Chronics – AQuAS Blog

Never before have we been so healthy and at the same time, never before have we been so sick

21 Apr

When I was born in 1950, life expectancy at birth was 65 years. I have now reached the 65-year mark and as such, according to the data, I should be starting to lose expectations. Fortunately, in recent years, medicine, health and lifestyles have improved and my reviewed life expectancy has increased, according to data from Idescat, by 20 years. This means that I have gained one year of life for every 3 years I have lived. That’s not bad! I am delighted with the figures, but there is one thing that worries me. That thing is called healthy life expectancy. This is calculated by combining mortality data which gives us life expectancy, together with morbidity data which can tell us how many years we are expected to be unhealthy. My healthy life expectancy is currently 12 years, in other words, I can spend 12 of the 20 years I have remaining healthy, and 8 unhealthy. Statistically speaking, that is.

And what diseases face me on the road ahead? Well the most serious life-threatening diseases are cardiovascular disease and cancer. Suffice to say that many of the gains we have achieved in terms of extending life expectancy have come from reducing cardiovascular mortality. Cancer is also in decline, thanks to improvements and research in health. Certain types of cancer are less common due to the decrease in the number of people who smoke. For example, lung cancer is declining in men but has increased in women. For other forms of cancer, there is now very effective treatment and medication that can relegate the disease to chronic status. However, despite the fact that these diseases are serious, they do not have us visiting the doctor every day. We visit the doctor complaining from high blood pressure, cholesterol, diabetes, heart failure, etc. Some of these diseases are linked to the largest public health problem today: obesity. Tobacco or alcohol are no longer the major public health problems, but instead it is obesity. The number of cases of are growing day by day and it is considered to be the root cause of certain diseases such as diabetes.

Obesity is caused by two factors: overeating and taking less exercise than we should. Most modern developments result in us doing less exercise: elevators, escalators, teleconferencing, etc., and a lot of the media input encourage us to eat more or to consume sugary drinks. The combination of these factors mean that today around 15% of the Catalan population is obese.

The most common disease in people over 65 years old today is called polypharmacy, in other words, the use of more than three types of medications on a daily basis. In many cases this can be more than 10 different drugs and there are some people who have a daily consumption of 20 drugs. Each drug is prescribed to address a particular health problem, and health problems have multiplied. Nowadays, we don’t have only one disease, we have several, and each disease has its own therapeutic arsenal. Doctors must monitor patients, not only to control the disease, but also to ensure they prescribe drugs that do not have adverse effects on the patient’s other conditions. When visiting our GP, they have to take into account a number of parameters, and a visit to the hospital can mean appointments with a number of different medical services. One of the most serious health issues today is derived from interactions between different drugs or therapeutic activities that can act as obstacles to each other.

Medicine has come a long way since I was born. We have discovered so much about diseases and we now have much more effective medicines and surgery to cure many conditions. Nevertheless, medicine is poorly prepared for the new patient: elderly, with several diseases, some mental (Alzheimer’s, dementia, depression, etc.), without family, and prescribed a lot of different medication. Because the system cannot cope with the complexity, they end up sending the patient to an elderly care nursing home.

For several years, voices have been raised in healthcare circles demanding the reorganization of services to meet the demands of these new patients. These voices have difficulty making themselves heard and it is very difficult to change the way health services operate. We have reduced mortality thanks to specialization and superspecilisation with diseases being defined with greater precision, but the patient has been reduced to a sack of diseases. The new medical perspective asks to view the patient as a whole and not only each one of the diseases they suffer from. There is still much work to do.

The current paradox is that we have never been so healthy and at the same time, we have never been so sick. Never before have we been able to live for so long in good health and never before have we lived so long with so many diseases to trouble us, to restrict us and make us dependent on health services. Faced with this situation, health services must adapt and patients must take a more active role in caring for their diseases.

Post written by Bohígas (@bohigasl), economist.

Stratification and morbidity database (2n part)

31 Mar

(This post is the second part of this post)

A key element for completing the stratification of population in risk groups is information system. It’s necessary to have a database that integrates information collected from different health records and therefore, in order to meet this demand, the population morbidity database was created.

The point is that every day there is more and more emphasis on the need to provide patients with a comprehensive and integrated health and social care, but the analysis and evaluation of this care can not be carried out correctly with fragmented information systems, on the contrary: it must be done starting from the integration of the data these contain.

Population morbidity database structure

The population morbidity database is based on a system of related tables that pivot around the users table, which includes the main data of the insured patient (demographics or health status, to name two examples).

Currently, there are three more tables: the diagnostic, the contact with health services and the pharmacy, but this type of structure relatively easily allows incorporating both information from new records (outpatient clinics, dialysis, respiratory therapy, etc.) and new tables with other relevant information, such as results of clinical findings:

Figure 2: Structure and content of the population morbidity database. The clinical determinations table in gray is not yet implemented.

Taula d'assegurats

The population morbidity database integrates information from the following records:

Registro Central de Asegurados – (RCA) (Central Registry of Insured Patients) managed by public relations management of CatSalut. This register basically provides all the information of residence, socio-demographics and health status of the insured patient.
Registros del conjunto mínimo básico de datos – (CMBD) (Records of basic minimum data set) managed by CatSalut Division of demand and activity analysis. These records feed both into the diagnoses table and in the contacts tables. There are different registers to collect information from the healthcare lines:
Hospitalization (CMBD-HA): information provided by general acute care hospitals (hospital admissions, outpatient surgery, home hospitalization, day hospital) from 2005 to 2014
Socio – sanitary (CMBD-SS): information of the care provided by the health centres of internment (long and medium stay and UFISS) and outpatient care equipment (PADES) from 2005-2014.
Psychiatric hospitalization (CMBD-SMH): information of the care provided by psychiatric hospitals from 2005-2014.
Outpatient Mental Health (CMBD-SMP): information of the care provided by outpatient mental health centres for the period 2005-2014.
Primary Care (CMBD-AP) information on the care provided by primary care teams from 2010 to 2014.
Emergency (CMBD-UR): information of emergency care (hospital and CUAP) from 2013 to 2014.
Pharmacy activity Log (RAF) managed by CatSalut’ management of pharmacy and medicine unit. This record provides all the information about outpatient pharmacy dispensing for the period 2011-2014.
Record health services turnover (RF) managed by the Division of care services provision. This record provides information on any activity financed by CatSalut, but that does not rely on a specific record: hospital outpatient clinics, dialysis, home oxygen therapy, rehabilitation or non-emergency medical transport. This record provides information mainly on the contacts table for the period 2011-2014.

The possible uses of the population morbidity database are multiple: the population stratification, the specific analysis of certain health problems (broken femur, IC, COPD,…), the development of population indicators of efficiency in the use of resources, etc.

We can conclude that, for the volume of data that integrates, this database has the characteristics of a structured “big data”, with a considerable capacity for growth and adaptation to new requirements and data sources and offers enormous possibilities for analysis.

Post written by Emili Vela, head of Modules for Tracking Quality Indicators (MSIQ). Health Care Area. CatSalut.

Mobile Is Everything

3 Mar

Barcelona Mobile Fira Barcelona is Mobile. The great mobile world exhibition has not gone unnoticed to the city. With a record 100,000 visitors, the Mobile World Congress took place last week in Barcelona, under the theme “Mobile is everything”. Considering the innovations presented in it, it appears that healthcare is also becoming mobile (mhealth).

The massive mobile technology world fair gathered mobile operators, technology manufacturers, providers, distributors, and content providers who presented the industry’s latest innovations. According to Genís Roca (@genisroca), the contents of this year’s Mobile World Congress has turned around these 6 topics:

1.   Graphene
2.   Virtual reality
3.   eSim
4.   Connected Car
5.   5G
6.   Internet of Things – IoT

Three of these large trends have very clear applications in the field of healthcare.

The first topic is graphene. The Catalan Institute of Nanoscience and Nanotechnology (ICN2), in collaboration with research centres from Barcelona and the Autonomous University of Barcelona, has presented a group of graphene electronic sensors that can be used to detect the electrical activity of the brain. The early detection of an epileptic crisis could be possible in patients suffering from epilepsy and implanted with these sensors. The implanted device on the cortex would alert the patient by, for instance, sending an alarm signal to an external mobile device.

Virtual reality has been the main character in the congress, or at least, the one that caused more anticipation. This was best seen in the long queues to visit Samsung’s roller coaster or SK Telecom’s submarine.

Gear VR Theater with 4D Virtual reality applications are starting to appear in the field of mental healthcare. Thus, startups such as MindWave (with their project HealthVR) or Psious offer treatments to tackle phobias, fears or generalised anxiety by exposing patients to virtual reality images, in some cases as part of a cognitive behavioural therapy.

Finally, the Internet of Things is gaining ground: Internet connected objects are creating new business models and involve more and more sectors. For instance, the monitorisation of vital signs (weight, glucose, blood pressure, physical training, etc.) is increasingly more common with connected wearables (smartwatches, bracelets, etc.) that allow to collect real time data. Connected devices also allow the control and follow-up of chronic diseases, such as diabetes with Insulclok.

The mobile industry will undoubtedly continue to evolve, and its applications in the field of healthcare will grow even more. I was lucky to attend the course Mobile Thinking Days-Digital Health (organised by Mobile World Capital Barcelona, IESE Business School and RocaSalvatella), and one of the key messages that appealed to me is that any product subjected to digital pressure will end up transformed into a service (Genís Roca dixit). Therefore, a big challenge of mhealth will be to offer disruptive, quality services that meet the patients’ needs.

Entry written by Elena Torrente (@etorrente), digital health coordinator in DKV Services.

Stratification and morbidity database

3 Dec

Emili Vela, Head of “Modules for Tracking Quality Indicators” (MSIQ) Health Care Area, CatSalut

In recent years there has been an increase in the prevalence of chronic diseases partly due to increased life expectancy, an aging population and improved health care. These factors have also led to the emergence of patients with a high number of simultaneous illnesses with a high risk of de-compensation. These patients represent a relatively small percentage of the population but they use up a high amount of health resources. In fact, we can say that, with respect to chronic patients, multiple morbidity is the norm, not the exception.

In these circumstances, the stratification of the population at risk groups, which allows us to know and anticipate future health resources needs is an objective set out in several strategic areas defined in the Catalan Health Plan (2011-2015) and is especially relevant in the transformation of healthcare models (making them more proactive), in the treatment of chronic diseases (establishing target populations for certain actions) and the integration of health and social care levels. Continue reading →

How to improve chronic patient medication … in only 9 cases!!

17 Sep

Arantxa Catalán, Head of AQuAS Pharmacy Assessment

To date, more than 900 physicians and primary care pharmacists have completed the “Management of chronic patient medication (MMPC)” an online course acreditated with 11.7 points by the Consell Català de Formació Continuada de les Professions Sanitàries (Catalan Council of Continuing Training of Sanitary Professions) which has just completed their 3rd edition.

Sense títol The MMPC course consists of 3 modules and 9 real clinical cases of multi-medication and multi- pathology patients (Figure 1) and is a 60 hour training course. During this time and by solving each case, the trainee acquires the knowledge and skills needed for the processes of reconciliation, review and de-prescription of medication for chronic patients; knowledge and skills whose systematic application will certainly promote relevant changes in clinical practice. Continue reading →

Promoting patients’ proactive attitude in the care of their illness, can this generate more inequalities?

23 Jul

Joan Escarrabill, Director Chronic Care Program at Hospital Clínic Barcelona

As participants in a mature society, we’re responsible for our actions and it’s clear that these actions have consequences. Take healthy habits as part of this responsible attitude. From the health point of view, this attitude of individual responsibility leads us to value this role of “active patient” to the maximum. In addition, we know that active patients have better health outcomes.

Now this storyline has a weakness that wouldn’t exist if we all had the same cards to play with. Unfortunately there are social inequalities. In 2014, in an article in the NEJM, Sayer and Lee explain very well this relationship between social conditions and health. Not all citizens (patients) start the race from the same point and in the same conditions. Social inequalities cause that not even “starting up early, very early…” can offset these imbalances. Naturally, from the point of view of the health care organization we can not attempt to resolve social inequalities. However, we can hope to mitigate them. From my point of view, to mitigate social inequalities we’d have to act in three directions simultaneously: Continue reading →

Can unnecessary hospitalizations be avoided?

18 Jun

Jordi Varela, Editor of the blog “Advances in Clinical Management“

It is said that the best savings in health is in avoidable hospitalisation that doesn’t occur, especially since the use of a hospital bed is the most expensive health resource of all the health offers, but also because if one person, let’s imagine an elderly one with several chronic conditions, can avoid being admitted in hospital, his/her health will suffer less compromising situations. For this reason, all health systems are very active in trying to launch all kinds of measures to reduce the admission of chronic and frail patients.

Dr. Sara Purdy, family physician and Senior Consultant at the University of Bristol, published under the auspices of the King’s Fund, in late 2010, an analysis of what actions reduce the unnecessary hospital admissions and which ones do not. The work of Dr. Purdy is focused only on organisational actions such as home hospitalisation or case management, and, in contrast, does not include strictly clinical factors such as the impact of a new drug for asthma conditions.

Continue reading →

New perspectives of assessment: good health outcomes in communities with unsatisfactory care

29 Jan

Mireia Espallargues. Head of Healthcare Quality AQuAS

Identifying patients with good results in communities with unsatisfactory care can be the key to finding success factors.

There are several initiatives that advocate a high value care in order to contribute to greater efficiency and sustainability of health systems. This value is interpreted as obtaining better health gains relative to the costs, which translates into better use of available resources (1). The more traditional approach to detect this potential value was based on the identification of patients with poor health in order to establish subsequent remedial measures that lead to a good result.

In an article published in The New England Journal of Medicine, Sequist and Taveras (2) propose to analyze the problem from a different perspective:

Identify patients who are doing good (“positive outliers“)
Analyze what factors may influence their good health
Disseminate the identified success factors and expand them to the rest of the system

To accomplish this, the authors propose a new approach to measure and analyze information. It’s about relating the supply system, the community and the patient in an effort integrated as a strategy with the aim of improving population health. This type of approach strengthens assessment models that AQuAS is applying in areas such as attention to chronicity and integrated health and social care in our country (3-5).

Health determinants and social determinants

According to the authors, the population’s health status is the result of a complex web of interactions between individual patient characteristics and other determinants of health dependent of the area of residence (community). The more evident is that most determinants that affect the health of people would be generated outside the health service delivery system. These factors, that some studies estimated constitute about 80%, have a profound effect on how the patients interact with the system and consequently, the quality of care they receive and their health outcomes.

Thus, the policies and the actions in areas such as housing, employment or social welfare can not be decoupled from assessments on health and from the health system. We must emphasize the need of introducing in the context of public and social policies, the concept of health as an item to be referred to in all its dimensions and evaluated in an integrated manner, together with other social determinants besides the health system (6).

The challenge of evaluating integrated care

Given this new approach it’s necessary to analyze the performance at the community level, usually focused on the area of residence. This analysis will allow provision system to obtain a better understanding of its population and identify where patients are grouped within communities, as well as what are the environmental factors that can affect health outcomes. This represents a quality leap beyond traditional analysis of each service providing system units (hospitals, primary care, care teams, etc.). Among the advantages of this new strategy we must specify the identification of patients who reside in communities where the quality of care and the results are not satisfactory, the detection of promising approaches for patients in these communities and integrating these successful strategies into care plans for the patients.

The definition of the community and the analysis of data for evaluation

To perform this type of assessment it’s necessary to first have a good working definition of “community” as well as a robust infrastructure for data analysis. The second step consists in identifying positive outliers – extreme values with good results- in communities with poor performance or with a high burden of disease – hotspot communities– more specifically, the identification of treated patients with good health outcome in an environment of unsatisfactory service provision and, in particular, those who historically had poor results and who recently improved. Once the success factors are identified, we would move on to the phase of climbing or extending the strategies in the rest of the territory.

In the precise case of the project assessment of the care for chronic diseases, the territories with programs or models of care to chronic diseases seeking greater care integration have been identified, given the large impact on morbidity and mortality and the use of resources caused by a complex chronic population. Consequently, the analysis from this territorial or community vision -taking into account the various healthcare resources and interventions in the territory- has allowed us to identify programs or models that perform better in relation to a number of health result indicators of various quality of care dimensions. This way we can select those that are “outstanding” (good outcomes for patients) and then identify good practices and success factors.

The last step is the integration of these strategies or models with the plans of patient care. Sequist and Taveras cite some other examples of community initiatives that relate to clinical practice (care or welfare services provision) as communicating vessels between the data analysis and the interventions that can be made in various areas.

This analytical approach can have several potential uses and can also be a powerful tool for addressing socioeconomic inequalities in health outcomes; as long as they focus on the differences at the context level, on patients’ membership to a community, on differences in gender, income, or education. Finally the authors mention that, as a prerequisite for a successful implementation, it’s necessary to have a well-defined operational infrastructure in which funding is aligned with the approach of linking the community and the health care.

Similarly, sustainability challenges also occur, as it may be that the service providing system “buys” this concept of factors that historically have been considered outside the area of influence or responsibility of health care. We must also ensure that resources and community interventions are safe and reliable if we want to have the support of professionals to refer patients to these resources as well as determining the most appropriate information updating intervals.

To conclude, we’re looking at an approach that instead of focusing on the “non-compliant” patients, it’s based on the observance and analysis of the best, especially in disadvantaged areas, with the purpose of applying the same keys to success to other territories.

Bibliography

(1) Porter ME. What is value in healthcare?. N Engl J Med. 2010;26:2477-81.

(2) Sequist TD, Taveras EM. Clinic-community linkages for high-value care. N Engl J Med. 2014;371(23):2148-50.

(3) Desenvolupament d’un marc conceptual i indicadors per avaluar l’atenció a la cronicitat. Primer informe. Barcelona: AQuAS; 2013.

(4) Consens i selecció d’indicadors per avaluar l’atenció a la cronicitat. Segon informe. Barcelona: AQuAS; 2013.

(5) Serra-Sutton V, Montané C, Pons JMV, Espallargues M. Avaluació externa de 9 models col•laboratius d’atenció social i sanitària a Catalunya. Barcelona: AQuAS; 2014 (en premsa).

(6) Determinants socials i econòmics de la salut. Efectes de la crisi econòmica en la salut de la població de Catalunya. Barcelona: Observatori del Sistema de Salut de Catalunya. AQuAS; 2014.