Monday, 20 March 2017

Right Care: focusing on the attitude

Continuing with the "Right Care" series of the Lancet magazine, in this third post (I recall that "Definition, gray areas and reversion" was the first, and "Between too much and too little", the second), I have taken into account the beliefs of patients who, according to Vikas Saini in "Drivers of poor medical care," encourage practices of little value, but I have also described the attitudes of doctors who don’t prioritise the value of clinical practices. Remember that, according to Donald Berwick, between 25% and 33% of health costs are wasted in medical actions that don’t contribute anything or do more harm than good.

Popular beliefs that encourage resource wastage

a) Many people are convinced that the practice of medicine is based exclusively on science, which, unfortunately, is far from reality. b) From the ignorance of the inherent limitations of each test to the technical and human inaccuracies, the belief that the diagnostic tests are infallible is quite widespread. c) The trust that many people place in their doctors, otherwise indispensable, blinds them when it’s time to evaluate their abilities. d) Many people don’t dare to ask too many questions when seeing their doctors for fear of offending them. e) The heuristic effect, which is due to the impact of emotions, often causes a loss of objectivity, for example when a patient demands treatment because it worked like a wonder on his cousin, ignoring reasoned recommendations that advise against it. f) Consumer thinking, i.e. "the more the better," is increasingly preponderant. g) There is an extended belief that confuses the advice to adopt expectant attitudes, often so necessary, with budget cuts. h) Finally, we must remember that diseases generate uncertainty that leads to anxiety, a feeling that ends up being the basis of many disproportionate medical actions.

Doctors’ attitudes that fail to prioritise value clinical practices

a) Many physicians base their clinical practice on personal perceptions rather than on published evidence. b) What is clear is that there are many health care professionals in the clinic who simply don’t know how to adequately interpret the statistics emerged from medical research (innumeracy). c) There is an excess of confidence in the correlation between the anatomical images, or the physio-pathological theories, with the symptoms expressed by the patients. d) There is a tendency to think in terms of relative (very influential) risks rather than absolute (population-based) risks, which are much stronger. e) Doctors (almost all) feel better when they act than when they wait and see. As Ian Harris says, if you have been taught to operate, you operate. f) Exaggerated enthusiasm for the most sophisticated technologies is detected, especially in the field of diagnosis and treatment.

In the privacy of the practice, patients and doctors are surrounded by beliefs and fears, but also by lack of understanding and complicities, and it’s in this context that the decision making is not always the most scientifically correct or the most appropriate for the particular circumstances of each patient.

Jordi Varela

Monday, 13 March 2017

Right Care: between too much and too little

In the "Right Care" series of the Lancet magazine, Donald Berwick, in "Avoiding overuse - the next quality frontier", says that inappropriate clinical practices consume between 25% and 33% of health budgets in all countries in the world, but beyond the staggering amount of so much wasted money, there are four characteristics of excess, which Berwick emphasises: a) they affect the full range of health services and all specialties, although unevenly; b) there are specific clinical processes where exaggeration is highly disproportionate; (c) they are not exclusive to rich countries being also found in developing countries and in poor countries, in the latter group still with some dramatic traits, and d) are not related to the greater consumption of resources, since wastage can also be found in areas with less frequencies. 

Some figures of world-wide overuse

In direct observation studies in the first report of the "Right Care" series, it’s estimated that 57% of the antibiotics consumed in China should not have been prescribed, that between 16% and 70% of US hysterectomies are not justified, that 26% of knee arthroplasties in Spain could have been avoided and that 30% of coronary angiographies performed in Italy should not have been indicated. To end this compilation, it’s estimated that there are 6.2 million caesarean sections in excess in the world, half of them in Brazil and China.

Monday, 6 March 2017

Right Care: definition, gray areas and reversals

One of the Right Care Alliance initiatives, led by Vikas Saini and Shannon Brownlee from the Lown Institute in Boston, has been the compiling of 4 reports that are analyzing the misuse, by excess and by default, of health resources from a global perspective.

What does the Lown Institute mean by "right care"?

Before defining the concept of "right care", we must take note of Donald Berwick's definition of quality in the introductory article of the series. The author believes that the quality of care, as we understand it, is too focused on the guarantee of procedures and, despite being correct, the question now is: what do the inappropriate clinical processes mean for people’s health? Berwick states that quality should be understood as the provision of services that respond to people's real needs. So, practically, appropriatness has been filtered in the realm of quality.

Monday, 27 February 2017

Shared clinical decision: Dr. Montori’s lessons

If you want to understand what the shared clinical decision is and have 16 minutes to spare, don’t hesitate and watch this interview from Dr. Selma Mohammed and Dr. Victor Montori.

Monday, 20 February 2017

Claims for adverse events: a predictive algorithm

Gloria Gálvez

Strategies focused on encouraging patients' participation in the health system, and more specifically those related to quality and safety, have seen some a great deal of progress in recent years. A person-centred health system should promote active patient participation and use the complaints handled by patient care services as a specific instrument of participation. When the patient expresses the disagreement with the attention received, he or she is providing us with valuable information that is very useful in the continuous monitoring and improvement of quality. It doesn’t seem that there are many health institutions that use complaints and claims as a learning tool, but they rather use it as a mere descriptive statistic in the annual report of the organization, thus losing the opportunity for improvement that their analysis and monitoring would provide.

Dr. Gallagher, who, as someone with extensive experience in issues related to patient safety and disclosure of medical errors, has published an article in BMJ Quality & Safety: “Taking complaints seriously: using the patient safety lens” in which he proposes analysing complaints from a point of view of patient safety and treating them as if they were adverse events, in the same way as with the more traditional ones, such as those related to safe surgery or the appropriate use of medications. This is an innovative approach that will provide relevant information when proposing proactive interventions.

Monday, 13 February 2017

The weekend effect on hospitals

A meta-analysis of 48 studies and nearly 2 million hospitalizations for acute myocardial infarction has concluded that, during the weekends, waiting time for the start of angioplasty is on average of minutes longer, while mortality at 30 days is also, on average, 6% higher, a deviation that can reach 12% if high ST segment infarctions, which are susceptible to angioplasty, are also taken into account. A North American study of nearly one million hospitalizations for acute renal failure found that patients admitted on weekends had, on average, a probability of dying 7% higher, and in another study, also with extensive databases, on scheduled surgery in English hospitals, concluded that patients operated on Friday had a 44% higher probability of dying, a figure that rose to 82% if the intervention was performed on Saturday or Sunday (see an earlier post on the subject in this same blog). The three studies cited are just a sample of the harsh reality of the phenomenon. Just perform quick search on the scientific search engines to extract, for example, three more studies that go along the same lines (Bell 2001, Freemantle 2012, Perez Concha 2014). I have even found a study that has observed a higher mortality in urgent paediatric surgery (Goldstein 2014).