Universal and equal access to effective health care services

1. Universal and equal access to effective health care services Zdenek Kalvach

2. Factorsof universal and equalaccess to health care services 1 • Financial accessibility • Fee for services • Health insurance covering • Poverty in old age • Gender aspect: lonely women (widows) • low pension • worse health state – health expectancy, disability, frailty, sarcopenia, osteoporosis, dementia • more unhealthy years of life (DFLE = Healthy life years, HLY)

3. Factorsof universal and equalaccess to health care services 2 • Regionalaccessibilityofhealth care facilities • Distances • Densityofthehealth care network • Conceptofcommunityprimary care • Localaccessibility • Barriers • Barrier-free environment • Wheelchairaccessiblefacility, transport • Universal, age-friendly design

4. Factorsof universal and equalaccess to health care services 3 • Discrimination • Racism – unequal approach to (old) gypsies • Ageism – including formal age limitations of some health performances – f.e. hemodialysis over 65 • Frailtism • inappropriate restriction in health care of the frail elderly – toward to cheaper, less sofisticated, less effective care • discriminatory de-medicination, inappropriate exclusion from the health care

5. De-medicination -a dangerousmisunderstanding • Humanistic de-medicination to submithealth care to natural life • Protectionof dignity, meaningoflife, socialroles • Personalizedmedicine • Humanizationofapproaches to geriatric, frailpatients • Reductionistic, discriminatory de-medicination to excludethefrailelderlyfromneedful care • Basic nursinginsteadofappropriatemedical care

6. De-medicination -a dangerousmisunderstanding It´sstrictlynecessary to draw a line between • Uselessexpenditures = expendituresforgenerallyuselesscure (therapyordiagnosticperformances) • Uselessexpenditures = expendituresforgenerallyusefulcureof „useless“ people (thefrailelderly) Ofcourseit´sinadmissible to distinguishuseful and uselesspeople but …

7. Overpopulation – the mankind , the elderly, sick or slowly dying people?

8. Pragmatismofeconomicgovernance by Niccolo Machiavelli (1469-1527)

9. Factorsof universal and equalaccess to health care services 4 • Low compliance of patients and caregiving families • Asocial behaviour – homeless elderly with addict • Health illiteracy • Lack of knowledge about • health in old age • Improvement of deficits and complaints of old age • potential health care services for the frail elderly

10. Factorsof universal and equalaccess to health care services 5a • To getinsideis not enough - Geriatricilliteracyofhealth care system and the most ofphysicians • In theframeworkofthedisease model - theworldof index diseases: • Mistakes and neglectbecauseofatypicalclinicalmanifestationofdiseases in oldage • Adverseeffectsofmedication and othertreatment • Geriatrichospitalism – iatrogeniclostofself-sufficiency, breakof dignity, overstress, complicationsofstay • Catastrophic management ofgeriatricgiants + nutrition

11. Geriatric giants of Bernard Isaacs Catastrophichospital management ofgeriatricgiants • instability • Immobility • Incontinence • intellectualimpairment • delirium (confusion) • dementia (maladaptation)

12. Thomas Jefferson (1743-1826) – a prophetofgeriatricmistreatment? „There is nothing more unequal than the equal treatment of unequal people.“ The quote attributed (with a question mark) to the 3rd elected president of U.S., the man of Declaration of Independence

13. Unequaloutcomescanbeconsequencesofequaltreatment

14. Equityofwhat -Equalapproachorequaloutcome? • Equity in approaches (input) – „thesame to all“ (socialism in thepractice) • Easystandards – society fascinated by • Normative standards • Unification • Replaceableelements • Discriminationofpeoplewithspecificneeds, difficulties • Throughthesametreatment to differentoutcomes

15. Equityofwhat -Equalapproachorequaloutcome? • Equity in outcomes (output) – „the same effectivness to all“ • Individualisation • Individual understanding • Specialised approaches to the frail geriatric patients with special needs and risks – geriatric affirmation • Through the different treatment to similar outcomes

16. The ancient alchemical axiom • In the world of (original) components there is no place for equivalents. • In our worl of (standardized, unified) equivalents there is no place for (original) components.

17. Factorsof universal and equalaccess to health care services 5b • Geriatric illiteracy of health care system and the most of physicians 2. Beyond the disease model - the world without index diseases: • Functional health • Frailty • Multicausal disability with weak link to index diseases • Multicausal geriatric syndromes • Exclusion of the frail patients without index diseases

18. Frailty – pathologicaldeterioration in oldage • More than natural biologicalinvolution • Much more than a newdiseaseor syndrome • A keystoneof basic approachofthe society and itshealth care system to thefrail, disabled, very oldpeople • A basic questionofpurviewofmedicine and healthinsurance – medical priority orsocialaffair? • „Wewon´tallowmedicinationof natural ageing“ – alsomedicalchallengesoffrailty?

19. Whatdoeshave I. Semmelweis in commonwith R. MacNamara? (NYT)

20. Connectionbetween I. Semmelweis and R. MacNamara Low-costmeasureswithextraordinarilysubstantialoutcomes • I. Semmelweis (1818-1865) – Hungarianobstetrician, pioneerofantisepticprocedures, „saviorofmothers“ (puerperalfever) – washyourhands • R. MacNamara (1916-2009) – American business executive, Secretaryof defense, president oftheWorld bank, as president ofFord´scomp. enforcedtheseatbelt

21. Geriatrics Geriatrics has been a field of a low-cost medicine with substantial outcomes because of good knowledge of both the proper patient (multidimensional comprehensive geriatric assessment) and common geriatric challenges including frailty and its effective interventions.

22. Coreofgeriatricdiscrimination and outcomeinequity Low medical responsibility and taking into consideration of complaints of the frail elderly Above all beyond the disease model Misunderstanding and underestimation of frailty. Mainstreaming of frailty or medical neglect?

23. What´s beyond the disease model • Health condition • Deterioration, wasting away, fatigue, decline of health potential • un-diagnosed diseases • challenge to functioning, „setting“ of the organism • Frequently a multicausal proces • Common un-patognomic symptoms • Disability without index diseases

24. A. Antonovsky 1923-1994

25. A. Antonovsky • Health and disease/sickness create a continuum • Health is more then absence of diseases • Challenges for medicine: • Diseases – diagnosis, treatment, prevention, rehabilitation • Health – salutogenesis • Interventions „beyond the disease model“

26. Consequencesof A. Antonovsky´sconcept • Questionable consequences: stress on social welfare • Useful consequences: there´s something substantial, there´s responsibility of health care system beyond the disease model

27. The end of the disease era? • New balance between interest of diseases and interest of other factors of „functional health“ • Mainstreaming of patients with complaints without index diseases – including the frail geriatric patients • Tinetti M, Fried T. „The end of the disease era“ Am. J. Medicine, 2004

28. Tinetti M, Fried T. The end ofthediseaseera. A.J.M. 2004 „The time has come to abandon disease as the focus of medical care. The changed spectrum of health, the complex interplay of biological and nonbiological factors, the aging population, and the interindividual variability in health priorities render medical care that is centered on the diagnosis and treatment of individual diseases at best out of date and at worst harmful.

29. Tinetti M, Fried T. The end ofthediseaseera. A.J.M. 2004 A primary focus on disease may inadvertently lead to undertreatment, overtreatment, or mistreatment…Clinical decision making for all patients should be predicated on the attainment of individual goals and the identification and treatment of all modifiable biological and nonbiological factors, rather than solely on the diagnosis, treatment, or prevention of individual diseases.

30. Tinetti M, Fried T. The end ofthediseaseera. A.J.M. 2004 Anticipated arguments against a more integrated and individualized approach range from concerns about medicalization of life problems to "this is nothing new" and "resources would be better spent determining the underlying biological mechanisms.„

31. Tinetti M, Fried T. The end ofthediseaseera. A.J.M. 2004 The perception that the disease model is "truth" rather than a previously useful model will be a barrier as well. Notwithstanding these barriers, medical care must evolve to meet the health care needs of patients in the 21st century.“

32. Spiralpathogenesisofmulticausalfrailty (J. E. Morley)

33. Summery • There are severalfactorsinterferingwith universal and equalaccesoftheelderly to effectivehealth care services. • Misunderstanding and underestimationoffrailty and otherchallengesbeyondthedisease model belong to the most importantfactors. • Itleads to medicalneglect, needlesssuffering, lowquality od life, dependency and …

34. Summery • Exclusion of the many misunderstood frail elderly from medical responsibility to the social basic long-term care.