Bad science, new chapters

Jordi Varela
Editor

In July of last year I commented on a work by Paul Glasziou and Iain Chalmers that concluded that taking into account methodological shortcomings, unpublished studies and poorly explained ones, the waste of biomedical research could be of the order of 85%. According to these authors, only 15% of what is investigated reaches the clinic in conditions of quality and appropriate communication. A little over a year later, other sources insist that biomedical research, in general terms, does not show signs of recovery and, to make it understandable, I will follow the same scheme that I used in the post I have quoted.

Measuring efficiency: is it going well?

Mª Luisa de La Puente

While the concept of efficiency is easy to understand if we consider it as the system that uses resources (inputs) to improve the health of the population, it's not as easy to measure as it appears due to the multiple methodological problems. The relationship between inputs and outcomes in the health sector is influenced by multiple factors external to the control of the health sector itself.

The European Union Health System Performance Assessment (HSPA) expert group has recently published a report on this (1).

It defines efficiency as the quotient between the inputs of the system (equipment, resources) and its outputs (the number of patients treated, for example) or its outcomes (the number of years of life gained, for example). He accepts them both but warns that using outputs as an approximation of outcomes can lead to false interpretations. It also highlights the importance of differentiating efficiency from cost control, since cost control is only concerned with reducing inputs without measuring the outputs/outcomes that that reduction causes.

In a health system, efficiency can arise for two different but related reasons. Efficiency materializes:

 1) When the same result could be produced, or even better, consuming fewer inputs, and

 2) When resources are spent on a mix of services that maximize the health of society as a whole (outcomes). These two typologies of efficiencies are conventionally cited, respectively, as technical efficiency and allocation efficiency. The allocation efficiency can be produced on a macro basis (paying attention to the service with the best cost/effectiveness ratio) and on a micro character (giving the treatment with the best cost/effectiveness ratio). The OECD idea of waste is associated with the notion of technical efficiency (2).

A survey is carried out in the 29 countries that are part of the group of experts, of which 22 answered. The survey only explores technical efficiency, since the assignment would require information on the relative value of the outputs of the services that don't it's available in most of the investigated countries. Half of the respondents state that they don't have a unified system to measure efficiency. Of the other half, approximately 40% respond that they consider the relationship between intermediate inputs and outputs, 40% between inputs and outcomes, and the remaining 20% consider the two previous possibilities. 80% responded that the hospital area is subject to regular measurements, not so much for strategy as for lack of information from other health areas such as primary care, mental health or social and health care. Technical efficiency in hospitals is also measured as it's the functional area with the highest cost. The results show how, although European countries place improving efficiency as their priority, the vast majority have real problems when it comes to having the necessary methodology and instruments to measure it.

The report presents as an example of evaluation of technical efficiency the management of the demand of acute pathology, which requires evaluating three moments of the process: before hospitalization, during the stay and after discharge, expanding the spectrum of the analysis to other areas such as primary care and social health care.

The OECD report insists on the same recommendation to broaden the spectrum when looking at the overuse of hospitals. This is exemplified by the excessive use of emergency services in mild pathologies and the excessive use of emergency and hospital services in chronic pathologies, both of which can be better managed in other devices. It also illustrates this with different examples of how certain OECD countries have made these changes.

The recommendations that emerged after reading the OECD report are:

1. It’s essential to have more homogeneous instruments for measuring and evaluating the efficiency of health systems that serve to guide decision-making.

2. It’s dangerous to make decisions based on comparisons and benchmarks with outputs/outcomes that are not well validated or contextualized.

3. When analyzing efficiency, as opposed to the concept of cost control, it's essential to broaden the spectrum of analysis to all services that address the care process. This formula also allows crossing the border between technical and assigned efficiency.

It seems, therefore, that the measure of efficiency is still at a very early stage. Improving the information that supports efficiency measurement is essential to support change. On the one hand, it will avoid inappropriate policies, on the other, it favours the evaluation of services with greater precision. Also, finally, it will promote the awareness of the population about what it means to obtain appropriate care, a necessary aspect in our country.

Bibliography

1. EU. Report by the Expert Group on Health System Performance Assessment. TOOLS AND METHODOLOGIES TO ASSESS THE EFFICIENCY OF HEALTH CARE SERVICES IN EUROPE. 2019

2. OCDE. Tackling wasteful spending on health. 2017.

Pedal and ask

Joan Escarrabill

On November 18, 2019, the so-called Experience Exchange Space (EIE), a living lab, was inaugurated at the Hospital Clinic. Setting dates of notable events allows build ephemeris or, at the least, landmarks. They say that on November 18 William Tell shoot the apple from his son’s head (1307), on November 18 Mickey Mouse was also seen for the first time (1928) and it’s also the day of the year in which Niels Bohr died (1885-1962). Naturally, the inauguration of the EIE will not be part of any general reference, but it’s an important point in the approach to evaluating (and taking into account) the experience of patients in our Hospital. 

For an integrated primary care network

When we think of primary care, we tend to stick to the services provided in health centres, but too often we forget that luckily, other actors work in the territory, such as continuous and urgent care devices, community-based services, social services, mental health and addiction teams, sexual and reproductive health care services, public health teams, rehabilitation providers, palliative care teams, and others that may specifically exist in some places.

A Nobel Prize in Economics for health interventions that alleviate extreme poverty

Pedro Rey

The recent 2019 Nobel Prize in Economics has been awarded to three academic economists: Abhijit Banerjee and Esther Duflo of MIT and Michael Kremer of Harvard "for their experimental approach to alleviating world poverty." His research has revolutionized the way of studying how the economic development of the more than 700 million people living in extreme poverty can be stimulated. It enunciates the prioritization of small interventions in pilot tests and based on the knowledge of why those affected do not make optimal decisions that could contribute to their prosperity. It also forwards a more macro and institutional approach that depends on large programs that "should" work in theory, but in which the cause-effect relationship of its effectiveness has not been empirically established in all cases.

Arrogance, condescension and indifference in communication with patients

Glòria Galvez

In traditional society, men have had an authority role and women a secondary and subordinate role. As a result of this form of behaviour comes the term mansplaining, a combination of the words man and explaining. The term appears for the first time in a text by Rebecca Solnit “Men explain things to me” to define the habit of some men to express their opinion with authority, condescension and a paternalistic tone on all kinds of subjects, even if their experience is little or non existent.

John Launer, in the article published in the Postgraduate Medical Journal, talks about medical condescension or "docsplaining" that, like mansplaining, has to do with paternalistic and condescending behaviour. In this case, it’s the professionals –men and women– who, to maintain control of the conversation with patients, address them with a certain arrogance exercised from parental ambiguity.

À la recherche du temps perdu

Alexandre Lourenço 

Portuguese studies from different entities have showed excess mortality from causes unrelated to COVID-19 since early April 2020. Entities like the National School of Public Health, the Faculty of Medicine of Porto, or the Faculty of Medicine of Lisbon have warned about this trend. Later, the Portuguese National Statistics Institute has confirmed it.

The response to COVID-19 has limited the regular provision of healthcare and the postponement of elective healthcare services has led to significant losses in the health and well-being of populations. In April, we called for creating conditions for resuming the regular health services in an organised and coordinated way, through a dual-track NHS. By this time, tens of thousands of surgeries and hundreds of thousands of consultations have been cancelled.

Clinical competences hidden in the curriculum and in coding

Gustavo Tolchinsky
 

José, 85, has a fever again. His wife is no longer worried; she knows that what has always worked is taking her husband to the emergency room. On the way she writes in the family chat that they are on their way to the hospital, but no one should move until she’s told if he gets admitted or remains under observation. Her children live in the suburbs and they always volunteer so that she doesn’t have to spend the night with José. Dementia has taken its toll on José and everything is more complicated; his urine infections, which previously warned with recognizable symptoms, have now become something abstract, but the fever is what always alerts the family. In the last year, José has been admitted several times for processes similar to this one, that started with urinary infections due to the underlying urological pathology. This time, on arrival at the emergency room, his wife thinks he is worse than ever, although his vital signs are OK and the Labs are quite anodyne, except for a slight worsening of kidney function. Again, as always, José is prescribed antibiotic treatment (guided by the latest available antibiogram) and fluid therapy, fever control and nursing care. But on this occasion, despite the fever disappearing, he is exhausted, probably due to delirium, he doesn’t cooperate with the care, the peripheral line is removed several times, he refuses to eat and the fever reappears. The family doesn’t cope well with this situation, José either. Family members are informed that imaging test could be performed, to asses  again with the urologist, and even to perform a procedure such as placing a urostomy could be considered if they suspect that there is an obstructive process. However, Jose's deterioration is not solved by treating only the current episode. The family and the healthcare team agree to make one more attempt with some changes in the treatment and, if he doesn’t improve, assume that only palliative treatment will be carried out.

Cyberchondria: improper use of the internet increases healthcare waste

Andrés Fontalba

The growth of the internet has made health information more accessible than ever. Increasingly more people are obtaining health information on the internet, which has probably become the most popular method of gaining knowledge in this field. The internet has brought great benefits and opportunities, such as offering instant answers about the nature, cause, prevention and treatment of any disease, as well as recommendations to maintain healthy habits, with more and more applications in the health field. We can connect to the internet with multiple devices (tablets, smartphones), in such a way that in Spain 93% of the population currently has an internet connection. However, people who are distressed or anxious about their health can access the internet for self-diagnosis and thus allegedly to calm down. This search for content on diseases aims to alleviate anxiety, but produces precisely the opposite phenomenon, increasing stress and worry. And this is even worse if the information obtained is inaccurate, incomplete and erroneous, as it often happens.

Lessons from the opioid crisis, a case of overtreatment with devastating consequences

Cristina Roure
 

If you are regulars of American series such as House, The Affair or This is us, you will be familiar with the classic protagonist who, after an episode of acute pain, ends up becoming addicted to prescription opioids such as Vicodin®, OxyContin® or Percocet®. Do not think that this is a writer’s exaggeration.

In 2015, life expectancy in the United States changed the trend and began to decline for the first time since the First World War. Among the causes, the epidemic of deaths from opioid overdoses, which multiplied by six between 1999 and 2017 (1), surpassing deaths associated with AIDS at its worst or those related to the Vietnam War. The epidemic was declared a national emergency by the United States Department of Health in 2017 and, despite the campaign deployed to combat it (2), 130 people still die in that country every day from opium overdose. If you are interested in the subject and want to delve into it, read the supplement that Nature dedicated to it in September last year.

Training is essential for change management

Nacho Vallejo

The actors who intend to get involved in the orchestration of changes in our healthcare system tend to agree on the difficulties and barriers that limit the development of improvement strategies for healthcare organizations. We have already seen it in previous posts on this blog, where we asked ourselves what has become of the professional's experience and how to "unclog" our institutions.

Misappropriation or necessary contribution?

Andreu Segura

If we understand that health is not, as suggested by the Andrija Stampar definition adopted by the WHO in 1946, the mere absence of disease or insanity, but something else, whether it’s well-being as the aforementioned description affirms, it’s a reasonable ability to functional adaptation as René Dubos proposed, it’s easier to understand the importance of the so-called social determinants of health, among which health care is but one more.

These comments don’t imply any disregard for health care, given its ability to ease a good part of the disorders caused by diseases and, sometimes, to cure them definitively. Incidentally, insanity is, according to the dictionary, madness or mental disorder, a distinction that highlights the specificities of psychiatric pathology.

Defend

Salvador Casado

Everyone defends something, mainly their interest. In the healthcare world in which I work, this also happens and it is very common for these interests to clash between some professional categories against others or those who think in one way against those who think the opposite. In fact, this division has been one of the main reasons for the high levels of institutional mistreatment of health professionals in our environment.

But, beyond the purely statutory, I would like to ask the following question What do I defend as a public family doctor in a rural health centre? What do you defend from your position?

A new study detects 396 clinical practices that should be reversed

A medical reversal is the need to stop a clinical activity because a well-done study shows that in the real world the desired results are not being met, or that the adverse effects don’t outweigh the benefits. In a previous review (2013) of over 2,000 NEJM articles, Vinay Prasad and his team already discovered 146 clinical practices that should be reversed and, given the significance of the finding, the Catalan Society of Healthcare Management (SCGS) invited Vinay Prasad to explain it to us live, which he did on March 18, 2018 (you can see the video of the conference at the link).

Exercise as a clinical management tool

Paco Miralles
 

In the consultation of any internist...

• Mr Sebastián (68 years old), your glycated haemoglobin is in adequate parameters. Your diabetes doesn’t appear to have affected your kidney because you are not losing albumin. The tension controls are correct and I do not notice hypoglycaemia in the provided tests. Your diabetes is under controll.
• Do I continue with the same treatment?
• Yes, let's review the treatment. With insulin, we will maintain the same scheme that has worked so well. I remind you: from the basal, the long-lasting, you put 24 units, with a fixed guideline in meals of 8 units and correct it with the scheme written in the report (I don’t reproduce it so as not to bore you more). The rest of the treatment will stay the same.
• And I continue with the exercise?
• Sure! Keep walking for at least 45 minutes along the promenade (those of us who are lucky to live in a coastal city, especially Malaga).

High blood pressure: please don’t lose your head

Xavier Bayona
 

Although I am sure that we well know the difference between a risk factor and a disease, I allow myself the license to start this post by defining them. Risk factor (hypertension, hypercholesterolemia...) is that situation that has been related to the development of a disease (maybe the disease never develops despite having one or more risk factors), while the disease is the alteration in the organism's state or of any organ that interrupts or disrupts vital functions, affecting the state of health (ischemic heart disease, embolism...).

Since Julian Tudor Hart, in an article published in the British Medical Journal in 1993 after following a cohort of hypertensive patients for 21 years, concluded that the basis of treatment is the detection of hypertension and that the most important measures are hygienic-dietary and working from the community, countless articles have been written. But the essence of management remains: detect it, decrease sodium intake, increase physical exercise, abandon toxic habits and if they do not achieve the desired objectives, start pharmacological treatment.

Integrated care, the pragmatic roadmap of Ontario

Marco Inzitari

I had an exceptional opportunity to be a visiting professor at the Institute of Health Policy, Evaluation and Management at the University of the Toronto School of Public Health, Canada. Before going on vacation, I would like to share some main lessons learned about integratedcare in Ontario, which is the most populous region in the country.

Upon arrival, I was invited to share the Catalan experience on integrated care in a very well-structured symposium, Essential Ingredients of Integrated Care (# IHPMEIC19, for those who want to rescue tweets), organized by prof. Walter Woodchips. The symposium ranged from "macro" aspects of public policy to teamwork; through interprofessional relationships, active patient participation, and cross-cutting facilitating aspects such as technology and recruitment tools. Besides these interesting contents, the symposium made it easier for me to land in reality and gave me a global vision of "who is who".

Emotional support to cancer patients regarding psycho-oncology

Andrés Fontalba
 

In my first post, “When it’s our turn?”, I addressed the need to promote shared clinical decision in mental disorders, from now on I will focus my interest in commenting on having emotional support in the diagnosis and cancer treatment.

The clinical dialogue between the doctor and the patient on the prognosis and care of cancer in advanced stages significantly influences how it tests both the benefits and the side effects of the treatment. It also affects how the time in which his life ends and how family members adapt to the patient's illness and death. It’s very important to detect personal differences regarding the need to receive information. Aside from a small percentage of patients who prefer not to be informed, most consider all the information they receive related to their prognosis and treatment to be precious. The exchange of information occurs in a sensitive relationship between the professional and the patient, in which they have to deal with highly emotionally charged communication and in which we must guarantee the information to be fully understandable. It’s clear that the patient, with great frequency, is anxious, among many other factors, because of the doubts about his prognosis, the family burden caused by the disease or the results of the tests. And these top levels of anxiety affect both the interpersonal relationship and the processing of information and the decisions made. It’s for all these reasons that research in psycho-oncology provides us with different tools to favour both the therapeutic link and the understanding of the patient's disease, as this review collects.

Reducing Overprescription with Psychology based Interventions

Pedro Rey

There exits consensus about drug overprescription having become a significant public health problem, both for its health effects and for its budgetary repercussions. The case of the opioid "epidemic" in the United States frequently comes under scrutiny. We must not forget the abuse of benzodiazepines (especially) during hospital treatment or the loss of efficacy of antibiotics due to the development and selection of bacteria that developed resistance due to improper and excessive use. Traditional methods of combating these problems have been to try to educate both the medical profession and patients, to train prescribers or to review prescribing practices and create automated alert systems. However, although in some cases these measures have been relatively successful in the short term, they have also been shown to be not cost-effective, to lose efficacy in the medium term, and to be challenging to transfer to significant interventions.

The patient's experience is key, but ... what about the professionals?

Anna Sant

Undoubtedly today we notice the relationship between the patient's experience and that of the professional. Although we often pay more attention to the former, both are equally important, and their improvement is essential to achieve satisfactory results.

This reflection is more pertinent because we work in healthcare organizations that aim to improve and/or reorganize the way they relate to their patients. Although we have long talked about the evolution of the Triple Aim concept of healthcare (better health outcomes, lower costs, better patient care) to that of the Quadruple Aim, adding the fourth dimension of the professional experience, we continue in operating patient experience and professional experience programs independently. Normally, the first led by the patient care area and the second by human resources or medical and nursing management.

From the humanisation of medicine to the dehumanisation of professionals

Gustavo Tolchinsky

The well-being of doctors is an issue that has a direct impact on the quality and quantity of care that healthcare systems can deliver to society. You only need review several of the entries of recent months and certain articles that even quantify the cost and waste that burnout implies for healthcare organisations. As has been shown in these articles, organisational factors, workloads, alienation from the values of organisations and professionals, the autonomy of professionals to manage their work, and even the type of clinical information management programs and their usability affect professional well-being.

The same challenge in Sao Paulo, Dallas and Phoenix: how to reduce unwarranted clinical variability?

David Font

Triple Aim, Right Care, Less is More, Nothing with Me without Me, Lean are concepts, principles and methodological approaches that are increasingly present in healthcare institutions and which we frequently discuss in the posts on Advances in Clinical Management. All of them aim to make better use of resources and allocate them to what adds value to the patient, thereby advancing sustainability, quality and safety. While it is clear that this is the way, the real challenge is how to put it into practice in each of our institutions. And so it is essential to read and travel to learn from other institutions.

With Amazon, there is no going back

Paco Miralles

A winter desert. The author discusses his post with friends: "The future of medicine is changing daily, but the point of no return will be when Amazon enters the healthcare market ..."

I noticed the smile on my friends' faces when I made these comments to them. I do not have enough scientific relevance to lavish myself in informative talks, so my remarks were in opinions of the same level as those referring to what Atletico will do if it does not qualify for the Champions League. They thought it was an exaggeration and that the medicine was indeed changing a lot, but no so much.

Centralisation of complex surgery: clear, obscure and proposals

@varelalaf

A large group of European and North American surgeons have published in Annals of Surgery a review of the difficulties of centralising complex surgery around the world. The complex issue has multiple actors, starting with governments and respective funding models and continuing by the hospitals, the doctors involved and their corresponding scientific societies. It is surprising, however, that patients rarely appear in such discussions.

Some proposals to reduce the things we do without reason

Nacho Vallejo

Reducing unnecessary tests and treatments in our organisations can be a complicated task, especially in its implementation. To facilitate its development, and in line with the previous reflection on the search for things we do without reason, we have new references that can serve as support.

Canadian Choosing Wisely's Diving into Overuse in Hospitals campaign aims to sensitise institutions to participate in this analysis by making changes (small or large) to reduce this excessive use. On their website, professionals have access to a large number of resources such as a "starter kit", webinars and other exciting supports.

Disruption doesn't show on the tip of the iceberg

Joan Escarrabill

By chance, a couple of years ago, I found some images of Gediminas Pranckevicius, a Lithuanian graphic designer. Some of these images present a (small) upper part in which he describes familiar scenes, but the rest of the image (the lower part) is very complicated. The metaphor is automatic: there is (extraordinary) life in the submerged part of the iceberg.

Pinterest

Disruptive changes take place in the submerged part of the iceberg that, in a short time, change the image of the visible surface. Taxi is a service that is changing in a profound way. The digital press also gives us some clues. In New York, it appears that there are ten times more alternative taxis than conventional taxis, which has caused a decrease in the income of taxi drivers (by almost 30%), a reduction in the value of licenses and a negative impact on traffic due to the large number of vehicles that circulate without passengers. It's a significant problem from many points of view, and the most impressive thing is that these profound changes have taken place in less than five years.

In search of the things we do without reason

Nacho Vallejo

In healthcare, there is usually a special appreciation for tradition or antiquity, which does not always translate into better clinical care. The reality is that there are things that we professionals do without the contrast of adequate evidence or, simply, without these actions providing sufficient value.

The Choosing Wisely initiative was launched a few years ago from a private North American institution. It was necessary to suggest to the scientific societies of that country the development of recommendations on clinical practices that both doctors and patients should rethink.

Exponential innovation, or getting ahead

Josep Maria Monguet

The sustainability of health services is associated with rational development. The key element is the generation of knowledge-intensive employment, which can only be the result of innovation.

In general terms, innovation in health must have an exponential dimension and be based on:

• The generation of intelligent demand by health professionals
• The participation of citizens and all social and economic agents
• The promotion of business models based on value for users