Arizona Averages Over 25 Opioid Overdoses Per Day

An Arizona Republic article and the Arizona Department of Health Services Director's blog, Dr. Cara Christ, brings the opioid crisis home (1,2). Christ states that over 3200 opioid overdoses with over 400 deaths occurred between June 15 and October 17 in Arizona. This averages to over 25 overdoses and 3 deaths per day.

Some of the data from Christ’s blog are below:

• Males 25-29 have the highest rates of suspected opioid overdoses.
• 37% of people experiencing a suspected opioid overdose had an opioid prescription in the two months prior to their overdose.
• The majority of overdoses occur at home.
• The most commonly cited pre-existing health conditions of those with suspected overdoses was chronic pain. Depression and other behavioral health conditions were also common health conditions noted.
• Meth and heroin were the most frequently cited drugs involved in reported neonatal abstinence syndrome.
• About 40% of people experiencing suspected opioid overdoses who had a prescription in the Controlled Substances Prescription Monitoring Program had been prescribed both benzodiazepines and opioids in 2017. When these medications are combined, it is so dangerous that the FDA gives it a “black box” warning.
• About 40% of people experiencing a suspected overdose that had prescription history in the Controlled Substances Prescription Monitoring Program (CSPMP) had received opioid prescriptions from 10 or more providers.
• Only about 25% of clinicians prescribing controlled substances checked the CSPMP prior to prescribing.

On October 16, a new mandate went into effect that requires clinicians to check the CSPMP prior to prescribing an opioid or benzodiazepine. Other states implementing such mandates have experienced reductions in people with 4 or more prescribers or pharmacies, reductions in opioid prescribing, and reductions in Morphine Milligram Equivalent daily doses.

The CSPMP requires registration and login but is relatively easy to use (3). You can search not only in Arizona but other states as well. Personally, as a pulmonary consultant I infrequently prescribe opioids or benzodiazepines. However, I have used the website once to check a benzodiazepam prescription for a patient I suspect might be addicted. No other prescriptions were found. It at least gave me some assurance that he was not obtaining prescriptions from multiple practioners while we attempt to wean him off this medication.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. McCrory C. More than 400 opioid-overdose deaths reported in Arizona since June 15. Arizona Republic. October 27, 2017. Available at: http://www.azcentral.com/story/news/local/arizona/2017/10/27/more-than-400-opioid-overdose-deaths-reported-arizona-since-june-15/809157001/ (accessed 10/28/17).
2. Christ CM. Opioid update: latest data and emergency rules update. October 17, 2017. Available at: http://directorsblog.health.azdhs.gov/opioid-update-latest-data-and-emergency-rules-update/ (accessed 10/28/17).
3. Arizona Board of Pharmacy. Arizona PMP Aware. Available at: https://pharmacypmp.az.gov/ (accessed 10/28/17).

Cite as: Robbins RA. Arizona averages over 25 opioid overdoses per day. Southwest J Pulm Crit Care. 2017;15(4):179-80. doi: https://doi.org/10.13175/swjpcc133-17 PDF 

Maryvale Hospital to Close

Abrazo Health Care has announced that it intends to close Maryvale Hospital effective December 18, 2017. Maryvale Hospital has had declining admissions and was realigned as a satellite facility of Abrazo West Campus in Goodyear in May 2017. Abrazo said they hoped to place most of the 300 Maryvale employees at other Abrazo medical centers.

Richard A. Robbins, MD

Editor, SWJPCC

Cite as: Robbins RA. Maryvale hospital to close. Southwest J Pulm Crit Care. 2017;15(4):164. doi: https://doi.org/10.13175/swjpcc129-17 PDF 

California Enacts Drug Pricing Transparency Bill

The Mercury News is reporting that California governor Jerry Brown signed a bill Monday making drug pricing more transparent (1). The legislation requires pharmaceutical companies to notify health insurers and government health plans at least 60 days before making price hikes and explain the reason for the increase. The pharmaceutical industry had lobbied hard against the measure, worried that it could become a national model and the first big step toward price controls. “The essence of this bill is pretty simple,” Brown told a room filled with supporters of Senate Bill 17. “Californians have a right to know why their medical costs are out of control, especially when the pharmaceutical profits are soaring. That’s the take-away message.”

“It is disappointing that Gov. Brown has decided to sign a bill that is based on misleading rhetoric instead of what’s in the best interest of patients,” said Priscilla VanderVeer, spokeswoman for the Washington, D.C.-based Pharmaceutical Research and Manufacturers of America. She added that there is “no evidence that SB 17 will lower drug costs for patients.”

The bill does not actually control drug prices, leading some critics to suggest it is toothless. However, the bill’s backers say that transparency in other health care sectors has been successful in reducing costs. Anthony Wright, executive director of Health Access California, agreed. He said the advance notice and information required under SB 17 “is invaluable” to large health care purchasers such as insurers, union trusts and employers, and would enable them to drive a better deal for consumers.

Brown also signed a related bill on Monday. Assembly Bill 265 will prohibit prescription drug manufacturers from offering discounts for name-brand drugs, if a less-expensive equivalent brand is available, preventing the use of higher-priced drugs when unnecessary.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Seipel T. Gov. Brown signs drug pricing transparency bill. The Mercury News. October 8, 2017 (updated October 9). Available at: http://www.mercurynews.com/2017/10/08/gov-brown-to-sign-drug-price-transparency-bill/ (accessed 8/10/17).

Cite as: Robbins RA. California enacts drug pricing trasparency bill. Southwest J Pulm Crit Care. 2017;15(4):159. doi: https://doi.org/10.13175/swjpcc122-17 PDF 

Senate Health Bill Lacks 50 Votes Needed to Proceed

Yesterday (7/17), two additional Senators – Sen. Roberts (R-KS) and Sen. Lee (R-NE) joined Senators Paul (R-KY) and Collins (R-ME) in announcing their intention to vote “no” on the motion to proceed on considering the Senate ACA repeal and replace legislation – effectively blocking Senate consideration of the current Senate Republican health care bill. Senators Paul, Lee and Roberts opposed the bill for not going far enough, while Senator Collins expressed her concern the bill goes too far.

With the 4 publicly announced NO votes – Senator Majority Leader Mitch McConnell does not have the 50 votes needed to begin debate on the bill, let alone assure final passage.

Speculation now turns to what happens next. President Trump has tweeted his preference to let Obamacare fail as a way to force Democrats to negotiate new legislation. Senator McConnell has suggested a series of symbolic votes on full repeal with multi-year delay to work on a replacement plan or voting on the House passed bill. However, three moderate senators, Capito (R-WV), Collins (R-ME) and Murkowski (R-AK), announced today they will not support procedural votes on an immediate ACA repeal bill.  Alternatively, Congress may abandon the health reform effort for the time being and pivot to other legislative priorities (tax reform and infrastructure). The failure of McConnell to lead the Senate effort may clear the way for a bipartisan effort to address the shortfalls of the ACA.

Please keep in mind the House repeal and replace effort “died” before the House ultimately passed its repeal legislation, so while the Senate effort looks to be “permanently stalled” it is probably premature to call it “dead.”

Nuala S. Moore

American Thoracic Society

Washington, DC USA

Cite as: Moore NS. Senate health bill lacks 50 votes needed to proceed. Southwest J Pulm Crit Care. 2017;15(1):45. doi: https://doi.org/10.13175/swjpcc093-17 PDF 

Medi-Cal Blamed for Poor Care in Lawsuit

Several sources are reporting a lawsuit filed in California alleging poor care in the state’s Medicaid program, Medi-Cal (1). The suit alleges that Medi-Cal failed to pay doctors enough to provide proper care. The suit was filed by five Latino residents on behalf of California’s 13 million lower-income residents, more than half of them Latinos. The suit alleges that "…California has created a separate and unequal system of health care, one for the insurance program with the largest proportion of Latinos (Medi-Cal), and one for the other principal insurance plans, whose recipients are disproportionately white.”

The state budget includes $107 billion in state and federal funding for Medi-Cal this year, but the spending is not enough to restore reimbursement cuts made during the Great Recession of 2008. A proposal in the U.S. Senate to repeal the Affordable Health Care law (ACA, Obamacare) could drastically reduce funding for Medicare and the individuals who can access it.

Thomas Saenz, an attorney with the Mexican American Legal Defense and Educational Fund who filed the lawsuit, said he believes it is the first time the civil rights approach has been tried in California. According to Saenz this legal approach is possible because California is one of the few states to specifically prohibit discriminatory effects in state programs.

Other states in the Southwest also have disproportionately large Hispanic populations in their Medicaid programs (Table 1).

Table 1. Percent Caucasian and Hispanic total population/Medicare population by State (2,3).

Reimbursement does appear disproportionately low in California which ranked 48th in the nation in 2015 in how much it paid hospitals, doctors and other healthcare providers for treating Medi-Cal patients, according to the Kaiser Family Foundation (4). In the Southwest the state with the highest reimbursement was Nevada (5-10). California reimbursement averaged only 47% of Nevada reimbursement for the procedures listed (Table 2).

Table 2. Medicare reimbursement for common procedures by state (4-9).

The reason for the wide differences in reimbursement rates is unclear but is likely historical dating back to cost containment programs from the 1980’s and 90’s (11). The differences do not appear to be explained by differing costs of living. None of the procedure reimbursements correlated with the cost of living in the largest city in each state (Phoenix, Los Angeles, Denver, Albuquerque, Honolulu, and Las Vegas, p>0.1, all comparisons).

The chances of the lawsuit’s success are unclear since there is no precedent. However, it seems likely that if the suit is successful, more suits will be filed since California Medi-Cal’s situation of disproportionately providing care to minorities is not unique.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Thompson D. Latino plaintiffs sue California alleging poor health care. Associated Press. July 12, 2017. Available at: http://abcnews.go.com/Health/wireStory/latino-plaintiffs-sue-california-alleging-poor-health-care-48592841 (accessed 7/13/17).
2. Kaiser Family Foundation. Population distribution by race/ethnicity. 2015. Available at: http://www.kff.org/other/state-indicator/distribution-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D (accessed 7/13/17).
3. Kaiser Family Foundation. Distribution of the nonelderly with Medicaid by race/ethnicity. 2015. Available at: http://www.kff.org/medicaid/state-indicator/distribution-by-raceethnicity-4/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D (accessed 7/13/17).
4. Dickson V. Low Medi-Cal payments could weaken expanded coverage for undocumented children. Modern Healthcare. June 17, 2015. Available at: http://www.modernhealthcare.com/article/20150617/NEWS/150619908 (accessed 7/13/17).
5. California Department of Health Care Services Medi-Cal. Medi-Cal Rates. June 15, 2017. Available at: https://files.medi-cal.ca.gov/pubsdoco/rates/rateshome.asp (accessed 7/13/17).
6. Arizona Health Cost Containment System. Physician fee schedules. 2017. Available at: https://www.azahcccs.gov/PlansProviders/RatesAndBilling/FFS/Physicianrates/ (accessed 7/13/17).
7. Colorado Department of Health Care Policy and Financing. Provider rates & fee schedule. June 2017. Available at: https://www.colorado.gov/pacific/hcpf/provider-rates-fee-schedule (accessed 7/13/17).
8. Quest Hawai’i. Medicaid fee schedule. 2013. Available at: http://www.med-quest.us/ (accessed 7/13/17).
9. Nevada Division of Health Care Financing and Policy. Fee schedules. Available at: http://dhcfp.nv.gov/Resources/Rates/FeeSchedules/ (accessed 7/13/17).
10. New Mexico Human Services Department. New Mexico Medicaid fee for service CPT code fee schedule. 2017. Available at: http://www.hsd.state.nm.us/uploads/FileLinks/e7cfb008157f422597cccdc11d2034f0/7.17_CPT_Codes__2_.pdf (accessed 7/13/17).
11. Tatar M, Paradise J, Grafield R. Medi-Cal managed care: an overview and key issues. Kaiser Family Foundation. Mar 02, 2016. Available at: http://www.kff.org/report-section/medi-cal-managed-care-an-overview-and-key-issues-issue-brief/ (accessed 7/13/17).

Cite as: Robbins RA. Medi-Cal blamed for poor care in lawsuit. Southwest J Pulm Crit Care. 2017;15(1):42-4. doi: https://doi.org/10.13175/swjpcc091-17 PDF 

Senate Republican Leadership Releases Revised ACA Repeal and Replace Bill

Today, the Senate Republican leadership released a revised version of a bill to repeal and replace the Affordable Care Act (ACA). The new bill draft includes an amendment sponsored by Sen. Cruz (R-TX) that permits insurers to offer health insurance plans on the ACA exchanges that do not cover the ACA’s 10 essential health benefits (EHB) as long as they offer at least one other plan that provides full coverage of EHB’s. The bill also includes more funding for opioid addiction and for state initiatives to reduce insurance premiums and additionally, some flexibility for state Medicaid funding in the event of a public health crisis. The bill must still receive a cost estimate from the Congressional Budget Office (CBO), which will include the impact of the bill on insurance coverage levels, expected out Monday. The ATS remains deeply concerned about the bill because under the Cruz proposal, insurance coverage costs for people with pre-existing conditions would soar, leaving coverage unaffordable for many people with chronic respiratory conditions. The Senate leadership aims to begin voting on the bill by the middle of next week in an open amendment process, so changes could be made to the bill with subsequent votes occurring quickly.

Just before the revised leadership bill was introduced, Sen. Graham (R-SC) and Cassidy (R-LA) released their own ACA repeal and replace bill, which focuses on sending ACA funding directly to the states, rather than the federal government and would preserve more state Medicaid funding. The Graham/Cassidy proposal would also permit states to waive the ACA’s EHB’s although full details of this bill are not yet clear and some aspects are still under revision.

Despite the release of the Senate leadership’s new bill, it is still not at all clear whether it will gain the support of all Senate Republicans, a number of whom have concerns with the funding reductions to Medicaid.

Nuala S. Moore

American Thoracic Society

Washington, DC USA

Cite as: Moore NS. Senate Republican leadership releases revised ACA repeal and replace bill. Southwest J Pulm Crit Care. 2017;15(1):41. doi: https://doi.org/10.13175/swjpcc092-17 PDF

Mortality Rate Will Likely Increase Under Senate Healthcare Bill

Today (6/27/17) an article was published in the Annals of Internal Medicine by Steffie Woolhandler and David Himmelstein from New York University on the effects of health insurance on mortality (1). The article has special significance because of pending healthcare legislation in the Senate.  

The Annals article concludes that the odds of dying among the insured relative to the uninsured is 0.71 to 0.97. However, the authors acknowledge that this is a very difficult study to conduct because of the nonrandomized, observational nature of the studies and lack of a strict separation between covered and uncovered Americans. For example, many people cycle in and out of insurance diluting differences between groups.

Of course, what is needed is a randomized trial, and surprisingly, one does exist which is discussed in the Annals article (1,2). In 2008, Oregon initiated a limited expansion of its Medicaid program for about 6,000 poor, able-bodied, uninsured adults aged 19 to 64 years through a lottery to win the opportunity to apply for Medicaid and to enroll if they met eligibility requirements. Compared to uninsured adults, mortality was 13% lower in the insured. However, the trial was underpowered and the mortality differences did not reach statistical significance.

Another study mentioned was one examining the mortality rates in New York, Maine, and Arizona after expansion of Medicaid (1,3). Compared to neighboring states that did not expand Medicaid, a significant decrease in all-cause mortality in the expansion states was observed (−25.4 deaths per 100,000 population; p = 0.02; Figure 1).

Figure 1. Unadjusted mortality and rates of Medicaid coverage among nonelderly adults before and after state Medicaid expansions (1997–2007). The vertical line represents the year during which the Medicaid expansions were implemented, meaning that year 1 was the first full year after the expansions.

Figure 1 shows roughly parallel death rates before Medicaid expansion, and a gradually widening split after Medicaid expansion. From this data, the authors calculated that Medicaid expansion to 176 adults would prevent one death per year.

On Monday (6/26/17), the Congressional Budget Office (CBO) concluded that the pending Senate healthcare bill, known as the Better Care Reconciliation Act, will result in 22 million fewer people having health insurance by 2026 (4,5). The bill would cut $772 billion in Medicaid spending and $408 billion in subsidies for individual enrollees. The net effect of these spending reductions is partially offset by $541 billion in tax cuts mostly to corporations and wealthier Americans. These numbers all approximate the effects under the similar House version of the bill that passed on May 4.

If Medicaid expansion prevents one death for each 176 enrolled (4), presumably dropping Medicaid for 176 Americans would result in one additional death per year. Given that the CBO estimates 22-23 million Americans will lose coverage under either bill, the potential increase in deaths is staggering. If either bill is passed, an increase in the death rate among the Medicaid population seems the likely consequence of the politics of reducing the Federal deficit and billions in tax cuts for corporations and the richest Americans.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Woolhandler S, Himmelstein DU. The relationship of health insurance and mortality: is lack of insurance deadly? Ann Int Med. June 27, 2017. Available at: http://annals.org/aim/latest (accessed 6/27/17) [CrossRef]
2. Baicker K, Taubman SL, Allen HL, Bernstein M, Gruber JH, Newhouse JP, Schneider EC, Wright BJ, Zaslavsky AM, Finkelstein AN; Oregon Health Study Group.The Oregon experiment--effects of Medicaid on clinical outcomes. N Engl J Med. 2013 May 2;368(18):1713-22. [CrossRef] [PubMed]
3. Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012 Sep 13;367(11):1025-34.  [CrossRef] [PubMed]
4. Congressional Budget Office. H.R. 1628, Better Care Reconciliation Act of 2017. June 26, 2017. Available at: https://www.cbo.gov/publication/52849 (accessed 6/26/17).
5. Frieden J. Senate GOP's ACA repeal bill would knock 22 million off insurance: CBO. MedPage Today. June 26, 2017. Available at: https://www.medpagetoday.com/PublicHealthPolicy/repeal-and-replace/66275?isalert=1&uun=g687171d5575R5764210u&xid=NL_breakingnews_2017-06-26 (accessed 6/26/17).

Cite as: Robbins RA. Mortality rate will likely increase under Senate healthcare bill. Southwest J Pulm Crit Care. 2017;14(6):318-9. doi: https://doi.org/10.13175/swjpcc084-17 PDF 

University of Arizona-Phoenix Receives Full Accreditation

University of Arizona (UA) officials announced yesterday that the UA College of Medicine-Phoenix, which was originally a branch of the UA-Tucson medical school, was granted full accreditation by the Liaison Committee on Medical Education (LCME) (1). The College of Medicine-Phoenix was created 10 years ago. In 2012, the UA College of Medicine-Phoenix received “preliminary” accreditation with the LCME, then “provisional” accreditation in 2015 and now full accreditation.

To date, the UA College of Medicine-Phoenix has graduated 354 physicians, with classes of about 80 students per year. One year ago this month, the Arizona Medical Association asked for an investigation after a half-dozen of the Phoenix medical school’s top leaders left for positions out of state. Among those departures was the school’s dean, Dr. Stuart D. Flynn. Dr. Kenneth Ramos served as interim dean and helped lead the Phoenix medical school through the accreditation. Dr. Guy Reed from Tennessee was recently hired as the school’s new dean and assumes his duties in July.

There are now five medical schools in Arizona: the two UA medical schools; the Mayo Clinic School of Medicine, which is opening its Arizona campus in Scottsdale this summer; and Midwestern University and A.T. Still University, which both operate osteopathic medical schools in the Phoenix area. A sixth medical school, Omaha-based Creighton University School of Medicine, has medical students doing third- and fourth-year rotations in Arizona.

Richard A. Robbins, MD

Editor, SWJPCC

Reference

1. Innes S. University of Arizona's Phoenix medical school receives full accreditation. Arizona Star. June 14, 2017. Available at: http://tucson.com/news/local/education/college/university-of-arizona-s-phoenix-medical-school-receives-full-accreditation/article_64a1da80-1866-5a51-a062-7cc04ecd261d.html (accessed 6/15/17).

Cite as: Robbins RA. University of Arizona-Phoenix receives full accreditation. Southwest J Pulm Crit Care. 2017;14(6):311. doi: https://doi.org/10.13175/swjpcc077-17 PDF 

Limited Choice of Obamacare Insurers in Some Parts of the Southwest

The New York Times is reporting that all of Arizona, much of Nevada, and portions of Utah and Colorado will have only one insurer available under the Affordable Care Act (ACA, Obamacare) marketplace (Figure 1) (1).

Figure 1. New York Times compilation of insurance company announcements for providing coverage under the ACA or Obamacare.

About 35,000 people buying insurance in Affordable Care Act marketplaces in 45 counties could have no choice in carriers in Ohio and Missouri (Figure 1), This would be the first time that has happened since the marketplaces were opened in 2014.

Some insurance companies are still deciding what they will do in 2018, and others may reverse course, so these numbers could go up or down.

Most Americans get health insurance from a job or government program, but about 22 million people buy individual policies under Obamacare. More than half of them use Obamacare marketplaces, where most of them get a federal tax credit to help pay for coverage. The rest buy directly from an insurer or broker, outside the Obamacare marketplaces. A recent New York Times analysis showed that many insurers are now choosing to sell exclusively outside the marketplaces, where their customers are not eligible for federal subsidies. Because customers cannot use subsidies for these plans, many may not be able to afford coverage.

Richard A. Robbins, MD

Editor, SWJPCC

Reference

1. Park H, Carlsen A. For the first time, 45 counties could have no insurer in the Obamacare marketplaces. New York Times. June 9, 2017. Available at: https://www.nytimes.com/interactive/2017/06/09/us/counties-with-one-or-no-obamacare-insurer.html (accessed 6/12/17).

Cite as: Robbins RA. Limited choice of healthcare insurers in some parts of the southwest. Southwest J Pulm Crit Care. 2017;14(6):295. doi: https://doi.org/10.13175/swjpcc074-17 PDF 

Gottlieb, the FDA and Dumbing Down Medicine

Gottlieb, the FDA and Dumbing Down Medicine

In the last few weeks several events have occurred that might impact drug approval in the US. President Donald Trump's pick for FDA commissioner, Dr. Scott Gottlieb. Gottlieb, like many of Trump’s picks for administration healthcare positions, is a physician. He also has experience as deputy FDA commissioner from 2005-7.  However, his confirmation hearing before the Senate Committee on Health, Education, Labor and Pensions alarmed some who say his deep ties to the pharmaceutical industry will cause a conflict of interest (1). Others praised Gottlieb as the right man to lead the FDA.

As opposed to Trump, Gottlieb denied any connection between vaccines and autism (1,2). Dr. Gottlieb called the issue "one of the most exhaustively studied questions in medical history," before saying, "There is no plausible link between vaccines and autism. At some point, we have to accept 'no' for an answer." However, Gottlieb did not give a straight answer when asked to share his thoughts on drug importation. While President Donald Trump has supported increased drug importation and is reported to be working with Democratic lawmakers on drug importation legislation, Dr. Gottlieb had previously opposed the measure (1). When asked if he opposes importing cheaper drugs from foreign countries, he said, "I can tell you I have a lot of ideas that I want to work on right away on how I think we can get more product competition onto the market."

Gottlieb stated that the FDA could speed up approval of new drugs and devices (1). However, a letter to the editor published in the New England Journal of Medicine examined compared review times for new therapeutic agents that were approved by the FDA or the European Medicines Agency (EMA), the primary drug regulator in Europe, between 2011 and 2015 (3). The median total review time was 306 days (interquartile range, 239 to 371) at the FDA, as compared with 383 days (interquartile range, 327 to 446) at the EMA.

In welcome news to many physicians, Gottlieb voiced uneasiness over increasing regulation of physicians’ practices (1). “My concern that the agency was losing confidence in physicians and felt it need[ed] …to supplant their judgment for the judgment of doctors,” Gottlieb said. He had previously referred to the FDA’s action on Arcoxia, a pain killer that was rejected in April 2007 because of concern that it could increase the risk of heart attack and stroke with prolonged use despite being meant for short-term pain relief. Gottlieb stated the opioid epidemic would be his "highest and most immediate priority." He added that the epidemic is a "public health emergency on the order of Ebola and Zika" that requires dramatic action from the FDA. "[T]o address it now, the types of actions that we are going to need to take are going to be more dramatic, perhaps, than the types of actions we would have taken 10 years ago."

Gottlieb did not note that some have linked the present opioid crisis to meddling by bureaucrats, administrations and politicians as an unattended consequence of the pain scale, opioid prescribing guidelines and patient satisfaction ratings (4). Furthermore, he did not note that increasing prescribing authority has been given to non-physicians with less education and clinical experience, e.g., unsupervised nurse practitioners in the Department of Veterans Affairs (5). Whether these non-physician clinicians will use drugs any more or less appropriately than physicians is unclear.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Dickson V. Gottlieb favors regulations that empower doctors while keeping FDA standards. Modern Healthcare. April 5, 2017. Available at: http://www.modernhealthcare.com/article/20170405/NEWS/170409965 (requires subscription, accessed 4/11/17).
2. Dodgson L. Trump has suggested vaccines cause autism — an idea that couldn't be more wrong. Business Insider. January 24, 2017. Available at: http://www.businessinsider.com/trump-vaccines-autism-wrong-2017-1 (accessed 4/11/17).
3. Downing NS, Zhang AD, Ross JS. Regulatory review of new therapeutic agents — FDA versus EMA, 2011–2015. N Engl J Med. 2017Apr 6;376:1386-7. [CrossRef] [PubMed]
4. Robbins RA. Pain scales and the opioid crisis. Southwest J Pulm Crit Care. 2017;14(3):119-22. [CrossRef]
5. Department of Veterans Affairs. VA grants full practice authority to advance practice registered nurses. December 14, 2016. Available at: https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2847 (accessed 4/11/17).

Cite as: Robbins RA. Gottlieb, the FDA and dumbing down medicine. Southwest J Pulm Crit Care. 2017;14(4):166-7. doi: https://doi.org/10.13175/swjpcc047-17 PDF 

Salary Surveys Report Declines in Pulmonologist, Allergist and Nurse Incomes

The 2016 Medscape Physician Compensation Report relates that orthopedic surgeons and cardiologists earn on average the most of those physicians surveyed ($443,000 and $410,000 annually) (1). Pulmonologists and critical care physicians fell in the middle of the spectrum of physician incomes ($281,000 and $306,000 respectively). Allergists were at the lower end ($205,000). Physicians in each category earned more or the same in 2016 than in 2015 except pulmonologists and allergists which were down compared to 2015 incomes of $296,000 ($15,000 decline) and $243,000 ($38,000 decline). As in years past, the survey is nonscientific. Physicians were asked to provide their annual compensation for patient care including salary, bonus, and profit sharing if employed, earnings after taxes, and deductible business expenses (but before income tax) if in private practice. 

The reason for the decrease is unclear but self-employed physicians (i.e., private practice) earned substantially more than employed physicians ($64,000 more for men, $44,000 more for women) (1). If more pulmonary physicians are becoming employed, this could be one reason for the decline in income. In 2016, the Medscape survey reported 59% of men and 72% of women were employed (1).

Nurses also made less on average in 2016. Incomes decreased from $79,000 annually for RNs in 2015 to $78,000 in 2016 (2). LPNs had a more substantial decrease from $46,000 to $43,000. RN’s not employed full time made the same hourly wage as those employed full time ($37/hour) and LPNs not employed full time actually made more per hour than those employed full time ($23 compared to $21/hour). The two most common reasons that nurses gave for decreased income was switching jobs or working less overtime.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Peckham C.  Medscape Physician Compensation Report 2016. Medscape. April 1, 2016. Available at: http://www.medscape.com/features/slideshow/compensation/2016/public/overview#page=1 (accessed 2/9/17).
2. Yox SB, Stokowski LA, McBride M, Berry E.  Medscape RN/LPN Salary Report 2016. Medscape. November 2, 2016. Available at: http://www.medscape.com/features/slideshow/nurse-salary-report-2016?src=WNL_specrep_nursesalary_170209_MSCPEDIT_usmds&uac=9273DT&impID=1286926&faf=1#page=1 (accessed 2/9/17).

Cite as: Robbins RA. Salary surveys report declines in pulmonologist, allergist and nurse incomes. Southwest J Pulm Crit Care. 2017;14(2):68. doi: https://doi.org/10.13175/swjpcc018-17 PDF 

CDC Releases Ventilator-Associated Events Criteria

A new term has been coined by the CDC, ventilator-associated events (VAEs) (1). In 2011, the CDC convened a working group composed of members of several stakeholder organizations to address the limitations of the definition of ventilator-associated pneumonia (VAP) definition (2). The organizations represented in the Working Group include: the Critical Care Societies Collaborative (the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society for Critical Care Medicine); the American Association for Respiratory Care; the Association of Professionals in Infection Control and Epidemiology; the Council of State and Territorial Epidemiologists; the Healthcare Infection Control Practices Advisory Committee’s Surveillance Working Group; the Infectious Diseases Society of America; and the Society for Healthcare Epidemiology of America.

VAEs are defined by an increase oxygen (>0.2 in FiO2) or positive end-expiratory pressure (PEEP) (≥3 cm H2O), after a previous stable baseline of at least 2 days. There are three definition tiers within the VAE algorithm: 1) Ventilator-Associated Condition (VAC); 2) Infection-related Ventilator-Associated Complication (IVAC); and 3) Possible VAP (PVAP) (2). There are also many other criteria to classify a VAE into the CDC’s tiers which are omitted for brevity. These definitions have been implemented in the National Healthcare Safety Network (NHSN) and according to the CDC are easily implemented, can make use of electronic health record systems to automate event detection, and identify events that are clinically important and associated with outcomes such as ICU and hospital length of stay and mortality. According to the CDC most VACs are due to pneumonia, ARDS, atelectasis, and pulmonary edema which “are significant clinical conditions that may be preventable”.

The CDC says "the VAE definition algorithm is for use in surveillance; it is not a clinical definition algorithm and is not intended for use in the clinical management of patients”. Based on the experience with the hospital acquired infections program this seems unlikely. What seems more likely is that hospitals will be measured on VAE rates with financial or public relations consequences shortly to follow.

The best evidence suggests that the VAE concept is not useful for guiding clinical decisions in the moment (1). Its performance characteristics as a screening test appear to be terrible, with poor sensitivity (~32%) for detecting VAP in the one of the only prospective studies. This is because clinically insignificant fluctuations in oxygenation/PEEP status are often recorded as VAEs, diluting signal with noise. Numerous retrospective reviews supporting the VAE concept listed on CDC's website strongly link VAEs with morbidity and mortality. However, these observations could be true of many events and may be very different from showing that a prospective (intervention-based) approach is helpful. Pulmonologist Dr. Richard Wunderink from Northwestern commented that “the central hypothesis of the VAE criteria—that VAP and other potentially preventable complications of mechanical ventilation can consistently be detected by worsening gas exchange—is clearly not true”.

The problems with VAE appear much the same as the problems with VAP. Neither is strongly evidence-based and neither has been shown to be helpful in patient care. Furthermore, it might be possible to “game” the numbers by adjusting PEEP, expiratory time, and FiO2 within the defined limits.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Pulm/CCM. What are ventilator-associated events (and why should you care)? Available at: http://pulmccm.org/main/2014/review-articles/ventilator-associated-events-care/?utm_source=Email+Updates+from+PulmCCM&utm_campaign=b1ee59472e-USP_mar_24_2014&utm_medium=email&utm_term=0_e9d9e09c7c-b1ee59472e-312029025 (accessed 1/24/17).
2. CDC. Ventilator-associated event (VAE). January 2017. Available at: https://www.cdc.gov/nhsn/pdfs/pscManual/10-VAE_FINAL.pdf (accessed 1/24/17).

Cite as: Robbins RA. CDC releases ventilator-associated events criteria. Southwest J Pulm Crit Care. 2017:14(1):40-1. doi: https://doi.org/10.13175/swjpcc009-17 PDF 

Medicare Bundled Payment Initiative Did Not Reduce COPD Readmissions

Implementation of the Medicare bundled payments for care improvement initiative has failed to cut readmission rates following hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD), according to a study published in the Annals of the American Thoracic Society (1).

Bhatt and colleagues (1) from the University of Alabama at Birmingham enrolled 78 consecutive Medicare patients in 2014 compared to 109 patients in the historic group from 2012. They found that patients from 2014 were more likely to have compliance with the bundled care payment requirements. However, there was no difference in all-cause readmission rates at 30 days (15.4% vs.17.4%; p=.711), and 90 days (26.9% vs 33.9%; p=.306).

The bundled care requirements include regular follow-up phone calls, pneumococcal and influenza vaccines, home health care, durable medical equipment, pulmonary rehabilitation, and to attend pulmonary clinic which were significantly increased after implementation of the bundled care requirements. However, these COPD interventions were implemented despite having not been shown to decrease COPD readmissions (2). Furthermore, Shah et al. (3) have reported that only 27.6% of COPD hospital readmissions are for COPD making these COPD interventions even less likely to reduce readmissions.

References

1. Bhatt SP, Wells JM, Iyer AS, et al. Results of a Medicare Bundled Payments for Care Improvement Initiative for COPD Readmissions. Ann Am Thorac Soc. 2016 Dec 22 [Epub ahead of print]. [CrossRef] [PubMed]
2. Robbins RA, Wesselius LJ. Reducing readmissions after a COPD exacerbation: a brief review. Southwest J Pulm Crit Care. 2015;11(1):19-24. [CrossRef]
3. Shah T, Churpek MM, Coca Perraillon M, Konetzka RT. Understanding why patients with COPD get readmitted: a large national study to delineate the medicare population for the readmissions penalty expansion. Chest. 2015;147(5):1219-26. [CrossRef] [PubMed]

Cite as: Robbins RA. Medicare bundled payment initiative did not reduce COPD readmissions. Southwest J Pulm Crit Care. 2016;14(1):26. doi: https://doi.org/10.13175/swjpcc104-17 PDF

Younger Smokers Continue to Smoke as Adults: Implications for Raising the Smoking Age to 21

A review article published in Pediatrics assesses the evidence that smoking is particularly harmful the younger a smoker begins (1). Not only do youths tend to accumulate more pack-years but they have more difficulty quitting. The recent shift in smoking trends from tobacco cigarettes to e-cigarettes may not be helpful since both contain the addictive component, nicotine. Although e-cigarettes are marketed as a smoking cessation tool, there is no strong evidence to support these claims, the authors report.

"I think most people realize nicotine is addictive, but I don't know if there's an understanding of just how addictive it is – particularly for youths," said Lorena M. Siqueira, MD, MSPH, lead author of the report (2).

Evidence shows that the earlier in life a person is exposed to nicotine, the more likely they will consume greater quantities and the less likely they will be able to quit (1,2). The vast majority of tobacco-dependent adults (>99%) started smoking before age 26 years. Approximately two thirds of children who smoke in sixth grade, become regular smokers as adults. In comparison, 46% of youth who begin smoking in the eleventh grade go on to become regular smokers as adults. Youths require more attempts to quit smoking before being successful compared to adults. Only about 4% of smokers aged 12 to 19 years have been shown to successfully quit each year.

"There are now seven published longitudinal studies showing that youths who initiate smoking with e-cigarettes are about three times more likely to be smoking conventional cigarettes a year later," said Stanton A. Glantz, PhD, of the Center for Tobacco Research and Education at the University of California and a coauthor of the review (2). Instead of making quitting easier, e-cigarettes make it harder, Dr. Glantz added.

An Institute of Medicine report notes that the age of initiation of smoking is critical (3). The report estimates that that raising the minimum age for the sale of tobacco products to 21 will, over time, reduce the smoking rate by about 12 percent. This reduction is estimated to result in reducing smoking-related deaths by 10 percent, which translates into 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost (3).

These data may prove valuable in evaluating the potential health impact of this legislation.  California became the second state to raise the tobacco sale age to 21 in 2016, joining Hawaii (3). At least 210 localities have raised the tobacco age to 21, including New York City, Chicago, Boston, Cleveland, Kansas City and Cottonwood, Arizona. Statewide legislation to do so is being considered in several other states and will probably be introduced in Arizona during this legislative session.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Siqueira LM; Committee on Substance Use and Prevention. Nicotine and tobacco as substances of abuse in children and adolescents. Pediatrics. 2017 Jan;139(1):e20163436. [CrossRef] [PubMed]
2. Melville NA. Nicotine's highly addictive impact on youth underestimated. Medscape. January 3, 2017. Available at: http://www.medscape.com/viewarticle/873955?nlid=111769_2863&src=wnl_dne_170104_mscpedit&uac=9273DT&impID=1266832&faf=1 (accessed 1/5/17).
3. Campaign for Tobacco Free Kids. Increasing the minimum legal sale age for tobacco products to 21. Available at: https://www.tobaccofreekids.org/research/factsheets/pdf/0376.pdf (accessed 1/5/17).

Cite as: Robbins RA. Younger smokers continue to smoke as adults: implications for raising the smoking age to 21. Southwest J Pulm Crit Care. 2017;14(1):24-5. doi: https://doi.org/10.13175/swjpcc002-17 PDF

Most Drug Overdose Deaths from Nonprescription Opioids

The Centers for Disease Control (CDC) is reporting in Morbidity and Mortality Weekly that the number of people dying from an opioid overdose rose 15.5% from 2014 to 2015, but the increase had little to do with prescription painkillers such as oxycodone or hydrocodone (1). Roughly 52,000 people died from drug overdoses in 2015 and of those deaths 33,091 involved an opioid. The increases in “death rates were driven by synthetic opioids other than methadone (72.2%), most likely illicitly-manufactured fentanyl, and heroin (20.6%)”. Deaths from methadone, which is usually prescribed by physicians, decreased 9.1%.

The largest increase in deaths occurred in the South and Northeast with 3% and 24% increases in deaths from synthetic opioids from 2014 to 2015. In the Midwest and West, there were more modest 17% and 9% increases during the same period. States in the Southwest with “good” to “excellent” reporting included Colorado, Nevada, and New Mexico which showed 33%, 14% and 30% decreases respectively.

Earlier this year, CDC Director Tom Frieden, MD, MPH, said "The prescription overdose epidemic is doctor-driven…It can be reversed in part by doctors' actions” (2). That characterization has rung in some physicians' ears as blame for the entire opioid crisis, including deaths from heroin and illegal fentanyl. The data in the present article suggests that characterization is inaccurate and that efforts by a number of State Boards to limit physician opioid prescribing may be marginally or non-effective in reducing overdose deaths.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. 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]
2. Lowes R. CDC issues opioid guidelines for 'doctor-driven' epidemic. Medscape. March 15, 2016. Available at: http://www.medscape.com/viewarticle/860452 (accessed 12/21/16).

Cite as: Robbins RA. Most drug overdose deaths from nonprescription opioids. Southwest J Pulm Crit Care. 2016;13(6):316. doi: https://doi.org/10.13175/swjpcc145-16 PDF

Lawsuits Allege Price Fixing by Generic Drug Makers

Two years after high generic drug prices became a public controversy, Reuters is reporting that 20 states filed a lawsuit Thursday against Mylan, Teva Pharmaceuticals and four other generic drug makers (1). The suit alleges the companies conspired to fix prices or allocated markets to prop up prices. The civil lawsuit, led by antitrust investigators in Connecticut, comes one day after the U.S. Department of Justice filed criminal charges against two former executives of the generic drug maker, Heritage. The states attorneys general asked the court to order the companies to disgorge ill-gotten gains, which were not defined, pay attorneys' fees and stop collusion. Of the states in the Southwest only Nevada is participating in the lawsuit.

The cases are part of a broader generic drug pricing probe that remains under way at the state and federal level, as well as in the U.S. Congress. In 2014, media reports of sharply rising drug prices led to Congressional hearings. "We believe that this is the tip of the iceberg," Connecticut Attorney General George Jepsen told Reuters in an interview. "Price fixing in the generic industry is widespread and pervasive, and it involves many other drugs and a number of other companies."

Both former Heritage CEO Jeffrey Glazer and former Heritage Vice President of Commercial Operations Jason Malek are expected to plead guilty. According to Reuters, it is typical for the Justice Department to file one lawsuit about an ongoing issue and use evidence from those defendants to build subsequent cases against others. Several companies have publicly disclosed receiving subpoenas from the Justice Department related to generic drug pricing including Mylan, Allergan, Lannett, Impax, Par, Sun and Mayne.

The drugs involved in the Justice Department lawsuit include two older drugs, doxycycline hyclate and glyburide. Doxycycline rose from $20 for 500 tablets to $1,849 between October 2013 and May 2014.

Richard A. Robbins, MD

Editor, SWJPCC

Reference

1. Bartz D, Lynch SN. U.S. states sue Mylan, Teva, others for fixing drug prices. Reuters. December 16, 2016. Available at: http://www.reuters.com/article/us-usa-drugpricing-idUSKBN14420C (accessed 12/17/16).

Cite as: Robbins RA. Lawsuits allege price fixing by generic drug makers. Southwest J Pulm Crit Care. 2016;13(6):313. doi: https://doi.org/10.13175/swjpcc142-16 PDF 

Knox Named Phoenix Associate Dean of Faculty Affairs

Dr. Kenneth S. Knox

The University of Arizona College of Medicine-Phoenix has announced the appointment of nationally recognized physician-scientist Kenneth S. Knox, MD, as the associate dean of faculty affairs. Dr. Knox who has been at the University of Arizona-Tucson since 2008, will oversee the Faculty Affairs Office whose charge is to promote an engaged, diverse community of faculty and scholars that sustain a culture of engagement, professionalism and inclusion. He also will serve as director of research at the Banner Lung Institute.

Dr. Knox is a pulmonologist known for his research in sarcoidosis, fungal diagnostics and immunologic lung disease. His work includes developing treatments for HIV, AIDS and valley fever. The division chief of Pulmonary, Allergy, Critical Care and Sleep Medicine in Tucson, Knox was responsible for dramatic growth. His accomplishments include increasing the number of clinical and basic science faculty from five to 30 and fellowship trainings from six to 20, rekindling the sleep program, establishing a section of allergy and revamping the teaching model in the intensive care unit. He also served as vice chair for education in the Department of Medicine.

Dr. Knox is co-principal investigator on the Arizona portion of a $9.7 million National Institutes of Health-funded clinical trial to test the use of fluconazole as an early treatment for valley fever. Additional grants for more than $6 million have been submitted for efforts to develop a valley fever vaccine. He has received continuous funding since 2001 for his research on the use of bronchoalveolar lavage for immunodiagnostics and lung immunity. He is NIH-funded to perform longitudinal translational studies correlating immunological findings and the lung microbiome with clinical disease in HIV as his lab seeks to understand the role of pulmonary inflammation in the development of HIV-related lung diseases.

A native of Youngstown, Ohio, Dr. Knox graduated cum laude with a bachelor’s degree in microbiology from Miami University in Oxford, Ohio. He completed his medical degree and residency training in Internal Medicine at Ohio State University and a fellowship in Pulmonary/Critical Care/Sleep Medicine at Indiana University where he remained on faculty for eight years, serving as educational director and director of the immunologic lung disease program before coming to Tucson. Dr. Knox is an associate editor of the SWJPCC and has edited the highly successful “Medical Image of the Week” section since its inception.

Richard A. Robbins, MD
Editor, SWJPCC

Cite as: Robbins RA. Knox named Phoenix associate dean of faculty affairs. Southwest J Pulm Crit Care. 2016;13(6):311-2. doi: https://doi.org/10.13175/swjpcc141-16 PDF

Rating the VA Hospitals

USA Today is listing the star rating system for the Department of Veterans Affairs medical centers based on the quality of care. The website has a link that allows searches for individual medical centers. The ratings have been done for years but the VA has refused to release the ratings saying they are meant for internal use only.

The top-rated hospitals received a 5 and the lowest a 1. According to the star ratings the best hospitals are in the Northeast and upper Midwest.  In the Southwest the ratings are not so good with the top-rated hospital Palo Alto and the lowest a tie between Phoenix and Albuquerque (Table 1).

Table 1. Southwest VA medical center star compare VA hospitals ratings.

Quality can be difficult to measure and it is not clear what metrics were used in the VA ratings. For this reason, the VA star ratings were compared to another hospital rating service Compare VA Hospitals (2). This scale uses a 1-100 scale with 100 being the best. In this scale the Palo Alto turned out to be the best in the country with Phoenix and the VA being more in the middle of the pack. There was no correlation between the ratings (r=0.2386, p>0.05). This is consistent with a previous publication in the SWJPCC which showed no or little correlation between the various hospital ratings.

The lack of correlation between rankings and not knowing the metrics which determine the rankings suggest that the VA is right, the rankings should remain for an internal use rather than adding to the confusion already generated by the various hospital rankings.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Slack D. Exclusive: Internal documents detail secret VA quality ratings. USA Today. December 7, 2016. Available at: http://www.usatoday.com/story/news/politics/2016/12/07/internal-report-details-secret-quality-ratings-veterans/94811922/ (accessed 12/14/16).
2. Health Grove by Graphiq. Compare VA hospitals. Available at: http://va-hospitals.healthgrove.com/ (accessed 12/14/16).
3. Robbins RA, Gerkin RD. A comparison between hospital rankings and outcomes data. Southwest J Pulm Crit Care. 2013;7(3):196-203. [CrossRef]

Cite as: Robbins RA. Rating the VA hospitals. Southwest J Pulm Crit Care. 2016;13(6):309-10. doi: https://doi.org/10.13175/swjpcc138-16 PDF 

Garcia Resigns as Arizona University VP

Dr. Joe G.N. "Skip" Garcia resigned his administrative duties as senior vice president for health sciences at the University of Arizona. Garcia said he would devote his full attention as a professor at the UA College of Medicine-Tucson according to the Arizona Republic (1). "After much thought and reflection, I have decided that the time is right for me to take a step back and focus on my continually growing research commitments," Garcia said. "Please know that this decision was an exceptionally difficult one and not reached lightly, and that I am humbled by all of your support during my time as senior vice president."

Garcia was hired in 2013 to oversee the university's medical schools in Phoenix and Tucson, as well as the schools of nursing, pharmacy and public health. Shortly after Garcia was hired, he reorganized UA health sciences, recruited a roster of academics and tightened oversight of the Phoenix medical school. However, after Dr. Stuart Flynn, the Phoenix medical school's longtime dean, and most of his leadership team resigned to join the staff of a newly created medical school in Fort Worth, Texas, Garcia faced increasing scrutiny and criticism. The departures prompted the Arizona Medical Association, a physicians' organization with 4,000 members, to ask the Arizona Board of Regents to interview the departed leaders as part of an investigation of the school's management.

In August, the regents' health affairs committee held public hearings in Tucson and Phoenix to gather input from medical-school stakeholders. The regents also hired an independent consultant to evaluate concerns about the two medical schools. The consultant delivered a report to the regents, who concluded in October following a closed-door meeting that no further action was needed. Even though the Board of Regents spent $179,653 in public funds on the report, the regents have refused to provide a copy of the report to the public, citing attorney-client privilege and work-product protections.

UA President Ann Weaver Hart who previously announced she would leave the president’s post in 2018 praised Garcia's track record. "The work accomplished by Dr. Skip Garcia in just three short years as the senior vice president for health sciences has had a profound impact on the future of the College of Medicine-Tucson, the College of Medicine-Phoenix, and the Colleges of Pharmacy, Nursing and Public Health at the University of Arizona," Hart said in a statement released by the university.

Garcia is a pulmonary physician whose research focused on the genetic basis of lung disease and the prevention and treatment of inflammatory lung injury (2). He had previously served in academic positions at the University of Texas Health Center at Tyler, Indiana University School of Medicine, Johns Hopkins University School of Medicine, the University of Chicago, and the University of Illinois at Chicago before coming to Arizona. He has been continuously funded by the NIH since 1988 and has authored or co-authored more than 400 peer-reviewed publications and over 35 book chapters. In 2016, Dr. Garcia received the Trudeau Medal from the American Thoracic Society in recognition of his lifelong major contributions to the prevention, diagnosis and treatment of lung disease through leadership in research, education and clinical care.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Alltucker K. Joe 'Skip' Garcia, the embattled University of Arizona med-school chief, quits his VP post. Arizona Republic. December 8, 2016. Available at: http://www.azcentral.com/story/news/local/arizona/2016/12/08/embattled-ua-med-school-chief-quits-vp-post-to-return-to-teaching-and-research/95156932/ (accessed 12/9/16).
2. The University of Arizona Health Sciences. Joe G. N. “Skip” Garcia, MD biography. Available at: http://uahs.arizona.edu/senior-vice-president-health-sciences/joe-garcia-bio (accessed 12/9/16).

Cite as: Robbins RA. Garcia resigns as Arizona university VP. Southwest J Pulm Crit Care. 2016;13(6):305-6. doi: https://doi.org/10.13175/swjpcc137-16 PDF

Combination Influenza Therapy with Clarithromycin-Naproxen-Oseltamivir Superior to Oseltamivir Alone

As we enter the influenza season, Ivan et al. (1) are reporting in Chest that oseltamivir-clarithromycin-naproxen combination for treatment of serious influenza results in reduced mortality, less frequent ICU admission, and shorter hospital-stay compared to oseltamivir alone. From February to April 2015, the authors conducted a prospective open-label randomized-controlled trial. Adult patients hospitalized for A(H3N2) influenza were randomly assigned to a 2-day combination of clarithromycin 500mg, naproxen 200mg and oseltamivir 75mg twice daily, followed by 3 days of oseltamivir; or oseltamivir 75mg twice daily for 5 days as control (1:1). Among the 217 influenza A(H3N2) patients enrolled, 107 were randomly assigned to the combination treatment. Ten patients succumbed during the 30-day follow-up. The combination treatment was associated with lower 30-day mortality (p=0.01), less frequent ICU/HDU admission (p<0.001), and shorter hospital-stay (p<0.0001). Multivariate analysis showed that combination treatment was the only independent factor associated with lower 30-day mortality (p=0.04). The authors advised further study on the antiviral and immunomodulatory effects of this combination treatment, but those caring for severely ill patients with influenza might wish to consider combination therapy since all these drugs are available.

Richard A. Robbins, MD

Editor, SWJPCC

Reference

1. Hung IF, To KK, Chan JF, et al. Efficacy of clarithromycin-naproxen-oseltamivir combination in the treatment of patients hospitalized for influenza A(H3N2) infection: an open-label, randomized controlled, phase 2b/3 trial. Chest. 2016 Nov 21. [Epub ahead of print] [CrossRef] [PubMed]

Cite as: Robbins RA. Combination influenza therapy with clarithromycin-naproxen-oseltamivir superior to oseltamivir alone. Southwest J Pulm Crit Care. 2016;13(6):302. doi: https://doi.org/10.13175/swjpcc136-16 PDF