The home as a centre for health and social care operations

Jordi Varela
Editor

 

@varelalaf

People, while enjoying independence, receive health care services in accreditated facilities, where professionals work in an appropriate environment and they manage everything that influences the quality of their work: noise, lights, computers, clinical devices, waiting rooms, etc. On the contrary, when people become dependents, their home takes centre stage. It is, however, an alien place for professionals, often with difficult access and full of unforeseen events. The point is that many doctors and nurses prefer not to have to step out of their comfort zone and, probably, for this reason, home care programs weaken whenever there are budget constraints or overly packed schedules.

Family medicine confined into an individualistic practice

88% of the demand for assistance requires some kind of coordination

If we glimpse at the memories of the primary care centres, we will notice they all attach great importance to the number of visits, especially family doctors, in the sense that the more visits, the less waiting time. Unhappy with this, I have clicked on the primary care document of the AQuAS Results Centre, one of the most advanced evaluation systems in the world, and I have observed that, in addition to efficiency, data on effectiveness, quality, and value practices and information technology development are collected. The indicators of adequacy warrant separate mention since they are the only ones that, although indirectly, give an estimate of the collaborative work of the primary care teams, implying that if the preventable hospitalizations and the number of multi-medicated patients are in low levels, should be an indicator that in that team there is some form of integrated model of clinical work.

Measuring the effectiveness and value of clinical practice

In the "XIV Conference of the Sign Foundation", Jens Deerberg-Wittram, Director of the Boston Consulting Group, gave the inaugural lecture entitled "From volume to value". It was a very timely speech, at a time when the obsessive control of budgets and waiting lists prevents clinicians and managers from reflecting on what contributes so much care activity to society. The concept of value expressed by the German speaker is very new for healthcare managers, who tend to understand clinical effectiveness as a rhetorical concept more typical of epidemiological studies.

Debate with Vinay Prasad on the value of clinical practice and doctors’ training

Vinay Prasad (University of Oregon) and Adam Cifu (University of Chicago), authors of "Ending Medical Reversal: Improving Outcomes, Saving Lives" (Johns Hopkins University Press, 2015), point out 146 clinical practices that should be ditched because it has been proved that they do not deliver the promised results. The list of these practices affects the whole range of the health activity; however, making a detailed reading, it has been observed that these are mainly found in four specialties: cardiology, gynaecology, orthopaedics and family medicine. It’s because of this reason that the Section of Clinical Management of the Catalan Society of Health Management (SCGS), in its Annual Conference to be held on May 18, in agreement with the team of the project Essencial of AQuAS, has organized a debate between one of the authors of the book, Vinay Prasad, and representatives of the 4 mentioned specialties: Xavier Viñolas, president of the Sociedad Catalana de Cardiología (SCC), Juan José Espinós, gynecologist at the Hospital de Sant Pau, Joan Miquel, orthopaedist at the Hospital de Igualada and Marta Expósito of the Sociedad Catalana de Medicina Familiar y Comunitaria (CAMFIC). The debate, which will rely on the moderation of Sandra Garcia Armesto, director of the " Instituto Aragonés de Ciencias de la Salud ", aims to not only find out first-hand about the work of Vinay Prasad, but also to find out what the related specialists think of these practices and what is the impact on our situation, differentiated in many aspects from that of the United States.

On the other hand, Prasad and Cifu, in the book, propose to significantly modify the training programs in medical schools, in order to train new physicians that are more demanding with regards to scientific rigor, more critical of practices with poor value, more sensitive to the needs of patients and more oriented to the evaluation of results. The proposed formula is very simple: the clinical sciences should be the priority, while the basic ones (as we understand them today) should be complementary. It’s not about studying models and then checking them (current system), but about doing it the other way around: from the findings of the clinic, doctors should review (or accept) the theories. Given the importance of the proposal, we thought it appropriate to organize, in the same framework of the Conference, a second debate moderated by Xavier Bayona, with three academic authorities in the training of doctors: Francesc Cardellach (Universitat de Barcelona), Ramon Pujol (Universitat de Vic - UCC) and Milagros García Barbero, president of the Sociedad Española de Educación Médica and, logically, also inviting Vinay Prasad to join them.

The program of the Conference is attached, with the clear purpose of encouraging all readers to register, because nobody should miss out on the opportunity to listen to and pose questions to Vinay Prasad and all invited speakers.

Organizes:

• Clinical  Management  Section  –  Catalan  Healthcare  Management  Society 

In  collaboration  with:

• IDIBAPS.  Institut  d’Investigacions  Biomèdiques  August  Pi  i  Sunyer  
• Centre  de  Recerca  en  Economia  i  Salut  (CRES)  –  Universitat  Pompeu  Fabra  
• Institute  for  Healthcare  Management  -  ESADE  
• Agency  for  Health  Quality  and  Assessment  of  Catalonia  (AQuAS)  
• Hospital  Clínic  de  Barcelona  
• Aragonese  Institute  of  Health  Sciences 
• Catalan  Society  of  Family  Medicine  (CAMFIC)  
• Catalan  Society  of  Cardiology    
• Catalan  Society  of  Gynecology  and  Obstetrics  
• Catalan  Society  of  Traumatology  and  Orthopedic  Surgery  
• Cochrane  Iberoamérica  

Sponsors:

• Vifor  
• Unió  Catalana  d’Hospitals  
• Consorci  de  Salut  i  Social  de  Catalunya  
• Novartis  

Measuring results in health is still very complicated

In order to evaluate health institutions based on the value they provide, health outcomes must be measured. However the efforts to achieve this are bearing dismal results. Pay-for-performance initiatives are drifting in an ocean of indicators that don’t translate into anything too operational. To give some examples, in the US, CMS (Medicare and Medicaid) handles nearly a thousand indicators to promote new funding models (see Health Affairs Blog "The Quality Tower of Babel") and, not so far away, in the Results Central of Catalonia (AQuAS), more than 300 indicators are recorded. Everything suggests that the excess of information will not bring light if we are not able to clarify what it means to add value to people's health, and to make this statement comprehensible, we must distinguish between two different approaches:

Health value for citizens

A long life free of disability is a goal that most mortals share but this indicator is not very useful for service providers because the impact of the health system on life expectancy barely reaches 20%.

Clinical practices that don't add value

The initiatives that warn of clinical practices that don’t add value or that contributes very little, are an advanced product of evidence-based medicine. This culture, which has the force of reason, often conflicts with several limitations to influence the actual practice of medicine. The first lies in the ‘original sin’, since most clinical trials leave out the very elderly and the multi-pathologies, the second has to do with the difficulties of adapting clinical practice guidelines to the actual circumstances surrounding each patient and the third is the influence of other factors, such as industry or popular culture, for example, when it comes to influencing clinical decisions.

This matter of little practical value is one of the most unclear of which I have addressed on the blog, and so I want to explain my opinion of the three main sources that today feed us information.

"Do not do” recommendations from NICE

This initiative stems from the futility that NICE experts have made of their own clinical practice guidelines. This is a list of quiet thousand recommendations including all specialties. Clearly they aren’t prohibited, but instead the prestigious agency experts warn that these practices don’t have sufficient scientific support.

To illustrate how these recommendations work, I have chosen five examples of the questions that NICE believes should not be posed:

• Indicate hysterectomy as a first choice in cases of even strong bleeding
• Prescribe antipyretics to prevent febrile seizures
• Prescribe bevacizumab as first line in cases of metastatic colorectal cancer
• Shaving the skin in surgical preparation
• Hospitalising women with gestational hypertension