Shared decisions, evaluate to advance

Jordi Varela

Editor

The progress of shared clinical decisions is being almost negligible and, for this reason, attention should be paid to the results of the clinical trial by Víctor Montori's research group, an evaluation that was carried out with almost a thousand patients with atrial fibrillation. which ones had to decide if they wanted to take anticoagulants and, if they did, which one they would choose. In the trial, the intervention group of patients tested a shared decision support instrument, while the control group followed the usual clinical pathway.

Aligning care objectives

In last week’s post, I was showing you the benefits of coordination and the difficulties of integration but only in terms of organizational models, of course. However, now I believe it’s time to enter another innermost level, the clinical process, and for this reason I want to emphasize that regardless of models, aligning care objectives is the key step to improving clinical outcomes. To illustrate what I mean, I thought of an example. Imagine an emergency doctor responding to a person suffocating and, as it can not be otherwise, his goal should be in reducing the clinical problem and helping the patient to recover his normal breathing as soon as possible. But if it turns out that the patient is a complex chronic, the issue is that the doctor should also bear in mind that his action should be performed by the wagnerian chronicity model: What are the circumstances of this patient? Does he live alone? How many relapses has he had lately? Is there a professional team that takes care of him continuously? Can I contact them? From the answers to these questions will depend that the undertaken actions after diuretics and oxygen, are really effective and that the system holistically is able to improve the quality of life of that person.

For those who are not used with the terminology and with the concepts of chronicity, allow me a brief reminder of the model "Chronic Care Model" attributed to Edward Wagner, Director Emeritus of McColl Centre for Health Care Innovation:

Back to Sutton’s Law

Last week we saw the status quo bias starting from the article "Assessing Value in Health Care Programs". Remember that this bias is due to the human tendency to keep doing things as usual, without questioning too much the meaning of what is being done.

But in this post I want to talk about exactly the opposite innovative attitude and the difficulties inherent to the changes in an environment as segmented and as regulated as the health system. For this reason I have chosen three examples that illustrate the obstacles that many professionals must overcome when they are eager to change routines or adopt a new drug they know is supported by scientific evidence. But the problem is that to adopt the novelty, investments are required, or simply more budget because the new drug is more expensive. So the question is: who pays for the novelty when we were told that we can not spend more?

Example 1 - Adherence to treatment

Let’s consider a program that may improve adherence to treatment, which barely reaches 45%, after myocardial infarction (Volpp 2012). Let’s imagine that a new program foresees increasing this adherence to up to 70% and as a result there would be a 10% reduction in readmissions both for new myocardial infarction and for stroke or revascularization, with a cost reduction that could collect savings for the association of $2,000 per case per year. Does this mean that the program should not be approved if its cost would be $3,000 per case and year?