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The most effective way to improve health outcomes

6842253071_a9b35831c0_zThere is no doubt that the demand for healthcare is rising in parallel with an aging demography and the increasing  prevalence of chronic conditions. Most healthcare is delivered in primary care. Only a relatively small proportion of people need specialist services or hospitalisation. Attempts to improve outcomes in healthcare are firmly focused on prevention and reducing the physical, social, economic and psychological impact of chronic illness. In most countries innovators are working with general practitioners to maintain the health and well being of our precious taxpaying workforce. In the following series of short videos there are some indications where and how to support GPs to take the next big step forward in improving the health of humanity.

Improve access to GP services.

Give GPs more quality time with their patients.

Show GPs where they can target their efforts in their local community.

Make patient data more accessible to GPs.

Provide GPs with better tools to communicate health messages.

Make guidelines easy to implement.

Write better discharge summaries to GPs.

Develop ways for other health professionals to share information with GPs.

Facilitate communication from GPs.

Encourage GPs to use their insights to improve healthcare outcomes.

Picture by UW Health

Ten things you should know about people who changed the face of healthcare

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They noticed things

They wanted to solve a problem

They were charismatic

They were risk takers

They were resourceful

They were tenacious

They were considered crazy

They were great communicators

They weren’t all doctors

Their ideas weren’t instantly adopted

Alexander Fleming noticed that mould had grown on the culture plates in his untidy laboratory, the rest is history. Edward Jenner wanted to rid the world of small pox, and did. Atul Gawande challenges the conventional wisdom and is an excellent communicator. Barry Marshall infected himself with Helicobacter Pylori. Timothy Presto designed child incubators from car parts. Florence Nightingale faced repeated opposition throughout her life. Ignaz Semmelweis was committed to a psychiatric institution because he promoted hand washing by doctors to reduce the risk of infection during childbirth. Anthony Atala gives a TED talk on regenerative medicine. Kiran Mazumdar Shaw, a zoologist, leads the largest biotech company in India, she was consider unfit to study medicine. William Harvey’s ideas on the circulatory system were not widely accepted by the medical profession. Two things are true of such people today, they are determined and they don’t all personally benefit from what they do for us.

Picture by U.S. Department of defence

Work with employers to improve health

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Annual profits confirm whether the staff of a company performed well. Profit margins, and the rate of innovation, closely reflect the health of the people who deliver that success. Employers are, and perhaps always have been, a key partner in the drive to improve the health of the nation. What has become a greater imperative to forge a partnership is the threat to profit margins from the looming spectre of chronic illness in epidemic proportions. Work is a vitally important aspect in most of our lives:

The average working American spends the majority of his or her waking hours on the job. Some of us live and breathe our work. Others of us work to pay our mortgages. Either way, the workplace has become an important source of social capital for millions of Americans – a center of meaning, membership, and mutual support. More than ever, we find our close friends and life partners on the job, we serve our communities through work-organized programs, and we use the office as a forum for democratic deliberation with people different from ourselves. Countless studies show that a workplace with strong social capital enhances workers’ lives and improves the employer’s bottom line.The workplace and social capital.

Similarly in Australia people spend most of their waking time at work. On average 34 hours a week . Sixteen percent of us work more than 50 hours per week. In contrast we spend 6-9 hours  per week doing house work and 6 hours and twenty seven minutes per day asleep. The impact of the working environment on health ranges from physical to psychological and can be both harmful and beneficial. Employers in most developed countries are therefore legally obliged to provide:

  • safe premises
  • safe machinery and materials
  • safe systems of work
  • information, instruction, training and supervision
  • a suitable working environment and facilities.

However there is much more that can be done to optimise the health of employees. The economic argument for this is clear and closely related to the rising incidence of chronic and complex illness among the working population. In 2002 approximately 59 per cent of global death was attributable to chronic, non-communicable diseases and the toll is projected to increase to 66 per cent by 2030.  The other outcomes that should worry employers is the prospect of premature retirement from the workforce.

It was found that individuals who had retired early due to other reasons were significantly less likely to be in income poverty than those retired due to ill health (OR 0.43 95% CI 0.33 to 0.51), and there was no significant difference in the likelihood of being in income poverty between these individuals and those unemployed. Being in the same family as someone who is retired due to illness also significantly increases an individual’s chance of being in income poverty. Schofield et al

A report by the Australian Institute of Health and Welfare in 2009 outlined the consequences of chronic illness and early retirement on the entire Australian economy. It concludes that:

  • People with chronic disease had, on average, 0.48 days off work in the previous fortnight due to their own illness, compared with 0.25 days for those without chronic disease.
  • The annual loss in workforce participation from chronic disease in Australia was around 537,000 person-years of participation in full-time employment, and approximately 47,000 person years of part-time employment.
  • For people participating full-time in the labour force, there was a loss of approximately 367,000 person-years associated with chronic disease, approximately 57,000 person-years in absenteeism associated with chronic disease and 113,000 person-years were lost due to death from chronic disease.
  •  Estimates of loss do not take into account lower performance while at work. Similarly, the effect of loss from participation in the unpaid labour force (carers, parents and volunteers) has not been accounted for. The estimates, therefore, underestimate the loss in workforce participation associated with chronic disease.

Therefore employers who wish to retain an effective workforce, and by corollary their profitability, need to invest in the well being of their workers. This responsibility extends beyond ensuring the physical safety of their workforce. A workforce that is under threat from an ageing population and an alarming incidence of retirement through ill health. If employees spend most of their waking hours at work then the following might concern the employer (click the links for the literature):

I believe health innovators who address these issues in their dealings with industry will discover an open door with massive potential for mutual benefit.

Picture by Vase Petrovski

Reflection a critical step in innovation

Pen, Diary and Glasses

Keeping
 a
 journal is
 a 
humbling 
process.
 You
 rely
 on 
your
 senses,
 your
 impressions 
and
 you
 purposely
 record
 your
 experiences
 as 
vividly,
 as
 playfully,
 and
 as
 creatively
 as
 you 
can.
 It
 is 
a
 learning 
process
 in
 which
 you
 are 
the 
learner
 and
 the 
one
 who 
teaches. Mary Louise Holly

For innovators inspiration is everywhere. In fact in our experience of any business in which like health care we are invited to trade money, directly or indirectly, for advice, products or services. This week I needed to register my car in another part of the country. I popped in to the licensing centre when I had a half hour to spare on Friday afternoon. A flustered concierge was helping people decide which queue to join. The waiting room was brimming with miserable people who had been there since lunch waiting for their turn at the counter. The officials seemed harassed, many were on phones while their customers leaned over the counter trying to make themselves understood though the small gap in the window. It was now 3.30 in the afternoon. I turned on my heels and walked out. The chore would have to wait, there were a list of jobs waiting for me back at the office. This was my third attempt at this. The registration is now overdue. My colleagues advised me that the ‘best’ time to get served is first thing in the morning. At the local health centre the same experience awaits and according to published research a man might procrastinate with much more worrying problems; bouts of chest pain on exertion, persistent dyspepsia, rectal bleeding, uncontrolled drinking, thoughts to self harm. The consequences should his condition deteriorate would be worse. A hospital bed for one night costs $1700-$2000 AUD.

Jennifer Moon tells us that in recounting any situation there are a number of considerations:

  1. The event or issue
  2. The context
  3. Your behaviour
  4. Your feelings
  5. Your intuitions
  6. Your previous experience
  7. The alternative ways to view the same situation
  8. Your awareness of your thinking.

Maintaining a diary, or a blog as is my habit, allows me to reflect on how people experience services. These reflections assist in developing innovations. It focuses on considering how other industries deal with the problem of limited resources and how those solutions work. Clearly the licensing office had decided that the best way to deal with demand is to stream people to the official most experienced with their issue. It’s a solution that doesn’t work on Friday afternoons, or any time other than first thing in the morning. It leads to people failing to deal with something that should be resolved sooner rather than later. So what’s the solution?

People are forced to attend an outlet that cannot cope with demand for staff time. Staff deals with urgent and important rather than simply important. Fire fighting rather than helping to deal with an issue that could generate income to the state and increase road safety. How many of the people sitting in that dismal office could be dealt with without having to get a ticket and wasting two or three hours of their time? My car could have been registered before I moved to this state if the removalist were able to complete the steps on line. In a healthcare situation much could be achieved by collecting the requisite information before the patient comes to the building. Saying that this is ‘how it has always been done’ is not satisfactory. People are seldom triggered to do the right thing if either motivation or ability is not aligned and in this case ability was lacking. Consequently frustration. However I was thankful for an experience that got me thinking. I will also be grateful for your reflections.

Picture by Generation Bass

How to communicate risk and benefit

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The average Australian spends $6 per week on lottery tickets even though the chances of winning the jackpot are 1 in 45million.

For every dollar you spend, you can expect to recover somewhere between 15 and 60 cents, depending on the game and the draw.  The rate of return is essentially the same irrespective of how many times you enter and irrespective of whether you buy a Standard or System ticket, but one thing you can be sure of is that the more you spend, the more you can expect to lose. David Wharton

On the other hand the lifetime risk of developing colorectal cancer is 1:21. Consuming vegetables is known to reduce the risk whereas drinking alcohol is known to increase the risk. On average Australians households spend less than $14 on vegetables but on average more than twice that amount on alcohol. What’s more the uptake of colorectal cancer screening is low.

In healthcare people may not act on risk even when it is appreciable and often overestimate benefit even when it is negligible. In the commercial world advertisers roll up their message in stories in which people imagine winning the lottery (” It could be you”), driving the car (Zoom, Zoom), buying the house (from the people ‘who give a little extra’). And so people spend money when they have no chance of benefit and households are said to be

Awash with debt.

When an adverse event is projected to be years in the future (a stroke or a heart attack) and is described by using the example of what happened to ‘other people’ it does not make an impression. If on top of that what is required to avoid that ‘catastrophe’ is going to take sustained effort (30 minutes of exercise most days of the week), then behaviour change is unlikely. On the other hand you might quickly part with the few coins in your wallet today if it could put millions of dollars in your pocket after the big draw tonight. Four things matter:

1. Are you talking about me? Does that fit with what I already think? Do I see myself clearly in this story?

2. What is this going to cost? And will I notice it straight away?

3. Do I have to keep on paying?

4. When will I get the reward?

The recipe for triggering behaviour change is already been used to great effect. That’s why households are ‘awash with debt’. The call to action is to communicate so that people are more likely to make choices from which they will benefit. Convenience, the hidden cost of ‘benefit now’ is another weakness. People will pay 100s of dollars in extra bank charges to be able to draw their money out of any convenient ATM machine, they will take on huge mortgages over lengthy periods if the monthly repayments seem modest. We already trade our privacy for free access to social media. If in the future it becomes possible to avert a major illness by simply swallowing a pill containing technology that also does things from which someone might profit then we might also relent.

Picture by Matthew Anderson

In a call to action timing is everything

Nebulizer Baby

I recall with shame that I had failed to protect our little boy when he scalded his hand while I was running his bath. At that moment the advice to keep toddlers out of the bathroom while a hot tap is running was hardly necessary. Similarly the dentist who advised us that dried fruit can cause dental caries rammed home the message when he announced that our five year old needed fillings.

Health professionals frequently impart information as a call to action:

You are drinking too much. You need to stop smoking. You need to take more exercise. You need a holiday. You are damaging your hearing. You are putting yourself at risk of skin cancer. You need to take the test.

The problem is that the advice is rarely followed. A wonderful paper by McBride, Emmons and Lipkus cited 487 times offers a heuristic model for ‘Teachable Moments’. Events such as: clinic visits, notification of abnormal test results, pregnancy, hospitalization and disease diagnosis. In many cases the impact of a health promotion message delivered in this context is substantial, and far better than any other intervention.

  • Clinical visits for health promotion and acute illness

It is more likely that a parent will stop smoking if their child is attending a clinic for a condition that is exacerbated by passive smoking. Similarly dentists are much more likely to promote successful quit attempts when they advise smokers attending with dental problems.

  • Notification of abnormal test results

It is more likely that people with abnormal spirometry results will quit smoking if advised at the time of receiving their results.

  • Pregnancy

Studies have reported that among those smoked prior to pregnancy 39% quit after becoming pregnant, a rate 8 times that reported among smokers in the general population.

  • Hospitalisation and disease diagnosis

The 12-month follow-up quit rates among hospitalised smokers who received no formal intervention ranges from 15-78%. Reason for hospitalisation has been suggested as an important co-factor in cessation rates. Long-term abstinence rates are higher among cardiac patients and those receiving care for cancers.

The evidence from research is that pregnancy and hospitalisation have the greatest potential as a ‘Teachable Moment’. It seems that the triggering effect of a health promotion message is much more effective given the heightened emotional state and the increased perception of risk and benefit from the suggested action. In addition ‘individuals see greater personal relevance in events that threaten or increase their self-esteem, undermine or enhance feelings of personal control and endanger positive expectations of the future‘. In these circumstances people will invest greater emotional and cognitive effort in achieving the necessary outcome.  It’s not just the message that needs to be considered but the ‘Teachable Moment’ and how that message is to be imparted. The most effective health professionals know how to do this without making a bad situation worse.

Picture by Kristy Faith

Ask the most embarrassing question

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A few years ago a friend told me about meeting his future mother-in-law for the first time. When he was brought into the family home she was in the lounge ‘reading’ a news paper. He discovered many years later that she could neither read nor write but in order to impress her daughter’s friend she had engineered to be seen reading when she was introduced to him.

Illiteracy is a dreadful condition:

I would go to the post office and get crippling anxiety. Just filling out a form or trying to pay a bill, simple stuff. When you go to the doctor and they give you the form to fill out, I couldn’t even spell my street name. It was awful. Talbot-Dunn

Doctors ask many embarrassing questions:

How often do you pee? Do you have a vaginal discharge? What are you using for contraception? Do you snore?

However they sometime fail to ask the most embarrassing question of all:

Can you read?

In 2005 a paper concluded:

Health literacy is basic reading and numerical skills that allow a person to function in the health care environment. Even though most adults read at an eighth-grade level, and 20 percent of the population reads at or below a fifth-grade level, most health care materials are written at a 10th-grade level. Safeer and Keenan

Literacy cannot be assumed. There are many test for reading age. For example the Burt reading test suggests that someone who cannot read more than two of the following words has a reading age of 5.3

To is up he at for my sun one of

The shocking truth is that around 3.7% of Australians aged 15-74 (620,000 in 2011-12) were at this level. A further 10% (1.7 million) were not much higher than this level. In addition literacy levels are lowest in groups that are most vulnerable:

Populations which are recognised as being the most vulnerable to the challenges posed by literacy and health literacy include migrants, refugees, older people, and people from low SES backgrounds.

Thomacos, N. & Keleher, H. (2009). Health literacy and vulnerable groups: What works? Melbourne: Department of Health Social Science, Monash University.

Therefore it is incumbent on health professionals to ascertain that their patients are suitably equipped to read written instructions. To assume otherwise when literacy is absent is to invite frustration and to court disaster. An innovation that alerts the health professional that his or her patient is challenged by text could go a long way to improving outcomes when the prevalence of this ‘condition’ is significant.

Picture by Kimberely Britt

First we have to agree that there is a problem

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In order to make progress when we are trying to help someone we have to understand their world view. This was wonderfully portrayed in the Dove commercial. To understand a person’s perspective we have to try to see them as they see themselves but also to accept that as health professionals we may have less influence on people’s choices then we like to think.

It was also underlined in a research paper which concluded:

Overweight and obese youth were significantly more likely to misperceive their weight compared with non-overweight youth (P<0.001). Multilevel modeling indicated that greater parent and schoolmate BMI were significantly associated with greater misperception (underestimation) of weight status among children and adolescents. Maximova et al

Large proportions of the population are now overweight or obese. It may be hard to believe this if you live in affluent suburbs where salad bars, gym membership, jogging and cycling are the norm. In other parts of town it might be routine to eat fast food and wear XL or XXL sizes. As health professionals we have to compete with the messages from ‘healthy’ juice bars where sugar is added to sweet fruit and sold to the public as a better choice than a Mcdonald’s smoothie. Supermarkets sell cereal bars as a healthy snack even though most are loaded in sugar and salt. But all of these pales compared to the gluten-free fad. It is reported that 90 million Americans now follow a gluten-free diet because they believe (despite the lack of research evidence) that it is healthier, or as a weight loss strategy or in some cases to treat extra-gastrointestinal symptoms like a ‘foggy mind’.

Unpacking these beliefs in the course of a routine consultation in primary care is challenging. The belief has to be volunteered and the context understood. The associated behaviours have to be outlined and if there are sufficient grounds challenged without engendering the impression that the health professional does not accept the person’s right to make a choice, even when that choice is dubious or could even be harmful. People have the right to follow a gluten free or lactose free diet whatever their reasons. They have a right to drink too much alcohol and or to smoke cigarettes. However for many such people the consequences may include chronic morbidity and a shorter life expectancy. It is therefore incumbent on health professionals to communicate effectively with those who seek help. This may include demonstrating the outcomes in a creative way. The task is to help people to decide what outcomes they would prefer. However in the first instance we have to understand the ‘why’ as well as the ‘what’ of the decisions they make. That means creating the conditions in which people will feel inclined to share. That only happens when they believe that their perspective as well as their right to choose matter to you.

Picture by Will Temple

Only one in four can locate the lungs

 

16665700260_ec2c765d31_zTopol says the writing is on the wall. People are more likely to consult google than make an appointment with a doctor. However that assumes that the human response to a threat, physical or psychological is logical.  There is seldom logic in much human behaviour. The myriad of factors that impact on a person’s decision to consult a doctor were explored by Campbell and Roland in 1996

Only one in 37 new symptoms were reported to a general practitioner…

A key reason why someone might seek medical advice is that they consider themselves susceptible to disease. However for that to be the case they have to understand how their body functions. Recent research suggests that this is not reliable. Weinman et al demonstrated in a survey of the general public that while most people knew the location of the human intestines, less than half could locate the liver, less than a third could place the kidneys and astonishingly just over one in four could locate the lungs. If knowledge of anatomy is limited than knowledge of pathophysiology is even more problematic. This was demonstrated in a study of perspectives on a child with symptoms of asthma from mothers of different ethnic backgrounds in London.

Some mothers mentioned avoiding certain foods; e.g. banana since it ‘contains a liquid that irritates the throat’, and cold milk or ice cream..Some mothers said they would utilise their normal strategy of what they do when their child is unwell with respiratory difficulties (e.g. menthol rubs, types of foods). In two sessions discussion involved remedies e.g. honey and lemon tea or remedies such as ‘bush tea’…Only one mother said she would find out what was wrong before trying a remedy. Most would first seek advice from their own family, friends and medical books. Cane et al.

In a recent study (2014) by Quaife and colleagues people were asked about their help seeking behaviours in relation to symptoms that may indicate a cancer diagnosis including a persistent cough, rectal bleeding and breast changes.

Recognition tended to be lower for men, older people, and those from ethnic minority and less-educated groups. These effects were significant for all three warning signs (P < 0.05).

This indicates that it may be some time before we can conclude that people will be safely self diagnosing.

Picture by Wellcome images

Twenty minutes every three months

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I recently said goodbye to my patients when I moved to another job. One of my general practitioner friends also said goodbye to his patients, albeit it temporarily. He has been visiting Australia this week. I am pleased to recount his story.  For him the light bulb moment came when he noticed that people were concerned that he ‘might never return’. He wondered if he could deploy this connection to encourage his patients to be more active and or stop smoking.

Two months before Dr Klein left ( for one year), he wrote to his patients, challenging them to set 1 health-related goal to work on while he was away. He suggested they consider a lifestyle change, such as losing weight or quitting smoking.

Two of his colleagues offered to support the patients in their efforts to achieve any goals they set in Dr. Klein’s absence.

About 1 in 8 adult patients (48 out of 350) set goals, including losing weight, exercising so many times per week, and quitting smoking; some set more than 1 goal.

The ‘intervention’ took only a few minutes to initiate and 20 minutes of staff time every 3 months. This was essentially a reminder letter every 3 months. The results were impressive.

Among the participants, 18 (38%) did not achieve their goals; another 15 (31%) could not be reached, so their results were unknown. The remaining 15 patients (31%) succeeded, 8 completely and 7 partially reaching their goals, and some meeting more than 1 goal. The successes included 3 patients who quit smoking, 7 who increased physical activity levels, 7 who lost weight, 1 who reported decreased shoulder pain after exercising more often, and 1 who made an overall lifestyle change.

It sounds as if the reminder letters were triggers to keep working towards the goal. This ‘lean innovation’ did not require a research grant or a large team to complete. No drugs were prescribed, no tests were required. It was rewarding and demonstrated the value of the social capital in the doctor patient relationship. A relationship that defines the role of the medical practitioner even in 2015. The same relationship that creates tangible results. Medicine is a people business. We do well to remember that at a time when there is an obsession with quantified self.  You can read more about Doug Klein’s experience here.

Picture by Kellan.