Other Blogs: Less Is More | An index of evidence-based, “less-medical” patient care

More "Less is More"!

Dr Bill Cayley Jr has started a Wordpress Blog, "Less is More EBM" to review studies that explore situations in which less involved/invasive/expensive/difficult/novel/etc. care is actually best for patients.

He writes, "This index is currently a personal (and extremely part-time!) project aiming to catalog literature documenting when “less is more” in a searchable and accessible format." It has just started, but there are already insights on papers about overuse of arthroscopy, the best treatment for paediatric upper respiratory infection, and creative solutions for low resource areas (eg. mosquito nets instead of mesh for hernia repair).

It's great to see interest booming. More people are writing books and blogs, talking at conferences, changing the care they deliver, and asking questions of their health care provider. The movement – still known by many names, a few of which are highlighted in the glossary – is growing!

If you are particularly interested in blogs, look at the left sidebar column, and under 'Similar Blogs' you'll find others writing about similar issues as you'll find on this site. Check 'em out!

Source: https://lessismoreebm.wordpress.com/

Day 1 of Road to Right Care #Lown2015 Recap

What a great day!

Hundreds of mainly American (I am one of 4 Canadians here) doctors, patients, nurses, health administrators, and other health providers gathered today for the first of three days on the Road to Right Care Conference, put on by the Lown Institute.

Being in a room with so many like-minded individuals is invigorating but also offers hope that together, we can actually do something radical.

Main Themes:

  1. Patients and their families and advocates must be at the centre of this movement; young health care providers are the future of this and must be engaged early in their training
  2. Health care is not about consuming, being sick; most of what we do in medicine has no impact on health; health care should be about being well, and about people not diseases:
    “A good physician treats the disease, the great physician treats the patient who has the disease.”  - DR. WILLIAM OSLER

  3. Social determinants of health, especially poverty must be addressed for greatest impact:
     "I can cure homelessness. You just house them and it's cured. Completely curable problem." - DR. MITCHELL KATZ

  4. Our system must be radically transformed; we have many ideas but they boil down to the fact that HIGER QUALITY CARE leads to LOWER COST

  5. Barriers to improvement: financial conflicts of interest, profit-based systems, not listening to what patients really want (eg. independence)

  6. Things that will help us achieve RightCare: team work, communication, destroying the imbalance of power, narratives

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

My actions as a result of today:

What was missing?

  1. Emphasis on relationships between patient and caregiver. The ONLY big mention about meaningful relationships was by a Reverend B. Stanfield during his reflection at the end; the data tell us that strong relationship = better care, and less costly care
  2. Focus on patient safety. Americans talk A LOT about cost! Cost is important, but were this conference anywhere else in the world, the main focus would be on reducing harms done to patients by too much or too little medicine.
  3. Acknowledgement of this as a world-wide cultural issue. There was a lot of discussion about insurance companies, ways of paying physicians, etc. as if these financial structure problems all explain the issue; some people seemed to believe that changing the way doctors are paid – abandoning fee-for service payments – would fix everything. But, there is no system of remuneration that incentivizes good care. "Wrong care" is a problem around the world, even in socially progressive and fully public health systems. 
     

I can't wait to see what is in store for us tomorrow!

The one chart you need to (begin to) understand any health study

Jullia Belluz, common-sense and evidence-oriented journalist (known to me from her great "Science-ish" Maclean's column) and Trudeau Scholar and Assistant Professor of Law at the University of Ottawa, Steven Hoffman, team up in their Burden of Proof column for Vox.

This week, in "The one chart you need to understand any health study" they help readers with a simple approach to understanding how to evaluate levels of evidence. Not all research is created equally:

This is a chart from the article, modified slightly. It has been beautifully "enhanced" with the added last line by Peter Cook,  @DoodlePeter . I couldn't resist sharing Peter's version!

This is a chart from the article, modified slightly. It has been beautifully "enhanced" with the added last line by Peter Cook, @DoodlePeter. I couldn't resist sharing Peter's version!

I think the chart it is a good start, and I wish it were as simple as this. Some sneaky (or inept) researchers are good at making trials look randomized, blinded, and so on but the controls, conflicts of interest, low study numbers, etc. mean that the data they gather is not very useful at all. Sometimes, the way the papers are written, it's easy to think of the conclusion as groundbreaking and accurate, but digging deeper into the methods it becomes clear that the authors did a little.... 'creative interpretation'.

Even the highest form of evidence comes in different flavours:

Not all systematic reviews are created equally, either.

And while some evidence is stronger than other evidence, it doesn't necessarily mean anything when it comes to applying it to you, the individual. Fortunately, Ms Belluz and Mr Hoffman get it.

Even with the best available evidence from around the world at our disposal, we have to analyze it and apply it to our particular circumstances. A personal experience with the success or failure of a drug, like an allergic reaction, is more informative for you than the most rigorous study on the drug ever could be. 

It can be challenging to spot issues with quality amongst the jargon and statistics. It is so refreshing to see journalists like Julia Belluz who get this and who are raising the bar for colleagues to be responsible with their science reporting.

Follow @JuliaOfToronto and @SHoffmania on Twitter

 

Source: http://www.vox.com/2015/1/5/7482871/types-...

BCMJ: Measuring and improving quality of care in family practice

With about 400 articles on the subject of "Less is More" overdiagnosis, overtesting, overtreatment, undertreatment, etc. in my Instapaper queue, I figured I should start tackling them again with brief précis or reflective posts so that you can have the benefit of my curating.

I'll probably alternate between older foundational articles and new interesting stuff.

Today: a new article in the British Columbia Medical Journal (BCMJ) by Dr. Martin Dawes, head of Family Practice at UBC, my alma mater.

Quality assurance for family practice should be determined locally and provincially, with a distributed model of quality assurance for the province rather than a centralized model, to increase the likelihood of positive change in response to variations in practice.

Dr Dawes captures it well when he writes of the need for a quality measurement system which takes into account appropriate variations in practice, and that such a system must flex and be  adjusted as we understand more about the meaning of the data we are collecting.

I was glad to see that Dr Dawes, unlike many others, doesn't put all the weight solely on achieving  "targets." It's not that guidelines and clinical measures should be forgotten about, however they are but one part of the larger quality picture and fortunately he spells this out. I worry that governments and health authorities have not yet arrived at this way of thinking.

While I appreciate that things like accessibility are mentioned in the article, I do note the lack of emphasis on (or even mention of) the role of a strong relationship or attachment between doctor and patient in high quality care. Hopefully this is something that decision-makers are well-aware of, and they take it so for granted that they don't explicitly mention it in their articles.  :P

This article is a timely piece as physician organizations, health authorities, and governments in Canada begin the discussion about 'what is good care?', 'how can we measure it?', and 'what can we do to make it better?'

Read more in the BCMJ.

Source: http://bcmj.org/premise/measuring-and-impr...

Specificity Vs Sensitivity: Who is the better radiologist?

A radiologist friend posted this illuminating article, Who is the Better Radiologist. It considers the challenges of selecting for quality, given the reality of trade-offs between sensitivity and specificity.

The article compares two fictional radiologists, one who is very detailed, never misses a thing, asks for lots of follow up testing, and is likely to over-diagnose. The other is faster, more direct, but may miss some subtle things.

 

If you were a patient who would you prefer read your scan, the under calling, decisive Dr. Singh or the over calling, painfully cautious Dr. Jha?

If you were a referring physician which report would you value more, the brief report with decisive language and a paucity of differential diagnoses or the lengthy verbose report with long lists on the differential?

 

Which would you rather have reading your images? We'd rather the careful one if the subtle thing they see is going to be a problem for us. We'd rather the more efficient one if the subtle thing they'll miss would not cause us harm.

But we can't actually choose. And the author of the article understands that.

Trade-off is a fact of life. Yes, I know it’s very un-American to acknowledge trade-offs. And I respect the sentiment. The country did, after all, send many men to the moon.

Nevertheless, whether we like it or not trade-offs exist. And no more so than in the components that make up the amorphous terms “quality” and “value.”

 

 

This is a very common problem in medicine! Balancing risk and uncertainty against avoidance of harm and cost is not something we can solve overnight, but even being aware of the struggle makes discussions with patients better-informed; that is a step forward to providing the right care.

Tensions Creating Less is More; Quality and Quantity

Per my last post, I just spent a week getting fired up about Integrative Thinking, thanks to the CMA and the Rotman School of Management.

The "Right Care" or "Appropriateness in Medicine" or "Less is More Medicine" movement – whatever you want to call it – is a synthesis of the tensions in the healthcare system that exist between the system's needs and the patients' needs. There are common goals, and even tensions between those, eg. between high quality care and a minimally disruptive process, between an efficient system and comprehensive services, between sustainability and quality, and between patient empowerment and provider accountability.

It is possible to have the "best of both worlds," but it is going to take a lot of work to figure out how to get there. Less is More begins by challenging the assumption that "More is Better." By accepting that quality and quantity are not inextricably linked, we open up a world of possibilities for the future of healthcare in Canada. Unsurprisingly, quality and quantity are often at odds for patients who are in their final years, which means that the "less is more" approach often naturally arises in end-of-life care.

In math class as a a kid, I always liked to solve a problem and then do the problem in reverse, to make sure my answer was right. Thinking about "appropriateness in medicine" I realized that maybe we already do have the solution. If I work backwards, will it ensure it's the 'right answer'? Or at least, one possible solution? Can we integrate High Quantity Care with Low Quantity Care to create the Right CareCan quality and quantity be reconciled for something in between, like the "just right bowl" of porridge that Goldilocks found?

The current, unsustainable and ineffective state of healthcare is in part due to the pathological thinking that arises from funding quantity rather than quality of care. By incentivizing disease rather than health care, it's no wonder cost are soaring and health outcomes are slipping. However, it is exceedingly difficult to measure quality, as we've yet to agree on a definition. One idea are QALYs, Quality-Adjusted Life Years, but this measure is not without issue.

If we pick the wrong measure, "payment for performance" models could also lead us astray. This year, we've learned that high patient satisfaction is correlated with increased morbidity and mortality. So, even though institutions and careers were made with this measure, giving patients what they want is not actually in the interest of their health!


There are many options:

-  Performance Measures: find useful quality measures, and create methods for measuring physician/nurse/system/etc. performance; make it auditable, provide feedback, unlicense those whose practices deviate significantly. This is scary for doctors because it diminishes our autonomy, something we value greatly, but it could lead to better access, quality, and efficacy. It may be quite a challenge since patients are ultimately responsible for their health. No matter what a nurse or physician does, there is a lot of the patient's health that is beyond the healthcare provider's control. As well it should be, since we ought to be shifting away from paternalism to patient-centred care, where people take ownership for their health and partner with experts who can guide them along the way.

- Bundled payments: where providers get a lump sum for the handling of one process (eg. hip replacement: it would include pre-, intra- and post-operative recovery including management of complications). Given a lump sum, the team would be motivated to provide the best care, which likely entails shorter stay, fewer medications, better quality surgery, best outcomes, etc. If they manage to save a lot of money by making the care efficient and effective, they profit. If they do a bad job, it costs the providers - not the system. This model provides a disincentive for unnecessary care, but doesn't allow for a lot of self-direction. Special consideration would be needed to account for more challenging patient populations.

- One price per patient per year: no matter how well or sick the individual, the system would have a fixed amount to care for them. This encourages providers to emphasize and support preventative health measures, and to use tests/treatments judiciously. For example, a practice would probably elect to follow Evidence-Based practices that show high value and efficacy. For example, doing colon cancer screening (a small cost) will allow detection and treatment of colon cancer at a time where it would be cost-efficient as well as in the best interests of the patient to intervene; if you don't screen, you find the colon cancer later and it is harder and more expensive to treat. Difficulties? It would take a long time to bear out successes. Also, the sickest patients might never find physicians. Also, physicians may have a hard time combating the consumer culture of "more is better" and thus be unable to provide efficient care.

- ?? More

I have a lot more reading and thinking and integrating to do. The next steps for me involve seeking out more opposing points of view, and to find those, I just have to talk to more and more people about these ideas and hope that I find lots of conflict and disagreement.