25 de maig 2018

The p53 nightmare

p53 and Me

This week you'll find a short piece in NEJM, a story written by a physician on how detecting a genetic p53 mutation changed her views. Key message:
Genetic knowledge is power only if both clinician and patient are equipped to move beyond a result and toward action, even if that merely means living well with what we know. I believe we need an expanded definition of genetic counseling; we require more data, yes, but also more sophisticated and sensitive ways of assimilating such data. And not just into databases we can mine to see what happens to people like me, but into programs for learning to live with uncertainty.

23 de maig 2018

The spanish flu, a century later

Pale Rider: The Spanish Flu of 1918 and How it Changed the World

Laura Spinney has made a great job with her latest book "The Pale Rider". For those that are interested on the largest recent epidemy and public health crisis -the spanish flu of 1918,- this is the book to read. I enjoyed specially the details of what should be avoided, and nobody cared about it. The conflict between religion and medicine. You'll not get the precise number of deaths, but it was an enormous tragedy in social terms.
The book also explains how physicians were exposed to the disease without any tools and how it was arriving to the remote and less inhabited places of the world.
It is specially helpful to recognise how vulnerable are all of us, still now. Highly recommended.

PS. You'll find it also in spanish, "El jinete pálido"

17 de maig 2018

The weirdest health financing system of the world (2)

Tracking Universal Health Coverage: 2017 Global Monitoring Report

If I had to summarise the best outcome of health policy in the last century in western countries, I would say mandatory health insurance. No doubt. And the joint report by WHO and WB reminds us that there is still a long way to achieve such goal for the whole population in the world.  Mandatory insurance is the most efficient way to solve the failures of the health insurance market. We al know the details and difficulties that arise as a result of information asymmetries and opportunistic behaviour.
Therefore the recommendation is clear, for those that already have a mandatory system, keep on it. This is precisely what hasn't happened here. In 2012 the system changed from universal towards a social security based membership funded by taxes. The weirdest health financing system of the world.

Maya Fadeeva with Club des Belugas

13 de maig 2018

Measuring morbidity in large populations


There is a unique study on measuring morbidity in a large population. In Valencia (4.7 million inhabitants) the Clinical Risk Group classification system has been applied. And you may find the results comparing the whole population, and one Department (Denia). The study shows details about the utilization and costs related with morbidity. Interesting application that replicates former ones. Epidemiologists, clinicians, policy makers and managers should be interested in using these approaches for taking decisions.

Pablo Picasso, by Arnold Newman

11 de maig 2018

Changing the production function of diagnostic tests

Next-generation diagnostics with CRISPR

Last week while reading Science I noticed a short and crucial article. Up to now CRISPR technology was focused on gene editing, now we can say that its usefulness is widening into diagnostics. It may change completely molecular diagnostics of "infectious diseases through detection of Zika virus (ZIKV), Dengue virus (DENV), and human papillomavirus (HPV) in human  samples, and noninfectious diseases, such as detection of gene mutations in circulating cell-free DNA from lung cancer patients." The production founction of lab testing would change completely.
Several articles explain details about it. The fight for patents is going to start again on CRISPR diagnostics. And this are unfortunately bad news.
Anyway, Science article reminds us:
These emerging diagnostic tools will by necessity be compared to standard diagnostics to ensure sensitivity and specificity and will need to be field-tested to guarantee performance in patient care settings, as environmental conditions and end-user application might affect performance. Proven assays, if affordable, promise to improve care in resource-limited settings where undifferentiated febrile illness is the norm and where gaps or delays in diagnosis, targeted care, and infection control contribute to infectious disease mortality and spread.
More details in The Verge.

08 de maig 2018

Cost-effectiveness of genome sequencing (2)

Application of next-generation sequencing to improve cancer management: A review of the clinical effectiveness and cost-effectiveness

If you want to go deeper on the issue, have a look at this article. It is focused on one disease, cancer and tries to combine clinical effectiveness and cost effectiveness. Sounds good. At the end you'll see that the number of available studies is limited (6), but that's the situation and these are the conclusions:

We report the rate of successfully detecting mutations from the clinical studies. The incremental cost-effectiveness ratio and sensitivity analysis outcomes are reported for the cost-effectiveness articles. Fifty-six articles reported that sequencing patient samples using targeted gene panels, and 83% of the successfully sequenced patients harboured at least 1 mutation.
 In our evaluation of the effectiveness of NGS, we found that NGS is effective at identifying mutations in cancer patients, and we reported that 37% of the diagnosed patients proceeded to receive therapy matching their genetic profile. However, with only 6 articles available that assess the cost-effectiveness of NGS in various settings, it remains an area for future research to determine whether the technology is cost-effective in routine cancer management.
PS. Today this blog has surpassed its 200.000 visits. That's great! Thank you for your loyalty.

Sally Mann, On the Maury, 1992, gelatin silver print, Private collection.
Washington National Gallery, current exhibition

06 de maig 2018

Cost-effectiveness of genome sequencing

Are whole-exome and whole-genome sequencing approaches cost-effective? A systematic review of the literature

It is quite difficult to talk about value in genetic tests without any reference to analytical validity, clinical validity and clinical utility. Once these three issues are appropriately solved, then we need to assess costs. Cost effectivenes makes sense once this three steps are covered successfully.
An analysis of cost-effectiveness of whole genome/exome sequencing it sounds too generic if there is no reference to specific baseline that allows to estimate incremental cost-effectiveness ratios.
That's the reason why a recent article trying to review existing studies fails to achieve any conclusion.
The current health economic evidence base to support the more widespread use of WES and WGS in clinical practice is very limited. Studies that carefully evaluate the costs,
effectiveness, and cost-effectiveness of these tests are urgently needed to support their translation into clinical practice.
 Let's start focusing on the assessment of three key perspectives before entering into a black hole.

02 de maig 2018

Mental health: the problem and what can be done

THRIVE: How Better Mental Health Care Transforms Lives and Saves Money

I have to recognise it. Mental health is a difficult issue, and all the efforts to decrease its impact on individual and social welfare are not enough by now. The book by Layard and Clark is a useful reference. I had to read it since long time. It says:
Mental illness is the great hidden problem in our societies, so most people are amazed when they hear the scale of it. In the Western world today one in six of all adults suffers from depression or a crippling anxiety disorder. Roughly a third of households currently include someone who is mentally ill.
I don't know the exact figure, but I agree with the statement.
Mental illness is not just a problem for those it affects directly. It also imposes huge costs on the rest of society. So the case for tackling the problem is not just humanitarian—it is also a matter of plain economics. Mental health problems diminish work, increase crime, and make additional demands on physical health care.
So, what is the cost? The answer is huge. Layard and Clark provide some figures. And in the second part of the book, they review the alternative approaches to the issue. A highly recommended book by one of the greatest economists of our time.

PS Great Tribute to Uwe Reinhardt in NYT by Paul Krugman.