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.

2208, 2018

Paper of the week: 22.08.18

Muir Gray’s paper of the week: Time for Value-Based Payment Models to Adopt a Disparities-Sensitive Frame Shift

Listen to the accompanying short podcast below, or on SoundCloud here

Reference: Chaiyachati KH, Bhatt J, Zhu JM. Time for Value-Based Payment Models to Adopt a Disparities-Sensitive Frame Shift. Ann Intern Med. 2018;168:509–510. doi: 10.7326/M17-2590

Bottom line, chosen by Muir from the paper

The health care industry cannot ignore true instances of poor quality, but it also should not worsen health care for at-risk populations. To address this tension, value-based payment models should adopt a disparities-sensitive frame shift to integrate measures of equity into hospitals’ financial calculus, incentivizing hospitals to tackle the disparities challenge without losing sight of quality. Achieving this frame shift requires us to continue determining which metrics matter most when addressing disparities in health care delivery and outcomes, both to improve risk adjustment and to establish which measures are actionable. To avoid underpaying hospitals that disproportionately serve socially at-risk patients, we should assess how risk adjustments would perform if they accounted for factors like socioeconomic position, social relationships, and community context, which the National Academy of Medicine has identified as key domains affecting health care outcomes.(1)

(1)National Academies of Sciences, Engineering, and Medicine. Accounting for Social Risk Factors in Medicare Payment: Identifying Social Risk Factors. Washington, DC: National Academies Pr; 2016.

Implications for value improvement

Inequity lowers value

The term value has significantly different meanings in the USA and in countries committed to universal health coverage. In 2008 an influential article was published from Harvard Business School with the key definition given below:

“Value in any field must be defined around the customer, not the supplier… the proper objective is the value of health care delivery, or the patient health outcomes relative to the total cost (inputs) of attaining those outcomes.”

Source: Porter, M.E. (2008) What is Value in Health Care? Harvard Business School. Institute for Strategy and Competitiveness. White Paper.

However, this would be classified as efficiency in any country committed to covering the population with a finite budget.  In the United States there is not a commitment to cover the whole population from a finite budget and therefore the allocation of resources is not made explicitly.  Neither is there explicit concern for inequity in populations underserved, who may derive more value than the people being treated. In fact a hospital that wants to be rewarded for efficiency might be prejudiced against people from the most deprived sections of the population because they may need longer to recover and therefore need a longer duration of stay for social reasons, so care needs to be taken that measures of quality and efficiency not only take into account the population served by the hospital but also are encouraged to ensure that access to care from the most deprived populations is at least as high as access from the least deprived even though the hospital has to expend more effort and therefore more cost to achieve this.

908, 2018

Paper of the week: 09.08.18

Muir Gray’s paper of the week: Seven Deadly Sins Resulting From the Centers for Disease Control and Prevention’s Seven Forbidden Words

Listen to the accompanying short podcast below, or on SoundCloud here

Reference: Castro KG, Evans DP, Del Rio C, Curran JW. Seven Deadly Sins Resulting From the Centers for Disease Control and Prevention’s Seven Forbidden Words. Ann Intern Med. 2018;168:513–514. doi: 10.7326/M17-3410

Bottom line, chosen by Muir from the paper

On 15 December 2017, The Washington Post reported on 7 words to be avoided by the Centers for Disease Control and Prevention (CDC) in official budget documents . The forbidden words are “vulnerable,” “entitlement,” “diversity,” “transgender,” “fetus,”

“evidence-based,” and “science-based.” Although the source of the prohibition is uncertain, this censorship, if real, carries the risk of jeopardizing the work of U.S. government–funded health care practitioners and professional organizations.

Implications for value improvement

In a healthcare organisation there are three principal elements- structure, systems and culture (as seen in the diagram below). Of these three elements most people would regard culture as the most important, although most energy is spent on reorganising the structure, but how can culture be changed by the leadership with the key role distinguishing leadership from management is that leadership creates the culture whereas management works within it.

“When we examine culture and leadership closely, we see that they are two sides of the same coin; neither can really be understood by itself.  If one wishes to distinguish leadership from management or administration, one can argue that leadership creates and changes cultures, while management and administration act within a culture.”

Source:  Schein, E.H.   (2004)   Organizational Culture and Leadership.  John Wiley & Sons Inc. (pp.10-11). 

We have tried to change the culture of healthcare by introducing a new language about value, using the triple value definition given below

  • Personal value determined by the outcomes that matter to an individual for a given amount of resources used by the health system and the individual and their family

and, for the population, two types of value

  • Allocative value determined by how well the assets are distributed to different sub groups in the population
  • Technical value, determined by how well the resources allocated for investment for a particular subgroup of the population, for example people with a symptom such as back pain, or a condition such as breast cancer or a common characteristic such as having multiple conditions or being in the last year of life are used for all the people in need in the population

This paper describes a move to change the culture of healthcare in the USA by banning language but whether or not this will be effective, only time will tell.

308, 2018

Paper of the week: 03.08.18

Muir Gray’s paper of the week: For Patients With Type 2 Diabetes, What’s the Best Target Hemoglobin A1C?

Listen to the accompanying short podcast below, or on SoundCloud here

Reference: Abbasi J. For Patients With Type 2 Diabetes, What’s the Best Target Hemoglobin A1C?. JAMA. 2018;319(23):2367–2369. doi:10.1001/jama.2018.5420

Bottom line, chosen by Muir from the paper

Medical organizations are at odds over new guidance that recommends easing hemoglobin A1C (HbA1c) targets for patients with type 2 diabetes. The updated guidance statement

from the American College of Physicians (ACP), which focuses on glycemic control with medications, says clinicians should personalize goals and aim to achieve an HbA1c level of between 7% and 8% for most patients with type 2 diabetes.

The ACP set its target higher than recommended by other prominent health groups. The American Diabetes Association (ADA) generally recommends anHbA1C goal of less than 7%, while the American Association of Clinical Endocrinologists (AACE) advises even tighter control of 6.5% or lower if it can be achieved safely.

…… These efforts to reach an HbA1c of less than 7% can also result in overburdened patients

with a poor quality of life, Lipska said. This can be especially true for patients who are managing multiple chronic conditions and medications, sometimes with limited social and financial support. “We have to be very mindful about the trade-offs in the benefits versus the harms on quality of life,” Lipska said….. Personalization Is Key.

Implications for value improvement

The classic Donabedian image below of 1980 shows the changing relationship between benefit and harm as the intensity of treatment increases.

What is the right level? Well that is a matter of judgement for the population because the lower the target, the higher the level of investment required and less favourable the benefit to harm ratio. Furthermore, the target needs to take into account the values the person we call the patient places on the benefits and the harms, as the article rightly emphasises.

2507, 2018

Paper of the week: 25.07.18

Muir Gray’s paper of the week: Global Budgets in Maryland Assessing Results to Date

Listen to the accompanying short podcast below, or on SoundCloud here

Reference: Sharfstein JM, Stuart EA, Antos J. Global Budgets in MarylandAssessing Results to Date. JAMA.2018;319(24):2475–2476. doi:10.1001/jama.2018.5871

Bottom line, chosen by Muir from the paper

The study also found that efforts to strengthen collaborative relationships with outpatient providers and community organizations are “in early stages and might not have an effect for some time.” Nowhere is this more clear than in the area of behavioral health. Maryland hospitals recognized early that patients with severe mental illness and substance use disorders account for disproportionate amounts of hospital services. Yet challenges in the public and private mental health systems have left hospitals struggling to manage acutely ill patients with mental illness. Indeed, the RTI study found that “most hospitals that we visited reported occasionally having to keep patients with mental health issues in inpatient beds because a safe option for discharge was not available.”

…..As the continued increases in health care costs crowds out other priorities, such as elementary and secondary education, it is reasonable to ask whether global budgets might be part of a broader solution. There is much to learn from the experience of Maryland, which has a diverse population served by rural, suburban, and urban hospitals including 2 major academic health centers. While the state’s reforms are very much still in progress, Maryland’s unique approach merits even greater attention in the months and years to come.

Implications for value improvement

Population healthcare arrives in the USA

2007, 2018

Paper of the week: 19.07.18

Muir Gray’s paper of the week: NHS England’s plan to pull the plug on ineffective procedures

Listen to the accompanying short podcast below, or on SoundCloud here

Reference:Robinson AnnNHS England’s plan to pull the plug on ineffective procedures 

Bottom line, chosen by Muir from the paper

NHS England ​proposed last week ​to stop or reduce routine commissioning of 17 interventions, including surgery for snoring, back injections, and knee arthroscopy for osteoarthritis, in favour of “less invasive, safer treatments that are just as effective”

NHS England’s states its aims as a “hierarchy of goals”: to reduce avoidable harm to patients, to save professionals’ time, to help clinicians keep practice in line with changing evidence, to create “headroom for innovation,” and to maximise value and avoid waste for patients and taxpayers

Implications for value improvement

The importance of this paper is that it separates out interventions into two different classes.  Firstly there are interventions for which there is no evidence of effectiveness and these are obviously of zero value.  Perhaps more interesting are the other interventions and it is good that the BMJ have put them into different colour categories.  These other interventions are effective, so to some individuals they are of high value. But what is needed is to identify which individuals who will receive high value.  Donabedian in 1980 pointed out that as you put more resources into service, for example resources to do more operations, you start by treating people who are most severely affected, so the benefit increases fast at first and then flattens off – the Law of Diminishing Returns.  Unfortunately the harm goes up in a straight line and if you subtract harm from benefit then you get the graph shown below, the classic graph:

Now from an individual point of view when you start off with an intervention you only offer it to people who are really going to benefit, so the benefit to harm ratio is very high.  As you do more interventions you start offering it to people who are less severely affected and for these people the maximum possible benefit is less, but the probability and size of harm is the same.  You may reach a point where it’s futile – does more harm than good – and here is the graph from the NHS Atlas of Variation showing this:

So, this is a key paper with key concepts because we have to consider value from both the population and a personalised point of view.

1307, 2018

Paper of the week: 13.07.18

Muir Gray’s paper of the week: Managing the Most Precious Resource in Medicine

Listen to the accompanying short podcast below, or on SoundCloud here

Reference: McMahon, Graham. (2018). Managing the Most Precious Resource in Medicine. New England Journal of Medicine. 378. 10.1056/NEJMe1802899.

Bottom line, chosen by Muir from the paper

Many health care institutions appear to have lost sight of the truism that our health professionals are our most precious resource. With increasing commoditization, commercialization, productivity targets, and administrative burdens, the volunteerism and soul that have typified our profession for generations are suffering. It is increasingly clear that many residents and physicians are focused on surviving rather than thriving.

Implications for value improvement

It is very important to remember that the term resources means much more than money. Other resources include carbon and time, the time of the people we call patients and the time of clinicians. We ignore the latter at our peril.


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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.