international Forum and Maureen Bisognano and hospital flow

Maureen Bisognano in her keynote speech referenced specifically Eugene Litvaks work, and the benefits accrued to Cincinnati Childrens by implementing the methods he espouses. See my previous post about Litvaks work. http://saferhealthcareireland.blogspot.com/2011/03/optimizing-patient-flow-to-enhance.html

Emily Friedman at the International Forum

Magnificent keynote from Emily Friedman about challenges and possibilities for healthcare in Cambodia, harrowing stories. www.emilyfriedman.com

Effective Crisis Management, Free WIHI session

The next WIHI should be mandatory listening, WIHI click here

Includes Uma Kotagal and Jim Conway.

Poster of the Forum

International Forum Quality Amsterdam

Outstanding plenary from Maureen Bisognano. talks about need to redefine healthcare leadership, both at a personal and sttructural level. Some interesting facts, medication compliance or lack of estimated to be 4th leading cause of death worldwide, accounts for >$150 billion in US health spend. Lots of opportunity to save, reduce waste, Gives various successful exemplars. Talks about need to refocus and suggests IHI Triple Aim as a useful model.

Quality Education

excellent piece from BMJ Q&S concerning education and training in healthcare quality and safety. The authors make a number of valid points.

There is a lack of suitably qualified experts in the area of health Quality and Safety to provide education
The traditional approach o education imposes an artificial barrier between clinical and improvement work; the two must be seen to be two sides of the same coin.
A consequence of this barrier is that front line staff fail to understand the true significance of quality improvement
This last point is one that has not previously occurred to me; the traditional method of teaching, asking questions, implies to the learner that every question and every problem has a solution, which is patently not the case.

The authors provide a framework to transform the way such training is delivered.

QI becomes an integral part of clinical practice and training
Students and teachers become co-learners, along with patients, families, and non clinical staff
QI is seen to result not from "great individuals", but from a team approach to problem solving
The end result is not judged by answering questions correctly, but how effectively a problem is solved.

Hot off the press

Just published, a supplement to BMJ Quality and safety, all open access, looks like some great stuff.

Tonsillectomy

I am currently reading John Wennbergs "Tracking Medicine". There are some great insights, and I cannot recommend it enough. One of the most striking pieces I came across relates to the belief, now vanished, that tonsillectomy was critical for a healthy childhood:

"The American Child Health Association’s research design used a random sampling of 1,000 New York City school children. On examination by a school physician, 60% were found to have already had a tonsillectomy, and of the remaining 40%, nearly half were deemed in need of the operation. To make sure that no one in need of a tonsillectomy was left out, the association arranged for the children not selected for tonsillectomy to be reexamined by another group of physicians. The second wave of physicians recommended that 40% of these children have the operation. Still not content that unmet need had been adequately detected, the association arranged for a third examination of the twice-rejected children by another group of physicians. On the third try, the physicians produced recommendations that another 44% should have the operation. By the end of the three-examination process, only 65 children of the original 1,000 emerged from the screening examination without a recommendation for tonsillectomy. If the association had put those 65 children through additional rounds of examination, it seems likely that virtually every last one would have been recommended for surgery, a thought that gives new meaning to the phrase “no child left behind.”

While we may laugh at such a practice, are we really that different? Look at the variation you practice yourself, let alone the variation amongst your colleagues, and then remember that the variation within an institution is far less than variation between hospitals. As Wennberg says,

"Thus regions have characteristic “surgical signatures” and regions with high rates of a surgery in the early 1990s still tend to have high rates today, and the cumulative effect is to expose large numbers of patients to surgical interventions that they may or may not have wanted." 

To screen or not to screen? That is the question.

Screening arouses great passion, well greatish. Sticking to prostate cancer, there has been a back and forth argument for many years. There is no doubt that using prostate specific antigen testing detects many cancers; however the key question remains whether finding these cancers impacts survival. In other words, would many of these men die with rather than because of their prostate cancer. According to Wennberg, if 1000 men are screened for 10 years, 1 cancer will be found and treated successfully, 4 men will die of their cancer regardless and 50 men will be over-diagnosed and over-treated.
A study just published finds that over a 20 year period, there is no differnece in death rate form prostate cancer between those screened and unscreended.
Again, this points to the potential for reducing variation and reducing costs in healthcare.

Simulation

There is increasing interest in the benefits of simulation to ensure improved outcomes in healthcare. A piece in the Economist piqued my interest in this area. They describe a story I had never heard before, involving the role of former US President Jimmy Carter in dealing with a reactor meltdown in Canada in 1952. Carter led a 23 man team to disassemble a reactor near Ottawa that partially melted down. Such was the radiation exposure that each person was limited to 90 seconds at the core. To ensure that the process went as smoothly as possible in such adverse conditions,

"The team built an exact replica of the reactor on a nearby tennis court, and had cameras monitor the actual damage in the reactor's core. "When it was our time to work, a team of three of us practised several times on the mock-up, to be sure we had the correct tools and knew exactly how to use them. Finally, outfitted with white protective clothes, we descended into the reactor and worked frantically for our allotted time," he wrote. "Each time our men managed to remove a bolt or fitting from the core, the equivalent piece was removed on the mock-up."

The take home message is no surprise, simulation to be successful must be as realistic as possible, with real time feedback. A paper published in January in PCCM reports that with increasing use of simulation of cardiac arrest in a children's hospital, survival post cardiac arrest increased to 50%, substantially above the national average.

Bertrand Russell on the scientific method

"Aristotle maintained that women have fewer teeth than men; although he was twice married, it never occurred to him to verify this statement by examining his wives' mouths"

Dr Yoda & the Pirates of the Caribbean

Rather than review some health related news stories, I thought Dr ZDogg would do a better job.
Have a great weekend.

Angry Bird Medicine

A wonderful title to a great blog entry on the BMJ blogs site. Talking about reducing medicine to an App that can be downloaded to ones phone. He has a fantastic quote, “6 years of medical school and 10 years of training can now be put onto an App and sold for a few dollars – where did I go wrong?”

I dont think a 99 cent app on your phone is going to take the place of a doctor just yet, but the natural progression is that knowledge becomes a commodity, it moves down the value chain, and it no longer becomes cost effective for a particular expert to broker that knowledge. So for example, there is no reason why someone with hypertension cant be monitored at home, blood pressure readings relayed by phone to a central station and feedback given around diet, medications etc, all without the person ever leaving home.

Disruptive Innovation & healthcare education

One of the great difficulties in bringing safety and quality to the fore in healthcare is that although it impacts everyone, no specialty sees it as their responsibility to take the lead, itself a damning sign of the inability of the profession to see the critical merits of teamwork and systems thinking. The IHI set up its Open School some years ago in an attempt to bring this knowledge directly to healthcare students. My impression is that it is certainly proving successful, but it is the nature of such developments to take many years to fully bear fruit. But bear fruit it will. The message is too compelling and students will naturally ask why they are not being exposed to this area by their own teachers. It's all part of a bottom up approach to change. As an example, I suggest you check out this video, part of the course materials for the Open School.

Learned Helplessness

It has struck me repeatedly that there is a huge degree of learned helplessness in the public sector around the world. I am unsre why this should be the case. Does it reflect a risk averse culture? An overly bureaucratic one in which every action must be backed by a memo? Who knows? The great pity is that one of the great motivating forces for skilled professionals is to have pride and autonomy on their work. See the video, (thanks John F) for a great example of the phenomenon.

Public Reporting of Surgical Outcomes

In this weeks Lancet, a discussion around public reporting of surgical outcomes. Specific mention is made of the Society for Cardiothoracic Surgery in Great Britain and Ireland. Since 2005, the society has made outcome data freely available to the public; this has been associated with a 50% reduction in risk adjusted mortality, i.e. half as many people have died as would have been expected to die.

In terms of cost savings, the program costs £1.5 million annually, but is estimated to save £5 million per year in reduced length of stay costs.

While clinicians may be resistant to public reporting of data, it is inevitable. My opinion is that it is better to be proactive, seek to develop such databases and ensure the data represents as accurately as possible the reality, i.e. risk adjusted. 

See also this post from Paul Levy.

Trends in youth mortality around the world

Published in The Lancet today, an analysis of WHO data looking at mortality trends in children and young adults around the world over the last 50 years. There have been dramatic improvements in mortality reduction around the world, as much as a 93% reduction in children aged 1-4. The smallest reduction occurred in young men, aged 15-24. More focus should be directed on reducing mortality in this group. However, this is a very encouraging and optimistic paper, showing that greta work can be achieved.

Statistics for dummies.

For anyone who love data, check this out. Rosling is magnificent and can summarise in 4 minutes of pictures what may are unable to do in a book. Wealth increases health.
Also see his website. www.gapminder.org

Reduced work hours for doctors

In both Europe and the US, there has been a push to reduce the hours worked by doctors. This has been based on the belief that tired doctors make more mistakes. An article in this weeks BMJ points out that to date there is no evidence that these measures have brought about an improvement in safety. Why should this be? There are many possible explanations, but in my view, these reductions in working hours have been implemented without taking a fundamental look at how doctors work. in other words, a dramatic change in work hours should have been accompanied by a radical restructuring of shifts, handovers, continuity and so on. It is likely that this has not occured. The other problem is that junior doctors work hour and patterns evolved to match those of senior physicians. The work patterns of these senior doctors also needs to be considered and modified.

Thank you for the music

Falls are an major problem for the elderly. An interesting piece in this weeks Archives of Internal Medicine reports that using music to in effect co-ordinate walking substantially reduces the risk of falls in a community based elderly population.

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

How not to deal with the media

St Stephens Green, Dublin

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.

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?

1. 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)
2. 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.
3. A recognition that an unplanned hospital admission represents a failure of care for the team providing care
4. 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.

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.

Art in Children's Hospitals

Fascinating website and project, thanks to Helene Hugel.

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:

• 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. 

It is likely that the most marked changes are ones we cannot even begin to envisage yet. One thing is certain, we will have to change. Or perish. As Deming said, “We do not have to change, survival is not mandatory”

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."

Pronovost

Great piece in todays Wall Street Journal, an interview with Pronovost, well worth reading.

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."

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."

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."

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."

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.

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 Analytics to Create Your Own Upturn

Check out this SlideShare Presentation:

Using Analytics to Create Your Own Upturn

View more presentations from Dublin Chamber of Commerce.

Sunset, Northern Ireland, Thanks Levette

Are you better off flying with a trainee pilot, or being operated on by a trainee surgeon?

One of the concerns that some people have relates to the way we train our doctors, essentially an apprenticeship system, with a trainee learning from a senior doctor. While I have some concerns about other aspects of this system, one of the unavoidable consequences is that trainees have to practice upon a patient. Is this safe? Surely being operated on by someone with less expertise increases the risk of something going wrong?
A study has just been published seeking to answer that question. The American College of Surgeons examined patient outcomes in more than 600,000 operations. They found that having a resident, (junior surgeon in training) while associated with a slightly higher risk of developing (usually minor) complications, was also more likely to be associated with a slightly reduced risk of death. The reasons obviously are unclear, but this important paper does provide some reassurance.

Wow, Oh Wow

That was Muir Grays Twitter post on seeing this weeks BMJ. Apart from the papers referenced below (Reducing Variation March 24th), there are a number of other papers worth checking out. A report from the Netherlands again finds a marked variation in utilization of medical interventions. An editorial on variation in the NHS; a look at how to redevelop care for long term conditions, and a lot more.

Why such emphasis on variation? Surely the areas with low utilization will balance out the high users for a zero sum game. This is unlikely to be the case, there is mounting evidence, mainly from the US, but also from other countries, that outcomes are not affected by the amount of care given above a certain amount. Therefore there are huge opportunities for reducing waste, saving money, and a lot more good stuff.

Sunrise on the equinox

Eliminate Variation, Part 2

A piece in the BMJ by John Wennberg summarizes much of the knowledge around variation in medical practice. He breaks unwanted variation into three categories, effective care, preference sensitive care and supply sensitive care.

• Effective care. This is care that is the right treatment for the vast majority of patients, and variation in this element relates to underuse, e.g. vaccination
• Preference Sensitive Care. This is care provided when there are more than one effective treatment, and choice of therapy should be dictated by patient preference; in fact, physician choice often determines this. Mastectomy rather than lumpectomy plus radiation for breast cancer for example. 
• Supply sensitive care. This is care that is dependent on the supply of services in a region. Roehmers law is one example of this; this states that in an insured popualtion, a hosoital bed is a filled bed. Dartmouth have found no corrleation between the amount of care received and outcomes, suggesting that there are areas with massive overuse of resources. Gawande in a brilliant article two years ago examined this discrepancy.

Also check out the NHS health Atlas. There are huge variations in care evident. Likely that this occurs everywhere.

Eliminate Variation

One of the godfathers of determining the extent of variation in medical practice and founder of the Dartmouth Health Atlas, Jack Wennberg, has recently published a book, "Tracking Medicine", available here. I have just downloaded it, will review it when finished, but it gets a great review here.

Primroses

Summer

A view looking east from the Delaire Graff wine estate, Stellenbosch, South Africa.

The Future of Nursing

Medicine is excessively hierarchical. That is pretty obvious. While there may have been some benefit to this in the past, (though I am at a loss to think what that might be), clearly healthcare must be seen as a team effort. The role and contribution of nurses in delivering more and more effective healthcare has not been utilized to anything like its full potential. From the Future of Nursing, comes the following recommendations;

1. Nurses should practice to the full extent of their education and training. 
2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 
3. Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. 
4. Effective workforce planning and policy making require better data collection and an improved information infrastructure.

Reform of Public Service

This is the subject of a special survey in this weeks Economist. While looking at public services generally, criticizing (rightly in my opinion) the growth and low productivity of services worldwide, it has a specific mention of health. Well worth reading.

Amongst the figures given; "McKinsey points out that American spending on this has grown at an annual lick of 4.9% over the past 40 years, whereas GDP per person has grown by just 2.1%. Pessimists are convinced nothing can be done to restrain it. A refreshingly different perspective is provided by Sir John Oldham, a British doctor who is clinical lead for productivity in the National Health Service."
"America, which currently spends 16% of its GDP on health care is theoretically on track to spend 100% of its GDP on health care by 2065."