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.

Frail elderly patients: the case of Torbay

The health and social care for elderly people in Torbay (England) is fully integrated today (see the King's Fund document). In 2004 a pilot in one of the county’s districts was launched and soon spread to the entire area. Each of the 5 teams that were set up serves a population in a range from 25,000 to 40,000 inhabitants. In 2005 Torbay Care Trust was created.

The main objective of the service integration:

Maintaining the frail patients at home or in a community setting for as long as possible.

Key elements to achieve the objectives:

• Integration of health and social care professional teams
• Team budgets’ fusion
• Deployment (or purchase if appropriate) of a wide range of intermediate services that facilitates home support
• The enthusiastic support of family doctors (even though they have not been integrated)
• Institutional support, especially local support

COPD: can patients’ quality of life be improved?

Chronic Obstructive Pulmonary Disease, as the name suggests, is characterized by a chronic airflow obstruction in the bronchi and in contrast to asthma, this limitation is poorly reversible and progressively worsens. The diagnosis of COPD is based on spirometry, a test available to primary care and nurses trained in the technique. According to an EPI-SCAN study of 2006-2007, the prevalence of COPD in the Spanish population aged 40 to 80 years is 10.2% (95% CI 9.2-11.1), with a stronger presence in men than in women (Soriano, 2010).

To better understand how you can relieve the daily lives of patients with this chronic disease, I have chosen a systematic review, not a meta-analysis, published in the Archives of Internal Medicine in 2007.

Governance in healthcare institutions Debate at CSC and IESE

Next Friday March 21st, the Consorci de Salut i Social de Catalunya and the Center for Healthcare Innovation Management at IESE will hold a public debate about governance in healthcare institutions following the presentation of a document written by a team of experts and a complementary study from University Pompeu Fabra.

The event arrives in the right time according the current controversy between transparency and efficiency in public institutions. Those interested in this topic will find a good incentive to attend on the 4 main elements of the program:

Readmissions (2). What are the experiences that are yielding results?

The Congress Investigation Services of the US (CRS) published in September 2010, in support of the Obamacare, a report on charges for Medicare of hospital readmissions. The very well documented report assumes that 17.6% of discharge bills issued by hospitals to Medicare are due to the readmissions occurred within 30 days of discharge. Therefore, the two economists who signed the report assumed that they found in the readmissions a source for collecting Medicare savings, moreover taking into account that the variations between areas were making it possible to foresee that an adjustment in the contracting model could be fruitful.

From this document I liked the classification of the actions aimed at reducing readmissions, actions that as it will be seen to be effective, must be tailored to the complexity of the elected patients.

Model 1: very complex patient, intensive action

Readmissions (1): what are the best policies to reduce them?

To create this readmissions post, I have chosen three publications, the first of which provides a critical review of how the American public insurers address the issue, the second publication gives the point of view, also critical, of two hospital doctors, whilst the third is a review promoted by "The Commonwealth Fund" on the policies of US hospitals that are having the lowest rates of readmissions nationwide.

First publication

According to this article, CMS (the public body that manages the Medicare and Medicaid contracts in the US) estimates the average for the 30-day readmissions rates for patients who have been hospitalized for myocardial infarction, pneumonia and heart failure. If a hospital’s rates go above the average, CMS penalizes it with a reduction in the fees of all income in the following year, in proportion to the deviation of readmissions of the three monitored conditions. It’s estimated that in 2013, in a particular centre, the punishment can reach up to 3% of the turnover. Ah! And there will be no prize for hospitals with rates lower than the average.

Heart failure: what works?

Heart failure is the end result of most heart diseases, especially ischemic coronary disease. This is a highly prevalent chronic condition among older people (6-10% in those over 65 years), which provides a great disease burden to the healthcare system.

Both for its origin, which is none other than the long-term failure of acute cardiac pathology, as well as for its diagnosis, the cardiologists, and not the family physicians are the ones leading the management of some clinical processes that are almost always torpid and uncertain and which require a lot of action in the community and a lot of coordination between the hospital and primary care; as you can see, it’s not an easy business.

Heart failure, unlike diabetes, is a chronic process that, as I have already mentioned, slips away from the hands of the family doctor. To begin with at the time of diagnosing, because the clinical diagnosis is only presumptive and sending the patient to the hospital for an echocardiogram confirmation is required. It now appears, however, that it has been shown that the "NT-proBNP*" test (Verdú 2012), detectable in both blood and urine testing is sufficiently cost-effective to be able to expect that primary care units could begin to autonomously solve the diagnosis.

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(*NT-proBNP. Natriuretic peptides are hormones with diuretic and vasodilator effects, segregated mainly in the left ventricle as a compensatory mechanism for a pressure overload).

Femur fractures. Could its incidence be reduced?

Femur fractures represent a major health issue burden for healthcare systems as it is estimated that one in 20 people will have a femur fracture throughout their lives. According to the 2005 issue of the Atlas de Variaciones en la Práctica Clínica and a subsequent document linked to the same organism (Bernal 2009), the incidence of femur fractures in Spain is 511 new cases per year per 100,000 inhabitants, with a gender distribution clearly tilted towards women (2.6 times). The incidence in Catalonia is the highest, 623, while in Galicia is the lowest, 317.

Although it’s believed that the incidence of femur fracture has little variability, note that the autonomous region that has the highest figure is almost twice of the lowest and on the other hand, if we carefully analyse the Bernal document, we can see that there are certain lifestyles that have a clear impact on the frequency of  femur fractures, such as the following finding: if older people are living in a residence, they are three times more likely to break their femur that if living in their own house.

The incidence correlates with hospitalisation in 99% of cases

Healthcare for diabetics: Is the Spanish model good enough?

Diabetes mellitus type 2 has a prevalence of 8% in the general population and 20% in over 65, and if you consider all the complications that arise, it is clear that this is a chronic disease that occurs most in everyday life of health systems. So, having the issue of diabetes well addressed is very important.

The Spanish model of primary health care included, since the beginning of its reform in the early 80s, a holistic model of diabetes care, with timely support from the endocrinologists and probably for this reason, the results recorded today are very satisfactory. See it in the OECD report of 2011, that when the rate of hospitalisations for admissions due to poorly controlled diabetes is analysed, Spain shows the lowest rate out of a group of 24 countries.

On the left side of the graph, where the accumulated data is, we can see that the admission of 3.3 per hundred thousand inhabitants and the year recorded in Spain represents half of the second country on the list, Israel, one-fifth of that of Portugal, one sixth of the U.S. and the UK, and so on, towards the worst performance in the series, which are those of Austria, with admissions of 187.9 per hundred thousand inhabitants a year.