Hopeful for a Quality, Quality Revolution

Help more than hurt.  Choose partnerships over charity. Create sustainable solutions rather than temporary relief. These are familiar themes at global health conferences around the world. Interestingly this month’s issue of Lancet Global Health features a work by Kruk et al that draws us to consider, Quality Improvement (QI). U.S. institutions are placing an ever increasing emphasis on QI. Even my own training institution has developed a “QI pathway” for interested residents. Kruk et al propose the need for a Quality Revolution in Global health and indeed a focus on providing quality care aligns well with many of the aforementioned popular themes of today’s global health discussion. It isn’t just about being there anymore, but on finding ways to ensure that the care provided is truly improving health outcomes in the world’s most under resourced populations. Since the Institute of Healthcare Improvement’s (IHI) landmark To Err is Human study from 1999 the IHI has developed six principles that they believe should be used to guide health systems and improve quality. They ask for care that is safe, effective, patient centered, timely, efficient, and equitable. Kruk et al sought to apply these quality dimensions to countries in sub-Saharan Africa with outcomes they felt were reflective of one of these six dimensions. For example in “safety” they chose a metric like “facility has water on site nearby” or “effective” metrics like how many women aged 18-69 had received a pelvic exam. They highlight that only 18% of women received a pelvic exam. Does this mean care for these women was not effective? I’d be interested to learn how many of those lucky 18 of 100 women had access to treatments that an abnormal pelvic exam would demand. Is simply getting a pelvic exam a measure of effectiveness or is it more similar to a women’s health clinic that only gets pelvic exams on 18% of women? Examples like this shows just how difficult measuring the quality of a health system can be. We must choose metrics that when improved will lead to better care. Perhaps practitioners in these clinics weren’t resourced with the solutions to the pathology they might find. Would I want to screen a woman for a cancer I had no treatment for? One area of quality care across institutions in the U.S. is a well-documented code status. The idea is to prevent an invasive and painful attempt to save a life that may be against the patient’s wishes, beliefs, or clinical situation. As I write this one of my night float colleagues is surely trying to discuss the code status with a recently admitted patient. This patient is inevitably tired from the day in the ED, likely feeling very ill or in pain, has met six doctors for the first time today and now the seventh is asking them very quickly “what would you like us do if your heart stopped?” For many patients this is first time they’ve been asked this question. Yet, every patient will have a verified code status by the time I arrive tomorrow morning. Did the quality of our admissions improve? I’m not so sure. Whether local or global we unquestionably need to seek opportunities to improve the care we provide. I only hope that our “quality revolution” in global health is a mindful pursuit because the health of the world’s most vulnerable populations depends on it.

Time for a quality revolution in global health. Kruk ME¹, Larson E², Twum-Danso NA³.

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century.National Academy Press, Washington, DC; 2001

September Global Health Readings

https://www.eiseverywhere.com/ehome/cugh2017/awards/reflection/

An opportunity for trainees and faculty alike to submit essays for a CUGH contest – prizes include money and waived registration at the conference.  Consider submitting a piece (deadline Dec 4th).

http://www.bu.edu/sph/2016/08/28/18-charts-that-make-the-case-for-public-health/

A great piece from the BU SPH Dean discussing public health in a US (and a bit global) context.  He does a great job of reviewing the big picture data around US health and health expenditures in a concise and nice fashion; worth a quick read.

 

http://www.nytimes.com/2016/08/13/health/polio-vaccination-africa-nigeria.html

Ongoing coverage of the polio outbreak in Nigeria. A nice continuation of the case study we reviewed in India.

https://www.yahoo.com/news/certifies-sri-lanka-malaria-free-nation-153516784.html

Sri Lanka has eradicated malaria, which is an impressive feat.  We knew it was feasible – the US itself did so last century – but to my knowledge no other countries have done so in the last few years.  While the eradication agenda presently focuses heavily on polio and to some degree measles (as well as guinea worm and other NCDs), malaria has been floated as a disease that could eventually be eradicated, though the tools for this are presently lacking.

Global Health Blog 2.0

Minasan, Kon’nichiwa!

I wanted to be the first to let you guys know that we will be now be updating our blog every 2 weeks with Global health topics and miscellaneous concerns. The goal is to have a new blog post out on the 1st and 3rd week of every month, starting with this post.

I am very excited to see how much interest we can gather for our global health endeavors. To that extent, I am also eager to recruit guest bloggers outside of our global health pathway residents, at BMC or otherwise, to blog about topics relevant to global health. Please subscribe to our blog, give us feedback and help us build a bigger online presence.

Now, back to your previously scheduled blogging.

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If you haven’t already guessed, we’ve all returned from our global health trip to India, safe and sound. Even better, I did not contract dengue fever (this time).

Our trip was enlightening and exciting. Coming back to my home country and observing medical care in India, after a year away in the US, gave me a new perspective on things. It deepened my interests in cost-effective care, and my desire to practice equitable health.

Obtaining perspective

We had a number of intense discussions and debates on topics ranging from the actual definition of global health,  the stakeholders that determine global health funding and care delivery, disease profiles and historical trends of diseases, and, the future of global health.

It was a grounding experience, that has left me with the essentials to begin to carve out a path towards my intended career in global health. For this, and many other reasons, I hope future residency applicants interested in a career in global health, choose BMC.

 

But I digress.

One of the things I’ve decided from this trip, is that I need to choose my words and actions carefully. The term used to describe what I thought was global health has changed frequently. Terms such as global health, local health and international health have been throw around in the past, and, in our discussions. I believe that what I intend to practice, is equitable health. I want to be able to provide equal opportunities in health care, i.e, to attempt to level the playing ground wherever help is needed to achieve that.

I am interested in a career in equitable health focused on obtaining renal replacement therapy where it is inaccessible. I envision that I will one day learn to place peritoneal dialysis catheters to start peritoneal dialysis in resource-limited settings, and eventually develop peritoneal dialysis centers that are self-sustained by the people that live in that country/region. I plan on spending the next few years of residency and fellowship, trying to figure out the best way to make this possible.

I will have more information on this, and other global health endeavors in nephrology, in the coming months.

For now, I will leave you with a picture of us on a swing in my home in Trichy

From left to right: My grandmother; Andrea; Jocelyn; Ed; Me (Yuvaram)

 

Until next time!

-Yuvaram

(@Yuv90)

P.S: My next topic will be Part 2 of the Medical Education System

 

August Global Health Readings

Starting next month, the residents in the BMC IM global health pathway will be publishing pieces every two weeks on topics in global health. Should be quite enjoyable!

 

http://www.thelancet.com/journals/langlo/article/PIIS2214-109X%2816%2930190-5/fulltext?rss=yes#.V7K_CjtRYaA.twitter

A brief piece touching up quality in global health and summarizing several other papers within the same issue. I do think that improving delivery and implementation is a hugely important in global health – perhaps the most important at this particular moment – and that future programs will necessarily have a heavy focus on this.

 

https://www.theguardian.com/news/2016/aug/11/world-bank-jim-yong-kim?CMP=oth_b-aplnews_d-2

Long piece focused on Jim Kim’s work at the World Bank – nicely lays out the changes he as an on-the-ground development sort is trying to actualize at an institution that does not have a strong history of working in that area.

 

http://news.trust.org/item/20160811184813-ru0pp

Resurgent polio in Nigeria – as we discussed on our global health trip, finishing off the eradication process has proven to be very difficult.

http://www.humanosphere.org/global-health/2016/08/haitis-nationwide-doctor-strike-continues-no-end-sight

A difficult situation in Haiti, where striking residents are holding out for a living wage and better working conditions – fair complaints – but as detailed, are leaving the health system without doctors to care for an already underserved population. No easy answers to this problem.

#KnowBeforeYouGo – Haitian pre-trip video

 

A group of Haitian medical students that my NGO works with produced this short, well-designed video that neatly captures key questions anyone should ask themselves before performing a volunteer medical experience. It’s great to hear what these partners of ours find most important.

A Different Kind of Opioid Crisis

poppy field

In America, the overuse and misuse of opioids is a growing health problem. Morbidity and mortality associated with opioid use has increased substantially over the last decade and a half. Both prescription opioid use and heroin use are contributing to the problem, and the trend is concerning enough to have been coined “the opioid epidemic.” The statistics associated with opioid misuse are quite shocking. Between 2000 and 2014, deaths from from overdoses quadrupled, and emergency room visits related to misuse increased by 153%. In conjunction with this, the number of opioid prescriptions have also increased, from 76 million in 1991 to over 240 million in 2014 (1).

The use of opiates to treat pain dates back to the 19th century. During this time, medical interventions were scarce, and the cause of medical complaints was usually not known. As a result, morphine injections were often given to quickly alleviate discomfort. As medical knowledge progressed and other types of analgesia came about, the use of morphine decreased significantly. It wasn’t until the 1980s that opioids started to be used for chronic pain. In 1995, oxyContin, which is a long-acting opioid, hit the market. Shortly thereafter, pharmaceutical companies started taking a vocal interest in the use of opioids for chronic pain. They were key players in initiating the “Pain is the 5th Vital Sign Campaign,” which encouraged physicians to aggressively treat chronic pain and to assess pain with the “same zeal” as they would with other vital signs. To counter concerns about the safety of opioids, campaign advocates downplayed their potentially negative consequences, using poor quality studies to claim that addiction rates were less than 1%. They also endorsed that the risk of respiratory depression was short-lived (2). The rise in opioid prescription rates and the broader acceptance of opioids stemming from these efforts has led to a greater environmental availability of opioids and a subsequent rise in their nonmedical use. (3)

In India, opioids play a much less prominent role in medical care. In contrast to America, where two years ago there were more than three bottles of opioids prescribed per adult, the availability and administration of opioids is scant. The statistics illustrating this are as equally disturbing as the drastic rise in opioid-related deaths in the states. A review of India’s opiate policies by the Pain and Policies group at Madison, Wisconson estimated that only 0.4% of people in need of opiates for cancer-related pain or chronic pain actually received them (4). During our travels, we visited a rural center for HIV care. The head physician there lamented that when a patient was made CMO, the only pain relief they received was from a combination of NSAIDs, Tylenol, and Tramadol, as anything stronger than tramadol wasn’t allowed.

Unlike many developing countries, India’s dearth of opioids is not related to supply or cost. Three states in northern India produce over 90% of the world’s legal opium. Although most of this is exported, the copious and internally-produced opium supply means that morphine could potentially be manufactured and distributed at a relatively low cost. Instead, it’s the Narcotic Drugs and Psychotropic Substances (NDPS) Act that prevents patients from getting adequate pain control. Instituted in 1985, its main purpose is to prevent drug trafficking and drug abuse. It allows the central government to control morphine production, from the cultivation of poppy seeds to its manufacturing and selling. The most significant upshot has been a depletion of India’s opioid supply, with medicinal use of morphine dropping by 97% in the twelve years following the NDPS (5).

On top of this, physicians and pharmacists face both logistical and cultural barriers to opioid distribution. Doctors have to obtain up to six licenses to prescribe morphine, and even minor offenses of the NDPS’s rules and regulations can lead to harsh punishments, including up to twenty years of imprisonment. Both of these things dissuade offices and pharmacies from even carrying morphine, and many manufacturers have stopped producing it. A secondary consequence of this strict regulation has been a somewhat exaggerated fear among medical professionals of using opioids and a reluctance among the general public to accept them. Moreover, medical trainees aren’t educated on how to safely prescribe them, and palliative care education occurs in fewer than 20% of medical colleges (4, 5).

In America, the overprescription of opioids has led to a crisis of addiction. In India, underpresciption has led to a crisis of pain. What ties these two crises together, though, is that they’ve resulted from marketing and policies that were driven by forces not so scientifically based. In America, economics helped push opioids onto the market. In India, fear of addiction and drug trafficking motivated creation of the NDPS.  Each country honed in on only one aspect of opioids rather than emphasizing the medical benefits they have when prescribed judiciously for a specific purpose. Now, both countries face very different problems but are both struggling with populations that are experiencing unnecessary suffering.

1. Wilson, et al. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. New England Journal of Medicine. 2016;374(2):154-163.
2. Kolodny, et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annu. Rev. Public Health. 2015. 36:559–74
3. The Opioid Epidemic: By the Numbers. Department of Health and Human Services. www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf. Published June 2016. Accessed August 2016.
4. Rajagopal MR, Joranson DE. India: Opioid availability – An update. J Pain Symptom Manage. 2007;33:615-622.
5. Sharif, Ume-e-Kulsoom. An Epidemic of Pain in India. The New Yorker. Published December 5, 2013. Accessed August 2016.

Thoughts on CPD

Continuing Medical Education (CME) or Continuing Professional Development (CPD – increasingly the preferred term) forms a challenge for health care professionals in all settings. The literature on CPD in high income countries is far from reassuring that CPD has the desired impact of changing the behavior of physicians to match the latest information (Cochrane, McMahon).

Within this context, I found it interesting to discuss CME/CPD with several of the physicians on our trip. All noted a wide range of options were available, and many availed themselves of these (or were teaching within them) – when asked, several noted that the majority of these were funded by pharmaceutical companies and focused on updates in therapeutics, with a smaller group of CME offerings from academic institutions and departments. This is not surprising – as the import of low and middle income country markets grow for pharmaceutical companies, their outreach will shift towards those locations as well. It is somewhat perturbing, both in that we are using the same technical approaches in these settings that likely have little impact, and that we have allowed private companies to take the lead in providing education.

I don’t claim to have an ideal answer – yet – but the question of effecting effective education in low-resource settings is one of great interest to me, and I’m hopeful that the years to come will find an increasing focus on the topic. As is readily evident, health care professionals cannot provide the best possible care without knowing what exactly that entails!

Cochrane review of CPD meetings (there are several others as well)

McMahon NEJM perspective piece from the ACCME (which I read as glass half-empty, he reads as half-full)