Primary health care: no more hype!

Pere Vivó

We live in convulsive times in terms of the health care system and especially in primary health care (PHC), this represents an opportunity for reflection and the construction of a substantially different model. The PHC constitutes the citizen's first contact with health care services and is a primary focus in the health care of a country. Aspects such as health promotion, attention to health needs throughout life or disease prevention contribute (sometimes silently) to progress and social spreading. For that reason, no one doubts that a health system is stronger if investments in PHC are enhanced and its resolving capacity and infrastructure are strengthened.

Precision health: recommendations for preventive strategies in the elderly

Marco Inzitari

In a post in this column more than three years ago (May 2016), I spoke about the need for a "precision medicine" approach regarding older adults with complex needs, because of ageing,  characterized intrinsically by complex and multi-factorial changes and aspects, including biological and clinical, vulnerability and prognosis, social and environment, and also the preferences of the individual.

"Precision care for older adults" was the motto of the 24th Catalan Congress of Geriatrics and Gerontology that was held in Barcelona. The event focused on how to take advantage and synthesize technological and big data aspects with an adequate care, centred on the individual within geriatrics and gerontology, but also on the many other disciplines and specialities that now face various problems of older adults.

The congress showed that it is essential to combine the management of complex situations, advanced or acute, with preventive strategies. For this broader context, we had chosen the motto "Precision Care" instead of just "Precision Medicine". In the optics of carrying out a personalized approach in the prevention, let's prepare to adopt the motto "Precision Health", already used by different institutions in the United States for the marketing of preventive programs.

Here is both good and bad news. The bad: implementing preventive strategies is also difficult, as it is to approach the complexity of the tip of the pyramid, if we aspire to have some impact. The base is also multi-factorial, and requires multi-component interventions. The effect is not entirely predictable given the individual response, so that we should avoid “stereotypes”; this is why the best interventions get the name of "complex interventions." As claimed by Mrs Mercè Mas a retired social worker, gerontologist and representative of the elderly FATEC delegate who joined us at the opening table of the congress, talking about "older people" does not make much sense either because they are a heterogeneous collective.

The painter and writer Miquel S Jassans, during the creation process

The good: in this sense, we have some progress. I’ll pass on the discovery from one of the findings of my research group. We were frankly tired of the studies and clinical trials applied to frail elderly people, in this case, those with relative autonomy and independent living, but with some indicators of imminent downturn risk and negative health consequences (I defined this population and described some successful studies in a previous post). If they are well designed and financed, they usually show benefits, at least in the short term.

We moved towards "border" projects on the threshold between organizational innovation and implementation. One of these, + ÁGIL Barcelona, a collaboration between Pere Virgili Sanitary Park and the primary care of the ICS of Barcelona, ​​focuses to this same group and tries to transfer to a real context, without specific finalist financing and a "final date", the evidence of clinical trials through the integration between primary care, geriatrics and community resources. We recently published in the European Journal of Internal Medicine a methodological work where, thanks to a consensus of experts based on international references and a practical application test, we proposed a Decalogue of principles of implementation of complex interventions for the management of frailty and disability prevention that could be applied to other similar complex interventions in other areas.

The principles of the "Decalogue" are:

1. Design and implement multi-component programs that incorporate physical activity and nutritional interventions.
2. With a patient-centred approach, taking into account their preferences and values.
3. Empower the person and their caregivers.
4. Implement interventions that are flexible and easily adaptable to the context.
5. Implement them near the person's environment, preferably in primary care or in the community.
6. Develop comprehensive care models that involve all agents, including those in the community.
7. Use opportunistic screening strategies to identify vulnerable older people.
8. Adapt them through user participation and co-design strategies.
9. Make dissemination and raise awareness among the population and decision-makers.
10. Design investment plans or evaluation of the appropriate results.

Apart from + ÁGIL Barcelona, other "allied" interventions in this area are emerging such as the "Presentes" program of primary care of the ICS in Barcelona, led by EAP Sant Antoni with Dr Ylenia García, which promotes the intergenerational interaction of high school students that help boost physical activity in older people. Scaling this type of intervention presupposes that we cannot simply replicate them exactly, but rather that the adaptation process described in the Decalogue is repeated (basically by users adapting the intervention to the specific context, which will have to be known first) and reinforcing other points such as communication, investment plan, enc., according to each case.

In addition, as Adelina Comas, a researcher at the London School of Economics insisted, in her brilliant presentation at the congress, that one must always reassess the impact on health, but also efficiency within the local context and not simply transfer it from studies of other latitudes given that local factors (system, costs, etc.) can affect the results. 

There may not be any program that can save the world on its own, but it is beginning to draw a network of initiatives with a solid scientific base and enough realism that we hope will allow us to have a good range of resources to offer “Precision Health ".​

Self-management is the way

In traditional companies, such as health companies, power is very concentrated. Individuals above distrust those below because they believe that if they allow them the autonomy they will blow their budgets and, as a result, professionals have simply become rigid gears in the machine with virtually no room to make decisions. For their part, politicians always find reasons to distrust managers in case of any budgetary deviation or up-tick in citizen unrest - waiting lists for example. Managers, fearful of their predicament, concentrate power in a few subordinates to maintain tight control of objectives whilst rejecting any innovations from those below due to suspicion of increasing expenses or creating scandals.

30% of digestive endoscopies have questionable indications

@varelalaf

In an article in the series "Less is More" by Gastroenterology, three digestiologists, Shaheen, Fennerty and Bergman, after an extensive review of the literature, conclude that 30% of digestive endoscopies have questionable indications. According to the authors, many clinical practice guidelines stimulate the exaggerated consumption of these tests in clinical situations of doubtful indication, such as recommendations for the follow-up of low-risk patients of Barrett's disease (oesophageal reflux), which they say they are "carefully misleading." On the other hand, the prevailing cancer phobia places a lot of pressure on the examination rooms, which are permanently overwhelmed, not only by inappropriate requests but by follow-up guidelines that anticipate the requirements demanded by the clinical practice guidelines themselves.