Tag Archives: Public Health

HTA in Italia: pessimismo dell’intelligenza, ottimismo della volontà

Il 24 ottobre scorso sono stato invitato da Giovanni Morana, dinamico direttore della radiologia dell’ospedale di Treviso, ad un convegno sul tema della TAC Dual Energy. Il programma prevedeva una parte dedicata a questa interessante tecnologia ancora in fase di sviluppo e ricerca e una dedicata all’HTA.

hta-venezia-2016hta-2-venezia-2016

L’incontro si è tenuto all’Ateneo Veneto, una fondazione istituita da Napoleone dopo il disfacimento della Serenissima Repubblica di Venezia, in uno splendido palazzo a fianco del Gran Teatro La Fenice.

Per un accidente della storia, il 9 ottobre 1996, nella stessa sede avevo organizzato un workshop, alla presenza dei politici e direttori generali della aziende sanitarie del tempo, dal titolo: “Razionamento o razionalizzazione dell’assistenza sanitaria – il ruolo dell’HTA”, starring Renaldo N. Battista al quale il collega direttore generale di Venezia (il compianto Carlo Crepas) aveva tributato gli onori che la Serenissima Repubblica tributava ai Capi di Stato e agli Ambasciatori in visita a Venezia: il corteo in barca lungo il Canal Grande.

hta-venezia-1996

L’invito di Giovanni Morana ha suscitato in me due sentimenti: il piacere di discutere oggi con i clinici (italiani, stranieri e un brillante giovane collega italiano che lavora a Charleston, Carlo De Cecco) e i produttori di tecnologia i metodi e le opportunità offerte dall’HTA; l’amarezza di toccare con mano la lentezza con la quale in questi vent’anni l’HTA si è diffusa in Italia!

Quanta strada ancora da percorrere! Se smettessimo di buttarci a pesce sulle cose urgenti e ci occupassimo un po’ di più delle cose importanti (De Gaulle) …..!!!

Il XXI secolo non ci ha portato ancora superare lo storicismo gramsciano: “Tutti i più ridicoli fantasticatori che nei loro nascondigli di geni incompresi fanno scoperte strabilianti e definitive, si precipitano su ogni movimento nuovo persuasi di poter spacciare le loro fanfaluche. D’altronde ogni collasso porta con sé disordine intellettuale e morale. Pessimismo dell’intelligenza, ottimismo della volontà”. (Q28, III)

Anzi…..

 

BETTER HEALTH CARE AND LOWER COSTS @leadmedit @medici_Manager @pash22 @WRicciardi

REPORT TO THE PRESIDENT BETTER HEALTH CARE AND LOWER COSTS: ACCELERATING IMPROVEMENT THROUGH SYSTEMS ENGINEERING

Executive Summary

In recent years there has been success in expanding access to the health-care system, with millions gaining coverage in the past year due to the Affordable Care Act. With greater access, emphasis now turns to guaranteeing that care is both affordable and high-quality. Rising health-care costs are an important determinant of the Nation’s fiscal future, and they also affect the budgets for States, businesses, and families across the country. Health-care costs now approach a fifth of the economy, and careful reviews suggest that a significant portion of those costs does not lead to better health or better care.

Other industries have used a range of systems-engineering approaches to reduce waste and increase reliability, and health care could benefit from adopting some of these approaches. As in those other industries, systems engineering has often produced dramatically positive results in the small number of health-care organizations that have implemented such concepts. These efforts have transformed health care at a small scale, such as improving the efficiency of a hospital pharmacy, and at much larger scales, such as coordinating operations across an entire hospital system or across a community. Systems tools and methods, moreover, can be used to ensure that care is reliably safe, to eliminate inefficient processes that do not improve care quality or people’s health, and to ensure that health care is centered on patients and their families. Notwithstanding the instances in which these methods and techniques have been applied successfully, they remain underutilized throughout the broader system.

The primary barrier to greater use of systems methods and tools is the predominant fee-for-service payment system, which is a major disincentive to more efficient care. That system rewards procedures, not personalized care. To support needed change, the Nation needs to move more quickly to payment models that pay for value rather than volume. These new payment models depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign processes of care around the patient and bring community resources, as well as medical resources, together in support of that goal.

Additional barriers limit the spread and dissemination of systems methods and tools, such as insufficient data infrastructure and limited technical capabilities. These barriers are especially acute for practices with only one or a few physicians (small practices) or for community-wide efforts. To address these barriers, PCAST proposes the following overarching approaches where the Administration could make a difference:

  1. Accelerate alignment of payment systems with desired outcomes,
  2. Increase access to relevant health data and analytics,
  3. Provide technical assistance in systems-engineering approaches,
  4. Involve communities in improving health-care delivery,
  5. Share lessons learned from successful improvement efforts, and
  6. Train health professionals in new skills and approaches.

Through implementation of these strategies, systems tools and methods can play a major role in improving the value of the health-care system and improving the health of all Americans.

Summary of Recommendations

Recommendation 1: Accelerate the alignment of payment incentives and reported information with better outcomes for individuals and populations.

 

1.1  HealthandHumanServices(HHS)shouldconvenepublicandprivatepayers(includingMedicare,Medicaid, State programs, and commercial insurers) and employers to discuss how to accelerate the transition to outcomes-based payment, promote transparency, and provide tools and supports for practice transformation. This work could build on current alignment and measurement-improvement efforts at the Center for Medicare and Medicaid Services (CMS) and HHS broadly.

1.2  CMS should collaborate with the Agency for Healthcare Research and Quality (AHRQ) to develop the best measures (including outcomes) for patients and populations that can be readily assessed using current and future digital data sources. Such measures would create more meaningful information for providers and patients.

Recommendation 2: Accelerate efforts to develop the Nation’s health-data infrastructure.
2.1 HHS should continue, and accelerate, the creation of a robust health-data infrastructure through widespread adoption of interoperable electronic health records and accessible health information. Specific actions in this vein were proposed in the 2010 PCAST report on health information technology and the related 2014 JASON report to the Office of the National Coordinator for Health Information Technology (ONC).

Recommendation 3: Provide national leadership in systems engineering by increasing the supply of data available to benchmark performance, understand a community’s health, and examine broader regional or national trends.

3.1 HHS should create a senior leadership position, at the Assistant Secretary level, focused on health-care transformation to advance information science and data analytics. The duties for this position should include:

  • Inventory existing data sources, identify opportunities for alignment and integration, and increase awareness of their potential;
  • Expand access to existing data through open data initiatives;
  • Promote collaboration with other Federal partners and private organizations; and
  • Create a more focused and deep data-science capability through advancing data analytics and
  • implementation of systems engineering.

3.2 HHS should work with the private sector to accelerate public- and private-payer release of provider-level data about quality, safety, and cost to increase transparency and enable patients to make more informed decisions.

Recommendation 4: Increase technical assistance (for a defined period—3-5 years) to health-care professionals and communities in applying systems approaches.

4.1 HHS should launch a large-scale initiative to provide hands-on support to small practices to develop the capabilities, skills, and tools to provide better, more coordinated care to their patients. This initiative should build on existing initiatives, such as the ONC Regional Extension Centers and the Department of Commerce’s Manufacturing Extension Partnership.

Recommendation 5: Support efforts to engage communities in systematic health-care improvement.

 

5.1  HHSshouldcontinuetosupportStateandlocaleffortstotransformhealthcaresystemstoprovidebetter

care quality and overall value.

5.2  Future CMS Innovation Center programs should, as appropriate, incorporate systems-engineering

principles at the community level; set, assess, and achieve population-level goals; and encourage grantees

to engage stakeholders outside of the traditional health-care system.

5.3  HHS should leverage existing community needs assessment and planning processes, such as the

community health-needs assessments for non-profit hospitals, Accountable Care Organization (ACO) standards, health-department accreditation, and community health-center needs assessments, to promote systems thinking at the community level.

Recommendation 6: Establish awards, challenges, and prizes to promote the use of systems methods and tools in health care.

6.1 HHS and the Department of Commerce should build on the Baldrige awards to recognize health-care providers successfully applying system engineering approaches.

Recommendation 7: Build competencies and workforce for redesigning health care.

 

7.1  HHS should use a wide range of funding, program, and partnership levers to educate clinicians about

systems-engineering competencies for scalable health-care improvement.

7.2  HHS should collect, inventory, and disseminate best practices in curricular and learning activities, as well as encourage knowledge sharing through regional learning communities. These functions could be accomplished through the new extension-center functions.

7.3  HHS should create grant programs for developing innovative health professional curricula that include systems engineering and implementation science, and HHS should disseminate the grant products broadly.

7.4  HHS should fund systems-engineering centers of excellence to build a robust specialty in Health-

Improvement Science for physicians, nurses, health professionals, and administrators.

Full Report: http://www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/pcast_systems_engineering_in_healthcare_-_may_2014.pdf

How and why do countries vary so much in their use of health services? @WRicciardi @leadmedit @Medici_Manager @pash22

BY ADAM WAGSTAFF , http://bit.ly/1e48HAI

I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.

I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?

WHS to the rescue – again

As in a recent post of mine on Let’s Talk Development, I thought the World Health Survey might shed some light on these issues. The WHS was fielded in the early 2000’s in 70 countries – spanning the World Bank’s lower-, middle- and high-income categories. The WHS enumerators asked a randomly-selected adult in each household about his or her use of inpatient care and outpatient care; in the numbers that follow I’ve focused on use in the last 12 months. As I said in the earlier blog post, the WHS does have some drawbacks: it covers some regions fairly fully, other much less fully; it’s 10 years old; and all we can tell is whether inpatient or outpatient care was received, not the number of contacts. But despite these problems, the WHS gets us quite a long way.

A lot of variation – but not necessarily what you’d expect

The maps below show the inpatient admission and outpatient visit rate – actually the fraction of people who had at least one admission or visit in the last 12 months. Green countries are above the developing-country average; red countries are below it.
For IP admissions, most of the OECD countries are above the developing-country average (6.98%). Brazil, Namibia and the European and central Asian countries are also above it. African and Asian countries are mostly below or close to the developing-country average.

The picture is different for outpatient visits. Several OECD countries are actually below the developing-country average (27.52%). And for the most part, the countries below the developing-country average are in Africa: many are considerably below it (Mali stands out dramatically); only a few are above it (Kenya and Zambia stand out). By contrast, several countries in Asia are above the developing-country average: India and Pakistan are dramatically above it, but China and Vietnam are also above it; a few Asian countries are below it – Laos and Myanmar are considerably below it, Malaysia and the Philippines less so.

Do variations in doctor numbers and infrastructure explain variations in utilization?

The maps below show data on doctors and hospital beds per 1,000 persons. I got the data from the World Development Indicators, and took the country averages for the first half of the 2000s. As before, green countries are above the developing-country average; red countries are below it. The countries above the developing-country averages are mostly those in the OECD and Europe and central Asia, though in the case of doctors per 1,000 some of them are also in Latin America and the Caribbean. Except for China, most of Asian countries fall below the developing country average.

Correlating the WHS utilization data with the WDI doctor and beds data shows that doctors and beds per 1,000 persons are positively associated with outpatient visit and inpatient admission rates. A lack of doctors and beds looks like it could indeed be part of the explanation for low utilization rates, though of course we haven’t established causality.

But a lack of doctors and hospital beds is only part of the story. Together they “explain” only 60% of the cross-country variation in inpatient admission rates, while doctors “explain” an even smaller 20% of the cross-country variation in outpatient visit rates.

Some countries – India and Pakistan are examples – are below the developing-country average on doctors per 1,000 persons, but above the developing-country average on the outpatient visit rate. Doctors and hospitals in these countries treat far more patients than one would expect given the number of doctors and hospital beds in these countries. In these countries, it doesn’t look like accessibility is the pressing issue; as research by my colleague Jishnu Das confirms, at least in India, poor quality is the bigger problem.

By contrast, much – but not all – of Africa is in the opposite camp: these countries have inpatient admission and outpatient visit rates that are below what would be expected on the basis of their doctor and beds per 1,000 figures. So it’s not just that these countries lack doctors and beds; it’s also that people are not getting the level of contacts you’d expect from the existing staff and infrastructure. Here it looks like absenteeism could well be part of the story; recent research from my colleague Markus Goldstein confirms it – pregnant women whose first clinic visit coincided with a nurse’s attendance were found to be 46 percent more likely to deliver their baby in a hospital.

Two take away messages

Message #1 is that countries differ considerably in their utilization rates. Much of Asia visits doctors more regularly than both the developing world and the entire world; India’s consultation rate is a third higher than the global average. Africa stands out as the continent where outpatient visits and inpatient admissions lag behind the rest of the world.

Message #2 is that these variations are partly explained by differences in doctors and hospital beds per capita, but only partly. The problem goes deeper than hiring more doctors and building more hospitals. Africa has lower outpatient visit rates than its doctors per 1,000 figures would suggest, while the opposite is true of India and Pakistan. In Africa, it looks like the binding constraint may well be absenteeism, while in S Asia it looks like the first-order problem is the poor quality of care that’s actually delivered.

Science alone can’t make tough decisions for us @kevinmd @Medici_Manager @pash22

by   http://bit.ly/1bjVWDk

On April 14, The United States Preventive Services Task Force concluded that women with an elevated risk of breast cancer – who have never been diagnosed with breast cancer but whose family history and other medical factors increase their odds of developing the disease–should consider taking one of two pills that cut that risk in half. The Task Force is an independent panel of medical experts who review the medical literature to estimate the pros and cons of preventive interventions. This is the same Task Force that in recent years raised questions about the benefits of mammograms in 40 to 50-year-old women, and PSA tests for men of all ages, tests that screen respectively for breast and prostate cancer. Despite the popularity of both of these tests, the Task Force concluded that their harms often outweigh their benefits.

The irony now is that with this report on breast cancer prevention pills, the Task Force has switched from rejecting something patients believed in to endorsing something most patients will reject.

The seemingly strange way the Task Force ping-pong’s between popular and unpopular recommendations is inevitable, because these kinds of recommendations must necessarily go beyond the medical facts – it is impossible to decide what preventive measures people need without making value judgments.

To understand the way facts and value judgments get mixed together in these kinds recommendations, let’s take a closer look at these breast cancer prevention pills.

For many years now, doctors have been prescribing tamoxifen as secondary prevention to women who have already undergone treatment for breast cancer, in an attempt to thwart any breast cancer cells remaining in their body. In women whose breast cancer cells express “estrogen receptors”, tamoxifen reduces the chance that this cancer will recur, by attaching itself to those receptors, in effect crowding outestrogen. In breast cancer cells, any estrogen landing on these receptors will spur that cell to divide and multiply. But when tamoxifen lands on these receptor sites, it does not stimulate cell growth.

Raloxifene is a close cousin of tamoxifen, which has primarily been used to treat women with osteoporosis. Like tamoxifen, it competes with estrogen for the attention of estrogen receptors. Also like tamoxifen, it slows down breast cancer by preventing estrogen from stimulating cell growth. As it turns out, both raloxifene and tamoxifen also have the strange property that when they collide with bone cells, they don’t fight against estrogen, but seem to mimic estrogen, and thereby improve bone health. (Because these drugs and sometimes act like estrogen and other times act like anti-estrogen, they are called selective estrogen blockers.)

Two very similar drugs, then. Both slow down breast cancer cells while stimulating bone cells. Each drug has been shown to cut the risk of a first breast cancer in half for women with a high risk of experiencing this disease. In what is known as the P1 trial, for example, women who faced an average five year risk of breast cancer of 6% saw that risk drop to 3%, if they took tamoxifen.

Sounds like a good deal, yes? Take a pill for five years, and cut your risk of breast cancer in half. But keep in mind, most women do not face a 6% chance of breast cancer in the next five years. Women with this kind of risk are generally retirement age or beyond, and usually have a bad combination of family history, early onset of menses, and late age of first pregnancy. It is these women the Task Force believes should talk with their doctors about whether to take these medications. And how did the Task Force reach this conclusion? By determining that for some women, at least, the benefits of these pills outweigh their harms. Before looking at this harm benefit ratio more closely, let’s put this Task Force conclusion into context.

The Task Force essentially produces three kinds recommendations, which I have taken the liberty to name.

  1. NADA: When it concludes that the harms of an intervention outweigh the benefits, the Task Force recommends that doctors and patients avoid the intervention. Think: ultrasound screening for pancreatic cancer.
  2. OUGHTA: When the Task Force concludes that the benefits outweigh the harms, it pushes to make the intervention standard of care. For example: routine screening for colon cancer in people 50 years or older.
  3. UP TO THE INDIVIDUAL: When the Task Force concludes that the benefits of an intervention potential outweigh the harms, depending on the patient’s individual preferences, it leaves the decision up to individual patients and their doctors to weigh. This is the recommendation the Task Force made both for mammography in 40 to 50-year-olds, and for tamoxifen and raloxifene to prevent breast cancer.

When making NADA or OUGHTA recommendations, the Task Force essentially makes its own value judgment. It looks at the risks and benefits of an intervention, and concludes that no sensible person could decide differently from the Task Force. In this third type of recommendation, however, the Task Force concludes that reasonable people could make different choices, based on how they weigh the risks and benefits of the interventions.

In the case of tamoxifen and raloxifene to prevent a first breast cancer, I expect the vast majority of women will conclude that the risks of the pills outweigh the benefits.  In the past two years, I have collaborated with a team of researchers at the University of Michigan (led by Angie Fagerlin, a decision psychologist in their medical school), to help women decide whether to take either of these pills. We developed an Internet-based decision aid, a tool designed to help patients weigh the pros and cons of their medical alternatives. (I write about the history of decision aids in my book, Critical Decisions.) Our decision aid provided women with individualized estimates of their odds of developing breast cancer in the next five years. We only directed women to the decision aid whose risk was high enough to have qualified for the P1 trial.

In the decision aid, we described the benefits of both drugs – the reduced risk of breast cancer and the strengthening of their bones. We also laid out the risks – a very small chance of endometrial cancer, a slightly larger chance of heart attack or stroke, a modest risk of cataracts, and finally a very strong likelihood of experiencing menopausal symptoms such as irregular menstrual bleeding and hot flashes. We actually provided them with precise numerical estimates of these side effects, with pictures illustrating the risks to make them easier to comprehend.

Women pondered the pros and cons and concluded, almost unanimously, that the side effects of these drugs outweighed the benefits.

The decision whether to take tamoxifen and raloxifene is no doubt a personal one, and the right choice will vary depending on how a given person weighs the respective risks and benefits of these medicines. For a woman with an extremely high risk of breast cancer over the next five years – say 10% or more – cutting that risk in half might very well be worth the hot flashes and the chance of experiencing blood clots. But very, very few women faced a five year risk is highest.

Consider, instead, a woman with a 3% chance of developing breast cancer over the next five years. That risk is much higher than average – most women face a five year risk of less than 1% – but is it high enough to justify taking one of these pills? For such a woman, tamoxifen and raloxifene only reduce that risk by 1.5%. Over five years. Five years with possible hot flashes. For a cancer women have not experienced yet. These modest benefits simply do not loom large enough to interest most women in these pills.

You might wonder at this point whether our decision aid biased women against these medications. As a physician trained in behavioral economics, I’m constantly on the lookout for decision biases. In the case of our study, however, we designed our decision aid in a manner that allowed us to test for well-known behavioral economic biases. For instance, research has shown  that when people face a choice between three options and two of the options are similar, they often opt for the more different alternative even if the other options are better. In other words, a person might believe that A > B, and A’ > B, but still choose B over A and A’, because they cannot decide between A and A’.

Aware of this problem, we created several different versions of our decision aid. In one version, we presented women with a choice between tamoxifen, raloxifene or no pill. Three choices in other words, two of which – the two medications – are quite similar to each other. In another version of the decision aid, we simply presented women with the choice between pill or no pill. We thought this simpler choice would increase women’s interest in these pills, by minimizing the difficulty of choosing between the two of them. But instead, this reframing of the decision did not increased women’s interest in either of these preventive medicines.

We also designed our decision aid to take account of another well-known decision bias, what are known as recency effects. When people learn about the risks of a medication and then learn about its benefits, that order of information leads them to look favorably upon the medication, because the information they remember best, the last information they receive, is about the pill’s benefits. By contrast, people who receive the same information about this medicine, but in the opposite order, like the pill less, because the last thing they learn about are the pill’s risks, and this information sticks in their minds. To make sure this recency effect was not influencing women’s decisions, we varied the order of information across women. We discovered that this did nothing to change their willingness to take either of these medications, mainly because whichever order women received information in, they did not like the idea of taking either pill.

If these pills are so unpopular among well-informed women, why would the Task Force come out in favor of them? It comes down to judgment. The Task Force concluded that a reasonable person could look at these risks and benefits and decide that the hot flashes and blood clots are acceptable prices to pay to reduce the chance of breast cancer. The majority of women don’t have to agree with this view for the Task Force’s recommendation to be correct. Even if only a small percentage of women decide these pills are worth taking, at least they have the freedom to make that choice. And at least they know that medical experts have concluded that such a decision is a reasonable one to make.

The same goes for whether to start mammograms before the age of 50 in women at normal risk of breast cancer. The Task Force never said that women shouldn’t start mammograms at this earlier age. They just said that it was a tough judgment call, and that some women, perhaps the majority even, might conclude that the harms of early screening – the anxiety caused by false negative tests, the pain caused by unnecessary biopsies – aren’t worth the modest benefits of screening at this age.

If the Task Force is going to leave all these tough decisions up to individual patients and their doctors, why should we care about their recommendations? For starters, you will have a hard time finding a more thorough and levelheaded evaluation of the pros and cons of these kinds of interventions. These people are very good at what they do. In addition, anyone reading through Task Force reports will be forced to recognize that science alone can’t make tough decisions for us. Ultimately, science can only provide us with the facts. The rest of us eventually need to make tough judgment calls. In effect, the Task Force is doing us a huge favor, by showing us which judgments are close calls, and which ones are no-brainers.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

Clinician Engagement: The Role of the Physician @Medici_Manager

By Amy Collins, M.D.
HealthCare Sustainability Consultant, Vanguard Health Systems 
http://bit.ly/15hNvA9

I was living a pretty green life, or so I thought. I had been composting for years, was an avid recycler, was known for turning off lights and computers not in use and grew up using reusable grocery bags – doing it all because it just made sense. But my attitude towards greenness and reason to be environmentally responsible changed in one minute back in April of 2007. On one of my days off from my full time job as an emergency physician, I was sitting in my car in the pick up line at my son’s school, absent-mindedly texting and listening to the radio while IDLING! My very wise 4th grader took no time to begin reprimanding me for my lapse in environmental responsibility. “You are idling,” he scolded.  “Ms. Gruenfeld (his teacher) taught us about climate change today and what is happening to the polar bears.” He went on. “I better not catch you idling EVER again and there’s a lot more you should be doing about climate change and to help the polar bears.”  Shame faced, I agreed and assured him that I would get right to work to try and correct my wrong. As a family, we watched “An Inconvenient Truth,” then set out to make our home as green as possible. Inspired by the urgency in the movie and by a wise little boy, we started doing such things as changing all of our light bulbs to fluorescents, drying clothes on a clothes line, planting a vegetable garden, making homemade cleaning products and much more.

Soon it became uncomfortable living one way at home and another at the hospital. It grew harder and harder to leave my environmental conscience at the door when I went to work. In response to this discomfort, I set out to start a recycling program in my ER but was told by a fellow employee that recycling was “illegal” in a hospital. Not satisfied with this response, I turned to the Internet and learned that not only was recycling not illegal in a hospital and that there were many exciting and practical opportunities for a hospital to reduce it’s environmental impact. It was at this moment that I knew that I had found my calling. I wrote a letter to my administrators and requested that we take steps to become a more sustainable operation, was given permission to run, started a green team and so began my mid-life second career path.

I realize that not all physicians will share my passion for health care sustainability or have the time to commit to a leadership role at their hospital, but there are many important opportunities for physician engagement at local and broader levels. When speaking to physicians I focus on sustainability as a preventative health strategy and an opportunity for improved health and health care delivery.  Let’s look at some of the issues. According to The Lancet, “Climate change is the biggest global health threat of the 21st century – the impacts will be felt all round the world – and not just in some distant future but in our lifetimes and those of our children.” Physicians need to advocate for health to be at the center of the climate debate as the health impacts are anticipated to be significant, including increases in respiratory illnesses, allergies, food and water borne illnesses, infectious diseases along with health impacts of weather disasters and heat waves.  In addition, there is scientific evidence linking the combustion of fossil fuels to lung cancer, respiratory illness, heart disease and other chronic illnesses.  I think that Margaret Chen, Director General of the World Health Organization, says it best, “The health sector must add it’s voice loud and clear – and fight to place health issues at the center of the climate agenda.”

Let’s briefly look at some of the other things I have learned over the past few years that concern me as a parent and a physician. The US spends billions annually to treat chronic diseases such as obesity and diabetes, both of which are increasing in incidence at an alarming rate and burdening our health care system. Scientists now suspect that endocrine disrupting chemicals may play a role in the development of both diabetes and obesity. These chemicals even have a name – “obesogens” – chemicals that may promote weight gain and obesity. Bet you never learned about this in medical school! The incidence of other chronic diseases with potential environmental links, such as asthma, autism and certain cancers are increasing at alarming rates. A 2008 Associated Press study found traces of pharmaceuticals in the drinking water of millions of Americans.  A 2005 study by the Environmental Working Group found over 200 industrial chemicals in the cord blood of ten newborn infants. DEHP, a plasticizer, which is an androgen antagonist, is found in many medical devices including IV bags and tubing. A 2007 Lancet study showed that nurses have the highest incidence of occupational asthma of any profession.  We have mercury, a potent neurotoxin, in our clinical and facility devices, pharmaceuticals and lab reagents. Around 80% of the antibiotics used in this country are used non-therapeutically in livestock, which experts agree is linked to antibiotic resistance in humans. I could go on and on, but it is beyond the scope of this blog.

So, what’s a busy physician to do with all this disturbing information?

At The Bedside

  • Incorporate environmental history taking into practice
  • Evaluate diagnostic imaging ordering practices and reduce patient’s exposure to unnecessary radiation
  • Educate patients about environmental exposures, healthy food and beverage options, proper medication disposal and the public health impacts of climate change
  • Practice “Green Pharmacy” – evaluate personal prescription practices (i.e. limit refills and quantities), consider non-pharmaceutical treatments when appropriate, regularly review medications with patients

In the Hospital

  • Advocate for procurement of healthy, local and sustainable food and beverages and for the elimination of sugar sweetened beverages
  • Advocate for toxicity reduction
    • ​Use of Green Seal Certified cleaning products
    • Mercury elimination
    • DEHP reduction
    • Fragrance-free and no-smoking policies
  • Advocate for pharmaceutical waste management program and education about proper medication disposal
  • Advocate for Grand Rounds and educational programs about environmental topics (or give a talk yourself!)
  • Advocate for a climate policy and preparedness
  • Encourage reprocessing of single use surgical devices and other sustainable initiatives in the OR
  • Join or start a green team
  • Encourage your hospital to join PGH and enroll in HHI
  • Agree to be your hospital’s “Clinical Champion”
  • Lead by example – support your hospital’s recycling program, use red bags properly, turn off lights not in use, reduce your paper usage!

Get Educated!!

Most physicians haven’t had any formal training or education about health care sustainability but there are some great opportunities for education

Advancing sustainability in the health care sector

  • Engage in research activities – the industry is in need of science based evaluation of sustainable best practices
  • Publications – write an article for your hospital newsletter, local newspaper or write a peer –reviewed article
  • Speaking engagements – speak to a variety of health care audiences

National Advocacy: advocate for climate change policy, chemical reform, antibiotic legislation and more. Let your voice be heard!

More and more physicians are recognizing the link between environmental choices and health and the environmental impact of hospital operations. Physicians have many opportunities to advance sustainability within their organizations and the health care sector and to bring this important work to our patients. Sustainability broadens my understanding of the Hippocratic Oath, as in my practice I now consider “First, Do No Harm” to mean doing no harm to patients, workers, the community and the environment.

6° Congresso Medici Manager inizia 21novembre a Roma @Medici_Manager @muirgray

Ecco il programma definitivo del 6° Congresso della Società Italiana Medici Manager che si terrà a Roma il 21 e 22 novembre 2013. http://bit.ly/19yyB9M

Dalla presentazione:

“Non può esserci crescita infinita in un sistema a risorse limitate, soprattutto se il sistema in questione è chiuso, complesso ed ha come obiettivo la tutela del diritto alla salute. La complessità, limite e forza della sanità del XXI secolo, nasce della definitiva emancipazione di tutti gli attori in gioco, dai cittadini alle professioni sanitarie, dai manager all’Industria: il risultato di questa evoluzione di ruoli e consapevolezze produce un vibrante tentativo di cambiamento, ma mai armonico.

La crisi internazionale, in aggiunta, sta colpendo duramente la tenuta del welfare in Europa e tra i primi interventi di razionalizzazione possono essere annoverati proprio quelli che hanno interessato i sistemi sanitari: Spagna, Grecia e Portogallo sono soltanto alcuni esempi. In Italia l’esperienza della regionalizzazione spinta, che ha generato 21 sistemi concorrenziali in perenne conflitto con il livello centrale, va probabilmente ripensata per creare una vera autonomia responsabile ed evitare il naufragio generale.

La Società Italiana Medici Manager (SIMM), nella consapevolezza che lo stato inerziale sia l’anticamera dello sfaldamento di un Servizio Sanitario Nazionale (SSN), equo, universale e solidale così come lo abbiamo finora conosciuto, ha deciso di dedicare il proprio VI Congresso Nazionale all’unità dei professionisti della salute ed alla centralità della leadership medica in sanità come strumenti per rivoluzionare e rilanciare il SSN. In questo la recente esperienza inglese di ristrutturazione del National Health Service (NHS), così vicina e così lontana allo stesso tempo, deve esserci di immediato aiuto per evitare errori da non commettere e, nel contempo, fornirci gli strumenti per disegnare ed esplorare vie del tutto nuove.

Tutti concordano sulla necessità di salvare il SSN ma nessuno possiede le coordinate della rotta da seguire, quanto mai incerta. Pertanto serve il coraggio di rivoluzionare, non solo di riorganizzare poiché soltanto un nuovo approccio culturale da parte dei medici e la valorizzazione delle energie e delle competenze migliori può guidare il cambiamento e fermare il declino.”

Concluso con successo il 6° Congresso SIHTA tenutosi a Bari dal 7 al 9 novembre 2013 @Medici_Manager

Si è concluso con successo il 6° Congresso Nazionale della SIHTA.

Esso ha dato un contributo, in un momento storico come quello attuale, caratterizzato da una forte crisi economica e da un’esasperata attenzione al contenimento della spesa, a compiere scelte che siano anche eticamente accettabili e socialmente condivise, un paradigma fondamentale per rendere sostenibili le decisioni che incidono in grande misura sul livello qualitativo dei sistemi sanitari.

E’ stata indagata la dimensione etica e d’impatto sociale dell’Health Technology Assessment affinché in ogni processo decisionale, non prevalgano più orientamenti poveri di dimensione valoriale quasi esclusivamente orientati ai tagli lineari piuttosto che a un sapiente disinvestimento che non incida sulla salute dei cittadini.

Si è ricordato che il percorso decisionale suggerito dalle metodologie di HTA costituisce un’ulteriore garanzia affinché le stesse vengano realmente interpretate come una leva per lo sviluppo economico del Paese.

Il Congresso si è articolato in quattro sessioni plenarie dedicate a:

1. La valutazione etica e di impatto sociale in HTA
2. HTA come leva per lo sviluppo economico del Paese
3. HTA tra innovazione e disinvestimento
4. Equità e sostenibilità del Servizio Sanitario Nazionale

Numerosi workshop, due dei quali svolti in collaborazione con l’Associazione Italiana Medicina Nucleare e l’Associazione Italiana di Fisica medica, e molte sessioni parallele hanno dato pregnanza al Congresso.

Da segnalare l’elevato livello scientifico delle presentazioni proposte dai partecipanti.

Prossimo appuntamento a Roma, nell’autunno 2014: il tema conduttore sarà “HTA e definizione dei LEA”. E’ un obiettivo ambizioso, ma ineludibile!

Direct costs of inequalities in health care utilization in Germany 1994 to 2009: a top-down projection

Lars Eric Kroll and Thomas Lampert

http://bit.ly/11lFlYS

Background

Social inequalities in health are a characteristic of almost all European Welfare States. It has been estimated, that this is associated with annual costs that amount to approximately 9% of total member state GDP. We investigated the influence of inequalities in German health care utilization on direct medical costs.

Methods

We used longitudinal data from a representative panel study (German Socio-Economic Panel Study) covering 1994 to 2010. The sample consisted of respondents aged 18 years or older. We used additional data from the German Health Interview and Examination Survey for Children and Adolescents, conducted between 2003 and 2006, to report utilization for male and female participants aged from 0 to 17 years. We analyzed inequalities in health care using negative binomial regression models and top-down cost estimates.

Results

Men in the lowest income group (less than 60% of median income) had a 1.3-fold (95% CI: 1.2-1.4) increased number of doctor visits and a 2.2-fold (95% CI: 1.9-2.6) increased number of hospital days per year, when compared with the highest income group; the corresponding differences were 1.1 (95% CI: 1.0-1.1) and 1.3 (95% CI: 1.2-1.5) for women. Depending on the underlying scenario used, direct costs for health care due to health inequalities were increased by approximately 2 billion to 25 billion euros per year. The best case scenario (the whole population is as healthy and uses an equivalent amount of resources as the well-off) would have hypothetically reduced the costs of health care by 16 to 25 billion euros per year.

Conclusions

Our findings indicate that inequalities and inequities in health care utilization exist in Germany, with respect to income position, and are associated with considerable direct costs. Additional research is needed to analyze the indirect costs of health inequalities and to replicate the current findings using different methodologies.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

The case for change slidepack @Medici_Manager @WRicciardi

Our Time to Think Differently programme has made the case for change and highlighted the trends that will influence the way health and social care is delivered in future.

To help you explore and share this work, we are creating a series of downloadable slidepacks. We hope that they will inform your thinking and discussions about the future of care.

The first pack in this series explores the pressures on the health and social care delivery system and why it needs to change to meet the challenges of the future.

You can download a powerpoint version of these slides here: The case for change slide pack. These slides cannot be edited in this format, but you can copy individual slides across to your own presentations. Please credit The King’s Fund www.kingsfund.org.uk/think if you use the slides elsewhere.

King’s Fund http://bit.ly/15mI8Sk

Richard Smith: Health and social care: lots of activity, little value @Richard56 @Medici_Manager

21 Jun, 13 | by BMJ Group http://bit.ly/11s23k4

My mother is a wonderful woman but has no short term memory and drinks too much alcohol. When she’s sober her language is complex and her sense of humour magnificent. “What a terrible world,” she says, watching the television news, “I’m glad I’m not in it.” In a way, she isn’t. She’s mildly disinhibited even when sober and chats to everybody. “You’re one of the sights of Barsetshire,” I say to her, “they’ll be organising coach parties.” “Well, nobody ‘ll pay,” she answers laughing. But how much have the health and social services helped my mother?

She’s clear that she wants to live on her own as long as possible. In an age gone by, but still present in most of the developing world, she would have lived with me or my brothers. It would be unthinkable that when widowed she should live alone. But those days are finished. We couldn’t stand it and nor, I’m confident (but maybe deceiving myself), could she.

It’s fascinated me how well and for how long she has lived alone despite having no short term memory. It’s been some six years. I thought an intact short term memory essential for living alone, but I was wrong. Luckily she doesn’t cook, so doesn’t leave the gas or the oven on. She forgets to put water in the electric kettle and sometimes blows the fuses, but she doesn’t blow up the house.

Every day is much the same. She gets up at about 8.30, has a cup of black coffee, looks at the Guardian (making no sense of it), puts on her shoes, and “stomps,” as she describes it, the mile into the centre of Barset. Greeting the man in the newsagent, she buys a bottle of wine, stomps home, hailing people as she goes, drinks the wine, and goes to bed. Perhaps two hours later she gets up and does it all again. And when the days are longest, she may attempt it a third time—unaware that it’s evening not morning and unsteady on her feet after two bottles of wine. That’s why I’m sat here in Barset writing this. I’m “mothersitting.” She giggles at the term but doesn’t really like it.

Back at the beginning I thought that we ought to “get her into the system.” I thought that we’d need some support and that it would be essential to be “on the books” to receive it. So we went to the GP, which she doesn’t like. The trainee said that she should have some blood tests and come back to have “the long test for memory.” That was two trips, 140 miles driving, and when we had the appointment for the long test, the doctor didn’t have time to administer it and so simply referred her to the memory clinic. There was no value added by all this as the postman could have told us that she has no short term memory.

The adventures with the memory clinic were long and drawn out with MRI scans, psychological tests, many interviews with a variety of people, and some 350 miles of driving. My mother hated it all, but in the end she was prescribed drugs to help her memory. She forgot to take them and didn’t, I think, want to take them anyway, although she said she did to please us all. Even if she had taken the drugs there was only a small chance that they would have done any good. Everybody was charming and helpful, but no value was added by all this activity—except that the diagnosis released some state benefits.  It was bureaucratic value that was added.

Social services became involved. They came and did a long assessment. Eventually, they said, she’d have to go into a home. This wasn’t surprising. They couldn’t do anything except give us a list of services. They couldn’t recommend any service even though they presumably know which are better than others. So no value in this.

We arranged for a “sandwich lady” to come three times a week to encourage my mother to eat. But that was hopeless, and eventually my mother herself told the sandwich lady that she didn’t need her anymore.

Social services assessed her again and told us the same as before. They did arrange a bath chair, which did add a little value. Unfortunately it broke down almost immediately and took a long time to fix. Now they’ve taken it away. I’m not sure why.

We arranged for carers to come in twice a day, and they have added value. But we found them and have to pay as my mother owns her house.

What about resuscitation, the care company asked. My mother is very clear that she doesn’t want to be resuscitated. We talk about death a lot. She’s not scared of death. But we can’t have a DNR in place without having the doctor approve it. So we haven’t bothered. If the carers find her in cardiac arrest they are highly unlikely to succeed in resuscitating her anyway. Having to have a doctor determine your eligibility for a DNR seems to me a process that subtracts value.

Now things have reached a crisis. With the long evenings my mother is going out late and drunk and having all kinds of adventures with neighbours, the police, and the burghers of Barset. The care company has contacted social services worried that it might be blamed if she goes under a bus. So have some neighbours. A young man from social services rings me in a state of high excitement. He asks me things that we have told social services many times. He’s rung the GP asking for an assessment. He offers us another assessment. “What good will that do?” I ask. He’s not clear. I say that we recognise she can no longer live alone even though she insists that she wants to. We’ve started finding a home.

They can’t, it’s apparent, really do anything. I ring the GP and speak to a friendly understanding doctor. They have been contacted by social services and discussed her in their meeting. But nobody knows anything about her. A doctor has visited twice but never got an answer. Somebody is going to try again. The young doctor agrees that they have little to offer. I’ve not heard from them since.
Social services keep ringing because people are ringing them. The care company tells me that they will do anything to help but in the same call, without irony, tell me that they can’t supply somebody in the light evenings.

My brother asks who social services are serving?  Are they there for my mother or the neighbours? We recognise the strain on the neighbours, and we know most of them. Some have been very helpful. Ages ago I delivered them all a letter asking them to contact any of us if they had worries. I’m not sure why they ring social services rather than us.

Then my mother has a fall. It had to happen. Indeed, it’s happened before. This time she has a scalp wound, and we doctors (and surely most others) know that scalps can bleed generously. I was abroad unfortunately, so my brother rings 111. Risk averse, as they have to be, they recommend a visit to A and E. Nobody can be sure that she wasn’t unconscious. A young doctor thinks she might have a urinary tract infection to account for her confusion and prescribes antibiotics. They can’t be taken with alcohol. He suggests a visit to the GP in four days’ time. I say poppycock to all this when I return, and we forget the antibiotics and the visit to the GP. She is fine. So again more activity, more expense for the NHS, and no value. At least she hasn’t developed diarrhoea through taking antibiotics.

A woman from social services rang again today. She’s weary. I tell her that we are in the final stages of the bureaucracy of finding a home. She’s relieved. I ask her what she might do if we weren’t doing anything. Eventually she would have to use the law to have my mother admitted to a care home. She could arrange an emergency admission to a home, but we agree that we should do all we can to avoid having to move her twice.

My mother is unaware that the phone lines of Barset are buzzing with concern about her. She’s not keen on moving to a home but will do what we advise. Seconds after we’ve had the conversation she has of course forgotten it.

When I reflect on the saga so far I can’t see that statutory health and social services have added anything but minimal value. But there’s been plenty of activity, form filling, and expense. My mother is not that unusual. We surely need better ways to get value out of the system.
I also reflect that people who have added a lot of value are those who work in the newsagent she visits every day. She likes them, and they are not only kind to her but also let her have goods without paying when she forgets her money and arrange a taxi to take her home when she’s tired and exhausted. Perhaps we need fewer expensive professionals and a revitalisation of communities.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

 

Ministers blame workers for system dysfunction created by Ministers @perfect_flow @Medici_Manager

What Poses More Danger To The NHS; Dirty Data Or Dumb Leadership? goo.gl/0ze7q

Writing blogs on poor management of the NHS is like shooting the proverbial fish in the barrel, but two articles in the papers this weekend have raised the insanity levels higher than ever. The first piece brought forth the startling revelation that Jeremy Hunt wants to criminalise the gaming of targets

The Government is going to solve the problems in the NHS by prosecuting anyone deemed to have fiddled figures to meet their targets. This angers me on many levels, so let me try to summarise the situation that Hunt is attempting to solve;

  • Government sets arbitrary targets, which trigger punishments if not met.
  • Targets become the important focus of attention for management, who push targets down the hierarchy, imposing them on the workers in the system.
  • Government sets the policies and thinking, which dictates how managers create systems and budgets, by which people must work to meet the targets.
  • Inadequate systems created by wayward thinking, cause targets to be missed.
  • Fearful of the punishments that will arise, people do the only thing available to them to meet the arbitrary targets: they “game” the system.
  • Patients die as a result of the poor systems, whilst management. focus on the targets and the workers.
  • Government is provided with copious evidence that the focus on targets has caused the system to fail patients.

Targets do not work. There is a tidal wave of evidence that tells us this, from bankers to schools, via policing and the NHS, but consecutive Governments have clung to them like a comfort blanket. Targets give the illusion of control, but the truth is the complete opposite. I do not intend to go into detail on why targets are such a bad thing, as I have done just that in previous blogs. If you want to find out more, please follow the links I have provided at the end of this blog. @AndyTBrogan nicely summed up the effect of targets when he said that “in the short term, they may get people to do stuff, but they suck the heart and soul out of what they are doing”.

So, what are our Government proposing to do to improve things? Is it;

  1. Abolish targets and refocus attention on the needs of patients;
  2. Remove some of the worst targets, most prone to gaming;
  3. Enforce the targets more rigorously and make it a criminal office to record inaccurate data

Only option 1 will work. Words fail me that any sane person could choose option 3. However, this is Jeremy Hunt we are talking about. To quote Deming; “wherever there is fear, there will be wrong figures”. This policy takes the culture of fear and ratchets it up to 11. More fear will lead to more wrong data, but it will just be more cunningly concealed.

Let’s think about Hunt’s proposal logically for a moment…

  • How will prosecutors distinguish between an honest mistake and a deliberate fiddle? If I transpose a figure, did I do it deliberately or accidentally?
  • Who will define exactly how the figures need to be prepared? Think of tax laws; is it avoidance of the target, or evasion?
  • If figures were found to be falsified, were they caused by a “rogue” worker, or systemic fraud? How will we truly know?

To answer those questions will require policing. The logical conclusion is that figures will have to be more rigorously audited. Will we have a specific accounting body that verifies hospital data? How much would that cost exactly? Cost that is, in terms of the auditors themselves and the time and effort incurred by the NHS in preparing and checking the figures.

Criminalising data falsification will focus management attention even further away from the patient and further into accountancy and accountability. It is the wrong thing spectacularly wronger. This policy is like recognising that corporal punishment isn’t working and then proposing that we make it more brutal.

The problem is that the system is the main factor affecting performance. In turn, the system is affected by the thinking of those at the top. We currently pass responsibility for performance down the hierarchy, but do nurses actually have the power and authority to change the system? If they can’t change the system, the only way to hit the targets is to cheat the system, or cheat the figures.

So what to do instead?

The unavoidable truth is that sustainable improvement will not happen until the thinking changes at the top. If the thinking changes, it will allow us to replace arbitrary targets with measures of performance that are linked directly to purpose. The crucial part is that measures must be used to learn about current performance, but not to make people accountable. Instead they must be used by the people who actually do the work to help them improve the system.

There are 5 tests of a good performance measure. To be truly useful they must;

  1. Helps us understand and improve performance
  2. Be derived from the work
  3. Demonstrate capability and variation
  4. Be in the hands of the people who do the work to control and improve the work
  5. Be used by managers to actively, act on the system

Which brings me to the second article, which alleges that the Government was guilty of  ignoring data on hospital death rates Professor Sir Brian Jarman, who co-founded the health statistics and research service Doctor Foster, claims that in 2010 he sent the then health secretary Andy Burnham a list of hospitals with higher-than-average death rates, but no action was taken.

The fundamental fact that most people fail to understand is that producing any sort of performance data does not in itself change anything. Measures can never provide us with any answers, but good ones will prompt us to go away and ask the right questions. Used correctly, managers can identify where they need to go and look, to see what actual performance looks like and why it is delivering the data seen in the measures. This is absolutely not achieved by sending others to carry out audit and inspection. This is managers using data intelligently to go and see the work themselves, which is the only way to understand and improve the systems they ask people to work in.

None of these changes are possible until the thinking changes at the very top of the NHS. If Government continues to believe that fear improves performance and enforces it with inspection and prosecutions, then the future looks very bleak indeed.

Here are some fantastic links that explain why targets do not work;

Try almost any of Inspector Guilfoyle’s blog entries here;

http://inspguilfoyle.wordpress.com/

Type targets into the search box here;

https://www.vanguard-method.com/

This is a great summary piece, which provides further links to plenty of evidence;

http://systemsthinkingforgirls.com/2013/02/17/the-9-main-arguments-for-targets-deconstructed/

You can also read my previous blogs to see the effect that targets had on me. For example;

http://www.perfect-flow.com/blog/barclays-bonus/

Il Big Bang del NHS @Medici_Manager

Gavino Maciocco http://bit.ly/Z9NRWy

È entrata in vigore la riforma che cambia radicalmente il volto delNational Health Service inglese, un vero Big Bang per il più noto, antico e imitato modello di sistema sanitario universalistico. Cosa ne resterà di quel modello? Ben poco sostengono i più.


Il 1 aprile è entrata formalmente in vigore la legge di riforma approvata lo scorso anno (Health and Social Care Act 2012) e tenacemente voluta dal governo guidato dal premier conservatore Cameron, che la mise in cantiere immediatamente dopo aver vinto le elezioni politiche nel 2010.

Una riforma che cambia radicalmente il volto del National Health Service (NHS)[1], un vero Big Bang per il più noto, antico e imitato modello di sistema sanitario universalistico.  I principali contenuti politici della riforma sono i seguenti:

  1. L’intera infrastruttura sanitaria pubblica, dalle Strategic Health Authorities (le nostre Regioni) ai Primary Care Trusts (le nostre ASL),   è stata abolita (a partire appunto dal 1 aprile).
  2. Se sul versante del finanziamento del sistema sanitario la responsabilità  rimane (per ora…)  a carico del settore pubblico e quindi della fiscalità generale, sul versante della produzione dei servizi curativi (territoriali e ospedalieri) si va verso una diffusa privatizzazione dei servizi sanitari, guidata da logiche di mercato  molto spinte, con l’irruzione nel sistema di  grosse e potenti  compagnie multinazionali.
  3. I servizi preventivi, quei pochi che erano rimasti in capo al NHS (come il controllo delle malattie infettive e gli screening) vengono interamente trasferiti alle municipalità.

Primary Care Trusts (ripetiamo, le nostre ASL) sono sostituiti da consorzi di General Practitioners (GPs, i medici di famiglia), denominati Clinical Commissioning Groups (CCGs).  I CCGs, organizzazioni private a pieno titolo, rappresentano il vero perno del sistema. Saranno complessivamente 211 in tutta l’Inghilterra e saranno i destinatari di 65 miliardi di sterline di fondi pubblici (quasi il 70% dei 95 miliardi di sterline dell’intero budget sanitario nazionale).

Tale cambiamento”, si legge in un articolo di Lancet, “mina uno dei meccanismi chiave attraverso cui il NHS riesce a garantire un pieno ventaglio di servizi indipendentemente dal luogo di residenza dell’assistito. I Primary Care Trusts sono responsabili per l’intera popolazione in una definita area geografica, non solo per i pazienti che sono iscritti in un determinato servizio. Questa responsabilità basata sulla popolazione consente una valutazione a lungo termine dei bisogni, la pianificazione e la committenza dei servizi per rispondere a quei bisogni, e la rendicontazione pubblica dell’uso delle risorse per quella popolazione. La proposta del governo abbandona il principio basato sulla popolazione; la committenza che sarà esercitata dai futuri consorzi dei medici di famiglia riguarderà solo gli assistiti iscritti con i medici di quel determinato consorzio all’interno di confini geografici amorfi e indefiniti. Verrà così meno la possibilità di programmare un’adeguata distribuzione geografica dei servizi per le comunità e le popolazioni locali”[2].

Con i fondi assegnati i CCGs finanzieranno le attività dei GPs e i servizi che verranno offerti ai loro pazienti da parte dei vari provider – pubblici e privati – a cui vengono commissionate le prestazioni: dalle cure domiciliari, all’assistenza specialistica e ospedaliera.  Ciò ha immediatamente sollevato la questione del loro potenziale conflitto d’interessi: GPs prescrittori di prestazioni erogate da provider privati, con possibili interessi a comune con GPs.  “Metà dei GPs nei CCGs  hanno legami finanziari con i provider privati”, sostiene il BMJ[3]. “Il fatto che i GPs abbiano interessi esterni può influenzare le loro decisioni nella scelta dei provider e può mettere a rischio il rapporto di fiducia con i loro pazienti, perché questi  possono diffidare del motivo per cui sono stati inviati per un determinato trattamento”: così si esprime Clare Gerada, Presidente del Royal College of GPs, che aggiunge: “Ciò inoltre può danneggiare anche il NHS perché avere molti differenti provider può aumentare i costi e frammentare l’assistenza, a tutto danno dei pazienti”[4].

Le cose potrebbero ulteriormente complicarsi se – come la legge prevede – i CCGs appaltassero l’attività di committenza a agenzie private, per le quali  gli interessi commerciali nella scelta del provider sarebbero ancora più evidenti.

Altro elemento critico è la perdita del livello nazionale di definizione dei livelli essenziali di assistenza, assegnato prima della riforma al Ministero della salute, che stabiliva le prestazioni che le strutture pubbliche erano tenute a tenute a garantire uniformemente  in tutto il territorio e anche i livelli di partecipazione alla spesa, per alcune limitate categorie di prestazioni. Con la riforma sarà ciascun CCG a stabilire quali prestazioni saranno garantite ai pazienti e anche i livelli di partecipazione alla spesa.

Ad aggravare la situazione ci sono anche i tagli apportati dal governo Cameron al budget della sanità (meno 20 miliardi di sterline entro il 2015) e ad altri settori del welfare, che si ripercuotono negativamente sull’assistenza sanitaria.  Scrive sul Guardian Simon Atkins, medico di famiglia: “Un crescente numero di persone affolla i nostri ambulatori a causa delle politiche del governo.  Questo infatti ha tagliato in maniera spropositata i servizi per i poveri, gli anziani e i disabili e ogni giorno vedo persone che sono in grande difficoltà a causa di ciò. Ad esempio, a causa dei tagli, è stato chiuso nel nostro quartiere un Centro Diurno che dava supporto e possibilità di compagnia a tante persone”[5].

Ciò che sta succedendo – sostiene Lucy Reynold della  London School of Hygiene and Tropical Medicine – è un vero mutamento genetico del NHS, anche se il governo cerca di minimizzare la portata del cambiamento sostenendo che non ci sarà differenza tra servizi erogati da provider pubblici e privati.  In realtà “nel settore pubblico i medici cercano di avere finanziamenti adeguati per rispondere in maniera adeguata ai bisogni dei loro pazienti. L’obiettivo è la cura e i soldi sono un mezzo per raggiungerlo. Quando invece ti trovi nel settore privato – afferma la Reynold – la compagnia si pone l’obiettivo di fare soldi, la priorità è quella di  distribuire i dividendi ai soci”.  Reynold prevede che la competizione tra provider  pubblici e privati, tutta basata sui prezzi, alla fine sarà vinta da quest’ultimi, con conseguenze irreversibili. “E ogni volta che il settore privato riuscirà a sottrarre un contratto  al settore pubblico, ciò provocherà la scomparsa di quel servizio perché verranno meno le risorse per pagare i salari dei dipendenti”[6].

Che la riforma rappresenti l’inizio della fine del NHS  è anche opinione di David Hunter, professore di politica sanitaria all’Università di  Durham, il cui punto di vista è così riassunto:  “quando la sanità è dominata dal mercato  dobbiamo aspettarci: a) una riduzione della qualità delle cure; b) un aumento dei costi; c) il trasferimento di  finanziamenti pubblici in profitti privati; d) la riduzione della libertà di scelta; e) la perdita di  controllo democratico e di public accountability nel campo dell’assistenza sanitaria”[7].

Bibliografia

  1. Dossier NHS su SaluteInternazionale
  2. Whitehead M, Hanratty B, Popay J. NHS reform: untried remedies for misdiagnosed problems? Lancet 2010; 376:1373-5.
  3. Limb A, Half of GPs on clinical commissioning groups have financial links with private providers, BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2431
  4. Campbell D. The Guardian, 27.03.2012
  5. Atkins S. The Guardian, 08.01.2013
  6. Reynold L. The future of NHS – Irreversible privatization? BMJ 2013;346:f1848 doi: 10.1136/bmj.f1848
  7. Hunter D. Will 1 April  mark  the beginning  of the end of England’s NHS? Yes, BMJ 2013;346:f1951 doi: 10.1136/bmj.f1951

Statement by Professor Malcolm Grant, Chairman of the NHS Commissioning Board @Medici_Manager @NHSCB

28 February, 2013

The Chair of the NHS Commissioning Board, Professor Malcolm Grant, today (Thursday) made the following statement at the organisation’s public board meeting held in Manchester.

He said:

“I want to make a statement about the Chief Executive. We stand at the moment poised at the commencement of one of the great momentous changes in the NHS. We will see the abolition of 161 statutory bodies and the creation of 211 new clinical commissioning groups.

“But this isn’t just a structural change. This is about a change in culture, it’s about a devolution, it’s about unleashing the power of commissioning – perhaps for the first time in the history of the NHS. It’s a complex, a hugely complex institution. The NHS treats in the order of 1 million people a day. There is no other organisation on earth with that reach and with that complexity, and with that function of being a remarkable, not just healthcare organisation but social support organisation that goes to the very heart of British society.

“The wakeup call that the Francis report has given us has drawn attention to numerous failings within the NHS – not just within Mid Staffs, but of a system which has from time to time focused upon the wrong things and has had dire consequences for those who have been unfortunate enough to be adversely affected by it.

“There has been a search amongst many people who suffer a sense of dismay and shock from the events that have been disclosed by Francis’s report – a search for accountability and in particular a focus upon the work of David Nicholson who through much of that period was a senior executive in Strategic Health Authorities. Indeed he held, because of the turmoil of reorganisation of that day, he held no fewer than seven jobs in six years within the NHS – culminating in his appointment in 2006 to be the Chief Executive of the NHS.

“David’s current formal position is that until 1 April he is employed 50% by the Government as Chief Executive of the NHS, and 50% by us, the Commissioning Board. With effect from 1 April his employment transfers 100% to the Commissioning Board. I have been deeply worried by speculation in the media about his future. Over the recent weeks I have reflected on several occasions with David about what has been said in the press. I have discussed it personally with each of the Directors of the Commissioning Board and I have discussed it collectively with the Non-Executive Directors of the Board.

“We have come to a clear view that David Nicholson is the Chief Executive of the Board. He is the person who we wish very strongly to lead a strong Executive Team on the Board. He is the person whose command of the detail of the NHS and his commitment and his passion to its future, we believe to be fundamental to the success of the Board. This is not, as it were, a statement of vulnerability but a statement of strength. We look David to you, to provide us with the leadership as we take through this exceptionally challenging set of changes. Thank you.”

http://bit.ly/YNyyBF

Vaccines and Autism: CDC Study Says No Connection @Medici_Manager @WRicciardi

Frank DeStefano, MD, MPH http://bit.ly/13g2KgW

New CDC Study of Vaccine Doses and Autism

Concerns about childhood vaccinations and the risk for autism persist for many parents and some members of the public. A new CDC study published in the Journal of Pediatrics [1]addressed a current concern about the relationship between autism spectrum disorder (ASD) and vaccination, which centers on the number of vaccines and vaccine antigens given to infants and children, according to the recommended childhood immunization schedule.

The study evaluated the association between the level of immunologic stimuli received from vaccines during the first 2 years of life and the development of ASD. The findings showed that neither the number of antigens from vaccines received on a single day of vaccination, nor the total number of antigens received during the first 2 years of life, is related to the development of autism.

About This CDC Study

This study is the first of its kind to evaluate the issue of “too many vaccines too soon” and the development of ASD. The study was conducted in 3 managed care organizations (MCOs), involving 256 children with ASD and 752 control children matched by birth year, sex, and MCO. In addition to ASD, researchers evaluated autistic disorder and ASD with regression and found no relationship with the number of vaccine antigens received in either of these categories.

Study data were obtained from immunization registries and medical records. The data used in this study had been collected and analyzed previously.[2] Children eligible for the study were born between January 1, 1994, and December 31, 1999, and were 6-13 years old at the time of data collection.

Each child’s total vaccine antigen exposure was determined by adding the number of different antigens in all vaccines that each child received in 1 day, as well as all vaccine antigens each child received up to 2 years of age. The number of vaccines and number of vaccine doses administered according to type of vaccine are shown in the Table.

Table. Antigens in Vaccines and Total Doses Administered by Vaccine Type

Vaccine Type Antigens per Dose Dosesa
Diphtheria toxoid/tetanus-diphtheria (DT/TD) 2 14
Diphtheria-tetanus-pertussis (DTP) 3002 235
DTP – Haemophilus influenzae type B (Hib) 3004 1659
Diphtheria-tetanus-acellular pertussis (DTaP) 4b 1165
DTaP 5b 789
DTaP 6b 492
DTaPHepatitis B 6b 3
Influenza 10 95
Hib 2 2123
Hepatitis A 4 22
Hepatitis B 1 3085
HepatitisB-Hib 3 215
Measles, mumps, rubella (MMR) 24 1093
Measles 10 2
Meningococcusc 2 285
Mumps 9 1
Pneumococcusd 8 698
Polio 15 3385
Rabies 5 1
Rotaviruse 14 57
Rubella 5 2
Typhoid 3000 4
Varicella 69 917
Yellow fever 11 1
aTotal vaccine doses administered in the study population from birth to 2 years of age
bNumber of antigens in DTaP vaccines varied by manufacturer
cMeningococcal C conjugate vaccine administered as part of a clinical trial at 1 MCO
dPneumococcal conjugate (7-valent) vaccine; some doses administered in a clinical trial at 1 MCO
eRotaShield® (no longer marketed)

The number of vaccine antigens has decreased in recent years although the number of recommended vaccines has increased. The routine immunization schedule in 2013 contains more vaccines than the schedule of the late 1990s. The maximum number of vaccine antigens that a child would be exposed to today by 2 years of age is 315, compared with several thousand in the late 1990s. This is the result of changes in vaccines that allow them to more precisely stimulate the immune system. For example, the older whole-cell pertussis vaccine induced the production of approximately 3000 different antibodies, whereas the newer acellular pertussis vaccines (such as DTaP) stimulate the production of 6 or fewer different antibodies.

This study strengthens the conclusion of a 2004 comprehensive review by the Institute of Medicine of the scientific evidence that favored a rejection of the causal association between certain vaccines types and autism.[3]

Knowledge, Attitudes, and Beliefs About Vaccines and Autism

Some parents are concerned that there is a link between vaccines (such as MMR) or certain vaccine ingredients (such as thimerosal) and autism. However, several large and reliable studies of MMR vaccine have been done in the United States and other countries.[3,4] None has found a link between autism and MMR vaccination. Furthermore, research[2] does not show a link between thimerosal in vaccines and autism. Although thimerosal was taken out of childhood vaccines in 2001, autism rates have continued to climb.

Although scientific evidence shows that vaccines do not cause autism, a 2012 HealthStyles survey showed that slightly more than 15% of parents are concerned that they do (LaVail K, Fisher A, CDC; unpublished data). Data from the survey found that 22.8% of parents are concerned that children receive too many vaccines at a single doctor’s visit, and 22.8% of parents are concerned that children receive too many vaccines by the age of 2 years. The vaccines, they believe, can cause learning disabilities, such as autism. In another recent survey,[5] more than 1 in 10 parents of young children refuse or delay vaccinations in the belief that delaying vaccines is safer than giving vaccines according to the CDC-recommended immunization schedule. Children do not receive any known benefits from delaying vaccines. Delaying vaccines puts children at risk of becoming ill with vaccine-preventable diseases.

What Clinicians Can Do

CDC research with parents about their vaccine attitudes and vaccination behaviors has found that most US parents believe that vaccines are important, and they vaccinate their children. In fact, coverage for most of the routine childhood vaccines remains at or exceeds 90% in children aged 19-35 months. CDC and other agencies and organizations continue to conduct research to learn more about the causes of autism.

Healthcare professionals are the main determinants of parents’ decisions about whether to vaccinate their children. This study provides evidence that clinicians can use to reassure parents that the number of vaccines received early in life is not associated with the development of autism. Clinicians can help parents to learn the signs of ASD and act early so that action can be taken to help their children reach their full potential. Online resources, tools, and educational materials for clinicians to use to communicate with parents and caregivers are found at the end of this article.

Web Resources

CDC. Developmental Milestones

CDC. Autism Spectrum Disorders. Screening and Diagnosis for Healthcare Providers

American Academy of Pediatrics. Community Pediatrics. Act Early on Developmental Concerns: Partnering with Early Intervention

Frank DeStefano, MD, MPH, is Director of the Immunization Safety Office of the Centers for Disease Control and Prevention (CDC). He is a graduate of Cornell University and the University of Pittsburgh School of Medicine. He received training in public health and preventive medicine in the Epidemic Intelligence Service and preventive medicine residency at CDC. He obtained a Masters of Public Health degree at Johns Hopkins University School of Hygiene and Public Health. He has had extensive epidemiologic research experience at CDC, the National Institutes of Health, and at non-governmental research organizations. His areas of research have included immunizations, autism and other developmental disabilities, reproductive health, veterans’ health, diabetes, cardiovascular diseases, and other chronic diseases. Dr. DeStefano is an author on over 150 publications in leading scientific and medical journals. For the past 16 years Dr. DeStefano has had a focus on vaccine safety.

Alla ricerca dell’informazione di qualità @Medici_Manager @specializzandi @giovanimedici @wricciardi

Carlo Favaretti, Presidente della Società Italiana di Health Technology Assessment (SIHTA), Coordinatore nazionale delle reti regionali HPH, presenta La ricerca documentale. Istruzioni per l’uso.
La possibilità e la capacità di recuperare informazioni significativeper assumere decisioni si dimostra ogni giorno di più come un fattore critico di successo, a maggior ragione nei settori dove la produzione di “conoscenze” assume un ritmo tumultuoso e la distribuzione delle “notizie” utilizza canali diversificati per quantità e qualità dei contenuti. In ambito clinico e assistenziale, come pure nella gestione delle organizzazioni sanitarie, la disponibilità di informazioni affidabili e validate può generare valore aggiunto per i professionisti, i pazienti, la comunità in generale e gli altri stakeholder solo se questa disponibilità viene “catturata” da tutti coloro che, nella pratica quotidiana, devono combinare al meglio le risorse disponibili con i bisogni e le domande dei cittadini.

Questa guida, La ricerca documentale. Istruzioni per l’uso, frutto di un appassionato lavoro di sistematizzazione di iniziative formative sviluppate da diversi anni nell’Azienda Ospedaliero-Universitaria di Udine dai miei collaboratori, vuole essere uno strumento ambizioso di agile e rapida consultazione per aiutare i decisori (clinici in particolare) a mettere a fuoco un quesito informativo, a cercare/navigare nei moderni contenitori elettronici e a selezionare dal mare magnum web-based gli elementi essenziali per le decisioni di tutti i giorni.

Ovviamente le “istruzioni per l’uso” non forniscono suggerimenti per sviluppare la curiosità intellettuale del ricercatore o strumenti per affinare lo spirito critico del professionista, qualità peraltro da coltivare con passione e costanza; cercano tuttavia di mettere in luce potenzialità e limiti dei diversi contenitori, a loro volta oggetto di selezione e validazione dei contenuti da parte dei curatori delle basi-dati.

Un ulteriore pregio di questo manuale è la selezione di “contenitori” ad accesso libero, dai più popolari ai più tecnici, col suggerimento di coinvolgere gli specialisti dell’informazione della propria organizzazione (azienda sanitaria, azienda ospedaliera, università ecc.) per il recupero di ulteriori documenti o di risorse a pagamento.
Concludo con l’auspicio che la ricerca documentale possa contribuire a migliorare la nostra capacità di lettura dei problemi clinici ed organizzativi, aiutandoci a coltivare il metodo scientifico e lo spirito galileiano del “cimento”, che il bombardamento informativo mette oggi a dura prova.

http://bit.ly/1549Ghb

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