Welcome to the July issue

By David Woods (david.woods@rxcomms.com)

Question: “How many people work in the public sector?"

Answer: “About half of them.”

It's an old one, to be sure, but it has its echo in the fairly recently-coined word “presenteeism.” While absenteeism means not being at work at all; presenteeism means being at work, but not working; or at least not working to capacity.

That was the theme of a project presentation by 2008 MD/ MBA candidate Jeffrey Clough during Thomas Jefferson Medical College’s Health Policy Department’s Fellows’ Day. The project, funded by the Pharmaceutical Manufacturers and Research Association (PhRMA) and also involving Thomas Bunz, PharmD, as primary investigator, set out to examine the impact of pharmaceutical intervention in eight chronic disease entities: asthma, coronary artery disease (CAD), congestive heart failure (CHF), depression, diabetes, dyslipidaemia, hypertension, and migraine.

The project’s methodology involved searching literally thousands of articles using key words relating to the eight diseases and their connection to absenteeism and presenteeism. These eventually reduced to about 300–400 applicable or usable ones. The goal was to condense this wealth of information and make it understandable. With healthcare costs being such a major issue, the project’s findings would have an effect on decision making; in other words, which drugs can save money in productivity and worker satisfaction.

The two researchers found that from an employer or payer standpoint the impact more than compensated for the cost of medications in diseases such as asthma or where younger patients were more heavily involved; the return on investment was less or minimal in diseases such as CHF that primarily affect older patients.

Jeffrey Clough points out, though, that for some diseases an employer would likely see a return on investment (ROI) quickly in direct medical costs (e.g. diabetes, asthma) and in others there would be no ROI (e.g. dyslipidaemia); still others, he says, could yield a positive ROI if productivity costs are included (e.g. depression, migraine). The key point for decision makers, he emphasises, is not to evaluate medication costs as a single item but to think of all costs that could be affected.

There are ways to measure presenteeism, Mr Clough and Dr Bunz agree, but no standardised way to determine costs. How, for instance, can you assess the cost in lowered productivity of an arthritic patient’s ability with a computer?

PhRMA was allowed to comment and review at various stages in the genesis of the 10,000 word project; but the researchers emphasise that they have the final say. They believe that their work will be published in a peer-reviewed journal within the next six months. PhRMA will work with employers to show how if you use available pharmaceuticals appropriately you can improve outcomes economically as well as clinically.

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By Ruth Whittington (ruth.whittington@rxcomms.com)

Part 3 – Conducting an observational study

Last month, we looked at the differences between observational studies and randomised controlled trials (RCTs). Here, we look at designing and conducting an observational study.

Observational studies should be conducted to high standards. You can use the following checklist when designing observational studies; all studies should be reviewed by a medical research committee.

• Non interventional: there must be no randomisation, and nothing in the study design that directs or interferes with the initial physician decision or subsequent care. No test results should be requested unless performed in the normal course of treatment. Data collection should be performed at normally scheduled visits. Additional patient questionnaires may be required.
• Scientifically valuable: the study must address a valid scientific question and have clear objectives and endpoints.
• Study design and size: The study design should clearly meet the research objectives. The study should be large enough to have adequate statistical power. As there is a high possibility of treatment switching, the study design needs experienced and thorough statistical input from the beginning
• Safety reporting: the study design should consider the need to collect safety data. Alternative mechanisms to monitor safety may be adequate, and adverse event reporting may not be required in non-interventional studies.
• Analysis plan: this should be finalised before the data become available, to minimise potential bias.
• Publication plan: this should be discussed with external investigators, and key publications should be agreed in principle. In observational studies in poorly researched areas, the baseline data can be of great value and interest to clinicians, so you should allow for some publications here as well as at later stages in the study.
• Patient consent: appropriate consent should be obtained. Typically, this is simpler than for an RCT, but is required where new patient data are collected (for example, quality of life questionnaires) and may be required before agreeing that existing data can be shared by the investigator.
• Ethical consent: appropriate ethics committee approval should be obtained.
• Appropriate reimbursement: investigators should be reimbursed for their time only, and not paid an amount that might be perceived as a subsidy for drug cost or act as an incentive. The last thing you want is for physicians’ decisions for treatment to be influenced.

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By Clare Gurton (clare.gurton@rxcomms.com)

There is an increasing need for all of us to develop strategies for dealing with different cultures as business becomes more international and cross communication among different disciplines increases. Liaising with colleagues from different cultures and backgrounds can become a large part of many jobs and is often a demanding task – working inside multi-cultural teams needs skill and sensitivity. Very likely there are simple language barriers, different communication styles and contrasting etiquettes. For example, in many Eastern cultures it's polite to copy executives in on all emails, while in the US this might be viewed as irritating because it creates clutter.

The first step in bridging cultural gaps is to understand ourselves; none of us are neutral observers, we all have ingrained prejudices and preconceptions of our own. This is part of the influence of our own culture. We should try to identify and be aware of what constitutes ‘normal’ behaviour; what are our values? How do we see the world? What kind of behaviours and preconceptions in social and business settings do we regard as the norm?

Next, we need to attempt to understand the factors that have determined what our counterparts in different countries regard as the norm, from factual to attitudinal to behavioural (for example, certain particular economic factors will influence attitudes and this will shape the behaviour of the culture). This demands careful analysis – it can help to think about the attitudes which you and others are likely to have to factors such as:

• time (e.g. how important is punctuality and sticking to deadlines?);
• truth/openness (e.g. what are the cultural attitudes towards honesty, right and wrong?);
• relationships (e.g. how are other people regarded, such as those who are older or senior, younger or junior etc?);
• communication (e.g. are there particular etiquettes, does the culture demand frankness or the converse?)

Whilst all of us will see these factors in different ways to some extent, people from the same cultural backgrounds generally exhibit similarities in their cultural assumptions and attitudes.

The third step is to know how we are seen by others and the last is to learn to adapt, whilst remaining true to our own values.
It really does help if we make a conscious, non-patronising effort to alter our communication styles if we are to work effectively with people from other cultures. Since English is now the international language, thinking about how we can adapt our native tongue to help non-English speaking colleagues can be a great way to start.

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By Jonathan Coopersmith (jonathan.coopersmith@rxcomms.com)

Benjamin Franklin said “An ounce of prevention is worth a pound of cure”. Perhaps the best way to reduce errors in medicine, then, is to prevent the need for medical treatment in the first place. Here are some websites dedicated to health and prevention.
A report from the Centers for Disease Control and Prevention (CDC) entitled “An Ounce of Prevention… What Are the Returns?” can be found at www.cdc.gov/epo/prevent.htm. The report outlines 19 strategies and demonstrates how spending money to prevent disease and injury and promote healthy lifestyles makes good economic sense. Each prevention strategy was evaluated based on the health impact and costs of the related disease, injury or disability, and the effectiveness and cost-effectiveness of the prevention strategy.

The CDC also maintains The Prevention Guidelines Database, at http://aepo-xdv-www.epo.cdc.gov/wonder/
prevguid/prevguid.html. It contains all of the official guidelines and recommendations published by the CDC for the prevention of diseases, injuries and disabilities, and was developed to allow public health practitioners and others to quickly access the full set of guidelines from a single point, regardless of where they were originally published. You can search the database or choose from a comprehensive list of topics sorted by title or by date.

The Office of Disease Prevention and Health Promotion (ODPHP), which is part of the US Department of Health and Human Services, developed a programme called “Put Prevention into Practice” or PPIP. In 1998, the project was transferred to the Department's Agency for Healthcare Research and Quality (AHRQ, formerly the Agency for Health Care Policy and Research). PPIP, which can be found at www.ahcpr.gov/clinic/ppipix.htm, is now a part of AHRQ's integrated programme in clinical prevention, which includes support for the US Preventive Services Task Force (www.ahcpr.gov/clinic/uspstfab.htm) and ongoing research on the costs, outcomes, and quality of preventive care.

A site entitled “A Pocketful of Prevention” can be found at www.medicalpublishing.com/prevention/prevention.htm, which contains a list of publications and guidelines adapted from a report by the aforementioned US Preventive Services Task Force. The latest version of the popular publication “Guide to Clinical Preventive Services” can be found at http://odphp.osophs.dhhs.gov/pubs/guidecps.

Another interesting site dedicated to health and prevention is www.healthypeople.gov. One page on their website, www.healthypeople.gov/lhi/englishfactsheet.htm, lists the ten leading health indicators, with corresponding sample resources available from the US Federal government. (And for more quotes by Benjamin Franklin, be sure to check out www.ushistory.org/franklin/quotable/index.htm.)

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Giving and taking feedback

by Clare Gurton (clare.gurton@rxcomms.com)

Somewhere inside all of us is the desire to be ‘good’ and to be liked. And, as a result, we may find we shy away from taking criticism (either positive or negative) and likewise get nervous about how to give criticism. Some of this nervousness is undoubtedly due to the very word ‘criticism’; it conjures up feelings of blame and failure. If the word ‘feedback’ is substituted for criticism, the whole thing almost immediately feels better and less confrontational.

Learning to both take and give feedback is an essential part of any job; these tips will help you examine both parts of the exchange and make the process less daunting and more effective.

Giving negative feedback

• Always try to resolve any issues face to face, in a quiet and private space – preferably in the space/office of the person whose work needs improvement – as this will make them feel more at ease and less threatened.
• Be calm and controlled; never let anger enter into this exchange.
• Give a clear message of exactly what is not working and what can be done to improve it. Be specific about the change or result you want and involve the person in thinking through solutions.
• Never criticise the person, only the work or the behaviour; and empathise as much as possible.

Positive feedback

• Giving positive feedback is as important as giving negative feedback and needs to be done in much the same way; don’t let emotion enter into the discussion and be clear about what was done well and why.
• Don’t give too many compliments too often otherwise their value will be diluted and the act may become suspect.

Taking negative feedback

• Try to focus on the issue and not the person or behaviour of the person who is giving the feedback.
• Make sure you understand exactly what is being said and take a moment to analyse it in your own mind.
• Don’t argue with the criticism and collect your feelings after the meeting. If you feel that you have been unfairly criticised then re-schedule a follow-up meeting to resolve this.

Accepting compliments

• Accepting a compliment means working out what the compliment is and demonstrating that you have understood and received the message.
• Don’t be coy and respond with a flippant statement which will only de-value and possibly offend the person giving you the compliment.

Candid feedback helps growth; if we are off track a little, or an employee of ours is, then the right kind of feedback can quickly re-route things. The more your career advances, the more your job should involve helping others to develop; knowing how to do it well increases the likelihood that it will be acted on and that you will be liked.

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Next month

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Healthcare Outcomes Communicator is designed to help you explain and enhance your role and value as healthcare economists and outcomes researchers. But we need input from you – the professionals working "in the trenches". So we encourage you to give us your feedback about how we're doing – to communicate with us so that we can better communicate with you.

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David Woods and the Rx Communications team

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