From Tokyo to Tarragona: connected health

28 Dec

Over the last few years, the number of medical applications for mobile phones or health apps has increased exponentially. Thus, in 2017, it is estimated that there are nearly 200.000 health apps on the market.

They are related to technological solutions that monitor data such as blood pressure, the steps we take, the minutes we run, our pulse, the calories we ingest and even whether we sleep well or badly. There are also mobile devices that can be synchronised with other devices such as a calculator of the levels of blood glucose.

Four years ago, the FDA published its guide on medical applications for mobile phones aimed at manufacturers. The regulatory agencies take into consideration aspects which could present a risk to users of a particular product; in the context of health apps, on the one hand, this refers to applications that function with a regulated medical instrument (for example, medical imaging) and on the other, to applications that function as a medical device (for example, ECG electrocardiograms for cardiovascular patients).

But what happens with the remainder of medical apps? The Agency for Health Quality and Assessment of Catalonia (AQuAS) has worked on a proposed theoretical framework to assess medical apps. It is important to identify what scales can be useful when assessing a health app in terms of scientific evidence, safety and aspects of privacy.

HTA agencies can play an active role in assessment as well as in the development of technological solutions. The role of the AQuAS is worthy of mention in its pilot experiences in different projects of connected health: PEGASO, centred on the promotion of healthy lifestyles among adolescents, DECIPHER, as a comprehensive solution to facilitate the geographic mobility of patients with chronic diseases and m-Resist, centred on schizophrenia and patients who have resistance to treatment.

In addition to these experiences, the AQuAS has recently signed an agreement of collaboration for the design and development of the mobile application Human-Castle, aimed at professionals and citizens. A delegation of Japanese health professionals from the company Kikkoman has been on an extended visit to the AQuAS with this objective in mind.

“It has been 25 years since Barcelona shared the human castle phenomenon with the rest of the world at the opening ceremony of the 1992 Barcelona Olympic Games. It is a historical coincidence that coincides with the birth of technological assessment in Catalonia two years later, in 1994. We have a considerable challenge ahead that could mean a change of paradigm, both sustainable and scalable.”

“If we bring all knowledge together and join forces, the probabilities of raising a human castle successfully will increase.”

These are two of the highlights of a brief article published in The Economist on this emerging Catalan-Japanese initiative which will probably become a reality in the setting of the upcoming Summer Olympics in 2020, officially known as The Games of the XXXII Olympiad, a sporting event which will take place between 24 July and 9 August, 2020, in the city of Tokyo.

It concerns a multidisciplinary and inclusive project that highlights the strength of the human castle phenomenon, Catalan architecture applied to the computing architecture of technological solutions and the methodology of assessment.

Wishing you a pleasant festive season from the AQuAS blog

21 Dec

From the blog at AQuAS, the Agency for Health Quality and Assessment of Catalonia, we would like to thank you for having accompanied us for yet another year.

With the aim of sharing knowledge and creating an area for reflection, we have published 40 posts in 2017.

The blog’s Editorial line looks at subjects such as health assessment and health systems, the participation of patients and citizens, low value practices, eHealth and connected health, data analysis, research, gender issues, inequalities in health, innovation and current affairs; with content generated by authors at the AQuAS as well as by guest contributors.

The five most read posts in 2017 have been the following (in alphabetical order):

•   Caregiving first hand, by Assumpció González Mestre
•   Double health insurance cover, by Lluís Bohígas
•   Adjusted morbidity groups: a new population morbidity classifier, by Emili Vela
•   Mendeley, from reference manager to discovery tool and scientific visibility, by Paula Traver
•   An indicator for a more fairly funded primary care, by Cristina Colls

Thank you very much for reading us and this is wishing you all a very pleasant festive season!

Post by Marta Millaret (@MartaMillaret), editor of the AQuAS blog.

To drip or not to drip (and thus, ship); that is the question!!

14 Dec
Sònia Abilleira

The proof given in 2015 of the efficacy of a mechanical thrombectomy in patients suffering from a severe ischemic stroke caused by a large vessel occlusion in the brain represents a change of paradigm because it forces us to reconsider the organised systems of care for people suffering from a severe stroke.

These models of organisation, or systems of stroke code as they are known in our environment, started being developed at the end of the 90s and beginning of the year 2000 in response to the evident difficulties observed in accessing intravenous thrombolytic therapy, a highly time dependent treatment, eminently due to the delay of the arrival of patients at emergency services.

Rightly, these difficulties were overcome by developing organised systems of care where a protocol was established for the rapid transfer of these patients to specially designated and previously alerted hospitals equipped to manage these cases expertly.

Recently, we have scientific evidence that establishes that a mechanical thrombectomy is the new therapeutic standard in the case of strokes caused by large vessel occlusion in the brain, clinically more severe, where the effect of intravenous thrombolysis is very limited (30% maximum rates of revascularisation). A mechanical thrombectomy, however, is a highly specialised and complex treatment that needs to be undertaken as quickly as possible in centres with advanced technology to guarantee adequate results.

This recentralising tendency in carrying out endovascular treatment contrasts with the decentralisation which was done in its day to ensure an adequate access to thrombolytic therapy which by nature needs to be administered in the first 4,5 hours after the onset of symptoms. This is why nowadays we talk about a change of paradigm to refer to the obsolescence of the models in stroke care developed in the era of thrombolysis, now that we are fully in the thrombectomy era.

The situation today is even more complex if we bear in mind what the mechanical thrombectomy trials established: that endovascular therapy was better than medical treatment, including intravenous thrombolysis. As a result, the current standard of care establishes that, with patients having no contraindications for thrombolytic treatment, this care must be given as soon as possible before a thrombectomy.

In urban metropolitan areas, mostly served by hospitals with the capacity of carrying out both treatments, the translation of the results of trials to clinical practice does not pose a problem.

However, the question is: what needs to be done when there is a stroke in one of the areas primarily covered by centres without endovascular capacity? Should we hold the patient back in the nearest stroke hospital, and in this way prioritise intravenous thrombolysis, even if by taking this decision we are in fact delaying the arrival of the patient at the tertiary stroke centre, the only one with the capacity of carrying out a thrombectomy? Or should we transfer these patients directly to the tertiary stroke centre with the understanding that a thrombectomy is the only valid therapeutic option in these cases, even if this means delaying or disregarding intravenous thrombolysis?

This is, in fact, the controversy between the “drip-and-ship” model which prioritises thrombolysis, and the “mother-ship” model which adopts the opposite approach and defends the direct transfer to a tertiary hospital where the entire process of care can be performed: from an ultra-rapid diagnosis to whatever type of reperfusion treatment.

If that weren’t enough, one must bear in mind that these models are based on the prehospitalisation selection of patients strongly suspected of having a stroke but without confirmation or diagnosis, nor of the subtypes of stroke, ischemic or haemorrhagic.

At present, we do not have the necessary evidence to prioritise the transfer of patients with acute stroke following either the “drip-and-ship” or the “mother-ship” protocol and this is why the RACECAT (NCT02795962) is being carried out in Catalonia since the beginning of 2017 which aims to provide answers to this controversy.

This study has been made possible thanks to the effort of a large number of health professionals: from those in charge of prehospital care (SEM/112), specially trained in the use of the RACE scale (a scale to assess the gravity of stroke and, therefore, those cases with a higher probability of having a large vessel occlusion and susceptible to being treated with mechanical thrombectomy), to the people in charge of care in each of the 26 hospitals in the stroke code network in Catalonia. Would you like to know more? Then you must watch this video.

The RACECAT trial is being carried out at present and in a couple of years, the evidence obtained from this study will allow us to modify the circuits of care in the case of a serious stroke code and so be able offer the greatest clinical benefit to these patients.

Post written by Sònia Abilleira.

Open access depredatory journals

7 Dec
Joan MV Pons

As soon as it has been published and identified with an email address, it will not come as a surprise to receive a lot, but I mean a lot, of emails that often invite one to publish in what are apparently scientific journals (by name), to participate in congresses or conferences on subjects that seem of interest or to join as a member of some board of editors. These emails come in constantly and which I always mark as junk mail so as not to waste more time on them.

And it is true that this type of business, which is purely that, has proliferated in recent times largely due to the inherent zeal of the human species for lining one’s pockets, but also perhaps because of the great proliferation of researchers and research institutes. There is a lot of money at stake and it is well-known, that with minimal effort, one ends up publishing anything that one desires. If editors of journals in the past strived for readers and subscribers, now in addition to these open access journals, what they are looking for are columnists, people who publish in their pages …. in exchange for a small (and not so small) fee. There is no need to talk about the advantages of these open access journals and how some of them have attained a pretty high impact factor within a short period of time. Here the impact factor is a correct measure because it gives an approximation of the citations the articles receive which are published in these journals; it is a mistake, we know, to use the impact factor of the journal as an approximate measure or substitute (proxy or surrogate) for the value of an article.

Jeffrey Beal, a librarian, is the person who introduced this term and who elaborates and updates a list of journals periodically that can fit in to this  typology. According Wikipedia’s definition, those considered as predatory journals are those open access publications that stem from a business model based on the exploitation of open access publications by means of charging a publishing fee to the authors without providing the editing and publishing services of journals considered as legitimate (be they open access or not). Beall’s List up to December 2016 – a good sample of how Wikipedia updates itself in some subjects – had some 1,155 journals included.

The same universal cybernetic encyclopaedia provides a series of associated characteristics with this type of predatory journal (also hunters, that hunt to survive).

Post written by Joan MV Pons