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.

On the other hand, Spittal et al. (Dr. Spittal is a lecturer at the Melbourne School of Population and Global Health at the University of Melbourne) in an article recently published in the journal, “The PRONE score: an algorithm for predicting doctors' risks of formal patient complaints using routinely collected administrative data.” focuses on the study of complaints of the Australian health system. It points out that half of the claims processed in 10 years have been related to 3% of doctors. This relevant fact alerts us to the importance of analyzing the cases of professionals who receive complaints repeatedly, and to promote interventions that address the risk that some doctors have to go through a lawsuit.

In their study, 13,849 complaints were made by Australian health service patients over a 12-year period involving 8,424 doctors. Researchers rank claims based on certain risk factors that have shown the high likelihood that a doctor will receive a complaint. Using the multivariate logistic regression analysis, they have created a predictive risk algorithm that will allow us to estimate, with some reliability, the probability that a particular professional will receive a complaint in the two years following an initial complaint taken as reference.

There have been previous attempts to use simple algorithms that would allow an alert system to predict the risk of malpractice claims, such as that developed by Hickson et al: Patient at Risk Score (PARS), which indicates that using this tool represents not only a benefit for the organization but also for patient satisfaction.

The PRONE system (Predict Risk of New Event) is based on four variables: a) the doctor's specialty, b) the sex, c) the number of previous complaints, and d) the time elapsed since the last complaint. The results show that it can be a valid method for assessing the risk of recurrent complaints in doctors (70% of claims registered in the two years following a related complaint were related to the same doctors), easily extrapolated to other health professionals and other organizations but the most important is the feasibility of implementing interventions aimed at avoiding the adverse event by modifying the professionals’ work environment and behaviour. Spittal poses three possible interventions: 1) informing doctors who are at risk of receiving a future complaint, 2) training them in issues that usually arise in their complaint profile, and 3) citing the doctor to a medical oversight body who may assess the appropriate professional intervention for each situation.

The first step in reducing adverse events is to consider that there is a preventable harm. Getting to know the patients’ needs and systematically analyzing their complaints from a safety point of view will allow us to design predictive models that are essential in health management as they allow us to optimize resources, reduce costs and improve the health care system.

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).

Monday, 6 February 2017

Primary health care perspective of clinical management: The legacy of Barbara Starfield

Xavier Bayona

Six years ago, the magnificent Barbara Starfield left us (December 18 1932 - June 10, 2011). She was a paediatrician and a major promoter of primary health care at the international level. Virtually her entire academic and professional life was tied to Johns Hopkins University. Since 1994 she directed the Department of Health Policy and Management of the Johns Hopkins Bloomberg School of Public Health in Baltimore (United States). From 1996, she was the co-director of The Johns Hopkins Primary Care Policy Centre (PCPC).

Those who had the opportunity to enjoy any of her conferences can say that she never left us feeling indifferent and she always allowed us to reflect on what we were doing and encouraged us to bring sanity to our workplaces as part of the health system. She was a great advocate for improving health systems by strengthening primary care and making sense of what is happening in the world by focusing health care on people and their needs. I still remember how in the conference room of the Catalan Oncology Institute (ICO), a few years ago, she told the audience that we were wasting time and resources with a lot of the screening we did and that we had to improve our orientation.

Monday, 30 January 2017

Please don’t resuscitate me

A follow-up of 6,972 people aged 64 years and older who had undergone a cardio respiratory arrest whilst they were hospitalised in an inpatient facility showed that the survival rate, after one year from the attack, was barely 10%, and if this estimate was restricted to people with no neurological injuries, the rate was halved. We don’t have data on the mid and long-term results for older people who are resuscitated outside of the hospital, but it all seems to be worse.

Aware of the bad omens of the heart failures at an advanced age, John Ballard, a retiree born and raised in the southern US, and an old fashioned liberal, as he defines himself, answered a tweet of mine on his blog in this manner:

Monday, 23 January 2017

Doctors strikes and medical congresses = less mortality

At a doctors' strike in Israel in 2000, the gravediggers noticed that their workload diminished in areas where the doctors’ strike was on, while it remained unchanged in areas where doctors did not adhere. Judy Siegel-Itzkovich, scientific editor of the Jerusalem Post, in a letter called “Doctors' strike in Israel may be good for health”  attributed the phenomenon to the shutdown of the scheduled surgery, which probably brings improvements of certain ailments, but which, by itself, can lead to complications and mortality. A few years later, in “Doctors' strikes and mortality: a review”, a systematic review of 156 papers analyzing the mortality impact of several doctors' strikes around the world, shows that during the doctors’ strikes, the population mortality either remains unchanged or lowers, but it never rises. The authors of the paper, like the Jewish publisher, also think that the phenomenon is an indirect measurement of the surgical over activity so common in clinical practice that, curiously, is shown when the programmed activity ceases drastically during a certain period.

Monday, 16 January 2017

Cardiopulmonary Resuscitation for older people: the mirage of numbers

New England Journal of Medicine published a study in March 2013, promoted by a group of researchers from the American Heart Association. It was a study performed with a sample of 6,972 people over 64 years who had been discharged in the period 2000-2008 after having survived a cardiac arrest during hospitalization. According to the study, 58.5% of the patients were still alive one year after discharge from hospital. The results, however, were significantly worse in the subgroup of 84 years plus (49.7%) and those who had suffered severe neurological sequels (42.2%) or had been in a vegetative coma (10.2%). The conclusions of this study, therefore, are favourable for the practice of cardiopulmonary resuscitation (CPR) during the cardiac arrest of the elderly. GeriPal, a blog of geriatrics and palliative care represented them in the "icon-box" that you can see above.