Monday, 11 December 2017

8 future proposals for primary care

Primary care is the key to the good running of the health system and therefore it must be promoted, protected, improved and, above all, invest in it. Many countries are immersed in renewal processes of their primary care and, therefore, we must be attentive to the contributions we receive, especially those in the United Kingdom, where primary care is very similar to ours. In an earlier post, I reviewed a paper by the Royal College of General Practitioners that provided an insight into the role of family physicians in 2022, and in this same direction I have a report from a committee of experts of the National Health Service Primary Care Workforce Commission), which has developed a set of reform proposals aimed at strengthening the future of primary health care, broader than the previous one which was limited to a corporate vision.

8 proposals that we can benefit from

Some of the proposals in the report are very specific to the English model, such as those referring to General Practitioners' working circumstances, quite different from those of family physicians in our country. Others, on the other hand, should be noted, since the general environment of primary care is very comparable; I have chosen eight proposals that can be suitable for us:

1. More communication with patients. In this sense, the document makes two very specific proposals: a) a good triage based on the demand should direct people to the type of professional that best fits their problem; this would mean, for example, that physicians would have more time to better meet the more complex clinical needs, and b) patients should be given an email address from their care team to efficiently answer their most frequently asked questions.

2. More multidisciplinary teams. Doctors and nurses should be free of bureaucratic burdens and, for this reason, administrative and para-medical professionals staff must be increased (the document does not specify this point too much). The motto would be: we don’t need more doctors or nurses but we need that health care professionals devote all their working hours to add value to the health of people instead of engaging in admin jobs that don’t correspond to them.

3. More community nurse work. The systems must invest more in nursing home work that guarantees the services on a continuous basis 24 hours a day and 7 days a week. English experts believe that only this way could avoid the unnecessary hospitalizations of many elderly people with diverse fragilities and chronic disease.

4. More functions for pharmacists. Both community pharmacists and clinicians should play a more important role, especially in issues as worrisome as the lack of adherence to medication or the poly-medication of older patients.

5. More integration of social services. In addition to deploying their own social services, primary care needs to have many more experiences of coordination and integration with community social services, both those managed by city councils and those of other providers.

6. More time for teamwork. The development of individualized therapeutic plans for patients with complex social and health needs requires that the professionals involved have the time to coordinate more than they do now.

7. More communication with hospital specialists. Primary care physicians and nurses must have an open communicative line with both specialists and hospitalization units. The communication channels can be diverse: the clinical history, the mail, the telephone, the remote meetings, etc. The current communicative barriers between primary care and the hospital make the matters worse.

8. More palliative services. Attention to the end-of-life episodes should not be confined to the last days of life, but should be extended to the care provided to people who have a reduced life expectancy. That is why we have to expand these services and offer them from the primary care with a real continuous care that includes nights and weekends.

Professor Martin Roland, President of the Primary Care Workforce Commission, explains that the reference point of the working group has been to develop proposals for the development of primary care that has provided quality and order to date, as well as guaranteeing accessibility to the system.

From my reading of the document I have extracted these 8 points that, in my opinion, can reinforce primary care services in the right direction and, at this point, someone will wonder where the money will come from in order to start the essential reform of primary care. My suggestion is that before we go to knock on the door of the Economic Adviser, whose answer, sadly, we can already guess, we could listen to the advice of John Wennberg, who says that if we dig into the waste of care for chronic patients in hospitals, we are sure to find the necessary funds to divert them in the right direction (of which Wennberg calls it Sutton's Law).

Jordi Varela

Monday, 4 December 2017

We need a fish tank

Pere Vivó

The American psychologist Barry Schwartz, who can be read frequently in The New York Times or listened to in TED (Technology, Entertainment, Design) conferences, invites us to reflect on the paradox of choice. His talk begins with what he calls the "official dogma" of all Western industrial societies, which states: "If we are interested in maximizing the welfare of our citizens, the way to do so is to maximize individual freedom." The reason for this is that freedom itself is good, valuable, praiseworthy and essential for human beings: "If people have freedom, each of us can act on their own to do things that will maximize our well-being and no one will have to make decisions for us. The way to maximize freedom is to maximize choice: the more possibilities people have, the more freedom and greater well-being they will have."

Monday, 27 November 2017

Let patients help!

Dave deBronkart, better known as "e-Patient Dave", is a marketing expert who on January 3, 2007, at 09:02, received a call from his doctor: "We have found something in your lung." DeBronkart remembers that moment with precision because that news changed his life. From that moment he abandoned his normal citizen status to become a metastatic patient of a tumour of renal origin and, given his clinical condition, in an advanced cancer patient. DeBronkart received a treatment that normally does not work, but luckily it worked for him.

So far a story with a happy ending, but Dave's story highlights his attitude (just look at the cover of the book with a picture of him with his doctor, Dr. Danny Sands). With the sentence above, far from adopting a fearful and docile attitude, searched Google, went to find other patients with the same diagnosis, and sat down to talk to his doctors using his own criteria, sharing with them each of the decisions that he was taking. Now e-Patient Dave has become a leader in what we call patient empowerment.

Monday, 20 November 2017

The fallibility of scientists

Nature has echoed the professional debate about the intrinsic quality of scientists’ work, in a dynamics of self-criticism comparable to what is taking place, in similar terms, in the clinical world. Scientists are also fallible, says the article writer and therefore, should enhance the mechanisms of self-criticism, rather than enrol in self-deception.

John Ioannidis, Meta-Research Innovation Center at Stanford, says scientists should work harder to understand the biases of their human fallibility if they want to overcome the crisis of confidence generated by the poor reproducibility of research results. And to illustrate his words, Ioannidis offers three examples: a) from a selection of one hundred psychology studies, only the results of just over a third of the work could be replicated, b) a group of Amgen researchers only succeeded in reproducing 6 of the results of 53 reference studies in the field of oncology and haematology, and c) the Ioannidis team itself was able to replicate completely only 2 of the 18 gene expression studies based on microarrays (DNA chips).

Monday, 13 November 2017

Measuring the value of anti-cancer drugs

Cristina Roure

Anti-cancer drugs, especially palliative drugs, are toxic, costly and sometimes of little benefit, as a result their value to the patient and society are often questionable. It’s also true that significant improvements in the survival rates are threatened by the difficulty in accessing them, due to their unsustainable cost.

Monday, 6 November 2017

Precision medicine in the elderly care

Marco Inzitari

One of the challenges launched by President Barack Obama ($215 million for 2016) is the "Precision Medicine Initiative" a concept that goes against the treatment focused on the "average-patient". According to this initiative, as a first step, cancer treatments should be oriented to the specific genetics of the patient. For this reason, we often refer to the future of oncology as a "precision medicine". As another example, to continue with oncology, the Watson Intelligent System (IBM) will provide support to oncologists for informed and well fitted decision-making, analyzing patients' medical records and looking for possible evidence-based options.

Monday, 30 October 2017

Prediabetes epidemic in sight

Prediabetes is a terminology that, recently, is used when a person is detected with higher than normal levels of blood glucose, but there is no pathology. Prediabetes could be understood as a disposition to develop diabetes in the future, a disease that, in turn, represents a condition that puts one at risk of serious affections such as nephropathy, retinopathy or cardiovascular disorders, among others. Due to this chain of risks, and with a healthy intention to reduce morbidity and mortality, the American Diabetes Association (ADA) led a study to consider that glycosylated haemoglobin (HbA1c) is a test that can be done without any preparation or need for fasting and see if it can become a new criterion for detecting prediabetes. The concern arises when, according to this diagnostic extension, it’s estimated that in millions of pre-diabetics would show up: in China 493, in the US 86 and in Spain 6, to cite three countries from which I have data.