Monday, 16 October 2017

The face as a mirror... of the pocket!

Pedro Rey

As this is my first post on this blog, let me introduce myself. I am a researcher into behavioural economics, a field that uses ideas from psychology to enrich the study of economic problems. More specifically, at present we are working on a project that – as I will explain at the end of this piece, and for various reasons – may have interesting implications in the field of medicine.

Our research aims to answer a simple question: what is the relationship between how much consumers like the products they buy and how much they are willing to pay for them?

This is a vital question is for economists, as we construct all our theories around the assumption that there is a very close relationship between the two. However, it is very difficult to prove the assumption, as that requires us to ascertain two things that are also difficult to measure. There is no clear way to objectively measure how much a consumer enjoys a product, nor is it in the consumer’s interest to tell us how much they are really prepared to pay for something. For this reason, we conducted an experiment in a theatre, the Sala Becket in Barcelona. There, we asked spectators to fill in questionnaires before and after the performance. Crucially, admission was not by conventional pre-paid ticket; rather, spectators could pay what they wanted after the show. The questionnaires provided two important measurements of enjoyment: how much spectators had enjoyed the show; and how much they expected to enjoy it before coming to the theatre. Asking audiences to pay what they want enables us to compare willingness to pay with what they really pay. Obviously, spectators could decide to pay nothing, but the production company we worked with, Sixto Paz, has been using the “pay what you want” strategy successfully for some years now. The most interesting result we have noted so far is that the amount paid depends less on how much spectators say they enjoyed the play than on the difference between how much they thought they would enjoy it and how much they actually enjoyed it. We therefore conclude that the most important thing is to satisfy expectations and that, although, in principle, one might think that it would be best to attract potential consumers by greatly raising these expectations, there also exists the risk of disappointing them. Accordingly, the greatest care should be taken when designing advertisements.

Nevertheless, we find using the method conventionally employed in marketing to measure levels of consumer satisfaction, the questionnaire, somewhat unsatisfactory. This is because the fact that we can find a link between how much a consumer pays and how much they say they enjoy a product may be due, simply, to the fact that we all try to be consistent. For this reason, we also used technology to obtain an alternative measure of enjoyment: deploying high-definition cameras, we filmed spectators during the performance, then processed the results using facial recognition software. This enables us to ascertain precisely, for example, how many times and how intensely a spectator laughs during a comedy, and how much attention they pay to the show. Obviously, people go to see comedies in order to enjoy a good laugh, so how much someone laughs can be a good way of measuring their enjoyment. We therefore decided to seek the relationship between data on payment and on facial expression.

I mentioned at the beginning that our study may be of medical interest. There are two reasons for this. Firstly, the show we used for the experiment, Lucy Prebble’s play The Effect, about a clinical trial for a new antidepressant drug. The plot is of interest to researchers, as the lead characters fall in love during the trial, and it is not clear whether this is due to the effects of the drug or whether the fact that they fall in love spoils the study, as it seems to demonstrate that the drug works, though this is not really proven. This gave us the idea of including this theme in our own experiment by conducting a clinical trial with the audience. Before the play, spectators were asked to take one of two pills: a placebo or a “real” pill (in fact, another placebo), which we said we were studying to see whether it enabled people to enjoy the show more. A surprisingly high proportion of spectators actually took one of these pills, without knowing which, and this enabled us to study whether the fact that someone is told that they have taken something that will increase their enjoyment effectively raises their expectations, their enjoyment or even how much they are willing to pay for a product. We have not yet obtained the final results, but we can note that the “supposedly effective” pill – like advertising which claims that those who buy a product will feel better – appears to generate positive effects on all three variables.

Moreover, the employment of facial recognition software may also have clinical utility. In particular, just as it is by no means easy for economists to measure a consumer’s enjoyment of a product, so doctors have difficulties in objectively assessing the degree of pain that a patient feels, and this can present problems when it comes to taking decisions about treatment. In both cases, the problem is similar: how do different people interpret the same scale? Different people may rate the same pain as a “7” or a “9”. That is why we are also conducting research to see whether we can use patients’ facial microexpressions when different levels of pain are applied to establish a new, more objective scale or link such a scale to conventional methods of assessing pain. As I hope to continue contributing to this blog, I will reveal the results in the near future. For now, I leave you with a video to give you an idea of the direction our research is taking.

Monday, 9 October 2017

An extensive model for complex chronic patients

The emergent phenomenon of multi-chronicity and geriatric fragility is analyzed from all points of view: demographic, epidemiological, the use of resources and the economic impact, to mention only the most outstanding. Now familiar with the tendency, we’re facing the challenge of finding out how to provide appropriate services to patients who, due to the precariousness of their health, or their social circumstances, or both, suffer instability and become frequent and directionless visitors.

This group of complex patients, although not too large, is stressing the rigidities of health systems in three ways: a) the saturation of hospital emergency services consuming ambulances and observation beds is unable to give effective responses to the needs of these people, b) lack of coordination of transfers between levels, especially between the hospital and primary care, and c) poly-medication due to prescription fragmentation.

Monday, 2 October 2017

What do chronic patients want?

Fragmentation of services is a disgrace for complex chronic patients, for people with combined health and social needs, for fragile people and, in short, for the elderly population. Hence, most governments are engaged in service integration initiatives, but progress is slow and the results are disappointing because systems are too fragmented: in budgets, in access rights, in circuits, in professional cultures, in institutions, in public and private providers, etc. However, the British have proposed a merger of services by 2020, and since they recognize that, as things stand, offering people-centred care will be a bulky process, in the summer of 2013 they launched a project, “People helping people", a project that is ambitious in vision but modest in methodology and budget.

What is "People helping people"?

The program is working on 25 pilot areas that volunteered to test (as previously done in Torbay) different ways of coordinating and integrating services in order to promote patient-centred care, for which they rely on a single operative objective of elaborating, on the part of all the actors, of individualized plans that adapt to each person’s particular needs and way of life. In terms of methodology, the project has adopted the "triple aim" (Institute for Healthcare Improvement), which develops the following principles: a) improve patient experience, b) improve the health and well-being of the population, and c) reduce the waste and, therefore, the cost per capita.

Monday, 25 September 2017

Hospitalizations and patients’ experiences

Peter Pronovost, a renowned expert in clinical quality and safety, argues that it’s a mistake for hospitals to focus on patient satisfaction surveys and states that instead it would be more helpful to ask selected patients what proposals they would make in order to improve the hospitalization experience. For example, one of the people Johns Hopkins chose for this assignment was Podge Reed Jr., a double lung transplant patient who had amassed six hospitalizations, two surgical and four medical, eight anaesthesia outpatient procedures, more than one hundred visits to appointments and 700 laboratory tests. With this curriculum, the hospital felt that Mr.Reed should be a person with a clear opinion.

In the article, Jane Hill, Johns Hopkins’ Patient Relations Director, says that most hospitalised people, although appreciating the technical quality of services, also ask to be treated with kindness and care. Not surprising, given that being bedridden in a hospital is not a pleasant experience for anyone. As a result of patients' contributions, Jane Hill has developed a Decalogue that should be read as a basis for transforming hospitalization rooms, on one hand from the perspective of tasks, functions and competencies and on the other hand, with a view of patients’ experience.

Monday, 18 September 2017

Sleeping well, a determinant of health

There are some health determinants that we can’t do much about such as those that are marked by our genetic endowment, our family, the place where we have to live and the historical moment that is contemporary to us. Other factors, however, are linked to the lifestyle we decide to lead, such as sleeping well (in quantity and quality) a factor that doesn’t yet occupy a prominent place in the collective imagination. However, many studies aim towards common sense: if one sleeps well, the next day is better, and vice versa. That is why I was not surprised by the finding of a Finnish research that associates sleeping insufficient hours with drowsiness and life quality for adolescents or another collected from Harvard Health Publications that limited sleep to five hours a night for one group of students at the Singapore institute for a week and compared their abilities to another group who had slept for nine hours each night, with predictable results of cognitive impairment due to lack of sleep.

Monday, 11 September 2017

Value Based Medicine (VBM)

Evidence-based medicine (EBM), after 25 years, has generated substantial advances in research methodology and has made it possible to distinguish more clearly between good and bad treatments, to identify biases of any order and even evidence of conflicts of interest between research and industry. However, a group of English authors (The importance of values in EBM, Kelly MP 2016) believes that, despite the uncontested advances, EBM has put too much focus on the technical aspects and has forgotten that values ​​have a lot of influence at all stages of the evidence-building processes.

What do we mean when we talk about values?

Science strives to understand the world as it is, but conversely, values ​​are what humans reflect upon. Seen this way, the conflict is served and, therefore EBM should learn to navigate better between these two waters according to the authors of the article quoted below, "Values may act as heuristics – shortcuts in our thinking of which we are barely aware – which get us to quick answers to complicated problems. They form the lens through which we perceive and act on our world. Values are often tricky to pin down because they are such a pervasive part of things we take for granted. A necessary first step towards achieving this is to make our values as explicit as we can, so that we can reflect on them individually and deliberate on them collectively".

Monday, 4 September 2017

Do we need "bonsai" hospitals?

Joan Escarrabill

The ideal size of the hospital and the minimal activity (number of procedures) it has to do to ensure quality is a recurring debate. Sometimes the issue of the hospital size is related to the primary care’s ability to solve and, therefore, the possibility of closing acute beds (and redistributing the budget that was intended for its operation). In the 2009 EESRI edition, in Table 10 (page 21), there’s a very significant information: the number of acute beds per 1,000 inhabitants. According to this document, in Catalonia we have 2.4 beds per 1,000 inhabitants and in the whole of Spain 2.5. Only Turkey (2.3) and Finland (1.9) have fewer beds per 1,000 inhabitants than we do. Despite the data, there are people who insist on the convenience of closing acute beds if the primary care resolution capacity increases. It seems to me that there’s a better question: too many beds or too many hospitals?