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.

Medicine based on customs

@varelalaf

The universe of my childhood was full of incontestable rules; most of them had to do with the precepts of religion, although the matter affected all aspects of daily life. I remember that you could not bathe in the sea or in the pool if you had eaten or drank within a minimum period of two hours, a period that the strictest families extended to three. When you were a teenager and you protested, the parents told you all kinds of calamities that could happen to you if you failed to comply with the rule, according to a lot of legends that were passed down from generation to generation.

Life quantity or more quality?

Ventricular assisting devices, VAD, or LVAD if for the left ventricle (the most common) are implantable instruments that help pump blood in situations where ventricular ejection force is severely compromised. In some cases the implantation of an LVAD facilitates the waiting for a cardiac transplant, but in others it’s adopted as a definitive solution. The price of the device is around $150,000 while the cost per QALY (cost per year of life earned) is between $200,000 and $400,000. The cost-effectiveness studies still don’t line up much, but the range of documented amounts is nowadays far above the $30,000 of Spanish per capita income. Remember that the WHO introduced the criterion of considering if a treatment is cost-effective when it doesn’t exceed three times the per capita income of a country.

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.

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.

____________

(*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).