More value for primary care

Xavier Bayona

A British Parliamentary report on primary health care in the National Health Service (NHS) was published at the end of April 2016. This report reflects the most relevant aspects of primary care such as the experience of care (satisfaction, accessibility, labour conflict and quality), new models of care, the construction of a new work team and financing. As you read the report, leaving aside some differences that exist between the primary care model of Great Britain and ours, the first thing that stands out is the ability they have to make a self-critical assessment and publish it. In our environment, it’s quite uncommon for self-critical assessments that engage and align professionals, managers and politicians in the improvement of services to be published.

Proximity versus quality

The proximity of the health services is a highly appreciated and defended value; not in vain regional hospitals have proliferated throughout the country as an essential instrument for territorial balance. The local organizations and the small communities have understood this and have protested fiercely against any councillor who has dared to suggest that it might be convenient to close some low-performing service. It seems generally accepted therefore; that the proximity of services is a value that favours the accessibility for dispersed populations and improves the equity of the system. However, it doesn’t escape anyone that too often, maintaining the quality of certain services when located far from the centres of reference is a challenge in itself.

This reflection has come to my mind after reading an article in the New England Journal of Medicine by Michael Porter and Thomas Lee "Why strategy matters now". One may rightly say that this source is a little far-fetched for the dilemma that I raised, especially and fortunately because the problems of our health system are very different from those of the North American system, but in return, I’ll insist that after rereading it, it seemed to me that the recipe of the two authors from Harvard can be useful in offering rational elements to the controversy around the proximity – an issue that always seems to be politicized.

Let's consider Porter&Lee’s 6 strategic proposals that can be tailored to our concerns:

1. The main objective of any strategy must be the value it brings

To give a couple of examples, in a strategy of chronic disease, community work is a value in itself; on the other hand, for the infarction code, the efficacy of clinical action is the tracer axis, so the planner must know how to balance the dispersion of the services with the excellence of the results.

2. Organization charts must be redesigned according to the needs of patients and processes

We ought to abandon the current organizational charts based on bodies, systems and levels of care and advance to multidisciplinary teams that are organized according to the needs of patients, who are responsible globally for clinical processes and that are accountable according to the value obtained ( remember that Porter’s value is the relation between clinical results and costs).

3. The portfolio of services must be adjusted to the organization’s capabilities 

In order to fulfil the main objective, hospitals must identify the services in which they are able to provide value, declining to maintain an offer that doesn’t correspond to their real possibilities or to the desired results. This adjustment is valid both for the regional hospitals’ historical difficulties in retaining talent, as well as for mid-level centres that despite all reason, focus on tertiarism as a sign of identity.

4. Clinical management units should be oriented to clinical effectiveness

The multidisciplinary teams must evolve towards "integrated" clinical management units when they have the capacity to approach a sufficient number of patients and the results obtained are good enough. In this situation, the units must be endowed with the essential resources, and even financing models based on adjusted capital or objectives, as the case may be.

5. Synergies can solve many of the current problems

To overcome the problems of excess installed capacity, duplicities, or the desire to act beyond the real possibilities, organizations must have the vision of generating synergies to solve these imbalances. Concentrating services to a single point or sharing professional teams are two strategies that, when they have been implemented rightly, yielded good results.

6. The referring hospitals must elaborate more strategies by looking at the territory

We ought to further deepen the current strategy of opening referring hospitals in the territory, with all kinds of agreements with hospitals of lower hierarchies. In the same way that it’s not good for regional hospitals to practice tertiarism, it’s also unreasonable for referring centres to dedicate their costly structures to solving case-mix typical of community centres.

It would be advisable that we take advantage of the lessons of Michael Porter and Thomas Lee in order to overcome the dilemma of proximity versus quality, generating more professional and social debate about the value of health services, since it’s pointless to have an emergency unit at every corner if we can’t support them, every day of the week and all hours of the day (and night), with qualified professionals.

Jordi Varela

Editor

8 future proposals for primary care

Primary care is the key to the good running of the health system and therefore it must be promoted, protected, improved and, above all, invest in it. Many countries are immersed in renewal processes of their primary care and, therefore, we must be attentive to the contributions we receive, especially those in the United Kingdom, where primary care is very similar to ours. In an earlier post, I reviewed a paper by the Royal College of General Practitioners that provided an insight into the role of family physicians in 2022, and in this same direction I have a report from a committee of experts of the National Health Service Primary Care Workforce Commission), which has developed a set of reform proposals aimed at strengthening the future of primary health care, broader than the previous one which was limited to a corporate vision.

We need a fish tank

Pere Vivó

The American psychologist Barry Schwartz, who can be read frequently in The New York Times or listened to in TED (Technology, Entertainment, Design) conferences, invites us to reflect on the paradox of choice. His talk begins with what he calls the "official dogma" of all Western industrial societies, which states: "If we are interested in maximizing the welfare of our citizens, the way to do so is to maximize individual freedom." The reason for this is that freedom itself is good, valuable, praiseworthy and essential for human beings: "If people have freedom, each of us can act on their own to do things that will maximize our well-being and no one will have to make decisions for us. The way to maximize freedom is to maximize choice: the more possibilities people have, the more freedom and greater well-being they will have."

Let patients help!

Dave deBronkart, better known as "e-Patient Dave", is a marketing expert who on January 3, 2007, at 09:02, received a call from his doctor: "We have found something in your lung." DeBronkart remembers that moment with precision because that news changed his life. From that moment he abandoned his normal citizen status to become a metastatic patient of a tumour of renal origin and, given his clinical condition, in an advanced cancer patient. DeBronkart received a treatment that normally does not work, but luckily it worked for him.

So far a story with a happy ending, but Dave's story highlights his attitude (just look at the cover of the book with a picture of him with his doctor, Dr. Danny Sands). With the sentence above, far from adopting a fearful and docile attitude, searched Google, went to find other patients with the same diagnosis, and sat down to talk to his doctors using his own criteria, sharing with them each of the decisions that he was taking. Now e-Patient Dave has become a leader in what we call patient empowerment.

The fallibility of scientists

Nature has echoed the professional debate about the intrinsic quality of scientists’ work, in a dynamics of self-criticism comparable to what is taking place, in similar terms, in the clinical world. Scientists are also fallible, says the article writer and therefore, should enhance the mechanisms of self-criticism, rather than enrol in self-deception.

John Ioannidis, Meta-Research Innovation Center at Stanford, says scientists should work harder to understand the biases of their human fallibility if they want to overcome the crisis of confidence generated by the poor reproducibility of research results. And to illustrate his words, Ioannidis offers three examples: a) from a selection of one hundred psychology studies, only the results of just over a third of the work could be replicated, b) a group of Amgen researchers only succeeded in reproducing 6 of the results of 53 reference studies in the field of oncology and haematology, and c) the Ioannidis team itself was able to replicate completely only 2 of the 18 gene expression studies based on microarrays (DNA chips).

Measuring the value of anti-cancer drugs

Cristina Roure

Anti-cancer drugs, especially palliative drugs, are toxic, costly and sometimes of little benefit, as a result their value to the patient and society are often questionable. It’s also true that significant improvements in the survival rates are threatened by the difficulty in accessing them, due to their unsustainable cost.

Precision medicine in the elderly care

Marco Inzitari

One of the challenges launched by President Barack Obama ($215 million for 2016) is the "Precision Medicine Initiative" a concept that goes against the treatment focused on the "average-patient". According to this initiative, as a first step, cancer treatments should be oriented to the specific genetics of the patient. For this reason, we often refer to the future of oncology as a "precision medicine". As another example, to continue with oncology, the Watson Intelligent System (IBM) will provide support to oncologists for informed and well fitted decision-making, analyzing patients' medical records and looking for possible evidence-based options.

Prediabetes epidemic in sight

Prediabetes is a terminology that, recently, is used when a person is detected with higher than normal levels of blood glucose, but there is no pathology. Prediabetes could be understood as a disposition to develop diabetes in the future, a disease that, in turn, represents a condition that puts one at risk of serious affections such as nephropathy, retinopathy or cardiovascular disorders, among others. Due to this chain of risks, and with a healthy intention to reduce morbidity and mortality, the American Diabetes Association (ADA) led a study to consider that glycosylated haemoglobin (HbA1c) is a test that can be done without any preparation or need for fasting and see if it can become a new criterion for detecting prediabetes. The concern arises when, according to this diagnostic extension, it’s estimated that in millions of pre-diabetics would show up: in China 493, in the US 86 and in Spain 6, to cite three countries from which I have data.

The Patient Revolution according to Victor Montori

In 2016, Victor Montori, a professor of medicine and diabetes doctor at the Mayo Clinic, launched The Patient Revolution, a foundation whose mission is to help make truly patient-centred treatment a reality. In his new book, Why We Revolt, Montori argues that “industrial medicine” has corrupted the mission of medicine to the point where doctors are now incapable of caring for the people who place their trust in them (for further information about the author in this same blog, search for “Montori, V." entries in the tags [top-right-hand column].

The face as a mirror... of the pocket!

Pedro Rey


As this is my first post on this blog, let me introduce myself. I am a researcher into behavioural economics, a field that uses ideas from psychology to enrich the study of economic problems. More specifically, at present we are working on a project that – as I will explain at the end of this piece, and for various reasons – may have interesting implications in the field of medicine.

Our research aims to answer a simple question: what is the relationship between how much consumers like the products they buy and how much they are willing to pay for them?

An extensive model for complex chronic patients

The emergent phenomenon of multi-chronicity and geriatric fragility is analyzed from all points of view: demographic, epidemiological, the use of resources and the economic impact, to mention only the most outstanding. Now familiar with the tendency, we’re facing the challenge of finding out how to provide appropriate services to patients who, due to the precariousness of their health, or their social circumstances, or both, suffer instability and become frequent and directionless visitors.

This group of complex patients, although not too large, is stressing the rigidities of health systems in three ways: a) the saturation of hospital emergency services consuming ambulances and observation beds is unable to give effective responses to the needs of these people, b) lack of coordination of transfers between levels, especially between the hospital and primary care, and c) poly-medication due to prescription fragmentation.

What do chronic patients want?

Fragmentation of services is a disgrace for complex chronic patients, for people with combined health and social needs, for fragile people and, in short, for the elderly population. Hence, most governments are engaged in service integration initiatives, but progress is slow and the results are disappointing because systems are too fragmented: in budgets, in access rights, in circuits, in professional cultures, in institutions, in public and private providers, etc. However, the British have proposed a merger of services by 2020, and since they recognize that, as things stand, offering people-centred care will be a bulky process, in the summer of 2013 they launched a project, “People helping people", a project that is ambitious in vision but modest in methodology and budget.

What is "People helping people"?

The program is working on 25 pilot areas that volunteered to test (as previously done in Torbay) different ways of coordinating and integrating services in order to promote patient-centred care, for which they rely on a single operative objective of elaborating, on the part of all the actors, of individualized plans that adapt to each person’s particular needs and way of life. In terms of methodology, the project has adopted the "triple aim" (Institute for Healthcare Improvement), which develops the following principles: a) improve patient experience, b) improve the health and well-being of the population, and c) reduce the waste and, therefore, the cost per capita.

Hospitalizations and patients’ experiences

Peter Pronovost, a renowned expert in clinical quality and safety, argues that it’s a mistake for hospitals to focus on patient satisfaction surveys and states that instead it would be more helpful to ask selected patients what proposals they would make in order to improve the hospitalization experience. For example, one of the people Johns Hopkins chose for this assignment was Podge Reed Jr., a double lung transplant patient who had amassed six hospitalizations, two surgical and four medical, eight anaesthesia outpatient procedures, more than one hundred visits to appointments and 700 laboratory tests. With this curriculum, the hospital felt that Mr.Reed should be a person with a clear opinion.

In the article, Jane Hill, Johns Hopkins’ Patient Relations Director, says that most hospitalised people, although appreciating the technical quality of services, also ask to be treated with kindness and care. Not surprising, given that being bedridden in a hospital is not a pleasant experience for anyone. As a result of patients' contributions, Jane Hill has developed a Decalogue that should be read as a basis for transforming hospitalization rooms, on one hand from the perspective of tasks, functions and competencies and on the other hand, with a view of patients’ experience.

Sleeping well, a determinant of health

There are some health determinants that we can’t do much about such as those that are marked by our genetic endowment, our family, the place where we have to live and the historical moment that is contemporary to us. Other factors, however, are linked to the lifestyle we decide to lead, such as sleeping well (in quantity and quality) a factor that doesn’t yet occupy a prominent place in the collective imagination. However, many studies aim towards common sense: if one sleeps well, the next day is better, and vice versa. That is why I was not surprised by the finding of a Finnish research that associates sleeping insufficient hours with drowsiness and life quality for adolescents or another collected from Harvard Health Publications that limited sleep to five hours a night for one group of students at the Singapore institute for a week and compared their abilities to another group who had slept for nine hours each night, with predictable results of cognitive impairment due to lack of sleep.

Value Based Medicine (VBM)

Evidence-based medicine (EBM), after 25 years, has generated substantial advances in research methodology and has made it possible to distinguish more clearly between good and bad treatments, to identify biases of any order and even evidence of conflicts of interest between research and industry. However, a group of English authors (The importance of values in EBM, Kelly MP 2016) believes that, despite the uncontested advances, EBM has put too much focus on the technical aspects and has forgotten that values ​​have a lot of influence at all stages of the evidence-building processes.

What do we mean when we talk about values?

Science strives to understand the world as it is, but conversely, values ​​are what humans reflect upon. Seen this way, the conflict is served and, therefore EBM should learn to navigate better between these two waters according to the authors of the article quoted below, "Values may act as heuristics – shortcuts in our thinking of which we are barely aware – which get us to quick answers to complicated problems. They form the lens through which we perceive and act on our world. Values are often tricky to pin down because they are such a pervasive part of things we take for granted. A necessary first step towards achieving this is to make our values as explicit as we can, so that we can reflect on them individually and deliberate on them collectively".

Do we need "bonsai" hospitals?

Joan Escarrabill

The ideal size of the hospital and the minimal activity (number of procedures) it has to do to ensure quality is a recurring debate. Sometimes the issue of the hospital size is related to the primary care’s ability to solve and, therefore, the possibility of closing acute beds (and redistributing the budget that was intended for its operation). In the 2009 EESRI edition, in Table 10 (page 21), there’s a very significant information: the number of acute beds per 1,000 inhabitants. According to this document, in Catalonia we have 2.4 beds per 1,000 inhabitants and in the whole of Spain 2.5. Only Turkey (2.3) and Finland (1.9) have fewer beds per 1,000 inhabitants than we do. Despite the data, there are people who insist on the convenience of closing acute beds if the primary care resolution capacity increases. It seems to me that there’s a better question: too many beds or too many hospitals?

Parachute trial: on the subject of knee arthroplasties

The concept "parachute trial" has been adopted to visualize that when a treatment is really effective perhaps one should not invest money in demonstrating what everyone knows, just as no one would think to make an essay on the effectiveness of the parachute. The New England Journal of Medicine has published a clinical trial (Skou 2015) that evaluates the clinical effectiveness of knee arthroplasty, and the journalist of the magazine asks: Did it have to be done? Arthroscopic knee replacements are one of the most significant advances in modern medicine. Everyone knows that many older people who could not leave the house, invalidated by pain, now not only go out every day to the market square but they often go cruising. Seen like this, is this not a "parachute trial"? A waste?

Keep calm and leave the mobile for a while

Josep Mª Monguet

The trade fairs tend to present the technological innovations somewhat passed by the commercial magic, which puts at risk the necessary objectivity to evaluate what they will actually contribute. This is aggravated if we consider that technology is nowadays advancing much faster than human capabilities. As technological innovation progresses exponentially, the adaptive and changing capacity of individuals and organizations is logarithmic.

In general, to take advantage of the new options that technology offers, you have to know where you want to go and what to do to get there; the problem is that we just grope. The good news, however, and the fair is a good exponent, is that so many of us are doing it that the possibilities for progress don’t stop multiplying. Remember Edison when he said he had discovered 10,000 ways of not making a light bulb.

Emergency services specific to the elderly

Elderly care is best resolved at the primary care level, with a geriatric orientation and in a community setting. However, sometimes older people need to go to the emergency room for a variety of reasons, such as a fracture, fibrillation, retention, sudden choking or blockage, to name just a few reasons. What happens then is easy to imagine, the geriatric patient is subjected to a triage that leads to a box full of devices, with many people asking the same things repeatedly, some of them with very little tact and almost always with little respect for intimacy, not to mention the discomfort caused by the racking in the corridor, bells and alarms, noise from machines and monitors, and a long etcetera, that easily produces the disorientation of the elderly patient, or delirium in the worst cases.

Improving by playing

David Font

Volkswagen launched a campaign, The Fun Theory, aiming to improve habits by introducing game techniques. Let's look at an example.

Anna Sort, a nurse, a professor at several universities and an expert in gamification (a new word) in health, in her blog Lost Nurse in the Digital Era defines gamification as "the use of playing techniques in activities that initially contained no play" with the objective of involving people and solving problems. She argues that we are all potential players and that video games have introduced the game into many aspects of our lives. Mechanics such as collecting, awarding points, providing feedback, promoting exchanges or personalizing, favour motivation and involvement. The challenge is to transform any activity into fun and to make the game difficult enough for people to be enthusiastic about solving it, without finding it impossible.

Evidence in the care continuum - one of the keys to the telemedicine’s success or failure?

Josep M. Picas

It’s notorious that there are a great number of experiments, publications and studies on the application of telemedicine. Over the last few years, this phenomenon that we could label as the "apps revolution" has given telemedicine a great boost. However, the results, in many cases, have not reached the expectations. 

Many studies have tried to identify the causes of this unsuccessful outcome. In a brief reference, we could mention the professionals’ inertia and resistance to change in their work processes, errors of design, i.e. not being focused on patients, regulatory aspects, lack of resources and patient adherence problems caused by, to name just two, little health literacy or the digital gap issue.

Justice and equity in the health system

Xavier Bayona

Should we review the principle of justice from an ethical perspective? If so, we’ll notice that it’s a principle of minimums (of coexistence) faced with the principle of happiness – a principle of maximums ("individual justice") and, unfortunately, we’re often erring by thinking we speak of justice when in fact we speak of happiness (or individual convenience). Similarly, from the bioethical standpoint, justice can be defined as the fact of treating each one appropriately, in order to reduce situations of inequality (ideological, social, cultural, economic, etc.). On the other hand, equity is defined as giving each individual no more and no less of what they need. Following these definitions, when we speak of justice and equity, deep down, we are doing a reiteration, because they are synonymous.

Dying in the hospital: some considerations

Glòria Galvez

Health inequalities are related to individual and social factors. The way people live, work and grow old as well as the political, social or economic factors that accompany them, vary greatly according to the place where they live. Death, which could be "the great equalizer", doesn’t appear to be equal at all, as Dr. Puri states in his article "Unequal Lives, Unequal Deaths," in which she argues that social and health differences during life, are also present at the time of death. As a group of Danish authors suggest in BMJ Supportive & Palliative Care: "Socioeconomic position and place of death of cancer patients” for people with fewer resources it’s more difficult to benefit from a worthy death in their own home.

When a patient chooses to die in a health institution he does it for different reasons. Higginson et al., In "Dying at home - is it better: A narrative appraisal of the state of the science" identified, besides the socioeconomic level, other determinant elements as the preferences of the patients, the access to the home attendance or the support of the family. Let's look at each one separately.

Cancer committees - a brake on shared clinical decisions?

Cancer committees are instruments for the coordination of cancer practice that have existed for many years. Now, however, a joint German-US research group (with the collaboration of Glyn Elwyn) wanted to know not only the quality of the work of these committees but also how they address the demand for greater involvement of patients in clinical decisions, and an observational study has been carried out on 15 cancer committees of the University Cancer Center Hamburg-Eppendorf. From the publication of this paper, I would like to highlight two key aspects: a) the reality of the organizational quality of cancer committees, and b) how these committees contemplate patients' preferences.

a) Organizational quality of cancer committees

The first observation is that the majority of the tumour committees’ members are doctors in senior positions and, on the other hand, the presence of young doctors is scarce. The participation of other professionals, also important for cancer patients, such as nurses or psycho-oncologists has not been observed in any of the cases. Researchers believe that the hierarchical influence of key members of the committees and the need to close many cases in a short time are limiting factors for productive and quality multidisciplinary work. In summary, the observation notes that guidelines and recommendations are generally applied with margins too scarce for other considerations.

Buurtzorg, a nurse work project with blue ocean strategy

10 years ago, the home care scenario for people with complex social and health needs in the Netherlands followed a bureaucratic scheme based on nursing work on one hand, social work on the other, in addition to the home support actions offered by companies, many of them from the cleaning service world. Jos de Blok, a community nurse, dissatisfied with this fragmented model, put an entrepreneur hat on, assembled a small group of nurses with whom he shared vision and discussed as much at large about a new model of care based on real needs of people. In an interview, Jos de Blok says, "What I wanted to show was that if you are a good nurse, you should know how to focus on the relationship and to build trust with patients in order to make them live with the maximum of independence possible. "

I do therefore I am or the bias of intervention in medicine

Cristina Roure

This week, thanks to a post of Sergio Minué in the blog "El Gerente de Mediado", I discovered the recent publication of "Ending Medical Reversal" The book refers to situations in which new studies more robust than the pre-existing ones contradict the standards of commonly accepted practices, which have now proved ineffective or even harmful.

Some will recall such vivid examples as the use of protein C activated in sepsis, high dose chemotherapy combined with autotransplant of stem cell in metastatic breast cancer, the aprotinin in cardiac surgery, or hormone replacement therapy in postmenopausal women. All of them were used for years until proven harmful.

I have not been able to read the book yet, but I read a report by the same author; Dr. Vinay Prasad in Mayo Clinical Proceedings exposes his vast research. Over ten years, 363 studies evaluating established practices were published, out of which 146 (40%), between 12 and 19 per year, were revoked (1). The author explains in the following video that such revocations usually occur after the precipitous adoption of new therapies based on incomplete or inadequate studies.

Chronic Complex Patients and the Blue Ocean Strategy

The book "Blue Ocean Strategy" by W. Chan Kim and Renée Mauborgne has been celebrating 10 years, having sold more than three and a half million copies, and now, to celebrate, a revised edition has just been published. The central thesis of the book is that today's markets are characterized by oversupply and therefore, companies must compete fiercely between them and the oceans (It’s a metaphor) are stained red with the blood of the fight. For this reason, the authors propose to companies to go on the search for blue oceans, like Cirque du Soleil or Ikea, where their products or services will be incontestable because people will see them as novel and useful. The strategy of these companies is clear: their contribution must be perceived as a value innovation, and as a consequence would able to open new unexplored markets like oceans that will not go red.

Leaving aside the commercial aspects of the theory, the book left me with the (attractive) vision of a blue ocean that, inevitably, I have contrasted with the difficulties that all health systems have when it comes to implementing convincing programs of patients’ care and I thought that perhaps at this point a blue ocean strategy would be beneficial when aiming to implement new projects that would arise from overcoming current difficulties. I have to admit that applying Chan and Mauborgne's theories to complex chronic patients is a bit far fetched, but I am convinced that there are some strategic methodology proposals that could be of some use.

The diagnostic process and medical errors

The past 15 years, since the publication of "To Err Is Human" report, has seen a great deal of progress in projects that promote patient safety, especially in programs such as increasing hand washing, identifying patients, surgical checklists or changes in nursing care, but on the other hand the diagnostic process continues to be a matter almost exclusive to medical work although it’s known that this is a very sensitive area for the safety of patients. This new report from the National Academy of Medicine (formerly Institute of Medicine), "Improving Diagnosis in Healthcare," is a follow up document to the aforementioned one, specifically focused on diagnostic errors.

The report defines the diagnostic error as the failure to obtain a detailed, timely explanation of a health problem. Experts have also included in the definition the physician’s inability to know how to explain the diagnosis to the patient. According to the report, diagnostic errors would have an incidence on medical consultations of 5%, accounting for 10% of deaths, 6-7% of adverse reactions in hospitals, as well as the leading cause of litigation in the health area (the figures correspond to the US).

Life quantity or more quality?

Ventricular assisting devices, VAD, or LVAD if for the left ventricle (the most common) are implantable instruments that help pump blood in situations where ventricular ejection force is severely compromised. In some cases the implantation of an LVAD facilitates the waiting for a cardiac transplant, but in others it’s adopted as a definitive solution. The price of the device is around $150,000 while the cost per QALY (cost per year of life earned) is between $200,000 and $400,000. The cost-effectiveness studies still don’t line up much, but the range of documented amounts is nowadays far above the $30,000 of Spanish per capita income. Remember that the WHO introduced the criterion of considering if a treatment is cost-effective when it doesn’t exceed three times the per capita income of a country.