Albert Mulley

Stop the silent misdiagnosis: patients’ preferences matter

Correct treatment recommendations require accurate diagnosis not only of the medical condition but of patients’ treatment preferences. Al Mulley, Chris Trimble, and Glyn Elwyn outline how to ensure that preferences are not misdiagnosed

Association of Pancreas Divisum and Pan reatitis and Its Treatment by Sphincteroplasty of the Accessory Ampulla

All 519 endoscopic pancreatograms performed in the Massachusetts General Hospital Endoscopy Unit from 1973 to 1980 were reviewed. Patients who underwent pancreatograms for documented pancreatitis were more likely (p less than 0.005) to have the duct anomaly pancreas divisum (12%) than those patients who had pancreatograms incidental to cholangiography (2.9%), or for unexplained chronic abdominal pain (3.3%). When compared with patients with pancreatitis and normal duct development, patients with pancreatitis associated with pancreas divisum tended to be younger and to have a clinical pattern of recurrent acute attacks of pancreatitis. Nine patients with recurrent pancreatitis or severe chronic abdominal pain and pancreas divisum were treated by surgical sphincteroplasty of the accessory ampulla. Five of the 6 patients with documented acute attacks of pancreatitis received good to excellent pain relief and had no further attacks of acute pancreatitis. None of the 3 patients with severe chronic abdominal pain without objective evidence of pancreatitis derived significant benefit. Accessory ampulla sphincteroplasty seems to relieve pain and prevent further attacks of acute pancreatitis in patients with pancreas divisum and recurrent pancreatitis. This response to sphincteroplasty adds further credence to the stated association between pancreas divisum and pancreatitis.

Trustworthy guidelines - excellent; customized care tools - even better.

BackgroundThe ability to do online searches for health information has led to concerns that patients find the results confusing and that they often lead to expectations for treatments that have little supportive evidence. At the same time, the science of summarizing research evidence has advanced to the point where it is increasingly possible to quantify treatment tradeoffs and to describe the balance between harms and benefits for individual patients.DiscussionTrustworthy clinical practice guidelines provide evidence-based recommendations to health care practitioners based on assessments of study-level averages. In an effort to customize the use of evidence and ensure that choices are consistent with their personal preferences, tools for patients have been developed. Gradually, there is recognition that the audience for high quality evidence is much wider than merely health care professionals – and that there is a case to be made for creating tools that translate existing evidence into tools to help patients and clinicians work together to decide next steps.SummaryWe observe two processes occurring: first, is the recognition that decision making in healthcare requires collaboration and deliberation, and second, to achieve this, we need tools designed to customize care at the level of individuals.

Cost-Effectiveness Study of the Extracorporeal Shock-Wave Lithotriptor

We performed a cost-effectiveness analysis to examine the relative efficacy and costs of percutaneous ultrasonic lithotripsy (PUL), extracorporeal shock-wave lithotripsy (ESWL), and surgery for the treatment of upper urinary tract stones. We developed a Markov model with 35 states, cycles of 3 months, and a time frame of 5 years. Probability estimates were derived from a meta-analysis of the published literature. For stones less than or equal to 2 cm, ESWL is preferred to PUL, since it prevents 2 additional days of morbidity and saves

The global role of health care delivery science: learning from variation to build health systems that avoid waste and harm.

440. For larger stones, PUL is preferable to ESWL, avoiding 4 days of morbidity, and saving

Mental healthcare in low and middle income countries.

722. Both ESWL and PUL were superior to surgery. Sensitivity analysis showed that the results are sensitive to ESWL efficacy rates, the stone recurrence rate, and the hospital component of the ESWL cost. Our analysis suggests that although ESWL is preferable, relatively small changes in the efficacy and cost can shift the preferred strategy; in addition, these findings underscore the need for more reliable data.

Delivering health with integrity of purpose.

This paper addresses the fourth theme of the Indiana Global Health Research Working Conference, Clinical Effectiveness and Health Systems Research. It explores geographic variation in health care delivery and health outcomes as a source of learning how to achieve better health outcomes at lower cost. It focuses particularly on the relationship between investments made in capacities to deliver different health care services to a population and the value thereby created by that care for individual patients. The framing begins with the dramatic variation in per capita health care expenditures across the nations of the world, which is largely explained by variations in national wealth. The 1978 Declaration of Alma Ata is briefly noted as a response to such inequities with great promise that has not as yet been realized. This failure to realize the promise of Alma Ata grows in significance with the increasing momentum for universal health coverage that is emerging in the current global debate about post-2015 development goals. Drawing upon work done at Dartmouth over more than three decades, the framing then turns to within-country variations in per capita expenditures, utilization of different services, and health outcomes. A case is made for greater attention to the question of value by bringing better information to bear at both the population and individual levels. Specific opportunities to identify and reduce waste in health care, and the harm that is so often associated with it, are identified by learning from outcome variations and practice variations.

New approaches to measurement and management for high integrity health systems

Should not replicate the inefficient, inaccessible, and insensitive Western model

Meeting the challenges of providing universal health coverage

Health systems must learn how to co-produce and deliver services that patients and the public value

Recommendations from the Salzburg Global Seminar on Rethinking Care Toward the End of Life

We need better tools to achieve the next generation reforms essential for delivering care that matters most to patients, say Albert Mulley and colleagues