evidence – AQuAS Blog

Improving the quality of healthcare in Intensive Care Units. The PADRIS programme in the Tarragona Datathon 2018 (part one)

7 Feb

Last November, the AQuAS played an important role by means of the PADRIS programme in the Critical Care Data analysis Summit and Tarragona Datathon 2018. Talking about it has been in the pipeline since then.

The PADRIS programme contributes to the improvement of people’s health by making anonymised health information available for re-use by researchers in Catalan research centres, in compliance with the current legal framework and established principles.

Is this seen in practice based on a professional’s experience?

Today we interview Maria Bodi (@mariabodi23), doctor of the Intensive Care Medicine service in the Hospital Universitari de Tarragona Joan XXII, expert in clinical management and aspects of quality and safety in healthcare. Like many health professionals, she combines healthcare practice with research.

What is your day to day like?

As head of the Intensive Care Medicine Service at the hospital, in my day to day my basic task focuses on managing the service and organising the care for critical patients by coordinating the work of the professionals involved. More than 150 people work in the service including medical professionals (specialists in intensive medicine, resident intern doctors), nurses, nurse aids, ancillary staff, physiotherapists and secretaries. In addition, it is a service which participates and collaborates in the teaching of medical, nursing and physiotherapy degrees or certifications.

I try to facilitate the participation of professionals in the strategy of the service. This requires articulating and coordinating all efforts made with a clear objective in mind, which is providing quality care to our patients. To a greater or lesser degree, it is necessary to encourage and coordinate the participation of professionals in care-giving, management, teaching and research. This will guarantee the commitment of a worker in the service’s strategy and its organisation.

If we focus on medical professionals, each member of the team is in charge of a specific area of our speciality and we therefore provide ongoing training for the entire team, assess results and commit ourselves to carrying out actions which derive from the analysis of our results.

What do you think about the format that was used for the Datathon?

The Datathon was the result of a series of developments over recent years within the field of secondary use of data in patients’ clinical records for management and for research at a top level. The experience was very good. Pure science, with doctors, technicians and technology all at the service of real-life data analysis in order to find the best scientific evidence.

In the last three years, our group has delved deeper into the study of data and also into the assessment of the quality and safety of data for secondary use. Our progress has allowed us to collaborate with other leading teams such as the team of Dr Leo Celi of the Massachusetts Institute of Technology with whom we organised this event.

In your opinion, how can the quality of care be improved in intensive care units?

We have to aim for excellence. We need to tackle all the dimensions regarding quality of care. We need to improve effectiveness, safety and efficiency. But when talking about good and efficient results, we are not referring to the number of actions done at a particular cost. We are talking about bringing value to the patient, to the work team, the organisation, the health system and society. How is this achieved?

Our team has worked on developing a methodology which enables us to have automatic indicators of quality. This has been possible because all of a patient’s bedside devices (mechanical ventilation, monitoring, dialysis machines, etc.… ) are connected to the system of clinical information and this information, from the hospital’s clinical records, from laboratories and imaging tests, is integrated. This information is incorporated by professionals in an ordered manner.

By means of these indicators designed with innovative technology, it is possible to assess the processes of care and their results. If the professional participates in the design of a process of care, in its planning, and knows how things are being done and what results there are, they get involved and commit themselves to the aims of the service and the organisation.

Likewise, one needs to move from a reactive to predictive medicine, preventive and personalised. We have data with which to start working along these lines. Nevertheless, the scale and complexity of this data makes it difficult for methods of artificial intelligence to easily translate it into relevant clinical models. The application of cutting-edge predictive methods and data manipulation require collaborative skills between professionals who are medical and technology experts, as well as new models in the treatment and analysis of data.

We have read that it is possible to assess risk in an intensive care unit in real time. It seems difficult to imagine this. What can you tell us about it?

It can indeed. We work on the assumption that we have access to the data stored from all patients that have been admitted to an ICU, or in more than one ICU. If the combination of a group of variables (demographic, clinical, laboratory results) leads to a complication or an adverse event, a trained computer model using this data can predict the risk of the same complication or event occurring if it detects the combination of this group of variables. This is the basis of predictive medicine.

Understood, but in practical terms, what is purpose of assessing the possibility of a risk?

It can range anywhere from analysing a risk or predicting the appearance of a complication in the course of a disease, a problem of safety, an adverse event, the need for or an increase in dosage of a specific drug, to a specific therapy. It can predict the probability of an improvement or worsening and even the risk of death for a patient as a result of their disease.

Medicine already has calculators to assess a risk of death due to a disease based on data bases created by professionals using manual registers. But these days, with the automation of data registration- an example of this being the Clinical Information Systems in our ICUs – today’s methodology based on big data and artificial intelligence allows us to have much more detail when assessing risks.

When there is talk of moving towards a health model based on value, what does this mean exactly?

It is about organising work around the specific conditions of a patient which optimises their cure. It is a question of paying organisations and hospitals for the value they bring. Their results and their costs are the key components of the value which a health system and its professionals offer patients. But if we are talking about results, we are not only interested in whether a patient survives the ICU or not. Results are measured in terms of quality, their capacity of going back to their normal lives, their jobs, etc…

Therefore, to push efforts for improvement, we need to base ourselves on multidisciplinary work and a health model based on value; this means changing an organisation’s business model and investing in systems of measurement, analysis of clinical results and costs.

What importance do you attribute to the fact that data is obtained automatically and not manually?

It means data can be analysed using one source only, errors are minimised and a professional’s time is not required for the task of inputting the data.

How is the data included automatically?

In the ICU, clinical information systems now enable all information to be integrated. Apart from the data which professionals input in an ordered manner during the process of care of a critical patient, laboratory results, imaging tests, clinical records and the data from all a patient’s bedside devices are integrated too (mechanical ventilation, monitoring, dialysis machines, etc…).

What does “secondary use of data” mean?

Primary use is that which is used on a day to day basis, at the patient’s bedside, to take decisions relating to diagnosis, treatment and the planning of the process of care. For example, a decision is made whether to increase the dosage of a drug based on laboratory results.

We talk about secondary use when we refer to using data for management or for research. Obviously, the end aim is still the improvement of care for a patient.

(To be continued …)

Preventing overdiagnosis 2018: Three key points to reduce overdiagnosis

8 Nov

This year, the annual Preventing Overdiagnosis conference was held in Copenhagen, co-sponsored by the World Health Organisation, where delegates from about 30 countries attended.

The space generated in this conference provides the opportunity to approach the subject of how health professionals, researchers and patients can implement solutions to problems related to overdiagnosis, overtreatment and overuse by using the evidence available.

Overall, some of the subjects discussed were the implementation of recommendations to “stop doing”, the challenge of dealing with excessive diagnosis in clinical visits, the impact of overdiagnosis, the fact of converting citizens into patients and the role of risk factors in excessive diagnosis.

John Brodersen, professor of family medicine at the University of Copenhagen, started the conference by making a reflection on what is and what is not overdiagnosis. In general, overdiagnosis means turning people into patients unnecessarily by identifying problems that were never going to cause harm or by medicalising ordinary life through expanded definitions of diseases. This overdiagnosis can trigger a cascade of excessive treatments.

Later, Iona Heath, general practitioner and member of the Organising Committee of Preventing Overdiagnosis, asked the audience the question Why are we so afraid of normal? She reflected on why doctors are willing to rush into a diagnosis and pointed out that the task of defining “who is normal” is a challenge. Who should define who is normal and with what criteria?

Gisle Roksund, general practitioner in Norway stated that the general tendency in medicine is: “find it as soon as possible and do more”. Similarly, he pointed out that people are being labelled as ill with “pre” conditions when they are not. And he ended off by saying that life itself is a “pre-mortality” condition.

On his part, Paul Glasziou, general practitioner and professor at the Bond University in Australia, presented three key points to reduce overdiagnosis: reducing over-detection, over-definition and medicalisation. Juan Pablo Brito, endocrinologist and researcher at the Mayo Clinic, talked about a new term in his conference on diagnosis centred on the person: Extradiagnosis: when the diagnosis is not appropriate for the biology, context or preferences of a patient. The diagnosis centred on the patient is based on identifying the problem and carrying out actions to find the solution. That is, “reaching a conclusion together which makes intellectual, emotional and practical sense”.

In mental health, Allen Frances, psychiatrist in the United States, highlighted that overdiagnosis in psychiatry could be avoided if general practitioners had more time in their visits to get to know their patients better.

On the other hand, Steven Woloshin and Lisa Schartz, general internists and co-directors of the Center for Medicine and Media at The Dartmouth Institute, explained that some advertising campaigns could broaden the definition of diseases which can lead to an overdiagnosis and a medicalisation of life experiences. These reflections highlight the importance of having regulation related to these campaigns.

Lastly, the Preventing Overdiagnosis is a space which allows for the sharing of experiences, both theoretical and practical, of what is being done in the world with regards overdiagnosis and overtreatment.

From the AQuAS, and in collaboration with health professionals and scientific societies, the Essencial project in Catalonia tries to address these issues by contextualising them in our environment and by trying to implement recommendations that avoid low value practices and in consequence, an overuse.

Post written by Johanna Caro Mendivelso (@jmcaro103).

Health and poverty are hereditary: can we remedy this?

17 May

In recent years, child poverty has increased in Catalonia as a result of the economic crisis. According to the 2016 figures from the Idescat, the latest figures available, and from 2009, children are the group most at risk of poverty, more than the adult population and also more than the 65-year-old or older population group.

“Child health and poverty. What can we learn from the data?” was the title of the conference held within the framework of the Celebration of the 2018 World Health Day.

Data from the latest report related to children and the effects of the crisis on the health of the population were highlighted at the conference, published by the Observatory of the Health System of Catalonia: children with a lower socio-economic level present up to 5 times more morbidity, consume more pharmaceutical drugs (three times more psychotropic drugs) than the remainder of the child population, visit mental health centres more frequently (5.9% of girls and 11.4% of boys as opposed to 1.3% and 2.2% in girls and boys with a higher socio-economic level) and are admitted more to hospitals (45 girls and 58 boys for every 1000 as opposed to 13 and 26, respectively) especially for psychiatric reasons.

A child’s health largely depends on the economy of their parents and those that belong to families with a lower socio-economic level have more health problems, a fact that can have disastrous consequences in other areas such as education and social life and which condition their future. This fact is exacerbated in the case of children with special needs or chronic diseases where their health suffers even more from the effects of poverty because in some cases their care requires specific products which families cannot afford.

This is one of the problems that we are facing right now. There is growing scientific evidence, both in biology and in social sciences, of the importance of the early years in life (including exposure in the womb) in the development of the capacities that stimulate personal well-being throughout the life cycle. Childhood is also a structural transmitter of inequalities, both from a health and socio-economic point of view. If nothing is done, boys and girls who belong to families with few resources run the risk of growing up into adults with worse health and a lower educational and socio-economic level than others.

What can we do? We can of course strengthen the social welfare state, with structural and institutional reforms which are more than ever necessary. Educational policy is fundamental, especially by reinforcing primary education, guaranteeing equal opportunities and putting the spotlight on those children in a disadvantaged situation. Once they are adult, active labour policies are also needed. And from health policies, despite their eminently palliative nature, primary and community care is particularly important as is guaranteeing care to all children.

Post written by Anna García-Altés (@annagaal).

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.

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

14 Dec

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

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

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

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

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

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

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

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

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

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

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

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

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

Post written by Sònia Abilleira.

PEGASO: Fit For Future: connected health and long-term strategy

16 Nov

Developing a platform based on mHealth that has mobile applications (apps), a game and intelligent sensors has been the goal of the European project PEGASO Fit For Future, which began in December 2013 and ended last July.

It is a platform that aims to improve both the lifestyles of adolescents (diet, physical activity and hours of sleep) and the knowledge that they might have about these life styles. To achieve this, intelligent sensors (t-shirt and bracelet) which record the physical activity and hours of sleep of an individual and also different apps which record the intake of food by means of a diary and footsteps taken by means of an accelerometer were developed and tested.

The PEGASO Fit For Future platform detects which lifestyles a user has and makes recommendations on how to improve them. In addition, it incorporates a gamification component: based on how healthy the lifestyle of a user is as well as how much their knowledge improves, which are then converted into obtaining a greater or lesser amount of points.

As an example, here we can see a screenshot of a fictitious user:

Professionals from different areas collaborated in the project: developers of games, apps and sensors, design and gaming experts, health professionals (doctors, nurses, experts in nutrition, experts in physical activity and psychologists) and also experts in health technology assessment and public health.

There were two different phases of the project: the development phase of the platform and the assessment phase.

During the development phase, while some professionals put their efforts into ensuring the quality and appropriateness of the medical and clinical content of the platform, others concentrated on aspects of a technological nature.

Nevertheless, the opinions of the end users themselves, adolescents, were always kept in mind during this process. In three iterative stages, boys and girls in Catalonia, Lombardy, England and Scotland tested this technology out in the different stages of its development.

The proposals for improvement made by the adolescents including their preferences were, whenever possible, kept in mind for the later versions of the platform. The aim was to guarantee as far as possible that what was being developed was practical for and accepted by the end users.

The last stage of the project was the assessment of the platform. The assessment of the different elements (apps, games and sensors) was to see if they really did help to improve the lifestyles and knowledge about lifestyles among adolescents and to assess the experience of the user after having used the platform.

To this end, a pilot study was carried out with adolescents from Catalonia, Lombardy, Scotland and England in which 365 mobile phones with the PEGASO platform installed were used by adolescents.

After six months of use, the intervention was assessed by means of validated questionnaires, a qualitative methodology and data obtained from the platform itself. A control group was introduced allowing for comparisons to be made with adolescents that did not have access to the platform.

The results of this study will help to evaluate whether new technologies are practical in helping adolescents improve both their lifestyles and knowledge about these lifestyles, a population group accustomed to using new technologies and that, in general, do not often visit health professionals.

Getting closer to the population by using mobile technology and the recreational aspect of gaming could be a good strategy for an intervention of this type related to the promotion of healthy lifestyles among adolescents. At a population level, it is a long-term strategy and hence the slogan “Fit For Future” of the PEGASO project.

Post written by Elisa Puigdomènech.

Time to digitally disconnect?

14 Sep

It is very common to see groups of people looking at their mobile devices in any place at any time: on holiday, at work, at home, in the underground, on the bus, in a congress, ….. wherever. It is also common to take advantage of our holidays to say that we will make the most of these days to disconnect from our routines. Does this include disconnecting our mobile phones, tablets, laptops, the TV or email?

At AQuAS, as an agency involved in health assessment, we do not know this. What we do know is that there is more and more talk of connected health, a term which includes mHealth, eHealth and all related concepts, which have been a part of everyday life for some time now.

At a level of the Catalan system of health, we have in this post by Òscar Solans an example of the development of technological tools which involve new ways of interaction between patients and the health system. In this way, La Meva Salut and eConsult are useful tools when placing the patient, the person that is, at the centre of all the interactions there are with the health professionals coming from different fields.

At a European level, Jean Patrick Mathieu and Rossana Alessandrello wrote about how complex the subjects of interoperability and the implementation of mobile technological solutions are, in this other post. This was the framework for the European project DECIPHER whose goal was to facilitate the access to health information from different countries and health systems.

Let’s change the perspective. At an individual level, who does not have an app downloaded on their mobile phone? Which of these apps have to do with something related to health, such as weight control, for example, or as support when doing physical exercise, to keep track of menstrual cycles, fertility calendars or aspects of mental and emotional health? And no need to limit ourselves to talking about mobile devices: who has not heard of calculators for aspects of health such as calculators of life expectancy?

Downloading an app is very easy and can even be free. In this post by Elisa Puigdomènech, she highlighted the fact that in mid-2016 The Economist explained there were some 165,000 apps related to health. This figure must no doubt have increased.

What does the success of an app depend on? What guarantees of quality and safety do they offer?

Regarding the first question, the user experience was the subject on which Elisa Puigdomènech put the emphasis, based on the experience obtained in the PEGASO project. Along the same lines, Santi Gómez spoke about the fact that the development of a health application must, in all phases of its development, include the participation of those who will ultimately be the end users.

And in terms of the second question, any health intervention should be safe, be based on evidence, on the best quality knowledge available and should be assessable. This is the premise with which we at the AQuAS work and this is the role that an assessment agency can play when thinking about connected health. Thus, this post by Toni Dedéu places the emphasis on the fact that technologists, assessors, professionals and citizens have the opportunity to work together and combine their expertise but not forgetting the speed of innovation.

In conclusion, the assessment of connected health is a current topic. This article was recently published, and is a good example of a proposal for a conceptual framework. We end this post with an editorial about innovation and evidence which invites one to reflect on assessment and innovation.

Post written by Marta Millaret (@MartaMillaret)

Crisis, inequalities and policies: proposed intinerary

7 Sep

Unfortunately, inequalities in health are still an issue today including in our country. The crisis of recent years has once again put the spotlight on this subject.

This is why we propose an itinerary taking us through the different texts which we have published on the subject in this blog and, in particular, we invite you to read the original texts which are mentioned here in more depth, a large proportion of which have been elaborated at the AQuAS.

In September of last year, Luis Rajmil reflected on social inequalities in child health and the economic crisis in this post placing the concepts of equality, equity and reality on the agenda for discussion.

“At present, there is enough accumulated information that shows that life’s course and the conditions of prenatal life as well as life during the first few years are very influential factors in the health and social participation of an adult to come.”

At a later date, the Observatory of the effects of the crisis on the health of the population published its third report but prior to that, a post was published with a collection of individual thoughts and reflections on this subject by Xavier Trabado, Angelina González and Andreu Segura focussing on, respectively, the effects of the crisis on the mental health of people, the coordination of different mechanisms in primary and specialised care, the urgency for community health actions and the need to engage in intersectoral actions.

“It is urgent to put community health processes into action; processes in which the community is the protagonist, which constitute the shift from treating an illness to a bio-psycho-social approach which gives an impulse to intersectoral work in a network with local agents, with who there is the shared aim of improving the community’s well-being. Based on the needs detected and prioritised in a participatory way and with the local assets identified, these processes activate interventions based on evidence which are assessed”

In this other post, Cristina Colls presented an interesting case of the application of scientific evidence to political action which occurred with the revision of the socio-economic dimension of the formula for allocating resources to primary care.

“Social inequality leads to an unbalanced distribution of the population in a territory, concentrating the most serious social problems in certain municipalities or neighbourhoods having higher needs for social and health services than other territories. In this context, more needs to be done where needs are greater if the aim is to guarantee equality in the allocation of resources”

Finally, the most recent post was written by Anna García-Altés and Guillem López-Casanovas. It is a text that provides food for thought based on the latest report published from the Observatory of the Health System of Catalonia on the effects of the crisis on the health of the population.

“Understanding the mechanisms by which social inequalities have an impact on the health of the population, so as to know how best to counter or neutralise them, in any place and at any time, is an issue that must still be addressed by our social policies”

We hope that you this very short itinerary through these texts, initiatives and analyses that aim to be useful in tackling inequalities has been of interest.

Post written by Marta Millaret (@MartaMillaret)

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

9 Mar

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

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

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

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

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

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

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

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

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

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

Artroplàsties PTM

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

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

Artroplàsties -taula

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

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

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

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

22 Dec

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.

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

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