Equity and QALYs, terra ignota

Incorporating equity in economic evaluations: a multi-attribute equity state approach

Ptolemy used the term terra ignota for regions that have not been mapped or documented. QALYs were born for maximizing health, without any distributive considerations. All the efforts to introduce equity in QALYs have failed up to now. The cartography of QALYs has a pending dimension.
Maybe this dimension is not possible to be defined under a technical perspective, its a societal and policy issue. And at this level decisions are difficult to take.
Anyway, after reading this article you may reach a similar conclusion than mine, or otherwise you can be optimistic about it. It's up to you.

PS. Today I'll give the kenote speech at Col.legi d'Economistes de Catalunya: "La producció eficient i equitativa de salut".

Ai Weiwei

DROPPING A HAN DYNASTY URN

Man and machine, sharing the decision making effort

Big Data and Machine Learning in Health Care

From JAMA article

It is perhaps more useful to imagine an algorithm as existing along a continuum between fully human-guided vs fully machine-guided data analysis. To understand the degree to which a predictive or diagnostic algorithm can said to be an instance of machine learning requires understanding how much of its structure or parameters were predetermined by humans. The trade-off between human specification of a predictive algorithm’s properties vs learning those properties from data is what is known as the machine learning spectrum

 Higher placement on the machine learning spectrum does not imply superiority, because different tasks require different levels of human involvement. While algorithms high on the spectrum are often very flexible and can learn many tasks, they are often uninterpretable and function mostly as “black boxes.” In contrast, algorithms lower on the spectrum often produce outputs that are easier for humans to understand and interpret.

The meta-informational challenge of molecular data

The future of DNA sequencing

Where does DNA sequencing goes from here?. Nowadays, this is an appropriate question to pose.  The answer appears in an article in an interesting article in Nature.

Now, geneticists would like to have DNA sequences for everyone on Earth, and from every cell in every tissue at every developmental stage (including epigenetic modifications), in health and in disease. They would also like to get comprehensive gene-expression patterns by sequencing the complementary DNA copies of messenger RNA molecules.

In a mere 40 years, the central goal of putting molecular data about cells to practical use has changed from an informational challenge to a meta-informational one. Take clinical applications of genome-sequence data. It may soon be possible to use DNA sequencing routinely to analyse body fluids obtained for any clinical purpose. But only a vast amount of well-organized data about the multi-year medical histories of millions of people will provide the meta-information needed to establish when to ignore such data and when to act on them.

The uncertain cost of clinical trials

How much do clinical trials cost?

A research on seven top pharmaceutical companies has provided fresh data about costs of clinical trials:

For the trials in the data set, the median cost of conducting a study from protocol approval to final clinical trial report was US$3.4 million for phase I trials involving patients, $8.6 million for phase II trials and $21.4 million for phase III trials.

If you compare these data with the total drug costs (2.6 billion), you may ask yourself how all these costs are estimated. Maybe all this information is wrong and useless.

PS. Waiting for the new book on Theranos scandal

Pharma sales 2017

Kupka au Grand Palais

Why is it so difficult to implement policies?

Governance and the Law

If you want to know an updated approach to policy reforms, then you have to read the World Development Report 2017
The main messages:

• Successful reforms are not just about “best practice.” To be effective, policies must guarantee credible commitment, support coordination, and promote cooperation.
• Power asymmetries can undermine policy effectiveness. The unequal distribution of power in the policy arena can lead to exclusion, capture, and clientelism.
• Change is possible. Elites, citizens, and international actors can promote change by shifting incentives, reshaping preferences and beliefs, and enhancing the contestability of the decision making process.
• Three guiding principles for rethinking governance for development are:
• Think not only about the form of institutions, but also about their functions.
• Think not only about capacity building, but also about power asymmetries.
• Think not only about the rule of law, but also about the role of law

You'll understand that the key element of any reform goes beyond evidence on what works and consensus. It should be clearly designed following specific steps. I suggest you have a look at it.

El gran Guillem Roma amb Alessio Arena

Integrating genome and epigenome studies

The Key Role of Epigenetics in Human Disease Prevention and Mitigation

I've said it many times: beware of snake-oil sellers. Nowadays you may find it everywhere, specially on internet. You may get a genetic test for a disease that creates a false illusion of safety, or another that provides an unnecessary and avoidable concern. Only evidence based prescribed tests can be considered appropriate.
Therefore, if you want to confirm that genome is not enough, you have to check the review at NEJM on epigenetics. At the end of the article you'll find the explanation on why we do need integrated genome and epigenome association studies. You'll understand that cancer is fundamentally an epigenetic disease.
The current knowledge is changing quickly some conventional truths and "known unknowns" that we've had for years. This is good news for citizens, and bad news for snake-oil sellers if detected. Governments should help citizens on this screening effort, and protect citizens from fake medical information.

Practice makes perfect (2)

The Volume–Outcome Relationship Revisited: Practice Indeed Makes Perfect

Why is it so difficult to accept it? There is wide "evidence for the practice-makes-perfect hypothesis by showing that volume is a driving factor for quality". Unfortunately, the opportunities for the health system are still larger than it should be. There is a resistance in organizations, there is inertia, and all these drivers play a role. In planned health systems, there is no reason to be strict on it.
Just for those that are dubious, I would suggest a look at this article and to my former post.

Parov Stelar

The smart money in tech would not have made this mistake

It's about Theranos. You may find my previous posts in this link. Now SEC has confirmed that was a "massive fraud". That's it. If you want a good analysis check FT.
Microfluidics is not an easy prêt-à-porter technology. Many people knew it but Mrs Holmes has been selling it as snake-oil. And as usual in these cases, the end of the film is already written. She can't go to the lab for the next 10 years, a fine, and the company may be closed. All started with and article by Mathew Herper in WSJ. An innocent article with an innocent question that she couldn't answer. That's all. Silicon valley smart money would not have made this mistake.

Modigliani exhibition in Tate Gallery now

The miracle of bread and fish

According to the Gospels, a large crowd had gathered and was following Jesus. Jesus called his disciples to him and said:

"I have compassion for these people; they have already been with me three days and have nothing to eat. I do not want to send them away hungry, or they may collapse on the way."

His disciples answered:

"Where could we get enough bread in this remote place to feed such a crowd?"
"How many loaves do you have?" Jesus asked.
"Seven," they replied, "and a few small fish."
"Jesus told the crowd to sit down on the ground. Then he took the seven loaves and the fish, and when he had given thanks, he broke them and gave them to the disciples, and they in turn to the people. They all ate and were satisfied. Afterward the disciples picked up seven basketfuls of broken pieces that were left over. The number of those who ate was four thousand men, besides women and children. After Jesus had sent the crowd away, he got into the boat and went to the vicinity of Magadan (or Magdala)."

Now let's imagine one country and his health expenditure in 2007 and 2017, let's think about a figure, let's say 1,186€. This was the per capita expenditure in 2017. What was the per capita expenditure one decade earlier? 1€ less!!! It was 1,185€. This is a miracle, if you take inflation into account the reduction of expenditure is huge. Technology and ageing were not the drivers of expenditure growth because there was no growth!
Between 2017 and 2016 the growth was 5.9% in public expenditure. In private health insurance  expenditure it was 5,4%. That's it.
If you have to think about health expenditure miracles, have a look at Catalonia, it's incredible.
And it is so incredible that today our government is in exile, or in prison, or bail pending trial. Today the spanish police has entered in our government palace and has arrested one high official.
This is the rogue state where the majority wants to leave, and unfortunately we are alone, prosecuted and it's not possible to decide the new president. Europe forgets the attack on civil liberties. Shame.

Now

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