Monday, 16 July 2018

Health incentives: don’t shoot the behavioural economists!

Pedro Rey



The debate on the allocation of (economic) incentives associated with the performance of health professionals has been relevant for a long time. A few months ago, VOX has published an editorial with a very clear title: Paying Doctors Bonuses for Better Health Outcomes Makes Sense in Theory. But it doesn’t Work. The article cites numerous recent studies, such as this one on the United Kingdom or the United States, that show no effect of giving incentives to physicians either in their clinical practice patterns (inputs) or in health outcomes (outputs). A systematic review of studies on "pay for performance" (P4P) in the Annals of Internal Medicine reaches similar negative conclusions. However, a marked anti-economist tone of these articles emerges that I believe comes from a confusion. According to these articles, economists only know how to prescribe the use of incentives, without evaluating their effects, and also the incentives that we advise are only monetary and don’t appeal to the many different motivations, not only monetary, that can affect doctors decisions.

My response to these criticisms is that they generalize and caricature the profession of economist. It’s obvious that there are many economists with media success or with political influence who talk rubbish, but we should stop listening to them (another day I’ll talk about how to discriminate between one type of economist and another). Not even the best economists would be inclined to recommend incentives based only on theoretical models without a previous empirical evaluation, ideally with randomized experiments. All economists have an extremely limited view of the human being (and the doctor) as someone for whom only financial incentives matter and therefore motivate them. The area of ​ Behavioural Economics, which a growing group of economists are working on, studies precisely the multiplicity of human motivations, as well as our cognitive difficulties to make "correct" decisions in situations of pressure. Both the multiple motivations and the fact of having to make decisions, literally of life or death under stressful conditions, are common characteristics of the day to day of the health professional. Designing incentives that really motivate and guide the doctor to make good decisions is therefore a crucial part of behavioural economists’ work, and not only of the so-called health economists. In the article "When and Why Incentives (Don’t) Work to Modify Behaviour", we review the use of incentives in very similar areas such as education or the creation of healthy habits. Perhaps some of these lessons can be applied to incentives for health professionals.

The problem in the indiscriminate use of monetary incentives among professionals is that at first glance, it seems to respond to that logic of domestic economy that our president, Mariano Rajoy, likes so much: "the more I get paid to do something, the harder I will try and be better at my job". Let's analyze the problem of these three phrases applied to the health field:

  1. "The more I get paid": it’s not very clear that any health system, moreover a public one, can offer monetary incentives high enough to compete with the pharmaceutical and health technology industries. In an environment in which these institutions combine financial capacity with very clear and biased interests so that the physician can make decisions that favours them, it doesn’t seem very effective to start an upward race to see who can guide the price to a higher level so that the most convenient decisions are made. As the title of one of the articles by one of the key economists of Behavioural Economics,  Uri Gneezy says, "Pay enough or don’t Pay at All". The problem is that we may never be able to pay "enough" to offset the incentives offered by institutions with other interests. But, beware: the possible motivations of doctors are much broader than simply monetary ones. If these motivations are diverse (prestige and professional stability, the altruistic feeling of improving the patient's health, the good image that a doctor projects towards others ...), so should the possible incentives that, properly designed, can be given to get a better performance from the professional. The health manager should realize that many other tools at his disposal also involve powerful incentive mechanisms for health professionals and can help, if used in a systematic and thoughtful way, to greatly improve performance: job stability, flexible scheduling, greater independence in decision making depending on results, possibility of training in other centres and other techniques, facilitating the ongoing contact with the treated and cured patients and greater transparency on the individual contribution of each doctor. In this recent study by Social Science and Medicine it’s shown that not even doctors who receive monetary incentives have greater job satisfaction than those who do not, so money doesn’t seem to be the only thing that motivates them. In addition, there is the classic problem of the possible negative interaction between different types of incentives: by giving a monetary incentive one can substitute the original motivation for which a person did his job well, for the economic motivation, which can have perverse effects and anyway, it makes it very difficult that once the incentive is withdrawn, the original motivation for "doing things right" is retained. For example, would you still be a blood donor if you were paid to do so from now on?
  2. "The harder I try": It doesn’t seem that the primary problem of the health professional is the of lack of effort. On the contrary, it’s not so clear what is translated "to try harder" when there are multiple treatment guidelines. Does the interventional surgeon make more effort than the one who decides on a more conservative treatment? Obviously, one can try to define the "appropriate" treatment, for example, through clinical practice guidelines and then study whether the doctors who receive incentives apply this method more, but even in such clear cases, the existing evidence clearly shows that Incentives work to change behavioural patterns of specialists with highly trained opinions on how to treat their patients. In many cases, resources are squandered by encouraging treatment guidelines that already exist, or the doctor who doesn’t follow the indicated pattern is penalized even in cases in which he should not do so simply because of the patient's individual character.
  3. "The better I do my job": The problem is even greater when we want to measure the effectiveness of incentives through results, such as health outcomes. In these cases, the problem is not so much in choosing the variable by which to measure the result, but in interpreting causally that this improvement has really been due to the change in behaviour of a doctor who receives an incentive. Separating historical effects, such as the evolution of a disease, is something that good economists could contribute with their econometric techniques as long as they had sufficiently rich data, ideally designed with an experimental approach, to do so. 

Therefore, the debate between managers and health professionals on the use of incentives should remain open, but should leave behind prejudices and listening better to what seems to motivate professionals. Neither economists only talk about "monetary" incentives, nor should doctors only worry about receiving more money. Let's be smarter by designing incentives that really appeal to the true motivations of the professional, to then evaluate their effectiveness (or lack thereof) according to the correctly defined objectives. 

Monday, 9 July 2018

Do we need audits or indicators to control the quality and safety of health centres?

Mª Luisa de la Puente 


Are care indicators useful in detecting the quality problems in hospitals? This question, which seems obvious, has its crumb. Alex Griffiths, of the School of Management at King's College London, has just published the results of a study of the usefulness of health indicators as predictors of the quality of care of English hospitals and the conclusion is that you can’t trust them too much.

The Care Quality Commission (CQC) is responsible for ensuring the quality of health and social services in England (more than 30,000 providers). Due to the scarcity of resources to carry out on-site inspections, the CQC used statistical surveillance through health indicators to prioritize those hospitals that had quality of care problems and subsequently send inspectors to these centres. The inspectors’ mission is to analyze the situation and give support to the suppliers for the orientation of the improvements. What was surprising to see was that the instrument "Intelligent Monitoring" (IM, scale of risk composed of 150 indicators, among others waiting list, mortality, surveys of users and professionals, etc.) is not able to predict which hospitals present quality problems or discern between those that work well and those that need improvements (compared to the classification of sanitary inspectors).

Monday, 2 July 2018

Improving the emergency and territory services: defragmenting the system

Xavier Bayona



In several articles of this blog you can read that one of the challenges to overcome in our and in most healthcare systems is the excessive fragmentation in health care that inevitably leads to duplication of tests and other dysfunctions that create pockets of inefficiency and malfunction. Several proposals to improve the continuity of care and reduce fragmentation have been presented with the aim of improving the quality of citizen attention, increasing the effectiveness and efficiency of the system.

Fragmentation is also present in emergency services. So if we look to the NHS, we can find a report published by the Royal College of Emergency Medicine with the Patients Association (Time to Act-Urgent Care and A & E: the patient perspective) published in May 2015, which concludes that primary care emergency services should join with those of hospitals. In this regard, as early as 2013, Bruce Keogh, medical director of the NHS, made the same recommendation. it’s commented within 2015 report that joint placement services should include emergency physicians, family physicians, nurses, frailty care, palliative care and mental health teams. It’s also commented that pharmacists and dentists could also contribute to the efficiency and effectiveness of the service.

Monday, 25 June 2018

The red line of health data

Elena Torrente




The great technological giants (Google, Apple, IBM or Microsoft) are recruiting scientists and experts in medical research. Their commitment to transform medicine is decided, but John T. Wilbanks and Eric J. Topol warn of possible risks in this interesting article published in Nature. Given the difficulties that medical research has always encountered in obtaining health data, the authors believe that it may be tempting for clinical scientists to access large-scale Internet projects, with significant data collection capabilities and algorithms for analysis.

But there is a risk that Google or other smaller companies such as 23andMe, will access health data with the aim of controlling the methods used to offer certain services based on digital profiles. This is what in other sectors of the Internet is called the society of the "black box". There are ads that are only offered to certain groups of people and if these algorithms incorporate health data, the authors say that pre-existing biases in our society would increase along with inequalities.

Monday, 18 June 2018

Vinay Prasad: Why is 40% of clinical practice wrong?








On May 18, Vinay Prasad offered a conference in Barcelona as part of the 5th "Right Care" Conference of the Clinical Management Section of the Catalan Society of Health Management (SCGS), where we had the opportunity to invite him to explain why he had created (with Adam Cifu and other collaborators) the list of 146 clinical practices that would have to be reversed and what are the criteria they had been used.

What is medical reversal?

According to Prasad, a medical reversal is the need to stop a clinical activity because a well-done study, usually a clinical trial with finalist indicators, shows that in fact, the desired results are not achieved, or that the adverse effects do not compensate the benefits. The speaker gave some very diverse examples, such as the Swan Ganz catheterization to monitor the hemodynamic balance of patients in shock, the hormonal treatment for post-menopausal women in order to reduce coronary or cerebral vascular risk and the placement of coronary stents in patients with stable angina to reduce the risk of infarction, increase survival or even to delay the effort angina. In all three examples, consistent clinical trials have shown that these were clinical activities that, in practice, did not meet the set objectives, and in addition had side effects, which were not unimportant.

Monday, 11 June 2018

Radiologists and incidental imaging findings








A group of radiologists from several American university hospitals (Massachusetts General, Cleveland, Brigham and Women's, etc.) started a debate in the Journal of the American College of Radiology about the eventuality that radiologists would stop reporting the incidental imaging findings lacking clinical significance. "The traditional role of the radiologist," they say, "is to warn of everything they see, leaving the interpretation of the findings’ relevance to the referring physician”. However, we now open the opportunity to go further, and not just intervene by saying, for example, that an observed abnormality is benign, but also taking the decision not to report the milder ones, given the possibility that our opinion generates confusion and ends up causing excessive medical actions".

Regarding level I renal cysts of the Bosnian classification

The radiologists who authored the article used the findings of renal cysts, which are very frequent with a prevalence of 36% in patients over 80 years of age, in order not to inform of renal cysts of level I of the Bosnian classification in their reports, in accordance with the following criteria: a) the cyst is not the reason for the examination, b) doesn’t generate local problems, c) has no malignant potential, and d) is not likely to generate a polycystic kidney disease.

Monday, 4 June 2018

Coronary Bypass and Hemodynamics: the amount matters








In the article "Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain", signed by a Spanish-English team in which Sandra García Armesto (IACS) and Enrique Bernal (REDISSEC) participated, it was concluded that the Spanish hospitals of the study operated in general with a smaller number of cases than the English (it was coronary bypass). Therefore, it is suggested that the number of cases intervened should be a tracer that could explain why mortality from this process is twice as high in Spain as in England.

European Collaboration for Healthcare Optimization (ECHO) is a European network of administrative databases for the analysis of clinical practice variations. In the following article: "Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine Safe Threshold", carried out by almost the same authors as the previous one, based on data from the ECHO project, confirms that for interventions of coronary bypass there is a clear relationship between volume and mortality and concludes that the minimum limit of interventions of a cardiac surgery team, if you want to safeguard the safety of patients, should be 415 per year. In the following graph (from the previous article) it is observed how the Spanish hospitals that participated in the study (dark spots), generally underwent fewer coronary bypasses (many did not reach 200) and showed greater mortalities.

Wednesday, 30 May 2018

In the rescue of health leaders and health guides

Salvador Casado





In the area of public health, where I have been working for a long time, we have suffered a profound crisis of leadership. Although all positions of responsibility are well filled and more and more management positions are being designed, paradoxically it is rare to find managers or professionals who lead teams towards specific objectives or missions that open new paths.

The usual path is the protocol, not to get out of the established, to avoid changes and innovation and not to leave the office or the consultation to skip hazards.

This attitude in management staff is being imitated by ordinary professionals who follow their instructions. The overload of care and institutional neglect cause family doctors to barely leave their offices to implement some community activities, nurses and social workers the same and in hospitals everything is considered within the service interacting as little as possible with primary care services or other agents.

Monday, 28 May 2018

Overdiagnosis in depression: there are doors better left closed

Andrés Fontalba




A young Cecilia, aged 13, in Sofia Coppola's brilliant film based on the homonymous novel, "The suicide virgins" advised:

-Obviously doctor, you were never a 13-year-old girl.

It’s obvious that depression in children and adolescents is an important cause of disability and generates great suffering for the person and his or her environment, requiring specific management adapted to the needs of that peculiar age. Based on the severity of this pathology, the availability of effective screening tools in the detection of depression, and a treatment that improves prognosis, the United States Preventive Task Force in 2009 recommended the screening for depression in all adolescents in a medical and integrated with mental health services setting, despite not having any previous trials that would justify this intervention.

Monday, 21 May 2018

The English surgeon, talking about Henry Marsh








Not too long ago, after having read his book "Surgery, the ultimate placebo", I wrote about Ian Harris, an Australian traumatologist. I remember that Harris defends the rigor in the surgical indications after having observed that more than half of the surgery that is practiced does not have enough support of consistent scientific evidence. Now I have finished the book "Do no harm", by Henry Marsh, an English neurosurgeon at the lintel of retirement, and I am inevitably immersed in the comparison between the two texts: first, Harris's, is written by someone who loves surgery and believes that too often is practiced with little rigor, while the second, Marsh’s, is a biography of great literary level, elaborated from the notes that the surgeon has been taking throughout his career, not in vain has he received several recognitions. Marsh, like Harris, is passionate about his work, but his literary contribution comes not from scientific exaltation but from the knowledge he has accumulated from his own mistakes. The veteran English neurosurgeon has not published any revealing research nor has he led any innovative discovery. His honesty and his hands are his strength.

Monday, 14 May 2018

Self-management: Buurtzorg Identity








Frederic Laloux in "Reinventing organizations" describes the teal-evolutionary companies as those based on the personal growth of their employees and chooses Buurtzorg Netherland as an organization to which we should be paying attention to if we are among those who believe that the time to do things differently has arrived.

What is Buurtzorg Netherland?

Buurtzorg Netherland is a non-profit company, which was founded in 2007 in the Netherlands, when a group of community nurses rethought their work and came to believe that, instead of only going to homes and exercising the functions of their profession, they should advance to becoming the patients’ referee and take charge of attending to their global needs.

Monday, 7 May 2018

I don’t know ... but it seems to me that times are changing

Joan Escarrabill




Health care’s future is an issue that is debated multiple times. The most academic visions or those that start from the observation of reality have common elements. Increasing the number of professionals (more doctors and nurses are needed, is strongly agreed), to the extent that the weight of the hospital will be reduced and interventions in the community will gain prominence, health education of the population is very important or in what way are we going to create sustainability in a system that has contributed significant improvements during the last years, can be just a few examples of these common places of all the debates.

Monday, 30 April 2018

Could we organize ourselves in a different way?








Frederic Laloux, in "Reinventing Organizations", a revealing book, at least for me, invites us to rethink the way we manage companies. The age of the internet, he says, has precipitated a new vision of the world that contemplates the possibility of a distributed intelligence instead of a vertical hierarchy. According to Laloux we should be able to invent a more powerful and meaningful way of working together if we would change our belief system.

In the first part of the book, the author makes an evolutionary analysis of the way in which humans organize companies, which I found colourful and insightful, and that is why I have prepared a summary (for more details I recommend going to the tables that are at the end of chapters 1.1 and 2.3):

Wednesday, 25 April 2018

Weapons of mass distraction in the National Health System

Salvador Casado




When we go to a health professional's office there are recurring constants, white coats, stretchers, blood pressure monitors and a computer on the table. The medical record is no longer a folder full of paperwork, but an electronic form on which health professionals work. There is no doubt that it has many advantages over the previous format but it has not yet been able to correct its major flaw: its great power of distraction of the professional who uses it.

The limitations of design and usability mean that at each clinical meeting a considerable amount of time has to be devoted to registering, filling in numerous protocols and making requests for analyses, consultations to other professionals or issuing prescription, bureaucracy  or reports of any kind.  The perception of many patients is that health professionals look at their screens more than they do at themselves, and that's usually not cool.  Nor is it a dish  for nurses and doctors who see how their limited time is spent on tasks that prevent them from devoting dignified attention to the people they attend.

Monday, 23 April 2018

Debate with Vinay Prasad on the value of clinical practice and doctors’ training








Vinay Prasad (University of Oregon) and Adam Cifu (University of Chicago), authors of "Ending Medical Reversal: Improving Outcomes, Saving Lives" (Johns Hopkins University Press, 2015), point out 146 clinical practices that should be ditched because it has been proved that they do not deliver the promised results. The list of these practices affects the whole range of the health activity; however, making a detailed reading, it has been observed that these are mainly found in four specialties: cardiology, gynaecology, orthopaedics and family medicine. It’s because of this reason that the Section of Clinical Management of the Catalan Society of Health Management (SCGS), in its Annual Conference to be held on May 18, in agreement with the team of the project Essencial of AQuAS, has organized a debate between one of the authors of the book, Vinay Prasad, and representatives of the 4 mentioned specialties: Xavier Viñolas, president of the Sociedad Catalana de Cardiología (SCC), Juan José Espinós, gynecologist at the Hospital de Sant Pau, Joan Miquel, orthopaedist at the Hospital de Igualada and Marta Expósito of the Sociedad Catalana de Medicina Familiar y Comunitaria (CAMFIC). The debate, which will rely on the moderation of Sandra Garcia Armesto, director of the " Instituto Aragonés de Ciencias de la Salud ", aims to not only find out first-hand about the work of Vinay Prasad, but also to find out what the related specialists think of these practices and what is the impact on our situation, differentiated in many aspects from that of the United States.



On the other hand, Prasad and Cifu, in the book, propose to significantly modify the training programs in medical schools, in order to train new physicians that are more demanding with regards to scientific rigor, more critical of practices with poor value, more sensitive to the needs of patients and more oriented to the evaluation of results. The proposed formula is very simple: the clinical sciences should be the priority, while the basic ones (as we understand them today) should be complementary. It’s not about studying models and then checking them (current system), but about doing it the other way around: from the findings of the clinic, doctors should review (or accept) the theories. Given the importance of the proposal, we thought it appropriate to organize, in the same framework of the Conference, a second debate moderated by Xavier Bayona, with three academic authorities in the training of doctors: Francesc Cardellach (Universitat de Barcelona), Ramon Pujol (Universitat de Vic - UCC) and Milagros García Barbero, president of the Sociedad Española de Educación Médica and, logically, also inviting Vinay Prasad to join them.

The program of the Conference is attached, with the clear purpose of encouraging all readers to register, because nobody should miss out on the opportunity to listen to and pose questions to Vinay Prasad and all invited speakers.






















Organizes:
  • Clinical  Management  Section  –  Catalan  Healthcare  Management  Society 
In  collaboration  with:
  • IDIBAPS.  Institut  d’Investigacions  Biomèdiques  August  Pi  i  Sunyer  
  • Centre  de  Recerca  en  Economia  i  Salut  (CRES)  –  Universitat  Pompeu  Fabra  
  • Institute  for  Healthcare  Management  -  ESADE  
  • Agency  for  Health  Quality  and  Assessment  of  Catalonia  (AQuAS)  
  • Hospital  Clínic  de  Barcelona  
  • Aragonese  Institute  of  Health  Sciences 
  • Catalan  Society  of  Family  Medicine  (CAMFIC)  
  • Catalan  Society  of  Cardiology    
  • Catalan  Society  of  Gynecology  and  Obstetrics  
  • Catalan  Society  of  Traumatology  and  Orthopedic  Surgery  
  • Cochrane  Iberoamérica  
Sponsors:
  • Vifor  
  • Unió  Catalana  d’Hospitals  
  • Consorci  de  Salut  i  Social  de  Catalunya  
  • Novartis  

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.

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.