Deconstruction of primary care

The renowned Harvard professor Michel Porter, with the collaboration of two GPs, one veteran, Thomas Lee, and the other on training, Erika Pabo, applied to primary care their well known proposals of adding value to clinical performances. Their article, published in Health Affairs, caused me to act cautiously because I didn’t believe any American proposal of reforming primary care could benefit us as we enjoy a much more evolved model. But when I noticed that the first author was Michael Porter, I couldn’t help taking a look.

Primary care (gatekeeper type), Porter and his colleagues say, is now served on a single dish, like a stew (they don’t actually say that). Continuous care prevails, always the same chef for every meal, an almost artistic development, case by case, plate by plate. According to them, this makes it difficult to measure the provided value. On the other hand, the most common model in the US, where the patient goes to a specialist in their own terms, is chaotic and promotes a disproportionate consumption of resources.

Recommendations against low value clinical practices. Are they useful?

As the Choosing Wisely campaign enters its final stages, Owen Dyer looks at whether it can change practice http://t.co/B8BfPvPdED
— The BMJ (@bmj_latest) October 4, 2013

Owen Dyer, a journalist and regular contributor to the British Medical Journal, following the Choosing Wisely campaign from the ABIM Foundation (a list of recommendations for clinical practice that both doctors and patients should question) in the US, makes an assessment of whether the lists of recommendations against low value clinical practices will manage to change the status quo or, on the contrary, the dynamics of the system will engulf them as it has done with many other initiatives.

The Hospital of the Future: New Report (UK)

Sir Michael Rawlins, Chairman of the National Institute for Health and Care Excellence (NICE) since its inception in 1999 until last year, is now Chairman of a committee called "Future Hospital Commission" which has been promoted by the Royal College of Physicians. In September 2013 this committee issued its first report and I think it’s worth discussing.

For starters, it seems appropriate to pick up the 5 challenges that hospitals are facing nowadays according to a previous Royal College of Physicians’ report:

1. Increased demand in an environment of reduced number of hospital beds

2. Case mixe’s gradual and persistent advance towards chronic diseases and geriatrics

3. Difficulties of coordination and continuity of services for admitted patients.

4. Services of uneven quality in the evenings and at weekends

5. Imminent crisis of professionals and training of new professionals

To face these challenges, according to the "Future Hospital Commission", the hospitals should consider reorganization based on the following principles:

Medicine focused on patient preference: visual aids

Use visual aids to teach patients and improve decision making http://t.co/lzCBq9URpG
— Kevin Pho, M.D. (@kevinmd) September 29, 2013

Some argue that the great innovation in this second decade of the twenty first century should be medicine based on patient preference. To understand it better, it’s about women being well informed of all probabilistic knowledge regarding the decision to have a mammogram screening or not. Therefore it is the woman who takes responsibility for her decision and not the government or insurance company of her choice. The same would be said for men and the PSA.

This approach would seem reasonable enough, if it were not for the fact that, according to a particular US survey (National Adult Literacy Survey), half of the population has difficulty in managing simple numerical operations. For this reason I have chosen this blog post by Kevin Pho, who has always been innovative in the field of clinical management, who presents an article by Peter Wei, a medical student, who gives us a visual aid developed by the Mayo Clinic. You can argue that those who struggle with mathematical operations will also have difficulties interpreting graphs, but if the graphics are designed to be understood its less of an issue and if that is not the case, consider the following:

High Value Healthcare: Porter and Lee proposals

Michael Porter, professor at Harvard Business School and Thomas Lee, Medical Director at Press Ganey, an organization aimed at improving the patient healthcare experience, published an article on the HBR Blog Network:  "Why health care is stuck and how to fix it". These two teachers, tired of analyzing the stubborn (and chaotic) reality of the American healthcare system, have decided to focus on making strategic proposals to change things.

How can it be that with so many good and well-intentioned people involved in reforming the American health system, they can’t find a solution? Almost the opposite happens: it seems that the opposing positions are increasingly reinforced.

The authors ask this rhetorical question, although they, far from disenchanted, still insist on the idea that solutions can only be systemic, as this is where the problems lie in the model.

Oncological Care: What does the IOM Report reveal?

Ten years after the first report, the Institute of Medicine has published a new study on the quality of cancer care in the United States, forced, according to experts, because the situation is far from improving. To better understand this work, we have to contextualize it in the United States, where they have serious problems of access to cancer care, coordination between professionals and exaggerated costs of clinical processes.

On the other hand, cancer care in our country is, obviously, more accessible and more coordinated than the United States, but nevertheless you will agree with me that we lack, by contrast, the evaluation and analytical capacity of Americans, and for this reason I believe that the findings presented in this report should teach us something with the intention of overcoming our own inefficiencies, because we do have them.

The IOM expert committee concluded that the model of cancer care in America is in crisis, mainly due to three factors: a) the clinical process too often does not focus on the patients’ preferences, b) many patients only receive palliative care at the end of life, and c) clinical decisions too often are not based on evidence.

"The Right Care Alliance" – The Statement of Principles

In 2012, The Lown Institute held a conference in Cambridge (Boston) with the motto "Avoiding Avoidable Care” which generated a statement aimed at creating a professional, academic and social movement in favour of a new health system that is sustainable, effective, rational, personalized and fair. You would think, of course, that the The Lown Institute refer only to the American system, which we all know is deeply unfair and expensive. And this would be so, if it wasn’t for the fact that, in a system like the Spanish, which is infinitely fairer than theirs, when we analyze it in detail we can also note the clinical practice’s undesirable variations of a scale comparable with the American’s.

For this reason, I think it's worth having a look at the statement promoted by The Lown Institute: "Declaration of Principles of the Right Care Alliance". Look at the following extract from the explanatory memorandum of the Declaration and judge whether they are timely or not:

• Modern medicine offers significant benefits, but at the same time also has a great ability to cause damage.
• The overuse of services is widespread and tacitly accepted by the modern healthcare system
• Overuse exposes patients to iatrogenic disease.
• Overuse distracts resources that could be used in real health needs or in investments in other non-health sectors that influence the health of people as social services, education, nutrition, etc.
• The health sector industry can distort clinical decisions to the point of betraying patients’ trust.