Sustainability in healthcare
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The bibliographic citation for this definition is: Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. The definition has not been amended since 1948.
Healthcare by definition cannot be restricted to the absence of disease . Healthcare is more ambitious. It requires that professionals define their disciplines not restricted to diseases but comprizing well-being; from patho-physiology to physiology; from care to prevention and therefore prioritizing healthcare of children. From empathy with suffering to empathy on improving well being. From docter managed care to docter-patient managed care.
Obviously, health care defined according WHO has a major impact on the classical medical approach; it questions borders between medical and non-medical but it provides guidance to longterm health care, comprizing, prevention treatment and to self management.
The present healthcare system in the Netherlands is extremely expensive.
Reconciling the more ambitious definition of the WHO at a first glance, care will even be more expensive as it adds up to the present care as provided. Business models suggest we have to reduce costs: With less people providing care as lean as possible to more people.
In this editorial, we aim to propose an alternative approach: sustainable health care with empathy for well being. Care, which impacts life for a prolonged time and not a fast and immediate result has to be prioritized. Prioritizing sustainable health care means priorizing care with value and it also means giving posteriority to care which is only transient and has little value.
Sustainable dermatology only can be understood in the light of the natural course of skin diseases, comprizing comorbidities, the impact of skin diseases on well being and last but not least prevention of skin diseases and the march of skin diseases with development of comorbidities.
The dynamics of skin diseases
In dermatology, largely 4 classes of diseases exist: oncology, inflammatory diseases without infection, infectious diseases and degenerative diseases.
In oncology preexisting lesions and pathogenetic factors are of eminent significance. So awareness of cosmetic appearance and attention for skin changes in the population is the beginning of skin cancer prevention and is mandatory for early recognition. Monitoring of dysplastic naevi, leukoplakia, actinic keratoses and reconciling pathogenetic factors, including exposition to sunlight, ionizing radiation immunosuppression is of significance to prevent cancer. In patients with skin cancer the intervention is not restricted to the curation. In particular basal cell carcinomas and squamous cell cancers may be multiple and for cancer prone patients a life long intervention/supervision may be required. Also patients with melanoma require a prolonged supervision. Therefore prevention of cancer, intervention with the cancer and follow up imply that onco-dermatology cannot be delt with as quick fix but require a sustainable organisation of care.
Infectious diseases may be transient, once only and related to a disruption of skin barrier, temporary immunosuppression or specific environmental infestation. However, many infections have a chronic relapsing course. Herpes viruses may cause repetitive sequellae of active infections during years. Immuno deficiences may explain the relapsing course of impetigo and mollusca and warts. Managing relapsing infections is not a quick fix but may cause chronic discomfort over years and requires sustained health control.
A large spectrum of inflammatory skin diseases is a substantial burden of disease. Psoriasis, eczema’s, acneiform dermatoses, immunodermatoses such as the lupus spectrum, scleroderma and several bullous diseases require long term intervention with active treatments. Internal manifestations in systemic lupus erythematodes and scleroderma and psoriasis require collaboration with other disciplines. Comorbidities, in particular in psoriasis and acneiform dermatoses, have become a concern, since evidence is accumulating that cardiovascular comorbidity is associated with moderate to severe disease activity. Therefore, inflammatory skin diseases often require a longstanding commitment in a well organised system of care, providing long-term disease management.
Degenerative diseases comprise the skin changes derived from vascular abnormalities, comprizing abnormalties of the venous system, arteriolar and the arterial sytem. Again awarenes in the population of skin appearance is mandatory for early recognition of changes. For example “pretibial pigmentary patches tell us about arteriolar insufficiency in a patient and varicous venes with blow outs and oedema tell us about venous insufficiency and without compression with elastic stockings, the patient is likely to develop chronic leg ulcers. Again, a coherent and not a fragmented health care system provinding long term safe control is what is needed.
The organisation of sustainable healtcare
Perhaps the most important problem in current health care systems is fragmentation. Further fragmentation, by bringing dermatological care in isolated treatment centres, without the integration with general care in multidisciplinary teams and not part of the natural collaboration between general practitionars and hospitals will worsen fragmentation and endanger the longterm sustained controle of diseases. Also integration of health care and wellness organisations is endangered by this fragmentation.
Another problem is the vision as if “there is market in health care”, where the ensurance companies decide in which hospitals they buy what seems attractive and healthy for their patients. Market oriented dermatological care is by definition fragmented and focussed on the quick win, can be very expensive and may not provide what is really needed: longterm health management.
Based on ill-defined definitions problems in patients are defined as complex or not complex. The criteria for this fragmented imaginary definition comprize:
Intensified treatment needed
Care requiring experimental approaches
A unique knowledges needed
At least 3 different disciplines,
Very seldom surgery needed
Patients with orphan disease
Referals from general hospitals for reason that care is needed which is not available at the general hospital
Off label expensive medication needed
Patients who fullfil criteria for very complex or complex care have to be seen in academic centres and general hospitals. Health care of individual patients does not work according to a stratified approach based on fixed criteria, but is a dynamic individualized proces.
In dermatology many patients require care during a prolonged period of time. In an individual patient this may carry aspects of prevention, of intervention and of longterm management of skin disease and comorbidities. A flexible referal system is needed to provide the continuity of care as close as possible to the living environment of the patient. The organisation of care requires regional networks to guarantee an individualised collaborative efford. Working according to complementary guidelines and building continuing medical education accross disciplines.
It has been shown that continuing medical education has to have a coninuity and is of little value if it is incidental. The principles of 1 ½ line care provide opportunities which help continuing medical education and provide low threshold consultation. To have joint sessions at the location of a healthcare centre of primary care serves both aspects. Working in a virtual treatment environment using image contact and working in joint patient files opens new ways of efficient collaboration.
Of crucial value is the patient him/herself. Empowerment of the patient to understand his her disease, aggravating factors, the efficacy -, side effects- and methods on how to carry out the treatments correctly. In particular the prevention of disease, the adherence to treatment schedules and to adapt lifestyles for a better health is in the hands of the patient. The patients need the information and such is an educational task of the hospitals in collaboration with the general practitionars, according to national guidelines and information available by patient organisations. At present the distribution of this information has to be improved and individualised.
Use of patient reported outcomes (PRO) help to allign treatment decisions to the state of the skin disease as experienced by the patient. By reporting PRO the patient is able to express his disease severity, close to what he/she experience.
Organisation of sustainable Dermatology
A coherent system of care between healthcare providers in dermatology is what matters. In this system the longterm wellness of the patient is the central aim, and not fragments of services.
The patient plays a central role in the proposed system. He/she is providing the question and is in communication with the dermatologist how to structure treatments and activities improving longterm health and wellness.
Step 1 Healthcare education and self management
Awareness programms for patients have to be provided and collaborative effords between the regional healtcare system and organisations for education and teaching social wellness and work providers have to optimize healthcare education to the population. This implies information via internet, news papers and magazins, patient organisations and educational days such as world psoriasis day, oncology screening day, etc.
Awarenes of the skin positions “cosmetic dermatology” in an entirely different perspective. Early recognition of skin changes requires attention for changes in the integrity of the skin. Splitting cosmetic dermatology from traditional dermatology is again fragmentation of care and is working against early recognition. Attention to skin physiology and aging with careful early diagnosis and adequate treatment also of benign lesions is in the interest of the patient-also of benign lesions -will help early recognition of skin cancers and recognition of degenerative skin conditions.
Step 2. Diagnosis and treatment of skin diseases
In sustainable dermatology the collaboration between general practitionars, general hospitals and academic centres provides continuity. According to the principle “as de-centralised as possible “the role of the hospital care has a focus on short, intensified and enlightening complexity .
Communication between first and second line care has to be revolutionized by working in virtual environment in the same patient file. In regions of care continuing medical education programms, including working in a joint patient session are needed in order to have knowledge and skills available as close as possible to the living environment of the patient.
Organisation of care is to diagnose and treat in the dermatological centre if needed the academic centre and to continue treatment and care in first line care by general practitionars and community services.
Step 3 Follow up and management of chronic disease
The general practitionar has a key role in manging the chronicity of the disease in the majority of patients. In many patients the dermatologist has to structure the treatment plans. However, in collaborative approaches the visits can be reduced significantly.
Eductional programms for the patient are of help to bring the patient in the position to manage his her disease with little help, possibly provided by e-consultation.
On the cost effectiveness of sustainable care in dermatology
Skin abnormalities get their significance in the light of health and wellness. What matters is the longterm care of patients with skin diseases, which are a burden and are working against wellness?
At a first glance dermatological care reconciling these aspects may be more expensive. In particular when also “cosmetic issues” have to be delt with, as far as they interfere with wellness. A re-definition of “cosmetic care” in the light of sustainable health care is a challenge and at the same time an opportunity.
By organising dermatological care as a continuum of first-, second- and third line care and improving the regional organisation of care by much more advanced information technology and exploiting new models in between first line and second line care sustainable dermatology will blossom.
Last but not least the role of the patient has changed from receiving care into a patient who is involved in the search for finding relevant factors eliciting/worsening the disease, treatment selection, how to control the disease long-term and how to cope with the disease.