Monthly Archives: maggio 2013

Medical schools signal readiness for revolution @Medici_Manager

A robust response to an AMA initiative underscores the fact that medical schools recognize the need for a necessary update of how they educate physicians.

Posted March 18, 2013. http://bit.ly/Z14L8o

Educator Abraham Flexner’s 1910 report evaluating American and Canadian medical schools is generally credited with transforming medical education into its current modern age. Flexner shined a light on the importance of a more rigorous education so that future physicians could be trained in — and have a sharp mind for — the rapid scientific and technological advances coming out of the Industrial Revolution.

Over the last decade, numerous studies have looked at one question: Should the Flexner model be updated so medical education can adapt to the rapid scientific and technological advances of today’s information revolution? The answer is uniformly, yes, and the call for change isn’t coming only from medical and educational observers. Recently, striking evidence has surfaced that the schools themselves are ready to make a change — one as revolutionary as anything Flexner envisioned.

That evidence is their overwhelming response to a $10 million initiative by the American Medical Association called “Accelerating Change in Medical Education.” Before a Feb. 15 deadline, 115 out of 141 U.S. medical schools sent five-page concept proposals explaining what transformative changes they would like to make in teaching future physicians. Changes might include new ways of teaching and assessing core competencies, or more of a focus on patient safety or quality improvement. The proposals reflect a changing health care delivery system transformed by technology so that the skill of finding and applying information is as important — or more so — than memorizing it. Of those proposals, 20 to 30 will be chosen to write a longer request for a proposal that is the equivalent of applying for a National Institute of Health grant. From there, eight to 10 schools will be announced at the AMA Annual Meeting in June as sharing in the $10 million to help implement their ideas.

The AMA helped bring Flexner’s report to bear, with its Continuing Medical Education division. It rated medical schools at the time and solicited the Carnegie Foundation for the Advancement of Teaching — which chose Flexner — for further efforts in improving physician education. This was at a time that many schools’ quality was poor, and there were few, if any, standards for training doctors.

The AMA again has stepped to the forefront, not only with its $10 million offer but also with other efforts to promote initiatives to improve education, publishing papers on change in medical education and organizing high-level discussions in which experts talk about what the future of medical schools should be.

But unlike 100 years ago, when substandard schools closed or fired faculty to catch up to Flexner’s standards, the relationship between medical schools and agents of change is markedly more symbiotic.

Schools already are part of the discussion about accelerating the pace of instruction to three years instead of four, as a way to train more doctors and confront the current crisis of a looming physician shortage.

They have recognized the impact that the Internet and mobile technology have had as a means for doctors to quickly and easily review treatment guidelines and look up information on diseases, pharmaceuticals and procedures. Business tracks have been added at some schools to help future physicians learn about how to manage the complex insurance and financial environment they will face. There are now programs where physicians are taught how to work not only in an individual practice setting but also as leaders and members of teams that stretch across different professions, locations and practice settings.

The AMA’s “Accelerating Change in Medical Education” program indeed will fund individual schools with particularly compelling ideas, schools that a panel of experts will choose to reflect a variety of regions and projects. But the goal is not merely to promote transformations at a few schools. By including those schools in a medical education consortium, by sharing their ideas with all medical schools, and also by sharing other worthy ideas from schools that weren’t selected, the hope is that the AMA program helps facilitate creative thinking and out-of-the-box ideas across the spectrum of medical education.

The reason the AMA emphasizes “accelerating” change is that incremental changes aren’t enough to ensure that future doctors get the training they need in a world in which rapid business, population and technological changes have made being a doctor a much more dynamic profession. These have to be systemic changes, as bold and far-reaching in our time as they were in the wake of the Flexner report.

Flexner’s triumph stemmed from an era when there were many medical schools unworthy of the name. This next revolution starts from strength, solid opportunities and a well-demonstrated willingness to embrace change.

EXTERNAL LINKS

“Accelerating change in medical education,” American Medical Association (link)

Why Organizations Are So Afraid To Simplify @Medici_Manager @CEOdotcom

While most managers complain about being overloaded with responsibilities, very few are willing to give up any of them. It’s one of the great contradictions of organizational life: People are great at starting new things — projects, meetings, initiatives, task forces — but have a much harder time stopping the ones that already exist.

Take this example: The CEO of a large consumer products company was concerned that the organization was becoming too complex and unwieldy — which was adding to costs and slowing down decisions. After a long discussion with her senior team, everyone agreed to identify committees, projects, and studies that could be stopped across the firm. However, when the executive team reconvened the next month to review the ideas, everyone pointed out activities that other teams should stop instead of opportunities in their own domains. They then spent an hour justifying why everything that they were doing was critical and couldn’t be stopped.

There are several deep psychological reasons why stopping activities is so hard to do in organizations. First, while people complain about being too busy, they also take a certain amount of satisfaction and pride in being needed at all hours of the day and night. In other words, being busy is a status symbol. In fact a few years ago we asked senior managers in a research organization — all of whom were complaining about being too busy — to voluntarily give up one or two of their committee assignments. Nobody took the bait because being on numerous committees was a source of prestige.

Managers also hesitate to stop things because they don’t want to admit that they are doing low-value or unnecessary work. Particularly at a time of layoffshigh unemployment, and a focus oncost reduction, managers want to believe (and convince others) that what they are doing is absolutely critical and can’t possibly be stopped. So while it’s somewhat easier to identify unnecessary activities that others are doing, it’s risky to volunteer that my own activities aren’t adding value. After all, if I stop doing them, then what would I do?

The final reason that unnecessary tasks continue is that managers become emotionally attached to them. We see this often with “zombie projects,” activities that are seemingly killed or deprioritized but somehow keep going because managers just don’t want to let go. Once people have invested in creating projects, committees, or processes, they feel a sense of ownership. Getting rid of them is like killing their own offspring.

Given these powerful underlying dynamics, what can you do to stop excessive activities in your own organization? Here are a few guidelines to keep in mind:

Separate cost-reduction from work-reduction. Since people are naturally (and understandably) protective of their livelihoods and careers, it’s difficult to ask them to do things that will result in the loss of their own job. So if cost-reduction is a key driver, try your best to eliminate jobs first. Only then should you work with the “survivors” to eliminate the unnecessary work.

Make work elimination a group activity. While managers are hesitant to point out stoppage possibilities in their own areas, they often can see opportunities elsewhere. By bringing teams together across different business units and functions, you stand a better chance of surfacing activities that can be brought to a halt.

Insert a “sunset clause” in the charter of all new committees, teams, and projects. Instead of swimming against the tide in trying to stop ongoing endeavors, make the shut-down process a natural event in the life cycle of organizational activities. If people know from the start that there is a beginning and an end, then managers will start to expect that things will be turned off at a specific time and can plan accordingly.

All organizations need to periodically hit the “off” button on activities that add unnecessary costs and complexity. Doing so however requires that you deal with the psychological dynamics that make it easier to get things started than to get them stopped.

http://bit.ly/XQ46az

Importante nomina UE a @WRicciardi. @SIHTA_Italia @Medici_Manager

5 Things Great Leaders No Longer Do @Medici_Manager

What worked in the past (if it ever did) definitely doesn’t work today.

Here are five things great leaders no longer do:

1. Stick to annual performance reviews.

Annual and semi-annual appraisals waste everyone’s time.

Years ago, my review was late so I mentioned it to my boss. He said, “I’ll get to it… but you realize you won’t learn a thing. You’ve already heard everything I have to say, good and bad. If anything on your review comes as a surprise to you I haven’t done my job.”

He was right. The best feedback isn’t scheduled; the best feedback happens on the spot when it makes the most impact, either as praise and encouragement or as suggestions for improvement and training.

Waiting for a scheduled review is the lazy way out. Your job is to coach and mentor and develop — every day.

2. Say, “Look, I’ve been meaning to apologize…”

Apologies should be made on the spot, every time. You should never need to apologize for not having apologized sooner. When you mess up, ‘fess up. Right away.

Don’t you want your employees to immediately let you know when they make a mistake? Model the same behavior.

3. Hold meetings to solicit ideas.

Many people hold brainstorming sessions to solicit ideas for improvement, especially when times get tough. Sounds great — after all, you’re “engaging employees” and “valuing their contributions,” right?

But you don’t need a meeting to get input. When employees know you listen, they’ll bring ideas to you.

Plus, the best way to ask for ideas is to talk to people individually and to be more specific. Say, “I wish we could find a way to get orders through our system faster. What would you change if you were me?”

Employees already have ideas. Trust me: They imagine themselves doing your job — and doing your job better than you do — all the time.

Be open, act on good ideas, explain why less than good ideas aren’t feasible and you’ll get all the input you can implement.

4. Create formal development plans.

Development plans are, like annual performance reviews, largely a corporate construct. (HR staffers love to monitor compliance and alert managers when supervisors are late turning in their employees’ development plans. Or maybe that’s just my experience.)

You should know what each of your employees hopes to achieve: skills and experience they want to gain, career paths they hope to take, etc. So talk about it — informally. Assign projects that fit. Provide training that fits. Create opportunities that fit. Then give feedback on the spot.

“Develop” is a verb that requires action; “development” is a noun that sits in a file cabinet.

5. Call in favors.

I know lots of bosses who play the guilt game, like saying, “John, I’ve been very flexible with your schedule the last few months while your wife was sick… now I really need you to come through for me and work this weekend.”

When you’re a boss, generosity should always be a one-way street. Be flexible when being flexible is the right thing to do. Be accommodating when accommodation is the right thing to do.

Never lend money to friends unless you don’t care if you are repaid, and never do “favors” for employees in anticipation of return. As a leader, only give — never take.

Want to be a great leader? Stop working so hard – it’s bad for your company @Medici_Manager @Inc @mmaghsoodnia

Think you have to work all the time to lead a great company? You’re wrong

http://bit.ly/14mI9aH

You’ve secured your funding, you’ve started making your idea a reality, and suddenly, the work starts piling up faster than you could have imagined.

What happens when your company starts to take off and you’re buried under tasks? How do you keep on top of the mountain of work that is assaulting you? If you’re struggling to figure this out, you’re in good company: Some of the best CEOs and founders struggle to define their role in a quickly growing organization.

The good news: You shouldn’t be working as hard as you think. Here’s how to make sure you’re focusing on the right tasks.

#1. Understand that you can’t do everything.

I often see start-up founders trying to take on every task, from product development to human resources manager, to finance guru and team cheerleader. This compulsion is understandable: When you’re all-in, the business can feel like your baby. But wearing so many different hats at once is going to hurt more than it will help. I’ve found that one of the keys to being an effective leader is knowing when you’ve reached your limit.

As important as it is for you to devote yourself to your business, it is equally important for you to have a life outside the bubble of your company. Your 5-to-9 with family, friends or even a good book is just as important to your business as your 9-to-5. Really. The last thing that a growing company needs is a tired, burned-out, dispassionate leader. You only have so much time in the day; I make sure that I’m still devoting enough of it to myself and to my family.

#2. Acknowledge that you SHOULDN’T do everything.

Here’s another way of looking at managing your leadership–if you’re doing everything, you have a hole in your staff. Being a leader doesn’t mean doing a bunch of different things decently well, it means being great at one thing: strategy or inspiration or vision. As I wrote about last week, the best leaders hire trustworthy people and allow them to lead in their areas of expertise.

A great leader is often someone who does very little. You can, and should, always be looking to hand problems to smart people around you. If you can inspire those people, their devotion, expertise, and time spent on the task will equal or outpace your own. If you want your business to thrive, you need to depend on the people around you to get things done. Your role becomes one of strategy, not execution. Growing a successful organization takes trust in those around you.

#3. Focus on being a big picture expert.

It may be hard, but try to recognize that not everything needs to get done immediately. It’s your role to be able to identify the top priorities. If you don’t know what those are, you’re already in way over your head–without even beginning the execution. You can make list upon list of things that need to get done, spend your time being the most organized CEO that ever existed, but ultimately, you need to hone your instincts and know what requires your immediate attention.

If things are so complicated that you need planners, productivity software, timers or widgets, then there is a part of the bigger picture that you’re missing. Sometimes long lists can be paralyzing; they often stop you from making meaningful progress on any one task.

Instead, try to keep the big, strategic tasks in your head, and rely on your staff to take on the rest.

Mehdi Maghsoodnia is the CEO of Rafter, which provides a cloud-based platform designed to help colleges make educational content more affordable and effective. He was previously SVP at CafePress and Intellisync. @mmaghsoodnia

Gli idioti di Twitter @Medici_Manager @aringherosse

Il rapido declino della civiltà occidentale in 140 caratteri secondo Matt Labash.

Pubblicato su Weekly Standard e tradotto da Il Foglio

http://www.slideshare.net/carlofavaretti/edit_my_uploads

Il mito de “la Rete” e del suo potere nel Paese di 20 milioni di non connessi @Medici_Manager @aringherosse

C’è uno spirito che circola nel Palazzo e che possiede, a turno, i politici italiani: la Rete. Articolo determinativo ed Erre maiuscola, come un’entità metafisica e trascendente, capace di decidere le sorti dell’Italia. Chi pensava che la retorica digitale fosse esclusiva del M5S — specializzato nel vedere nel web la soluzione di tutti i mali — è stato costretto a ricredersi: la Rete è diventata per tutti gli schieramenti la ragion politica di candidature, rinunce e cambiamenti. L’elezione del Presidente della Repubblica è stato il trionfo della sua transustanziazione. Insospettabili compresi: da Stefano Rodotà («La mia candidatura girava in Rete da mesi» ha dichiarato) a Mario Monti, secondo cui il nome di Anna Maria Cancellieri è emerso «con forza dalla Rete».

Nei talk show che affollano il palinsesto televisivo, quando la discussione si fa difficile, ecco comparire la Rete a smuovere le acque, nemica o amica dello schieramento a seconda di chi parla. Tanto nessuno può smentirla, la Rete.

Chissà cosa pensano i venti milioni di italiani non connessi a Internet quando — mentre guardano i tg, ascoltano la radio, leggono i giornali per trovare risposte — spunta la Rete sulla bocca dei loro rappresentanti. E anche se restiamo tra i 29 milioni che si connettono almeno una volta al mese, c’è da scommettere su quanti sarebbero in grado di darne una definizione.

Viene il dubbio che la maggior parte dei politici italiani abbia finito con l’identificare la Rete con gli influencer di Twitter, le poche centinaia di utenti — giornalisti e opinionisti — animatori del dibattito su un social network che conta meno di 4 milioni di iscritti. Un bacino decisivo per il consenso mediatico e no, ma che rischia di allontanare i rappresentanti dei cittadini dalla maggioranza dei cittadini stessi. E di fornire una interpretazione della realtà pericolosa per le urne e per il Parlamento dove, nel bene o nel male, la Rete non vota. Perché la Rete non esiste.

http://bit.ly/14cJ1LB

La scuola di medicina in Ospedale

Girolamo Sirchia

L’Ospedale è un fondamentale luogo di insegnamento. Infatti si possono attuare le seguenti attività educative:

  • educazione sanitaria dei pazienti (esempio: smettere di fumare)
  • educare i giovani medici all’uso della medicina basata sull’evidenza
  • uso dei social media
  • comportamenti professionali adeguati
  • indirizzare i giovani verso le attività per le quali mostrano più attitudine
  • capacità di comunicare con i pazienti e i colleghi
  • sicurezza dei pazienti e uso saggio della medicina parsimoniosa
  • modalità per reperire fondi di ricerca
  • Continuous Professional Development (CPD), costruzione e gestione del portfolio della conoscenza
  • uso appropriato della letteratura medica
  • importanza dell’empatia con i pazienti
  • importanza del lavoro interdisciplinare
  • fondamentale importanza della clinica oltre ai test strumentali minimi necessari.

Tutte queste attività vedono il Primario in funzione di guida e promozione. E così si rafforza “la scuola di medicina”.

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You’re Only As Strong As Your Weakest Manager @Medici_Manager

Management is leadership and leadership is management. Your success may depend on it.

Leaders who are detached from the messy process of managing fail. They need to recruit board members, executives, and managers who are doers, not just joiners.

The headlines scream about leadership failure after failure around the globe every day–at the world’s biggest companies, in government agencies, at venture-backed startups, and even in organizations such as the Vatican. So why does leadership fail?

Henry Mintzberg in BusinessWeek writes:

It became fashionable some years ago to separate “leaders” from “managers”–you know, distinguishing those who “do the right things” from those who “do things right.”

In practice, leaders who are detached from the messy process of managing fail. They don’t know what’s going on in their organizations. Stanford University Professor Emeritus James G. March has said “Leadership involves plumbing as well as poetry.” And I couldn’t agree more having experienced this throughout my career. The devil is in the details. Great leaders fail without good management.

There are a host of definitions of what constitutes leadership and what is management, including the idea that leaders envision and inspire, while management creates systemic processes for planning and execution. I would argue that among other things, one of the key elements is having transparent and repeatable management processes from the boardroom to the project teams.

Why Boards and Management Fail

Consider the following recent examples:

• At JPMorgan Chase, Ina Drew, the senior banker who has taken the fall for massive trading losses, was reportedly already faltering in 2010, two years after navigating the banking behemoth through the worst of 2008’s financial storm.
• High-flying Chesapeake Energy CEO Aubrey McClendon borrowed as much as $1.1 billion over the last three years against his stake in thousands of company wells without anyone raising a hand before facing the ire of shareholders.
• The U.K. Culture Minister Jeremy Hunt said he became worried about “a massive failure of corporate governance” at News Corp. in July 2011 after the media giant’s News of the Worldhacked the voice mail of a teenage girl who was later found to have been murdered. It then became apparent that the still-ongoing debacle had been of “growing concern to News Corp.” for months, according to Hunt.

Without the board of directors, senior management, and line managers all working together to execute strategy and ensure strict adherence to ethical practices and operating standards at a detailed level, it’s too easy for aberrations to go unnoticed.

The key is focusing on operational governance. Companies like to have marquee names on their boards–VIPs like former governors, senators and university presidents–as directors. Unfortunately, such celebrities often lack expertise in the businesses they’re overseeing, or have no time (or sometimes even the inclination) to roll up their sleeves and really do the work. To be able to do the work, one must understand the complex sets of decisions that are required in today’s interconnected environment.

Dimensions of Management Decisions

What distinguishes today’s successful enterprise is knowledge–such as knowledge of the customer, the suppliers, and new business ideas that could emerge from anywhere. The challenge for leaders is managing such extended enterprises which requires breaking many of the management rules we grew up with. Rather than top-down hierarchical processes and approaches, they need to manage and govern cross-collaboratively. In order to do this, the organizational structure must be adapted to nourish true coordination inside and beyond the extended enterprise.

In my last book, The Power of Convergence, we defined four decision dimensions to lead these extended, ever-evolving, knowledge-based enterprises:

Process: Is someone responsible for each process from beginning to end as it crosses divisions and bridges to outside entities? Where are the strengths and weaknesses in the process? How does it mesh with others? How many bridges are there to the outside? Are they coordinated? Are these processes and bridges maximized for the benefit of the customer, or for internal benefit? By what metrics do you know?

Organization: Which people or groups make which decisions? Do they have enterprise-wide information if they need it? Do they have an enterprise-wide perspective? Are incentives in place to encourage this? Do the incentives actually discourage this? Do they have proper authority? Who is empowered to step outside of traditional roles and boundaries to make a stand for the customer? Or to make a stand for the supplier?

Information: What information do the various players need to perform the preceding actions? What should you know about suppliers and customers, and how can you get this information? At what level should it be collected? When collected, how is it processed? Does it go to people who can make decisions to change how the organization operates? What incentives discourage the “not invented here” syndrome?

The really critical information will appear on the outer periphery of the extended enterprise: with your customers’ customers; their markets and new technologies they may be considering. It will appear in the commodities markets and technological innovations that fuel your suppliers. It may appear in think tanks or universities or in someone’s garage. Is your radar picking up these signals?

Technology: Not only must the technology be managed as one with the business internally, it must be planned for, purchased, and managed with the outside world in mind, as well. Look to standards, to web-based applications, to open architectures, and to the new social networking technologies for the appropriate tools. Closed, proprietary technologies do not fit an organization seeking to be part of a larger community. Look also to component-based architectures and cloud computing for the agility needed to sense and respond. All is in flux today; you can’t be tied down.

Strategic Business Risks

Leaders must provide active oversight over how business risks impact the business, and ensure the effectiveness of the governance models in mitigating these risks. Strategic risk refers to the risks facing the firm due to poorly envisioned or executed business strategies. Some of these risks include the following:

• Business model risk: This refers to the robustness of the business model and how well it is being executed.
• Competitive risk: This refers to the ability to sustain itself against competitive action and retaliation.
• Integration risk: This refers to the risks of inadequate integration between business strategies, execution processes, and supporting technology infrastructures.
• Misalignment risk:This refers to inadequate alignment between spending and business priorities.
• Governance models risk:This refers to inadequate participation and involvement of executives on key decisions and lack of understanding of inter-dependencies.

Leaders need to recruit board members, executives, and managers who are “doers,” not just “joiners.” Management governance requires the accountability of everyone within the enterprise, along with partners, distributors, suppliers, and anyone who plays a role in carrying out a business plan.

Dilbert (by Scott Adams) on Management

Dilbert has long made fun of leadership and management failure. On a lighter note, I thought the animation below captures the sentiments of organizational disconnects quite well. Happy trails…

http://bit.ly/16We5Sw

La medicina parsimoniosa

Girolamo Sirchia

Trasformare la medicina attuale in “Medicina Parsimoniosa” significa prestare solo le cure utili, eliminando quel 20% di pratiche mediche inutili che continuano ad essere effettuate e che fanno lievitare la spesa sanitaria senza alcun vantaggio per i pazienti. Evitare procedure e terapie inutili è un attributo della professionalità medica (Tilburt JC, Cassel CK. Why the ethics of parsimonious medicine is not the ethics of rationing. JAMA 309, 773-74, 2013) anche perchè bisogna ricordare che ciò che è superfluo per alcune categorie di pazienti può non esserlo per altre categorie, e quindi è alla fine la capacità clinica e il buonsenso del medico che entrano in gioco. Non basta fare riferimento a elenchi di prestazioni (quali ad esempio la eTable disponibile sul sito http://www.Jama.com), anche se questi elenchi sono utili per orientare il medico (Elshaug AG et al. The value of low-value lists. JAMA 309, 775-76, 2013).

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I grandi ospedali sono più sicuri @Medici_Manager @WRicciardi

17 maggio 2013 di Denis Rizzoli http://bit.ly/10bEciV

Il rischio di morte per un intervento chirurgico è significativamente più alto negli ospedali di piccole dimensioni. È il risultato di uno studio condotto dall’ Agenzia sanitaria per i servizi regionali(Agenas) e il Dipartimento di epidemiologia del Lazio. Si chiama Volumi di attività ed esiti delle cure: prove scientifiche in letteratura ed evidenze scientifiche in Italia e vuole dimostrare quali sono le malattie curate meglio negli ospedali con alti volumi di attività. Le conclusioni parlano chiaro. Farsi operare in una struttura che svolge poche operazioni potrebbe essere fatale per almeno 14 diverse patologie: l’aneurisma dell’aorta addominale non rotto, l’angioplastica coronarica, l’artoplastica del ginocchio, il bypass aortocoronarico, il tumore del colon, del pancreas, del polmone, della prostata, dello stomaco e della vescica, la colecistectomia laparoscopica, l’endoarterectomia carotidea, la frattura del femore e l’infarto. Per dimostrarlo, hanno svolto una ricerca sistematica negli studi internazionali pubblicati. Questi risultati sono stati poi confrontati con i dati del Programma Nazionale Esiti 2012, già pubblicati da Wired nella mappa interattiva #doveticuri con le performance di tutti gli ospedali italiani, cliccabile qui sotto.

VOTA LA MAPPA DI WIRED AL DATA JOURNALISM AWARD
Quali sono gli interventi più sicuri in un grande ospedale? 
L’ infarto è una delle patologie che fa più vittime con una media nazionale elevata: il 10,28% dei pazienti è morto entro 30 giorni dall’intervento, nel 2011. In questo caso, tuttavia, l’ospedale in cui si viene operati può fare la differenza.

È bastato incrociare la percentuale di decessi per infarto in ogni struttura (sull’asse verticale) con il numero di casi trattati nello stesso ospedale (sull’asse orizzontale) – escludendo però i centri con meno di 6 casi l’anno perché statisticamente fuorvianti. La curva risultante mostra che il numero di morti crolla fino a circa 100-150 casi l’anno e continua a diminuire al crescere dei ricoveri, come mostra il grafico tratto dallo studio di Agenas. È errato tuttavia parlare di una soglia di interventi oltre la quale si può ritenere un ospedale sicuro. “ Nei casi che abbiamo studiato, la mortalità continua a diminuire al crescere dei volumi quindi non è possibile trovare un punto esatto, una soglia minima”, spiega Marina Davoli del Dipartimento epidemiologia del Lazio. Forse non è un caso se tra gli ospedali con l’indice di rischio per infarto più alto (66,67%) nel 2011 ci siano strutture con un volume di 7 casi l’anno, come l’Ospedale Civile di Giaveno, in provincia di Torino, oppure l’ Ospedale di Pieve di Cadore, Belluno, con un volume di 9 interventi annuali. Tra i centri più virtuosi, invece, c’è una struttura con 891 casi l’anno, l’ Azienda Ospedaliera-Universitaria Careggi di Firenze, che ha un indice di rischio del 6,47%.

Anche per i malati di tumore si presenta un rischio analogo. Per esempio, il 5,88% dei pazienti operati di cancro allo stomaco sono morti nel 2011 ed è una delle malattie oncologiche più pericolose. Anche per questo intervento si è più sicuri in un grande centro.

I dati sulla mortalità di ogni struttura sono stati collocati sull’asse Y, mentre il numero di interventi effettuati sull’asse X. I pazienti che non sopravvivono dopo 30 giorni dall’intervento si riducono drasticamente negli ospedali che operano fino a circa 20-30 casi all’anno e la curva continua ad abbassarsi al crescere dei volumi di attività. Anche qui, uno dei centri con l’indice di rischio particolarmente alto (50%) è l’ospedale Rummò di Benevento con volume di 8 casi, mentre tra i più virtuosi c’è il Policlinico Universitario Agostino GemelliRoma, con una mortalità dell’0,62% e un volume di 96 interventi l’anno.

Passando alla frattura del femore, non ci sono sorprese rispetto ai casi precedenti. Questo intervento ortopedico è piuttosto pericoloso per i pazienti più anziani. Nel 2011, sono deceduti in media il 5,91%.

Il rischio di morte entro 30 giorni diminuisce a picco nelle strutture che operano fino a 100 interventi all’anno e continua a diminuire lievemente fino a stabilizzarsi.

Perché gli ospedali piccoli sono più pericolosi?
Riguardo ai motivi per cui il rischio di morte cala negli ospedali con più ricoveri gli esperti sembrano essere tutti d’accordo. “ È una relazione già ampiamente documentata dalla letteratura internazionale – spiega Carlo Perucci, direttore di Agenas – nella chirurgia c’è una linea d’apprendimento riguardo alla manualità e alle competenze. Più si lavora, più si diventa bravi”. Anche la numerosità delle equipe è un fattore determinate. “ Oltre alle abilità del singolo medico, c’è anche l’organizzazione. Un ospedale grande ha affrontato più casi particolari e quindi ha più medici specializzati in singole variazioni della stessa patologia”, illustra Stefano Nava, primario di pneumologia all’ Ospedale Sant’Orsola diBologna. Infine, anche il maggior numero di attrezzature sembrano giocare a favore dei grandi centri. “Solo le strutture con alti volumi, possono avere tutta l’infrastruttura necessaria per affrontare il problema”, prosegue Perucci. “ Se un paziente ha un trauma cranico e va nell’ospedale più vicino che non ha imaging o il radiologo non è reperibile, è chiaro che perde tempo. Il fattore tempo è fondamentale per molte patologie”, conclude Nava.

La mappa # doveticuri di Wired, dove sono contenuti le performance di tutti gli ospedali italiani, è stata scelta tra le finaliste dei Data Journalism Award, il premio del  Global Editors Network (Gen) dedicato alle migliori inchieste di data journalism. Da quest’anno anche i lettori possono esprimere la loro preferenza sul sito datajournalismawards.orgFate sentire la vostra voce.

Per valutare medici e ricercatori

Girolamo Sirchia

Per valutare i medici

Bisogna considerare 4 aree:
1. Conoscenza medica
2. Abilità professionale
3. Attività per la salute pubblica su temi prioritari
– invecchiamento della popolazione
– multimorbilità
– frammentazione dei servizi
– ineguaglianze
– risorse limitate
4. Necessità dei pazienti

Per valutare i ricercatori

In Gran Bretagna per valutare i ricercatori si chiede loro di segnalare le 4 migliori pubblicazioni per originalità, importanza e rigorosità, ma anche l’impatto della ricerca sull’economia, la società, la qualità della vita, l’ambiente, la salute e i servizi sanitari.

(Watt G. The UK’s research excellence framework 2014, BMJ 2012;345:e7797)

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La rivalidazione dei medici in Gran Bretagna

Some older adults get unnecessary colonoscopies @Medici_Manager

(Reuters Health) – Close to one-quarter of colonoscopies performed on older adults in the U.S. may be uncalled for based on screening guidelines, a new study from Texas suggests.

Researchers found rates of inappropriate testing varied widely by doctor. Some did more than 40 percent of their colonoscopies on patients who were likely too old to benefit or who’d had a recent negative screening test and weren’t due for another.

Guidelines from the U.S. Preventive Services Task Force, a government-backed panel, recommend screening for colon cancer – every 10 years, if it’s done with colonoscopy – between age 50 and 75.

After that point, “It involves an unnecessary risk with no added benefit for these older patients,” said Kristin Sheffield, the new study’s lead author from the University of Texas Medical Branch in Galveston.

Those risks include bowel perforation, bleeding and incontinence, as well as the chance of having a false positive test and receiving unnecessary treatment.

Even for screening tests that are universally recommended for middle-aged adults, the balance of benefits and risks eventually points away from screening as people age. Any cancers that are caught might never have shown up during a patient’s lifetime if the person is too old or the cancer too slow-growing.

But because there has been so much effort to educate the public about reasons to get screened, the potential harms are often overlooked – and the idea of stopping screening isn’t regularly discussed, researchers said.

Sheffield and her colleagues looked at Medicare claims data for all of Texas and found just over 23 percent of colonoscopies performed on people age 70 and older were possibly inappropriate.

For patients age 76 to 85, as many as 39 percent of the tests were uncalled for, the researchers wrote Monday in JAMA Internal Medicine. The rest were likely done for diagnostic purposes.

A MORAL OBLIGATION?

Another study published in the same journal supports the idea that many Americans are so focused on the possible benefits of screening that they don’t realize harms are involved as well.

Dr. Alexia Torke from the Indiana University School of Medicine in Indianapolis and her colleagues surveyed 33 adults between age 63 and 91 and found many saw screening as a moral obligation.

Few of the older adults had discussed the possibility of stopping routine screening, such as for breast cancer, with their doctor, and some told the researchers they would distrust or question a doctor who recommended they stop.

“There’s very limited data for any cancer test that it leads to any benefit for older adults,” said Dr. Mara Schonberg, from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.

“You want to be doing this thinking it’s going to be helping you live longer,” she told Reuters Health – especially because the chance of suffering side effects from screening or treatment may be higher among older people.

Schonberg, who wrote a commentary on Torke’s study, said time spent unnecessarily screening older adults may take away from conversations that could actually benefit their health – such as about exercise and eating better.

“There’s really a strongly held belief that you need to get screened, that it’s irresponsible if you don’t,” said Dr. Steven Woloshin, who has studied attitudes toward screening at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

“There have been all these messages for years about the importance of screening that people have been inundated with, and I think it’s really hard to change the message now, even though it’s become clear that screening is a double-edged sword,” Woloshin, who wasn’t involved in the new research, told Reuters Health.

The researchers agreed screening should be an individual decision as people get older, but that everyone should fully understand what they stand to gain – if anything – and what they could lose by getting screened.

For colon cancer in particular, Sheffield recommended elderly people who really want to be screened go with a less-invasive method than colonoscopy, such as fecal occult blood testing.

OVERUSING ANESTHESIA?

In another analysis of Medicare beneficiaries undergoing colonoscopy, researchers led by Dr. Gregory Cooper from Case Western Reserve University in Cleveland learned the proportion of procedures using anesthesia – most likely propofol – increased from less than nine percent in 2000 to 35 percent in 2009.

The cost of a procedure using anesthesia is about 20 percent higher than one without it, the researchers noted.

Patients in their study suffered a complication – including perforation or breathing problems – during one in 455 procedures using anesthesia, compared to one in 625 without anesthesia. The researchers said so-called deep sedation may impair patients’ airway reflexes and blunt their ability to respond to procedure-related pain.

SOURCE: bit.ly/KEPNSw JAMA Internal Medicine, online March 11, 2013.

Colonoscopy ‘Potentially Inappropriate’ for 30% of Seniors @Medici_Manager

Cheryl Clark, for HealthLeaders Media, March 12, 2013 http://bit.ly/YKa2Fn

During the year after an influential U.S. task force advised providers to stop routine screening colonoscopies in seniors over age 75 because risks of harm outweigh benefits, as many as 30% of these “potentially or probably inappropriate” procedures were still being performed, with huge pattern variation across the nation, especially in Texas.

“We found that a large proportion of colonoscopies that are performed in these older patients were potentially inappropriate based on age-based screening guidelines,” says Kristin Sheffield, PhD, assistant professor of surgery at the University of Texas Medical Branch at Galveston, lead researcher of the study.

For patients between 70 and 74, “procedures were repeated too soon after a negative exam,” increasing the odds of avoidable harm, such as “perforations, major bleeding, diverticulitis, severe abdominal pain or cardiovascular events,” she says. The guidance, from the U.S. Preventive Services Task Force, which was released in 2008, also set a 10-year interval for routine colonoscopies for people between age 70 to 75 unless the patient develops certain symptoms.

The task force’s prior guidance issued in 2002 had no age limit recommendation, Sheffield says.

“For some physicians, more than 30% of the colonoscopies they performed were potentially inappropriate according to these screening guidelines,” she says. “So this variation suggests that there are some providers who are overusing colonoscopy for screening purposes in older adults,” Sheffield said.

Her report, published in this week’s JAMA Internal Medicine,looked at Medicare data from the Dartmouth Atlas between October 1, 2008 and September 30, 2009, to see hospital referral region patterns of variation across the nation as a whole. For the state of Texas, Sheffield used claims data from smaller hospital service areas, so she could see practices of individual physicians who performed colonoscopies.

She discovered that Medicare beneficiaries were much less likely to have a “potentially or probably inappropriate” colonoscopy if they lived in a non-metropolitan or rural area. Practitioners who were more likely to perform potentially or probably inappropriate colonoscopies were more likely to have been graduated from medical school before 1990 rather than after, and were more likely to perform a higher volumes of the procedure on Medicare beneficiaries each year.

The data was de-identified, so as not to reveal the practice pattern of an individual physician by name.

“Our purpose was not to point fingers at individual physicians or specialties. We just wanted to examine patterns in potentially inappropriate colonoscopy, because patterns can illustrate issues in everyday practice. It can help illuminate and show the range of practice in terms of the range of inappropriate colonoscopies.

Sheffield says that it may be that colonoscopists were simply slow to adapt the recommendations to their practices in certain parts of the country. In a subset of cases, she acknowledges, there may have been legitimate reasons why a physician recommended the procedure in a patient, and perhaps failed to code it properly for the claims database.

“For example, in adults between the ages of 76 to 85, there are some considerations that would support the use of screening colonoscopy, for example, a patient has a higher risk of developing an adenoma. But in general, screening guidelines indicate that should be exception, rather than the rule.”

And if that were the case, there wouldn’t be such a huge variation. For example, in the wedge of west Texas that includes El Paso, the percentages of colonoscopies that were potentially inappropriate was between 13.3% and 18.79%. But in large areas including Austin, Corpus Christi, San Antonio Houston, and Waco, the percentages ranged between 23.3% and 34.9%.

Nationally, areas of higher potentially inappropriate colonoscopies­—with rates between 25.27% and 30.51%— included eastern Washington state, Idaho, and eastern Nevada, Minnesota, parts of North and South Dakota, all of New England, Arkansas and large portions of North Carolina and Tennessee.

Low utilization areas—with rates between 19.45% and 22.64% — included New Mexico and north Texas, Central and Northern Inland areas of California, and all parts of Florida except Pensacola and areas of South Florida.

The issue included a related article and related commentary.

In the related article, Alexia M. Torke, MD, and colleagues, of the Indiana University for Aging Research, interviewed several dozen patients about their reasons for screening. They found that these patients considered screening at their age to be an automatic part of healthcare, and “a moral obligation.”

For example, one told investigators that discontinuation of routine colonoscopy screening, at age 84, “would be the same as me taking my life. And that’s a sin.”

Discontinuation would mean a much more difficult and significant decision they would have to make.

And they were skeptical of recommendations that they should not have screening, saying it would threaten their trust in their doctors and make them suspicious that a guideline they shouldn’t be screened was made only to save money.

“Public health education and physician endorsements (of cancer screening) may have created a high degree of ‘momentum’ for continuation screening, even in situations in which the benefits may no longer outweigh the risks or burdens.”

In an invited commentary, Mara Schonberg, MD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, noted that as much as colonoscopies are celebrated as a preventive therapy, they also cause harm.

“Harms of cancer screening are immediate and include pain and anxiety related to the screening test, complications…(e.g., bowel perforation from colonoscopy,) or additional tests after a false positive result, and overdiagnosis (finding tumors that would never cause symptoms in an older adult’s lifetime). Overdiagnosis is particularly concerning because some older adults experience significant complications from cancer treatment.”

She blames “unbalanced public health messages” for contributing to “perceptions that cancer screening should be continued indefinitely,” she also points to the physician’s recommendation as a strong driver of whether a senior citizen undergoes one.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.