Our health and its determinants (2)

The Relative Contribution of Multiple Determinants to Health Outcomes

There are five major categories of health determinants: genetics, behavior, social circumstances, environmental and physical influences, and medical care. If this is so, do we know the relative importance of each factor?
Last February I posted in this blog a figure by Kindig that explains their contribution. Now a Health Affairs brief summarises different views. Check Exhibit 1, and you'll see there that behaviour represents 35-50% of health status according to different estimates.
The message is clear in our current evironment of mostly non-communicable diseases, we have to find better ways to change behaviour towards healthier people. Decisions and actions, short and long term, risk and responsibility, costs and benefits, trade-offs of every day life.

PS. Must read:  The Ethics of Ebola.

The first three doses of ZMapp were administered to the American medical missionaries Kent Brantly and Nancy Whitebol, who have recovered, and the Spanish priest Miguel Pajares, who has since died. Some offered a practical justification for the widely criticized selection of Brantly and Whitebol: It makes sense to treat health workers first, so that they can continue to help others. But this argument largely fell apart with the selection of the 75-year-old Pajares.

PS.  "Only four companies today make vaccines, compared to 26 companies 50 years ago.". My concerns about a future systemic drug industry are closer than expected (at least in vaccines).

Patient switching-behaviour

Enquesta de salut de Catalunya 2013

Consumer loyalty is a top goal for any maketeer, and the Nielsen Global Survey of Loyalty Sentiment says that to achieve it, offering the best price is the most persuasive tool to motivate consumers to swap devotion to a brand, service provider or retailer. If you enter into healthcare arena, service prices don't play the same role, mandatory insurance coverage is the standard (in developed countries), and voluntary insurance is the option (prices are relevant in this latter case).
What happens when one fourth of the population (~24%) buys voluntary insurance?. They have two options for healthcare access. The last health survey gives the answer (Table 3. p. 44): 57,9% of members go to private services, 29,5% use public services, 12,4% don't use any service. This is the switching behaviour pattern according to access and perceived quality of services, not price.

PS. I suggest a close look to the survey, many interesting things appear inside. Deeper analysis is needed using microdata.

PS. A former post on a related topic.

The impact of information and communication technologies

The number of primary care visits per capita in 2007 was 7,1, nowadays this figure has dropped to 5,9, a reduction of 17% in six years. That's a lot. In absolute terms you get the astonishing figure of 4,5 million visits less! In 2013 the total number of visits in primary care was 44,7 million.
I have taken 2007 as the year for comparison for one reason: there was no electronic drug prescription. I don't know all the reasons behind such huge decrease, however information technology has helped for sure. Righ now, 92% of all prescriptions are electronic. A wide assessment of such period is needed.
Such figures are only a partial evidence of the transformation through technology in one specific area - drug prescription-, now the next step is to go further in other fields: organization of work and communication between physician and the patient. These areas may take advantage of technology and help to change the "production function". However, somebody should also think about the impact on a redefiniton of professional roles and tasks, an issue that is frequently left for another day.

PS. Unfortunately, this good news you'll not find in any newspaper. Nowadays, most of them are interested only in the dark side.

PS. Don't forget that such a decrease in utilization of services has been achieved without any copayment strategy.

The deprivation of human rights and the health crisis

The  situation in northern Irak is critical. More than 1.4 million displaced people, severe human rights abuses and violation of international humanitarian laws. Those people are in need of water and basic sanitation services. Health services are overwhelmed by this situation.
Maybe this is the largest tragedy of our days, innocent people taken out from home and left without anything.
The answer by developed countries is becoming too late and too little. Have a look at EU press release (20 m € in 2014 while Saudi Arabia 500m $, Lancet says). This is an additional reason why I feel very far from european policies and citizenship.

PS. Must read (please beware of potential conflicts of interest): Updating Cost-Effectiveness — The Curious Resilience of the $50,000-per-QALY Threshold

PS. FT :  " the right to vote stands above the decisions of a political tribunal.”

Sisley. From Tita Cervera  St. Feliu exhibition

The people's support for public health care

If you want to know what may drive you to participate in a demonstration, just ask the people. This is precisely what CEO report has done with this question:
"Tell me, please, if the following could have driven or push you to participate in a protest or claim" and the options were: tax increase, improving democracy ,corruption, defense of public education, defense of public health care, evictions, budget cuts, the right to vote.
And the winner is? The defense of public health care with 91,1%.
Good to know, if you didn't before. A clear message for any politician that cares about well-being of the population.

PS. If you want to know how many citizens consider that fundamental changes in health care are necessary, CIS has published the figure: 33%, the highest in the period 1995-2013 (p.10), those who think that  some changes are necessary: 45% (p.9). Something should be done.
Support for public provision of primary care: 60%, on hospital care: 50%. Closer data on 2013 by CEO-CatSalut have not been published, my last comment is here.

Homer. From Tita Cervera  St. Feliu exhibition

Copayments as deterrents

If you want to know if copayments deter drug consumption just ask the people.This is precisely what CEO has done. In their report p.33 they reflect that 85% of citizens have not decreased their consumption, while 13% say yes, and 2 % dont know (?). The posted question maybe is not the best since the word copayments doesn't appear and there is no adjustment over the former copayment regime (retired vs active population). Anyway, we don't know if this 13% of people that say they have reduced it, is for inappropriate medications or appropriate ones. Still looking for the right assessment, this is only the first glance.

PS. How can we measure media power?

 Andrews. From Tita Cervera  St. Feliu exhibition

The uncertainty over genomics sequencing value in clinical decision making

Assessing Genomic Sequencing Information for Health Care Decision Making: Workshop Summary

"The value of genetic sequence information will depend on how it is used in the clinic", key statement that needs some elaboration. This is precisely what the IOM report does, you'll find in their pages the current situation about how genomics may impact in decision making. In chapter 5 you'll understand how an insurer decides about coverage of such tests according to 5 criteria:

1. The test or treatment must have final approval from appropriate governmental regulatory bodies, where required;
2. scientific evidence must permit conclusions about its effect on medical outcomes;
3. technology must improve net health outcomes;
4. the technology must provide as much health benefit as established alternatives; and
5. the improvement in health must be attainable outside investigational settings.

Unfortunately, if you start from the first one, you'll find a complete lack of references by governmental bodies on the approval of such tests. Therefore, I can't understand from the chapter how successful they are on such process.
While reading the book you'll increase your uncertainty about outcomes and value of genomic tests instead of reducing it. This was my impression. Let's wait for future good news, again.

PS. Summary of the report:
"Clinical use of DNA sequencing relies on identifying linkages between diseases and genetic variants or groups of variants. More than 140,000 germline mutations have been submitted to the Human Gene Mutation Database and almost 12,000 single nucleotide polymorphisms have currently been associated with various diseases, including Alzheimer’s and type 2 diabetes, but the majority of associations have not been rigorously confirmed and may play only a minor role in disease. Because of the lack of evidence available for assessing variants, evaluation bodies have made few recommendations for the use of genetic tests in health care."