From the blog AQUAS we hope you are having a good festive season and would like to thank you for reading and following us.
We publish weekly in Catalan, Spanish and English on subjects related to the projects that are being carried out at AQuAS and we also publish contributions from guest authors. The editorial line of the blog includes a focus on assessment from different points of view and areas of the health system.
Along these lines, we have dealt with healthcare and quality results presented by the different agents who make up the healthcare system, the whole range of observatories of the Catalan Health System (including that which deals with the effects of the economic crisis on the health of the population and innovation), qualitative research, integrated care, the assessment of mHealth, inequalities in health, patient involvement, doctor-patient communication, shared decisions, patient and citizen preferences, variations in medical practice, the prevention of low-value clinical practices, the impact of research, information and communications technology, data analysis in research, tools for the visualisation of data, innovation and health management, the gender perspective in science, statistical issues, clinical safety with electronic prescriptions, chronicity (not forgetting chronicity in children), the effects of air pollution in health and current topics.
The European Innovation Partnership on Active & Healthy Ageing (EIPonAHA) is an initiative of the European Commission to deal strategically with the social challenges associated to active and healthy ageing, to make good practices in innovation more visible and to facilitate exchanges between regions, all of which promote interregional cooperation and the value of excellence.
What is its aim? To improve the health and quality of life of Europeans, especially of people older than 65, and to give support to the sustainability and efficiency of health and social care systems in the long term as well as to enhance the competitiveness of EU industry through expansion in new markets.
The reflection on how health systems interact with an ageing population and care in chronicity has been been one of the main lines followed in the AQuAS blog during 2016; they are subjects that affect our society and, precisely because of this, are part of the Health agenda.
In this context, having links to European projects is fundamental, where networking, collaborative projects and assessment are absolutely essential.
This is the underlying idea of the Reference Sites awards which assess regional European health ecosystems based on four axes:
Political, organisational, technological and financial willingness for an innovative approach to active and healthy ageing
The capacity to share knowledge and resources for innovation
Contributiing to European cooperation and transferability of own practices
Providing evidence of positive impact
The status of “Reference Site” is awarded to systems, alliances and ecosystems in health which comprise different players at a regional European level (government authorities, hospitals and care organisations, the health industry, SMEs and start-ups, research and innovation organisations and civil society) which have invested in developing and implementing innovative-based approaches to active and healthy ageing. These practices must be carried out with a comprehensive approach and vision and proof of the impact of their results must be provided.
Four stars is the highest distinction awarded by EIP on AHA and this is the score obtained by Catalonia as a leading health ecosystem and a reference for institutions and European organisations in the area of innovation in active and healthy ageing. These factors encourage the internationalisation and visibility of the Catalan health system and at the same time increase the possibilities for creating initiatives and forming consortiums for collaborative work with other European regions.
Last 7 December in Brussels, on behalf of the Department of Health, I received the award for the Catalonia Reference Site group given by the European Commission. It is relevant because this fact defines Catalonia as one of the most dynamic and leading European regions in number and quality of initiatives, investment and results in generating and implementing innovative solutions to resolving problems in care and health to elderly people, chronic patients and other groups of risk patients.
The fact that Catalonia has obtained this distinction from the European Commission has a very clear meaning: Catalonia is recognised as one of the leading European regions regarding active and healthy ageing and innovation.
On we go.
Post written by Toni Dedéu (@Toni_Dedeu), Managing Director of AQuAS.
Within the framework of the Programa de Millora de la Pràctica Clínica (Programme for improvement in Clinical Practice) of the Vall d’Hebron University Hospital – VHIR Institut de Recerca (VHIR Research Institute) and in collaboration with the Essencial project, work has been done to explore what barriers health professionals (hospital doctors and nurses) come up against in order to implement clinical recommendations aimed at reducing inadequate practices or those of low clinical value. A group of 15 health professionals (with medical or surgical specialities) collaborated in two discussion sessions to identify these barriers. The work done by Dimelza Osorio of the Vall d’Hebron University Hospital and by Liliana Arroyo of the University of Barcelona has been really outstanding.
When talking about inadequate practices or those of low clinical value, we are referring to inappropriate health interventions in certain circumstances, whether it be because the risks involved outweigh the benefits, because their efficiency is not proven or because there is not a clear cost-benefit correlation. These low value practices are present in everyday clinical practice and can lead to an over-diagnosis and/or over-treatment, meaning diagnosing or treating a clinical condition in which there are no notable health benefits for patients.
The barriers identified can be classified into four levels: micro, meso, macro and those of the context. At a first level (micro), those deriving from the characteristics of professionals themselves were identified, such as the tendency for self-protection in the face of claims or legal problems (defensive medicine), dealing with uncertainty or having had bad experiences previously; scepticism towards scientific evidence as a result of out-dated or contradictory information; other attitudes of professionals such as inertia or resistance to change; and the lack of training. All these constitute barriers. Patients’ characteristics were also identified, such as their reluctances and demands; the figure of the expert patient or beliefs acquired in the past.
At a second level (meso), barriers as a result of the interaction between professionals and patients were identified. Some barriers have to do with the relationship between professionals; that is to say, difficulties related to clinical leadership, the coordination between different professionals (or specialists), or the cohesion within teams. There are also barriers of organisational leadership such as a lack of institutional support in legal issues, the inertia of the organisation itself, economic incentives, wrongly applied penalties or the lack of foresight of certain costs. And then barriers of information flow, namely, the inefficiency of information systems such as the lack of operating capacity of e-mailing, or intoxication due to an excess of corporate information.
At a third level (macro), barriers are influenced by the structure and management characteristics of a hospital and the Catalan health system. The healthcare conditions stand out, such as the burden of healthcare, the duration of the attention given to patients, or how much technology is used in care, that is, greater access to facilities and tests. But also the design of the health system, such as in the lack of systemic leadership, or the lack of coordination between different levels of healthcare (primary care, hospital care, social healthcare, ….) . And then also the characteristics of the health system like territorial differences and the legal and bureaucratic context.
Lastly, certain external factors to the health system (the context) can also lead to low value clinical practices persisting. Although a lot less present in this case, the political context and the influence from the media are included.
The importance of each barrier is shown in the following graph:
Potential solutions were explored or proposed in the same session so as to eliminate these barriers; a series of solutions have been proposed mainly related to the creation of a leadership strategy and a series of clear options, which require rationlising processes and using available information properly.
Stroke has a high incidence, a growing prevalence and is the pathology with the second highest impact in the world in terms of disability among adults. Despite important advances in acute stroke management, which have led to a progressive decrease in acute stroke deaths, in terms of residual disability, stroke continues to have an extremely high impact on survivors, their families, their caregivers and on society in general.
On the other hand, and in self-criticism, even though stroke is one of the main reasons for using intermediate or long-term healthcare services, this sector almost never takes part in the decision making process of stroke care organisation. Neither does it do much research in stroke and in general, tends to put little thought into improving knowledge in treatments or in innovating the organisation of services compared to, for example, other conditions such as thighbone fractures.
This is why the Parc Sanitari Pere Virgili organised a monothematic symposium on 27 October, two days before the World Stroke Day. It focused on the treatment and management of stroke in elderly people from a different perspective: we traced the trajectory from the “needle” of the thrombolysis in the acute phase, passing through rehabilitative care and “reablement” in the post-acute phase, to the transition back to home life, describing the care given to patients especially, but not forgetting the attention caregivers need.
The presentations reflected and reinforced the need for a multidisciplinary approach in all phases of stroke. As an added value, in all cases the speakers not only combined recommendations derived from literature with their own practical healthcare experience but also provided data from their own research or innovation projects, in many cases with data published recently.
Among the speakers there was a varied representation from very different disciplines which included neurologists, geriatricians, physiotherapists, occupational therapists, speech therapists, social workers, a health economist and the representative of the stroke patients association who chaired a roundtable.
Some of the items that were highlighted most strongly during the symposium were:
The large amount of increasingly more accurate data available on all phases of stroke management. In Catalonia, this data is being provided by the Results Centre, which encourages transparency and allows for benchmarking thereby facilitating a reduction in variability and the sharing of best practices.
Despite improvements in the treatment of acute stroke patients using mechanical thrombectomy together with systemic thrombolysis, 40% of patients are left with a considerable disability as a consequence of stroke. This “glass half-full” should therefore encourage more to be done in terms of acute stroke management, and also in post-acute care which is still vital.
In acute care, age should not be a discriminating factor. This is in line with the concept that chronological age does not correspond necessarily to biological age and that two elderly people of the same age can have a totally different “functional potential” (a concept which in practice in the field of geriatrics is understood as meaning more or less “frail”).
Advances have not only been made in acute care but also in the field of primary and secondary preventive care. Accordingly, the development, the approval of and the use of NOACs (new oral anticoagulants) have been a determining factor since they offer an alternative for those patients where traditional anticoagulants are not a therapeutic option.
The rehabilitation prognosis is multifactorial. A recent proposal stemming from a multi-centre Catalan study led by our hospital and published recently, is based on a simple algorithm which incorporates the social factor (presence of the caregiver) together with the severity of the stroke (using the NIHSS score), functional status (according to the Barthel index) and cognitive function (a result of the Rancho Los Amigos scale). This allows patients to be classified in three levels of rehabilitation complexity, but who might evolve differently, with different needs for intervention, both in the rehabilitation process and regarding their return home.
Integrated interventions in geriatric rehabilitation can be home-based for certain patients as an alternative to a hospital admission. This model, deeply rooted in England and which has proven to be beneficial, is producing good results in our context in different pathologies including stroke. Innovative formulas such as “Comprehensive Home-based Hospitalisation” have, in our context, come about from the alliance between home-based geriatric care teams (doctor, nurse and social worker) and those of home-based rehabilitation (rehabilitation doctor, physiotherapist, occupational therapist and speech therapist).
In terms of physiotherapy, treatments should be more standardised and their efficacy demonstrated. During the symposium, interesting evidence was presented on the control of the trunk and its importance throughout the rehabilitation process in stroke.
Dysphagia is a very prevalent risk condition in patients who have suffered a stroke. Different proposals of scales for assessment at the bedside were shown which can be applied by nurses, reserving the speech therapist’s intervention for the most complex cases which require a more specialised assessment.
In rehabilitation, the support from the ICT (“telerehabilitation” which patients can receive following the instructions and programme configuration of the physiotherapist) allows treatments to be extended in time and intensity along with face-to-face treatment.
Working with caregivers is important. Apart from guiding them within the system, the availability of support groups for exchanging personal experiences, for a social worker, for example, could have an impact on the adaptation of the caregiver to the new situation. To this effect, an innovative experience was developed in our centre with a high degree of acceptance by patients and their families.
Continuity in the recovery process is key and the integration of health and social services guarantees an added value. The pilot “Return Programme” in the city of Barcelona, the result of the alliance between the Catalan Health Service and the City Council of Barcelona was presented. It allows for the direct activation of social services, from acute care and long-term care hospitals so that patients can receive the necessary aid when they return home and thus avoid unnecessary and dangerous delays.
In summary, much progress has been made in the treatment of stroke, especially in the acute phase, but innovation is also being carried out in the successive phases and the symposium showcased different experiences which have been implemented in our context. Drawing conclusions from the symposium, the take home messages are that a comprehensive view of the entire process is key, as well as an integrated and coordinated approach between the different levels of healthcare and social services. On the other hand, more research needs to be carried out especially in the post-acute and chronic phases resulting from the disease and this poses a challenge because of the difficulty in designing and implementing complex interventions where designs such as standard clinical trials are not the solution.
Post written by Marco Inzitari (@marcoinzi) and Laura Mónica Pérez, Parc Sanitari Pere Virgili, Barcelona.
There is no doubt that a qualitative methodology considerably enriches the development and assessment of public health interventions. It is often the ingredient which gives a dish that very special flavour or sometimes is even its main ingredient which, if of quality, makes the dish a real winner.
When both quantitative and qualitative methodologies are applied respectively to the same project, the necessary nutrients are provided to make the project work and can even produce compound molecules of a high nutritional value if applied in combination. The flavours of qualitative methodology acquire specially relevance in the dish when an innovative intervention is being cooked up using new channels of communication to reach the target population. We are talking of the PEGASO Fit for future.
The chefs at the the Agency for Health Quality and Assessment of Catalonia (AQuAS) and those at the Catalan Agency of Public Health (ASPCAT), together with other European chefs, have the PEGASO platform brewing on the stove. Centred around the smartphone, it aims to be a new creative recipe for the promotion of healthy lifestyles among adolescents. Eating habits, physical activity and hours of sleep are the real protagonists of the signature dish which has begun to be served in different secondary education schools in Catalonia, Scotland, England and Italy in the way of different health apps, games and movement sensors.
The PEGASO project is using qualitative methodology in all phases to ensure that the “food” gets to the table successfully and that it be a well-received recipe which spreads out cheerfully and quickly to all kitchens. Thus, the focus groups held with adults and adolescents before the start of pre-pilot phase allowed us to draw up a clear shopping list to get the necessary ingredients before we donned our aprons. Subsequently, and during the 3 stages of the pre-pilot phase, adolescents in several focus groups carved up the different prototypes of the platform’s components after having appraised their quality to decide whether they should be included in the recipe or not.
But what are the key elements for qualitative research with adolescents? A focus group with adolescents is an intense activity which is worth doing. In fact, in the pre-pilot phase of the PEGASO project, we had the opportunity to lead teams in different schools; Nou Patufet school in Barcelona, Verge de la Salut de Sant Feliu de Llobregat and IES Ramón de la Torre in Torredembarra. These teams were made up of wonderful players that converted each match into a real show. To be able to see thrilling sporting events, we used the extra motivational bonus before each match. This is the first key element for qualitative research with adolescents.
The setting up of a group is essential for its later development and just like a pep talk in the locker room, the tactics of the game were explained in a simple way and the importance of each individual’s contribution to working as a team was highlighted. Additionally, and also prior to setting up groups, the importance given by the PEGASO project that participants choose their best skills while also enjoying the match was highlighted. In this way, the players gave their best at all times leaving the supporters dumbstruck from minute 1.
When dealing with highly motivated groups, the coach has no need to scream and shout from the sideline but rather just guide the team with a simple gesture so that it can progressively achieve the pre-established objectives. In this way, spectacular goals are scored which surprise everyone, including the coach and technical staff. This is pretty much what happened to the PEGASO team where good communication and the initial extra motivational bonus helped great sporting events of two or more hours to take place.
In the focus groups of the PEGASO project, the dribbling and passing between participants has been constant and at an individual level, enjoyment was apparent. This is the second key element in qualitative research with adolescents: that they enjoy themselves. If this is achieved, a group of adolescents can get to wherever they want with endless energy. In this way, attributes which collective imagination often assigns to the adolescent population such as passiveness or a lack of interest have been totally ousted and annulled by freshness, creativity and the urge to participate. Undoubtedly, as Jaume Funes would say, the adolescents who have participated in the PEGASO project have been unbearably charming; and I would add, extremely funny and insatiable players.
And after a hard workout, to bed ….! All the information provided by adolescent genius must be given the chance to rest. Rest after an activity is also a nutritious element. A calm demeanour after the adequate hours of sleep enables one to carry out a qualitative in-depth analysis. It is under these conditions that an outcomes report can be written which gives value to the development of the intervention that, as we have already commented, aims to promote a healthy diet, physical activity and rest. The PEGASO project aspires to be a useful tool in promoting these healthy habits among adolescents. Have a good day, a good match and good night!