Integration of social and health services: 3 issues and 3 solutions

Aging population has many interpretations, some of them very positive such as the fact that more and more people are fortunate that they live for longer with a fairly healthy life. The other side of the coin is that there are also problems such as increased multiple combined chronic diseases, social deprivation and the fact that many people reach an advanced stage of geriatric frailty. And this is where service delivery models that have been consolidated in recent decades are still struggling to give satisfactory answers. Governments know it and, for this reason, are launching initiatives to address chronic disease and frailty in a more effective manner but these programs often face political difficulties, resistance to change and difficult to overcome bureaucracies.

From everything I've seen in this issue, I think the British are the most daring, so I chose the report of the "Commission on the future of health and social care in England" published by King's Fund, because it synthesizes very well what the problems of current models are and what are the solutions to be put on the table.

First problem: the current model is unfair. The health system is universal and free, while access to social services is restricted. Let's say two examples: people affected by cancer enjoy global coverage, regardless of process costs and economic level of the patient, while Alzheimer's patients suffer from limited access to services, especially in more advanced stages when their needs are more social than medical.

Second problem: funding sources are different. The health system feeds directly from the public budget, while social funding source is hybrid, with participation of different administrations, including the local, and with a variety of complex management copayments.

Physical examination is reclaimed

Acute vestibular syndrome, characterized by dizziness, nausea and vomiting, is often due to a local neuritis of the inner ear, despite the fact that a doctor cannot overlook that with these symptoms he or she must first rule out the vertebrobasilar stroke, a less common aetiology, but obviously a lot more serious. I chose this health condition because the neurologist David Newman-Toker from Johns Hopkins (and the team) have systematized HINTS (Head Impuls, Nystagmus and a Test Skew), an examination that requires nothing more than some basic neurologist’ tasks: a) the patient is asked to move his head while focusing at the examiner’s nose; b) the nystagmus is measured on lateral gaze, and c) one of the patient's eyes is covered with the hand while the other eye will focus at the examiner’s  nose and then the other eye is suddenly uncovered. On the understanding that family physicians and emergency room doctors know how to do this (and they probably do) the essential neurological examination before a persistent vestibular syndrome, should be aware that the study published by the team Newman-Toker in the Stroke journal states that HINTS has shown 100% sensitivity and 96% specificity so that the doctor can rule out the vertebrobasilar stroke in people with acute vestibular syndrome, values exceeding those of nuclear magnetic resonance.

Saving Plans: 5 Errors and 5 Proposals

Remember the games of the analogue times, precisely the moment when the player put the piece in the wrong place and there came a warning sound and the red light lit up the nose? Now it looks like a naff old thing, but I liked that Robert Kaplan and Derek Haas have chosen the image of one of these games, precisely one that is for operating a patient and that they have chosen it to illustrate their article published in the Harvard Business Review blog, "How not to cut health care costs".

When faced with budget cuts, they say, health managers around the world apply the same recipe: reducing staff costs (both in numbers and in wages), optimize the use of space to save general services, stop investments and rationalize spending. The authors do not maintain that this package of measures is poorly done, but they question whether behind these policies there isn’t a strategic way of thinking that combines resources to achieve the best results in the most efficient manner possible and the efforts of the basic savings pack can become counterproductive for the health of people and also for the economy of organizations.

Therefore, we should appreciate that the article analyzes five errors of the basic savings pack, while proposing five alternatives focused on efficiency and effectiveness.

Hospital general vs factory hospital

In the post October 5, I explained how, according to the report "Future Hospital Commission" (Royal College of Physicians 2013), it would be ideal that, as soon as possible, the organizational models of the hospitals would be able to evolve in two directions: a) about one third of the health care activities should apply techniques of industrial quality, and b) the other two thirds of patients admitted (complex case-mix) should be treated radically differently from how it is done now, given the shortcomings of the work organization in the hospital wards.

In the current model, each admitted patient has a medical service and a medical specialist assigned. The clinical activity of this medic develops primarily through the clinical course of medical orders (including requests for evidence and pharmaceutical prescriptions) and through interdepartmental advice from colleagues from other specialties. As for the nursing work , there are several intensity models ranging from a major involvement in the clinical process to a trivial change of shifts.

Summary of the limitations of the current model of care for inpatients and the arising risk situations:

1. The allocation of a medical specialist doesn’t guarantee at all the care continuity because many of these specialists also have their other technical functions, specific to their speciality that are often more attractive that visiting the wards.
2. The guards’ medical model does not guarantee the maintenance of a homogenous quality of care, nor at night, nor on holidays.
3. The interdepartmental work, generally means little involvement. Specialists try to fulfil the commitment with an opinion and, rarely, joint clinical work derives from this activity.
4. In many hospitals, nurses have a working commitment to the continuity of care quality for admitted patients but this is not universal, and great variations between centres are detected.
5. Inpatients often undergo changes of bed, or even ward changes for reasons of centre’s logistics organization, and this fact is known to subject the patient to avoidable risks.
6. The quality of transfers of complex patients from the hospital to their homes is not guaranteed in all places and at all times.

Factory Hospital vs General Hospital

The report "Future Hospital Commission" (Royal College of Physicians 2013) proposes organizing hospitals into two distinct divisions. According to the described model, patients would enter two alternatives doors that lead to almost opposite paths: a) there would be a specific route for standard processes (lower part of the graph), such as: laparoscopic procedures, hemodynamic, scheduled surgeries, stroke codes, heart attack codes, etc, and b) the other route would be for patients admitted through the emergency room (except the codes) or suffering complexities that require general assistance, with the occasional support of specialists (the trajectory above the graph).

This proposal seems not only timely, but also hospital models nowadays are or should be largely along this line. But the publishing of an article in Health Affairs, signed by a team from the service of Cardiac Surgery at Mayo Clinic, has led me to consider that we should advance more in the methodology inherent to each of the two paths. This referenced work is titled: "From "Solution Shop" Model to "Focused Factory" in hospital surgery. Increasing care value and predictability", or the equivalent of a study of the evolution from store solutions where every client is different and requires a tailored response towards the targeted factory that uses the methodology of an industrial process. And this is where the Mayo Clinic are pushing the  accelerator: if we are able to indicate certain clinical procedures for well-defined types of patients –they say– we ought to know how to prepare to act with criteria of maximum efficiency and effectiveness.

ICU: the elasticity of demand

The intensive care units are the most expensive health system resources, and it’s logical that both the funders and the general public wonder whether the way these are used meets their full potential. But, despite this interest the data in this area are sadly rather scarce. Of the few that I have had access to, I will highlight two: a) the variations are impressive: in the US the cost of ICU represent 1% of GDP, while in the UK only 0.1%, ten times less b) misuse, or if you prefer - therapeutic obstinacy towards the end of life of people with chronic diseases- is detected; continuing in the United States, it’s estimated that between 13% and 35% of chronic patients die in an ICU, or they die in a hospital bed after being admitted to the critical care unit (J. Wennberg. Tracking Medicine. Oxford University Press, 2010).

Two intensive carers at the University of Pittsburgh, Dr. Rebecca Gooch and Dr. Jeremy Kahn, published in JAMA a conceptual model on the elasticity of demand for ICU admissions. In a 2x2 table they’re showing the severity of the disease crossed with  the chances of survival.

Low cost medicine "made in India"

By Josep Mª Monguet

On 25th February, the first building of the Health City hospital complex which plans to grow up to 2,000 beds and be accredited by the JCI, offer all kinds of advanced tertiary health services and even open their own university, was inaugurated in the Cayman Islands. But what really draws the attention towards all of this is the origin of the initiative, which is none other than innovation in the health business model from India. Between 2001 and 2012, Narayana Health, a project led by Dr. Devi Shetty evolved from a 300-bed hospital in Bangalore to an aggregate of 6,000 beds in 17 hospitals, 80,000 patients and 3,500 interventions per month. And now they have switched their antipodes to enter the global market, offering, via a one and a half hour flight from the United States, open-heart surgery, prosthesis or neurosurgery, for obviously very competitive prices.

Telehealth, only expectations for now

The technology of data transmission is experiencing an explosion in all areas of social and professional activities and, of course, the specialised industry can see a big opportunity for introducing it as a tool for improving life quality of chronic patients. Doubts, however, appear in the minds of the funders of health services as they see themselves forced to adopt new investments in electronics, which have not yet been able to demonstrate good enough clinical results to compensate the effort.

Seen this way, it seemed to me that in this article about telehealth, it is appropriate to discuss two papers, one English and one Catalan, which aim to answer the question of whether the investment is worthwhile.

This article about findings from the Whole System Demonstrator, project led by Nuffield Trust researchers which sought to evaluate the clinical effect of home interventions with remote data exchange between patients and professionals (telehealth). The project was carried out with the collaboration of 3,230 patients with diabetes, COPD or heart failure from three geographical areas (Cornwall, Kent and Newham) over a 12 month period between 2008 and 2009.

Back to Sutton’s Law

Last week we saw the status quo bias starting from the article "Assessing Value in Health Care Programs". Remember that this bias is due to the human tendency to keep doing things as usual, without questioning too much the meaning of what is being done.

But in this post I want to talk about exactly the opposite innovative attitude and the difficulties inherent to the changes in an environment as segmented and as regulated as the health system. For this reason I have chosen three examples that illustrate the obstacles that many professionals must overcome when they are eager to change routines or adopt a new drug they know is supported by scientific evidence. But the problem is that to adopt the novelty, investments are required, or simply more budget because the new drug is more expensive. So the question is: who pays for the novelty when we were told that we can not spend more?

Example 1 - Adherence to treatment

Let’s consider a program that may improve adherence to treatment, which barely reaches 45%, after myocardial infarction (Volpp 2012). Let’s imagine that a new program foresees increasing this adherence to up to 70% and as a result there would be a 10% reduction in readmissions both for new myocardial infarction and for stroke or revascularization, with a cost reduction that could collect savings for the association of $2,000 per case per year. Does this mean that the program should not be approved if its cost would be $3,000 per case and year?

Better health per dollar spent

"Better health for dollar spent", Michael Porter’s celebrated phrase, summarizes, like no other quote, the spirit of the current focus of clinical management. Porter is a professor at the Harvard Business School renowned worldwide for his work on company strategy and competitiveness. This professor shocked the world of health services when in 2006 he published ”Redefining Health Care", a book in which the author put his finger on the pulse of the American health care system, when he said he did not understand the organization in specialties that had little to do with the needs of patients. Neither did he understand how there were no indicators to measure the value that the ”health industry” contributed to the people’s health, nor how the clinical activities are remunerated per volume of work done, regardless of achieved health outcomes.

In an article in JAMA in 2007, Porter said that competitiveness in values ​​is the basis of the economy and that in the health system only the doctors can achieve it, if they set themselves the goal that clinical activities have a final purpose and not a meaning in themselves. 

Waste, the oncologists say

"In first world countries, cancer treatment has adopted a culture of excess: excess in diagnosis, excess in treatment, excess in promises"

The chosen title belongs to the report that “The Lancet Oncology Commission" published and which was signed by a large group of oncologists. In the excerpt below you can see on the right, the heading of the list of authors that extends over two pages.

This is an important document critically reviewing all aspects of approaching cancer in Western countries: the cost effectiveness, the use of technology, the mad race of the new drugs, the adequacy of the research, the role of medical oncology, the surgery, the radiotherapy, the genomics, the palliative, but mostly the question that the authors pose is whether the path followed by oncology is the most appropriate, and if as a society we can afford it.