Regarding the generational changeover

31 Jan
Joan Escarrabill

The day before turning 65 last November, I climbed up the 238 steps of the Pyramid of the Sun in Teotihuacan (near FD Mexico). I did it with only a short break halfway up. At the top I had dyspnoea but I was able to hold a conversation without difficulty. I went down backwards holding onto the guide rope because my left knee didn’t allow me to go down in a conventional way, face forward, but I did get down. Human beings have the tendency of setting temporary goals arbitrarily. Establishing 18 as the legal age has nothing to do with the maturity of a person and nor does being 65 make you old. To understand the idea of “getting old” it might be more objective to remember, for example, “the first time that  …”

  • … a resident doctor or student speaks to you in a formal way.
  • … an unknown person, on the street, identifies you with a “sir”.
  • … a young person offers you their seat on the underground or bus.
  • … you come across a book in a second-hand bookshop and see that you have the same one, bought many years ago (and remember perfectly well where and when you bought it).
  • … you realise you are no longer able to run.
  • … you forget to hail your bus or don’t run down the stairs in an underground station to catch a train.
  • … you look for the banister to descend a staircase.
  • … you receive a letter from the Town Council saying that you are eligible for a “pink pass” (senior citizen’s transport pass)
  • … in a professional meeting you are asked directly how long you have before retirement.
  • … your presentation is appreciated because you know the history of the problem well.
  • … or comments are made saying that your beard puts years on you.

All this does not happen to you at 65. All this occurs little by little, in an irreversible manner. It is biology. And worse for those who don’t get there.

That is why retiring at 65 is no more than an illogical convention bereft of justification. There are people who anxiously wait for retirement to be able to “do the things they like”. I don’t understand this idea of retirement at all. Maybe it’s because I don’t understand retirement with a set date (like an expiry date). Whatever the case, I don’t see the need to retire to do other things because I really like what I do.

A very different thing is to reject retirement and to hold onto the monopoly of space, time and ideas. A generational change over is essential. With time, we all tend towards stability and Darwin showed us that the more stable a system, the less possibility it has for survival. A stable system has little variability and therefore little capacity to respond to new situations. The limited capacity of response impedes adaptation and therefore leads us to the same future as that of the dinosaurs.

It is much more important to talk about a generational changeover than retirement. Some key ideas in my opinion are:

  1. No generation has the right to stipulate how their successors should live. Each generation has the right (and obligation) to live as they see fit.
  2. No generation has the right to leave the space they have occupied in a way that impedes successive generations to design it the way they think best.
  3. No generation has the right to prevent successive generations from moving forward at their own chosen speed. Each one can move forward at the speed they desire but there comes a time when generations that have more past than future cannot monopolise the fast lane on the motorway.
  4. There is no need to consider retirement as a “set date” although it is imperative to be clearly aware that natural evolution will lead us to gradual invisibility.
  5. Experience DOES NOT generate knowledge. Experience is very useful to identify patterns more quickly, to increase the “bank of solutions” or to carry out repetitive tasks with greater precision (although it won’t be long before machines beat us at this). What generates knowledge is curiosity, critical thinking and hard work (very hard work), in other words, perseverance.
  6. Each generation has the duty to explain what they have done and why they did that. They need to put this forward for general consideration. This should not be done to gain recognition but to be questioned so as to help learn from mistakes and to avoid others committing unnecessary reiterations.
  7. Naturally, no generation has the right to define the agenda that a succeeding generation needs to follow. Giving an opinion with a critical spirit, yes, always, but stipulating the itinerary based on experience is doing a great disservice to the generational changeover.

All this is not a justification for paralysis. There are always challenges in this process. It is always possible to find “blue oceans” on which to sail. Joaquim Mª Puyal has returned to the radio. I have not listened to him at all but I have read some declarations in which he stated that “at my age, a challenge is a luxury”. We can (should) look for challenges at any given time, but with the rules of the game in mind.

A friend of mine, Josep Mª Monguet, told me that he went to visit a friend of his who was very ill. He said that the man, now ill, had always been very active. When he saw him, my friend, using a stereotype said to him: “What are you up to these days?” “I think up concepts”, he replied. After all, you are very fortunate if you can still “think up concepts”.

Post written by Joan Escarrabill (@jescarrabill)

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

25 Jan
Olga Martínez, Xavier Mora

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 …)

Innovate or innovate

29 Sep

What do the following have in common? An integrated circuit of home based hospitalisation, a telephonic nursing management project, a plan to minimise risks and the safe use of drugs, the use of ICTs in patients treated with oral anticoagulants, an assistance route of collaboration between primary and specialised care, the redesign of a programme of assistance in sexual and reproductive health, a functional unit of chronic and subacute patients, the optimisation of assistance to a patient who has undergone surgery and an oncological-geriatric unit of intermediary care?

They are all innovative projects or experiences which are compiled in the  Observatory of Innovation in Healthcare Management, a reference framework to detect innovative initiatives and tendencies in the Catalan Health System. You can read about it in this post by Dolors Benítez.

“Promoting collaborations between organisations by creating synergies, interest groups and setting up challenges.”

If talking about challenges, we have quite a few and innovation is in fact intended to provide solutions to make improvements.

Innovating, therefore, can be seen as a constant and necessary attitude that we can identify in all professional fields and areas of life.

In the AQuAS blog, we have shared some projects with a strong innovative component.

Is it possible to combine active and healthy ageing with innovation?

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

“Virtual Nurse”, a promotional and educational portal for health at the service of people

Elderly person with stroke: integrated care from the acute phase to the return home

Post written by Marta Millaret (@MartaMillaret)

Wishing you all a Joyous Festive Season from the AQuAS blog

29 Dec
nadal-2016-marta-millaret
Marta Millaret

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.

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The most read articles in 2016 have been:

However, we have published many more texts, 51 posts to be precise, without counting this one, with the aim of sharing knowledge and generating a space for reflection, open and useful for everyone.

Thank you very much, a joyous festive season and see you in the new year!

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

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Is it possible to combine active and healthy ageing with innovation?

22 Dec
toni-dedeu
Toni Dedéu

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.

eiponaha

This is the underlying idea of the Reference Sites awards which assess regional European health ecosystems based on four axes:

  1. Political, organisational, technological and financial willingness for an innovative approach to active and healthy ageing
  2. The capacity to share knowledge and resources for innovation
  3. Contributiing to European cooperation and transferability of own practices
  4. 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.

Being self-critical of the  different health systems is as important as the knowledge and recognition of one’s own strengths and values. Sharing this is a way of acknowledging the involvement and work done by many professionals. We do not work in isolation; as a whole, this work has involved and involves AQuAS, the Fundació TicSalut, the HUBc (Health University of the Barcelona Campus), the ICS  (Catalan Health Institut),  the IDIAP Jordi Gol (Institute for Research in Primary Care), the Pere Mata Institute, the IRB Lleida (Biomedical Research Institution of Lleida), the VHIR (Vall d’Hebron Institut de Recerca), the Consorci Sanitari del Garraf  and the Institut Guttmann.

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.

The Great Escape

21 Jan
Joan MV Pons, Head of Evaluation AQuAS
Joan MV Pons

A few days ago, Anna Garcia-Altés in a previous post referred to the Nobel Prize in Economics, which Alfred Nobel never granted – that was awarded in 2015 to Angus Deaton and his work on inequality. This is not the subject that I wish to talk about today but another that also features in the recent book from this Nobel proze winner which is titled “The Great Escape” (The Great Escape). Yes, just like the movie, set in a German camp for prisoners of war starring Steve McQueen and recalling a real fact of World War II. Unlike reality, the book predicts a better ending. For Deaton, the greatest escape in human history was in overcoming poverty and ageing.

For centuries, those who did not die at a young age could face years of misery. Beginning in period called the Enlightenment, with its scientific revolution and subsequent later industrial revolution, some people in certain countries began to escape this meagre fate.

Meanwhile, germ theories founded in the late nineteenth century surpassed the paradigm of the miasma theory in explaining contagious diseases. The key was and still is scientific knowledge and its dissemination. This point in history marks the extraordinary increase in life expectancy, initially for the better-off and then for the rest of the population.

This higher life expectancy, manifested especially in the developed countries, is largely due to the remarkable reduction in infant mortality and, more recently, to the epidemiological transition to chronic non-contagious diseases, the improvement in life expectancy in adulthood (increased life expectancy ≥ 50 years from 1950), but without a substantial improvement in longevity. Deaton shows us all this with data and graphics.

To illustrate it, Deaton mentions the progress in combating smallpox with a vaccination of smallpox (initially using matter from infected people and later the much safer vaccine Edward Jenner introduced in 1799). The public health measures introduced in the last few hundred years, including sanitation, water supply, nutrition and better hygiene, have led to a significant reduction in infant mortality.

Here, it was due to not only the knowledge but also the determination of the authorities in improving the conditions of the population. The improvement in life expectancy in adulthood is explained largely by reducing cardiovascular mortality through diagnostic and therapeutic advances in this field.

As mentioned before, we witnessed not only increased life expectancy but also a significant increase in the world population, an authentic explosion starting in the second half of the twentieth century. Malthusian alarms re-emerged but they were fortunately overcome by improvements in agricultural productivity, without excluding initiatives – for better or worse – for controlling the birth rate in developing countries; again, examples of scientific knowledge and its dissemination.

Deaton is very critical about the operating methods in which help flows from developed countries to developing countries. From the times of imperialism and colonization where (natural) resources were moved from poor countries to rich ones (Nineteenth century) and since the end of World War II we’ve also seen a flow of resources from developed countries to developing countries.

This external help, whether from governmental or NGO sources and despite the illusion that might it create if it continues as usual, may end up doing more harm than good. There’s no shortage of examples in the book of wasted resources by governments and corrupt politicians, granting donations or grants to countries (government to government) without these ever reaching the people. Not to mention situations where these grants are part of the geopolitics of the former colonies or contemporary powers.

Contrary to what an engineered hydraulic vision (communicating vessels) may show, we must invest in projects and programs that promote conditions for economic development to make external aid unnecessary, as is the reality in Africa, where paradoxically, the more external help yields the least growth in GDP per capita.

Health aid, without underestimating its achievements (vaccination campaigns, infrastructure construction, drugs against HIV / AIDS, mosquito nets), continues to be in most cases, vertical health programs with a very specific focus. This contrasts with the horizontal programs aimed at strengthening local health care systems, especially a good network of primary and community care.

Often foreign aid and the development of local capacity are not aligned; on the contrary, often one damages the other. Rich countries’ subsidies to their agriculture – consider the famous European PAC – is detrimental to farmers in poor countries where most of the workforce still works the land. There are more effective ways to help.

(It notes that another Nobel laureate in economics, Robert Fogel (1926-2013), had already written about the great escape in “The Escape from Hunger and Premature Death, 1700-2100” (2004), Deaton and had revised appointment. Thank Anna Garcia-Altés to call me about this)