War stress

Andrés Fontalba
 

By EFE

Stress is an adaptive reaction. When a change occurs, an effort is made to face the new challenge and, thus the organism itself adapts and can experience emotions, even pleasant ones, in the face of this process. In this case, stress is stimulating and motivating. Unfortunately, in situations as distressing as those caused by the current war, stress becomes so intense that it is seriously detrimental to health and one of its most severe consequences is post-traumatic stress disorder, a disease that arises as a delayed reaction to extremely threatening or catastrophic situations. This disorder is characterized by repeated episodes in which the traumatic event is relived in the form of dreams, flashbacks, or intrusive memories, often accompanied by emotional numbing and dissociation. It may involve detachment from others and avoidance of activities that are reminiscent of the event. Anxiety and depression may also be present, and substance abuse and suicidal thoughts are common.

Treat us like adults

Alexandre Lourenço
 

The development of the Portuguese health system suffered, like so many others, from excessive paternalism and over-centralization. Perhaps part of our failures in responding to the covid-19 pandemic lies in these two issues.

Last December, a Spanish friend shared an article from the El Mundo magazine where he gave some inputs: "nos tratam como niños, y nosotros tan contentos." The infantilization of Society - "the NHS will take care of everyone, everything is fine, the warm weather is the only cause for the excessive mortality, the cold weather is the sole cause for the excessive mortality, the vaccines are there and will solve everything" - demotes individual responsibility. Look at the peskiest kids fighting for the first sweets: vaccines. In the face of terrible mortality indicators, it is not so strange to see people's gatherings without any protection at the first ray of sunlight.

A year later, the inability to deploy an effective contact tracing and testing apparatus demonstrates our failure to do more than the routine. As with the ever-forgotten prevention, the system tends to focus exclusively on the conventional cure structures.

Last month, the British Government presented to its parliament the white-paper "Integration and innovation: working together to improve health and social care for all".  The topic is not new, but it is a sign that gives us hope in the middle of a pandemic. It is this kind of discussion that engages citizens and brightens our future.

It is not the millions from the European "bazooka" that will make us better. Persons, their ideas, and a vision that unites them will make us better.  As my colleague said: If the Government wants to engage Society, the first thing it has to do is to conceive us as adults.

Social agriculture

Josep Vidal-Alaball

In this section, we talked about the benefits for the community and public health of things as diverse as including health in all government policies, having community health agents, implementing telemedicine services, or using neighbourhood pharmacies or drug stores and public markets to carry out social and community actions. On the same topic, I would like to relate another initiative aimed at enhancing the community’s capacities such as agriculture and social farms. Social farming is the practice of participating in family farms as a form of social support service. In return, farmers have the opportunity to increase their income by developing the provision of social services, thereby further exploiting their agricultural skills. Participants can go to the farm one to five days a week. Each social farm is unique and offers its program of activities and opportunities. Similarly, participants confirm the activities they want to participate in.

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.

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.

The urgencies and the elderly

Reflections (and proposal) in the face of the impending winter emergency crisis

@varelalaf

If nothing is done, vulnerable people will increasingly go to the emergency room because of their multi-pathology, the presence of certain symptoms that are difficult to manage from home or the problems of their environment, they call 061 increasingly often. And that is how hospital emergency services become refugee camps within health systems. A clinical trial conducted in 24 French hospitals, which included more than three thousand people over 75 years of age in a clinically critical situation, showed that the centres most likely to enter older people in critical units, in addition to not reducing their long-term mortality term, neither improved their functional capacity or their quality of life.

Improving health takes a lot more than exercising, dieting and quitting smoking

Josep Vidal-Alaball

In 2014, Ryan Meili, a Canadian family doctor, wrote a provocative article criticizing the health promotion policies implemented since the 1970s in most developed countries. With the title "Improving our health is about more than diet, smoking and exercise", Meili reviewed the determinants of a population’s health.

As is known, among the elements that determine  population’s health, health care is the least important when compared to the weight of social factors such as, for example, income and distribution, education, housing, employment or the social support available to the individual. Although the importance of these factors is evident, and although study after study has shown the differences in health caused by social inequalities, health policies continue to be largely committed (and budgetary priorities demonstrate this) by allocating available resources to improve health care of the population, often forgetting the other factors that are also determinants.

Self-management: Buurtzorg Identity

Frederic Laloux in "Reinventing organizations" describes the teal-evolutionary companies as those based on the personal growth of their employees and chooses Buurtzorg Netherland as an organization to which we should be paying attention to if we are among those who believe that the time to do things differently has arrived.

What is Buurtzorg Netherland?

Buurtzorg Netherland is a non-profit company, which was founded in 2007 in the Netherlands, when a group of community nurses rethought their work and came to believe that, instead of only going to homes and exercising the functions of their profession, they should advance to becoming the patients’ referee and take charge of attending to their global needs.

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.

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.

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. "

Strategies for the integration of services

King's Fund has published a timely and in depth document "Acute Hospitals and Integrated Care" where they question what role should hospitals play in the integration of services. Given the approach, one could ask: What role should primary care play? How about community services? And the social health services? However it may be best, King's Fund has focused on it in this way and I believe it has its reasons for doing so because, right now, the organizational model that everyone tends to is that of territorial management or that of integrated health organizations, all of which are intended to integrate services from a hospital-centred position.

Who should lead the integration of services?

According to the document, it’s fundamental to generate the network of services on a territorial basis and the question of leadership should depend on the nature of each clinical process. Let's take a few examples: a) A remote dermatology project should be led by specialized care, b) An infarct ought to be led by cardiologists, intensive carers and emergency specialists, c) Care for type 2 diabetes mellitus, should be led by the primary care, d) Individualized therapeutic plans of complex chronic patients, should be led by primary care with the community nurse and the social worker taking a high profile role, e) Complex end-of-life processes should be led by community-based multidisciplinary palliative teams.

Chronic Elderly Patients: new evaluative proposals for community programs

Marco Inzitari

In recent years, we have witnessed the implementation of various community programs based on proactive monitoring and secondary prevention interventions aiming to improve the health of chronically ill patients and reduce costs to the system, such as avoiding unnecessary hospitalizations. But when studies have been conducted to evaluate the effectiveness and efficiency of these studies, the results have been rather poor.

Some of these disappointing results were presented during the Congress of the European Union Geriatric Medicine Society (EUGMS). The symposium called "Strategies in primary care to promote the autonomy of frail elderly people" presented the preliminary results of three large randomized cluster studies (cluster Randomized Clinical Trial) of the Netherlands:

Mental Health, the strongest transformation

The provision of mental health services have taken a dramatic shift in the last 40 years, which is why I think a blog like this, specialized in "Advances in clinical management," is bound to echo.

The mass closure of asylums

The critique of institutionalizing psychiatric patients in mental hospitals began in the late ‘60s, although the closure of beds was observed during the ‘80s, and especially ‘90s, as seen in the following graph:

According to a report by the London School of Economics and Political Science (Medeiros 2008), where the above graph came from, psychiatric deinstitutionalization has three main components:

• The transfer of patients from psychiatric hospitals to the community
• The involvement of general hospitals
• The deployment of alternative community services

The cited document reflects the vicissitudes that European countries came across when trying to address these policies, starting especially with the famous Italian Law 180 of 1978 which ordered the dismantling of psychiatric institutions. The document admits however, that despite the success of this policy, the difficulties in the operation of each of the three components mentioned above have been large.

Frail elderly patients: the case of Torbay

The health and social care for elderly people in Torbay (England) is fully integrated today (see the King's Fund document). In 2004 a pilot in one of the county’s districts was launched and soon spread to the entire area. Each of the 5 teams that were set up serves a population in a range from 25,000 to 40,000 inhabitants. In 2005 Torbay Care Trust was created.

The main objective of the service integration:

Maintaining the frail patients at home or in a community setting for as long as possible.

Key elements to achieve the objectives:

• Integration of health and social care professional teams
• Team budgets’ fusion
• Deployment (or purchase if appropriate) of a wide range of intermediate services that facilitates home support
• The enthusiastic support of family doctors (even though they have not been integrated)
• Institutional support, especially local support

COPD: can patients’ quality of life be improved?

Chronic Obstructive Pulmonary Disease, as the name suggests, is characterized by a chronic airflow obstruction in the bronchi and in contrast to asthma, this limitation is poorly reversible and progressively worsens. The diagnosis of COPD is based on spirometry, a test available to primary care and nurses trained in the technique. According to an EPI-SCAN study of 2006-2007, the prevalence of COPD in the Spanish population aged 40 to 80 years is 10.2% (95% CI 9.2-11.1), with a stronger presence in men than in women (Soriano, 2010).

To better understand how you can relieve the daily lives of patients with this chronic disease, I have chosen a systematic review, not a meta-analysis, published in the Archives of Internal Medicine in 2007.

Heart failure: what works?

Heart failure is the end result of most heart diseases, especially ischemic coronary disease. This is a highly prevalent chronic condition among older people (6-10% in those over 65 years), which provides a great disease burden to the healthcare system.

Both for its origin, which is none other than the long-term failure of acute cardiac pathology, as well as for its diagnosis, the cardiologists, and not the family physicians are the ones leading the management of some clinical processes that are almost always torpid and uncertain and which require a lot of action in the community and a lot of coordination between the hospital and primary care; as you can see, it’s not an easy business.

Heart failure, unlike diabetes, is a chronic process that, as I have already mentioned, slips away from the hands of the family doctor. To begin with at the time of diagnosing, because the clinical diagnosis is only presumptive and sending the patient to the hospital for an echocardiogram confirmation is required. It now appears, however, that it has been shown that the "NT-proBNP*" test (Verdú 2012), detectable in both blood and urine testing is sufficiently cost-effective to be able to expect that primary care units could begin to autonomously solve the diagnosis.

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(*NT-proBNP. Natriuretic peptides are hormones with diuretic and vasodilator effects, segregated mainly in the left ventricle as a compensatory mechanism for a pressure overload).