September 29, 2017

One of the biggest financial scandals of all-time (and remains unsolved)

The LIBOR scandal involved the illegal fixing of this rate. Banks would over or under-report the rate so as to benefit them – making tons of cash in the process. Raise the rate a few basis points, and suddenly you’ve made an extra $200 million dollars in two minutes.
The size of fines for banks up to now is  €9 billion, and the most surprising thing is that it is still working as before. VoxEU explains
You might think that after this costly scandal, and knowing challenges of maintaining LIBOR, market participants and regulators would have quickly replaced LIBOR with a sustainable short-term interest rate benchmark that had little risk of manipulation. You’d be wrong. The current administrator (ICE Benchmark Administration), which replaced the BBA in 2014, estimates that this guide (now called ICE LIBOR) continues to serve as the reference interest rate for “an estimated $350 trillion of outstanding contracts in maturities ranging from overnight to more than 30 years"
In short, LIBOR is still the world’s leading benchmark for short-term interest rates
Sounds incredible but it is true. I'm reading the book: The spider network and it reports the worst professional financial practices that you can imagine. Where is the regulator? The european one is on vacation, for sure.



September 28, 2017

Public Health and behaviour change

Behavioral Epidemiology. Principles and Applications

It is quite surprising that a new book on Behavioral Epidemiology forgets Tversky and Kahneman, or Thaler. I couldn't find any reference to their works. After all these decades it seems that their works should be taken into account. Epidemiology and Public Health need to review its foundations, basically its rational decision making paradigm that has been their foundations.
I thought that this book could help, but finally I saw that only the first chapters are partially of interest. We'll have to wait.





September 27, 2017

Health in all policies narrative

Engagement of Sectors Other than Health in Integrated Health Governance, Policy, and Action

A good review on the topic is welcome. You'll find this article in Annual Reviews of Public Health. If health is created largely outside the health sector, engagement in health governance, policy, and intervention development and implementation by sectors other than health, is therefore important. I have reviewed this topic earlier, but I suggest a close look at it and its assumptions:
(a) Health is created largely outside the health care (or disease) sector; (b) the health care (or disease) sector, however, often carries social ownership of all health issues, even when they are beyond its control; (c) the health sector itself is a reproduction of (power) divisions in the public and private sectors and, while calling for integration, is itself fragmented; and (d) calls for broad social engagement with integrated research, policy, action, and governance for health may not align well with assumptions a–c.
The purpose of the article is to provide an evidence-based overview of how broad social engagement in health policy, action, and governance can be initiated, developed, and sustained.

 In Barcelona Caixaforum, right now.



September 15, 2017

Behavioral provider payment systems: the next step

Impact of Provider Incentives on Quality and Value of Health Care

Experimenting with incentives for quality is a risky task. The variable requires a precise measure and it must indicate the appropriate signal to the provider to have impact in decisions and behaviour. Usually, rational behaviour is assumed int the models. A recent review highlights this is issue:
Advocates of pay-for-performance in health care maintain that its early failures are the result of inadequate design, a failure to incorporate a more sophisticated understanding of provider motivation into program design (26). On the basis of evidence from early schemes and readings of economic and psychological theory, several researchers have produced blueprints for secondgeneration pay-for-performance frameworks. Their recommendations for designers include making rewards large enough to be meaningful; using penalties in addition to rewards; aligning incentives to professional priorities; using absolute rather than relative performance targets; providing frequent, discrete rewards or punishments; and making an explicit long-term commitment to incentives
But the authors admit that: " Some of these solutions are difficult to implement, are contradictory, or introduce further unintended consequences". And this paves the way to a pessimist view:
Programs are slowly becoming more sophisticated, but unless clear evidence for cost-effectiveness emerges soon, the incentive experiment may have to be abandoned. Many commentators see this abandonment as inevitable, believing incentive programs to be fundamentally flawed. Some concerns are technical in nature and relate to the difficulty of accurately defining and measuring the most important aspects of quality with the greatest impacts on patient outcomes
My impression is that the unit of analysis is usually wrong. Until we are not able to measure patient focused episodes of care properly, in a holistic way, will miss something. This should be the first concern. Of course, this is an overwhelming task, not an easy one.


Camille Pissarro in Sant Feliu de Guixols right now

September 14, 2017

Understanding The Value Of Innovations In Medicine

Video of the yesterday Health Affairs conference in Washington
Agenda and slides
Health Affairs site

Quite surprising the initial definition of value, quality over price?. It is not a ratio, it is the economic surplus, the worth created, one part for the producer and another for the consumer. But in healthcare the consumer is at the same time producer of surplus. This is unique. Maybe someday we should talk about how to split the value according to its contribution, and not only on value based payment.

September 13, 2017

How global health stands?

Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016

The Global Burden of Disease (GBD) report shows in an aggregated way how is the world population health. It tries to give an index, and the summary would be:
The median health-related SDG index was 56·7 (IQR 31·9–66·8) in 2016 and country-level performance markedly varied, with Singapore (86·8, 95% uncertainty interval 84·6–88·9), Iceland (86·0, 84·1–87·6), and Sweden (85·6, 81·8–87·8) having the highest levels in 2016 and Afghanistan (10·9, 9·6–11·9), the Central African Republic (11·0, 8·8–13·8), and Somalia (11·3, 9·5–13·1) recording the lowest.
Sustainable Development Goals (SDG) were set by UN   and there are specific indicators for health. However the study takes into account 37 of the 50 indicators. I have explained before some technicalities about the use of DALYs for such studies. And you may know that I am concerned about its use. Today I would add a new concern, it is the projection to 2030 for all these indicators. In my opinions it is a useless effort. Nobody knows, nad using the past to project the future, it is exactly a guarantee of a mistake. However, The Lancet will publish your article.
Let's have alook at the expenditure side:
By comparing performance on the health-related SDG index in 2016 with total health expenditure and DAH (Development Assistace for Health) per capita received from 2010 to 2014,insights might be gleaned regarding the association between overall health funding and performance on the health-related SDG index and whether DAH is being directed toward those countries with the greatest need. Generally, total health expenditure is positively correlated with performance on the health-related SDG index; however, considerable variation exists at the same level of expenditure. For example, among countries with a health-related SDG index of 30 to 70, the association between total health expenditure per capita and performance varied massively, spanning at least a 7 times difference in spending with similar levels of performance on the health-related SDG index.
That's a lot of variation, it would require a closer look. And a clear prescription:
For countries that received DAH between 2010–14, some of the most pronounced differences in cumulative DAH per capita received in the 2016 index were in sub-Saharan Africa, with several countries in southern sub-Saharan Africa posting nearly 3 times more cumulative DAH per capita than a number of countries in central and western sub-Saharan Africa. Most notably, some of the poorest performers on the health-related SDG index, such as the Central African Republic, South Sudan, Somalia, and Niger, received relatively little DAH.
All in all, GBD is what we have, it has limitations but it allows to understand the situation. It is unnecessary to project the future, in my opinion. We have to work for the improvement of current population health.

PS. By the way, there is a ranking. You'll see that Spain has fallen from 7th to 23rd. Forget it. It is still worse but useless. The health variations inside Spain are so huge that the unit of analysis is wrong.



September 8, 2017

The long and bumpy road to CRISPR

A Crack in Creation:The New Power to Control Evolution

I've read the same book than Diane Coyle this summer. If you want a clear understanding of what's going on in genomic editing, it should be your first choice. A crack in creation is a description and analysis by Jeniffer Doudna the main researcher on the topic. For those that are excited by genome editingit is good to read this statement:
It’s easy to get caught up in the excitement. The fact that gene editing might be able to reverse the course of a disease—permanently—by targeting its underlying genetic cause is thrilling enough. But even more so is the fact that CRISPR can be retooled to target new sequences of DNA and, hence, new diseases. Given CRISPR’s tremendous potential, I’ve grown accustomed over the past several years to being approached by established pharmaceutical companies asking for my help in learning about the CRISPR technology and about how it might be deployed in the quest for new therapeutics.
But therapeutic gene editing is still in its infancy—indeed, clinical trials have only just begun—and there are still big questions about how things will progress from here. The decades-long struggle to make good on the promise of gene therapy should serve as a reminder that medical advances are almost always more complicated than they might seem. For CRISPR, too, the road leading from the lab to the clinic will be long and bumpy.
Deciding what types of cells to target is one of the many dilemmas confronting researchers—should they edit somatic cells (from the Greek soma, for “body”) or germ cells (from the Latin germen, for “bud” or “sprout”)? The distinction between these two classes of cells cuts to the heart of one of the most heated and vital debates in the world of medicine today.
Germ cells are any cells whose genome can be inherited by subsequent generations, and thus they make up the germline of the organism—the stream of genetic material that is passed from one generation to the next. While eggs and sperm are the most obvious germ cells in humans, the germline also encompasses the progenitors of these mature sex cells as well as stem cells from the very early stages of the developing human embryo.
Somatic cells are virtually all the other cells in an organism: heart, muscle, brain, skin, liver—any cell whose DNA cannot be transmitted to offspring.
Therefore, caution is required and ethical implications are huge as I've said before.
Highly recommended.