COPD Working Group. VA/DOD clinical practice guideline for management of outpatient chronic obstructive pulmonary disease. Available at: http://www.healthquality.va.gov/copd/copd_20.pdf (accessed 7/7/13)
7. Hilleman DE, Dewan N, Malesker M, Friedman M. Pharmacoeconomic evaluation of COPD. Chest. 2000;118(5):1278-85. [PubMed] [PubMed]
8. Falciglia M, Freyberg RW, Almenoff PL, D'Alessio DA, Render ML. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med. 2009;37(12):3001-9. [CrossRef] [PubMed]
9. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-97. [CrossRef] [PubMed]

*The opinions expressed are those of the author and not necessarily the Southwest Journal of Pulmonary and Critical Care or the Arizona, New Mexico or Colorado Thoracic Societies.  

Reference as: Robbins RA. Treatment after a COPD exacerbation. Southwest J Pulm Crit Care. 2013;7(1):28-30. doi: http://dx.doi.org/10.13175/swjpcc089-13 PDF

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.

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.