The challenges of medical practice variations

Medical Practice Variations

The title of this post is not original, it is really from a book published in 1990, 27 years ago! And Wennberg started such research on the 70's. What is new is the book "Medical Practice Variations" released last year. After all these years concerns have spread, methodological improvement is huge, and unfortunately evidence says that practice still shows wide range of variability. This is the main concern, what to do about it.
The description is excellent, 23 chapters and 527 pages reflect an effort of many years of several projects on the issue. A must read is the chapter 4, p. 53 by Enrique Bernal and his team: Medical Practice Variations in Elective Surgery. Variations may harm and produce waste, therefore understanding how to prevent low-value care is crucial. They say:

Two key steps in reducing low-value care, proposed by García-Armesto et al. (García-Armesto et al. 2013), are the following:
• Identifying those technologies ineffective in their usual indications or less effective than alternatives
– Dropping them from the benefits basket or making them subject to avoidable copayments
– Restricting indications to certain types of patients (choice guided by evidence of positive benefit/risk balance)
– Specifying and limiting the types of providers more suitable to offer each service (therefore substantiating indication becomes a requisite, discouraging irrelevant use)
– Capping the frequency or length of treatments
• Producing and making available guidance on a regular basis to reduce inappropriate use of procedures
– Highlighting and tackling unwarranted variations in elective surgery (naming and “shaming” to prompt query and change)
– Fostering best practices and improving coordination of care

As I said, a must read. Congratulations to the authors. Unfortunately the barrier is the price: $279. Notwithstanding that, health policy makers and managers should have it as a key reference for their decisions.

PS. If you want to know more about current projects, check the ECHO  website.

The tough figures of worldwide health spending

Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries

We live in a disparate world, and the range of health care expenditure per capita goes from $33 in Somalia to $9.267 in USA. These are tough figures, while in Somalia you'll understand that access is the problem, in USA disparity is inside, waste and access at the same time are the problems. The Lancet article shows the reality of world health expenditure. It worths reading it.

The availability of prepaid resources for health, such as government spending, is one of many determinants of access to health care, and can lead to population health gains. Economic development is associated with an increase in spending and specifically an increase in prepaid resources. This is at the core of the pursuit for universal health coverage. This research also points to countries that deviate from the trends, spending more or less than expected, based on their level of economic development. This information is valuable to planners assessing funding gaps and financing opportunities, and can be used to provide insight into what future health financing challenges are likely. Tracking changes in health financing patterns across time and benchmarking against global trends is vital to addressing missed opportunities, ensuring access to medicines and high quality services, and the pursuit of universal health coverage.

Gorgeous new album by Joan Miquel Oliver. Atlantis

ACOs state of the art

L’expérience américaine des Accountable Care Organizations:des enseignements pour la France ?

After all the efforts, ACOs coverage in US is right now only for 9% of population (28 million citizen). It seems a low figure. You can check the details of the current situation in an excellent report (en français) by IRDES. However, they consider that this approach could be useful for France, and I'm not so sure. The differences are huge to introduce something similar.

Parov Stelar - State of the Union

In Barcelona soon

Toolkit for comparative effectiveness

Methods in comparative effectiveness research

If comparative effectiveness is the new fram for valuing health technologies, then we need the appropriate toolkit. This is not new, I said the same in 2010 and afterwards in this blog. Right now there is a difference, you may read in this 600 pages book all the details about it (a chapter on machine learnisn is missing).
A clear understanding of comparative effectiveness is precisely what the authors of this report have neglected, unfortunately. It doesn't make any sense to start economic evaluation without an assessment of comparative effectiveness. It doesn't make any sense to back for QALYs as an accounting approach. Forget this guidelines, and suggest to read this book.

This volume covers the main areas of quantitative methodology for the design and analysis of CER studies. The volume has four major sections—causal inference; clinical trials; research synthesis; and specialized topics. The audience includes CER methodologists, quantitative-trained researchers interested in CER, and graduate students in statistics, epidemiology, and health services and outcomes research. The book assumes a masters-level course in regression analysis and familiarity with clinical research.

What is population health?

What does improving population health really mean?

Population health means the health outcomes of a defined group of people, as well as the distribution of health outcomes within the group.
Therefore, measuring and understanding the reasons for differences in health is a key factor for tackling them.
Kindig paper is the most relevant, and this one reflects the begining.
From the post by Kings Fund :

Approaching the golden age of epigenomics and epitranscriptomics

A new twist on epigenetics

If epigenomics is crucial to discard the genetic predestination paradigm, now we can add a new 'omics to the paradigm: epitranscriptomics. Last February, Nature published interesting news related to recent scientific developments:

The epigenome helps to explain how cells with identical DNA can develop into the multitude of specialized types that make up different tissues. The marks help cells in the heart, for example, maintain their identity and not turn into neurons or fat cells. Misplaced epigenetic marks are often found in cancerous cells.

 Chuan He and Tao Pan are two researchers that have been working on new ways of controlling gene expression

He and others have shown that a methyl group attached to adenine, one of the four bases in RNA, has crucial roles in cell differentiation, and may contribute to cancer, obesity and more. In 2015, He’s lab and two other teams uncovered the same chemical mark on adenine bases in DNA (methyl marks had previously been found only on cytosine), suggesting that the epigenome may be even richer than previously imagined.

The team had shown for the first time that RNA methylation was reversible, just like the marks found on DNA and histones.

Methylated adenine bases are the focus of research on gene expression.

Exercise as a socially contagious activity

Exercise contagion in a global social network

Disciplines as diverse as economics, sociology, medicine, computer science, political science and physics have recently become interested in the interdependence of behaviours across the human social network. In particular, scientists have begun to ask whether our health and other behaviours are contagious, in that our decisions and actions affect the decisions and actions of our peers. If behavioural contagions exist, understanding how, when and to what extent they manifest in different behaviours will enable us to transition from independent intervention strategies to more effective interdependent interventions that incorporate individuals’ social contexts into their treatments

A new  study offers some of the first hard evidence that health-related habits can spread — and so perhaps could be deliberately seeded and encouraged — by social influence and peer pressure. Previous research has sought such a contagious effect in factors such as obesity and smoking, but the results have been inconclusive.

Studies in social differences in health have a a new hurdle to tackle. How to boost social permeability? As Mackenback said in The Lancet on health inequalities: now it's personal.

PS. These are the results of the study in one figure: