tag:blogger.com,1999:blog-47736743410069843982024-03-14T18:31:59.887+01:00Advances in Clinical ManagementUnknownnoreply@blogger.comBlogger473125tag:blogger.com,1999:blog-4773674341006984398.post-77418477772694238982022-09-19T08:00:00.096+02:002022-09-19T09:26:51.150+02:00How to get the most out of virtual primary care?<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdAZ0gf1Id8K2bSoHqxH2VHy33SPrqhMzn7SBWnk_OqrK56Cw6Z_HsWJfCuQqbs-uu2I5bfsLK443YedHw6UMEZ8NnAcwWgJPj-cIvrtvmVD0VltDn6G-IYx7EtxZsnew-91kCuL0MADyVwQu1WMOODB7ugmKVB-M37E5vnaJ4cBQbfIGUfDeEkj0EAQ/s288/Jose%CC%81%20Cerezo.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="288" data-original-width="219" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdAZ0gf1Id8K2bSoHqxH2VHy33SPrqhMzn7SBWnk_OqrK56Cw6Z_HsWJfCuQqbs-uu2I5bfsLK443YedHw6UMEZ8NnAcwWgJPj-cIvrtvmVD0VltDn6G-IYx7EtxZsnew-91kCuL0MADyVwQu1WMOODB7ugmKVB-M37E5vnaJ4cBQbfIGUfDeEkj0EAQ/w153-h200/Jose%CC%81%20Cerezo.png" width="80" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Cerezo%20J." target="_blank">José Cerezo</a></span></b><br /> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkpJQqWTW0tf4ay44jwxKb-ut4sRp5Uczzwdq7BhvfWHgItW4oUPTAqdTqgRvsHrKiQNomySI_lDpToFVKFenW5OPDtVFZyIGLN19m8Qz-pCekTeGjLcVgj66GR7wvpaxO1suN6yjmoUgWC7vzsFEXkcyb61rIfLNWxAFVsebHoT2dkKUVzZLFZBnzMQ/s320/Sense%20nom-3.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="320" data-original-width="231" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkpJQqWTW0tf4ay44jwxKb-ut4sRp5Uczzwdq7BhvfWHgItW4oUPTAqdTqgRvsHrKiQNomySI_lDpToFVKFenW5OPDtVFZyIGLN19m8Qz-pCekTeGjLcVgj66GR7wvpaxO1suN6yjmoUgWC7vzsFEXkcyb61rIfLNWxAFVsebHoT2dkKUVzZLFZBnzMQ/s1600/Sense%20nom-3.jpg" width="231" /></a></div><div style="text-align: justify;">From the onset, the pandemic has acted as a powerful catalyst, accelerating the introduction of reforms and the experimentation with new models of care, many of which had long been simmering in the labs of European health systems. These transformations have quickly and deeply affected primary care due to the indispensable – and little recognized – role it has played during the pandemic.</div><p></p><p style="text-align: justify;">Primary care, on many occasions in a chronic context of precariousness and lack of resources, has played a dual role: diagnosing and monitoring COVID-19 patients who did not require hospitalization (the vast majority) and maintaining the rest of the essential services, being of special importance the follow-up of patients with chronic diseases and non-delayable and urgent cases. Among these transformations, the most radical was the overnight change in the conditions of access to primary care services. In a matter of weeks, primary care went from being fundamentally face-to-face to being almost exclusively virtual with the aim to preventing infections in health centres and protecting both patients and health professionals.</p><p style="text-align: justify;"><b>Virtual primary care is here to stay</b></p><p style="text-align: justify;">The combination of various modes of provision of primary care services is a reality. These include face-to-face visits, both in health centres and in homes or community activities; face-to-face visits by mobile teams, especially in rural settings; and virtual visits (online appointment systems, telephone consultations, videoconferences, SMS, emails). All of them constitute a fundamental feature of primary care for the present and the future.</p><p style="text-align: justify;">For this reason, and after more than two years of the pandemic, it is more important than ever to analyze international experiences to ensure that virtual primary care contributes to reducing inequalities in access to primary care services and to improving its quality.</p><p style="text-align: justify;">This is the intention of an outstanding report published earlier this year by the Nuffield Trust and written by Dr Charlotte Paddison and Isabelle McGill entitled "<a href="https://www.nuffieldtrust.org.uk/research/digital-primary-care-improving-access-for-all-rapid-evidence-review" target="_blank">Digital primary care: Improving access for all?</a>". The authors carried out a quick review of the national (United Kingdom) and international evidence published during the years 2020 and 2021, which yields a series of important messages, which are highlighted below.</p><p style="text-align: justify;">First, patients with the least need for health care, young people and people of high socioeconomic status are the most likely to benefit from virtual access to primary care. This constitutes a new form of the "inverse care law" and can enhance health inequalities since those groups that have worse health and greater health needs (people with socio-economic vulnerability, ethnic minorities and people with cognitive or communication difficulties) can see their access negatively affected. Regarding Catalonia, <a href="https://www.jmir.org/2021/5/e28629" target="_blank">a recently published study</a> concluded that remote consultations tripled during the first three months of the pandemic. Most users were predominantly female, systematically younger, more actively employed, and with less complex pathologies. This helped mitigate, to some extent, the decline in face-to-face visits in younger age groups, but also suggests that profiles with greater clinical and social complexity benefit less from non-face-to-face visits.</p><p style="text-align: justify;">Secondly, virtual primary care may lead to the replacement of some access barriers (distance, time, transport problems) by others (internet access, digital skills, device capacity). The report includes an staggering fact about the United Kingdom: almost two million people do not have access to the internet and cannot afford it, so they are automatically excluded from online care.</p><p style="text-align: justify;">However, the review also shows optimistic results. In situations where digital tools improve the accessibility of primary care, such tools can lead to improvements not only in access but also in the quality of care. Choosing between different consultation modalities can benefit patients who were previously disadvantaged in face-to-face primary care in two ways: by overcoming geographic barriers to access and by promoting patient autonomy. Particularly in the field of mental health, evidence shows that remote consultations increase the contact time that these patients can have with their primary care provider, in addition to expanding the scope of programs run by specialized mental health services.</p><p style="text-align: justify;"><b>Three recommendations to overcome the digital divide</b></p><p style="text-align: justify;">The report also points out a series of recommendations for decision-makers interested in getting the most out of digital tools in primary care, while also addressing inequalities in access.</p><p style="text-align: justify;"></p><ul><li style="text-align: left;">Commit to the right goal: to ensure that all citizens can access primary care under equal conditions.</li><li style="text-align: left;">Asses the impact that the change in access conditions may have on different groups of patients and clearly, identify potential “winners and losers”.</li><li style="text-align: left;">Introduce virtual primary care, so that it never reduces the possibilities of access but rather contributes to increasing and personalizing them based on the individual characteristics of each patient and the dynamics of use by different groups. In this sense, studies such as the one cited above from Catalonia, which characterize the profiles that most actively use teleconsultation and other virtual care tools, are essential.</li></ul><p></p><p style="text-align: justify;">In this process, primary care professionals must play a fundamental role in three areas: understanding the needs of their population, addressing access barriers by co-designing inclusive access to clinical circuits, and ensuring that access modalities are customised appropriately.</p><p style="text-align: justify;"><b>Virtuality must be a means to reduce inequalities and increase the quality</b></p><p style="text-align: justify;">Although not mentioned in the report, it is vitally important for policymakers to study the context in which primary care services operate, before jumping into the introduction of digital solutions. Virtual primary care should never be seen as an alternative to strengthening primary care with sufficient human resources. In addition, there is a sort of magical thinking about the time that digital tools and telematic care can save health professionals. This can end up overloading, even more, the workload of primary care professionals that isin a state of chronic unsustainability in many European countries. In Spain, the expansion of the use of remote care not only did not decrease but rather <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8603466/" target="_blank">increased the work of primary care professionals</a>. For example, since September 2020, the increase in e-consultations has not been associated with a decrease in face-to-face consultations. This increases the total number of consultations and the workload of PC professionals by adding telematic attention to the face-to-face consultations already existing. In addition, increased accessibility often goes hand in hand with increased demand, which in turn requires increased triage and demand management efforts (and resources) to prevent delays in the attention of the most relevant problems. Finally, the digital skills of professionals must be at the centre of any virtual care development strategy.</p><p style="text-align: justify;"><span style="font-size: medium;">Virtual primary care should never be an end in itself, but rather a means to a greater purpose: to reduce inequalities in access to the health system and improve the quality of service provision.</span></p><p style="text-align: justify;"><i>José Cerezo Cerezo is health policy analyst and works as a consultant for the WHO European Center for Primary Health Care and the WHO Barcelona Office for the Financing of Health Systems.</i></p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-91212353259401704032022-09-12T08:00:00.064+02:002022-09-19T09:27:21.443+02:00Why do good deeds sometimes fail to work?<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrM6-dOiFBVYe9-k-CpWtPaPTbxg5Kx7nf8UoG65XPON1ruwSC0-HNMxyVnI92COzu_jNJzrg2D9KAF5JBKqTvj5skSdys7ge5nKOOa5f-pmAENFdwOfRNNKo8YpsbJt7mdiKJD0CH82aljGDoPoSwAgNInB4rC01DlwnJSIdha2qOMGlztqfJwi-D2g/s314/JOan%20Escarrabill%20copia.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="288" data-original-width="314" height="93" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrM6-dOiFBVYe9-k-CpWtPaPTbxg5Kx7nf8UoG65XPON1ruwSC0-HNMxyVnI92COzu_jNJzrg2D9KAF5JBKqTvj5skSdys7ge5nKOOa5f-pmAENFdwOfRNNKo8YpsbJt7mdiKJD0CH82aljGDoPoSwAgNInB4rC01DlwnJSIdha2qOMGlztqfJwi-D2g/w200-h183/JOan%20Escarrabill%20copia.png" width="100" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Escarrabill%20J." target="_blank">Joan Escarrabill</a></span></b><p></p><div><b><br /></b></div><div><b><br /></b></div><div><br /></div><div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiaaot2FajE-VB-hOwT-Wa1EYWhRbNwNJK43Onx7qK5_tafCAOmZHczOKgZcTwPrDJBIZCeW5DRhYMiqIbv7Dzal6E_GnMdNU1noBa4h9PlknLVhr2z2FxaAFYTdjCjD1XZ8f0AYfu27_yeHIhcX50jS3CQDHSLsyw1F2I7STuTEbiGGIhqv1fCEmr3IQ/s320/Sense%20nom-2.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="310" data-original-width="320" height="310" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiaaot2FajE-VB-hOwT-Wa1EYWhRbNwNJK43Onx7qK5_tafCAOmZHczOKgZcTwPrDJBIZCeW5DRhYMiqIbv7Dzal6E_GnMdNU1noBa4h9PlknLVhr2z2FxaAFYTdjCjD1XZ8f0AYfu27_yeHIhcX50jS3CQDHSLsyw1F2I7STuTEbiGGIhqv1fCEmr3IQ/s1600/Sense%20nom-2.jpg" width="320" /></a></div><div style="text-align: justify;">Cities are looking for elegant solutions for severe and complex problems. Barcelona's Eixample can be a good example of an elegant solution. But in cities, sometimes, there are also critical points for which a good solution is never found. Glòries Square in Barcelona can be one of those critical points of bad solution: heavy traffic in all directions and subway and railway tunnels that pass very close to the water table. Many solutions have been proposed in recent years and the latest one has taken more than six years to come true. I do not know engineering or urban planning, but I am sure that the proposed design has been carried out by competent professionals who have sought the best solution or, at least, the best viable solution or the one that most minimizes the negative impact. I am also sure that the designers have thought about the needs of all the people who will be using the infrastructure. <a href="https://www.lavanguardia.com/local/20220418/8203612/barcelona-movilidad-area-metropolitana-caos-carreteras-soluciones.html" target="_blank">But from the very moment it opened, in early April, it hasn't worked and nobody seems to be happy about it</a>. In real life, we have a difficult problem with the best possible solution and a bad result. How can it be that things well done sometimes don't work? I don't know, but I think the metaphor of Glòries Square in Barcelona helps me to comment on three articles I've recently read.<span><a name='more'></a></span></div></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Hughes <i>et al.</i><span style="font-size: x-small;">(1)</span> contemplate why integrated care interventions do not achieve the expected goals in the UK. The term integrated care is imprecise enough to make comparisons difficult. In any case, several models try to coordinate care (and social) devices to care for patients with serious chronic diseases at home. Perhaps integrated care focuses more on the organizational model between professionals and only responds to part of the resources that the patient needs to deal with his illness. Coordinating resources to reduce admissions or avoid visits to the emergency room is important, but patients with serious chronic illnesses have other needs that must be addressed for them to be at home in comfort and safety.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Boehmer <i>et al.</i><span style="font-size: x-small;">(2)</span> describe the conceptual framework of minimally disruptive medicine (MDM), of which some basic elements are respected for the values and preferences of patients and the proposal of therapeutic plans that are as individualized as possible, taking into account the needs of patients and emphasizing the need to revisit the care process to ensure proper coordination and promote the role of the generalist. The authors acknowledge that, after ten years, this project has not been widely implemented. Perhaps interventions need to assess more carefully the treatment burden and the patient's capability to cope. Furthermore, from a clinical point of view, it is not easy to think about the perspective of MDM in patients with multimorbidity. Yamb BP<span style="font-size: x-small;">(3)</span>, in the editorial accompanying the article, suggests a play on words. We do not have good tools to measure capacity or treatment overload, so instead of aspiring to practice a MDM we should try to practice a medicine that minimizes disruption. Ask the patient if they have been asked for their opinion on the suggested treatment and find out the personal and environmental context in which they will have to apply the therapeutic proposals so that an approximation can be made to assess to what extent the patient will be able to assume the burden of this treatment. In short, discuss what comes first: the load or the capacity.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">The third article I read is about personalized medicine and genomics. Roberts <i>et al.</i><span style="font-size: x-small;">(4) </span>explain that more than twenty years ago genomics generated many expectations regarding the potential benefits it could bring, but the transfer of research to the first line of care is much more limited than might be expected and perhaps genetic studies have been developed solely in the academic field, without taking into account other factors. The context (how the health system will be able to incorporate these innovations) and the real world (what is the composition of the population served) are key elements. But the authors also suggest that research should incorporate evidence-based implementation strategies that take into account planning, education, changes to be made, or economic impact. In addition, let's consider genomics with a perspective of collaboration between all those involved (patients, service providers, researchers, health managers or community leaders). Boehmer et al. spoke of the treatment burden for the individual as a key factor. Perhaps in the case of genomic medicine, we should think about the burden of treatment that genomic innovation represents for society. I won't go into it in-depth, it's just a suggestion.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Perhaps good projects are not implemented well because we haven’t thought about two things: the real needs of the people who will receive them and the burden of applying the proposals (both from an individual and collective point of view).</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Needs and load: two interesting concepts to think about. And I return to Glòries Square. Given the circulation problems generated by the new development of the square, a senior municipal official (whose name I will not mention so as not to misrepresent the orientation of the debate) stated: "It is highly recommended that citizens do not use the new Glòries tunnel between 7:00 and 9:30 in the morning. It is good advice. Outside these hours the tunnel is very valuable. But this proposal does not take into account two things: the needs (a very important percentage of citizens start work early in the morning) and the burden that the alternative represents (public transport does not provide the required response in many cases).</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Not aiming at a professional intrusiveness in the field of engineering or urban planning, I would dare to say that when we formulate a care proposal we try to answer a couple of questions: have we asked what are the needs of the people who are to benefit from this proposal? And, secondly, does the proposal we make represent a personal or community load that makes it unattainable?</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><i>I want to thank Joan Fernando PhD and Anne-Sophie Gresle MP, for their comments on the manuscript.</i></div></div><div style="text-align: justify;"><i><br /></i></div><div><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;"><b>Bibliography</b></p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;">1. Hughes G, Shaw SE, Greenhalgh T. Why doesn't integrated care work? Using Strong Structuration Theory to explain the limitations of an English case. Sociol Health Illn. 2022;44:113-129.</p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;">2. Boehmer KR, Gallacher KI, Lippiett KA, Mair FS, May CR, Montori VM. Minimally Disruptive Medicine: Progress 10 Years Later. Mayo Clin Proc. 2022;97:210-220.</p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;">3. Yawn BP. Can We Work Toward Medicine to Minimize Disruption? Mayo Clin Proc. 2022;97:202-204.</p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;">4. Roberts MC, Kennedy AE, Chambers DA, Khoury MJ. The current state of implementation science in genomic medicine: opportunities for improvement. Genet Med. 2017;19:858-863.</p></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-81485040658615790702022-09-05T08:00:00.025+02:002022-09-12T09:09:20.221+02:00Value-based healthcare: what comes next?<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAdDvmeDfW69acvWKJQ2iQFn73muNTZ0x9anY5bOlZoGm63LSr6PSCsX54T5MNk-ppAatW2LKD7g78Ta_Dq6_Vq-hkkxouGWbnDjlpwfas9frxlWaST8QvYB6uP0XNIrLU-9N1q5BcMBVtyXvt5tqY4JPxnxVaS6wKOdILawliTbmkZ4teSPDRwPnbTg/s112/Alexandre%20foto.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="102" data-original-width="112" height="94" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAdDvmeDfW69acvWKJQ2iQFn73muNTZ0x9anY5bOlZoGm63LSr6PSCsX54T5MNk-ppAatW2LKD7g78Ta_Dq6_Vq-hkkxouGWbnDjlpwfas9frxlWaST8QvYB6uP0XNIrLU-9N1q5BcMBVtyXvt5tqY4JPxnxVaS6wKOdILawliTbmkZ4teSPDRwPnbTg/w200-h184/Alexandre%20foto.png" width="100" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Lourenço%20A." target="_blank">Alexandre Lourenço</a></span></b><p></p><div><b><br /></b></div><div><b><br /></b></div><div><br /></div><div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCQ4Te1EBvTUAAzhzDuuJ3Tz3s_CglBmEGOacWw-TfLLyH9h8SVwkfUW8cFEm2gx3ARLt0EOQaKT5Z4jkwRaZMJZ-QvR_TZpZNnoq4rxtkGUYUDDH0HLqa8YWTXzVoGNi-YrZ9OBZxP61e26uEuMnEovD2C_859OuZvhuDLFmEiEGCq_TQ2S9KhSPuig/s320/71HKsJP-u0L.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="320" data-original-width="216" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCQ4Te1EBvTUAAzhzDuuJ3Tz3s_CglBmEGOacWw-TfLLyH9h8SVwkfUW8cFEm2gx3ARLt0EOQaKT5Z4jkwRaZMJZ-QvR_TZpZNnoq4rxtkGUYUDDH0HLqa8YWTXzVoGNi-YrZ9OBZxP61e26uEuMnEovD2C_859OuZvhuDLFmEiEGCq_TQ2S9KhSPuig/s1600/71HKsJP-u0L.jpg" width="216" /></a></div><div style="text-align: justify;">More than 15 years have passed since the publication of Michael Porter and Elizabeth Teisberg's iconic book <i>Redefining Health Care</i>.</div></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">As a seasoned consultant, Porter delivered a simple message: Value-Based Healthcare (VBHC), an attractive concept to healthcare professionals, providers and payers. Presented as a solution to the health care crisis in the United States, the concept of value – the relationship between results and the cost to achieve them – quickly spread throughout Europe, South America and Australia. Like a magic potion, it provided a solution for almost all health-system problems: addressed fragmentation, variation, over-provision of care, financial lack of sustainability, medical errors, clinical compromise, lack of trust, patient disengagement, etc.<span><a name='more'></a></span></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Soon, recognizing the need to implement a simple concept in a complex system, Porter partnered with the Boston Consulting Group (BCG) and Karolinska University Hospital to create the International Consortium for Health Outcomes Measurement (ICHOM). Taking the rich clinical databases in Sweden as an example, it was suggested that only extensive registries would ensure the measurement of outcomes. In the absence of concrete examples, the Martini Klinic localized prostate cancer example was repeatedly presented and, based on this convincing example, which shows significant differences concerning erectile dysfunction and incontinence outcomes, the concept of value was easy to sell. Dealing with coding diversity and the need to adjust for individual patient risk, the first sets of clinical standards were developed, and several pathology-specific sets of standards were developed some years later.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">However, data collection for outcome measurement across the continuum of care is laborious and, in some cases, a questionable use of clinical resources. Moreover, the specific pathology-focused approach to developing the sets of standards and the high level of independence of individual expert groups resulted in insufficient harmonization of measures across pathologies. From a practical point of view, organization-centric health information systems still constitute barriers to the rapid implementation of measurement and comparability of results. From the cost point of view, implementation issues also arise for comparability. Although it is commonly acceptable to use activity-based costing over time, carrying out the methodology requires additional resources and organizations are unwilling to share cost data.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">We are in September 2022 and it has rained a lot. Where are we now? Where are the evidence and success stories of the VBHC? Please don't get me wrong. The VBHC has shown new ways of looking at the health system, influencing payers around the world to move from fee-for-service or case-based payments to blended payments and pay-for-performance. The Affordable Care Act (also known as Obamacare) was heavily influenced. Hospitals started to question their vertical organization according to medical specialities and some have evolved towards new organizational models (eg, clinics based on specific pathologies, and clinical trajectories). Karolinska University Hospital is probably the boldest among the major hospitals in abolishing traditional departments and developing new organizational models based on the clustering of clinical pathways. Some international organizations have adopted the concept and associated it with ICHOM. The OECD has developed Patient-Reported Indicator Surveys. The pharmaceutical industry has been the most open to the concept among healthcare players, seeking value-based acquisitions and joint ventures based on clinical results. But where are we now and what comes next?</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">As Peter Drucker mentioned, hospitals are one of the most complex organizations in modern society. Several forces defend the <i>status quo</i> and a concept is not enough to counteract the institutional and professional forces. Only adequate management will ensure the necessary force to promote change. Neither VBHC nor any other idea will emerge without sound and committed leadership.</div></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-1571584178456671012022-08-29T08:00:00.060+02:002022-08-29T08:00:00.162+02:00Ten attributes of future healthcare according to McKinsey<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEibp2HSqAGxD3f4J4ehI4FuRKgw8VuoNuXlEwTrE3utA3Os_z3SB2pSVZtYeJw6XAK6Kff3X_BG6rML0ALihmiDFW6vh-4gnwagcfwItZCmJsDBLlPHP_eXqFxlT9bt9rOMkvKOegw6PHZwPvioi-WriR3qDL1FLeTLzJXJhm3SNbKz8kQeHQ7AVynnpw/s313/Tino%20Marti%CC%81.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="288" data-original-width="313" height="94" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEibp2HSqAGxD3f4J4ehI4FuRKgw8VuoNuXlEwTrE3utA3Os_z3SB2pSVZtYeJw6XAK6Kff3X_BG6rML0ALihmiDFW6vh-4gnwagcfwItZCmJsDBLlPHP_eXqFxlT9bt9rOMkvKOegw6PHZwPvioi-WriR3qDL1FLeTLzJXJhm3SNbKz8kQeHQ7AVynnpw/w200-h184/Tino%20Marti%CC%81.png" width="100" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Mart%C3%AD%20T." target="_blank">Tino Martí</a></span></b><p></p><div><b><br /></b></div><div><b><br /></b></div><div><br /></div><div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivgK_dPyNF_n7CfUP16LgJ4qFo1PtzY_W31HTUFxowyVkPWBz7gmp2yejcHxiIPR8hEOvkeQQ2lHz3Hh6vzQeLnYDV0_2Y3lF4iObTz-GxNGrRgrSTg9kZ8nyZULEDRJh1Br57atzke724OB9n9nHDXxBOF38kBHsQdWlmcqA1wESFu4z2BGpwAUufyQ/s320/Captura%20de%20pantalla%202022-04-13%20a%20les%2011.42.45.png" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="291" data-original-width="320" height="291" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivgK_dPyNF_n7CfUP16LgJ4qFo1PtzY_W31HTUFxowyVkPWBz7gmp2yejcHxiIPR8hEOvkeQQ2lHz3Hh6vzQeLnYDV0_2Y3lF4iObTz-GxNGrRgrSTg9kZ8nyZULEDRJh1Br57atzke724OB9n9nHDXxBOF38kBHsQdWlmcqA1wESFu4z2BGpwAUufyQ/s1600/Captura%20de%20pantalla%202022-04-13%20a%20les%2011.42.45.png" width="320" /></a></div><div style="text-align: justify;">In late March, McKinsey published "<a href="https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/the-next-frontier-of-care-delivery-in-healthcare" target="_blank">The next frontier of care delivery in healthcare</a>," an analysis of the trends that will define healthcare delivery in the United States in the coming years, drawn from expert input and led by Shubham Singhal, Mathangi Radha, and Nithya Vinjamoori.</div></div><div><br /></div><div style="text-align: justify;">According to McKinsey, there are ten attributes of future health care, defined below and displayed in the accompanying infographic:</div><div><ol style="text-align: left;"><li><b>Patient-centred</b>: this attribute brings together various aspects such as a holistic and personalized vision, accessibility to health services and data, the use of wellness services and user satisfaction.</li><li><b>Virtual</b>: the pandemic has triggered the use of remote health and has predisposed providers and patients to new models of care that combine virtual care with face-to-face care in services such as urgent care, scheduled consultation, home care or medication administration at home.</li><li><b>Ambulatory</b>: care provided in health centres represents a third of the activity invoiced in the United States. Outpatient care is associated with shorter waiting and visit times and lower complication rates.</li><li><b>Home care</b>: care provided at home expands to new models such as home dialysis or home hospitalization. The combination of the above attributes allows the redefinition of care processes.</li><li><b>Based on value and risk-taking</b>: the expectation of growth in value-based contracts in the coming years is associated with the prevention orientation of services and the role of primary care.</li><li><b>Driven by data and technology</b>: digital health and the use of data for decision-making and personalization of care can change the trend of healthcare costs, improve productivity and facilitate the deployment of value-based healthcare.</li><li><b>Transparent and interoperable</b>: new regulations force the publication of rates, restrict the blocking of data between providers and facilitate access to health data.</li><li><b>Facilitated by new medical technologies</b>: self-service opportunities for the management of chronic pathologies, remote monitoring, home telemetry or robotics are examples of technologies applied to the transformation of care models that include outpatient, home and virtual care.</li><li><b>Financed by private investors</b>: Private investment in healthcare is growing significantly and is geared towards new models of care that take advantage of the trends described above to overhaul the patient experience.</li><li><b>Integrated despite being fragmented</b>: the integration of care is based on the coordination of ecosystem agents through technological platforms.</li></ol></div><div><br /></div><div style="text-align: justify;">Despite being predictions based on and directed to the United States healthcare sector, most of the attributes described are directly applicable to our European context with certain nuances. It‘s worth retaining as positive the consolidation of new models of care around the needs of the person, the value of care and the possibilities of de-concentration provided by technologies and data. The centrifugal trend toward more ambulatory, home and virtual care draws a substantial paradigm shift in the provision of services with deep consequences on how these services should be purchased, managed and provided. This new constellation leads to prevention and care but requires fundamental changes in the messages that are transferred to health providers.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">In the "difficult to transfer" chapter, the increase in private investment in the health sector arouses opposing sentiments. On the one hand, the social centrality of health caused by the pandemic and shaken by technological innovation offers the opportunity to join forces to improve, from within and from outside, systems with a tendency to immobility. On the other hand, the expectation of suggestive returns on investment – explains the investors' interest and can aggravate existing inequalities.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Everything indicates that guiding the future of health care through these consolidated trends will be a challenge full of balances and compromises between the necessary change and the undesirable consequences that will require decision-makers to have a sophisticated compass.</div></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-12535993859487391762022-08-22T08:00:00.052+02:002022-08-29T16:13:06.126+02:00Ageism and risk of technological Darwinism<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4VnTtTMtUCw975B-RCJkdFp1IRDTpwGPSKaUNX9wGAc-Q3XGFqqjd4mXz9aP-omrdRzyA0LzR53o272mMmr6J0OXEYRxzaew-E4yPQmLTrb-Yon9e3VmcplF5M_yx_5bip7JWE679z4B4R1MJMyQRervw0bR60UxGlmvShL2Hic435D7I7bKHz7pVxA/s297/Gloria%20Galvez.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="297" data-original-width="283" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4VnTtTMtUCw975B-RCJkdFp1IRDTpwGPSKaUNX9wGAc-Q3XGFqqjd4mXz9aP-omrdRzyA0LzR53o272mMmr6J0OXEYRxzaew-E4yPQmLTrb-Yon9e3VmcplF5M_yx_5bip7JWE679z4B4R1MJMyQRervw0bR60UxGlmvShL2Hic435D7I7bKHz7pVxA/w191-h200/Gloria%20Galvez.png" width="91" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Galvez%20G." target="_blank">Glòria Galvez</a></span></b><p></p><div><b><br /></b></div><div><b><br /></b></div><div><br /></div><div><br /></div><div><div><br /></div><div><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEYC6vzCS70fZidAVGyYjXgEkWcBxbLe6hDTBZX51BuRG08lXkVoVnBG3V-Yl_jR149FDRMhvSSqPAcnCKUe2djSHSWwXBzbPoXA5FBw603uWvp8qqg4Br_b7I5ty_GcI-Yq1KzSt8pj9cfnRWzN2CxS0WsMgH3y5szia2h7BhsCK-LwaTGK5UZCur4g/s222/Untitled-3.png" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="167" data-original-width="222" height="167" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEYC6vzCS70fZidAVGyYjXgEkWcBxbLe6hDTBZX51BuRG08lXkVoVnBG3V-Yl_jR149FDRMhvSSqPAcnCKUe2djSHSWwXBzbPoXA5FBw603uWvp8qqg4Br_b7I5ty_GcI-Yq1KzSt8pj9cfnRWzN2CxS0WsMgH3y5szia2h7BhsCK-LwaTGK5UZCur4g/s1600/Untitled-3.png" width="222" /></a></td></tr><tr><td class="tr-caption" style="text-align: right;"><span style="font-size: x-small;">Image by <a href="https://www.flickr.com" target="_blank">Flickr</a></span></td></tr></tbody></table><div style="text-align: justify;">According to the Spanish National Institute of Statistics <a href="https://www.ine.es/jaxiT3/Tabla.htm?tpx=50171" target="_blank">(INE), in 2020</a> about half of the people over 75 years of age-connected to the internet daily. The pandemic and the need to feel integrated into society have forced them to enter the digital world, although their opinions, aptitudes or preferences have not been taken into account in the design of the tools used.<span><a name='more'></a></span></div></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">This may be one of the reasons why, according to the <a href="https://www.mayoresudp.org/la-brecha-digital-y-las-personas-mayores-nuevo-informe-del-barometro-de-mayoresudp/" target="_blank">UDP Barometer</a>, in the last two years more than a quarter of older people were unable to carry out some daily management that could only be done electronically. This percentage increases to almost 60% if they are also people with low income. Thus, although data on the use of ICT by older adults have improved, the intergenerational digital divide has not disappeared. A large part of older people do not have an internet connection or do not have the necessary skills to use digital devices designed without taking their needs into account. In addition, reduced mobility, disability, housing in rural settings or the fact of perceiving their ageing negatively are just a few of the many barriers to their digital inclusion, which continues to be a challenge for our society.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><i><b>A large part of older people do not have an internet connection or do not have the necessary skills to use digital devices designed without taking their needs into account.</b></i></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">According to this same barometer, 14% of the telematic procedures that older people could not carry out were about heatlh care. According to the <a href="https://www.jstor.org/stable/30036540" target="_blank">unified theory of acceptance and use of technology (UTAUT)</a>, <a href="https://euroageism.eu/wp-content/uploads/2021/03/Ageism-and-Technology-Policy-Brief.pdf" target="_blank">chronological age</a>, together with digital ageism, are the main barriers that older people encounter in accessing this technology. If we add to this double marginalization the lack of knowledge and the <a href="https://www.researchgate.net/publication/350461825_Una_propuesta_para_mejorar_la_experiencia_de_los_adultos_mayores_con_las_redes_sociales#fullTextFileContent" target="_blank">limitation of their sensory and motor skills</a>, the result is a situation of isolation and loneliness that puts them at risk of social exclusion or <a href="http://www.entremayores.es/spa/em_formacion.asp?var2=EM%2020%20Aniversario&var3=%27Los%20mayores%20poseen%20una%20mirada%20fresca%20sobre%20la%20tecnolog%EDa%20que%20otros%20grupos%20de%20edad%20no%20tienen%27&nar1=61&nar2=62&nar3=48914&nar5=1" target="_blank">technological Darwinism</a>: either they adapt to the imposed conditions or they will be excluded.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b><i>Ageism and the limitation of sensory and motor skills of older people cause a situation of isolation and loneliness that puts them at risk of social exclusion.</i></b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">The sustainability of an ageing society largely depends on our ability to create inclusively designed technology environments where older adults can participate regardless of their health status. Otherwise, if we focus healthcare accessibility exclusively on digital media, inequalities will inevitably be generated. To avoid this, it is necessary to guarantee that <a href="https://www.w3.org/TR/2018/REC-WCAG21-20180605/#abstract" target="_blank">web accessibility guidelines for people with disabilitie</a>s are met, promote digital literacy, carry out designs with the participation of older people and have a viable, effective and safe alternative that respects the right to consent or oppose the use of digital tools for the care they are going to receive.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b><i>The challenge of our society is to create inclusive design technological environments so that older people can participate regardless of their health status.</i></b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">In this sense, gerontechnology or AgeTech as it is known in many European countries and the United States, puts into practice "inclusive technology for age", designed with and for older people, going beyond the design of devices with large buttons. and loud sounds. Age Tech tries to put older adults at the centre of the design process to meet their needs and aspirations.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">The International Society for Gerontechnology (ISG) publishes an <a href="https://www.gerontechnology.org" target="_blank">open-access academic journal</a> that encourages and promotes technological innovations that respond to the needs of older people. A recent <a href="https://journal.gerontechnology.org/archives/2e0cb6b8554b4b50a1077f1449c06fe8.pdf" target="_blank">review</a> in this journal explores the factors influencing mHealth adoption among older adults: 1) Disposition barriers, 2) Mobile device usability, and 3) Social influence.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Disposition barriers are related to older people's lack of confidence in their abilities and in technology, which in turn generates anxiety. Additionally, age-related physical and cognitive decline can also be a major barrier to mHealth use. Older adults who overcome these barriers depend on the social support of the family and health professionals to recognize mHealth as a good tool for their health care.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b><i>Older people's lack of confidence in their abilities and technology, in addition to age-related physical and cognitive decline, can be a major barrier to mHealth use.</i></b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">For its part, the <a href="https://forodepacientes.org/2022/02/01/el-foro-espanol-de-pacientes-propone-10-cuestiones-prioritarias-para-evitar-el-aislamiento-digital-de-los-pacientes-mayores/" target="_blank">Spanish Patient Forum</a> proposes 10 priority issues to avoid the digital isolation of older people in healthcare:</div><div><ol style="text-align: left;"><li>Provide alternatives to online access to health centres and hospitals (for appointments and waiting lists).</li><li>Guarantee access in written form to information about your treatment. </li><li>Alternative telephone access for those over 65 years of age.</li><li>Special measures to facilitate access to health benefits and services for the elderly with sensory diversity.</li><li>Alternatives in access to the health system for older people living in rural areas with no or low connectivity.</li><li>Basic training for the elderly on the internet and health.</li><li>Agreement with patient associations to develop actions against the digital isolation of elderly patients.</li><li>Agreements in the Interterritorial Council to solve the problems that the digital transformation of the National Health System may entail for the elderly.</li><li>Inclusion of the digital health gap in the Digital Health Strategy.</li><li>Finally, the Forum asks the General Secretariat of Digital Health to set up a table on digitization and healthcare for older patients to identify the necessary improvements to access healthcare and interact with professionals, adapted to the level of the current digitization of the more than nine million people over the age of 65 in Spain.</li></ol></div><div style="text-align: justify;">Ageism is a very common type of discrimination, although subtle and without the explicit intention of harming. Avoiding it requires understanding what digital technology older people need, what their ability to use it is, and how they are included to give them a 'voice' in the design process and related policies. In this way, they will not be forced to depend on third parties and we will be able to respect their right to information and their autonomy in decision-making.</div></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-70537256786535305112022-08-15T08:00:00.029+02:002022-08-29T16:12:54.208+02:00Request and exercise economic evaluation<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8_MIbbBL8coZqz_G_wawG2yu2DE7uy90m6-qi7heQS5xARj8uQeZaDZOkufAi12CLQfhV9VS3Z0izBN2ThAqNxzgrgXz2yqqyj5VOd6_kfcJjiU2HEOMiYRPlU3KhpFCD8jw8xSHWYg4dBHs2HNciZ-4XucN--RqXa28WIqL3C_zFfyVFG-BEipGKhg/s164/Cristina%20Adroher.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="164" data-original-width="146" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8_MIbbBL8coZqz_G_wawG2yu2DE7uy90m6-qi7heQS5xARj8uQeZaDZOkufAi12CLQfhV9VS3Z0izBN2ThAqNxzgrgXz2yqqyj5VOd6_kfcJjiU2HEOMiYRPlU3KhpFCD8jw8xSHWYg4dBHs2HNciZ-4XucN--RqXa28WIqL3C_zFfyVFG-BEipGKhg/w179-h200/Cristina%20Adroher.png" width="88" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Adroher%20C." target="_blank">Cristina Adroher</a></span></b><p></p><div><b><br /></b></div><div><b><br /></b></div><div><br /></div><div><br /></div><div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIIpqwIfTpOoT1_oNzcqQxRZ1_DcoK7zAJGT6B5_rJU2PDq5SQH0cQmKYhc60VsMcPOmXcCqGEWE6urSON_xWyNP0paPI6ZhaEPPTyEQKxZCWNLSMldJ_MRJAMEt3M3EEEg_Sb0GPCbEHZjM49G3T_jusIEwsW6UifFtbN1ou37gcn7cCnuhtmHidFSQ/s320/Sense%20nom.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="320" data-original-width="278" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIIpqwIfTpOoT1_oNzcqQxRZ1_DcoK7zAJGT6B5_rJU2PDq5SQH0cQmKYhc60VsMcPOmXcCqGEWE6urSON_xWyNP0paPI6ZhaEPPTyEQKxZCWNLSMldJ_MRJAMEt3M3EEEg_Sb0GPCbEHZjM49G3T_jusIEwsW6UifFtbN1ou37gcn7cCnuhtmHidFSQ/s1600/Sense%20nom.jpg" width="278" /></a></div><div style="text-align: justify;">Even before COVID-19, OECD countries allocated an average of 7.9% of their GDP to public spending on health (6.1% in Spain) [see <a href="https://www.oecd-ilibrary.org/governance/government-at-a-glance-2019_8ccf5c38-en" target="_blank">Government at a Glance</a> report, OECD 2019]. After pensions and social benefits, health spending is the most important item of public spending in all countries. For responsibility, transparency and common sense, it is important to know and analyze what health resources are used for and evaluate the results obtained thanks to your investment.<span><a name='more'></a></span></div></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">The evaluation of health policies is defined as that activity that allows evaluating the performance of public action. It requires evidence regarding its design, implementation, costs and results. It must serve to determine the degree of achievement of the proposed objectives, improve the implementation of policies, contribute to their scientific basis and be accountable to the public. Its value in the public sphere lies in ensuring truthful and consistent information, guiding budget allocation, assessing the quality of spending and helping to define new priorities. At the same time, it responds to citizen demands for greater transparency in public action and accountability. It is known that improving the quality and transparency of the health government has an impact on the health of the population through policies, organizational management and clinical practice (<a href="https://www.gacetasanitaria.org/es-la-transparencia-toma-decisiones-salud-articulo-S0213911116300954" target="_blank">see this article </a>by García-Altés and Argimon ).</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">The economic evaluation is relevant at the three levels of organization of the health system. Let us see some recent cases that have occurred in the Catalan sphere. At a macro level, referring to health policy allows knowing the social return of the resources allocated to it: for example, <a href="https://www.mdpi.com/1660-4601/18/13/7028" target="_blank">the analysis of the resources allocated to massive screening</a> for COVID-19 in asymptomatic citizens. At the intermediate level, that of health management, the evaluation helps to know the impacts of the organizational changes of the institutions, allowing detection of the best practices and thus extending them to the rest of the system. We know that the comparison between centres and the feedback of the results in a transparent way to the professionals and the public contribute directly to an improvement in the results. For example, <a href="https://pediatrics.jmir.org/2022/1/e31628/" target="_blank">the analysis of the paediatric home care program </a>of the Hospital Sant Joan de Déu. Finally, at the micro-level, in the field of clinical management, economic evaluation allows knowing the most efficient therapeutic alternatives, making it easier to relate the cost to the clinical results obtained. See, for example, <a href="https://www.scielosp.org/article/gs/2019.v33n2/106-111/en/" target="_blank">this article </a>that analyses the reduction of pharmaceutical spending through the adequacy of medications in multi-medicated elderly. In this context, it is worth highlighting the highly praiseworthy work of the clinical practice adaptation commissions, which are being extended to various health centres.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">In the current economic situation of scarce resources and underfunding, attention should be turned more than ever to economic evaluation as a tool to inform resource allocation. It is a tool that is as useful as it is necessary to provide information and thus<a href="http://www.econ.upf.edu/~ortun/publicacions/EvEcMedClin1.pdf" target="_blank"> help clinicians and managers</a> to improve decision-making, measuring and comparing the allocation of resources from one intervention to another, as well as assessing its impact, scalability and sustainability, always with a holistic vision, considering the effects on all possible actors and accompanying it with complementary perspectives.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">As a “veni, vidi, vici”: let's evaluate, learn and improve. Citizen health will benefit by ensuring that economic evaluation is incorporated into the decision-making process, variability in clinical practice is reduced, and evidence-based policies are implemented. The social return is clear, so we will all win if we invest in the economic evaluation of health policies.</div></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-88243207457244302072022-08-08T08:00:00.030+02:002022-08-16T17:42:54.759+02:00War stress<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitvmlpMO8EuY4Pt4UaPndW2TKmpTU4fsxbGowpCDAWB2wfO4vax9WOIWv3oDPGO1h9vYg617D-vbE9_E6hmqYGiMBUwbGulId47uQIGCMyIXfi2XP_Bq7wfiBRWOudAgVTINHFbgfNLQJQowz-MuGPRguyE2RHiYeppNYlphDkqTyelJlh-bM2aGP9ag/s174/Andre%CC%81s%20Fontalba.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="174" data-original-width="154" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitvmlpMO8EuY4Pt4UaPndW2TKmpTU4fsxbGowpCDAWB2wfO4vax9WOIWv3oDPGO1h9vYg617D-vbE9_E6hmqYGiMBUwbGulId47uQIGCMyIXfi2XP_Bq7wfiBRWOudAgVTINHFbgfNLQJQowz-MuGPRguyE2RHiYeppNYlphDkqTyelJlh-bM2aGP9ag/w177-h200/Andre%CC%81s%20Fontalba.png" width="90" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Fontalba%20A." target="_blank">Andrés Fontalba</a></span></b><br /> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"></p><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgl-APaITtiXSqAwSN5Aho1BnR9M2GtX2BcHaXhqovWncNPt93v0Md4GTQVR959V84ZT-iPYeSvQDU0gui8yOSq3XH5pAhIS3sHcYCrgC6TEu2jYTjcbiehHw-RTZKzqM5skPsWvL9VhzVk6MUCPFYr_sE8kjI3H--ifQb6kHYiJWXESuYZJXzb1iqTqg/s320/image.png" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="220" data-original-width="320" height="220" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgl-APaITtiXSqAwSN5Aho1BnR9M2GtX2BcHaXhqovWncNPt93v0Md4GTQVR959V84ZT-iPYeSvQDU0gui8yOSq3XH5pAhIS3sHcYCrgC6TEu2jYTjcbiehHw-RTZKzqM5skPsWvL9VhzVk6MUCPFYr_sE8kjI3H--ifQb6kHYiJWXESuYZJXzb1iqTqg/s1600/image.png" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: right;"><span style="font-size: x-small;">By EFE</span></td></tr></tbody></table><p></p><div style="text-align: justify;">Stress is an adaptive reaction. When a change occurs, an effort is made to face the new challenge and, thus the organism itself adapts and can experience emotions, even pleasant ones, in the face of this process. In this case, stress is stimulating and motivating. Unfortunately, in situations as distressing as those caused by the current war, stress becomes so intense that it is seriously detrimental to health and one of its most severe consequences is post-traumatic stress disorder, a disease that arises as a delayed reaction to extremely threatening or catastrophic situations. This disorder is characterized by repeated episodes in which the traumatic event is relived in the form of dreams, flashbacks, or intrusive memories, often accompanied by emotional numbing and dissociation. It may involve detachment from others and avoidance of activities that are reminiscent of the event. <a href="https://www.sciencedirect.com/science/article/pii/S003335061630436X?via%3Dihub" target="_blank">Anxiety and depression may also be present, and substance abuse and suicidal thoughts are common</a>.<span><a name='more'></a></span></div><p></p><p style="text-align: justify;">The most recent wars have mainly affected low and middle-income countries with limited health resources. In these settings, up to a third of the surviving population has been affected by post-traumatic stress disorder. Regulated psychological interventions have been developed aimed at survivors of massive conflicts that have demonstrated their effectiveness in both young and adult populations. However, <a href="https://gh.bmj.com/content/6/7/e006303" target="_blank">most low-income countries, and even more so after a conflict</a>, lack, on the one hand, financial resources and, on the other, trained professionals to implement these therapies.</p><p style="text-align: justify;">The digital tools that we have today applied to health can be useful and have a very high degree of acceptance by the population. They serve both for the treatment and prevention of mental health and substance abuse disorders that appear during and after wars. Numerous studies show the effectiveness of telephone, text message or online support interventions, as well as digital applications for mobile devices, which offer good results in both clinical and community settings. <a href="https://www.sciencedirect.com/science/article/abs/pii/S2215036617300962?via%3Dihub" target="_blank">These technologies also amplify the scope of people we can reach and are a great support</a> for care interventions and the training of available professionals.</p><p style="text-align: justify;">The collective feeling of anxiety and, specifically, the high degree of suffering endured by people affected by war highlight the need to allocate more resources to improve the mental health of the population, even more so for people who are vulnerable due to adverse circumstances. This approach must be global and also requires a strengthening of primary care and the promotion of psychosocial interventions carried out by non-professionals who are trained to apply them, highlighting the role of families and informal caregivers. Attention should be focused on both the person and the community.</p><p style="text-align: justify;">Without forgetting that to avoid deaths, suffering and the painful stress of war, it is necessary to build and maintain peace.</p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-4345419136910563902022-08-01T08:00:00.092+02:002022-08-16T17:42:36.546+02:00Humanism and reasoning versus cookbook medicine<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWXpsrAbVBBWPdKtwtj_8-JuZWFIe2EeVogJcP1W3cM89K412ujf0XA3bSnnB66SvXqKDAyL6dvY6lJF0pHKaDHGdGXn3zZQEUa9ovHi8qM10y3WUtvGTRpau5MK4KVNr7kDGxXyTCuYdq4jKnf1oufyv6a5BTlMdZOBJMaKp0j1nZcgtvn0jeXIVZiA/s87/Soledad.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="87" data-original-width="87" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWXpsrAbVBBWPdKtwtj_8-JuZWFIe2EeVogJcP1W3cM89K412ujf0XA3bSnnB66SvXqKDAyL6dvY6lJF0pHKaDHGdGXn3zZQEUa9ovHi8qM10y3WUtvGTRpau5MK4KVNr7kDGxXyTCuYdq4jKnf1oufyv6a5BTlMdZOBJMaKp0j1nZcgtvn0jeXIVZiA/w200-h200/Soledad.jpg" width="100" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Delgado%20S." target="_blank">Soledad Delgado</a></span></b><br /> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><b>From "criaderas" to "soleras"</b></p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqetB8i6iwi2x_zCmx1_dJL0ThXxhv7vEvPfCLEPbEQW6NlOX10d53disjq4qYPlqCrKp4VcoCIGF04Bkx3fIjsE5ft5_ncst1Uq4BhhUCLxssFZXVrNLIGKI_AVhtPk3sfLn2c69acrL3XaFrjelKn5dhhWYBrO3v7VdQVb0NhvWdMsQYK56zqx3s-Q/s320/IMG_3325.JPG" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em; text-align: justify;"><img border="0" data-original-height="240" data-original-width="320" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqetB8i6iwi2x_zCmx1_dJL0ThXxhv7vEvPfCLEPbEQW6NlOX10d53disjq4qYPlqCrKp4VcoCIGF04Bkx3fIjsE5ft5_ncst1Uq4BhhUCLxssFZXVrNLIGKI_AVhtPk3sfLn2c69acrL3XaFrjelKn5dhhWYBrO3v7VdQVb0NhvWdMsQYK56zqx3s-Q/s1600/IMG_3325.JPG" width="320" /></a></div><i><div style="text-align: justify;"><i>At the onset of autumn, my land fills with the smell of must. Freshly extracted from the pressed grape, it ferments and then passes to American oak barrels for ageing. The containers are stacked at three levels. From the lower one, the "<b>solera</b>", a third of its content is extracted for consumption. That part is filled with wine from the intermediate level, the <b>first “criadera"</b>, and the same happens with this one, which receives wine from the upper level, the <b>second “criadera"</b>. It's the one who receives the fresh must, full of life and potential. This wine, still young, is mixed during its ageing with matured wine, from which it takes some characteristics and to which it gives back the freshness of new aromas and flavours. The two wines are enriching each other, sheltered by the <b>flower veil </b>that promotes biological ageing.</i> <span><a name='more'></a></span></div></i><p></p><p style="text-align: justify;">Not many days ago, while on duty, I was involved in a debate about the value of troponin in a patient with atrial fibrillation. My resident, with a carefully studied protocol, relied on a normal troponin value that had suffered a 5% increase in a second blood test (which, even so, was still normal) to defend the admission of a patient for observation, but not for the reason that brought him to our service, which was palpitations, but hiding behind the possibility that he had a heart attack. I tried very hard, and not very successfully, to make him see that our patients are not an analytical value or an X-ray: <b><i>they are people, who must be evaluated as a whole, giving the necessary value to the clinical history, examination and the additional tests we have.</i></b></p><p style="text-align: justify;">While I was defending my position, I was reminded of the book by Leana Wen MD and Joshua Kosowsky MD "When doctors don't listen," in which current clinical practice is compared to a cookbook medicine, where everything is measured and directed: if you have symptoms A and tests B, you have to do test C and you will arrive at diagnosis D. Using the same phrase as Wen and Kosowsky in their book, I tried to make him see that the best way to treat patients is to join scientific knowledge, common sense and the, sometimes so forgotten, art of medicine. Despite all these arguments, the resident continued to cling to troponin as the only element that justified his decision. The debate was enriching: we shared different and complementary points of view, scientific and clinical.</p><p style="text-align: justify;">At that moment I was struck by an anguished doubt: <b>if scientific knowledge is prioritized in medical schools over practical training and humanities, will we be training doctors who only see algorithms and results of complementary tests?</b> Where will the lesson of how to take care of the person? The anguish ended when, staring at him, I said: "Let's take the patient to the consultation, let's see what happens to him."</p><p style="text-align: justify;">In Jordi Varela's book "<a href="https://www.amazon.es/intensidades-provisión-para-sanidad-valiosa/dp/1795324570/ref=sr_1_fkmr0_1?s=books&ie=UTF8&qid=1549616332&sr=1-1-fkmr0&keywords=5+intensidades+de+provisión+para+1+sanidad+más+valuosa" target="_blank">5 intensidades de provisión para 1 sanidad más valuosa</a>," we find a chapter dedicated to the value of medical training, research and innovation from which we can draw the following conclusions:</p><p style="text-align: justify;"></p><ol><li>Research must leave the scientific field and approach clinical reality, giving greater importance to effectiveness than to efficacy.</li><li>Innovating must also mean having a critical capacity with the way of doing things, with the established protocols, and proposing new ways that give more value to medical practice.</li><li>It is necessary to train doctors with scientific knowledge, researchers and innovators who, in addition, possess social and communication skills.</li></ol><p></p><p style="text-align: justify;">All this raises the need for a change in the current training system, the Flexner training model, based first on training in basic sciences (anatomy, biochemistry...), followed by training in the human body (healthy and sickness) to finish with clinical practice. This change implies giving way to another training model, such as the one proposed by Prasad and Cifu, whose basis must be clinical reasoning, shared decision-making and learning the clinic and above it basic sciences, always linked to the practice.</p><p style="text-align: justify;">There should be three levels in training, interrelated with each other and whose fundamental basis is clinical reasoning, research and experience. <b>Levels, training, knowledge, acquisition of value, nourishment from experience... all this seems familiar to me</b>.</p><p style="text-align: justify;">Our winery, healthcare, is nourished by the best fruits: students who have been required to excel to access medical schools. A winery that has the best containers: faculties and health centres where, under the flower veil of scientific knowledge, research and experience, professionals grow and develop, acquiring values and further increasing those they already have. Our healthcare has great potential, with the best raw material. Perhaps the time has come to change the way of doing things; to prioritize the quality of the results and not their quantity. For that, we have to continue counting on the best and not let the best harvests go to other wineries. <b>Let's take care of their upbringing, and their training, so that they have the knowledge, but above all so that they become doctors and practice this wonderful, and sometimes forgotten, art of medicine.</b></p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-18837476311891893452022-07-25T08:00:00.045+02:002022-08-01T10:09:54.656+02:00“Noisy” healthcare decisions<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKj0z5UlhbZHiu4R7Ri6TpD7byG6ammsjt-YpUTvck4nAaV51f98MblYrA-U3HwCDW0onAKElisGSjKop77sN3wEsWnf1fOkU7CbNM6sShcCc0_R2anSiYBuppx475xwyzUndjECrIGCwA4KsTiER8ljIaB_lFn7o1YADMqYMWf2luEak2tbeD0Z3l2Q/s156/prey.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="156" data-original-width="148" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKj0z5UlhbZHiu4R7Ri6TpD7byG6ammsjt-YpUTvck4nAaV51f98MblYrA-U3HwCDW0onAKElisGSjKop77sN3wEsWnf1fOkU7CbNM6sShcCc0_R2anSiYBuppx475xwyzUndjECrIGCwA4KsTiER8ljIaB_lFn7o1YADMqYMWf2luEak2tbeD0Z3l2Q/w190-h200/prey.png" width="90" /></a></div><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Rey%20P." target="_blank"><b><span style="font-family: verdana; font-size: medium;">Pedro Rey</span></b></a><br /><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"></p><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUXUynU5xqXL_0dE20ANQjT0wjtzKvnivpK_KEAExYHVXzs0WQVFvyR_MPNStCcA_Yw8X9M3YQW2E1lAfSXgTrzLWJDNUM7DM7DkjbXAZMuN0y8SRl9kIqO2nR0TgP6u-YwLEbXLot1z6Q3yTBoqLD81Ze99wHAdVQ4HwOnM4k4HDO-SPnZc6iEoyIhA/s200/kahneman.jpg" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="200" data-original-width="200" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUXUynU5xqXL_0dE20ANQjT0wjtzKvnivpK_KEAExYHVXzs0WQVFvyR_MPNStCcA_Yw8X9M3YQW2E1lAfSXgTrzLWJDNUM7DM7DkjbXAZMuN0y8SRl9kIqO2nR0TgP6u-YwLEbXLot1z6Q3yTBoqLD81Ze99wHAdVQ4HwOnM4k4HDO-SPnZc6iEoyIhA/s1600/kahneman.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: right;"><span style="font-size: x-small;">Daniel Kahneman</span></td></tr></tbody></table><div style="text-align: justify;">A few months ago, Paco Miralles published in this blog "<a href="http://gestionclinicavarela.blogspot.com/2022/02/en-medicina-hay-demasiado-ruido.html" target="_blank">In medicine, there is too much noise</a>", where he reviewed the latest book by psychologist and Nobel Prize winner in Economics Daniel Kahneman (together with Olivier Sibony and Cass Sunstein) <i>Noise: A Flaw in Human Judgment</i>. Since Paco himself suggested that the issue of noise in decision-making "could provide for several posts", I decided to make a slightly more extensive critique of what the reader will find in the book.<span><a name='more'></a></span></div><p></p><p style="text-align: justify;">Noise understood as the variability in decisions made in the face of the same facts, is, along with cognitive biases –which I have talked about in previous posts–, one of the fundamental reasons why human beings make decision errors in all kinds of fields, starting with medicine, but also in the fields of law, economics, police decisions, food safety or personnel selection. Since it is a statistical concept, it cannot be heard but must be observed through the data. While cognitive biases produce deviations in decisions that always go in the same direction, noise implies that these deviations occur in any direction, without a systematic pattern. The book authors use the metaphor of a target: while the shots of an individual with cognitive biases would always move away from the centre towards the same place, the presence of noise would imply that the failures observed in the target would be distributed throughout the space, in unpredictable patterns.</p><p style="text-align: justify;">The key effect of noise is not that the shot is missed, but the lack of consistency in decision making. The authors equate consistency with fairness. If cognitive biases are removed, the “correct” solution can be reached. On the contrary, the lack of consistency produces erroneous results that diminish the credibility of the decision systems that produce those evaluations. Given that we live in a time when polarization and mistrust in institutions are important, eradicating the noise that leads to random and unfair decisions can help restore trust between human beings and, in our context, improve the credibility of our sanitary system.</p><p style="text-align: justify;">Biases are difficult to detect if you don't know where the centre is, but they are easy to correct once you know in which direction the deviation tends to occur. Noise is very easy to observe; it's enough to verify variability in decisions, but it is more complicated to correct because there is no pattern of deviation to address.</p><p style="text-align: justify;"><b>Noise in healthcare decisions undermines doctor-patient credibility</b></p><p style="text-align: justify;">In the health field, faced with the same patient with the same symptoms, different doctors can diagnose completely different diseases and therefore prescribe different treatments and interventions that may not only fail to improve the underlying disease but even aggravate the problem. That is why it is very difficult to establish an appropriate level of trust between doctor and patient, since trusting the wrong doctor can be just as bad as asking for second and third opinions from different doctors who offer incompatible diagnoses. Noise in medicine appears especially in areas that lend themselves to greater subjectivity, such as psychiatry, but even in more objective areas such as radiology, doctors do not unequivocally interpret the same X-ray they observe. And not even this very diagnosis is the same when the doctor himself observes the same case at two different times. For example, as recounted in the book, a study of 22 physicians examining the same 13 angiograms twice, at different times, found that each physician disagreed with their prior diagnosis between 63% and 92%. % of the time on average.</p><p style="text-align: justify;"><b>Decision hygiene: how to reduce the noise?</b></p><p style="text-align: justify;">A common aspect of all the examples shown in the book is that from all of them an attempt has been made to create instruments to reduce the presence of noise. In medicine, for example, there are clinical practice guidelines, while in law there is a debate about the standardization of sentences and in human resources, there is a recommendation for avoiding interviews and for converting the selection of personnel into tests of ability and personality with objective evaluation. However, although these measures can reduce noise, there is also logical reluctance, in some cases of a corporate nature, because reducing noise also implies losing the richness that discretion and experience can provide. To put it humorously, one of Groucho Marx's most remembered phrases is: "If everyone agrees with me, I know I'm wrong."</p><p style="text-align: justify;">What is the optimal noise level? How can we identify when noise is only harmful? And, in those cases, how can we reduce it? These are the topics that this book deals with. The authors dedicate the first part to differentiating and relating the cognitive biases of noise. Then they focus on a type of noise of special importance: the variability in the predictions of each phenomenon and how to attack it through rules, formulas and algorithms that, although in many cases do not increase knowledge about the phenomenon that is trying to be predicted, contribute to reducing the noise. A third part, perhaps the most interesting, deals with the psychological causes of noise. Among the causes, the authors highlight the cognitive and personality differences between human beings, the different weight that individuals give to the different factors behind a phenomenon, and the different use we make of the measurement scales that characterize it. The final part of the book focuses on practical considerations on how decision-making, both individual and collective, can be improved and error prevented. They give this part the striking name of "decision hygiene". Finally, the authors offer a general decision-making protocol that is intended to help evaluate the different options and incorporates some practices to help structure the decision process, such as replacing the most complicated evaluations in absolute terms with comparative evaluations. Let's take a practical example when a teacher evaluates an exam, a more objective grade would be obtained if, as a previous step to correct the exams, they were ordered in a ranking through systematic comparisons.. is this exam better than this other one?</p><p style="text-align: justify;"><b>A good anecdote, but a bit repetitive</b></p><p style="text-align: justify;">The book continues a fashion trend in recent years that consists of publishing popular science based on data analysis and social experiments with great success. Among the best-known examples of publications along the same lines, readers will remember <i>Thinking Fast,</i> <i>Thinking Slowly</i> by Kahneman himself, <i>Nudge</i> by Thaler and Sunstein, <i>Freakonomics</i> by Dumber and Levitt, or <i>The Traps of Desire</i> by Ariely. All of them have been best-sellers that have helped to popularize research in the social sciences and to develop areas such as behavioural economics and social psychology. In this sense, a book that unites Kahneman, a psychologist, and Sunstein, a lawyer, both authors of two of the best-selling books (I don't know if they have also been read) in the area, explaining the psychological causes of human errors and how to correct them to better institutions, seems like a winning proposition. In fact, from the very design of the cover to its structure, the book has practically sold as a sequel to Kahneman's. A sort of "Think Fast, Think Slow 2: The Noise Attack."</p><p style="text-align: justify;">The book is motivating and includes many compelling and engaging examples that can serve the reader with successful stories to tell at social gatherings. The main argument about how we have underestimated the presence of noise in our society and the mechanisms it offers to solve it is intuitive. The effort made by the authors to provide general practice guidelines for employing a more structured decision-making process is especially noteworthy.</p><p style="text-align: justify;">However, I suspect that the book arrives a little late in a market perhaps already saturated with writings of this genre. I believe its reading will be less attractive to the reader who has already read some of the cited references. In the first place, because it is excessively long and repetitive. Five hundred pages is a lot to expose an idea already summed up precisely in some of the academic reviews of the book. The examples, many of them from the health area, are numerous, but the text ends up exhausting the reader, not by conviction, since it only shows that noise is everywhere, but by the fact that new examples do not lead to learning new lessons.</p><p style="text-align: justify;">In addition, the presence of three different authors who have not managed to unify the same style of writing is excessively noticeable. It is perceived that in most cases they try to simplify concepts of probability and statistics for the non-expert reader, but sometimes they go too far, both by oversimplification and by default, which will frustrate the different types of readers. Plus, it feels like the authors have already expended their best bullets on previous books. Many of the examples they use have already appeared in other works by the co-authors, and the practical implications of how to make better decisions are not entirely new. Unlike the other books, which are based largely on the authors' research, many of the stories illustrated here are based on subsequent investigations by others, which makes the argument lose some rigour and credibility. A notorious example is a confusion that occurs in various chapters between the concepts of correlation and causality when analyzing the data.</p><p style="text-align: justify;">In any case, I deem the book interesting for anyone involved in the decision-making process and correcting the individual and institutional consequences of mistakes. However, I venture to predict that for most readers, the first two chapters, motivating the topic with very good examples and possible solutions, and perhaps the decision guides included at the end, will be more than enough. </p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-48221818556841063032022-07-18T08:00:00.042+02:002022-07-25T09:26:10.818+02:00Is it possible to humanize health organizations?<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAHspQ9Lwi3nLLdsXg_1O2DGebOqs087U183qVblx7gfIdJdscRnQog2pGugN_LB9yJnSsRVQ92BZx-Lq3Ltx8X8vHyK3Y4Gs5qPMvCqdCmrGsDywe4qfUJeqmRMh9_sgS3DZ4n-SaxCkPOT7d6eBCqFlacwEUFB8A0xaQTzguYCz3dmiha4FTF1zMdQ/s617/Jordi.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="617" data-original-width="512" height="120" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAHspQ9Lwi3nLLdsXg_1O2DGebOqs087U183qVblx7gfIdJdscRnQog2pGugN_LB9yJnSsRVQ92BZx-Lq3Ltx8X8vHyK3Y4Gs5qPMvCqdCmrGsDywe4qfUJeqmRMh9_sgS3DZ4n-SaxCkPOT7d6eBCqFlacwEUFB8A0xaQTzguYCz3dmiha4FTF1zMdQ/w167-h200/Jordi.png" width="98" /></a></div><span style="font-family: verdana;"><b><span style="font-size: medium;">Jordi Varela</span></b><br /><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Jordi%20Varela" target="_blank">Editor</a></span><br /><p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMbIa9PivPXxQm0RpqnOCxdP6cn7kPgbgmo73LhRP_OPZ9NqptdvexmO__ks6kVTg-Tb6MPlr3tRojxaJCQfezdhkAJHXVKGc8_g543TVGK71ORdRrkhcNlnCLnNDxIMowx8FJFcONUCrWBfIzSYERV97ozIBdemjcDg9FVqtJD-6Lh96Njctw49AJBg/s320/4144-1140x0.jpeg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="168" data-original-width="320" height="168" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMbIa9PivPXxQm0RpqnOCxdP6cn7kPgbgmo73LhRP_OPZ9NqptdvexmO__ks6kVTg-Tb6MPlr3tRojxaJCQfezdhkAJHXVKGc8_g543TVGK71ORdRrkhcNlnCLnNDxIMowx8FJFcONUCrWBfIzSYERV97ozIBdemjcDg9FVqtJD-6Lh96Njctw49AJBg/s1600/4144-1140x0.jpeg" width="320" /></a></div><div style="text-align: justify;">Today, more than ever, the human part of the contact between patients and clinicians is taking centre stage, from health centres to critical care units and, therefore, the former must strive to be more accessible, while the latter has to demonstrate that the services they go beyond sophisticated clinical practice. Right now, we are at a point where the technical preparation and dedication of clinical professionals cause admiration, but it must be recognized that, with few exceptions, the warmth in human treatment has a lot of room for improvement.<span><a name='more'></a></span></div><p></p><p style="text-align: justify;"><b>The spider caught in its web</b></p><p style="text-align: justify;">Health systems strive to write health plans and strategic plans, in which a lot of experts define high concepts, usually the mission, vision and values and outline strategies and objectives to reorient the provision of services towards community health, patient-centred care, multidisciplinary teamwork and, ultimately, towards a more valuable clinical practice. However, later comes the moment of truth, that of budgets, contracts and organization charts, and the web that the weight of history has been weaving, acquired customs, corporate behaviour, resistance to change and the pressure of exacerbated consumerism means that noble intentions become mere speeches and some pilot experiences never receive the desired push.</p><p style="text-align: justify;"><b>The influence of organizational culture</b></p><p style="text-align: justify;"><a href="https://www.mayo.edu/research/faculty/montori-victor-m-m-d/bio-00085102" target="_blank">Víctor Montori</a> says that he has an infallible indicator to perceive the penetration of humanism among hospital workers. He says that when he arrives at a centre that he does not know, he stands in the middle of the reception room adopting a disoriented posture and counts the time that passes until a worker asks how he can help him. His research, with a very simple methodology, has shown him that there are organizations with always busy professionals for whom the people in the corridors are just a noise that disorients them from their obligations, while others, rather few, have dedicated themselves to deploying, among their employees, the habits of a welcoming culture.</p><p style="text-align: justify;"><b>The importance of letting brains into the work</b></p><p style="text-align: justify;"><a href="https://corporate-rebels.com/rebel/brendanmartinbuurtzorg/" target="_blank">Brendan Martin</a>, head of <a href="https://buurtzorg.org.uk" target="_blank">Buurtzorg Britain & Ireland</a>, <a href="https://corporate-rebels.com/reinventing-the-nhs-removing-the-shackles-of-bureaucracy/?mc_cid=a03f75906d&mc_eid=bfc0f5e2ff" target="_blank">writes in a Corporate Rebels post</a> that a group of innovators who had redesigned the garbage collection system in many American cities had told him that the success of the changes relies on knowing how to create an adequate climate so that workers did not need to park their brains at the entrance to work. Martin states that, unfortunately, in most hierarchical organizations, such as the English NHS, officials have been trained to do what they are told and not what they think would be best, and thus many of them are engulfed by the prevailing bureaucracy and they are not able to look up to see that there is a disoriented person in the middle of their hospital reception. On the other hand, that action is not defined in the task list of the civil servants does not help at all.</p><p style="text-align: justify;"><span style="font-size: large;">To promote the friendly face of health organizations, it is first necessary to evolve the prevailing hierarchical-bureaucratic model towards one that is more respectful of workers and, in addition, to promote a welcoming culture.</span></p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com1tag:blogger.com,1999:blog-4773674341006984398.post-17865827083405732502022-07-11T08:00:00.056+02:002022-07-18T09:26:38.168+02:00Digital twins in the health sector: objects, people and systems<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBtA8n5MDDEYO8ZVBfqBaUrOvjAdSzWxKT007jEA1nFH4Nug4NxSaAJ1rgkrvZnW8NckQU-LXljQ_moj54qwmJl3dlS4uLOzwiMRcQHFEpAJMblnn1vcVRKJRzxE4igis4DB4zUry2e4r3JfB96oOmoVGdF9UEBaDMv1A_F-jqYKqa7Yl7-vr3fdRw1g/s313/Tino%20Marti%CC%81.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="288" data-original-width="313" height="94" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBtA8n5MDDEYO8ZVBfqBaUrOvjAdSzWxKT007jEA1nFH4Nug4NxSaAJ1rgkrvZnW8NckQU-LXljQ_moj54qwmJl3dlS4uLOzwiMRcQHFEpAJMblnn1vcVRKJRzxE4igis4DB4zUry2e4r3JfB96oOmoVGdF9UEBaDMv1A_F-jqYKqa7Yl7-vr3fdRw1g/w200-h184/Tino%20Marti%CC%81.png" width="100" /></a></div><b><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Mart%C3%AD%20T." target="_blank"><span style="font-family: verdana; font-size: medium;">Tino Martí</span></a></b><br /><div class="separator" style="clear: both; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZ-Jk8sZddIBAl8lGigaxq6K11_OGbIKL3KnaEWcF3feLrJxNu-NV-V6k98g2eHNoGfCubKUGqfiSIyqGsIHL8khzKT40fgLiCGYGvgvnOIMKLPdXNDqFlAxFyrd6WAp9GTH5NCCRqC1ifiLtLRBUaT2svJbpZvrkwEg_Fg42gVfrMDXc29TrBP0MR3Q/s320/Untitled-3.png" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="179" data-original-width="320" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZ-Jk8sZddIBAl8lGigaxq6K11_OGbIKL3KnaEWcF3feLrJxNu-NV-V6k98g2eHNoGfCubKUGqfiSIyqGsIHL8khzKT40fgLiCGYGvgvnOIMKLPdXNDqFlAxFyrd6WAp9GTH5NCCRqC1ifiLtLRBUaT2svJbpZvrkwEg_Fg42gVfrMDXc29TrBP0MR3Q/s1600/Untitled-3.png" width="320" /></a></div><div style="text-align: justify;">A digital twin is the virtual representation of a physical entity that feeds on data captured by sensors. This information offers the status of the equipment in real-time and facilitates the application of artificial intelligence (AI) to identify potential problems, allowing their resolution in advance.<span><a name='more'></a></span></div></div><p style="text-align: justify;">The term digital twin is getting popular in multiple forums. It was first used in 2003 in the field of product lifecycle management when virtual representations of physical items were still in their infancy. With the advancement of computing power and the advent of the Internet of Things, digital twins are sparking interest in many industries, including healthcare. Gartner ranked digital twins in the top 10 strategic technology trends in <a href="https://www.gartner.com/smarterwithgartner/gartner-top-10-strategic-technology-trends-for-2018" target="_blank">2018</a> and <a href="https://www.gartner.com/smarterwithgartner/gartner-top-10-strategic-technology-trends-for-2019" target="_blank">2019</a> and from 2020 they were included in the hyper-automation trend.</p><p style="text-align: justify;">In the field of health, digital twins have multiple possibilities and can be applied to physical objects (medical equipment or biological organs), but also virtual versions of people, care centres or health systems.</p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="315" src="https://www.youtube.com/embed/H6JzPCbyVSM" width="560" youtube-src-id="H6JzPCbyVSM"></iframe></div><p style="text-align: justify;"><b>Object simulation</b></p><p style="text-align: justify;">A digital twin of medical equipment allows maintenance needs to be identified before they appear, thus reducing interruptions such as cancellations of exploratory test visits with their consequent impact on waiting lists, user satisfaction or even clinical results. Digitizing equipment also enables rapid prototyping of new or improved versions.</p><p style="text-align: justify;">Organ virtualization is also the subject of digital twins. The French company Dassault Systèmes has carried it out through the <a href="https://www.3ds.com/products-services/simulia/solutions/life-sciences-healthcare/the-living-heart-project/#player1190078" target="_blank">Living Heart</a> project, which allows cardiological research with 3D <i>in silico</i> models from conventional scanners.</p><p style="text-align: justify;"><b>Patient simulation</b></p><p style="text-align: justify;">The application of digital twins to patient simulation allows progress in personalized therapies and the identification of anomalies by combining information from other patients with similar characteristics. It can also help improve prevention by simulating the effects of the passage of time on various hypotheses of healthy habits. Thus, for example, a wearable sensor could monitor blood pressure and associate it with adherence to medication, diet, lifestyle habits and genetics. All of this information would help suggest changes in the medication plan and behaviour to optimize the individual's health.</p><p style="text-align: justify;">The telemedicine company <a href="https://www.babylonhealth.com/en-gb/product/healthcheck" target="_blank">Babylon Health</a> applies it as part of the family medicine services it offers in the United Kingdom. Based on a health questionnaire about diseases suffered and current physical activity habits, it represents a digital twin of the patient that allows exploring the health and risk factors of organic nature of twenty diseases from the exploitation of millions of data collected. Its use is intended to provide health information for the patient, in no case to diagnose.</p><p style="text-align: justify;"><b>Systems Simulation</b></p><p style="text-align: justify;">In the field of management and planning, the simulation of care systems is especially attractive. A digital twin of a centre or a healthcare network could provide clues for better decision-making with results in population health. The experience of the COVID-19 pandemic is a good example of how systems simulation could have helped to better manage the bottlenecks experienced in primary care, emergencies or hospitalization units.</p><p style="text-align: justify;">To simulate health systems, electronic medical records and the use of AI are essential travel companions. The former has been available for years, although with difficulties in their aggregation and semantic interoperability, which makes the application of AI difficult. For this reason, it is not surprising that system simulation experiments are in an embryonic phase, such as the <a href="https://www.researchgate.net/publication/345373895_HospiT'Win_a_digital_twin_framework_for_patients'_pathways_real-time_monitoring_and_hospital_organizational_resilience_capacity_enhancement" target="_blank">HospiT'Win project</a>.</p><p style="text-align: justify;">The development of control towers for monitoring surgical areas or hospital centres is an appropriate field of application for digital twins, simulation and optimization of care processes; by managing information from a single centre, the problems of information availability become insignificant.</p><p style="text-align: justify;">Digital twin technology will make it easier for providers and health systems to approach the needs of patients individually and also by population. Its potential to improve the patient experience and the overall efficiency of the system will mean a true digital transformation if the value of the data is firmly committed.</p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-68404078946792688192022-07-04T08:00:00.063+02:002022-07-11T09:29:29.760+02:0010 proposals to transform our hospitals<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYSi-xWKY9Zd2AeNHW6VHu292mQXwsyk9b6GDfaioxMC0LSPlbTv95QHSvI8YZe3ylZIvwH1gFYgG5WEQtVseYCFLC77yj7sT6EoGo0e6Bma_OEdIsfs6NKJ3cGNf8Mi4t4wl6h4OyghXi9EC6gAcCPlm4nXvpechQQuLGZbiL9HcJR8qTf69uXkaP9w/s175/Nacho%20Vallejo.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="175" data-original-width="155" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYSi-xWKY9Zd2AeNHW6VHu292mQXwsyk9b6GDfaioxMC0LSPlbTv95QHSvI8YZe3ylZIvwH1gFYgG5WEQtVseYCFLC77yj7sT6EoGo0e6Bma_OEdIsfs6NKJ3cGNf8Mi4t4wl6h4OyghXi9EC6gAcCPlm4nXvpechQQuLGZbiL9HcJR8qTf69uXkaP9w/w177-h200/Nacho%20Vallejo.png" width="93" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Vallejo%20N." target="_blank">Nacho Vallejo</a></span></b><br /> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><b>The history of the NASA pirate group</b></p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYkfd1ZXrNu3JkXBWbh7fffmcgcnr0v0dsqP9xkYmnzQvMlq6hZ_4KGVizZO8FXgxBdOHqaPeqAYjOwEDVx0QOh5GTutYSYGWQTcehppQzAtLWFGhon2h5j3gVdbF8D_3jNEhWBEYedgfdBil1JJwhfIPb51hwn_bO6WYGzdq8L0or9e-KlZVMXwqsLQ/s320/Untitled-2.png" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="180" data-original-width="320" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYkfd1ZXrNu3JkXBWbh7fffmcgcnr0v0dsqP9xkYmnzQvMlq6hZ_4KGVizZO8FXgxBdOHqaPeqAYjOwEDVx0QOh5GTutYSYGWQTcehppQzAtLWFGhon2h5j3gVdbF8D_3jNEhWBEYedgfdBil1JJwhfIPb51hwn_bO6WYGzdq8L0or9e-KlZVMXwqsLQ/s1600/Untitled-2.png" width="320" /></a></div><div style="text-align: justify;">In the 1980s, the space agency NASA began work on the development of space shuttles. Responsible for landing man on the Moon, it zealously maintained the use of the Apollo-era operating system. At that time, a group of young engineers who had recently joined the agency questioned whether the system was going to be able to respond to the challenges posed. Calling themselves "<a href="https://www.bbc.com/mundo/vert-cap-57353092" target="_blank">the Nasa pirates</a>", they proposed an alternative mission control. The agency's mantra "we've always done it this way, so it must be the best" didn't stop these rebels from <a href="https://twitter.com/HelenBevanTweet/status/1407394746864226304?s=20" target="_blank">writing their own "manifesto"</a> challenging the <i>status quo</i>.<span><a name='more'></a></span></div><p></p><p style="text-align: justify;">The story, a priori far from the orientation of this blog on healthcare management, may not arouse the interest of our regular readers. But an unexpected turn of events encourages me to share it because it can serve as an example for change in our health institutions.</p><p style="text-align: justify;">The initial rejection of the "hacker" ideas ended when a legendary director of mission control and the group's efforts provided an opportunity: the pirate operating system would coexist with the official one for a few months. And it did it with remarkable results. While there were continuous falls and blockages of what had been the operative star of the agency, the new system not only continued to serve but also facilitated the execution of projects and ended up being the seed for the development of the future international space station.</p><p style="text-align: justify;"><b>Transforming our hospitals</b></p><p style="text-align: justify;">The history of these mavericks teaches us that innovation and change <a href="http://gestionclinicavarela.blogspot.com/2021/03/tres-claves-del-exito-en-la-gestion-del.html" target="_blank">do not usually have an easy pat</a>h. The same thing happens in our organizations. Although most of us are capable of original and novel ideas, we are not usually confident enough to bring novelties to healthcare. <a href="http://varelaclinicalmanagement.blogspot.com/2022/04/transforming-our-health-system-requires.html" target="_blank">Improving what we do and also doing better things</a> usually finds natural barriers: our culture, the hierarchy, the bureaucracy, the need for resources and time, the managers, the professionals themselves and the "here it has always been done that way".</p><p style="text-align: justify;">Trying to change the system is not easy. It is a journey we undertake to test ourselves by expanding our comfort zone. It is a real adventure. We have to trust that we can bring something new, find partners who facilitate the journey and try to offer the best of ourselves in improving care for our patients.</p><p style="text-align: justify;">The story of change also needs a certain sense of self-criticism, tenacity to modify some rules in the interest of the organization itself and the search for catalysts that help in the transformation. In my case, it was a chance encounter on social networks with other committed professionals. With them, and using the hashtag <a href="https://twitter.com/search?q=%23cambiahospital&src=typed_query&f=live" target="_blank">#cambiahospital</a>, we have talked over the years about the need to respond not only to what is urgent but also to what is important; what it means to build together, to surpass prejudice; to work as a team; to manage people. We talked about the value of service leadership, the search for results relevant to our patients, that we must care for ourselves and encourage them to care for us, that we must give the patient and the professional a voice and that we must look for new ways to organize ourselves.</p><p style="text-align: justify;">And, together, we have built our <i>rebel manifesto</i>. A decalogue, some rules that can serve to light the way. To challenge the growing inertia in our organizations and face the current and future challenges presented by healthcare in our hospitals, we propose…</p><p style="text-align: justify;"><b>...A decalogue of rules to change the hospital</b></p><p style="text-align: justify;"></p><ol><li style="text-align: left;">Hospitals must have a clear and inspiring<b> mission</b> that overcomes bureaucracy, prejudice and egos and helps unleash the full potential of professionals and managers, facilitating co-creation with patients.</li><li style="text-align: left;">Hospitals must orient the <b>organizational model</b> towards a fluid network of teams, changing roles, providing new skills to their workers and making it easier for them to acquire responsibilities. In this task, it is important to incorporate patients and front-line professionals.</li><li style="text-align: left;">Hospitals ought <b>to share authority</b> to facilitate the work of those who are willing, from humility, to lead by example, to build and guide teams.</li><li style="text-align: left;">Hospitals must facilitate <b>experimentation</b>, make it visible and reward it. Incorporate<b> innovation</b> as part of the process, with its risks, successes and failures.</li><li style="text-align: left;">Hospitals must facilitate the <b>autonomy of workers</b>, with accountability, and trust that people work in the best interest of the institution, helping patients and families in the best possible way.</li><li style="text-align: left;">Hospitals have to facilitate the flow of <b>information</b> and have greater <b>transparency</b>, avoiding fearful silence, normalizing the conversation, supporting an environment with psychological safety and increasing the precision and speed of decision-making.</li><li style="text-align: left;">Hospitals have to let people <b>work in what they like best</b> and that best suits their interests and strengths. Make it easier for talent to grow and let people grow.</li><li style="text-align: left;">Hospitals must <b>take action on patient-centred care</b>. This is not making people and families happy; it's about instilling confidence in the way we do things every day.</li><li style="text-align: left;">Hospitals have to <b>lower the barriers </b>between managers, professionals and patients, making it easier for the latter to join governance bodies on an equal footing.</li><li style="text-align: left;">Hospitals have to share a <b>purpose</b>, which goes far beyond a vision and mission. It is to go straight to the bowels and hit a part of the most primitive being of each one. It's working to bring people together with similar primitive purposes and getting them all moving in the same direction, it's doing incredible things, it's doing the impossible, the inevitable.</li></ol><p></p><p style="text-align: justify;"><b>To change</b>, in short, is to have the humility to identify what we do not know and the curiosity to rethink the way we have always worked. It is about grow making grow. Together we must create the right conditions for things to happen, for patients, professionals and managers and for us to move forward and contribute positive new ideas for the benefit of people's health care and the much-needed care for professionals. And we must always involve patients because if we do not include them in the design and decision-making, it is very likely that we will develop brilliant paths elaborated by experts, but without any value for people.</p><p style="text-align: justify;">I share in the post <a href="https://www.youtube.com/watch?v=i8tSP7TfFDw" target="_blank">the video about a conference focused on this topic at the San Jorge Hospital in Huesca on October 20, 2021</a>.</p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-59013306224829377722022-06-27T08:00:00.043+02:002022-07-04T11:37:39.102+02:00#FAP_ICSCC Primary care pharmacists, support for patient-centred care<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMiRUsHjjjB6PDcQ7GyAnM5FvTAlIWqYsub2lh-fJCcVfIVHL_-4S8GoJC5m1AUd7R_9HHldxwm-1GTx63bYKizVSOReAmFAYS-xvAXrl8v9DwSKQ61AHw3rYg906NSlz0AfNYWA6Zfic2-P5QY1EYidkH89dPfrKAfwHDiqIHhT-K5f8E8ZoHzepPgg/s538/Josep%20Vidal-Alaball.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="538" data-original-width="497" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMiRUsHjjjB6PDcQ7GyAnM5FvTAlIWqYsub2lh-fJCcVfIVHL_-4S8GoJC5m1AUd7R_9HHldxwm-1GTx63bYKizVSOReAmFAYS-xvAXrl8v9DwSKQ61AHw3rYg906NSlz0AfNYWA6Zfic2-P5QY1EYidkH89dPfrKAfwHDiqIHhT-K5f8E8ZoHzepPgg/w185-h200/Josep%20Vidal-Alaball.png" width="92" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Vidal-Alaball%20J." target="_blank">Josep Vidal-Alaball</a></span></b><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><br /><p style="text-align: justify;"><i>For writing this post, Josep Vidal-Alaball has shared authorship with Anna Maria Bonet Esteve and Aïna Fuster Casanovas.</i></p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjzdhiLeZmPJ7D1smw92lGNelEl-qwZ9mdMfsVulX3-z-OIaZgl3OT1V92I9lrgWcr30NCinjd3TZ2AgeHA1guzYUwKD1ptmHw0ERb4xkix3spKrjJbM0GA6FGTQswzGCcx8RnHJefgQa8SXox5lXhc-MxY5q73UuhL2rYIKoid8sf_0-IH4HEuDrCv3g/s320/Sense%20nom.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="195" data-original-width="320" height="195" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjzdhiLeZmPJ7D1smw92lGNelEl-qwZ9mdMfsVulX3-z-OIaZgl3OT1V92I9lrgWcr30NCinjd3TZ2AgeHA1guzYUwKD1ptmHw0ERb4xkix3spKrjJbM0GA6FGTQswzGCcx8RnHJefgQa8SXox5lXhc-MxY5q73UuhL2rYIKoid8sf_0-IH4HEuDrCv3g/s1600/Sense%20nom.jpg" width="320" /></a></div><div style="text-align: justify;">Health systems have always been more disease-oriented than patient-oriented. In a paternalistic way, the patient's medication has been managed, indicating what he or she has to take and how they have to do it. What consequences has this had? Discomfort in those patients for whom the medication does not suit them, with the consequent interruption of the treatment and the frustration of the professionals for not obtaining results, in addition to the high cost associated with the health system. The social profile of the Catalan population is characterized by progressive ageing and, therefore, by an increase in chronic pathology and associated comorbidities. Fragmented health care among multiple health providers in the system can complicate treatments that are already complex per se. In a context of excessive medicalization of daily life due to the use of medication as one of the main therapeutic resources in the provision of health care, there is an acute need to change the paternalistic management model to promote care that takes into account all stakeholders <span style="font-size: x-small;">(1)(2)</span>.<span><a name='more'></a></span></div><p></p><p style="text-align: justify;">Today, leading health systems are characterized by having a patient-centred health care model or moving towards such a model. Patient empowerment, shared decision-making and the formation of multidisciplinary teams are essential to promoting an effective and efficient health system. Precisely for this reason, we want to make you part of the incorporation of the figure of primary care pharmacists (PCF) to the primary care teams (PCT) for the improvement of the patient-centred management model in the Catalan Institute of Health of Central Catalonia.</p><p style="text-align: justify;">The Pharmacy Unit and the Healthcare Directorate of Central Catalonia decided to promote the role of the pharmacist in PCTs and implement an innovative patient-centred model through the Pharmacy Unit Functional Plan approved in 2018 <span style="font-size: x-small;">(2)</span>, a plan that stands out for promoting the more clinical role of PCFs with a more individualized approach to patients. Its objective is to optimize the pharmacological treatment of patients and, therefore, improve the quality of life and safety of care, contribute to the sustainability of health care and improve patient and health provider satisfaction <span style="font-size: x-small;">(2)</span>. Thus, this innovative model not only complies with the three dimensions of the Triple Aim, the improvement of the patient experience, the clinical results in the population and the reduction of per capita costs but also seeks to <a href="http://varelaclinicalmanagement.blogspot.com/2016/08/from-triple-aim-to-quadruple-aim.html" target="_blank">comply with the fourth dimension that provides the Quadruple Aim</a>: the promotion of professional satisfaction <span style="font-size: x-small;">(3)</span>.</p><p style="text-align: justify;"><b>The importance of developing a plan to implement the reforms</b></p><p style="text-align: justify;">Before putting the functional Plan into operation, the "pharmaceutical need" of each PCT was defined in a reasoned way to assimilate it into the already used "allocated quota" that other primary care professionals have. Different variables were set to calculate the estimated workload of primary care pharmacists for the performance of their functions. In this way, the assignment of PCFs to PCTs relied on the result of a synthetic index that corresponded to the weighted sum of a set of variables (dispersion, socio-economic index, assigned population, attendance, institutionalized population, number of residences places geriatric and psychiatric, number of residences, the synthetic value of the quality index of pharmaceutical prescription, percentage of polypharmacy patients, percentage of adherence to the Prescription Guide for geriatric centres, amount/resident, percentage of complex chronic patients, and drug safety incident rate). In addition, a communication plan aimed at giving visibility to the figure of the primary care pharmacist, both internally and among the reference population, with the creation of a logo and its hashtag on Twitter (<a href="https://twitter.com/search?q=%23FAP_ICSCC" target="_blank">#FAP_ICSCC</a>), was added.</p><p style="text-align: justify;">The Functional Plan was implemented in 2019 and was structured in two phases. The first involved the face-to-face transition of the PCFs from the primary care services, where the management and technical bodies reside, to the PCTs. Its principal role aimed to progressively transform the culture of approaching pharmacological treatment, giving more value to the structured review of medication within the framework of multidisciplinary teams. To this end, different actions were carried out, such as the creation of PCF's agendas integrated into the primary care clinical station (eCAP). Non-face-to-face visits also started to order medication reviews, prioritise multi-medicated patients and record the proposed recommendations in the patient's clinical history. In addition, the classic PCF activities focused on the population view of drug use were reorganized and a specific dashboard was defined to monitor the prioritized strategies, which are periodically updated. These strategies included the polypharmacy approach, the use of antibiotics or the treatment of anxiety or insomnia. Despite more than two years of the COVID-19 pandemic, this phase is currently the most consolidated, representing the leitmotif of the clinical role of the PCFs within the PCTs. The second phase proposed a more direct interaction with the patient and COVID-19 favoured a unique opportunity to make it operational. Although the plan included face-to-face visits with patients, especially multi-medicated patients, the start of the COVID vaccination campaign allowed the innovative interaction to be adapted to telephone contact to resolve the population's vaccine doubts. The data on the number of visits for the last two years is revealing: 2,883 visits in 2020 and 5,722 visits in 2021.</p><p style="text-align: justify;"><b>Patient-centred care, the challenge</b></p><p style="text-align: justify;">The Pharmacy Unit of Central Catalonia has opted for the patient-centred care model, contributing in an innovative, pioneering and effective way to the multidisciplinary teams of primary care centres. Even so, the next objective is to implement face-to-face visits with patients. In this context, the growing increase in mental health problems is a challenge where the role of the PCFs can be decisive and, in this sense, they will be a reference framework with the start of a project aimed at reducing the use of benzodiazepines. Finally, we have to congratulate ourselves on the disruptive vision of the model that contemplates incorporating a PCF to each of the PCTs and that wants to be a source of inspiration for other teams.</p><p style="text-align: justify;"><i>I give thanks the PCFs of Central Catalonia: Mar Casanovas Marfà, Vanesa García Sánchez, Amanda López Ínsua, Adrián López Cortiña, Marta Massanés González, Carol Rovira Algara, Ester Vizcaíno Vilardell and Anna Bonet Esteve.</i></p><p style="text-align: justify;"><i><br /></i></p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px;"><b>Bibliography</b></p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px;"></p><ol style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px;"><li style="margin: 0px 0px 0.25em; padding: 0px;">ENASPIC. Estratègia Nacional d’atenció primària i salut comunitària. :1–38. </li><li style="margin: 0px 0px 0.25em; padding: 0px;">Bonet A. Pla Funcional. Unitat de Farmàcia d’Atenció Primària. Gerència Territorial Catalunya Central. 2018; </li><li style="margin: 0px 0px 0.25em; padding: 0px;">Roure C. Avances en gestión clínica: <a href="http://varelaclinicalmanagement.blogspot.com/2016/08/from-triple-aim-to-quadruple-aim.html" style="color: #29527b; text-decoration: none;" target="_blank">From the Triple Aim to the Quadruple Aim</a>. 2016.</li></ol></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-89612254903423913792022-06-20T08:00:00.070+02:002022-06-27T10:10:11.964+02:00Lack of nurses: a serious social problem<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBKr2KTTMVd_RqcymI5R6FytMc5_sP2WmZdEXfccYGEeEWUe_bJawm6v_JE9d1Tr60zVEV8JF-H6_kwFQb_i-sW_qegmMDTdROpwf50rXIz3tUFHYO-y00bS8YhYkuQjl2At2Y2EZgz9Jrfw5K0EdPTc306XJWVYJ16DXTs1ROQM-jD7b4hRWiBn3agw/s172/Alba%20Brugue%CC%81s.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="172" data-original-width="171" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBKr2KTTMVd_RqcymI5R6FytMc5_sP2WmZdEXfccYGEeEWUe_bJawm6v_JE9d1Tr60zVEV8JF-H6_kwFQb_i-sW_qegmMDTdROpwf50rXIz3tUFHYO-y00bS8YhYkuQjl2At2Y2EZgz9Jrfw5K0EdPTc306XJWVYJ16DXTs1ROQM-jD7b4hRWiBn3agw/w200-h200/Alba%20Brugue%CC%81s.png" width="100" /></a></div><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Brugués%20A." target="_blank"><b><span style="font-family: verdana; font-size: medium;">Alba Brugués</span></b></a><br /> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;">The nursing shortage is a well-known problem throughout the world and has been exacerbated by the effect of the pandemic. According to a WHO report published in 2020, there are 28 million nurses in the world, constituting 59% of health professionals. Currently, the shortage of nurses is estimated at 5.9 million. The report highlights that if action is not taken, by 2030 there will be a shortage of 10.6 million nurses worldwide. In Spain, it is estimated that there are 120,000 missing and in Catalonia 24,000.<span></span></p><a name='more'></a><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhTJ-ju7vOx0kbOLq34iSiXtNzCvF4nfkM5GYiD5LkB3zKxiHiGw4IGPwP83O3fomFIhi5Hgumt7YaU6AUzqOMXJpTohJjaHYUex_UsIBYRB2Sy6aAphNGDSwVrAiA5V6IDH35AHL-2RrV5oI3i4-pNOrnsZ7SYOKgLMkqi18sAPOB1pPk_-xeH9QIUsg/s640/Untitled.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="342" data-original-width="640" height="324" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhTJ-ju7vOx0kbOLq34iSiXtNzCvF4nfkM5GYiD5LkB3zKxiHiGw4IGPwP83O3fomFIhi5Hgumt7YaU6AUzqOMXJpTohJjaHYUex_UsIBYRB2Sy6aAphNGDSwVrAiA5V6IDH35AHL-2RrV5oI3i4-pNOrnsZ7SYOKgLMkqi18sAPOB1pPk_-xeH9QIUsg/w640-h344/Untitled.png" width="580" /></a></div><p style="text-align: justify;">The age of the nurses shows that they are relatively young, but with disparities between countries, and that Europe and America are the two continents with the highest ageing rate. Having an ageing population of nurses increases the rate of abandonment of the profession, a factor to which must be added the forecast of annual retirements which, in turn, increases the structural deficit. <a href="https://www.icn.ch/system/files/2021-07/ICN%20Policy%20Brief_Nurse%20Shortage%20and%20Retention_SP.pdf" target="_blank">It is expected that in the next ten years 17% of nurses worldwide will retire </a>and <a href="https://www.who.int/es/publications/i/item/9789240003279" target="_blank">that 4.7 million more will have to be trained and hired just to maintain the current numbers of professionals</a>.</p><p style="text-align: justify;">According to a report from the Nursing Council of Spain in 2020, in the member countries of the Organization for Economic Co-operation and Development (OECD), there is considerable disparity in the ratios of nurses per 1,000 inhabitants, a fact related to the nursing model, health system and the socio-economic level of each of the countries. Currently, the highest rate is in Norway, with more than 18 nurses per 1,000 inhabitants, while Spain is in eighth place from the bottom, with 5.9, while the average value is 9.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgW-IJcp6kaF2i8JbfLjEN1nQDc_thWenwm4XNodFuu4dp4IsNEniXAN7MS4vJF3nZOhPFgkQwet3jZ6L2njYdXsNC6HRlO_iOtqKNzWEW1EC3iAkY4u7lMBQHKOJd_R6C7c9vNrJBmk9Myjey-XLYI7fq10lborHUn5bJ7JzLgueLdcFm1UEv6OxXDHA/s639/2-2.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="360" data-original-width="639" height="340" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgW-IJcp6kaF2i8JbfLjEN1nQDc_thWenwm4XNodFuu4dp4IsNEniXAN7MS4vJF3nZOhPFgkQwet3jZ6L2njYdXsNC6HRlO_iOtqKNzWEW1EC3iAkY4u7lMBQHKOJd_R6C7c9vNrJBmk9Myjey-XLYI7fq10lborHUn5bJ7JzLgueLdcFm1UEv6OxXDHA/w640-h360/2-2.png" width="580" /></a></div><p style="text-align: justify;"><a href="https://www.consejogeneralenfermeria.org/normativa/documentos-de-interes/otros-documentos/send/69-otros-documentos/1446-informe-de-recursos-humanos-de-enfermeria" target="_blank">As for the different autonomous communities of the Spanish State, there is a big difference in the number of nurses per 1,000 inhabitants</a>. Navarra has the highest ratio, with 8.6, Murcia the lowest, with 4.5, and Catalonia's is 6.2.</p><p style="text-align: justify;">If we look at the ratio of nurses in primary care, Rioja is the best equipped, while Madrid is at the bottom with almost half the ratio.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSGLaGTxxZTUswnelbvGnX8Gm0-ZmVBubVdinyDnqUOIWI_un1izcE53Z_J6sRNXvanvao_fzHwjByVRsquR0K85q8bYABLBIQP_FAG2P_7v5Htqp5SArkFQD9mf86OqqIKDFUj3ydRVc559i9XJ8khwld-NEP5Ucp4Ot9ROsA75r730xwOvK0PUzR_w/s640/3-2.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="366" data-original-width="640" height="348" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSGLaGTxxZTUswnelbvGnX8Gm0-ZmVBubVdinyDnqUOIWI_un1izcE53Z_J6sRNXvanvao_fzHwjByVRsquR0K85q8bYABLBIQP_FAG2P_7v5Htqp5SArkFQD9mf86OqqIKDFUj3ydRVc559i9XJ8khwld-NEP5Ucp4Ot9ROsA75r730xwOvK0PUzR_w/w640-h368/3-2.png" width="580" /></a></div><p style="text-align: justify;"><b>What factors explain the lack of nurses in Spain?</b></p><p style="text-align: justify;"></p><ul><li style="text-align: left;">The economic crisis of 2008 led to cuts in health structures that considerably affected the ratios of nurses, which have never recovered.</li><li style="text-align: left;">As of 2008, the Bachelor of Nursing (3 years) became a Bachelor of Science (4 years), leaving all universities without graduating new nurses for one year. This deficit was also not recovered and the cuts balanced supply with demand at the time.</li><li style="text-align: left;"><a href="https://www.researchgate.net/publication/328732166_La_migracion_de_enfermeras_formadas_El_caso_de_Espana" target="_blank">The emigration of nurses to other countries in search of more attractive working and professional conditions coincided</a> with the 2008 crisis, so this was added to the moment of greater mobility of nurses to Europe, mainly to the United Kingdom. According to data from the SATSE nursing union, there are currently more than 8,000 Spanish nurses working in European countries.</li><li style="text-align: left;">Little foresight on the part of governments in the offers of places in universities, both public and concerted, to study the degree in nursing. It must be taken into account that the actions that are started today will have effects four years from now, or six if a speciality is added.</li><li style="text-align: left;">Given the progressive ageing of the population, the increase in chronicity and social changes, intensity and skill in care, the main function of nurses, are increasingly necessary.</li><li style="text-align: left;">The rough calculation of the number of retirements that are taking place and that will take place in the next few years of nurses who entered the labour market 40 years ago.</li><li style="text-align: left;">The abandonment of the profession, is a very worrying effect, especially if the reason is the precariousness of hiring and the lack of recognition in jobs.</li></ul><p></p><p style="text-align: justify;">To these, and possibly other, factors, the COVID-19 effect must be added, since according to <a href="https://www.icn.ch/system/files/documents/2020-07/COVID19_internationalsupplyofnurses_Report_FINAL.pdf" target="_blank">a study by the International Council of Nursing (IIC)</a>, between 10% and 15% of nurses have left the profession due to the effect of the pandemic, a deficit that will affect all health services in the post-COVID-19 era to the extent that it may become the main determinant of health in the next decade.</p><p style="text-align: justify;"><b>What are the consequences of the lack of nurses?</b></p><p style="text-align: justify;"></p><ul><li style="text-align: left;">The impoverishment of care provision at all levels of care affects the care received by individuals, families and communities, especially the most vulnerable.</li><li style="text-align: left;">Reduction of health prevention and promotion programs that affects people's long-term health. This is happening now.</li><li style="text-align: left;"><a href="https://pubmed.ncbi.nlm.nih.gov/33989553/" target="_blank">There are studies carried out in the hospital setting</a> that show that the mortality rate and the improvement in health status are directly related to the number of patients attended by a nurse. <a href="http://gestionclinicavarela.blogspot.com/2021/10/mas-evidencia-de-la-efectividad-de-las.html" target="_blank">More nurses equal less mortality and improved recovery</a>.</li><li style="text-align: left;">In the field of primary care, studies show that an increase in the contingent of people assigned to the referring nurse and cared for by her translates into a higher workload that significantly increases <a href="https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1135-57272016000100405" target="_blank">poor control of diabetes <i>mellitus</i> </a>and <a href="https://bmjopen.bmj.com/content/5/12/e009126.long" target="_blank">hypertension arterial</a>.</li><li style="text-align: left;">There is currently an excess of competition in contracting between healthcare levels, providers, autonomous communities and even between countries. This struggle by employers to find nurses has not managed to improve the situation of the entire group, but on the contrary, it has harmed the residential and socio-healthcare spheres, rural areas and the hospitals farthest from the large urban centres – where working conditions are less attractive – who currently have serious problems finding staff.</li></ul><p></p><p style="text-align: justify;"><b>How to alleviate the current situation?</b></p><p style="text-align: justify;">In my opinion, there are three blocks of essential actions:</p><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px;"><p style="text-align: left;">1. <u>Increase university places to study a degree in nursing</u></p></blockquote><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px; text-align: left;"><p style="text-align: left;">According to the WHO report, to solve the shortage of nurses by 2030, the number of nursing graduates would have to be increased by 8% per year. This recommendation has to be adjusted according to the previous particular shortcomings of each country or region, as in the case of Spain and some autonomous communities with the greatest deficit. In Catalonia, an increase of 600 places is planned in public universities in the 2022-23 academic year, but this increase will not ease the historical deficit that we have if other measures are not implemented.</p><p style="text-align: left;">2. <u>Improve working conditions</u></p><p style="text-align: left;">- Stable contracts loyalty jobs. This action would prevent some nurses from emigrating to other countries for contractual and instability reasons and, at the same time, the workforce would be stabilized and the plundering of nurses between providers, care levels, areas, autonomous communities and countries would be avoided.</p><p style="text-align: left;">- Go to category A1 as academic recognition of degree, equating nursing to the rest of university degrees for all purposes.</p><p style="text-align: left;">3. <u>Recognize the specific competencies</u> of both skills and recognized specialities, which would put an end to hiring linked to job banks. A change in the contractual model based on competencies is needed.</p></blockquote><p style="text-align: justify;">But, beyond concrete actions, it would now be essential to define what the current and future population needs. Government and nursing organizations have to work together to determine the roadmap for the most appropriate care model. For years patches have been put on a situation that requires a thoughtful, courageous and forward-looking commitment.</p><p style="text-align: justify;">We have the diagnosis and know part of the solutions and the effects of not allocating resources to care. When shall we take action?</p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-48531118220615895852022-06-13T08:00:00.080+02:002022-06-20T09:32:13.545+02:00Digital transformation as a new determinant of health<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSmTLp8cOoyx2jA7DSSYVrDzNcV3USj6ITfhMPUf9Y2NKkmuzy2O7dcul8KsmTYq8vlxgpWNUOyK65KrO50UuvYFuO21Yk0-_RNy4Gv7GPw47Zym8Bb7X0gMAEPjML124GAb9wKNsnTLZqlduQzTsyMMGF76eELeBd735I58yQfaAnCDO5JQy_6P8qpA/s320/Elena%20Torrente.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="290" data-original-width="320" height="98" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSmTLp8cOoyx2jA7DSSYVrDzNcV3USj6ITfhMPUf9Y2NKkmuzy2O7dcul8KsmTYq8vlxgpWNUOyK65KrO50UuvYFuO21Yk0-_RNy4Gv7GPw47Zym8Bb7X0gMAEPjML124GAb9wKNsnTLZqlduQzTsyMMGF76eELeBd735I58yQfaAnCDO5JQy_6P8qpA/w200-h182/Elena%20Torrente.png" width="105" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Torrente%20E." target="_blank">Elena Torrente</a></span></b><br /> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiF33NVqAl5gQo629q8k1FJmrM84oE-32e0eCe88ypp2ACd1DDo6A8ZPDgxuQSw3zHD3tvp7eOhsjF89zwoaqlOjfsfJf3SbNKG6qeIaVGtB_gw-2VhvDu3-HfMLOQ_QFFRE8uY7JU9D53tc1dLriSuLWhn0Df3w4tHAJ86lcsKzBx5Qznpt3TvGvzBGw/s320/1.png" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="320" data-original-width="254" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiF33NVqAl5gQo629q8k1FJmrM84oE-32e0eCe88ypp2ACd1DDo6A8ZPDgxuQSw3zHD3tvp7eOhsjF89zwoaqlOjfsfJf3SbNKG6qeIaVGtB_gw-2VhvDu3-HfMLOQ_QFFRE8uY7JU9D53tc1dLriSuLWhn0Df3w4tHAJ86lcsKzBx5Qznpt3TvGvzBGw/s1600/1.png" width="254" /></a></div><div style="text-align: justify;">The Spanish Ministry of Health has recently published the <a href="https://www.mscbs.gob.es/ciudadanos/pdf/Estrategia_de_Salud_Digital_del_SNS.pdf" target="_blank">Digital Health Strategy of the National Health System</a>. The document, closely aligned with the WHO and European Union strategy on this matter, presents three main lines of action:</div><p></p><p style="text-align: justify;"></p><ol><li style="text-align: left;">Development of <b>digital health services</b> aimed at people, organizations and processes that make up the health protection system, with an equity approach.</li><li style="text-align: left;">Generalization to the maximum of the <b>interoperability</b> of health information.</li><li style="text-align: left;">Promotion of <b>the analysis of data</b> related to health, its determinants and the health system.<span><a name='more'></a></span></li></ol><p></p><p style="text-align: justify;">The three lines seem very appropriate given the new context of the digital health boom that COVID-19 has brought with it.</p><p style="text-align: justify;">The first point appeals to the <b>accessibility</b> that technology allows. The pandemic has meant a before and after in the use of telemedicine throughout the world and new channels of access to health services have been generated, both in the public and private sectors. In many cases with a reasonable degree of satisfaction on the part of professionals, according to recent articles like this one, and also on the part of citizens whose expectations to continue using virtual care when the pandemic ends are high, according <a href="https://www.accenture.com/_acnmedia/PDF-128/Accenture-Patient-COVID19-Treatment-Survey.pdf" target="_blank">to this study</a>.</p><p style="text-align: justify;">The second point deals with <b>interoperability</b>, that is, the need to adapt computer systems to guarantee the exchange of clinical information between health systems on a national and international scale. Finally, the reinforcement of <b>data analysis</b> is promoted as a means to optimize clinical decision-making, planning and management, something that will be essential in the future as Cristina Adroher magnificently analyzes in her <a href="http://gestionclinicavarela.blogspot.com/2021/11/datos-para-la-gestion-la-misma-logica.html" target="_blank">recent post</a>.</p><p style="text-align: justify;">Another element that appears in the strategy and that I would like to point out is the <b>participation of people in managing their health</b>, emphasizing lifestyles and prevention.</p><p style="text-align: justify;"><b>The contribution of digital technology to health</b></p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiirm5IuJAcl-GQzD2hbYg5nyOfubpf24l1lRG8-78gIcCtyVX8cG4OZbvBE_Ys57qpKlYcLxV3fRg_ClyDNWTlGxMwXHtMZFQA40COSjsqrDtHJv7AnWWP4cUao4ji8bquMg2Rtqu8XJCc55g8y70ZEnfkniWfOMc3MAC2Xu9bxhxuhnCIWWKM5AUTbw/s320/2.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="148" data-original-width="320" height="148" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiirm5IuJAcl-GQzD2hbYg5nyOfubpf24l1lRG8-78gIcCtyVX8cG4OZbvBE_Ys57qpKlYcLxV3fRg_ClyDNWTlGxMwXHtMZFQA40COSjsqrDtHJv7AnWWP4cUao4ji8bquMg2Rtqu8XJCc55g8y70ZEnfkniWfOMc3MAC2Xu9bxhxuhnCIWWKM5AUTbw/s1600/2.png" width="320" /></a></div><div style="text-align: justify;">There are many opportunities that technology offers to promote healthy lifestyles, from the creation and dissemination of content on a global scale to the numerous devices, wearables and health apps that are created daily. Technology should be used as one more tool at the service of health promotion and disease prevention interventions, given the potential for <b>personalization</b> that it entails.</div><p></p><p style="text-align: justify;">We know that individual behaviour and lifestyle habits make up an important <b>determinant of health</b> along with factors such as genetics, the environment and the socio-economic context, among others. Recently, <i>The Lancet and Financial Times Commission</i> has published an interesting report (<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01824-9/fulltext" target="_blank">see here</a>) where the need to consider <b>digital transformations as a new determinant of health is raised</b>.</p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEioY0OnWo2zGJzs9agh7bBJHJTxozGuq6B7y3QwxeMjmUePydPys_xn1me3bnszstQwA2FQCQzc57qWv4PvEJ0V5hDkvuJe3mWGqbmlCZwEGv0iDQ2RmHJJFuP2SLtFE_hPhrquPqJWCOVJJk_YcmOIqr_HKT0LSV_0uETf4Sfd4gRQw3GH43WXkIVxLw/s400/3.png" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="400" data-original-width="388" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEioY0OnWo2zGJzs9agh7bBJHJTxozGuq6B7y3QwxeMjmUePydPys_xn1me3bnszstQwA2FQCQzc57qWv4PvEJ0V5hDkvuJe3mWGqbmlCZwEGv0iDQ2RmHJJFuP2SLtFE_hPhrquPqJWCOVJJk_YcmOIqr_HKT0LSV_0uETf4Sfd4gRQw3GH43WXkIVxLw/w389-h400/3.png" width="389" /></a></div><div style="text-align: justify;">The article states that social determinants of health, such as age or socioeconomic background, have a <b>direct influence on how technologies are used </b>for issues related to health and well-being. In this sense, the usefulness of digital health depends on the level of digital health literacy that each person has. On the other hand, we know that access to technology and proven and reliable sources of information are essential for making decisions that promote healthy lifestyles. During the pandemic, it has been clearly shown how technology influences<b> trust</b> in health systems, both in a positive sense (dissemination of contagion prevention campaigns on social networks) and negative (anti-vaccine movements, dissemination of hoaxes...).</div><p></p><p style="text-align: justify;">The report concludes with four areas for action to shape the future of health in a digital world:</p><p style="text-align: justify;"></p><ol><li style="text-align: left;">Consideration of <b>digital technologies as increasingly important determinants of health.</b></li><li style="text-align: left;">Construction of <b>a governance architecture that generates trust </b>in digital health by granting rights to patients and vulnerable groups.</li><li style="text-align: left;"><b>Collection and use of health data based on the concept of data solidarity </b>to simultaneously protect individual rights, promote the public good potential of such data, and build a culture of data and capital justice.</li><li style="text-align: left;">Definition of <b>digital health strategies and clear investment roadmaps </b>in all countries, which help prioritize those technologies that are most necessary at the different levels of digital health maturity.</li></ol><p></p><p style="text-align: justify;">It seems that on the last point the homework has already been done in Spain, another thing will be its start-up and implementation by the competent bodies in the territory. For all this, the activation of European Next Generation funds through the <a href="https://nexteugeneration.com/el-gobierno-aprueba-el-perte-de-salud-de-vanguardia-que-preve-movilizar-1-469-millones-de-euros/" target="_blank">Strategic Project for Economic Recovery and Transformation (PERTE) for Vanguard Health</a> to mitigate the determinants of health of digital origin will be essential.</p><p style="text-align: justify;"><br /></p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;"><b>Bibliography</b></p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;"></p><ul style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; line-height: 1.4; margin: 0.5em 0px; padding: 0px 2.5em;"><li style="margin: 0px 0px 0.25em; padding: 0px; text-align: left;">Accenture Patient Survey May 2020. How COVID 19 will permanently alter patient behavior.</li><li style="margin: 0px 0px 0.25em; padding: 0px; text-align: left;">Prof. Ilona Kickbusch, PhD; Dario Piselli, MSc; Prof. Anurag Agrawal, PhD; Prof. Ran Balicer, PhD; Prof. Olivia Banner, PhD; Michael Adelhardt, MD, <i>et al</i>. <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01824-9/fulltext" style="color: #29527b; text-decoration: none;" target="_blank"><i>The Lancet and Financial Times Commission</i> on governing health futures 2030: growing up in a digital world</a>. October 24, 2021.</li><li style="margin: 0px 0px 0.25em; padding: 0px; text-align: left;"><a href="https://www.mscbs.gob.es/ciudadanos/pdf/Estrategia_de_Salud_Digital_del_SNS.pdf" style="color: #29527b; text-decoration: none;" target="_blank">Ministerio de Sanidad. Estrategia de salud digital del Sistema Nacional de Salud</a>. </li><li style="margin: 0px 0px 0.25em; padding: 0px; text-align: left;">Vidal-Alaball J. <i>et al</i>. (2020). <a href="https://www.mdpi.com/1660-4601/17/11/4092" style="color: #29527b; text-decoration: none;" target="_blank">Primary Care Professionals’ Acceptance of Medical Record-Based, Store and Forward Provider-to-Provider Telemedicine in Catalonia: Results of a Web-Based Survey.</a> Int. J. Environ. Res. Public Health, 17, 4092 2 of 13. </li></ul>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-56874049054416536672022-06-06T08:00:00.084+02:002022-06-13T09:31:14.366+02:00Universal health coverage in Spain, myth or reality?<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLBu4-7aMpBhwZqZ1PK4wtsvkGsSs7Tg1N4iQKC84TA1zgcimbgZQqvT-vxKUxIInigSNQbIBCDBmV82n6bzcGenQmxgeJOEoDQHk2QirTSwtnHONtmA4sEDqMON9U7jq445NJtmSYPnHh5DoKWLFm2BBVlvbtG69U2pA9lUokH5dm7gqUGnJhA8RM8w/s288/Jose%CC%81%20Cerezo.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="288" data-original-width="219" height="110" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLBu4-7aMpBhwZqZ1PK4wtsvkGsSs7Tg1N4iQKC84TA1zgcimbgZQqvT-vxKUxIInigSNQbIBCDBmV82n6bzcGenQmxgeJOEoDQHk2QirTSwtnHONtmA4sEDqMON9U7jq445NJtmSYPnHh5DoKWLFm2BBVlvbtG69U2pA9lUokH5dm7gqUGnJhA8RM8w/w153-h200/Jose%CC%81%20Cerezo.png" width="88" /></a></div><b><span style="font-family: verdana; font-size: medium;">José Cerezo</span></b><p></p><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlP-OY99mI9cFjlHlLH5ASSyz7XO6qNpoV68blhsmJ0qcjUqzda3QDSHshQRqFCx38pP2O2blYyKxEzypkaUraDPr3BpnAdC0JiX8gMjPjOVaKzDbkCuUw7v_x04vphuUfIBdq1w_upoFKiYwa6fEhiDzb6b2hzRVMx3HBsVVDSFWgoFSwHF_3JY3klA/s873/Sense%20nom.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="873" data-original-width="630" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlP-OY99mI9cFjlHlLH5ASSyz7XO6qNpoV68blhsmJ0qcjUqzda3QDSHshQRqFCx38pP2O2blYyKxEzypkaUraDPr3BpnAdC0JiX8gMjPjOVaKzDbkCuUw7v_x04vphuUfIBdq1w_upoFKiYwa6fEhiDzb6b2hzRVMx3HBsVVDSFWgoFSwHF_3JY3klA/s320/Sense%20nom.jpg" width="231" /></a></div><div style="text-align: justify;">The WHO Barcelona Office for Health Systems Financing has promoted the first exhaustive analysis of financial protection in Spain, led by a team of national experts. The report entitled <i><a href="https://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/2021/can-people-afford-to-pay-for-health-care-new-evidence-on-financial-protection-in-spain-2021" target="_blank">Can people afford to pay for Health Care? New evidence on financial protection in Spain</a></i> jointly analyzes microdata from the INE Family Budget Surveys between 2006 and 2019 (the latest data available at the time of publication) and data on unmet needs for health services provided by the European Union Statistics on Income and Living Conditions (EU-SILC).<span><a name='more'></a></span></div></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Financial protection, what is it and why is it important?</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Financial protection is a paramount element of universal health coverage and the performance of health systems and is measured by two indicators: catastrophic health spending</b>, which occur when out-of-pocket payments for health care exceed 40% of the household's ability to pay once it has met its basic needs for shelter, food and supplies, and <b>impoverishing health spending</b>, which occur when out-of-pocket payments push households below the poverty line or they become even poorer if they were already below that threshold. The lack of financial protection can undermine access to health care, and health status, deepen poverty and exacerbate health and socioeconomic inequalities. People experience financial difficulties when out-of-pocket payments—formal payments (copayments) and informal payments made at the time of using any health good or service—are high relative to a household's ability to pay for health care.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>How many people experience financial hardship in Spain and what services cause it?</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">According to the latest data available in the report, nearly <b>300,000 households have catastrophic health expenses in Spain</b>. Of these, some <b>200,000 households belong to the poorest quintile.</b> These households are forced to decide between paying for access to health services or meeting other essential payments such as rent, heating or food. In addition, about <b>150,000 households are made poorer, or poorer still</b>, as a result of out-of-pocket (or out-of-pocket) payments for health care.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>The services responsible for these financial difficulties are fundamentally dental care and optical care in all home</b>s. The first is covered to a very limited extent by the National Health System (SNS) and the second (glasses, contact lenses) is excluded from its coverage. <b>In the poorest households, medicines </b>(subject to co-payments) also play an important role in generating financial difficulties.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Spain in the European context</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Despite having worsened during the economic crisis, the incidence of catastrophic health spending in Spain is one of the lowest in Europe</b>. This is explained by the strengths shown by the SNS coverage policies: coverage of practically the entire population based on residence; a fairly broad portfolio of health services with minimal variations between autonomous communities; Limited copays for prescription drugs and ortho-prosthetic devices, and different protection mechanisms for these copays (reduced copays and cap per prescription for drugs for chronic diseases, exemptions from co-payments for disadvantaged groups, and monthly income-based caps for pensioners).</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Impact of the economic crisis and lessons learned</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>The economic crisis had a detrimental effect on the financial protection of Spanish households and modified the profile of households with catastrophic </b><b>health </b><b>spending</b>. Although the incidence of catastrophic spending began to decline in 2016, in 2019 it was still above pre-crisis levels. Catastrophic spending increased between 2008 and 2015, reflecting a decline in the ability of households (especially the poorest) to pay for health care. The austerity policies implemented between 2012 and 2014 contributed to worsening this situation. Public health spending was cut, access to the SNS was limited for undocumented migrants and co-payments for prescription drugs were introduced for pensioners or co-payments were increased in the case of the active population and children. <b>During the crisis, households with catastrophic spending went from being headed by pensioners to being headed by people of working age, couples with children, and unemployed people</b>. The protective effect of the pension system and the monthly caps established in the copayment scheme for pensioners (which do not exist for the active population and children) explain this situation.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Since 2018, various measures have been taken to strengthen financial protection in Spain</b>. In 2018, the residence was reestablished as a criterion for SNS coverage, which formally meant that undocumented migrants regained full coverage. In 2021, new co-payment exemptions for the pharmaceutical benefit were established for various disadvantaged groups, including recipients of the minimum vital income, low-income pensioners and children with moderate and severe disabilities.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Pending challenges and recommendations to overcome them</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>The <a href="https://www.mscbs.gob.es/normativa/audiencia/docs/DG_67_21.pdf" target="_blank">draft Law on Equity, Universality and Cohesion</a> approved by the Spanish Government in November is a necessary step, but insufficient to substantially reduce financial difficulties and unmet health needs in Spain.</b> The draft bill introduces new exemptions to healthcare co-payments, extending those approved in 2021 for pharmaceutical benefits to the ortho-prosthetic benefit. It also contemplates establishing the necessary guarantees to avoid the introduction of new co-payments. However, the current co-payment scheme for medications and ortho-prosthetic benefits does not offer sufficient guarantees of protection to the poorest households, especially those headed by people of working age, so it is necessary to <b>establish income-related caps for the general working population</b>. In addition, it is essential <b>to address the main coverage gaps of the National Health System by expanding the coverage of dental and optical care services</b>.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>The persistent problem of waiting lists for secondary care and certain surgeries, which worsened during the economic crisis and has been exacerbated by the current pandemic, needs urgent attention.</b> Waiting lists represent a significant barrier to accessing health services and push people to pay out of pocket for services included in the NHS benefit package. In addition, they are behind the gradual increase in the contracting of voluntary health insurance and, since the contracting of voluntary health insurance increases with the level of income, they contribute to increasing inequalities in access to health care.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Finally, for population coverage in Spain to be truly universal, the administrative obstacles</b> faced by <b>undocumented migrants</b> must be eliminated (legal loopholes and delays for social services to authorize access), <b>foreigners legally regrouped with family members</b> residing in Spain and <b>asylum seekers</b> (delays in the process of recognition as asylum seekers).</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Spain is in an excellent position to continue leading the way toward universal health coverage in Europe, but it needs to act fast and effectively without becoming complacent</b>. The recommendations included in the report would contribute to strengthening resilient health coverage, one that guarantees that people keep health coverage when their standard of living or their health declines and that entitles them to greater protection when they find themselves in situations of socioeconomic vulnerability.</div><div style="text-align: justify;"><br /></div><div class="separator" style="clear: both; text-align: justify;"><iframe allowfullscreen="" class="BLOG_video_class" height="315" src="https://www.youtube.com/embed/LcltHPiuHqY" width="560" youtube-src-id="LcltHPiuHqY"></iframe></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">José Cerezo Cerezo is a health policy analyst (consultant) at the <a href="https://www.euro.who.int/en/about-us/organization/office-locations/who-barcelona-office-for-health-systems-financing,-spain" target="_blank">WHO Barcelona Office for Health Systems Financing</a> and technical editor of the report Can people afford to pay for health care? New evidence of financial protection in Spain.</div></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-83075059062373524522022-05-30T08:00:00.060+02:002022-06-06T10:13:13.545+02:00Challenging stimuli predicting the future<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxlYXIwBII3NOPF0PmLaN9__E99RoxwD3dJJD5zq7hoqDJPXQSBOW7UjMFwvYTq1fvoor4IJPw7qApwwyz9lXwA6pIjkjzh2PmRDe_dzG7x5O5m0EA0PtFl9-Tpi8x1rxmacyv4EvelEilvvle5NcfcI4P_HuqiaBIewrDeWOXxPw30hwaGsGeeVXgPQ/s163/David%20Font.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="163" data-original-width="150" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxlYXIwBII3NOPF0PmLaN9__E99RoxwD3dJJD5zq7hoqDJPXQSBOW7UjMFwvYTq1fvoor4IJPw7qApwwyz9lXwA6pIjkjzh2PmRDe_dzG7x5O5m0EA0PtFl9-Tpi8x1rxmacyv4EvelEilvvle5NcfcI4P_HuqiaBIewrDeWOXxPw30hwaGsGeeVXgPQ/w184-h200/David%20Font.png" width="92" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Font%20D." target="_blank">David Font</a></span></b><br /> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"></p><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7N1BXNM7EyE_kUXsWlcFv4XPIRJzFNUoCaJmvtSEb24iU6TvpmGdR3O--cgr_mHPRCTG-9nmcvG_9sldoucoIDLxuB0B9qqluZb5eUMAuZY2U_cm3QJIGG-FUyTe8c0ZlYIHkpPv2xHk1JGB0UIjHBGAVaFlyQBUHn87QEiDY_mOhtHIs6GtRjfsJZw/s320/Untitled-2.png" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="186" data-original-width="320" height="186" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7N1BXNM7EyE_kUXsWlcFv4XPIRJzFNUoCaJmvtSEb24iU6TvpmGdR3O--cgr_mHPRCTG-9nmcvG_9sldoucoIDLxuB0B9qqluZb5eUMAuZY2U_cm3QJIGG-FUyTe8c0ZlYIHkpPv2xHk1JGB0UIjHBGAVaFlyQBUHn87QEiDY_mOhtHIs6GtRjfsJZw/s1600/Untitled-2.png" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: right;"><span style="font-size: x-small;">Photography by Alejandro García (EFE)</span> </td></tr></tbody></table><div style="text-align: justify;">I reread an article published in 2014 in the <i>British Medical Journal</i>, "A Glimpse into the Future: Typical day in the NHS in the year 2050", in which Hannah Wilson, a student at Imperial College, imagines a healthcare system that screens patients admitted to Singapore and New York from London, within the framework of a global hospital, and which operates on patients by remote surgeons using robots. The Euthanasia Department and the Genomics Clinic are, for her, hospital departments in 2050. She describes patients convinced of the suffering of two diseases when they know their genomic sequence and also "digitally addicted" patients in times when a day may end up in an isolation pod due to a virus raised to epidemic levels.<span><a name='more'></a></span></div><p></p><p style="text-align: justify;">I listen as Eric Topol, cardiologist founding and director of the Scripps Research Translational Institute points out in <i>Eric Topol and the Future Of Medicine</i> that clinical pathways based on means and population studies contain errors, with the example of the amount of sodium in the diet that cardiology routes recommended time ago. He explains how personalized medicine, combining the different diagnostic platforms focused on the individual, will modify –and is already beginning to do so– the diagnostic and therapeutic approach to diseases. Samsung, Google and Apple will integrate the data into their platforms to be accurate health advisors; a daughter diagnosing her mother with heart attack using an electrocardiogram taken by a watch. She also talks about toothbrushes that send information to dentists about whether you brush correctly or forks that tell you if you eat too fast and chew well; devices and platforms for a preventive, predictive and personalized medicine radically different from the traditional one.</p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="315" src="https://www.youtube.com/embed/yLU5dK9PjYw" width="560" youtube-src-id="yLU5dK9PjYw"></iframe></div><br /><p style="text-align: justify;">I review the project approach of the MIT Operation Research Center and the MIT'S J-Clinic in artificial intelligence (AI) in health, such as optimizing bed management by integrating occupancy data and clinical data to anticipate discharges and propose actions within 5-7 days in advance and with resolution capacity hour by hour. And that of optimizing the location of the patient in the most appropriate resource of the health system; Science fiction projects.</p><p style="text-align: justify;">Concerning organizational transformation, I read Jordi Varela's post "<a href="http://varelaclinicalmanagement.blogspot.com/2022/03/medical-services-anachronism.html" target="_blank">Medical services, an anachronism</a>", from September 2021, in which he proposes, inspired by the latest articles by Michael Porter and Thomas Lee and by the reading of <i>Corporate Rebels. Make Work More Fun</i> – a highly recommended book – that the medical services have to stop being management structures and that the functional clinical units have to take the helm. He also argues that scheduled surgery and diagnostic and rehabilitation services must be managed according to factory criteria.</p><p style="text-align: justify;">At the Hospital Clínic, we continue to work on the New Clínic Universe with the vision of being a nearby, intelligent, sustainable and pioneering Clínic. We ask professionals for stories about how we will be 10-15 years from now with stories similar to those of Hannah Wilson. In parallel, different projects submitted to the internal innovation awards address AI-based transformations and propose new devices in line with Eric Topol's presentation.</p><p style="text-align: justify;">All these stimuli come to me when a commission with representatives from the Department of Health of the Generalitat de Catalunya, the Barcelona City Council and the Barcelona Provincial Council analyzed the demand for a new Clinic and the possible location alternatives in the city of Barcelona. Today we analyze what a new hospital should be like, which should be a reality within 10-15 years and be functional and sustainable for many years. I wonder how, when making its functional plan, we have to consider all the ideas collected in this post. How do other centres do it? It seems obligatory to take them into account, but it is complex and requires courageous visionaries like J. F. Kennedy. It is essential to listen to his speech on September 12, 1962, at Rice University in which he outlined how the Americans would reach the Moon seven years before that happened.</p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="315" src="https://www.youtube.com/embed/_RaRC6YuYCQ" width="560" youtube-src-id="_RaRC6YuYCQ"></iframe></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-3173635602309634102022-05-23T08:00:00.080+02:002022-05-30T15:27:00.147+02:00Is this the problem: too little (or no) innovation in service delivery?<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQWWHRHAx1eJR8r-FSL7x7QdQ7UoWN2wACRx8hr28ZW48RzvLLzMcwfICsz3782KTk7_RAtzTs2z7UmAfEF0l_nGfMeYMI42qkj88aYCX5ZAJzGdSETxImOseaqo6ZCW2uT2KBqEGhEXaeCTtvH95WVS5WIGcW8JzkvofgionZBfU82d8BdMWzSr15uw/s87/image004.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="87" data-original-width="87" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQWWHRHAx1eJR8r-FSL7x7QdQ7UoWN2wACRx8hr28ZW48RzvLLzMcwfICsz3782KTk7_RAtzTs2z7UmAfEF0l_nGfMeYMI42qkj88aYCX5ZAJzGdSETxImOseaqo6ZCW2uT2KBqEGhEXaeCTtvH95WVS5WIGcW8JzkvofgionZBfU82d8BdMWzSr15uw/w200-h200/image004.png" width="100" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Escarrabill%20J." target="_blank">Joan Escarrabill</a></span></b><br /> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"></p><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh51wwc8inqC_UMUk0C9i7IRWSFHiT2lh_2NxtbQn2-sE-6qttthWzqvtfxcLPfeFwQF7bLboNucj_CVVYlAbv_LElzGRs7JUrXWH1mQywQleErQjLUffrCVl2p-k2iwbt-RFWzwyyxHIptua9D4KslKbTLm93QOL3gg5wLjgCGw_scLPSeBLWdZ_HOww/s320/20211117_131111.jpg" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="240" data-original-width="320" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh51wwc8inqC_UMUk0C9i7IRWSFHiT2lh_2NxtbQn2-sE-6qttthWzqvtfxcLPfeFwQF7bLboNucj_CVVYlAbv_LElzGRs7JUrXWH1mQywQleErQjLUffrCVl2p-k2iwbt-RFWzwyyxHIptua9D4KslKbTLm93QOL3gg5wLjgCGw_scLPSeBLWdZ_HOww/s1600/20211117_131111.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: right;"><span style="font-size: x-small;">Interdisciplinary team to evaluate patient experience</span></td></tr></tbody></table><p></p><div style="text-align: justify;">The meaning of words is sensitive to the determinants of space and time. The context gives meaning to the words. For example, what is the point of referring to cosmopolitanism as a remarkable quality when planetary interconnectivity is a generalized fact?<span style="font-size: x-small;">(1)</span> Without going into a debate about whether this "cosmopolitanism" is of any interest, can the same thing happen with innovation? The Mayo Clinic suggests that the main current problem is the lack of innovation in the provision of health services<span style="font-size: x-small;">(2)</span>. The first question that this proposal suggests is whether innovation in the field of health has a "Darwinian" behavior, In other words, innovation is not linear, but is best explained by Stephen Jay Gould's (1941-2002) "punctuated equilibria" proposal: short periods of great agitation followed by long periods of calm or even lethargy<span style="font-size: x-small;">(3)</span>. Maybe. Furthermore, perhaps innovation is not homogeneous in all fields.<span><a name='more'></a></span></div><p></p><p style="text-align: justify;">Directly or indirectly, I experienced three innovations in the provision of services during the 1990s. I am referring to major outpatient surgery, hospital at home, and home mechanical ventilation. In all three settings the characteristics are the same:</p><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px; text-align: left;"><p style="text-align: left;">a) These innovations had been developed throughout the world for years and with good results.</p><p style="text-align: left;">b) Practically no new technological requirements were needed to put them into practice since ambulatory anaesthesia was well known and portable ventilators too, for example.</p><p style="text-align: left;">c) They were implemented due to a change in mentality promoted by professionals. In the first phase, there was no financial incentive for health care organizations to promote this alternative.</p></blockquote><p style="text-align: justify;">Of the first two innovations, I have direct references from two good friends, Dr. Jordi Colomer(4) and Dr. <a href="https://annalsdelsagratcor.org/docs/Annals_vol10n2.pdf" target="_blank">Francesc Rosell</a> (e. p. d.)<span style="font-size: x-small;">(5)</span>. In the case of home mechanical ventilation, I was directly involved in the process at the Hospital Universitari de Bellvitge<span style="font-size: x-small;">(6)</span>. It would be difficult for me to understand a large part of my work caring for people with chronic respiratory insufficiency without reference to the "Vida als Anys" (Life to Years) Program (1986). Some projects dazzle, but stimulating, rooted, and fruitful projects are the ones that constantly enlighten. The "Vida als Anys" Program would be a clear example of these successful innovations in the provision of services, both in the field of elderly care and in an intermediate care or the palliative care<span style="font-size: x-small;">(7)</span>.</p><p style="text-align: justify;">The Dutch experience with the Buurtzorg model (small teams led by nurses who care for groups of elderly people in the community) is a disruptive option and it seems that with good results<span style="font-size: x-small;">(8)</span>, a good model of success.</p><p style="text-align: justify;">At the other extreme, we find the disruption in the provision of services based on access twenty-four hours a day, seven days a week, with technological support. The Chinese insurer Ping A Good Doctor<span style="font-size: x-small;">(9)</span> offers online consultations with a good experience in most cases (except for acute respiratory infections or dermatological problems). <i>JAMA</i> magazine has recently published an opinion on virtual visits<span style="font-size: x-small;">(10)</span>. A North American insurer has offered cheaper care programs if they include virtual visits 24 hours a day, seven days a week, as the first option for contact with primary care. It can be argued that these last two examples could be labeled as technological innovations, but the truth is that the technology they use has been around for a long time. What is innovative is using it differently, using existing technology in such a different way that it profoundly changes how the service is delivered.</p><p style="text-align: justify;">It would also be necessary to analyse whether <i>a priori </i>disruptive, convenient and sustainable conceptual frameworks have been properly used. I am referring to the entire conceptual framework of integrated care. Hughes <i>et al</i>.<span style="font-size: x-small;">(11)</span> wonder why integrated care does not work: there are no significant changes in the patient experience and no reduction in admissions. The conclusion of the study is this: "However, integrated care structures were only part of the complex network of resources that patients used to manage their pathologies in the long term. For integrated care to work (for structures affect the material and concrete results), patients must be able to resort to relevant and timely resources". Perhaps the key is to define what are the "relevant and timely" resources and, perhaps, there are more "relevant and timely" resources in the social field than in the health care field. Without discussing the need for and how to achieve social and health care integration, it would perhaps be interesting to learn more about the experience of Barcelona's "social superilles" (inspired by the Buurtzorg model), <a href="https://ajuntament.barcelona.cat/dretssocials/es/innovacion-social/supermanzanas-sociales" target="_blank">a community home help service</a>, and <a href="https://lleiengel.cat/barcelona-gent-gran-lsuperilles-socials/" target="_blank">proximity</a>.</p><p style="text-align: justify;">Regina E. Herzlinger<span style="font-size: x-small;">(12)</span> says that three main types of innovations stand out: those that focus on the "consumer", those based on technology, and those based on changes in the financing system. All three forms of innovation have to face resistance and barriers. In the case that concerns us in this article, innovations focused on the "consumer" (on the person receiving the service) generate resistance because they are seen as a direct threat to the <i>status quo</i>. Overcoming the barriers implies considering all the professional sectors involved, the legislation, the payment system, technology, and accountability. But in the case of consumer-focused innovations, the active role of the person receiving the service is key. In our case, it is clear that it is the patients and the caregivers.</p><p style="text-align: justify;">The patient experience is now the driving lever of innovation in the provision of health services. At the Hospital Clínic de Barcelona we have systematically introduced the patient experience to improve the provision of services globally at the Clinical Institute of Nephrology and Urology, in a project promoted by Dr. Beatriu Bayés and the Hospital's living lab, with relevant short-term results: start-up of new assistance devices ("Hotel-Health" to welcome patients undergoing study or recovery, through "protected early discharge"), improvements in information for patients and caregivers (videos, electronic bulletins, and live seminars), new functions for volunteers (hosting) or reinforcing various professional roles (psychological support or nutritionists) and promotion of alternatives to face-to-face visits (peritoneal dialysis). All these projects share a common denominator: taking into account the perspective of the person receiving the service. The tool is simple: just ask.</p><p style="text-align: justify;">Ask with meaning, with intention.<a href="https://twitter.com/edgarmorinparis/status/1467449550952673284?t=euD5RjIU9sCHdrkXRJjBlw&s=03" target="_blank"> Edgar Morin has written on Twitter</a>: "If we knew how to understand before condemning, we would be on the way to humanizing human relations." We could substitute "condemn" for "assume" or for "it has always been done this way" or "this is not possible in our environment" and, perhaps, in this way "we would be on the way to humanizing human relations". Asking to understand is the key to make innovative proposals in the provision of health care services based on who receives the service.</p><p style="text-align: justify;"><br /></p><div style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px;"><b>Bibliography</b></div><div style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px;"><b><br /></b></div><div style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px;"><div><div>1. Garrigasit, Raül. <i>El gos cosmopolita i dos espècimens més</i>. Barcelona. Edicions de 1984. 2021.</div><div>2. LaRusso N, Spurrier B & Farrugia G. <i>Think Big, Start Small, Move Fast: A Blueprint for Transformation from the Mayo Clinic Center for Innovation</i>. New York. McGraw-Hill. 2014.</div><div>3. Gould, Stephen Jay; Eldredge, Niles. Punctuated equilibria: the tempo and mode of evolution reconsidered.<i> Paleobiology</i>, 1977;3:115-151.</div><div>4. Calvo, J. Jiménez, <i>et al</i>. <i>Cirugía mayor ambulatoria: nuestra experiencia.</i> <i>Actas Urológicas Españolas</i>, 2002, 26.6: 384-391. It refers to the creation of the first Outpatient Major Surgery Unit at the Hospital de Viladecans (Barcelona).</div><div>5. Morcillo C, Sort D, Palomer JM, Fàbrega E, Aguado O, Rosell F. <a href="https://annalsdelsagratcor.org/docs/Annals_vol10n2.pdf" style="color: #29527b; text-decoration: none;" target="_blank"><i>Gestión de la hospitalización domiciliaria en la insuficiencia cardiaca</i></a>. <i>Annals del Sagrat Cor</i> 2004;10:34-35. </div><div>6. Escarrabill J, Estopà R, Robert D, Casolivé V, Manresa F. <i>Efectos a largo plazo de la ventilación mecánica a domicilio con presión positiva mediante máscara nasal</i>. <i>Med Clin</i> (Barc). 1991;97:421-3. </div></div><div>7. Gómez-Batiste X, Porta-Sales J, Pascual A, Nabal M, Espinosa J, Paz S, Minguell C, Rodríguez D, Esperalba J, Stjernswärd J, Geli M; Palliative Care Advisory Committee of the Standing Advisory Committee for Socio-Health Affairs, Department of Health, Government of Catalonia. Catalonia WHO palliative care demonstration project at 15 Years (2005). <i>J Pain Symptom Manage</i>. 2007;33:584-90.</div><div>8. Sheldon T. Buurtzorg: the district nurses who want to be superfluous. <i>BMJ</i>. 2017;358:j3140.</div><div>9. Jiang X, Xie H, Tang R, Du Y, Li T, Gao J, Xu X, Jiang S, Zhao T, Zhao W, Sun X, Hu G, Wu D, Xie G. Characteristics of Online Health Care Services From China's Largest Online Medical Platform: Cross-sectional Survey Study. <i>J Med Internet Res</i>. 2021;23(4):e25817.</div><div>10. Whitehead DC, Mehrotra A. The Growing Phenomenon of "Virtual-First" Primary Care. <i>JAMA</i>. 2021 Nov 22. doi: 10.1001/jama.2021.21169. Epub ahead of print. PMID: 34807253.</div><div>11. Hughes G, Shaw SE, Greenhalgh T. Why doesn't integrated care work? Using Strong Structuration Theory to explain the limitations of an English case. <i>Sociol Health Illn</i>. 2021 Nov 6. doi: 10.1111/1467-9566.13398. Epub ahead of print. PMID: 34741766.</div><div>12. Herzlinger RE. Why innovation in health care is so hard. Harv Bus Rev. 2006;84:58-66.</div></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-3852824115462255702022-05-16T07:00:00.002+02:002022-05-23T09:59:46.125+02:00Team stuck? The three factors to drive change successfully<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEju7jK-ZyttQSdSlWTFG9ONBjG0-JxYwo1VYfj80xBKN055fXKimcfIi-iSlSwJcAnDeTC-s8-NTRdGBzMH3_cY1Vletkx-518W3EJ8SiaJcQ3eXsG58dRRxUKRwoHok3-5uVaKA_wnOIpBYMx9MRymVWUB3ptaqrboBN-PqRng868xvzgTPvMADO3blQ/s162/Pere%20Vivo%CC%81.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="162" data-original-width="131" height="105" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEju7jK-ZyttQSdSlWTFG9ONBjG0-JxYwo1VYfj80xBKN055fXKimcfIi-iSlSwJcAnDeTC-s8-NTRdGBzMH3_cY1Vletkx-518W3EJ8SiaJcQ3eXsG58dRRxUKRwoHok3-5uVaKA_wnOIpBYMx9MRymVWUB3ptaqrboBN-PqRng868xvzgTPvMADO3blQ/w162-h200/Pere%20Vivo%CC%81.png" width="84" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Vivó%20P." target="_blank">Pere Vivó</a></span></b><p></p><div><b><br /></b></div><div><b><br /></b></div><div><br /></div><div><b><br /></b></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdTJ4Gx4jYrVgi9_XuZOAmonYmG1BDfk6VEpV7Hqzw7jXJwMTMxs6f2LWiLK-QsfA-2iqiBga8s6X_rS4cYC5NzcPjA92Xfk7aBSRdtsHvbhHRW50lz5VFPSggTaTzk90tIkYmRWDcH3swRR71wRUng_HvH8Y2d-EjFo8YmLsXQ0mY4jkzZ0lHR5uHkg/s320/image0.jpeg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="214" data-original-width="320" height="214" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdTJ4Gx4jYrVgi9_XuZOAmonYmG1BDfk6VEpV7Hqzw7jXJwMTMxs6f2LWiLK-QsfA-2iqiBga8s6X_rS4cYC5NzcPjA92Xfk7aBSRdtsHvbhHRW50lz5VFPSggTaTzk90tIkYmRWDcH3swRR71wRUng_HvH8Y2d-EjFo8YmLsXQ0mY4jkzZ0lHR5uHkg/s1600/image0.jpeg" width="320" /></a></div><div style="text-align: justify;">Let's see if you recognize this situation: endless care agendas full of telephone visits that do not add value, repeated requests that do not follow a scheduling logic or a reasonable priority, few and highly complex face-to-face visits that take up more time than expected, tense situations with some patients and, finally, ending the day with a bitter feeling that the work is pending or poorly resolved...</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">If the answer is yes, you are in luck because <b>your organization will need deep changes</b> that can be an opportunity for transformation and collective motivation.<span><a name='more'></a></span></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Although the factors that can influence the construction of a successful model are innumerable, we are going to focus on three elements that can help boost your health team. Let's get started!</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>1. We will innovate in the consultation: it is time to make it different!</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Change is a door that always opens from within. For this reason, in your team, change necessarily involves <b>revising the attitudes of its professionals and managers</b>. Although the pandemic has exacerbated the historical burnout of healthcare professionals and structural criticism has been imposed in a loop, it is often based on old problems and doesn't respond to the new needs of the patient or the organization.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Yes, it is true, innovating is more pricey than criticizing! But we must make an effort to overcome this impediment and make <b>professionals aware</b> of their potential to promote different ways of working and of the impact that their actions have on the health team as a whole. and, especially, in their patients.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">An effective measure is the creation of <b>a weekly space for the management, organization, and anticipation of the consultation,</b> where all those bureaucratic tasks that on many occasions constitute real-time thieves could be concentrated, such as reviewing medication plans, sick leave, reports, or review of analytics or tests, among many other tasks.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Another relevant element is the management of the <b>clinical interview and the management of time</b> in the consultation. Each professional must find their balance between increasing the offer of face-to-face visits that respond to the needs of their patients in a reasonable time and, at the same time, the ability to reserve some space to deal with situations that require more time than expected.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>2. Let's bet on the team! New roles need to be promoted.</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Answer honestly: does your team take advantage of the capabilities of all its members? Surely not. To move forward, professionals must develop new skills, improve their interactions and synergies, and review <b>strategic processes</b> to be more decisive. Let's look at some examples.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">The group of nurses is essential in a health team, not only because of their skills but also because of their dynamism, experience, and collaborative spirit. If you still don't have an effective circuit for the resolution of acute pathologies, it is time for nurses to lead it. The commitment to the newly released nurse prescription can help you clear the way.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">The<b> chronic patient</b> care strategy must expand its perimeter. The classic "basic care unit" made up of a doctor and a nurse admits many other formats and can be added to it by health administrators, clinical assistants, and even other doctors or nurses who serve the patient as complementary references.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Nurses carry out a necessary task in the field of health education but, in some cases, the <b>health administrators</b> to whom they can be assigned and to the population must also be involved in this task. They can also participate in the delivery of results and even in the detection of incipient signs of decompensation due to lack of connection with the team, due to lack of therapeutic compliance, or due to the presence of some guiding symptom.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">And what about <b>clinical assistants</b>? Well, their role goes beyond replenishing consultations since their involvement is clear in performing techniques such as electrocardiograms, eye fundus, or obtaining the INR, both in the workplace and at the patient's home. </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>3. Accessible yes. But also, adaptable and flexible</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Can you list the means your patients can use to contact you? Direct programming systems from apps, electronic consultations, web programming systems for reasons, telephone visits, administrative consultations, and, of course, face-to-face visits have been added to the classic call centres</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">In this new scenario, we could say that<b> accessibility is good, but at what cost?</b> The culture of immediacy and the widespread use of new communication systems cause an increase in non-face-to-face consultations and on many occasions directed to the wrong professional, so we are facing a risk of lack of value.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">And what can we do about this? Well, we just have to <b>adapt and experiment</b>. The face-to-face and non-face-to-face models must coexist forever and although this relationship is not going through its best moment, the organization must review it regularly and dare to try new work schemes with each professional until they achieve their own balance.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Good health teams, in addition to being accessible, must be <b>flexible and be able to react quickly and adapt rapidly</b>, to be able to face future innovations that we are currently still unaware of.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">As Mario Benedetti said: "Just when we thought we had all the answers, suddenly the questions changed." And it is that fortunately the system is alive, it evolves and progresses continually. So everything is possible! The only impossible thing is to resist change and not evolve or transform. If we have reached that point of blockage, we face the challenge of changing ourselves.</div></div><div style="text-align: justify;"><br /></div><div><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;">Bibliography</p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;">- <i><a href="https://scgs.cat/innovnt-en-latencio-primaria-a-catalunya-una-aproximacio-a-la-realitat/" style="color: #29527b; text-decoration: none;" target="_blank">Innovant en l’atenció primària a Catalunya. Una aproximació a la realitat</a>. </i></p></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-8022290225782359122022-05-09T08:00:00.046+02:002022-05-16T10:08:50.115+02:00Improve the safety of your patients… share your ideas!<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvoFe5LBd-GmmZyrfDvj2CmsJI5MyzyeGZevzcWrXkBAIkDgRsxTLfQ78dgST7gb0NnTH23GA-cPE4kbb0jNbu4LxdiYosihFsVzW7uabI9AjQ_vYdrXRJvqq4l5diZ1LEDQ1Cc0gI6tNr9guFMo-crxmiKhW2A7j_v4tWePa-4NOGvJT_WaTT4NqSpw/s87/JJMira.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="87" data-original-width="87" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvoFe5LBd-GmmZyrfDvj2CmsJI5MyzyeGZevzcWrXkBAIkDgRsxTLfQ78dgST7gb0NnTH23GA-cPE4kbb0jNbu4LxdiYosihFsVzW7uabI9AjQ_vYdrXRJvqq4l5diZ1LEDQ1Cc0gI6tNr9guFMo-crxmiKhW2A7j_v4tWePa-4NOGvJT_WaTT4NqSpw/w200-h200/JJMira.png" width="100" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Mira%20JJ" target="_blank">José Joaquín Mira</a></span></b><p></p><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><div><br /></div><div style="text-align: justify;">"But, if you don't know how this goes...!" "What are you in for?" "Shut up, you're better!" Expressions like these are common. They modulate the culture of our organizations and, although we do not give them excessive significance, they condition our behaviour. I don't know if it has happened to you, but sometimes we have the feeling that it is better to remain silent than to speak. Sometimes, the fear of being disliked, receiving a bad response, or receiving a reprimand causes us to keep quiet. In the workplace, there are hierarchies, unwritten rules, customs, and group dynamics that determine when and how things are done and what should and should not be said. But this way, the quality of care will never improve and patients will have a higher risk of suffering an adverse event. The culture of the organization contributes to speaking up or shutting up. Individual differences do the rest.<span><a name='more'></a></span></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDngBCJuJet1d1KbblMi0lZQtTB4cQ1Pjd9WC17tzZB_z57zVL2HtuNSWIxnlFt11vOXqzpCjn6NveQDsf-6ICweARtVMFnyDR_FDKQMapInySVCyqicNcO3rofmMGfZsKPf81VNhOQkLH_C3dOwRWU9gRlhS9qoTP8K4ndcebYnBZT6K9scvKf9AeoA/s553/Sense%20nom.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="553" data-original-width="281" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDngBCJuJet1d1KbblMi0lZQtTB4cQ1Pjd9WC17tzZB_z57zVL2HtuNSWIxnlFt11vOXqzpCjn6NveQDsf-6ICweARtVMFnyDR_FDKQMapInySVCyqicNcO3rofmMGfZsKPf81VNhOQkLH_C3dOwRWU9gRlhS9qoTP8K4ndcebYnBZT6K9scvKf9AeoA/w164-h320/Sense%20nom.jpg" width="164" /></a></div>If teams don't promote talking about the things we do well and the things we don't do so well, it's difficult for someone to spontaneously break that rule. Moreover, we do not like being called out due to carelessness, forgetfulness, or an error, so the conditions are in place for these situations to be repeated and thereby put patients at risk due to circumstances that they could have avoided. In the health field, we have known for a long time that "shutting up" has adverse effects.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">We have been emphasizing for some time the importance of the work environment and the culture of the organization to achieve better results in <a href="https://www.seguridaddelpaciente.es/es/presentacion/" target="_blank">patient safety</a>. That is why we look for formulas that promote a proactive safety culture, convinced that this is an essential step to tackle system failures and to contain the most frequently repeated errors in time.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>The safety culture of institutions is key to tackling letdowns and reducing errors</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Due to this situation, in health care organizations, we have recovered the concept of "psychological safety", introduced in 1999 by <a href="https://web.mit.edu/curhan/www/docs/Articles/15341_Readings/Group_Performance/Edmondson%20Psychological%20safety.pdf" target="_blank">Amy Edmondson</a>, which is based on the belief that we are better able to face complex challenges when we do so in an environment of mutual respect and trust. <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-4931-2" target="_blank">Psychological safety</a> is related to how:</div><div><ul style="text-align: left;"><li style="text-align: justify;">Clinical errors and system failures are addressed.</li><li style="text-align: justify;">Clinical decisions are made in environments of complexity and uncertainty.</li><li style="text-align: justify;">Feelings and worries derived from overload and seeing that "things are not going the way we thought they should be" are managed.</li></ul></div><div style="text-align: justify;"><b>The feeling of psychological safety is key to reducing adverse events</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">The feeling of psychological security expresses to what extent we feel confident that we can raise and discuss with colleagues how we do things, what we can improve and what we have to change to achieve a better result without fear of rejection, criticism, or sanctions. In short, better care is provided when the members of a team feel integrated, interact freely, share achievements, shortcomings, and problems and talk about all of this "without cutting each other".</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">One of the essential components of psychological safety is "speaking up," which is defined as the assertive communication of quality and safety concerns to patients to prevent harm and to ensure patients receive the best care possible. It might be expected that this would be the most common among members of care teams, but some data suggest otherwise.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Talking about everything without fear reduces errors and improves the work environment</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">In a recent study conducted in Austria, 32.3% of the doctors and nurses surveyed said that they usually kept their concerns about patient safety to themselves, and 41.6% that they preferred not to share their ideas for improving quality assistance. A similar study that we are carrying out with students of health disciplines suggests that 59% do not feel capable of speaking out in a critical situation and prefer to remain silent due to the consequences that "sharing their views" may have on their future.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Half of the professionals choose to keep quiet</b></div><div style="text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDb9jLqRBAmIM94ADNh7hSo-bICK-ac9aAG6Cgyi4TWMFFA4Ec3JSowKiYvsLYU7bKuhLO8UnHWsPo9R6VzfSIFycCEAXomsOyFHKQ9b8ntjRmEKUxkPolqfaJoEmVoBm2HU8y1DiMH2QFpNtS7Bppfl9tym18tYkYNJ8IXBi8iUXOJpNELMZ_odNnNg/s579/Sense%20nom.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="404" data-original-width="579" height="223" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDb9jLqRBAmIM94ADNh7hSo-bICK-ac9aAG6Cgyi4TWMFFA4Ec3JSowKiYvsLYU7bKuhLO8UnHWsPo9R6VzfSIFycCEAXomsOyFHKQ9b8ntjRmEKUxkPolqfaJoEmVoBm2HU8y1DiMH2QFpNtS7Bppfl9tym18tYkYNJ8IXBi8iUXOJpNELMZ_odNnNg/s320/Sense%20nom.jpg" width="320" /></a></div><div style="text-align: justify;">Since it is obvious that clinical practice has its risks, it is absurd to act as if everything were perfect and that therefore nothing bad, unexpected, or negative could happen. It is still too common that when "things don't go well" we resolve the situation by looking for who is to blame (normally, the last one to "be with the patient"). But this way we don't improve anything and, on the contrary, the rest of the team learns that it is best to hide the problems and look the other way. The proactive safety culture we aspire to suggests that when an error occurs, the team should first repair the damage if it exists, then analyse its causes and look for ways to prevent similar incidents in the future. That is, go from the red traffic light area to the green traffic light area in the attached diagram. This, which seems simple, is complicated in the reality of everyday life.</div></div><div style="text-align: justify;"> </div><div style="text-align: justify;">Identifying and overcoming the barriers that prevent sharing concerns and proposals to achieve optimal quality must be a commitment of managers, middle managers, and all professionals. The available data do not allow us to doubt this.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">In this health crisis caused by the new coronavirus, there has been a growing concern since its inception about how to support the teams so that they would be able to cope with the workload that caring for COVID-19 patients was assuming. And in this case, we have been able to observe that the response to the challenges posed by the pandemic has been more efficient in institutions where the organizational culture and <a href="https://academic.oup.com/intqhc/article/33/1/mzaa153/5998956?login=false" target="_blank">managers</a> have facilitated working in multidisciplinary teams and an environment open to debate before making organizational and clinical decisions. Leadership, multidisciplinary and psychological safety (with its key component of speaking out and without fear) have been fundamental during the pandemic and are daily to achieve a safer environment for patients.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Lessons from the pandemic: leadership, team and finding solutions together</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">There are no easy solutions, but we have learned some lessons and it may be a good time to apply them. Formulas are being sought to motivate professionals again after the pandemic hit, and for this, some simple recipes could be put into practice: listen to what professionals have to say, share information with them, involve them in decisions and create a suitable atmosphere to talk about how to deal with problems and improve what we do, because professionals continue to be key elements to achieve it.</div></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-88584028149142102142022-05-02T08:00:00.100+02:002022-07-12T12:00:46.780+02:00Shadowing for understanding the patient experience<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7q1dRLtX9PSefPWxKl2m4Zsz1kDNeheQV3s3Tkvxn2kFWLkFjhtl7_cWEHW2MSTyTQ4UI1N8jnEWGBEh0E7xqhjc67JA30hcSuoK9g9f8eq0nqbohzIjffn9fqhUAEyGWhtkhipFoi0PO-dYnORZ4iAYZXeLi6WkpK_H5AZ0vsWUaD2SV8qoiisS7Ag/s297/Gloria%20Galvez.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="297" data-original-width="283" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7q1dRLtX9PSefPWxKl2m4Zsz1kDNeheQV3s3Tkvxn2kFWLkFjhtl7_cWEHW2MSTyTQ4UI1N8jnEWGBEh0E7xqhjc67JA30hcSuoK9g9f8eq0nqbohzIjffn9fqhUAEyGWhtkhipFoi0PO-dYnORZ4iAYZXeLi6WkpK_H5AZ0vsWUaD2SV8qoiisS7Ag/w191-h200/Gloria%20Galvez.png" width="91" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Galvez%20G." target="_blank">Glòria Galvez</a></span></b><br /><div class="separator" style="clear: both; text-align: left;"><span style="text-align: justify;"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhX4_3Z4gqFXfMqftuVgPa0g6syrz7-16MvFqUDFxWTP40SXMgBNrqQUEjP7JY3jLv4kRFvgpj-cTHje0DKXcM8-5XR6O03ARuB9X8Ozmw06J_mKHEehRInAKdikrji6-1ZyWNAErczOmjoi-OH-Bo_CHB3v6y62IeoRYUHlheLacUL1jGzDx5UsGLSdw/s320/Untitled.png" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="124" data-original-width="320" height="124" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhX4_3Z4gqFXfMqftuVgPa0g6syrz7-16MvFqUDFxWTP40SXMgBNrqQUEjP7JY3jLv4kRFvgpj-cTHje0DKXcM8-5XR6O03ARuB9X8Ozmw06J_mKHEehRInAKdikrji6-1ZyWNAErczOmjoi-OH-Bo_CHB3v6y62IeoRYUHlheLacUL1jGzDx5UsGLSdw/s1600/Untitled.png" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: right;"><span style="font-size: x-small;">Reference: <a href="https://soyarte.com" target="_blank">SoyArte</a></span></td></tr></tbody></table><div style="text-align: justify;">Who has not seen and cared for a patient who seems lost in the corridors of the hospital and asks for information from every person in a white coat that he comes across? It is likely that if a few days later you asked how it went, they would state that they are generally satisfied with the care, focusing their narrative on the most clinical part, or perhaps they could omit information of interest, giving the answers that he thought we expected to hear.<span><a name='more'></a></span></div></span></div><p style="text-align: justify;">Questionnaires and focus groups, although the most widely used methods to measure and understand patient experience, are not always the most appropriate. Some studies conclude that what the patient remembers is different from what he experiences in real-time, <a href="https://pubmed.ncbi.nlm.nih.gov/24595066/" target="_blank">depending on the time that has elapsed since he has received care until we ask him about his experience of it</a>. <span style="font-size: x-small;">(1)</span></p><p style="text-align: justify;">Knowing the patient's experience is closely related to the Lean "<a href="https://blog.toyota-forklifts.es/ir-al-origen-el-genchi-genbutsu" target="_blank">Genchi Genbutsu</a>" concept, which proposes "going and seeing" where things are happening to capture what does or does not add value. Along the same lines, <a href="https://es.wikipedia.org/wiki/Gemba" target="_blank">Genba</a> identifies the place where the action takes place. Using these Lean concepts, the Vall d'Hebron Hospital has begun to use the <a href="http://www.ihi.org/communities/blogs/_layouts/15/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=172" target="_blank">Shadowing patients</a><span style="font-size: x-small;">(2)</span> methodology to capture the patient's experience individually, in real-time, and at the different points where they receive care.</p><p style="text-align: justify;">It has been a pilot project, intending to continue to use this methodology if the results are satisfactory. And the excellent results have encouraged us to think about other processes in which it would be appropriate to use it, such as in solid organ transplant patients or with oncohematology or neuro-rehabilitation problems.</p><p style="text-align: justify;">Patients with Marfan syndrome who have developed heart disease were selected for the project. Through the shadowing technique, an observer accompanied the patient who had an outpatient visit as if it were her shadow and observed her as she progressed in each step of her journey, including those sections that professionals do not see because they are outside their area of direct responsibility (corridors, entrances, and exits of the centre, patient admission monitors...). In this way, she detected areas for improvement that would otherwise have been impossible to identify.</p><p style="text-align: justify;">The observer did not participate in the care, although he did have informal conversations with the patient, so the patient did not perceive him as an intruder and showed his trust, sharing comments and sensations. He captured every detail of every interaction with the organization, identifying barriers the patient encountered, even those she wasn't aware of. In his field notebook he recorded the number of contacts and professionals with whom she interacted directly or indirectly, the time she needed to travel each section and to complete the entire route, how many and what kind of forms she was asked to fill out, the ease (or difficulty) that she had to find her way around the hospital, how many professionals she had to ask, the type of questions she asked the clinicians and if the answers were clear and given at the right time and place, if there was deliberation about the proposed treatment, or how was the treatment received.</p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigO43kUecuyIFcmwKItYMG8AG7MYVMVndPm3xPfjjdxs9uWEWfG4ZlF0VUJYOSb-P4HsMh2p4XyUYbIP61kYWMJl7tBtmSQzbveUTBjWaYuGbr53pmJUF65hSqgnDmI6MonHAF6sDJA5IsqSn_nf407iuJr331GQvOZznZwRabLcG3a1azp7ei2Z8sYQ/s320/Untitled1.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="229" data-original-width="320" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigO43kUecuyIFcmwKItYMG8AG7MYVMVndPm3xPfjjdxs9uWEWfG4ZlF0VUJYOSb-P4HsMh2p4XyUYbIP61kYWMJl7tBtmSQzbveUTBjWaYuGbr53pmJUF65hSqgnDmI6MonHAF6sDJA5IsqSn_nf407iuJr331GQvOZznZwRabLcG3a1azp7ei2Z8sYQ/s1600/Untitled1.png" width="320" /></a></div><div style="text-align: justify;">In parallel, he mapped the flow of care with a spaghetti diagram (image illustrating the post), in which each step of the journey was recorded, from when the patient entered the centre until she left, making a quantitative and qualitative analysis of the different moments. In the quantitative document, each point of contact was documented, the time spent in each section and throughout the process, where the patient was going and the difficulty or ease she had in orienting hemself, how many professionals she interacted with and how many contacts she had with the organization. In the qualitative analysis, he evaluated the patient's experience and made a description of her comments and her emotional state. </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">The result was a diagram that was difficult to interpret due to the tangled circuit since the patient had difficulty orienting herself, which led to continuous advances and setbacks along her route, as well as contacts with professionals who she asked for help to reach the destination. The numerous, and often unnecessary, trips caused nervousness and uncertainty in the patient, in addition to increasing the time to reach her destination and the number of people in the organization with whom she necessarily had to interact. (The average time from when the patients entered the hospital until they left the hospital was 2 hours and 30 minutes and they needed to contact an average of seven people.) This is the part of the process that in Lean language is called "waste" since that does not add value. I recommend using this type of graph and showing it to professionals in the results report, since the visual impact it causes, foments empathy with the patient.</div><p></p><p style="text-align: justify;">A possible limitation to putting this methodology into practice is the <a href="https://es.wikipedia.org/wiki/Efecto_Hawthorne" target="_blank">Hawthorne effect</a> in professionals, which happens when the participants in a study can alter their behaviour knowing that they are being observed. It has been advised to change the observer with each patient.</p><p style="text-align: justify;">In his book, <a href="https://conectasoftware.com/produccion/change-by-design/" target="_blank">Change by Design</a>, Tim Brown highlights a concept that can be applied to patient shadowing: person-centered design thinking – especially when it includes direct observation – captures spontaneous information that will lead to innovation that more accurately reflects patients' wishes. Shadowing takes Tim Brown's concept and takes it a step further, allowing us to move from perception to action.</p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;"><b>Bibliography</b></p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;">1. Kjellsson G, Clarke P, Gerdtham UG. Forgetting to remember or remembering to forget: A study of the recall period length in health care survey questions. <i>J Health Econ</i>. 2014;35(1):34–46.</p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: justify;">2. Gualandi R, Masella C, Viglione D, Tartaglini D. Exploring the hospital patient journey: What does the patient experience? <i>PLOS ONE</i> 2019;14(12): e0224899. https://doi.org/10.1371/journal.pone.0224899.</p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-607911427805525112022-04-25T08:00:00.057+02:002022-05-02T09:43:11.923+02:00Express authorization of medicines, a double-edged sword<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhn7FRt51OXY73_a--4AXwKMLJ6yWPnDxeykhCjQprcF7VJcZIA2M1nHX3b_h1reWws1ttMxco46fNVhITgh9WgMrzoX6SZ-eNrzYQPBa8AZqF07WZueU-fOv0klDtCP1fuCuiWQPIo8VETXSXtSnKK0erFY9NQFPIuYUyx00no7FWZNKBilfP_U9Dggw/s302/Cristina%20Roure.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="302" data-original-width="301" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhn7FRt51OXY73_a--4AXwKMLJ6yWPnDxeykhCjQprcF7VJcZIA2M1nHX3b_h1reWws1ttMxco46fNVhITgh9WgMrzoX6SZ-eNrzYQPBa8AZqF07WZueU-fOv0klDtCP1fuCuiWQPIo8VETXSXtSnKK0erFY9NQFPIuYUyx00no7FWZNKBilfP_U9Dggw/w199-h200/Cristina%20Roure.png" width="99" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Roure%20C." target="_blank">Cristina Roure</a></span></b><p></p><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><div><br /></div><div style="text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrrC6yhP6Xhvar9PI5sgbumAWP-6JyR3gUjzYFo8oBtTz9dgs5deAcVPt1QvyfP2AEjcxML3FV4A2ZYwVarE7lIZZyT8dlYvXkR5t712SOrVhwKjbDv4YYiMlUT_lnDnnaMou6WQgHXovxD0tP4e8-YnCLMr4ghJTxN1MBEvcLspxQUqDBqqWgzJPsaA/s320/Untitled.png" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="200" data-original-width="320" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrrC6yhP6Xhvar9PI5sgbumAWP-6JyR3gUjzYFo8oBtTz9dgs5deAcVPt1QvyfP2AEjcxML3FV4A2ZYwVarE7lIZZyT8dlYvXkR5t712SOrVhwKjbDv4YYiMlUT_lnDnnaMou6WQgHXovxD0tP4e8-YnCLMr4ghJTxN1MBEvcLspxQUqDBqqWgzJPsaA/s1600/Untitled.png" width="320" /></a></div>The approval of Aducanumab by accelerated route, by the Food and Drug Administration (FDA), for the treatment of Alzheimer's has been carried out against the unanimous opinion of its Advisory Committee on this matter, which has raised enormous dust. It is the first drug that attacks a supposed cause of the disease instead of its symptoms and has generated great expectations in a therapeutic area in which the gap is notable.<span><a name='more'></a></span></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Aducanumab reduces amyloid-beta protein plaques in the brain, but the clinical trials have not shown any clinical benefit in patients. Reduction in amyloid burden has also not been shown to predictably correlate with cognitive improvement. The FDA's decision has led to the resignation of three of the 11 members of its Advisory Committee, the request to President Biden – made by a United States senator – to relieve the head of the FDA, and numerous criticisms in scientific journals and the media Communication. If you want to know more about this controversial topic, <a href="https://theconversation.com/the-fdas-big-gamble-on-the-new-alzheimers-drug-162396" target="_blank">watch the 6-minute video produced by The Conversation</a>.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Expedited or conditional authorization</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">The fast-track authorization of the FDA in the United States or the conditional authorization by the European Medicines Agency (EMA) in Europe are extraordinary mechanisms or "shortcuts" created in the 1990s so that useful drugs for serious diseases without treatment options, such as AIDS or cancer, will reach the market more quickly. The shortcut consists of the use of what are known as <b>surrogate variables</b> that do not properly measure the clinical benefit (live longer or better), but rather are approximations, biological markers that seek to indirectly predict clinical benefit more quickly and easily. Uncertainty about the true benefit to patients – and risk, let's not forget – is the price you pay for speed. Since clinical trials based on surrogate variables are generators of hypotheses and not evidence, it is expected that in the years following the conditional approval, this hypothesis will be confirmed or refuted by adequate confirmatory clinical trials, with real clinical variables of clinical benefit. and not subrogated. Its result should lead to regular approval if the hypothesis is confirmed, or to the withdrawal of the drug from the market, if not.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">In 2002, the accelerated approval of Imatinib based on a 98% complete response (surrogate endpoint) in patients with chronic myeloid leukaemia made it possible that a treatment that subsequently demonstrated a dramatic increase in survival (true clinical benefit) to reach patients faster. By the regular way, it would have taken much longer to be approved. However, success stories like this are the exception rather than the norm. The results are often not as dramatic and confirmatory trials are often not carried out or are carried out too late, so that ineffective or even harmful drugs for patients remain on the market for years, often at exorbitant prices.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Surrogate variables of clinical benefit</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Surrogate variables, as with all shortcuts, are irresistible. Being fast, convenient and cheap, they started being used in the early stages of the clinical research process (phase 2 trials) as rapid preliminary evidence of the presence/absence of clinical activity, thus saving time and money in the subsequent stages of research. But the presence of activity does not necessarily imply real clinical benefit. That is where “the trap” lies, since, in reality, they do not in themselves add any value to the patient. In the words of Adam Cifu, it is “something that patients did not know was important until their doctor told them about it”<span style="font-size: x-small;">(1)</span>.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">However, for someone desperate who suffers from a serious and incurable disease, the existence of some positive data, even if it is a mirage in analysis or an examination, is hope to cling to and therefore the surrogate variables are the perfect allies of commercial exaggeration and the generation of disproportionate expectations in patients. In approving Aducanumab, the FDA argued that the Alzheimer's Patients Association said it was willing to accept some uncertainty about clinical benefit in exchange for quick access to such a promising therapy. Is this argument enough for a regulatory agency that must be based on evidence to approve drugs without proven efficacy or safety? Do patients have a single voice? What about future patients? What about the conflicts of interest of the Association, which received considerable funding from the manufacturer of Aducanumab? As the authors of an excellent article that I highly recommend titled "FDA Approval and the Ethics of Desperation"<span style="font-size: x-small;">(2)</span> state, agencies need to listen to all stakeholders, but they should not dictate their decisions. Understandably, desperate patients and their families believe that "something is better than nothing", but agencies cannot fall into the ethic of despair and abdicate their mission to ensure that the safety and clinical efficacy of medicines are proven by evidence that meets one's minimum quality standards before being approved since this is its reason for existence.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Recently, regulatory agencies are abusing accelerated approval based on surrogate variables, especially in some pathologies such as cancer where 70-80% of approvals are based on progression-free survival or response rate and not on evidence of real clinical benefit<span style="font-size: x-small;">(1,3)</span>. It is difficult to quickly demonstrate clinical benefit in a field such as oncology, but lowering the level of requirement so much leads to low-value health care that can directly or indirectly harm patients<span style="font-size: x-small;">(4,5)</span>.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>The risks of abuse of authorizations based on surrogate variables</b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">• <b>Uncertainty and low-quality evidence</b>. A review of the risk of bias in the pivotal trials used in the approval of anticancer drugs by the EMA between 2014 and 2016 shows that 50% of the clinical trials had a risk of bias and that this was greater if the primary objective of the trial it used surrogate variables and not overall survival<span style="font-size: x-small;">(6)</span>. Huseyin Naci, from the London School of Economics, describes it to us in less than 4 minutes in the following video:</div><div style="text-align: justify;"><br /></div><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="315" src="https://www.youtube.com/embed/EePHa9vysP0" width="560" youtube-src-id="EePHa9vysP0"></iframe></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">• <b>The probability that the evidence</b> will be generated once the drug is available on the market, plummets because the incentives for research, which is expensive and lengthy, no longer exist. Why choose a “hard” clinical variable such as overall survival in confirmatory clinical trials if they will be longer and likely to have negative results? The industry claims that using “hard” clinical variables in trials is too expensive, but the question is: too expensive for whom? This supposed saving occurs at the cost of patients and society paying the price, bearing the economic cost and the health cost of keeping expensive and harmful drugs on the market for years.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">• <b>Risk of toxicity</b>. By definition, trials for accelerated approval focus on efficacy as the primary objective, and, as these are trials of shorter duration, we must remember that they trade speed for uncertainty and that the risk of rare serious adverse events unnoticed is high. Rosiglitazone was approved in 2001 for the treatment of diabetes based exclusively on clinical trials with surrogate variables of glycaemia and glycosylated haemoglobin. Years later, in 2007, it was discovered that it produced, among other effects, an increased risk of myocardial infarction, but its final withdrawal did not occur until 2010, causing avoidable damage.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">• <b>Regulatory inertia and use in clinical practice despite the publication of negative results in confirmatory trials.</b> Expedited authorization is rarely revoked, even if confirmatory trials do not demonstrate the expected clinical benefit. Of 18 indications with accelerated approval by the FDA and negative results in confirmatory trials since the year 2000, six currently remain unchanged in the drug's datasheet. The NCCN guidelines, followed by oncologists around the world, maintained the second recommendation (the second category of recommendation) in half of the indications despite the negative results of the confirmatory trial<span style="font-size: x-small;">(5)</span>.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">• <b>Opportunity cost.</b> Despite the uncertainty about their clinical benefit, fast-track approved drugs command high prices and, as this type of approval is more and more frequent, the economic impact is increasing. In the case of Aducanumab, the annual cost of treating a patient is 56,000 dollars and it is estimated that 6 million people would be suitable to receive it in the United States. This vast amount of resources could be used for more value-oriented interventions, such as providing support to the overburdened caregivers of these patients.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Demonstrating improvements in survival or quality of life is difficult and time-consuming. Accepting a certain degree of residual and transitory uncertainty in exchange for faster access to promising drugs seems reasonable in serious diseases that lack alternatives. However, when the level of demand is so low, the uncertainty about the clinical benefit is excessive and remains unresolved for years, it is worth asking if the regulatory agencies are fulfilling their mission of guaranteeing the safety and clinical efficacy of medicines to society and if we are not all contributing to health care of little value.</b></div></div><div style="text-align: justify;"><b><br /></b></div><div style="text-align: justify;"><b><br /></b></div><div style="text-align: justify;"><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px;"><b>Bibliography</b></p><p style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px;"></p><ol style="caret-color: rgb(34, 34, 34); color: #222222; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15.4px; text-align: start;"><li style="margin: 0px 0px 0.25em; padding: 0px;">Vinayak K Prasad. <i>Malignant: How Bad Policy and Bad Evidence Harm People with Cancer</i>. Jo</li><li style="margin: 0px 0px 0.25em; padding: 0px;">Largent EA, Peterson A, Lynch HF. FDA Drug Approval and the Ethics of Desperation. <i>JAMA Intern Med</i>. Published online October 25, 2021. doi:10.1001/jamainternmed.2021.6045 </li><li style="margin: 0px 0px 0.25em; padding: 0px;">Schuster Bruce C, Brhlikova P, Heath J, McGettigan P. The use of validated and nonvalidated surrogate endpoints in two European Medicines Agency expedited approval pathways: A cross-sectional study of products authorised 2011-2018. <i>PLOS Med.</i> 2019 Sep 10;16(9):e1002873. doi: 10.1371/journal.pmed.1002873. PMID: 31504034; PMCID: PMC6736244. </li><li style="margin: 0px 0px 0.25em; padding: 0px;">Yudkin JS, Lipska KJ, Montori VM. The idolatry of the surrogate. <i>BMJ</i>. 2011 Dec 28;343:d7995. doi: 10.1136/bmj.d7995. PMID: 22205706. </li><li style="margin: 0px 0px 0.25em; padding: 0px;">Lenzer J, Brownlee S. Should regulatory authorities approve drugs based on surrogate endpoints? <i>BMJ </i>2021; 374 :n2059 doi:10.1136/bmj.n2059</li><li style="margin: 0px 0px 0.25em; padding: 0px;">Bishal Gyawali Regulatory and clinical consequences of negative confirmatory trials of accelerated approval cancer drugs: retrospective obser-vational study <i>BMJ </i>2021;374:n1959http://dx.doi.org/10.1136/bmj.n1959. </li></ol></div>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-26003394119415399802022-04-18T08:00:00.071+02:002022-04-25T11:43:04.420+02:00Digital health: about the inequality of the elderly<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOLWo0cXFf1zN5MFr-hmqf-iv9LKTFLmX455CN5BQ9M3qwW9fNeTrPDXFYylq7maHjc7C1nL3HUTuXbb3d6k2_oVE5EDQWQv_FGOBwJwywGZZ66YHe_-JkmbikgyLDn2l9mKhFDFdufkRtD9b-tGpyvXCGLNkMOFumABuhiaNBYwKPitcF7xWIYbqeiw/s323/Marco%20Inzitari.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="304" data-original-width="323" height="98" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOLWo0cXFf1zN5MFr-hmqf-iv9LKTFLmX455CN5BQ9M3qwW9fNeTrPDXFYylq7maHjc7C1nL3HUTuXbb3d6k2_oVE5EDQWQv_FGOBwJwywGZZ66YHe_-JkmbikgyLDn2l9mKhFDFdufkRtD9b-tGpyvXCGLNkMOFumABuhiaNBYwKPitcF7xWIYbqeiw/w200-h188/Marco%20Inzitari.png" width="104" /></a></div><b><span style="font-family: verdana; font-size: medium;">Marco Inzitari</span></b><br /> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZSHELE_Q2uG7yJVqwRXSmvQOGxcCWgB_RIF4q2DYNygAqm_b9ZjDU27PBlG0kMwDul899GqOc3KKF78lRF6IlV6Mcgqt38WcdGa6EmE3yegVJKBltBgf5Rg-DkYIq_hNh7tuD08ietHGHUMmo_R1BiQr9q_F67TlxmdDjtn88E_qsJHZk9SysaJC4-g/s320/mobile-phone-smartphone-old-human-seniors-communication-phone.jpeg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="218" data-original-width="320" height="218" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZSHELE_Q2uG7yJVqwRXSmvQOGxcCWgB_RIF4q2DYNygAqm_b9ZjDU27PBlG0kMwDul899GqOc3KKF78lRF6IlV6Mcgqt38WcdGa6EmE3yegVJKBltBgf5Rg-DkYIq_hNh7tuD08ietHGHUMmo_R1BiQr9q_F67TlxmdDjtn88E_qsJHZk9SysaJC4-g/s1600/mobile-phone-smartphone-old-human-seniors-communication-phone.jpeg" width="320" /></a></div><div style="text-align: justify;">"The prioritization of care for COVID-19 changed the doctor-patient relationship reducing scheduled face-to-face visits for the detection and monitoring of chronic diseases, of almost 41%. To return to pre-pandemic levels of diagnosis and management of chronic diseases, primary health care services would have to reorganize themselves and carry out specific actions for the groups at greatest risk. I quote verbatim an interesting recent article by the group of <a href="https://www.linkedin.com/authwall?trk=ripf&trkInfo=AQFGzdSaP11qKQAAAX-7L0aAIiC-MrlrO3RUdCzsNR1RIyh8m9byLPgjGlEoWFADZMXCYOIqnPQFo_UMO8wtx9eVPFty-VgKl-m94yQJKHI32kDOqkii30Api7tWYxCo_DDBpFU=&originalReferer=http://gestionclinicavarela.blogspot.com/2021/11/salu-digital-acerca-de-desigualdades-en.html&sessionRedirect=https%3A%2F%2Fes.linkedin.com%2Fin%2Fantoni-sis%25C3%25B3-almirante-bb84841a" target="_blank">Dr. Antoni Sisó</a>, current president of the Catalan Society of Family and Community Medicine (CAMFiC) and an outstanding researcher.<span><a name='more'></a></span></div><p></p><p style="text-align: justify;">What will be the real role of digital technologies and virtual environments in the care of the elderly in this reorganization? I have shared the reflections of this post with Carme Carrión (<a href="https://twitter.com/CarmeCarrion" target="_blank">@CarmeCarrion</a>), <a href="https://www.uoc.edu/portal/en/news/kit-premsa/guia-experts/directori/carme-carrion.html" target="_blank">professor of Health Sciences and principal investigator of the UOC's health lab</a>, an expert in digital health, with whom we have undertaken some collaborative projects to promote healthy aging. Certainly, her expert outlook can add value (and credibility!) to my reflections.</p><p style="text-align: justify;">Looking to the future, to create a good mix of face-to-face and remote care, we must be aware of the real added value of technology and of this new way of serving people. But we also have to consider their limitations to overcome them. <a href="http://gestionclinicavarela.blogspot.com/2020/01/2020-contribuira-la-salud-digital-los.html" target="_blank">As Elena Torrente reminded us just before the pandemic</a>, digital health is one of the objectives of the WHO, in line with the UN Sustainable Development Goals. Remote or partially remote care is also possible for people with chronic pathologies, and healthy lifestyle habits can even be promoted remotely, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803024/" target="_blank">also in the elderly</a>.</p><p style="text-align: justify;">Regarding the ability and willingness to use technology by older people, myths and realities intermingle, initially convinced that older people and technology are profoundly divorced worlds. Now, suddenly, we are demystifying it, as if the fact that many "old people" we know use WhatsApp certifies their digital training. Probably, the fundamental point is that talking about "old people" is not correct, we are mixing a great diversity in a single group: people of 65 and 85 years old, robust or frail, healthy or sick, with more or less support and social network, with greater or lesser skills and technological knowledge, with more or less economic and technological resources.</p><p style="text-align: justify;">The data we have, which unfortunately are scarce in our context(Catalonia, Spain, southern Europe in general), tells us that:</p><p style="text-align: justify;"></p><ol><li style="text-align: left;">The digital readiness of older people worsens with age so that the skills of an 85-year-old generally cannot be compared to that of a 70-year-old.</li><li style="text-align: left;">As is always the case in ageing, chronological age is not everything: cognitive decline or lack of confidence in one's digital abilities (as well as probably other factors) play a role.</li><li style="text-align: left;">The digital divide is worse for older people than for other disadvantaged groups, and it is clear that when old age joins disability and poverty, the divide can lead to total exclusion.</li></ol><p></p><p style="text-align: justify;">To give greater consistency to the three statements made, <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768772" target="_blank">a recent article</a>, well structured, by researchers from the Geriatrics Division of the University of California San Francisco (UCSF) and published in the journal<i> JAMA Internal Medicine</i> shows that, in 4,525 older people in the United States assessed in 2018, "digital readiness" (defined as "having sensory deficits of such magnitude that they cannot use the telephone or watch TV, suffering from dementia, not having tools that connect to the Internet or not knowing how to use them or not having used email, messaging, or the internet at all in the last month) was potentially seven times worse in people aged 85 and older, compared to those aged 65-74. It was also potentially worse in men than in women, as well as, as might be expected, in less-educated, lower-income, poorer health, and non-white people.</p><p style="text-align: justify;">Other factors, such as cognitive impairment or lack of confidence in one's ability to use technology, would reduce the possibility of contacting friends or other people, searching for information, using digital banking, or shopping on the Internet, <a href="https://doi.apa.org/doiLanding?doi=10.1037%2Fpag0000643" target="_blank">in a representative sample of older people in Germany</a>.</p><p style="text-align: justify;">If we move to Korea, it turns out that the digital divide (low "digital literacy" or digital skills) in older people is greater than that of other "technologically disadvantaged" groups, such as people with disabilities, low income, peasants, or fishermen, and which has increased over the years. Regarding the priorities, it seems that always considering the reality of Korea, training towards use is more urgent than access.</p><p style="text-align: justify;">For the people with the profile that we have described, non-face-to-face attention would be more easily diverted towards telephone attention, in case of need for remote visits.On the other hand, particularly in people with complex needs, the same UCSF article highlights that telephone attention is not and will not be enough. In addition, this group will surely not be favoured in the new contact channels and visit requests through electronic tools.</p><p style="text-align: justify;">For the future, we think that:</p><p style="text-align: justify;">1. <u>In the field of care,</u> <b>an adequate balance is necessary between different modes of health care provision</b>, especially for people with chronic multiple morbidities and complex needs. This correct mix has to be reconsidered for all users of health organizations. We talk about personalized medicine, but we focus a lot on biomedical aspects; on the other hand, we often do not consider the way each person interacts with professionals and the system. When should you use digital tools and when not? Who can and wants to use them? What changes must be made to offer personalized attention to each group of people? The organization of these aspects must derive from an <b>agreement between the health system and the professionals</b>, especially in the case of primary care and other specialities on an outpatient basis. Practitioners, with evidence in hand and with user participation, need to define this “new way of working” and how it applies to their direct local context, which will be different from many others. We also think that remote care of other pathologies to specific segments of the population can "free up" time so that professionals can dedicate themselves to attending the most complex ones in person, a principle that is consistent with one of the pillars of the Topol Report on digital health, about which <a href="http://gestionclinicavarela.blogspot.com/2021/02/la-revision-topol-y-las-claves.html" target="_blank">Tino Martí enlightened us a few months ago</a>.</p><p style="text-align: justify;">2. <u>Concerning technology innovation</u>, we will witness a further expansion of digital tools, some of which are better known, such as mobile applications, and others that seem more futuristic, such as virtual reality, which can have added value for people who live in the community and who spend much of their time alone. These tools can help the "care continuum". They can be elements that favour physical activity, a healthier diet, they can make them feel more connected or they do not have to go to their health centre periodically. It is necessary, however, to follow some guidelines to be able to develop and evaluate them:</p><p style="text-align: justify;"></p><ul style="text-align: left;"><li>The tools must result from the interaction between different agents, especially the users and their caregivers, the professionals who possess the knowledge, the companies, and the administrations.</li><li>It is necessary to identify what determines a person's resort to technology to take care of their health and which people will never resort to such tools.</li><li>Methodologically robust studies must be designed and evidence generated on which tools are effective and which are not sufficiently safe.</li></ul><div style="text-align: justify;">For all these reasons, and to implement effective strategies, we need more research with specific data from the territory, from Catalonia in our case, and well-conducted innovation processes.</div><p></p><p style="text-align: justify;"><a href="http://varelaclinicalmanagement.blogspot.com/2020/01/precision-health-recommendations-for.html" target="_blank">As I had already pointed out on this page</a>, "coffee for everyone" is not a good recipe and we are currently putting all people over 65 years of age in the same bag, which means that we consider that, for exemple, 19% of the population of Catalonia is homogeneous. And it is not.</p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-89112428100648855772022-04-11T08:00:00.052+02:002022-04-18T11:42:26.071+02:00From our trench<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhn5A9Zzy1kIaKiRVdnivntv34y5ZivbLFtgb_0StAeE-Z31TTtdEZrfC7bt_MHedZkZUoO59iCFfuE2wpFJl6amGLBX7F_5le9cwW-x7xrN2Ok3HW2Rz4mH6e242FsDjV7xnJ_rUfCMD8kiPhNr-5nDpG00ug-Z_EDTJqh-4rAhS8FdrJAyRK-Tx0VwA/s87/Soledad.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="87" data-original-width="87" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhn5A9Zzy1kIaKiRVdnivntv34y5ZivbLFtgb_0StAeE-Z31TTtdEZrfC7bt_MHedZkZUoO59iCFfuE2wpFJl6amGLBX7F_5le9cwW-x7xrN2Ok3HW2Rz4mH6e242FsDjV7xnJ_rUfCMD8kiPhNr-5nDpG00ug-Z_EDTJqh-4rAhS8FdrJAyRK-Tx0VwA/w200-h200/Soledad.jpg" width="100" /></a></div><b><span style="font-family: verdana; font-size: medium;"><a href="http://varelaclinicalmanagement.blogspot.com/search/label/Delgado%20S." target="_blank">Soledad Delgado</a></span></b><br /> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"></p><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIEGdMzzgslLf51aOVq8PX43dFq_XpN_aOXMD967C224emajkWE2lgpx1ec533K05oNUbUNykGvibeW1Ghucg3aWS0Ixly80JR6EzQ0TRScYUfuvMCS9FbcYnocb-qR6Wm9veiJ1KfY6wDIPsRSyXdE5jHgPXO2S2pLDYJBjDsj2Y6ZdeyvbPO0K1bzg/s320/%C2%A1Armas%20al%20hombro!%20Chales%20Chaplin%20(1918).jpg" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="320" data-original-width="253" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIEGdMzzgslLf51aOVq8PX43dFq_XpN_aOXMD967C224emajkWE2lgpx1ec533K05oNUbUNykGvibeW1Ghucg3aWS0Ixly80JR6EzQ0TRScYUfuvMCS9FbcYnocb-qR6Wm9veiJ1KfY6wDIPsRSyXdE5jHgPXO2S2pLDYJBjDsj2Y6ZdeyvbPO0K1bzg/s1600/%C2%A1Armas%20al%20hombro!%20Chales%20Chaplin%20(1918).jpg" width="253" /></a></td></tr><tr><td class="tr-caption" style="text-align: right;"><span style="font-size: x-small;"><i>Shoulder Arms</i> Charles Chaplin (1918)</span></td></tr></tbody></table><p></p><div style="text-align: justify;">From our trench, everything looked different. Time seemed to have stopped and each day was the same as the previous one. Same path, same faces, the same ritual of preparation to fight an enemy advancing in waves. The pandemic filled everything, to such an extent that we stopped seeing that life continued its course and that other diseases continued their course, seemingly unchecked, appearing before us when, sometimes, it was already too late.<span><a name='more'></a></span></div><p></p><p style="text-align: justify;">The spread of the disease forced us to erect barriers, to put them between us, our families, and our patients. A high but transparent wall that allowed us to see what was on the other side so as not to lose the way to follow. Paradoxically, this wall, rather than separating, made us see how necessary it was to treat our patients humanely, the importance of empathy, listening, and understanding, both with them and with their families.</p><p style="text-align: justify;">Walls knocking down other invisible walls, built over the years and that we thought were insurmountable: the separation between the different medical specialties, a pending issue when it came to establishing continuous patient care, was vanishing. Behind the mask, we were all soldiers of the same army, finding the support we needed in what until then had been almost unknown. Humanity… humanity on the same side of the trench.</p><p style="text-align: justify;">What will we do when all this happens? That was the question. A question that was answered with a "we will have to be consistent with our work, with our successes and our mistakes, each one of us, each one from the responsibility of it." No one verbalized it, but for many, this phrase reflected a certain sadness and also a feeling of loneliness. Because sometimes we have felt alone... alone. Feeling that the pandemic had managed to shake the foundations of an already weakened health system gave us a feeling of emptiness and uncertainty about the future. The applause and recognition of an entire society were not enough, nor with the look of support and the words of consolation from a comrade: we also needed a word of encouragement from those responsible for directing our struggle, to feel that they were there, with us, acknowledging our work. But sometimes we have felt alone.</p><p style="text-align: justify;">And now what do we need? Now that our day-to-day continues, with another intensity, with other challenges, we need to feel comforted with improved human treatment as professionals. We need to feel that humanization is also reaching management. The dictionary defines humanization as the action or effect of humanizing, that is, making someone or something human, familiar, and affable. To humanize is to understand, feel affection and show solidarity with other people. Humanization in care is just that, and it is also applicable to management.</p><p style="text-align: justify;">Albert Cortés's book "<i>Humanizar la gestión sanitaria"</i> proposes a change in the humanized management model based on respect for people "management of people for people". Health professionals want to work in institutions that value us and increase our potential. "The leader in health must observe and focus their efforts on the transformation and use of knowledge, skills, and aptitudes to carry out good management by competencies, taking advantage of the best of each professional", says Daniel Goleman in his work "<b>What defines a leader</b>"<span style="font-size: x-small;">(1)</span>, where he explains that "A person can have a high IQ and impeccable technical training, but be unable to lead a team to success. They can only be effective leaders who have emotional intelligence, that is, the ability to capture the emotions of the group and lead them towards a positive result.</p><p style="text-align: justify;">Now, from our trench, we can lift our heads and breathe, look ahead and see the upcoming changes, the new challenges, and some that we are already facing. It is the opportunity to grow and change, to learn from what has been lived. It is the moment of humanization at all levels. The election of leaders with soul and intelligence, capable of encouraging when forces decline and making us all move forward, is a challenge that the system must face, also for its survival. It seems simple, isn't it? Listen, empathy, recognition. Humanity… humanity in health management.</p><p style="text-align: justify;"><span face="Arial, Tahoma, Helvetica, FreeSans, sans-serif" style="background-color: white; caret-color: rgb(34, 34, 34); color: #222222; font-size: 15.4px;"><i>1. Harvard Business Review, ISSN 0717-9952, vol. 82, nº 1, 2004</i></span></p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0tag:blogger.com,1999:blog-4773674341006984398.post-53695043837507134772022-04-04T08:00:00.091+02:002022-04-11T09:16:08.788+02:00Transforming our health system requires continuity and coherence<p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhT2SG3PB625pt7D3Y7JfQAcisQBdrNEXllHPQhiKXsIH3DrL1rDOgBz8Jpu-bW2_cgCdPGj58Bq3yQZBnDXb74AFzeUqakifqTJJIcuOiHoIox4ToG3-3Lr6X15cztUG-L2P5Vud4P4_SqL3EgnuQLWn_IcbRnK54bVdfT-dTfIW6qopSfRabFbCpi2A=s175" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="175" data-original-width="155" height="105" src="https://blogger.googleusercontent.com/img/a/AVvXsEhT2SG3PB625pt7D3Y7JfQAcisQBdrNEXllHPQhiKXsIH3DrL1rDOgBz8Jpu-bW2_cgCdPGj58Bq3yQZBnDXb74AFzeUqakifqTJJIcuOiHoIox4ToG3-3Lr6X15cztUG-L2P5Vud4P4_SqL3EgnuQLWn_IcbRnK54bVdfT-dTfIW6qopSfRabFbCpi2A=w177-h200" width="95" /></a></div><b><span style="font-family: verdana; font-size: medium;">Nacho Vallejo</span></b><br /><a href="http://gestioclinicavarela.blogspot.com/search/label/Vallejo%20N." style="caret-color: rgb(41, 82, 123); color: #29527b; font-family: verdana; font-size: 15.4px; text-decoration: none;" target="_blank">Atenció integral</a> <p></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"><br /></p><p style="text-align: justify;"></p><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhHfVGDKG1ty1zXMfzcGCJAX0UaefqTAZbyu8TY_tyCeNpHckvroLSjB1axMO1wA4oXn6Qcvj9tfI4TKhtfi25eN_QnpDLWcMF4uiFh4fXeIVVFcWKyEkgy1rLpA_wVJ8CepJyMyvHV-pqeYg7aD2G9EvCKYaVfU8zUxVPUPsX3gObI7bTSO6kK-mzQJQ=s320" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="214" data-original-width="320" height="214" src="https://blogger.googleusercontent.com/img/a/AVvXsEhHfVGDKG1ty1zXMfzcGCJAX0UaefqTAZbyu8TY_tyCeNpHckvroLSjB1axMO1wA4oXn6Qcvj9tfI4TKhtfi25eN_QnpDLWcMF4uiFh4fXeIVVFcWKyEkgy1rLpA_wVJ8CepJyMyvHV-pqeYg7aD2G9EvCKYaVfU8zUxVPUPsX3gObI7bTSO6kK-mzQJQ" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: right;"><span style="font-size: x-small;">Photo of Alexas. Photos in Pexels</span></td></tr></tbody></table><div style="text-align: justify;">“<a href="https://hbr.org/2015/12/transforming-health-care-takes-continuity-and-consistency" target="_blank">Transforming health care requires continuity and consistency.</a>” This is the title of a <i>Harvard Business Review</i> article written by Mark Britnell. <a href="https://home.kpmg/ca/en/home/contacts/b/mark-britnell.html" target="_blank">Dr. Britnell</a> is an executive of KPMG International and a global health systems expert. He dedicated his professional life to this field and has worked in more than 80 countries, a circumstance that has allowed him to gain first-hand unique experience of healthcare models. In 2000 he was appointed chief executive of University Hospitals Birmingham NHS Foundation Trust where he was responsible for the design of the largest NHS hospital. He is also the author of the book <i><a href="https://home.kpmg/xx/en/home/insights/2015/09/video-about-the-book.html" target="_blank">In Search of the Perfect Health System</a></i>.<span><a name='more'></a></span></div><p></p><p style="text-align: justify;">After several years of searching for the best health system, the author reflects and draws attention to the fact that we all want to provide safe, coordinated, and financially sustainable health care, but few have been able to achieve this goal.</p><p style="text-align: justify;">Our healthcare systems share similar ambitions: value-based care with improved outcomes, lower costs, and increased patient satisfaction; converting hospitals into centres that provide health; focusing on preventive actions rather than treating the disease; implementing technology to make the care more efficient; empowering patients... However, despite these goals, we only see a few examples of systems that are achieving truly transformative changes.</p><p style="text-align: justify;">He also reports that he has been able to identify cases of excellent health care, although all too often the people who inspire these role models have been hindered rather than helped. It remains a serious drawback to innovation and progress that the different actors in health systems do not have a shared purpose. Changes occur, albeit slowly, fragmented and difficult.</p><p style="text-align: justify;"><b>Problems that hinder sustainable change</b></p><p style="text-align: justify;">Three problems impede, according to Britnell, a large-scale sustainable change:</p><p style="text-align: justify;">Firstly, the myopia of our organizations, which tend to think that they are good. Often, their leaders see the need for change in the rest of the system and do not reflect on the importance of transforming their own "house".</p><p style="text-align: justify;">Secondly, the usual tendency to make transactional changes (do things better) over transformational changes (do better things). It is often easier and less threatening to make small, seemingly important changes than it is to make a transformational change that will produce better care and add value.</p><p style="text-align: justify;">Thirdly, large-scale changes are seldom understood. A compelling vision of a better future must generate energy, motivation and communicate well. Professionals and patients are generally not involved. Empowering them is a necessary element that is often absent, which prevents them from being able to shape changes and challenge the status quo.</p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9XfTtKYwPxeM2PUpFlDbO4fycO4T90UCL7OHQaJebel-O3QIcAFCmnSZP8lZ3_eZwF3E3ZL-uPVQf06mcy8rhcGNrQAS01Y3uacHuyKGhUb6l1PtiA0HZOGAQNSYKvToWxIg5UK7ftz1hcust-_1lx7EVTEZ_bFOb2nXzB6e3QQi8KgGMBFSJ6QUTkw/s875/Sense%20nom.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="462" data-original-width="875" height="318" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9XfTtKYwPxeM2PUpFlDbO4fycO4T90UCL7OHQaJebel-O3QIcAFCmnSZP8lZ3_eZwF3E3ZL-uPVQf06mcy8rhcGNrQAS01Y3uacHuyKGhUb6l1PtiA0HZOGAQNSYKvToWxIg5UK7ftz1hcust-_1lx7EVTEZ_bFOb2nXzB6e3QQi8KgGMBFSJ6QUTkw/w640-h338/Sense%20nom.jpg" width="580" /></a></td></tr><tr><td class="tr-caption" style="text-align: right;"><span style="font-size: x-small;">Reference: <a href="https://hbr.org/2006/05/why-innovation-in-health-care-is-so-hard" target="_blank">Why Innovation in Health Care is So Hard</a></span></td></tr></tbody></table><br /><div><b style="text-align: justify;">Solutions</b></div><p style="text-align: justify;">Dr. Britnell cites the <a href="https://pubmed.ncbi.nlm.nih.gov/25057539/" target="_blank">Crossing the Quality Chasm </a>report, published in 2001 by The National Academy of Medicine, which identifies and recommends improvements in different dimensions of health care, in this case in the United States. This document recommends four ingredients for a high-quality health care system, which can be extrapolated to any institution:</p><p style="text-align: justify;"></p><ul><li>A correct outlook</li><li>The design of clinical processes from the perspective of the patient</li><li>The integration of organizations</li><li>The modification of the legal framework and the financing of the institutions</li></ul><p></p><p style="text-align: justify;">Translating these inputs into<a href="http://gestionclinicavarela.blogspot.com/2021/03/tres-claves-del-exito-en-la-gestion-del.html" target="_blank"> successful management of change</a> is challenging. But, as we have previously mentioned in this blog, <a href="http://varelaclinicalmanagement.blogspot.com/2016/07/clinical-management-as-mechanism-of.html" target="_blank">clinical management must be a lever and engine of change</a>. Rigorous application of best practices, approaching complex processes with trial-and-error mechanisms, making decisions as a team, and learning how to change things, also daily, can improve the effectiveness and optimization of our resources.</p><p style="text-align: justify;">This roadmap should not miss a look at what health care has <a href="https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0098" target="_blank">to learn from the business world</a>. It seems key to the future of care to reorganize around the needs of patients in the same way that businesses reorganize around the needs of customers.</p><p style="text-align: justify;">It also seems interesting to reflect <a href="http://anabasint.blogspot.com/2021/08/motivos-para-no-cambiar.html" target="_blank">on the reasons for not changing</a>. In this sense, an entry on this matter written by the psychiatrist<a href="https://twitter.com/JCamiloVazquez" target="_blank"> J. Camilo Vázquez</a> on his blog <i>Anabasis</i> is highly recommended.</p><p style="text-align: justify;">A couple of further reads. We have already talked about <a href="http://gestionclinicavarela.blogspot.com/2018/11/the-corporate-rebels-se-agradece-un.html" target="_blank">Corporate Rebels</a> in this blog. Well, the Dutch friends have released their book in a Spanish edition. There are no longer any excuses for not reading them and finding pioneering organizations that decided to radically change their way of working and take advantage of what we can incorporate into our institutions. Lastly, Transforming Management in Health Institutions (<i><a href="https://axon.es/ficha/libros/9788494083167/esencial-transformando-la-gestion-en-las-instituciones-sanitarias" target="_blank">Esencial. Transformando la Gestión en las Instituciones Sanitarias</a></i>), a book published in 2020 whose main author is Vicenç Martínez Ibáñez. The text analyses the problems of our health system proposes alternatives and suggests an operational methodology to be able to implement change.</p><p style="text-align: justify;"><b>Change requires skill, will, time, and doing so through a rigorous process. This is the paradox of change: it requires continuity and coherence. But as long as our leaders don't spend enough time on change and don't trust professionals and patients in their ability to develop and implement sustainable solutions to problems, we will continue to settle for only one reward: survival. We need to make more use of our energy. Not just to do better, but to do better things.</b></p>Jordi Varelahttp://www.blogger.com/profile/17818537096804304003noreply@blogger.com0