June 12, 2020

Primary Care value and physician compensation

Realising the Potential of Primary Health Care

If Primary Care is so important why so few physicians choose it as specialty for the residency programs?. The answer is that there is a difference in perception of value and compensation. Well, this is only the first answer. High value, high effort and low relative compensation compared to other specialties. Governments should care about it and about integrated care is finally organised. This is what OECD report says:
These new models of organisation should be more widely adopted to move away from the traditional and reactive solo-practice model. While there is no one-size-fits-all model of organisation, an integrated model of primary health care often meets the following four characteristics:
 Multi-disciplinary or inter-professional practices with a various mix of primary health care professionals (including GPs or family physicians, registered and advanced nurses, community pharmacists, psychologists, nutritionists, health counsellors, and non-clinical support staff), different models of teamwork, and different target populations (for example as seen in Australia, Canada, the United Kingdom and the United States) (Socha-Dietrich, 2019[101]).
 Comprehensive health services in the community, (for example in Costa Rica), including disease prevention and health promotion, curative services, rehabilitation and management of chronic diseases. Care co-ordination between health professionals is key to enabling the early detection of disease, reducing the exacerbation of diseases, avoiding duplication of services, and increasing provider and patient satisfaction.
 Population health management, generally based on risk stratification using sophisticated IT systems (for example in Canada and Spain), is implemented to better understand the health and risk profiles of the community and to undertake proactive management of patients’ needs. Patients are stratified to identify opportunities for intervention before the occurrence of any adverse outcomes for individual health status.
 Engagement of patients in shared decision making,


June 10, 2020

Precision medicine, here and now

Great article by David Cutler. The time for the returns of precision medicine has arrived in his opinion.
Precision medicine raises hopes for patients and fears for those who try to ride herd on health care spending. Will patients finally live longer and healthier lives? Will society be able to afford it? Surprisingly, at this point, personalized medicine has had less effect on both health and medical spending than either its strongest backers hoped or its most apprehensive actuaries feared.
 To date, total spending on anticancer drugs has been relatively modest. Although inflation-adjusted spending on anticancer drugs increased by $30 billion between 2011 and 2018, this is only 6% of the total increase in personal health care spending over the period. Given that administrative expenses cost an estimated 4 times the amount spent on anticancer drugs, one should be cautious about focusing excessively on the cost of precision medicine.
A better metric than total spending is cost effectiveness: do the benefits of the drugs outweigh the cost? The “drug abacus” tool developed by Memorial Sloan Kettering Cancer Center, which evaluates the cost-effectiveness of 52 anticancer drugs approved between 2001 and 2013, estimates that only a handful of new drugs are worth the cost at conventional valuations of life. If anticancer drugs were priced based on cost-effectiveness criteria, spending would fall by 30%.
This is a US based article, we need some estimates of our health system.


June 9, 2020

Regulating voluntary health insurance

La regulació de l'assegurança voluntària de salut

Market inefficiencies can be eased with proper regulation. In a specific issue of Revista Economica de Catalunya, you'll find an article that I've written on the topic.
There is a specific and actionable proposal to improve the current situation.
Voluntary insurance in Catalonia covers 26% of citizens, possibly the most widely used duplicate insurance in Europe. Given its relevance, the regulator has to decide whether to consider the set of market failures shown in this article and act or, in contrast, put it to one side and watch its impact increase over time. For now, it is clear that government has chosen the second option.
Considering that health is such a highly valued asset individually, surely the public deserves a satisfactory response.
I can't summarise all details here. I suggest a close look at the article and the remaining ones in the same issue.

June 8, 2020

Covid-19 testing landscape

COVID-19 diagnostics in context

This is the best summary of current supply of diagnostic tests for Covid-19:
COVID-19 tests can be grouped as nucleic acid, serological, antigen, and ancillary tests, all of which play distinct roles in hospital, point-of-care, or large-scale population testing.
Table 1 summarizes the existing and emerging tests, current at the time of writing (May 2020). A continuously updated version of this table is available at https://csb.mgh.harvard.edu/covid
Eric Topol says:
There are now *88* @US_FDA  cleared (by EUA) #COVID19 tests so far. Their false negative rates range from 10-48% (by post-release reports).
Might be better to have less tests, more accuracy, with faster turnaround
I agree.

Table 1 Performance comparison of different test types.
Throughput is determined by process type and assay time. In general, automated plate-based assays have higher daily throughputs. Hashtag (#) indicates example systems that have received FDA emergency use authorization (FDA-EUA). See https://csb.mgh.harvard.edu/covid to access continuously updated information. PCR, polymerase chain reaction; PCR-POC, PCR–point-of-care; ddPCR, digital droplet PCR; NEAR, nicking endonuclease amplification reaction; RCA, rolling circle amplification; SHERLOCK, specific high-sensitivity enzymatic reporter; DETECTR, DNA endonuclease-targeted CRISPR transreporter; NGS, next-generation sequencing; μNMR, micro–nuclear magnetic resonance; LFA, lateral flow assay; ELISA, enzyme-linked immunosorbent assay; CLIA, chemiluminescence immunoassay; EIA, enzyme immunoassay; ECLIA, electrochemiluminescence immunoassay; ECS, electrochemical sensing; VAT, viral antigen assay; IFM, immunofluorescence microscopy; WB, Western blot.

TypeTargetVirusAssay timeProcess typeFDA-EUAExamples
PCRViral RNASARS-CoV-22–8 hours; >12 hoursPlate56#Roche, #LabCorp,
#Becton Dickinson,
#Luminex, #Thermo
Fisher, others
PCR-POCViral RNASARS-CoV-2<1 hour="" td="">Cartridge2#Cepheid, #Mesa,
ddPCRViral RNASARS-CoV-22–4 hoursManual1#BioRAD
NEARViral RNASARS-CoV-215 minCartridge1#Abbott
OMEGAViral RNASARS-CoV-21 hourPlate1#Atila BioSystems
RCAViral RNASARS-CoV2 hours0
SHERLOCKViral RNASARS-CoV-21.5 hoursKit1#Sherlock
DETECTRViral RNASARS-CoV-21 hourKit0Mammoth
NGSViral RNASARS-CoV-2Days1#IDbyDNA, Vision,
μNMRViral RNASARS-CoV-22 hoursCartridge0T2 Biosystems
LFAIgG, IgMSARS-CoV-215 minCartridge3#Cellex,
#ChemBio, Innovita
ELISAIgG, IgMSARS-CoV-22–4 hoursPlate4#Mount Sinai,
#Ortho-Clinical (2),
Inc., BioRAD, Snibe,
Zhejiang orient,
Creative Dx
CLIAIgG, IgMSARS-CoV-230 minCartridge2#Abbott, #DiaSorin
EIAIgG, IgMSARS-CoV-22 hoursPlate1#BioRAD
MIAIgG, IgMSARS-CoV-2Plate1#Wadsworth Center
ECLIAIgG, IgMSARS-CoV-220 minPlate1#Roche
ECSIgG, cytokineSARS-CoV-21 hourCartridge0Accure Health
VATViral antigenSARS-CoV-220 minCartridge1#Quidel, Sona NT,
RayBiotech, SD
Biosensors, Bioeasy
MicroarraysIg epitopesSARS-CoV-21.5 hoursPlate0RayBiotech,
IFMViral proteinSARS-CoV3 hoursManual0
WBIgG, IgM; viral proteinSARS-CoV4 hoursManual0

June 7, 2020

Intercepting symbiomes

Intercepting pandemics through genomics

It makes sense:
There is an urgent need to establish a global, genomic-based biosurveillance platform, a developmentwhich would be of immense value to biosecurity, biodefense, and the economy. If implemented, this“pandemic interception system” would hugely advance our understanding of the natural world. Three major research programs are poised to support this effort: BIOSCAN, the Earth BioGenome Project (EBP), and the Global Virome Project (GVP). Each of these global programs is now working to develop approaches in comparative genomics that are needed to discover all species and to reveal their interactions. The diversity of infectious agents involved in host–pathogen interactions needs immediate clarification, especially  with regard to those agents that transfect phylogenetically divergent lineages.
A pandemic interception system needs to be based on detailed knowledge of symbiomes, which are the constellations of organisms that interact with all multicellular species. Efforts to describe the structure of symbiomes are motivated by the fact that parasites, parasitoids, and microbes can devastate host populations, especially those that are evolutionarily naïve. Symbiome complexity is governed by rules.

Daido Moriyama

June 6, 2020

Tackling COVID-19 beyond testing

How We Can Tackle the COVID-19 Crisis Beyond Testing

If you wear a smartwatch or fitness tracker, you can play a role in monitoring the spread of COVID-19 and other viral diseases like the flu. In this Front Row lecture, Eric Topol, MD, and Jennifer Radin, PhD, discuss how they’re calling on the public to share data from wearable devices for a study that’s helping scientists flag the early onset of contagious respiratory illnesses. By harnessing this key data—including heart rates, sleep and activity levels—from hundreds of thousands of individuals, they seek to improve real-time disease surveillance.