30 d’abril 2017

ACOs state of the art

L’expérience américaine des Accountable Care Organizations:des enseignements pour la France ?

After all the efforts, ACOs coverage in US is right now only for 9% of population (28 million citizen). It seems a low figure. You can check the details of the current situation in an excellent report (en français) by IRDES. However, they consider that this approach could be useful for France, and I'm not so sure. The differences are huge to introduce something similar.

Parov Stelar - State of the Union
In Barcelona soon

26 d’abril 2017

Toolkit for comparative effectiveness

Methods in comparative effectiveness research

If comparative effectiveness is the new fram for valuing health technologies, then we need the appropriate toolkit. This is not new, I said the same in 2010 and afterwards in this blog. Right now there is a difference, you may read in this 600 pages book all the details about it (a chapter on machine learnisn is missing).
A clear understanding of comparative effectiveness is precisely what the authors of this report have neglected, unfortunately. It doesn't make any sense to start economic evaluation without an assessment of comparative effectiveness. It doesn't make any sense to back for QALYs as an accounting approach. Forget this guidelines, and suggest to read this book.

This volume covers the main areas of quantitative methodology for the design and analysis of CER studies. The volume has four major sections—causal inference; clinical trials; research synthesis; and specialized topics. The audience includes CER methodologists, quantitative-trained researchers interested in CER, and graduate students in statistics, epidemiology, and health services and outcomes research. The book assumes a masters-level course in regression analysis and familiarity with clinical research.

24 d’abril 2017

What is population health?

What does improving population health really mean?

Population health means the health outcomes of a defined group of people, as well as the distribution of health outcomes within the group.
Therefore, measuring and understanding the reasons for differences in health is a key factor for tackling them.
Kindig paper is the most relevant, and this one reflects the begining.
From the post by Kings Fund :

21 d’abril 2017

Approaching the golden age of epigenomics and epitranscriptomics

A new twist on epigenetics

If epigenomics is crucial to discard the genetic predestination paradigm, now we can add a new 'omics to the paradigm: epitranscriptomics. Last February, Nature published interesting news related to recent scientific developments:
The epigenome helps to explain how cells with identical DNA can develop into the multitude of specialized types that make up different tissues. The marks help cells in the heart, for example, maintain their identity and not turn into neurons or fat cells. Misplaced epigenetic marks are often found in cancerous cells.
 Chuan He and Tao Pan are two researchers that have been working on new ways of controlling gene expression
He and others have shown that a methyl group attached to adenine, one of the four bases in RNA, has crucial roles in cell differentiation, and may contribute to cancer, obesity and more. In 2015, He’s lab and two other teams uncovered the same chemical mark on adenine bases in DNA (methyl marks had previously been found only on cytosine), suggesting that the epigenome may be even richer than previously imagined.
The team had shown for the first time that RNA methylation was reversible, just like the marks found on DNA and histones.
Methylated adenine bases are the focus of research on gene expression.

18 d’abril 2017

Exercise as a socially contagious activity

Exercise contagion in a global social network
Disciplines as diverse as economics, sociology, medicine, computer science, political science and physics have recently become interested in the interdependence of behaviours across the human social network. In particular, scientists have begun to ask whether our health and other behaviours are contagious, in that our decisions and actions affect the decisions and actions of our peers. If behavioural contagions exist, understanding how, when and to what extent they manifest in different behaviours will enable us to transition from independent intervention strategies to more effective interdependent interventions that incorporate individuals’ social contexts into their treatments
A new  study offers some of the first hard evidence that health-related habits can spread — and so perhaps could be deliberately seeded and encouraged — by social influence and peer pressure. Previous research has sought such a contagious effect in factors such as obesity and smoking, but the results have been inconclusive.

Studies in social differences in health have a a new hurdle to tackle. How to boost social permeability? As Mackenback said in The Lancet on health inequalities: now it's personal.

PS. These are the results of the study in one figure:

10 d’abril 2017

The useless prediction of the end of liberalism

Francis Fukuyama predicted 25 years ago the end of history, the triumph of liberal democracy and the arrival of post-ideological world, Now Y. N. Harari predicts the end of liberalism and the arrival of a post-humanism (?). All these efforts are useless in my opinion and the reason is obvious, those that predict the future don't have more information than any other human being. They could devote their time to fruitful initiatives.
If I knew that the second half of Homo Deus was devoted to the end of liberalism and the birth of a post-humanism, I wouldn't have read it. I always try to avoid snake-oil sellers. Reading is an asymmetric information game, the writer knows more than the reader. I would suggest to start a global snake-oil writers lists to reduce asymmetric information.
The New Yorker publishes a sound review of the book,
Harari’s larger contention is that our homocentric creed, devoted to human liberty and happiness, will be destroyed by the approaching post-humanist horizon. Free will and individualism are, he says, illusions. We must reconceive ourselves as mere meat machines running algorithms, soon to be overtaken by metal machines running better ones. By then, we will no longer be able to sustain our comforting creed of “autonomy,” the belief, which he finds in Rousseau, that “I will find deep within myself a clear and single inner voice, which is my authentic self,” and that “my authentic self is completely free.” In reality, Harari maintains, we have merely a self-deluding, “narrating self,” one that recites obviously tendentious stories, shaped by our evolutionary history to help us cope with life. We are—this is his most emphatic point—already machines of a kind, robots unaware of our own programming. Humanism will be replaced by Dataism; and if the humanist revolution made us masters the Dataist revolution will make us pets.
Does this makes any sense? Is it possible to remain as the current best seller with such a message?

Norah Jones. It's a tragedy

07 d’abril 2017

When science and regulation don't talk to each other

An Evidence Framework for Genetic Testing

National Academy of Sciences and Food and Drug Administration don't talk to each other. At the same time that NASEM publishes a report on how to assess genetic testingFDA clears genetic testing for 23andme without any precise assessment, for the following tests:

  • Parkinson’s disease, a nervous system disorder impacting movement
  • Late-onset Alzheimer’s disease, a progressive brain disorder that destroys memory and thinking skills
  • Celiac disease, a disorder resulting in the inability to digest gluten
  • Alpha-1 antitrypsin deficiency, a disorder that raises the risk of lung and liver disease
  • Early-onset primary dystonia, a movement disorder involving involuntary muscle contractions and other uncontrolled movements
  • Factor XI deficiency, a blood clotting disorder
  • Gaucher disease type 1, an organ and tissue disorder
  • Glucose-6-Phosphate Dehydrogenase deficiency, also known as G6PD, a red blood cell condition
  • Hereditary hemochromatosis, an iron overload disorder
  • Hereditary thrombophilia, a blood clot disorder
Meanwhile NASEM recommends a decision framework for the use of genetic tests in clinical care:
1. Define genetic test scenarios on the basis of the clinical setting, the purpose of the test, the population, the outcomes of interest, and comparablealternative methods.
2. For each genetic test scenario, conduct an initial structured assessment to determine whether the test should be covered, denied, or subject to additional evaluation.
3. Conduct or support evidence-based systematic reviews for genetic test scenarios that require additional evaluation.
4. Conduct or support a structured decision process to produce clinical guidance for a genetic test scenario.
5. Publicly share resulting decisions and justification about evaluated genetic test scenarios, and retain decisions in a repository.
6. Implement timely review and revision of decisions on the basis of new data.
7. Identify evidence gaps to be addressed by research.
If you want further details, check Mathew Herper blog. My first impression after reading it is that this move, paves the way for recreational genetic testing. An approach that should be completely banned by legislation. If FDA has done so, let's wait for what it may happen in Europe where the regulator is still planning a change of the regulation in 2022!!! Meanwhile, the door is open (to the worst for citizens).

01 d’abril 2017

Learning to say no

Cost effective but unaffordable: an emerging challenge for health systems

There are big questions unanswered in health policy, and the social willingness to pay for a costly and effective technology is one of them. In a recent article, a description and controversies of NHS budget impact policies are explained:
The budget impact test means that technologies costing the NHS more than an additional £20m a year will be “slow tracked,” regardless of their cost effectiveness or other social or ethical values. This risks undermining the existing opportunity costs framework.
Therefore if there is a costly and effective therapy that has an impact budget greater than 20m, than next steps are uncertain in UK. This is the setting.
Really this affects all health politicians, and the issue is related to prioritisation and price regulation. The "solution" to the first issue is to delay prioritisation to the next minister, and what it is possible is to renegotiate prices of drugs. As I have said many times, prices are a fiction, because what it is under negotiation is a contract with the government, therfore the whole amount (p·q).
Budget impact is essentially the price per patient multiplied by the number of patients treated. Yet the prevalence of someone’s condition should not determine their access to treatment. The principle of equity means that like cases should be treated as like; the NHS Constitution requires the NHS to respond to the clinical needs of patients as individuals.
Righ now in Catalonia cost-effectiveness is a also a fiction, since prices are confidential, and it is not possible to estimate the ratio. Budget impact is the option.

Prix Pictet. Photo Exhibition in Barcelona
You can't miss it