CONFERENCE: Hellish Decisions in Healthcare Jan 2017

Hellish Decisions in Healthcare is designed as a space for healthcare leaders, professionals and researchers within the international healthcare community to shape healthcare policy and systems to deliver Triple Value.

  • Personalised value, the delivery of services informed by what matters to the individual

  • Technical value, determined by how well resources are used within services for each purpose

  • Allocative value, determined by how the assets are allocated to services for different purposes.

The decisions and strategies needed to deliver Triple Value will not always be immediately apparent and nor will they be easy to make; the Value in Healthcare Forum is a safe place where these strategies can be developed and where strategic discussions can be had with the key thought and implementation leaders in healthcare.

Read more on the website and do Register by Oct 15 for the Early-Bird Discount.  The event will be in Oxford, Jan 12 to 13th, 2017.


For more events related to "Less is More," "Choosing Wisely," "Preventing Overdiagnosis," "Shared Decision-Making," etc, go here.

 

Source: https://www.phc.ox.ac.uk/events/hellish-de...

No evidence that N95 respirators are better than surgical masks

 From NinjaCat14 on  Deviant Art  I can't make this stuff up!

From NinjaCat14 on Deviant Art
I can't make this stuff up!

Specialized technologies are always sexier than their basic alternatives.

We often think that new and complicated is better. Or that if something is more expensive if must work better, right? 

One small trial found that a more expensive placebo was much more effective than the cheap one in Parkinson's patients. There is a lot of interesting research around how cost influences thinking and choice, and much of it is applied by manufacturers to influence their markets (see for example: Relative thinking in consumer choice between differentiated goods and services and its implications for business strategy).

Sometimes we think again about something that is not new, but an existing technology or process that we just use by habit, having assumed for years that it was better than the alternatives. Rarely are these things scrutinized, but sometimes when they are, we find out we are  "all wrong." For example, we have long assumed that acetaminophen is helpful for lower back pain but a meta-analysis in the BMJ in March 2015 found this is not the case.

In a recent Canadian Medical Association Journal (CMAJ) article, Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis, we learned that there really is not a lot of clinical research that supports the effectiveness of N95 masks. In the lab, yes, surrogate markers suggest the N95 masks could be "better" than normal surgical masks, but the data in practice is so lacking. 

Smith et al. concluded that "Although N95 respirators appeared to have a protective advantage over surgical masks in laboratory settings, our meta-analysis showed that there were insufficient data to determine definitively whether N95 respirators are superior to surgical masks in protecting health care workers against transmissible acute respiratory infections in clinical settings."

Of course 'insufficient data' doesn't mean we should abandon these masks. While I will still wear N95s for seeing TB patients and for performing high risk interventions on patients with influenza like illness, I now begin to wonder if this is really necessary.

There are so many 'fancy' technologies that we have discovered are no better than the old ones, and our knowledge of the waste, cost, and sometimes harms associated with them makes it hard to  not carefully scrutinize every 'new alternative' and 'innovation.' 

As I head to Toronto for a meeting of the CMA's Joule Innovation Council this week, I must laugh a bit. I imagine my experience in critical review of medical literature and knowledge of the harms from overtesting/treating/diagnosis, will make me one of the toughest judges of our colleagues' submissions! We are reviewing grant proposals for development of innovations from Canadian physicians.

I hope that with this privilege, I can be both enthusiastic and measured in my assessments, though I won't be surprised if I'm one of the more, uh 'fiery,' of the dragons in the den. With the collective wisdom of the group, I'm certain we will support some elegant, thoughtful, and effective innovations to make a positive difference for patients and health care systems.

Source: http://www.ncbi.nlm.nih.gov/pubmed/2695252...

Making change: The Right Care Movement

If you are reading this, you already know there is an epidemic of overuse in health care. Yes, there is underuse too, and this has been the subject of many lobbying and quality improvement initiatives to date. The medical-industrial complex, particularly in the United States, has capitalized on the fears of individuals who worry they might be victims of underuse, to the tune of billions in unnecessary and harmful "just to be sure" testing, medications, and procedures.

Of course the health of individuals and populations is primary, but we cannot discuss this in isolation, without due attention to cost and sustainability. Given the finite resources we have in health care, we can't afford to throw away the precious time of patients and clinicians, or the money of patients and taxpayers. The best way to fix either problem is to see them – under- and over-use – as one. We need the right amount of care.

Who doesn't dream of a problem in which all you have to do is shuffle the deck to solve it!? This resonates strongly with my predisposition (and tiny amount of training) with Integrative Thinking.

The classic example of two sisters splitting an orange is a good illustration of the potential of integrative bargaining, as well as its elusiveness (Follett, 1940). Two sisters both want an orange, and they compromise by cutting the orange in half. What they would have discovered had they discussed it, however, is that one sister wanted the pulp for juice, and the other wanted the peel for a cake. Discovering that they each wanted different aspects of the orange would have helped the sisters to split the orange in a way that each gets the most individual utility out of the agreement
– Kirk D, Oettingen G. Gollwitzer, PM. (2011). Mental contrasting promotes integrative bargaining. International Journal of Conflict Management, 22(4), 324-341.

This is not a traditional way of thinking. The idea that "less" can lead to "more" is not intuitive. Some examples may help to illustrate the meaning of this when applied to health:

1.By ordering fewer unneeded tests and consultations for one patient (say, to review their cardiovascular profile), the clinician can instead emphasize and support the role of lifestyle changes and free up the patient's time and energy to exercise (which will improve their health far more than any cholesterol test or drug could).

2. If a patient can stop paying for a medication she doesn't need, she has a better chance of making rent payments that month, decreasing stress and the morbidity associated with homelessness as well as reducing the chance of an adverse event or side effect from medication.

3. If one patient's MRI for a sore knee is cancelled because it was planned to assess for a meniscus tear and is not needed as meniscus surgery is not shown to be effective, then timely access is now an option for another patient who needs that MRI (perhaps they've clinically had a stroke and the CT was normal, so the pattern of pathology on the brain MRI would change the treatment plan to prevent further strokes)

It goes on. However, because many people don't think about the big picture for themselves, their practice, or society as a whole, it can be hard to convince them to consider the 'Less is More' mentality. They may only hear "less" and run screaming.

This is why we need to create a huge swell of support, a cultural shift to make the discussion about overuse and underuse the norm. Jeanne Lenzer explains more about how the Lown Institute is attempting this with the Right Care Alliance in The Backstory—Is US healthcare a frontier for a new civil rights movement?

Source: http://blogs.bmj.com/bmj/2016/05/13/jeanne...

VIDEO: Take Back Health: Join the #RightCare Alliance

Although the USA is a slightly different animal, with more emphasis on health care as a for-profit industry, many of the same problems exist in Canada and other nations with a primarily single-payer, public system.

The solution to health care interventions that are unnecessary, unwanted, or even harmful is: a social movement. That's what the Lown Institute thinks, and the Right Care Alliance is gaining momentum.

Watch this:

Source: https://www.youtube.com/watch?v=mdeH1bwYYD...

VIDEO: Wasted: Waste and Harm and Unnecessary Tests (Four Corners)

In just 45 minutes, the problem of overdiagnosis, overtesting, and overtreatment is clearly summarized using examples from the Australian system. The costs and harms to patients are incredible, and an analogy – taking the wrong train and winding up where you never intended – is an effective illustration of the issues.

Some key messages:

Billions of dollars are spent on procedures that are not needed, simply because patients expect them and because doctors continue to lobby to be paid to do their 'favourite' procedures.

What is your estimate of how many of those knee arthroscopies are unnecessary? - Dr Normal Swann, Interviewer
Uh, I would say, at least half. - Dr. Ian Harris, orthopedic surgeon

This is no surprise. Dr James Rickert has been advocating for more appropriate care in orthopaedics, for example with an alternative Choosing Wisely list  (despite what the article says, not just 'one guy's opinion' but rather a summary based on the best available evidence, presented most recently at Preventing Overdiagnosis), for years. But conflict of interest, particularly in industry lobbying and influence in the creation of guidelines, continues to be a problem. So does fee-for-service payment systems which encourage higher throughput rather than best care. 

There are other pressures too:

Often the best medicine is no medicine at all, or the best intervention is no intervention at all. But those conversations with patients that take that time to explain that the evidence simply doesn't support doing a test or prescribing a drug  - are long conversations and it's much easier in clinical practice to do things quickly and prescribe or order a test. - Dr Rachelle Buchbinder, rheumatologist

 

Patients and physicians are both uncomfortable with uncertainty, so tests 'just to see,' continue to be ordered, despite the evidence that they are needless and carry risks. We need to realign expectations, save the waste, and re-direct it into areas of health care that will really help people instead of harming them.

Watch the video for more cutting commentary and alarming statistics.

 

FULL VIDEO: FOUR CORNERS: WASTED

TEASER: 


Source: http://www.abc.net.au/4corners/stories/201...

Showing surgeons ‘massive’ cost of disposable supplies leads to big savings for hospitals | National Post

In our disposable culture, it is unsurprising that the bleed of this trend into healthcare has gone largely unchecked.

Operating rooms now use scads of throwaway equipment, saving sterilizing time and shaving off some intra-operative minutes by using devices that are slightly more specialized for components of the procedure.

Surgeons, nurses, and patients are all unaware of the cost. In fact, "Surgical residents and staff have a generally poor knowledge of the cost of common consumable products used in the operating room," according to a recent study in Laryngoscope by Canadian otolaryngologists.

Tom Blackwell of the National Post highlighted the issue and discovered some of the simple changes that administrators and surgeons could make to save costs without significantly impacting operation times. These efforts would also reduce landfill waste, something not emphasized in the article, but a very important consideration for the long term sustainability of our health care system.

See the video and article: Showing surgeons ‘massive’ cost of disposable supplies leads to big savings for hospitals.



Source: http://news.nationalpost.com/news/canada/s...

I love Healthcare Triage! VIDEO: Malpractice, Healthcare Costs, and Tort Reform

Dr Aaron Carroll (@aaronecarroll) & Co. are amazing!

Healthcare Triage (@HCTriage) has a YouTube channel that hosts a range of videos, most of which pertain to the "Less is More in Medicine" movement. The Less is More blog has featured their work before, 1) when Healthcare Triage did a video about Choosing Wisely, and 2) when Dr Carroll wrote Why Survival Rate Is Not the Best Way to Judge Cancer Spending for Upshot in the NY Times. In early June, they posted another great video, busting some major medico-legal myths.

One of the main excuses physicians make for ordering too many tests and treatments is that they have to practice defensive medicine. You must 'cover your ass' (CYA) to ensure nothing is missed, lest you face a horrible lawsuit. Physicians pay a ransom to malpractice insurance in order to help protect their reputation (and earnings) should a case come forward.

Many frivolous lawsuits exist and a lot of poor care is not legally pursued. Physicians think that tort reform will solve everything. Not so. Watch the video to learn more:

Source: https://www.youtube.com/watch?v=sK-E_d1MGt...

Shrinking demand for blood products behind closure of blood donor clinics

Too much blood.

Remembering last year's crisis  – a severe shortage of blood products in Canada – it was surprising to read that Canadian Blood Services will be shutting down four permanent and 16 mobile clinics.

I am a blood donor.* It is with delight that I learn we have too much blood.

Experts cite five main reasons for this surplus:

  1. Minimally-invasive/robotic surgery reduces the amount of blood needed for each patient
  2. Doctors are transfusing when patients have symptoms, not for an arbitrary hemoglobin number (thanks to recommendations that have been made more popular thanks to initiatives like Choosing Wisely, eg item 5 on this list)
  3. Pre-surgery management can help increase patient's blood counts
  4. Better drugs during surgery prevent blood loss
  5. Blood supply is better managed by sharing blood products through hospital networks

It would be interesting to know which of these is has been the most effective at reducing the amount of blood required, but it sounds like most of these are in the best interests of patients and it results in a savings of $2.9 Million annually. However it happened, this is a big win for Canadians.

 

Well, I have donated blood, but every time I travel overseas (often to areas where malaria is present) it seems to prohibit me from donating for a year, and then I got my weird medical condition, so it has been about 3 years since I last donated.

Source: http://www.thewesternstar.com/News/Local/2...

What Can Patients Do In The Face Of Physician Conflict Of Interest?

I had the pleasure of meeting Dr James Rickert, an orthopedic surgeon and a patient, at the Road to Right Care conference put on by the Lown Institute in March. Dr Rickert works with the The Society for Patient Centered Orthopedic Surgery, advocating for health care reform and patient care that puts the patient in the centre.

One of the topics that he writes and speaks about frequently is conflict of interest in medicine and the financial incentiviazation of care which may be unnecessary or harmful to patients. 

To that end, his most recent contribution to the Health Affairs blog, What Can Patients Do In The Face Of Physician Conflict Of Interest?, describes some the major issues that emerge when caring becomes a business. There are also suggested Action Steps for patients to take when confronting these concerns.

Strong relationships between patients and providers are the heart of healthcare; we must work together to improve our culture and hold providers to a high ethical standard to stop the erosion of trust.

Source: http://healthaffairs.org/blog/2015/04/10/w...

VIDEO: Choosing Wisely and Encouraging Effective Treatment

Healthcare Triage briefly presents the notion that we should "stop doing things that don't work" in medicine. In the United States, vast amounts of money are being wasted on unnecessary care. Fortunately, the Choosing Wisely campaign helps enable patients and providers to take part in "reducing spending without negatively affecting quality of care."

In Canada, it is framed a little bit differently. We focus mostly on preventing harm and promoting high quality care. We expect that there will be significant financial benefits to the system from working in this way but saving money is not the primary motivation behind the Choosing Wisely Canada campaign. 

There are also some things the campaign (whether in the US, Canada, or elsewhere) doesn't address, like the fact that people respond to financial incentives and if we do not change the way health care providers are paid, they will continue to do unnecessary things to patients simply for the monetary gain (in direct violation of medical professionalism and most would say the Hippocratic Oath).
 

See the video here:

Source: https://www.youtube.com/watch?v=E505JhAIfp...