The world of lifestyle medicine is one that recognises the whole individual, their community, the environment and many interacting components. The lifestyle medicine complexity presents some significant challenges. Often in healthcare, and probably in most areas of life, there is a tendency for problems and paradigms to be simplified to make them useful and useable. This works well unless the paradigm is wrong, and in hindsight there are many wrong paradigms that lead to widespread unhelpful healthcare practices; such as aspirin for primary prevention of cardiovascular disease. And what about bloodletting as an example of how a wrong paradigm can allow well-meaning healthcare practitioners to cause harm.
When Charles II (1630–1685) suffered a seizure he was immediately treated with 16 ounces of bloodletting from the left arm followed by another 8 ounces from cupping. Then he endured a vigorous regimen of emetics, enemas, purgatives, and mustard plasters followed by more bleeding from the jugular veins. He had more seizures and received further treatment with herbs and quinine. In total he had about 24 ounces of blood taken before he died.
THE HISTORY OF BLOODLETTING Issue: BCMJ, vol. 52 , No. 1 , January February 2010
An additional problem in healthcare is that it is big business, financially, which will distract from the core purpose of healthcare. Additionally in lifestyle medicine there is another potential influence relating to our own behaviours, personal values, and health beliefs.
So how can quality improvement help?
Quality improvement (QI) is steadily being embedded into healthcare organisations. QI has its roots in the manufacturing industry. W. Edwards Demming (1900-1993) is widely acknowledged as the one of the godfathers of modern QI methodology. His work included developing the Japanese manufacturing industry post World War II, helping it to become world leading in producing high quality products, such as cars, efficiently. There are many parts of QI methodology that assists continuous improvement in healthcare. The PDSA cycle (Plan, Do, Study, Act) may be something you are aware of, and in primary care there is a shift away from audit towards use of PDSA cycles to improve care.
QI methodology, once seen, is actually pretty simple, and often when being learnt will trigger a “I wish I had known this before” response. The NHS has some fantastic resources. The NHS Model for Change document brings together a lot of the QI theory:
Also the US Institute for Healthcare Improvement website is a very useful resource, www.ihi.org.
But how does this relate to direct patient care?
The trigger for writing this article was after seeing the debates in the lifestyle medicine world about which diet is best for a person to follow. How do we take the evidence base, with all its limitations, and apply it to the individual. Healthcare’s desire to use RCTs as the gold standard for interventions is probably not always helpful when translated to the complexity of an individual person. QI methodology can help to address this problem. QI methodology, including the PDSA cycle, is about knowing what the goal is, knowing how to measure for an improvement, and then testing change ideas and noticing the impact the change has on the measurements of improvement.
This pdf summarises some of this theory and how to utilise it for type 2 diabetes.
Looking at type 2 diabetes in more detail using a case study:
John Smith is 65 years old. He has had type 2 diabetes for 15 years. His HbA1c is 87mmol/mol. His current treatment is metformin and he injects 120units of insulin a day. He weighs 110kg. His blood pressure is 138/80mmHg
John discusses his type 2 diabetes management with his GP. John is keen to minimise the burden of the diabetes on his life, he is keen to avoid future complications. In the consultation they agree that John’s current blood glucose level (HbA1c) is an indicator that he is at higher risk of complications.
What is the best next step for John? Using the QI methodology John and his GP can create an improvement plan to lower John’s HbA1c. They agree to use the HbA1c as the primary outcome measure to signify improvement in John’s type 2 diabetes. They then think about what balancing measures they will need to monitor to ensure their management plan doesn’t have unnecessary adverse effects; they agree weight, blood pressure, lipids, and hypoglycaemic episodes would be useful measures.
The first change idea is for John’s daily insulin dosage to be increased. They agree to increase the insulin to 140units/day and to reconvene in 3 months with a repeat HbA1c, lipids, weight, and blood pressure measurement to assess the impact of the change.
Three months later John attends. He has recorded his daily insulin injections, and this shows he followed the agreed plan (i.e. the process measures were achieved). His HbA1c is now 80mmol/mol (his primary outcome measure has improved). Next his weight, blood pressure, and lipid measures are reviewed. John has gained 3kg and now weighs 113kg. His lipids show a rise in his triglycerides, and his blood pressure is now higher at 145/85mmHg.
So, was the change an improvement? The primary outcome measure was improved, but unfortunately all the balancing measures have worsened. This would suggest the intervention, the increased insulin dosage, may not be an appropriate management option.
John and his GP discuss these results. They then wonder if making a lifestyle change could help. John has been reading about how various different diets can help type 2 diabetes, potentially placing it into remission. John and the GP are a bit confused and overwhelmed by what seems to be conflicting reports on diet. They decide to use the same QI measures (HbA1c, lipids, weight, blood pressure) to assess any changes to diet John will make. In addition to achieve more rapid feedback on the impact of what he eats John plans to test his blood glucose at home before and after meals.
In the first week John quickly discovers that eating sugar and starchy foods causes his blood sugar to rise rapidly. He telephones his GP and they discuss this. They agree that John should start to reduce his sugar and starch intake and continue to monitor his blood glucose level, titrating down his insulin to prevent hypoglycaemic episodes.
3 months later John is back to see his GP. His HbA1c has dropped to 52mmol/mol, and his weight has reduced to 98kg. His triglycerides are now normal. His blood pressure has also reduce to 136/74mmHg. John is now using just 10units of insulin a day, and they agree he could now stop his insulin all together.
So in John’s healthcare journey, there was a desired outcome to achieve, and the measures of improvement were decided. Then two different change ideas were trialled, first increasing insulin, and secondly changing diet. The use of QI methodology and clarity on the aim, and testing change ideas with clear measurement enabled John to see that increased dosages of insulin was not a good approach. However the dietary change allowed him to improve his health, despite the confusing media stories on what diet would be best for him.
QI applied directly to the individual patient offers a very helpful methodology to ensure all healthcare practices, including lifestyle medicine, is safe and effective.