General – Page 5 – AQuAS Blog

Is assessment still the pending issue of health apps?

22 Mar

An article in JAMA has recently been published presenting the first smart watch approved by the FDA to predict epileptic seizures. It is called Embrace, a connected device which detects seizures linked to movement and electric fluctuations in the skin of a person and sends an alert so they can receive medical attention.

Last February, the Mobile World Congress was held in Barcelona. Among the different activities to be highlighted which are organised around this congress there is one called 4 Years From Now (#4YFN18), the part of the Mobile which connects companies, investors and institutions with each other to encourage collaboration in developing different ideas, business models and technological solutions.

The Digital Health & Wellness Summit 2018, organised by 4YFN Connecting Startups, the Mobile World Capital Barcelona and the Mobile World Congress with the collaboration of ECHAlliance, the European Connected Health Alliance, is the meeting point of technological and health issues. This year, among others, Neil Gomes, Maria Salido and Elena Torrente participated.

Neil Gomes from the Thomas Jefferson University of the USA pointed out that one of the challenges in mHealth is facilitating feedback between patients and health professionals.

Maria Salido, co-founder and CEO of the health app, SocialDiabetes, raised key issues for success with health apps: regulation + industry + users. And in particular, she highlighted the importance of the final users. An article published in The Economist was much commented on here with a provocative title:

Elena Torrente, Digital Health Coordinator at DKV, commented on Digital Doctor, a health app that incorporates a detector of symptoms and a tool to request a doctor’s appointment. She pointed out that there were more women than men in the user profile of the app.

In general, there was consensus on the fact that prior to developing an app, an analysis to identify needs must be done. That is, the first step should be to detect the needs of a user and then, based on the mapping of these needs, the moment would come to develop technological solutions.

The content of all these presentations is available and you can also read a compilation of the main ideas that were highlighted here and here.

Despite it not being the main subject of their presentations, in the follow up debate the need and convenience of assessment was brought up. At present, there are already 320,000 health apps on the market. But,… How are they assessed? Who does this? With what criteria? Can we already talk about the safe prescription of health apps?

We close the circle once again with the conceptual framework of mHealth Assessment published in JMIR mHealth and uHealth with which the Agency for Health Quality and Assessment of Catalonia (AQuAS) provides the culture of assessment to the everyday reality in which we find ourselves (in 2016 it was published in the first quartile, in the categories “Health Care Sciences & Services” and “Medical Informatics”, respectively, in the Journal Citation Reports). There are an increasing number of health apps and the debate concerning their assessment remains open.

Post written by Marta Millaret (@MartaMillaret).

Towards research in nursing with a (greater) impact

15 Mar

What is it that makes a particular research have an impact on society beyond the strictly academic and which is truly transformative? Can a whole series of actions be planned in the way that one follows a cooking recipe which leads directly to the desired social impact? Unfortunately, the answer is no. The impact is multifactorial and depends on so many different elements and actors that it is difficult to establish a formula to guarantee it.

However, having said that, the fact that there is research which has a particular social impact does not mean that it is a totally random phenomenon and that there is no way of predicting, facilitating or promoting it. Years ago, from the Research Assessment group at the Agency for Health Quality and Assessment of Catalonia (AQuAS), and with the help and complicity of the International School on Research Impact Assessment, ISRIA, we identified a series of facilitators with regards the impact of research.

A fundamental facilitator is people, and the values, culture and capacity of leadership they have. Two identical results of research can have different impacts if the capacity of leadership, drive and will to get beyond academic impact is different. But this is still not enough. The strategy, organisation, collaborations and openness that institutions have will be a great facilitator or barrier for the researchers that have carried out the research.

Finally, both people and institutions will need two indispensable elements in order to aspire to having an impact: on the one hand, a close and effective communication with the different social actors that can play a role in transferring the results of research, and on the other, an approach focused on the participation of all these key players.

To paraphrase Confucius when he said “explain it to me and I will forget, show me and maybe I will remember, involve me and I will understand”, it is all about involving all the necessary actors to bring about a real change and make research transformative.

It is in this context that SARIS (Catalan acronym) came into being, the Assessment System of Research and Innovation in Health. It is a strategic tool which emerged from the PERIS (Strategic Plan for Research and Innovation in Health 2016-2020) with the aim of assessing the research carried out in health in Catalonia from the perspective of always wanting to facilitate and influence so that it has an impact beyond academia. To do this, the motivation and involvement of actors has been defined as a key factor for its development.

Last November, we started a series of participative sessions with nurses who were selected from the PERIS 2017 call in which a line of intensification of nursing professionals was financed.

It is important to emphasise that launching this line with nursing research makes full sense for three reasons: on the one hand, one of the thematic priorities of the PERIS is clearly that of “the development of clinical and translational research which facilitates the growth of scientific and technological knowledge, putting special emphasis on primary care agents and research in nursing”. In addition, the PERIS 2017 nursing fund has been the first to come to an end and it was appropriate to address ourselves to them first and foremost.

Last but not least, the conditions in which nursing research is carried out, with patients and their recovery as its central goal, makes it especially appropriate to ensure that this research has a direct impact on health. Hence, it is important that the research done in nursing be capable of demonstrating the impact that this group of professionals has because it can give it a comparative advantage with regards other biomedical disciplines. Indeed, nursing research is intrinsically translational.

Therefore, the first session centred on identifying the influential actors and in empowering the nurse to carry out an effective communication which amplifies the productive interactions needed to transform the results obtained into benefits for a better and improved health for patients.

We would like to express our deepest gratitude to the nurses for their participation (readiness and motivation) who attended of their own free will and in their time off work ensuring thus that the session was a success. This demonstrates that from the AQuAS we have leverage to give support to those researchers who are motivated to driving the impact of their research.

At present, we are preparing other sessions that will enable mutual learning between researchers and the assessment agents at the AQuAS.

Post written by Núria Radó Trilla (@nuriarado).

Jornada SARIS: Participación en recerca Barcelona, April 4th 2018.

Building gender equality

8 Mar

The media systematically show us examples of the persistence of discriminatory situations for women such as the gender wage gap, the lack of women in managerial positions and the violence towards women, among other things.

These situations are a result of our social construct which is still based on an androcentric model where man is placed at the centre, as a reference of values and of the view of the world while at the same time subordinating women and rendering them invisible.

Taking advantage of the fact that today is March 8, International Women’s Day, we would like to review and reflect on how we are tackling this reality with the Government of Catalonia’s public policies.

The history of gender policies of the Catalan Government Administration goes back a long way. The Catalan Women’s Institute was created almost 30 years ago and it was this institution which began to formulate programmes for equality with the aim of guaranteeing real equality between men and women. In this context, the concept of equality has been reinterpreted and broadened and is now multidimensional:

Formal equality: the affirmation of the equality of rights in legislation
Equality of treatment: the absence of direct or indirect discrimination for reasons of sex
Equal opportunity: the compensation of existing inequalities in the conditions and positions of women and men
Gender equality: the assessment and consideration of the diversity and differences between women and men

The evolution of the concept of equality has run parallel to the evolution of strategies for intervention by public administrations. The first programmes of policies for women were centred on guaranteeing equal rights and on the absence of discrimination between men and women. Later, once the shortcomings of this concept had been verified, new measures for positive action were introduced to guarantee equal opportunities. More recently, gender mainstreaming has been introduced and prioritised.

Gender mainstreaming is a concept that arose in Sweden in the early nineties of last century to promote policies for women and was incorporated in the international agenda within the framework of the 1995 Fourth World Conference on Women held in Beijing. The inclusion of this strategy to develop policies for women was a turning point.

Gender mainstreaming in the area of the Catalan Government requires the incorporation of the gender perspective in all policies and the promotion of specific actions in favour of women from the different areas of Government Administration. This is the framework within which work is being done at present by the Government of Catalonia. The Department of Health has taken part in the six programmes led by the Catalan Women’s Institute and also in elaborating the four reports on gender mainstreaming.

On the other hand, the drive and implementation of measures and actions linked to gender policies in the Department of Health takes place within the framework of the Work Group for gender mainstreaming. This group is made up of people of reference from all the units and entities of the department, including the Agency for Health Quality and Assessment of Catalonia (AQuAS), and it is coordinated by the Technical Cabinet of the General Secretary.

Aside from the achievements made based on measures taken and actions carried out, some of the most significant advances have been those made via regulation. Particularly noteworthy are:

Organic Law 3/2007 for effective equality of women and men
Law 5/2008 of the right of women to eradicate male violence
Law 17/2015 of effective equality of women and men

Among the most noteworthy aspects of the Law of Equality (2015) is the regulation of interdepartmental bodies for coordination, in charge of applying gender mainstreaming both consultative and advisory in nature, and also of implementing mechanisms of collaboration, cooperation, control and sanction. Via this Law, the creation of the Observatory for Gender Equality was foreseen, a body which began functioning last June and of which the AQuAS forms a part of.

Despite the progress made, a lot of work remains to be done which we need to do together, not only as a legal obligation but also as a commitment to building a fairer society. No policy is neutral, and it affects men and women in different ways and this is why it is essential for us to put on our “gender glasses” during our daily tasks to identify possible differences so as to deal with them.

As you all know, dealing with gender is one of the editorial lines of the blog AQuAS (with posts written by Mercè Piqueras, Esther Vizcaino and Dolores Ruiz Muñoz) and we will be delving deeper into this subject shortly within the framework of the activity done at the AQuAS.

Post written by Iria Caamiña.

The experience of assessing innovation

1 Mar

Clàudia Pardo, a consultant of open innovation at Induct accompanies and helps entities in the health sector to adapt to the new needs of the future. Clàudia Pardo, together with Dolors Benítez, led the first edition of Innovate and Assess (see the previous post), a training programme of the Observatory of Innovation in Healthcare Management in Catalonia (OIGS).

This is why today we offer you an interview in which Clàudia Pardo of Induct talks to Francesca Moya, a specialist doctor in rheumatology, at present the Director of Processes and Quality in the Area of Healthcare in Mútua de Terrassa. We would like to share her experience at the OIGS in the context of the Innovate and Assess workshop because we feel that it could be of use to many other professionals.

What would you highlight about the OIGS in terms of assessing innovation?

The observatory has been an important lever in introducing the concept of innovation in micromanagement and healthcare practices among professionals and management teams. Personally, the OIGS has given me the necessary methodology and support to identify potential innovative practices and to introduce assessment in the project development process of projects that professionals themselves propose. It has also allowed me to get to know the experiences of other centres, to learn from this and to encourage relationships between other professionals.

In your opinion, why is assessing innovation in healthcare practices important?

The only way to quantify a clinical or organisational improvement that has been put into practice is to assess it. We learnt this during this OIGS course. The scientific interest that professionals have in innovation, with the aim of including new practices or technologies to bring us closer to an improved healthcare, can sometimes mean that certain resources are assigned to practices which do not provide any value and this can have a high cost, not only economic but also of opportunity and lead to inequality in the system.

How did the need arise to start assessing good practices in healthcare in your centre?

Innovation in healthcare practices is necessary if they are to be improved, and assessing it is essential to quantify improvements. I would say that the need to assess arose out of the curiosity and need to know whether what we are doing, including the novelties that we implement and the resources of all types that we assign, are in any way relevant to our clients and to the organisation. But there is another important aspect which encouraged and motivated us, by no means a minor one; giving visibility to everything we do and sharing it all as well as acknowledging the efforts and contributions of the professionals who make it possible to improve the health system. The OIGS is a tool aimed at facilitating the entire process.

What advice would you give when incorporating assessment in innovation?

In my experience, I think the first thing to consider when wanting to assess what is being done is to think about this from the start of any project that is to be implemented. Let me explain myself: one of the greatest problems that I have had personally when wanting to assess a practice, experience or project has been the lack of necessary data, problems of design and the lack of knowledge regarding the adequate methodology needed to do it. Therefore, my advice would be to start any new project by planning what you want to achieve and what you need to measure in order to know whether you have been successful or not. Methodology is basic in the field of assessment and that is the expertise of the AQuAS.

What reasons would you give the centre to take on this approach?

I consider that knowing the results of what we do is basic for our organisations so that we are aware of the value it has, what it offers us, whether we should continue doing it, whether we can apply it to other areas of care, whether we should forget about it and change it for other practices or whether we can improve it.

Interview by Clàudia Pardo (@Claudiia_Pardo), Induct (@InductES).

Innovate and Assess: how to incorporate assessment in innovation

22 Feb

Incorporating the culture of assessment in innovative initiatives was the starting point and the challenge from which the Observatory of Innovation in Healthcare Management in Catalonia (OIGS) initiated the first edition of the Innovate and Assess training workshop, a programme to train “Agents of Change” with the focus set on assessment and innovation.

What were the contents of this initiative?

What is innovation, what is assessment and what is the OIGS’s process of assessment?
The management of change to provide tools to encourage assessment

A practical session in assessment
The conceptualisation of a proposal to implement the assessment of an innovative initiative

From the Agency for Health Quality and Assessment of Catalonia (AQuAS) and via the Community for Innovation of the OIGS, a process of assessment has been driven allowing the quality of methodology in innovative practices to be measured within the framework of the public healthcare system of Catalonia, offering professionals in health and organisations the opportunity to opt for the certification of their experiences as an added stamp of quality.

This workshop has enabled experts in innovation to get in touch with experts in assessment and share their knowledge with each other in order to improve the quality of assessment of innovation.

This training activity has been accredited with 2,0 credits by the Catalan Council of Ongoing Training for Healthcare Professions.

The main aim has been to create and facilitate the necessary tools to be able to carry out assessment and innovation in healthcare centres in an adequate manner.

On the one hand, Cari Almazán, Cristina Colls, Núria Radó, Dolores Ruiz-Muñoz and Maite Solans, experts at the AQuAS in different disciplines participated, working with professionals and provided their knowledge and recommendations from the point of view of assessment.

On the other hand, Dani Bernard, Ignasi Clos, Xavi Olba and Clàudia Pardo of Induct, offered their expertise in the field of innovation using dynamics and techniques such as user journey map and cubbing.

Cubbing

With the intention of boosting the number of certified innovative initiatives (as we mentioned, using criteria to measure the quality of methodology), as well as spreading the word about the Observatory as a support tool in the assessment of the Catalan healthcare system as a whole, the AQuAS provides assistance, or mentoring, to all those professionals that provide self-evaluations of their own experiences but who do not attain the required quality of methodology to obtain certification.

At present, the OIGS has become a point of reference within the Catalan healthcare system, and day after day it places value on the effort made by organisations that share and divulge their innovative experiences and who promote the assessment of innovation.

Post written by Dolors Benítez.

Medical information in the press and the doctor-patient relationship

15 Feb

For years, I have been under the impression of not having a clear idea of how information related to the complex world of medicine and health should be disseminated in the daily news media, both of the science that it is based on and of the difficulties and dilemmas in applying it in practice.

I have repeatedly refused offers, with only rare exceptions, to write texts on these subjects in newspapers or books of a non-professional nature: I had serious doubts of how to transmit this knowledge to the public at large. Looking back critically on these reservations I have had, I think they have been related to the paternalism inherent in the medical training received by the professionals of my generation: the fear that the public will make an incorrect interpretation and come to abhorrent conclusions of the facts disseminated, an audience with little knowledge on the theoretical foundations and subtleties of these facts, which are only accessible with proper professional training. Indeed, experience has shown me that these reservations were indeed justified.

However, at the same time, I have witnessed the growth of citizens’ autonomy, now widely acknowledged, and their right to take “informed decisions”. This position, which has come to define the 21^st Century as “the patients’ century”, acknowledges their right to know relevant professional data so as to be able to take accurate decisions autonomously; it has an undeniable foundation but if we are to avoid that this leads to the proliferation of distorted facts it will require a rigorous preparation and an absence of spurious interests on the part of those divulging information. Ideally, these informants should contribute to “health literacy” in a way that is balanced, objective and unemotional.

The tension between these two conceptions of health information goes in parallel with that which exists between two extreme views of the doctor-patient relationship: the classical paternalistic one (“the doctor knows better than anyone what is best for a patient and their decision must be accepted”) and that of the “informed consumer” with autonomous decisions. The other extreme of this corresponds to an “imminent revolution” in which it would be the very well-informed patient, (basically as a result of the spread of refined computer technology) that would take the most important decisions concerning themselves.

Personally, like many others, I prefer a more balanced approach: that corresponding to the “interpretative” and “deliberative” models of the doctor-patient relationship, in which the experience and knowledge of the former interact with the latter respecting their autonomy.

I think that this dilemma runs parallel to the medical information found in daily news media: on the one hand, there is the social demand to inform citizens of current advances so they know their options or opportunities as “informed consumers”; on the other, there is the temptation to fuel the emotions (triumphalism or fear) of the reader who is untrained by offering them information which is largely uncritical, lacks rigour or is insufficient, with the risk of a biased, distorted or exaggerated interpretation. The more or less unreal notions that some informants may have on medical and health problems (common, alas, among many professionals) can be transmitted like this directly to the citizen and to their emotions and desires.

In the case of news related to medical advances and innovations, I would like citizens to know what expectations these novelties raise, maybe now within their reach, and the magnitude or relevance of the problem that can be lessened or resolved, and that this be done by using a rigorous and prudent terminology so that citizens can also create their own opinion on the solidity or temporariness of an innovation, and of the related uncertainties and limitations: not only of the benefits that they can provide them with but also of the undesired, uncomfortable or harmful side effects they might produce, and whether they are in anyway frequent or probable. In other words, I would not like the main aim of this information to be that of creating hope or fear in the reader, or give them the idea in a triumphal tone that in the wonderful world of science, the war against disease has claimed a new victory, especially at the hands of local researchers.

I have recently taken part in an analysis of the news published in the daily press in Catalonia on medical innovations.

Even though some well-documented news described in sufficient detail was found that could provide balanced information to the reader in this analysis, in many other cases the information was one-sided or not very thorough and was devoid of facts related to questionable aspects of the innovation and their risks. It resulted in a biased message which often tended to induce optimism in the reader rather than educate them in the knowledge of the pros and cons of the medical innovations.

At a time when there is a call for a user’s well-informed autonomy, I would be delighted if healthcare culture and the attitude of the news media did not amount to a paternalistic doctor-patient relationship. In this regard, there is no doubt that much still needs to be done.

Post written by Gaietà Permanyer Miralda. Emeritus physician. Unit of Epidemiology, Cardiology Service. Hospital Vall d’Hebron, Barcelona.

What are we doing about low-value medical practices?

8 Feb

The aim of the Essencial Project is to improve the quality of healthcare by providing professionals with evidence that is useful for them to make informed decisions in their day to day work.

What is special about this project is that this is done by identifying routine low-value practices in the health system and by using a strategy aimed at avoiding these practices.

Cari Almazán, the person in charge of this project, responds to questions in an interview.

What is the Essencial Project?

It is a project of the Department of Health of Catalonia led by the Agency for Health Quality and Assessment of Catalonia (AQuAS – its Catalan acronym), in which researchers from the AQuAS, health professionals, scientific societies and the Advisory Board of Patients participate. Each and every one, in their role, work with a clear objective: improving the quality of healthcare using a very specific strategy to identify low-value practices and thereby provide information to professionals to help them avoid doing all the things they do which do not offer any health benefits to the patient.

What is a low-value practice?

In usual medical practice, there are known routines that do not offer any benefit to the patient and it is difficult to understand why these occur but it is even more difficult to try and avoid them. In all likelihood there is a resistance to change and we need to spend a lot of time explaining what this project is about.

How does the Essencial Project work?

It works at different levels and we try to be systematic and transparent. This involves a line of work which includes: identifying low-value practices, finding knowledge (the evidence), informing about and implementing the project.

If a routine does not offer any benefit to the patient, why is it followed?

This is precisely what we ask professionals in primary care, among many other things. The comments “because we have always done it like this” or “because it is a request of the patient” are frequent. There is a certain tendency to want to feel we are being useful, a human one I would say. Both the professional and the patient feel better but on occasion, there is evidence which indicates that this “feeling better” is not accompanied by any benefit for the patient. This is what needs to be explained very carefully.

What role does the Essencial Project have in the day to day activity of a health professional and that of a potential patient?

There are many projects aligned with the initiative to improve the quality of healthcare. In this context, the Essencial Project is a tool of the health system to help health professionals make decisions. The Essencial Project thus aims to be useful to the health system and professionals. In addition, for a potential patient, knowing about this project can also help contribute to their understanding of why a health professional does not recommend a certain diagnostic test or treatment.

I am unsure as to whether the project is aimed at professionals or at citizens.

The Essencial Project is aimed at the entire population. On the one hand, it is aimed at professionals to provide them with this tool, but also at citizens. Why not? Whether citizens want this information is another thing altogether.

Do citizens show an interest in having all this information available to them?

We don’t know, we should ask them. We know of experiences where it is not clear that the information which is given is the information that citizens want but at the AQuAS we believe that sharing knowledge and methodology is an exercise in responsibility.

Who chooses the recommendations?

Cari: They are chosen in collaboration with the different scientific societies. Right now, there is a participative process on the go to prioritise low-value clinical practices in the framework of the Third Conference of Care in Sexual and Reproductive Health. In the Essencial Conference 2017 subjects for recommendation were prioritised based on the participation of the professionals that attended the conference. The idea is that it is the professionals themselves who identify when and where practices of this sort occur.

Who creates the contents of the Essencial Project?

The contents that accompany each recommendation are the result of the participation of many expert professionals in different disciplines. These contents are then validated. In terms of the videos, professionals at the AQuAS along with health professionals produce these which explain the key idea of each recommendation in the first person in an informative manner.

What would you highlight of the Essencial Project?

That we offer every recommendation, the chance to collaborate with health professionals, a bibliography and files for patients in a systematic way. This last idea of files for patients is a subject which we will delve into more deeply shortly from the agency. Perhaps, what I would say is most important here is that all this forms a part of a commitment to bring the culture of assessment and the culture of Choosing Wisely at all levels closer to everyone: the citizenry, professionals and the health system.

Hip and knee arthroplasty: What prosthesis did you say I would get? (part two)

1 Feb

We continue the interview with Olga Martínez expert at the Catalan Arthroplasty Register (RACat) and Xaxier Mora, specialist in traumatology and orthopaedic surgery with a Master in biomaterials.

The aim of today’s post is to know a little more about prostheses and the biomaterials used in arthroplasties.

With this post and the previous one, we have wanted to present the opinions of these two professionals.

Are all prostheses the same?

Xavier: No, because each patient is different. Therefore, the orthopaedic surgeon will recommend one type of prosthesis or another, depending on the extent to which the bone is affected, the patients’ age, associated diseases and the daily activity of a the patient.

Olga: At present, there are different types of prosthesis on the market in terms of design, materials used in their manufacture and the way they are anchored to the bone. There are prostheses that range from replacing only a part of the joint to more complex joint replacements in situations where bone damage is extensive.

As a user of the health system, to which hospital should I go to receive the best prosthesis?

Xavier: One cannot talk about better or worse prostheses because all prostheses used for implants have to follow a standardised procedure according to specific international standards, such as those of the American FDA and the European CE seal of approval, for materials that will be implanted in humans. In the same way, hospitals in Catalonia are certified to be able to carry out this type of surgery.

Olga: The prostheses which are commercialised in Catalonia meet the international standards of quality and public hospitals base their choices of prostheses on the scientific evidence available. This is allows them to select those with the best results according to arthroplasty registries, using recommendations from different institutions such as the NICE (National Institute of Healthcare and Clinical Excellence) and the ODEP (Orthopaedic Data Evaluation Panel).

Olga: In addition, the new European legislation passed in 2016, regarding implants used in health, aims to increase the supervision of the industry by implementing stricter norms and regulations including the obligation of clinical assessment, while at the same time fostering innovation in this field.

Who does the research into the best materials available and what factors are taken into account?

Olga: These days, the research of new materials and manufacturing techniques as well as the design and improvement of new prosthetic implants is a multidisciplinary process. The contributions of orthopaedic surgeons are especially important together with studies in joint biomechanics and surgical technique. In Catalonia there are research centres in biomaterials such as Leitat and the Technical University of Catalonia (UPC).

Olga: From the AQuAS we have written up and published short reports on biomaterials (polyethylene, cements and ceramics and metals) aimed at professionals that work in services of orthopaedic surgery and traumatology, with the aim of updating their knowledge.

Reports available in Catalan:

Xavier: Nowadays, when manufacturing new materials, the interaction between the surface of a biomaterial and the bone is taken into account more and more often, so that bone cells can consider an implant as part of its own structure and thereby avoid the prosthesis from moving about because this is one of the biggest problems in getting an implant to function well.

How have materials evolved since the first prostheses to the present day?

Olga: The discovery of new materials and/or the progress made both in terms of manufacturing techniques and the knowledge gained in the biomechanics of the human body have influenced the design of prostheses over time.

Xavier: The first experiences in joint implants date back to the 20s of last century. One of the first attempts at replacing the surface of the head of the hip was done by manufacturing a metal socket or dome (Smith-Petersen).

Xavier: In the last 20 years, many important advances have been made regarding the use of new biomaterials, much safer and of greater resistance to wear, thus extending the life of an implant in a biological environment such as the human body. Together with metallic biomaterials, these days ceramic biomaterials are used with good results in relation to their integration in bone tissue.

Xavier: On the other hand, research in 3D technology has paved the way for a more precise surgery, and in the future it will be possible to manufacture more personalised implants.

Xavier and Olga: We both agree that we are getting closer and closer to having a prosthesis that is for life.

Hip and knee arthroplasty: What prosthesis did you say I would get? (part one)

25 Jan

Today, we interview Olga Martínez expert at the Catalan Arthroplasty Register (RACat) and Xavier Mora, specialist in traumatology and orthopaedic surgery with a Master in biomaterials. They are two professionals involved in arthroplasties, a subject of great impact among a large sector of the population. We focus on aspects of recommendation and prognosis related to the pathology and on the value of registries for quality care.

In what cases is an arthroplasty intervention recommended?

Xavier: The most important surgical indication to carry out a knee or hip arthroplasty is arthrosis. Advanced arthrosis has a considerable social impact with a loss of life quality for the person affected due to pain, a loss of personal autonomy and an increase in dependency. In addition, the loss or reduction in mobility can worsen existing diseases such as diabetes or heart diseases. It is in these situations when an arthroplasty is recommended which will reduce pain and improve joint mobility.

Olga: In our field, according to the data from the Conjunt Mínim de Dades dels Hospitals d’Aguts (Minimum Set of Data from Acute Care Hospitals) and the Catalan Arthroplasty Register (RACat), the main reason for an intervention in knee and also hip arthroplasties is arthrosis. In the case of the hip, femoral neck fractures are the second cause for arthroplasty recommendation.

It seems that there are more and more people who undergo arthroplastic surgery each day to implant a prosthesis. Is this a fact?

Xavier: Yes, around 9,6% of the Spanish population suffer from this disease to some degree, a percentage that increases up to 33,7% among people aged between 70 and 80. With the ageing of the population, it is evident that there will be an increase in the number of people who could be candidates for arthroplastic surgery in the future. In the context of Catalonia, if we do a simulation with 2026 as the time horizon, based on data from the Idescat, the population aged between 15 and 39 will decrease while the population of 40 to 64 will increase (227,000 people and 330,000 people respectively).

Olga: At present, knee arthrosis has a prevalence of 10,2% and that of the hip is around 5%, more frequent among women, even though the data vary between one study and another.

The AQuAS, the Agency for Quality and Health Assessment of Catalonia, has been managing the Catalan knee and hip arthroplasty registry (prosthesis) for many years. What purpose does a registry like this have?

Xavier: The aim of all orthopaedic surgery is the survival and good functioning of a prosthesis and in consequence, the improvement in the quality of life of patients. Although a prosthetic implant undergoes strict manufacturing procedures before being used and follows a rigorous surgical technique during surgery, the functional results in a patient need to be assessed via follow up sessions from the time they receive an implant. To this effect, arthroplasty registries can help detect models of prosthesis with a malfunction, both in the short and long term, and identify the patients who have received these implants.

Olga: This is what happened a few years ago with the ASR model, a hip prosthesis that some publications and registries, such as the National Joint Registry, pointed out due to an unusual increase in the rate of revisions. This motivated an international health alert and a protocol was adopted to monitor patients.

Olga: One of the first prosthetic failures that prompted the creation of registries was that of the 3M Capital Hip, a hip prosthesis introduced in 1991 in the United Kingdom as an inexpensive prosthesis. After six years and more than 4,600 prosthesis implants, the risk of undergoing a revision was considered to be 4 times higher than that expected with the added difficulty of the traceability of the implants as no registry existed at a national level.

Olga: The Registry for Arthroplasties of Catalonia created in 2005, an epidemiological tool of surveillance in the Catalan Health System, stemmed from the collaboration between the AQuAS, CatSalut and the Catalan Society of Orthopaedic Surgery and Traumatology.

Are there other similar experiences of registries of this type in other countries?

Olga: Sweden (1975) and Finland (1980) were the first countries to push for a national registry of arthroplasties of a demographic nature.

Olga: At present, many countries have implemented this tool, be it in Europe, America, Oceania, etc… with different territorial coverage, but with a common aim: to be a valid instrument in assessing arthroplasty procedures and implants used.

As a patient or as a family member of a person that suffers from joint arthrosis, what is the message that you would like to get across based on your experience?

Xavier: The first consultation that a patient has is always because of the pain they are experiencing in the hip or knee joint when walking, going up or down stairs, getting up from a sitting position in a chair, having difficulty to put on shoes, etc. The aim of treatment should be to eliminate pain by using medication, doing physical exercise and physiotherapy that help improve 95% of patients. An arthroplasty intervention should only be considered as a last therapeutic resort. In this context, shared decisions between professionals and patients are very important too when talking about arthroplasties. We should all ask ourselves whether the best option to reduce this pain is to implant a prosthesis.

Does a patient go back to normal routine life after an arthroplasty intervention?

Xavier: After a surgical intervention and once the period of functional recovery has come to an end, a normal lifestyle can begin, due to the disappearance of pain and an improvement in joint mobility. In certain cases, constraints will be limited to intense activity that could overburden the joint.

(To be continued …)

Sleep apnea: towards precision medicine

18 Jan

Obstructive sleep apnea is a chronic disorder characterised by recurrent episodes of a blockage of the upper airways during sleep which affects between 5% and 14% of adults from 30 to 70 years of age, mainly men. In addition, sleep apnea leads to a reduction of the intake of oxygen (hypoxia) during sleep. In order to counteract this lack of oxygen, the brain reacts by forcing a short awakening known as arousal which reactivates the muscles in the upper airway and allows air to pass through (reoxygenation).

These cycles of hypoxia-reoxygenation produce stress to the circulatory system and leads to an increase in the risk of cardiovascular, hypertensive, metabolic, cerebrovascular, or neoplastic diseases, and lastly, a risk of death. At the same time, the arousals prevent a person from having a good night’s rest, produce the feeling of tiredness and an excessive desire to sleep during the day, which is associated with an increase in road accident rates and a decrease in life quality.

A standardised approach in the treatment of sleep apnoea exists: the use of continuous positive airway pressure (CPAP) during the night in order to keep the upper airways open which helps the person rest.

However, treatment with CPAP shows contradictory results. On the one hand, it has been demonstrated that the use of a CPAP for at least 4h per night increases quality of life and reduces blood pressure among population groups with high blood pressure. In contrast, it has not been demonstrated that the use of CPAP reduces the risk of major cardiovascular events or deaths. Therefore, sleep apnea is a heterogeneous disorder and the use of CPAP is not equally effective with all patients. Which patients can benefit most from the treatment? Should all patients be treated in the same way?

We believe it is important to look for patients with sleep apnea profiles that can benefit from a treatment with CPAP. The creation of the PADRIS programme (Public Data Analysis for Health Research and Innovation Programme in Catalonia), whose aim it is to make related health data available to the scientific community to drive research, innovation and assessment in health, has given us the opportunity to be able to analyse all subjects with sleep apnea treated with CPAP in Catalonia. We are talking about 71,217 people, approximately 1% of the general population who were attended by the public health system in Catalonia (primary care, hospital care, social health and/or pharmacy) in the period 2012-2013.

To establish these profiles (that is, groups of patients having similarities with each other but at the same time very different from the remainder) the most frequent comorbidities of patients with sleep apnea have been taken into consideration as well as the clinically relevant comorbidities. Six different profiles of patients were identified among patients with sleep apnea and treated with CPAP in Catalonia.

Despite defining these six different patient profiles, we can safely say that the population of Catalonia receiving CPAP is divided into two large basic groups: on the one hand, old age patients, with a high mortality rate and a frequent use of resources, and on the other, patients with fewer comorbidities, a low mortality rate and an infrequent use of resources. You can read it in an article in Plos ONE.

Do both groups need to be treated in the same way? It seems not. In the group with fewer comorbidities, a low mortality rate and an infrequent use of resources, it seems that sleep apnea is the most important determinant in the prognosis of these patients and there is evidence that this would be the group that could most benefit from treatment with CPAP. In contrast, it seems that in the other group sleep apnoea is at a secondary level, given that the predominant diseases are more serious.

The study has allowed us to assess the association between treatment with CPAP and mortality; that is, whether more people die who are being treated with CPAP or whether more people die having the same comorbidities but without sleep apnea.

To be able to achieve this objective, for each patient treated with CPAP we looked for three people with similar characteristics but without sleep apnea. What we observed was surprising, namely that despite presenting a greater number of comorbidities, treatment with CPAP is associated with a decrease in mortality rate at a population level (Am J Crit Care Med 2018).

We now need to continue working to find out what occurs in each of the patient profiles. Having access to this volume of data helps us to make an estimate of the groups of patients with sleep apnoea that will benefit more with CPAP treatment and this means that we are getting closer and closer to precision medicine.

Diseases do not exist, ill people do

Post written by Ferran Barbé, Hospital Institut de Recerca Biomèdica de Lleida.