Letters
In Reply Burklow and colleagues discuss third-party elements and their use on government health information websites.1 Third-party elements include not only tracking elements, but also nontracking elements that serve advertising, provide site traffic analytics to the owner, or deliver page functionality. Thus, “third-party elements” are not synonymous with “tracking elements.” Burklow and colleagues state that all 4 National Institutes of Health (NIH) websites use tracking elements. All use third-party elements. The main NIH site uses only nontracking elements such as Google Analytics, unless the user navigates away from nih.gov to, for example, cancer.gov. The PubMed, Medline Plus, and National Cancer Institute (NCI) sites use Omniture, WebTrends, and/or JSAPI Stats Collection elements, which serve no purpose other than tracking.2 These uses, as I wrote, are fully disclosed in the sites’ privacy policies and deidentification of data are stressed. My view is that PubMed, Medline Plus, and NCI conform to the government guidelines and that the objective is “optimizing the user experience.” Nonetheless, my results raise some questions. How can the main NIH and Food and Drug Administration1 sites function without tracking elements? They use Google Analytics, a simple, nontracking website traffic tool.3 A repeat visitor will not be identified as such; the user experience seems fine. Conversely, why do the other 3 sites use consumer tracking tools commonly used by commercial sites?4,5 Marco D. Huesch, MBBS, PhD Author Affiliations: USC Sol Price School of Public Policy, Schaeffer Center for Health Policy and Economics, Los Angeles, California; Department of Community & Family Medicine, Duke University School of Medicine; Duke Fuqua School of Business, Health Sector Management Area. Corresponding Author: Marco D. Huesch, MBBS, PhD, USC Sol Price School of Public Policy, Duke School of Medicine, Community & Family Medicine, 3335 S Figueroa St, USC Gateway Unit A, Los Angeles, CA 90089-7273 ([email protected]). 1
Conflict of Interest Disclosures: Since the publication of his article, Dr Huesch discloses receiving payments for consulting and manuscript preparation from Parkland Center for Clinical Innovation. 1. Huesch MD. Patient privacy risks when seeking online health information: analysis of 20 popular websites. JAMA Intern Med. 2013;173(19):1838.
sequent iatrogenic damages are high and conclude that these patients would probably benefit from a more cautious approach; hence the expression, “less is more, not too intensive in ICU [intensive care unit] management.” The idea, at the first glimpse, is remarkable and worthy of further consideration. However, one should not overlook the fact that the nature of ICU is critical, and any reductions in vigilance, monitoring, and treatment intensity might lead to undesirable poorer outcomes. Lower values do not necessarily equate to less intensity in treatment, as decreasing tidal volume in patients with adult respiratory distress syndrome, fluid intake during resuscitation, and the duration of antibiotic therapy and changing sedation approach from continuous to intermittent would be associated with a more appropriate patient outcome, yet require more cautious and rigorous care and monitoring in critically ill patients. Implementing a high-intensity staffing model has been associated with significant improvements in the length of ICU stay and bed utilization of critically ill patients.2 Furthermore, reducing sedation and its associated consciousness might challenge the patient with undesirable thoughts requiring a narrative on the emotions and awareness throughout the ICU stay to avoid any probable posttraumatic stress disorders, often associated with longterm ICU stay.3 As with the critically ill patients requiring mechanical ventilation, high-intensity ICU structures have been reported to be of more favorable mechanical ventilatory outcomes and lower mortality rates. 4,5 Critically ill patients require intensive treatment and in case any reductions in the treatment course intensity are intended, further vigilance would be inevitable; hence, the less intensive the treatment strategies, the more vigilant the caring system should be. Ata Mahmoodpoor, MD Samad E. J. Golzari, MD Author Affiliations: Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran (Mahmoodpoor); Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran (Golzari). Corresponding Author: Samad E. J. Golzari, MD, Imam Reza Hospital, Daneshgah St, Tabriz, Iran ([email protected]). Conflict of Interest Disclosures: None reported.
2. Evidon. Ghostery options. http://www.evidon.com/consumers-privacy /ghostery. December 24, 2013.
1. Kox M, Pickkers P. “Less is more” in critically ill patients: not too intensive. JAMA Intern Med. 2013;173(14):1369-1372.
3. Google. Google analytics. http://www.google.com/analytics. Accessed November 19, 2013.
2. Hawari FI, Al Najjar TI, Zaru L, Al Fayoumee W, Salah SH, Mukhaimar MZ. The effect of implementing high-intensity intensive care unit staffing model on outcome of critically ill oncology patients. Crit Care Med. 2009;37(6):1967-1971.
4. WebTrends. Precision targeting with full session scoring. http://webtrends .com/files/overview/Overview-Optimize-PrecisionTargeting-Webtrends.pdf. Accessed November 19, 2013. 5. Adobe Analytics. Actionable insights for marketing. http://success.adobe .com/assets/en/downloads/whitepaper/22066_analytics_solution-overview_ue _v2.pdf. Accessed November 19, 2013.
Management of Critically Ill Patients: The Less Intensive the Treatment, the More Vigilance Demanded To the Editor Intensive treatment strategies in critically ill patients have recently been challenged by Kox and Pickkers,1 who state that the chances of unwanted adverse effects and con-
3. Herbst A, Drenth C. The intensity of intensive care: a patient’s narrative. Glob J Health Sci. 2012;4(5):20-29. 4. Singer JP, Kohlwes J, Bent S, Zimmerman L, Eisner MD. The impact of a “low-intensity” versus “high-intensity” medical intensive care unit on patient outcomes in critically ill veterans. J Intensive Care Med. 2010;25(4):233-239. 5. Carson SS, Stocking C, Podsadecki T, et al. Effects of organizational change in the medical intensive care unit of a teaching hospital: a comparison of “open” and “closed” formats. JAMA. 1996;276(4):322-328.
In Reply We thank Mahmoodpoor and Golzari for their letter in response to our special communication.1 The authors argue that reductions in treatment intensity inevitably result in
jamainternalmedicine.com
JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
477
Letters
the need for increased vigilance. While we acknowledge that the intensive care unit (ICU) is, and will always remain, a highintensity monitoring and treatment environment, in our article we explicated that more intensive monitoring and treatment is in many cases not associated with better outcome and may even do harm. We therefore do not agree with the authors’ suggestion that any reduction in vigilance, monitoring, and treatment intensity will lead to undesirable clinical outcomes because there is simply no evidence to support this. For instance, with regard to monitoring, a recent metaanalysis confirmed the results found in the observational study2 we initially referred to by showing that a restrictive chest radiograph policy is not associated with harmful effects.3 Furthermore, the authors point out that reduction of sedation levels might increase posttraumatic stress disorders (PTSDs). However, daily interruption of sedatives during the ICU stay was shown not to be associated with adverse long-term psychological outcomes.4 In fact, PTSDs were less likely to develop in intermittently sedated patients.4 We already discussed exceptions to the “less is more” rule in our article. For instance, as the authors correctly point out, high-intensity physician and nurse staffing is associated with better outcome. However, there even appears to be a limit to this because nighttime inhospital intensivist staffing was recently shown not to improve patients outcomes.5 As such, reallocation of resources in the expensive ICU environment might be considered. In conclusion, similar to many phenomena in medicine, the relationship between monitoring and treatment intensity on the one hand and patient outcome in the ICU on the other is probably best represented by a U-shaped curve: while too little is not enough and probably dangerous to our patients, this does not imply that more is always better, as too much can also be harmful. Matthijs Kox, PhD Peter Pickkers, MD, PhD Author Affiliations: Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands (Kox, Pickkers); Department of Anesthesiology, Radboud University Medical Centre, Nijmegen, the Netherlands (Kox); Nijmegen Institute for Infection, Inflammation, and Immunity, Nijmegen, the Netherlands (Kox, Pickkers). Corresponding Author: Matthijs Kox, PhD, Department of Intensive Care Medicine, Radboud University Medical Centre, Internal Mail 710, Geert Grooteplein 10, 6500 HB Nijmegen, the Netherlands (Matthijs.Kox @radboudumc.nl). Conflict of Interest Disclosures: None reported. 1. Kox M, Pickkers P. “Less is more” in critically ill patients: not too intensive. JAMA Intern Med. 2013;173(14):1369-1372. 2. Graat ME, Choi G, Wolthuis EK, et al. The clinical value of daily routine chest radiographs in a mixed medical-surgical intensive care unit is low. Crit Care. 2006;10(1):R11. 3. Ganapathy A, Adhikari NK, Spiegelman J, Scales DC. Routine chest x-rays in intensive care units: a systematic review and meta-analysis. Crit Care. 2012;16(2):R68.
478
Assessment and Management of Back Pain To the Editor We wish to congratulate Mafi and colleagues1 on their article “Worsening Trends in the Management and Treatment of Back Pain.” The assessment and management of back pain has long been recognized as suboptimal in the United States, with perceived overutilization of health services that are not in accordance with recommendations from evidencebased clinical practice guidelines (CPGs) and underutilization of recommended health services. Nevertheless, this article has stimulated additional thought on several issues that warrant attention. It appears somewhat unusual to have combined diagnoses related to neck pain, mid-back pain, and low back pain within the International Classification of Diseases, Clinical Modification, Ninth Revision (ICD-9-CM) under the umbrella of “back pain” because symptoms from each region of the spine present their own challenges for assessment and management. Furthermore, the analysis of guideline concordance for the observed utilization of health services appears to have been based solely on CPGs for low back pain (eTables 8 and 9 in the article by Mafi et al1). The authors may wish to consider whether their findings were in accordance with recommendations from CPGs for neck pain, such as those of the Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders.2 We are not aware of CPGs focused specifically on mid-back pain, which is combined somewhat arbitrarily with neck pain or low back pain in various CPGs. The authors may also wish to consider the scope of their study, which appears to have included an unspecified number of reason-for-visit codes and 96 spine-related ICD-9-CM diagnoses (eTable 21). It can be challenging to translate symptoms associated with “back pain” into ICD-9-CM codes, given the breadth of clinical presentations and limitations of this diagnostic system. Cherkin et al3 validated an algorithm based on the ICD-9-CM system to identify codes definitely (n = 27) or possibly (n = 39) associated with low back pain hospitalizations. It would be interesting to conduct further analyses according to these validated patient subgroups with low back pain and to develop validated lists of diagnoses relating to neck or mid-back pain. Perhaps part of the challenge experienced in the assessment and management of “back pain” in the United States is attributable to misconceptions stemming from complexity in the many and diverse clinical conditions that may present as such. Incidentally, the authors reported a mean of 73 million visits annually for back pain when, in fact, this appears to represent the mean number of such visits per biennial period. John C. Licciardone, DO, MS, MBA Robert Gatchel, PhD Simon Dagenais, DC, PhD, MSc
4. Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168(12):1457-1461.
Author Affiliations: The Osteopathic Research Center, University of North Texas Health Science Center, Ft Worth (Licciardone); Department of Psychology, College of Science, University of Texas at Arlington, Arlington (Gatchel); Spine Research LLC, Winchester, Massachusetts (Dagenais).
5. Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):22012209.
Corresponding Author: John C. Licciardone, DO, MS, MBA, The Osteopathic Research Center, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Ft Worth, TX 76107 ( [email protected]).
JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
jamainternalmedicine.com
In Reply Burklow and colleagues discuss third-party elements and their use on government health information websites.1 Third-party elements include not only tracking elements, but also nontracking elements that serve advertising, provide site traffic analytics to the owner, or deliver page functionality. Thus, “third-party elements” are not synonymous with “tracking elements.” Burklow and colleagues state that all 4 National Institutes of Health (NIH) websites use tracking elements. All use third-party elements. The main NIH site uses only nontracking elements such as Google Analytics, unless the user navigates away from nih.gov to, for example, cancer.gov. The PubMed, Medline Plus, and National Cancer Institute (NCI) sites use Omniture, WebTrends, and/or JSAPI Stats Collection elements, which serve no purpose other than tracking.2 These uses, as I wrote, are fully disclosed in the sites’ privacy policies and deidentification of data are stressed. My view is that PubMed, Medline Plus, and NCI conform to the government guidelines and that the objective is “optimizing the user experience.” Nonetheless, my results raise some questions. How can the main NIH and Food and Drug Administration1 sites function without tracking elements? They use Google Analytics, a simple, nontracking website traffic tool.3 A repeat visitor will not be identified as such; the user experience seems fine. Conversely, why do the other 3 sites use consumer tracking tools commonly used by commercial sites?4,5 Marco D. Huesch, MBBS, PhD Author Affiliations: USC Sol Price School of Public Policy, Schaeffer Center for Health Policy and Economics, Los Angeles, California; Department of Community & Family Medicine, Duke University School of Medicine; Duke Fuqua School of Business, Health Sector Management Area. Corresponding Author: Marco D. Huesch, MBBS, PhD, USC Sol Price School of Public Policy, Duke School of Medicine, Community & Family Medicine, 3335 S Figueroa St, USC Gateway Unit A, Los Angeles, CA 90089-7273 ([email protected]). 1
Conflict of Interest Disclosures: Since the publication of his article, Dr Huesch discloses receiving payments for consulting and manuscript preparation from Parkland Center for Clinical Innovation. 1. Huesch MD. Patient privacy risks when seeking online health information: analysis of 20 popular websites. JAMA Intern Med. 2013;173(19):1838.
sequent iatrogenic damages are high and conclude that these patients would probably benefit from a more cautious approach; hence the expression, “less is more, not too intensive in ICU [intensive care unit] management.” The idea, at the first glimpse, is remarkable and worthy of further consideration. However, one should not overlook the fact that the nature of ICU is critical, and any reductions in vigilance, monitoring, and treatment intensity might lead to undesirable poorer outcomes. Lower values do not necessarily equate to less intensity in treatment, as decreasing tidal volume in patients with adult respiratory distress syndrome, fluid intake during resuscitation, and the duration of antibiotic therapy and changing sedation approach from continuous to intermittent would be associated with a more appropriate patient outcome, yet require more cautious and rigorous care and monitoring in critically ill patients. Implementing a high-intensity staffing model has been associated with significant improvements in the length of ICU stay and bed utilization of critically ill patients.2 Furthermore, reducing sedation and its associated consciousness might challenge the patient with undesirable thoughts requiring a narrative on the emotions and awareness throughout the ICU stay to avoid any probable posttraumatic stress disorders, often associated with longterm ICU stay.3 As with the critically ill patients requiring mechanical ventilation, high-intensity ICU structures have been reported to be of more favorable mechanical ventilatory outcomes and lower mortality rates. 4,5 Critically ill patients require intensive treatment and in case any reductions in the treatment course intensity are intended, further vigilance would be inevitable; hence, the less intensive the treatment strategies, the more vigilant the caring system should be. Ata Mahmoodpoor, MD Samad E. J. Golzari, MD Author Affiliations: Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran (Mahmoodpoor); Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran (Golzari). Corresponding Author: Samad E. J. Golzari, MD, Imam Reza Hospital, Daneshgah St, Tabriz, Iran ([email protected]). Conflict of Interest Disclosures: None reported.
2. Evidon. Ghostery options. http://www.evidon.com/consumers-privacy /ghostery. December 24, 2013.
1. Kox M, Pickkers P. “Less is more” in critically ill patients: not too intensive. JAMA Intern Med. 2013;173(14):1369-1372.
3. Google. Google analytics. http://www.google.com/analytics. Accessed November 19, 2013.
2. Hawari FI, Al Najjar TI, Zaru L, Al Fayoumee W, Salah SH, Mukhaimar MZ. The effect of implementing high-intensity intensive care unit staffing model on outcome of critically ill oncology patients. Crit Care Med. 2009;37(6):1967-1971.
4. WebTrends. Precision targeting with full session scoring. http://webtrends .com/files/overview/Overview-Optimize-PrecisionTargeting-Webtrends.pdf. Accessed November 19, 2013. 5. Adobe Analytics. Actionable insights for marketing. http://success.adobe .com/assets/en/downloads/whitepaper/22066_analytics_solution-overview_ue _v2.pdf. Accessed November 19, 2013.
Management of Critically Ill Patients: The Less Intensive the Treatment, the More Vigilance Demanded To the Editor Intensive treatment strategies in critically ill patients have recently been challenged by Kox and Pickkers,1 who state that the chances of unwanted adverse effects and con-
3. Herbst A, Drenth C. The intensity of intensive care: a patient’s narrative. Glob J Health Sci. 2012;4(5):20-29. 4. Singer JP, Kohlwes J, Bent S, Zimmerman L, Eisner MD. The impact of a “low-intensity” versus “high-intensity” medical intensive care unit on patient outcomes in critically ill veterans. J Intensive Care Med. 2010;25(4):233-239. 5. Carson SS, Stocking C, Podsadecki T, et al. Effects of organizational change in the medical intensive care unit of a teaching hospital: a comparison of “open” and “closed” formats. JAMA. 1996;276(4):322-328.
In Reply We thank Mahmoodpoor and Golzari for their letter in response to our special communication.1 The authors argue that reductions in treatment intensity inevitably result in
jamainternalmedicine.com
JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
477
Letters
the need for increased vigilance. While we acknowledge that the intensive care unit (ICU) is, and will always remain, a highintensity monitoring and treatment environment, in our article we explicated that more intensive monitoring and treatment is in many cases not associated with better outcome and may even do harm. We therefore do not agree with the authors’ suggestion that any reduction in vigilance, monitoring, and treatment intensity will lead to undesirable clinical outcomes because there is simply no evidence to support this. For instance, with regard to monitoring, a recent metaanalysis confirmed the results found in the observational study2 we initially referred to by showing that a restrictive chest radiograph policy is not associated with harmful effects.3 Furthermore, the authors point out that reduction of sedation levels might increase posttraumatic stress disorders (PTSDs). However, daily interruption of sedatives during the ICU stay was shown not to be associated with adverse long-term psychological outcomes.4 In fact, PTSDs were less likely to develop in intermittently sedated patients.4 We already discussed exceptions to the “less is more” rule in our article. For instance, as the authors correctly point out, high-intensity physician and nurse staffing is associated with better outcome. However, there even appears to be a limit to this because nighttime inhospital intensivist staffing was recently shown not to improve patients outcomes.5 As such, reallocation of resources in the expensive ICU environment might be considered. In conclusion, similar to many phenomena in medicine, the relationship between monitoring and treatment intensity on the one hand and patient outcome in the ICU on the other is probably best represented by a U-shaped curve: while too little is not enough and probably dangerous to our patients, this does not imply that more is always better, as too much can also be harmful. Matthijs Kox, PhD Peter Pickkers, MD, PhD Author Affiliations: Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands (Kox, Pickkers); Department of Anesthesiology, Radboud University Medical Centre, Nijmegen, the Netherlands (Kox); Nijmegen Institute for Infection, Inflammation, and Immunity, Nijmegen, the Netherlands (Kox, Pickkers). Corresponding Author: Matthijs Kox, PhD, Department of Intensive Care Medicine, Radboud University Medical Centre, Internal Mail 710, Geert Grooteplein 10, 6500 HB Nijmegen, the Netherlands (Matthijs.Kox @radboudumc.nl). Conflict of Interest Disclosures: None reported. 1. Kox M, Pickkers P. “Less is more” in critically ill patients: not too intensive. JAMA Intern Med. 2013;173(14):1369-1372. 2. Graat ME, Choi G, Wolthuis EK, et al. The clinical value of daily routine chest radiographs in a mixed medical-surgical intensive care unit is low. Crit Care. 2006;10(1):R11. 3. Ganapathy A, Adhikari NK, Spiegelman J, Scales DC. Routine chest x-rays in intensive care units: a systematic review and meta-analysis. Crit Care. 2012;16(2):R68.
478
Assessment and Management of Back Pain To the Editor We wish to congratulate Mafi and colleagues1 on their article “Worsening Trends in the Management and Treatment of Back Pain.” The assessment and management of back pain has long been recognized as suboptimal in the United States, with perceived overutilization of health services that are not in accordance with recommendations from evidencebased clinical practice guidelines (CPGs) and underutilization of recommended health services. Nevertheless, this article has stimulated additional thought on several issues that warrant attention. It appears somewhat unusual to have combined diagnoses related to neck pain, mid-back pain, and low back pain within the International Classification of Diseases, Clinical Modification, Ninth Revision (ICD-9-CM) under the umbrella of “back pain” because symptoms from each region of the spine present their own challenges for assessment and management. Furthermore, the analysis of guideline concordance for the observed utilization of health services appears to have been based solely on CPGs for low back pain (eTables 8 and 9 in the article by Mafi et al1). The authors may wish to consider whether their findings were in accordance with recommendations from CPGs for neck pain, such as those of the Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders.2 We are not aware of CPGs focused specifically on mid-back pain, which is combined somewhat arbitrarily with neck pain or low back pain in various CPGs. The authors may also wish to consider the scope of their study, which appears to have included an unspecified number of reason-for-visit codes and 96 spine-related ICD-9-CM diagnoses (eTable 21). It can be challenging to translate symptoms associated with “back pain” into ICD-9-CM codes, given the breadth of clinical presentations and limitations of this diagnostic system. Cherkin et al3 validated an algorithm based on the ICD-9-CM system to identify codes definitely (n = 27) or possibly (n = 39) associated with low back pain hospitalizations. It would be interesting to conduct further analyses according to these validated patient subgroups with low back pain and to develop validated lists of diagnoses relating to neck or mid-back pain. Perhaps part of the challenge experienced in the assessment and management of “back pain” in the United States is attributable to misconceptions stemming from complexity in the many and diverse clinical conditions that may present as such. Incidentally, the authors reported a mean of 73 million visits annually for back pain when, in fact, this appears to represent the mean number of such visits per biennial period. John C. Licciardone, DO, MS, MBA Robert Gatchel, PhD Simon Dagenais, DC, PhD, MSc
4. Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168(12):1457-1461.
Author Affiliations: The Osteopathic Research Center, University of North Texas Health Science Center, Ft Worth (Licciardone); Department of Psychology, College of Science, University of Texas at Arlington, Arlington (Gatchel); Spine Research LLC, Winchester, Massachusetts (Dagenais).
5. Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):22012209.
Corresponding Author: John C. Licciardone, DO, MS, MBA, The Osteopathic Research Center, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Ft Worth, TX 76107 ( [email protected]).
JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
jamainternalmedicine.com
