Allocating expenditures to diseases

Guidelines for Measuring Disease Episodes: An Analysis of the Effects on the Components of Expenditure Growth

One of the most interesting reports by OECD was produced 15 years ago. The title was "A Disease-based Comparison of Health Systems What is Best and at what Cost?". The approach was clear, in order to compare health systems we do need to focus on specific diseases and its costs and outcomes.
Now you can read in Health Services Research an interesting article that shows what and how you should do to measure episodes. The comparison between person based and episode based approach is useful and it depends on the goals of research. For insurers and health population managers: episode-based. For officials and statistical offices: person-based
All the stuff on decomposition of health expenditures should be readjusted after reading this article. A hard work forward.

PS. OECD made an update on 2013. Good news.

The rethorical work of modern medicine

Bodies in Flux; Scientific Methods for Negotiating Medical Uncertainty

Evidence and persuasion play a crucial role in everyday task of any physician. That is, knowing the evidence of what works, and persuading that the treatment will succeed in a specific disease.

But how are evidential worlds assembled from bodies in perpetual flux? From where does medicine’s evidential weight hail? What protocols and procedures elevate everyday
biological activities to positions of argumentative authority?

 Defining and diagnosing disease is a kind of quixotic empiricism. It requires taking what’s known now and making best guesses about what’s to come. Yet, as physicist and philosopher David Bohm (1981) argues, “all is flux”

 After nearly a decade of studying evidential construction in the biomedical backstage, I have identified four specific methods with which medical professionals attune to corporeal flux in cancer care: evidential visualization, assessment, synthesis, and computation.

These are the approaches that a new book highlights in detail. In chapter 6 I suggest you read the section "Medical care as phronesis",

Phronesis is one of “the five expressions of care discussed in Book VI of the Ethics” and is a “mode that deals with the contingent and the possible”. Typically, phronesis (defined by Aristotle in the Nicomachean Ethics as “prudence”) is set counter to another rhetorical construct, metis.

A book highly recommended for those that want a fresh perspective on evidence based medicine and rethorics.

Medicine trends

The future of medicine

A new supplement in Nature explains the main trends in Medicine. It is really helpful to have a quick look focused on those approaches that are the more promising for the next future. From the issue, I would pick one article: A CRISPR edit for heart disease, A one-off injection to reduce the risk of cardiovascular disease is now a prospect thanks to advances in gene editing.This is amazing, it changes current perspectives on the first cause of death worldwide (18 million people per year).

 In 2014, Musunuru and his team showed that more than half of Pcsk9 genes in the mouse liver could be silenced with a single injection of an adenovirus containing a CRISPR–Cas9 system directed against Pcsk9. This led to a roughly 90% decrease in the level of Pcsk9 in the blood and a 35–40% fall in blood LDL cholesterol⁴. Next, they used a mouse engineered to contain human liver cells, and tuned the CRISPR–Cas9 payload to target human PCSK9⁵. The team succeeded in showing that the human gene can also be switched off.

This is changing the focus of drug research, and a recent article explains the new approach.  Let's see if finally delivers what they say.

Setting priorities explicitly (or not)

PRIORITISING HEALTH SERVICES OR MUDDLING THROUGH

A chapter of this book explains who does what in prioritisation (resource allocation and rationing).
I've found of interest this classification of rationing:

• Rationing by denial. Exclusion of specific services or treatments from the National Health System portfolio (often explicitly) or from one healthcare provider (near always implicitly) that believes that such treatment or service is inappropriate.
• Rationing by selection. Exclusion of some patients of some treatments because they do not meet certain eligibility criteria fixed by the regulator (often explicitly) or the provider (near always implicitly). 
• Rationing by delay. The demand that cannot be met by a rigid offer remains on hold (waiting list) and the wait acts as a barrier to access and, in many cases, as a de facto denial of care. 
• Rationing by deterrence. Barriers placed, either consciously or unconsciously, by the healthcare providers that make it difficult for patients to find out about, and book appointments with, some healthcare services. 
• Rationing by deflection. Patients being shunted off to another institution, agency or programme. 
• Rationing by dilution. Services continue being offered to patients, but with fewer resources, and the quality of care gets worse

 And the summary:

In conclusion, adequate priority setting is not about choosing either to muddle through implicit rationing or to be corseted by an exhaustive, rigid and explicit interventionist structure at the macro, meso and micro decision-making levels. This dichotomy fails to capture the complexity of priority setting in practice. We need more and better explicit priority setting, not to substitute but to improve implicit priority setting.

 

 Weegee by Weegee

In vitro, veritas

El Diagnóstico In Vitro Hoy. Un cambio de paradigma en la calidad de vida y en el proceso de atención a los pacientes

A new report highlights the role of clinical laboratory in medical decision making. Though its increasing complexity, it requires larger recognition in terms of the value that creates. Some selected statements:

Desde el punto de vista de los costes, el IVD es económicamente muy accesible, tanto por su competitividad en costes de producción como por no necesitar de grandes inversiones iniciales en equipamiento: – El IVD consume una proporción de recursos de los hospitales muy baja, inferior en todos los estudios al 4% del coste hospitalario y supone en promedio un 0,8% del total del gasto sanitario4. – La mayoría de equipamientos se ceden mediante la contratación de los reactivos, lo que elimina la barrera de inversión inicial para su adquisición 

El Diagnóstico In Vitro es sin duda el proceso diagnóstico más utilizado con carácter habitual. A diferencia de otros grandes equipamientos diagnósticos que se utilizan muy selectivamente, el IVD se utiliza masivamente para la gran mayoría de pacientes y en la mayoría de los actos asistenciales.

Paradójicamente, y a diferencia de otros equipamientos, el IVD es cada vez más complejo tecnológicamente, pero también más simple en su utilización. La innovadora y alta tecnología incorporada internamente contrasta con la apariencia de simplicidad. – Si se compara con otros equipamientos médicos de alta tecnología, como los de diagnóstico por la imagen o de cirugía robótica, los equipamientos de IVD, cada vez más pequeños, automatizados y fáciles de utilizar, tienen una visibilidad más bien escasa.

I suggest a close look.

 Yesterday Impressionist Art Auction at Christie's

Resource allocation principles and process

Public Preferences About Fairness and the Ethics of Allocating Scarce Medical Interventions

Fair allocation of health care resources is a challenge that we can't solve strictly with some criteria or principles. Of course, we do need some benchmark but we require a fair and transparent process. This is precisely the focus of a chapter by Govind Persad in a recent book. The key issue is how in fact resources should be allocated.

Society is ultimately interested not only in empirical surveys of how its members believe medical interventions should be allocated, but also in answers to the normative question of how medical resources should be allocated.

Survey methods, experts opinion,...

Even though public attitudes do not directly determine the solution to moral problems, empirical research into public attitudes can be useful in a variety of  ways. By showing which beliefs are popular among the public, or which beliefs are points of division, empirical research can help to focus moral inquiry on those claims or beliefs, thereby ensuring that philosophical reasoning is relevant to real-world problems. Furthermore, even though popularity does not constitute correctness, the unpopularity of a normative position can justify placing it under scrutiny.

Pharma R&D failure and success

Clinical Development Success Rates 2006-2015

In the russian rulette as a lethal game of chance you may have 1/6 chance of being shot. If the chamber of the revolver holds 6, a 16,6%.
In drug industry the probability of R&D failure is 90.4%. We all know that in the drug cost we are paying also for failures, but we forget the figure.

These are the key takeaways of the report:

• The overall likelihood of approval (LOA) from Phase I for all developmental candidates was 9.6%, and 11.9% for all indications outside of Oncology.
• Rare disease programs and programs that utilized selection biomarkers had higher success rates at each phase of development vs. the overall dataset.
• Chronic diseases with high populations had lower LOA from Phase I vs. the overall dataset.
• Of the 14 major disease areas, Hematology had the highest LOA from Phase I (26.1%) and Oncology had the lowest (5.1%).Sub-indication analysis within Oncology revealed hematological cancers had 2x higher LOA from Phase I than solid tumors.
• Oncology drugs had a 2x higher rate of first cycle approval than Psychiatric drugs, which had the lowest percent of first-cycle review approvals. Oncology drugs were also approved the fastest of all 14 disease areas.
• Phase II clinical programs continue to experience the lowest success rate of the four development phases, with only 30.7% of developmental candidates advancing to Phase III.

PS. The growth in R&D expenses was 14% in 2016, while revenues grew 4% (p.36).

Public funding of succesful Pharma R&D

Contribution of NIH funding to new drug approvals 2010–2016

If we consider the 210 new molecular entities (NMEs) approved by the Food and Drug Administration from 2010–2016, then you'll find that NIH funding contributed to published research associated with every one. A PNAS article explains that:

Collectively, this research involved 200,000 years of grant funding totaling more than $100 billion. The analysis shows that 90% of this funding represents basic research related to the biological targets for drug action rather than the drugs themselves. The role of NIH funding thus complements industry research and development, which focuses predominantly on applied research. This work underscores the breath and significance
of public investment in the development of new therapeutics and the risk that reduced research funding would slow the pipeline for treating morbid disease.

This public funding is forgotten in the costs of a new molecule. Although in the price, the manufacturer surplus doesn't remunerate such contribution. Some adjustment should be applied, to be fair.

 Brassai at Mapfre Foundation in Barcelona

Digital medicine, or just medicine

Digital medicine, on its way to being just plain medicine

You may remember at the begining of this century. Everybody was talking about e-business and right now nobody talks about it, because it is just business.The same will happen with digital medicine, it ill be just medicine in the next future. A future that is closer than you may think. And this is what E. topol explains in the editorial of the new open journal, and says_

And finally, quite paradoxically, we hope that npj Digital Medicine is so successful that in the coming years there will no longer be a need for this journal, or any journal specifically focused on digital medicine.

I agree. But meanwhile, somebody should review current syllabus and studies of medicine, to introduce a change in the profession and the scope of practice.

Spending a lot for many years: understanding persistence

Long-Term Health Spending Persistence among the Privately Insured in the US

If you don't want to read this article, check this presentation. It is one of the best efforts to understand persistence of health expenditures. Summarised findings:

First, persistence by demographic characteristics is generally lower than persistence by co-morbidities. Because co-morbidities are harder to assess, particularly for new enrollees, than demographics, this highlights the need for robust risk prediction models. 

Second, people with a co-morbid condition relative to those without the condition are considerably more likely to be in the top 10 per cent of spenders in year t regardless of whether they were in the top 10 per cent in year t–1. However, people with a co-morbid condition are even more likely to be in the top 10 per cent in year t if they were also in the top 10 per cent in year t–1.

Third, those most likely to be in and remain in the top 10 per cent are those with myocardial infarction, congestive heart failure and peptic ulcer disease and in several psychiatric diagnostic groupings, which indicates that these conditions might be appropriate targets for longer-term disease management programmes.

Fourth, although most conditions are less common at younger ages, when they do occur they are more predictive ofpersistently high spending at younger ages, as almost all conditions have the highest predicted probabilities on being in the top 10 per cent of spenders in the following year when they occur at ages under 25 and the lowest predicted probabilities when they occur in the 65-and-over population. Essentially, the presence of a condition at a younger age more clearly differentiates a person’s health care trajectory from that of their peers.

These are conclusions for US population, closer studies are needed.
PS. An article written 23 years ago, on concentration and an abstract 11 years ago.

How morbidity explains health expenditures in ageing

Ageing and healthcare expenditures: Exploring the role of individual health status

Everybody admits that ageing increases health expenditures. However the dynamics of this growth, and the factors that contribute it, are less known. In our recent article, we explain why morbidity is the main factor that explains growth of health expenditures in ageing. In our analysis, closeness to death is not the main cause.

Regardless of the specific group of healthcare services, HCE at the end of life depends mainly on the individual health status. Proximity to death, sex, and marginally age approximate individual morbidity when it is excluded from the model. The inclusion of morbidity generally improves the goodness of fit. These results provide implications for the analysis of ageing population and its impact on HCE that should be taken into account.

We do need further research on the cost and intensity of care in the last months of life, and this is our next challenge.

Diversity and differences in nature and society

Inequality in nature and society

If the title of an article is about "inequality", our brain starts thinking inmediately about equality, with some moral background. It's unavoidable. If the title is "diversity and differences", than we admit it as statement. I would suggest to have a look at this interesting article in PNAS that compares what happens in society and in nature, please forget any previous influence of values.

As a first illustration of the similarities of patterns in nature and society, consider the wealth distribution of the world’s richest individuals compared with the abundance distribution of the Amazon’s most common trees (Fig. 1 A and B). The patterns are almost indistinguishable from one another. For a more systematic comparison, we also analyzed the Gini indices of a wide range of natural communities and societies (Fig. 1 C and D). The Gini index is an indicator of inequality that ranges from 0 for entirely equal distributions to 1 for the most unequal situation. It is a more integrative indicator of inequality than the fraction that represents 50%, but the two are closely related in practice (SI Appendix, section 3). Surprisingly, Gini indices for our natural communities
are quite similar to the Gini indices for wealth distributions of 181 countries (data sources listed in SI Appendix, section 1).

This is only a statement that you can confirm.

 Our analysis suggests that even if all actors are equivalent, in the absence of counteracting forces, there is an intrinsic tendency for significant inequality to arise from multiplicative chance effects. Although the surprising similarity between inequality of species abundances and wealth may have the same roots on an abstract level, this does not imply that wealth inequality is “natural.” Indeed, in nature, the amount of resources held by individuals (e.g., territory size) is typically quite equal within a species.

Now the metaphor has been clarified. Differences in wealth does not imply that are "natural". Fortunately our country is less different now than before. We have moved from a Gini of 33 in 2013 to 31.4 in 2016, quite good. You'll not find this reflected in any newspaper -it seems that this statement does not sells issues-, though these are the official figures.

Estimating health expenditures

Modeling Health Care Expenditures and Use

The skewed distribuition of health expenditures with a large number of 0 observations poses difficulties. A recent article in Annual Review of Public Health explains the details and the right approach, in my opinion.

We compare estimation and interpretation of the effect of a change in insurance policy on health care expenditures using OLS and a two-part model. The two-part model is based on a statistical decomposition of the density of the outcome into a process that generates zeros and a process that generates positive values. A logit or probit model typically estimates the parameters that determine the threshold between zero and nonzero values of the outcome. In general, alternative specifications of the binary choice model (the first part) yield nearly identical results. However, the choice of model for the distribution of the outcome conditional on it being positive (the second part) is critically important. Different models can yield quite different results.We use a generalized
linear model to estimate the parameters that determine positive values. Generalized linear models accommodate skewness in natural ways, give the researcher considerable modeling flexibility, and fit health care expenditures extremely well.

The use of two parts models, and GLM is the standard approach to take into account. The book Health econometrics using Stata is the key reference.

On experts and priorities

Priorización de intervenciones sanitarias. Revisión de criterios, enfoques y rol de las agencias de evaluación

Often I hear that prioritisation of benefits could be solved by evaluation agencies and the appropriate application of cost-effectiveness analysis. As times goes by, I'm convinced that this is a way to avoid if we consider how priorities should be set. In other words, leaving this issue to a technical perspective is not enough. There is a need for a deliberative way to tackle the complexities of prioritisation.
Anyway, if you want to know a review that takes as given the experts view, check this article. If you want to understand the whole issue from a broader perspective, then read the book I quoted in this post some months ago.

 Carlos Diaz at Sala Parés