Monday, 13 February 2017

The weekend effect on hospitals








A meta-analysis of 48 studies and nearly 2 million hospitalizations for acute myocardial infarction has concluded that, during the weekends, waiting time for the start of angioplasty is on average of minutes longer, while mortality at 30 days is also, on average, 6% higher, a deviation that can reach 12% if high ST segment infarctions, which are susceptible to angioplasty, are also taken into account. A North American study of nearly one million hospitalizations for acute renal failure found that patients admitted on weekends had, on average, a probability of dying 7% higher, and in another study, also with extensive databases, on scheduled surgery in English hospitals, concluded that patients operated on Friday had a 44% higher probability of dying, a figure that rose to 82% if the intervention was performed on Saturday or Sunday (see an earlier post on the subject in this same blog). The three studies cited are just a sample of the harsh reality of the phenomenon. Just perform quick search on the scientific search engines to extract, for example, three more studies that go along the same lines (Bell 2001, Freemantle 2012, Perez Concha 2014). I have even found a study that has observed a higher mortality in urgent paediatric surgery (Goldstein 2014).

Monday, 6 February 2017

Primary health care perspective of clinical management: The legacy of Barbara Starfield


Xavier Bayona




Six years ago, the magnificent Barbara Starfield left us (December 18 1932 - June 10, 2011). She was a paediatrician and a major promoter of primary health care at the international level. Virtually her entire academic and professional life was tied to Johns Hopkins University. Since 1994 she directed the Department of Health Policy and Management of the Johns Hopkins Bloomberg School of Public Health in Baltimore (United States). From 1996, she was the co-director of The Johns Hopkins Primary Care Policy Centre (PCPC).

Those who had the opportunity to enjoy any of her conferences can say that she never left us feeling indifferent and she always allowed us to reflect on what we were doing and encouraged us to bring sanity to our workplaces as part of the health system. She was a great advocate for improving health systems by strengthening primary care and making sense of what is happening in the world by focusing health care on people and their needs. I still remember how in the conference room of the Catalan Oncology Institute (ICO), a few years ago, she told the audience that we were wasting time and resources with a lot of the screening we did and that we had to improve our orientation.

Monday, 30 January 2017

Please don’t resuscitate me








A follow-up of 6,972 people aged 64 years and older who had undergone a cardio respiratory arrest whilst they were hospitalised in an inpatient facility showed that the survival rate, after one year from the attack, was barely 10%, and if this estimate was restricted to people with no neurological injuries, the rate was halved. We don’t have data on the mid and long-term results for older people who are resuscitated outside of the hospital, but it all seems to be worse.

Aware of the bad omens of the heart failures at an advanced age, John Ballard, a retiree born and raised in the southern US, and an old fashioned liberal, as he defines himself, answered a tweet of mine on his blog in this manner:


Monday, 23 January 2017

Doctors strikes and medical congresses = less mortality








At a doctors' strike in Israel in 2000, the gravediggers noticed that their workload diminished in areas where the doctors’ strike was on, while it remained unchanged in areas where doctors did not adhere. Judy Siegel-Itzkovich, scientific editor of the Jerusalem Post, in a letter called “Doctors' strike in Israel may be good for health”  attributed the phenomenon to the shutdown of the scheduled surgery, which probably brings improvements of certain ailments, but which, by itself, can lead to complications and mortality. A few years later, in “Doctors' strikes and mortality: a review”, a systematic review of 156 papers analyzing the mortality impact of several doctors' strikes around the world, shows that during the doctors’ strikes, the population mortality either remains unchanged or lowers, but it never rises. The authors of the paper, like the Jewish publisher, also think that the phenomenon is an indirect measurement of the surgical over activity so common in clinical practice that, curiously, is shown when the programmed activity ceases drastically during a certain period.

Monday, 16 January 2017

Cardiopulmonary Resuscitation for older people: the mirage of numbers








New England Journal of Medicine published a study in March 2013, promoted by a group of researchers from the American Heart Association. It was a study performed with a sample of 6,972 people over 64 years who had been discharged in the period 2000-2008 after having survived a cardiac arrest during hospitalization. According to the study, 58.5% of the patients were still alive one year after discharge from hospital. The results, however, were significantly worse in the subgroup of 84 years plus (49.7%) and those who had suffered severe neurological sequels (42.2%) or had been in a vegetative coma (10.2%). The conclusions of this study, therefore, are favourable for the practice of cardiopulmonary resuscitation (CPR) during the cardiac arrest of the elderly. GeriPal, a blog of geriatrics and palliative care represented them in the "icon-box" that you can see above.


Monday, 9 January 2017

Measuring results in health is still very complicated








In order to evaluate health institutions based on the value they provide, health outcomes must be measured. However the efforts to achieve this are bearing dismal results. Pay-for-performance initiatives are drifting in an ocean of indicators that don’t translate into anything too operational. To give some examples, in the US, CMS (Medicare and Medicaid) handles nearly a thousand indicators to promote new funding models (see Health Affairs Blog "The Quality Tower of Babel") and, not so far away, in the Results Central of Catalonia (AQuAS), more than 300 indicators are recorded. Everything suggests that the excess of information will not bring light if we are not able to clarify what it means to add value to people's health, and to make this statement comprehensible, we must distinguish between two different approaches:

Health value for citizens

A long life free of disability is a goal that most mortals share but this indicator is not very useful for service providers because the impact of the health system on life expectancy barely reaches 20%.