The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man. GB Shaw
Thursday, March 31, 2011
How to wash your hands properly in hospital
Great video from NEJM, free to view. Obligatory for all healthcare staff, (and also patients, families, kids so they can be sure their carers are doing it the right way.)
Immunisation
I was going to do a piece on immunization. These guys do a far better job than I ever could. Check out zdoggmd.com
Wednesday, March 30, 2011
Overdiagnosis
A fantastic piece in the Archives of Internal Medicine, about incidental findings (incidentalomas) picked up while testing for something else. This opens up a whole Pandoras box. A great line about a New York Times columnist who believed he had survived a brush with death following the finding of one such incidentaloma. No, the authors say, he survived a brush with overdiagnosis.
This is very important. The fundamental issue is that each patient will feel they have been saved and each becomes an advocate for more and more testing. However, there is no evidence that many of these findings, even if malignant, will ever pose a threat to health. The authors provide some practical suggestions as to how best to approach these matters.
This is very important. The fundamental issue is that each patient will feel they have been saved and each becomes an advocate for more and more testing. However, there is no evidence that many of these findings, even if malignant, will ever pose a threat to health. The authors provide some practical suggestions as to how best to approach these matters.
Clinically Integrated Systems
Following on from my thoughts about disruptive innovation, what structures in the UK and Irish setting might prove disruptive? Starting from the assumption, which may be mistaken, that some disruptors will be players in the current system, what could one possible future look like?
I believe the likeliest candidates are current general practice and primary care structures. They have the benefit of decent infrastructure, a critical mass of clinical, (not just medical) staff, and a population base that is large and varied enough to allow sub-specialistation. What are the missing ingredients?
I believe the likeliest candidates are current general practice and primary care structures. They have the benefit of decent infrastructure, a critical mass of clinical, (not just medical) staff, and a population base that is large and varied enough to allow sub-specialistation. What are the missing ingredients?
- Seamless integration between priamry care and hospitals; to deliver this, I believe there needs to be consultant presence in the primary care teams. Consultants would work between hospital and primary care, with benefits to staff and patients, (improved access to specialist opinion, greater communication between professionals, enhanced learning opportunities for all)
- A payment system that rewards health, and is not just based on following processes, (e.g. check blood pressure every visit). What would this look like? Look at it from the patient perspective. What he/she wants is health, as few visits as possible, as little interruption to daily life, mot missing school or work. Can this be done. I believe it can, but it will require a fundamental shift in the way health, (as opposed to healthcare) is delivered.
- A recognition that an unplanned hospital admission represents a failure of care for the team providing care
- Quality and outcome metrics allied with an IT system sensitive enough to provide real time data
There is an interesting paper just published on the BMJ site by Chris Ham discussing this. They report the experience of Torbay, summarised below:
- Reduced use of hospital beds (daily average number of occupied beds fell from 750 in 1998-9 to 502 in 2009-10)
- Low use of emergency bed days among people aged ≥65 (1920/1000 population compared with regional average of 2698/1000 population in 2009-10)
- Minimal delayed transfers of care
"hospital providers could also take the initiative in moving in this direction, especially in areas where general practitioners are relatively weak and specialists strong. London is a case in point, not least because it has several academic health sciences centres that present the potential to extend high quality care from hospitals into the community. In this context, integration might build on the strengths of academic health sciences centres by allocating them a capitated budget in conjunction with general practitioners and community health service providers. Patients would be able to choose between integrated systems based on academic health sciences centres and could also access care outside these systems in order to create an incentive for providers to deliver responsive care of high quality."
Are guidelines tainted?
One of the truisms of healthcare is that we should adhere to guidelines in so far as possible, to reduce variation, to improve outcomes and to minimize waste. Guidelines are developed by eminent professionals in a field; it is assumed that they are guided only by the evidence. However, many of these guidelines are sponsored by pharma companies.
A study just published in the Archives of Internal Medicine examined conflicts of interest amongst panel members charged with developing almost 20 cardiology guidelines. They find that 56% of panel members have a declared conflict of interest, e.g. owning stock in a company whose product is recommended, and 81% of panel leaders have a COI. That is not to say that these were unduly influenced by these conflicts, but some wonder whether like Caesars' wife, all should be above suspicion.
One suggestion is to prohibit all guideline developers to have a COI; my own view on this is that it may just exclude those who have the most to offer.
A study just published in the Archives of Internal Medicine examined conflicts of interest amongst panel members charged with developing almost 20 cardiology guidelines. They find that 56% of panel members have a declared conflict of interest, e.g. owning stock in a company whose product is recommended, and 81% of panel leaders have a COI. That is not to say that these were unduly influenced by these conflicts, but some wonder whether like Caesars' wife, all should be above suspicion.
One suggestion is to prohibit all guideline developers to have a COI; my own view on this is that it may just exclude those who have the most to offer.
How the iPhone is going to save the world. Seriously!
An artist with an interest in healthcare recently asked me for my thoughts about the future direction of art (broadly defined) in children's healthcare. It's not an area to which I had given much thought but it caused me to consider the benefits, if any, of art and media in healthcare. Simply put, how best to use that which is the favorite activity of children, playing, to assist them in the treatment of their illness.
Just published in JAMA yesterday is a commentary which outlines some of the potential uses and benefits of video games. Before anyone rubbishes the concept, there are good precedents here. My younger patients undergoing a lung function test in which they must breathe into a machine as fast as possible are encouraged to do so by a screen with a birthday cake and candles; the harder they blow, the more candles are extinguished.
The paper in JAMA describes various tools. Mindless Eating Challenge, a weight loss program, is a game where users support one another by sharing photographs of portion sizes. Lit to Quit allows iPhone users to puff into the phone to simulate the experience of smoking.
While the skeptics may rightly laugh off these efforts, bear in mind these are very early days. Analogous to measuring urine glucose in diabetics in the 1920's. This took 5 minutes using some very sophisticated reagents. Underestimate the power of technology at your peril.
While I am not an expert in this area, it seems to me that the real focus of opportunity lies in the nexus of massive multiplayer on line games (MMOG) and social networking. Christakis has published a number of very significant papers showing the effects of social networks on depression, happiness, weight gain and smoking. Imagine a game, aimed at children with diabetes, where children can interact and earn from one another, in which the game incentivizes the appropriate behaviors, such as diet, exercise, compliance with screening and so on. Crazy? Yes, without a doubt. Crazier than our current system where we believe that seeing a child a few times a year in a busy environment with numerous distractions is going to deliver the best outcomes? You decide.
Just published in JAMA yesterday is a commentary which outlines some of the potential uses and benefits of video games. Before anyone rubbishes the concept, there are good precedents here. My younger patients undergoing a lung function test in which they must breathe into a machine as fast as possible are encouraged to do so by a screen with a birthday cake and candles; the harder they blow, the more candles are extinguished.
The paper in JAMA describes various tools. Mindless Eating Challenge, a weight loss program, is a game where users support one another by sharing photographs of portion sizes. Lit to Quit allows iPhone users to puff into the phone to simulate the experience of smoking.
While the skeptics may rightly laugh off these efforts, bear in mind these are very early days. Analogous to measuring urine glucose in diabetics in the 1920's. This took 5 minutes using some very sophisticated reagents. Underestimate the power of technology at your peril.
While I am not an expert in this area, it seems to me that the real focus of opportunity lies in the nexus of massive multiplayer on line games (MMOG) and social networking. Christakis has published a number of very significant papers showing the effects of social networks on depression, happiness, weight gain and smoking. Imagine a game, aimed at children with diabetes, where children can interact and earn from one another, in which the game incentivizes the appropriate behaviors, such as diet, exercise, compliance with screening and so on. Crazy? Yes, without a doubt. Crazier than our current system where we believe that seeing a child a few times a year in a busy environment with numerous distractions is going to deliver the best outcomes? You decide.
Tuesday, March 29, 2011
Healthcare; time to be disrupted.
A disruptive innovation (the term was first coined by Clay Christensen) is a technology or strategy, which disrupts an existing market by radically lowering price, increasing productivity or by gaining an alternative set of customers. Examples include the transition from sail to steamships, the adoption of personal computers in place of mainframes and so on. Henry Ford put it well; “to build a better motorcar one could either develop a faster and stronger horse or do something completely different.”
The question for healthcare is whether disruptive innovations are required to radically improve value and outcomes? Alternatively can tinkering with the system, (QIPP, ACO, Medical Homes, pay for performance, increase measurement and accountability) drive sufficient performance and improvement. To truly understand the significance of this question, one has to understand both the power of disruptive innovation and the failure of those agencies being disrupted to challenge the disruption.
Disruptive innovations essentially create a market for a product or service that the incumbents fail to recognize. They do so, often by offering a cheaper, slimmed down product; think Ryanair. One may not like them but they not only offer a cheaper reliable service, but developed a market for services that no-one could have imagined, (London Lodz anyone?).
Existing airlines had no incentive to develop such innovations; they were happy with their quasi-monopolies. Ryanair had to develop such markets in order to grow. if existing companies were to chase these market opportunities, they would cut into their existing markets and reduce their profit margins. In a sense they are helpless to do anything, apart from resisting and fighting back, (think lobbyists, negative advertising campaigns)
Jump to healthcare, the structures are identical. Seemingly strong vested interests, institutional, professional, academic, who will do their best to fight any interloper promising a better cheaper service. And they are helped immensely by the emotional arguments that if the service they offer is undercut, people will die.
Are there examples of such disruption in health? They are likely to appear when the current model no longer makes financial sense, or where Western models are not applicable. It is likely that if this economic downturn persists that we will begin to see disruptors emerge in both the West, and emerge from the developing world into the West. For example, “Aravind the world’s biggest eye-hospital chain, performs some 200,000 eye operations a year. It takes the assembly-line principle literally: four operating tables are laid side by side and two doctors operate on adjacent tables. When the first operation is done, the second patient is already in place.” (Economist April 2010)
A paper by Robert Brook of the RAND corporation outlined one vision of potential disruptors. These include:
The question for healthcare is whether disruptive innovations are required to radically improve value and outcomes? Alternatively can tinkering with the system, (QIPP, ACO, Medical Homes, pay for performance, increase measurement and accountability) drive sufficient performance and improvement. To truly understand the significance of this question, one has to understand both the power of disruptive innovation and the failure of those agencies being disrupted to challenge the disruption.
Disruptive innovations essentially create a market for a product or service that the incumbents fail to recognize. They do so, often by offering a cheaper, slimmed down product; think Ryanair. One may not like them but they not only offer a cheaper reliable service, but developed a market for services that no-one could have imagined, (London Lodz anyone?).
Existing airlines had no incentive to develop such innovations; they were happy with their quasi-monopolies. Ryanair had to develop such markets in order to grow. if existing companies were to chase these market opportunities, they would cut into their existing markets and reduce their profit margins. In a sense they are helpless to do anything, apart from resisting and fighting back, (think lobbyists, negative advertising campaigns)
Jump to healthcare, the structures are identical. Seemingly strong vested interests, institutional, professional, academic, who will do their best to fight any interloper promising a better cheaper service. And they are helped immensely by the emotional arguments that if the service they offer is undercut, people will die.
Are there examples of such disruption in health? They are likely to appear when the current model no longer makes financial sense, or where Western models are not applicable. It is likely that if this economic downturn persists that we will begin to see disruptors emerge in both the West, and emerge from the developing world into the West. For example, “Aravind the world’s biggest eye-hospital chain, performs some 200,000 eye operations a year. It takes the assembly-line principle literally: four operating tables are laid side by side and two doctors operate on adjacent tables. When the first operation is done, the second patient is already in place.” (Economist April 2010)
A paper by Robert Brook of the RAND corporation outlined one vision of potential disruptors. These include:
- Considering the entire cost of care, to include not just the cost to the individual but the energy cost, (carbon cost)
- Unifying the two great silos of medicine and education so that educators play a central role in improving children’s health and healthcare providers are judged partly on their success at improving educational attainment in their patients
- A shift to non-physican care, e.g. nurse practitioners
- Reduce the training required for repetitive technical task; for example why go to medical school, residency and fellowship to train how to remove cataracts. Pretty radical.
- Routine healthcare delivered 24/7. So no more 9-5 operating rooms or clinics.
- Outsourcing or off-shoring of many tasks, including diagnostics, elective surgery which is already happening.
Innovation
For some reason, posting a lot of stuff from the WSJ recently, but it's all good. Check out this piece about the need to innovate in healthcare.
"Unlike many other industries, health care has remained highly fragmented, with a hierarchical culture resistant to change, and a payment system that rewards providers for quantity rather than quality of care. It has been slow to adopt technologies like electronic medical records that have the potential to make care more efficient and safer for patients. Even when new practices have been shown to improve care and reduce error, hospitals and doctors have been slow to adopt them."
"Unlike many other industries, health care has remained highly fragmented, with a hierarchical culture resistant to change, and a payment system that rewards providers for quantity rather than quality of care. It has been slow to adopt technologies like electronic medical records that have the potential to make care more efficient and safer for patients. Even when new practices have been shown to improve care and reduce error, hospitals and doctors have been slow to adopt them."
Pronovost
Great piece in todays Wall Street Journal, an interview with Pronovost, well worth reading.
Monday, March 28, 2011
Europe's Failing Health (Systems)
Great piece in todays Wall Street Journal. Discusses the challenges facing healthcare systems, from the funding perspective, throughout Europe. My favourite line,
"In 1995 the cost of a hip replacement was the equivalent of buying a flat-screen TV in Germany," he says. "In 2008 you could get 10 flat-screen TVs for the amount of money you paid for a hip replacement."
"In 1995 the cost of a hip replacement was the equivalent of buying a flat-screen TV in Germany," he says. "In 2008 you could get 10 flat-screen TVs for the amount of money you paid for a hip replacement."
The conclusion? Healthcare funding and design must change, and change radically.
Does improving quality save money?
The instinctive answer is, "yes, of course." If only it were that easy. I am more and more coming around to the view that to change a complex system like healthcare will require radical restructuring, which will only happen in the Western World when we realise we can no longer afford to deliver our current service. It wont be easy, it wont be pleasant.
Levette has sent me a paper which suggests that improved quality and lower costs may not go hand in hand. Bottom line;
"The evidence suggests that there are ways of saving money at the same time as improving quality. But doing so on a large scale requires changes in how services are financed, and increasing the capability of ordinary services to make changes. Approaches that look effective in theory rarely seem to have the same impact when implemented in practice and on a large scale. In this respect, the challenges of achieving real finan- cial savings by improving quality and reducing waste are no different from any other attempt to change a complex system."
Levette has sent me a paper which suggests that improved quality and lower costs may not go hand in hand. Bottom line;
"The evidence suggests that there are ways of saving money at the same time as improving quality. But doing so on a large scale requires changes in how services are financed, and increasing the capability of ordinary services to make changes. Approaches that look effective in theory rarely seem to have the same impact when implemented in practice and on a large scale. In this respect, the challenges of achieving real finan- cial savings by improving quality and reducing waste are no different from any other attempt to change a complex system."
Training for the future: from 20th century medicine to 21st century healthcare delivery
Check out this great piece from Peter Lachman. Nicely aligns with what I wrote about yesterday.
Disruptive Innovation
Hope to write a bit today about disruptive innovation in healthcare. Just to get into the mood. Thanks Lils.
From Apple Computers Think Different (R) campaign.
"Here’s to the crazy ones. The misfits. The rebels. The troublemakers. The round pegs in the square holes. The ones who see things differently. They’re not fond of rules. And they have no respect for the status quo. You can quote them, disagree with them, glorify or vilify them. About the only thing you can’t do is ignore them. Because they change things. They push the human race forward. And while some may see them as the crazy ones, we see genius. Because the people who are crazy enough to think they can change the world, are the ones who do."
From Apple Computers Think Different (R) campaign.
"Here’s to the crazy ones. The misfits. The rebels. The troublemakers. The round pegs in the square holes. The ones who see things differently. They’re not fond of rules. And they have no respect for the status quo. You can quote them, disagree with them, glorify or vilify them. About the only thing you can’t do is ignore them. Because they change things. They push the human race forward. And while some may see them as the crazy ones, we see genius. Because the people who are crazy enough to think they can change the world, are the ones who do."
Sunday, March 27, 2011
Medical Education; Fit for the 21st Century?
My personal view is that the current model of medical education is no longer fit for purpose; it is too heavily oriented to rote learning, is excessively hospital focused, pays little attention to the overwhelming needs of disease prevention, is excessively focused on providing healthcare as opposed to health, does not have a word to say about systems thinking and pays lip service to the concept of teamwork. There is no emphasis on the need to provide value, it does not provide the tools that allow professionals to continuously improve their service and has nothing to say about the economics of health and importantly our obligations as professionals to ensure money is spent to ensure that society receives the maximal benefit.
A very clever intern spoke to me recently, and I was discussing the concept of safety and quality. She told me she had never heard anyone in 6 years of medical school discuss these concepts. A shocking state of affairs.
Which brings me to the purpose of this post. A paper was recently published in the Lancet, and I will let the authors speak for themselves. Fundamentally, it is a call to arms, laying out the clear need to radically reform the model of medical education, in similar fashion to the Flexner report 100 years.
"Professional education has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The problems are systemic: mismatch of competencies to patient and population needs; poor teamwork; persistent gender stratification of professional status; narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labour market; and weak leadership to improve health-system performance. Laudable efforts to address these deficiencies have mostly floundered, partly because of the so-called tribalism of the professions—ie, the tendency of the various professions to act in isolation from or even in competition with each other.
Redesign of professional health education is necessary and timely, in view of the opportunities for mutual learning and joint solutions offered by global interdependence due to acceleration of flows of knowledge, technologies, and financing across borders, and the migration of both professionals and patients. What is clearly needed is a thorough and authoritative re-examination of health professional education, matching the ambitious work of a century ago."
A very clever intern spoke to me recently, and I was discussing the concept of safety and quality. She told me she had never heard anyone in 6 years of medical school discuss these concepts. A shocking state of affairs.
Which brings me to the purpose of this post. A paper was recently published in the Lancet, and I will let the authors speak for themselves. Fundamentally, it is a call to arms, laying out the clear need to radically reform the model of medical education, in similar fashion to the Flexner report 100 years.
"Professional education has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The problems are systemic: mismatch of competencies to patient and population needs; poor teamwork; persistent gender stratification of professional status; narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labour market; and weak leadership to improve health-system performance. Laudable efforts to address these deficiencies have mostly floundered, partly because of the so-called tribalism of the professions—ie, the tendency of the various professions to act in isolation from or even in competition with each other.
Redesign of professional health education is necessary and timely, in view of the opportunities for mutual learning and joint solutions offered by global interdependence due to acceleration of flows of knowledge, technologies, and financing across borders, and the migration of both professionals and patients. What is clearly needed is a thorough and authoritative re-examination of health professional education, matching the ambitious work of a century ago."
The Great Crack Up
"The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function. One should, for example, be able to see that things are hopeless and yet be determined to make them otherwise."
F.Scott Fitzgerald, The Great Crack-up, 1936
I think the quote above will resonate with many of those who faced with the daily challenge of improving a health service still believe it is possible.
F.Scott Fitzgerald, The Great Crack-up, 1936
I think the quote above will resonate with many of those who faced with the daily challenge of improving a health service still believe it is possible.
Is informed consent bad for your health?
A letter in this weeks Lancet is worth considering. Having been involved in a number of clinical studies in paediatric intensive care units, this resonated with me. The purpose of seeking informed consent from an individual enrolled in a clinical study is to ensure that they are protected in so far as possible and are fully aware of any possible risks entering this study may entail. The benefits of enrolling in a study, apart from the societal good of increasing knowledge is that there is some evidence that patients in a clinical study, regardless of whether they receive the experimental treatment or conventional treatment receive better quality of care. There is also the possibility that they may benefit from the experimental intervention.
Using data from the CRASH trial, researchers estimated that in hospitals which sought consent from relatives, there was a 1.2 hour delay in initiating treatment compared to those hospitals in which no consent was sought. Applying these data to an analysis of the CRASH-2 trial, the researchers estimated that a one hour delay in commencing treatment resulted in a reduction in the percentage of patients responding to treatment from 63% to 49% with a likely increase in death and disability being the result.
There are two consequences; first the delay results in an increased risk of poor outcomes, second, the delay may obscure benefits that accrue from administering a time sensitive treatment.
This has important ethical and scientific implications.
Using data from the CRASH trial, researchers estimated that in hospitals which sought consent from relatives, there was a 1.2 hour delay in initiating treatment compared to those hospitals in which no consent was sought. Applying these data to an analysis of the CRASH-2 trial, the researchers estimated that a one hour delay in commencing treatment resulted in a reduction in the percentage of patients responding to treatment from 63% to 49% with a likely increase in death and disability being the result.
There are two consequences; first the delay results in an increased risk of poor outcomes, second, the delay may obscure benefits that accrue from administering a time sensitive treatment.
This has important ethical and scientific implications.
Saturday, March 26, 2011
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