Hàbits saludables i risc cardiovascular a Catalunya

El concepte de factor de risc ha comportat un canvi radical a la medicina i a les polítiques de salut pública. Al llibre "PUBLIC HEALTH AND THE RISK FACTOR A History of an Uneven Medical Revolution" de William G. Rothstein hi trobareu un relat apassionant. En especial al capítol 5, on explica com el concepte de factor de risc va arribar a la medicina fruit de l'aplicació de l'estadística a l'assegurança de vida. Frase destacada de l'introducció:

When the risk factor and its statistical methodology became accepted as a method of investigation in the health sciences about 1960, it provided a new basis for understanding the relationship between a disease and its causes: (1) multiple factors internal and external to the individual are involved in the etiology of every disease; (2) the inherent limitations of scientific methodology mean that all of the etiological factors can never be identified or measured precisely2 and; (3) statistical analyses can determine the degree to which a specific factor by itself or in conjunction with others can increase or decrease the probability of occurrence of the disease. This approach is in striking contrast to the nineteenth-century doctrine of specific etiology, under which diseases were investigated as though they resulted from particular identifiable external causes, such as bacterial pathogens.
A social and intellectual revolution of this magnitude requires a number of basic discoveries and applications. The thesis of this study is that five historical innovations were necessary to produce the public health concept of the risk factor: (1) the development and adoption of probability and statistics as methods of quantifying the risk of death and disease and the benefits of treatment and public health measures; (2) the recognition that healthy lifestyles are essential to improve the health of the population; (3) the use of educational campaigns by public health departments to encourage the public to adopt healthy lifestyles; (4) the acceptance of probabilistic and multifactorial models of disease etiology; and (5) a disease, in this case coronary heart disease, that was so serious and prevalent as to warrant educational programs designed to change the lifestyles of the entire population.

Ara acaba de fer-se públic l'estudi ENRICA que permet conèixer els factors de risc cardiovascular de la població catalana. Certament hi ha dades esperançadores com que la proporció de fumadors es troba al 28%, el resum és que en homes baixa i en dones s'estanca la disminució (30% homes a 25% dones). La Unió Europea es troba a 26% segons Health at a glance 2010. Ara bé anem passats de voltes amb la ingesta de greixos i el colesterol. Els valors mitjans es troben per sobre els recomanables. Un de cada dos ciutadans és hipercolesterolèmic (colesterol total>200) però no parlen de quin és el LDL de la població. I l'excés de pes afecta al 59% de la població, diuen. Però ho han mesurat amb l'índex de massa corporal i no mitjançant el perímetre abdominal.
En definitiva, un estudi de qualitat a tenir molt en compte i que ha de permetre establir estratègies més fermes de millora dels estils de vida que afavoreixin una millor salut.

Referència clau

A limited-sample benchmark approach to assess and improve the performance of risk equalization models

Quan algú es planteja compensar capitativament a una població ja sap que ha d'ajustar pel risc d'emmalaltir que tingui. El problema és quin és el cost legítim i aleshores la mitjana del cost poblacional es premia com a referència. Sabem que aquest opció és errònia i que penalitza els comportaments més eficients (efecte ratchett i regression to the mean amb el pas del temps). Al JHE podeu trobar l'article que proposa un esquema suggerent i aplicable per a resoldre un sistema de pagament capitatiu. Una referència clau a tenir en compte.
El resum:

A new method is proposed to assess and improve the performance of risk qualization models in competitive markets for individual health insurance, where compensation is intended for variation in observed expenditures due to so-called S(ubsidy)-type risk factors but not for variation due to other, so-called N(onsubsidy)- type risk factors. Given the availability of a rich subsample of individuals for which normative expenditures, YNORM, can be accurately determined, we make two contributions: (a) any risk equalization scheme applied to the entire population, YREF, should be evaluated through its performance in the subsample, by comparing YREF with YNORM (not by comparing YREF with observed expenditures, Y, in the entire population, as commonly done); (b) conventional risk equalization schemes can be improved by the subsample regression of YNORM, rather than Y, on the risk adjusters that are observable in the entire population. This new method is illustrated by an application to the 2004 Dutch risk equalization model

PS. Aquesta altra referència sobre el mateix tema al JHE no m'ha convençut "Capping risk adjustment?" i aquesta no gaire "Risk adjustment in health insurance and its long-term effectiveness". Ho rellegiré a veure si li sé trobar el què.
Trobareu alguns altres papers a Risk Adjustment Network