The genome price plummets: Good news?

What can laparoscopic cholecystectomy teach us about genomic testing? Read here to find out http://t.co/TBdTarqNDk

— Peter Ubel (@peterubel) 26 agost, 2014

Peter Ubel is a researcher at Duke University in North Carolina and author of "Critical Decisions" book. We already had a post mentioning Dr Ubel: "Teaching patients to make the timely question." Now, along with that tweet, he sent us to a post written by himself on the Forbes magazine blog which analyzes the impact of plummeting prices for the genome test.

Meaningful use of electronic medical records

If you want to know if something is serious in health policy, check whether a budget allocation has been reserved for its implementation. Therefore I consider relevant that in 2011, the US federal government started a long term incentive program (until 2020) for the adoption of electronic medical records (EMR). The program is called "Meaningful use" which could be translated as meaningful use of medical records. That is, it encourages not the investment in information systems but its use and is measured by various indicators grouped into 3 stages.

Earlier this year Botta and Cutler published "Meaningful use: floor or ceiling?" an article where the process of encouragement was studied from expert interviews and from data from implementing a survey of American Hospital Association. Well, according to this analysis, the "Computerised Physicians Order Entry" (computerized physician orders) increased their deployment when they were encouraged by the "Meaningful use" program and even went ahead in the use of barcodes for drug delivery, action that was not encouraged by the government program (see figure).

Overscreening: new excess data

Cancer Screening Rates in Individuals With Different Life Expectancies http://t.co/Kefm8bPEiQ

— JAMAInternalMed (@JAMAInternalMed) 21 agost, 2014

JAMA Internal Medicine has just published the results of a study from the National Health Interview Survey (NHIS) - US in the period 2000 to 2010. The study included 27,404 participants aged 65 years or more, and used a NHIS specific index to assess the risk of mortality to 9 years of life.

The conclusion is that a substantial proportion of US population with limited life expectations received screenings for prostate, breast and colorectal cancer. These results show that the overscreening is standard practice in the US. These practices, the study's authors relate, rarely produce any benefits to these population groups and instead, increase health spending and induce therapeutic overbearing from with complications arise.

This American study warns us that we need more professional and social debate, not only about the advantages and disadvantages of preventive practices in healthy people, but also about the limits of such practices in geriatric patients who already have their own clinical management difficulties.


Jordi Varela

Editor

Cancer: are the military metaphors appropriate?

military metaphors may harm patients. @bmj_latest column http://t.co/84KgmVb3VU

— Margaret McCartney (@mgtmccartney) agost 15, 2014

Many people are convinced that when someone close has cancer, they ought to encourage them to fight, but this tweet by Dr. Margaret McCartney, author of "The patient paradox", refers to an article published in the BMJ, defending a critical attitude to this position. The reason is simple: the moral struggle is not associated with an improved survival rate (Petticrew 2002).

Personal health data: a new treasure for science

It’s time to make disease give, not just take. Find out more. http://t.co/m3ebqiyi78 pic.twitter.com/gZlJ78QPgp

— PatientsLikeMe (@patientslikeme) juliol 16, 2014

At seeing a survey by the Institute of Medicine (IOM) one fact stands out: 94% of Americans who are diagnosed with a chronic disease and are also social network users would be willing to donate their data to encourage research thus helping other patients like them.

In this context, the website "PatientsLikeMe", the most developed patients social network in the world, has launched a campaign to encourage the donation of data, so I invite you to see this promotional video: "Your data has a heartbeat that gives life to medical research.”

More on Personal Health Budgets in the UK

Due to the opportunity of the subject, in this second post about the Personal Health Budget (PHB) British program, I want to raise three questions: a) how the PHB process is being approached, b) what do professionals think of it, and c) illustrating another true story (in the first PHB post I talked about the case of Roger, a patient with COPD):

The 7 steps of the PHB process (according to Nuffield Trust) are:

1. Individual needs evaluation for the candidate to enter the program.
2. Elaboration of an indicative budget.
3. Identification (according to the professional team) of personal health and wellness goals.
4. Development and approval of personalized plan (there is no other requirement apart from trust).
5. Flexible money availability: directly from the pocket, intermediaries or service payment.
6. Commissioning of services and necessary supports.
7. At least a yearly evaluation.

The National Health Service estimates that this year 55,000 people with chronic and degenerative diseases and complex health and social needs, could benefit from a Personal Health Budget.

What do the professionals involved in the pilot say:

Personal Health Budgets: good beginnings in the UK

Two-thirds of hospital emergencies correspond to chronic patients’ decompensation which is why the health care system has a vested interest in helping people with chronic diseases to take care of themselves and learn to decrease their attendance to hospitals. Knowing that this can not be prescribed, the English have developed a system of budgetary self-accountability.

In 2009, the National Health Service launched a Personal Health Budget (PHB) Pilot Program in 70 localities and after an evaluation, it has been extended to the entire population, according to the following principles: People who need long term health and social care agree with their local professional teams (social services, primary care and NHS administrators) the arrangement of an amount of money that should allow them to reach the objectives of the individualized therapeutic plans previously agreed.

The PHB’s intention is that people with multi-pathologies or with degenerative or disabling diseases, have their service buying options nearby such as social services, psychological or physical therapy support. However, primary care services, pharmacies and hospitals are excluded. The first assessments offered by Nuffield Trust are positive in terms, particularly, of life quality. The economic aspects of the evaluation are more controversial as it is very difficult to quickly collect the savings of inappropriate hospital services that have been reduced thanks to PHB.

Last century belonged to the doctor, this one should belong to the patient

RT @gesclinvarela Historia oral de la Práctica Basada en la Evidencia #PBE http://t.co/jXEyQ4o3o8

— X.M. Meijome (@EnferEvidente) julio 6, 2014 

This twitter account, @enferevidente, specializing in clinical safety, has offered us the link to a paper on the history of the EBM which is a jewel in itself. If you click on the tweet, you may access a collaboratively edited video from the British Medical Journal and The JAMA Network. It’s a chat, moderated by Richard Smith, where Gordon Guyatt, Kay Dickersin, Drummond Rennie, Brian Haynes and Paul Glasziou – all ‘parents’ of EBM. There are also connections with David Sakkett, Iain Chalmers and Muir Gray. If you wish to press the play button (do it through the link in the tweet), you will see how veteran scientists explain their conversion to the, new (at that time) way of seeing clinical research, along with their views on the current circumstances.

The future of EBM from its "parents"

What interested me most, however, was the last round of the chat, when Richard Smith questions the guests about how they see the future of EBM and clinical practice, and on this I made some notes as follows:

Patient-Centered Coordination (PCC): case report

In a hospital a fragile geriatric patient dies with multiple cronic diseases

Antonio dies at the age of 88 during one of his many hospital admissions and the primary care team closes the case with the following diagnosis: a) Parkinson 7 years of evolution, b) Heart failure due to valvular dilated cardiomyopathy, c) high blood pressure, d) cardiac arterial arrhythmia by fibrillation that required pacesetter e) depressive-anxious syndrome, f) frequent urinary tract infections, and e) progressive protein-calorie malnutrition leading to death.

The daughter needed her father’s small amount of  money therefore she didn’t want to send him to a residence for the elderly.

In the two years preceding the death, Antonio showed an absolute dependence in activities of daily life with a Barthel zero. He lived with a divorced daughter who had no income, and with his two grandchildren, her children. The dependency aid (destined for the caregiver not for the professional) and Antonio’s small pension were the biggest family’s sources of income so this was always an impediment on the proposed admission to a nursing home; although it was clear that the daughter, even with little support from the municipal home help, could not meet the needs for long term attention in the period towards of Antonio’s end of life.

In the last 3 years of life, this patient had consumed more than 100,000 Euros in services, with an impressive degree of incoordination.

In  Antonio’s case history for the three years prior to the hospital admission when he died, the primary care team counted 24 attendances to the emergency room of the hospital, for very different reasons, many of them linked to heart disease, but also due to falls, fever, depression, pain in the penis, etc. Of these visits, 15 did not result in hospitalization, but, instead, almost all required attention in the short stay unit or follow-up day hospital or an outpatient clinic. Nine hospitalizations (three per year) were made in Cardiology, Internal Medicine and Geriatrics, with a total of 77 stays. Nine interventions of social work at the hospital were also counted. The activity that Antonio has generated in the primary health care and at the municipal social services has not been recorded, but there’s no doubt that it was also plentiful.

Men (of my generation) don’t cry

By Joan Escarrabill

Emotional training has changed over time. A part of the men of my generation were taught to contain their emotions. Men don’t cry. Publicly expressing certain emotions can be considered rude (or, worse, a weakness). Privacy (i.e. solitude) is the only space suitable for male emotions. The intimacy understood as a personal space that is never shared. Privacy is a right and, above all, a way of working. There are some things can only be the product of personal reflection, in the strictest privacy.

I know I simplify things. Maybe we should not talk about emotions and intimacy. Maybe we should talk about "privacy". But now there are a couple of phenomena related to digitizations that, at the very least, are at on the verge of privacy: the collective intelligence and transparency.

Collective intelligence challenges the individual reflection as a basic tool for understanding. Adding up is so powerful! Adding up from different perspectives gives unprecedented solutions to complex problems. But I will focus on transparency.

Facebook generation or my generation understand transparency differently. The generation of men who don’t cry understand transparency from a simple perspective "we must always tell the truth, but we don’t have to always tell it all" and the question is, "Can so much transparency become toxic?"

Knowledge chain sanitation, a difficult undertaking

By Cristina Roure 

In one of my posts  from "Pantone" series, August 17, I was talking of the need for crystal clear knowledge sources so we can make appropriate decisions, but the point is that our sources are contaminated by a number of biases that permeate the decisions we make as citizens, as patients, as health professionals or managers, and this leads to over diagnosis and overtreatment. Faced with these biases, Gerd Gigerenzer and Muir Gray, in the book "Better Doctors, Better Patients, Better Decisions" propose some sanitization measures, to which I have allowed myself to add some homemade ones:

1. How to make research more relevant to patients

a) Regulatory agencies, such as the FDA or the EMA, should require studies demonstrating the superiority of the new drugs compared to the best treatments available, not placebo.
b) Independent sponsors should promote research on simple, beneficial and patient relevant treatments and practices that do not involve the use of drugs or technology, practices that for this reason lack sponsorship (exercise, healthy diets or checklists to improve clinical safety).
c) I would add that the so called Patient Reported Outcomes should be included in clinical trials, which unlike conventionally employed variables, report on the effectiveness of treatment perceived by the patient.

Hospital general vs factory hospital

In the post October 5, I explained how, according to the report "Future Hospital Commission" (Royal College of Physicians 2013), it would be ideal that, as soon as possible, the organizational models of the hospitals would be able to evolve in two directions: a) about one third of the health care activities should apply techniques of industrial quality, and b) the other two thirds of patients admitted (complex case-mix) should be treated radically differently from how it is done now, given the shortcomings of the work organization in the hospital wards.

In the current model, each admitted patient has a medical service and a medical specialist assigned. The clinical activity of this medic develops primarily through the clinical course of medical orders (including requests for evidence and pharmaceutical prescriptions) and through interdepartmental advice from colleagues from other specialties. As for the nursing work , there are several intensity models ranging from a major involvement in the clinical process to a trivial change of shifts.

Summary of the limitations of the current model of care for inpatients and the arising risk situations:

1. The allocation of a medical specialist doesn’t guarantee at all the care continuity because many of these specialists also have their other technical functions, specific to their speciality that are often more attractive that visiting the wards.
2. The guards’ medical model does not guarantee the maintenance of a homogenous quality of care, nor at night, nor on holidays.
3. The interdepartmental work, generally means little involvement. Specialists try to fulfil the commitment with an opinion and, rarely, joint clinical work derives from this activity.
4. In many hospitals, nurses have a working commitment to the continuity of care quality for admitted patients but this is not universal, and great variations between centres are detected.
5. Inpatients often undergo changes of bed, or even ward changes for reasons of centre’s logistics organization, and this fact is known to subject the patient to avoidable risks.
6. The quality of transfers of complex patients from the hospital to their homes is not guaranteed in all places and at all times.

Factory Hospital vs General Hospital

The report "Future Hospital Commission" (Royal College of Physicians 2013) proposes organizing hospitals into two distinct divisions. According to the described model, patients would enter two alternatives doors that lead to almost opposite paths: a) there would be a specific route for standard processes (lower part of the graph), such as: laparoscopic procedures, hemodynamic, scheduled surgeries, stroke codes, heart attack codes, etc, and b) the other route would be for patients admitted through the emergency room (except the codes) or suffering complexities that require general assistance, with the occasional support of specialists (the trajectory above the graph).

This proposal seems not only timely, but also hospital models nowadays are or should be largely along this line. But the publishing of an article in Health Affairs, signed by a team from the service of Cardiac Surgery at Mayo Clinic, has led me to consider that we should advance more in the methodology inherent to each of the two paths. This referenced work is titled: "From "Solution Shop" Model to "Focused Factory" in hospital surgery. Increasing care value and predictability", or the equivalent of a study of the evolution from store solutions where every client is different and requires a tailored response towards the targeted factory that uses the methodology of an industrial process. And this is where the Mayo Clinic are pushing the  accelerator: if we are able to indicate certain clinical procedures for well-defined types of patients –they say– we ought to know how to prepare to act with criteria of maximum efficiency and effectiveness.

Research and Health Policy "to blog or not to blog"

By Tino Martí

That is the question. The strength of the link between research and health policy looks different depending on the perspective. Health services researchers expect a lot more feedback regarding their work in political decisions while the politicians need to be informed about the most effective way to ease the configuration of health policies based on scientific evidence. It’s a difficult transition bridge where the surface is eminently communicative.

In the "Web first" section of the influential Health Affairs, a study on the use of social media and perceptions of researchers has been published and is well worth reviewing (Grande D et al, 2014). During the Academy Health Annual Research Meeting, 215 investigators were interviewed using a mix of techniques (cases, assessment of broadcasting effectiveness and open qualitative questions). In the cases’ section, three ways of communicating research results to policy makers were presented: traditional media, social media and direct contact with decision-makers. Social media includes the blogosphere and the different social networks, particularly Twitter.

ICU: the elasticity of demand

The intensive care units are the most expensive health system resources, and it’s logical that both the funders and the general public wonder whether the way these are used meets their full potential. But, despite this interest the data in this area are sadly rather scarce. Of the few that I have had access to, I will highlight two: a) the variations are impressive: in the US the cost of ICU represent 1% of GDP, while in the UK only 0.1%, ten times less b) misuse, or if you prefer - therapeutic obstinacy towards the end of life of people with chronic diseases- is detected; continuing in the United States, it’s estimated that between 13% and 35% of chronic patients die in an ICU, or they die in a hospital bed after being admitted to the critical care unit (J. Wennberg. Tracking Medicine. Oxford University Press, 2010).

Two intensive carers at the University of Pittsburgh, Dr. Rebecca Gooch and Dr. Jeremy Kahn, published in JAMA a conceptual model on the elasticity of demand for ICU admissions. In a 2x2 table they’re showing the severity of the disease crossed with  the chances of survival.

Integration of social and health services: a must!

Integration matters, but so too does additional money into #socialcare: @MMitchMS gives her response to #barkercomm http://t.co/Inpgt4zEUa

— The King's Fund (@TheKingsFund) May 27, 2014

King's Fund, through this tweet, offers us access to an interim report of an independent commission that is working for the unification of the social and health services for complex chronic patients and patients with disabling degenerative processes. The report's proposal is clear: one organization and one budget with the aim of promoting access to social and health services tailored to the needs.

According to the Commission, in the UK, with regard to chronic disease care, there’s a misuse due to different barriers to access to services, with little public money on social services and waste in health services. The question is whether it’s possible to redistribute public funds to meet the real needs of this ever-growing population group.

"Patient Centred Coordination" a CCM evolution

Edward Wagner, the creator of the Chronic Care Model (CCM), when asked why he promoted a new system, responds. "The initiative came from my own clinical practice. For me, it was frustrating to see how well prepared and well-meaning doctors, were not achieving good results when dealing with the care of chronic patients, while we were starting to see evidence that by doing things differently, patients could better understand what happened to them and clinical outcomes could improve. And for this reason I thought it appropriate to communicate these new findings with the doctors "(The full interview can be found in the post "The chronic model: The Wagnerian Keys").

The current care model for complex chronic patients is usually based on individualized care plans developed for each sector: the primary care teams generally have individualized plans (ICP-PCT in the graphic), the municipal social services also work with customized plans (ICP-MSS) linked to the service portfolio of the dependence law; the long-term centers, meanwhile, develop their specific plans for each admitted patient (ICP-LTC), whereas in nursing homes, healthcare professionals who work there tend to write different plans for each resident (ICP-NH).

Microbial resistance: a Triple Aim example

To continue "Antibiotics: resistance and costs" post, given the importance of the subject, in this post I want to present the template design that may be helpful to those responsible for infection control in hospitals.

In 2007 two American scientific societies published a guide to deploying Antimicrobial Stewardship Programs (ASP) in health institutions. Five years later, three Spanish scientific societies adapted those guidelines and laid the foundations of the Programs for Optimizing Antimicrobials Use (PROA in Spanish).

These methodological developments are relevant because there is enough evidence to believe that management programs reduce antimicrobial resistance and costs. Therefore, with the rationalization (not rationing) of antimicrobial use we’re faced with a clear example of Triple Aim program. Remember that a Triple Aim program is a program that, in a balanced way, achieves three types of objectives: improved clinical outcomes, enhanced the patients’ experience and reduced costs.

When less is more: a strategic agenda

When Less Is More: Issues Of Overuse In Health Care – Health Affairs Blog http://t.co/9BabaZFFUY

— Joan Figueres Sendra (@joan_figueres) April 26, 2014

Dr. Joan Figueres, expert in the evaluation of health services, announces with his tweet, of the publication of a post signed by Shannon Brownlee and Vikas Saini, Vice President and respectively President of Lown Institute, along with Christine Cassel, President of ABIM Foundation. This post was published on the blog of Health Affairs on 25 April and in total agreement with Dr. Figueres, I also find it remarkable as I believe that the article does a good overview of the current grade of clinical waste outbreaks and suggests some strategies for engaging physicians, patients and the media in improving the situation, and I will focus on the latter:

Crystal clear knowledge for decision making

By Cristina Roure 

Excellent health care is one in which patients, professionals and managers apply the best available knowledge in decision making. Only well-informed agents can take the most appropriate decisions for an effective, safe and efficient health system. We often think that the big problem of the system is the lack of money, and only devoting more resources will solve the problems, but lack of knowledge is much more worrying than it may seem at first glance.

Sir Muir Gray, Chief Knowledge Officer of the National Health Service (NHS), uses an analogy that I find very spot on: "It takes knowledge as crystal clear as the water we drink if we want to take the right decisions." But the current reality is very different because we drink from contaminated sources of knowledge.

Medical Practice: an honest wage for an honest job

"outcomes-based reimbursement works only in a limited sector of healthcare" http://t.co/XFFymLHA8i

— Dr. Luis Ramos Neira (@lramosneira) April 29, 2014

Dr. Luis Ramos is a very professional dedicated to networking. He defines himself as a quali -  epidemiologist. Well, his tweet brings us to a post in The Health Care Blog, signed by a Swedish family physician, Dr. Hans Duvefelt, who works in a town in Maine, on the east coast of the United States. It’s a short clear post, from which I have extracted the main ideas.

We're hearing now that doctors should be paid in accordance with the clinical results of their work and of course we’re not talking about parameters such as controlling blood pressure or glycaemia, but about death, strokes, heart attacks, amputations, hospital infections, etc. But the question is: How can we measure the patients degree of involvement now that there’s so much talk about them? Should the doctor charge less if his diabetes patient is not doing well despite his good work? Wouldn’t this model lead us to the selection of patients?

Nurses: (+) training (-) workloads = (-) mortality

A few months ago, Mireia Subirana, Director of Care at "Consorci Hospitalari de Vic" explained in a post the results of her doctoral thesis that can be summarized as: "more nurses and more training (in hospital wards) was associated with better clinical outcomes". Following this thread, The Lancet has just published the results of a retrospective observational study that has explored whether the nurses training levels and workload ratios could influence the mortality of patients admitted for medium complexity scheduled surgery.

It’s an important work undertaken in 300 hospitals in 9 European countries by surveying 26.516 nurses and analysing 422.730 hospitalization surgical episodes. Despite the expected methodological difficulties of a project of this nature, it can be considered as a rigorous study.

Low cost medicine "made in India"

By Josep Mª Monguet

On 25th February, the first building of the Health City hospital complex which plans to grow up to 2,000 beds and be accredited by the JCI, offer all kinds of advanced tertiary health services and even open their own university, was inaugurated in the Cayman Islands. But what really draws the attention towards all of this is the origin of the initiative, which is none other than innovation in the health business model from India. Between 2001 and 2012, Narayana Health, a project led by Dr. Devi Shetty evolved from a 300-bed hospital in Bangalore to an aggregate of 6,000 beds in 17 hospitals, 80,000 patients and 3,500 interventions per month. And now they have switched their antipodes to enter the global market, offering, via a one and a half hour flight from the United States, open-heart surgery, prosthesis or neurosurgery, for obviously very competitive prices.

Leadership: difficulties and challenges

Managers from National Health Service consortiums now seem an endangered species, according to the King's Fund. Politicians have demanded cuts and they have fought greatly so that their centres can maintain the required levels of care. The result: the leakage of first level managers disappearing from the public system.

The first reference documents, which has as its subtitle "No More Heroes" (the green one), describes the new leadership style beyond the mandatory compliance to the objectives imposed from above. It said that Managers who have an inside perspective are essential if we want to get the doctors, nurses and other health professionals to do their work with quality. The new leadership should not only correspond to the manager, the heroism no longer makes sense. Therefore, now we need to have leaders throughout the organization, leaders who are present in every corner of all processes and, above all, know how to involve professionals in the management of resources, but also know how to facilitate the participation of patients in the decisions that affect them.

End of life: how to avoid hospitalizations?

24% of GPs think that hospitalisations can be avoided in last 3 months of life: http://t.co/EyYCmrKNBP Proactive communication vital. #hpm

— Palliative Medicine (@PalliativeMedJ) abril 9, 2014

Many people are sent to hospital to be attended to during the clinical stage complications they suffer from in the last months of life. We are all aware that we’re not dealing with this issue very well and in addition we haven’t gone to great lengths to improve it. What do these hospitalizations bring? Could they be avoided?

Palliative Medicine magazine just published a timely survey addressed to Dutch family physicians in order to gain insights into their thoughts about hospitalizations during the end of life for their own patients. And the results are quite suggestive:

Colorectal Cancer: prevention strategies

Colorectal cancer is the third most common cancer among men and the second among women. Most of these cancers develop from adenomatous polyps in a period that can be ten years or more. This long progression offers enough time to adopt preventive strategies with reasonable levels of effectiveness in a context of a mucosa where the presence of polyps is fairly common, despite only some of them evolving toward malignancy.

Colonoscopy is a technique that has been proven effective in reducing mortality from colorectal cancer, but no one can ignore the difficulties of applying this technique extensively, given the low adherence to the calls and the high costs of the program, without forgetting the side effects inherent to the practice of colonoscopy. For this reason I thought it opportune the study lead by Dr. Enrique Quintero (Hospital Universitario de Canarias) and Dr. Antoni Castells (Hospital Clínic Barcelona) which compares, in a prospective clinical trial involving more than 50,000 calls, the practice of a one time colonoscopy with the analysis of a stool sample (with immunochemical test) every two years. The work has an expected 10-year follow-up, and aims to measure the impact in terms of deaths avoided, and although it is still evolving, New England has published a progress report.

Complex Chronic Patients: UK progress in funding

good article by Sam Everington on general practice http://t.co/Qk0iIs2ZZQ

— Chris Ham (@profchrisham) marzo 13, 2014

Director of King'sFund, Chris Ham’s tweet, takes us to Sam Everington’s article in The Guardian, about new experiences of financing (commissioning) towards community services deployed to address chronic complex patients in their own homes, even in episodes of clinical exacerbations, and thus avoiding likely unwise hospitalizations.

Chronic Models: the Wagnerian keys

Chris Ham, King's Fund Director, interviews Edward Wagner, Director Emeritus of MacColl Center for Healthcare Innovation Group Health Research Institute and promoter of the chronic patients care model (Chronic Care Model or CCM). As I think it is worth it, I decided to share a transcript summary of the conversation. It will not disappoint you.

Ham: How did you come up with the idea for CCM?

Wagner: From my own clinical practice. For me it was frustrating to see how well prepared and well-meaning physicians, when they had to deal with caring for chronic patients, failed to achieve good results, while we were starting to have evidence that by doing things differently, patients could better understand what was happening to them and could improve clinical outcomes. And for this reason I thought we had to share this evidence with the doctors.

Surgical Checklist: a challenged guarantee

The efficacy of surgical checklist questioned in the Ontario study. The importance of a good implementation program. http://t.co/p85tRgnJKh

— Elvira bisbe (@EBisbe) abril 1, 2014

The tweet from Dr. Elvira Bisbe ​​warns us that New England has sprung a surprise: a study in Ontario, deployed in 101 hospitals and more than 200,000 cases revealed that the application of a surgical checklist doesn’t significantly reduce complications nor mortality.

Palliative chemotherapy: an oxymoron?

An oxymoron is a figure of speech which consists in using contradictory terms in conjunction. In this case: chemotherapy and palliative care. From US data it’s well known that between 20 and 50% of patients with advanced cancer receive chemotherapy 30 days before death. I think these figures are impressive and even more so after reading the results of the work conducted by Professor Wright of Harvard Medical School. This is an ample view of over 386 patients with advanced cancer who averaged 4 months of life after entering the study. In this group it was noticed that patients who were treated with chemotherapy in the last months of life were more likely to receive towards the end of their life inappropriate clinical performances such as cardiac resuscitation or mechanical ventilation or to end their days in the intensive care units.

The American Society for Clinical Oncology (ASCO) believe that the disappearance of palliative chemotherapy would be a true "Triple Aim": better life quality for patients, fewer unwanted effects and lower costs, although the great difficulty with this issue, according to ASCO, lies in deciding when it’s time to stop treatment.

More participation, better policies?

Elena Torrente @etorrente


“For us [the Athenians legislators], the debate is not a stepping stone towards action, but the first step essential to taking any wise decision.” – Pericles

I read this quote in the book “És la política, idiotes!” by Professor of Political Science Quim Brugué where he firmly defends politics and the need for collective decisions in politics. Right now when political disaffection prevails, this is an interesting book to say the least that points to an issue that for me is paramount: Intelligence is always collective.

Nowadays, in the era of social networks where we can share knowledge and contribute ideas, interesting debate has never been so easy. But, how about in the area of public policy? Is collective intelligence taken into consideration when they design it? Does it make sense to do it?

Antibiotics: resistance and costs

The progressive power loss of antimicrobials against the most active microorganisms in infectious disease, especially in the hospital setting, makes systematic intervention absolutely necessary to optimize its prolonged use and its life, especially considering that there is sufficient evidence to think that with well-structured programs, we can reduce resistance and therefore solve very complicated clinical situations and in turn, lower the costs. A clear case of "Triple Aim", remember?: a) better quality, b) better outcomes, and c) lower costs.

What is ASP (PROA in Spanish)?

Persuasion is not the way to changing behaviours

Don’t Persuade Customers — Just Change Their Behavior http://t.co/K9QVUK7FhS
— Harvard Biz Review (@HarvardBiz) February 10, 2014

Harvard Business Review’s tweet links back to their own blog where you’ll find a post signed by Art Markman, a professor at the University of Texas and author of "Smart Thinking"  a book about traditional topics of marketing on how to change attitudes and ultimately sell more and for this reason the first thing I thought of when reading the promotional post of the book was that these are issues specific to the commercial world, so far from clinical management. But then I gave it another try and suddenly I found an interest in the author’s approach to the topic.