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.
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).
What is it that makes a particular research have an impact on society beyond the strictly academic and which is truly transformative? Can a whole series of actions be planned in the way that one follows a cooking recipe which leads directly to the desired social impact? Unfortunately, the answer is no. The impact is multifactorial and depends on so many different elements and actors that it is difficult to establish a formula to guarantee it.
However, having said that, the fact that there is research which has a particular social impact does not mean that it is a totally random phenomenon and that there is no way of predicting, facilitating or promoting it. Years ago, from the Research Assessment group at the Agency for Health Quality and Assessment of Catalonia (AQuAS), and with the help and complicity of the International School on Research Impact Assessment, ISRIA, we identified a series of facilitators with regards the impact of research.
A fundamental facilitator is people, and the values, culture and capacity of leadership they have. Two identical results of research can have different impacts if the capacity of leadership, drive and will to get beyond academic impact is different. But this is still not enough. The strategy, organisation, collaborations and openness that institutions have will be a great facilitator or barrier for the researchers that have carried out the research.
Finally, both people and institutions will need two indispensable elements in order to aspire to having an impact: on the one hand, a close and effective communication with the different social actors that can play a role in transferring the results of research, and on the other, an approach focused on the participation of all these key players.
To paraphrase Confucius when he said “explain it to me and I will forget, show me and maybe I will remember, involve me and I will understand”, it is all about involving all the necessary actors to bring about a real change and make research transformative.
It is in this context that SARIS (Catalan acronym) came into being, the Assessment System of Research and Innovation in Health. It is a strategic tool which emerged from the PERIS (Strategic Plan for Research and Innovation in Health 2016-2020) with the aim of assessing the research carried out in health in Catalonia from the perspective of always wanting to facilitate and influence so that it has an impact beyond academia. To do this, the motivation and involvement of actors has been defined as a key factor for its development.
Last November, we started a series of participative sessions with nurses who were selected from the PERIS 2017 call in which a line of intensification of nursing professionals was financed.
It is important to emphasise that launching this line with nursing research makes full sense for three reasons: on the one hand, one of the thematic priorities of the PERIS is clearly that of “the development of clinical and translational research which facilitates the growth of scientific and technological knowledge, putting special emphasis on primary care agents and research in nursing”. In addition, the PERIS 2017 nursing fund has been the first to come to an end and it was appropriate to address ourselves to them first and foremost.
Last but not least, the conditions in which nursing research is carried out, with patients and their recovery as its central goal, makes it especially appropriate to ensure that this research has a direct impact on health. Hence, it is important that the research done in nursing be capable of demonstrating the impact that this group of professionals has because it can give it a comparative advantage with regards other biomedical disciplines. Indeed, nursing research is intrinsically translational.
Therefore, the first session centred on identifying the influential actors and in empowering the nurse to carry out an effective communication which amplifies the productive interactions needed to transform the results obtained into benefits for a better and improved health for patients.
We would like to express our deepest gratitude to the nurses for their participation (readiness and motivation) who attended of their own free will and in their time off work ensuring thus that the session was a success. This demonstrates that from the AQuAS we have leverage to give support to those researchers who are motivated to driving the impact of their research.
At present, we are preparing other sessions that will enable mutual learning between researchers and the assessment agents at the AQuAS.
For years, I have been under the impression of not having a clear idea of how information related to the complex world of medicine and health should be disseminated in the daily news media, both of the science that it is based on and of the difficulties and dilemmas in applying it in practice.
I have repeatedly refused offers, with only rare exceptions, to write texts on these subjects in newspapers or books of a non-professional nature: I had serious doubts of how to transmit this knowledge to the public at large. Looking back critically on these reservations I have had, I think they have been related to the paternalism inherent in the medical training received by the professionals of my generation: the fear that the public will make an incorrect interpretation and come to abhorrent conclusions of the facts disseminated, an audience with little knowledge on the theoretical foundations and subtleties of these facts, which are only accessible with proper professional training. Indeed, experience has shown me that these reservations were indeed justified.
However, at the same time, I have witnessed the growth of citizens’ autonomy, now widely acknowledged, and their right to take “informed decisions”. This position, which has come to define the 21st Century as “the patients’ century”, acknowledges their right to know relevant professional data so as to be able to take accurate decisions autonomously; it has an undeniable foundation but if we are to avoid that this leads to the proliferation of distorted facts it will require a rigorous preparation and an absence of spurious interests on the part of those divulging information. Ideally, these informants should contribute to “health literacy” in a way that is balanced, objective and unemotional.
The tension between these two conceptions of health information goes in parallel with that which exists between two extreme views of the doctor-patient relationship: the classical paternalistic one (“the doctor knows better than anyone what is best for a patient and their decision must be accepted”) and that of the “informed consumer” with autonomous decisions. The other extreme of this corresponds to an “imminent revolution” in which it would be the very well-informed patient, (basically as a result of the spread of refined computer technology) that would take the most important decisions concerning themselves.
Personally, like many others, I prefer a more balanced approach: that corresponding to the “interpretative” and “deliberative” models of the doctor-patient relationship, in which the experience and knowledge of the former interact with the latter respecting their autonomy.
I think that this dilemma runs parallel to the medical information found in daily news media: on the one hand, there is the social demand to inform citizens of current advances so they know their options or opportunities as “informed consumers”; on the other, there is the temptation to fuel the emotions (triumphalism or fear) of the reader who is untrained by offering them information which is largely uncritical, lacks rigour or is insufficient, with the risk of a biased, distorted or exaggerated interpretation. The more or less unreal notions that some informants may have on medical and health problems (common, alas, among many professionals) can be transmitted like this directly to the citizen and to their emotions and desires.
In the case of news related to medical advances and innovations, I would like citizens to know what expectations these novelties raise, maybe now within their reach, and the magnitude or relevance of the problem that can be lessened or resolved, and that this be done by using a rigorous and prudent terminology so that citizens can also create their own opinion on the solidity or temporariness of an innovation, and of the related uncertainties and limitations: not only of the benefits that they can provide them with but also of the undesired, uncomfortable or harmful side effects they might produce, and whether they are in anyway frequent or probable. In other words, I would not like the main aim of this information to be that of creating hope or fear in the reader, or give them the idea in a triumphal tone that in the wonderful world of science, the war against disease has claimed a new victory, especially at the hands of local researchers.
Even though some well-documented news described in sufficient detail was found that could provide balanced information to the reader in this analysis, in many other cases the information was one-sided or not very thorough and was devoid of facts related to questionable aspects of the innovation and their risks. It resulted in a biased message which often tended to induce optimism in the reader rather than educate them in the knowledge of the pros and cons of the medical innovations.
At a time when there is a call for a user’s well-informed autonomy, I would be delighted if healthcare culture and the attitude of the news media did not amount to a paternalistic doctor-patient relationship. In this regard, there is no doubt that much still needs to be done.
Post written by Gaietà Permanyer Miralda. Emeritus physician. Unit of Epidemiology, Cardiology Service. Hospital Vall d’Hebron, Barcelona.
During the fifth edition of the international Preventing Overdiagnosis Congress, strategies for implementing solutions to avoid overdiagnosis and overuse were addressed based on the available scientific evidence.
In this year’s edition, which was held in Barcelona last year, apart from the involvement of professionals and organisations, patients had the opportunity to actively participate.
Experiences in different healthcare areas were shown in the use of best practices to communicate and to empower patients to achieve a better understanding of shared decisions.
Different world initiatives addressed the best practices to empower citizens in subjects related to low value practices, overdiagnosis and overtreatment. Experiences were shared and a debate was initiated on fundamental subjects such as the communication and participation of patients.
In recent years, the Essencial Project has studied the perspective of health professionals on low value practices, their causes and possible solutions so as to avoid them.
For example, in a previous post, we explained the results of a survey we carried out with professionals in the field of primary care. The results of this survey highlighted the need to involve and empower the population more. Patients are also important decision makers in relation to their needs and in the demand for certain health services. Hence, the project must be accompanied by a communications strategy aimed not only at patients but also at citizens in general.
That is why we, from the Essencial Project, have been interested in finding out the opinion of patients in addition to the perspective of professionals. In the international Preventing Overdiagnosis 2017 Congress we participated explaining how an exploratory first approach was made to identify the beliefs, attitudes and perceptions of patients regarding the most important elements in consultations, low value practices and the essential components of an effective dialogue between professionals and patients. The end purpose of this was to understand the position of people before initiating possible interventions in the citizenry and to determine the most effective communicative tools and channels.
In Catalonia, AQuAS carried out the first exploratory qualitative study at the end of 2016 using a focus group of parents and children assigned to a primary care team. Low value practices in paediatrics are frequently associated with an over-diagnosis regarding antibiotics, bronchodilatadors, antipyretics or imaging tests, among others. These scenarios have been transferred to the debate with patients themselves. In total, seven women, mothers and grandmother of 14 children participated.
The first point of discussion was the most important elements in a consultation with health professionals and it was found that the treatment (29%) and information received (28%) are the most important elements received by professionals (representing approximately 60% of those mentioned). The relationship with the professional comes next (15%, often related to the degree of trust), followed by the feeling that their wishes or needs are met (12%), information requested (9%) and the diagnosis (5%).
The participants did not know the concept of low value practice but did recognise situations of an excessive prescription of medication or the request of unnecessary tests, especially in emergency services and private consultations.
Regarding communication, the participants said they appreciated that professionals communicate in a simple and direct manner, explaining the reasons for decisions. Similarly, that they felt it was important to receive printed information from professionals which they could peruse later at home. They also said they would like more informative sessions or community groups where these types of subjects could be explained to them and so gain more knowledge about these types of practices.
In our context, this is the first exploratory study done to identify low value practices and the communicative strategies of the citizenry, being the start of a series of studies on the population. Nonetheless, one of the limitations with which we find ourselves was that the participation was lower than expected. Although the term ‘low value practices’ is not known, participants identify situations in which they have experienced them.
Similarly, it is important to underline how patients value the treatment and information received as well as the professional-patient relationship. In the same way, patients recognise the need for a professional’s communication skills and the need for tools to support an effective communicative exchange.
Post written by Johanna Caro Mendivelso (@jmcaro103).
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.
What motivates this interest is also something shared: the feeling that the involvement of patients in important decisions must inevitably reduce costs and improve clinical outcomes. It is also a general phenomenon that doctors feel cornered by this new expectation adding to their already existing agendas that compete for the meagre 7 minutes per patient.
In light of this reality, the promises to take shared decisions that better reflect the situation of a patient and how to deal with it, based on the informed participation of the patient, end up putting the onus on the patient of taking decisions by means of tools in web pages or on printed forms. But what about sharing the process of taking decisions? Corporate poetry, an academic dream.
Taking shared decisions requires patients and clinicians to work together so as to mutually agree on the best way to proceed in order to improve the patient’s situation. The outcome of this effort is a plan of care. To establish this plan it is important to understand what the situation of the patient is and what action is needed, as well as the options available to respond to the demands that the situation dictates in the best way.
The conclusion reached must make sense, intellectually, emotionally and practically. That is, the plan must reflect the best medical science, it has to be agreeable within the biological and biographical circumstances of the patient and be able to be implemented with the least possible inconvenience in the life of the patient. This work is not for the patient to do, nor the clinician, but for both. It is challenging and is based on a clinician-patient relationship, and it takes time.
Many clinicians tell me that they already take decisions together with their patients. This is not evident when we watch videos of clinical encounters in North America (15-30 minutes in length). In these, we see clinicians interrupting patients after less than 11 seconds from the time a patient begins talking, using humour to avoid emotional situations and offering recommendations before listening to the patient’s point of view.
Victor M.Montori in the Shared Decisions Conference (SCGS and AQuAS). Barcelona, 19 May 2017
The fact that patients want to participate or that they do in fact participate actively in the taking of decisions is not evident either and yet, patients report high levels of satisfaction in the way that decisions are taken. However, a critical look reveals that many decisions are taken without patients realising it, given that these decisions are disguised as the logical steps to follow in managing a problem rather than being opportunities for the patient to contribute in the process with their opinion, point of view, experience and knowledge.
The effort of converting the taking of shared decisions from what it is (a unicorn) to what it should be (something routine in the care of patients) is enormous and full of uncertainty. There is no country, in my opinion, nor any health system which is at the forefront on this subject. At the tail end, there are of course countless systems that are still hugely in debt with their populations for not yet having been able to guarantee universal access to health with minimum levels of quality and safety.
What those at the forefront need to do, in my opinion, has more to do with attitude and opportunity than with tools or incentive and training programmes. The latter must be there when attitude and opportunity appear.
In my visit to Barcelona I saw great willingness, but with noticeable limitations in attitude and opportunity. In attitude, as health professionals we need to value what patients know about their context, about their biology and biography and about the way in which they want to lead their lives.
We must acknowledge how essential it is that treatment plans make sense and that it is possible to implement them in the lives of patients, especially in the case of chronic patients. And we must be aware that practical guides and other management tools for management are useful to guide our treatment of “patients like these” but are not enough to determine the treatment for “this patient”.
But attitude is not enough. In addition, we need to work at creating opportunities for conversation between clinicians and patients and that these become therapeutic relationships. I believe that our intellect has evolved in the taking of decisions with others. In the same way that I believe in deliberative democracy for social problems, I believe in taking shared decisions for clinical problems.
Clinical problems are not simple (such as in the problem of baking biscuits, with a known recipe and ingredients and an expected result), they are not complicated problems (like flying a 747, with algorithms and feedback that lets one be confident of achieving the desired result) but they are complex problems (like raising a child, with known ingredients, without a recipe or algorithms and with sometimes unexpected results).
Complex problems cannot be solved by technical investments only. These are solved within human relations. Specific results cannot be expected, but one can respond to adverse situations with resilience. Without the fuel of opportunity for this, the flame of a favourable attitude in the taking of shared decisions will be extinguished in the end.
The taking of shared decisions needs human relations between clinician and patient to resolve the human problems of the patient with resilience. In turn, the solution of these problems requires decisions to be shared for the solution to make intellectual, emotional and practical sense in the life of the patient.
Besides attitude and opportunity, it is important to have interpersonal skills (or train up to acquire whatever is possible) so as to communicate with a patient with empathy, to understand their situation and to assess each reasonable option in the context of a conversation.
In this context, tools based on evidence designed specifically to support these conversations can be useful and can facilitate the efficient taking of shared decisions in any context, from emergencies to specialised care.
I am aware that many have found the motivation to participate in taking shared decisions thanks to training or the use of tools for taking shared decisions. This makes it important to understand what is necessary and where so that taking shared decisions becomes routine practice in the care of patients.
But what does all this effort achieve? Many colleagues say that the taking of shared decisions can improve clinical outcomes, the adherence to treatments, the use of services and the costs of care. Taking shared decisions might also help in preventing global warming.
My critical appraisal of the evidence available does not allow me to discern any of these benefits with a sufficient level of certainty. This forces us to consider why we must thus make the effort to create the conditions to be able to take shared decisions and to implement this as routine practice.
For me, as a clinician, the answer comes by means of understanding the aim of a treatment, of clinical care as well as by allowing each patient to fulfil their dreams with the least pathological interruption and the least therapeutic inconvenience possible. To achieve this, we need to design treatments that respond to a patient’s situation – seen in high definition – treatments that make sense for the patient, and a clinician cannot do this without the patient.
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.
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.
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.
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.
In recent years, the debate about what we should do with health apps has centred around accreditation, certification or assessment. At the same time, multiple lists of health apps recommended by a range of known and recognised initiatives have been drawn up.
In this context, and with the Mobile World Congress 2017 in Barcelona in full swing, we can ask ourselves what role a Health Technology Assessment (HTA) agency has when considering mHealth.
There is a reality which we cannot evade. Any health intervention needs to be based on evidence, on knowledge of the highest quality at hand, and must be evaluated.
This cannot be done by turning our backs on the real world or innovation. A health app is a tool to carry out a health intervention and so health apps need to be seen as just another intervention, but of course, with some characteristics of their own which will mean there is an extra demand placed on one and all.
Technologists, HTA experts, professionals and citizens have the opportunity to understand each other if we want to be facilitators of recommending safe apps in health. We are not talking about initiatives that can be developed from one sector only and it is not only about apps.
Now more than ever, we need to be flexible and work from a multidisciplinary position. We already talk about co-creation and co-design; quite simply, of co-produced mHealth initiatives based on the expertise of multiple agents including, obviously, citizens.
AQuAS is participating in the assessment of several mHealth projects financed by the European Commission. The PEGASO project stands out, centred on promoting healthy lifestyles among adolescents, and DECIPHER, as an integral solution to facilitate the geographical mobility of patients with chronic diseases such as diabetes type 2 and m-resist, centred on schizophrenia and patients resistant to treatment.
We are faced with the challenge of integrating totally different fields such as the language of technologists and developers; the speed of innovation and the culture of assessment. In addition, this needs to be done without losing sight of the key role of scientific societies and the different points of view of health professionals and end users.
We know there is a lot of work to be done. Technologists and experts in health technology assessment, respectively, have the opportunity to learn a lot from each other. It is about sharing knowledge and expertise to facilitate, ultimately, health tools for citizens and professionals, which have been assessed, are based on evidence, are safe and reliable and have a strong collaborative component.
Post written by Toni Dedéu (@Toni_Dedéu) and Elisa Puigdomènech.
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.
Stroke has a high incidence, a growing prevalence and is the pathology with the second highest impact in the world in terms of disability among adults. Despite important advances in acute stroke management, which have led to a progressive decrease in acute stroke deaths, in terms of residual disability, stroke continues to have an extremely high impact on survivors, their families, their caregivers and on society in general.
On the other hand, and in self-criticism, even though stroke is one of the main reasons for using intermediate or long-term healthcare services, this sector almost never takes part in the decision making process of stroke care organisation. Neither does it do much research in stroke and in general, tends to put little thought into improving knowledge in treatments or in innovating the organisation of services compared to, for example, other conditions such as thighbone fractures.
This is why the Parc Sanitari Pere Virgili organised a monothematic symposium on 27 October, two days before the World Stroke Day. It focused on the treatment and management of stroke in elderly people from a different perspective: we traced the trajectory from the “needle” of the thrombolysis in the acute phase, passing through rehabilitative care and “reablement” in the post-acute phase, to the transition back to home life, describing the care given to patients especially, but not forgetting the attention caregivers need.
The presentations reflected and reinforced the need for a multidisciplinary approach in all phases of stroke. As an added value, in all cases the speakers not only combined recommendations derived from literature with their own practical healthcare experience but also provided data from their own research or innovation projects, in many cases with data published recently.
Among the speakers there was a varied representation from very different disciplines which included neurologists, geriatricians, physiotherapists, occupational therapists, speech therapists, social workers, a health economist and the representative of the stroke patients association who chaired a roundtable.
Some of the items that were highlighted most strongly during the symposium were:
The large amount of increasingly more accurate data available on all phases of stroke management. In Catalonia, this data is being provided by the Results Centre, which encourages transparency and allows for benchmarking thereby facilitating a reduction in variability and the sharing of best practices.
Despite improvements in the treatment of acute stroke patients using mechanical thrombectomy together with systemic thrombolysis, 40% of patients are left with a considerable disability as a consequence of stroke. This “glass half-full” should therefore encourage more to be done in terms of acute stroke management, and also in post-acute care which is still vital.
In acute care, age should not be a discriminating factor. This is in line with the concept that chronological age does not correspond necessarily to biological age and that two elderly people of the same age can have a totally different “functional potential” (a concept which in practice in the field of geriatrics is understood as meaning more or less “frail”).
Advances have not only been made in acute care but also in the field of primary and secondary preventive care. Accordingly, the development, the approval of and the use of NOACs (new oral anticoagulants) have been a determining factor since they offer an alternative for those patients where traditional anticoagulants are not a therapeutic option.
The rehabilitation prognosis is multifactorial. A recent proposal stemming from a multi-centre Catalan study led by our hospital and published recently, is based on a simple algorithm which incorporates the social factor (presence of the caregiver) together with the severity of the stroke (using the NIHSS score), functional status (according to the Barthel index) and cognitive function (a result of the Rancho Los Amigos scale). This allows patients to be classified in three levels of rehabilitation complexity, but who might evolve differently, with different needs for intervention, both in the rehabilitation process and regarding their return home.
Integrated interventions in geriatric rehabilitation can be home-based for certain patients as an alternative to a hospital admission. This model, deeply rooted in England and which has proven to be beneficial, is producing good results in our context in different pathologies including stroke. Innovative formulas such as “Comprehensive Home-based Hospitalisation” have, in our context, come about from the alliance between home-based geriatric care teams (doctor, nurse and social worker) and those of home-based rehabilitation (rehabilitation doctor, physiotherapist, occupational therapist and speech therapist).
In terms of physiotherapy, treatments should be more standardised and their efficacy demonstrated. During the symposium, interesting evidence was presented on the control of the trunk and its importance throughout the rehabilitation process in stroke.
Dysphagia is a very prevalent risk condition in patients who have suffered a stroke. Different proposals of scales for assessment at the bedside were shown which can be applied by nurses, reserving the speech therapist’s intervention for the most complex cases which require a more specialised assessment.
In rehabilitation, the support from the ICT (“telerehabilitation” which patients can receive following the instructions and programme configuration of the physiotherapist) allows treatments to be extended in time and intensity along with face-to-face treatment.
Working with caregivers is important. Apart from guiding them within the system, the availability of support groups for exchanging personal experiences, for a social worker, for example, could have an impact on the adaptation of the caregiver to the new situation. To this effect, an innovative experience was developed in our centre with a high degree of acceptance by patients and their families.
Continuity in the recovery process is key and the integration of health and social services guarantees an added value. The pilot “Return Programme” in the city of Barcelona, the result of the alliance between the Catalan Health Service and the City Council of Barcelona was presented. It allows for the direct activation of social services, from acute care and long-term care hospitals so that patients can receive the necessary aid when they return home and thus avoid unnecessary and dangerous delays.
In summary, much progress has been made in the treatment of stroke, especially in the acute phase, but innovation is also being carried out in the successive phases and the symposium showcased different experiences which have been implemented in our context. Drawing conclusions from the symposium, the take home messages are that a comprehensive view of the entire process is key, as well as an integrated and coordinated approach between the different levels of healthcare and social services. On the other hand, more research needs to be carried out especially in the post-acute and chronic phases resulting from the disease and this poses a challenge because of the difficulty in designing and implementing complex interventions where designs such as standard clinical trials are not the solution.
Post written by Marco Inzitari (@marcoinzi) and Laura Mónica Pérez, Parc Sanitari Pere Virgili, Barcelona.