The Pisa Syndrome: reflections on Patient Centred Innovation and Organizational Change Prof. Jan M....

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





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)


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)


System change depends on External pressureInternal “strategic” interventionsIncremental but strategic “little steps”

System change takes time

(H. De Ridder)


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)





patient management

4. The way forward

The Pisa syndrome

From problem-oriented to

goal-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 ]

http://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.”





patient management

4. The way forward

The Pisa syndrome

• translational research

• education

• policy development

• threats and opportunities

• leadership

The way forward

? €

€

Efficacy

Effectiveness

Efficiency &

equity

Medical

Contextual

Policy

Quality of care

EVIDENCE


• education



• 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


• education



• 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

36

42,645,9

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


• education



• 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

Thank you!

[email protected]

The Pisa Syndrome: reflections on Patient Centred Innovation and Organizational Change Prof. Jan M....

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