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.



The consequences of aversion to revocation are evident:

a) Patients’ exposure to adverse effects in exchange for a zero benefit
b) Waste of health resources and threat to the system’s sustainability 
c) Patients’ distrust in the system and in the professionals
d) Contamination of the shared clinical decision process.

Therefore, it would be logical to correct quickly and abandon the revoked practices as soon as possible, but this isn’t usually the case, and on average the practice persists for ten years before being abandoned.

Cognitive bias is the tendency to maintain a partial perspective that distorts the perception of what is obvious is called cognitive bias and appears to be prevalent in medical practice.

Intervention Bias  is the unconscious tendency of professionals or the medical community to intervene, either with drugs, diagnostic, tests or with procedures, when non-intervention would be a reasonable alternative or even better. The existence of this intervention bias has been demonstrated in several surveys carried out with professionals who, before two equivalent options, they usually choose the interventionist versus conservative option (2).

The causes that explain these biases are diverse. We are often seduced by elegant and sophisticated rationally impeccable and basic science arguments, with the illusion that they can predict what will happen in practice, and we adhere to it without waiting for the necessary evidence regarding its benefits and the real risks to be generated. Here we can add the confirmation bias, or the unconscious tendency to favour the information that confirms our hypothesis (3). Conflicts of interest, not necessarily economic, don’t help either; these sometimes, intentionally, conceal or delay the publication of the complete results of studies when they are negative (publication bias). Defensive medicine that abuses diagnostic tests while being aware of their futility doesn’t help and neither does the relative incompetence of the medical community for the critical evaluation of evidence or the understanding of risk that explains the tendency of professionals to overestimate the benefits of treatments against risks.

But if faced with the new options we can frequently observe an intervention bias, in contrast, when faced with the revocation of established practices, other biases such as the status quo bias, the anchoring or aversion to loss biases predominate. One example is the persistence of screening programs for some cancers despite accumulated evidence of their ineffectiveness in reducing mortality.

The status quo bias occurs when the individual gives more value to the losses associated with the decision than to the potential gains. I recommend you read Jordi Varela’s post illustrating the bias of the status quo with some examples where, despite having been revoked, the often preventive clinical practice is maintained. This type of bias is reinforced by other biases such as the aversion to loss or anchoring bias or the omission that occurs when faced with two reasonable alternatives; the fear of negative consequences of action is greater than that fear derived from the eventual consequences of the inaction and, therefore, the maintenance of the status quo is strengthened.

We can see that the medical community is enthusiastic about new practices and tends to adopt them quickly, even when they are based on studies with clear limitations, but the same medical community is much more reluctant to abandon them when they are ineffective or harmful, even when faced with clear evidence. Despite the famous “primum non nocere”, if the question is to do or not to do, it’s clear that in medicine, the tendency is toward the first option. 

Bibliopgraphy:

  1. Prasad V et al. A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices. Mayo Clinical Proceedings 2013;88(8):790-798.
  2. Foy A, Filippone E. The Case for Intervention Bias in the Practice of Medicine.Yale Journal of Biology and Medicine 2013; 86: 271-280.
  3. Schiff G et al. Principles of conservative prescribing. Arch Intern Med 2011; 171(16):1433-1440.

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.

The three qualities to generate a blue ocean

If the aim is to generate a disruptive project of complex chronic patients’ care, that is, to create a blue ocean, it would be imperative that the most involved professionals: primary care doctors and nurses, municipal social workers and geriatricians, abandon the heavy meetings of circuit and coordination and see if they are able to define the three qualities of blue ocean generation proposed by Chan and Mauborgne: a) What is the focus of the project? b) Why are the differences between the involved actors not being negotiated? c) Can they agree on a convincing central message?

The four actions to be undertaken

Once the three qualities of the project have been defined, the promoters should focus on four actions to value what they do. They are supposed to be clear that the aim is to go beyond simple coordination. If so, I recommend implementing the following scheme: a) What actions should they create? b) What actions should be increased? c) Which ones should be reduced? d) Which ones should be eliminated? If you do this exercise, you will probably realize that, from the communicating vessels between these four groups of actions, resources that would feed the new actions could arise, starting from abandoning those actions that have already been proven not to bring any value. 

Overcoming the four barriers to innovation

The blue ocean strategies depart from the status quo, so you have to know that if you want to innovate in a disruptive project, based on current experience and knowledge, strategies should be defined to address the four barriers that are sure to be encountered on the way: a) The motivational barrier - that is why it’s necessary to know how to transmit project values ​​to team professionals; b) The cognitive barrier - being able to explain all the details of organizational changes and how they involve each one; c) The resource barrier - detecting the waste of those actions that don’t add value (remember Sutton's law?) and d) The political barrier – knowing how to harmonize political interests existing in all elements of power related to the project.

Leadership by turning point

Finally, if you’re interested in the blue ocean strategy, you must pay attention to the concept of leadership by turning point. The authors' recommendations for disruptive leaders are that they have the ability to define hot zones, where few resources can achieve high yields, in addition to the cold areas, which are the ones that are wasting large resources with poor results. Another tip is that leaders must be able to work in the field of disproportionate influences, both positive and negative, because these can change the progress of the project.
In complex chronic patient policies, the theories are well defined but, between the status quo of care levels, institutional competencies and the myopic clinical visions of many specialties, the results are still scarce. I think it’s time to embrace blue ocean strategies with the intention of developing projects with added value and with disruptive force, following the methodology of first defining the qualities of the initiatives, then taking the necessary actions, knowing how to fight the barriers and enabling leadership by point of inflection. In a nutshell: less theory and more strategy.


Jordi Varela
Editor


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).

Monday, 5 June 2017

Life quantity or more quality?








Ventricular assisting devices, VAD, or LVAD if for the left ventricle (the most common) are implantable instruments that help pump blood in situations where ventricular ejection force is severely compromised. In some cases the implantation of an LVAD facilitates the waiting for a cardiac transplant, but in others it’s adopted as a definitive solution. The price of the device is around $150,000 while the cost per QALY (cost per year of life earned) is between $200,000 and $400,000. The cost-effectiveness studies still don’t line up much, but the range of documented amounts is nowadays far above the $30,000 of Spanish per capita income. Remember that the WHO introduced the criterion of considering if a treatment is cost-effective when it doesn’t exceed three times the per capita income of a country.

Monday, 29 May 2017

Caesarean section as a consumer good








In private medicine in Brazil, the rate of caesarean section has reached 90% of births. In that country, gynaecologists and midwives, if any, have lost the job of helping women to give birth, and some obstetrical clinics only work to schedule and during office hours. Bad research has not helped either. In the year 2000, a team of researchers led by Dr. Mary Hannah revealed that the caesarean section was a safer practice in breech presentations, information that had an almost immediate impact on clinical practice. Four years later it was found that the research had been poorly done and that its conclusions were wrong, but gynaecologists had already lost the skills (not easy) to practice vaginal births for breech babies. The result is that nowadays the breech foetal position is, assumed to be equivalent to caesarean section, despite the lack of evidence that supports the indication.

Monday, 22 May 2017

Beyond the reforms (on the subject of Franco Basaglia)








What can we do when reforms are in short supply? This is a question that many of us ask ourselves when rigidities and bureaucracies show us their sordid face. Without going any further, the integration of services and community work is the only way (I think there are no dissenters in this) to adequately care for complex chronic patients, but when it comes to the truth, it turns out that the levels of care, professionals’ abilities and the fragmentation of medical specialties are a drag on the progress of the necessary reforms.

I’ve pondered on this when I read that The Guardian had just published a book by John Foot, "The man who closed the asylum" that tells the life of Franco Basaglia, a psychiatrist with an exceptional entrepreneurial force. During the war, according to the author, Basaglia was imprisoned as an antifascist and this experience was key to the fact that when he was appointed director of an asylum in the early 1960s, he realized that the psychiatry practiced in that establishment was inspired by and took the shape of prisons.

Monday, 15 May 2017

The controversy of health checks








The National Health Service announces health checks by making use of the mood of the "Full Monty" or "The Calendar Girls." Let yourself be undressed for a good cause - they say - your body deserves it. In Spain, on the other hand, this approach is more typical to the private offer. "The best way to take care of your health is to open your eyes to possible diseases and not hesitate to undergo periodic tests to prevent them," says "10 Minutos" magazine in an article on the subject. Many private centres have "Medical check-ups" and most insurers and clinics offer health check-ups, as can be seen in an announcement from the Quirón Teknon Hospital: "basic preventive check-up: previously € 820 - now € 690; advanced preventive check: was € 1,800 - now € 1,520". The Sanitas proposal that offers the possibility of choosing between "checks: classic, integral and complete" is also interesting just as the National Conference of Marketing and Sales Management of the Health Sector that says "the most demanded from the iGlobalMed platform are the health checks for managers who are going to work abroad". To end this journey through the world of health reviews, see the clip below from the University Hospital of Navarre website:

Monday, 8 May 2017

What if I decide to do nothing?








TIME magazine has surprised us with a question on its front page: "What would happen if I decided to do nothing?" Desiree Basila, a 60-year-old teacher, had just been diagnosed with ductal carcinoma in situ (DCIS) and, overwhelmed by the aggressiveness of the treatment proposals offered to her, began to investigate on her own and realized that there were many unknown elements about the progression of this type of injury and also saw that there was no agreement in the scientific community on what should be the most appropriate therapy for her case. For this reason she made a bold decision and asked her oncologist to do nothing, which resulted in two checks a year and a treatment with Tamoxifen, a drug that blocks estrogens that could cause the tumour to grow.

The case of Desiree Basila is quite valuable because when she made this decision, 8 years ago, it was not yet known that the mortality of women with DCIS, regardless of the type of treatment they adopt, is 3.3%, a figure comparable to that of the general population, and it was also not known that chemotherapy has no effect on tumours in initial staging. But to better understand the pressure that Desiree had to endure, it should be added that the attitude of most oncologists, even in the case of DCIS, was, and remains, "the sooner the better and the more the better."

Monday, 1 May 2017

Primary care: segment to reform?







In a paper published in Health Affairs, Redesigning Primary Care: A strategic vision to improve value by organizing around patients' needs (see commented post) Michael Porter invited us to rethink the organizational model of primary care in accordance with the real needs of the population.

Following the Porterian advice, and just to think a little, it’s worth the excellent Memory of the Catalan Institute of Health (ICS) of 2013, with data from 288 primary health care teams spread throughout the territory, from small local clinics to metropolitan centres with several basic health areas under their care. On page 7 of the document you will see a table elaborated with the attendance of more than 4 million people (who have been visited at least once during the year). The segmentation of this population, grouped with Clinical Risk Group, shows that segments 5, 6 and 7 (different intensities of chronicity) have represented 64.5% of the people who have visited, a group that has consumed 88.8% of the pharmacy and generated 74.7% of urgent hospitalizations (among patients who have been hospitalized two or more times in a year).

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.

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.

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).

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.