Diagnostic Imaging: adjusting the indication

Saurabh Jha, a radiologist at the Hospital of the University of Pennsylvania, in an article in New England (From imaging gatekeeper to service provider: a Transatlantic journey) explains that when he undertook MRI in the UK, residents feared the radiologists, not in vain, since one of them known as “Dr. No”. Migrated to the United States, quickly realized that there, the radiologists who were operating and issuing invoices as service providers, were rather “Dr. Yes”. The involvement of the radiologist in clinical reasoning was gone.

There is a widespread perception that the large investments of modern screening equipment are increasing their disproportionate use and the position of the radiologists, many of them involved in investments, is far from the function of gatekeepers, so praised by Dr. Jha. To this effect, it is revealing in a letter published in JAMA Internal Medicine (Overuse of Magnetic Resonance Imaging) about a consensus methodology (Rand Corporation University of California Los Angeles UCLA) to determine the degree of indication of MRI for low back pain and headache cases. The results say that 77% of the experts consulted, for example, believe that the MRI indication for back pain of less than 6 weeks duration is inappropriate or not well founded.

Integrated Practice Units: what for?

Hospital medical divisions are based on rigid organizational charts, in accordance with the official medical specialties. This organizational model is quite efficient when you need to provide services to patients with acute pathologies, especially when the derived procedures are more or less standardized. But in any other circumstances, of which there are plenty, the shortcomings found in coordination between medical services often cause frankly disappointing results that leave a lot of room to be improved.

In the fields of Mental Health and Oncology, particularly those sensitive to transversality, long ago instruments designed to overcome the closed compartments (circuit meetings, tumours committees) were created. These organizational models are based on protocols, individualized treatment plans and a lot of intense coordination; and, as a consequence of the positive results of these experiences, we have witnessed the emergence of the Integrated Practice Units, which are often initiatives that want to go beyond simple coordination, although most of them fail to overcome two tough limitations: real management autonomy (can they contract?) and lack of own resources (do they have an attached budget?).

Integrated Practice Units

At the moment, we're seeing many official initiatives aimed at giving legal backing to the establishment of Integratec Practice Units, precisely to overcome the above obstacles and thus get more management autonomy and accountability of clinicians in the management of resources. Even admitting that this new framework is encouraging, the question remains:  Why do we want Integrated Practice Units? Will they bring more value or end up as a new constellation in the firmament of the chaotic management of patients with complex and little standardisable pathologies?

Deconstruction of primary care

The renowned Harvard professor Michel Porter, with the collaboration of two GPs, one veteran, Thomas Lee, and the other on training, Erika Pabo, applied to primary care their well known proposals of adding value to clinical performances. Their article, published in Health Affairs, caused me to act cautiously because I didn’t believe any American proposal of reforming primary care could benefit us as we enjoy a much more evolved model. But when I noticed that the first author was Michael Porter, I couldn’t help taking a look.

Primary care (gatekeeper type), Porter and his colleagues say, is now served on a single dish, like a stew (they don’t actually say that). Continuous care prevails, always the same chef for every meal, an almost artistic development, case by case, plate by plate. According to them, this makes it difficult to measure the provided value. On the other hand, the most common model in the US, where the patient goes to a specialist in their own terms, is chaotic and promotes a disproportionate consumption of resources.

Recommendations against low value clinical practices. Are they useful?

As the Choosing Wisely campaign enters its final stages, Owen Dyer looks at whether it can change practice http://t.co/B8BfPvPdED
— The BMJ (@bmj_latest) October 4, 2013

Owen Dyer, a journalist and regular contributor to the British Medical Journal, following the Choosing Wisely campaign from the ABIM Foundation (a list of recommendations for clinical practice that both doctors and patients should question) in the US, makes an assessment of whether the lists of recommendations against low value clinical practices will manage to change the status quo or, on the contrary, the dynamics of the system will engulf them as it has done with many other initiatives.

The Hospital of the Future: New Report (UK)

Sir Michael Rawlins, Chairman of the National Institute for Health and Care Excellence (NICE) since its inception in 1999 until last year, is now Chairman of a committee called "Future Hospital Commission" which has been promoted by the Royal College of Physicians. In September 2013 this committee issued its first report and I think it’s worth discussing.

For starters, it seems appropriate to pick up the 5 challenges that hospitals are facing nowadays according to a previous Royal College of Physicians’ report:

1. Increased demand in an environment of reduced number of hospital beds

2. Case mixe’s gradual and persistent advance towards chronic diseases and geriatrics

3. Difficulties of coordination and continuity of services for admitted patients.

4. Services of uneven quality in the evenings and at weekends

5. Imminent crisis of professionals and training of new professionals

To face these challenges, according to the "Future Hospital Commission", the hospitals should consider reorganization based on the following principles:

Medicine focused on patient preference: visual aids

Use visual aids to teach patients and improve decision making http://t.co/lzCBq9URpG
— Kevin Pho, M.D. (@kevinmd) September 29, 2013

Some argue that the great innovation in this second decade of the twenty first century should be medicine based on patient preference. To understand it better, it’s about women being well informed of all probabilistic knowledge regarding the decision to have a mammogram screening or not. Therefore it is the woman who takes responsibility for her decision and not the government or insurance company of her choice. The same would be said for men and the PSA.

This approach would seem reasonable enough, if it were not for the fact that, according to a particular US survey (National Adult Literacy Survey), half of the population has difficulty in managing simple numerical operations. For this reason I have chosen this blog post by Kevin Pho, who has always been innovative in the field of clinical management, who presents an article by Peter Wei, a medical student, who gives us a visual aid developed by the Mayo Clinic. You can argue that those who struggle with mathematical operations will also have difficulties interpreting graphs, but if the graphics are designed to be understood its less of an issue and if that is not the case, consider the following:

High Value Healthcare: Porter and Lee proposals

Michael Porter, professor at Harvard Business School and Thomas Lee, Medical Director at Press Ganey, an organization aimed at improving the patient healthcare experience, published an article on the HBR Blog Network:  "Why health care is stuck and how to fix it". These two teachers, tired of analyzing the stubborn (and chaotic) reality of the American healthcare system, have decided to focus on making strategic proposals to change things.

How can it be that with so many good and well-intentioned people involved in reforming the American health system, they can’t find a solution? Almost the opposite happens: it seems that the opposing positions are increasingly reinforced.

The authors ask this rhetorical question, although they, far from disenchanted, still insist on the idea that solutions can only be systemic, as this is where the problems lie in the model.