Monday, 14 August 2017

Emergency services specific to the elderly








Elderly care is best resolved at the primary care level, with a geriatric orientation and in a community setting. However, sometimes older people need to go to the emergency room for a variety of reasons, such as a fracture, fibrillation, retention, sudden choking or blockage, to name just a few reasons. What happens then is easy to imagine, the geriatric patient is subjected to a triage that leads to a box full of devices, with many people asking the same things repeatedly, some of them with very little tact and almost always with little respect for intimacy, not to mention the discomfort caused by the racking in the corridor, bells and alarms, noise from machines and monitors, and a long etcetera, that easily produces the disorientation of the elderly patient, or delirium in the worst cases.

Towards a new design of emergency services specific for the elderly

In the blog of the British Geriatrics Society, Dr. Rosa McNamara advocates for the creation of specific emergency services for the elderly, points out the similarity to what happened a few years ago with the creation of paediatric emergency services. Children, she says, have different psychological, physical, and social characteristics than adults, and need care by nurses and specialized doctors to ensure appropriate treatment. Today it would be unthinkable to have to treat a child in a general emergency room environment and, worse, by nurses and doctors with no experience in paediatrics.

How should a geriatric emergency department be?

American Geriatrics Society and three other scientific societies, also North American, related to emergency services, have together published the document, "Geriatric Emergency Department Guidelines," which provides guidelines for the creation of geriatric emergency services. This is a document that talks about the structural characteristics that the space should feature: the least noisy possible, the cubicles should preserve privacy, the lighting should adapt to circadian cycles (day/night), there should be large and visible analogue clocks on the walls, the floors should be non-slip, anti-decay mattresses, comfortable chairs, there should be handholds in key locations, etc. it’s a matter of defining a space, usually next to the general emergency service, adapted to the geriatric needs. But the structure is obviously not everything, and that is why the document defines criteria for triage, professional functions and protocols to avoid the most common geriatric complications and, above all, what should be the basic training of the assigned professionals (nurses, social workers and doctors).

The first geriatric emergency room opened its doors to Holy Cross Hospital of Silver Spring in the US in 2008, and nine years later there are already hundreds of US hospitals offering this service. That is why it has seemed relevant to me that the British Geriatrics Society has opened the debate on the opportunity to boost geriatric emergency services within the framework of European public services.


Jordi Varela
Editor

Monday, 7 August 2017

Improving by playing


David Font




Volkswagen launched a campaign, The Fun Theory, aiming to improve habits by introducing game techniques. Let's look at an example.


Anna Sort, a nurse, a professor at several universities and an expert in gamification (a new word) in health, in her blog Lost Nurse in the Digital Era defines gamification as "the use of playing techniques in activities that initially contained no play" with the objective of involving people and solving problems. She argues that we are all potential players and that video games have introduced the game into many aspects of our lives. Mechanics such as collecting, awarding points, providing feedback, promoting exchanges or personalizing, favour motivation and involvement. The challenge is to transform any activity into fun and to make the game difficult enough for people to be enthusiastic about solving it, without finding it impossible.

Monday, 31 July 2017

Evidence in the care continuum - one of the keys to the telemedicine’s success or failure?

Josep M. Picas



It’s notorious that there are a great number of experiments, publications and studies on the application of telemedicine. Over the last few years, this phenomenon that we could label as the "apps revolution" has given telemedicine a great boost. However, the results, in many cases, have not reached the expectations. 

Many studies have tried to identify the causes of this unsuccessful outcome. In a brief reference, we could mention the professionals’ inertia and resistance to change in their work processes, errors of design, i.e. not being focused on patients, regulatory aspects, lack of resources and patient adherence problems caused by, to name just two, little health literacy or the digital gap issue.

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.

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.

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).

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.