Testing, testing

The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis

As a citizen you may be concerned about taxes, as a patient about quality and safety (if you are in a universal publicly funded health care). As both, you should be concerned on cost, quality and access.
Imagine that someone says to you that there is a benefit that is accessible, relatively low cost and at the same time it is ordered but not indicated in 20% of cases, and it is not demanded although necessary in 44% of situations (!). For sure you should be extremely "preoccupied".
The most important difficulty, is that you'll never know that, and this reduces your concerns artificially. If you look at PLOS you'll find such figures from a meta-analysis of last 15 years:

Overall mean rates of over- and underutilization were 20.6% (95% CI 16.2–24.9%) and 44.8% (95% CI 33.8–55.8%). Overutilization during initial testing (43.9%; 95% CI 35.4–52.5%) was six times higher than during repeat testing (7.4%; 95% CI 2.5–12.3%;

Overutilization measured according to restrictivecriteria (44.2%; 95% CI 36.8–51.6%) was three times higher than for permissive criteria (12.0%; 95% CI 8.0–16.0%;P,0.001). Overutilization measured using subjective criteria (29.0%; 95% CI 21.9–36.1%) was nearly twice as high as for objective criteria (16.1%; 95% CI 11.0–21.2%;P=0.004).

With all these statistics together, somebody should do something. The first thing is to know what is happening nearby. Do you know it?

PS. Although this meta-analysis states that underutilization is 44,8%, I would suggest to take caution over this figure. I think that nobody has analysed properly its implications if it were true.

Meanwhile, dancing with Parov Stelar - Shuffle

The massive information leak ever known

No Place to Hide: Edward Snowden, the NSA, and the U.S. Surveillance State

 If someone says to you that a governmental agency has been collecting  data on more than 97 billion emails and 124 billion phone calls in just 30 days, you'd probably think that it is not possible. Imagine a system that has the capacity to reach up to 75% of US emails (!). This is impressive.
Unfortunately, this is absolutely true. Nobody has  rejected it at NSA.One year after the Snowden disclosure of surveillance activities, the US Congress has had to change existing laws and Courts  that allowed such practices.

The international data collected in a single thirty-day period from Germany (500 million), Brazil (2.3 billion), and India (13.5 billion). And yet other files showed collection of metadata in cooperation with the governments of France (70 million), Spain (60 million), Italy (47 million), the Netherlands (1.8 million), Norway (33 million), and Denmark (23 million).

As you may imagine this is not a US issue, but unfortunately the impact and public pressure for change over politicians is different across countries.

I've finished reading the Greenwald book and The Snowden files. I suggest you to start with Greenwald one, the original source better than the remake. I think that one of the most interesting parts is when he explains the rationale for his information disclosure, in Chapter 2:

“The true measurement of a person’s worth isn’t what they say they believe in, but what they do in defense of those beliefs,” he said. “If you’re not acting on your beliefs, then they probably aren’t real.”

  “I do not want to live in a world where we have no privacy and no freedom, where the unique value of the Internet is snuffed out,” Snowden told me. He felt compelled to do what he could to stop that from happening or, more accurately, to enable others to make the choice whether to act or not in defense of those values.

 The book is a milestone over the conflict between freedom and surveillance, over the value of privacy in our current times. It explains many details and raises a lot of uncertainty when using internet for any reason.

PS. By the way, I haven't seen any request to our politicians about how many emails have been suplied to US authorities, how they can justify such leakage and how they have selected them. Somebody must responsible for that.


PS. New report on integrated care, by Antares.

Parov Stelar, All night

The size of the private hospital market

There are two sources to find the size of the private hospital market: EESRI and DBK a consulting firm. The number of beds is close to 30.000 in both sources, the size of income is 6.185 m€ for 2013 according to DBK, and additional 1% compared to the previous year. Private hospitals receive 66% of their income from insurance companies. In 2013 it grew 3,4%, while health insurance premiums rose 2,8%. Public funding of private hospitals is decreasing, -4% and private out-of -pocket as well -3,2%. Insurance companies are increasingly funding private hospitals beyond its growth in premiums. Such figures show a clear pattern that is being replicated in the last years. I wrote a post on such trend about three years ago. What I said there, is already confirmed today.

PS. For those that consider privatization as public funding of services in private organizations, and for those that support that the size of privatization is growing, these data testify just the opposite. Therefore, where is the underpinning of the argument?

PS. In my opinion, as I said in this post some time ago, it is not privatization, it is commercialism.

High-performing boards' agenda

Source: High-performing boards: What’s on their agenda?

Boards' oversight of quality

Hospital Board Oversight of Quality and Patient Safety: A Narrative Review and Synthesis of Recent Empirical Research

Usually we focus our debate more on cost than on quality. As far as cost measurement is easier, we are able to comment, critise the level of expenditures, wether it is low or high. Concerns about quality and safety should be up in the agenda.And in recent years there has been relevant efforts in this direction. However, since there is no aggregated measure on quality, we have to enter into specific details and justifications.
The determinants of quality and safety are diverse. However, if we look at the top of the organization, board of trustees implication is crucial. Unfortunately, this is not always the case, they are more prone to discuss bugets and investments.
At Milbank you'll find a review on how hospital boards that take care of quality and safety issues have better results:

Recent empirical studies linking board composition and processes with patient outcomes have found clear differences between high- and lowperforming hospitals, highlighting the importance of strong and committed leadership that prioritizes quality and safety and sets clear and measurable goals for improvement. Effective oversight is also associated with well-informed and skilled board members. External factors (such as regulatory regimes and the publication of performance data) might also have a role in influencing boards, but detailed empirical work on these is scant.

Is there anybody nearby boosting such role for boards?

Inequality in the winner-take-all society (2)

The message of the former post was partial. It didn't raise suggestions for improvement in our unequal world. Fortunately, today's op-ed from Shiller adds some fresh air. He retrieves his book The New Financial Order: Risk in the 21st Century written a decade ago and proposes a new tool:

Inequality insurance would require governments to establish very long-term plans to make income-tax rates automatically higher for high-income people in the future if inequality worsens significantly, with no change in taxes otherwise. I called it inequality insurance because, like any insurance policy, it addresses risks beforehand.

This is only one of the six proposals that he develops in such an interesting book.The idea maybe good, the implementation is for sure uncertain. Govenments should commit to efficient redistribution approaches (although up to now I haven't seen them). And beyond this, the constraint again is the same as yesterday: global coordination on tax pressure and on inequality insurance design.

PS A year after Snowden leakage on how privacy has been systematically circumvented, check its impact in this report.

Inequality in the winner-take-all society

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.