Monday, 16 April 2018

To optimise the expense, the cost must be reduced

Josep Mª Monguet

It’s well known that the budget allocated to health services has endured brutal cumulative reductions over recent years. This is a detrimental fact, but one can not deny the merit of having suffered and then having survived the cut, the professionals - in the first instance and the users alike. It’s sad but praiseworthy.

The health budget is unlikely to improve in the short to medium term because the situation is what it is and by definition the public deficit has a ceiling. Lamenting that resources were not well managed during the "good times" doesn’t change anything. Although it seems a contradiction, the financial management cannot be improved if the health system and its users, collaboratively, are incapable of reducing the avoidable costs that weigh us down. Only thus we can free up resources and allocate them to make the system more efficient.

The scope of the costs that can be and should be avoided are diverse but I propose that we look at an aspect that, although it has been studied, it may not have been focused upon enough. The question is: Should the lack of patient preparation and inappropriate behaviour, be treated as factors of unjustified increase in health costs? Expressed in other terms: Is it time for patients to assume greater responsibility with regard to their own health? When one talks about patients, does one refer to society as a whole?

By making an informal search in the literature, we can find revealing data. Although the majority of the following examples refer to studies undertaken in the USA, to some extent the conclusions can be extrapolated to our cicumstances.

Obesity/Inactivity: The direct cost of lack of physical activity can represent more than 2% of health expenditure, and the direct cost of inactivity and obesity together could exceed 9% of the health system budget.

Substances: 4% of health expenditure in smokers over 45 years of age is a consequence of smoking. Health costs derived from excess consumption of alcohol can represent an expense equivalent to that derived from smoking. Illegal drugs only account for 20% of the health costs derived from the total consumption of drugs.

Pollution: Air pollution causes 6% of total annual mortality and half can be attributed to motorized traffic.

Work environment: Between 5% and 8% of annual health costs can be attributed to management practices in companies and the impact, among others, on employee stress.

Loneliness: Work is being undertaken to measure the cost of loneliness; 

We can find other cost elements that are as relevant as those listed above. What is the extra-cost of being homeless? What economic impact does the lack of health education (health literacy) imply? What is the cost of not maintaining a balanced diet? What is the extra-cost of therapeutic noncompliance?

The data leaves little room for doubt and it’s time for patients and society to assume responsibility for their health. There is a lot of work to be done, but it’s of the utmost urgency for someone to really lead this question further. Who’s in?

Monday, 9 April 2018

Home sweet home and some other lessons

David Font

An article in the New England Journal of Medicine explains that the Department of Health in Victoria, Australia in 2010, announced the construction of a 500-bed hospital without using bricks. This virtual hospital currently receives 33,000 patients per year. And the introductory paragraph of the article ends by asking: What was the incredible technological progress that made it possible? Caring for the patient at home!

Let's continue without leaving the house. I remember post by Jordi Varela introducing the experience of Buurtzorg Netherlands, the Dutch home care company, described as a success story by King's Fund. During a Congress in Barcelona, I heard Jos de Blok, the leader of the project, explaining the experience as a paradigm of innovation success. Let's see why.

Monday, 2 April 2018

Plea for the end of clinical practice guidelines

James McCormack, a professor of pharmacy at British Columbia University, posted on his YouTube channel, a video clip that adapts the song of the Traveling Wilburys group, "End of the Line", to become "End of the Guidelines". The video begins with a scene from “Life of Brian" where the actor Graham Chapman as a fake Jesus Christ, addresses his followers from the window of his house and says: "You are wrong; you have no need to follow me. Follow no one; be yourselves, each of you is a different person."

Monday, 26 March 2018

Inappropriate use of large healthcare structures

The healthcare system has many resources that can be used appropriately, or not. Think of the child with fever who leaves the paediatrician’s office with a prescription of antibiotics, the elderly lady who ends her days in an intensive bed, when, in their case, a palliative action would have been more appropriate or the person with a moderate headache, without other neurological manifestations, which, by insistence, ends up undergoing a tomography. George Halvorson, in "Health care will not reform itself", echoes an investigation that, after reviewing 5 million medical records, concluded that waste due to clinical practices that don’t add value could be considered to reach at least 25% of the total health expenditure.

This waste affects practically all areas of healthcare, but now I would like to focus on what happens with the inadequacy of the use of large health structures: operating theaters, emergencies units, intensive care units, wards and primary care.

Monday, 19 March 2018

Experience versus evidence, regarding Ian Harris

Professor Ian Harris, author of the book, "Surgery, the ultimate placebo", is a traumatologist who directs a research unit focused on the results of surgical practice in Sydney. Harris says in the book's introduction: "Lack of evidence allows surgeons to practice techniques for the simple reason that they have always been done, because they learned them from their mentors, because they are convinced that it works or simply because it does everybody. It's easier to have no problems if you behave like most colleagues, my argument, says the author, is that trusting tradition and perceptions often leads, in terms of clinical effectiveness, to unconvincing results."

Monday, 12 March 2018

The myth of lack of adherence

Cristina Roure

It's not that they don’t know or don’t want to know, it's that they can’t

I recently read of a doctor complaining that when he began his career, he assumed that if a disease was treated, the patient would improve, but in reality the results were far from expectation. It isn’t surprising if we remember that adherence to advice and treatment in chronic patients is less than 50%, as shown by a recent survey conducted in Spain in a sample of 1,400 chronic patients.

Despite attempts to change the attitude and pardon the patient, such as calling those that don’t comply or adhere, the truth is that systems to increase adherence to treatment always focus on changing patients’ attitudes or aptitudes. Lack of adhesion is rarely viewed as a system problem.

Wednesday, 7 March 2018

Is it possible to design a health system without a narrative basis?

Salvador Casado

One of the most complex issues in health organizations is to design structures and processes that combine quality, effectiveness and user satisfaction. So far no one has found the holy grail of “the good, beautiful and cheap” in healing. Where I would like us to pause for a moment is in the analysis of the founding fact of any health system: the clinical act. The point of contact between patients and health professionals is the clinical meeting that will lead to a therapeutic relationship.

The problem is that nowadays this is very expensive and at the moment nobody dares to automate it using technology, algorithms or artificial intelligence. When you're sick, you want someone to treat you, not a robot.

Monday, 5 March 2018

Capacity, environment and diversity: changing the vision of aging

Marco Inzitari

Judging by appearances, one might think that health professionals build their fortune on the misfortune of others. Traditionally, in fact, we deal with risk, diseases and their negative impact, more or less catastrophically. And, in the face of an aging population, we focus on multi morbidity, chronic disease, geriatric syndromes, disability and the end of life.

The recent report of the World Health Organization (WHO), entitled "World Report on Aging and Health" (September 2015), is committed to a change of focus. The report, which is positioned as a reference of health policies on aging, is long and complex, and addresses many dimensions of aging, from prevention to manifestations and consequences, to the need for long-term care (not in the mere sense of resource, if not of necessity continued in time, no matter how it’s provided).

Monday, 26 February 2018

Causing a necessary epidemic

Anna Sant

I wanted to premiere this blog with a reflection that led me, a few years ago, to refocus my activity of corporate communication and marketing to the healthcare sector, an exciting sector in which there is a tremendous vocation by all its actors to provide the best service to their “clients". However, paradoxically, and this is the reason for this article, despite this strong vocation that led our professionals to practice the profession, it seems that nowadays, not only do patients feel that their expectations are not being met, but the same professionals are more alone than ever in the struggle to offer better assistance to their patients. A study of 800 patients hospitalized in the US in 2011 showed that more than 80% of them considered empathy as a basic factor for success in treatment, but only 53% believed that their referral centre was providing it.

Monday, 19 February 2018

What are the objectives of cancer prevention programs?

Vinay Prasad and Adam Cifu in "Ending Medical Reversal, Improving outcomes, Saving lives" affirmed that in order to interpret the meaning of secondary cancer prevention programs, three objectives must be kept in mind: 1) cancer ought to be discovered ahead of time, 2) specific mortality ought to be reduced and 3) overall mortality should be decreased.

The authors say that what really matters is objective number 3, given that the first two are purely instrumental. After all, if a healthy person accepts a screening, this is supposed to be because he or she wants to live longer. Unfortunately, the data shows that preventive programs (cancer of the colon, prostate, breast, cervix and lung) obtain the following results (with small nuances among them): a) objective 1: achieved, b) objective 2: weak, and c) objective 3: not reached.

Monday, 12 February 2018

Medical schools: reductionism versus empiricism

The current competitive drive has reached the medical schools to the extent that it now delivers batches of new doctors with higher scientific preparedness whose priorities are influenced by their impact, competitiveness for research funds and, to a lesser extent, clinical practice. Young doctors know that in order to fight for the most coveted positions they will have to show a curriculum full of publications, while the clinical skills, although present, will not be the element that differentiates them. What is apparent is that educational reforms are part of the mechanism which is focused on academic success.

Monday, 5 February 2018

Are we all mentally ill? On the subject of Allen Frances

Allen Frances, psychiatrist professor emeritus of Duke University (USA) led the working group that developed the DSM-4 (Diagnostic and Statistical Manual of Mental Disorders). I follow the activity of the author, always critical and always documented on Twitter (@AllenFrancesMD) and, unfamiliar with the framework of psychiatry, a question began to run through my mind. How could it be that someone who had led the fourth edition of the DSM, was now the most lucid voice against the excesses of modern psychiatry? If I wanted to know the answer, I had no choice but to read his latest book "Saving Normal. An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma and the medicalization of ordinary life"

Monday, 29 January 2018

The old is not an enemy of the new: quality standards for health institutions

Mª Luisa de la Puente

This provocative title intends to join the debate that appeared in JAMA this year on what are the quality results that an institution should establish and publish. Common objectives among institutions, from one or different countries for certain diseases selected by international agencies? Or specific objectives of each institution established according to their priorities and the preferences of their professionals?

Professionals from Kaiser Permanente (KP) and from the Department of Veterans Affairs Center (VA) and the Joint Commission Accreditation Agency (JC) disagree. The authors of KP/VA recognize that the measurement and publication of the results of certain prioritized diseases have undoubtedly contributed to the improvement of quality, but they believe that, while continuing to focus on the performance of accounts, it’s necessary to establish innovative formulas for measuring results.

Monday, 22 January 2018

The paternalism of presenting the glass half full or half empty

Pedro Rey

In previous entries, both Cristina Roure and Jordi Varela have talked about how cognitive biases and, in particular, our difficulty in understanding what probabilistic calculations really mean, can affect important decisions about our health. Today I want to show you an example, originally due to psychologists Daniel Kahneman and Amos Tversky, about the importance of the way in which health information is presented in cases in which it is necessary to make a clinical decision, given that there is uncertainty and thus, there exist different possible options which may not offer certain results. In order to better understand the example here presented, I suggest that after reading the following paragraph, you stop for a second to think and decide, before moving on to read the paragraph that follows.

“Imagine that you are a health manager who must decide between two possible measures in the face of the outbreak of an epidemic that is expected to kill 600 people. The information you have about the consequences of the two measures you should choose is as follows: if you decide to take measure A, you know with certainty that 200 people will be saved. If you decide to take measure B there is a 1/3 chance that the 600 people will be saved (and therefore, a 2/3 chance that no one will be saved). Which of the two measures would you choose?”  Please take a moment to think about it and write it on a piece of paper before continuing reading.

Imagine now that, faced with the same epidemic, you must choose between these two other measures. If you choose measure C, 400 people will die. If you choose measure D, there is a 1/3 chance that no one will die (and a 2/3 chance that 600 people will die). Which of the two measures would you decide now?

Having read the two paragraphs, you have probably already realized that there exists contradiction: measures A and C are identical in their expected consequences, as are measures B and D. However, it’s likely that you, like 72% of the subjects of multiple experiments who are asked to decide between A and B, may have chosen A, while, like 78% of the subjects who are asked to choose between C and D, you may have chosen D in the second question. How can this inversion of preferences occur?

Kahneman and Tversky, based in evidence from simple experiments like the one I have shown you, are responsible for the so-called "prospective theory", which offers an explanation. Summarizing it briefly, the theory says that human beings suffer more from negative events than what they enjoy from positive events, which leads us to behave as risk-averse when dealing with positive outcomes, and instead behaving like risk-lovers when faced with events which may have negative consequences. When we must choose between A and B many of us value more the certainty of saving 200 lives with measure A than taking the risk inherent to measure B, which with a low probability will save even more people. However, when it comes to assuming deaths, i.e., when choosing between C and D, we feel better when taking measure D (equivalent to B), which with low probability can achieve not deaths, than when taking measure C (equivalent to A) which assures us that we’ll have to take responsibility for the death of 200 people.

The problem presented by this example is not so much that it demonstrates that human beings are contradictory, which barely surprises us anymore, but that it opens the door for us to be manipulated when making decisions, merely by how the data is presented to us. This manipulation capacity is of particular importance in clinical practice where, for example, in an environment in which an attempt is made to promote shared decision making between doctor and patient about which treatment to follow, the doctor can continue to exercise full control over the patient through presenting the information of the healing possibilities or possible side effects in a positive or negative way. Therefore, it’s important to recognize that, if you really want to favor freedom of choice in situations that by definition involve risks, and thus probabilities, it’s necessary either to move towards greater education of those who receive the information so that they are able to interpret it correctly being aware of their own cognitive biases, or to do an enormous exercise of honesty and exposing this type of mind tricks, dedicating enough time to helping others  understand in an objective way, and not biased by our own self-interest, the expected consequences of their decisions, in some cases literally of life or death;  Give me freedom of choice or paternalism based on the specialists’ expertise but don’t disguise one as the other.

Monday, 15 January 2018

The orientation to the patient: a health service as a "service"

Sophia Schlette

One year ago, while I was still working for Kaiser Permanente, I was invited to give a talk on primary care concepts in an adult education academy in the vicinity of Berlin. I thought I would present a theoretical framework of evaluation, based on evidence, consisting of ten dimensions, similar, but not identical, to the ten building blocks of Bodenheimer already presented in this blog. I arrived on the previous afternoon and saw the participants with a certain air of frustration in being saturated with so much theory. The models and concepts of the talk had little to do with the experience in the German medical practice or with the doctor-patient relationship in real life. In Germany, if you go to the doctor, you have to take half a day off. Wait up to 40 minutes, despite having an appointment just to have 5 precious minutes with the doctor. Typically, neither the doctor nor his employees will give any explanation, nor apologize for the delay. There is no electronic medical record everywhere and where there is, the doctor begins to read it only when the patient is present: “Here’s the recipe. Have a good day. Goodbye” This is the German system, as we know it since childhood.

Monday, 8 January 2018

“The patient will see you now” on the subject of Eric Topol

Eric Topol, Director of Scripps Translational Science Institute, published in 2012 "The Creative Destruction of Medicine" and in 2015 "The patient will see you now. The future of medicine is in your hands." For a long time I had this last book on the waiting list and finally I could read it taking advantage of the holidays. It’s an important work, which talks about technology based on in-depth knowledge of clinical practice. It’s a literary piece, for my taste, a bit too overloaded, to the extent that, in some chapters, it’s difficult to follow the thread of the main thesis, but despite this, I have to admit that the contributions of the professor of genomics (and cardiologist) are relevant and I think they deserve to be discussed.

Monday, 1 January 2018

The induced gray areas

From scientific points of view, one tends to think that the clinical practice is binary. That is, it’s thought that the medical actions are either effective or ineffective. The reality of the practice teaches, however, that on the ground, the gray zone is much broader than one would hope because many clinical practices are neither clearly effective nor clearly ineffective. In an article in The New England Journal of Medicine, "Addressing the Challenge of Gray-Zone Medicine," Chandra and colleagues claim that due to the dazzling effects of new drugs and technologies, the gray area is expanding and therefore, these authors claim strategies to reduce the phenomenon.