Categories
Healthcare Delivery

Why patient experience would be the key in the post covid world?

In January 30 2020, India recorded its first case for Corona Virus popularly known as Covid19. Since then India has seen a series of lockdowns and as we inch towards somewhat of a partial recovery, the question around the state of our healthcare system has become centre stage again.

Since the 1940’s where the Bhore committee gave its recommendations for developing the healthcare structure in India, as a nation we have been playing catch up with demand far exceeding the supply in terms of doctors, diagnostic equipment, hospital beds and medicines.

In addition the wellness programs have been struggling and preventive measures have not been very successful. In this context the corner stone of the healthcare system in India has become the hospital.

What determines a successful healthcare intervention is patient experience. Today with the advent of telehealth and the guidelines given by Medical Council of India, it becomes even more important for hospitals to focus on patient experience and add to the growth of the industry.

What is Patient Experience?

Private hospitals have long tracked patient satisfaction ratings, but they didn’t always carry great significance. While all hospitals want happy patients, most hospitals have been historically plagued with the “doctor knows best” mentality — a mentality where clinical outcomes outweigh “touchy-feely” indicators such as patient satisfaction or overall patient experience.

However, in recent years, some leading institutions in India have begun to focus more heavily on providing an outstanding patient experience. Drivers for this include growing consumerism and transparency for healthcare services and increased interest from both consumers and providers in patient-centred care.

Why Patient Experience is important to Hospitals?

Healthcare consumers increasingly view their experience with a provider as a key consideration for determining if they’ll return to or recommend the provider, largely because it remains one of the few ways consumers can differentiate providers. Over the past few decades, clinical outcomes have improved dramatically, and patients no longer view favourable outcomes as a key differentiator as these are expected. What remains is the patient’s overall experience, which encompasses everything from customer service to patient-centeredness and care coordination among providers.  Also given the growth of Tele Health, it would become even more important for hospitals to focus on patient experience in order to create a favourable experience and create the hook that would bring patients and others in the community back to the hospital.

We are working on a report on understanding the current digital levers to manage patient experience. We will be releasing the report soon.

Categories
Healthcare Delivery

Regular patients are severely affected as India battled Corona Virus

In the last week of April 2020, a septuagenarian in the state of J&K who was a renal dialysis patient for 2 years, was asked to get his next round of dialysis from a private nursing home as the hospital where he normally went for treatment refused the dialysis procedure since the entire hospital was converted into a COVID care center. The nursing home neither had the apt infrastructure nor the skilled personnel to handle any kind of complications that is common during a dialysis. Unfortunately, the patient died in less than a week. Another dialysis patient in Mumbai had to wait for 7 hours for treatment as he was not carrying his covid test result report. Around 1,30,000 patients are on dialysis in India and most of them depend on private dialysis centers.

In another caustic case, last week, a 25 yr old pregnant woman in Delhi, visited 2 of the leading government hospitals in Delhi for antenatal care. Both the hospitals denied her admission as she was not Covid-19 positive. As a result, she visited 6 hospitals and maternity clinics in next 48hrs before giving birth outside AIIMS. Many hospitals and nursing homes are completely shut even if one case comes up in them.

There are a plethora of such cases rising across the country as our healthcare system is under stress from managing the contagion outbreak. This is despite the fact that the Government of India has asked state chief secretaries to ensure that hospitals and clinics do not ask for a Covid test report from every patient who requires medical treatment. This raises red-flags and serious questions on the local authorities and regulatory bodies who have also threatened to cancel the operating license of hospitals and clinics if they turn away any non-Covid patient. Patients also fear the escalated economic cost if their treatment cost is not claimed or reimbursed as not all nursing homes and clinics fall under health insurance policies.

Similar danger mounts on Cancer and TB patients. India has the world’s largest TB load of 25%. In Mumbai, due to COVID, lack of adherence to TB drug regimen has risen to 40% from 15%. A significant decrease in TB notification has been witnessed which indicated that access to a TB center and subsequent diagnosis and reporting has been severely hit. These are dangerous signs which are being ignored. A TB patient can infect 10-15 more, and such patient can become a breeding-ground of new Coronavirus cases as Covid hits hard on low immunity patients. Many senior oncologists have claimed that due to difficulty in travelling during lockdown, many hospitals not providing regular treatment, hospitals shutting down and fear of contracting covid, have resulted in a delayed diagnosis of cancer patients which can push them to an advanced stage of cancer.

There has to be clear and stringent guidelines by MoH to each state health authorities highlighting the delirious effect of not providing critical care to non-Covid cases. State should ensure that no patient is denied treatment for any ailment by a hospital (government or private). Instead of shutting down the entire hospital even for one covid case, a wiser approach of creating zones within the hospital can be implemented. Online, phone consultation and Tele-medicine modules should be made widespread thorough proper communication channels.

Our healthcare infrastructure is one of the weakest in the world with a lack of adequately qualified health care professionals adding to the woes. We certainly can’t afford to inflict more burden on the already fragile healthcare services by denying treatment to those who are in need.

About the author

Dr Sumeet Kad is a Healthcare and Artificial Intelligence Leader, focusing on leveraging technology to create a model for affordable care

Categories
Healthcare Delivery

Working towards a Lean Healthcare system

With the increasing emphasis on the application of concepts of lean management in hospitals across the world, gaining popularity as ‘Lean Healthcare’, Value Stream Mapping (VSM) is an elementary tool that allows one such implementation. The common principle behind lean management is ‘to do more using less’. The VSM model is particularly designed for hospitals and healthcare settings that have a direct influence on the admission of patients and their time of treatment. This article presents a case study of a tertiary care hospital of India where the ‘Lean transformation-VSM’ of the ‘Patient-admission’ process is administered for the reduction of time taken by the admission process. Efforts were made to reduce the admission of the patient for making the process smoother and faster when compared to the existing process in the hospital.

The first step involved in the experiment was to gather information of existing patient admission process followed in the hospital by: Direct observations, Interviews and Patient follow-ups. A comprehensive study of the patient admission operations was accomplished, which was later successfully utilized to recommend improvements to reduce delays. Analysis of the existing state was done using a ‘time-motion study’.

The non-value-added steps were identified in conducting the ‘Root-cause Analysis’ of every step involved in the patient admission cycle. A new process was designed by syndicating them, streamlining or reviewing the categorization of events to support greater competency or even discarding few steps. Efforts were made to implement the ‘Modified value stream process map’.

The result was astonishing! The entire experiment helped in bringing down the time of whole process of admitting the patients from an average of 25 minutes per patient to 15 minutes per patient. The hospital was able to achieve almost 40% of reduction in overall patient’s time for their admission process. This in turn offered the hospital with the earnings of higher patient satisfaction.

The understanding of recreation and the steps involved in conducting this recreational study built a strong groundwork for verifying and validating the simulation model-VSM.

John F. Kennedy said ‘We must use time as a tool, not as a crutch’. Efficient optimization with the help of Lean Management can enhance not only the operational efficiency but also the quality of care provided to the world. The experiment was just a drop into the wide oceans of Lean!

About the Authors


Dr. Feroz Ikbal
Assistant Professor,
Tata Institute of Social Sciences Mumbai campus
EmailID: feroz.ikbal@tiss.edu


Dr. Megha Jogi
Master of Hospital Administration (MHA),
Tata Institute of Social Sciences Mumbai campus
EmailID: meghajogi9@gmail.com
With the increasing emphasis on application of concept

Categories
Healthcare Delivery

Common causes of pain in foot and ankle in the elderly

Our feet tolerate a lot of pressure whenever we stand, walk, or run. The pressure of our entire body weight is transmitted to our foot. Mobility in the joints of our feet is responsible for our ability to walk on uneven surface, shock absorption and thus enabling forward propulsion of our body. As we grow old, there are lot of factors- systemic (related to blood vessels, nerves and skin) and local (wear and tear of joints, stiffness, deformities and weak bones) that can contribute to pain in the foot. Foot pain in elderly can cause walking difficulty and further impair balance. This could lead to loss of independence which would be detrimental to their overall well-being.

The most common triggers of pain in foot and ankle region in elderly are:

Trigger #1: Corns/callus

The skin on the heel and ball of the toes is thicker to withstand pressure which these areas encounter during weight bearing. With ageing, the pressure remains constant but the ability of the skin and fat to withstand stress diminishes, thus predisposing to calluses. Callus is an area of thickened skin in the sole of feet in response to increased pressure. It may be simply due to loss of fat with age, due to underlying unnoticed deformities in the foot or may be a prequel of something sinister like an ulcer in a diabetic patient.

Corns are painful areas of thickened skin that might occur due to ill-fitting shoes. As people grow old, the shape of the foot may change and resultant misfit shoes may predispose to corns. They are most commonly seen in outer aspect of little toe, top of small toes as well as in space between the toes.

Treatment:

Wearing a well-fitting comfortable footwear is the first thing to do when you notice corn or callus. Medicated corn caps may be tried but with caution as it can dissolve the normal skin as well thus worsening the situation. Corn caps and salicylic acid creams are contraindicated (not to be used) in diabetics and with poor blood flow. For diabetics, evaluation of the foot is necessary if a callus is noticed. Pairing of calluses can be done for painful corn and excessive callus by a foot and ankle specialist but an underlying bony problem needs to be identified as well.

Trigger #2: Ingrown toe nail

Cutting of toes nails require flexibility in joints of the body, manual dexterity and a good vision. Unfortunately, all of these are affected with age thus limiting the ability to cut the toe nails. The nails also become dull and brittle with age thus making them more prone to nail disorders. All these factors topped up with inability to maintain a good toe nail hygiene predisposes elderly people to develop toe nail disorders. Ingrown toe nails happen when the side of the nail grows under the skin next to the nail. It mainly affects the big toe but can involve any other toe. Inflammation secondary to nail growing under the skin may cause pain, swelling, redness or pus discharge under the nail.

Treatment:

Soaking feet in warm water, cutting toe nails straight, pushing the skin away with a cotton ball and using over the counter medicine or creams can be used in the beginning for those who develop ingrown toe nails. An infected ingrown toe nail needs oral or topical antibiotics but in few cases may need surgery to decompress the infection. In cases where the condition does not settle down despite the above mentioned procedures, a small surgical procedure to remove full/ part of toe nail may be needed.

Trigger #3: Bunion

A deformity where big toe deviates towards the second toe is called bunion. In elderly population, development of arthritis and other mechanical factors can predispose one to develop bunions. Also, wearing narrow toed shoes in adulthood predisposes one to have bunion and lesser toe deformities in elderly. Bunion may lead to pain not just in the big toe but can also cause secondary pain under second or even third toe.

Treatment:

Once a bunion develops in elderly, the only way to remove it is by surgery. However, measures like using a proper footwear and doing some exercises can help in alleviating the pain arising from bunion. Also, bunion pads, inserts and arch supports can be used for symptomatic relief. In severe cases, surgery is needed to align the toe to its normal position by releasing the soft tissues and even cutting the bone. These surgeries are normally performed as day surgery by foot and ankle specialists and patient can immediately walk post-surgery with a special shoe.

Trigger #4: Flat feet

As the ligaments and muscle responsible for maintaining the arch stretch out with time, in old age the arch of the foot reduces its height. This condition is named Adult Acquired Flat Foot (AAFD). Due to this problem, people may experience pain in inner aspect of ankle and in severe cases on outer aspect, which is worse with physical activities. They may also notice swelling in the inner ankle or arch region. People also notice a change in the shape of the foot. A consequence of this deformity is alteration of not just the foot but the whole lower limb biomechanics and thus can result in overpronation, ankle/foot sprain, hip/knee/lower back pain, limb length discrepancy and loss of stability. 

Treatment:

Evaluation and treatment of flatfoot requires a comprehensive knowledge of this deformity and resultant altered biomechanics as well as critical clinical judgement. Mainstay of treatment in earlier cases may be insoles including medial arch support and heel wedges as well as physiotherapy to strengthen and stretch the muscles of your feet. Surgery is reserved for those cases which are way too advanced or have failed a trial of non-operative management and can vary from heel shift procedures and tendon transfer to fusing the joint in severe cases.

Please refer to my detailed article on flat feet for more info on this ailment and treatment protocols: https://bit.ly/3b9idoe

Trigger #5: Arthritis/Osteoarthritis

The progressive wear and tear of the joints due to a multitude of reasons trigger arthritis. The loss of protective cartilage in the joint as we grow old leads to osteoarthritis. It may cause episodes of inflammation which manifests as pain, swelling and stiffness around the joints.

In India more than 180 million people in India suffer from arthritis and its prevalence is much higher than many well-known diseases such as diabetes, AIDS and cancer. According to arthritis foundation, close to half of the people in their 60s and 70s may be suffering from arthritis affecting their feet. It can reduce the walking speed and can lead to impaired balance thus leading to difficulty in performing daily activities in the geriatric population.

Treatment:

While we should understand that there is no research-proven treatment as yet that can reverse/ stop the progression of arthritis, there are still a lot of options that can reduce the symptoms. Wearing comfortable shoes, exercises, weight reduction, gentle massage of the foot and over the counter pain killers and creams may help us combat the symptoms associated with arthritis. In more advanced cases, surgery may be needed which may include cleaning of the joint (debridement), fusion (arthrodesis) or replacement (arthroplasty).  

About the Author

Any pain in the foot or ankle should be evaluated by a foot and ankle specialist to accurately diagnose the condition. Dr. Anuj Chawla is one of the leading Orthopedics and foot & ankle surgeon in India. He can be contacted at dranujchawla@gmail.com. For consultation with Dr. Anuj, book an appointment by visiting the website: http://dranujchawla.com/.

Dr. Anuj’s social channels:
Twitter: @dranujorthoFacebook: https://www.facebook.com/doctoranujchawla/

Categories
Healthcare Delivery

Can pharmacists reduce the disease burden of doctors?

The following is a guest post by Pharmacists and Medical Expert Katta Anand Srinivas

Problem: There is one doctor for every 1,445 Indians as per the country’s current population estimate of 135 crore, which is lower than the WHO’s prescribed norm of one doctor for 1,000 people. This is a known stat and this problem has been highlighted over and over again. My attempt with this writeup is to highlight if we can manage our existing talent resources of Pharmacists (PharmD graduates or Post-graduates / Doctorate in Pharmacology only) professionals to reduce the burden on Physicians.

Facts: Before going into the details of how Pharmacists can contribute to the subject under discussion, it is worthwhile to look at the current health status of Indians in workforce.

  • Lifestyle diseases are hitting India where it hurts — its workforce
  • Over 61 per cent of all deaths in India are due to lifestyle.
  • 33% of the population above 30 are suffering from one or more lifestyle diseases.
  • Every 12th Indian a diabetic — India ranks second in the list of countries with highest diabetes patients.
  • Nearly 26% of deaths in India are caused due to heart ailments.
  • The number of overweight and obese people in India doubled.
  • 42.5% of corporate employees suffer from depression
  • 52 per cent of corporate employees are afflicted to lifestyle diseases
  • lifestyle habits of employees result in productivity loss worth Rs 24,000 crore to the IT sector in Bengaluru every year which is around 7% of the IT sector’s total revenue in the city.
  • Employees in the age group of 30-40 years of age contributes to highest share which is 42 per cent of total cost to IT sector due to productivity loss.
  • 23% of women and 19% of men in the workforce are obese.

Discussion: This lifestyle diseases are mostly caused in the younger population due to Metabolic syndrome. Metabolic syndrome is a cluster of conditions that occur together, increasing your risk of heart disease, stroke and type 2 diabetes. These

conditions include increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.

High Blood Pressure: White coat hypertension is a condition affecting patients whoexperience stress or anxiety at a medical setting such as doctor’s office or hospital. This results in a higher than normal blood pressure reading during their visit. White coat hypertension is reported to occur in as many as 25 per cent of the population, increasing the risk of misdiagnosis.

Undiagnosed Hypertension: As per one of the study 10.1 % among the study population were not even aware that they have hypertension until they observe symptoms related to heart disease, makes the scenario rather grim. When left undetected, hypertension can cause damage to the cardiovascular system and internal organs, such as the kidneys.

Globally, 51% of stroke (cerebrovascular disease) and 45% of ischaemic heart disease deaths are attributable to high systolic blood pressure. At any given age, the risk of dying from high blood pressure in low- and middle-income countries is more than double that in high-income countries.

A patient might visit a doctor’s office maybe twice a year or sometimes only when they are sick, unlike their visit to their local chemist. Chemist / Medical stores are visited by the patients at least 3-4 times a month for buying prescription medicines, OTC, Diapers, Feminine hygiene, cosmetics and patients might see the pharmacist / pharmacy when they pass by, as they reside in the same community. This increases the comfort level and reduces the anxiety hence less chances of white coat hypertension. Additionally, hypertension screening at the local chemist shop as they are frequently visited by people (above the age of 30) for minor ailments like diarrhoea, headache, muscle sprain, band aid, vomiting thus reducing the cases of undiagnosed hypertension.

Diabetes Mellitus (“diabetes”) is one of the fastest growing chronic diseasesworldwide, and is associated with significant morbidity, mortality, and health care costs. Diabetes is characterized by high levels of glucose in the blood (hyperglycaemia).

The statistics related to diabetes mellitus globally are alarming. The International Diabetes Federation (IDF) Diabetes Atlas, Seventh Edition, 2015, provides the following estimates: one in 11 adults have diabetes (416 million), nearly half (46.5%)

of adults with diabetes are undiagnosed, and a person dies from diabetes every 6 seconds.

Adults with diabetes have a two- to threefold increased risk of suffering a heart attack or stroke compared to those without diabetes. The microvascular complications of diabetes mellitus make it the leading cause of preventable blindness (Diabetic Retinopathy), renal disease (Diabetic Retinopathy), and amputation (Peripheral Neuropathy and vascular disease) in developed countries.

Diabetes has widespread effects, for every 4 people who have Type 2 DM, about one is undiagnosed. Some of the factors that put a person at risk for diabetes include a family history of the disease, obesity, physical inactivity, high blood pressure, and high cholesterol.

Pharmacists are in a prime position to identify these and other risk factors in patients. Routine and simple tests such as blood glucose testing conducted at health fairs and wellness clinics at pharmacies across the country are an example of how a simple test conducted in the pharmacy or by the pharmacy team may provide an efficient method for identifying a patient with a potential diagnosis and help direct them to appropriate medical attention.

For those who are diagnosed, pharmacists can provide counselling about monitoring glucose levels and how to manage out-of-range levels, including developing an action plan for what to do for hypoglycaemic episodes. Pharmacists can counsel on an appropriate diet and exercise routine to compliment medication management in treating diabetes. This can be especially useful in underserved areas where access to nutritionists or dieticians may be unavailable.

The number of treatment options for diabetes has increased substantially over the past few years, and pharmacists are best positioned to help patients understand the fundamentals and intricacies regarding the medication. For patients requiring insulin, the pharmacist can help instruct the patient on how to administer the medication, as well as answer common questions and concerns.

Community pharmacists are the most accessible health care professionals, as no appointments are required to see them, and to have the highest level of patient contact. Pharmacists are key players in the betterment of patients’ health, not just in terms of screening but in the lifelong management of the disease.

Lifestyle Modifications: it is reported that being overweight or obese contributessignificantly to the burden of diabetes (44%), ischemic heart disease (23%), and certain cancers (range 7%–41%). Yet, obesity is preventable, and strategies to prevent diabetes and cardiovascular disease both include the common goal to optimize peoples’ weight through diet and exercise.

Obesity is currently a worldwide pandemic. Of the world’s population, an estimated 35% of adults are overweight – defined by the World Health Organization (WHO) as a body mass index (BMI) of ≥25 kg/m2. Globally, an estimated 12% of adults are obese (BMI ≥30 kg/m2), half of whom live within just a handful of countries, including the United States of America, People’s Republic of China, India, Russia, Brazil, Mexico, Egypt, Germany, Pakistan, and Indonesia.

The rise in obesity can be attributed to multiple factors, most notably modern lifestyles, which allow for easy access to inexpensive unhealthy foods, sedentary lifestyle, and environmental factors that limit access to healthy diet and exercise management. Effective management of the obesity pandemic requires the promotion and fundamental acceptance of healthy lifestyle habits, which in turn depend upon the availability of resources such as affordable nutritious food options and access to venues that promote exercise. In addition, counselling and guidance by health care professionals is necessary for disease state prevention and treatment. The WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases outlines several objectives to be attained by 2020, including increasing physical activity; decreasing the risk of premature mortality from cardiovascular disease, cancer, diabetes, and chronic respiratory diseases; and halting the rise in diabetes and obesity.

Pharmacists were well suited to delivering weight management services, especially given their regular contact with patients. Participants felt that pharmacists were already well trained to perform basic physical assessments such as weight, waist circumference, blood glucose monitoring, and pharmacotherapy counseling, while additional training could be easily obtained for services that would encompass dietary counseling, guidance on physical activity, and behavioral counseling. Programs that have been developed exist either within community pharmacies alone or as part of collaborative agreements between pharmacists, physicians, and other health care providers. Pharmacists have demonstrated that they can improve drug therapy for patients through medication therapy management (MTM) for chronic diseases such as hypertension, diabetes, and dyslipidemia. Increasing the awareness and knowledge of lifestyle modification strategies may help pharmacists implement more comprehensive MTM services.

Other Areas: A Pharmacists goes through a gamut of questions in his everyday work. They can range from which medication to use for a rash, which is a preferred diabetic meter, demonstrating an asthmatic patient as to how to use an inhaler. An elderly gentleman who came to pick up his blood thinner medication wanted to know which foods he needs to avoid when he is on this medication and a teenager required insights from the pharmacist on which acne cream needs to be used. There was also a concerned mother of a 5 yr old boy who needed recommendation of which medication she can use for her son’s diarrhoea and vomiting. Pharmacists can be a valuable resource of smoking cessation.

Conclusion / Summary: Pharmacy is a profession that is expanding beyond the traditional compounding and dispensing of medication towards a more professional advisory and primary health care role. They are an integral part of the community and serve as an important source of knowledge. Pharmacists are dynamic, patient-centric professionals committed to fulfilling the health care requirements of their patients and they would serve in reducing the burden of our Doctors for treating minor ailments, answer queries related to medicine and medical devices and also provide guidance in disease management.

About the Author

Katta Anand Srinivas is a Pharmacologist, Clinical Pharmacist, Medication Counsellor, Marathoner, and Yoga Practitioner. He has received his MS in Pharmacology from the University of Toledo, Ohio, USA. He is a licensed pharmacist in Washington State and North Carolina, USA and a
a certified reviewer of Elderly Medications from American Pharmacists Association, USA. Anand also runs a website http://www.askyourpharmacist.in.

You can contact Anand at contact@askyourpharmacist.in

References:

  1. https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/expert-answers/white-coat-hypertension/faq-20057792
  1. https://www.business-standard.com/article/pti-stories/doctor-patient-ratio-in-india-less-than-who-prescribed-norm-of-1-1000-govt-119111901421_1.html

https://www.medbroadcast.com/channel/medications-and-your-health/how-your-pharmacist-can-help/the-role-of-a-pharmacist