June 18, 2020

Opioid crisis

Deaths of Despair and the Future of Capitalism

Beyond covid crisis there is still another one in US: the opioid crisis. The most relevant book on the topic is the Case-Deaton one.
We are telling the story in the way that we uncovered it, starting with midlife deaths of all kinds. We then focused on the immediate causes, which turned out to be deaths of despair among whites plus a slowdown and reversal in deaths from heart disease, which, until then, had been a main engine of mortality decline. Unfortunately, deaths of despair are not only afflicting middle-aged whites. While the elderly have been largely exempt, there have also been rapid increases in deaths of despair—particularly from overdoses and suicides—among younger whites. For whites between the ages of forty-five and fifty-four, deaths of despair tripled from 1990 to 2017. In 2017, this midlife age-group
had the highest rate of mortality from deaths of despair. But whites in younger age-groups were also doing badly and their deaths rose even more rapidly, accelerating in the last few years.
 Drug overdoses are the single largest category of deaths of despair. They are part of a broader epidemic that includes death from alcoholism and suicide, a reflection of the social failures that we have described in this book. Yet the behavior of the pharmaceutical companies caused more deaths than would otherwise have happened, showering gasoline on smoldering despair. Stopping the drug epidemic will not eliminate the root causes of deaths of despair, but it will save many lives and should be an immediate priority. Addiction is extremely hard to treat, even with the cooperation of the addict. There appears to be wide agreement that medication-assisted treatment can be effective, but it is not available to everyone, often because of cost.

Ps. Medicaments i risc de pneumònia

 Els analgèsics opiacis causen depressió respiratòria amb la hipoventilació pulmonar resultant;
alguns d’ells (codeïna, morfina, fentanil i metadona) també tenen efectes immunosupressors.
Incrementen el risc de pneumònia i la mortalitat respiratòria en un 40 a 75%.26,27,28
L’any 2018, uns 50 milions de persones als EUA (15% de la població adulta, 25% entre els més
grans de 65 anys) reberen una mitjana de 3,4 prescripcions d’analgèsics opiacis, i 10 milions de
persones reconeixien consum exagerat d’analgèsics de prescripció mèdica.29 A Europa en els
últims anys el consum d’opiacis suaus y forts ha augmentat, sobretot entre la gent gran.30,31
Fentanil i morfina son els opiacis forts més consumits, i més recentment oxicodona. El
tramadol, que és també inhibidor de la recaptació de serotonina, és l’opiaci suau més consumit.
En dos estudis observacionals de publicació recent, el consum de tramadol, comparat amb el
d’AINE, es va associar a una mortalitat 1,6 a 2,6 vegades més alta,32,33 sobretot en pacients
amb infecció i en pacients amb malaltia respiratòria.

June 17, 2020

LATAM Health at a glance

Panorama de la Salud:Latinoamérica y el Caribe 2020

Health at a Glance: Latin America and the Caribbean 2020

This is a joint report by OECD and World Bank. It is a key reference to understand health in LATAM and Caribbean. You'll find:
Key indicators on health and health systems in 33 Latin America and the Caribbean countries. This first Health at a Glance publication to cover the Latin America and the Caribbean region was prepared jointly by OECD and the World Bank. Analysis is based on the latest comparable data across almost 100 indicators including equity, health status, determinants of health, health care resources and utilisation, health expenditure and financing, and quality of care. The editorial discusses the main challenges for the region brought by the COVID-19 pandemic, such as managing the outbreak as well as mobilising adequate resources and using them efficiently to ensure an effective response to the epidemic. An initial chapter summarises the comparative performance of countries before the crisis, followed by a special chapter about addressing wasteful health spending that is either ineffective or does not lead to improvement in health outcomes so that to direct saved resources where they are urgently needed.

Spain Health expenditure per capita 2.446 € , Cuba Health expenditure per capita 2.484 $ !!!

June 16, 2020

Risk adjustment, a work in progress

Risk Adjustment, Risk Sharing and Premium Regulation in Health Insurance Markets: Theory and Practice

This is a handbook on an unfinished topic. Risk adjustment is required for any managed competition model to work properly (Enthoven model) and for any funding of plans that tries to promote efficiency and avoid selection:
The Enthoven model has evolved as its ideas have been applied in particular institutional contexts. Today, sophisticated risk adjustment models give a regulator an effective tool to quantify differences among individuals in their expected healthcare costs. Rather than a system of risk-rated premiums, regulators rely more on risk adjustment to pay plans more for higher-risk enrollees. Also, the countries in which the regulated competition model has become dominant (e.g., Germany, the Netherlands) are characterized by separation of the functions of health insurance and healthcare provision. Regulated competition can and has been implemented without the presence of integrated HMO type
risk-bearing delivery systems. In these countries, and in other settings such as Medicare Advantage in the United States, regulated competition is oriented to the health insurers, not the healthcare delivery system.
Throughout this evolution, the key feature of Enthoven’s model remains: an active collective agent on the demand side of health insurance structures and manages the health plan market to overcome market failures. Enthoven calls this agent a “sponsor,” a role that can be fulfilled by various organizations. In health insurance markets today, sponsors are mainly governments (as is common in Europe and the United States) and employers (as is common in the United States). In this volume we will generally refer to a “regulator.”
Therefore, any regulator interested in mitigating health insurance market failures should read it.

June 15, 2020

Hospital governance: the road not taken

Effective Governance and Hospital Boards Revisited: Reflections on 25 Years of Research

There is a lot of pending work for Hospital Boards to increase its effectiveness. This article shows what has happened in the last years. However, in our close environment, things are still getting worse. Albeit, more research is needed. This is a useful framework that is applied in the article:

Table 1. Board Governance Framework for Mapping the Literature.
Research Themes
Individual actors
•• Board member
•• Board chair/officers
•• CEO/executive director
Governing bodies
•• Governing board as a body
•• Governing board subunits and affiliated
enterprises (e.g., advisory councils)
•• Board–CEO relationship
•• Board–Organization relationship
•• Unitary and single-organization hybrids
•• Multitiered organizations
•• Organizations as actors in alliance or
Networks, alliances, and multiorganizational initiatives
•• Network or alliance as an organization
•• Interorganizational relationships (IOR;
when IOR is the actual focus)
•• Hybrid nonprofits–government networks
Note. Table adapted by Renz (2015) from Hambrick, Werder, and Zajac (2008) and Renz and Andersson

June 14, 2020

Measuring morbidity vs. measuring episodes: Two parallel views

Clinical risk groups and patient complexity: a case study with a primary care clinic in Alberta

In order to assess the health risk of a population there are two main options: Morbidity adjustment and Episodes of care. The first one can use Clinical Risk Groups, while the latter Patient focused episodes. The morbidity adjustment is useful for adjusting at population level, it is a categorical system, while episode measurement adjusts at patient level .
In this article you'll find an interesting application to a primary care center.
CRGs have definite value with respect to predicting health care utilization, but it is important to note the limitations of the CRG as a stand-alone classification of complexity, particularly for the categorization of patients in the health status 1 through
5 categories. In order to enhance the accuracy, relevance and predictive value of the CRG classification methodology, we see great value in pursuing methods that allow for the careful and systematic inclusion of information from the care record.
The article is trying to use the CRGs for episode measurement, and this is a wrong approach. CRGs are useful as a whole picture, physicians need details, only episodes can provide such information.


June 13, 2020

Why are we waiting? (5)

Waiting Times for Health Services. Next in Line

Long waiting times for health services is an important policy issue in most OECD countries. Reducing the time that people have to wait to get a consultation with a general practitioner, or a diagnostic test or treatment, can go a long way in improving patient experience and avoiding possible deterioration in their health. Governments in many countries have taken various measures to reduce waiting times, often supported by additional funding, with mixed success. This report looks at how waiting times for elective treatment, which is usually the longest wait, have stalled over the past decade in many countries, and have started to rise again in some others. It also analyses the differences in how long people have to wait to get a consultation with general practitioners or specialists across countries. The report reviews a range of policies that countries have used to tackle waiting times for different services, including elective surgery and primary care consultations, but also cancer care and mental health services, with a focus on identifying the most successful ones.
Just a few words. For citizens, this is the hottest topic in our health system. And policymakers are neglecting it, while some citizens are voting with their feed...only those that can.

Bowery men waiting for bread in bread line, New York City, Bain Collection

June 12, 2020

Primary Care value and physician compensation

Realising the Potential of Primary Health Care

If Primary Care is so important why so few physicians choose it as specialty for the residency programs?. The answer is that there is a difference in perception of value and compensation. Well, this is only the first answer. High value, high effort and low relative compensation compared to other specialties. Governments should care about it and about integrated care is finally organised. This is what OECD report says:
These new models of organisation should be more widely adopted to move away from the traditional and reactive solo-practice model. While there is no one-size-fits-all model of organisation, an integrated model of primary health care often meets the following four characteristics:
 Multi-disciplinary or inter-professional practices with a various mix of primary health care professionals (including GPs or family physicians, registered and advanced nurses, community pharmacists, psychologists, nutritionists, health counsellors, and non-clinical support staff), different models of teamwork, and different target populations (for example as seen in Australia, Canada, the United Kingdom and the United States) (Socha-Dietrich, 2019[101]).
 Comprehensive health services in the community, (for example in Costa Rica), including disease prevention and health promotion, curative services, rehabilitation and management of chronic diseases. Care co-ordination between health professionals is key to enabling the early detection of disease, reducing the exacerbation of diseases, avoiding duplication of services, and increasing provider and patient satisfaction.
 Population health management, generally based on risk stratification using sophisticated IT systems (for example in Canada and Spain), is implemented to better understand the health and risk profiles of the community and to undertake proactive management of patients’ needs. Patients are stratified to identify opportunities for intervention before the occurrence of any adverse outcomes for individual health status.
 Engagement of patients in shared decision making,


June 10, 2020

Precision medicine, here and now

Great article by David Cutler. The time for the returns of precision medicine has arrived in his opinion.
Precision medicine raises hopes for patients and fears for those who try to ride herd on health care spending. Will patients finally live longer and healthier lives? Will society be able to afford it? Surprisingly, at this point, personalized medicine has had less effect on both health and medical spending than either its strongest backers hoped or its most apprehensive actuaries feared.
 To date, total spending on anticancer drugs has been relatively modest. Although inflation-adjusted spending on anticancer drugs increased by $30 billion between 2011 and 2018, this is only 6% of the total increase in personal health care spending over the period. Given that administrative expenses cost an estimated 4 times the amount spent on anticancer drugs, one should be cautious about focusing excessively on the cost of precision medicine.
A better metric than total spending is cost effectiveness: do the benefits of the drugs outweigh the cost? The “drug abacus” tool developed by Memorial Sloan Kettering Cancer Center, which evaluates the cost-effectiveness of 52 anticancer drugs approved between 2001 and 2013, estimates that only a handful of new drugs are worth the cost at conventional valuations of life. If anticancer drugs were priced based on cost-effectiveness criteria, spending would fall by 30%.
This is a US based article, we need some estimates of our health system.


June 9, 2020

Regulating voluntary health insurance

La regulació de l'assegurança voluntària de salut

Market inefficiencies can be eased with proper regulation. In a specific issue of Revista Economica de Catalunya, you'll find an article that I've written on the topic.
There is a specific and actionable proposal to improve the current situation.
Voluntary insurance in Catalonia covers 26% of citizens, possibly the most widely used duplicate insurance in Europe. Given its relevance, the regulator has to decide whether to consider the set of market failures shown in this article and act or, in contrast, put it to one side and watch its impact increase over time. For now, it is clear that government has chosen the second option.
Considering that health is such a highly valued asset individually, surely the public deserves a satisfactory response.
I can't summarise all details here. I suggest a close look at the article and the remaining ones in the same issue.

June 8, 2020

Covid-19 testing landscape

COVID-19 diagnostics in context

This is the best summary of current supply of diagnostic tests for Covid-19:
COVID-19 tests can be grouped as nucleic acid, serological, antigen, and ancillary tests, all of which play distinct roles in hospital, point-of-care, or large-scale population testing.
Table 1 summarizes the existing and emerging tests, current at the time of writing (May 2020). A continuously updated version of this table is available at https://csb.mgh.harvard.edu/covid
Eric Topol says:
There are now *88* @US_FDA  cleared (by EUA) #COVID19 tests so far. Their false negative rates range from 10-48% (by post-release reports).
Might be better to have less tests, more accuracy, with faster turnaround
I agree.

Table 1 Performance comparison of different test types.
Throughput is determined by process type and assay time. In general, automated plate-based assays have higher daily throughputs. Hashtag (#) indicates example systems that have received FDA emergency use authorization (FDA-EUA). See https://csb.mgh.harvard.edu/covid to access continuously updated information. PCR, polymerase chain reaction; PCR-POC, PCR–point-of-care; ddPCR, digital droplet PCR; NEAR, nicking endonuclease amplification reaction; RCA, rolling circle amplification; SHERLOCK, specific high-sensitivity enzymatic reporter; DETECTR, DNA endonuclease-targeted CRISPR transreporter; NGS, next-generation sequencing; μNMR, micro–nuclear magnetic resonance; LFA, lateral flow assay; ELISA, enzyme-linked immunosorbent assay; CLIA, chemiluminescence immunoassay; EIA, enzyme immunoassay; ECLIA, electrochemiluminescence immunoassay; ECS, electrochemical sensing; VAT, viral antigen assay; IFM, immunofluorescence microscopy; WB, Western blot.

TypeTargetVirusAssay timeProcess typeFDA-EUAExamples
PCRViral RNASARS-CoV-22–8 hours; >12 hoursPlate56#Roche, #LabCorp,
#Becton Dickinson,
#Luminex, #Thermo
Fisher, others
PCR-POCViral RNASARS-CoV-2<1 hour="" td="">Cartridge2#Cepheid, #Mesa,
ddPCRViral RNASARS-CoV-22–4 hoursManual1#BioRAD
NEARViral RNASARS-CoV-215 minCartridge1#Abbott
OMEGAViral RNASARS-CoV-21 hourPlate1#Atila BioSystems
RCAViral RNASARS-CoV2 hours0
SHERLOCKViral RNASARS-CoV-21.5 hoursKit1#Sherlock
DETECTRViral RNASARS-CoV-21 hourKit0Mammoth
NGSViral RNASARS-CoV-2Days1#IDbyDNA, Vision,
μNMRViral RNASARS-CoV-22 hoursCartridge0T2 Biosystems
LFAIgG, IgMSARS-CoV-215 minCartridge3#Cellex,
#ChemBio, Innovita
ELISAIgG, IgMSARS-CoV-22–4 hoursPlate4#Mount Sinai,
#Ortho-Clinical (2),
Inc., BioRAD, Snibe,
Zhejiang orient,
Creative Dx
CLIAIgG, IgMSARS-CoV-230 minCartridge2#Abbott, #DiaSorin
EIAIgG, IgMSARS-CoV-22 hoursPlate1#BioRAD
MIAIgG, IgMSARS-CoV-2Plate1#Wadsworth Center
ECLIAIgG, IgMSARS-CoV-220 minPlate1#Roche
ECSIgG, cytokineSARS-CoV-21 hourCartridge0Accure Health
VATViral antigenSARS-CoV-220 minCartridge1#Quidel, Sona NT,
RayBiotech, SD
Biosensors, Bioeasy
MicroarraysIg epitopesSARS-CoV-21.5 hoursPlate0RayBiotech,
IFMViral proteinSARS-CoV3 hoursManual0
WBIgG, IgM; viral proteinSARS-CoV4 hoursManual0

June 7, 2020

Intercepting symbiomes

Intercepting pandemics through genomics

It makes sense:
There is an urgent need to establish a global, genomic-based biosurveillance platform, a developmentwhich would be of immense value to biosecurity, biodefense, and the economy. If implemented, this“pandemic interception system” would hugely advance our understanding of the natural world. Three major research programs are poised to support this effort: BIOSCAN, the Earth BioGenome Project (EBP), and the Global Virome Project (GVP). Each of these global programs is now working to develop approaches in comparative genomics that are needed to discover all species and to reveal their interactions. The diversity of infectious agents involved in host–pathogen interactions needs immediate clarification, especially  with regard to those agents that transfect phylogenetically divergent lineages.
A pandemic interception system needs to be based on detailed knowledge of symbiomes, which are the constellations of organisms that interact with all multicellular species. Efforts to describe the structure of symbiomes are motivated by the fact that parasites, parasitoids, and microbes can devastate host populations, especially those that are evolutionarily naïve. Symbiome complexity is governed by rules.

Daido Moriyama

June 6, 2020

Tackling COVID-19 beyond testing

How We Can Tackle the COVID-19 Crisis Beyond Testing

If you wear a smartwatch or fitness tracker, you can play a role in monitoring the spread of COVID-19 and other viral diseases like the flu. In this Front Row lecture, Eric Topol, MD, and Jennifer Radin, PhD, discuss how they’re calling on the public to share data from wearable devices for a study that’s helping scientists flag the early onset of contagious respiratory illnesses. By harnessing this key data—including heart rates, sleep and activity levels—from hundreds of thousands of individuals, they seek to improve real-time disease surveillance.

June 5, 2020

Regulating the healthcare bazaar

What to Do about Health-Care Markets?
Policies to Make Health-Care Markets Work

Martin Gaynor in the Brookings Report proposes three types of policy reforms that would increase competition in health care and improve market functioning:

  • Reduce or eliminate policies that encourage consolidation or that impede entry and competition.
  • Strengthen antitrust enforcement so that federal and state antitrust enforcement agencies can act effectively to prevent and remove harms to competition.
  • Create an agency responsible for monitoring and overseeing health-care markets, and give that agency the authority to flexibly intervene when markets are not working
Well, these are only 3 issues, the report highlights the details into the implementation. And if you want to know how far healthcare is from competitive markets, you must start understanding markets. There is a book that may help as a useful guide to start:

June 4, 2020

Forming beliefs

The Value of Beliefs

Relevant article with key messages:
We construct our beliefs to meet two sometimes conflicting goals: forming accurate beliefs to inform our decisions and forming desirable beliefs that we value for their own sake. In this NeuroView, we consider emerging neuroscience evidence on how the brain motivates itself to form particular beliefs and why it does so.
Our beliefs are fundamental parts of what makes each of us unique. They are a major cause of both harmony and discord; shared beliefs bring people together, while divergent beliefs can spark revolutions. In this age of the internet and social media, the ability of beliefs to both invigorate and polarize is more apparent than ever. This raises a fundamental question: how do people arrive at their beliefs? A traditional approach to studying beliefs is grounded on the idea that people build an internal model of the world for the purpose of informing their decisions to help them achieve external goals, such as gaining rewards and avoiding punishments.
 In particular, individuals often prefer to hold positive beliefs and hold beliefs with high certainty. To achieve this, changes in information seeking and belief updating are motivated by tapping into the same circuits that drive primary reward seeking. However, unlike primary rewards such as food, beliefs on their own do not directly promote survival.

June 3, 2020

The narrative of pandemics (2)

Información científica especializada, información pública y medios de comunicación durante la crisis del coronavirus

Today you'll find our article on communication in pandemic times in Blog Economía y Salud AES, how markets of attention and radical uncertainty drive current situation.

David Hockney

June 2, 2020

Public Health ethics

Ética en, para y de la Salud Pública

From Andreu Segura, a good article on public health ethics:
Modern public health has not paid much attention to ethics until very recently. Perhaps because a large part of their functions have been developed in public administrations, which are subject to regulations and laws and not to the deontological standards of professional corporations, but also because having such a lovely formal purpose -- health promotion and protection-- it seems that it is not  necessary to go to ethics to assess their activities. As it happened in the time of Enlightened Absolutism. An arrogant attitude that could explain popular distrust of some of their recommendations. One obstacle that the application of ethics could overcome.

David Hockney

June 1, 2020

In memoriam: Adam Wagstaff, a giant of health economics

The Virtual Legacy of Adam Wagstaff in Health Economics: So Much More than Old Wine in New Bottles

On 10 May 2020, the health economics community lost one of its giants with the death of Adam Wagstaff. During his career, Adam made tremendous contributions to the development and analysis of health care financing policies, with a focus on both health equity and efficiency in countries around the world. The huge volume of his work is partially reflected through articles and citations to his work published in Health Economics. The Health Economics Editorial Board, in conjunction with Wiley, prepared this Virtual Issue in Adam's honor. The issue starts with remembrances of Adam by Eddy van Doorslaer, a long-time friend and colleague. The issue also contains, in chronological order, links to the 28 Health Economics articles which Adam wrote or co-authored. We hope this compilation increases awareness of the brilliance of a leading health economist whose contributions were cut short by most unfortunate illness.