Medical services, an anachronism

Jordi Varela
Editor

 

@varelalaf

Clayton Christensen says that if you want to be efficient, you have to offer services as close as possible to where the need arises. Michael Porter and Thomas Lee, for their part, defend the creation of Integrated Practice Units (IPU), while those of Corporate Rebels affirm that attractive projects are made because of the commitment of professionals and not because of the hierarchical command structure. This post is contrary to the status quo of hospital organization charts and, for this reason, I have chosen these three references that, from various perspectives, direct us against centralism, corporatism, and the hierarchy that current medical services give off, anchored in a vision more typical of the last century than of the demanding complexity of today's health problems.

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.

Why is the integration of services not encouraged?

Jordi Varela
Editor

 

@varelalaf

Health and social services are fragmented between various institutions, levels of care and a lot of specialities and each one of the fractions of the system provides a service that makes sense in itself, such as a three-hour weekly service of a family worker for lending a hand at the home of an elderly person who lives alone, or angioplasty intervention for a woman who has just suffered a myocardial infarction and, according to this system, funders pay differently for each activity.

How to inform, persuade and remind about COVID-19 vaccination

Pedro Rey
 

@varelalaf

After a year in which the fight to control the transmission of COVID-19 has set the agenda, the debate is now focused on how to get a sufficient percentage of the population vaccinated to achieve the so-called "group immunity" as soon as possible. The objective now goes to the supply side: it is about establishing the sequence in which different population groups should be vaccinated (and with which vaccine each one) and making sure that the prioritization is fulfilled. We must also resolve as soon as possible how to eliminate bureaucratic obstacles so that vaccines are more easily accessible, more operational from a logistical point of view and can be purchased by the states at a reasonable price. However, solving the supply problem will be futile if we fail to stimulate demand so that the effective vaccination rate is as high as possible. For this, it is essential to understand both how the potential vaccination subjects behave ‒guided by their beliefs, their perceptions about safety and risk and by their cognitive biases‒ and in what way we can influence that behaviour to guide them towards the socially desirable direction that allows the reduction of disease incidence. 

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.

Providing courage, balance and humanity in the emergency services

Nacho Vallejo
 

@varelalaf

Urgency is a unique environment in healthcare. It works intending to deal with situations that can put the person's life at risk, but it’s also a "safety net" or, as we have defined it on some occasion in this blog, "a refugee camp of the health system". The care for people in this field of health isn’t only due to pathological and physiological disorders, but sometimes those who go to the emergency room do so as a consequence of dysfunction of our healthcare system that manifests itself with "collateral damage" derived from poor accessibility and, in other cases, from an excess of activity.

Centralisation of complex surgery: clear, obscure and proposals

@varelalaf

A large group of European and North American surgeons have published in Annals of Surgery a review of the difficulties of centralising complex surgery around the world. The complex issue has multiple actors, starting with governments and respective funding models and continuing by the hospitals, the doctors involved and their corresponding scientific societies. It is surprising, however, that patients rarely appear in such discussions.

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.

For a more conservative medicine

@varelalaf

Last week I discussed the influence of machine learning on clinical practice, a dynamic loaded with chiaroscuro and, for this reason, I think it is worth echoing today the manifesto "The case for being a medical conservative" written by four doctors: John Mandrola (cardiologist), Adam Cifu (internist), Vinay Prasad (oncologist -haematologist) and Andrew Foy (cardiologist). The authors clarify that their manifesto has nothing to do with politics, but that, given the dazzle of technology and the pressure of consumerism; they are forced to embrace conservatism, a way of saying enough when nobody is willing to do it.

"Machine learning" and clinical practice

@varelalaf

Machine learning is a branch of artificial intelligence based on the idea that systems can learn, identify patterns and make decisions with minimal human intervention, as is the case, for example, with weather forecasting. When I was little, the men of the time (then there were no women in these jobs) drew isobar lines on a blackboard where they had made their predictions based only on their experience and the four sources of data that came to them from the meteorological observatories. Now, as the forecasts are made by the models, meteorologists have enough time to comment on photos sent by viewers, in addition to raising awareness of the effects of pollution and climate change.

Hospitals need internists with a broader view (and functions)

@varelalaf

Internal medicine is a speciality of long tradition and the mother of almost all non-surgical specialities, so what is expected of it is to provide a general vision in the hospital care of complex patients. The internists are formed under the principle that no adult clinical issue is foreign to them, although they cannot cover in-depth all the knowledge and techniques that are available to modern medicine, so they should lead, more than they do now, multidisciplinary teams, to offer complex patients comprehensive care, instead of having to suffer the sum of multiple often uncoordinated actions.

Primary care: the law of reverse healthcare 49 years later

@varelalaf

The current primary care operation system guarantees citizens that they will be able to see their family doctor, or whoever replaces them, whenever they deem it convenient and, in this way, doctors, in their day to day, are faced with an agenda full of unfiltered visits, a source of widespread dissatisfaction, both for the neediest patients who feel under-served, as well as for doctors, who waste too much time in resolving matters that are not their own, not forgetting that, in this scenario, nurses are relegated to a secondary role.

Surgery and the elderly

@varelalaf

More and more elderly people are being seen in the operating room, especially for large joint replacement interventions, for colorectal cancer resections or for vascular pathologies, to cite the most frequent casuistry. Many of these actions are aggressive and generate risks of postoperative complications, which often require catheters, serum, transfusions, intubations, etc. Therefore, a lot of clinical circumstances are generated that induce immobilization, a situation that adds a new chain of risks, especially thromboembolism, bedsores, infections, disorientation, delusions, malnutrition and dehydration.

30% of digestive endoscopies have questionable indications

@varelalaf

In an article in the series "Less is More" by Gastroenterology, three digestiologists, Shaheen, Fennerty and Bergman, after an extensive review of the literature, conclude that 30% of digestive endoscopies have questionable indications. According to the authors, many clinical practice guidelines stimulate the exaggerated consumption of these tests in clinical situations of doubtful indication, such as recommendations for the follow-up of low-risk patients of Barrett's disease (oesophageal reflux), which they say they are "carefully misleading." On the other hand, the prevailing cancer phobia places a lot of pressure on the examination rooms, which are permanently overwhelmed, not only by inappropriate requests but by follow-up guidelines that anticipate the requirements demanded by the clinical practice guidelines themselves.

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.

The early diagnosis of colorectal cancer, thirty years later

@varelalaf

Health systems have long-planned population programs for the early detection of certain cancers through diagnostic techniques arising from the clinical setting, such as prostate-specific antigen (PSA), mammograms, ultrasound or the study of faecal occult blood that is the case at hand. This issue is generating confusion in society because one thing is to take care of one's health and the other, quite different, is to undergo medical tests to discover tumours in their early stages. On the other hand, discomforts are also generated among professionals, because it’s not the same to treat patients who seek help for health problems, than to propose extensive tests to the healthy population.

Hospital emergencies: the refugee camp of the healthcare system

@varelalaf

The society witnesses the emergence of population groups with social and health care needs that are difficult to fit in the current model of service offer. Thus, we see how fragile and vulnerable people are picked up by ambulances and go to hospital emergency rooms, which become like refugee camps, as Sara Kreindler, head of health systems innovation research at the University of Manitoba (Canada), likes to call them. Many initiatives, observed everywhere, aim to put an order in these refugee camps of healthcare: implantation of triage, observation units, geriatric units, new case management nurses, nurses trained in geriatric evaluation. To help us analyze a problem that we don’t know how to address, Sara Kreindler has developed a qualitative study in the framework of a region of Canada. The study has concluded that partial interventions aiming to improve the flow of urgent care for patient’s complex show three paradoxes:

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.