organized curiosity

Improving health care through research


1 Comment

Sustainability of the Canadian health care system: In “evidence” we trust!

ShashiLast year when I was at a local Cancer Research Conference, I struck up a conversation with a very sweet, older lady about the status of cancer treatment options in Canada. She told me that she was a breast cancer survivor and felt very lucky to be living in a country that has a publically funded healthcare system. But then, she also expressed that she was not happy about the fact that our hospitals did not have the very latest machine, the one she had heard about in the news that diagnoses breast cancer at early stages. She insisted that we are not spending enough money to get these new technologies.

That conversation really got me thinking about how we perceive our healthcare. Is it really true that Canada does not spend enough on healthcare?

Well, according to the Canadian Institute for Health Information (CIHI), we spent an estimated $211,000,000,000 (yes, that is 211 billion dollars!) on healthcare in 2013.

If we spent such an immense amount of money on healthcare, why are only certain things funded? Why can’t we afford everything that is on everyone’s medical wish list? Or why can’t we just spend more (we are spending $211 billion right now anyways so what’s another few million dollars)?

In reality, we are already spending too much. Most policy makers now agree that at the current rate of expenditure, the Canadian healthcare system will soon become unsustainable. This realization has forced us to make some tough decisions regarding funding.

But who gets to say what to fund and what not to? How do we go about making these decisions in a fair, ethical, and economically sound way without affecting the quality of healthcare?

There is no magical formula to answer these questions. But, one of the most appropriate solutions to achieve sustainable healthcare would be to make our decisions based on the evidence.

So what is evidence? In general terms, evidence is a body of facts that is collected through scientifically valid means of research.

Thus, it is explicit that the generation of evidence requires research activities. However, who performs such research and how it gets decided what needs to be researched?

Traditionally, such evidence was derived by researchers doing their research in academic settings. In this model, researchers do research and policy makers do policies in their respective “silos”. What we have lacked, in most part thus far, is the collaboration between researchers and policy makers. The biggest criticism for this traditional system is that the knowledge synthesized by “researchers” is very academic and lacks the context of the feasibility in the real world which is sought by “policy makers”.

Such disconnect between researchers and policy makers restricts the evidence-informed policy making practices.

Not surprisingly, in recent times many research agencies have explicitly advocated for the active collaboration between researchers and policy makers. This new trend is exemplified by two examples: one at the national level and the other at the local level. The Canadian Institutes of Health Research (CIHR), the Government of Canada’s health research investment agency, launched a new program called the Evidence-Informed Healthcare Renewal (EIHR) to “support researchers and decision makers to work together to advance the current state of knowledge, generate novel and creative solutions, and translate evidence for uptake into policy and practice to strengthen Canada’s healthcare systems.” Similar collaboration between researchers and policy makers is also promoted through the Translating Research Into Care (TRIC) Grants of QEII and IWK Foundations.

TRIC

It is now clear that the solutions for sustainable healthcare will come through the collaborative efforts between the various components of the system. In this multi-disciplinary model, researchers will work alongside with policy makers and draw upon each other’s expertise to develop academically sound and practically feasible solutions. Only through such an integrated approach, we will be able to produce the evidence that will aid our mission to develop the policies to sustain our healthcare system.

~ Dr. Shashi Gujar, is a scientist with Strategy and Organizational Performance, at the IWK Health Centre, and also works with Faculty of Medicine, at Dalhousie University as a researcher.


Leave a comment

Blaming patients

blameblogWhenever something is wrong in health care, we tend to blame the patient or if the patient is a child, we blame the parents (especially the mother).

Patient blaming takes lots of different forms. One is what I call the psychogenic bogeyman. If we cannot find the cause of a problem, we say it is psychological or “all in your head”.

Now I am not against recognizing the incredible value of psychology. After all I am a clinical psychologist and founded and led for a decade the PhD program in Clinical Psychology at Dalhousie University.

One of my first research studies published in 1983 was on recurrent abdominal pain.  Recurrent abdominal pain was described as pain in children that kept coming back and no known organic cause could be found. It was quite common, especially in girls around 12 years of age.  At the time, it was assumed that the problem was a difficult personality and a difficult family. I was just starting out in my career and this was a great problem to tackle because it was common and assumed to be psychological in nature. I was very disappointed because in this study of 30 children with recurrent pain and 30 children without pain, I failed to find any differences between children with recurrent abdominal pain and children without pain. I had to conclude that we should not diagnose pain as psychogenic unless we had positive evidence.

Unfortunately, people still make what Patrick Wall, a distinguished physiologist in pain, called “a leap to the head,” the tendency to say a disease is psychological in origin just because we can not understand it.

Although we now know that autism is not in any way caused by parents’ behavior, the myth that cold rejecting or “refrigerator mothers” cause autism persists.

How else do we blame patients?

We blame patients for overuse of medical tests and treatments. Even the Choosing Wisely campaign which I have endorsed several times in this blog implies that patients are responsible along with their doctors for unneeded tests and treatments. I think patients can provide a very helpful boost to getting the best care but patients are not the problem.

I recently saw a post in an excellent blog, the Incidental Economist, on a study published in JAMA Oncology about patient requests.  They studied 5050 patient cancer visits by interviewing the doctors right after the visit. There were 3624 patients and 60 clinicians involved. Four hundred and forty or about 9% involved a patient request for a test or treatment. Doctors granted 83% of the appropriate requests. There were 50 requests that the doctors felt were not appropriate and they granted only 7 of these.  That is, inappropriate requests were granted in only 0.14% (7 of 5050) of visits. Here is a graph from the blog.  An editorial in JAMA Oncology “The myth of the demanding patient” argued it is about time we stopped blaming patients for inappropriate tests or treatments.

BlamingPatientsGraph

Another way we blame patients is by calling them derogatory names. Dr. Brian Goldman the host of White Coat, Black Art on CBC radio published The Secret Language of Doctors in which he tells about different terms that have been used for patients.

  • FLK for funny looking kid
  • Yellow Submarine for an obese patient with cirrhosis of the liver
  • LOL in NAD for a Little old lady in no apparent distress

This hostile approach to patients has, in my opinion, declined in recent years but it has been replaced by the “lifestyle blame.” In the lifestyle blame, patients are blamed for their bad choices in not being active or in being overweight.

Adults and children who are overweight may be able to make better choices in their food.

But…

Try and find:

  • Fresh fruit and vegetables in the poor areas of town or in rural areas where many poor people live (there often are not even supermarkets).
  • Places that are safe to walk in poor or rural areas.
  • Social assistance that pays enough to have a nutritious diet
  • Cooking classes emphasizing nutritious inexpensive foods for kids and parents.
  • Physical education time in school that is appealing to kids, especially overweight kids.
  • Time for physical activity if you hold down two jobs to make ends meet.

I don’t mean to absolve each of us for our health choices but let’s be realistic.  Eating well is a lot easier if your income is not below the poverty line. In Nova Scotia child poverty is a huge problem with 22% of children living in poor families. It is a staggering 33% in Cape Breton!

Why do we blame patients?  I don’t think it is because we are bad people. Doctors and other health professionals are no better or no worse as human beings than anyone else. We blame patients because we don’t like to admit when we don’t know what to do or we are frustrated or feel powerless.

We are better off admitting to the limitations of our knowledge and our own feelings of inadequacy than to blame our patients. We, the health professionals and the health bureaucrats, need to realize that in everything we do patients are the reason for the health system; our job is to serve patients. Let’s put an end to patient blaming.

~Dr. Patrick McGrath


1 Comment

Overcoming the Fear of Numbers

Number blog

I failed my first statistics course. I am reasonably bright but had a phobia of numbers and formulae. More importantly, I was not motivated to learn all of those strange concepts.

After all, I was studying to be a clinical psychologist and help people. I didn’t want to become a statistician or an accountant. It also didn’t help that the statistics professor felt it was his job to intimidate students and make them feel stupid. From his point of view this helped students study hard and learn.

Thank goodness when I took my first statistics course in my PhD program, I totally lucked out and had a brilliant teacher in Dr. Alastair MacLean.  His goal was to help his students understand numbers and statistics so that they could accomplish what they wanted.

Since that time, I have learned much more about statistics and numbers. Let me tell you why I am glad I overcame my fear of numbers.

Whenever, I go to the doctor, I ask “How likely is it this treatment will help me?”  I usually get something like “It is pretty good’” or “There are randomized trials showing it works.”  Nothing too precise.

There is, however, a great statistic to answer that question with. It is called Number Needed to Treat or NNT.  NNT refers to the number of patients that are needed to have one person benefit above what would happen naturally. Of course NNTs have to be used in the context of the patients’ values.

So if a disease or disorder is inevitably going to kill me in a year and 1 in 5 patients survive with the treatment, the NNT would be 5 and I would certainly try it unless the side effects were so horrendous that I would rather die. But if the NNT were 100 and it would make my remaining time uncomfortable or if it would cost so much as to make my wife penniless if I did die, I probably would not take it.

Number Needed to Harm or NNH is very similar but the number refers to a specific side effect.

Most diseases have some natural remission and so NNT is a bit more complicated to figure out.

Technically, NNT is the inverse of the absolute risk reduction or 1/absolute risk reduction. It is calculated for two treatments, usually an intervention and a placebo intervention for a defined endpoint. So if a drug for face rash eliminates 80% of the rash within 1 month in 70% of patients and 50% get 80% better on a placebo drug, the NNT would be 1/(0.7-0.5)=5.  An NNT of 5 is very good and if the treatment was of modest cost, I would probably do it.

There is a great web site that has carefully collated data and calculated NNTs.  It is called The NNT. Here are a few examples from that site.

-Mediterranean diet for those with a previous heart attack, to prevent a second heart attack NNT=18; to prevent death NNT=30; to prevent cancer NNT=30.  There were no harms seen.

-Training for falls prevention in the elderly NNT=11 with no harm seen.

-Low dose aspirin each day for a year to prevent a heart attack NNT=2,000  or to prevent stroke NNT=3,000  NNH for a major bleeding event was 3333.

-Statins taken for 5 years for those with known heart disease

  • NNT=83 for life saved; NNT=39 to prevent non-fatal heart attack; NNT=125 to prevent stroke

Many treatments do not have NNTs worked out but we will see this statistic increasingly being made available. There are not many NNTs worked out for children’s illnesses because very often drugs are not tested on children.

Another source of information about whether a treatment or a test is likely to do harm or good is Choosing Wisely which I mentioned in my June 12, 2014 blog. Choosing Wisely has developed lists of tests and treatments that you should be talking to your doctor about.  But they may do more harm than good. For example bone density tests are often used to see if older people (like me) have weak bones. The problem is that for most the test is not needed and the finding of weak bones often leads to being put on drugs that not only don’t do much good for most people but also have significant risks. There are other things we can all do to keep our bones strong such as stopping smoking, limiting alcohol, exercising and eating well.

As you can see there are things you and I can do to answer the question, “Will this work for me?”

~Dr. Patrick McGrath


1 Comment

The Seniors Report

The Canadian Institute of Health Information, a federal agency that focuses on health statistics just released a survey on healthcare in older Canadians. The report was in conjunction with the Commonwealth Fund, a not for profit think tank based in the USA.

The first thing I have to object to is that anyone who is over 55 was classified as older. None of us thinks we are as old as we are. In fact most people over 25 think they are really about 20% younger than they are. But on the cusp of my 68th birthday, I don’t feel a day over 45. However, I do relish the senior rate on the bus and at the movies.

The nice thing about the CIHI survey was that it compared each province with the average of other developed countries. One of the problems is that the sample size for each province was quite small, Nova Scotia only had 258 responses. The response rate was only 28%.

So how did we do?  Most older Canadians (96%) had a regular doctor they went to for healthcare. But Canadians in every province had a longer wait time for primary and specialist care than other developed countries .

SR1

Canadians also have a hard time getting after hours care without going to the Emergency Department.

SR2

As a result, almost 40% of Canadians went to an Emergency Department for something that could be treated at a family doctor. As well, Canadians wait more than any other country for specialists. 25% of older Canadians waited more than 2 months for a specialist. This has not improved over time.

But most Canadians report positives about their doctors.

SR3

I was pleased to see that the Maritimes did a bit better than most in continuity of care.

SR4

Canadian’s talk to their doctors about life issues

SR5

Finally, lets look at what Canadians over 55 think about their health and our health system.

SR6

What do you think? Let me know.

~Dr. Patrick McGrath