The Distillery

The Distillery 2018-05-09T10:33:31+00:00

Wisdom Distillery from Professor Sir Muir Gray

These updates will include essential books, papers, and essential glossary items for understanding value in health and healthcare. For each book there is the full reference, the distilled message (the essence of the book in the author’s own words) and why this book is important (the relevance of the book and other related titles or key terminology to note).

Better Value Healthcare scans 28 key journals on medicine, healthcare, and value. From these we select about 20 papers a month for our training programmes, and then distil the contents for a weekly paper on value.

706, 2018

Paper of the week: 06.06.18

Muir Gray’s paper of the week: Overcoming overuse

Listen to the accompanying short podcast on SoundCloud here

Reference: Overcoming overuse: the way forward is not standing still—an essay by Steven Woloshin and Lisa M Schwartz BMJ 2018;361:k2035

Bottom line, chosen by Muir from the paper

Sledgehammer or Swiss Army Knife

The goal of the less-is-more movement is not to mindlessly lower rates of medical use. Instead, it is to create a system that makes it easier for doctors and patients to understand their options and for patients to choose the most effective care that reflects personal values rather than commercial forces, ignorance, or fear.2 Furthermore, it emphasises the inextricable link between overuse and underuse: reducing wasteful care could enable resources to be redirected to counter the real problem of medical underuse, improving patient outcomes all round.

Rosenbaum worries that efforts to reduce low value care could eliminate appropriate care. She imagines an inexperienced cardiologist who refers all patients with chest pain for coronary angiography and is told to reduce his referral rates by the practice manager of an accountable care organisation. How do we know, she wonders, that this doctor won’t stop referring patients who genuinely need the test? Does this possibility mean that the health system should ignore what the cardiologist is doing? Of course not. Reducing needless angiography makes patients safer by reducing rare but serious complications that include bleeding, stroke, heart attack, and even death……

Rather than an indiscriminate sledgehammer, however, reform should resemble a flexible Swiss Army knife, with multiple approaches to reduce overuse, including tools to support clinical decision making, mechanisms to track unintended consequences, physician led guidelines, performance feedback from peers, and—most importantly—decisions shared among doctors and patients to influence care safely and appropriately. Although peer feedback is common, other approaches are inconsistent and remain aspirational

Implications for value improvement

When I meet with clinicians or the public I explain both the Wennberg story and the Donabedian curve (as seen in the image below), then ask people to turn to their neighbour and identify overuse. I must have done this 100 times and here is what comes up, in every country:

  • Imaging
  • Lab testing
  • Last month of life
  • Polypharmacy
  • Elective surgery

However, the key is to start with underuse of high value interventions; that is what motivates, then ask people to think how they would fund underuse from overuse.

This is a CLASSIC.

Reflective Learning Questions

  • If you have read this paper already, how does our commentary relate to the impact the book made on you?

  • Would you have chosen a different bottom line?

  • If you have not read the paper yet, how could  you use our bottom line and commentary in your work during the next year?

  • Would you recommend it to your team, or make it required reading?

3105, 2018

Paper of the week: 31.05.18

Muir Gray’s paper of the week: Changing how we think about healthcare improvement

Listen to the accompanying short podcast on SoundCloud here

Reference: Changing how we think about healthcare improvement Braithwaite Jeffrey. 2018; 361 :k2014 

Bottom line, chosen by Muir from the paper

How do we move forward? Whatever solutions we choose must reflect the complexity of the system and respect its resilient features.40 We must change our approach to understanding health systems and their intricacies.4142

One way is to break with the NHS’s pattern of attempting systems improvement from the top down. Complex adaptive systems have multiple interacting agents with degrees of discretion to repel, ignore, modify, or selectively adopt top down mandates. Clinicians behave how they think they should, learning from and influencing each other, rather than by responding to managers’ or policy makers’ admonitions. Frontline clinicians in complex adaptive systems accept new ideas based on their own logic, not that of those in the upper echelons. Healthcare is governed far more by local organisational cultures and politics than by what the secretary of state for health or a remote policy maker or manager wants.

Change, when it does occur, is always emergent. This is when features of the system, and behaviours, appear unexpectedly, arising from the interactions of smaller or simpler entities; thus, unique team behaviours emerge from individuals and their interactions.

Those on the frontline of care (clinicians, staff, patients) navigate change through their small part of the system, adjusting to their local circumstances, and responding to their own interests rather than to top down instructions. Thus, healthcare is naturally resilient, always buffering itself against change that does not make sense to those who are on the ground, delivering care.

Implications for value improvement 

This article sets out the principles of service evolution very clearly. The 20th century was the century of the hierarchy and the bureaucracy, the 21st century is the century of the complex adaptive system and the network. The model is not Toyota or the airline industry but the ant colony.

2405, 2018

Paper of the week: 23.05.18

Muir Gray’s paper of the week: Hospital-Based Physicians’ Intubation Decisions and Associated Mental Models when Managing a Critically and Terminally Ill Older Patient

Listen to the accompanying short podcast on SoundCloud here

Reference: Hospital-Based Physicians’ Intubation Decisions and Associated Mental Models when Managing a Critically and Terminally Ill Older Patient. Haliko et al. Medical Decision Making  Vol 38, Issue 3, pp. 344 – 354 First Published November 22, 2017

Bottom line, chosen by Muir from the paper

“Sixty-six (90%) physicians provided preference-concordant treatment and 7 (10%) provided

preference-discordant treatment (i.e., they intubated the patient). Physicians who intubated the patient were more likely to emphasize the reversible and emergent nature of the patient situation, their own comfort and rarely focused on explicit patient preferences”

Implications for value improvement 

Inappropriate or futile care in the last weeks of life is a common type of low or negative value care, and not only clinicians but also the public are aware of the problem. One way to reduce it is to encourage the public to prepare advance directives, to reduce their chance of a bad death. However, as this study shows clinician attitudes are still important even when the person’s preferences are clearly stated.

1705, 2018

Paper of the week: 17.05.18

Muir Gray’s paper of the week: Artificial intelligence in health care: enabling informed care

Listen to the accompanying short podcast on SoundCloud here

Reference: Artificial intelligence in health care: within touching distance. The Lancet , Volume 390 , Issue 10114 , 2739

Full text article: 

Bottom line, chosen by Muir from the paper

Deep learning as a form of AI risks being overhyped. Deep neural networks contain multiple layers of nodes connected by adjustable weights. Learning occurs by adjusting these weights until the desired input to-output function…

Clinicians should be aware of the capabilities as well as current limitations of AI. Properly integrated AI will improve patient outcomes and health-care efficiency. Augmented intelligence at the point of care is likely to precede AI without human involvement.

Implications for value improvement 

How do we add value to human intelligence?

This short contribution very cleverly addresses the hype about Artificial Intelligence by pointing out that AI also stands for Augmented Intelligence – namely using the power of technology to help humans with tasks they find difficult, for example, giving information about probabilities clearly. If we adopt this approach, decisions will be better not only cognitively but also emotionally because it will allow the clinician to focus on something which machines cannot, as yet, manage – empathy.

905, 2018

Papers of the week: 09.05.18

Muir Gray’s paper of the week: The positive and negative value of precision medicine

Listen to the accompanying short podcast on SoundCloud here

Paper 1: In the Era of Precision Medicine and Big Data, Who Is Normal?

Reference: Manrai AK, Patel CJ, Ioannidis JPA. In the Era of Precision Medicine and Big Data, Who Is Normal?. JAMA. Published online April 23, 2018. doi:10.1001/jama.2018.2009

With the evolution of medicine into fully personalized or “precision” medicine and the availability of large-scale data sets, there may be interest in trying to match each person to an increasingly granular normal reference population. Is this precision feasible to obtain in reliable ways and will it improve practice?

Paper 2: Reducing Overtreatment of Cancer with Precision Medicine – Just What the Doctor Ordered

Reference: Katz, Steven & Jagsi, Reshma & Morrow, Monica. (2018). Reducing Overtreatment of Cancer with Precision Medicine: Just What the Doctor Ordered. JAMA. 319. 10.1001/jama.2018.0018.

Precision medicine most effectively reduces over treatment because it can remove a more extensive treatment option from consideration if that treatment is deemed by clinicians to be futile. Precision medicine in cancer uses information derived from patient factors (age, comorbidity, and, increasingly, genetic predisposition) and characteristics of the diagnosed tumour to quantify the net benefit of a treatment option in an individual patient. The 3 steps to harnessing precision medicine to address over treatment are:

  1. increasing the evidence base for less vs more extensive treatment in key clinical subgroups;
  2. formulating more precise clinical algorithms to tailor treatment to the relevant subgroup; and
  3. ensuring consensus among clinicians with regard to applying the algorithm to individual patients.

Bottom line

Like all medical advances precision medicine can do good as well as harm. The clearest example of ‘good’ is the identification of people for whom a particular treatment would be futile, and this has been demonstrated best in cancer. The harm is what has been called disease mongering, the creation of new conditions that are US, i.e. of unknown or uncertain significance. These two papers summarise the two sides of the coin clearly.

305, 2018

Paper of the week: 02.05.18

Muir Gray’s paper of the week is: ‘Beware the medicalisation of loneliness’

Beware the medicalisation of loneliness. McLennan, Amy K et al. The Lancet , Volume 391 , Issue 10129 , 1480

Listen to the accompanying short podcast on SoundCloud here

The bottom line

The medicalisation of social issues has not worked in the past. From obesity to HIV/AIDS, health researchers and practitioners are fighting, with limited success, to convince society that public health problems require integrated and holistic approaches.

Medicalisation of loneliness will discourage the collaboration needed, and medicine probably has no effective instruments with which to single-handedly address the absence of human connection.

The importance of this paper

This is a very important point, health services need to focus on the causes of loneliness they can address, namely mobility problems, visual impairment and deafness, with the latter being the one most frequently overlooked.

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102, 2018


‘Optimality is reached when resources or productivity create maximal benefit with the least harm.’

Significance: There are two different uses of the term optimality, both important.  One developed by Vilfredo Pareto describes the best possible allocation of resources. When Pareto Optimality is reached it is not possible to get more value by switching a pound from anyone budget to another.  Another term for this is allocative efficiency, which is different from the technical efficacy with which each budget’ s resources are used.  The other meaning is from Avedis Donabedian’s work because he used the term to mean the rate at which a service is being delivered that gives the best balance of benefit to harm to a population.

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106, 2018

Book of the month: 01 June 2018

Muir Gray’s book of the month is: How much is enough; shaping the defense system 1961-1969 by Alain C Enthoven and K Wayne Smith (1971) Rand

Listen to the accompanying podcast on SoundCloud above or click here

[the six basic ideas of] a Planning Programming Budgeting System:
1. decision making based on explicit criteria in the national interest
2. the consideration of the needs and costs together
3. the explicit consideration of alternatives at the top level
4. active use of analytic staff at the policy making top level
5. a plan…which projected into the future the foreseeable implications of current decisions
6. each analysis should be made open to all interested parties

The NHS RightCare initiative promoted the use of programme planning principally to engage the commissioners in thinking about allocative value and the allocation between programmes, still 1.5 to 2.0, and the clinician and patient community in thinking about allocative value within each programme.

102, 2018

Setting Limits Fairly: Learning to Share Resources for Health

Daniels, N. and Sabin, J.E. (2008) Setting Limits Fairly, Learning to Share Resources for Health. (p44) Oxford University Press.

Distilled message:

“Accountability for reasonableness is the idea that the reasons or rationales for important limit-setting decisions should be publicly available. In addition, these reasons must be ones that ‘fair-minded’ people can agree are relevant to pursuing appropriate patient care under necessary resource constraints. This is our central thesis, and it needs some explanation. By ‘fair-minded’, we do not simply mean our friends or people who just happen to agree with us. We mean people who in principle seek to cooperate with others on terms they can justify to each other. Indeed, fair-minded people accept rules of the game –or sometimes seek rule changes –that promote the game’s essential skills and the excitement their use produces.”

Why is this book important?

This is one of the most important texts to help you think about decisions that affect allocative efficiency or trying to reach “A situation in which it is not possible to improve the welfare of one person in an economy without making someone else worse off.”

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No one will ever read all the books that they need to read or could read in their particular topic. It is far more important to know about a book and its core message, preferably in the author’s own words, and to understand how that book fits into the culture and relates to other books and concepts then not to know that a book existed.

This is the principle behind our essential book list.  At Better Value Healthcare we provide a distillation service whereby the core message from 1000+ books are presented in the author’s own words with an additional commentary from Sir Muir Gray about the importance of the book and how it relates to other key published material.

Confusion about language and the meaning of the terms being used is one of the main causes of arguments, fruitless arguments, which disappear if everyone shares the same

understanding of the term. At Better Value Healthcare we developed the 21st Century Healthcare Glossary with the principles of clarifying the meaning of commonly used terms to improve dialogue and decision making. The glossary consists of 1000+ terms and their meanings in use. Some of these ostensive definitions are long and can be unwieldy for everyday use so we have, where appropriate, presented a shorter, more useful definition, which we call the bottom line for that term.