Archivi delle etichette: HTA

Multiplicity: il contributo di @richard56 Smith al Convegno per Alessandro Liberati @Medici_Manager

In attesa degli atti completi! Un convegno ispirato a Italo Calvino e le sue “Lezioni americane: sei proposte per il prossimo millennio”.

Quali ispirazioni può ricavare la sanità dalla letteratura! Un libro da leggere, rileggere, studiare.

http://slidesha.re/XiQY2d

The Effective Health Care Program (AHRQ) @Medici_Manager

Comparative effectiveness research is designed to inform health-care decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. The evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care.

There are two ways that this evidence is found:

  • Researchers look at all of the available evidence about the benefits and harms of each choice for different groups of people from existing clinical trials, clinical studies, and other research. These are called research reviews, because they are systematic reviews of existing evidence.
  • Researchers conduct studies that generate new evidence of effectiveness or comparative effectiveness of a test, treatment, procedure, or health-care service.

Comparative effectiveness research requires the development, expansion, and use of a variety of data sources and methods to conduct timely and relevant research and disseminate the results in a form that is quickly usable by clinicians, patients, policymakers, and health plans and other payers. Seven steps are involved in conducting this research and in ensuring continued development of the research infrastructure to sustain and advance these efforts:

  1. Identify new and emerging clinical interventions.
  2. Review and synthesize current medical research.
  3. Identify gaps between existing medical research and the needs of clinical practice.
  4. Promote and generate new scientific evidence and analytic tools.
  5. Train and develop clinical researchers.
  6. Translate and disseminate research findings to diverse stakeholders.
  7. Reach out to stakeholders via a citizens forum.

Common questions about comparative effectiveness research

Q: Why is comparative effectiveness research needed? What problem is it trying to solve?

  • If you don’t get the best possible information about your treatment choices, you might not make an informed decision on what treatment is best for you.
  • When you shop for a new car, phone or camera, you have lots of information about your choices. But when it comes to choosing the right medicine or the best health-care treatment, clear and dependable information can be very hard to find.
  • It’s true that some treatments may not work for everyone, and that some treatments may work better for some people than others. This research can help identify the treatments that may work best for you.

Q: What are the practical benefits of comparative effectiveness research?

  • You deserve the best and most objective information about treating your sickness or condition. With this research in hand, you and your doctor can work together to make the best possible treatment choices.
  • For example, someone with high blood pressure might have more than a dozen medicines to choose from. Someone with heart disease might need to choose between having heart surgery or taking medicine to open a clogged artery. Reports on these topics and others include the pros and cons of all the options so that you and your doctor can make the best possible treatment decision for you or someone in your family.
  • Every patient is different — different circumstances, different medical history, different values. These reports don’t tell you and your doctor which treatment to choose. Instead, they offer an important tool to help you and your doctor understand the facts about different treatments.

http://www.effectivehealthcare.ahrq.gov

http://www.effectivehealthcare.ahrq.gov/index.cfm/glossary-of-terms/

Recommended Reading: Reflecting on the Choosing Wisely Journal Articles of 2012 @Medici_Manager @ABIMFoundation

Written by Amy Cunningham on December 21, 2012

Since nine medical specialty societies announced their lists of “Five Things Physicians and Patients Should Question” in April, 55 published journal articles have referenced the Choosing Wisely® campaign. For the final Recommended Reading post of 2012, we’ve culled a selection of those articles, and will share more in the new year.

In order of publication date:

  • In From an Ethics of Rationing to an Ethics of Waste Avoidance, Howard Brody argued for a stepwise strategy to eliminate unnecessary care given the limitations of comparative-effectiveness research, saying, “it is better first to eliminate interventions for which we have the most solid and indisputable evidence of a lack of benefit.”
  • In Application of “Less Is More” to Low Back Pain, the authors found strong evidence supporting the American Academy of Family Physicians’ recommendation as part of theChoosing Wisely campaign, “Don’t do imaging for low back pain within the first 6 weeks unless red flags are present.” The article was accompanied by a commentary by ABIM Foundation Executive Vice President and Chief Operating Officer Daniel Wolfson.
  • In the New England Journal of Medicine article, A Systemic Approach to Containing Health Care Spending, Ezekiel Emanuel, MD, PhD and co-authors outlined a number of recommendations for bending the health care cost curve, including the development of credible practice guidelines.
  • British Medical Journal piece on unnecessary care said that a “newly launched movement lead by prominent doctors is challenging the basic assumption in U.S. healthcare that more is better” and cited Choosing Wisely as part of the movement
  • Authors of a JAMA commentary mentioned the Choosing Wisely campaign as one of several recent initiatives addressing the physician’s role in health care expenditures. They then call for a new model of medical education that celebrates restraint in ordering health care tests and procedures.
  • An Annals of Internal Medicine piece discussed the potential impact of Choosing Wisely recommendations for radiology and argues, “Current campaigns that draw attention to overuse of imaging studies coupled with greater physician knowledge and use of the criteria for appropriate imaging can help to ensure a further reduction in unnecessary testing—a result that would benefit both patients and our health care system.”
  • In Choosing Wisely: Low-Value Services, Utilization, and Patient Cost Sharing, researchers from the University of Pennsylvania reflected on the Choosing Wisely campaign and asked, “But if it is difficult in many situations for patients to choose wisely, and if there are significant challenges in getting physicians to choose wisely, then who should be doing the choosing?”

We look forward to continuing the conversations on professionalism and Choosing Wisely in 2013, and wish our readers a happy and healthy new year.

How many times have you done this procedure, Doc? @Medici_Manager @kevinmd

Questions such as this from proactive, increasingly knowledgeable patients place a physician on the horns of an ethical dilemma.  Although fellows are closely supervised and trained under a gradually increasing responsibility principle (based upon subjective evaluation), a time will come when there is no one available to back you up in the catheterization lab.

Fact: Someone has to be a physician’s first case of any given type. However, no one really wants to be that person.

Access to extensive medical information on the web has satiated some of our patient’s desire for information and expectations regarding medical procedures, which is a good thing. However, increased transparency and public awareness of medical errors has opened up a Pandora’s box regarding a physician’s skill level and experience.  The September 2012 issue of Men’s Health went as far as publishing peer reviewed data regarding the minimum numbers for particular procedures taken directly from medical journals. Specifically, coronary angioplasty and angiography minimums were reported as 50 and 82 procedures respectively.

Take home message: Hard numbers to meet your first month into fellowship.

Similar experience-responsibility disparities exist in commercial aviation.  However, in contradistinction to the patient-doctor encounter, passengers are neither cognizant of their captain’s flight hours nor face-to-face prior to boarding.  Further increasing the stakes, a new pilot’s first manifest could be 50 passengers or more. In response to public demand for greater safety, the airline industry was an early adopter of systems to increase reliable pilot performance including flight simulation technology and pre-flight checklists, which were quite effective in reducing fatal incidents for air travelers.  As a result, the latest National Safety Council in the U.S.A. calculated the lifetime odds of death for flying to be 1:7178 in 2008 compared to 1:98 for automobile deaths.

Interestingly, even experienced pilots are required scheduled simulation training to maintain their skills and prepare for rare-but-catastrophic events, which cannot be realistically produced in the air.  The auto industry, unique in their in inability to increase motorists’ skills, have been forced to develop safety technology to make the highways safer.

Reality check: Patients do not come with air bags or crash sensors.  Simulation and checklists are proven methods to increase safety.

Virtual reality simulation training programs allow students of all levels to gain familiarity with equipment selection, proficiency of the detailed steps for a given procedure as well as an awareness of the potential pitfalls and crucial moments in a safe environment. Furthermore, under experienced tutelage during practice, a modicum of fingertip finesse may be learned prior to laying hands upon their first patient.

While “ain’t nothing like the real thing” is unarguably the best way to learn any motor skill, having solid theoretical and practical experience makes the transition to live cases easier and might ameliorate the patient’s and the beginner’s shakes.

Max Berry is a vascular and interventional radiology fellow.

http://www.kevinmd.com/blog/2012/10/times-procedure-doc.html

Solving the Health Care Cost Challenge: Leveraging RAND Expertise @Medici_Manager @RANDCorporation

In its second term, the Obama Administration and the 113th Congress must address the relentless growth of health care spending, a major contributor to America’s long-term fiscal imbalance.

Growing health care spending is fueling the federal budget deficit, crowding out other priorities in state budgets, hindering the competitiveness of American businesses, restraining job growth, and jeopardizing the finances of American families. Victor Fuchs, considered by many to be the father of health economics,summarized the enormous payoff of confronting this issue: “If we solve our health care spending, practically all of our fiscal problems go away.”

However, while there is no lack of ideas for how to slow spending, action is hindered by a lack of consensus.

In a series of research briefs dedicated to flattening the trajectory of health care spending, RAND Health outlines four broad strategies for constraining spending growth in our market-oriented health care system:

http://www.rand.org/health/feature/health-care-cost.html

Letture consigliate per l’health technology assessment @Medici_Manager @SIHTA_Italia

Letture consigliate:

Goodmann Cl.: HTA 101 Introduction to health technology assessment, National Library of Medicine, 2004, http://www.nlm.nih.gov/nichsr/hta101/hta101.pdf

Topfer L.A e Auston I. (Eds.): Etext on Health Technology Assessment (HTA) Information Resources, National Library of Medicine, 2006,  http://www.nlm.nih.gov/archive//20060905/nichsr/ehta/ehta.html

Francesconi A.: Innovazione organizzativa e tecnologica in sanità: il ruolo dell’health technology assessment, Franco Angeli/Sanità, 2007

Cicchetti A. (Ed.): Introduzione all’health technology assessment, Il Pensiero Scientifico Editore, 2008

Health Equality Europe: Comprendere l’health technology assessment, Italian Journal of Public Health, 2009

Favaretti C., Cicchetti A., Guarrera G., Marchetti M. e Ricciardi W.: Health technology assessment in Italy, Intl. J. of Technology assessment in Health Care, 2009, 25: Supplement 1, 127-133, http://www.carlofavaretti.it/pdf/art_HTA_Italy_2009.pdf

Ricciardi W. e La Torre G.: Health technology assessment: principi, dimensione e strumenti, SEEd, 2010

De Rosa M. e Scroccaro G. (Eds): L’applicazione delle tecniche di HTA alla valutazione di farmaci e dispositivi medici, Infosan, 2010

Cicchetti A. e Marchetti M. (Eds.) Manuale di health technology assessment, Il Pensiero Scientifico Editore, 2010

Drummond M.F., Sculpher M.J., Torrance G.W., O’Bien B.J., Stoddart G.L.: Metodi per la valutazione economica dei programmi sanitari, Il Pensiero Scientifico Editore, 2011, (Edizione italiana a cura di Mennini F.S., Cicchetti A., Fattore G. e Russo P.L.)

Favaretti C.: La valutazione della tecnologia sanitaria: omogeneità o difformità, in Falcitelli N., Gensini G.F., Trabucchi M. e Vanara F. (a cura di): Fondazione Smith Kline Rapporto Sanità 2010 – Federalismo e Servizio sanitario nazionale, Il Mulino, 2010, 201-212

Autori vari SIHTA: Clinical Governance, 2007 (agosto)

http://www.carlofavaretti.it/pdf/art_clinicalgov_2007_3.pdf

Clinical Governance, 2008, 1

http://www.carlofavaretti.it/pdf/art_clinicalgov_2008_1.pdf

Favaretti C., De Pieri P., Fontana F., Guarrera G.M., Debiasi F., Betta A. e Baldantoni E.: La governance clinica nell’esperienza dell’Azienda provinciale per i servizi sanitari di Trento, in Wright J. e Hill P.: La governance clinica, McGraw-Hill,  2005, XXI-LXI, http://www.carlofavaretti.it/pdf/art_governance_2005.pdf

http://www.slideshare.net/carlofavaretti/letture-consigliate-per-hta

Livelli Essenziali di Assistenza: la grande incompiuta? @Medici_Manager @SIHTA_Italia @GIMBE

Le recenti valutazioni del Presidente Monti sulla limitata sostenibilità della sanità pubblica hanno seminato il panico tra tutti gli stakeholders della sanità italiana.

In questo scenario particolarmente critico per il SSN, spettatore di un perenne conflitto tra Governo e Regioni che ha portato perfino alla mancata sottoscrizione del Patto della Salute, è quanto mai istruttivo rileggere tre principi dievidence-based policy making enunciati dal DPCM 21 novembre 2001 che ha introdotto i Livelli Essenziali di Assistenza (LEA).

1. “I LEA includono tipologie di assistenza, servizi e prestazioni sanitarie che presentano, per specifiche condizioni cliniche, evidenze scientifiche di un significativo beneficio in termini di salute, individuale o collettiva, a fronte delle risorse impiegate”.

2. “I LEA escludono tipologie di assistenza, servizi e prestazioni sanitarie che:

  • non rispondono a necessità assistenziali tutelate in base ai principi ispiratori del SSN;
  • non soddisfano il principio dell’efficacia e della appropriatezza, ovvero la cui efficacia non è dimostrabile in base alle evidenze scientifiche disponibili o sono utilizzati per soggetti le cui condizioni cliniche non corrispondono alle indicazioni raccomandate;
  • non soddisfano il principio dell’economicità nell’impiego delle risorse, in presenza di altre forme di assistenza volte a soddisfare le medesime esigenze”.

3. “Le prestazioni innovative per le quali non sono disponibili sufficienti e definitive evidenze scientifiche di efficacia possono essere erogate in strutture sanitarie accreditate dal Servizio Sanitario Nazionale, esclusivamente nell’ambito di appositi programmi di sperimentazione, autorizzati dal Ministero della Salute”.

Tali principi, se correttamente e uniformemente attuati, avrebbero potuto apportare uno straordinario contributo alla sostenibilità del SSN, perché attestano la volontà del legislatore di integrare le migliori evidenze scientifiche nelle decisioni di politica sanitaria, in particolare nel finanziamento di servizi e prestazioni sanitarie essenziali. Si afferma, infatti, che il SSN può rimborsare con il denaro pubblico solo gli interventi sanitari di documentata efficacia, facendo esplicito riferimento alle evidenze scientifiche. Viceversa, servizi e prestazioni sanitarie inefficaci, inappropriati o caratterizzati da una limitata costo-efficacia non possono rientrare nei LEA. Infine, in assenza di prove di efficacia definitive, in linea con una strategia di Ricerca & Sviluppo, l’erogazione di interventi sanitari innovativi deve essere circoscritta all’interno di specifici programmi di sperimentazione.

Di fatto, nel corso degli ultimi 11 anni, la progressiva resistenza delle autonomie regionali a riconoscere un decreto centralista, la mancata attuazione dei principi evidence-based e il ritardo nell’aggiornamento e nell’espansione degli elenchi di servizi e prestazioni hanno progressivamente ridimensionato il ruolo dei LEA. Nati come uno strumento per definire i criteri e monitorare l’appropriatezza di servizi e prestazioni sanitarie, oggi si limitano ad adempiere a una funzione esclusivamente finanziaria. Infatti, utilizzando la “griglia LEA”, un set di 21 indicatori per la verifica sintetica dell’adempimento sul mantenimento dei LEA, vengono individuate, rispetto all’impiego delle risorse assegnate, le Regioni virtuose (adempienti) e quelle dissennate (rinviate al Piano di Rientro).

Nel Decreto Balduzzi il Ministro ha dedicato ai LEA un intero articolo, ma – bando agli entusiasmi – si tratta solo di una dichiarazione di intenti che annuncia l’aggiornamento sia dei LEA (con riferimento a malattie croniche, malattie rare e ludopatia) entro il 31 dicembre 2012, sia del nomenclatore tariffario entro il 31 maggio 2013.

Se la storia è maestra di vita (DPCM 23 aprile 2008 sui “nuovi LEA” revocato da un Governo diverso da quello che lo aveva elaborato) ai LEA non rimane che confidare nel Monti-bis!

FonteCartabellotta A. La grande incompiuta dei LEA è madre della spending review? Il Sole 24 Ore Sanità 27 novembre – 3 dicembre: pag 20,22.

5° Congresso Nazionale SIHTA: statement finale @SIHTA_Italia

Il 5° Congresso Nazionale della Società Italiana di Health Technology Assessment si è concluso con una presa di posizione per richiamare tutti alla necessità di lavorare insieme affinché gli investimenti per l’innovazione e i disinvestimenti rispetto a tecnologie obsolete o di scarso valore per la salute siano ispirati a espliciti processi di valutazione multidisciplinare che coinvolgano tutti gli stakeholder.

http://www.slideshare.net/carlofavaretti/documento-finale-5congressosihta

 

 

Give patients the pros and cons of treatment options @Medici_Manager @kevinmd

Questions such as this from proactive, increasingly knowledgeable patients place a physician on the horns of an ethical dilemma.  Although fellows are closely supervised and trained under a gradually increasing responsibility principle (based upon subjective evaluation), a time will come when there is no one available to back you up in the catheterization lab.

Fact: Someone has to be a physician’s first case of any given type. However, no one really wants to be that person.

Access to extensive medical information on the web has satiated some of our patient’s desire for information and expectations regarding medical procedures, which is a good thing. However, increased transparency and public awareness of medical errors has opened up a Pandora’s box regarding a physician’s skill level and experience.  The September 2012 issue of Men’s Health went as far as publishing peer reviewed data regarding the minimum numbers for particular procedures taken directly from medical journals. Specifically, coronary angioplasty and angiography minimums were reported as 50 and 82 procedures respectively.

Take home message: Hard numbers to meet your first month into fellowship.

Similar experience-responsibility disparities exist in commercial aviation.  However, in contradistinction to the patient-doctor encounter, passengers are neither cognizant of their captain’s flight hours nor face-to-face prior to boarding.  Further increasing the stakes, a new pilot’s first manifest could be 50 passengers or more. In response to public demand for greater safety, the airline industry was an early adopter of systems to increase reliable pilot performance including flight simulation technology and pre-flight checklists, which were quite effective in reducing fatal incidents for air travelers.  As a result, the latest National Safety Council in the U.S.A. calculated the lifetime odds of death for flying to be 1:7178 in 2008 compared to 1:98 for automobile deaths.

Interestingly, even experienced pilots are required scheduled simulation training to maintain their skills and prepare for rare-but-catastrophic events, which cannot be realistically produced in the air.  The auto industry, unique in their in inability to increase motorists’ skills, have been forced to develop safety technology to make the highways safer.

Reality check: Patients do not come with air bags or crash sensors.  Simulation and checklists are proven methods to increase safety.

Virtual reality simulation training programs allow students of all levels to gain familiarity with equipment selection, proficiency of the detailed steps for a given procedure as well as an awareness of the potential pitfalls and crucial moments in a safe environment. Furthermore, under experienced tutelage during practice, a modicum of fingertip finesse may be learned prior to laying hands upon their first patient.

While “ain’t nothing like the real thing” is unarguably the best way to learn any motor skill, having solid theoretical and practical experience makes the transition to live cases easier and might ameliorate the patient’s and the beginner’s shakes.

Max Berry is a vascular and interventional radiology fellow.

http://www.kevinmd.com/blog/2012/10/times-procedure-doc.html

Where the Candidates Stand on Medicare and Medicaid @ProPublica @Medici_Manager

Ecco come funziona l’informazione e la discussione su grandi temi politici nei paesi civili!

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

by Suevon Lee ProPublica, Sept. 14, 2012 http://www.propublica.org/article/where-the-candidates-stand-on-medicare-and-medicaid

Medicare and Medicaid, which provide medical coverage for seniors, the poor and the disabled, together make up nearly a quarter of all federal spending. With total Medicare spending projected to cost $7.7 trillion over the next 10 years, there is consensus that changes are in order. But what those changes should entail has, of course, been one of the hot-button issues of the campaign.

With the candidates slinging charges, we thought we’d lay out the facts. Here’s a rundown of where the two candidates stand on Medicare and Medicaid:

THE CANDIDATES ON MEDICARE

Big Picture

Earlier this year, the Medicare Board of Trustees estimated that the Medicare hospital trust fund would remain fully funded only until 2024. Medicare would not go bankrupt or disappear, but it wouldn’t have enough money to cover all hospital costs.

Under traditional government-run Medicare, seniors 65 and over and people with disabilities are given health insurance for a fixed set of benefits, in what’s known as fee-for-service coverage. Medicare also offers a subset of private health plans known as Medicare Advantage, in which roughly one-quarter of Medicare beneficiaries are currently enrolled. Obama retains this structure.

The Obama administration has also made moves that it says would keep Medicare afloat. It says the Affordable Care Act would extend solvency by eight years, mainly by imposing tighter spending controls on Medicare payments to private insurers and hospitals.

In contrast, Rep. Paul Ryan, Mitt Romney’s running mate, has proposed a more fundamental overhaul of Medicare, which he says is on an “unsustainable path.” On hiscampaign website, Romney says that Ryan’s proposals “almost precisely mirrors” his ideas on Medicare. But he’s been fuzzy on other aspects of the plan.

A Romney-Ryan administration would replace a defined benefits system with a defined contribution system in which seniors are given federal vouchers to purchase health insurance in a newly created private marketplace known as Medicare Exchange. In this marketplace, private health plans, along with traditional Medicare, would compete for enrollees’ business. These changes wouldn’t start until 2023, meaning current beneficiaries aren’t affected – just those under 55.

Under the Romney-Ryan, the vouchers would be valued at the second-cheapest private plan or traditional Medicare, whichever costs less. Seniors who opt for a more expensive plan would pay the difference. If they choose a cheaper plan, they keep the savings.

Who’s covered

In the current system, people 65 and over are eligible for Medicare, which Obama has said he would keep for now.

Romney has proposed raising the eligibility age for Medicare beneficiaries from 65 to 67 in 2022, then increasing it by a month each year after that. In the long run, he wouldindex eligibility levels to “longevity.” Ryan’s budget plan proposesraising Medicare eligibility age by two months a year starting in 2023, until it reaches 67 by 2034.

Many others looking to keep Medicare solvent have also proposedraising the age of eligibility.

The Congressional Budget Office estimates that raising the minimum age from 65 to 67 would reduce annual federal spending by 5 percentBut it would also result in higher premiums and out-of-pocket costs for seniors who would lose access to Medicare.

Obama’s health care law also adds some benefits for seniors, such as annual wellness visits without co-pays, preventive services like free cancer screenings and prescription drug savings.

Proposed Savings

The Affordable Care Act is projected to reduce Medicare spending by $716 billion over the next 10 years. These reductions, as detailed by Washington Post’s Wonkblog, will come mostly from reducing payments to hospitals, nursing homes and private health care providers.

While Ryan criticized such spending cuts in his speech at the Republican National Convention, his own budget proposed keeping these reductions.

“The ACA grows the trust fund by giving more general revenue to the Treasury, which then gives the trust fund bonds. But it then uses the money from those bonds to expand coverage for low- and middle-income people,” explains Dylan Matthews on Washington Post’s Wonkblog.

Romney hasn’t really come up with a solid answer: he previously said he would restorethe $716 billion savings that the health care law imposes. Per this New York Timesstory, the American Institutes for Research calculates this would increase premiums and co-payments for Medicare beneficiaries by $342 a year on average over the next 10 years.

For more on where the candidates stand on the $716 billion, the private health policy Commonwealth Fund offers this helpful explanation.

Caps on Spending

Both Obama and Ryan have set an identical target rate that would cap Medicare spending at one-half a percentage point above the nation’s gross domestic product.

But they have different ideas on mechanisms to achieve it.

The Affordable Care Act establishes a 15-member Independent Payment Advisory Boardthat, starting in 2015, would make binding recommendations to reduce spending rates. As Jonathan Cohn points out in the New Republic, the commission is prohibited from making any changes that would affect beneficiaries.

Ryan has proposed hard caps on spending and derided this panel of appointed members as “unelected, unaccountable bureaucrats.” When laying out his plan in a 2011 memo, Ryan wrote that to control spending, “Congress would be required to intervene and could implement policies that change provider reimbursements, program overhead, and means-tested premiums.”

Romney hasn’t stated clear proposals for imposing a cap on spending.

THE CANDIDATES ON MEDICAID

Big Picture

Though, it’s far less discussed on the campaign trail, Medicaid actually covers more people than Medicare. The joint federal-state insurance program for the poor, the disabled, and elderly individuals in long-term nursing home care currently covers about 60 million Americans.  The Affordable Care Act has expanded Medicaid coverage further. Beginning 2014, Medicaid will include people under 65 with income below 133 percent of the federal poverty level (roughly $15,000 for an individual, $30,000 for a family of four). This was estimated to cover an additional 17 million Americans as eligible beneficiaries.

In June, however, the U.S. Supreme Court ruled that states could opt out of the Medicaid expansion. A ProPublica analysis estimated that the 26 states that challenged the health care law, and thus may possibly opt out, would account for up to 8.5 million of those new beneficiaries.

Romney and Ryan would overhaul this current system by turning Medicaid into a system of block grants: the federal government would issue lump sum payments to the states, who would determine eligibility criteria and benefits for enrollees. These grants would begin in 2013.

Effects on spending

The Congressional Budget Office estimates that Medicaid expansion under the new health care law would cost an additional $642 billion over the next 10 years.

Under the Ryan plan, federal Medicaid grants would be adjusted only for inflation, but not health care costs, which grow at a much higher rate. The CBO estimates Ryan’s plan would save the federal government $800 billion over the next 10 years. Another study conducted by Bloomberg News shows that the block-grants could decrease Medicaid funding by as much as $1.26 trillion over the next nine years.

Actual Impact                                                                                                     

The New York Times points out that more than half of Medicaid spending goes toward the elderly and disabled. An Urban Institute analysis estimates the Ryan plan would result in 14 million to 27 million fewer people receiving Medicaid coverage by 2021.

Though rarely mentioned by any of the candidates, Medicaid costs are soaring to cover the elderly who require long-term nursing care. As the Times’ details how, states saddled by high Medicaid costs have begun turning to private managed care plans to blunt the cost.

Envisioning the future of health technology @SIHTA_Italia @Medici_Manager @DocComLtd

Why the future of health?

Technology is the ultimate democratizing force in society. Over time, technology raises lowest common denominators by reducing costs and connecting people across the world. Medical technology is no exception to this trend: previously siloed repositories of information and expensive diagnostic methods are rapidly finding a global reach and enabling both patients and practitioners to make better use of information.

This visualization is an exercise in speculating about which individual technologies are likely to affect the scenario of health in the coming decades. Arranged in six broad areas, the forecast covers a multitude of research and developments that are likely to disrupt the future of healthcare.

INFOGRAFICA

http://envisioningtech.com/health/

It’s time for less research and more thinking @drsilenzi @trishgreenhalgh @muirgray

Less research is needed

By Trisha Greenhalgh http://blogs.plos.org/speakingofmedicine/2012/06/25/less-research-is-needed/

The most over-used and under-analyzed statement in the academic vocabulary is surely “more research is needed”.  These four words, occasionally justified when they appear as the last sentence in a Masters dissertation, are as often to be found as the coda for a mega-trial that consumed the lion’s share of a national research budget, or that of a Cochrane review which began with dozens or even hundreds of primary studies and progressively excluded most of them on the grounds that they were “methodologically flawed”. Yet however large the trial or however comprehensive the review, the answer always seems to lie just around the next empirical corner.

With due respect to all those who have used “more research is needed” to sum up months or years of their own work on a topic, this ultimate academic cliché is usually an indicator that serious scholarly thinking on the topic has ceased. It is almost never the only logical conclusion that can be drawn from a set of negative, ambiguous, incomplete or contradictory data.

Recall the classic cartoon sketch from your childhood. Kitty-cat, who seeks to trap little bird Tweety Pie, tries to fly through the air.  After a pregnant mid-air pause reflecting the cartoon laws of physics, he falls to the ground and lies with eyes askew and stars circling round his silly head, to the evident amusement of his prey. But next frame, we see Kitty-cat launching himself into the air from an even greater height.  “More attempts at flight are needed”, he implicitly concludes.

On my first day in (laboratory) research, I was told that if there is a genuine and important phenomenon to be detected, it will become evident after taking no more than six readings from the instrument.  If after ten readings, my supervisor warned, your data have not reached statistical significance, you should [a] ask a different question; [b] design a radically different study; or [c] change the assumptions on which your hypothesis was based.In health services research, we often seem to take the opposite view. We hold our assumptions to be self-evident. We consider our methodological hierarchy and quality criteria unassailable. And we define the research priorities of tomorrow by extrapolating uncritically from those of yesteryear.  Furthermore, this intellectual rigidity is formalized and ossified by research networks, funding bodies, publishers and the increasingly technocratic system of academic peer review.

Here is a quote from a typical genome-wide association study:

“Genome-wide association (GWA) studies on coronary artery disease (CAD) have been very successful, identifying a total of 32 susceptibility loci so far. Although these loci have provided valuable insights into the etiology of CAD, their cumulative effect explains surprisingly little of the total CAD heritability.”  [1]

The authors conclude that not only is more research needed into the genomic loci putatively linked to coronary artery disease, but that – precisely because the model they developed was so weak – further sets of variables (“genetic, epigenetic, transcriptomic, proteomic, metabolic and intermediate outcome variables”) should be added to it. By adding in more and more sets of variables, the authors suggest, we will progressively and substantially reduce the uncertainty about the multiple and complex gene-environment interactions that lead to coronary artery disease.

If the Kitty-cat analogy seems inappropriate to illustrate the flaws in this line of reasoning, let me offer another parallel. We predict tomorrow’s weather, more or less accurately, by measuring dynamic trends in today’s air temperature, wind speed, humidity, barometric pressure and a host of other meteorological variables. But when we try to predict what the weather will be next month, the accuracy of our prediction falls to little better than random. Perhaps we should spend huge sums of money on a more sophisticated weather-prediction model, incorporating the tides on the seas of Mars and the flutter of butterflies’ wings? Of course we shouldn’t. Not only would such a hyper-inclusive model fail to improve the accuracy of our predictive modeling, there are good statistical and operational reasons why it could well make it less accurate.

Whereas in the past, any observer could tell that an experiment had not ‘worked’, the knowledge generated by today’s multi-variable mega-studies remains opaque until months or years of analysis have rendered the findings – apparently at least – accessible and meaningful. This kind of research typically requires input from many vested interests: industry, policymakers, academic groupings and patient interest groups, all of whom have different reasons to invest hope in the outcome of the study. As Nic Brown has argued, debates around such complex and expensive research seem increasingly to be framed not by régimes of truth (what people know or claim to know) but by ‘régimes of hope’ (speculative predictions about what the world will be like once the desired knowledge is finally obtained). Lack of hard evidence to support the original hypothesis gets reframed as evidence that investment efforts need to be redoubled.[2] And so, instead of concluding that less research is needed, we collude with other interest groups to argue that tomorrow’s research investments should be pitched into precisely the same patch of long grass as yesterday’s.

Here are some intellectual fallacies based on the more-research-is-needed assumption (I am sure readers will use the comments box to add more examples).

  1. Despite dozens of randomized controlled trials of self-efficacy training (the ‘expert patient’ intervention) in chronic illness, most people (especially those with low socio-economic status and/or low health literacy) still do not self-manage their condition effectively. Therefore we need more randomized trials of self-efficacy training.
  2. Despite conflicting interpretations (based largely on the value attached to benefits versus those attached to harms) of the numerous large, population-wide breast cancer screening studies undertaken to date, we need more large, population-wide breast cancer screening studies.
  3. Despite the almost complete absence of ‘complex interventions’ for which a clinically as well as statistically significant effect size has been demonstrated and which have proved both transferable and affordable in the real world, the randomized controlled trial of the ‘complex intervention’ (as defined, for example, by the UK Medical Research Council [3]) should remain the gold standard when researching complex psychological, social and organizational influences on health outcomes.
  4. Despite consistent and repeated evidence that electronic patient record systems can be expensive, resource-hungry, failure-prone and unfit for purpose, we need more studies to ‘prove’ what we know to be the case: that replacing paper with technology will inevitably save money, improve health outcomes, assure safety and empower staff and patients.

Last year, Rodger Kessler and Russ Glasgow published a paper arguing for a ten-year moratorium on randomized controlled trials on the grounds that it was time to think smarter about the kind of research we need and the kind of study designs that are appropriate for different kinds of question.[4] I think we need to extend this moratorium substantially. For every paper that concludes “more research is needed”, funding for related studies should immediately cease until researchers can answer a question modeled on this one: “why should we continue to fund Kitty-cat’s attempts at flight”?

 

This blog was informed by contributions to my Twitter page @trishgreenhalgh
Trish Greenhalgh is Professor of Primary Health Care at Barts and the London School of Medicine and Dentistry, London, UK, and also a general practitioner in north London.

[1] Prins BP, Lagou V, Asselbergs FW, Snieder H, & Fu J (2012). Genetics of coronary artery disease: Genome-wide association studies and beyond. Atherosclerosis PMID: 22698794

[2] Brown N (2007). Shifting Tenses: Reconnecting Regimes of Truth and HopeConfigurations DOI: 10.1353/con.2007.0019

[3] Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M, & Medical Research Council Guidance (2008). Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ (Clinical research ed.), 337 PMID: 18824488

[4] Kessler R, & Glasgow RE (2011). A proposal to speed translation of healthcare research into practice: dramatic change is needed. American journal of preventive medicine, 40 (6), 637-44 PMID: 21565657

Choosing wisely: video. @Medici_Manager

Alcuni video fanno il punto sul programma Choosing wisely dell’ ABIM Foundation.

http://www.abimfoundation.org/Resource-Center/Video/Choosing-Wisely.aspx

Overtreatment Is Taking a Harmful Toll @FLAHAULT @LeapfrogGroup @drsilenzi

By TARA PARKER-POPE THE WELL COLUMN AUGUST 27, 2012, 2:37 PM http://well.blogs.nytimes.com/2012/08/27/overtreatment-is-taking-a-harmful-toll/

When it comes to medical care, many patients and doctors believe more is better.

But an epidemic of overtreatment — too many scans, too many blood tests, too many procedures — is costing the nation’s health care system at least $210 billion a year, according to the Institute of Medicine, and taking a human toll in pain, emotional suffering, severe complications and even death.

“What people are not realizing is that sometimes the test poses harm,” said Shannon Brownlee, acting director of the health policy program at the New America Foundation and the author of “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.”

“Sometimes the test leads you down a path, a therapeutic cascade, where you start to tumble downstream to more and more testing, and more and more invasive testing, and possibly even treatment for things that should be left well enough alone.”

Have you experienced too much medicine? As part of The New York Times’s online series The Agenda, I asked readers to share their stories. More than 1,000 responded, with examples big and small.

Some complained that when they switch doctors they are required to undergo duplicate blood work, scans or other tests that their previous doctor had only recently ordered. Others told of being caught in a unending maze of testing and specialists who seem to forget the patient’s original complaint. I heard from doctors and nurses, too — health professionals frustrated by a system that encourages these excesses.

Terrence Power of Breckenridge, Colo., said that after his wife, Diane, learned she had Wegener’s disease, an uncommon autoimmune disorder, the couple found it difficult to refuse testing recommended by a trusted doctor. The doctor insisted on office visits every three weeks, even when she was feeling well. He frequently ordered blood tests and X-rays, and repeatedly referred her to specialists for even minor complaints. Even when tests came back negative, more were ordered, and she was hospitalized as a precaution when she developed a cold. During one six-month period, she had 25 doctor visits. The couple was spending about $30,000 a year out of pocket for her care.

“He was convincing enough that we felt we needed to have it done,” said Ms. Power, 60, who recalls being sedated before an endoscopy procedure, one of the last tests she allowed her doctor to perform. “When they were getting ready to knock me out I was thinking, ‘Why am I doing this?’ But we felt like the doctor knew what to do and we trusted him.”

After several years of physical suffering and near financial ruin from the medical costs, the couple began questioning the treatment after consulting with other patients in online support groups. Mr. Power spoke with his own primary care doctor, who advised him to find a new specialist to oversee Ms. Power’s care. “It’s a really hard thing to determine when they’ve crossed the line,” Mr. Power said. “You think she’s getting the best care in the world, but after a while you start to wonder, what is the objective? He seemed caring, but he didn’t really consider my wife’s time and the suffering she was going through having all these tests done.”

Under the new doctor’s care, the regular testing stopped and Ms. Power was finally able to achieve remission. Now she sees the doctor only four or five times a year.

Sometimes the toll of too much medicine is brief, but emotional. Kara Riehman, 43, of Atlanta was vacationing in California when she lost a struggle with an ironing board in her hotel room and ended up with a black eye.

As the bruising peaked around 10 days, she called her doctor to make sure everything looked normal. But instead of seeing her, the doctor, through a conversation with the nurse, ordered a CT scan. She had no symptoms other than a bruised eye, but the doctor never spoke with her or examined her. The scan came back with an ambiguous finding, and the nurse told her it could be a tumor. She was then given an M.R.I. and for two weeks while she waited for the results, she worried she had brain cancer. The nurse called to tell her the M.R.I. was fine.

“It was really terrible,” she said. “It was only two weeks, but there is a lot of cancer in my family. I never actually talked to my doctor through this whole thing.”

The total cost to her insurance company was about $7,000. “It did change how I think about interacting with the medical system,” Ms. Riehman said. “It made me much more of a questioning consumer.”

Jim Donohue, a Brooklyn bank examiner, had to intervene on behalf of his father, now 79, who had a stroke in March 2007. Doctors in Florida put him on several medications, including two antidepressants, and soon after the man began hallucinating and showing signs of dementia. Mr. Donohue began researching the drugs, and learned they were associated with cognitive problems. He persuaded his father’s doctors to change the medication, and his father quickly improved. He has since recovered, and has been living on his own for four years.

“All the medical professionals seeing him along the way, the hospital, twonursing homes and nobody thought of this,” said Mr. Donohue, who said his father never should have been given a diagnosis of depression in the first place. “I don’t know if we have too many specialists and every one is trying to practice their specialty, but it should not have happened.”

When Kathryn Gullo, a teacher in the Los Angeles area, gave birth to twinsjust 25 weeks into the pregnancy, she was thrust into the intense medical care of the neonatal ward that saved her children’s lives. But when her daughter, Grace, was 3 months old she was transferred to a different hospital, where the doctors insisted on subjecting her to a battery of tests for symptoms that other doctors had dismissed as normal for her condition. “We felt like we were being bullied,” Ms. Gullo said. “I had enough faith in her previous doctors that it was then easy to say no.”

The family switched hospitals and their daughter, now 5 and living with mild cerebral palsy and some vision and feeding issues, continues to require specialized care. But recently, when doctors suggested an M.R.I. that would require that their daughter be anesthetized, Ms. Gullo and her partner, Katie Ingram, said they asked two key questions: “What new information will this give us?” and “Will it change what we are doing?” After talking to the doctor, they declined the M.R.I.

“Not every mystery has to be solved, and not every problem has to be addressed,” Ms. Gullo said. “That’s hard to get your brain around.”


The series is part of a larger New York Times project called The Agenda, which focuses on critical issues facing the next president and Congress. Join the conversation at The Agenda.

 

The Disciplined Pursuit of Less @drsilenzi @agnescheer

by Greg McKeown http://blogs.hbr.org/cs/2012/08/the_disciplined_pursuit_of_less.html

Why don’t successful people and organizations automatically become very successful? One important explanation is due to what I call “the clarity paradox,” which can be summed up in four predictable phases:

Phase 1: When we really have clarity of purpose, it leads to success.
Phase 2: When we have success, it leads to more options and opportunities.
Phase 3: When we have increased options and opportunities, it leads to diffused efforts.
Phase 4: Diffused efforts undermine the very clarity that led to our success in the first place.

Curiously, and overstating the point in order to make it, success is a catalyst for failure.

We can see this in companies that were once darlings of Wall Street, but later collapsed. In his book How the Mighty Fall, Jim Collins explored this phenomenon and found that one of the key reasons for these failures was that companies fell into “the undisciplined pursuit of more.” It is true for companies and it is true for careers.

Here’s a more personal example: For years, Enric Sala was a professor at the prestigious Scripps Institution of Oceanography in La Jolla, California. But he couldn’t kick the feeling that the career path he was on was just a close counterfeit for the path he should really be on. So, he left academia and went to work for National Geographic. With that success came new and intriguing opportunities in Washington D.C. that again left him feeling he was close to the right career path, but not quite there yet. His success had distracted him. After a couple of years, he changed gears again in order to be what he really wanted: an explorer-in-residence with National Geographic, spending a significant portion of his time diving in the most remote locations, using his strengths in science and communications to influence policy on a global scale. (Watch Enric Sala speak about his important work at TED). The price of his dream job was saying no to the many good, parallel paths he encountered.

What can we do to avoid the clarity paradox and continue our upward momentum? Here are three suggestions:

First, use more extreme criteria. Think of what happens to our closets when we use the broad criteria: “Is there a chance that I will wear this someday in the future?” The closet becomes cluttered with clothes we rarely wear. If we ask, “Do I absolutely love this?” then we will be able to eliminate the clutter and have space for something better. We can do the same with our career choices.

By applying tougher criteria we can tap into our brain’s sophisticated search engine. If we search for “a good opportunity,” then we will find scores of pages for us to think about and work through. Instead, we can conduct an advanced search and ask three questions: “What am I deeply passionate about?” and “What taps my talent?” and “What meets a significant need in the world?” Naturally there won’t be as many pages to view, but that is the point of the exercise. We aren’t looking for a plethora of good things to do. We are looking for our absolute highest point of contribution.

HPOC_DR.jpg

Enric is one of those relatively rare examples of someone who is doing work that he loves, that taps his talent, and that serves an important need in the world. His main objective is to help create the equivalent of National Parks to protect the last pristine places in the ocean — a significant contribution.

Second, ask “What is essential?” and eliminate the rest. Everything changes when we give ourselves permission to eliminate the nonessentials. At once, we have the key to unlock the next level of our lives. Get started by:

  • Conducting a life audit. All human systems tilt towards messiness. In the same way that our desks get cluttered without us ever trying to make them cluttered, so our lives get cluttered as well-intended ideas from the past pile up. Most of these efforts didn’t come with an expiration date. Once adopted, they live on in perpetuity. Figure out which ideas from the past are important and pursue those. Throw out the rest.
  • Eliminating an old activity before you add a new one. This simple rule ensures that you don’t add an activity that is less valuable than something you are already doing.

Third, beware of the endowment effect. Also known as the divestiture aversion, the endowment effect refers to our tendency to value an item more once we own it. One particularly interesting study was conducted by Kahneman, Knetsch and Thaler (published here) where consumption objects (e.g. coffee mugs) were randomly given to half the subjects in an experiment, while the other half were given pens of equal value. According to traditional economic theory (the Coase Theorem), about half of the people with mugs and half of the people with pens will trade. But they found that significantly fewer than this actually traded. The mere fact of ownership made them less willing to part with their own objects. As a simple illustration in your own life, think of how a book on your shelf that you haven’t used in years seems to increase in value the moment you think about giving it away.

Tom Stafford describes a cure for this that we can apply to career clarity: Instead of asking, “How much do I value this item?” we should ask “If I did not own this item, how much would I pay to obtain it?” And the same goes for career opportunities. We shouldn’t ask, “How much do I value this opportunity?” but “If I did not have this opportunity, how much would I be willing to sacrifice in order to obtain it?”

If success is a catalyst for failure because it leads to the “undisciplined pursuit of more,” then one simple antidote is the disciplined pursuit of less. Not just haphazardly saying no, but purposefully, deliberately, and strategically eliminating the nonessentials. Not just once a year as part of a planning meeting, but constantly reducing, focusing and simplifying. Not just getting rid of the obvious time wasters, but being willing to cut out really terrific opportunities as well. Few appear to have the courage to live this principle, which may be why it differentiates successful people and organizations from the very successful ones.

More blog posts by Greg McKeown
Greg McKeown

GREG MCKEOWN

Greg McKeown is the CEO of THIS Inc., a leadership and strategy design agency headquartered in Silicon Valley. He was recently named a Young Global Leader by the World Economic Forum. Greg did his graduate work at Stanford. Connect with him on Twitter @GregoryMcKeown.