The Pisa Syndrome:reflections on
Patient Centred Innovation and Organizational Change
Prof. Jan M. De Maeseneer, MD PhDHead of Department of Family Medicine and Primary Health Care – Ghent University
Director Primafamed-Centre Ghent University
Pisa, 31.08.10
1. Clinical approach
2. Major diagnostic components
3. From chronic disease
management to participatory
patient management
4. The way forward
The Pisa syndrome
Clinical presentation
• Pleurothotonus• Abnormally posturing• Flexion of the body and
head to one side• Slight axial rotation of the
trunk • Cause:
long-term use of neuroleptic medication
• Recent report: cholinesterase inhibitors
Source: The Lancet, 2000; 355:2222
1. Clinical approach
2. Major diagnostic components
3. From chronic disease
management to participatory
patient management
4. The way forward
The Pisa syndrome
1. Guidelines are not based on research in PC, none
is based on research with complex multimorbidity
2. You talk to patients, you do not enrol them.
(G. Tognoni)
Major diagnostic components
1. Strengthening primary care: Important differences in context and national strategies
2. Weak incentives and voluntary basis: Is it enough?
3. How to convince governments, doctors, insurance organisations, patients of the urgency?
4. How to balance paternalism and patient choice?
5. EU-countries provide a laboratory for comparative research
(P. Groenewegen)
Major diagnostic components
As reported by FD and nurses in NDPHS Workshop “Tomorrows role of Family doctors and Nurses” (Baltic Conference of Family Medicine, Piarnu, Estonia Sept 2009)• Unequal distribution of PHC practices – not
attractive rural areas • Increasing workload • Extended PHC team needed• More emphasis on patient centered, holistic care• Introduction of EB performance indicators• Apropriate incentive payment schemes
(A. Jurgutis)
Major diagnostic components
System change depends on External pressureInternal “strategic” interventionsIncremental but strategic “little steps”
System change takes time
(H. De Ridder)
Major diagnostic components
Strategy for Change in Health Systems
• Achieving primary care• Avoiding an excess supply of specialists• Achieving equity in health• Addressing co- and multimorbidity• Responding to patients’ problems• Coordinating care• Avoiding adverse effects• Adapting payment mechanisms• Developing information systems that serve care
functions as well as clinical information• Primary care-public health link: role of primary care
in disease prevention
(B. Starfield)
1. Clinical approach
2. Major diagnostic components
3. From chronic disease
management to participatory
patient management
4. The way forward
The Pisa syndrome
From problem-oriented togoal-oriented medical care:A paradigm-shift
Source: Mold J et al, Fam Med 1991;23:46-51
“Problem-oriented versus goal-oriented care”
Problem-oriented Goal-oriented
Definition of Health Absence of disease as defined by the health care system
Maximum desirable and achievable quality and/or quantity of life as defined by each individual
“Problem-oriented versus goal-oriented care”
Problem-oriented Goal-oriented
Evaluator of success Physician Patient
What really matters for patients is
• Functional status
• Social participation
PHC and Contextual Evidence
From “chronic disease management”
“participatory patient management”
‘Chronic Disease Management’ might
lead to vertical disease oriented
programs, leading to inequity by
disease
[ see www.15by2015.org ]
Domains for quality indicators in QOF 2009• Clinical
– Secondary prevention of coronary heart disease
– Cardiovascular disease: primary prevention
– Heart failure– Stroke & TIA– Hypertension– Diabetes mellitus– COPD– Epilepsy– Hypothyroid– Cancer– Palliative care– Mental health– Asthma– Dementia– Depression– Chronic kidney disease– Atrial fibrillation– Obesity– Learning disabilities– Smoking
• Organisational– Records and information– Information for patients– Education and training– Practice management– Medicines management
• Patient experience– Length of consultations– Patient survey (access)
• Additional services– Cervical screening– Child health surveillance– Maternity services– Contraception
Patient experience• Little research on patient related/reported impact
• Continuity and relationship affected
• Fragmentation of care
• Little explanation provided to patients
Wilkie. Does the patient always benefit? In…
“A slim, active 69-year-old patient attending for influenza vaccine was faced with questions about diet, smoking, exercise and alcohol consumption. There was no explanation for why these questions were asked; they seemed irrelevant to havinga ‘flu vaccine. Blood pressure and weight had to be recorded and a cholesterol test organised. A short appointment lasted almost 15 minutes without the patient having the opportunity to ask a question about any aspect of ‘flu vaccine.”
1. Clinical approach
2. Major diagnostic components
3. From chronic disease
management to participatory
patient management
4. The way forward
The Pisa syndrome
• translational research
• education
• policy development
• threats and opportunities
• leadership
The way forward
• translational research
• education
• policy development
• threats and opportunities
• leadership
The way forward
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2
3
4
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Efficacy
Effectiveness
Efficiency &equity
Medical
Contextual
Policy
Quality of care
EVIDENCE
• translational research
• education
• policy development
• threats and opportunities
• leadership
The way forward
WHO-five star doctor
- assess and improve the quality of care
- make optimal use of new technologies
- promote healthy lifestyles
- reconcile individual and community health requirements
- work efficiently in teams
THE FIVE STAR DOCTOR
Need for interprofessional learning
www.the-networktufh.org
ACTION IS NEEDED!
Towards socially accountable faculties:
ACTION IS NEEDED!
We invite you for the next EFPC conference in Graz on September 16, 2011 in Austria
Followed by the Annual Conference of the Network Towards Unity For Health (TUFH) :
Integrating Public and Personal health care in a world on the move. 17-22 Sept 2011
• translational research
• education
• policy development
• threats and opportunities
• leadership
The way forward
Shojania, K. G. et al. JAMA 2006;296:427-440.
The Effectiveness of QI Strategies: findings from a Recent Review of Diabetes Care
Policies improving cost efficiency
“The government should strongly encourage patients to
consult their general practitioner first as a general rule
(except for emergencies) by not reimbursing medical
expenses for patients not referred by their GP
(gatekeeper).”
OECD economic surveys 2005 - Belgium, pag 68
− There is a social gradient in health – the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health.
− Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health.
− Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.
Key recommendations of the Marmot Review
Healthy life expectancy in Belgium, 25 years, men
28,1
3842,6
45,9
2025303540455055
basic secundaryschool: 1st cycle
secundaryschool: 2nd
cycle
university/highereducation
Socio-economic inequalities in health
Healthy life expectancy in Belgium(Bossuyt, et al. Public Health 2004)
Healthy life expectancy in Belgium, 25 years, men
28,1
3642,6
45,9
2025303540455055
basic secundaryschool: 1st cycle
secundaryschool: 2nd
cycle
university/highereducation
Socio-economic inequalities in health
Healthy life expectancy in Belgium(Bossuyt, et al. Public Health 2004)
− Reducing health inequalities will require action on six policy objectives:
• Give every child the best start in life
• Enable all children young people and adults to maximise their capabilities and have control over their lives
• Create fair employment and good work for all
• Ensure healthy standard of living for all
• Create and develop healthy and sustainable places and communities
• Strengthen the role and impact of ill health prevention
Key recommendations of the Marmot Review
Integration of welfare and health
• translational research
• education
• policy development
• threats and opportunities
• leadership
The way forward
• translational research
• education
• policy development
• threats and opportunities
• leadership
The way forward
Become a member of the EFPC and join us in Go:teborg on 3- 4 Sept 2012
for The Future of Primary Health Care in Europe
IV
- How will we develop in Europe a health system characterized by : - Relevance- Equity- Quality- Cost-effectiveness- Sustainability - Patient-centredness- Innovation
Conclusions
