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21 junio, 2013

Health Information Technology and Patient Safety

03 mayo, 2013

Overdoing prevention: Beware of regular check-ups, healthism by numbers and genetic profiling

Medicine Drug Pills on Plate (Photo credit: epSos.de)

Overdoing prevention: Beware of regular check-ups, healthism by numbers and genetic profiling

Author : Pierre Biron © 2013

Affiliation : Honorary professor, Faculty of Medicine, Université de Montréal, Montreal, Canada

Full Text

Humane medicine as usually practised by general practitioners is a threatened species. In the old days doctors observed their patients in the circumstances of their lives; at least they watched them walk from the waiting room into the consultation room and they listened more than 123.4 seconds before interrupting them.

Another historical period bore witness to a technological medicine centred on systems, organs and cells, practised by true engineers of the human body, these second- and third-line specialists better paid than a dedicated general practitioner with a good clinical judgment. Medical progress became synonymous with medical specialisations in hospital settings which required expensive machines, expensive drugs and expensive training programmes to learn their use. High-technology fragmented care saves lives but treats Homo Mechanicus.

In the wake of the craze for a healthy lifestyle (mostly associated with our social, economical, educational and environmental status), we’ve entered another period characterized by proactive laboratory-based preventive measures based on schedules to screen for anomalies in plasma molecules, in body images and soon in genetic material, in hot pursuit of markers and risk factors, the significance and utility of which will unquestionably be exaggerated by interested parties.

It is your dossier that is dealt with, and nobody asks you any more how you’re getting on in general; no interest is shown in your social or economic situation, your living environment or habits, whether you live alone; nobody inquires about the stability of your job or your relationship, nobody even touches you any more [1], and nobody wastes any time over non-verbal signals that might differentiate a real depression from a bout of hypochondria.

The ritual stethoscope is applied over the clothes, missing a melanoma brooding on the back; the pulse is felt half-heartedly, a hand is passed over the abdomen without conviction, the blood pressure taken rather too swiftly, the lymph nodes are not systematically palpated, the breasts are examined too coyly. Your life, your body, your worries are less important than your blood assays, your body images, your answers to simplistic questionnaires.

Following the successful dissemination of medicalization (disease mongering), the giving of disease-names to all the natural symptoms that may well be turn up in the course of a life, wealthy societies are now facing prevention zealotry, based on test results and known as health by numbers.

An ideology maintaining that any aberrant value in your specimens is a disease that ought to be treated. If your health check is within standard values, then you are in good health.

If not, you ought to follow official recommendations and make sure your results return to the accepted range. The way is now open for a general intimidation of the population and for considerable wealth for the sponsors of preventive medicines, which a decade ago was already qualified as presumptuous, authoritarian and overbearing by a father of evidence-based medicine.[2]

08 marzo, 2013

Evidence Based Medicine: what is it and what isn´t

English: German Network for Evidence Based Medicine Deutsch: Deutsches Netzwerk Evidenzbasierte Medizin (Photo credit: Wikipedia)

Evidence-based medicine (EBM) (sometimes called evidence-based health care or EBHC to broaden its application to allied health care professionals) has been defined as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."^[1]^[2] Trisha Greenhalgh and Anna Donald define it more specifically as "the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients."^[3]
EBM seeks to assess the strength of the evidence of risks and benefits of treatments (including lack of treatment) and diagnostic tests.^[4] This helps clinicians predict whether a treatment will do more good than harm.^[5]
Evidence quality can be assessed based on the source type (from meta-analyses and systematic reviews of triple-blind randomized clinical trials with concealment of allocation and no attrition at the top end, down to conventional wisdom at the bottom), as well as other factors including statistical validity, clinical relevance, currency, and peer-review acceptance. EBM recognizes that many aspects of health care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to quantitative scientific methods. Application of EBM data therefore depends on patient circumstances and preferences, and medical treatment remains subject to input from personal, political, philosophical, ethical, economic, and esthetic values.
Because EBM is used in allied fields, including dentistry, nursing and psychology, evidence-based practice (EBP) is a more encompassing term.

16 diciembre, 2011

2011: was the year that…

Lancet, Volume 378, Issue 9809, Pages 2062 - 2063, 17 December 2011

doi:10.1016/S0140-6736(11)61889-8

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2011: was the year that…

This year had a heady mix of health reforms, revolutions, groundbreaking research in HIV and spinal cord medicine, and a world population milestone. Udani Samarasekera reports.

Goodbye NHS

On Jan 19, UK Health Secretary Andrew Lansley unveiled the Health and Social Care Bill. The legislation dictated a massive shake-up of the National Health Service (NHS), which included putting general practioners in charge of commissioning health services and allowing price competition between state and private health-care providers. Many health professionals felt reforms of the speed and scale outlined in the bill were unnecessary, damaging, and tantamount to privatisation of the NHS. The hugely unpopular bill united health-care professionals in England in protest, with many taking to the streets throughout the year. Minor changes were made to the draft legislation after a public “listening exercise” in June. In October, in a letter in The Telegraphrepublished in The Lancet, more than 400 of the country's leading public health experts urged the House of Lords to reject the legislation. As The Lancet went to press, the bill continued its passage through parliament.

Au revoir French drug scandals?

The fallout from France's Mediator (benfluorex) scandal continued this year, with the publication of a damning report in January by accountability organisation Inspection Générale des Affaires Sociales. The report criticises drug manufacturer Servier for deceptive marketing of Mediator and the French drug regulator for being an ineffective and overworked bureaucracy. Mediator, used as an adjuvant for diabetes, might have contributed to the deaths of 500 people from valvular heart disease in its 33 years on the market by conservative estimates. France pulled the drug in November, 2009, years after other countries had made the move. From March to May this year, a national consultation about the regulation of prescription drugs culminated in a bill by French Health Minister Xavier Bertrand in August to overhaul the drug regulatory system. The legislation called for a crackdown on conflicts of interest, restructuring of the French drug regulator, and improvements in drug licensing processes and post-approval monitoring.

Arab Spring

Starting on Dec 18, 2010, the wave of uprisings across the Arab world has been a defining event of 2011. This year has seen revolutions in Tunisia and Egypt, civil war in Libya, and major uprisings in Bahrain, Syria, and Yemen. Smaller protests have also occurred in other Arab countries. Health and humanitarian concerns remain high in the region. According to WHO, at least 50 000 people are thought to have been wounded during the Libya conflict, 20 000 of them seriously. Conflict-related injuries remain the country's main health priority, followed by non-communicable diseases—due to lack of health staff, drugs, and medical supplies—and mental health. In Bahrain, health professionals have been targeted in crackdowns by government forces whereas hospitals have become places of torture in Syria, according to a recent report by Amnesty.

Full-size image (53K) AFP/Getty Images

Disaster in Japan

At 05:46 GMT on March 11 a magnitude 9·0 earthquake struck off the coast of northeast Japan—the country's most powerful earthquake in recorded history. The large tsunami that followed caused widespread destruction to buildings and communications and transport infrastructure. The Fukushima Daiichi nuclear power plant, 240 km north of Tokyo, was damaged and all six reactors had failures of their cooling systems, releasing radioactive material into the area. Several hospitals were also destroyed and other health services faced challenging circumstances such as loss of electricity and lack of essential supplies. The disaster killed more than 16 000 people, and displaced more than 100 000 others. Many of the displaced survivors were elderly people who were housed in temporary accommodation as temperatures plummeted during the Japanese winter.

HIV treatment as prevention

In May, results from the phase 3 HPTN052 trial provided definitive proof that highly active antitretroviral therapy (HAART) can prevent the sexual transmission of HIV in serodiscordant couples when one is HIV positive and the other negative. The study involved 1763 couples at 13 sites in nine countries in Africa, the USA, and Asia. The trial was stopped early by the international data and safety monitoring board after it showed that immediate HAART given to the HIV- infected partners at a CD4 cell count between 350 and 550 cells per μL could reduce the sexual transmission of HIV by 96%—the primary endpoint. Immediate HAART was also associated with a 30% decrease in the combined endpoint of disease progression and death and an 83% reduction in incidence of pulmonary tuberculosis.

Small steps, giant leap

In May, Susan Harkema and colleagues reported in The Lancet that electrostimulation of the spinal cord of a patient with paraplegia along with task-specific training led to several minutes of standing and fairly coordinated stepping without any input from the brain. 23-year-old Rob Summers became paraplegic after being hit by a motor vehicle in 2006 and showed no spine-controlled leg movement despite 2 years of rehabilitation. However, continual direct electrical stimulation from a surgically implanted epidural array in his lower spinal cord was able to mimic signals that the brain normally transmits to initiate movement. As noted in an accompanying Comment, the level of recovery achieved in this case study was “unprecedented”.

Europe's E coli outbreak

The European summer was seriously disrupted this year by a novel strain of Shiga-toxin-producing Escherichia coli. On May 22, Germany first reported a substantial increase in patients with haemolytic uraemic syndrome and bloody diarrhoea caused by enterohaemorrhagic E coli O1O4:H4. Between May 22 and July 21, the virulent strain caused 4075 cases of infection and led to the deaths of 50 people, mainly in Germany with some cases elsewhere in Europe and in North America. The source of the outbreak was eventually traced to bean sprouts produced at a German farm but only after several vegetables were erroneously blamed, including raw tomatoes, lettuce, and Spanish cucumbers. As an Editorial in The Lancet put it: “communication surrounding the outbreak has been haphazard at best, dismal at worst.”

Donors give to GAVI

There was good news for the GAVI Alliance in June when donors committed substantial new funds to the organisation during apledging meeting in London, UK. The meeting, attended by UK Prime Minister David Cameron, raised US$4·3 billion, exceeding the $3·7 billion target. The funds will allow GAVI to expand its portfolio to include vaccines such as those against the human papillomavirus that causes cervical cancer. Meanwhile, for other multilaterals, it was a disappointing year: the Global Fund to Fight AIDS, Tuberculosis and Malaria announced suspension of its latest funding round because of a lack of donor support.

Famine declared

The worst drought in 60 years in the Horn of Africa, coupled with conflict in Somalia, left more than 13 million people in need of food or humanitarian assistance in July. On July 20, the UN declared famine in two regions of Somalia, southern Bakool and Lower Shabelle. It was the first time that the UN had declared famine in a part of Somalia since 1991—92. Across the country, nearly half the Somali population—3·7 million people—remain in crisis. In October, the UN Office for the Coordination of Humanitarian Affairs stated: “The famine in the Horn of Africa remains the biggest crisis in the world today…The regional aid effort will need to continue well into 2012, both to meet immediate needs and—in the longer-term—to tackle the underlying problems and vulnerabilities which have put so many people in danger.”

New York, New York

On Sept 20, heads of state and governments made progress on global efforts to tackle non-communicable diseases (NCDs) at the UN High-Level Meeting of the General Assembly of the UN in New York, NY, USA. Countries approved the Political Declaration on the Prevention and Control of Non-communicable Diseases. However, many health experts and observers were disappointed that no time-bound targets appeared in the final document, not even the very broad one proposed by the NCD Alliance, of a 25% decrease in NCD deaths by 2025. WHO is now charged with developing voluntary targets for member states to reduce the burden of NCDs and for establishing a process to monitor progress by the end of 2012.

A vaccine for malaria

Promising interim results from a phase 3 trial of GlaxoSmithKline's experimental vaccine against malaria were published in theNew England Journal of Medicine in October. The study showed that the RTS,S/AS01 vaccine roughly halved the risk of clinical and severe malaria in African infants aged 5—17 months a year after vaccination. However, meningitis and generalised convulsive seizures occurred more frequently in those receiving the RTS,S/AS01 vaccine than in the control group, and the vaccine did not reduce deaths from malaria. The data for 6—12-week-old infants are due to be reported next year, and the full trial results in 2014.

Full-size image (38K) Corbis

7 billion and counting

The end of October saw the world's population hit 7 billion people, according to the UN Population Fund (UNFPA). The planet's human population has almost doubled during the past 50 years. Average life expectancy has increased from about 48 years in the early 1950s to about 68 years in the first decade of the new century. Infant deaths have decreased from about 133 in 1000 births in the 1950s to 46 per 1000 between 2005 to 2010. The number of children a woman has also fell from about 6·0 to 2·5. But despite these successes, UNFPA note that poverty gaps between rich and poor people are widening everywhere. Things are only set to get bigger (and hopefully better): the UN foresees a global population of 9·3 billion people in 2050, and more than 10 billion by the end of this century.

Full-size image (21K) Reuters

14 diciembre, 2011

En epocas de ajustes......alguien entenderà esto ?

Image via Wikipedia

The Savings Illusion — Why Clinical Quality Improvement Fails to Deliver Bottom-Line Results

Stephen S. Rauh, M.B.A., C.F.A., Eric B. Wadsworth, Ph.D., C.P.A., William B. Weeks, M.D., M.B.A., and James N. Weinstein, D.O.

December 14, 2011 (10.1056/NEJMp1111662)

Article
References: It has become a core belief in U.S. health care that improving clinical quality will reduce health care costs. It seems intuitive that reducing readmissions, shortening lengths of stay, and building efficiency into clinical processes will reduce resource utilization and thereby lower costs. Certainly, evidence suggests that there is no association between high quality and high costs.1 Yet true bottom-line savings from improved clinical quality rarely materialize, and costs continue to climb. Manufacturing and service companies around the world have demonstrated the cost benefits of improving product quality and production efficiency. So why haven't nearly two decades of work on improving health care quality had a measurable effect on health care costs?
The explanation lies in the cost structure of the typical health care setting. Its management and organization create a rigid cost structure that is relatively insensitive to small changes in patient volume, resource use, or the severity of patients' health conditions. This fixed-cost dilemma leaves most health care costs insensitive to changes in volume and utilization, so clinical quality improvements typically create additional capacity rather than bottom-line savings.2 An examination of the different cost layers highlights the distinction between variable costs, such as supplies and medications, where reduced use produces true savings, and fixed costs, such as facilities and ancillary services, where the costs persist despite reduced use.
To better understand the cost structure of health care delivery, it can be useful to consider how different costs behave depending on the degree to which they are sensitive to changes in resource utilization. The four cost layers we have identified are defined in the tableBehavior of the Various Cost Layers in the Health Care System..
Clinical improvements that reduce layer 1 costs, such as those of supplies and medications, will generally create bottom-line savings, since these are the only truly variable clinical costs in a hospital. To generate savings by reducing use of the resources that account for layer 2 costs, the need for the resource must be reduced enough to allow elimination of a payable unit. For instance, a single nursing unit might have to discharge multiple patients before any savings in hourly nursing labor costs could be captured by allowing an hourly employee to go home early. Reducing layer 3 resources — those for equipment, operating-room time, or physicians' salaries, for example — almost always produces additional capacity without bottom-line savings. If an intervention reduces operating-room time by 15 minutes, the costs of the equipment and salaried staff required to run the operating room do not change. Nonclinical layer 4 costs are primarily fixed in the short run, but reducing administrative labor costs by achieving administrative efficiency will produce true savings in future operating cycles.
Because of these cost behaviors, quality-improvement efforts that reduce lengths of stay or readmissions or increase radiology throughput do not create substantive bottom-line savings. They generally create capacity to treat additional patients. Similarly, efforts to expand the access of disadvantaged populations to primary care under the assumption that such access will be paid for through avoiding use of high-cost care sites — such as emergency departments — do not generate cost savings. The cost of staffing and equipping an emergency department does not change if there are small reductions in utilization. Indeed, improved access will increase health care costs if new physicians and staff are hired to serve new patients in primary care practices.
Although capacity creation does not generate bottom-line savings, it does create an opportunity to admit another patient and collect additional revenue. Because health care costs are relatively fixed and do not change much at the margin, the cost of admitting a new patient is remarkably low, making volume growth a highly profitable strategy. Volume growth also can give the appearance of reducing costs, since the cost per case decreases when the high fixed costs are spread over a larger number of patients, although total costs will probably continue to rise. Growing volume and increasing revenue, rather than creating true bottom-line savings, are typically at the core of the business case for high-quality care.3
Because of the rigid cost structures, incremental reductions in resource use are unlikely to generate cost savings for either a health care setting or the health care system. The most meaningful way to achieve savings is to focus on overall reductions in utilization rates for health care services and to eliminate the associated unnecessary capacity.
In a recent article, Kaplan and Porter argue that most health care costs are not fixed.4 Postulating that personnel costs can be adjusted and space reallocated on the basis of demand and patient mix, they suggest that cost behaviors are not responsible for the inability to generate cost savings, but “management inattention” is. Although we do not dispute this logic, its practical application is dependent on both procedure volume and the time horizon required for aligning resources with demand. High-volume procedures and treatments for which resource use can be standardized across the cycle of care and for which capacity can be readily adjusted to accommodate appropriate volume appear to be best suited to the aggressive cost management advocated by Kaplan and Porter. Presumably, lower-volume treatments and procedures would have to be consolidated regionally to be more amenable to effective cost management. Until that happens, the fixed-cost dilemma will remain an obstacle. Cost layering provides management with a framework for targeting changes that will generate the most immediate savings.
Whereas quality improvement is producing significant benefits for patients, quality initiatives will continue to produce disappointing bottom-line savings as long as the capacity created is used to support growth in patient volume. As the U.S. health care system begins shifting its focus from volume to value, hospitals will need to adapt their cost structures and capacity to accommodate lower per capita utilization rates as well as reductions in the per-episode intensity of care.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp1111662) was published on December 14, 2011, at NEJM.org.
SOURCE INFORMATION
From the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.

Evidencias Medicas

Sitios Principales

21 junio, 2013

Health Information Technology and Patient Safety

03 mayo, 2013

Overdoing prevention: Beware of regular check-ups, healthism by numbers and genetic profiling

Overdoing prevention: Beware of regular check-ups, healthism by numbers and genetic profiling

08 marzo, 2013

Evidence Based Medicine: what is it and what isn´t

Contents

16 diciembre, 2011

2011: was the year that…

2011: was the year that…

Goodbye NHS

Au revoir French drug scandals?

Arab Spring

Disaster in Japan

HIV treatment as prevention

Small steps, giant leap

Europe's E coli outbreak

Donors give to GAVI

Famine declared

New York, New York

A vaccine for malaria

7 billion and counting

14 diciembre, 2011

En epocas de ajustes......alguien entenderà esto ?

The Savings Illusion — Why Clinical Quality Improvement Fails to Deliver Bottom-Line Results

SOURCE INFORMATION

Sitios Principales

21 junio, 2013

Health Information Technology and Patient Safety

Related articles

03 mayo, 2013

Overdoing prevention: Beware of regular check-ups, healthism by numbers and genetic profiling

Overdoing prevention: Beware of regular check-ups, healthism by numbers and genetic profiling

Related articles

08 marzo, 2013

Evidence Based Medicine: what is it and what isn´t

Contents

Related articles

16 diciembre, 2011

2011: was the year that…

2011: was the year that…

Goodbye NHS

Au revoir French drug scandals?

Arab Spring

Disaster in Japan

HIV treatment as prevention

Small steps, giant leap

Europe's E coli outbreak

Donors give to GAVI

Famine declared

New York, New York

A vaccine for malaria

7 billion and counting

Related articles

14 diciembre, 2011

En epocas de ajustes......alguien entenderà esto ?

The Savings Illusion — Why Clinical Quality Improvement Fails to Deliver Bottom-Line Results

SOURCE INFORMATION

Related articles