The fight between commercialism and professionalism in medicine (2)

Ensuring America's Health

The Public Creation of the Corporate Health Care System

A second book on the same topic on US healthcare. And the regulatory messages are:

Despite the political uproar surrounding the ACA, many citizens, including the legislation's opponents, acknowledged the need for some type of reform. Indeed, ACA antagonists were most effective raising the specter of how federal programming would worsen health care rather than boasting about prevailing arrangements. Poor service distribution, fragmented care, and uneven service quality had long characterized U.S. medicine. But policymakers and voters were primarily concerned about the uninsured and the exorbitant costs that ranked American health care as the world's most expensive. These flaws helped push the ACA over the finish line. And the program has thus far proven resilient, withstanding presidential and congressional contests as well as significant court challenges.
The ACA built new rooms atop a defective, jerry-built edifice. The public option would have put the nation firmly on the path toward a nationalized, universal system by creating a government-managed plan and using regulations and mandates to enfeeble and eventually drive out private coverage. Readers can decide for themselves the wisdom of creating a centralized system. Nonetheless, because the ACA failed to secure fundamental, structural reform, it will be unable to rein in costs while also maintaining or improving the quality of care. Indeed, this narrative has illustrated how a fusion of public and private power constructed an institutionally tangled health care system that, even under the banner of comprehensive reform, policymakers were ultimately unable to rescue from the insurance company model.

Right now it seems that ACA is not enough. Let's wait and see.

The fight between commercialism and professionalism in medicine

Remaking the American Patient
How Madison Avenue and Modern Medicine
Turned Patients into Consumers

I've found this book of interest specially for europeans. Our health systems are currently under pressure. Public budgets are constrained and the private sector is growing. If you want to know what happens next, then this is the book to read. Just to prevent the disaster that comes afterwards, remember that US life expectancy has been declining in the last three years!. Maybe the time to act is now, just to avoid this predictable outcome. Take care.

Digital health transformation

Health in the 21st Century
Putting Data to Work for Stronger Health Systems

A new report by OECD highlights the potential digital health environment. We are still far from what they say. However, while reading it you'll be aware of its relevance. Chapter 5 is a must read:

Big data, and big data analytics, can be used at all three levels of health promotion and disease prevention – research, surveillance, and intervention – by:
-Allowing a more precise identification of at-risk populations, through a more comprehensive understanding of human health and disease, including the interaction between genetic, lifestyle, and environmental determinants of health;
-Enabling better surveillance of both communicable and non-communicable diseases; and
- Facilitating better targeted strategies and interventions to improve health promotion and
disease prevention.

Against the riggers

El enemigo conoce el sistema
Manipulación de ideas, personas e influencias después de la economía de la atención

Uno de los errores recurrentes de la izquierda es pensar que el populismo es la estrategia de los imbéciles, cuando la historia demuestra que no puede ser tan imbécil cuando consigue un éxito arrollador. Ya en Los orígenes del totalitarismo, Hannah Arendt explica que este tipo de estrategia está diseñada deliberadamente para desprender a la sociedad educada de sus recursos intelectuales y espirituales, convirtiendo a la población en cínicos o en niños, dependiendo del ego y el aguante de cada uno. Una doctrina del shock que precede a la escuela de Chicago y que ha sido característica de todos los totalitarismos contemporáneos, del nazismo alemán al estalinismo ruso, pasando por el fascismo italiano.

En un mundo eternamente cambiante e incomprensible, las masas han llegado hasta el punto de que podrían, al mismo tiempo, creer todo o nada, pensar que todo era posible y que nada era verdad... Los líderes de masas totalitarios basaban su propaganda en la correcta premisa psicológica de que, en esas condiciones, uno podía hacer que la gente creyera la declaración más fantasiosa un día, y saber que si al día siguiente les dieran la prueba irrefutable de su falsedad, encontrarían refugio en el cinismo. En lugar de abandonar a los líderes que les habían mentido, clamarían que supieron en todo momento que la declaración era mentira y admirarían a los líderes por su agudeza táctica superior.

How much do countries spend on health?

‌Health at a Glance 2019: OECD Indicators

The european country that spends the most is Switzerland 12,2% over GDP. In Catalonia this figure was 7,6% in 2016 (less than Greece). Per capita income in 2016 was 35% more in Switzerland than in Catalonia, while health expenditure was 60% more in Switzerland.  Where have the catalan taxes gone?. You know it and I know it. And everybody is aware that there is only one solution to have the appropriate public health expenditure. We have to say good bye as soon as possible.

How to identify lab tests of low effectiveness?

Prevalence and Predictability of Low-Yield Inpatient Laboratory Diagnostic Tests

A new approach to understand the size of useless lab tests is to apply: "regularized logistic regression, regress and round, naive Bayes, neural network multilayer perceptrons, decision tree, random forest, AdaBoost, and XGBoost". This means that machine learning has its own space in laboratory medicine. In the article, they show high level of prediction for useless tests.

The best performing machine learning models predicted normal results with an AUROC of 0.90 or greater for 12 stand-alone laboratory tests (eg, sodium AUROC, 0.92 [95%CI, 0.91-0.93]; sensitivity, 98%; specificity, 35%; PPV, 66%; NPV, 93%; lactate dehydrogenase AUROC, 0.93 [95%CI, 0.93-0.94]; sensitivity, 96%; specificity, 65%; PPV, 71%; NPV, 95%; and troponin I AUROC, 0.92 [95%CI, 0.91- 0.93]; sensitivity, 88%; specificity, 79%; PPV, 67%; NPV, 93%) and 10 common laboratory test components (eg, hemoglobin AUROC, 0.94 [95%CI, 0.92-0.95]; sensitivity, 99%; specificity, 17%; PPV, 90%; NPV, 81%; creatinine AUROC, 0.96 [95%CI, 0.96-0.97]; sensitivity, 93%; specificity, 83%; PPV, 79%; NPV, 94%; and urea nitrogen AUROC, 0.95 [95%CI, 0.94, 0.96]; sensitivity, 87%; specificity, 89%; PPV, 77%; NPV 94%).

 This approach goes further than this book:

It's always about quality

La qualité des services de santé. Un impératif mondial en vue de la couverture santé universelle

Improving healthcare quality in Europe. Characteristics, effectiveness and implementation of different strategies

The essential element of access to healthcare overshadows the understanding that better health can only be achieved if accessed services are also of high quality. The Sustainable Development Goals spell this out quite clearly: “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” (Goal 3, Target 8). Indeed, ensuring that healthcare services are of good quality is an imperative for policy-makers at all levels and an important contributor to health system performance.

Oriol Maspons