Archivi del mese: agosto 2012

Healthcare 2020 – Bain & Company @drsilenzi @agnescheer @muirgray

By George Eliades, Michael Retterath, Norbert Hueltenschmidt and Karan Singh

We have been talking about healthcare costs for more than 40 years, but the worldwide financial crisis and subsequent climate of austerity are finally catalyzing change. Payers are searching for all available tools to stunt the growth of a sector that has successfully resisted cost containment for decades. Adding to the urgency for action is an anticipated global surge in demand precipitated by several factors: an aging population with chronic care needs, population and income growth in emerging markets and the potential for insurance coverage expansion due to health reform in the US and around the globe.

An increase in demand—even one accompanied by cost pressures—is generally good for companies supplying products to the healthcare sector. But in this case, it is concomitant with a precipitous decline in research and development productivity for pharmaceutical and medical technology companies, leading to a more than $100 billion loss in product exclusivity by 2015.1 Despite ongoing medical need across many diseases, these players can no longer depend on their innovation engine and pricing power to drive ongoing profit growth. The net result will be an unprecedented decline in the share of the overall healthcare profit pool captured by innovation-driven companies in favor of lower-margin sectors like generic manufacturers and providers.2

We do not suggest that healthcare will be less innovative over the coming decade, but rather that the focus of innovation will shift from the product arena to healthcare delivery. A demand surge in an environment of fiscal constraint and slower product innovation will create a climate that favors investment in new ways of delivering care, in part by applying the power of information technology—long overdue in healthcare, relative to other sectors. Indeed, the shift in emphasis from managing inputs, like the rate of adoption of new products and the number of physician visits, toward delivering outputs, like patient satisfaction, clinical outcomes and overall system savings, is already well underway.

Going forward, the critical question for companies will be how they can evolve their business model and thrive in a world of shifting profit pools by focusing on delivering better outputs, rather than by simply generating more inputs—more products, more procedures and ultimately more cost to the payers.

All of these disruptive changes will have two significant implications for the global healthcare market:

  • There will be radical changes in the relative size and growth of the various parts of the global healthcare profit pool. In the past, growth by sector has been relatively consistent, but by 2020 and beyond, growth rates across sectors and geographies will diverge.
  • The basis of competition in the marketplace will change as well. Different therapeutic areas will be affected in distinct ways by two significant trends: growing consumer engagement and increasing standardization of care (“protocolization”).3

How will you compete as global profit pools shift?

Even though the global profit pool will expand over the next 10 years, most players will need to develop new business models to win. We believe the total profit pool will grow at a compound adjusted growth rate (CAGR) of 4%—from $520 billion in 2010 to $740 billion in 2020—but lag overall healthcare expenditure as profitability declines in aggregate worldwide4 (see Figure 1).

Your business plans for the next decade will require a deeper understanding of the sector and regional shifts embedded in these global figures. For example, most of the growth in the global profit pool will come from increased volume in the delivery of care, while another significant source of growth will come from smaller sectors like contract research or manufacturing and nutrition, which are experiencing significant growth from a smaller base, particularly in the emerging markets.

Pharmaceutical companies will see low growth and some decline in margins over the coming decade. Brand-name pharmaceuticals will grow only 1%, and the market will become increasingly fragmented, as the main source of revenue growth will be smaller items like targeted oncology products.5 In the US the situation will be even worse, as the forecasted 1% growth rate will depend on substantial growth in the second half of the decade, overcoming patent expirations and pricing pressures. At the same time, generics will grow by 7%, driven by those same patent expirations as well as increased volume in emerging markets (and a few underpenetrated developed markets).

healthcare-2020-fig-01A_embedClick to enlarge

healthcare-2020-fig-01B_embedClick to enlargeGlobal medical technology products will grow 3%, but with lower profit margins due primarily to worldwide pricing pressure. The slowdown will come mainly from peak penetration of products, such as stents, in developed markets and competition everywhere from “good enough” products. In China there is already fierce competition from locally produced stents, and this pricing pressure will continue as the Chinese and others develop cheaper alternatives.6

New healthcare value chain players will expand the overall profit pool to some degree. While margins in almost every other sector will slow, the growth in these sectors will be dramatic. Contract research, manufacturing and sales companies and healthcare IT companies will see significant volume growth as pharmaceutical companies outsource more functions and the demand for data accelerates.7 Contract research organizations will expand through greater use of strategic alliances and risk-sharing arrangements with pharmaceutical companies. Contract manufacturing organizations will see 8% CAGR, in part due to their expansion into China and India.

Because of the uncertainty of health reform in the US, payers are not likely to experience the growth they have experienced in the past. Even if there is more insurance coverage, there will be lower margins because of pressure on premiums. In fact, the traditional business model of US health insurers is increasingly coming into question with the rise of accountable care organizations (ACOs). The net result is that the expansion in worldwide insurance coverage will come largely from emerging markets, with growth in Europe remaining fairly stagnant.

Providers of care worldwide will see the largest volume gains, but not necessarily any increase in their overall margins. These volume increases will drive 30% of the overall profit pool growth (about $70 billion), but profitability will be flat or will decline. In fact, the overall profitability of healthcare players is expected to decrease by about 1% by 2020.8 The slower growth in US and European markets will be offset to some degree by expansion in emerging markets like China and India, specifically for generic drug products. Rapid economic growth and the rise of chronic diseases will produce substantial gains for price-sensitive generic products, but weak medical insurance and gaps in delivery capability in rural areas will remain challenges for these economies.

China’s healthcare profit pool will grow from about $22 billion in 2010 to $113 billion in 2020, a CAGR of 18%, 9 suggesting appealing opportunities for new investments, but hospitals and other providers will drive 40% of that growth (see Figure 2).10 Those providers will benefit from an aging population and a rising middle class, and there are also some signs of government policies that are favorable to private investment in the sector. Pharmaceutical and medical technology companies will continue to realize attractive earnings before interest and tax (EBIT), but brand, generic and over-the-counter products will shrink by one percentage point because of government-enforced price cuts and the increasing purchasing power of distributors.

Likewise, in India, the delivery of care and pharmaceutical sales will make up most of the fragmented $65 billion market.11

healthcare-2020-fig-02_embedClick to enlarge
Disruptive changes will alter the basis of competition, creating new opportunities to redefine business models and enter new markets

The sheer size of emerging markets makes them attractive offsets to more stagnant growth in other regions of the world. But to be successful, companies will need new business models to take advantage of the opportunities there (see Figure 3). Profit pool shifts and the lack of access to healthcare in many countries, for example, may spur some pharmaceutical and medical technology companies to meet the challenge by opening clinics in the developing world, or even entering the private insurance market.

In the developed world, providers and payers are already entering the device or drug market. Companies like Fresenius Medical Care, which started out producing dialysis machines, have emerged to “own” an entire segment of care—vertically integrated with machines, clinics and drugs. With global government spending estimated at about $50 billion for dialysis products and services, but with shrinking reimbursement per treatment, the vertically integrated model may be an effective path to capture a very specific part of the profit pool.12

healthcare-2020-fig-03_embedClick to enlarge
While the specificities differ by market, the overall trend is that companies are seeking incremental growth in new profit pools that tie to disease knowledge or market know-how.

On what basis will you compete? If you can no longer depend only on increased volume or control pricing, where can you most profitably operate in the newly configured global market? This is where the acceleration of twin trends—consumer-driven demand and standardized and protocolized care—comes into play. These two trends are powerful and have the capacity to facilitate the shift to outputs over inputs, stimulating new opportunities for profitable growth, if you can adapt your business model.

  • With more information about treatments available to an increasing number of consumers or patients around the globe, every company with a product to sell must understand how best to engage with consumers, in a way that speaks to their individual needs and patient experience. Search engines have produced a vast engaged patient population we could not have imagined even 10 years ago: 80% of Internet users now search for health information online, and more than half look for specific information about a medical treatment or disease.13 The demand for more engagement is not limited only to the US and Europe. Mobile phones and Internet access are now available in most emerging economies. While there will continue to be cultural differences in the way consumers engage with their care, the degree of engagement itself will only intensify globally. More than one-third of Indians, for example, currently use the Internet to search for health information, with similar percentages of younger, more educated people seeking health information online in Brazil, Mexico and China.14
  • Along with the trend toward increased consumer engagement is an increasing professionalization of medical care processes. We call this trend protocolization because physicians and other providers are accepting and using more standardized protocols and guidelines for treating their patients. US providers have been somewhat slower to embrace clinical protocols than their European or Asian counterparts, but there is little doubt about the direction of this change. No longer will the individual physician be the lone decision maker. The cottage industry of medical care is being industrialized, as payers and providers increasingly align their businesses—and results—which may be threatening to some, but may well produce better care at lower cost.

Protocolization and consumerism will not affect all therapeutic areas equally

There are at least four “landscapes” where healthcare companies will have to make strategic decisions in order to survive and win (see Figure 4).15

On one axis of Figure 4, we included the conditions and diseases for which consumer engagement will be the main market driver; on the other, we have shown the degree to which standard protocol will guide treatment decisions. In some areas of treatment, both consumer engagement and protocolization will be in play, leading to an opportunity for patient-provider “teaming.” Both of these trends translate into reduced autonomy and decision-making control for physicians for established conditions.

Where there is a high degree of consumer engagement but low protocolization, the patient experience will impact the outcomes most strongly. Such treatment options are often cash-based or lifestyle therapies, like breast implants or erectile dysfunction. Brands will initially rule for these types of procedures because of their familiarity and marketing clout, but prices may be forced down over time as the experience curve is applied to these markets. The degree of protocolization for these therapies will start out weak, but will increase with competition, especially for treating conditions like infertility, where buyers perceive proprietary protocols to be an advantage.

healthcare-2020-fig-04_embedClick to enlarge
The more routine, protocol-driven therapies, such as for conditions like hypertension or procedures for knee or hip replacement, involve processes of care that are generally well accepted, but result in less physician discretion and patient choice. Manufacturers of products for these conditions will need to have good data to accurately price their products and ensure that they are included in any protocols being developed to guide treatment. Whatever patient marketing exists for these types of conditions will largely focus on adherence because care management, not just the specific product, results in better outcomes.

Where there is a high degree of consumer engagement along with a high degree of protocolization for diseases like breast cancer or Type 1 diabetes, manufacturers will need to be sure that they shape the protocols being used and target their marketing to those preferred therapeutic options. The “teaming” between providers and patients will be a significant challenge for payers and manufacturers. In the area of breast cancer alone, the existence of multiple effective patient advocacy organizations will inform patients of their options, and they in turn will put pressure on doctors to find the optimal treatment regimen. Payers will attempt to control the protocol development in this area in order to control costs.

The physician-driven quadrant, with its lower degree of consumer engagement and protocolization, is a “business as usual” state, and there is unlikely to be significant growth in those types of markets. Therapies for migraines or attention deficit hyperactivity disorder (ADHD), for example, have fewer accepted protocols, and thus payers will continue to struggle to control utilization beyond mere cost shifting. New physician-driven therapies will, of course, continue to emerge, but the overall trend is clearly away from full physician control as markets mature and consumers become more involved in their own healthcare.

Over time, more diseases will move up and to the righthand side of Figure 4. Protocolization and consumerism will increase, and payers will demand and use better data about outcomes. Although these changes will not guarantee increased revenue, good outcomes should result in a better share of the profit pool for players that can shape the protocol development by demonstrating how their products create value.

Where can you play—and win—by 2020?

Only transformational business models will enable future winners to capitalize on the disruptive market changes at play (see Figure 5). The models identified in Figure 5 are very different from the business models being discussed in boardrooms today. Becoming a consumer marketing powerhouse, a disease population manager or a successful integrated care company will require different organizational capabilities. For example, for treatments and conditions where the degree of consumer demand is high, like health and wellness programs, or for treatments with high brand recognition, a consumer powerhouse approach can help produce differential growth and market share. For conditions with a high degree of protocolization like hypertension, a population- manager approach may be the answer. The most challenging model of all will be to create integrated care solutions that manage the full suite of products and services across the patient journey. This approach will require deep expertise in patient-centered care and the tools that support that care, such as real-time feedback, secure communication and digital technology to enhance patient participation.

These new approaches require a fresh look across the profit pool for each condition. Here are a few examples to think about:

  • For businesses in the more traditional, physician-dominated quadrants of Figure 4, winners will build the capabilities to deliver risk-sharing models, potentially partnering with payers and providers— or even directly becoming more involved in the delivery of care.
  • If you are operating in the top right-hand quadrant of Figure 4, patient-provider teaming, then you may need to partner or develop capabilities in data sharing and coordination to ”wrap around” the patient and manage a population for a payer or provider organization.
  • If you operate more in the consumer world, you may need to move beyond branding the product and start branding the procedure by forming alliances with certified providers that can perform the procedure or provide medication, such as exclusive, branded and certified botulinum toxin clinics.

healthcare-2020-fig-05_embedClick to enlarge

  • Where the various components of the profit pool have created silos, with products and patients being passed around among them, the trend toward protocolization and consumerization will break down barriers and create a more integrated approach for a given medical condition or procedure. Firms like Fresenius and DaVita are already doing this, and other healthcare companies will either participate in this trend or risk becoming mere commodity suppliers.
  • The industry’s metrics will need to change. Using annual budgets and per person savings will not reflect value adequately for either private or government payers. Can payers stay involved for long-term gain when paying for chronic diseases? Public payers may not be able to resist the pressures to simply reduce their costs. Private payers will need to identify ways to reduce cost and demonstrate improved quality. For providers, it will be a choice of joining the rush to become an integrated care company or trying to find room to be a branded provider of choice.

For a select few, the old models could work—breakthrough innovation will still drive profitable growth, but few, if any, have proven the ability to sustain this over time. Cost pressures will force nearly every company in the industry to rethink how and where it will grow moving forward. Good strategic choices will still yield growth. A profit pool that is growing at a breakneck pace will no longer shelter poor choices. Executives and investors can and must know where the profit pools are shifting—and how they will change course to successfully compete.

George Eliades is a partner with Bain & Company based in San Francisco and a leader in the firm’s Global Healthcare practice. Michael Retterath is a Bain partner based in New York and a leader in the Global Healthcare practice. Norbert Hueltenschmidt is a partner based in Zurich and the head of Bain’s Global Healthcare practice. Karan Singh is a partner based in New Delhi and head of Bain’s Asia-Pacific Healthcare practice.

  1. IMS Institute for Healthcare Informatics, “The Global Use of Medicines: Outlook Through 2015,” May 2011.
  2. The methodology Bain used for developing this profit pool analysis is based on detailed health sector revenue and EBIT margin analysis for US and global sectors. The sector revenues are based and triangulated on latest market reports; the sector margins are based on company annual reports; the 2010-2020 CAGRs are based on market reports, where available, and Bain estimates; and the margin changes from 2010 to 2020 are based on proprietary Bain analysis.
  3. The term “protocolization” refers to the application of proven standards of care and consistent protocols and guidelines to reduce variation in the delivery of healthcare.
  4. Sources: Bain analysis, IMS, Datamonitor, Business Insights, Freedonia, annual reports, analyst reports, Centers for Medicare and Medicaid Services (CMS), OECD
  5. Sources: Datamonitor; based on top 50 branded pharma companies
  6. Sources: Business Insights, Datamonitor, analyst reports, Bain analysis
  7. Sources: Business Insights, Datamonitor, Parexel, analyst reports, Bain analysis
  8. Sources: IMS, Datamonitor, Business Insights, Freedonia, annual reports, analyst reports, CMS, OECD, Bain analysis
  9. Sources: IMS, BMI, Espicom, annual reports, analyst reports, China Health Yearbook, National Bureau of Statistics of China, Bain analysis
  10. Sources: IMS, BMI, Espicom, annual reports, analyst reports, China Health Yearbook, National Bureau of Statistics of China, Bain analysis
  11. Source: Bain analysis
  12. Fresenius Medical Care, “Forward Looking Statements,” 2009, p.31.
  13. Susannah Fox, Pew Research Center’s Internet & American Life Project – Health Topics, February 1, 2011,
  14. “Indians Increasingly Use Internet for Their Healthcare Needs,” Express Healthcare,
  15. Sources: International Guideline Library, National Guideline Clearinghouse data, National Health Service in UK, Medtech Insight and proprietary Bain analysis The methodology for determining the degree of consumer engagement and protocolization in Figure 4 was developed by collecting all the protocols on each disease from a variety of sources, scoring the current level of protocolization on a scale of one to 10 and then adjusting for prevalence and total spending on the disease. For consumerism, we monitored the presence of topics for each disease on a variety of patient websites and corrected for prevalence.


L’health technology assessment (HTA) è, in estrema sintesi, uno strumento per migliorare i processi decisionali a livello macro (politica sanitaria nazionale e regionale), meso (gestione delle aziende sanitarie) e micro (decisioni cliniche del singolo professionista sul singolo paziente).La valutazione multidisciplinare e multistakeholder dell’impatto sanitario, economico, etico e sociale dell’uso della tecnologia è il focus del HTA.

Nell’attuale momento storico, caratterizzato da una particolare e significativa riduzione delle risorse a disposizione della sanità e da una crescita della domanda di servizi sanitari, l’HTA può dare un contributo rilevante a chi deve prendere decisioni sempre più difficili per tenere fede ai principi di universalità e di equità di accesso ai servizi sanitari e per assicurare equità dei livelli di salute della popolazione.

Il dibattito politico di questi mesi è incentrato sulla necessità di rigore economico e di controllo della spesa pubblica, da una parte, e di sviluppo e crescita economica, dall’altra. La…

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European Observatory on Health Systems and Policies: crisi economica e servizi sanitari @drsilenzi @agnescheer

European Observatory on Health Systems and Policies

Joint HEN – OBS policy summaries

Alcune riflessioni di Richard Smith @drsilenzi @richard56

Richard Smith (@Richard56)
13/09/11 20:23
50% of studies are undertaken without any systematic review of previous work. The public would be astonished if they knew.

Richard Smith (@Richard56)
13/09/11 20:26
85% of clinical research is waste because the question is unimportant, the design is not right, nothing is published, or the paper is biased

Richard Smith (@Richard56)
13/09/11 20:29
People need to understand the many things wrong with academic medicine, so that they can help put it right.

Richard Smith (@Richard56)
13/09/11 20:28
Academic medicine suffers from “reductionist snobbery.” The smaller the object you studied the greater the status. Molecules > society



Health policy responses to the financial crisis in Europe. How have European health systems responded to financial crisis? @martinmckee @drsilenzi

Available in:

Key messages

  • Economic shocks present policy-makers with three main challenges:
    • Health systems require predictable sources of revenue. Sudden interruptions to public revenue streams can make it difficult to maintain necessary levels of health care.
    • Cuts to public spending on health made in response to an economic shock typically come at a time when health systems may require more, not fewer, resources – for example, to address the adverse health effects of unemployment.
    • Arbitrary cuts to essential services may further destabilize the health system if they erode financial protection, equitable access to care and the quality of care provided, increasing costs in the longer term. In addition to introducing new inefficiencies, cuts across the board are unlikely to address existing inefficiencies, potentially exacerbating the fiscal constraint.
  • The response to the crisis across the European Region varied across health systems. Some countries introduced no new policies, while others introduced many. Some health systems were better prepared than others due to fiscal measures they had taken before the crisis, such as accumulating financial reserves. There were many instances in which policies planned before 2008 were implemented with greater intensity or speed as they became more urgent or politically feasible in face of the crisis. There were also cases where planned reforms were slowed down or abandoned in response to the crisis.
  • European Region countries employed a mix of policy tools in response to the financial crisis. Some of the policy responses were positive, suggesting that some countries have used the crisis to increase efficiency. The breadth and scope of statutory coverage was largely unaffected and in some cases benefits were expanded for low-income groups. However, some countries reduced the depth of coverage by increasing user charges for essential services, which is a cause for concern. Little was done to increase efficiency through policies to improve public health.
  • Policies to secure financial sustainability in the face of the financial crisis, and to improve the health sector’s fiscal preparedness for financial crises, should be consistent with the fundamental goals of the health system.
  • To risk over-simplifying, policy tools likely to promote health system goals include: risk pooling; strategic purchasing; health technology assessment; controlled investment; public health measures; price reductions for pharmaceuticals combined with rational prescribing and dispensing; shifting from inpatient to day-case or ambulatory care; integration and coordination of primary care and secondary care, and of health and social care; reducing administrative costs while maintaining capacity to manage the health system; fiscal policies to expand the public revenue base; and counter-cyclical measures, including subsidies, to protect access and financial protection, especially among poorer people and regular users of health care.
  • Policy tools that risk undermining health system goals include: reducing the scope of essential services covered; reducing population coverage; increases in waiting times for essential services; user charges for essential services; and attrition of health workers caused by reductions in salaries.
  • Where the short-term situation compels governments to cut public spending on health, the policy emphasis should be on cutting wisely to minimize adverse effects on health system performance, enhancing value and facilitating efficiency-enhancing reforms in the longer run.


HTA on the Net provides a list of resources that can be used to collect information for a health technology assessment. While there have been twelve past editions of this popular publication, 2012 marks a new direction for this publication. IHE has collaborated with Information Specialists and others in Spain to broaden the audience of the publication. Part 1 of the publication still includes all of the resources recommended by the Information Specialists at IHE. Part 2 of the publication now includes all of the additional resources that Information Specialists in Spain consider searching when they prepare health technology assessments. In future years, we hope to add additional sections from other geographic locations to truly make the publication an international effort.


Methodological Papers


Institute of Health Economics, Osteba, Agencias y Unidades de Evaluacion de Tecnologias Sanitarias (AUnETS)


Institute of Health Economics

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How much does surgery cost? About $147 a minute @drsilenzi

Interessante valutazione dei costi di procedure complesse in ospedale.

by  | in PHYSICIAN Nate Johnson is a medical student who blogs at Costs of Care

The patient had a large abscess surrounding his spleen. On a large screen in the middle of the operating room, I watched a surgeon drain the fluid collection and remove the organ with small metal tools.

I remember the surgeon navigating the complex anatomy with alacrity, handling the laparoscopic equipment with expert finesse, and quickly and confidently answering the battery of questions from the assisting medical student. To a young and reverent observer, this surgeon seemed to know everything.

So at the end of the case I asked how much the procedure would cost the patient.

“I’m not really sure. It’s … kind of complex,” the surgeon vaguely responded.

Indeed, surgical procedure charges are confusing and consist of many different fees. There are fees for medications, instruments, and devices, there is the “initial” operating room fee, the recovery room fee (billed per hour), the anesthesia fee, the surgeon’s fee, and the operating room fee (billed per minute), among others.

But at the time I was surprised and a little disappointed that this surgeon – who expertly performed the surgery and had an incredible breadth of medical knowledge – had no idea what the patient would be charged. It just seemed like such a simple question. I decided to look into it myself.

As it turns out, the total charge to the patient in this case was $43,226.18. The patient was in the operating room for 3 hours and 31 minutes and was charged a $30,966 operating room fee. That’s just under $147 per minute! A closer look also revealed that, from incision to surgery end, the procedure lasted 2 hours and 35 minutes. This leaves 56 minutes of non-surgical operating room time.

Of course, this time is not squandered. Before the surgery begins, for example, anesthesiologists need time for induction, the sterile surgical field must be set-up around the patient, instruments have to be prepared, checklists have to completed, and the surgeons have to scrub in.

Yet the question must inevitably be asked: did all of this additional work require almost an hour? At $147 per minute, the question deserves serious consideration. And the answer should be anything but vague.

Cataract surgery may prevent efficiently hip fractures in elderly which is huge cost for Medicare 10bn$/yr @FLAHAULT @drsilenzi

Quando l’analisi economica ha un punto di vista societario e non si esaurisce in una valutazione d’impatto sul budget di un singolo ospedale!


Context  Visual impairment is a known risk factor for fractures. Little is known about the association of cataract surgery with fracture risk.

Objective  To determine the association of cataract surgery with subsequent fracture risk in US Medicare beneficiaries with a diagnosis of cataract.

Design, Setting, and Participants  Retrospective study of 1-year fracture incidence in a 5% random sample of Medicare Part B beneficiaries with cataract who received and did not receive cataract surgery from 2002 through 2009.

Main Outcome Measures  One-year incidence of hip fractures. Analyses were adjusted for age; sex; race/ethnicity; US region of residence; systemic comorbidities, including Charlson Comorbidity Index (CCI) score; ocular comorbidities; cataract severity; and presence of physically limiting conditions. Adjusted odds ratios (ORs) of hip fractures were calculated using logistic regression modeling.

Results  There were 1 113 640 US Medicare beneficiaries 65 years and older with a diagnosis of cataract between 2002 and 2009 in the 5% random sample; of these patients, 410 809 (36.9%) received cataract surgery during the study period. There were 13 976 patients (1.3%) who sustained a hip fracture during the study period. The most common fracture-related comorbidity was osteoporosis (n = 134 335; 12.1%). The most common ocular comorbidity was glaucoma (n = 212 382; 19.1%). Compared with 1-year hip fracture incidence in patients with cataract who did not have cataract surgery, adjusted OR of hip fracture within 1 year after cataract surgery was 0.84 (95% CI, 0.81-0.87) with an absolute risk difference of 0.20%. Compared with matched subgroups of patients who did not receive cataract surgery, patient subgroups that experienced lower odds of hip fracture after cataract surgery included patients with severe cataract, patients most likely to receive cataract surgery based on propensity score, patients 75 years and older, and patients with a CCI score of 3 or greater.

Conclusion  In a cohort of US Medicare beneficiaries aged 65 years and older with a diagnosis of cataract, patients who had cataract surgery had lower odds of hip fracture within 1 year after surgery compared with patients who had not undergone cataract surgery.

Fractures secondary to falls are a significant cause of morbidity and mortality in the elderly population,accounting for more than 60% of expenses resulting from fall-related injuries and costing the United States more than $10 billion in the year 2000.Visual impairment has been found to be strongly associated with an increased risk of fractures,– with reports of increased fracture incidence in patients with poor visual acuity,depth perception,contrast sensitivity,and visual field loss.7

Specifically, vision plays an important role in providing a reference frame for postural balance and stability, and cataract-induced changes in vision have been found to be associated with postural instability.A systematic review found that patients who wait more than 6 months for cataract surgery had an increased rate of falls.Furthermore, cataracts have been found to be the most common cause of fracture-related visual impairment,10 with untreated cataract causing up to 49% of visual impairment in patients with femoral neck fractures related to decreased vision.10

Despite the association of poor vision and cataracts with increased fall and fracture risk, only a limited number of studies11 – 15 have examined the influence of cataract surgery on fall incidence in visually impaired adults, and only 2 of these studies11 – 12 examined the incidence of fractures secondary to falls. These 2 studies examined the relationship of first and second eye cataract surgery with fall and fracture risk in the same population of women in the United Kingdom older than 70 years, with sample sizes of fewer than 350 patients in each study. To our knowledge, no other studies have examined the association of cataract surgery and fracture incidence in visually impaired adults. This study examined the association between cataract surgery and fracture incidence in a cohort of US Medicare beneficiaries.



La rete HPH & HS,un fondamento essenziale e non accessorio, utile per promuovere sistemi, reti e percorsi in un contesto sanitario in fase di riorganizzazione

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Contributo dell’Azienda Ospedaliero-Universitaria S. Maria della Misericordia di Udine alla ricerca della documentazione scientifica per   l’HTA.

Pubblicato un lavoro su E-LIS.

Il motore di ricerca dell’AOU è stato reso disponibile nel sito della Società Italiana di Health Technology Assessment

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Patient safety is harder than aviation safety @DocComLtd @drsilenzi

By Jeff Terry
Jun 9, 2012

And five practices to borrow from aviation. Please spare me the oversimplified comparisons between aviation safety and patient safety. I say “oversimplified” because healthcare is harder than aviation. As such, improving patient safety is harder and will require more effort. Don’t get me wrong. We should draw inspiration and lessons from aviation’s journey. After all, aviation reduced deaths per million passenger miles from 5 in 1965 to 0.0003 in 2009. Wow. That’s incredible. The risk, however, is that by overemphasizing the parallels we underestimate the difficulty of patient safety. When we do, we create unrealistic expectations that distract from the real work of understanding and reducing the risks of patient harm.1Why is patient safety harder? You be the judge:

  1. On any given day in the United States, there are about 800,000 inpatients and many more outpatients. By contrast there are about 30,000 flights per day.
  2. The major US airlines fly about 25 different types of planes. By contrast, the ICD-10 lists 12,420 diseases. Each plane, like each disease, requires different protocols to manage.
  3. There are 2.5M nurses compared to 200,000 pilots.

Still, it’s hard to ignore the success of aviation. Particularly remarkable is that between 1990 and 2010, aviation became not only much more safe, but also much more efficient. We’re after the same improvement. With that in mind, here are five aviation practices worth embracing in our world:

  1. Focus on usability. Aviation used Commercial Aviation Safety Teams to improve the usability and safety of things like cockpits. This has great applicability in healthcare and there is a movement afoot, led by Peter Pronovost, to do the same for medical devices.2
  2. Make it safe to talk about events. Aviation led with ASRS. Healthcare has followed with Patient Safety Organizations. Hopefully PSOs will fulfill their potential and unleash a torrent of new data about the nuanced roots of error. This will require that PSOs become functional and culture change within most healthcare providers.
  3. Crew Resource Management.
  4. Simulation. Captain Sullenberger was able to land his plane in the Hudson for many reasons. One of those was that he had practiced landing a plane down in the water dozens of times in the simulator. Simulation is spreading in healthcare for everything from warm-ups, to surgeon training, to crew training to credentialing. That’s a good thing.
  5. Prediction. Aviation has gotten better and better at predicting air traffic.

Healthcare is beginning to do the same. This bodes well for safety as surveillance capabilities begin to anticipate specific procedures, patients, time period and units when there may be elevated risk of harm.

For my part, you’ll see me push to bring practices from aviation to healthcare that can improve safety. But, please spare me the comparisons. We get it. Aviation has done great work. Healthcare is harder.

2. Reducing Health Care Hazards: Lessons From The Commercial Aviation Safety Team, Pronovost et al, Health Affairs 28, no. 3 (2009): w479-w489 (published online7 April 2009; 10.1377/hlthaff.28.3.w479)

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Faculty of Medical Leadership and Management @muirgray @drsilenzi @FMLM_UK

FMLM Conference 2012

Four Nations, One Challenge – Improving patient outcomes
16-17 October 2012
Venue: Manchester Central, Manchester, M2 3GX

Join the smartest minds in medicine: those that recognise the importance of leadership in making tomorrow better for our patients.

FMLM’s first annual conference will bring together FMLM’s diverse and multi-specialty membership to offer an exciting agenda. In this Olympic year, the conference will draw on lessons from sport which focuses on performance and excellence, and will rethink how best to imagine and then achieve success; how to take decisions and implement them; and how to celebrate and reward achievement for individuals and teams.

Uniquely, the four workstreams of the conference will be charged with making recommendations for FMLM’s future strategy. These will be brought together in what promises to be a exceptional final session. The themes which will form our roadmap to success are:

  • Healthy doctors
  • Effective medical leadership
  • Commissioning 2015
  • Value for patients

This is the must attend event for anyone looking to improve quality for our patients and achieve essential efficiencies in these challenging times.

Reflecting FMLMs diverse membership, delegates will range from senior medical leaders in primary care, public health and secondary care, consultants and GPs, to the medical leaders and managers of the future – doctors in postgraduate training and medical students. Click here for the Benefits of attending.

Registration is free for Faculty of Medical Leadership and Management members and associates. Click here to secure your place.

Non-Member conference rates are:

Early bird rate* Full rate
 One day Two days  One day  Two days
  Public, Charity and Voluntary sector  £226  £375  £330  £575
  Private sector  £582  £965  £790 £1375

*Early bird price is available up to and including Mon 3 September 2012.

Rebecca Onie: E se l’assistenza sanitaria ci mantenesse in salute? @drsilenzi

Rebecca Onie si pone domande coraggiose: E se le sale d’aspetto fossero luoghi fatti per migliorare le cure sanitarie quotidiane? E se i medici potessero prescrivere cibo, casa, e riscaldamento in inverno? A TEDMED Rebecca Onie parla di Health Leads, un’organizzazione che fa proprio questo — e lo fa attraverso una base volontaria dedicata quanto una squadra sportiva universitaria.

Una conversazione TED di Rebecca Onie: In 1996, as a sophomore in college, Rebecca Onie had a realization: The health care system in the United States was not set up to diagnose nor treat the socioeconomic issues that lead to poor health, and that health care providers are not given tools to address basic problems like nutrition and housing. So, while still a sophomore, she co-founded Health Leads, a program that assists low-income patients and their families to access food, heat, and other basic resources they need to be healthy. With the additional insight that college volunteers could be recruited and trained into an elite group just like a college sport team, she found the people and skills needed to produce such an audacious idea. Since then it has grown tremendously, and now operates in Baltimore, Boston, Chicago, New York, Providence, and Washington, DC, and in the last year assisted over 8,800 patients. In 2009, Rebecca was awarded a MacArthur “Genius” Fellowship.

Atul Gawande: Come si fa a guarire la medicina? @Atul_Gawande @drsilenzi @muirgray

I nostri sistemi sanitari non funzionano. I medici sono in grado di somministrare cure straordinarie (e costose), ma stanno perdendo di vista l’obiettivo principale: curare la gente. Il medico e scrittore Atul Gawande suggerisce di fare un passo indietro e guardare a nuovi modi di fare medicina, con meno “cowboy” solitari che fanno tutto da sé e più squadre coordinate.

Una conversazione TED di Atul Gawande, autore di “Checklist”: una lettura obbligatoria!

Atul Gawande: A general and endocrine surgeon at Brigham and Women’s Hospital in Boston, Atul Gawande is also a staff writer at The New Yorker who’s changing the way we think about best practices in medicine (and, necessarily, about the state of the US healthcare system). In 1996 Gawande wrote his first piece for Slate, an analysis of the then-controversial illness known as Gulf War Syndrome. At The New Yorker, he turned in a shocking June 2009 piece, “The Cost Conundrum,” about McAllen, Texas, the town with the second most expensive health-care market in the U.S., taking on America’s high-cost low-quality healthcare system. (The piece was cited by President Obama during his campaign for healthcare reform.)

Gawande approaches medicine with a personal outlook, emphasizing the importance of a doctor’s intention and reliability, and urging doctors to make small changes to improve performance. In his most recent book, The Checklist Manifesto, Gawande shows how even a simple five-point checklist can decrease up to two-thirds of ICU infections. He suggests that as modern medicine — and indeed, the modern world — becomes increasingly complex, we should respond with ever-simpler measures.


Max Hardy in

Just what is the general attitude of Australian health professionals to the practice of consumer and community engagement and shared decision-making?

That’s the very question we sought to answer via Twyfords’ just-completed national survey. Targeted at a wide cross-section of health professionals including executives, administrators, clinicians, academics and policy designers, our questionnaire was designed to ascertain:

• the perceived value of engagement in improving healthcare strategies
• the perceived value of shared decision-making in improving health outcomes
• the extent to which engagement and shared decision-making initiatives are resourced
• the types of benefits derived from engagement and shared decision-making
• the prevailing awareness around various methodologies

As far as we know, ours is one of the first attempts to examine and understand attitudes towards consumer engagement and shared decision-making within the Australian health sector.

Lack of benefit awareness

One message that rings out loud and…

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