March 2017 – AQuAS Blog

PERIS and people: research assessment by AQuAS

30 Mar

The first call of the Strategic Plan for Research and Innovation in Health 2016-2020 (PERIS in Catalan) for funding research and innovation, still pending resolution, prioritizes programmes which foster talent and employability and programmes of excellence in knowledge.

Accordingly, four actions have been initiated by competitive tendering to finance:

The inclusion of scientists and technicians in national research groups
The increase of nursing professionals in order to free up some of their workday so they can do research work
Research projects aimed at primary care
Major programmes focusing on four different subjects: personalised medicine, regenerative medicine, cooperative independent clinical research and cohort studies.

How are the PERIS calls assessed to determine which applications deserve funding?

The criteria for assessment are defined by the order of the requirements, forgive the repetition, and the requirements of each call. This is the instrument that sets out the rules to determine which projects or people are susceptible to receiving finance. Some will always be discarded and, depending on the specific criteria and resources available, others chosen which are considered worthy of funding.

Deciding which criteria to use and how they are assessed/rated/applied is a powerful science policymaking tool to design the research system it aspires to be: excellence, the subject, the discipline, the age of the applicants, the territoriality of the organisations or foreseeable impact are different variables to bear in mind when deciding who is worthy of being able to develop their research.

The Research Team at AQuAS has been commissioned to manage this process of assessment. This is why we accompanied the General Manager for Research and Innovation of the Health Department, Dr Andreu, in the public presentations he gave in different health research institutions linked to hospitals. We were impressed by the attendance at these informative sessions.

The assessment has been done by a panel of experts involving a total of 42 research professionals throughout Catalonia and Spain. It has required intense activity given that more than 490 applications of a very high level were received.

Looking back after having completed the assessment of the this first call, we feel, more than ever, that we made the right decision by putting people in the centre of the PERIS logo, large and circled by a prominent colour.

It is not only the plan itself which has been designed like this, to promote research with people at its centre, involving and motivating a great variety of professional profiles. PERIS has been a catalyst for mobilisation in the health system and in health research, even before the starting gun was fired, as seen in the packed informative presentations and in the involvement of the participants in the assessment panels, working deep into the night.

As can be expected, getting the staff at the Agency for Health Quality and Assessment of Catalonia (AQuAS) involved, has not been difficult either. We are eager to contribute to this strategic project by using a key tool for selection, accountability, continuous analysis and improvement of opportunities which is what assessment is all about.

Long life to PERIS!

Post written by Núria Radó (@nuriarado) and Paula Adam (@PaulaAdam4).

***Full information available here:

How long will I live? About forecasters

23 Mar

The robustness and solidity of a science (which is why informally we sometimes talk about “hard sciences” and “soft sciences”) depends on its capacity to predict.

A science does not only need to explain what is happening in a very plausible way but also needs to be able to predict what will happen, with as great precision as possible.

In the same way that econometric models (mathematical, full of formulae and equations) want to demonstrate, in numbers, how closely they approximate to reality and therefore how by modifying initial parameters a calculation will produce a result that we would expect, so-called “life expectancy calculators” or “death clocks” also abound these days. You can find quite a few on the internet, some more serious while others more entertaining.

Asking oneself how much longer we have to live is in any case a good question.

We know a lot about the factors that have an influence on disease and which bring death closer to us and we also know how progress (it is not clear in what, as it is not exclusively medical) has increased our life expectancy (which should not be confused with longevity even though this is often the case), at least in developed countries.

We also know that health professionals despite their experience, are not as accurate in predicting as are the predictive statistical models that can include a multiplicity of variables. A comment in the BMJ recently spoke about these prognostic factors and life expectancy calculators. I have included several, of the more serious ones, in the bibliography.

Forgive me for taking the liberty for doing so, but today I will share with you, with irony, a cruise I took on the internet while searching for some of these prognostic tools that want to predict how long we have left to live in this world.

Abaris is one of these mathematical prognostic tools, developed by “professors” at the University of Pennsylvania with the support of The Times and The Wall Street Journal and which seems to be one of the most accurate. It factors in sex (it might be more accurate to refer to “gender” but “sex” is the nomenclature used in the application), weight and height (beware! You need to choose the metric system because if not the information given is in pounds and inches), to get to the body mass index, a well-known prognostic factor with a U-shaped curve in relation to the probability of dying, level of education, marital status (married, widow or widower, divorced, never married, separated – I am unaware of the difference between the third and last), if you are already retired, level of income (in dollars), the amount of exercise you do, what your general health is like, whether you have diabetes and what vices you have in general (alcohol, tobacco).

You choose from all this presented with colourful computer graphics and then, if you press the button, it performs all the calculations for you but if you want the results you have to give them your email address where they will send them. Someone might be inclined to do this but at this stage, I’m not giving anything away (and less on the network; they already take without asking).

Let’s move on to another forecaster sponsored by an insurance company (what more could you ask for?). The nice thing about Lifespan calculator is that as you answer questions it starts showing you your life expectancy and so you can see how it increases or decreases depending on what you answer. However, it does not ask you about your marital status or your level of income or studies but it does ask you about your family history, blood pressure, level of stress, the exercise you do, diet, whether you use a seat belt or not while in the car and toxic habits, among other details. On this one you also have to convert height into feet and inches.

The social security in the United States also offers a calculator but it is a lot more impersonal and does not take risk factors or protective factors into consideration. It only asks you for your sex and date of birth and provides you with your life expectancy according to your current age and your birth cohort. So, as I am 58 and 8 months, I can expect to live 24.4 years longer until I reach 83.1 as estimated for my cohort. It must be said that this calculator also estimates your age of retirement.

Another forecaster, a little less sophisticated created by a physician on his own initiative, Living to 100, includes a lot more elements than the others: nutrition, social relationships, level of anxiety, sleep and common habits but also includes the intake of coffee and tea, air pollution, exercise and family history. Unfortunately, it also sends you the results via email.

There is yet another way of looking for forecasters of this type: typing in ”death clock”, never better said.

There are some very entertaining ones with their humoristic screens (death and its scythe waiting for you at the tomb which is already prepared). The The Death Clock asks you for your date of birth, sex, height and weight (in centimetres and kilos in this case), your country of residence, whether you smoke, how you see yourself (pessimist, optimist, neutral, suicidal) and how much alcohol you drink. This “clock” calculates quickly and accurately and it even goes so far as to tell you the day on which you will die (comically foreseen derived from the fact that the date is engraved on the tombstone). However, it seems too simple.

Finally, whilst I am certain that more can be found, I have found another. This other, called The Death Clock, is very similar to the one before and also contains gloomy images to make it clear that we are entering very dark terrain. This forecaster also asks you for your sex and date of birth and like the others it asks you to work out your body mass index. Instead of alcohol, it asks you about tobacco (smoker or not, outright, no subtleties) and in terms of your state of mind it considers being normal, pessimistic and optimistic (like in the previous one), but it adds sadistic which is very surprising. It also asks you for your weight and height to calculate your body mass index. If all turns out well, it also tells you the day, month and year in which you will die and within seconds shows you the countdown.

It is precisely this calculator which, very elegantly, I having put pessimist (by nature) said: I’m sorry but your time has expired. Have a nice day.

Post written by Joan MV Pons.

Pediatrics in the Pyrinees, an innovative experience in the Alt Urgell (Catalonia)

16 Mar

Today we interview Jordi Fàbrega (@jorfabrega), director of Pediatria en els Pirineus (Pediatrics in the Pyrenees), a cooperative of pediatricians that already has 7 years of life.

Glòria Ruiz, Neus Méndez, Toñi Parra, Jordi Fàbrega

The existence of rural areas hard to reach, remoteness with respect to large urban centres, an extensive area of land, a low population density and something of a shortfall of paediatricians in the area are the characteristics of the Alt Urgell that have given rise to the Pediatrics initiative in the Pyrenees., an innovative initiative from the Observatori d’Innovació en Gestió de la Sanitat a Catalunya (OIGS).

With the experience acquired during these seven years, what improvements has the project provided in your opinion?

I think the most important has been stability and in ensuring a health care continuum for our boys and girls. We have been able to give 100% cover from the start in primary and hospital paediatric care and in on-going medical care including localised standby calls. This has meant excellent access for the population, with a 100% success rate of pre-arranged appointments for the same day, and, in addition, with a high success rate at primary level, with an increase in standards in the quality of care.

This has led to a drastic decrease in emergency visits to hospitals as well as in admissions and transfers beyond the borders of the territory. Although there are fewer admissions, a fact that brings with it an increase in the complexity of child admissions, the average hospital stays for these admissions have been reduced.

In keeping the umbilical cord tied to the Hospital Sant Joan de Déu for training paediatricians and in the referral our patients, it has meant that this rate of success has in fact increased in our territory.

In this way, children and their parents are always attended by the same paediatrician, or team of paediatricians, where all know the problem at hand and provide solutions following the same protocols that would be followed in the Hospital Sant Joan de Déu.

Another noteworthy element is that by integrating ourselves within the Maternal and Child Unit of the Alt Urgell, with obstetricians and midwives, we have widened the homogeneity of interventions to include the whole mother-baby area and this has allowed us to begin projects such as early postpartum discharges with follow ups by paediatricians/midwives together and postpartum support groups which have been very well received by the population.

The web set up in 2011 has also brought us closer to the population enabling us to spread information on paediatric subjects. In particular, the virtual doctor’s consulting room is a frequently used tool by parents to clarify doubts with great flexibility and without having to travel to the doctor’s rooms.

Good results and awards endorse the entity’s task that you began which has been able to guarantee efficient paediatric, primary and hospital care. What are the keys of this success?

I think having the autonomy to manage ourselves is fundamental. Being able to manage our own agendas, timetables and cover for each other, among other things, has allowed us to adapt the task of caring to the reality of the territory and also to the realities of each professional by trying to reconcile our work and family life. What is more, it allows for on-going training.

The other key point is the relationship with a top-level centre like the Hospital Sant Joan de Déu which ensures we get on-going training and it solves problems of professional isolation that we might experience in zones a long way from the metropolis.

In a way, we feel we have a ‘big brother’ that helps us when there are difficulties and who accompanies along our journey.

Do you think this innovative model of self-management could be applied to other medical specialities and extrapolated to other regions?

I am absolutely convinced that it is a model which can be reproduced in almost all areas of care and in all regions. The important thing is to find professionals who are willing to accept the challenge and that the administration believes in it and is willing to back it.

Information and communication technologies (ICT) have played a key role from the beginning. Of all the innovative actions you have fostered, which one has worked the best?

The web page and virtual consulting room without a shadow of a doubt.

The web page, with its internal part, gives us access to all professionals and it is where all protocols are hung and this means we all work in the same way, including family doctors that are on call in different doctor’s rooms in the Alt Urgell and who have access to it.

The virtual doctor’s consulting room, likewise, means parents’ doubts can be clarified in a relaxed way and without interrupting visits (as always happens with untimely phone calls). On-site visits that require time investment by parents and, above all, discomfort are thus avoided.

You opened a virtual doctor’s consulting room on your web page five years ago, addressed to parents and tutors. Do you receive a lot of consultations via this channel?

As a matter of fact, no. We get 12 consultations a day on average, shared between the four paediatricians on duty in the region (paediatrician and paediatric nurse).

It must be stressed that we have very good accessibility to on-site visits and we attend a total of 3400 children meaning that numbers are logically not very high. The family’s and professional’s satisfaction, respectively, is very high.

Innovation has been the motor of your initiative. Do you have plans for implementing a new project this year?

In December last year, we incorporated the obstetricians from La Seu d’Urgell into the cooperative society. In practical terms, they were already working in close collaboration since 2012 and now form part of the cooperative; this fact consolidates the project a lot.

We would like to have the midwives from the Alt Urgell in the cooperative because with a few small changes, this would allow us to improve care, especially in community health which is lacking at the moment in our region.

This year, CatSalut has asked us to implement the model in other areas of the Pyrenees where there are problems of cover and it is now one of the issues we are looking into.

Interview prepared by Neus Solé Peñalver (@neussolep).

Scientific evidence and clinical practice: the case of hip prostheses in Catalonia

9 Mar

A total hip replacement is one of the surgical procedures which provide greatest satisfaction among patients due to the significant improvement in the quality of life they experience.

So much so, that it has been defined by some authors as the surgery of the 20th Century. It is a procedure which consists in substituting the hip joint with an artificial joint or prosthesis.

The most common reason for surgical intervention is arthrosis, a disease caused by the wear-and-tear of the cartilage which leads to a malfunction of the joint. It is especially common in older people, older than 65, who live with pain and which can limit their day-to-day activities considerably.

In today’s context of continuous technological innovations and advances and facing the enormous pressure from manufacturers, the range of prosthesis available to orthopaedic surgeons is wider than ever. This situation demands that the prostheses used have supporting scientific evidence based on clinical studies or on data from arthroplasty registries.

The legislation which regulates the commercialisation of medical devices, such as prostheses, is more lax than that which regulates drugs which means that not the same type of studies are required for their approval and in consequence, neither is the scientific evidence. In fact, this precise legislation is undergoing a review at present and a new one on this matter will soon be made available.

Several years ago, the prestigious journal BMJ (British Medical Journal) published an article in which it was highlighted that in the UK, 24% of hip prostheses used had no scientific evidence to demonstrate their clinical effectiveness.

As a consequence of that publication and applying the same methodology, at the Hospital Sant Rafael and in collaboration with the Catalan Arthroplasty Registry (RACat) of the Agency for Health Quality and Assessment of Catalonia (AQuAS), we embarked on the task of analysing what the scientific evidence was on hip prostheses used in public hospitals in Catalonia which had sent their data in to the RACat during the period 2005-2013.

We did this via a search on different platforms putting the spotlight on Orthopaedic Data Evaluation Panel (ODEP), as well as Tripdatabase, PubMed and Google acadèmic.

Following the analysis of the 18,816 acetabular or hip cups and 19,546 femoral stems (the main components of the hip prosthesis) collected in the registry, our first surprise was to observe that 123 different models of cups had been used and 138 different models of stems. In the group of participating hospitals in the RACat during the period of the study, it was seen that with many of these models less than 10 units in number of each had been used.

As these models only represent 1% of implants used, they were excluded from the study and in the end 74 models of hip cups and 75 models of femoral stems were studied.

Artroplàsties PTM

The results of the analysis, either recently published or not yet published, now at a pre-publication stage, show that less than 50% of components used had the highest level of scientific evidence in accordance with the ODEP. This top level is achieved when there are studies having 10 years at least of monitoring with a number of prostheses evaluated exceeding 500 units.

What also caught our attention was not finding any evidence for 18 hip cups or 16 femoral stems which represented, respectively, 13.56% and 9.53% of all implants carried out during this period.

Artroplàsties -taula

All scientific studies show limitations and it is not always possible to offer exhaustive results. Aware of this, and of the fact that the data in our study are the results of a research project which might not be able to reflect what the reality of public hospitals in Catalonia is in absolute terms.

We do want to stress that the task of the orthopaedic surgeon needs to be more and more regulated by evidence based medicine and this is, precisely, one of main purposes of arthroplasty registers: to carry out studies like the one we have been able to do at Hospital Sant Rafael with the aim of improving the health care of people.

Post written by Miquel Pons, Danieol Chaverri and Luis Lobo, Hospital Sant Rafael, Barcelona.

The main challenge in mHealth is understanding each other

3 Mar

Toni Dedéu - DECIPHER final event 2017 — Toni Dedéu

In recent years, the debate about what we should do with health apps has centred around accreditation, certification or assessment. At the same time, multiple lists of health apps recommended by a range of known and recognised initiatives have been drawn up.

An example of this would be the iSYScore2017 ranking of the Fundació iSYS which was presented in the context of the CAMFiC a few weeks ago.

In this context, and with the Mobile World Congress 2017 in Barcelona in full swing, we can ask ourselves what role a Health Technology Assessment (HTA) agency has when considering mHealth.

There is a reality which we cannot evade. Any health intervention needs to be based on evidence, on knowledge of the highest quality at hand, and must be evaluated.

This cannot be done by turning our backs on the real world or innovation. A health app is a tool to carry out a health intervention and so health apps need to be seen as just another intervention, but of course, with some characteristics of their own which will mean there is an extra demand placed on one and all.

Technologists, HTA experts, professionals and citizens have the opportunity to understand each other if we want to be facilitators of recommending safe apps in health. We are not talking about initiatives that can be developed from one sector only and it is not only about apps.

Now more than ever, we need to be flexible and work from a multidisciplinary position. We already talk about co-creation and co-design; quite simply, of co-produced mHealth initiatives based on the expertise of multiple agents including, obviously, citizens.

AQuAS is participating in the assessment of several mHealth projects financed by the European Commission. The PEGASO project stands out, centred on promoting healthy lifestyles among adolescents, and DECIPHER, as an integral solution to facilitate the geographical mobility of patients with chronic diseases such as diabetes type 2 and m-resist, centred on schizophrenia and patients resistant to treatment.

We are faced with the challenge of integrating totally different fields such as the language of technologists and developers; the speed of innovation and the culture of assessment. In addition, this needs to be done without losing sight of the key role of scientific societies and the different points of view of health professionals and end users.

We know there is a lot of work to be done. Technologists and experts in health technology assessment, respectively, have the opportunity to learn a lot from each other. It is about sharing knowledge and expertise to facilitate, ultimately, health tools for citizens and professionals, which have been assessed, are based on evidence, are safe and reliable and have a strong collaborative component.

Digital Health and Wellness Summit – MWC17

Post written by Toni Dedéu (@Toni_Dedéu) and Elisa Puigdomènech.