This is a textbook on applied behavioral economics for public policy issues. In chapter 5 you'll find the health section and this is the summary:
Where people live, what they eat, how careful they are about taking their medications, and even what they do in their spare time are very much related to the quality of their lives and their health-related outcomes. While our genetic makeup accounts for a signifcant portion of our health outcomes, we know that health is also heavily infuenced by what are known as social determinants: education, wealth, neighborhood safety, housing, and health literacy, among many others. Throughout the day, we face many decisions that have a direct or indirect impact on our health and quality of life. Many of these choices can be infuenced toward healthier options by behavioral interventions.
This chapter presents behavioral insights and interventions that have a high potential to impact the health of community members, reduce disparities, and improve their overall quality of life. These insights and interventions range from increased medical adherence to improved nutritional choices using nudges, regulations, provision of information, or rewards for positive behaviors
A Anglaterra després de la pandèmia, l'agència de salut pública en va sortir perjudicada per tot el que havia passat. Va desaparèixer i en van crear dues: UK Health Security Agency and the Office for Health Improvement and Disparities. Però en Peter Littlejohns et al. en un llibre acabat de sortir ens expliquen que caldria una alternativa diferent, caldria bastir un nou contracte social.
Al llibre primer repassen com han arribat fins aquí, i aquest gràfic ho resumeix:
i com diferents determinants de la salut es dilueixen en moltes agències:
i precisament per això cal revisar en profunditat l'organització i la coordinació.
I acaba així:
Unless our broken political and governance system, with its numerous systemic failings, is confronted, then attempts to tackle complex problems like public health, which requires long- term commitment, proper investment and a relentless focus on delivery, will fail.
Tinc la impressió que els britànics han fet marxa enrera els darrers anys en moltes de les polítiques de salut, i no només en els resultats, també en les idees i la capacitat de dur-les a la pràctica. Ara bé tenen una capacitat d'explicar-ho i criticar-ho que no tenim aquí. Una reflexió sobre l'organització que tenim de la salut pública seria especialment desitjable. Es precisament aquest pensament crític el que crec que ens convindria replicar.
El Pla Interdepartamental i Intersectorial de Salut Pública (PINSAP) de la Generalitat de Catalunya era una iniciativa pionera alineada amb les recomanacions de l’Organització Mundial de la Salut (OMS) per impulsar la salut des de tots els àmbits de l’acció del Govern i la societat, és a dir “salut a totes les polítiques” i va desaparèixer de les prioritats governamentals d'aquí el 2020, i ningú ha dit res al Parlament a hores d'ara. Ara farà una dècada que va començar i no he sabut veure cap avaluació recent de l'impacte. Molt trist tot plegat, podem fer desaparèixer prioritats i polítiques sense dir res, i no passa res. Després de tants esforços, ha anat a parar a la paperera de la història?
PS. Si voleu donar pistes a la nova ministra sobre com posar en marxa l'agència de salut pública o com no fer-ho, l'informe original en pdf és de fet millor que el llibre. El títol de llibre té atractiu, però el contingut del contracte social és imprecís.
I still don't know why do we talk about inequalities, I've always thought that we should care about differences. The word inequality drives your mind towards equality, and we all know that this will not happen. Therefore, there are differences that are unfair and avoidable, and these are the ones we have to be concerned.
And when we talk bout social determinants, maybe we should focus on commercial determinants and it would help. Why commercial? Because these factors are more actionable compared to others.
You will not find all these reflections in the new report by OECD. Anywasy it is worth reading to confirm it, though the perspective is the standard one (Marmot) and not new.
What you really have to read is the notice at the begining of each chapter that says:
Note by Turkey:
The information in this document with reference to “Cyprus” relates to the southern part of the Island. There is no single authority representing both Turkish and Greek Cypriot people on the Island. Turkey recognises the Turkish Republic of Northern Cyprus (TRNC). Until a lasting and equitable solution is found within the context of the United
Nations, Turkey shall preserve its position concerning the “Cyprus issue”.
Note by all the European Union Member States of the OECD and the European Union:
The Republic of Cyprus is recognised by all members of the United Nations with the exception of Turkey. The information in this document relates to the area under the effective control of the Government of the Republic of Cyprus.
Shame on Turkey. This notice is an example of the decision that needs to take the OECD urgently: to exclude Turkey from his organization. It is really unacceptable what Turkey has done and it is doing in Cyprus. Europe and OECD are avoiding the conflict saying "The information in this document relates to the area under the effective control of the Government of the Republic of Cyprus". The conflict should be solved as soon as possible with the withdrawal of Turkey from Cyprus. That's all.
PS. Carta de lluny. Tot d'una passejant pel carrer Ledra vaig topar amb una frontera. Em trobava a una capital europea, dividida, envaïda. L'illa de Xipre va quedar escapçada el 1974. Aquella invasió va provocar 200.000 desplaçats que van perdre-ho tot fins el dia d'avui. El genocidi cultural i el saqueig posterior encara dura. He tingut ocasió de visitar dues exposicions que mostren l'espoli que s'està produint a la regió de Morphou (pot visitar-se al Banc de Xipre) i el rescat d'algun botí d'antiquari de l'any passat a Alemanya (Makarios Foundation). Vaig quedar tocat en veure-ho. Tresors artístics destruits per tal que la cultura d'altres desaparegui definitivament. Molt fort.
La situació política és delicada després de l'explosió de l'arsenal de Limassol a mitjans de juliol. Vam assistir a concerts on l'electricitat la subministràven amb generadors, i a Limassol moltes botigues no tenien llum. Tenen una bombolla urbanística com una catedral i està a punt d'esclatar.
L'escapada cap al Nord va tenir tres destins: Salamina, Famagusta i Kyrenia. Arribar a Salamina suposava fer un visat i assegurança del cotxe però el difícil era arribar-hi perquè no hi havia cap cartell. Salamina és un complex interessant però descuidat i menystingut. Famagusta té una mescla que em va sobtar visualment, catedrals gòtiques escapçades amb minarets. Havia de ser extraordinària però s'han encarregat deliberadament de destruir-la, s'observa clarament quan passeges. Kyrenia va ser un descans, lloc acollidor. Al port amb una calor sofocant vam passar una bona estona. Vam oblidar per pocs moments el país envaït on ens trobàvem.
Crec que els governs que faciliten, impulsen o s'inhibeixen davant del genocidi cultural haurien de ser exclosos del circuit, pena d'infàmia, cosa que per ara no fa ningú.
Hem tingut ocasió de visitar Pafos, els Troodos i les esglésies patrimoni de la humanitat, Kourion, i molts altres llocs. El menjar i en especial la qualitat del peix és envejable. Un bon record i una experiència més per a compartir.
Step one involves sorting patients into one of three risk groups (high, medium, and low) based on objective data, which we take from claims or our electronic health record (EHR). We make our determinations based on the presence or absence of such factors as chronic conditions, advanced age, multiple comorbidities, physical limitations, substance abuse, a lack of health insurance, low health literacy, frequent hospitalizations or emergency department (ED) visits, recent major surgery or brain trauma, polypharmacy, or difficulty following a treatment plan. Some EHRs will calculate a risk score automatically based on this data. In either case, it is important to adjust the score based on additional, subjective considerations, which are the focus of step two.
In step two we assign each patient to one of six risk levels based on how physicians and staff answer the following questions:
Is the patient healthy with no medical problems? If so, are his or her biometrics in or out of range?
Does the patient have chronic conditions but he or she is doing well?
Does the patient have chronic conditions that are out of control but without complications?
Does the patient have complications of chronic disease or high-risk social determinants of health? (If you or your care team are unsure how to assess or address a patient's social determinants of health, the AAFP's EveryONE Project1 includes tools and resources.)
Is the patient potentially in danger of dying or being institutionalized within the next year?
I missed any reference to morbidity and episode measurement. My impression is that objective measure is the first mandatory step through groupers, and risk stratification improves with subjective sources of information. And levels can be allocated through probabilistic fuzzy systems.
An update on the focus of public health is welcome. The article in the annual review is a good starting point:
Public health needs to transition from a twentieth-century model grounded in a biomedical model and categorical funding of disease-specific interventions to emphasize changes in the greatest determinants of health: our social and physical environments. Although improvements to date from public health need to be sustained, new perspectives and capabilities are essential to address contemporary and projected disease and injury burdens effectively.
The suggestion to analyse life trajectories sounds interesting.
Els hàbits i comportaments són determinants per la salut, ho sabem tots i alhora sovint fem com si sentíssim ploure. El més difícil de tot és que una vegada tenim consciència del risc adoptem l'actitud acurada per prevenir les conseqüències del nostres hàbits i comportaments. Al principi hi ha tenir la consciència del risc, sense això ben poc hi pot haver després. Fa temps que en vaig parlar i allà insistia en la importància de la comunicació de riscos a nivell poblacional. Això no s'improvisa, i els anys passen i podem veure que s'ha fet ben poc al respecte.
Ara que l'OCDE i l'OMS han publicat un bon informe sobre el sedentarisme, convé impulsar totes les polítiques de salut pública per afrontar-lo. Altrament ja us puc assegurar que davant l'obesitat creixent, l'opció que alguns ja entreveuen és combinar sedentarisme amb fàrmacs per aprimar. Un estil de vida privat que acabarà fent-se càrrec el finançament públic, és clar. Hi som molt aprop.
Altrament per passar a l'acció, cal llegir el capítol 4 on explica quines són les tasques a fer des de la vessant política:
Despite many countries having stepped up their efforts to promote physical activity, there remain gaps in the policy response. For example, schemes to promote active travel to school or work are only present in 14 and 17 out of 27 EU Member States, respectively.
A wide range of policy options exist to increase population physical activity, which improve population health, as well as reduce health care expenditure, including: setting-specific programmes, in schools, workplaces and the health care system, policies to increase access to sports facilities, urban design, environment and transport policies, communication and information policies
As physical activity is a complex behaviour, a comprehensive package of policies is needed to target all its drivers at the same time, with sufficient and sustained funding and evaluation.
A policy package aimed at increasing physical activity, implemented in 36 countries, would save around EUR 14 billion in health cost by 2050 (equivalent to the total annual health care expenditure of Greece) and return EUR 1.7 for every EUR 1 invested.
Malauradament no trobareu Catalunya a l'informe de l'OMS, encara que financem una oficina a Barcelona amb els nostres impostos i no sabem què en rebem a canvi. Però aquí en teniu un sobre pràctica esportiva de l'any 2019, que va servir pel Pla d'activitat física i esport, mentre es van oblidar que hi havia una enquesta de salut on explica moltes coses d'això amb força detall. I és que la guia de prescripció de l'exercici físic per la salut és de l'any 2007... Això no es resoldrà fent Youtubes que han vist 500 persones al llarg de 6 anys! I tampoc es resoldrà si es confon l'activitat física amb activitat esportiva, com fa el Pla vigent. Una petita ullada a l'informe seria molt recomanable.
Aquest abril passat va fer 100 anys que es publica el Milbank Quarterly, revista de referència absoluta en política sanitària. I van preparar un especial d'obligada lectura per a tots aquells que els preocupa la salut poblacional. Avui destacaré un article tant sols.
El missatge de l'article és que cal més pensar en polítiques de salut poblacional que en polítiques d'assistència sanitària. Fins aquí, res de nou. Proposen un esquema per fer-ho operatiu. Es tracta de la Piràmide d'impacte en la salut poblacional:
Fixeu-vos per on comença, amb la formació de les professions sanitàries. Elemental, claríssim. Si no hi ha la formació en la qualitat i quantitat necessària de professionals difícilment tindrem millora en la salut.
I si hi ha un embús en l'accés als serveis perquè no hi ha professionals o la seva productivitat és baixa, aleshores tenim molts més problemes en cascada.
A UK la llista d'espera és de 7,75 milions de persones, a Espanya és de 4,8 milions de persones (quirúrgica i ambulatòria, sense comptar l'espera per proves diagnòstiques), a Catalunya 844.255 persones esperant a data de juliol 2023 (186.665 per cirurgia, 476.623 per consultes i 180.967 per proves). El 10,6% de la població catalana està esperant per a ser atès al sistema de salut. A UK l'11,5% de la població està esperant. A Espanya el 10,1% de la població segueix també esperant.
Podem parlar de determinants socials, comercials i polítics de la salut, però el problema el tenim al capdamunt de la piràmide. Aquesta és la qüestió de fons a la que tantes vegades m'he referit i que no es resol estrictament amb diners. Cal reforma organitzativa, del context de l'assistència sanitària (també a la piràmide).
Com podeu veure amb el meu comentari he girat la orientació de la fletxa, perquè crec sincerament que l'ordre dels factors és erroni. Malgrat considerem la importància dels determinants socials i de l'entorn, si hi ha el 10% de la població esperant perquè no pot accedir als serveis, aleshores allò de que l'atenció sanitària influeix menys que altres factors en l'assoliment de la salut no se sosté. I no se sosté perquè si no hi ha accés no hi ha atenció. Així de clar. Quan es parla dels determinants de la salut, la premisa és que l'atenció sanitària existeix, però quan hi ha llistes d'espera d'aquesta magnitud i sense prioritzar, aleshores ja som en un altre entorn. Un entorn indesitjable on parlar de determinants socials està bé, però que primer caldria reduir fonamentalment aquest 10% de la població que espera massa temps per ser atesos.
Per tant el missatge avui hauria de ser hem de pensar el polítiques de salut poblacional però si no hi ha accés, aleshores la prioritat són les polítiques d'assistència sanitària, i per sobre d'això la formació de professionals i la disponibilitat de recursos i infraestructures. Ens trobem a prop d'una emergència sanitària. O potser ja hi som i no ens n'hem adonat.
A recent op-ed by Joseph Stiglitz on "Innovation enigma" brought me to retrieve a book of 1995 by Robert H. Frank, "The Winner-Take-All Society: Why the Few at the Top Get So Much More Than the Rest of Us". Nowadays, the issue of raising inequality is on headlines, and often it is considered as a consequence of economic crisis. Frank argued two decades years ago that more and more the current economy and other institutions are moving toward a state where very few winners take very much, while the rest are left with little. He attributes this, in part, to the modern structure of markets and technology. It was written before the impact of internet on business and it was a clear alert about what has happened.
Now Thomas Piketty in his book "Capital in the 21st century" argues additionally that when the rate of capital accumulation grows faster than the economy, then inequality increases. And inequality is not an accident but rather a feature of capitalism that can be reversed only through state intervention. The book thus argues that unless capitalism is reformed, the very democratic order will be threatened.
If you combine both perspectives, you must be convinced that it is not only an issue of state intervention, I can't imagine certain parts of global markets ("winner-take-all" ) being abolished or reformed without a global government. That's why I'm not sure about the size of the current threat and when it will explode.
Stiglitz adds an uncertain landscape for innovation, and therefore for future dynamic efficiency of markets (Shumpeter style).
Taking all these pieces together, there is no clear recommendation. Today I just want to state again that correlation is not causation. Inequality and crisis are a contemporary fact, though the trend goes back a long way and it is very much deeper. Avoiding reductionist perspectives is my first suggestion.
PS. Since the implications of wealth inequality and health are huge as I explained in this post, my today comment maybe adds more shades instead of light.
PS. "Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health." The Marmot Review: Fair Society Healthy Lives
PS. If you want to know why Messi's salary has increased this week, have a look at Frank's book, the answer is there.
Life expectancy in the US increased 3.3 years between 1990 and 2015, but the drivers of this increase are not well understood. We used vital statistics data and cause-deletion analysis to identify the conditions most responsible for changing life expectancy and quantified how public health, pharmaceuticals, other (nonpharmaceutical) medical care, and other/unknown factors contributed to the improvement. We found that twelve conditions most responsible for changing life expectancy explained 2.9 years of net improvement (85 percent of the total). Ischemic heart disease was the largest positive contributor to life expectancy, and accidental poisoning or drug overdose was the largest negative contributor. Forty-four percent of improved life expectancy was attributable to public health, 35 percent was attributable to pharmaceuticals, 13 percent was attributable to other medical care, and −7 percent was attributable to other/unknown factors. Our findings emphasize the crucial role of public health advances, as well as pharmaceutical innovation, in explaining improving life expectancy.
A must read article. This is the kind of messages that can inform policymakers and redefine priorities. Unfortunately, there is no similar study for my country.
PS. If you want the same study over two centurys, check here
We all know that improving population health is a task that exceeds the healthcare system. The political debate is too focused on healthcare rather than other determinants to improve health. However, today is a different day. A new plan to introduce health in all policies has been approved and this means a change in the agenda. We'll see how this will be managed, since it is a new approach.
Have a look at the document. The authors have been working hard for months on it. Such policy follows EU criteria and represents an innovation in the current health policy landscape. Let's see how effective it is.
The foundation for a new era of data-driven medicine has been set by recent technological advances that enable the assessment and management of human health at an unprecedented level of resolution—what we refer to as high-definition medicine. Our ability to assess human health in high definition is enabled, in part, by advances in DNA sequencing, physiological and environmental monitoring, advanced imaging, and behavioral tracking. Our ability to understand and act upon these observations at equally high precision is driven by advances in genome editing, celular reprogramming, tissue engineering, and information technologies, especially artificial intelligence.
This is what high definition medicine is about:
the dynamic assessment, management, and understanding of an individual’s health measured at (or near) its most basic units. It is the data-driven practice of medicine through the utilization of these highly detailed, longitudinal, and multi-parametric measures of the determinants of health to modify disease risk factors, detect disease processes early, drive precise and dynamically adjusted interventions, and determine preventative and therapeutic intervention efficacy from real-world outcomes
In this framework, precision medicine is only a small piece of the engine.
The article published in Cell by scholars from Scripps Translational Science Institute sheds light on the new perspectives of the practice of medicine, a milestone on the current knowledge of life sciences and its application.
Aquesta setmana el NEJM ens ofereix un article excepcional tot commemorant els 200 anys de la revista. El califico a la categoria "el millor dels millors", a l'estil APM. Es tracta d'una visió breu sobre com ha canviat la medicina i les malalties en els darrers dos segles mirant la revista. Evitaré fer-ne un resum, cal llegir-lo sencer i guardar-lo. Destacaré alguns paràgrafs com aquest:
Disease is always generated, experienced, defined, and ameliorated within a social world. Patients need notions of disease that explicate their suffering. Doctors need theories of etiology and pathophysiology that account for the burden of disease and inform therapeutic practice. Policymakers need realistic understandings of determinants of disease and medicine's impact in order to design systems that foster health. The history of disease offers crucial insights into the intersections of these interests and the ways they can inform medical practice and health policy.
I un podria pensar, però si això és elemental!. Doncs precisament, perquè ho és cal dir-ho novament i posar-ho en context. O aquest:
We must continue to adapt health systems and health policy as the burden of disease evolves. But we must also do more. Diseases can never be reduced to molecular pathways, mere technical problems requiring treatments or cures. Disease is a complex domain of human experience, involving explanation, expectation, and meaning. Doctors must acknowledge this complexity and formulate theories, practices, and systems that fully address the breadth and subtlety of disease.
És aquesta subtilesa de la malaltia la que ens ha de fer recordar que al darrera hi ha malalts, més enllà de mol·lècules.
PS. Comparteixo l'opinió d'en Quim Monzó a LV sobre la coca de llardons. I afegeixo que el problema es troba a la matèria primera. Afortunadament, cercant s'acaba trobant,, però sempre lluny de la corona metropolitana. El to de l'article magnífic, al més gran estil del més gran entre tots, Josep Pla. La seva vida de cada dia explicada aquí.
PS. Un gran moment emotiu al que no vaig poder assistir.
Ara mateix enfilo aquesta agulla
amb el fil d'un propòsit que no dic
i em poso a apedaçar. Cap dels prodigis
que anunciaven taumaturgs insignes
no s'ha complert, i els anys passen de pressa.
De res a poc, i sempre amb vent de cara,
quin llarg camí d'angoixa i de silencis.
I som on som; més val saber-ho i dir-ho
i assentar els peus en terra i proclamar-nos
hereus d'un temps de dubtes i renúncies
en què els sorolls ofeguen les paraules
i amb molts miralls mig estrafem la vida.
De res no ens val l'enyor o la complanta,
ni el toc de displicent malenconia
que ens posem per jersei o per corbata
quan sortim al carrer. Tenim a penes
el que tenim i prou: l'espai d'història
concreta que ens pertoca, i un minúscul
territori per viure-la. Posem-nos
dempeus altra vegada i que se senti
la veu de tots solemnement i clara.
Cridem qui som i que tothom ho escolti.
I en acabat, que cadascú es vesteixi
com bonament li plagui, i via fora!,
que tot està per fer i tot és possible
Ara Mateix, de Miquel Martí i Pol
PS Els de FT han anat a Santa Pau, Rupit i Besalú i han quedat meravellats. Del paisatge, dels fesols, del pa amb tomaquet i dels Fogons de Can Llaudes.
A remake of what you may already know has been published as article in The Lancet. It could be good as a reminder but something else is needed. The authors recognise:
Many individual elements we have described will befamiliar to global health scholars and practitioners. Manylessons have been learned in discrete areas. What we lackis a true field. We need a clearing-house for informationabout programme design, best practices, lessons learned,synergies, policy constraints, environmental determinants, and other elements of global health-caredelivery. In an age of information, the collection of datacan run seamlessly from bedside to seminar room andback to the field.
I'm uncertain about the outcome of such proposal. The details are so important and difficult to capture that the challenge is huge. On the other hand, I suggest to have a look at this Mckinsey Quarterly article that focus on the opposite: against benchmarking. After reading it, you'll notice that competition pressure in IT may not fit exactly with health care industry, and the message may not apply as straightforwarding.
Anyway, we need an evaluation effort to understand those strategies that are able to deliver more value. Now it's time.
Unhealthy commodity industries (UCIs) are defined as industries in which a significant share of their product portfolio comprises unhealthy products including tobacco, alcohol, energy‐dense and low‐nutrient foods and beverages, and gambling services.
Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions.
“Medical measures appear to have contributed little to the overall decline in mortality in the United States since about 1900.” Readers might assume that this statement is from a recent research article or policy report featuring the social determinants of health. But no, it is from the 1977 seminal Milbank Quarterly article by John and Sonja McKinlay titled “The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century.”
In the section of Milbank Quarterly Classics, David Kindig explains his favourite topic while reviewing the McKinlays 1977 article:
“if they [medical measures] were not primarily responsible for it [the decline in mortality], then how is it to be explained?” They did not answer this question themselves, but referred back to McKeown, who had concluded that “the main influences were: (a) rising standards of living, of which the most significant feature was a better diet; (b) improvements in hygiene; and (c) a favorable trend in the relationship between some micro‐organisms and the human host.”2 However, in their conclusion they magnified this point, stating that “profound policy implications follow from either a confirmation or a rejection of the thesis.
For many years, I taught a session of my population health course featuring the two contemporary papers that frame what we know today—the first by McGinnis and colleagues, based on CDC surveys, argues that medical care is responsible for about 10% of preventable mortality, and the second an econometric analysis by David Cutler argues that medical care was responsible for 50% improvement in certain causes of mortality over the period of 1960 to 2000. When students are shocked by this range, I remind them that, in a world that still predominantly assumes the pre‐McKinlay reality of medical care being close to fully responsible for preventing or curing disease and death, it is still a profound statement to many that much more than medical care goes into the production of health.
A must read. There are still many unanswered questions.
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.
In former posts I have advocated that healthy life expectancy should be used as an aggregated indicator of outcomes of health determinants. Unfortunately although it is imperfect, it is the best we have, and today you can check the latest estimates in a salient article in The Lancet.
Countries with highest healthy life expectancy, both sexes, 2013
1
Japan
2
Singapore
3
Andorra
4
Iceland
5
Cyprus
6
Israel
7
France
8
Italy
9
South Korea
10
Canada
Spain has disappeared from the former top10. I have always said that ordinal rankings have flaws, however, comparisons across time are worth taking into account.
Internally in Spain it is difficult to reverse this trend. If you consider geographic variations of the indicator you can see a range from 55 years up to 65 (p.25) .Therefore there is too much noise when you focus on the state as the unit of analysis. Forget the results and the ranking.
The only situation that is unique in the ranking is Andorra, it always appear at the top and it is a small state. That's remarkable and merits close analysis.
En teoria de jocs es diu que tenim un punt focal quan trobem una solució que la gent tendeix a utilitzar per coordinar-se quan falta comunicació, perquè sembla que satisfà tothom. El concepte va ser introduït per l'economista guanyador del Premi Nobel Thomas Schelling en el llibre The Strategy of Conflict (1960). El que aquest punt focal o equilibri sigui eficient o no ho sigui ja són figues d'un altre paner..
Tot d'una, quan llegia un l'informe de l'IOM sobre tests genètics, m'ha vingut a la memòria Schelling i els seus punts focals. Resulta que s'explica com davant dels biomarcadors s'ha encetat un cercle viciós (punt focal) que només es pot trencar mitjançant un canvi regulatori i d'incentius. Afegeixo un paràgraf d'interès:
The basic problem is that there has been relatively little consistency regarding which biomarkers have been introduced into clinical practice. Very few cancer biomarkers with demonstrated clinical utility have been introduced over the past 30 years. Even among those tests that have been integrated into practice, their use in certain settings has not always been supported by evidence of benefit, such as the use of prostate-specific antigen (PSA) as a screening test (Andriole et al., 2009), said Hayes. This has helped to create what Hayes has termed a “vicious cycle” in which tumor biomarkers are systematically undervalued (Figure 2-1). This undervaluation has led to limited use of these diagnostics by health care providers and poor reimbursement when a marker has been able to navigate the regulatory environment to be brought to market. Lack of use and reimbursement in turn leads to limited funding for biomarker research because the return on investment is low. The perception that markers have little utility has also led to an environment of lower academic recognition for developing biomarker-based tests. The overall result is reduced ability and incentive to conduct properly designed clinical trials to generate high-quality evidence of clinical utility. In return, there is reduced data certainty, higher skepticism, and few recommendations for clinical use, said Hayes, which completes the cycle by contributing to the poor valuation of marker utility. Hayes focused his recommendations for breaking the “vicious cycle” of undervalued tumor biomarkers on two areas: the regulatory environment and marker reimbursement.
Actualment als USA (i aquí encara menys) no hi ha un procés de revisió de la FDA per a les proves diagnòstiques de laboratori del tipus Laboratory Developed Tests LDT on s'avaluï la validesa analítica, validesa clínica i utilitat clínica. Es regula per la llei CLIA tal com s'explica al text. La proposta és doncs que la FDA prengui part del procés de revisió i es reformuli la regulació existent. I des de la vessant dels incentius, se suggereix que s'estableixin anàlisis cost-efectivitat de les proves que permetin situar el seu preu en funció del valor que aporten.
Ens trobem doncs en un llibre clau per a un moment clau. I qui tingui ulls i vulgui que el llegeixi, són tant sols 105 pàgines fonamentals per entendre una de les qüestions determinants de la medicina del futur.
Em costa admetre que el punt focal per aquí aprop es redueixi a veure passar els dies inexorablement i la innovació tecnològica resti sense avaluar, un equilibri ineficient. En Schelling diria que cal comprometre's de forma creïble per sortir-ne, però per ara i pel que fa al regulador, no ho sé veure per enlloc.
PS. La sindicatura emet informe sobre l'Hospital Clínic. Enmig del desori observo que s'han deixat de cobrar 40 milions d'euros amb trasplantaments a forasters!
PS. A DM trobareu alguns detalls sobre el nou sistema de pagament. Esperem més informació en el futur.
PS. Les autopistes sense cotxes ens constaran 290 milions el 2012, l'any passat van costar 80 milions.
