Dear Stewardship People: Can't We All Just Get Along?

The following post is by Dr. Jasmine Marcelin from University of Nebraska Medical Center.

Teams should work together, not compete

I am an Antimicrobial Stewardship Leader. As the Associate Medical Director of Antimicrobial Stewardship at my institution, I work with another physician (Antimicrobial Stewardship Medical Director) and an ID-trained Antimicrobial Stewardship PharmD. We have a great setup, share audit and feedback responsibilities, and have different interests clinically and for research, which makes it great to divide tasks for initiatives. I focus on outpatient ASP and SSI prophylaxis, PharmD on AU initiatives and cost, and other MD on CDI. We cover for each other, review and co-author each other’s grants, papers and presentations, and present education to various hospital groups together. We work well as a TEAM.

Teams are great things. Nothing meaningful can be accomplished when working alone and in silos. Some ASP teams also include nurses, infection preventionists, advanced practice providers and laboratory personnel, and the specific ASP leadership model will depend on the resources at an individual hospital. Each of these groups bring a very specific and unique skillset to the ASP team. Why is it then, that we seem to find ourselves in the midst of an MD-PharmD power struggle?

In February 2018, the IDSA, SHEA and PIDS released a statement that ID physicians should be leading the way in Antimicrobial Stewardship. This statement shared the unique skillset that ID doctors bring to the ASP table, including years of clinical training in the diagnosis and management of infections. This position paper reads as a statement of support from our societies demonstrating our value to hospital leadership. “Hey C-suite, we have these requirements for ASP, and it says you need a leader that has ID expertise. We literally went to school for ID, and we already work for you, so here are these reasons why you should actually PAY us for what we know how to do well, instead of asking us to do it for free while we are on hospital consults?” The position paper did not say, “ID physicians are better than Pharmacists at ASP”. In fact, the document went on to state, “An ASP should also include at least 1 pharmacist, ideally with subspecialty training in ID. While ID physicians and pharmacists may often have the most central roles in an ASP, all members of the ASP team, including microbiologists and infection preventionists, provide distinct skills of great value.”

Notwithstanding the explicit acknowledgement of the value of the team model of ASP, perhaps the conclusion “ID physicians are well equipped to lead multidisciplinary ASPs given their training, expertise, and experience” offended some of our pharmacist colleagues. The publication was followed by a letter to the editor in May 2018 that stated, “In identifying ID physicians as uniquely qualified for these functions, the paper fails to acknowledge the essential leadership and skill set of ID pharmacists in stewardship”. The letter then concludes, “Best care for patients is achieved through multi-disciplinary stewardship where pharmacist leaders are key to success”. This letter led to a flurry of social media posts misguidedly comparing the “value” of ASP physicians vs pharmacists. A real world study of ID fellow experiences with ASP shared that fellows looked to “pharmacists, not ID physician leaders as primary resources for antibiotic teaching”, and there was a social media frenzy that pharmacists should lead ASP, not ID physicians.

Seriously?

People, this is not a competition! Pharmacists are uniquely equipped to lead ASP because of their special training in the PK/PD of antibiotics, adverse drug effects, drug-drug interactions, and costs. ID physicians are uniquely equipped to lead ASP because of their special training in direct patient care, being boots on the ground as well as eyes in the sky, and can always use the “peer” card when approaching rogue prescribers. The thing is, we are BOTH essential for a successful ASP, and organizations should strive to fund BOTH, because we complement each other. The thing is, we ID physicians have had a long struggle for institutional acknowledgement and respect of our invaluable contribution to patient care. In our fight for recognition, perhaps we have failed to let our pharmacist colleagues know that we appreciate what they do, and that our work is enriched by their contributions. Perhaps we should be intentional to thank our pharmacists for this contribution so that they do not feel we are trying to usurp them and dismiss their value.

Physicians acknowledge and applaud pharmacists’ tireless contribution and value added to the ASP team. We support you in leadership roles. When we say we as physicians are suited to be ASP leaders, it is because we are. It does not diminish your role as co-leaders in a multidisciplinary team; neither does your teaching of antibiotics to ID fellows diminish our role as clinical experts to trainees. Can’t we all just get along? Time to put this superfluous competition to rest and support each other’s value, for the patients’ sake!

Work Attire

I'm a creature of habit. My first activity every day is to read the New York Times. Depending on my schedule, some days I read more articles than others. This week I was away at a conference and found myself with some early morning extra time before the first meeting session, so I delved into the Arts section. I began to read the first article: Women of the Philharmonic Can Play It All. Just Not in Pants. It begins:

Women can wear pants at the Oscars, the Tony Awards and state dinners. They can wear pants while graduating from the Naval Academy, figure skating at the Olympics and running for president. They can wear them at just about any workplace in America.

But when the women of the New York Philharmonic walked on stage at David Geffen Hall recently to play Mozart and Tchaikovsky, they all wore floor-length black skirts or gowns. And they’re required to: The Philharmonic, alone among the nation’s 20 largest orchestras, does not allow women to wear pants for formal evening concerts.

The article goes on to discuss some of the unique problems that this dress code presents for musicians, such as the difficulties encountered when playing large stringed instruments, and one woman who plays the English horn recounted how the folds of her long dress got caught in the keys of her instrument during a critical passage.

I found the article interesting, but as an outsider to the music world simply thought that it's another example of how the frivolous often eclipses the big issues in life. Then I came to this quote from a female violinist, “One thing is really clear: People in the orchestra want to remain dressy. It’s important that we look like we care. That is sending a message. We put so much into the preparation of our programs that, yes, we need to look good as well.” At this point the light bulb turned on and all of the dots connected for me: here is the musical equivalent of the judgmental doctors who think that all doctors must wear white coats. And then I knew that the pathologic manifestations of professionalism are not limited to medicine.

Well at least in medicine our clothing police aren't sexist, I thought. But then I remembered that it was only three years ago that Mayo Clinic dropped its pantyhose requirement for women physicians. And in a recent essay, Roshini Pinto-Powell, the Associate Dean of Student Affairs at the Geisel School of Medicine at Dartmouth, writes about how professionalism forces nearly every woman interviewing for medical school or residency to follow rigid rules of dress that makes her look like a penguin. Maybe we aren't ahead of the New York Philharmonic after all.

You might think that in medicine we've overcome ageism and classism in our sartorial expectations. However, it's worth pointing out that the Department of Medicine at Johns Hopkins is just now dropping the requirement of short white coats for interns. In the video attached to this article about that in the Baltimore Sun, the Internal Medicine Chief Residents express their sorrow at the loss of the short coat. Really? In 2018? Yet almost everywhere medical students are still relegated to the short coat. How about we just get rid of them all given that hierarchy with its associated authority gradient in medicine makes it much less likely that a short-coated person will speak up when she sees a long-coated person about to make an error?

On a happy note, there are always positive deviants, and I want to point out two of them. In the musical world, there is Seiji Ozawa, who was the conductor of the Boston Symphony for three decades. Instead of wearing the customary white tie and tails, he boldly wore a white turtleneck and tails, a look that became his trademark. The other is Jorge Mario Bergolio. As he was about to step out onto the balcony in St. Peter's Square to be introduced to the world as Francis, he was handed the mozzetta, a short red velvet cape trimmed in ermine worn only by the pope. He declined this heirarchical symbol despite the professionalistic expectations of his peers in the College of Cardinals.

I remain convinced that we need to assess work attire using simple humanistic criteria. Your clothes should be clean, comfortable, functional, and safe. No need for white coats. No long gowns. No mozzetta. No penguin suits. And the only people that will care are those who remain blinded by professionalism.

Safer.

AHRQ.

Pushing the Needle on Influenza Vaccination

Despite continued debates about the use of influenza vaccination mandates in healthcare settings (see prior discussions just on this blog here, here, here, here, and here), facilities continue to move toward implementing some form of ‘mandatory’ program to ensure sustained high levels of influenza vaccination coverage among their staff.  A new article published in JAMA Network Open documents this increase with an update to a multi-year survey project asking about facility infection prevention practices.  I use the word ‘mandatory’ in quotes above on purpose because, as I detailed in an accompanying editorial, the definition of a mandate, when it comes to vaccination policy, is not standardized.

“…Most importantly, it does not appear that mandate was defined. Among respondents who reported having a vaccination mandate, only 74% reported having penalties for noncompliance and 13% allowed declination without a specified reason. Of those reporting no mandate, 21% reported penalties for noncompliance with hospital policy on influenza vaccination and 41% reported requirements for wearing masks if unvaccinated. An article in a bioethics journal⁵ offers the following criteria for using the term mandate in this setting: limiting acceptable reasons for refusal, penalizing nonparticipation, and enforcing these expectations. By these criteria, it is not clear how many programs described in this survey should appropriately be referred to as mandatory—the number may be higher or lower than that reported, although an increase over time seems likely.”

The authors of the survey article also note that the VA is moving to a mandatory vaccine or mask policy this year, which will again increase the number of facilities using some type of mandate.  Hopefully, the VHA will take advantage of their more comprehensive healthcare delivery system to evaluate the impact of the program on both inpatient AND outpatient influenza among their patients, something that has been a persistent gap in prior reports.

ALSO, did you appreciate how easy it was to click the link and access the whole article?  Note that the article and the accompanying editorial are in JAMA Network Open, a new, fully open access journal “in which all content is made freely available to all readers immediately on publication. ….[they] will publish online only, every Friday.” Read more here.

How I chose my doctor

Four years ago after moving back to Iowa City, I needed to find a new primary care doctor. I went to the University’s website and scanned the list of general internists. There I noted a physician that I had known when she was a medical student during my prior stint at the University of Iowa twenty years earlier. She had been an amazing medical student--very bright, hardworking, conscientious, and intellectually curious. My guess was that she now was an amazing internist. I asked a few colleagues about her and the responses were consistent: a superb clinician, an internist’s internist. Exactly what I was looking for.

I scheduled a new patient visit with Dr. B. Was I ever impressed! No stone was left unturned. She didn’t treat me like a doctor (for non-medical readers, that's a good thing). She took a complete history, including asking me if I ever used IV drugs. She took a sexual history. She then performed a complete exam, including genital and rectal exams. I note this as sometimes doctors skip these parts of the H&P given the somewhat awkward situation when they know the patient (another doctor) personally. At the end of the visit, I recall telling her that the encounter should have been videotaped for use as an exemplar for students and residents. When I arrived back to my office, I sent a note to the Chair of Internal Medicine to apprise him of her superb care. He wrote me back: “Yes, Dr. B is the crown jewel of the Department of Internal Medicine.”

Now let’s leave my story for a minute and examine a new study in the BMJ from the University of Michigan on patient preference for physician attire. This is a survey of a convenience sample of 4,000 patients at 10 US academic medical centers. It included both inpatients and outpatients, and used the design of many previous studies, showing patients the same doctor dressed seven different ways (scrubs, formal with white coat, etc.). After viewing the photographs, patients were questioned as to their preference of physician based on attire, as well as asked to rate the physician in the areas of knowledge, trust, care, approachability, and comfort.

The survey is well-designed and well-executed. I’ll let you review the paper if you want to know the results, since I don’t think the results have much validity, don’t merit much discussion, and I’ve blogged about these types of studies, previously (here, here, here, and here). I’m much more interested in why such studies are conducted, the biases they may represent, whether the researchers have an underlying agenda, the utility of the results, and how these studies are pathologic manifestations of professionalism.

Back to my story. Never once, before, during or after my clinic visit with Dr B, did I for a millisecond think about how she would be or was dressed. Granted, I’m not the typical patient as I have insider knowledge regarding doctors that the average patient does not. Even still, all patients want an authentically kind, compassionate, competent doctor who listens intently, and makes access to them easy. While they may have a preference for physician attire, when placed in context (as shown in a previous study), appearance is the least important patient satisfier. When appearance is further studied, attire is the least important characteristic, with hygiene and grooming taking precedence.

To ask patients to infer characteristics such as knowledge and trust on the basis of clothing is ludicrous on its face, and an insult to the study participants. "I chose the doctor with the beautiful tie," said no patient ever. I dislike this study for the same reasons that I dislike the tactics of Disney service excellence and Press-Ganey patient satisfaction initiatives. The common theme is that you can and should manipulate patients' perceptions without changing reality. Per the Michigan study, a white coat makes the doctor look more caring, but all of us know that a jerk in a white coat is still a jerk. If the doctor sits down while talking to a patient, the patient will perceive that they stayed in their room longer. How about sitting down because it makes the patient more comfortable?

The authors argue for patient-centered care and that “attire may be an important, modifiable component of patient care.” How does this study help us to provide patient-centered care since no matter how the data were sliced there was always a sizable fraction (often nearly half) of patients that didn’t agree with the majority opinion? Does this mean we should ask each patient which of the seven attire modes they would prefer before entering the exam room?

Lastly, I don’t think this study is really about what patients think of how doctors dress. Underneath it all, it’s a study about what some doctors think about how other doctors dress. And this is the ugly side of professionalism. Imagine a study where physicians are surveyed on the attire of nurses or carpenters. I think most people would find that creepy. Don’t most of us think that judging people on the basis of how they dress is superficial and somewhat creepy? And the test of whether this is about professionalism is to remove the occupational label in the survey. If patients were told to assess the attire of other people (not doctors) what would be the study implications? If we look at attire through the lens of humanism rather than professionalism, then what matters is simply that your work clothes are clean, comfortable, functional, and safe.

My advice to the Michigan doctors is this: take good care of your patients and they will love you, white coats and all.

New evidence supports high-dose influenza vaccines

People older than 65 years are at particularly high risk for influenza-related medical complications including hospitalizations and death. In 2009, the FDA approved a trivalent inactivated vaccine with four-times the hemagglutinin antigen per strain, which was thought to improve immune response in seniors.

Background data has largely supported high-dose vaccination among seniors. In a multicenter, randomized controlled trial of high vs standard dose vaccine that included almost 32,000 patients during 2011/12 and 2012/13, 1.4% of high-dose and 1.9% standard-dose patients had an influenza-confirmed influenza-like illness, resulting in a relative efficacy of 24%. Adverse events were slightly, but significantly lower in the high-dose group but 3 high-dose recipients had serious vaccine-related events (which all resolved) vs none in the standard-dose group. A very large Medicare study during 2012/13 and 2013/14 reported similar benefits but only during 2012/13 when H3N2 was more common. Perhaps it is difficult to measure a benefit during more mild, H1N1 seasons? There have been other studies supporting the effectiveness and cost-effectiveness (at least during the 2011/12 and 2012/13 H3N2 seasons) of high-dose vaccine.

One of the larger groups of seniors in the US are patients in the Veterans Health Administration (VHA) system, so it makes sense to measure the benefits of high-dose vaccine using the VHA integrated EMR. In the June 1st JID, authors reported results of a large (industry-funded) retrospective cohort study completed using data from the 2015/16 influenza season (an H1N1 year) that included seniors with at least one inpatient or outpatient visit during the prior year (2014/15). The primary outcome was any hospitalization for pneumonia or influenza. The study used a number of nice methods to adjust for confounding including matching on baseline characteristics and the Care Assessment Need (CAN) score, that is a proxy for frailty. They also adjusted for residual confounding using the prior event rate ratio (PERR) method, which you can read more about here. Basically, PERR adjusts for outcome rates in the baseline period (before vaccination) by dividing the relative rate post-vaccination by the relative rate pre-vaccination (in the baseline period).

The final cohort (before matching) included 104,965 standard-dose and 125,776 high-dose recipients during the 2015/16  influenza season. The matched cohort had 49,091 standard-dose and 24,682  high-dose patients. Using the unmatched and matched cohorts, and using the PERR method with each, the relative vaccine effectiveness of high-dose influenza vaccine was 23% and 25%, respectively. This suggests that high-dose vaccine was effective in preventing influenza or pneumonia-associated hospitalizations among VHA patients.

These results are encouraging since they were from a more mild H1N1 season. Even more encouraging, the authors plan to automate the data extraction process and report vaccine effectiveness within 3 months of the end of each influenza season. But one note of caution, having a high-dose vaccine that is 25% more effective isn't a huge improvement, since influenza vaccines in general aren't very effective. So high-dose influenza vaccine is a small step in the right direction - but more research and new influenza vaccines are needed.

Upon Further Review: Reexamining the Illinois MRSA Active Surveillance Mandate

“Thinking without the positing of categories and concepts in general would be as impossible as breathing in a vacuum” – Albert Einstein (1949)

A couple weeks ago, Scott highlighted a study in CID by Lin et al. that sought to estimate the benefits of the 2007 Illinois state-wide mandate of MRSA active surveillance cultures in ICU settings. The post was titled “Good Intentions Does not Always Mean Good Policy” and concluded “There may be many reasons the hospitals in Illinois overall are seeing an estimated 30% decrease in their hospital-onset MRSA BSI (as most states are) since the 2010 NHSN baseline, but admission screening isn’t one of them.” 

I would like to list several reasons why I think we should reconsider the study authors’ conclusions. And if you skip to the end, you will read why I think this study might make more valid conclusions about the lack of benefits of CHG bathing.

Let’s start with validity from Shadish (2001) et al: “We use the term validity to refer to the proximate truth of an inference. When we say something is valid, we make a judgement about the extent to which relevant evidence supports that inference as being true of correct.” Cook and Campbell (1979) outlined four components of validity: statistical conclusion validity, internal validity, construct validity and external validity. I’ve written about their validity typology here, if you’re interested. 

Now let’s review the Illinois study methods. They included data from 25 ICUs and completed eight, one-day point prevalence surveys AFTER the mandate was initiated (twice annually 2008-2011 and annually in 2012 and 2013). There was no concurrent control group.

Thus, this quasi-experimental study design has very low internal validity. It has no measurement before the intervention (sometimes called historical controls) and no concurrent controls. Shadish labeled this design as a “one-group post-test only design” and summarized its limitations with “this design is rarely useful.”

The Illinois study also lacks statistical validity, since it is underpowered to detect a benefit of active surveillance. Shadish lists low statistical power as the first threat to statistical validity since “the experiment may incorrectly conclude that the relationship between treatment and outcome is not significant.” Since the Illinois study is a negative one – claiming active surveillance for MRSA didn’t work, power is particularly important. If you jump ahead to my ICAAC abstract, you will begin to see why the study is likely very underpowered. Point prevalence is very insensitive to changes in acquisition or transmission, so you would need very large studies to see a benefit.

I’ll admit that a statewide study has strong external validity – that is generalizability. 

But let’s focus on construct validity. Construct validity - what Einstein was hinting at in the quote above - describes whether a study measures what it claims to be measuring. For example, if a study claims that active surveillance for MRSA and isolation doesn’t prevent MRSA transmission, that study better measure MRSA transmission. 

Let’s pause here. Now some might say, we don’t care about transmission, we just care about MRSA prevalence or MRSA infections or MRSA CLABSI (or even deaths in Avengers movies). Yet, active surveillance for MRSA doesn’t work like that – it prevents transmission between patients. 

But what if measuring MRSA point prevalence was good enough at detecting MRSA transmission? Thought experiment: what if we found PCN allergy alerts in the EMR annoying and so we eliminated them? To see if this was safe, we then checked to see if anyone was having a PCN allergic reaction every St Patrick’s Day for the next 5 years. Good enough, right? Probably not. Why would we be comfortable saying yearly point prevalence is an adequate way of measuring the benefits of MRSA transmission? I don’t think we should and here’s why:

Back in 2002 I presented an abstract at ICAAC titled: “Point Prevalence and Clinical Culture Positivity of Vancomycin Resistant Enterococci are Poor Estimates of Infection Control Intervention Impact.” This study was based on the VRE model that we eventually published in CID (2004). Anyway, we modeled VRE transmission in the ICU under a condition where active surveillance compliance on admission increased from 60% to 100% and I assumed that isolation prevented 71% of transmissions. This is a math model, so we know that the intervention worked– but could we detect it? The answer was yes but only if we used admission/discharge screening cultures.  If we used point prevalence, like the Illinois study, we would falsely claim that the intervention didn’t work 54% of the time. However, if we used admission/discharge cultures, we would correctly determine that the intervention worked 96% of the time. Here is our conclusion:

“Point prevalence or clinical culture positivity often failed to detect a benefit due to stochastic fluctuations in prevalence and high prevalence of VRE in patients entering the ICU. Studies to assess the benefits of active surveillance for VRE should measure new incident cases. Relying on point prevalence or clinical culture positivity to assess the benefits of infection control interventions may underestimate the magnitude of their benefit and may be responsible for a persistent bias against the broader institution of active surveillance. The benefits of active surveillance and other infection control interventions are probably underestimated.”  

Not bad for 16 years ago – replace VRE with MRSA and you can see why the study by Lin et al cannot be used to evaluate the benefits of active surveillance. Our conclusion was partially driven, as we said, by high rates of VRE colonization on admission. What did Lin et al say about their study: “we assessed MRSA prevalence in a region where MRSA is widely endemic both in the community and within healthcare facilities.” Thus, the MRSA situation in Illinois fits closely with what we modeled.

In conclusion – the study by Lin et al should not be used to claim active surveillance was ineffective in Illinois or elsewhere. When drawing inferences, it is important to remember all four components of validity described by Cook and Campbell 40 years ago. We still need to figure out why MRSA has declined by 30% in Illinois and elsewhere. I do wonder why we are so quick to claim CLABSI bundles, CHG bathing (see below) or other interventions have been driving these MRSA reductions and not active surveillance. If I had to guess, it’s something yellow and not the data.

-----

Side note: In this same study, the number of hospitals using CHG bathing in their ICUs went from 5 (20%) to 17 (68%). It appears the authors could use these same data and methods to show that CHG doesn’t prevent MRSA in ICUs settings. Interestingly since CHG bathing works at the level of transmission and also on individual patients’ decolonization, point prevalence data would have higher construct validity for evaluating CHG. The study might even be better powered to detect a benefit of CHG.