Personalising medicine : feasibility and future implications from a payers' perspective

There are considerable differences in how patients respond to treatments due to a number of factors calling for personalised approaches to care, which is happening. However, the early promise of personalised medicine has not always translated into improved care for patients. Payers have concerns that current tests can be costly, requests for funding specific tests have subsequently been reversed as more information becomes available, and there is currently fragmentation in the funding of diagnostic tests. Payers also have concerns that pharmaceutical companies are exploiting the situation by seeking orphan status for their new targeted medicines driving up requested prices. It is also not clear who should fund biomarkers that accompany new expensive medicines. This is changing as the cost of tests come down, and payers develop new models to optimise the managed entry of new medicines as well as evaluate potential prices for new medicines for orphan diseases. There are also developments with ‘big data’ offering new understanding of disease complexity to enhance pipeline productivity and diagnosis as well as ongoing developments with drug resistance testing and research into the role of microbiomes to improve future health. Current challenges and concerns are being addressed. This will continue to improve patient care

Managing the Yellow River: Questions of Borders, Boundaries and Access

The Yellow River basin is the site of myriad water resource problems. The Yellow River has natural geomorphological characteristics that include seasonally variable flow, very high sediment load, and the capacity to flood with devastating effect. However, people have long sought to harness the water of the Yellow River to their own industrial and agricultural ends, so as to attain the things that they value, like good health, economic growth, and employment. Intensive human use of the basin now poses new managerial problems. The Yellow River’s problems thus now include water scarcity, pollution, and flood risk. In 1997 there were 226 ‘no flow’ days, when the River failed to reach the sea; the dry point started up to 700km inland (Jun 2004). This is not part of the natural flow regime of the Yellow River, which rarely ceased to flow before 1992. The Yellow River is also one of China’s most polluted rivers. While a major breach of the levees has been averted since the People’s Republic was founded in 1949, there is each year significant flooding in the Yellow River basin. The threat of a major levee failure is real and millions of lives and vast sums of capital investment will be lost in such an event, or if one of the many dams along its length fails. In this paper, we characterise the problems of the Yellow River in order to assess the significance of borders, boundaries and access in understanding the management of water. Events and conditions in particular localities have local causes; and in this sense the bounding of regions is significant. Yet borders and boundaries are permeable, permitting causes also to derive from conditions in neighbouring and distant regions. Furthermore, places have causes at a larger scale, such as the nation, since borders, like the regions they bound, are hierarchical and scaled

The treatment of disabling intermittent claudication in patients with superficial femoral artery occlusive disease—Decision analysis

ObjectiveTo determine the preferred approach to superficial femoral artery (SFA) revascularization of Trans-Atlantic Inter-Societal Consensus (TASC) B and C lesions in claudicants requiring intervention based on a review of published data.DesignDecision analysis, Markov state transition model.SubjectsHypothetical cohorts of claudicants with TASC B or TASC C superficial femoral artery lesions considered candidates for either angioplasty with selective stenting (PTA/S) or greater saphenous vein bypass (GSVB).Main outcome measureQuality adjusted life years (QALYs).ResultsFor a 65-year-old man with disabling claudication, percutaneous transluminal angioplasty and selective stenting (PTA/S) was preferred over GSVB for a TASC B SFA lesion. In an otherwise identical patient with a TASC C lesion, bypass was the preferred therapy. Treating PTA/S failures with subsequent bypass increased the utility of PTA/S but bypass remained the preferred initial therapy for TASC C lesions. Sensitivity analysis showed that PTA/S surpasses bypass efficacy for TASC C lesions if PTA/S primary patency is >32% at 5 years, patient age is >80 years, or GSVB operative mortality is > 6%.ConclusionPTA/S is the preferred initial therapy over GSVB for TASC B SFA lesions in patients with disabling intermittent claudication who require intervention. Given contemporary published outcomes for TASC C lesions, GSVB is the preferred therapy in operative candidates. In elderly patients or patients at high risk for bypass, PTA/S should be considered over GSVB. Improved technology that results in a 5-year primary patency of 32% would also justify PTA/S for TASC C SFA lesions

Ongoing initiatives in China to enhance prescribing efficiency : impact and proposals for improvement

Pharmaceutical expenditure is currently rising by 16% per annum in China, greater in recent years. Initiatives to moderate this growth include drug pricing regulations, essential medicine lists and encouraging generic prescribing. These measures are principally concentrated in hospitals as they account for over 80% of total pharmaceutical expenditure. However, no monitoring of prescribing and perverse incentives enhances irrational prescribing. Review the influence of recent measures on subsequent utilization and expenditure of high-volume classes in China to provide future guidance. Principally a narrative review of published studies of the proton pump inhibitors (PPIs), statins, renin–angiotensin inhibitor drugs and traditional Chinese medicines (TCMs) between 2004 and 2013 in the largest teaching hospital group in Chongqing District. Appeciable increase in drug utilisation including TCMs. Generics typically only 30% to 34% of total utilisation for the molecule for CV medicines, with decreasing trends in recent years. Greater utilisation of generic PPIs; however, this includes generic injectable preparations with considerably higher prices. Prices decreased over time, with appreciable reductions for some generics. Overall, considerable opportunities to save resources without compromising care. Restricting the formulary to just one statin, angiotensin receptor blocker or PPI based on the cheapest one would have saved 50-84% of total accumulated expenditures. Encouraging to see high utilisation of generic PPIs and low prices for some oral generics. However, real progress will only be made by addressing current perverse financial incentives. Potential reforms could include limiting the number of available medicines in a class to enhance the quality and efficiency of prescribing

Review of ongoing initiatives to improve prescribing efficiency in China; angiotensin receptor blockers as a case history

Pharmaceutical expenditure is rising by 16% per annum in China and is now 46% of total expenditure. Initiatives to moderate growth include drug pricing regulations and encouraging international non-proprietary name prescribing. However, there is no monitoring of physician prescribing quality and perverse incentives. Assess changes in angiotensin receptor blocker (ARB) utilization and expenditure as more generics become available; compare findings to Europe. Observational retrospective study of ARB utilization and expenditure between 2006 and 2012 in the largest hospital in Chongqing district. Variable and low use of generics versus originators with a maximum of 31% among single ARBs. Similar for fixed dose combinations. Prices typically reduced over time, greatest for generic telmisartan (-54%), mirroring price reductions in some European countries. However, no preferential increase in prescribing of lower cost generics. Accumulated savings of 33 million CNY for this large provider if they adopted European practices. Considerable opportunities to improve prescribing efficiency in China

Initiatives to improve prescribing efficiency in China and their influence : cardio-cerebral vascular medicines as a case history to provide future direction

Background: Pharmaceutical expenditure has grown by 16% per annum in China during the past decade. This has been enhanced by increased coverage as well as incentives to physicians and hospitals. Hospital pharmacies dispense 80% of medicines in China, with medicines currently accounting for 46% of total hospital expenditure. Hospitals currently rely on revenues from procurement of medicines for their sustainability. Principal measures to moderate growth in drug expenditure include initiatives to reduce procured drug prices. However, to date no formal pricing policies for generics in China similar to Europe and limited demand-side measures to enhance appropriate prescribing, e.g. no universal measures to monitor the quality of prescribing. Current incentives have led to irrationality in prescribing; e.g. high use of injectable drugs, antibiotics and traditional Chinese medicines (TCMs) despite the development of essential medicine lists. Objective: Assess current utilisation and expenditure of CV medicines including TCMs between 2006 and 2012 and compare the findings with Western European countries. Methods: Uncontrolled retrospective study of prescriptions to treat cardio-vascular disease in one of the largest hospitals in Southwest China. Results: Utilisation of CV drugs increased 3.3 fold during the study period, greatest for TCMs. Procured expenditure increased 4.85 fold. Variable utilisation of generics at 29% to 31% of the total for each molecule in recent years among high volume pharmacotherapeutic products. However, low prices for generics have been achieved through multiple supply-side measures, matching those achieved among some European countries. Continued irrationality in prescribing is seen with high use TCMs despite limited evidence and the utilisation of drugs dropping significantly once low prices procured. Conclusion: Prices still have appreciable impact on the subsequent utilization of different CV drugs in China. Consequently, there is appreciable potential to introduce measures similar to Western Europe to improve future rationality and reduce overall drug costs. This could include robust formularies, quality targets and financial incentives. We are beginning to see improved rationality in the use of medicines with a reduction in TCMs. This will be monitored along with other suggestions to further enhance accessibility to medicines in China without prohibitive increases in pharmaceutical and overall expenditure

Analysis of the influence of recent reforms in China : cardiovascular and cerebrovascular medicines as a case history to provide future direction

Background: Pharmaceutical expenditure has grown by 16% per annum in China, enhanced by incentives for physicians and hospitals. Hospital pharmacies dispense 80% of medicines in China, accounting for 46% of total hospital expenditure. Principal measures to moderate drug expenditure growth include pricing initiatives as limited demand-side measures. Objective: Assess current utilization and expenditure including traditional Chinese medicines (TCMs) between 2006 and 2012. Methods: Uncontrolled retrospective study of medicines to treat cardiovascular and cerebrovascular diseases in one of the largest hospitals in southwest China. Results: Utilization increased 3.3-fold for cerebrovascular medicines, greatest for TCMs, with expenditure increasing 4.85-fold. Low prices for generics were seen, similar to Europe. However, there was variable utilization of generics at 29-31% of total product volumes in recent years. There continued to be irrationality in prescribing with high use of TCMs, and the utilization of different medicines dropping significantly once they achieved low prices. Conclusion: Prices still have an appreciable impact on utilization in China. Potential measures similar to those implemented among western European countries could improve prescribing rationality and conserve resources

Rodenticide Exposure Among Endangered Kit Foxes Relative to Habitat Use in an Urban Landscape

Endangered San Joaquin kit foxes (Vulpes macrotis mutica) inhabiting Bakersfield, California exhibit a high incidence of exposure to anticoagulant rodenticides (ARs). We examined kit fox habitat use in an effort to determine potential sources of AR exposure. Kit fox capture, den, night, and mortality locations were assigned to one of 10 habitat categories. Using all available locations, foxes that tested positive for second generation anticoagulant rodenticides (SGARs) were located more frequently on golf courses while those testing negative were located more frequently in commercial areas. Foxes that tested positive for first generation anticoagulant rodenticides (FGARs) were located more frequently in industrial areas while those testing negative were located more frequently on golf courses. Based on night locations (when foxes are foraging), foxes that tested positive for SGARs were found more frequently in undeveloped and golf course habitats. Foxes that tested positive for FGARs were found more frequently in undeveloped, campus, and industrial habitats. Although available data were not sufficient to identify specific point-sources of AR exposure for foxes, golf courses appeared to be used more frequently by foxes exposed to SGARs. However, sources of exposure likely are abundant and widespread in the urban environment. Based on the results of this study, we recommend (1) investigating patterns of AR use in Bakersfield, (2) conducting an outreach program to emphasize the risk from ARs to kit foxes and other wildlife, and (3) continuing to monitor the incidence and patterns of AR exposure among kit foxes in Bakersfield

Providing a single ground-truth for illuminant estimation for the ColorChecker dataset

The ColorChecker dataset is one of the most widely used image sets for evaluating and ranking illuminant estimation algorithms. However, this single set of images has at least 3 different sets of ground-truth (i.e. correct answers) associated with it. In the literature it is often asserted that one algorithm is better than another when the algorithms in question have been tuned and tested with the different ground-truths. In this short correspondence we present some of the background as to why the 3 existing ground-truths are different and go on to make a new single and recommended set of correct answers. Experiments reinforce the importance of this work in that we show that the total ordering of a set of algorithms may be reversed depending on whether we use the new or legacy ground-truth data

Antiretroviral treatment for children

No Abstract. South African Medical Journal Vol. 96(9) (Part 2) 2006: 988-99