More material against low value clinical practices

How Many Contemporary Medical Practices Are Worse Than Doing Nothing or Doing Less? http://t.co/tUoybTcMSe & http://t.co/kXNYbBKMGR
— joan escarrabill (@jescarrabill) August 26, 2013

Dr. Joan Escarrabill is the Chronic Care Program Director of the Clínic Hospital. As a pulmonologist, he trained and developed his career in Bellvitge Hospital, where he had the opportunity to exercise various responsibilities in the field of clinical management. And now he has given us the selected tweet that leads to "Mayo Clinic Proceedings".

If you click on the two links from Dr. Escarrabill’s tweets, you’ll reach a project (and the introductory editorial) which reviewed over two thousand articles published over 10 years in the New England Journal of Medicine with the rank of "Originals". This work has identified 146 studies that advise stopping certain medical practices that are failing to demonstrate expected clinical outcomes.

Therefore, Dr. Escarrabill with his tweet, offers us a new key to strengthen programs calling for clinical practice to focus only on the actions that are known to add value to the health of people (see posts from: "Too much medicine", "Less is more", "Choosing Wisely", "Do not do" and "Projecte Essencial"). This movement of clinical containment led by professionals is taking shape in the United States under the name "The Right Care Alliance".

New diseases: new?

Ways of expanding disease definitions: promoting awareness about pre-diseases, & early and ↓ thresholds of diagnosis http://t.co/Xne8Xb2l1V
— Enrique Gavilán (@enriquegavilan) August 14, 2013

Enrique Gavilán is a family physician who has a habit of providing good professional quality "material" on Twitter, especially with regards to evidence in overdiagnosis and overtreatment.

On this occasion, I have chosen a tweet from Dr Gavilán which refers to a work published in "PLOS Medicine" that analyzes 16 studies where there have been criteria changes in the diagnostic definitions of common diseases such as: hypertension, asthma, attention deficit hyperactivity disorder (ADHD), COPD and dementia, among others.

One finding of the study was that these changes in criteria were mainly in three directions: creation of pre-conditions, lowering superior analytical values ​​and introduction of methods of early diagnosis. Another discovery is that these changes in criteria, which only serve to increase the legion of people affected by supposedly pathological conditions, are not accompanied by evaluations of the negative or even harmful impact to the health of "new patients". And there's a final finding: many of these studies have been developed by researchers with an economic interest linked to pharmaceutical companies directly involved in the proposed criteria changes.


Jordi Varela
Editor

Rethinking the doctor’s appointment

It's time to Flip the Clinic: a new concept for the doctor/patient encounter we're brewing up at RWJF http://t.co/WV5x8xbcE7
— Thomas Goetz (@tgoetz) July 18, 2013

Thomas Goetz, the author of the this tweet, has been executive director of "Wired" magazine (a reference in the world of technology and futurism), and he has joined the Robert Wood Johnson Foundation (RWJF). According to him, he now intends to implement innovative concepts that he has been promoting from "Wired" to see the intellectual production of RWJF, surely he will succeed.

The chosen tweet refers us to the RWJF Blog where he writes that the doctor's office is a place where the real value activity is being conducted and recognizes that the doctor's office is the most important resource of the health system. But then he adds from his particular vision, that in fact this resource has many details yet to be improved: the information between the parties is asymmetric, the communication is full of misunderstandings and as a result, often the patient leaves the office having heard, but not having understood some fact that then reduces a lot the effectiveness of the subsequent planned clinical procedure.

As he states in the blog, Thomas Goetz will devote his energy and knowledge to encourage improvements in this field. Therefore we’re looking forward to it.


Jordi Varela
Editor

Clinical safety: "The Leapfrog Group" and other benchmarkings

The Hospital Safety Score is a scaled assessment (A / B / C / D / E / F) of American hospitals that aims to provide that insurers and citizens have access to proven clinical safety information offered by each hospital in the system. The Hospital Safety Score is a summary of 26 parameters that feed on both a voluntary survey and official sources: AHRQ (Agency for Healthcare Research and Quality), CDC (Centre for Disease Control and Prevention), CMS (Centres for Medicare and Medicaid Services) and "American Hospital Association Annual Survey."

Hospital Benchmarking: Top 20 Iasist and "US News Best Hospitals"

Benchmarking is a healthy exercise but to do it in the healthcare field it’s necessary to have solid databases, to know how to select consistent indicators and how to adjust and refine the data to the maximum so that the results are really comparable. In this post I want to discuss the essence of two famous private competitions, one Spanish and one North American.

Iasist, a company specializing in health information management has announced the 15th edition of the Top 20, a competition amongst Spanish hospitals which is voluntary, free and anonymous where only the results of the nominees and the winners are published. The purpose of this competition is in the winners’ institutional prestige.

The heuristic effect on shared clinical decision

Great piece from @NewYorker on how shared decision-making looks in practice & how it can help improve #HCQuality http://t.co/NlBVP1xOQV
— Commonwealth Fund (@commonwealthfnd) July 13, 2013

The Commonwealth Fund is a private, nearly century old organization that was created with the mission of promoting efficiency, quality and accessibility of the American health system.

Our tweet of the week, issued by the foundation, brings us to a very interesting article written by Lisa Rosenbaum, cardiologist, and published in "The New Yorker", where she uses several examples from her own practice to illustrate the difficulty of the exercise of "shared clinical decision." One of the cases discussed is that of her own mother, a cardiologist like her, who broke her arm in four places, and when faced with the severity of fractures, the orthopaedic surgeons advised her that she consider the possibility of surgery, which included a risk of between 20 and 50% of developing avascular necrosis of bone, while, if following a conservative treatment with immobilization and subsequent rehabilitation there was a risk, not estimated numerically, of  residual functional limitation and post-traumatic arthritis.

As Dr. Rosenbaum says in the article that the "shared clinical decision" is a very attractive proposition for politicians, investors and researchers, but, instead, in practice each day, the doctor who practices this technique faces two phenomena that are very difficult to handle: the first is called "heuristic effect", a concept that reflects the idea that us people, at decision time, allow ourselves to be influenced more by emotion than by the figures, such as: "a friend of mine died in the operating room and therefore no matter what they say, the doctor will not trick me", or the opposite: "the upstairs neighbour was operated on when it was too late to save her leg. I'll have to talk to the doctor to see if they should send me to the operating room". The second phenomenon is the unequal agency relationship established with the patient, and this is expressed when at the end, after sharing lots of information and lots of numbers, the patient looks at the doctor and asks, "Doctor, if it was your mother, what would you do?” Or as the author writes "You're my quarterback. Do you understand?".



Jordi Varela
Editor

Nurse demand management in primary care

Nurse demand management, aims to respond, within the scope of the nursing profession, to people who go to a primary care centre with a health problem that requires special attention. This clinical activity must be differentiated from the nurse triage in the emergency services, which offers: reception, attendance and classification of the problem, without any  further clinical activity.

In 2005, the Primary Care Center Can Bou in Castelldefels, near Barcelona, launched a pioneering experience in nurse demand management and subsequently prepared a "Guide to nursing interventions" with the following groups’ classification:

1. The health problems where the formalization allows the nurses to be the ones who finalize the clinical process and therefore they themselves are responsible for the reception of patients and resolution of health problems.
2. Problems of possible emergency intervention in which nurses are autonomous only in the first part of the algorithm. After, there’s a protocol point where the doctor intervenes.
3. Health problems requiring an initial assessment of severity by the nurse prior to the doctor’s intervention.