We’ll it’s winter and for many of us across the northern parts of the continent snow shoveling is as much a part of the routine in winter as cutting the grass in the summer. Up until now there haven’t been any large studies looking at the risk of snow shoveling and having a heart attack. Researchers at the Kingston General Hospital, in Kingston, Ontario studied 500 men between the ages of 19 and 94 who had heart attacks (acute coronary syndrome). At total of 35 (7%) had documented events related to snow shoveling. The only significant variables were a family history of heart disease and male sex. They conclude a family history of heart disease and male sex have strong, independent associations with having a snow-shoveling-related heart attack. Now, having both risk factors, I have to go shovel the driveway so I can get to work.
Apathy and depression often develop after a stroke. Some estimates say 1 in 4 or 5 stroke victims suffer from apathy. The mechanism isn’t well known. Its presence is generally predictive of greater functional decline. There is no effective treatment. Does generalized apathy represent an as yet unrecognized neurological symptom? Or perhaps apathy is too vague a cognitive condition to differentiate between not voting and not getting out of bed. Who cares? You might ask.
Diagnostic error in medicine is starting to grab media headlines again. There is a growing literature on diagnostic errors mostly in the field of cognitive psychology. The consensus of this literature is that most errors are cognitive and result from the application of one or more cognitive biases. Such biased reasoning is usually associated with ‘System 1’ (non-analytic, pattern recognition) thinking. However, there is actually very little evidence to relate diagnostic errors with System 1 (non-analytical) reasoning. Studies show that ‘experts’ are as likely to commit errors when they are attempting to be systematic and analytical. The burning platform is whether various approaches to reduce medical errors are effective. An educational approach to teach medical students about diagnostic pitfalls doesn’t appear to work. There is an accumulation of research that interventions directed at specifically encouraging both analytical and non-analytical reasoning has been shown to result in only small improvements in accuracy. However, diagnostic errors are not simply a consequence of cognitive biases or over-reliance on one kind of thinking. As we know from the aviation industry for example errors result from multiple causes and are associated with both analytical and non-analytical reasoning. There is some research evidence to suggest encouraging both types of reasoning can lead to limited gains in accuracy. So what’s the answer? First, we live in a universe of probability so the fundamental question is how to drastically reduce the likelihood of error, not eliminate it. Artificial intelligence and the convergence of information and biotechnologies offers hope to give us humans better tools to help us overcome our innate flaws. After all, if President Garfield’s attending physicians had an x-ray machine they could have found the source of the assassin’s bullet that didn’t kill him, but the medical care and the biases of his physicians did.
As we’ve seen in some recent high profile deaths reported by the U.S. media, physicians can play an important role in reducing the skyrocketing prescription drug death epidemic. On January 13, 2012 the U.S. Centers for Disease Control (CDC) reported in the Morbidity and Mortality Weekly Report almost 27,000 people died in the United States died as a result unintentional drug overdose. This translates to 1 death every 19 minutes across the U.S. And it’s not just a U.S. problem. Prescription drug abuse is the fastest growing drug problem across North America, and it’s not just in big cities, in small rural and remote parts of Canada it is a silent epidemic that is ripping apart whole communities. This dramatic increase in the unintentional drug overdose death rate is fueled largely by prescription opioid analgesics. Since 2003, prescription opioid analgesics deaths have been double that for the illegal drugs heroin and cocaine combined. And the prescription drug death rate is only the tip of the iceberg. It also drives up the utilization costs for many health services. For every unintentional overdose death from opioid analgesics, 9 people seek treatment for substance abuse, 35 visit emergency departments, 161 report dependence, and 461 report recreational or non-medical uses of opioid analgesics. Do the math, this is a costly epidemic in more ways than one. Physicians have an vital role to play in both practice and in leading the call for a research-based public policy strategy that targets those at greatest risk.
1. Move routine specialty services such as endoscopies out of hospitals
2. Create focused factories of care independent from hospitals to improve access, throughput and quality
3. Use technology to improve productivity, for example email to arrange for referrals, appointments and routine prescription renewals
4. Encourage grassroots, provider-based innovations
5. Facilitate mergers and acquisitions of health service organizations
6. Modernize the way health services are funded to reward new ways of delivering services, in different ways; have funds follow the patient
7. Restore choice as a dimension of quality
For more ideas on Fiscal Accountability and The Transformation of Canada’s Healthcare System see the report Shifting Gears from The Mowat Centre and the School of Public Policy and Governance at the University of Toronto.
End of life care is difficult to really talk about in the abstract, that is separate from the care needs of the individual children, teenagers, adults or senior citizens needlessly suffering in their final days and hours. The lack of coordinated care for this stage of life stands in stark contrast to the excellent standards of care generally achieved for example in obstetrical care across the country. For sure there are pockets of excellence in palliative care and many dedicated people doing what they can to provide care and relief.
The roots of neglect lay in the origins of Medicare. End of life standards of care are very different today from when Medicare was first established. Originally established to provide coverage for hospital and physician care, Medicare did not envision the exponential growth in medical technology and the ability to offer many more options for treatment to prolong life, to enable many people to live longer with chronic disease, so that many more will require end of life care. It should come as no surprise then that an end-of-life care strategy is desperately needed across Canada. One that is person-centred, family-focused and community-based, and one that addresses suicide prevention and abuse. Societies are going to need to find creative ways to reallocate limited funds to make home care, long-term care, and palliative care consistently insured services under Medicare and to define a commitment to make excellence in palliative care an achievable, measureable goal.
A recent poll conducted by Environics Research published in Health Edition reports that Canadians think inefficiency is the source Medicare’s woes.
Of those surveyed 62 per cent think inefficient management is the root problem while 30 per cent think it is insufficient funding. This is a shift from a 2002 poll when Canadians were almost equally divided on the issue: 41 per cent citing inefficiency and 44 per cent citing lack of funding.
Canadians have a strong preference for the government-funded Medicare program while interest in private health care options remains consistently low.
So here’s the question: is public opinion based on knowledge, experience, or media reporting?
Could innovation in population health be found in a little known Manitoba pilot project from the 1970s? Few people know about the amazing social experiment conducted in Dauphin Manitoba between 1974 and 1979 called Mincome. The pilot project quietly shut down and there was no real evaluation—until now. Evelyn Forget a researcher at the University of Manitoba published her results in Canadian Public Policy in 2011. Using routine administrative data she documented an 8.5 percent reduction in hospitalization rates for participants in the pilot project relative to controls. These results were particularly relevant for accidents and injuries and mental health conditions. Her analysis also found that participants had fewer doctor visits, especially for mental health issue, and more young people continued past grade 12 in school. Her study found no increase in fertility rates, family dissolution rates, or birth outcomes. The study concludes a relatively modest guaranteed annual income (GAI) can improve population health with potentially significant health savings. With the rising cost of health care, an aging population and the need to reduce the size of government, could real health innovation be buried in a little known social experiment? Maybe it’s time this innovative idea had some serious consideration.
Our friends over at the Canadian Institute for Health Information (CIHI) say the Medicare insurance system needs to address gaps in the continuity of seniors’ care. The aging population will hit Canada faster than many other countries, and the number of people over 65 is expected to double to 25 per cent of the population by 2036.
So far the impact of an aging population on health costs has remained fairly stable, the report says seniors are frequent users of Medicare and cost more than any other segment of the population. At present seniors (over 65) account for only 14 per cent of the population, but they use 40 per cent of hospital services and account for approximately 45 per cent of all provincial and territorial government health spending.
A number of ideas are put forward in the report to help alleviate the cost pressures and provide better care for seniors. Clearly, improving the integration of care across the continuum, more focus on primary and secondary prevention measures, making efficient use of new technologies, and better use of information on seniors’ medical conditions.
Integration of care is key and can make a big difference. In Australia the use of a care facilitator was able to reduce seniors’ emergency department visits by 21 per cent and hospital admissions by 28 per cent. In Canada, according to CIHI, one in every 11 emergency department visits by seniors is for a chronic condition that can potentially be managed at home or elsewhere in the community. However, less than half of seniors are able to get a same- or next-day appointment with a family doctor, and more than a third wait a week or more.
Medication safety is another area where well-integrated seniors’ care could help. The report says almost two out of three seniors in 2009 took five or more prescription drugs, with close to a quarter taking ten or more, increasing the potential for very serious drug interactions.
In an era of slashing Medicare budgets innovations such as these could improve elder care and save money. However, slashing budgets without targeted investment in key areas such as those noted in the CIHI report could have the unintended consequence of increasing Medicare costs, drive up costs of emergency and acute care and ultimately drive the percentage of GDP spent on health care to a staggering new high.
Most people don’t think about the risks of being admitted to a hospital. In some countries, and some hospitals the risks are greater than others. The Canadian Institutes for Health Information (CIHI) released a report Learning from the Best: Benchmarking Canada’s Health System, an analysis of international data by the Organization for Economic Cooperation and Development (OECD) on how its member countries have fared regarding access to quality health care.
In the OECD study (see: www.oecd.org/dataoecd/13/0/49084244.pdf) Canada is in the top 25 per cent for avoidable hospital admissions for conditions such as asthma and some other chronic conditions. Canada ranks third for five-year breast cancer survival rates, and is above average for colorectal cancer survival.
But CIHI said Canada has some of the highest rates among 17 reporting countries for accidental puncture, and for foreign bodies left in during surgical procedures. It also has among the highest rates of obstetrical injury of 20 countries. In July 2011, the World Health Organization (WHO) reported Canada has among the highest rates of health care-associated infections in major developed countries. These issues are directly related to how health care providers perform their jobs and the working environments in which they work. Is the future of patient safety better health human resources management and better working conditions? It’s work a closer look.