The challenges of medical practice variations

Medical Practice Variations

The title of this post is not original, it is really from a book published in 1990, 27 years ago! And Wennberg started such research on the 70's. What is new is the book "Medical Practice Variations" released last year. After all these years concerns have spread, methodological improvement is huge, and unfortunately evidence says that practice still shows wide range of variability. This is the main concern, what to do about it.
The description is excellent, 23 chapters and 527 pages reflect an effort of many years of several projects on the issue. A must read is the chapter 4, p. 53 by Enrique Bernal and his team: Medical Practice Variations in Elective Surgery. Variations may harm and produce waste, therefore understanding how to prevent low-value care is crucial. They say:

Two key steps in reducing low-value care, proposed by García-Armesto et al. (García-Armesto et al. 2013), are the following:
• Identifying those technologies ineffective in their usual indications or less effective than alternatives
– Dropping them from the benefits basket or making them subject to avoidable copayments
– Restricting indications to certain types of patients (choice guided by evidence of positive benefit/risk balance)
– Specifying and limiting the types of providers more suitable to offer each service (therefore substantiating indication becomes a requisite, discouraging irrelevant use)
– Capping the frequency or length of treatments
• Producing and making available guidance on a regular basis to reduce inappropriate use of procedures
– Highlighting and tackling unwarranted variations in elective surgery (naming and “shaming” to prompt query and change)
– Fostering best practices and improving coordination of care

As I said, a must read. Congratulations to the authors. Unfortunately the barrier is the price: $279. Notwithstanding that, health policy makers and managers should have it as a key reference for their decisions.

PS. If you want to know more about current projects, check the ECHO  website.

Unwarranted variations, what's next?

Geographic Variations in Health CareWhat Do We Know and What Can Be Done to Improve Health System Performance?

We all know that there are unwarranted variations in health care. Unfortunately we haven't the same analysis about the drivers and its impact on health outcomes for such variations. OECD has just released a report on this topic, and suggests the following:

Eight types of policies might be envisaged:
• Public reporting on geographical variations, in order to raise questions among stakeholders and prompt actions, particularly in “outlier” regions.
• Setting targets at the regional level can support public reporting and help promoting  appropriate use.
• The re-allocation of resources to increase (or reduce) supply of resources (e.g., beds, doctors) in regions with low (or high) utilisation rates.
• Establishment and implementation of clinical guidelines in order to promote greater consistency in clinical practice.
• Provider-level reporting and feedback to improve clinical practice and discourage unnecessary provision of health services.
• Changes in payment systems to promote higher (or lower) use when there is high suspicion of underuse (or overuse).
• The measurement of health outcomes, to promote greater consistency in clinical practice that ensures improved patient outcomes.
• The utilisation of decision aids for patients, to promote more informed decisions about benefits and risks of various interventions, and to better respond to patient preferences.

These proposals fall short in my opinion. After a decade of publishing information on variations, public reporting has not raised deep questions for "stakeholders", at least as far as I know. Incentives have not changed substantially in order to reduce differences in utilization. Current payment systems require a redefinition from scratch in order to take into account such issues. Any citizen should be concerned about the results of the report. Something should be done.

PS. By the way, regarding OECD recommendations, they have not explained clearly what Wennberg suggested: shared decision making

PS. Bad journalism at LV. Why CAC doesn't care about complaints on written press.

Ferrando at Galeria Barnadas

La fascinació tecnológica

Sabem que hi ha variacions a la pràctica mèdica. S'han documentat de fa temps. Fa 5 anys, en un article de Peiró-Bernal s'avançava la hipòtesi de fascinació tecnològica per explicar les variacions, més enllà dels supòsits habituals de Wennberg.
Ara en Chandra-Skinner ens mostren una categorització de com la tecnologia afecta a la millora de la salut. Resumidament seria així:

(I) highly cost-effective “home run” innovations with little chance of overuse, such as
anti-retroviral therapy for HIV, (II) treatments highly effective for some but not for all (e.g. stents), and (III) “gray area” treatments with uncertain clinical value such as ICU days among chronically ill patients. Not surprisingly, countries adopting Category I and effective Category II treatments gain the greatest health improvements, while countries adopting ineffective Category II and Category III treatments experience the most rapid cost growth.

L'article conté molts aspectes d'interès, però sobretot, quedeu-vos amb aquesta afirmació:

Attributing cost growth and improvements in outcomes to “technology growth” is too simplistic and tells us little about where the cost growth is occurring, whether such growth should be tamed, and if so, how it should be done.

El dia que Diego Rivera faria 125 anys, acompanyat de Frida Khalo

Només una paraula

Si algú em pregunta quina és la paraula clau que hauria de resumir qualsevol estratègia de millora de la salut dels catalans, i només en pogués dir una aleshores sense embuts diria: incentius. És a dir canviar alló que ens motiva a prendre una decisió o fer una acció en l'àmbit de la salut per tal de millorar-la. Canviar els motius pels que preferim determinades alternatives que creen poc valor cap a d'altres que en creen més, prioritzar-les.
Ens caldria canviar incentius en molts àmbits, el primer de tots en els ciutadans i la seva preocupació per la salut. Això vol dir hàbits saludables i compliment terapèutic, per exemple. Caldria canviar en els professionals sanitaris, que la presa de decisions clíniques s'orientés cap a maximitzar la capacitat de benefici en cada pacient. Canviar els incentius dels proveïdors, contractes ferms i amenaces creïbles davant incompliments. I també el regulador, justament modificant el marc per fer aquests incentius possibles.
És evident que això no es resol en un paràgraf, i volia posar tant sols l'èmfasi en la paraula perquè no la veig per enlloc. Si els recursos es mostren més escassos que mai, no podem mantenir indefinidament la mateixa estructura d'incentius en el sistema. O la canviem o el sistema actual té tots els incentius per corcar-se tot sol.

PS. L'altra paraula clau en la que sovint penso és "variacions" en la pràctica mèdica. Però sobre això ja hi ha un llibre sencer de Wennberg on mostra què cal fer i que per aquí no tenim en compte.

PS. I si sou dels que creieu que això dels incentius no va amb el sector públic, cal llegir Dixit.

PS. La història de com s'ha reduit la mortalitat infantil infantil a Xile, comentari d'un llibre al Lancet.

Teniu fins el febrer per veure l'exposició de Leonardo da Vinci a la National Gallery

Virtual Mentor

Quan en una revista veig un cognom com Eddy, Emmanuel, Fisher, Berwick, Wennberg, Goldfield m'aturo i els llegeixo sempre (molts d'ells de procèdencia ètnica i política similar). Resulta que als USA hi ha un grapat de metges que han tingut l'oportunitat i la voluntat de reflexionar sobre la pràctica de la medicina profundament. Malauradament aquí aprop en tenim pocs que alhora dediquin temps a escriure i difondre les idees, conceptes i experiències.
En David Eddy és un que es troba al capdamunt del meu ranking i ara amb l'article que ha publicat a Virtual Mentor ho torna a desmostrar. És un article senzill, aquell que recomanaries a qualsevol estudiant per si vol conèixer la història de la medicina basada en proves i el cost-efectivitat, com va començar i com ha evolucionat.
Per cert, l'exemplar de gener de VM val la pena, així que no us limiteu a Eddy.

PD.Declaracions del CEO de Sanofi al blog de Forbes:

" If you make potato chips and soft drinks you’re going to have a higher P/E than we do, but it’s because potato chips and soft drinks are a more sustainable business."

No cal afegir res més.