Cross-functional units, a challenge within reach

Jordi Varela

Editor

In 2003, a study led by Chris Ham observed that for eleven clinical situations related to chronicity and age, the NHS allocated up to three and a half times more hospital beds than Kaiser Permanente. This was such a surprising result that it generated great admiration for the European health managers by the Californian insurer, especially considering that, according to the researchers themselves, the success of KP lies in the transversal integration of its services, the promotion of self-care, the active role of community nurses and the involvement of physicians to achieve maximum resolution of problems in the framework of primary care.

Vertebroplasty and knee arthroscopy: two interventions questioned by the evidence

@varelalaf

The measurement of the clinical effectiveness of surgical interventions is, regrettably, not too frequent. In this field, the design of rigorously and well executed clinical trials has its complexities, especially when the control group undergoes sham surgery. For this reason, it’s worth disseminating the conclusions of consistent studies that arouse doubts about the effectiveness of the decisions made every year by the operating rooms to thousands of citizens, who must accept the risks, not negligible, inherent in surgical intervention. In this regard, I already mentioned the poor results that a clinical trial had shown for coronary angioplasties with stenting in patients with stable angina and, in the same vein, today I have selected two clinical trials related to orthopaedic interventions.

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?

The parsimonious medicine

I started the last Mondays’ post with the "Too much medicine" campaign from the British Medical Journal but in this one I want to talk about the "Less is more" article from "JAMA Internal Medicine" that began in April 2010 with the aim of bringing to our attention the side effects of diagnostic tests and treatments that from the outset are not expected to add any value.

Parsimonious medicine versus spending cuts

Dr. Jon Tilburt, an internist and researcher in biomedical ethics at the Mayo Clinic, and Dr. Christine Cassel, president of ABIM Foundation (see the Video that presents the "Choosing Wisely” campaign), in an article published in JAMA, attempt to differentiate between the ethics of "no budget and therefore I can’t request a test" and those of "this test does not suit you, it will not contribute anything new to what we already know, and additionally, the test itself carries risks that do not outweigh the expected benefits". According to the authors, as at the moment the two ethics are competing on the same stage, an effort must be made to explain them better from a professional point of view.