Archivi del mese: marzo 2013

Good piece on potential for social media in improving patient safety @tkelsey1 @Medici_Manager

Harnessing the cloud of patient experience: using social media to detect poor quality healthcare

Recent years have seen increasing interest in patient-centred care and calls to focus on improving the patient experience. At the same time, a growing number of patients are using the internet to describe their experiences of healthcare. We believe the increasing availability of patients’ accounts of their care on blogs, social networks, Twitter and hospital review sites presents an intriguing opportunity to advance the patient-centred care agenda and provide novel quality of care data. We describe this concept as a ‘cloud of patient experience’. In this commentary, we outline the ways in which the collection and aggregation of patients’ descriptions of their experiences on the internet could be used to detect poor clinical care. Over time, such an approach could also identify excellence and allow it to be built on. We suggest using the techniques of natural language processing and sentiment analysis to transform unstructured descriptions of patient experience on the internet into usable measures of healthcare performance. We consider the various sources of information that could be used, the limitations of the approach and discuss whether these new techniques could detect poor performance before conventional measures of healthcare quality.

NHS group to consider weekend services @Medici_Manager @tkelsey1 @specializzandi

A group is to be set up to examine why the NHS in England cannot provide some routine services at weekends – like day surgery – the BBC understands.

The NHS Commissioning Board is due to announce the move on Tuesday, when it publishes its planning guidance for the NHS for the first time.

The group will include patient representatives, health providers and people from outside the health service.

The government said it “fully supported” a seven-day service.

The health minister, Lord Howe, said patients needed the NHS “every day”.

“Offering easier access to hospital consultants, GPs and routine hospital services seven days a week will reduce delays and ensure that patients get seen and treated by experienced healthcare professionals,” he said.

The British Medical association said it was “open to discussion” about the changes.

The setting up of the group follows research that suggests patients are more likely to die if they are admitted to hospital over the weekend.

Board medical director Sir Bruce Keogh told the BBC the new group would look at “the barriers that stop us heading in the direction of a seven-day service.”

‘Moral case’

He said the new group would “invariably have to look at terms and conditions [of hospital staff] and see what incentives there might be”. But he stressed that “this is not about forcing people”.

“I am just trying to build a practical, moral and compassionate case on behalf of patients.

“You have got to get people to believe in the moral case,” he said.

Sir Bruce added: “It is time for the NHS to offer more routine services at the weekend, in addition to emergency services. This will be a big cultural change, but our focus should be on convenience and compassion for those seeking our help.”

He also said the focus of the new NHS Commissioning Board – which was set up under the government’s re-organisation of the health service – is to be patient focused, and that that was why he was setting up the group.

Our political reporter, Susana Mendonca, says Sir Bruce has long been a supporter of the idea that patients would be better served if routine services – like scans – were available at weekends.

Research suggests that patients are more likely to die in hospital if they are admitted at the weekend.

Earlier this year, research, carried out at University College London and the universities of Birmingham and East Anglia, was published showing patients in England were 16% more likely to die if they were admitted on a Sunday, rather than mid-week.

Staffing – and in particular the presence, or absence, of senior doctors – has been highlighted as a key factor.

The Department of Health said some hospitals were already thinking about treating patients at weekends for non-urgent operations and procedures.

For example, in Birmingham and Torbay, hospitals have had scanners open to provide tests over the weekend, as well as operations being carried out.

They also have more more senior staff and consultants around at weekends.

Responding to Sir Bruce’s comment, the British Medical Association – which represents doctors – said it was “open to discussions on ways of further improving the service patients receive at evenings and weekends”.

“Flexibility will be key – solutions that work for one specialty may not work for others,” a spokesman said.

Hospital Kaizen: Habit-Building @MikeLombard @Medici_Manager @fabriziofontan2

I’m really liking The Power of Habit:  Why We Do What We Do in Life and Business by Charles Duhigg.  Taken along with the Mike Rother’s Toyota Kata, you have the basics of what it takes to create a continuous improvement culture.
For clarity’s sake, I define a continuous improvement culture as an environment in which we strive to improve every process, every day, with everybody involved.  No improvement is too small, we don’t batch all our improvements into big projects, and anybody in the organization can be an improvement leader.  For more information on this concept applied to healthcare, see Graban & Swartz’ book Healthcare Kaizen.
Anyway, in Duhigg’s book, the habit-building loop is presented.  It has three components:
  1. Trigger:  this is the cue to perform a routine
  2. Routine:  this is the standard steps performed to arrive at the desired result
  3. Reward:  this is the payoff for performing the routine on-cue
When these three elements are in-place and clearly related, a craving eventually forms.  This craving causes the habituated person to anticipate the reward at the trigger point, even before performing the routine.  This phenomenon is the indicator of a well-formed habit (for better or for worse!).
While Duhigg’s book is about the science behind habit-forming, Rother’s book is about the habits needed to drive continuous improvement.  Specifically, he emphasizes two habits (he uses the term ‘kata’):
  • Improvement Kata:  this is a 4-step routine that helps us 1) see the ideal condition to which we strive, 2) study the current condition to see our gaps, 3) set a short-term target condition to pursue that is on the path to the ideal condition, and 4) pursue the target condition using PDSA (another 4-step routine).
  • Coaching Kata:  this is a routine, drawing upon the Socratic Method of teaching (asking questions instead of giving answers), that is designed to reinforce the proper execution of the aforementioned Improvement Kata.
So, how do we put in place the three elements of the habit-building loop for the two kata?  How do we create a craving for the kata?  The routines (element #2 of the habit-building loop) are established by Rother’s book.  The other two elements, triggers and rewards, are TBD for me personally.  Some thoughts:
  • Triggers:  eventually, the ideal would be that the trigger is the detection of a problem/gap/opportunity for improvement, but in the short-term, more artificial triggers may be needed (i.e. require each manager to perform one PDSA cycle per month…not a long-term solution, but can get the ball rolling in the short-term).
  • Rewards:  eventually, the ideal would be that the reward would be the intrinsic motivators of mastery, autonomy, and purpose (see Daniel Pink’s Drive), but in the short-term, more artificial rewards may be needed (i.e. gamification:  badges, achievements, recognition, compliance tracking, small gifts, etc.)
This type of habit-building is tricky business.  Culture change is hard.  It takes a wide range of knowledge, organizational finesse, and a lot of trust and patience on the part of senior leadership.  But the payoff is huge.  A culture of continuous improvement is the best, most sustainable competitive advantage available.

4 essential elements of true health reform @kevinmd @Medici_Manager


I recently said I would describe the essential elements of “true reform.” I realize others might add or subtract from my list, but here it is – at least for today:

Payment reform. I put this first because no matter what form or structure healthcare takes, without payment reform it will be doomed to failure. And by “payment reform” I mean switching from the “fee for service” model I discussed in an earlier column – which basically pays more for doing more whether or not it is needed – to some kind of “outcomes” payment system.

There are many “outcomes” payment ideas – bundling, global, etc. – but they are all designed in theory to force providers to live within a certain budget for a given patient. Obviously, this is a huge culture change and will require many years – and many mistakes – to figure out.

But I think it is probably the most essential ingredient of true reform. (I would also include malpractice reform in this category; by switching to a no-fault system we would remove a large incentive to do unnecessary testing and treating.)

Electronic records. While I recognize there are many issues (privacy, compatibility, etc.) to be yet worked out before electronic records can become near universal in our hospital and personal healthcare, I believe it will be impossible to intelligently cut costs and improve safety without them. Imagine, again, the U.S. commercial airline industry in this country without computers able to “talk to each other” with the same language no matter the location.

Comparability data. And once such a computer system is widely in place, we can start making better use of “outcomes” data – i.e., data from studies that tell us what works best at the lowest cost.

Another name for this would be “cost effectiveness” data but those two words strike fear – understandably – in the hearts of doctors and patients who assume that means choosing the cheapest option regardless of quality concerns.

Right now there is a paucity of such data – in part because the “medical industrial complex” has often fought true comparison studies. But the need for such data will only grow as cost issues become paramount.

Primary care. Ultimately, all of the above will only work well in the setting of good primary care – meaning a place and professionals readily available, at least by phone, when a person thinks they (or a member of their family) might be sick.

The phrase so often used to describe this “place” today is “the medical home.” Obviously a “medical home” – like any home – can physically exist in many different kinds of settings ranging from a traditional office to a clinic to a setting in a hospital.

But the key ingredients of such a home, in my judgment, are the traditional three A’s: availability, affability, and affordability.

Timothy Johnson trained as an emergency room physician but switched careers in 1984 when he joined ABC News as its first full time Medical Editor. Although he retired from that role in 2010, he continues as Senior Medical Contributor.  He blogs atTimothy Johnson, MD: On Health.

The NHS deserves better than this dash to market @Medici_Manager @WRicciardi @fgodlee

Fiona Godleeeditor, BMJ

With apologies to those for whom it holds no interest, I am writing for a second week about England’s NHS (doi:10.1136/bmj.f1850). We are now only days away from the introduction of new NHS regulations. Drafted in February, hastily revised by the government last week because of fierce criticism, and due to be enacted in a few days’ time, they are designed to open up the NHS in England to competition by for-profit corporations. TheBMJ has a reputation for anti-market sentiment when it comes to the provision of healthcare, and views on the new regulations are polarised. So to balance last week’s coverage we have commissioned a debate aiming to reflect both sides of the argument and inform readers about what’s going on.

Does April 1 mark the beginning of the end of England’s NHS? David Hunter says it does, and he invites those who think this is just left wing scaremongering to take a close look at what is happening in other health systems where similar marketisation is underway (doi:10.1136/bmj.f1951). Julian Le Grand, former advisor to Tony Blair during the New Labour healthcare reforms, says the fear of competition is misplaced, especially since “large chunks of the NHS are already private and have been since 1948.” (doi:10.1136/bmj.f1975) We should direct our fears towards austerity measures, he says, not the market.

I asked last week whether people understand what is happening. Clare Gerada confirms my view that we don’t. In her editorial she says that we are dealing with “a set of regulations that no one understands and that seem to conflict with the previously stated intentions of the government that wrote them.” (doi:10.1136/bmj.f1977). Even someone as engaged and impressive as the chief executive of NHS London, Ruth Carnall, admits to confusion. In a recent tweet quoted by Gerada, Carnall says, “I’m supposed to know what’s going on re all of this. I don’t.” And she’s not alone. The House of Lords committee responsible for scrutinising the regulations concluded last week that there is “no common understanding” of the new rules, saying that the Department of Health has given “insufficient time” to set the system up properly and enable thorough scrutiny.

Gerada herself is in no doubt about what the new regulations mean. They allow for “the wholesale dismantling of the NHS and privatisation of the supply, organisation, planning, finance, and distribution of healthcare.” Nor does she doubt the consequences. The regulations will leave general practitioners “bearing the brunt of the public’s wrath, while much of the health budget is handed over to the for-profit commercial sector, services are closed, and entitlements to universal healthcare are eroded.”

The government wants the regulations in place when the National Commissioning Board takes over England’s NHS on April 1. But members of the House of Lords may still be able to limit the extent of subsequent privatisation by forcing a debate at the end of April (doi:10.1136/bmj.f1983). If they succeed, this will be a once in a lifetime chance to influence the future of England’s NHS, and we must seize it on behalf of present and future generations.

Cite this as: BMJ 2013;346:f1994

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ@bmj_latest

10 talks on predicting the future @Medici_Manager @muirgray


We’re just a week into 2013, and the year seems filled with possibility. The turn of the New Year is generally an occasion to look back and reflect on the year that’s passed — the victories and defeats, the lives lost and the experiences found. But after we look back, we inevitably turn forward. We make resolutions and predictions for the year to come, taking educated guesses as we gaze into the abyss of the unknown. Here,10 TED Talks that offer visions for the future.

Ian Goldin: Navigating our global future
“This could be our best century ever, or it could be our worst,” says Ian Goldin. In this absorbing talk from TEDGlobal 2009, Goldin argues that the accelerating impact of globalization has the potential for miraculous human achievements, but also presents immense challenges — specifically in inequality. We may see incredible advances in technology, science and the quality of life, but will only the rich have access? Offering predictions for life in 2030, Goldin reminds us that “the rest of our lives will be in the future, so we need to prepare for it now.”

Kevin Kelly: The next 5,000 days of the web
At EG 2007, Keven Kelly noted that we had 5,000 days of the World Wide Web behind us. In this talk, he looks at what’s to come next. He foresees a smarter, more personalized and more ubiquitous web in the next 10 years, with the digital cloud forming the underpinnings of our physical environment. As the web doubles in power every two years, he shares why it’s expected to exceed human power by 2040.

Kirk Citron: And now, the real news
Projecting a “Long News” perspective onto the present, Kirk Citron analyzes the headlines at TED2010, trying to predict what will still be relevant in 10, 100 and 10,000 years. It’s not Michael Jackson’s death or the miraculous landing of a US Airways plane on the Hudson River that will matter, he says, but innovations in science. Why? Because research in 2010 paved the way for genetically modified food to feed the planet, for people to drink water on the moon, and for nanobees to enter the brain and zap tumors with bee venom. In the long run, Citron points out that some news stories are just more important than others.

Rob Hopkins: Transition to a world without oil
Rob Hopkins wants to tell a different story about the future. Not one of apocalypse or salvation but of transition — specifically, transition from our dependence on oil. As the founder of the Transition movement, he advocates for petroleum-free communities stripped of modern-day luxuries, but also free from the trappings of oil. Sustainability isn’t the solution, Hopkins says at TEDGlobal 2009, because we can’t simply invent our way out of oil dependence.

Martin Rees asks: Is this our final century?
Zooming in on the “tiny sliver of earth’s history” that has involved humans, and zooming out again to the full past, present and future of the universe, astronomer Sir Martin Rees explores the future of our planet. Highlighting the immense changes that will occur, he reminds the audience at TEDGlobal 2005 that when the sun extinguishes in 6 billion years, the creatures living on this earth will be as different from us as we are from bacteria.

Nicholas Negroponte, in 1984, makes 5 prediction 

Danny Hills: Back to the future (of 1994)

This pair of talks from the TED archives highlights the challenges and successes of predicting the future. Nicholas Negroponte’s talk from TED1984 offers five eerily on-point predictions, ranging from touchscreen phones to the future of CD-ROMS. Ten years later, Danny Hills offers a timeless theory of technological evolution that mirrors our own biological trajectory.

Larry Burns on the future of cars
Computer-enhanced cars — that run on clean hydrogen and contribute to the energy grid — are just around the corner, says Larry Burns. You’ll even refuel your hydrogen-fueled car at home, he shares. At TED2005, GM vice president for research and design Larry Burns details his exciting task of reinventing the automobile.

Aubrey de Grey: A roadmap to end aging
You could live to see the next millennium, suggests researcher Aubrey de Grey. Arguing that we could live to be 1,000 years old, de Grey explains that if we simply extend our lives by 30 years right now, we can reach the “longevity escape velocity,” with the rate of life-extending discoveries outpacing our 30-year life extension. And, he says at TEDGlobal 2005, the tools to start this process exist right now.

Stewart Brand on the Long Now
“It would be helpful if humanity got into the habit of thinking of the now not just as next week or next quarter but the next 10,000 years,” notes Stewart Brand in this talk from TED2004. Disrupting our conception of time and space, Brand describes his current project to build a 10,000 year clock that would be able to withstand the wear and tear of deep time.

Shared Decision Making to Improve Care and Reduce Costs @Medici_Manager

Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D.

A sleeper provision of the Affordable Care Act (ACA) encourages greater use of shared decision making in health care. For many health situations in which there’s not one clearly superior course of treatment, shared decision making can ensure that medical care better aligns with patients’ preferences and values. One way to implement this approach is by using patient decision aids — written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options; each option’s outcomes, including benefits and possible side effects; the health care team’s skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients’ values.

However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making. We believe that the Centers for Medicare and Medicaid Services (CMS) should begin certifying and implementing patient decision aids, aiming to achieve three important goals: promote an ideal approach to clinician–patient decision making, improve the quality of medical decisions, and reduce costs.

In a 2001 report, Crossing the Quality Chasm, the Institute of Medicine recommended redesigning health care processes according to 10 rules, many of which emphasize shared decision making. One rule, for instance, underlines the importance of the patient as the source of control, envisioning a health care system that encourages shared decision making and accommodates patients’ preferences.

Unfortunately, this ideal is inconsistently realized today. The care patients receive doesn’t always align with their preferences. For example, in a study of more than 1000 office visits in which more than 3500 medical decisions were made, less than 10% of decisions met the minimum standards for informed decision making.1 Similarly, a study showed that only 41% of Medicare patients believed that their treatment reflected their preference for palliative care over more aggressive interventions.2

There’s also significant variation in the utilization of procedures, particularly those for preference-sensitive conditions, which suggests that patients may receive care aligned not with their values and preferences, but with their physicians’ payment incentives. Among Medicare patients in more than 300 hospital regions, the rate of joint-replacement procedures for chronic hip arthritis varied by as much as a factor of five, and the use of surgery to treat lower back pain varied by nearly a factor of six. Other studies have found wide regional variation in the treatment of early-stage breast and prostate cancers and in the use of cardiac procedures.

Section 3506 of the ACA aims to facilitate shared decision making. Primarily, it funds an independent entity that would develop consensus-based standards and certify patient decision aids for use by federal health programs and other interested parties. In addition, the secretary of health and human services is empowered to fund, through grants or contracts, the development and evaluation of these tools. Decision aids are meant to be evidence-based and inform patients of the risks and benefits of tests and treatments, their relative effectiveness, and their costs. Health care providers will be eligible for grants to implement these tools and to receive training and technical support for shared decision making at new resource centers. The ACA also authorizes the Center for Medicare and Medicaid Innovation to test shared-decision-making models designed to improve patients’ and caregivers’ understanding of medical decisions and assist them in making informed care decisions. For approaches that provide savings or improve quality of care, implementation can be mandated throughout Medicare without additional legislation.

Randomized trials consistently demonstrate the effectiveness of patient decision aids. A 2011 Cochrane Collaborative review of 86 studies showed that as compared with patients who received usual care, those who used decision aids had increased knowledge, more accurate risk perceptions, reduced internal conflict about decisions, and a greater likelihood of receiving care aligned with their values. Moreover, fewer patients were undecided or passive in the decision-making process — changes that are essential for patients’ adherence to therapies.

Studies also illustrate the potential for wider adoption of shared decision making to reduce costs. Consistently, as many as 20% of patients who participate in shared decision making choose less invasive surgical options and more conservative treatment than do patients who do not use decision aids.3 In 2008, the Lewin Group estimated that implementing shared decision making for just 11 procedures would yield more than $9 billion in savings nationally over 10 years. In addition, a 2012 study by Group Health in Washington State showed that providing decision aids to patients eligible for hip and knee replacements substantially reduced both surgery rates and costs — with up to 38% fewer surgeries and savings of 12 to 21% over 6 months.4 The myriad benefits of this approach argue for more rapid implementation of Section 3506 of the ACA.

The Department of Health and Human Services could quickly launch pilot programs for shared decision making while it works to standardize and certify decision aids. The International Patient Decision Aid Standards Collaboration has developed evidence-based guidelines for certification indicating that decision aids should include questions to help patients clarify their values and understand how those values affect their decisions; information about treatment options, presented in a balanced manner and in plain language; and up-to-date data from published studies on the likelihood of achieving the treatment goal with the proposed intervention and on the nature and frequency of side effects and complications. In addition, it would be helpful to include validated, institution-specific data on how often the specified procedure has been performed, the frequency of side effects and complications, and the cost of the procedure and any associated medication and rehabilitation regimens. We believe that decision aids should be written at an eighth-grade level and should be brief.5

In our view, it seems most critical to begin with the 20 most frequently performed procedures and to require the use of decision aids in those cases. Many decision aids have already been rigorously evaluated, so CMS could rapidly certify these tools and require their use in the Medicare and Medicaid programs. To give such a requirement teeth, full Medicare reimbursement could be made contingent on having documentation in the patient’s file of the proper use of a decision aid for these 20 procedures. Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics.

In addition, the improved quality of care and savings gained through shared decision making can be maximized by integrating this approach into other ACA initiatives. For example, the documented use of patient decision aids could be used as a quality metric in patient-centered medical homes, accountable care organizations, and systems caring for patients eligible for both Medicare and Medicaid. Eligibility criteria for incentives to adopt electronic health record technology might be expanded to include the use of shared decision making and patient decision aids. Moreover, information gathered by the Patient-Centered Outcomes Research Institute (PCORI) could be incorporated into certified decision aids and used to provide physicians and patients with valuable information for making health care decisions. Data about the effectiveness of shared-decision-making techniques could also be collected and disseminated by PCORI for continuous improvement of these approaches.

Unfortunately, implementation of ACA Section 3506 has been slow. More rapid progress on this front would benefit patients and the health care system as a whole.

Add your thoughts here… (optional)

La Sanità sbarca in Parlamento @Medici_Manager @derossire


Comunicato stampa – 22 marzo 2013

La Sanità sbarca in Parlamento

Nella legislatura che si è aperta in questi giorni, la XVII, il “partito della Sanità” conta ben 73 parlamentari, quasi tutti alla prima esperienza. Lo rileva un servizio pubblicato sul prossimo numero del settimanale “Panorama della Sanità” (in uscita lunedì 25 marzo) che ha raccolto nomi, volti e curricola di tutti i parlamentari provenienti dalle fila della sanità italiana.

Dei 73 nuovi parlamentari solo 8 sono stati i rieletti (4 al Senato e 4 alla Camera), mentre 7 deputati della passata legislatura sono stati eletti al Senato e 4 ex-senatori sono stati eletti alla Camera. 

Il drappello più consistente è costituito dai medici che contano ben 43 parlamentari (9 donne) di cui 26 senatori e 17 deputati. Seguono gli infermieri e altre professioni sanitarie con 9 parlamentari (6 donne) di cui 5 deputati e 4 senatori. Quindi i farmacisti con 5 parlamentari (1 donna), 3 senatori e 2 deputati. I medici veterinari sono invece 3 di cui 1 donna e 2 deputati e 1 senatore. Tre sono anche i biologi (1 donna) di cui 2 senatori e 1 deputato. Mentre i 3 psicologi (2 donne) sono tutti deputati. Al solo Senato siedono anche 3 amministrativi della sanità pubblica e privata (1 donna) e anche un’assistente sociale (1 donna).

In merito poi all’appartenenza politica il gruppo più consistente con 23 parlamentari appartiene al Pdl  (17 senatori e 6 deputati), segue il Pd con 21 parlamentari (12 deputati e 9 senatori), il Movimento 5 stelle con 15 deputati (8 senatori e 7 deputati), Scpi 8 parlamentari (6 deputati e 2 senatori) e infine Lega e Unione valdostana con 1 senatore ciascuno.

E’ poi il Nord che da il numero più consistenti di parlamentari della Sanità con ben 30 eletti. Un numero consistente, con 29 parlamentari, arriva anche dal Mezzogiorno. Una speranza quindi per la Sanità meridionale le cui regioni sono tutte, eccetto la Basilicata, sottoposte a piano di rientro. Mentre il Centro è rappresentato con 9 parlamentari. 


@ProfAlanMaynard on NICE approval: Lucentis for Macular Oedema why not Avastin? @Medici_Manager

NICE approves eye drug for diabetes

By James GallagherHealth and science reporter, BBC News

A drug that can save the sight of people with diabetes may now be made available on the NHS in England and Wales – reversing an earlier decision.

At least 50,000 people in the UK have diabetic macular oedema which can leave people unable to read, work or drive.

In 2011, the National Institute for Health and Clinical Excellence (NICE) said ranibizumab, which is sold as Lucentis, was too expensive.

A final decision will be made in February.

Macular oedema occurs when fluid leaks from the small blood vessels in the eye.

Diabetes can trigger changes to the blood vessels leading to fluid collecting in the central part of the retina called the macular area.

Saving sightProf Carole Longson, from NICE, said the manufacturers had agreed to reduce the price which led to a review of the guidance.

“NICE is pleased to recommend ranibizumab as a treatment option for some people with visual impairment caused by diabetic macular oedema in new draft guidance.”

Clara Eaglen, eye health policy and campaigns manager at the charity RNIB, said: “We believe NICE has thrown a lifeline to the growing number of people with diabetes facing blindness.

“Currently people are needlessly losing their sight from diabetic macular oedema.”

Barbara Young, the chief executive of Diabetes UK, said: “We are delighted that NICE have reconsidered their previous decision, and that this draft guidance recommends that Lucentis is made available on the NHS, as this would mean more people with diabetes would have a better opportunity to preserve and possibly improve their vision.”

Doctors’ appearance may be more important than they think @Medici_Manager

Erica Cohen, A third-year law student concentrating in health at Drexel

While physicians are usually more concerned with monitoring patient heart rates and reading lab results than with their personal grooming, a recent study showed that a physician’s appearance can be quite important. It is part of making patients’ families feel comfortable in a high-stress hospital environment.

The study, published by the Journal of the American Medical Association (JAMA), found that about one-third of patient families members in an intensive care unit (ICU) considered a lack of tattoos and piercings important in their first impression of a physician. While this number is considerably less than those for other professional attributes that respondents deemed important – wearing an easy-to-read name tag (77%), neat grooming (65%) and professional dress (59%) – the number is still considerable.

Respondents also favored traditional medical attire, such as a white coat (52%) or scrubs (24%). They were less partial to a suit (13%) or casual attire (11%).

So what it is about a clean-cut, tattoo-less doctor in a white coat that makes family members more comfortable with the care the patient is receiving?

According to the study, respondents associated professional attire with honesty, knowledge, and better care. Surprisingly, professional appearance was more important to patients than even age, which is typically an indicator of experience. Patients’ families may believe that a physician is more competent or intelligent if he or she is dressed appropriately for the hospital.

Physician grooming may be particularly important in an ICU because of the high-pressure environment in which patients’ families need to bond quickly with the physician who is working to keep the patient alive.

While professional grooming and attire send clear signals to family members in a hospital, it is less clear why a physician with a tattoo would seem any less trustworthy than one without. Tattoos and piercings seem to retain a stigma.

According to a 2010 Pew Research study, almost four-in-ten teens and twenty-somethings (so-called millennials) have a tattoo. About half of those with tattoos have between two and five, and 18% have six or more. And nearly one-in-four individuals in this age group have a piercing on a body part other than an earlobe.

Right now, patient family members in the ICU are more likely to be Baby Boomers. And the numbers are drastically different for them – far fewer have body piercings and multiple tattoos. That could account for the difference in attitudes.

While it is possible that opinions may change as the millennials age and become the family members holding vigil in ICU waiting rooms, one thing is clear. For the time being, critical care doctors should consider covering up the tattoos, taking out the eyebrow ring, and putting on a white coat. It may seem trivial to some, but it is a small price to pay to increase the trust of patients’ families in those taking care of their loved ones.

By Erica B. Cohen

Assistenza primaria. Confronto shock tra UK e USA @Medici_Manager

Inserito da  on 14 marzo 2013 – 11:06


Gianfranco Damiani, Serena Carovillano, Andrea Poscia e Giulia Silvestrini

L’Inghilterra, ideatrice e promotrice del modello Beveridge, apre le porte del suo NHS al privato. Mentre gli Stati Uniti, storicamente affezionati all’idea di una sanità di  libero mercato,  iniziano a sperimentare modelli di assistenza universalistica.

Alla luce delle quasi contemporanee riforme di due dei principali sistemi sanitari mondiali (Regno Unito e Stati Uniti) ci si propone di descrivere gli approcci di questi due Paesi nell’ambito della Primary Health Care (PHC). In particolare nel presente post verrà proposto un focus sulla componente di PHC di pertinenza medica (Primary Medical Care), indagando le differenti modalità organizzative proprie dei Medici di Medicina Generale (MMG) proposte nei due contesti presi in esame.

Per una più chiara comprensione delle trasformazioni avvenute, è necessario ripercorrere le principali tappe di costituzione e sviluppo dei Sistemi Sanitari in questione.

Regno Unito

Il Sistema Sanitario del  Regno Unito (National Health Service – NHS), nasce nel 1946 con il “National Health Service Act“, con il proposito di garantire a tutti i residenti sul suolo britannico, senza distinzioni geografiche, assistenza primaria, ospedaliera e servizi specialistici.

Successivamente nel 2010 viene pubblicato il libro bianco “Equity and Excellence: Liberating the NHS”[1], divenuto legge nel marzo 2012 “Health and Social Care Act 2012″[2]. Sebbene i principali obiettivi dichiarati di tale riforma sembrino essere una semplificazione dell’apparato burocratico volta a recuperare la centralità del paziente[3], molti dubbi, già ampliamente discussi in questo blog[4,5,6], hanno caratterizzato e ostacolato il suo percorso legislativo[7,8,9]. Molte delle trasformazioni introdotte dalla riforma interessano i MMG Inglesi, in particolare una delle principali innovazioni previste è l’abolizione dei Primary Care Trust (PCT, un equivalente delle nostre Aziende Sanitarie Locali –ASL) e delle “Strategic Health Autorities” (SHA – Strutture che esplicano funzioni simili ai nostri assessorati Regionali alla Sanità). Questi enti verranno sostituiti sia fisicamente che funzionalmente dai Clinical Commisionig Group (CCG), ovvero grandi consorzi di medici di famiglia (General Pratictioners – GPs-). (Vedi anche Dossier NHS)

Stati Uniti

Per quanto riguarda gli Stati Uniti, il sistema sanitario americano è basato prevalentemente sul settore privato, sia sul versante del finanziamento, tramite le assicurazioni, sia su quello dell’offerta e della produzione dei servizi, anche con una rilevante componente assicurativa pubblica, finanziata dal Governo federale e statale[10,11]. Da qui la definizione di tale sistema sanitario come fondato sul libero mercato. Dalla campagna elettorale del 1912 del candidato progressista Theodore Roosevelt, negli Stati Uniti, si dibatte sulla necessità di una riforma che assicuri l’assistenza sanitaria a tutti i cittadini[11]. Barack Obama, con l’approvazione  il 23 marzo 2010 della riforma sanitaria, pur avendo rinunciato all’idealistico obiettivo di una Assicurazione Sanitaria Pubblica, è stato di fatto il primo Presidente Americano a far approvare una riforma che punta a contenere la spesa sanitaria, ma anche a ridurre i larghi margini di inappropriatezza, di iniquità e di inefficienza che affliggono la sanità in questo paese, con l’obiettivo ultimo di migliorare gli outcome di salute della popolazione, contrastando in particolare la diffusione delle malattie croniche (in primis obesità e diabete)[12,13]. In questo contesto di cambiamento ha iniziato a muovere i primi passi un nuovo modello di erogazione di assistenza di primo livello, le Accountable Care Organization (ACO). Un modello assistenziale rivolto esclusivamente a quella parte di  popolazione americana beneficiaria dell’assistenza sanitaria “gratuita” offerta da  Medicare e Medicaid (entrambi programmi assicurativi statali che la Sanità Americana offre a tutti i cittadini ultrasessantacinquenni e pazienti dializzati senza limite di età, e a gruppi di popolazione a basso reddito come bambini, donne in gravidanza, disabili, anziani indigenti e malati di AIDS)[14,15].

L’intento di questo approfondimento sarà quello di analizzare i principali punti di forza e debolezza finora evidenziati in letteratura dei due modelli di ”Medical Primary Care” proposti nell’ambito delle due riforme: i Clinical Commissioning Group (CCG) e le Accountable Care Organization (ACO).

Modello Regno Unito: Clinical Commissioning Group

I CCG sono organizzazioni private, formate da gruppi di GPs con almeno un accountable officer, che hanno l’obiettivo di garantire assistenza ai loro iscritti. Tale assistenza dovrà essere erogata direttamente o commissionando i servizi, promuovendo l’uguaglianza e coinvolgendo il paziente e la comunità nella definizione dei percorsi assistenziali più idonei e nella successiva valutazione.  I CCG collaborano con altre figure sanitarie e con le “Local Communities” e le “Local Authorities”. Ogni associazione di medici di famiglia (GP practice) deve appartenere ad un CCG, che deve formarsi in modo tale da assicurare “la migliore assistenza ed i migliori risultati in termini di salute”. Sebbene sia prevista la libertà del paziente, che sceglie a quale practice iscriversi, i CCG dovrebbero avere confini che “normalmente” non oltrepassano quelli delle Local Authorities e con un numero di pazienti oscillanti tra i 100.000 ed i 750.000. Il finanziamento, basato sugli iscritti alle practice (e quindi non più in riferimento all’area geografica come avveniva prima della riforma) proviene da un organismo centrale autonomo (NHS Commisioning Board) con funzione di “accreditamento” e controllo dei CCG. Infatti l’NHS Commisioning Board può anche assegnare, qualora lo ritenesse necessario, una practice ad un CCG. A livello locale, invece, sarà il “New Health and Wellbeing Boards“, con sede nelle Local Authorities, ad assicurare la soddisfazione dei bisogni dei cittadini, raccogliendo ogni eventuale necessità proveniente dagli utenti. Tale organismo vedrà la partecipazione di rappresentanti dei CCG, esperti di sanità pubblica, altri servizi per l’assistenza di minori e adulti, nonchè rappresentati della società civile (Healthwatch).

Tra i principali punti di forza dei CCG spicca sicuramente il maggior coinvolgimento (ed al tempo stesso responsabilizzazione) dei clinici, in particolare dei GP, associato ad una conseguente riduzione della burocrazia a livello centrale, con un consistente trasferimento delle funzioni di programmazione e controllo al livello locale. In questo senso, alcuni definiscono questa non come una rivoluzione, ma la naturale evoluzione del ruolo di committenza svolto dai GP già a partire dagli anni ‘90[16]. Nell’ottica sponsorizzata dal Governo di mettere il paziente al centro dell’NHS, si predispone il sistema alla generazione ed erogazione di un’offerta di qualità che, costituendo sicuramente un vantaggio dal punto di vista dell’iscritto “malato”, potrebbe comportare un potenziale indebolimento dell’attenzione all’iscritto “sano”, in termini di medicina preventiva e di comunità. D’altra parte, la letteratura ha messo in evidenza, già in questo breve periodo, rischi e punti di debolezza della riforma, tra i quali spicca la riduzione dei servizi offerti dall’NHS, solo parzialmente delegati alle “Local Autorities”, con un incremento del ricorso al privato con pagamento “out of pocket”[17]. Su quest’ultimo aspetto molto forti sono le preoccupazioni legate al rischio di una massiccia “commercializzazione” dei CCGs, destinati a entrare nell’orbita di multinazionali  ampiamente coinvolte, già prima della riforma, nel “mercato” sanitario (un rapporto di luglio 2010 riferiva che grandi compagnie private, tra le quali spiccavano Virgin, Care UK e Chilvers McCrae, controllavano 227 GP[18], mentre un recente articolo del Guardian ammonisce sul potenziale conflitto d’interesse che sembra coinvolgere almeno la metà, se non tutte, le GP afferenti ai nascenti CCG[19]). Uno dei rischi è che la “competition”, elemento distintivo del libero mercato ed esaltata dall’attuale riforma, potrebbe diventare “consolidation”[20], con ripercussioni negative non solo nella lotta tra i medici di medicina generale appartenenti a diversi CCG per assicurarsi un maggior numero di pazienti, ma anche nell’attività di committenza, per la quale ogni CCG gode della propria autonomia. In questo modo può avvenire che due cittadini della stessa zona e con lo stesso bisogno (manifesto o meno), ma iscritti a due CCG diversi, possano ricevere trattamenti (o attività di prevenzione) differenti per tipologia e costi.

Ma le perplessità principali provengono dal fronte della Sanità Pubblica per gli aspetti legati all’incertezza dei confini geografici e alle modalità di costituzione dei CCG che si potrebbero ripercuotere negativamente sulla tutela dei soggetti che vivono all’interno di determinate aree geografiche. Vi sono infatti numerose riserve in merito al potenziale rischio di selezione dei pazienti da parte dei CCG che potrebbe facilmente aumentare le iniquità e diseguaglianze[21]. Rischi che potrebbero essere acutizzati anche dalla modalità di allocazione delle risorse da parte dell’NHS, non più pesata sulla base dello studio dei bisogni di una determinata area geografica, ma dipendente principalmente dalla composizione dei pazienti afferenti ai vari CCG. D’altra parte, l’equità nell’accesso è un “vago dovere” e non un outcome voluto e valutato nell’ottica del miglioramento continuo[22].

Un ulteriore problema riguarda i sistemi informativi informatizzati. Infatti gli attuali studi di prevenzione e di analisi dei bisogni utilizzano flussi di dati sanitari raccolti su base geografica (flussi dei PCT) che facilmente si interfacciano con quelli derivanti da altre istituzioni (ad esempio le Local Authorities). Mentre i dati raccolti dai CCG, oltre a poter risultare incompleti, faranno riferimento alla lista degli iscritti senza alcun riferimento alla zona geografica di residenza, rendendo difficile l’esecuzione di analisi di popolazione che hanno da sempre caratterizzato l’attività della Sanità Pubblica inglese[23].

Modello USA (Medicare/Medicaid): Accountable Care Organization (ACO)

La sezione 3022,  “Medicare Shared Savings Program” dell’ “Affordable Care Act” propone un nuovo modello di erogazione dell’assistenza, mediante l’istituzione delle “Accountable Care Organizations”.  Attraverso  le ACO ci si propone  di ridurre i costi relativi alla quota di spesa sostenuti da quella piccola fetta di assistenza pubblica fornita da Medicare e Medicaid. Di fatto però, tramite la loro istituzione si costituisce un nuovo modello di assistenza con l’obiettivo ultimo di implementare qualità e coordinamento dell’assistenza sanitaria nell’ambito della PHC[24,25,26]. Il termine ACO è stato coniato per la prima volta dal Dottor Elliott Fischer nel 2006 per descrive lo sviluppo di partnership tra Ospedali e Medici al fine di fornire e coordinare un’assistenza sanitaria  efficiente nell’ambito di Medicare[27].

Come riportato dal testo di legge le ACO sono costituite da medici che si occupano di assistenza primaria, Ospedali, ed Operatori sanitari di altro tipo che si uniscono “volontariamente” per coordinare e fornire un’alta qualità di assistenza ai pazienti fruitori di Medicare che decidono, anche questi volontariamente, di essere inseriti all’interno di queste modalità assistenziali. L’obiettivo del coordinamento dell’assistenza  è quello di garantire che gli stessi pazienti, in particolare i malati cronici, ottengano risposte adeguate ai loro bisogni di salute al momento opportuno, evitando inutili duplicazioni di accessi ospedalieri, nonché di prevenire gli errori medici[27,28,29].

L’Affordable Care Act specifica che l’ACO è costituita da Professionisti ACO (ad esempio, i medici e gli ospedali che soddisfano i criteri di legge ed inseriti nel sistema Medicare) in modalità associativa, ma anche reti di pratiche individuali dei medici ACO, partnership o accordi di joint venture tra ospedali e medici delle ACO e tra ospedali che impiegano i medici delle ACO[27].

Il Dipartimento dei Servizi Sanitari e Assistenziali Americano (MSSP) nell’ambito della istituzione e gestione delle singole ACO sostiene che debbano essere rispettati alcuni punti considerati imprescindibili nella gestione delle stesse[30].

Ad esempio: in ogni ACO deve essere presente un numero congruo di medici di famiglia, i pazienti potranno usufruire di tutti i medici che faranno riferimento a tale sistema senza distinzione tra un ACO e un’altra.

L’ACO si fa inoltre promotrice della Evidence Based Medicine e del coinvolgimento del paziente e in ognuna verrà istituito un sistema di reporting e di valutazione dei costi. Il coordinamento dell’assistenza avverrà tramite l’utilizzo della Telemedicina, ed il monitoraggio del passato del paziente attraverso l’utilizzo di altri dispositivi tecnologici[27].

Come sostenuto dal New England Journal of Medicine il modello ACO combina i principi fondamentali di assistenza primaria (primo contatto,  continuità assistenziale) con le innovazioni del 21° secolo come l’uso dei sistemi informativi elettronici, la gestione informatizzata di tutto il percorso di cure con particolare attenzione alle malattie croniche, e al miglioramento continuo della qualità delle cure stesse. Una delle pietre miliari di questo modello è il focus sulla soddisfazione delle esigenze e sulle preferenze dei pazienti, e sulla riforma di pagamento che migliora il rimborso per le pratiche di assistenza primaria[28,31,32].

Ad oggi il modello delle ACO è stato approvato dai contribuenti, dai medici e dai gruppi di pazienti e attualmente sono in essere numerosi progetti pilota in tutto il paese, tuttavia é ancora necessario affrontare le barriere culturali, giuridiche, legali e di risorse per la creazione di nuove organizzazione di “Providers di Cure” nei  vari Stati Americani.

Alla luce della rielezione del Presidente Obama ora che la minaccia di abrogazione è svanita, quale sarà  il futuro della riforma  sanitaria? Quali saranno  le sfide ed i conflitti  soprattutto a livello dei singoli Stati federali che si prospetteranno sulla lunga strada di implementazione della  riforma stessa?[27]

L’analisi della letteratura effettuata sulla riforma in corso sia nel Regno Unito che negli Stati Uniti, sebbene narrativa e nonostante le riforme siano ancora in una fase preliminare di attuazione, ha messo in evidenza diversi aspetti. In particolare per quanto riguarda il Regno Unito vi sono state fortissime critiche ai CCG da parte dei principali esponenti di Sanità Pubblica e della Medicina Generale (rappresentati dalla British Medical Association) comunemente preoccupati per quella che hanno definito una “legge da uccidere”[33] per evitare “la fine del Sistema Sanitario Inglese”[34].  Di fatto l’Inghilterra, ideatrice e promotrice del modello Beveridge, apre le porte del suo NHS al privato. Mentre gli Stati Uniti, storicamente affezionati all’idea di una sanità di  libero mercato, in cui la salute viene equiparata ad una “merce di consumo” che può essere venduta al miglior offerente, iniziano a sperimentare modelli di assistenza “universalistica sotto la positiva scia del sogno del New National Health Plan” del presidente americano Barack Obama[11].

È come se d’improvviso la “deriva dei continenti” avesse invertito la sua “rotta” e l’America e l’Europa avessero iniziato il loro riavvicinamento: sarà di nuovo “Laurasia”? Noi osserviamo i cambiamenti e dalla nostra prospettiva e sarebbe interessante capire se in questa tettonica delle zolle l’Italia resterà unita alla “placca” Inghilterra, oppure tenterà di aggrapparsi alla “placca” USA o, perché no, darà origine ad un nuova e separata “Isola”.

Gianfranco Damiani, Professore Associato Istituto di Igiene e Medicina Preventiva – UCSC. Serena Carovillano, Andrea Poscia, Giulia Silvestrini, Scuola Specializzazione Igiene e Medicina Preventiva – UCSC.


  1. Department of Health. Equity and excellence: Liberating the NHS. The Stationery Office Limited on behalf of the Controller of Her Majesty’s Stationery Office: 12 July 2010
  2. Health and Social Care Act 2012CHAPTER 7 [PDF: 214 Kb]. 27th March 2012.
  3. Gavino Maciocco. Liberating the NHS. Svolta shock nella sanità inglese. Salute Internazionale, 02.09.2010.
  4. Gavino Maciocco. I medici inglesi contro la riforma del NHS. Salute Internazionale, 02.11.2010.
  5. Gavino Maciocco. La fine del sistema sanitario inglese. Salute Internazionale, 07.02.2011
  6. Gavino Maciocco. È tempo di uccidere la legge. Salute Internazionale, 07.10.2011.
  7. Dalamothe T, Goodle F. Dr. Lansley’s Monster. BMJ 2011; 342:d408.
  8. Whitehead M, Hanratty B, Popay J. NHS reform: untried remedies for misdiagnosed problems?Lancet 2010; 376:1373-5.
  9. Des Spense. Greed isn’t good. BMJ 2011; 342:d524.
  10. World Health Report 2000. Health Systems: improving performance. WHO, Geneva, 2000. Il Rapporto è stato interamente  tradotto, ed integrato per la  realtà italiana, nel  numero  monografico  di  Igiene  e  Sanità  pubblica  2001; 2:1-176.
  11. Gavino Maciocco. Riforma sanitaria e cure primarie negli USA. [PDF: 80 Kb]. CARE 2010; 3: 29-30
  12. Armando Muzzi. La riforma sanitaria degli USA. Ig. Sanità Pubbl. 2010; 66: 147-154
  13. Phillips RL, Bazemore AW. Primary care and why it matters for US health system reform. Health Aff 2010; 29: 806-810
  14. Robert L. Phillips .Case Study of a Primary Care–Based Accountable Care System Approach to Medical Home Transformation. J Ambulatory Care Manage ;34(1): 67–77.
  15. Managed Care – Understanding Managed Care., ultima visita 01.05.2012
  16. Letter. Health reforms ‘will benefit most vulnerable in society’. The Telegraph, 10.05.2011.
  17. Pollock AM,  Price D, Roderick  P. Health and Social Care Bill 2011: a legal basis for charging and providing fewer health services to people in England. BMJ 2012;344:e1729 doi: 10.1136/bmj.e1729
  18. More than 200 GP surgeries now run by private companies. Circle News, 15.07.2010
  19. GPs’ shares in private healthcare firms prompt conflict of interest fears. The Guardian, 27.03.2012.
  20. Nunns A and NHS support federation. The year of cataclysm for the NHS. NHS Support Federation
  21. Pollock AM,  Price D. How the secretary of state for health proposes to abolish the NHS in England. BMJ 2011; 342 doi:
  22. Hawkes N. Allocation of NHS resources: are some patients more equal than others? BMJ 2012;344:e3362
  23. Pollock AM, Macfarlane A, Godden S. Dismantling the signposts to public health? NHS data under the Health and Social Care Act 2012. BMJ 2012;344:e2364 doi: 10.1136/bmj.e2364
  24. Grunbach K, Bodenheimer T. A primary care home for Americans, JAMA 2002; 288: 889-893.
  25. Whitcombe ME, Cohen JJ: The future of primary care medicine. NEJM 2004; 351: 710-712.
  26. Bodenheimer T. Primary care: will it survive? NEJM 2006, 355: 861-864
  27. “The Patient Protection and Affordable Care Act” disponibile on line al sito USA.GOV, ultima visita il 26.11.2012
  28. Brook RH, Young RT. The primary care physician and health care reform. JAMA 2010; 303: 1535-1536.
  29. Rieselbach RE Kellermann AL. M.P.H.A Model Health Care Delivery System for Medicaid. N Engl J Med 2011; 364:2476-2478
  30. Medicare Payment Advisory Commission: Accountable care organizations,chapter 2, in: Report to the Congress: improving incentives in the Medicare program. Washington (DC), 2009.
  31. Patient-Centered Primary Care Collaborative. Evaluation/evidence of PCMH. Washington (DC), 2009.
  32. Oberlander J. The Future of Obamacare. N Engl J Med 2012, DOI: 10.1056/NEJMp1213674
  33. Editorial.  It’s time to kill this Bill [PDF: 27 Kb]. Lancet 2011, DOI:10.1016 /S0140-6736(11)61555-9
  34. Editorial. The end of our National Health Service. Lancet 2011; 377: 353.

Girolamo Sirchia

Il Royal College of Physicians e il Royal College of Nursing, congiuntamente, hanno fatto un appello perché il giro in corsia venga ripristinato negli Ospedali inglesi e ad esso partecipi tutta la squadra dei sanitari del Reparto. Il giro è un poco caduto in disuso, ma le sue funzioni sono ancora oggi molto importanti. Si pongono le diagnosi, si affinano i trattamenti e gli approfondimenti diagnostici, si pianifica la dimissione, si investe nella sicurezza e nell’insegnamento, si migliorano i rapporti con il paziente e la sua famiglia, si aumenta la loro fiducia nella squadra. Il giro deve essere guidato dal Primario nella mattinata, deve essere centrato sul paziente e sulla sua cartella e deve includere check-lists per ridurre eventuali omissioni e prevenire errori.

(Kmietowicz S. Restore word round to former glory to improve patient care and team working, say Royal Colleges. BMJ 2012,345,e6622)

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Selling Proton Therapy to the Public: High Costs Without Benefit @Medici_Manager

In Trentino si sta mettendo in funzione la protonterapia! Auguri per la sostenibilità!

Written by Daniel Wolfson on March 20, 2013

Arriving in a train station in a Northeast city the other day, I was struck by the number of advertisements for proton therapy at a local academic medical center (AMC) plastered throughout the station and in local subways. The ads feature a bicycle racer with the tag line: “THE WIND IN YOUR FACE IS WORTH PROTON THERAPY: A cancer treatment that has fewer side effects.”

A bold statement, I thought, considering several studies have shown that proton therapy provides no long-term benefit over traditional radiation and comes with significantly higher cost for most conditions. There are a limited number of conditions—such as pediatric oncology—where proton therapy is shown to be effective.  Most striking, however, was the fact that this ad was specifically created to target a public that is not aware of the proton therapy’s marginal benefit and in what limited conditions it is effective.

“Marginal benefit” is when two procedures have small differences in benefits but large cost differences. Usually the more expensive intervention yields more benefits, like fewer side effects. But in this case, we have a procedure with no added benefits that is a lot more expensive.

Proton therapy uses atomic particles to treat cancer rather than X-rays. The particle accelerator is the size of a football field and costs about $180 million. According to the Yale study, Medicare pays over $32,000 for the treatment compared to under $19,000 for radiation. When applied to treat prostate cancer, outcomes were no different than intensity-modulated radiotherapy. Urinary function side effects were slightly better within six months but those advantages disappeared with 12 months post-therapy.

The ad directly contradicts the findings of this study and claims that proton therapy has fewer side effects than traditional therapy. This claim is true for pediatric cases but not for prostate cancer, the one primarily targeted by these ads.

What bothers me the most is that an AMC is peddling a more expensive procedure with no clear added benefit to the public through a massive advertising campaign. Isn’t there a moral imperative for an AMC to work in the best interest of their community based on the best available clinical evidence? Isn’t this supposed to be the era of value services? If they must advertise the therapy (possibly to recoup some of their costs or at least break even), why not target referring physicians rather than an unsuspecting public that is prone to request the latest and greatest technology just because it’s new? Perhaps referring physicians are wise to the lack of proton therapy’s marginal benefit and the AMC is hoping they will acquiesce to their patients’ demand for this marginal procedure. Is the public to know what cases are best for this type of therapy and for which conditions it is not well suited?

We should expect more and we should demand better. Proton therapy is clearly a more expensive procedure where a just-as-effective procedure exists. Quality and safety has not been raised, only the cost of medicine.

7 social media mistakes made in health care @Medici_Manager @kevinmd

If you’re a health care professional, chances are you know a bit about social media, possibly feel compelled to use it sometimes and you might actually be participating in the Facebook/Twitter/LinkedIn/blog revolution.

But there can be real problems in using social media in the health care context. Whether you are in private practice or work for a group of large hospital network, social media mistakes can be costly in terms of misrepresenting your specialty, breaching patient confidentiality, or limiting your business growth. Do you make the following mistakes when using social media?

1.  Avoidance.  Most health care professionals wish social media didn’t exist.  They see it as confusing and a distraction.  The questions about how, when and why social media is important and useful give them indigestion and some go to great lengths to tell others to” just say no”  to all thing social media. The problem with this is social media exists for millions of people (500 million on Facebook alone) and to ignore all things social media is to ignore your patients’ needs and a wide-range of new business development opportunities.

If you’re reading this, you probably aren’t a total avoider, but reading and engaging are two very different things.  Social media is here to stay. Your clients and patients probably use it more than you can even imagine. If you hear colleagues “pooh-pooh”ing social media, correct them quickly.  It’s here, it’s real, it’s a force to be reckoned with and made your own.

2. Fear. After avoidance, many health care professionals move to the stage of reluctant acceptance, but aren’t happy about it.  They are ignorant of why social media is important or how to effectively leverage it to help their patients and grow their practice.Ignorance plus anxiety = fear and we’ve got a lot of fear in health care about social media.   But the fear seems silly from some of the most educated and intelligent people on the planet. I mean, we are not born to do heart or brain surgery (and I sure as hell fear the idea of me doing any kind of surgery), support someone through a suicidal crisis or diagnose schizophrenia. We had to learn how to do these things over time. So too social media.  The sky is not falling. You can learn how to do social media well and effectively. Learning is kinda your thing.

It does take courage to try something new and work at it until we see a positive return.  Will you be a courageous health care provider and learn, experiment and grow via social media?

3. Sloth. Doing social media well is work. Not save-a-life work or Alaskan salmon fishing work, but it requires time, thought and energy.  I hear many health care professionals bemoan the fact that “social media is hard work,” and then vent on and on about the unfairness of health care reform, patients not valuing them, the jerks over at health care insurance companies 1,2 and 3.

It’s important to remember that we all have the same number of hours in a day. Someone who spends an hour writing and talking about negative stuff has wasted 60 minutes of their life.  Another person who uses that time to connect with people is doing a service and building their future. Use your time wisely, work to achieve positive goals. How are you currently using your time?

4. Narcissism. Many health care professionals see Twitter as the place where people talk about their life and what they had for lunch. One of my colleagues has this as his email signature: “Follow me on Twitter: I’ll tell you how I feel.”  Ugh. Narcissistic.  Why? First, he doesn’t get it, second, instead of trying to learn more and understand, he mocks it and looks foolish.  (As an aside if you don’t understand a technology, it is best to say nothing, rather than look stupid in front of colleagues who do understand … just saying.)

Despite how it may seem, social media is not about you. No one reading your wall or tweets really cares about how you feel.  Social media is about making connections, helping others with useful information, sharing ideas and building business opportunities.  If you’re not into doing the above things, by all means avoid social media. But if you want to touch lives and grow professionally, social media is a neat way to jump start the process.

5. Selfishness. Social media is about giving. Giving great content, information, tips that people can use to live a better, healthier life. Sharing articles and info from other sources that you know will help your readers.  The more you give, the more people follow you and when you make an offer to sell a service or product, your followers are so impressed with your quality as a person and a professional, they can’t wait to pay to get more support and help from you.

Social media is not advertising, nor is it your personal water cooler.  Selfish use of social media includes only broadcasting your articles and blog posts, using Twitter as an advertisement stream rather than an opportunity for connection. If you stream only includes your posts about your business and you, take note.  The most powerful use of Twitter is when you use the retweet (RT) and the @ reply.  The people who are leveraging Twitter to the max say that they retweet and reply 90% of the time, with only 10% of their tweets about their own stuff.  Share, converse, introduce people to one another .. you’ll get so much more out of the social media experience.  How do you give on social media?

6. Unethical shenanigans. Social media can be used unethically. The problem is,most health care professionals don’t realize when they are being unethical online.  So let’s try to make this simple. It is unethical to breach your clients’ confidentiality online.  Do not, under any circumstances mention your clients’ experiences or demographics in your social media space.

Another unethical move is to tell your clients how to use social media vis-a-vis your professional relationship. Why? By doing this you are misusing your position of power in the treatment dynamic.

Let’s talk about this for a bit.

Some mental health professionals want to develop social media policies and often these policies say things like, “I have a Twitter account, but if I find you’re following me I’ll remove you,” or “I’m on Facebook, but you can’t friend me because it could be a breach of confidentiality.”

At first glance these statements seem ok, until you think about what the professional is saying here.  Essentially she’s saying “I have a social media life and you can’t participate. I will tell you how to engage in social media.”  The problem is, social media is free and open access. When you have an open Twitter account you imply that anyone who wants to can follow you.  Otherwise, you can make the account private.  So while you can prevent your clients from calling you at home or knowing where you live, you really can’t tell them what to do in social media if you have public accounts.  Well, you can try to tell them what to do but how does that impact your relationship and how do you enforce it?

The attraction of social media is it puts all of us on an equal playing field. There is no cost to entry. If I want to follow Lance Armstrong, President Obama, or musician John Mayer, I can.  When we try to tell our clients what to do in the social media space we are abusing our power. If you’re not comfortable with the openness of this, privatize your accounts or simply don’t participate.

One more unethical trap: Googling clients.  Awhile ago this was a topic of discussion in mental health circles.  Some argued that, in cases of emergency, it’s acceptable to Google a client to get more information. I disagree.  It’s a violation of privacy and opens you up to a pandora’s box of legal liabilities.

7.  Lack of imagination. This may be the worse sin of all.  I’ve realized over the last few months just how powerful social media can be to influence people’s ideas, change behavior and educate large groups of people.  We in health care get so stuck on the first 6 sins in this list that we don’t consider all of the positive possibilities. We stop at simplistic uses, put up barriers by citing HIPAA,  wait for someone more official than we are to give us permission, and essentially stop growth for ourselves and our clients. It’s frustrating.

What if we saw social media as a problem solver? What if we devised ways to use it to educate, inform, treat and improve lives?  What if we become open to the possibilities and then grapple with the confidentiality and access issues?  In health care we tend to put the cart before the horse. We think, “How can this all go wrong?” before we imagine how the world will look if it all goes right.

We can send humans into space for months at a time, do all our banking securely online and video chat with people on the other side of the world. I think we can find a way to make the technology of social media work for health care. Don’t you?

Susan Giurleo is a psychologist who blogs at the BizSaavy Therapist.