Monday, 24 July 2017

Justice and equity in the health system

Xavier Bayona

Should we review the principle of justice from an ethical perspective? If so, we’ll notice that it’s a principle of minimums (of coexistence) faced with the principle of happiness – a principle of maximums ("individual justice") and, unfortunately, we’re often erring by thinking we speak of justice when in fact we speak of happiness (or individual convenience). Similarly, from the bioethical standpoint, justice can be defined as the fact of treating each one appropriately, in order to reduce situations of inequality (ideological, social, cultural, economic, etc.). On the other hand, equity is defined as giving each individual no more and no less of what they need. Following these definitions, when we speak of justice and equity, deep down, we are doing a reiteration, because they are synonymous.

A few months ago, an editorial was published in "Atención Primaria", reflecting on the justice and equity of copayments (Simó Miñana 2015). The author highlighted some aspects such as:
  • It’s fair to say that in a health system of universal and free access it’s necessary that its financing be made from taxes;
  • Copayments can introduce inequality in access especially among the most ill and among the poorest or socially disadvantaged population groups;
  • Health needs and health demand are virtually synonymous, so the urgent health demand is when the citizen expresses it; 
  • No expressed demand doesn’t mean that there’s no need; the most disadvantaged social sectors have a disadvantage;
  • Exaggerated health expectations generate health consumerism in an environment of limited resources and an infinitely increasing demand.
In an environment of budgetary austerity, different decisions can be made:
  • Raising taxes by insisting on the "social responsibility" of anonymous tax payers;
  • Excluding from public coverage some services that in practice are equivalent to a 100% copayment of exclusions, payments that end up exclusively  in private hands;
  • Introducing copayment of part of the benefits, with the consequent individual co-responsibility and the secondary benefit in the system’s financing. 
The challenge is to combine social and individual responsibility and solidarity. The author of the editorial ended by asking the following question: "To what extent do bad uses and their consequences have their origin in indifference at a cost that none of its actors, except the anonymous tax payer, bear?"

Although a whole book could be written on this theme, I hope the reader will forgive me for simplifying the proposed reflections on the theme of adjusting the fairness in an economic environment as adverse as ours which, as the experts say, has come to stay.

I will insist once again that it’s necessary for the different levels of care to coexist harmoniously and to strengthen cooperation and networking, while focusing on a citizen-centred approach. All levels of care are necessary, but the time has come to take action, we can not wait any longer. We need:
  1. Health policies accompanied by resources that should be more focused on the community and primary care so that the system can be more efficient and equitable;
  2. To recover resources from the existing waste, to redistribute them where they will be more necessary and cost-effective; 
  3. To evaluate the introduction of new diagnostic and therapeutic strategies; what is the added value that these contribute; we need to use tools of analysis of cost-utility as for example the QALY (years of life adjusted by quality) for the evaluation; 
  4. To promote payment for health results (not by procedures) that is obtained in the community;
  5. To raise awareness that the citizens are responsible for their health decisions are binding, therefore self-care and self-responsibility must be encouraged.

To conclude, I’ll use a quote from the General Practitioner and professor at the University of Leicester, Marshall Marinker (1930), editor of the book Constructive Conversations about Health Policy and Values ​​(2006), and many other contributions to the National Health Service. "The specialist's diagnostic task is to reduce uncertainty, to explore the possible and to marginalize the error. It contrasts openly with the general family doctor’s task, who is accepting uncertainty, exploring the probable and marginalizing the risk."

Monday, 17 July 2017

Dying in the hospital: some considerations

Gloria Gálvez

Health inequalities are related to individual and social factors. The way people live, work and grow old as well as the political, social or economic factors that accompany them, vary greatly according to the place where they live. Death, which could be "the great equalizer", doesn’t appear to be equal at all, as Dr. Puri states in his article "Unequal Lives, Unequal Deaths," in which she argues that social and health differences during life, are also present at the time of death. As a group of Danish authors suggest in BMJ Supportive & Palliative Care: "Socioeconomic position and place of death of cancer patients” for people with fewer resources it’s more difficult to benefit from a worthy death in their own home.

When a patient chooses to die in a health institution he does it for different reasons. Higginson et al., In "Dying at home - is it better: A narrative appraisal of the state of the science" identified, besides the socioeconomic level, other determinant elements as the preferences of the patients, the access to the home attendance or the support of the family. Let's look at each one separately.

Patient preferences and the role of caregivers. Lessening the family burden can be decisive when choosing the place where one wishes to die. In the study by Agar, Currow, Shelby-James et al. published in Palliative Medicine, it was possible to associate patients' preference for dying in hospitals with the feeling that they had towards becoming a family burden. In this sense, the caregivers’ role is of great relevance, since death at home, even if it’s calmer and less painful, requires a wider caregiver support. This is highlighted in the article published in BioMed Central: "Dying at home leads to more peace and less grief, but requires wider support", and in different studies that point to a strong relation between place of death and family support, to the point that the availability of a caregiver in the family is the predictor of greater possibility for the patient to decide to die at home.

Disease Progression 

As the disease progresses, it becomes more difficult to manage pain and control symptoms. At this time, patients and caregivers may consider that in the hospital the patient would benefit from better treatments than at home. In this sense, the article published in Plus One: How Could Hospitalisations at the End of Life Have Been Avoided? A Qualitative Retrospective Study of the Perspectives of General Practitioners, Nurses and Family Carersen sets out 5 key elements that could help avoid hospitalization at the end of life:

1) The change of mentality when death approaches;
2) Being able to provide treatment and care at home in times of crisis;
3) Interventions to cope with expected complications;
4) Guiding the patient and his family in a global way against the disease;
5) Continuity of care and treatment in the home.

The availability of home care services such as home hospitalization, palliative care and other social and health resources are some of the most important factors associated with the place of death. Thus, the geographical context in which people live will condition access to this type of resources, being a factor to be taken into account when analyzing the place where the patient dies.

Several studies highlight the importance of information on the place where the patient dies as a reflection of social and territorial inequalities, which should promote decisions based on the evidence on health policies according to the different territories and degrees of accessibility to appropriate services. In addition, they provide us with interesting information about patient and caregiver while allowing us to review the stereotype of patients with little responsibility in their self-care. The reality is more complex, so the health team must facilitate decisions taken in a fair and equitable environment. Recognizing this reality must allow alternative places to be cared for at the end of their lives and provide them with the most comfortable and dignified options for everyone, not only for those who enjoy socio-economic stability.

Monday, 10 July 2017

Cancer committees - a brake on shared clinical decisions?

Cancer committees are instruments for the coordination of cancer practice that have existed for many years. Now, however, a joint German-US research group (with the collaboration of Glyn Elwyn) wanted to know not only the quality of the work of these committees but also how they address the demand for greater involvement of patients in clinical decisions, and an observational study has been carried out on 15 cancer committees of the University Cancer Center Hamburg-Eppendorf. From the publication of this paper, I would like to highlight two key aspects: a) the reality of the organizational quality of cancer committees, and b) how these committees contemplate patients' preferences.

a) Organizational quality of cancer committees

The first observation is that the majority of the tumour committees’ members are doctors in senior positions and, on the other hand, the presence of young doctors is scarce. The participation of other professionals, also important for cancer patients, such as nurses or psycho-oncologists has not been observed in any of the cases. Researchers believe that the hierarchical influence of key members of the committees and the need to close many cases in a short time are limiting factors for productive and quality multidisciplinary work. In summary, the observation notes that guidelines and recommendations are generally applied with margins too scarce for other considerations.

Monday, 3 July 2017

Buurtzorg, a nurse work project with blue ocean strategy

10 years ago, the home care scenario for people with complex social and health needs in the Netherlands followed a bureaucratic scheme based on nursing work on one hand, social work on the other, in addition to the home support actions offered by companies, many of them from the cleaning service world. Jos de Blok, a community nurse, dissatisfied with this fragmented model, put an entrepreneur hat on, assembled a small group of nurses with whom he shared vision and discussed as much at large about a new model of care based on real needs of people. In an interview, Jos de Blok says, "What I wanted to show was that if you are a good nurse, you should know how to focus on the relationship and to build trust with patients in order to make them live with the maximum of independence possible. "

Monday, 26 June 2017

I do therefore I am or the bias of intervention in medicine

Cristina Roure

This week, thanks to a post of Sergio Minué in the blog "El Gerente de Mediado", I discovered the recent publication of "Ending Medical Reversal" The book refers to situations in which new studies more robust than the pre-existing ones contradict the standards of commonly accepted practices, which have now proved ineffective or even harmful.

Some will recall such vivid examples as the use of protein C activated in sepsis, high dose chemotherapy combined with autotransplant of stem cell in metastatic breast cancer, the aprotinin in cardiac surgery, or hormone replacement therapy in postmenopausal women. All of them were used for years until proven harmful.

I have not been able to read the book yet, but I read a report by the same author; Dr. Vinay Prasad in Mayo Clinical Proceedings exposes his vast research. Over ten years, 363 studies evaluating established practices were published, out of which 146 (40%), between 12 and 19 per year, were revoked (1). The author explains in the following video that such revocations usually occur after the precipitous adoption of new therapies based on incomplete or inadequate studies.

Monday, 19 June 2017

Chronic Complex Patients and the Blue Ocean Strategy

The book "Blue Ocean Strategy" by W. Chan Kim and Renée Mauborgne has been celebrating 10 years, having sold more than three and a half million copies, and now, to celebrate, a revised edition has just been published. The central thesis of the book is that today's markets are characterized by oversupply and therefore, companies must compete fiercely between them and the oceans (It’s a metaphor) are stained red with the blood of the fight. For this reason, the authors propose to companies to go on the search for blue oceans, like Cirque du Soleil or Ikea, where their products or services will be incontestable because people will see them as novel and useful. The strategy of these companies is clear: their contribution must be perceived as a value innovation, and as a consequence would able to open new unexplored markets like oceans that will not go red.

Leaving aside the commercial aspects of the theory, the book left me with the (attractive) vision of a blue ocean that, inevitably, I have contrasted with the difficulties that all health systems have when it comes to implementing convincing programs of patients’ care and I thought that perhaps at this point a blue ocean strategy would be beneficial when aiming to implement new projects that would arise from overcoming current difficulties. I have to admit that applying Chan and Mauborgne's theories to complex chronic patients is a bit far fetched, but I am convinced that there are some strategic methodology proposals that could be of some use.

Monday, 12 June 2017

The diagnostic process and medical errors

The past 15 years, since the publication of "To Err Is Human" report, has seen a great deal of progress in projects that promote patient safety, especially in programs such as increasing hand washing, identifying patients, surgical checklists or changes in nursing care, but on the other hand the diagnostic process continues to be a matter almost exclusive to medical work although it’s known that this is a very sensitive area for the safety of patients. This new report from the National Academy of Medicine (formerly Institute of Medicine), "Improving Diagnosis in Healthcare," is a follow up document to the aforementioned one, specifically focused on diagnostic errors.

The report defines the diagnostic error as the failure to obtain a detailed, timely explanation of a health problem. Experts have also included in the definition the physician’s inability to know how to explain the diagnosis to the patient. According to the report, diagnostic errors would have an incidence on medical consultations of 5%, accounting for 10% of deaths, 6-7% of adverse reactions in hospitals, as well as the leading cause of litigation in the health area (the figures correspond to the US).