The growing evidence on compression of morbidity

Health, functioning, and disability in older adults—present status and future implications

There is currently a wide debate about chronic care and multimorbidity. Some messages appear that this is strictly connected with ageing, and forget the details. Though disease process have to be tackled, we have to ask ourselves about wellbeing in later life. A key issue is to understand its impact on functioning and disability. This is precisely what a recent article in The Lancet offers. The research question:

Will the years gained be productive and healthy, or will elderly people live longer lives in conditions of ill health? Three main hypotheses have been proposed to address this question.² The compression of morbidity hypothesis posits a situation for which the age of onset of morbidity is delayed to a greater extent than life expectancy rises, thereby compressing morbidity into a short period at a late age.³ The expansion of morbidity hypothesis maintains the opposite, that increases in life expectancy are matched or exceeded by added periods of morbidity.⁴ Both compression and expansion of morbidity could happen in absolute or relative terms—ie, changes in the absolute number of years lived with disability—or in terms of healthy life expectancy as a proportion of total life expectancy.

And a conclusion:

 Our systematic examination of the scientific literature shows that support for morbidity pattern hypotheses varies mainly according to the type of health indicator. Disability-related or impairment-related measures of morbidity tend to support the theory of compression of morbidity, whereas chronic disease morbidity tends to support the expansion of morbidity hypothesis.

This is an article to read and file for the future. The basic approach is defined, the difficulty is about the data. My impression is that we need to use morbidity adjusted life expectancy measures, as those I presented in this blog some months ago. The advantages are clear compared to healthy life expectancy that needs a lot of hypothesis and are based on surveys and self perceptions. Morbidity adjusted measures use  disease codes directly. Why not apply them widely?

PS. The whole series on ageing in The Lancet.

Fasten seat belts (3)

My former posts (1) and (2) alerted about the end of drug pricing as we have known and the begining of an opaque world where nobody knows how much money is involved in getting the value of a specific drug, except the manufacturer. The rationale for that are the confidential agreements between governments and drug firms. Up to now have been seven risk-sharing agreements, and beyond these, central government has set up additional five agreements. This latter agreements are really open-ended budgetary ceelings because it is difficult to estimate when the maximum amount is reached. This is precisely what it is explained by the official in charge of this issue in the journal.
Therefore we have changed the pricing system for an opaque open-ended budgetary ceeling system. It sounds incredible, but that's how it is. I can't believe that nobody worries about it.

PS. Genes and behaviour, on TE. I posted the initial research three years ago in this blog.

Health care under civil conflict

Current situation in Syria deserves a better understanding and international support. Beyond the refugee crisis there is a huge health tragedy:

More than 12 million people are impacted by the violence, with 7.6 million people displaced inside the country and more than 3 million displaced in neighboring nations. Some refugees live in formal camps, but the majority are living in Jordan, Lebanon and Turkey. Refugees have also fled to Egypt and Iraq, and many remain inside Syria but have had to leave their homes. Many have also been affected by the terrorist Islamic State group.

A difficult moment, and things may get worse. I would like to suggest a look at this documentary from PBS Frontline:  The Rise of ISIS in english and in catalan here until Jan 18th.

Involved in our own health

People in control of their own health and care

 From King's Fund report:

Different perspectives (p.11)

• A consumerist approach: health and health care is seen as a marketplace in which patients (consumers) are involved by making choices about services, and the health care market responds to their preferences. Patient involvement is then a means to improve quality.
• A democratic approach: people have political, social and economic rights as citizens, and those who use or are affected by a public service should be involved in how it is run, and have certain rights regarding what they receive from that service.
• An ethical and outcomes-based approach: involvement is seen as the ethical thing to do, and the best approach to improve outcomes. This means recognising that good care comprises the application to individual circumstances of evidence-based medicine along with knowledge and experience. Patient involvement is essential to the judgement of relative risk and benefit associated with decision-making.
• A value-based approach: to achieve truly the best value for money from our health and care system, we must know and respond to what people need and want. In this way, we can deliver care that meets their preferences and patients receive ‘the care they need (and no less), and the care they want (and no more)’ (Mulley et al 2012).
• An approach based on sustainability: it is increasingly difficult for health systems to provide the best possible care to everyone as the prevalence of long-term conditions increases and the population ages. By involving people in managing their own health and care, and keeping well and independent, we can minimise our use of services.
• A person-centred care approach: our health and care system should be  focused on its users, promoting independence and co-ordinated around people’s full needs rather than being fragmented and siloed. Patient involvement is an essential component of delivering a more person-centred service that is tailored and responsive to individual needs and values.

The forgotten perspective in the list, though quoted in the text (p.16):  A behavioural economics approach: we try to do our best for our health but the autopilot decides without our full control. Some help (nudging) is needed.

The message:  "Embarking on an honest conversation about rights and responsibilities requires consideration of people’s motivation and the capability to engage."

PS. Nudging and the European Union, by Alberto Alemano.

PS. BIT Publication: EAST.Four simple ways to apply behavioural insights

PS. Regarding Hepatitis C treatment costs, It is good to remember this post by U. Reinhardt:

With this offer curve, a health system confronts the rest of the nation with two morally challenging questions:

1. Is there a maximum price above which society no longer wishes to purchase added QALYs from its health system, even with the most cost-effective treatments (e.g., Point C)?

2. Should that maximum price be the same for everyone, or could there be differentials – for example, a lower maximum price for patients covered by taxpayer-financed health programs (e.g., Medicaid, Tricare, the Veterans Administration health system and perhaps Medicare), a wide range of higher prices for premium-financed commercial insurance, depending on the generosity of the benefit package that the premium covers, and yet higher prices for wealthy people able to pay out of their own resources very high prices to purchases added QALYs for the family?

Collapse and equilibrium in public-private health care provision

The Public–Private Pendulum — Patient Choice and Equity in Sweden 

Circle and the NHS: operation game

The introduction of competition and private provision in publicly funded systems is under unstable equilibrium. The case of Sweden is explained in detail at NEJM. The focus of the article is on primary care and pharmacy.
The collapse of the first privately operated hospital of NHS is described in the FT.
Four years ago I quoted in this post a McKinsey report about how to introduce choice in health care.  The UK failure reflects at least that the government and Circle forgot to read the McKinsey article, while Sweeden has done its homework.



FT Video: Circle and the NHS: operation game
Jan 9, 2015 : Circle, the first private company to take over the running of an NHS hospital, said it was negotiating to end its contract on Friday, two years after it began. Lex's Oliver Ralph and Joseph Cotterill discuss what went wrong.

This is the end, and now what do we do?

Last November I wrote a post asking myself if we had arrived at the end of the public health care system  as we have known it. Today I confirm that we have arrived at this point. I am not alone in this feeling, check this blog, and you'll find similar views. It is really sad to see how a society can lose its opportunities for the future, because neighbours are enacting laws that block any potential solution.Therefore, if we can't change the law there is no need to agree on resolutions in our "Parliament" against it. We can't agree against rule of law, therefore what we have to do is to disconnect as soon as possible and create our own regulations.

Forget current troubles, enjoy this video clip by Juan Luís Guerra - Tus besos

Individual decisions and behaviours: the key for a better health

Informe de salut 2013

After looking at this report on the health of catalans, I would select three issues of general concern: premature death, overweight and alcohol intake (p.29). On premature death, there are five leading causes (p.28): lung cancer, ischemic heart disease, suicide, traffic accidents and other heart diseases. Lung cancer is related to tobaco consumption and we all know that this is the leading preventable cause of disease, disability and death. Though taxation may impact, it relates to an individual decision and behaviour.
The second issue, overweight, needs to be addressed through public policy and depends partially on individual decision and behaviour, again. And the same applies to alcohol intake.
We already knew all that, therefore, what is the next step?

The risk society

One of the most important achievements of our society is how we have been able to manage certain risks in the last century. The mandatory pooling of health risks is in my opinion the most crucial one. Risk regulation on different hazards has protected population from many damages. Medicines regulation agencies would be a good example of that if they worked properly, and we all know it is not always the case. However, it is much better to have them than not, as happens with medical devices in Europe.
Last week, Ulrich Beck died. He is one of the most prominent sociologists of our times. His book, The Risk Society, is still a key reference after four decades. Anthony Giddens has written an excellent obituary that reflects his contributions. We all have to learn from Beck's clever perspectives and observations. In my opinion, up to now we have been able to improve the social management of risks, however there are many shadows that raise doubts about the future. Some people call them the end of the welfare state, while I would like to focus is on new ways of risk protection that are affordable, given the current (and critical) state of public finances.

Health and income 2013

Understanding the autopilot and nudging it

Nudging: A Very Short Guide


Today I would suggest you to spend one hour watching an excellent documentary about "The magic of unconscious", in catalan here until Jan 9th, and in english here.

Cass  Sunstein recently has published the short guide to nudging and those interested in any concrete application should look at these ten tools:

1. Defaults
2. Simplification
3. Social norms
4. Increases in convenience
5. Disclosure
6. Warnings
7. Precommitments
8. Reminders
9. Eliciting intentions
10. Informing people of the nature and consequences of their own past choices.

Wether they may work or not depends on the details and environment. The hardest task.

The price of life

A documentary about the rationing of high cost cancer drugs by the National Institute for Health and Clinical Excellence.

Do you really want to know about it?

Recreational genetics is entering into the consumer market. I have explained that governments should be active in restricting such practices because they are closely related with false advertising. Beyond that, governments should be aware also about the implications of creating anxiety in population. This documentary asks if patients should know about their genes, when there is no treatment.

La Noche Temática: '¿Realmente quieres saberlo?' -Avance

PS. Have a look at this one, about ethical dilemmas on genetic testing:

La Noche Temática: 'Descifrar nuestro código genético' -Avance

Le mécontentement des médecins liberaux

Les médecins libéraux français ont initié une grève jusqu'au 31 Décembre. Les raisons sont dans le projet de loi de santé qui disent l'"etatalisation" du système de santé. Ils demandent vraiment une augmentation de 8,6% des prix de visites de 23 à 25 € . Aujourd'hui, je ai lu l'éditorial de Le Monde:  

Le revenu annuel moyen brut d'un generaliste est de 76.600 euros et celui d'un spécialiste de 121.00 euros. Ces revenus restent inférieurs de 25% à 30% à ceux de leurs homologues européens.

Pas mal. Les médecins urgence de l'hôpital ont déclaré une autre grève, le ministre a admis de baisser de 20% le nombre d'heures travaillées par an (!). Cela on peut dire que est un parfait opportunisme, selon le dictionnaire.
L'agitation pour la nouvelle loi est servi. De même en France se plaignent d'un projet de loi de nationalisation inexistante, près d'ici il ya des gens qui parlent de privatisation lorsque toutes les entités sont sous le contrôle publique. La perversion du langage a atteint les limites de l'empoisonnement de l'environnement. 

Juan Luis Guerra - En el Cielo No Hay Hospital

Mental Health in the policy agenda

Mental Health for Sustainable Development

The need for action in mental health is increasingly recognised. Although relevant improvements have been introduced in developed countries, there is a common view that more should be done. Some diseases like depression are at the top of the burden of disease and bring enormous pain and suffering to individuals and their families and communities. An interesting recent report has been released on the topic. This is the infographic:

PS. UK Health Secretary. Keynote address: the political imperatives to address mental health and depression

European health regulator on holiday

After Canada, the first european country that has allowed recreational genetic testing is UK. Some weeks ago the Ethics Research Committee approved the commercialisation of 23andme test that provides 100 genetic reports. Wired says:

The £125 spit test kit is not a diagnostic test, but instead identifies genes that are associated with inherited conditions including cystic fibrosis, Alzheimer's disease, Parkinson's disease and sickle cell anaemia. It's not just health information that can be discovered within the results of the test though -- there is also the opportunity for customers to learn more about their inherited traits and genetic ancestry.

Why has the UK approved it and the FDA has restricted the same test in the US?.  Some months ago I explained that european legislation was outdated. Now the genetic testing firm has profited from bad regulation to enter into european market with CE mark. Does anybody know where the regulator is spending their holiday?

PS. While being  so easy to regulate recreational genetic testing under current false advertising rules, why is only the US doing that?. You should know that closer than you think similar tests are available for you. Where is the catalan health regulator?

PS. Why is the tax regulator not on vacation?

Emile Claire Barlow - Jardin d'Hiver