8 future proposals for primary care

Primary care is the key to the good running of the health system and therefore it must be promoted, protected, improved and, above all, invest in it. Many countries are immersed in renewal processes of their primary care and, therefore, we must be attentive to the contributions we receive, especially those in the United Kingdom, where primary care is very similar to ours. In an earlier post, I reviewed a paper by the Royal College of General Practitioners that provided an insight into the role of family physicians in 2022, and in this same direction I have a report from a committee of experts of the National Health Service Primary Care Workforce Commission), which has developed a set of reform proposals aimed at strengthening the future of primary health care, broader than the previous one which was limited to a corporate vision.

Telehealth, only expectations for now

The technology of data transmission is experiencing an explosion in all areas of social and professional activities and, of course, the specialised industry can see a big opportunity for introducing it as a tool for improving life quality of chronic patients. Doubts, however, appear in the minds of the funders of health services as they see themselves forced to adopt new investments in electronics, which have not yet been able to demonstrate good enough clinical results to compensate the effort.

Seen this way, it seemed to me that in this article about telehealth, it is appropriate to discuss two papers, one English and one Catalan, which aim to answer the question of whether the investment is worthwhile.

This article about findings from the Whole System Demonstrator, project led by Nuffield Trust researchers which sought to evaluate the clinical effect of home interventions with remote data exchange between patients and professionals (telehealth). The project was carried out with the collaboration of 3,230 patients with diabetes, COPD or heart failure from three geographical areas (Cornwall, Kent and Newham) over a 12 month period between 2008 and 2009.

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?

Four ways to make Sutton’s law a reality

It occurs to me that there are four possible approaches to address Sutton's law (remember that this law tells us that we have to go after the waste to raise funds for activities that really provide a health value to people, see post March 28th) and I think we need the four approaches at once:

1. Medical service based on patient preference (see post February 27th)

There is a report from a Cochrane review that says that when patients have contrasting information, other than from their doctor, they have a tendency to choose more conservative therapies within the range that is offered with their diagnosis. And, according to some researchers, up to a 20% reduction in some scheduled surgical procedures can be expected with this method.

2. The role of scientific associations in addressing evidence-based medicine

The difficulties in the practice of medicine begin in the gap that exists between the scientific evidence and the reality of clinical practice. In this area there is a missing link that causes a striking variability in clinical practice and the utilization of health care resources. For this reason, in recent times interesting professional initiatives are being observed (which we will discuss further in later posts), of which highlight "Do not do" from NICE in the UK and "Choosing Wisely” from ABIM Foundation in USA.

End of Life Overtreatment: Hospital Care Intensity (HCI) Index

Hospital Care Intensity (HCI) Index is a summary measure of the intensity of hospital resource consumption that is constructed, starting from the number of hospital stays and the number of visits to a specialist. Through this index, created by The Dartmouth Atlas, John Wennberg discusses the use of hospital services series by chronic patients for the last two years of their life, and notices a change in HCI up to 4 times between regions with more extreme data: New Jersey (NJ) and Salt Lake City (SLC).

HCI last two years of life in patients with chronic

The healthcare systems are all clear that if an 80 year old lady’s femur breaks she should be operated. After the intervention, she’ll have more or less successful results and this will determine the functional recovery of the patient, the permanent disability, or the death. But instead, when a patient with one or more chronic diseases grows older and his chronic diseases multiply or aggravate, then the response of almost all the systems is to provide disproportionate and costly hospital services, but all very uneven, as seen in the table above.

Wennberg: ten thoughts about chronic care

In Chapter 12 of his book "Tracking Medicine", John Wennberg reflects on how the American health system is treating chronic patients and, as I think it is a careful and timely analysis, I want to dedicate this post to comment these reflections.


First thought

Blind trust in hospital medicine does not work for the chronically ill patients

It is considered that Medicare spends 18% of its budget on hospital admission bills during the last two years of life of chronic patients. While it is true that overactive hospitals can add some days to the lives of chronic patients, the question is what is the quality and how big is the suffering... and at what cost.

Second thought

Sutton's law: If you are interested in saving money, have no doubt that the saving is to be found in hospitals

Willie Sutton was a bank robber, and when asked why he did it, he answered: "That's where the money is, right?". Wennberg proposes a strategy for implementing Sutton’s law in a less bleeding way: benchmarking. I mean, if you get the hospitals that admit more chronic patients to reduce these rates to levels of those hospitals who admit less, you could raise enough money for community programs more tailored to the needs of these patients, and also could really make a saving.