Outcomes Assessment and Health Care Reform

Argues for the use of outcomes assessment in measuring cost-effectiveness and quality to capture the overall impact of multi-dimensional treatment strategies and to identify healthcare systems that both adopt appropriate technologies and perform well

High School and College Athletes Should Be Required to Undergo Pre-Participation Cardiac Screening Prior to Participation in Competitive Sports

Sudden Cardiac Arrest (SCA) is the leading cause of death in young athletes. Most of these athletes are unaware they have a condition that puts them at risk. In addition it is estimated that approximately 1 in 220,000 young athletes experience Sudden Cardiac Death (SCD) each year, although, these numbers are not truly reliable because there is no national mandatory reporting system in the United States. My paper argues that all high school and college athletes should be required to undergo pre-participation cardiac screening (i.e. an ECG and extensive family health history) as a part of a required physical exam to identify student-athletes at risk of SCD. Studies in Italy, where pre-participation screening is mandatory, and at some US universities in the US where collegiate athletes received cardiovascular screening prior to sports participation suggest that including ECG improved overall sensitivity, mass ECG screening is achievable and cost-effective, and that screening lowered the death rates in the population screened. Some critics believe that the cost of the screening is not cost-effective, but others believe the costs are reasonable; some hospitals in the US now provide student athletes with free ECG screening, or at reduced cost. ECG screening will save lives, and should not be discounted as being too costly. Every parent who has a child participating in school athletics should be informed of the risks, and be given the opportunity to have their child tested. Saving someone’s child is worth the cost of testing. My interest in this topic comes from my family’s personal experience with a student athlete who experienced a cardiac event characterized by shortness of breath and dizziness while playing in a collegiate baseball game. Our son, Neil, was a healthy 21-year-old student athlete who had participated in organized sports since he was seven years old. His event was initially diagnosed as a panic attack, but after he underwent a series of cardiac testing, including an ECG that showed an abnormality, he was diagnosed with Arrhythmogenic Right Ventricular Dysplasia (ARVD), a progressive heart disease. We have no family history to link to Neil’s disease, and we had no idea he was at risk. Today Neil lives with an implantable cardioverter defibrillator (ICD), takes anti-arrhythmic medication, and no longer participates in team sports. Neil is one of the lucky ones who survived, and his survival impelled me to get involved in my community to promote awareness about sudden cardiac arrest, and the importance of CPR training and the availability of automated external defibrillators (AEDs). Our experience also inspired me to research adding pre-participation cardiac screening for young athletes. If such a program had been instituted at his high school or college, Neil’s disease would have been diagnosed and treated, keeping him from being at risk during athletics

The U.S. Commitment to Global Health: Recommendations for the New Administration

Outlines the need for making a commitment to improving global health an integral part of U.S. foreign policy. Suggestions include creating a White House Interagency Committee on Global Health and directing more funds to chronic disease programs

3D printing is a transformative technology in congenital heart disease

Survival in congenital heart disease has steadily improved since 1938, when Dr. Robert Gross successfully ligated for the first time a patent ductus arteriosus in a 7-year-old child. To continue the gains made over the past 80 years, transformative changes with broad impact are needed in management of congenital heart disease. Three-dimensional printing is an emerging technology that is fundamentally affecting patient care, research, trainee education, and interactions among medical teams, patients, and caregivers. This paper first reviews key clinical cases where the technology has affected patient care. It then discusses 3-dimensional printing in trainee education. Thereafter, the role of this technology in communication with multidisciplinary teams, patients, and caregivers is described. Finally, the paper reviews translational technologies on the horizon that promise to take this nascent field even further

Focal Spot, Fall/Winter 1998

https://digitalcommons.wustl.edu/focal_spot_archives/1080/thumbnail.jp

Health Care Costs and the Arc of Innovation

Health care costs continue their inexorable rise, threatening America’s long-term fiscal stability, competitiveness, and standard of living. Over the past half-century, efforts to rein in spending have uniformly failed. In this Article, we explain why, breaking with standard accounts of regulatory and market dysfunction. We point instead to the nexus of economics, mutual empathy, and social expectations that drives medical innovation and locks in low-value technologies. We show how law reflects and reinforces this nexus and how and why health-policy-makers avert their gaze. Next, we propose to circumvent these barriers instead of surmounting them. Rather than targeting today’s excessive spending, we seek to leverage available legal tools to bend the arc of innovation, away from marginally-beneficial technology and toward high-value advances. To this end, we set forth a novel, value-based approach to pricing and patent protection—one that departs sharply from current practice by rewarding innovators in proportion to the therapeutic benefits new tests and treatments yield. Using cancer therapy as an example, we explain how emerging information technology and large troves of electronic clinical data are opening the way to near-real-time assessment of efficacy. We then show how such assessment can power ongoing adjustment of pricing and patent terms. Finally, we offer a blueprint for how laws governing health care payment and intellectual property can be tailored to realize this value-focused vision. For the reasons we lay out, the transformation of incentives we urge will both slow clinical spending growth and greatly enhance the social value that this spending yields

The Market-based Lead Phasedown

The U.S. lead phasedown was effective in meeting its environmental objectives, and did so more quickly with the allowance of permit banking. The marketable lead permit system was highly costeffective, saving hundreds of millions of dollars relative to comparable policies not allowing trading or banking. Estimates suggest that transaction costs brought about only a modest reduction in program efficiency. The market-based nature of the program also provided incentives for more efficient adoption of new lead-removing technology, relative to a uniform standard. Distributionally, it is likely that the program was actually more responsive to the cost concerns of small refiners than a similar uniform standard would have been. The flexibility of the program likely increased the amount of violations, however, and added an unexpected monitoring and enforcement burden. On the other hand, one of the efficiency advantages of the incentive-based program is that it provided opportunities for unanticipated means of cost-effective compliance.lead phasedown, gasoline, tradable permit, market-based policy, technology adoption

How Registries Can Help Performance Measurement Improve Care

Suggests ways to better utilize databases of clinical information to evaluate care processes and outcomes and improve measurements of healthcare quality and costs, comparative clinical effectiveness research, and medical product safety surveillance

The economic benefits of health and prevention in a high-income country: the example of Germany

This paper complements the current health policy debate, which is largely confined to the cost aspects of health systems, by considering explicitly the potential economic benefits of investing in health in general and via - chiefly primary - prevention. While concerns about high and rising health care costs are justified, we see a pressing need to also measure the benefits, ultimately enabling a complete economic assessment of the socially optimal level of resources for health. Despite the use of Germany as our point of reference, our approach and findings likely apply to a wider set of European highincome countries. Using new and already existing data, we find that in sheer health terms Germany has a lot to gain from more and better illness prevention. Assuming part of this existing burden can be reduced via effective preventive interventions, we find that the resulting economic benefits - expressed in people's willingness to pay for a reduction in mortality risk - would be substantial. We also gather Germany-specific evidence to suggest that the existing burden of ill health - whether caused by lack of prevention or treatment - negatively impacts a number of important economic outcomes at the individual and macro-economic level. Referring to work carried out in parallel to this project, we find that a number of cost-effective, primary preventive interventions exist to tackle part of the avoidable disease burden. Yet we note a deficit of economic evaluations, in particular in non-clinical interventions - a finding that underlines the role of government in the production of research on specifically non-clinical prevention. In light of the market failures discussed, from an economic perspective the role of government not only consists of research, but also - surprisingly to many - extends to actual interventions to address the health behaviour-related determinants of chronic disease. With the stakes as high and the economic justification for action in place, the case for scaling up preventive efforts in Germany, backed up by solid epidemiological and economic research, is hard to deny. -- Die vorliegende Studie ergänzt die gegenwärtige gesundheitspolitische Debatte, die sich vorwiegend auf Kostenaspekte des Gesundheitswesens konzentriert, indem sie den potentiellen ökonomischen Nutzen von Gesundheitsinvestitionen im allgemeinen und (Primär-)Prävention im besonderen hervorhebt. Auch wenn die Sorge um hohe und steigende Kosten des Gesundheitswesens berechtigt ist, bleibt die Notwendigkeit, auch den Nutzen der Gesundheitsausgaben zu erfassen, um somit zu einer ökonomisch vollständigen Einschätzung des sozial optimalen Niveaus der Gesundheitsausgaben zu gelangen. Trotz des Fokus auf Deutschland sind unser Ansatz und die Ergebnisse auch auf andere Mitgliedsländer der EU übertragbar. Wir zeigen anhand neuer und schon bekannter Daten, dass der Spielraum für Gesundheitsverbesserungen, vorwiegend durch Prävention, in Deutschland erheblich ist. Der ökonomische Nutzen - gemessen an der Zahlungsbereitschaft der Bevölkerung - der durch Reduktion eines Teils dieser Krankheitslast mittels Interventionen erzielt werden kann, ist nach unseren Berechnungen beachtlich. Darüber hinaus zeigen mehrere Studien, wie die aktuell gegebene Krankheitslast, ob durch einen Mangel an Prävention oder Versorgung verursacht, eine Reihe relevanter ökonomischer Grössen auf individueller und gesamtwirtschaftlicher Ebene beeinträchtigt. Wie eine parallel durchgeführte Studie der Autoren ergab, existieren auch eine Reihe kosten-effektiver Interventionen im Bereich der primären Prävention. Dennoch bestehen noch Lücken in der ökonomischen Bewertung insbesondere nicht-klinischer Interventionen - ein Ergebnis, das die Rolle des Staates in der Evaluation dieser Interventionen unterstreicht. Aufgrund von Marktversagen in einigen relevanten Bereichen besteht eine ökonomische Rechtfertigung für staatliches Handeln nicht nur im Bereich der Forschung, sondern - überraschend für manche - auch im Bereich der (Primär-)Prävention der nicht-ansteckenden und mit dem individuellen Gesundheitsverhalten verbundenen Krankheiten. Aufgrund des in diesem Papier dokumentierten hohen gesundheitlichen und ökonomischen Nutzens sowie der ökonomischen Rechtfertigung der Rolle des Staates kann das Argument für eine Verstärkung der Prävention in Deutschland nur schwer bestritten werden.