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.

The use of operating theaters

John Wennberg in "Tracking Medicine" shows the results of his 1975 investigation that showed that the probability of Waterville citizens being operated on for haemorrhoids is six times higher than that of Portland citizens. Some thought that this was due to the malfunction of the American health system. The harsh reality, however, is that the variations of clinical practices, and those of surgical practices in particular, are omnipresent and persistent and even affect interventions of recognized effectiveness. A 2002 report from the Atlas of Variations in Medical Practice concludes that, in Spain, the chances of being operated on by very common processes reach differences of almost five times between territories. Exactly what intensity of interventionism is appropriate for each condition isn’t known, but everything indicates that in places like Waterville, they operate in excess, while, perhaps, in Portland they don’t do it enough, with a personal hunch that excess predominates over the shortcoming, evidently in the populations with health coverage.

The use of emergencies units

The emergency rooms in hospitals are expensive and sophisticated structures, with a high degree of motion. For this reason a lot of bewilderment occurs when noticing that people with mild pathologies access the ER so easily. In a study in Spain in 2010, Salvador Peiró, and his colleagues, analysed the percentage of hospitalizations that were generated from emergency services and found that there were territories that were around 10% (out of every 10 people who went to the emergency room, only one was admitted), while there were others that were around 30%, an indicator that reflected a casuistic attended to with a lot of complexity. In Catalonia, the 2015 report on Primary Care of the Results Centre, which had already taken into account the new methods of triage, showed that, out of every 100 inhabitants, there are 34 who attend the emergency room for reasons of low complexity (levels 4 and 5), with some variations as impressive as, for example, that in Roda de Ter only 8% of people went to the emergency room with pathologies of low complexity, while in Navarcles 48% of the population attended.

The use of intensive care units

If emergency rooms are costly structures, intensive care is the luxury of the system, to which, logically, it would be convenient to rationalize access in a very careful way. Unfortunately we don’t have local data, which is curious, but the sensations are in line with inappropriate use. A study by Rebecca Gooch and collaborators showed that in the United States the number of intensive beds installed is 10 times higher than in the United Kingdom, without having any apparent impact on the mortality of either country. As for adequacy, John Wennberg says that in American university hospitals, between 13% and 35% of chronic patients die in an intensive care unit or in a hospital bed after having passed through a critical unit. Strangely the health systems, always so lacking in resources, don’t show more interest in evaluating the suitability of critical units.

The use of wards

Potentially preventable hospitalizations (an adaptation of "Ambulatory Care Sensitive Conditions") are a collection of chronic pathologies that should be seen less by the hospitals on the understanding that these are theoretically preventable. The list feeds on the following pathologies: heart failure, COPD, asthma, complications due to diabetes mellitus, bacterial pneumonia, dehydration, urinary tract infections, angina pectoris and hypertension. Variations of the Medical Practice, in a monograph of 2015, and the Results Centre in the Primary Care report also of 2015, show variations of this indicator by up to three times. According to this last source, in Catalonia there are almost one hundred thousand potentially avoidable hospitalizations every year, this means that the system is spending some 220 million euros on the inadequate use of hospital beds. This is a considerable waste of resources that instead should feed the squalid community budgets for chronic and fragile people. 

The use of primary care

Spanish health system has an enviable deployment of close and effective primary care. It’s true that it lacks resources in relation to the current growing needs, but this should not hide the fact that there are data that suggest that, on occasion, the use made of this level of care isn’t the most appropriate. I have information, not contrasted, which says that approximately one third of medical time is applied to non-medical subjects, while another third is dedicated to practices that would be more typical of nursing competencies. Looking for data in this line, in the Primary Care report from the Results Centre in 2015, I found an indicator that indirectly, warns of certain inadequacies. This fact shows that 23% of children from 0 to 2 years old are visited more than 20 times a year (if I am not mistaken, the healthy child program recommends 12 visits per year). Well, in Figueres there is an area (Ernest Lluch) where, of every 100 children, only 9 go more than 20 times to the doctor, while in the town of Vilafant, near Figueres, 65% of the children are over-users. 

We waste resources with excessive surgical interventions, with hospital emergency services that care for people with low complexity conditions, with inadequate resources allocated to intensive units, with unnecessarily high tech end-of-life episodes, with potentially avoidable hospitalizations and with the exaggerated use of primary care services. But on the other hand, we lack the resources to deploy essential community services for the attention to fragility and complex chronic patients, or for truly effective treatments. Now we only have to apply the law of Sutton* (with common sense please). 

* John Wennberg borrowed the name of the most famous US robber of the last century, Willie Sutton, who when he was arrested and asked why he robbed banks, responded that it was because that’s where there money was. Inspired by Sutton's words, Wennberg encourages us to detect waste and to redirect those resources towards the community programs that are so necessary for the current casuistry.

Jordi Varela

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