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Why mHealth tech must advance in Africa, other emerging areas

by System Administrator - Tuesday, 8 September 2015, 8:18 PM

Why mHealth tech must advance in Africa, other emerging areas

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Why Non-Specific ICD-10 Codes Are a Non-Issue

by System Administrator - Wednesday, 8 July 2015, 10:04 PM

Why Non-Specific ICD-10 Codes Are a Non-Issue


A safe harbor or grace period that would allow the submission of “less specific” ICD-10 codes after the ICD-10 transition continues to be raised as a way to alleviate the burden of the transition on physicians. For example, HR 2247, the ICD-TEN Act, would prohibit Medicare from denying claims “due solely to the use of an unspecified or inaccurate subcode.” A letter to the Centers for Medicare & Medicaid Services (CMS) from several members of Congress recommends that CMS indicate “whether claims must include the ICD-10 diagnosis code with the highest level of specificity immediately upon the October 1, 2015 effective date, or whether a clinically accurate but less granular code will be accepted. This letter further recommends that a “period during which less specific codes are accepted while providers get accustomed to the new system would be appropriate.”

In considering this issue, it is essential to understand that both ICD-9 and ICD-10 are structured so that there is always a “clinically accurate but less granular code” available. Under ICD-9, Medicare has ALWAYS accepted “less specific” codes, and providers are well-accustomed to the level of specificity required. During the transition to ICD-10, the level of specificity required will be no different than is currently required under ICD-9. CMS has reiterated numerous times that their acceptance of unspecified codes will not change as a result of the ICD-10 transition. For example, see this MLN Matters article on information and resources for submitting correct ICD-10 codes to Medicare.

Furthermore, it would be inappropriate and a violation of coding rules to require a level of specificity that is not documented in the medical record. Indeed, CMS has made it abundantly clear that it would be inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing in order to determine a more specific code. The ICD-10-CM Official Guidelines for Coding and Reporting state:

Each healthcare encounter should be coded to the level of certainty known for that encounter …… When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate ‘unspecified’ code. Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of the particular encounter.

To reiterate for emphasis, “it is acceptable to report the appropriate ‘unspecified’ code”. This is the official policy approved by CMS. All HIPAA-covered entities are required to abide by this policy because it is part of the official HIPAA ICD-10 code set standard. We are unaware of any payers that have stated an intention to violate this policy and disallow unspecified codes. Thus, the issue of the level of code specificity required is a non-existent problem.

The meaning of “subcode” in the ICD-TEN Act is not clear, although it has been suggested that “subcode” refers to the characters after the decimal point in an ICD-10 code. However, the characters after the decimal do not represent optional pieces of additional information. A code is invalid if it is missing any of the applicable characters, including those after the decimal point, just as the area code “312” by itself is not a valid phone number. All of the characters before and after the decimal are required to have a valid ICD-10 code and the characters after the decimal point are not analogous to CPT modifiers, which may or may not be appended to the base CPT code depending on the given situation. Also, information provided in the characters after the decimal point is not limited to highly specific details such as laterality or anatomic site. The nature of the disease or injury itself may also be described in characters after the decimal. For example, “Other disorders of muscle” (M62) provides no information about the type of muscle disorder – the characters after the decimal provide that information, such as rupture of muscle, contracture of muscle, or muscle spasm.

Calls for a safe harbor or grace period based on code specificity appear to be a reaction to physicians’ fears that there will be a huge uptick in claims denials if non-specific codes are reported. However, these fears are refuted by the results of CMS’ recent end-to-end testing, which showed only a 2% denial rate associated with ICD-10-related errors, thus demonstrating that the transition to ICD-10 will have a minimal impact on the rate of claims denials. Clearly if CMS had rejected all the claims containing non-specific codes, the ICD-10 rejection rate would have been much higher. A safe harbor for the use of non-specific codes is unnecessary and detracts industry attention from getting ready for the ICD-10 compliance date. There is no evidence supporting the need for a safe harbor. Unfortunately, the proposals to create a safe harbor for the use of less specific codes increase physicians’ fears and anxieties around the ICD-10 transition because they erroneously imply there is the possibility of widespread claims denials due to use of nonspecific codes. “We fear things in proportion to our ignorance of them.” (author Christian Nestell Bovee)

As an example of the appropriate use of an unspecified code, if the only available information is that the lower leg is fractured, without specification of the type of fracture or specific bone involved, there are codes for unspecified fracture of left and right lower leg and even a code for unspecified fracture of unspecified lower leg (although one would hope that at least left or right side would be in the clinical documentation). If specific details about the type of otitis media are unknown, there is a code for unspecified otitis media. And even if there is no “unspecified” code, there are default codes designated for use when specific clinical details are unknown. For example, while there is no code for fracture of unspecified part of tibia, the index makes it clear that a code for fracture of the shaft of the tibia should be assigned when the part of the tibia involved in the fracture is not specified.

Using less specific diagnosis codes is not ideal and adversely impact the quality of healthcare data, and so every effort should be made to capture the most complete clinical documentation to support the most specific code. But when no more information is known about the clinical condition to assign a more specific ICD-10 code or the information simply isn’t available, providers should report the appropriate less specific code, without fear of a Medicare denial solely on the basis of the specificity of the reported code – just as they have been doing under ICD-9. 

The Coalition for ICD-10 is a broad-based healthcare industry advocacy group — hospitals, health plans, hospital and physician office coding experts, vendors, and the health information technology (HIT) community— united in support of the U.S. adoption of the ICD-10 coding standard. The Coalition for ICD-10 promotes the critical importance of ICD-10 to improving quality measurement, public health surveillance, clinical research, and healthcare payment through research, education, advocacy, and mobilization.


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Will (Human) Radiologists Be Turned Into Digital Apps?

by System Administrator - Thursday, 4 September 2014, 6:55 PM

Will (Human) Radiologists Be Turned Into Digital Apps? Don’t Worry, It Won’t Be Like That

by Mark Hagland

It was fascinating to read a rather existential blog in the past week about radiologists' role in the new healthcare.

It was fascinating to read a rather existential blog written by Douglas G. Burnette, Jr., M.D., a practicing radiologist, in the online edition ofDiagnostic Imaging.

In his August 22 blog, Dr. Burnette says this: “Radiologists along with the rest of society are becoming digitally detached and the more detached we are, the harder it is to assert our value. Our virtual omnipresence and digital efficiency may have sown the seeds of our destruction.”

Further, “Have you noticed how often websites offer live chats lately?” he asks. “I believe that while this is a very efficient way to communicate, it also removes the barriers and stigma of language and ethnicity from the exchange of information. The frustration of dealing with someone in a phone bank in India is gone. It will be just that easy to replace us someday.”

Then, Burnette asks, “What do we offer to counter this? Radiology services are being effectively commoditized. I admire the efforts to educate the public and put our best face forward to patients and referring physicians. Unfortunately, in today’s busy practice, it is rarely practical to speak directly with patients on a routine basis. I have found that my pace has gradually increased to cope with peak work flow times and I am unable to slow the pace even when there is a lull in the action.”

What Burnette worries about—quite legitimately—is this: “Radiology services are rapidly becoming commoditized.”

Thus, arguably the most technology-focused and technology-enabled medical specialty is facing a rather existential conundrum: the same advances in medical, imaging, and information technology that have made radiologists hyper-efficient have also potentially made their specialty the very easiest (and one of the few in actuality) to offshore.

And Burnette is far from the only radiologist pondering the place of himself and his colleagues in the emerging healthcare. How will radiologists show their value to their referring physician peers? Inevitably, with offsite, sometimes offshore, radiologic studies having become commonplace, how can those radiologists affiliated with hospitals, medical groups, and integrated health systems feel themselves integrated with their physician colleagues anymore?

In fact, Burnette concludes his blog with this thoroughly pessimistic statement: “Over the years it has been difficult to earn the respect of my medical colleagues even to the extent on occasion of having to assert that I am a real doctor not a technologist. I suspect that as medicine evolves or devolves (depending on your point of view) we may, indeed, become essentially technologists. One day we may even become an app on a digital device—the ultimate in digital detachment.”

It was fascinating to read a rather existential blog in the past week about radiologists' role in the new healthcare

That viewpoint seems a bit dystopic to me. But what is true is that radiologists need to begin to concretely demonstrate their value to the care delivery process in their organizations. Back in December of 2013, Rasu Shrestha, M.D., vice president of medical information technology and medical director for interoperability and imaging informatics at the vast University of Pittsburgh Medical Center (UPMC) health system, told me this, about radiologists in the new healthcare:  “[L]et’s focus on two challenges. One challenge is that of what I call efficiency pressures; everyone is being challenged to do more with less. And the other type of pressure is quality of care pressures. And that means you’re being challenged to make sure to give the appropriate treatment to a patient at the point in time of care. So even if we focus on these two specific challenges, for that average Joe radiologist or chief of radiology or CMO—the average radiologist knows he’s being judged on his throughput and productivity. But what that’s evolving into is being measured on value.”

As Dr. Shrestha went on to say, “The problem is that in today’s siloed systems, it’s very difficult to measure real value. So you have metrics that say, I read 40 studies and yesterday, I read 50. Does that make me less valuable? If the outcomes were better today, and I was able to close the loop better with the ordering physician, or able to communicate test results more efficiently, that’s value. And without data liquidity, if the transformation of healthcare is in the balance, we need to have the right metrics in place. So what’s my value score at a particular point in time? Where are my peers, and what’s my target? I need a dashboard and I need it to be ingrained into the fabric of my workflow.”

And that’s where CIOs, CMIOs, CTOs, directors of imaging informatics, and other healthcare IT leaders need to step in, both to support radiologists in their work, and to partner collaboratively across all medical specialties, to help shift patient care organizations towards new, value-driven missions and visions. Will such efforts towards shifting the fundamental mentality of healthcare organizations and the healthcare system be difficult? Of course they will.

But radiologists won’t be alone in this. Instead, everyone will be in this together, as the healthcare system begins to move forward in this conceptual shift—one with a very strong practical component—away from a purely volume-based incentive system to one based on a combination of volume, efficiency, and true value. And inevitably, what radiologists do and how they work, will be impacted very strongly by that shift, going forward.



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by System Administrator - Wednesday, 15 October 2014, 8:03 PM


Written By: Peniel M. Dimberu

In 1978, Louise Joy Brown made human history as the first “test tube baby” ever born after her mother underwent a revolutionary fertility treatment known as in-vitro fertilization (IVF). In the following decades, several million children have been conceived using IVF, which has since become a routine treatment for those suffering from some common forms of infertility.

Recently, doctors at Sweden’s University of Gothenburg pushed the envelope a little further when they announced the results from over a decade of research into absolute uterine factor infertility. This type of infertility, which previously had no treatment, often results when a woman is born without a uterus or loses it to a disease like cancer.

In a paper published in the medical journal Lancet, the research team, led by Dr. Mats Brännström, describe delivery of a moderately pre-term but otherwise healthy baby boy to a 35-year-old Swedish woman with a transplanted womb. The woman suffered from congenital Rokitansky syndrome, meaning she was born without a uterus.

The uterus was donated by a 61-year-old woman and transplanted in a 10-hour surgery last year. Doctors monitored the recipient closely for a year and found she returned to a regular menstruation schedule in less than two months. Using IVF, the doctors produced a viable embryo and introduced it into the woman’s new uterus.

Though this procedure is considered a remarkable success, it wasn’t without complications. The woman had three mild cases of rejection, a common occurrence for transplant recipients. Although one of the cases of rejection appeared during the pregnancy, immunosuppressive drugs were used successfully to treat it.

Further, in the 32nd week of the pregnancy, the woman began suffering from pre-eclampsia, a disorder characterized by kidney dysfunction and high blood pressure. As it was, the mother was already missing one kidney.

Realizing the baby could also be harmed from this condition, the doctors followed clinical protocol and removed him earlier than planned via Caesarean section. The baby boy, who had a birth weight of 3 lbs, 14.6 oz was otherwise healthy, as was the mother.

Although it is not clear what caused the woman’s pre-eclampsia, women who have become pregnant via IVF are at increased risk for the condition. The doctors also speculated the age of the donor might have been a factor, though it is not conclusive.

Although uterus transplants had been tried before, this was the first time one resulted in a live birth. Previous attempts resulting in pregnancy ended in miscarriages. There are several other women in this current study who have also received a uterus transplant and are undergoing IVF in the hopes of getting pregnant.

The success of this transplantation brings hope for women who are infertile due to loss of a functional uterus and wish to carry their own baby. Though far from perfect, the study proves that a uterus can be transplanted to successfully carry a baby to term.

However, the doctors note wide availability of the procedure is likely still years away and partly dependent on the results of their study. Further, because it requires major surgery for both the donor and mother, ethical questions remain, and paid surrogacy (illegal in Sweden) remains a viable alternative in other parts of the world.

That said, the capability is still in its infancy. And just as IVF has become routine in a few decades, it’ll be interesting to see where this new procedure takes us.

Image Credit:

This entry was posted in Singularity and tagged in vitro fertilizationIVFMats BrännströmRokitansky syndromeThe LancetUniversity of Gothenburg,womb transplant.



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Women in Technology 2014

by System Administrator - Friday, 12 September 2014, 4:05 PM


Are women flourishing in IT? Find out by downloading the Women in techology report from Computer Weekly and Mortimer Spinks.

  • The average number of women in technology teams is 12%, down from 15% last year
  • 71% of men have asked for a pay rise compared to 61% of women
  • 94% of people are happy to be working in technology

Please read the attached whitepaper.

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Workforce Management Technology in the Cloud: Reducing Costs and Improving Efficiencies

by System Administrator - Monday, 22 December 2014, 3:25 PM

Workforce Management Technology in the Cloud: Reducing Costs and Improving Efficiencies

Nearly one-third of best-in-class organizations are now using cloud-based solutions for all their workforce management needs. And that number is growing. Why?

Find out in this new Aberdeen report on the benefits of moving to the cloud. You'll discover:

  • The business imperative that is driving the move to the cloud
  • Five functional areas of an organization that can benefit from the cloud
  • The greatest advantage of investing in cloud technology
  • The ROI of the cloud?
  • Who else besides IT benefits from the cloud?

You'll also read how Senior Lifestyle Corporation, one of the leading senior living specialists in the U.S., reduced IT spending by 45% by moving to the Kronos cloud-based solution.

Please read the attached whitepaper.

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Your Doctor Can Now Examine an Exact 3D Replica of Your Heart in Virtual Reality

by System Administrator - Thursday, 13 August 2015, 7:30 PM

Your Doctor Can Now Examine an Exact 3D Replica of Your Heart in Virtual Reality

By Ron Schilling

Not so long ago, the only way to see what was going on inside a person’s body involved something sharp. Now, we can image the body’s organs without a single incision.

However, though we’ve made huge strides in medical imaging, it’s still far from perfect. One of the biggest challenges? Patients are three-dimensional, but medical images are flat; they each show a different slice of the anatomy in question. This makes gaining a volumetric understanding of what you’re looking at—which is critical when dealing with anatomy—a key skill.

To get a good picture of what they’re dealing with, doctors have to imagine the actual 3D organ by mentally piecing together all these flat images. This isn’t easy, and some doctors are better at it than others. In short, they’re preoccupied with a visualization problem—a process that is prone to errors, wastes time and causes fatigue for physicians—instead of concentrating on solving a clinical problem—their primary and most important job.

Take surgical planning, for example. Today, radiologists look through hundreds and hundreds of flat images, and then draw a diagram (yes, by hand) to show the surgeon how to approach a given procedure. Then the surgeon operates on the patient with no advance knowledge of his or her actual volumetric anatomy.

One surgeon I spoke with summed it up perfectly: “I’ve never opened up a patient and seen a 2D view!” Another surgeon specializing in image-guided surgery told us that “half the time I am guessing” when navigating 3D anatomy using 2D images.

Sounds a little scary, no? Never fear. It won’t be like this much longer.

There’s a pretty powerful solution just now arriving—advanced image rendering through interactive virtual reality. EchoPixel (my company) uses virtual reality to help doctors visualize each patient’s unique anatomy and internal structure in a floating 3D image. The software uses DICOM data, which is already embedded in every MRI scan, CT scan, or ultrasound image.


Here’s how it works:

You stand at a workstation wearing a pair of 3D glasses. (Our software works with any VR hardware device, but we’re currently partnered with Zspace for the display.) A 3D image of an organ floats in front of you, an exact replica of a patient’s heart, colon, or brain. Using a stylus, you can turn, dissect, zoom, remove pieces—basically manipulate the image however you want.

It’s about as close as you can get to visualizing and interacting with the real thing.

Indeed, medical imaging is an ideal early use-case for virtual reality, because these volumetric imaging datasets already exist (unlike in entertainment, for example, where developers will have to create new content to run on VR devices). If we can help solve the 3D problem, then doctors can refocus their energy and expertise on diagnosis and treatment.


We see a huge opportunity for this sort of imaging technology to shape the way doctors work.

For example, the virtual colonoscopy procedure is becoming a popular alternative to the dreaded optical colonoscopy (recommended as a regular procedure for every person over age 50). Instead of requiring total sedation and a full day of recovery, the virtual procedure allows the doctor to examine a CT scan of the colon to identify any potentially cancerous lesions.

Even President Obama recently opted for this less invasive virtual procedure.

Even so, it’s not easy on doctors. They have to scan through hundreds of flat images, trying to identify cancerous lesions. It generally takes 30-40 minutes, is mentally fatiguing, and carries significant risk of missing a dangerous growth.

Using virtual reality, on the other hand, a doctor can “fly through” each segment of the colon in 3D space. The difference is extraordinary. One of the nation’s top specialists at UCSF (who we’re working with currently) is completing the procedure in just 5-10 minutes using interactive VR.

And she’s finding her ability to correctly identify cancerous lesions is up a full 100%.

In another example, we’ve been working with specialists at a leading implantable device manufacturer on a procedure to implant a heart device for atrial fibrillation. This device helps prevent blood clots from entering the bloodstream in certain patients at high risk for strokes.

The challenge here is determining the correct size for the device. Generally, it requires several iterations to implant the correctly sized device. Sizing can take up to 45 minutes, and still results in a 2.7 device per implant ratio with a cost of $20,000 for each incorrectly sized implant.

However, using an accurate 3D image takes away much ambiguity in sizing the device. As a result, doctors were consistently completing the procedure in just two minutes! Once again, virtual reality is proving to be not just an aid, but a complete game-changer in the operation.

We’re at the early stages, but are seeing similar results across a range of procedures that rely on medical images. With the ability to more fully understand a patient’s anatomy, doctors can produce better outcomes for patients in less time, which not only benefits the doctors themselves, but significantly reduces risks to the patient in question.

And this is just the beginning.


Imagine that doctors and medical students could practice surgery multiple times in VR before ever stepping into an operating room, following a step-by-step procedure from the best specialist in the world. Or a patient could carry around a digital file of their anatomy, with localized annotations from different specialists they had visited.

Instead of talking to each other with hand-drawn diagrams, now radiologists and surgeons can plan an operation together using a 3D image, making digital notes on key structures to operate on (and just as crucially, to avoid). This kind of communication “gap” is common among healthcare professionals, and we see VR technology as a communications tool as well.

Most people now agree that digital medicine is the future of health. But that doesn’t just mean numbers in a spreadsheet. We think virtual reality has a huge role to play in the healthcare industry, and it’s just getting started.

Ron Schilling, PhD, is the CEO of EchoPixel. Dr. Schilling has 35 years of operating and general management experience in the medical device and technology industries, at Toshiba, Diasonics and General Electric. He also teaches business strategy at Stanford and serves on several corporate boards in the medical field. You can learn more about Echopixel here

To get updates on Future of Virtual Reality posts, sign up here.

Image credit: and Echopixel

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¿Pueden los enfermos hacer lo que les pedimos que hagan?

by System Administrator - Monday, 13 July 2015, 11:29 PM

¿Qué es la "carga de tratamiento"?

Autor: Frances S Mair, professor of primary care research, Carl R May, professor of healthcare innovation Fuente: BMJ 2014;349:g6680 Thinking about the burden of treatment

¿Pueden los enfermos hacer lo que les pedimos que hagan?

Asistimos a enfermos del siglo XXI con un sistema pensado para la epidemiología del siglo XIX. Cómo sobrevivir con enfermedades crónicas a la fragmentación y a la falta de coordinación en el cuidado de los más vulnerables.

"¿Puede usted realmente hacer lo que yo le estoy pidiendo que haga?"

Los sistemas de salud a lo largo del mundo deben enfrentar un incremento de la demanda y de los costos. El incremento de la expectativa de vida ha sido acompañado por una explosión de enfermedades de largo plazo (crónicas) y por la multimorbilidad.1

Los clínicos están trabajando con sistemas heredados que fueron desarrollados para tratar problemas del siglo XIX –aportar respuestas especializadas a enfermedades agudas e infecciones-. Al mismo tiempo la práctica cotidiana ha sido influenciada por un modelo centrado en la enfermedad que no refleja el panorama de la realidad de la práctica clínica actual, en particular la ubiquidad de la multimorbilidad.2

El resultado de ellos es la fragmentación, la pobre coordinación de los servicios de salud para aquellos más vulnerables y sus necesidades –pacientes con múltiples condiciones crónicas-3.

Los profesionales actuales que se ocupan del cuidado de la salud enfrentan no solo interacciones enfermedad / enfermedad, sino fármaco / fármaco y fármaco / enfermedad en poblaciones con multimorbilidad así como las consecuencias evidentes de las desigualdades socio-económicas.

Mientras tanto, los pacientes, sus familias y sus redes sociales extendidas experimentan no solo la carga de síntomas sino la carga de tratamientos.4 Este es un fenómeno emergente y poco investigado. Ha recibido una atención creciente en los últimos tiempos y el interés se ha centrado en definir y comprender mejor este concepto.
Algunos de los componentes centrales de la “carga de tratamiento” han sido evaluados por revisiones sistemáticas5 6  y estudios cualitativos.7 8 9

Los resultados muestran que los pacientes y los cuidadores de salud ponen con frecuencia bajo enormes demandas a los sistemas sanitarios. Tales demandas pueden incluir cambiar sustancialmente su comportamiento y la vigilancia de la conducta de los demás con el fin de adherirse a las modificaciones de estilo de vida recomendados.

Los pacientes o sus cuidadores a menudo tienen que controlar y manejar sus síntomas en casa, lo que puede incluir la recolección y la introducción de datos clínicos. La adhesión a los regímenes de tratamiento complejos y la coordinación de múltiples medicamentos también pueden contribuir a la carga de tratamiento.10

Para asegurar su acceso a los servicios los pacientes a menudo se enfrentan a complejos sistemas administrativos y a la necesidad de hacer frente a los sistemas de salud y a la falta de coordinación de la atención social que puede añadir un suplemento más a la carga.

La carga continúa aumentando a medida que los sistemas de salud desplazan de una lista cada vez mayor de las responsabilidades de gestión y tareas a los pacientes y a sus cuidadores. Este es un trabajo real, que requiere de un considerable esfuerzo por parte de los pacientes, sus cuidadores y de sus redes sociales extendidas. Para muchos esto puede ser abrumador, es mucho tiempo, requiere de un alto nivel de alfabetización aritmética y, a veces, de un conocimiento técnico. A menudo también se requieren destreza manual y habilidades prácticas.

Las personas que están socialmente aisladas, que tienen bajo nivel de educación, bajo nivel de alfabetización en salud, que se deterioran cognitivamente, que no hablan el idioma local, o que tienen dificultades sensoriales o físicas es poco probable que prosperen en tales contextos.

Tampoco las personas que no tienen estos problemas disponen del tiempo suficiente. A las personas que tienen tres trabajos para pagar el alquiler les puede resultar difícil adherir a los requerimientos de las múltiples guías clínicas. Estas personas tendrán dificultades para cumplir con las recomendaciones de tratamiento, arriesgando con ello obtener malos resultados y desperdiciar los recursos sanitarios cada vez más escasos.

Un primer paso para la disminución de la carga del tratamiento es el desarrollo de métodos para medir esa carga. Dichos instrumentos deben incluir algo más que los efectos secundarios del tratamiento. Tienen que incluir los efectos perturbadores que la adherencia al tratamiento tiene para la vida laboral (por ejemplo, tener que ir varias veces a las clínicas para pruebas) y para la vida social (por ejemplo, tener que reducir las actividades debido a los efectos secundarios del tratamiento).

Los costos ocultos son también un problema los costos, para acudir a las citas clínicas, tomar tiempo fuera del trabajo, y el pago de todos o algunos de los tratamientos deben ser tenidos en cuenta. Además, el esfuerzo necesario para aprender las habilidades de autocuidado, tales como la forma de administrarse a sí mismo o a otras personas dependientes las inyecciones regulares, deberían ser incluidos.

Por último, hacer frente a los problemas causados por la discontinuidad y la atención fragmentada, así como por el potencial de la carga psicosocial de ser medicalizado y ser convirtido en un paciente deben ser considerados. El trabajo preliminar se ha comprometido a desarrollar las escalas y las medidas de carga de tratamiento, pero es necesario seguir trabajando acerca de la capacidad de los individuos para hacer frente a una determinada carga.1112


La carga del tratamiento impuesto por la prestación de servicios de salud podría convertirse en un barómetro clave de la calidad de la atención. Sin embargo, tendrán que diseñarse instrumentos e intervenciones adecuados para tener en cuenta las diferencias entre los sistemas de salud y las combinaciones de condiciones, así como los gradientes de la capacidad individual para hacer frente a esa carga.13 Así que, aunque la evidencia indica que la carga de tratamiento tiene muchas características genéricas, también es probable que difieran entre, por ejemplo, Nebraska y Norfolk y entre el astrocitoma y el asma.

No toda la carga de tratamiento es irrazonable o evitable. Por ejemplo, la polifarmacia puede ser necesaria para controlar los síntomas de varias condiciones o para reducir el riesgo de exacerbaciones de la enfermedad o de eventos adversos a largo plazo.

Alguna carga tratamiento puede ser circunstancial y transitoria, en relación con una crisis aguda específica. Por otra parte, la carga puede ser mejor tolerada por las personas que están bien equipadas y que sean resistentes que por los que no lo son. Los métodos para predecir con precisión los que están en mayor riesgo de ser abrumados por la carga de tratamiento todavía no están disponibles, pero un punto de partida razonable pueden ser asumir que todo el mundo está en riesgo.

Hemos argumentado anteriormente acerca de la "medicina mínimamente impertinente o disruptiva": enfoque centrado en la atención al paciente que haga hincapié en las preferencias individuales, que tenga en cuenta la multimorbilidad, y que busque reducir la carga de trabajo para los pacientes y sus cuidadores.14

Las intervenciones que pongan en práctica la medicina mínimamente impertinente y que ataquen la carga del tratamiento necesitará proporcionar una atención coordinada centrada en la persona en lugar de la enfermedad y aportar el máximo apoyo posible. Mientras esperamos, las medidas fiables y validadas de la carga de tratamiento, una pregunta simple del médico puede ser suficiente: "¿Puede usted realmente hacer lo que yo le estoy pidiendo que haga?"

  1. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012;380:37-43.
  2. Guthrie B, Payne K, Alderson P, McMurdo ME, Mercer SW. Adapting clinical guidelines to take account of multimorbidity. BMJ2012;345:e6341.
  3. Payne RA, Abel GA, Guthrie B, Mercer SW. The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. CMAJ2013;185:E221-8.
  4. May CR, Eton DT, Boehmer K, Gallacher K, Hunt KJ, MacDonald S, et al. Rethinking the patient: using burden of treatment theory to understand the changing dynamics of illness. BMC Health Serv Res2014;14:281.
  5. Sav A, King MA, Whitty JA, Kendall E, McMillan SS, Kelly F, et al. Burden of treatment for chronic illness: a concept analysis and review of the literature. Health Expect2013;15:351-9.
  6. Gallacher K, Morrison D, Jani B, Macdonald S, May CR, Montori VM, et al. Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research. PLoS Med2013;10:e1001473.
  7. Bohlen K, Scoville E, Shippee ND, May CR, Montori VM. Overwhelmed patients: a videographic analysis of how patients with type 2 diabetes and clinicians articulate and address treatment burden during clinical encounters. Diabetes Care2012;35:47-9.
  8. Sav A, Kendall E, McMillan SS, Kelly F, Whitty JA, King MA, et al. “You say treatment, I say hard work”: treatment burden among people with chronic illness and their carers in Australia. Health Soc Care Community2013;21:665-74.
  9. Gallacher K, May C, Montori VM, Mair FS. Understanding patients’ experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med2011;9:235-43.
  10. Gallacher K, Batty GD, McLean G, Mercer SW, Guthrie B, May CR, et al. Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1 424 378 patients in Scotland: implications for treatment burden. BMC Med2014;12:151.
  11. Eton DT, Ramalho de Oliveira D, Egginton JS, Ridgeway JL, Odell L, May CR, et al. Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Relat Outcome Meas2012;3:39-49.
  12. Tran VT, Montori VM, Eton DT, Baruch D, Falissard B, Ravaud P. Development and description of measurement properties of an instrument to assess treatment burden among patients with multiple chronic conditions. BMC Med2012;10:68.
  13. Shippee ND, Shah ND, May CR, Mair FS, Montori VM. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol2012;65:1041-51.
  14. May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ2009;339:b2803.


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