Monday, 16 September 2019

A new clinical visit format: shared medical appointments (SMA)

Gloria Gálvez

The model of patient-centred care suggests the need to redefine some models of care and look for others that respond at the same time to the needs of patients and professionals. An example of innovative care is that which affects the traditional medical consultation, which is insufficient to address certain diseases with a prominent psychosocial component.

Shared medical appointments (SMAs) have been used successfully for more than a decade at the Cleveland Clinic, Kaiser Permanente and some Australian centres. They were proposed for the first time by Noffsinger in the United States, in the mid-1990s, as a complementary tool, but not as an alternative, to individual visits. Shared medical appointments have the potential to reinforce the interaction between patients and professionals, evidencing greater accessibility, less frequent visits and better results reported by patients, as well as increasing their satisfaction and capacity for self-care. They are performed in sessions of between 60 and 90 minutes in which 8 to 14 patients participate along with several healthcare professionals. Previously, and in accordance with ethical and legal considerations, patients are asked to sign the informed consent to participate in the session. Patients, family members and professionals interact in an environment that facilitates the raising of doubts, in addition to sharing concerns and experiences, which favours the learning of the participants. This innovative form of care entails a change in the dynamics of power, since it’s the patients who set the pace of the session according to their needs and not the priorities of the professionals. In this group setting, everyone (patients, relatives and professionals) listen, interact and learn by exchanging more information than in an individual visit.

At Hospital Vall d'Hebron, some experience has been carried out with patients diagnosed with prostate cancer accompanied by relatives and with professionals from the multidisciplinary team (urologists, radiation oncologists, nurses, social workers). In these sessions the patients had more and better interaction with the professionals, being able to ask and exchange impressions, advice and experiences. At the end of the session it was evident that group visits are effective not only for patients with chronic diseases such as diabetes, but also for patients with urological conditions such as prostate cancer, erectile dysfunction or benign prostatic hyperplasia, despite the sensitive nature of the topics discussed. The experience was evaluated satisfactorily by patients, family members and professionals, so it has been decided to extend this type of session to patients with other pathologies to which it’s applicable.

These visits have several advantages for both patients and professionals. Thus, Egger et al. affirm that patients improve their accessibility, care is provided in a more relaxed environment, they feel that there is mutual support and feedback between them, they receive a fully multidisciplinary care, they get answers to useful questions that they might not have formulated in a traditional visit, they improve education for self-care and get answers to their psychosocial needs.

For professionals, on the other hand, they offer a more efficient management of time, better management of waiting lists, reduce the repetition of information and advice and have the opportunity to get to know patients better in an interactive environment.

But the advantages are also for the health system. The systematic reviews of Edelman and Quiñones list the benefits for patients with chronic diseases: they reduce urgent visits, hospitalizations, improve metabolic control in diseases such as diabetes, reduce visits to specialized care and there is better knowledge about the disease and healthy behaviours

A health based on value, which takes into account the benefits for the patient, for professionals, for the system and for society, requires a change in the focus of care, with innovative models that improve the patients' experience. Shared medical appointments are an example of innovation in health care, which, in addition to many other advantages, have the potential to strengthen the relationship between patients and professionals.

Monday, 9 September 2019

The shared decision making through a behavioural economics view

Pedro Rey

Last year I participated in a session on shared clinical decisions between doctors and patients during the XXXVIII Conference on Health Economics of the AES, which this year was focused on shared decisions making, including a plenary talk by Alistair McGuire. As a behavioural economist, I find that informed decision-making in an area with as much uncertainty as health is precisely one of the fields in which a more interesting and, hopefully, more productive dialogue can be generated among health and behavioural economists. As I have commented in other posts, behavioural economics departs from the traditional economics assumption that which individuals are rational beings that always know what is best for them and make optimal decisions according to established and well-defined preferences. It’s obvious that this theoretical ideal is rarely met, especially in a context such as health where asymmetries of information, uncertainty about our own preferences or the difficulty in interpreting the risks associated with the multiple decisions that must be made makes it very difficult to choose well, and even evaluate ex post if the decision was optimal. Therefore, the premise from which the movement claims for more shared decision making between doctors and patients produces both hope and doubts.

Monday, 2 September 2019

Vertebroplasty and knee arthroscopy: two interventions questioned by the evidence

The measurement of the clinical effectiveness of surgical interventions is, regrettably, not too frequent. In this field, the design of rigorously and well executed clinical trials has its complexities, especially when the control group undergoes sham surgery. For this reason, it’s worth disseminating the conclusions of consistent studies that arouse doubts about the effectiveness of the decisions made every year by the operating rooms to thousands of citizens, who must accept the risks, not negligible, inherent in surgical intervention. In this regard, I already mentioned the poor results that a clinical trial had shown for coronary angioplasties with stenting in patients with stable angina and, in the same vein, today I have selected two clinical trials related to orthopaedic interventions.

Monday, 26 August 2019

For a research based on value. The failed model of antibiotics

Cristina Roure

As we have commented on some occasion in this blog, neither the price nor the volume of investment in R&D of the medicines corresponds to the value they provide. Antibiotics, along with vaccines, have saved millions of lives, have allowed to address challenges such as transplants and complex surgeries with guarantees of success and, if this were not enough, they also add enormous value to the productivity of the agricultural sector.

Monday, 19 August 2019

More time to generate quality conversations with patients?

Anna Sant

The fight of the click in the consultation

Two studies published last year in the Annals of Internal Medicine and Health Affairs compared the time that doctors spend with the patient in consultation with the time they spend with the computer. Jordi Varela analyzed these results in his post dedicated to Danielle Ofri, a Bellevue Hospital doctor and professor at the NYU School of Medicine, who said, referring to the electronic medical record (EHR), that "The beast is insatiable and every time it needs more and more food. It ends up claiming all the time I dedicate to human interaction and, given that I ought to, I have to stay late, just to satisfy its cravings.” Both studies concluded that the time spent on the screen is longer than that dedicated to the patient.

Monday, 12 August 2019

A Viktor Frankl for the healthcare system

Gustavo Tolchinsky

“For only to the extent to which man commits himself to the fulfilment of his life's meaning, to this extent he also actualizes himself.” 
Viktor Frankl

Recently, in a meeting about the health of physicians, Dr. Clare Gerada, responsible PHP caring program for NHS doctors, commented on something that had never crossed my mind... How is it that we continue accepting that the Declaration of Geneva, which emanates from the Hippocratic Oath and was ratified in 2005 by the World Medical Association in France, keeps stating that "we (doctors) promise to consecrate our lives to the service of humanity"? Such a load seems unaffordable in these terms, but seeing the conditions in which we work, gives us the feeling that sometimes we are paying with a large part of our lives practicing as doctors.

Monday, 5 August 2019

Migration and mental health: the risk of exclusion

Andrés Fontalba

The human being has managed to colonize all habitable regions of our planet thanks to migrations. Due to cultural, economic, political or geographic movements, the population has moved en masse from prehistory to the present day, these movements being in some cases spontaneous and others forced. It is, therefore, a process of mobility intimately linked to us as a species.