The hype over genetic tests

Implementation of a companion diagnostic in the clinical laboratory:The BRAF example in melanoma

Analytical validity is one of the three steps for any assessment of genetic tests, combined with clinical validity and clinical utility. Understanding how this process affects specific tests is not that easy.Fortunately you can find a detailed explanation of one of them:the BRAF genotype analysis in tumor tissue samples for identification of melanoma patients that can benefit treatment with BRAF inhibitors.
Once you begin to read the article you'll understand the complexity of being precise in a test. This is the reason why if specificity and sensibility is uncertain, different methodologies are needed (check Figure 1).
But how to do it?. How to set up external controls of quality?. All these issues are covered in this article, that explains what's going on in practical terms. I'm concerned if due to such complexity, all "genetic test talent" is not concentrated in one site of the organization-hospital, and many departments and services -oncology or cardiology- are developing their own genetic tests. Somebody should block this option before it is too late.

The size of the health budget

In 2015 the per capita expenditure (1,120€) will be the same as in 2006, nine years earlier (p.46). The economy follows exactly the same pattern. GDP per capita in 2014 was less than in 2006. Therefore, those that are concerned about stagnation and cutbacks, should look at statistics. The health budget is set according to political criteria, and what this amount reflects is exactly the same social effort to cover health risks as before the crisis.
Unfortunately I haven't seen this argument in any debate, up to now. It's really annoying that ideology overpowers evidence.

PS. James Buchanan blog in BMJ

PS. Robbed by the Kremlin in the WSJ.

Mandatory complementary private insurance

Compulsory private complementary health insurance offered by employers in France: Implications and current debate

It looks strange at a first glance. Why a country with statutory Social Health Insurance (SHI) has to set up a mandate to employers to buy private health insurance for their employees?. In France by 2016 all employers will have to do it, and this complementary insurance covers basically copayments in the SHI system. It is really strange, because copayments are created to reduce moral hazard, hence if somebody insures copayments, then its impact on utilization is the same as if it were no copayments in the SHI but with a high and avoidable loading fee. And, as far as this insurance is mandatory and private, then it makes no sense at all.
Each country decides politically according to the context, nothing to add, though this is a very weird case. You'll find more details in this article.

Is this the end my friend? (2)

Once upon a time there was a country with seven Schools of Medicine for 7,5m inhabitants. The needs for future physicians were estimated 8 years ago and the time goes by but somebody seems he is not aware of that. Some months ago I said that the organization of health care system as we have known it, was at their final days, now I can confirm that medical profession structure is also in the same situation.
A big and unnoticed change has occurred. In 2006, only 1,8% of resident physicians were foreigners, in 2013 this figure has jumped to 32,3% (!). Does this makes any sense?.
How is it possible that our citizens can't study medicine and we are able to open the system to foreigners without the right level of qualifications?. Who is boosting this?. I explained it in this post some years ago, here and there.
The time to disconnect is coming. Enough is enough!

The Dunning Funnel criteria for the health basket

The basic benefit package: Composition and exceptions to the rules. A case study

In the Netherlands there are four criteria to assess any benefit to be included in the health basket:

1. Care should be essential: Does the illness, disability or the care needed justify a claim on solidarity within the existing cultural context?
2. Effectiveness: Does the intervention do what it is expected to do? In other words: it is proven to be effective and evidence based.
3. Cost-effectiveness: Is the ratio between the cost of the intervention and the outcome
acceptable?
4. Feasibility: Is it feasible to include the intervention in the basic package, now and in the future?

This is known as the funnel originated by a commission report chaired by Mr. Dunning in 1991. The application of such criteria has been evolving and a recent article says that some benefits have followed a yo-yo effect, being in and out of the package for unspecified reasons. I think that it is better to have some clear principles and justify its application, than not having any.
Here we have some principles, sometimes we change them, sometimes we assess them, sometimes not and nobody knows why.

PS. The Irish  have made a recent effort of definition in this report.

The challenge of setting fair priorities

Public views on principles for health care priority setting: Findings of a European cross-country study using Q methodology

The clash between equity and efficiency is featured nowadays with hepatitis C drugs. High prices mean that access requires some kind of prioritisation. An interesting article may help to understand it:

 Resources available to the health care sector are finite and typically insufficient to fulfil all the demands for health care in the population. Decisions must be made about which treatments to provide. Relatively little is known about the views of the general public regarding the principles that should guide such decisions

The tension between equity and efficiency in the health care sector is apparent in a range of routine decisions and practices. For instance, in the prioritisation of patients on a waiting list, the aim to maximise overall health benefits from treatment may be at conflict with that of obtaining an equitable distribution of health and health care.

 Now ask yourself about the following principles to allocate health resources:

(I) “Egalitarianism, entitlement and equality of access”;

II) “Severity and the magnitude of health gains”;

(III) “Fair innings, young people and maximising health benefits”; 

(IV) “The intrinsic value of life and healthy living”; 

(V) “Quality of life is more important than simply staying alive”.

 Are you able to set a ranking? Does a general ranking of priorities always apply to all cases?. Not so easy. This is exactly what they do in the article and the results are:

Given the plurality of views on the principles for health care priority setting, no single equity principle can be used to underpin health care priority setting. Hence, the process of decision making becomes more important, in which, arguably, these multiple perspectives in society should be somehow reflected.

Let's think about the somehow...

PS. Sofosbuvir vs. NICE . And the winner is?

The satisfaction paradox and the need for a dose of realism

A paradox is a "situation that is made up of two opposite things and that seems impossible but is actually true or possible". This is exactly what is happening to satisfaction with health services in times of economic recession. Everybody would think that less budget damages satisfaction perception. What's going on is exactly the opposite. Satisfaction with health services is increasing (from 79% of people satisfied with the public system in 2006 to 88% in 2013). And this is also happening in the UK, John Appleby et al. from King's Fund say:

Overall public satisfaction with the NHS increased to 65 per cent in 2014 – the second highest level since the British Social Attitudes survey began in 1983. Dissatisfaction with the service fell to an all-time low of 15 per cent.

One interpretation of the increase in overall satisfaction for the NHS is that it is likely to reflect a vote of support for the NHS as an institution in difficult times. A lack of objective improvement in NHS services and the fact that improvements in satisfaction appear to have been driven by an 11 percentage point increase in satisfaction among Labour supporters and those without recent contact with the service, may lend weight to this analysis. This may especially be the case given that some see the NHS as currently under threat, for example from privatisation, and some feel ministers and others have been too critical of the NHS and its staff.

Official measures of performance tell a different story: NHS funding has been under increasing pressure since 2010 and there have been well-publicised performance problems with high-profile targets such as the 4-hour A&E waiting time standard and the 18-week maximum wait from referral to treatment. At the same time, the media has featured negative stories about the financial position of NHS hospitals and the need for additional investment in the service.

This context suggests a possible alternative explanation for the increase in satisfaction in 2014. We know that what drives changes in satisfaction is not straightforward – and almost certainly is never simply satisfaction with the NHS per se, for all respondents to the survey. Political beliefs, attitudes towards the government of the day, media stories and expectations of the NHS will shape people’s satisfaction.

So, while satisfaction improved in 2014, this is not necessarily synonymous with an improvement in the actual performance of the NHS, nor does it simply reflect an actual improvement in satisfaction. Nevertheless, it is clear that public satisfaction with the NHS and support for it as an institution remains high.

I suggest you have a look at the report. Satisfaction is a different dimension from performance, good point. If overall performance is based on healthy life expectancy, then the conclusion for us would be the same. We have increased healthy life expectancy all these years.

Those that complain about austerity want to forget such results. Also journalists. They don't figure out that the issue is a balanced budget and cutbacks have not been applied on an ideological foundation as some pretend. Anybody can blame over budget cuts, but immediately they would have to understand what they would do at home if their income is 7 years less than  before (2013 GDP per capita is less than those in 2006!!!). For sure they would return to an expenditure level simliar to previously,  in one way or another. Can anyone defend that these are ideological budget cuts at home?.
You can't live permanently in increasing debt, I'm satiated of cheap populism. A dose of realism is required.

PS. As you may notice, realism begins after reading the data, but you have to read them.

Stratified medicine in Europe

Stratified medicine in European Medicines Agency licensing: a systematic review of predictive biomarkers

The potential of predictive biomarkers for the development of stratified medicine has been highlighted for more than a decade. The current situation is very concrete. In Europe, EMA has accepted 49 biomarker-indication-drug combinations over 16 years, mostly used in cancer and as a predictive of drug efficacy, and in a minor scale of drug toxicity (4 cases).
These data confirm that currently the new wave of "personalised" or stratified medicine is really minor, although the investments and return expectations are huge.

Given the large body of literature documenting research into potential predictive biomarkers and extensive investment into stratified medicine, we identified relatively few predictive biomarkers included in licensing. These were also limited to a small number of clinical areas.

 Just released

Healthy behavior strategies

Healthy Behavior Change in Practical Settings

This is the article to read today. If you don't have enough time, have a look at this figure and ask yourself if you can apply it.

PS. Afterwards you may fill the questionnaire (Article 4) to check your understanding.

Psychological wellbeing and health

Subjective wellbeing, health, and ageing

What is the relationship between wellbeing and age?. This is precisely what this article tries to disentangle considering three types of subjective wellbeing:

• Evaluative wellbeing: evaluations of how satisfied people are with their lives
• Hedonic wellbeing: feelings or moods such as happiness,sadness and anger
• Eudemonic wellbeing: judgments about the meaning and purpose of life

Is it possible that positive subjective wellbeing is a protective factor for health?
Their conclusion:

Research into subjective wellbeing and health at older ages is at an early stage. Nevertheless, the wellbeing of elderly people is important, and evidence suggests that positive hedonic states, life evaluation, and eudemonic wellbeing are relevant to health and quality of life as people age. Health-care systems should be concerned not only with illness and disability, but also with supporting methods to improve positive psychological states.

Do you have any clue of how to do it?

Deciding by default

Choosing Not to Choose. Understanding the Value of Choice

The core of the application of behavioural economics to decision making on health lies in my opinion in choice architecture. I explained that 2 years ago in this post. Now Cass Sunstein is providing us with a new book that shows the details and rules for "choosing no to choose", a must read.

The choice among impersonal default rules, active choosing, and personalized default rules cannot be made in the abstract.To know which is best, both choosers and choice architects need to investigate two factors: the costs of decisions and the costs of errors (understood as the number and magnitude of mistakes). An understanding of those kinds of costs does not tell us everything that we need to know, but it does help to orient the proper analysis of a wide range of problems.
It should be obvious that a default rule can much reduce the costs of decisions. When such a rule is in place, people do not need to focus on what to do; they can simply follow the default. But a default rule can also increase the costs of errors, at least if it does not fit people’s situations; it can lead them in directions that make their lives go worse.

In approaching the underlying issues, he shows five propositions. I'm right now in the middle of the book. I can't have a final opinion, however I'm sure that this will be a key reference for the future.

Knowing what works

A systematic review of barriers to and facilitators of the use of evidence by policymakers

Evidence-based health policy should be grounded on knowledge on what works. Too often we see that policy-maker decisions' are far from that. Understanding why, is the first step to fixing it. In this article you'll find a systematic review on this topic:

The most frequently reported barriers were the lack of availability to research, lack of relevant research, having no time or opportunity to use research evidence, policymakers' and other users not being skilled in research methods, and costs . The most frequently reported facilitators also included access to and improved dissemination of research, and existence of and access to relevant research. Collaboration and relationships between policymakers and research staff were all reported as important factors.

Incentives, a modern frame (2)

Ética de los incentivos a profesionales sanitarios

Revisitng this report released 5 years ago, and comparing some statements with a former post, I can find relevant differences. Though this one is applied and the former is more general, the perspective is focused on having clear answers to specific problems. The definition, appropriateness and foundations of the argument requires deeper elaboration, in my opinion. That's why I suggest you should read the book.

Incentives, a modern frame

Strings Attached: Untangling the Ethics of Incentives

I've found extremely appealing the chapter 2 of the book "Strings Attached", it helps to understand the etimology of incentives as a word in the english language and its meaning:

For more than 250 years, starting in about 1600, the word “incentive” meant “inciting or arousing to feeling or action, provocative, exciting.” Uses cited by the authoritative Oxford English Dictionary include: “The Lord Shaftesbury . . . made an incentive speech in the House of Lords (1734),” or “This Paper is principally designed as an incentive to the Love of our Country (1713).” The last example cited of the term in this sense is dated 1866 and, like the others, it comes from an English source. Then there is a striking change. “Mr. Charles E. Wilson . . . is urging war industries to adopt ‘incentive pay’—that is, to pay workers more if they produce more.” This is the first example from the same dictionary of the use of the term in its contemporary sense, and it is an American example dated three quarters of a century later in 1943.

There is a huge gap in time, place, and meaning between the two sorts of citations, a gap that introduces several puzzles. What was happening in America when the new meaning of incentives was introduced? Why is this conception missing from the vocabulary in the seventeenth and eighteenth centuries, the very years in which the idea of a market economy was being discovered and articulated? We are accustomed to believe that our thinking about political economy rests on the work of the likes of John Locke, Bernard Mandeville, Adam Smith, David Hume, Jeremy Bentham, James Mill, John Stuart Mill, and the authors of The Federalist Papers. But with very few exceptions, “incentive” does not appear in any of their writings.

Beyond chapter 2, the whole book deserves to be read.

Data, data, data

That's the buzzword: big data. You'll find it in the top articles of 2014 in Health Affairs or in the Forbes Health Care Summit. This summit is where to go if you want to know what's going on in health care in the US, otherwise you cuold have a look at the video. Wether this is really going to create more value widely still remains to be seen.

The politics of calories

Why Calories Count

Marion Nestle says in her book:

In some ways, the calorie environment could not have been more brilliantly constructed to overcome physiological controls of overeating.

The new labeling initiatives have been really minor up to now. Wether they will have beneficial effects in the long run is still unknown. Calorie labeling should be extended when eating outside home and to alcohol.
The government has not paid enough attention to food regulation and specially to information about calories. In the book there is a guide for improvement. This is the previous step in any nudging effort. To be clear, information disclosure is the very beginning of any consumer protection and health promotion policy in this field.

The pivotal role of MSF in global health

Life in Crisis: The Ethical Journey of Doctors Without Borders
MSF: how a humanitarian charity found itself leading the world’s response to Ebola

I've just finished reading a book on MSF, a compelling story of more than 4 decades of support in health and humanitarian crisis.

Life in Crisis tells the story of Doctors Without Borders/Médecins Sans Frontières (MSF) and its effort to save lives on a global scale. Begun in 1971 as a French alternative to the Red Cross, MSF has grown into an international institution with a reputation for outspoken protest as well as technical efficiency. It has also expanded beyond emergency response, providing for a wider range of endeavors, including AIDS care. Yet its seemingly simple ethical goal proves deeply complex in practice. MSF continually faces the problem of defining its own limits. Its minimalist form of care recalls the promise of state welfare, but without political resolution or a sense of well-being beyond health and survival. Lacking utopian certainty, the group struggles when the moral clarity of crisis fades. Nevertheless, it continues to take action and innovate. Its organizational history illustrates both the logic and the tensions of casting humanitarian medicine into a leading role in international affairs.

Their achievements are really impressive and nobody can imagine what could have happened this year with the Ebola outbreak without them. To understand their contribution I would like to recommend the article in BMJ:

 The charity had a team in Guinea when the outbreak began in March and has followed the virus as it has spread—building treatment centres in locations as disparate as the jungle and capital cities, deploying mobile units, providing technical support to governments, and training staff. Today MSF has more than 3400 staff on the ground (with one international staff member for every 10 local staff members) and says that it has cared for almost 4000 patients confirmed to have Ebola and many more suspected cases.

 We all have to appreciate their enormous work in such a difficult conditions and their example offers a good guide to understand that beyond governments, well organised nonprofit institutions play a critical role in supporting public health.

PS. I am quite concerned about the nurse's behaviour in the spanish ebola case. Yesterday she admitted that she hadn't told the physician about her exposure to an ebola case. This situation has strong ethical implications, does anybody care about it?

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

Thinking and deciding

World Development Report 2015: Mind, Society, and Behavior

Our decision making patterns are based on multiple foundations. The new WB report summarises them in three sources: automatic, social and mental models.  In chapter 8 you'll find applications to health. Some of them may be naive, while others potentially useful. There is a trial and error process in all this stuff because of cultural implications. If there is a particular area to focus on, it is on health communication for behavioural change. There is a lot to learn from behavioral economics:

Understanding that people think automatically, interpret the world based on implicit mental models, and think socially allows policy makers to make major strides in improving health outcomes. Individuals sometimes value information highly (for example,
when seeking curative care), but at other times providing information is not sufficient to get people to change behaviors that undermine health. Framing effects that make social expectations and social approval more salient can sometimes encourage individuals to seek preventive care and adhere to treatment when they otherwise would not, even though the individual benefits exceed the individual cost.

PS. My former posts on nudging

PS. Post by BIT.

PS. TE on poor behavior.

PS. Excellent "30minuts" documentary about the Snowden's massive information leak ever. (Only until Dec 28th)

Global health surveillance

Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Is there any health convergence across countries?. You'll find the answer using the Global Burden of Disease study in a recent Lancet article (a must read).

Part of the answer depends on how the goals are framed—for example, what does convergence mean? In the development literature on economic convergence, convergence has been framed in terms of poverty rates or in terms of income inequality measured by the Gini coefficient or other measures of inequality. Work on convergence in life expectancy has tended to focus on measures of absolute difference rather than relative difference. We found unequivocal divergence in mortality rates for women aged 25–39 years and older than 80 years and for men aged 20–44 years and 65 years and older, similar to previous estimates of divergence of life expectancy at birth since the 1980s. In these age groups, both the Gini coefficient and the mean absolute diff erence in death rates are rising. In all other age groups, except girls aged 10–14 years, relative inequality is increasing but the absolute gap is  narrowing.

For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries.

If longevity is mostly improving everywhere, now the key issue should be to analyse global convergence on quality of additional years of life. 

PS. Check p.3499 of the supplementary information. And p. 150 for changes in total Life Expectancy 1990-2013,  (5,6 y men, 3,9 y women). If you read my previous post, you'll find interesting differences about what is going on with healthy life years for women.

Rethinking the practice of medicine

Team-Based Care: Saving Time and Improving Efficiency

When two years ago Eric Topol published a book on "The creative destruction of Medicine", many people thought it was a provocation. He was just borrowing the term keyed by Joseph Shumpeter for the economy as a whole. However, his message in my opinion still falls short. He was focusing strictly on changes that rely on technological innovations and he forgot organizational innovation.
Now, have a look at this recent article at FPM 

Drs. Hopkins, Sinsky and Peter Anderson all state that most outpatient visits can be divided into four distinct stages: 1) gathering data, 2) the physical exam, 3) medical decision-making, and 4) patient education/ plan of care implementation. Rather than the physician being responsible for all four stages, they recommend that a clinical assistant (a registered nurse, licensed practical nurse, or highly skilled medical assistant) perform the more clerical stages, one and four, while the physician focuses primarily on stages two and three. The clinical assistant stays in the room with the patient during the entire visit, gathering the history and doing all the documentation. The physician joins them for stages two and three before moving on to the next exam room where a second clinical assistant has set the stage by performing stage one. This allows the physician to see more patients, thus covering the costs of additional clinical assistants.

This proposal requires coordination and a reallocation of resources, roles and tasks. In certain diseases such a model has already been implemented. Is anybody able to extend it and amplify its impact on efficiency of the whole healthcare system?

PS. FT books of the year

PS. In UK some hospital mergers are prohibited. What a difference on the rule of law compared to ours!

Vertical equity in waiting lists

Three years ago I explained that it was good to know that prioritisation was going to start on the waiting lists. It was only the anouncement. Afterwards, it came the uncertainty after a phone call. On March 7th, 2013 the headline post of this blog was: Still waiting after all these months.
Many theoretical efforts have been devoted to improve vertical equity in waiting lists, now it's time to apply them. The moment of truth arrives when somebody has to apply objective criteria, and this raises concerns on the  status quo. This is precisely what it comes to my mind when reading this document. I can't find any reference to shared decision-making with patients, taking into account their interests and social preferences. It emphasizes the autonomy of the physicians for waiting lists management, but this is absolutely not enough.
Finally, the document says that budget cuts have to finish. Is this a political or a professional statement?. Everybody should know that budget cuts are related to our critical economic situation, with an unacceptable fiscal deficit. Why is there no reference to this constraint?. Is this a political or a professional option?

Overcoming political decay

Political Order and Political Decay: From the Industrial Revolution to the Globalization of Democracy

If I had to highlight two books of 2014 that will be considered classics in the near future, the first would be Piketty's on Capital in XXI century, and the second would be the Francis Fukuyama one: Political Order and Political Decay.
Both are worth reading. I've just finished the Fukuyama one, and covers one topic that appears in everyday headline news: corruption. In chapter 5 you'll find a wider explanation of patronage and clientelism and its impact on democracy.

Patronage is sometimes distinguished from clientelism by scale; patronage relationships are typically face-to-face ones and exist in all regimes wether authoritarian or democratic; whereas clientelism involves larger-scale exchanges of favors between patrons and clients, often requiring a hierarchy of intermediaries.

Clientelism is very different from a purer form of corruption where an official steals from the public treasury and sends the money to a Swiss bank account for the benefit of himself and his family alone. This type of corruption is sometimes labeled, following Weber,  prebendalism.

Fukuyama gave a speech to present his book last October at Harvard. Comments on his book appeared at FT, WSJ, The Guardian.or The Economist :

Political decay can take away the great advantages that political order has delivered: a stable, prosperous and harmonious society.

In my opinion, there are many signs of political decay. The question is wether we will be able to overcome such a situation in a disconnected state. Meanwhile, a better understanding in a historical perspective as the Fukuyama one, is highly recommended.

PS. Video of the Presentation at Harvard Institute of Politics

PS. Just released. OECD Foreign Bribery Report. An Analysis of the Crime of Bribery of Foreign Public Officials

Bribes are generally paid to win contracts from state-owned or controlled companies in advanced economies, rather than in the developing world, and most bribe payers and takers are from wealthy countries.

Bribes were promised, offered or given most frequently to employees of state-owned enterprises (27%), followed by customs officials (11%), health officials (7%) and defence officials (6%). Heads of state and ministers were bribed in 5% of cases but received 11% of total bribes.

PS. An example of how excess of transparency may inhibit some talented individuals to commit to public service as officials. We are creating strong barriers for a future high performing public service.

The successful recent trends in healthy life expectancy (3)

The Cost of an Additional Disability-Free Life Year for Older Americans: 1992–2005

We already know that the trend of healthy life expectancy is on the right track. If we all agree that under a universal coverage system, the aim should focus on being efficient and equitable at purchasing population health,  then a crucial question would be: how much does it cost an additional healthy life year?.
We do have such estimates for USA. A quite recent article says that the average discounted cost per additional disability-free life year is $71,000, assuming that half of the gains in healthy life expectancy were attributable to increases in spending.
Is this more or less than you would be willing to pay for it?. Recall how much we are spending per month of survival with cancer treatments. You can check it on p.254 of this article. As a society, currently we are paying from €562 (Erlotinib+Chemotherapy) up to €66,164 (Ipilimumab) for one month of additional survival and nobody cares about it. That's life!. Glups!

Where is value created in hospital mergers?

Hospitals, Market Share, and Consolidation

In the current wake of private hospital mergers, somebody should ask the right question. Where is value created?. If the goal is to reduce competition and create an environment close to a monopoly, than we can understand that market rivalry will decrease, prices will be higher, consumers will lose. In my opinion, the current mergers process shows signs of value destruction or value redistribution rather than value creation. Antitrust authority has been condescendent with the recent events and its resolution has forgotten the basics. Once you approve the merger, there is no way out, no easy reversal of a "quasi-monopoly" as it is the case of Barcelona private hospitals from today, that 64% of beds will belong to one firm.
Cutler and Morton published a JAMA article stating that something should be done to prevent such situations.

Antitrust authorities are examining these consolidated systems as they form, but broad conclusions are difficult to draw because typically the creation of a system will generate both benefit and harm and each set of facts will be different. Moreover, the remedies traditionally used (eg, blocking the transaction or requiring that the parties divest assets) by antitrust authorities in cases of net harm are limited. For this reason, local governments may want to introduce new policies that help ensure consumers gain protection in the event of consolidation, such as insurance products that charge consumers more for high-priced clinicians and health care centers, bundling payments to clinicians and health care organizations to eliminate the incentives of big institutions to simply provide more care, and establishing area-specific price or spending target

And their point is: local governments. Antitrust authorities are unable to understand the unique conditions of local competition. Unfortunately, local governments have no authority over such matters here. Meanwhile, the harm (to competition) has already been made.

PS. As far as the poor quality regulation is the norm in our current state, the only way out is to escape from this disordered world. To disconnect asap, there is no other option.

PS. If you want to know the answer to my today's question, have a look at this article: The Impact of Hospital Mergers on Treatment Intensity and Health Outcomes. You'll find strong reasons to be concerned:

The primary specification results indicate that mergers increase the use of bypass surgery and angioplasty by 3.7 percent and inpatient mortality by 1.7 percent above averages in the year 2000 for the average zip code. Isolating the competition mechanism mutes the treatment intensity result slightly, but more than doubles the merger exposure effect on inpatient mortality to an increase of 3.9 percent.The competition mechanism is associated with a sizeable increase in number of procedures.

PS. If Antitrust economics helps to support these processes, then somebody should rethink the theory and its application from scratch.

Cartier-Bresson. Rome Exhibition. Must see.

The successful recent trends in healthy life expectancy (2)

Health at a Glance: Europe 2014

A new european health report by OECD has been released. It includes key data and information regarding how health systems are performing and citizen's health. Some days ago I was highlighting the successful achievement in healthy life expectancy in our country (as a temporal trend). Now we can compare these data with other countries and we can see that we are at the top 10 of EU-28.
Data can raise many comments. If you want to know the big change in health expenditure, look at p. 121. In 2000-2009 european expenditure growth rate was 4.7%, in 2009-2012 is -0.6%. In our specific case is still less. Now is the moment to remember those that some years ago said that health expenditure would never collapse because there were some factors (technology and ageing,...) beyond the control of decision makers.
In summary, we can confirm that healthy life expectancy has increased and resources have shrunk. That's all folks (up to now).

PS. On cross-fertilization between health economics and management.

 

Norman Rockwell. Rome exhibition. Must see.

How much does it cost (a drug)?

Once again you can check the cost of developing a new drug ($2.6 billion in years 1995-2007), a jump in real terms of 145% from its former 2003 estimate $802m. These figures were widely criticised. And now as you may imagine this is again a huge nonsense. The Economist and Forbes joke about this numbers and my view is even more sceptical.
I'm still waiting for an estimate of new drugs costs adjusted by value. Unless somebody is able to provide such a figure, I will avoid analysing in detail any cost accounting exercise.

Risky lifestyle regulation, what's new?

Regulating Lifestyle Risks The EU, Alcohol, Tobacco and Unhealthy Diets

Since we all agree that lifestyles affect health, then more evidence is needed on what to do and how to do it. Fortunately, a new book summarises the state of the art on regulating lifestyles. Selected sentences from two selected chapters 14 and 15:
Nudging healthier lifestyles: Informing the non-communicable diseases agenda with behavioural insights
by Alberto Alemanno

In sum, most behavioural insights consist of ‘mechanisms rather than law-like generalizations’.66 For purposes of policy, it would therefore be valuable to have a better understanding of how the major findings of behavioural research apply within heterogeneous groups. Unfortunately, due to methodological and empirical complexity, current variety of behavioural studies.71 A number of different types of studies are possible, such as (a) experiments, (b) randomized controlled trials (RCTs) and (c) surveys. 

Using outcome regulation to contend with lifestyle risks in Europe Tobacco, unhealthy diets, and alcohol
by Stephen d. Sugarman

In conclusion, outcome regulation offers a new way to deal with lifestyle risks – risks that people now take but at a deep level want reduced. That is, mature peoplemostly do not want to smoke or get drunk or eat unhealthily. They have been enticed into doing so in substantial part because of marketing efforts by sellers of these products who have created social norms in support of their consumption. People also drink, smoke, and eat the wrong things because they provide short-termpleasure, even if they also bring with them long-term serious harms.

There are some debatable conclusions, however this book is a required reading for any health regulator.

PS, NYT article on mediterranean diet, original in BMJ..

The opportunity cost of delay in applying HTA

Some weeks ago I attended the meeting of the Spanish Health Techonology Assessment Association. The presentations and communications highlighted the current status on economic evaluation, and to be honest, an uncertain application and usefulness for public policy in our country. The reason?. There is a fear, a deep fear, that economic evaluation could guide some coverage decisions. Since this represents a reduction of discretionary powers, politicians prefer the status quo. Any change that represents an introduction of health technology assessment will reduce the degrees of freedom in their decisions. Is this fair for society? I would like somebody to calculate the opportunity cost for such a delay.

PS. I suggest you have a look at Sculpher, Peiró and Culyer presentations. My presentation was about stratified medicine, and J. Pons about the state of the art in HTA.

PS. Tomorrow, Conference at Fundació Grifols: Personal and collective determinants of health ailments, Whose responsibility is it?. Determinantes personales y colectivos de los problemas de salud, ¿de quién es la responsabilidad? I'll give a speech in the first session.

The successful recent trends in healthy life expectancy

Esperança de vida, lliure de discapacitat i en bona salut a Catalunya

If there is one measure to monitor continously in welfare policy, this is the case for healthy life expectancy. If somebody wants to track wether citizens, clinicians, health managers, politicians, firms, etc... are contributing to better life in the health arena, then this is the aggregate measure. If somebody were able to establish the right incentives for achieving the best benchmark, this would be great. Kindig suggested long time ago that "purchasing population health" should be valued according to healthy life expectancy.
Fortunately, new data about recent trends has been published and we can confirm that has increased over a period of 7 years, between 2005 and 2012 from 63 to 65.7 years for men and from 60.6 years  to 66.1 for women . In women the proportion of years lived in good health has gone up by 5 percentage points, from 72 to 77 % in men and has increased only one point from 81 to 82 %. In any case, in marginal and in absolute terms there is a substantial improvement . Nobody would have been able to foresee changes of this magnitude.
Some months ago I showed in this blog an alternative measure, the morbidity-adjusted life expectancy.  An alternative construct that allows easier geographic and temporal comparisons.
We are on the right track, contrary to those that thought with the crisis and cutbacks things would worsen. As you know and I have explained many times, there are lot of areas for improvement and we have not to reduce our effort to mantain this successful trend.

PS. My congratulations to the authors of the report. Excellent and helpful work.

Manufacturing disease

Lethal But Legal: Corporations, Consumption, and Protecting Public Health

The quest for better regulation is an open-ended learning process. In democracy, governments maximize impact during their political term and better regulation deserves a longer term commitment. The costs and benefits of inaction for society are larger than for politicians. A recent new book explains that public health regulation and specifically on food policy, needs a complete overhaul. I've said this many times, in the book you'll find the details to take into account.
The author, Nicholas Freudenberg, DrPH, is Distinguished Professor of Public Health at the City University of New York School of Public Health and Hunter College and founder and director of Corporations and Health Watch, an international network of activists and researchers that monitors the business practices of the alcohol, automobile, firearms, food and beverage, pharmaceutical, and tobacco industries.I strongly suggest a quick look at their site, you'll find many interesting information, like the one related to Berkeley and soda-tax.

The fifth wave in population health

For debate: a new wave in public health improvement

Required reading.UK CMO et al. in The Lancet say:

A fifth wave of public health development is needed, and needed now, as a consequence of shifts in the burden of disease and persisting health inequalities, but also against the background of emergent features of modern society. In consideration of the previous waves, there has been a shift from the top-down approach involving structural changes (such as the public works of the 19th century), towards a positing of shared responsibility for health. This shift mirrors changing political ideology and increasing understanding of the contribution of individual behaviours and lifestyle choices to health outcomes.

PS. Health spending around the world in The Economist.
PS. Piketty under scrutiny, in WSJ.