Five levels of care integration

 The importance of understanding and measuring health system structural, functional, and clinical integration

A helpful framework on integrated care from the Health Services Research article:

The framework focuses on how systems are structured and governed, what people who work in the system believe and how they behave, and activities intended to integrate patient care into a single coordinated process within the system. We chose this model because, while there are many different ways to characterize health systems, we wanted to focus on those characteristics that might prove to be meaningful with regard to performance differences.

Hypothetical relationships are depicted in the model using arrows that move from left to right. The five types of integration depicted in the model (structural, functional, normative, interpersonal and process integration) are hypothesized to effect intermediate and ultimate outcomes. From Singer SJ, Kerrissey M, Friedberg M, Phillips R. A Comprehensive Theory of Integration. Med Care Res Rev. 2020;77(2):204, Sage Publications, Inc. 

• Structural integration (physical, operational, financial, or legal ties among operating units within a system)
• Functional integration (formal, written policies, and protocols for activities that coordinate and support accountability and decision making among operating units)
• Process (or clinical) integration (actions or activities intended to integrate patient care across people, functions, activities, and operating units within the system). In our discussion, we refer to this as clinical integration.

Structural and functional integration are under the direct control of system executives. Our intent was to understand the kinds of strategic decisions they were making, why they made them, and how they saw their decisions affecting their goals for their systems. Understanding the organizations that make up the systems and the extent to which systems are structurally and functionally integrated is a vital starting point for understanding whether process/clinical integration is happening within systems, how it is happening, or indeed whether it is even possible.

Two additional types of integration—normative and interpersonal. 

Normative integration refers to sharing a common culture; interpersonal integration refers to collaboration or teamwork.

Economics and epidemiology

An Economist's Guide to Epidemiology Models of Infectious Disease 

Bossert et al provide some useful information on the structure and use of epidemiology models of disease transmission, with an emphasis on the susceptible/infected/recovered (SIR) model. And they discuss high-profile forecasts of cases and deaths that have been based on these models, what went wrong with the early forecasts, and how they have adapted to the current COVID pandemic. 

Understanding the process by which these models’ predictions and insights can be accessed by policymakers has also gained importance. The normal process of writing, vetting, and publishing scientific and economic research is being stretched to its limits given the urgency of the pandemic. Direct and wide dissemination can work for certain types of knowledge: detailed predictions from empirical models lend themselves to the now ubiquitous COVID “dashboards” that make those predictions available to policy-makers and others with just a click or two. There is no reason to believe that the models which have the best designed websites and interfaces are the ones producing the most careful and accurate predictions, though. Conveying more subtle insights, such as how government policies might interact with endogenous social distancing, seems substantially more difficult but no less important. One would hope that robust lines of communication and established respectful relationships between experts and policy-makers could facilitate such dialogues.

 

Climate and health

 Estimating The Costs Of Inaction And The Economic Benefits Of Addressing The Health Harms Of Climate Change

From Health Affairs issue on Climate and Health, first of all:

To accurately describe the health-related costs of climate change, it is important to distinguish between key terms. Climate-sensitive exposures (such as ozone smog air pollution, extreme heat, and extreme precipitation) and health outcomes include those with demonstrated responses to one or more meteorological variables or seasonal patterns.6,7 In recent years, statistical analyses have enabled detection and attribution of the influence of human-caused climate change on extreme weather and other climate-related exposures.8 These climate change–related impacts on the environment include incremental contributions to the frequency and magnitude of extreme rainfall during hurricanes8,9 and increased temperatures during heat waves,10 among others. It is not yet possible to apply analogous methods to directly quantify the attributable portion of climate-sensitive health outcomes to the incremental effects of climate change, as preexisting medical conditions, health vulnerabilities, and multiple exposures are among the many health determinants and causal factors involved. There is currently a knowledge gap that must be addressed for more complete understanding of climate change–related exposure-response relationships.´

Therefore, 

 Expanded valuation analyses of the costs of climate-sensitive health outcomes are urgently needed to inform public policy. The findings from such studies can be linked to provide a sense of the overall scope of health costs from climate change in communities, cities, states, regions, and countries.

At present, it is difficult to characterize the costs of health harms linked to climate-sensitive exposures in the US. Given the current inability to comprehensively track recent damage, there is limited understanding of the scope of projected future climate-sensitive health risks and costs. 

So, there is not any estimate of inaction so far. 

Profiling complex patients

 Use of Latent Class Analysis and k-Means Clustering to Identify Complex Patient Profiles

Instead of predictive modeling using costs, this is the right approach from a clinical point of view:

This cohort study analyzed the most medically complex patients within Kaiser Permanente Northern California, a large integrated health care delivery system, based on comorbidity score, prior emergency department admissions, and predicted likelihood of hospitalization, from July 18, 2018, to July 15, 2019. From a starting point of over 5000 clinical variables, we used both clinical judgment and analytic methods to reduce to the 97 most informative covariates. Patients were then grouped using 2 methods (latent class analysis, generalized low-rank models, with k-means clustering). Results were interpreted by a panel of clinical stakeholders to define clinically meaningful patient profiles.

And the figures below reflect these results.

Great article.

Figure 1.  Seven Patient Profiles Derived From Latent Class Analysis

 

Figure 2.  Comparison of k-Means Clustering With Latent Class Analysis (LCA)

Table 1.  Baseline and 1-Year Follow-up Characteristics of the Overall Population and by Patient Profile

Table 2.  Key Defining Features and Suggested Management Strategies for the 7 Clinical Profiles of Medically Complex Patients

How plagues end

Apollo's Arrow. The Profound and Enduring Impact of Coronavirus on the Way We Live

From the book:

After its dramatic initial appearance, SARS-2 will ultimately become endemic; it will regularly circulate among us at some low, steady level. This is connected to the second kind of end, which we have already considered: herd immunity. Here, the pathogen is still around, but it has a much more difficult time reestablishing itself. This resembles a well-vaccinated population for any infectious disease; there are only occasional, small outbreaks among nonimmune people.

By 2022 or so, we will reach this outcome naturally or via vaccination. Of course, if we do rapidly develop and distribute a safe and effective vaccine, we could reach herd immunity with fewer deaths. Based on the fundamental R0 of SARS-2, as we saw in chapter 2, up to an estimated 60 to 67 percent of the population could be affected (or roughly two hundred million people in the United States). The necessary percentage could be lower, closer to 40 to 50 percent, given that social network structure means that different people spread the virus to different extents (as we also saw in chapter 2); or it could be higher, if the epidemic moves extremely fast and we overshoot the level required for herd immunity. Whatever the exact percentage, as a pathogen spreads, some people will die and others will recover and become immune, so eventually the virus will run out of places to go. This is the ordinary, natural way that, biologically speaking, epidemics end.

This is what we mean when we say that a pathogen is under control. But sometimes, plagues are so devastating that a society never recovers. It’s very important to emphasize that, as bad as COVID-19 is, it’s not remotely as bad as epidemics of bubonic plague, cholera, or smallpox that have killed much larger fractions of the population and that have had much larger and longer-lasting effects. Those types of plagues are even associated with the iconography of the Four Horsemen of the Apocalypse, Pestilence riding side by side with War, Famine, and Death. Those epidemics vindicated the adage that “too few of the living were left to bury the dead.”

N. Christakis says at the begining of the book 

The god Apollo, for example, was both a healer and the bringer of disease. During the Trojan War, with his silver bow and quiver of arrows, he rained a plague down on the Greeks to punish them for kidnapping and enslaving Chryseis, the daughter of one of his favored priests.

I found myself thinking again about Apollo and his vengeance as I contemplated our own twenty-first-century barrage more than three thousand years after the events described in The Iliad. It seemed to me that the novel coronavirus was a threat that was both wholly new and deeply ancient. This catastrophe called on us to confront our adversary in a modern way while also relying on wisdom from the past.

Excerpts from the last chapter, How plagues end: 

The pathogens evolve to respond to us, but we, at a slower pace, also evolve to respond to them. Infectious diseases have been a part of our evolutionary history for so long that they have left a mark on our genes. For instance, humans have evolved genetic changes that have proven useful in coping with malaria beginning over one hundred thousand years ago, tuberculosis over nine thousand years ago, cholera and bubonic plague over six thousand years ago, and smallpox over three thousand years ago.36

Infectious pathogens (even if nonepidemic) have arguably been a crucial selective pressure throughout the evolution of our species.37 The primary killers of human beings across evolutionary time are other human beings. Humans do not have any natural predators that substantially affect survival.38 Except for our microscopic enemies.

The SARS-2 virus is a lot less lethal to people of reproductive age and can be combated with the lifesaving tools of modern medicine, so the impact on human evolution is surely going to be minimal. But, at least in theory, another way epidemics end is that hosts evolve to be resistant. And in fact, we may already have naturally occurring genetic variation in our species that affects the severity of COVID-19 in different populations, which would lay the groundwork for such evolution. Over generations, this can result in changes to the genetic makeup of the afflicted populations.

 This social construction of COVID-19 means that the end of the pandemic can also be socially defined. In other words, plagues can end when everyone believes they are over or when everyone is simply willing to tolerate more risk and live in a new way. If everyone willingly risks infection and resumes a semblance of normal life (or, implausibly, if everyone decides to employ physical distancing forever), then the epidemic can be said to have ended, even if the virus is still circulating. We got a glimpse of this phenomenon as well in the summer of 2020 as different states, tired of the lockdowns, acted as if the epidemic were over, even though, biologically speaking, it was not. It was wholly understandable that everyone was eager to leave the epidemic behind as quickly as possible. But the epidemiological reality did not submit to our desires. The pandemic was still claiming roughly a thousand lives per day, although Americans seemed inured to it. Many people, and not just self-interested politicians, seemed to believe the SARS-2 epidemic could end by fiat.

Last paragraph:

 Microbes have shaped our evolutionary trajectory since the origin of our species. Epidemics have done so for many thousands of years. Like the myth of Apollo’s arrows, they have been a part of our story all along. We have outlived them before, using the biological and social tools at our disposal. Life will return to normal. Plagues always end. And, like plagues, hope is an enduring part of the human condition.

A must read. This is my preferred book reference on current pandemic.

 

Figure 16: The mortality impact of COVID-19 in the United States can be quantitatively compared to that of other modern epidemics.

Nudging effectiveness

 The effectiveness of nudges in improving the self-management of patients with chronic diseases: A systematic literature review

From a review article:

We identified 26 studies, where 13 were of high or moderate quality. The most commonly tested nudges were reminders, planning prompts, small financial incentives, and feedback. Overall, 8 of 9 studies with a high or moderate quality ranking, focused on self-management outcomes, i.e., physical activity, attendance, self-monitoring, and medication adherence, found that nudges had significant positive effects.However, only 1 of 4 studies of high or moderate quality, analyzing disease control outcomes (e.g.,glycemic control), found that nudges had a significant positive effect for one intervention arm.In summary, this review demonstrates that nudges can improve chronic disease self-management, but there is hardly any evidence to date that these interventions lead to improved disease control. Reminders,feedback, and planning prompts appear to improve chronic disease self-management most consistently and are among the least controversial types of nudges.

And the message:

 There is hardly any evidence to date that these interventions lead to improved disease control.

So now what?

Cartier Bresson

 

Episode based payments (3)

 Medicare's Bundled Payment Initiatives for Hospital‐Initiated Episodes: Evidence and Evolution

The Impact of Medicare’s Alternative Payment Models on the Value of Care

Bundled payments have been promoted as an alternative to fee‐for‐service payments that can mitigate the incentives for service volume under the fee‐for‐service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality.

Main messages:

•  Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee‐for‐service contracting, although bundled payment models may not reduce absolute costs.
• Bundled payments may be more effective than fee‐for‐service payments in containing costs for certain medical conditions.
• For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions.
• Bundled payment contracting involves trade‐offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee‐for‐service payment.

Both articles reflect the current situation on payment systems in US. The effort to change fee-for-service is more difficult than expected. There is a lot of money at stake.

 

The Gossips by Norman Rockwell

Atul Gawande on this pivotal moment

 Atul Gawande on Taming the Coronavirus

Can a vaccine be distributed fairly? What will be the impact of a large number of people not taking it—as they say they won’t? Atul Gawande, a New Yorker staff writer who was recently appointed to President-elect Joe Biden’s covid-19 task force, walks David Remnick through some of the challenges of this pivotal moment

 And in FT:  "I do think that the fundamental disaster of the United States is tying where you get your healthcare to where you work,"

Agree

 Podcast in The New Yorker radio:

Unwarranted variation in clinical practice

 Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems

Variation is not bad or unwarranted per se. To some extent, variation should always exist, because patients are unique and different. Care could be called appropriate when decisions reflect such differences, especially differences in informed patient preference [1].

Variation may be unwarranted when it cannot be explained by sensitivity to patient characteristics or well-informed preferences. In this perspective, we propose alternative hypotheses for mechanisms underlying unwarranted variation in healthcare and  propose new target points for research to better understand, reduce and improve unwarranted variation in care quality in daily medical practice.

 A key element in this new focus in research should be on the complex cohesion of network effects, reflective medicine, patient beliefs and objective criteria for treatment choices.

After all these years and the large amount of research on variations in medical practice, it's time to act. 

Shara Hughes

 

The social media industrial complex and the tiranny of trends

 The hype machine

From the book:

We’ve constructed an expansive, multifaceted machine that spans the globe and conducts the flow of information, opinions, and behaviors through society. This Hype Machine connects us in a worldwide communication network, exchanging trillions of messages a day, guided by algorithms, designed to inform, persuade, entertain, and manipulate us.

The object of this machine is the human psyche. It was designed to stimulate our neurological impulses, to draw us in and persuade us to change how we shop, vote, and exercise, and even who we love. It analyzes us to give us options for what to read, buy, and believe. It then learns from our choices and iteratively optimizes its offerings. As it operates, it generates a data exhaust that traces each of our preferences, desires, interests, and time-stamped, geolocated activities around the world. It then feeds on its own data exhaust, refining its process, perfecting its analysis, and improving its persuasive leverage. Its motivation is money, which it maximizes by engaging us. The more precise it gets, the more engaging and persuasive it becomes. The more persuasive it becomes, the more revenue it generates and the bigger it grows. This is the story of the Hype Machine—the social media industrial complex: how it was designed, how it works, how it affects us, and how we can adapt to it.

 

 

What is the alternative to Friedman’s capitalism?

 Milton Friedman 50 Years Later

Angus Deaton says:

“Milton Friedman was one of the foremost thinkers who challenged the post-war Keynesian consensus. He was immensely successful in arguing the pro-market case, and questioning the ability of government to improve on market outcomes. Today, we need to reopen these questions, using new economic thinking and new evidence; is the market bringing the unalloyed benefits that Friedman thought it would? This book is an important contribution to that reevaluation,”

And this is the capitalism that Martin Wolf expects:

“in which companies would not promote junk science on climate and the environment; it is one in which companies would not kill hundreds of thousands of people, by promoting addiction to opiates; it is one in which companies would not lobby for tax systems that let them park vast proportions of their profits in tax havens; it is one in which the financial sector would not lobby for the inadequate capitalisation that causes huge crises; it is one in which copyright would not be extended and extended and extended; it is one in which companies would not seek to neuter an effective competition policy; it is one in which companies would not lobby hard against efforts to limit the adverse social consequences of precarious work; and so on and so forth.”   

 

The largest global public-health initiative

 The COVID-19 vaccines are here: What comes next?

From McKinsey:

As vaccine availability nears, communities and consumers will want answers to many questions, including:

• Is the vaccine effective and safe?
• Who will get vaccinated first?
• Which vaccine will we receive, especially if multiple vaccines are available?
• Where and when can we get vaccinated?
• Will we have to pay?
• Above all, what do we need to worry about?

Although the scale of the task may seem daunting, countries benefit by starting end-to-end planning immediately. Our 6A framework lays out a structured approach to ensure vaccines are available, administrable, accessible, acceptable, affordable, and accountable while taking into account strategic considerations associated with uncertainty (for example, vaccine clinical and technical profile) and building system capabilities (Exhibit 2). We have developed, in granular detail, the individual activities and considerations behind each component of the framework. Through the collective initial effort of the pharma industry, the scientific community, global health institutions, and governments, most elements of the “available” segment of the 6A journey are being addressed

 

Paul Strand

 

Platforms as essential services

Essential Platforms

Competition in Digital Markets 

Imagine you own a company, and you see millions of potential customers for a new product. But there is a problem: all these customers live on the other side of a river and the only way to reach them leads over a privately owned bridge. The owner of that sole bridge either prevents you from passing altogether or charges excessive fees. Long story short, if that is the case, this product line and, potentially, your entire business are doomed.

 Digital platforms can behave in that manner because they do not face serious competition. The platforms’ monopoly power mainly stems from network effects—that means the participation of additional users almost exponentially increases the utility of the network and creates enormous market entry barriers for potential competitors. The characteristics of data and algorithms further foreclose the markets.

 Google, Amazon, Facebook, Apple, and others behave just like the railroads did 100 years ago. Instead of physical infrastructure, like bridges and tunnels, the digital platforms leverage network effects that shield them from effective competition. 

To define the suitable remedies and to open the digital economy for competition, we can learn from the past. In the early twentieth century, the railroads controlled critical infrastructure and excluded competitors from crucial markets. The railroad monopolies rested on enormous investments in physical infrastructure that could not be replicated.

After all these years, a clear message, while the regulator is still on vacation. 

 

 

 

Rethinking technology evaluation

 Reviewing our methods for health technology evaluation: consultation