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.

Clinical Practice Guidelines of dubious ethical values feed malpractices

Clinical guidelines by authors with conflicts of interest = Anti-Evidence Based Medicine. Our latest Right Care blog: http://t.co/Zy3XY7BDok
— Shannon Brownlee (@ShannonBrownlee) June 24, 2013

Shannon Brownlee is the author of "Overtreated. Why too much medicine is making us sicker and poorer." This book is the most significant piece of literature in the academic and social movement that empowers valuable clinical practice. The tweet chosen this week refers to "The Right Care Blog". It is an institutional blog of the "Lown Institute" where Mrs. Brownlee is vice president.

Upon entering the blog, you will see that the recommended post is "Conflicted guidelines breed conflicted practice", a text that comments on an article by Jeanne Lenzer in the BMJ, where it is argued that the connivance between the promoters of clinical practice guidelines and the industry are feeding inadequate practices. And to illustrate it, the author selects two examples that have experienced these problems with negative health outcomes of affected patients. One example is TPA, a clot solvent, and the other a recommendation of high dose of corticosteroids for the treatment of spinal cord injuries.

Now that there are many people and many institutions involved in making possible the practice of evidence should reach all corners of the system, it is relevant that there aren’t any ethical questions about the scientific basis of clinical practice.


Jordi Varela

Editor

Deprescribing in older people

Cristina Roure, Pharmacist and Vice President of Acadèmia de Ciències Mèdiques i de la Salut de Catalunya i de Baleares will explain a "deprescribing" project in her own hospital (Hospital de Terrassa). She also filled my desk with references that do no more than highlight the interest in combating, from the professional, clinical and pharmaceutical perspective, the polymedication of frail and elderly people. From all the references that I consulted, I have chosen a New Zealand-Australian source that I will summarize next. 

In New Zealand it has been estimated that 30% of people over 74 take five or more drugs, and about 10% take 10 or more. The drugs, says the reviewed publication, are often prescribed by different specialists, each of whom has followed a specific clinical practice guide for a condition or illness. Let's exemplify with a 70 year old woman suffering three chronic diseases and a couple of risk factors. This woman could easily be taking 19 daily doses of 12 different drugs at 5 different times of day, with a chance of generating 10 or more interactions.