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Most attempts to describe the value of health care were market oriented and left the aspects of effectiveness with the care providers (Roberts, 1989; van de Ven, 1996). A recent approach entitled “Evidence-Based to Value-Based Medicine” (Brown et al., 2005) provides an elegant link between health economics and evidence-based medicine but does not include the final step from evidence-based to everyday medicine. In this chapter, we define the term “CLINECS.” The term was created by fusing the names of the disciplines that contribute to the assessment of useful health care services, that is, clinical practice, clinical epidemiology, health economics, psychology, ethics, and philosophy (Table 1.1).

The art of medicine concentrates on diagnosis (finding problems) and treatment (fixing problems). The task of physicians might be described as “find it and fix it.” The find-it/fix-it model exemplifies what engineers call linear thinking. The linear model has been the predominant view of the world since the time of Sir Isaac Newton, who focused his attention on discrete components of the world and assumed that these components operated independently from one another. Many things work in a linear fashion. For a complex machine or organism, linear function means that each component operates independently of the others. The environment receives relatively little attention. Ackoff (1994) explained that the industrial revolution, which began in England during the 18th century, ushered in new ways of thinking that dominated nearly all fields for several centuries. This thinking was dominated by three concepts: reductionism, analysis, and mechanism.

The simplest definition of justice is the fair distribution of burdens and benefits. A just society seeks to implement this principle for all its citizens. Within of justice is an array of , such as money, honors, food, shelter, health care, welfare, and education, that a just society attempts to distribute justly (Walzer, 1983). Within of justice is an array of , such as urgency of need, capacity to benefit, value to society, future potential, and past services rendered, that a just society would consider when distributing a scarce resource (Schneiderman & Jecker, 1996). How can we proceed from these generalities to the specifics of health care justice?

When 1000 women undergo mammography, breast cancer is diagnosed in 33 of them. Without mammography, breast cancer would be found in only 20 women. With mammography 4 of 1000 women die of breast cancer; without mammography 5 of 1000 women die of breast cancer. These facts present the difficult question of whether is it justified to save the life of 1 woman and burden 13 with the diagnosis of breast cancer and the consequent therapy and follow-up. We scientists have the duty to present facts lucidly. The interpretation of these facts and the conclusions drawn from them are not the task of science but of the society concerned.

Johann Nepomuk Nestroy, Austrian author and actor (1801–1862), said of progress that it appears to be much greater that it really is. This is not only because no one wants to contradict the promise that the term itself implies— advancing toward improvement. Above all, it concerns the fact that every advance of a certain dimension is accompanied by undesired collateral results, which in extreme cases can invalidate the benefit of the progress.

Decisions must be made constantly in all areas of life. This is also true for medical research and health care, when, for example, one must decide which parameters to apply to measure effectiveness (output) or value for patients (outcome) of medical interventions. In patients with diabetes mellitus, lowering elevated blood glucose is an output. We accordingly call the results of all health care services. If the result of a health care service can be described as (re)gained years of life or (re)gained improvement in quality of life, we refer to it as an .

Throughout this book, we have considered the assessment of inputs and outputs of health care systems. Furthermore, we have suggested that measuring outputs is not enough. The goal of health care is to provide value for patients. This requires that we show the value of investments in terms of patient outcomes. But how can patient outcomes be quantified? In this chapter we consider the quantification of patientreported outcomes.

The proportions of old people and people suffering from dementia are steadily increasing in industrial societies. Consequently, the number of people depending on institutional care is growing. Such care is provided in general hospitals, geriatric hospitals, nursing homes, private homes, senior residences, and by the families. Obviously, there are large differences in costs and efficacy of these various types of care.

Over the past decade, the idea of patient empowerment has been increasing in popularity. Although there is no consensus on the definition of this term, the concept contains some essential elements on which all can agree. They include involvement of the patient in decisions about personal health care and increased sharing of knowledge by health professionals to ensure that decisions are made wisely. However, it is not surprising that there is a range of views about the degree of power that patients should and do have and the context in which they should exercise this power. These views are rooted in ideological, political, and historical frameworks; and they center on ideas about professional dominance and, more broadly, on changes in structures and institutions that deliver health care.

During the last decades, a great change has taken place in doctor–patient relationships (Shorter, 1991). Improved diagnostic and therapeutic competence among physicians has led to increasing neglect of history taking and consideration of patients’ interests. The patients’ biology has become more important to physicians than their psyche, and patients often do not have the opportunity to voice their concerns or express their anxieties. This often causes patient dissatisfaction with the consultation, and there is a loss of trust and mutual respect in the doctor–patient relationship. A greater consideration of patients’ concerns and more information exchange between physician and patient could therefore result in a more effective health care system. Decisions have to be made based on the doctor’s knowledge and the patient’s preferences.