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Recipe for effective ways to improve health outcomes

  • Improvements in healthcare outcomes warrant small changes. [Previous post].
  • Those best placed to know where and how to make those adjustments will change the future.
  • The most effective changes will trigger behaviours that we are already motivated and easily able to assimilate in practice.
  • The best interventions are those in which all concerned are rewarded in some way.

Such interventions:
1. Build on something the target is already doing. Anything that adds to workload or requires practitioners or indeed patients to do something significantly different in the course of going about their business is a waste of effort [example].
2. Need very few people to adopt them.  Ideas that require an orchestrated change in patient and or their general practitioner and or the specialist will disappoint [example].
3. Must be anchored by something that already occurs in practice. Practitioners routinely reach the point where they must agree or disagree with the patient and then do something.  An intervention that is anchored at that point is more likely to be assimilated in practice [example].
4. Can be incorporated into the habits or rituals of the target. Doctors vaccinate patients and patients regularly use their phones. Ideas that combine such aspects are likely to succeed [example].
5. Provide something the target wants. Interventions that are at odds with the target’s ideas, concerns or expectations are unlikely to succeed [example]. Interventions that speak to the target’s desires can be highly effective [example].

 

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Small changes big impact in healthcare

According to the Royal College of General Practitioners, UK:

The consultation is at the heart of general practice… As a general practitioner, if you lack a clear understanding of what the consultation is, and how the successful consultation is achieved, you will fail your patients. RCGP

The impact of the consultation varies because of the different perspectives between doctors and their patients:

…. in the consultation the patient is most commonly construed as a purely “biomedical” entity—that is, a person with disconnected bodily symptoms, wanting a label for what is wrong and a prescription to put it right. Even under this guise the patient still sometimes fails to report their full biomedical agenda. Not all symptoms were reported and not all desires for a prescription were voiced. Barry et al BMJ

Much of what transpires in the consult is a ritual. Over the course of a professional lifetime most doctors will greet the patient in the same way, say the same sort of thing, prescribe similar drugs and order the same sorts of tests.  This occurs for a variety of reasons perhaps because a doctor learns to present herself and behave in a specific way but also because the doctor’s training and experience has a significant impact on their clinical practice. There is ample evidence that how doctors interact with their patients is crucial to the outcome of the consultation and ultimately to outcomes in healthcare:

An increasing body of work over the last 20 years has demonstrated the relationship between doctors’ non-verbal communication (in the form of eye-contact, head nods and gestures, position and tone of voice) with the following outcomes: patient satisfaction, patient understanding, physician detection of emotional distress, and physician malpractice claim history. Although more work needs to be done, there is now significant evidence that doctors need to pay considerable attention to their own non-verbal behavior. Silverman BJGP 2010

With this in mind, if you are a doctor you may want to consider seven components of your interaction with patients that warrant occasional re-evaluation:

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On the question of quality context is everything

The question of quality in primary care is a vexed one. According to the King’s Fund:

We have suggested some ways that practices could begin to audit their own practice…. and made recommendations about how the work we have begun could be used as the basis for future development of quality indicators in general practice. While some of these are harder to define we think that many of these aspects of care can be captured by measuring how patients experience care. King’s Fund 2011

The issue is addressed in some detail in the report which includes the following key points:

The key activity in general practice is the consultation. The consultation has been dissected for its component parts by Deveugele et al :

8% Social behavior, 15% agreement, 4% rapport building, 10% partnership building, 11% giving directions, 28% giving information, 14% asking questions and 7% counselling.

Much of what transpires in that consultation can only be reliably interpreted within the local context of that consultation. Therefore any interpretation of the outcome must take into account factors that are not generalisable. That makes it difficult to draw reliable and safe conclusions and by corollary to set benchmarks that apply across every setting.

If the King’s Fund report makes any contribution it is that it highlights the need for further research into interventions that can be deployed within the context of the consultation to reduce diagnostic errors, to understand differences in referral rates and to explain variation in prescribing practice. It also highlights that we have inadequate data on what interventions are best deployed in the context of primary care to support health promotion.

Finally the report makes a very important observation that patients need to be more involved in their healthcare and that the patient experience should be the basis on which we focus on this issue going forward.

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What is the role of doctors in health promotion?

Our health is a cause for concern.

  • Over 1 in 5 Australians aged 18+ (22%) reported having Cardiovascular disease in 2011.
  • In 2009, the risk of being diagnosed with cancer before their 85th birthday was 1 in 2 for males and 1 in 3 for females.
  • 1 in 10 Australians aged 18+ (10%) had biomedical signs of chronic kidney disease in 2011–12, with the majority of these showing early signs of the disease.
  • 1 in 19 Australians (5.4%) had diabetes in 2011–12 (self–reported and measured data). This is includes approximately 1% of the population who did not self-report they had diabetes, which may indicate they were unaware they had the condition.
  • In 2007, 1 in 5 Australians aged 16–85 (20%) experienced a mental disorder in the previous 12 months.
    In 2013–14, 1 in 7 children aged 4–17 (14%) were assessed as having mental health disorders in the previous 12 months .
  • Over 1 in 4 Australians (28%) reported having arthritis and other musculoskeletal conditions in 2011–12. The most prevalent conditions were back problems, osteoarthritis, osteoporosis and rheumatoid arthritis.
  • 3 in 10 Australians aged 25–44 had untreated tooth decay in 2004–06.
  • 1 in 10 Australians (10%) reported having asthma in 2011–12. This rate is significantly lower than the rate of 11.6% in 2001.
    1 in 42 Australians (2.4%) reported having COPD in 2011–12. The development of COPD occurs over many years and mainly affects middle aged and older people.

It seems:

  • We eat too much. Almost 2 in 3 Australian adults (63%) are overweight or obese. 1 in 4 Australian children (25%) are overweight or obese.
  • We don’t take enough exercise. Based on estimates that between 60 and 70 per cent of the Australian population is sedentary, or has low levels of physical activity, it has been suggested that increasing participation in physical activity by 10 per cent would lead to opportunity cost savings of $258 million, with 37 per cent of savings arising in the health sector.
  • We drink too much alcohol and have been drinking more every year.
  • We don’t eat enough vegetables. In 2007–08, just over half of all children aged 5–7 years (57%) and a third of children aged 8–11 years (32%) ate the recommended amount of fruit and vegetables but only 5% of people aged 12–18 years and 6% of people 19 years and over did so.
  • Too few of us avail of cancer screening tests.
  • We drive too fast. Speeding is a factor in about one third of road fatalities in Australia. Additionally, more than 4100 people are injured in speed-related incidents each year.

Someone must be to blame for all this- if only they would do their job and tell us to eat and drink less, exercise more and slow down.  But wait there are industries profiting from our bad choices. We are influenced by more than our doctor. We have known this for decades. It is known as the Bronfenbrenner’s Ecological Model:

Hchokr

At the core of Bronfenbrenner’s ecological model is the child’s biological and psychological makeup, based on individual and genetic developmental history. This makeup continues to be affected and modified by the child’s immediate physical and social environment (microsystem) as well as interactions among the systems within the environment (mesosystems). Other broader social, political and economic conditions (exosystem) influence the structure and availability of microsystems and the manner in which they affect the child. Finally, social, political, and economic conditions are themselves influenced by the general beliefs and attitudes (macrosystems) shared by members of the society. Wikipedia

Most Australians (13 Million) spend over 18 hours a day online. One in every five minutes (3.6 hours) a day is spent on social media. On the other hand time spent with general practitioners (GPs) is declining:

The proportion of GPs providing ‘Level C’ consultations (longer than 20 minutes) is substantial (96%) and constant; however, the number of long consultations provided per GP decreased by 21% between 2006 and 2010. The proportion of GPs providing Level D consultations (longer than 40 minutes) decreased from 72% in 2006 to 62% in 2009, while the number of Level D consultations provided per GP decreased by 26%. AHHA

Secondly the number of problems presented to doctors in increasing. In one survey of the 8707 patients sampled from 290 GPs, approximately half (47.4%, 95% CI: 45.2–49.6) had two or more chronic conditions.

Junk food is cheap and readily available. It is advertised to children. Fresh fruit and vegetables are less available, more expensive and of poorer quality in rural and remote Australia. These areas are also among our most economically disadvantaged and residents generally have less disposable income to spend on expensive, healthier food options. According to one report a multinational fast food company paid $500 million in taxes to the Australian government and might be due to pay more.

A 2017 poll  found that most Australians (78 per cent) believe Australia has a drinking problem, 74 per cent believe our drinking habits will worsen over the next five to ten years, and a growing majority (81 per cent) think more should be done to reduce alcohol harm. A price increase of 10%  on alcohol has been shown to reduce consumption by an average of 5%. Similarly for every 10% increase in price, consumption of tobacco reduces by about 4%. Finally a significant proportion of people are unhappy at work and this has been associated with snacking and weight gain.

So it seems that we are choices are triggered by far more than a doctor informing us that we are making bad choices. Doctors can make a huge difference to the individual who seeks advice in a teachable moment and can be triggered to make better choices. This requires more time with the patient and a greater focus on the needs of that individual patient rather than the distraction of a public health agenda.  At a public health level doctors’ impact is miniscule because of the much more powerful and ubiquitous drivers of poor choices that are fueled by those who profit from our dubious behaviour. A summary:

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Why our jobs are making us fat

We spend most of our time at work.

  • Expressed as terms of a percentage of your life, this 39.2 hours a week spent working is equivalent to:
  • 14% of your total times over the course of a 76 year period (based on the average projected life expectancy of 76 for people born in the year 2000 according to the ONS’s National Life Tables for the United Kingdom.)
  • 23.3% of your total time during the course of a 50 year working-life period
  • 21% of your total waking hours over a 76 year lifespan, assuming 8 hours of sleep a night.
  • 35% of your total waking hours over a 50 year working-life period assuming 8 hours of sleep a night
  • 50% of your total waking hours during any given working day. ReviseSociology

This is a significant chunk of our lives. Yet we note that many people are disengaged at work.

Gallup

This is a problem because being disengaged at work is also associated with other behaviours that are problematic. Faragher and colleagues reported in the BMJ:

A systematic review and meta-analysis of 485 studies with a combined sample size of 267 995 individuals was conducted, evaluating the research evidence linking self-report measures of job satisfaction to measures of physical and mental wellbeing. The overall correlation combined across all health measures was r = 0.312 (0.370 after Schmidt-Hunter adjustment). Job satisfaction was most strongly associated with mental/psychological problems; strongest relationships were found for burnout (corrected r = 0.478), self-esteem(r = 0.429), depression (r = 0.428), and anxiety(r = 0.420). The correlation with subjective physical illness was more modest (r = 0.287).

There is increasing evidence for an association between job dissatisfaction and the most significant health challenge we face in the next decade- namely obesity. A survey of nurses in Ohio concluded that:

..disordered eating differed significantly based on perceived job stress and perceived body satisfaction. Nurses with high levels of perceived job stress and low levels of body satisfaction had higher disordered eating involvement. King et al

A more recent paper in BMC obesity reported that obesity rates varied across industries and between races employed in different industries:

Obesity trends varied substantially overall as well as within and between race-gender groups across employment industries. These findings demonstrate the need for further investigation of racial and sociocultural disparities in the work-obesity relationship to employ strategies designed to address these disparities while improving health among all US workers. Jackson et al

Lui and colleagues suggest a possible explanation:

Study 1 sampled 125 participants from 5 Chinese information technology companies and showed that when participants experienced higher levels of job demands in the morning, they consumed more types of unhealthy food and fewer types of healthy food in the evening. In addition, sleep quality from the previous night buffered the effect of morning job demands on evening unhealthy food consumption. Study 2 used data from 110 customer service employees from a Chinese telecommunications company and further demonstrated a positive association between morning customer mistreatment and evening overeating behaviors, as well as the buffering effect of sleep quality. J Appl Psychol

Possibly a very useful question we can ask people seeking medical advice with weight management: ‘ What do you do for a living and how do you feel about it?’. It may be that they are eating their feelings. Review what people are eating at their desk or during breaks. Snacks have become the fourth meal of the day — accounting for 580 extra calories per day, most of which come from beverages — and may be a primary contributor to our expanding waistlines. Here’s why employees become disengaged at work. A summary:

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What’s the shortest route to where you want to go?

As the conference season begins we note that response rates in the order of 10-20% are not unusual in primary care research. Hardly generalisable. And yet we need sustainable and workable solutions that will promote health and well being in an ageing demography with increasing multimorbidity. Researchers take note the traditional gatekeeper in primary care, the general practitioner is occupied just keeping up with demand. There is no time to recruit, to seek informed consent or to deliver interventions that are being tested in a traditional randomised trial. At one time membership of networks with ‘committed’, well meaning practitioners were considered essential to successful research. In 2017 relying on anyone or any organisation that purports to guarantee recruitment rates or ‘collaboration’ seems at best naive and at worst risky.

Health requires people to make different choices. Eat better, drink less, take more exercise, jettison bad habits, consider when and where to seek medical advice. The traditional model of healthcare is evolving. The evolution is driven by technology that has fundamentally changed our experience of many if not all things. People consider themselves more time poor than they ever were.

The ability to satisfy desires instantly also breeds impatience, fuelled by a nagging sense that one could be doing so much else. People visit websites less often if they are more than 250 milliseconds slower than a close competitor, according to research from Google. More than a fifth of internet users will abandon an online video if it takes longer than five seconds to load. When experiences can be calculated according to the utility of a millisecond, all seconds are more anxiously judged for their utility. The Economist

The lesson for those hunting for better ways to reach people is to consider the least that can be done to get there. The answer may be waiting in all of our pockets.

Picture by Toshihiro Gamo

You are one of us doctor you’ll understand

The door opened a crack and I could just make out a face in the half light.

The doctor I spoke to was Irish, who are you?

I assured the patient that I was indeed the person they spoke with when they requested a home visit. Reluctantly, they let me in. It must have been evident from my reply that in contrast to my brown face I had an Irish accent. Roll forwards a few years and I was in a consulting room in England. The healthy middle eastern man spoke with me earnestly.

You are one of us. You will understand. It is our culture. My son is disabled. I am a father and I need to look after him as our family requires. The social security people say I must work. Please just sign me off for a few months to stop them harassing me.

A few years later I stood in the dinning room of a large conference centre in Sydney scanning the room looking for a friend. One of the delegates queuing for breakfast tapped me on the shoulder:

Excuse me sir, there aren’t enough spoons at the table.

I sorted the matter of the spoons as I hope a gentleman and not just a waiter would. The consultation consists of the stage (consulting room), the props ( the equipment), the script and the action and of course the actors (doctor and patient). We are occasionally reminded that the actor’s appearance has a significant impact on how they are perceived by the other in the ritual that is the consultation. If we come to this unprepared then we may be wrong footed even in the opening exchanges. My experience has taught me what it is like to have people make assumptions about you even before you open your mouth. I believe that has made me a better doctor and personally aware of the issues.

Picture by elysianfields

If your fix only works if people choose option A abandon it

There is an obsession with getting clinicians to ‘follow guidelines’. There are those in the world who appear to believe with an evangelical zeal that ‘if only’ people over there would do as we tell them everything would be fine. They rely on the questionable assumption that human behaviour is always rational.

If only doctors would refer those people or prescribe that drug in this instance. If only doctors ordered this or that test in these circumstances. If only this or that which relies upon someone making choices that solve somebody else’s problem.  And so as conference season approaches academics will share stories about experiments that all too predictably didn’t end well. Or pretend that they have finally solved a problem that no one in history could sort out. Except that neither have they.

Because access to specialists is limited by cost there is a belief that family doctors can ration care by referring urgently only those cases that ‘merit’ referral based on criteria determined by ‘experts’. Cancer is a case in point. Except that ‘cancer’ is not a single condition, its biology varies as do the complex responses of its victims. General Practitioners (GPs) know this. A patient can present with hardly any symptoms and die of metastatic cancer within 3 months or present with a plethora of complaints and be diagnosed with a very early and treatable malignancy.

The ‘solution’ to selecting people considered to be at high risk for referral to a specialist appeared to be an interactive referral tool that automatically deploys algorithms based on guidelines. This ‘solution’ relies on GPs recognising anyone who presents with ‘red flag’ symptoms, deploying the software and patients being prioritised once an urgent referral is received at the hospital. The solution is based on the assumption that if one person in the chain does X then the people in the other part of the system would do Y and the outcome would be Z. Maybe you can already see it wasn’t going to end well.

  1. GPs did not always recognise the symptom complexes that were touted as the hallmarks of risk.BMJ open
  2. GPs were reticent to deploy the software other than in the conditions of a simulation. BMC Family Practice
  3. Specialists did not prioritise those cases that guidelines identified as urgent. BJGP

There is also limited evidence that people referred with reference to such criteria are always going to have better outcomes.

Here’s the thing:

  1. Diseases like cancer have a different impact on everyone
  2. People with cancer don’t present the same way
  3. Doctors may not agree with the experts
  4. Doctors may choose not to deploy an innovation for reasons various
  5. The ‘system’ consists of many moving parts. Supposing there were seven such parts. If the ‘right thing’ was to occur 80% of the time at each step then only 21% of people would benefit from the ‘plan’. Glasziou and Haynes

In the innovation business solutions cannot rely on the ‘if only’ option. Effective innovations trigger people to do what they already want to do. The best innovators work on solutions that are easily and enthusiastically adopted by their target audience.

Picture by Jurgen Appelo

A cough is not minor in any sense

 

 Acute cough, which often follows an upper respiratory tract infection, may be initially disruptive but is usually self‐limiting and rarely needs significant medical intervention. Thorax

In adults or children with acute cough, the evidence does not support the effectiveness of over the counter preparations. Cochrane Review

On the other hand:

Oral syrups segment is expected to expand at 2.9% CAGR (Compound annual growth rate) over the estimated period and be valued more than US$ 10 Bn by the end of 2026. The segment is expected to create absolute $ opportunity of a little more than US$ 300 Mn in 2017 over 2016. The segment is the most acceptable dosage form for cough, cold, and sore throat medicines due to ease of administration and pleasant taste. The oral syrups segment dominated the global cold, cough and sore throat remedies market in terms of revenue in 2016 and the trend is projected to continue throughout the forecast period. Oral syrups segment is the most attractive segment, with attractiveness index of 1.5 over the forecast period. FMI

Cough, cough, cough. Every hour on the hour. There appears to be no end to it this season. No symptom is driving more people to seek treatment than the misery of upper respiratory tract infections (URTIs). The impact of the URTIs season on the population is massive as has been demonstrated in data from the US:

More than half (52%) of Americans reported that their cold impacted their daily life a fair amount to a lot. Productivity decreased by a mean 26.4%, and 44.5% of respondents reported work/school absenteeism (usually one to two days) during a cold. Overall, 93% of survey participants reported difficulty sleeping. Among all respondents, 57% reported cough or nasal congestion as the symptoms making sleep difficult. Drug Store News

One issue that appears to be bound up with the epidemic of URTIs is rates of prescribing of antibiotics. Here the available data are encouraging:

Professor Bell suggests that 20–25% of acute URTIs are likely to need antibiotics…..We have shown that over the last 13 years GPs in Australia have decreased their level of prescribing of antibiotics for acute URTI and to a lesser degree, for ‘other RTIs’. Britt et al

However there is an opportunity here over and above the treatment of an annoying self-limiting infection. Most people who seek help want more than anything else to feel better. By 2026 they will spend $10Bn in the attempt. The conversations in consulting rooms and pharmacies around the country focus on symptoms that will improve, eventually. Antibiotics won’t help. But, in the end what people want is to feel better not a lecture on virology. There is an opportunity for a ‘set play’.

Yes, you have a nasty infection and I see that it is making you miserable. Here’s what you can do to help your self.

There is an opportunity to forge a relationship with the patient. The ritual of the consultation complete with examination has the potential to create enormous deposit of social capital. Something that might be critical when the patient presents later in life with life-limiting pathology. There is the chance to understand a lot more about the patient for whom a cold is the final straw. But what’s the context? Be curious, very curious that’s why it’s called the art of medicine.

Picture by Rebecca Brown

It is time for primary care to enter the triggering business

It has been suggested, some would say demonstrated that doctors know very little about their patients. If you are a doctor could you identify your patient’s partner from a line-up of strangers (other than people you see as a couple)?  Or could you tell without seeing the name on the document if this bank statement belonged to that patient? Or whether that utility bill was from where that person lives? Is this internet search history theirs? Do you know how much they spend on lottery tickets? Alcohol? Vegetables?

A few years ago our team then based in the UK was evaluating an intervention to increase access to general practitioners. If the intervention worked we would have to demonstrate improvement over the course of a whole year. Here’s the thing, we noted that year after year there was a pattern to the demand for same day (emergency) appointments- with definite peaks and troughs. So if the intervention worked it would have to be sustained during both the peaks and the troughs. It did. The data on out-of-hours services exhibited very similar patterns- with definite peaks and troughs and at unexpected times of the year. We could not explain the patterns but noted that when the meteorological office recorded  22 hours or more of sunshine in the week the demand for appointments dropped. Not the prevalence of viral or other community pathogens but sunshine of all things! Okay may it was some factor that we hadn’t modelled in the analysis but there was a definite pattern that we could not immediately explain on the basis of what seemed plausible at the time. We called it the Spring Cleaning Effect– we hypothesised that people in the UK were less likely to attend doctors in general practice when there was a run of sunny days on which to do outdoorsy things. We didn’t anticipate this- nor did clinic managers because the patterns of demand were not used to inform the scheduling of doctors’ on-call rosters. It was clear that they were blind to a phenomenon nobody understood fully.

More recently I reviewed some data on certification for low back pain and noted the pattern that as unemployment rates in a locality increased the rates of certification dropped and then plateaued.

Our team is now investigating similar data from a large employers’ records. We hypothesise that rates of submission of sickness certification will show a sharp drop when vacancy rates fall and other markers of economic health decline. People may be far less likely to take time off sick if they are fearful of upsetting their supervisor. With respect to primary care, it is unlikely that doctors will know everything that impacts on their patient’s choices. Time spent with the patient in discovering these things is unlikely to increase as it comes at a financial cost. Therefore doctors will never fully anticipate all the drivers to patient behaviour. Why does that obese person fail to take action on weight management? Why does this other person take ‘medication holidays’ when they need to take the treatment consistently to benefit? Why does the next person refuse to have an X-ray? Why is there a rush of people with relatively minor conditions demanding appointments this week and not last?

Some drivers lead people to behave in unexpected ways as I have commented here previously. Not only that but as Mullainathan and Shafir have postulated people are often unable or perhaps unwilling to follow doctor’s advice. In the end, the best we can hope is to trigger the relevant behaviour in people who are already motivated and seek teachable moments to inspire people to act for their benefit. Primary care may be more about recognising or fishing for opportunities and much less ‘educating’ for change. Such triggers need to fit within the final moments of a 15-minute consult. The work to develop and evaluate such triggers is only beginning. Counselling patients to stop smoking will yield 1:20 quits in a year, showing them a trigger (in less than 5 minutes) that appeals to their vanity results in 1:7 quits. A substantial number (1:5) of obese people will lose weight in 6 months if they are shown what difference that would make to their appearance without having to be extensively counselled on diet and exercise.

Picture by Aimee Rivers