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).