The home and the neighborhood

Transforming Specialty Practice — The Patient-Centered Medical Neighborhood

The coordination of health services requires intense relationships between primary and specialized care. Though this is obvious, sometimes there is a need to insist on it. And this is precisely what an article at NEJM does. It explains the components to assess the Patient centered medical home and the patient centered specialty practice.
This is a US style organizational design, although some european private organizations should keep an eye on such developments. The current organization of private practice is too far from the requirements of a modern practice of medicine and to fulfill patient expectations. The pressures for organizational change unfortunately will not arise from inside, the confort zone always plays its role.

PS. Video on low value care and how to avoid it, at NEJM.

The Health of Catalans

La salut de la població de Catalunya en el context europeu

Comparing population health between countries allows to understand the scope of the differences. Some of them are unwarranted and others require an explanation. Anyway, it is good to confirm in a new report that the health of catalans has achieved a top level in Europe. The key indicator is healthy live years. As a summary it works, but when you go into details, then some  problems arise: obesity, tobacco, colon cancer, diabetes,...
Comparing public expenditures , Catalonia spends less than other countries with similar GDP. And the opposite is true for private expenditures (p.16). Unfortunately, data is  from 2010 and things have changed a lot, on GDP and health expenditure. My guess is that right now we are spending publicly a larger percentage than 6%. An update is needed in order to know better our current position.

A pivotal moment in the history of medicine

What the Tamiflu saga tells us about drug trials and big pharma

Today the long article by Ben Goldacre published in  The Guardian is a required reading. Those that have some doubts regarding the effectiveness of oseltamivir will see them vanishing. The Cochrane review explains the size of side effects and controversies that have surrounded such drug since flu pandemic in 2009.
The most important message goes beyond tamiflu, it is related to transparency in drug trials:

This is a pivotal moment in the history of medicine. Trials transparency is finally on the agenda, and this may be our only opportunity to fix it in a decade. We cannot make informed decisions about which treatment is best while information about clinical trials is routinely and legally withheld from doctors, researchers, and patients. Anyone who stands in the way of transparency is exposing patients to avoidable harm. We need regulators, legislators, and professional bodies to demand full transparency. We need clear audit on what information is missing, and who is withholding it.
Finally, more than anything – because culture shift will be as powerful as legislation – we need to do something even more difficult. We need to praise, encourage, and support the companies and individuals who are beginning to do the right thing.

Understanding UK health reform

A primer on health economics and policy

Social values in health and social care

In just 38 pages Tony Culyer explains  the basics of health policy. It is not a review, these are a collection of key insights that basically come from his book. This is the outline:

• Introduction
• Liberalism versus libertarianism
• The market versus the state
• Public versus private insurance
• Equity versus equality
• Inequalities of health versus inequalities of health care
• Equity versus efficiency
• Needs versus wants
• Prices versus rationing
• Financial protection versus quality of life
• Public versus private
• Agents versus principals
• Universality versus selectivity
• Comprehensiveness versus limited benefit bundles
• Centralisation versus decentralisation
• Competition versus collaboration
• Experts versus citizens
• Mixing values and other things
• Key messages 

Take this sentence, as an exemple:

Cost is also a value and no mere matter of accountancy. If we introduce a new
health care procedure, the cost will have to come out of expenditure elsewhere
in the NHS –unless there is a concurrent increase in the NHS budget. But less
expenditure elsewhere will normally imply reduction of service elsewhere and
a consequential health loss. The true cost of getting more care (and hence
health) in one area of activity is therefore the minimum necessary loss of care
(and loss of health) elsewhere. This is the important notion of opportunity cost.

Many politicians don't want to hear such messages. I stronlgy suggest you to read this booklet from Kings' Fund.
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Cost-effectiveness as a proxy of value

GUIA I RECOMANACIONS PER A LA REALITZACIÓ I PRESENTACIÓ D'AVALUACIONS  ECONÒMIQUES I ANÀLISIS D'IMPACTE PRESSUPOSTARI DE MEDICAMENTS EN L’ÀMBIT  DEL CATSALUT

As resources are scarce we do have to prioritise. That's it, we can't escape. We do need a proxy to assess relative incremental value of the technologies and procedures for a disease, otherwise decisions would be arbitrary. In such situation a methodologic guide is welcome to provide credible information. This is precisely what the guide by CatSalut is contributing to. It explains criteria and ways to present economic evaluation and budget impact analysis. A well designed guide that unfortunately right now will have a limited application. The reason is that government can't completely decide about it. It's an issue of months.

Unsafe medical devices regulation

Improving Medical Device Regulation: The United States and Europe in Perspective

The regulatory differences between Europe and US are quite well known since the breast implants scandal. A US citizen was not able to receive such implant because FDA had not approved. The rationale is not related to such a case, it is the current system of notified bodies that really doesn't protect population health. However, US needs also to improve. Milbank Quarterly article says:

Overall, US and European evidence requirements for devices introduce not only risks to patients but also the wrong incentives to generate the needed evidence to better understand and evaluate the benefits and risks of new devices. Considering that manufacturers often take advantage of existing evidence from already marketed devices to gain approval for a new device, they are reluctant to undertake new clinical studies. In addition, because later devices may be able to claim equivalence, the first manufacturer to market does not have a very strong incentive to undertake extensive clinical studies.

The steps to improve regulation are detailed in the article. Surprisingly, notified bodies is again the chosen option in the current review of the legislation. Citizens should know it before voting.

PS. Milbank says it is an original investigation, you may check the same title and authors some months before in Value in Health