Monday, 24 April 2017

The value of clinical practice in chronic complex patients









Lost in the country of the pink bibs

To illustrate what kind of patients Dr. Meier is talking about, I found an article in The New York Times, where the writer Marcy Cottrell House explains the case of her father, who at age seventy, developed dementia and also broke his femur. Cottrell says that during the long postoperative period, the father got much worse and often found him in a room with other insane patients, all of them with a pink bib around their necks. The quiet of the place was impressive and the old man's gaze no longer recognized anyone. The nurse told them not to worry, it was normal to be more disconnected because of the tranquilizers they gave him to avoid the aggressiveness that he displayed during his stay. The writer ended up going in the office of a good geriatrician, who told him that the postoperative pain or that of poly-arthritis was likely to be torturing his father. He clarified that cognitive problems don’t stop him feeling the pain of bones and joints. The fact - explains the author - is that with a gram of Tylenol three times a day (a painkiller), his father revived and returned to smile when he heard his music and, better still, managed to escape the country the pink bibs.

4 tactics to bring more value to patients with complex needs

Dr. Diane Meier says (in the video) that most people, if they have a serious illness, would give priority to preserving their personal independence, while only a minority (10% according to her) say they would accept any measure in order to stay alive. On the other hand, if we pay attention, we notice that the money from the health systems circulates in the opposite direction: there is usually no limitation to the extreme clinical performances, many of them clearly disproportionate, while money is always lacking for dependency aids.




In order to increase the value of the services offered to complex patients, Dr. Meier suggests four tactics:

a) Ask the patients and their families, explicitly, what are their wills, and ensure that they are recorded in the medical record in a position well visible for all specialists and healthcare centres that at one time or another will end up intervening in the often long clinical processes.

b) Encourage that all physicians, nurses, social workers and other professionals involved are trained in the detection and treatment of uncomfortable symptoms for patients, especially pain. Encourage training in alignment of care objectives, coordination and integration of services.

c) Denounce the perverse economic incentives that foment the inappropriate assistance activity above the services that contribute value.

d) Provide palliative care to all people suffering from complex pathologies, without having to wait to do so only in the last days.

Many think that to adequately address patients with complex chronic pathologies, we must rethink the model, and this is true, but now the writer Marcy Cottrell House and Dr. Diane Meier remind us of the importance of introducing geriatric thinking and palliative care on how to treat people when their problems begin to be difficult to manage.



Jordi Varela
Editor

Monday, 17 April 2017

The attitude of the doctor when faced with the biological opportunity of death


Gustavo Tolchinsky


During one of my postings in a small county hospital I found myself in the resuscitation room. A colleague had been trying for some time to understand how to tackle the cascade of problems harbored by an elderly patient: the monitor roars at 150 beats per minute, the pulse-oximeter shows 78%, despite the FiO2 1 of the high concentration mask; the patient, with a blank stare, the breathing strongly audible and the arterial tensions hardly captured. While the nurses are desperate to find a vein, to probe, to administer the prescribed corticosteroids and digoxin, to perform the electrocardiogram and to anticipate the next steps that the emergency doctor will order. Around her, another nurse points out, with great conscientiousness, what time it is and what procedure has been performed.

Faced with this situation it is reasonable to act by instinct driven by our eagerness to ‘solve’ the problem. I had already framed a first diagnosis. The patient presents a fall in rapid atrial fibrillation in the context of acute respiratory failure due to a respiratory infection, perhaps caused by bronchoaspiration. The hypotension is secondary to the haemodynamically poorly tolerated tachyarrhythmia. At this moment, knowledge put into practice demands that you slow down the heart rate, indicates serum therapy to overcome stress and starting treatment with antibiotics, relieving symptoms, etc.

Monday, 10 April 2017

Strategies for the integration of services








King's Fund has published a timely and in depth document "Acute Hospitals and Integrated Care" where they question what role should hospitals play in the integration of services. Given the approach, one could ask: What role should primary care play? How about community services? And the social health services? However it may be best, King's Fund has focused on it in this way and I believe it has its reasons for doing so because, right now, the organizational model that everyone tends to is that of territorial management or that of integrated health organizations, all of which are intended to integrate services from a hospital-centred position.

Who should lead the integration of services?

According to the document, it’s fundamental to generate the network of services on a territorial basis and the question of leadership should depend on the nature of each clinical process. Let's take a few examples: a) A remote dermatology project should be led by specialized care, b) An infarct ought to be led by cardiologists, intensive carers and emergency specialists, c) Care for type 2 diabetes mellitus, should be led by the primary care, d) Individualized therapeutic plans of complex chronic patients, should be led by primary care with the community nurse and the social worker taking a high profile role, e) Complex end-of-life processes should be led by community-based multidisciplinary palliative teams.

Monday, 3 April 2017

Overdiagnosis: the case of thyroid cancer








The thyroid cancer rate has doubled or possible tripled in the last twenty years in most Western countries; however there’s a paradigmatic case, according to an article published in New England by Ahn HS and collaborators: South Korea, where this rate has multiplied by fifteen. What has happened in this country? Is there an epidemic? This should not be the case given that when experts analyse specific population mortality (as shown in the chart), this figure remains unchanged. Therefore, everything points to a spectacular case of national over-diagnosis.

The authors explain that many government-encouraged providers offer very attractive and widely accepted preventive packs, including the use of ultrasound and other more sophisticated imaging tests for the early detection of thyroid cancer. It should be clarified that in South Korea, despite there being a national health system, there are co-payments for almost all health activities and as a consequence people pay close attention to the price of combined service offerings.

Monday, 27 March 2017

Right Care: How to reduce waste








This fourth and last post related to the series "Right Care" from the Lancet magazine ("Definition, gray areas and reversion" was the first, "Between too much and too little", the second, and "Question of attitude", the third), talks about various proposals to reduce the waste with the understanding that the inadequacy in the provision of health services is a wicked problem for which there are no magic solutions and, for this reason, the article "Levers for addressing medical underuse and overuse: achieving high-value health care" makes an effort, which is appreciated, to provide useful ideas to incorporate into the working agendas of both clinical managers and health managers, according to the following proposals to increase the value that health systems should bring to people.

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.

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.