Looking at Statistics in Isolation Can Lead to the Wrong Conclusions

One aspect of public health is violence.  For example, at the Johns Hopkins Bloomberg School of Public Health we have a Center for Gun Policy and Research.  And, recently, there has been a lot of violence in the local news.  That, of course, is on top of numerous stories about gun violence nationally and internationally over the past several years.  So, it may seem like we should be looking for more ways to incentivize against violence and to find cost-effective solutions to preventing gun violence in particular and all types of violence in general.

In contrast, if we looked at the fact that the rate homicides appears to be going down, we might wonder, "Well, is there a problem with our perception of violence?  Maybe it is just lots of anecdotes and we don't need to look for more solutions or allocate more resources."

A piece in the Wall Street Journal recently entitled "In Medical Triumph, Homicides Fall Despite Soaring Gun Violence," (which is not available for free) they looked at this issue.  What the article reported on was an improvement in the survival after being shot in recent years.

Now, we could ask whether heroic treatment after gunshot wounds is cost-effective.  It is definitely expensive.  The trauma centers that have been set up to treat such patients (and that contribute to the much higher survival rate) have high fixed costs and high variable costs.  The WSJ article indicates that they deal with a great amount of uncompensated care in our current system and are reported to lead to losses for the hospitals at which they are located.  Thus, the demand for resources from society and resources that are taken away from the hospital are notable.  Importantly, I am not saying that we should not be saving lives.  Only that we need to be cognizant of the costs of saving the life and cognizant of the additional costs during any rehabilitation phase afterwards.

Then, once we are aware of the costs, we might ask whether the medical triumph is the most economically favorable way to decrease deaths from guns or whether we might be better off economically by trying to limit gun violence as a way to limit deaths rather than needing to treat those who do suffer gunshot wounds.

The contrasting inferences one might make based on different pieces of the data and even the contrasting steps one might take in structuring a cost-effectiveness analysis (e.g., comparing only prevention methods or only treatment methods or treatment with prevention) illustrate how important it is to try to assemble all relevant data before making a decision on further resource allocation and the need for and usefulness of economic evaluations.  

Pharmaceutical Cost-Effectiveness and Diet

I saw an interesting short piece in the Washington Post discussing the discovery that the number of drugs with important interactions with grapefruit has increased substantially since an initial report on the matter 20 years ago and particularly since 2008.

I will refer interested readers to the article for the details, but the short description of the issue is that grapefruit (but not all citrus fruit and not regular oranges) contain a chemical that interacts with some pharmaceutical products and substantially increases the bioavailability of the product.  In this case, more is not necessarily better.  In fact, more can be toxic, particularly to the kidneys.

This raises an interesting question that was probably not considered when any cost-effectiveness analysis related to the drugs is conducted.  Essentially, how does the cost-effectiveness change when you have this type of potential interaction.  It is not a typical drug-drug interaction.  It is not an adverse event due solely to the drug.  It is an event that is purely avoidable by properly reading the packaging or listening to a physician or pharmacist and then following up on what a person has been told.  Sounds simple enough.

I suppose if people were constantly have drug-grapefruit interactions, it would make the news and we would all become aware.  It is probably in the category of "things that sound scary but really are pretty rare" even though an article without additional information about the incidence of such events may make it sound very scary.

If this were a big issue, it would not seem too hard to provide better education at a fairly low cost and prevent events. If it is not a big issue, then while the increasing number of drugs that have this characteristic is interesting but probably not worth more than the short article that I saw.  I'd be intrigued to know more--such as whether anyone has personal knowledge of this issue for themselves or someone they know.

It does point to a larger issue of how we might evaluate the economic importance of better counseling about the interaction between drugs and diet more generally.  

Changing Medical Practice

In today's newsfeed from the Johns Hopkins Bloomberg School of Public Health there is a link to a blog entry about a study that asked medical care leaders why studies that seem to provide strong evidence of the relative effectiveness make such a small impact on the practice of medicine.  THe blog entry can be found here.

A key message from this blog entry seems to be--because the incentives don't point in the direction of adopting things that are less expensive.  The examples of studies with little impact tended to be things that would cost less money than the current approach to care.

We all hear from political leaders that we, in the United States, are spending too much on medical care.  We hear the same thing from business leaders.  We hear very similar things from insurance companies.  And, many individuals chime in with the same type of comment.

What we forget is two groups who aren't complaining--those who make the pharmaceutical products and devices on which we spend so much money and the physicians who prescribe their use.  Even with everyone else calling for reducing expenditures, the manufacturers do not have a strong incentive to save money.  The system right now pays in a way that bears at least some relationship to what is charged.  As such, companies that manufacture more expensive products that can be sold at a higher margin make more profits.

Physicians have only limited time to sort through the literature and to decide how to change their practice.  They listen to the way things are presented by manufacturers.  And they do not, at present, have to respond to incentives to provide care at a lower cost.

This is why I worry so much about the perspective of the cost-effectiveness or comparative effectiveness analyses.  The cost savings come from the societal perspective.  They may even characterize numerous other perspectives.  However, when all is said and done, if the economics don't work for the manufacturers and providers, change is unlikely to occur.  And, in a poor use of scarce resources, the manufacturer will spend money marketing (i.e., trying to convince people) that their products should continue to be used despite evidence to the contrary.

Unfortunately, that does not characterize an efficient system.  And changing the incentives in the first place may be much harder than changing practice patterns at any point.    

Flu Shots

First, an admission.  I have done research on flu shots.  I have helped a student of mine write a dissertation on the timing of flu shots.  However, neither I nor anyone in my family has ever had a flu shot.  Why was that our health economic decision?  We have never thought that the risk was all that large and we have never felt that the time costs were sufficiently low (even with minimal monetary costs) to warrant getting flu shots.

Now, to share an interesting piece of information.  In yesterday's Johns Hopkins Bloomberg School of Public Health news feed there was a link to a piece about a report on flu shot effectiveness.  The report that the blog had written about concluded that there was surprisingly little randomized trial evidence (the gold standard) of the effectiveness of flu shots--for almost any population and even for preventing excess transmission in hospital settings when hospital workers get vaccinated.  The blog points out the history of how we ended up with influenza vaccination being recommended for the older adult population and how difficult it would be to ever go back and rethink policy.  In short, the Surgeon General in 1960 made the recommendation and ever since then it has been considered unethical to withhold a recommended vaccine.  The author of the linked blog entry calls flu shots a sales job.

Here is where economics and ethics may come together.  Maybe if we could realize how many resources we may be over-utilizing, we could ask how it could be ethical to continue to use the resources without asking if it is efficient.  In other words, is a known inefficiency unethical?  Is a potential inefficiency unethical?  Is acting like a supposition is fact without high quality data on the facts unethical?  In any case, this would require some consultation with bioethicists and likely a new cost-effectiveness study based on the latest report showing the lack of data on the effectiveness of flu shots.  Then we could use that to motivate a new study.

It is not a common use of a cost-effectiveness study but it would be extremely useful in this case.   

Patients "Google" and Get More Out of Visits

Here is an interesting news piece about a study of patients "googling' to get information about their conditions before they go to a general practitioner and then feeling a set of more positive feelings about the experience of the visit with the general practitioner.

At first glance, I might have thought that patients googling would not help patient/provider relationships.  My intuition may have been that the process of obtaining information from the world wide web would have been seen as a substitute for positive patient/general practitioner interaction.  Instead, it seems to be complementary to and encouraging of positive interaction.

Patients have a choice--go to the general practitioner, invest their time in conversation with the GP, and come away with an experience that will guide their future health and well-being.  Alternatively, they can spend time before the visit gathering information (a use of a scarce resource), then engage in conversation with the general practitioner.  While my intuition may have been to think that patients would use the information as a substitute for interaction with the general practitioner.  What seems to happen is that the patients are taking the information and using the information to strengthen their interaction with their general practitioner.

This suggests that at least some patients see the value of the improved interaction with the physician as being more than the value of the time that it takes to search for information on the internet.  This suggests that the value of improved interaction must be substantial.

Of course, this is not just a patient issue. It is also a physician issue.  The physicians must believe that the information that patients bring to them is useful and does not interfere with the interaction.

The information from this new study may help patients and providers to plan better for more effective and more efficient interaction in the future.  

Obesity and the Public Interest

I am teaching a course on Coursera called "Principles of Obesity Economics" which is a mini-version of the online course that I typically teach at the Johns Hopkins School of Public Health each summer that is called "Obesity Economics".  The course has only been going for a day, but the preparation for it has actually demonstrated that as far as the "production of education" is concerned, there are interesting economies of scope from needing to prepare materials that are not interchangeable but that can be used with some variation in multiple settings.  But that is not the main point I want to make today.

When I typed in "Obesity Economics" as a search in google, I saw that several things with which my teaching is concerned and a blog entry at The Economist magazine.   In this entry, the author, discusses why American politics and culture makes it unlikely (in the author's opinion) that the United States will do anything that makes a serious impact on obesity in the next several decades.

That is an interesting conclusion in light of how much this gets talked about all the time.

The author concludes that the focus on individual rights to make decisions in their own self-interest and to focus only on their self-interest leads to high levels of obesity.  That is an interesting interpretation.  I am not sure I agree that this is the exact answer, but it is worth thinking about whether, from an economic perspective, there is reason to think that this might actually be the case.

Individual self-interest means that individuals maximize their own utility.  No one that I know wants to be obese.  Some people are more willing to accept it than others.  But does that necessarily mean that obesity should increase as much as it does.  That would suppose that people make poor decisions. Or that people don't have enough information to make decisions.  Or that people are given wrong information to make decisions.    Or that people don't look forward enough when making decisions.  Each of these might involve a government intervention.  Very little would necessarily need to be changed in terms of leaving individuals witha high degree of free choice of what they want to eat and when and how they want to use their energy and when.  Perhaps we could think a little harder about regulating business.  And perhaps that is truly the issue. Perhaps we do not need to be regulating or incentivizing individual behavior (although for all of America's focus on individual rights we still tend to think that we should not have to pay all of our own medical care costs so the responsibilities that come along with those rights don't necessarily seem to be taken as strongly). Perhaps we should regulate business more.  Although that does not seem to be a large part of American culture either.  And that may be the just as important a rate limiting factor to achieving goals having to do with weight control in the United States.

We would still have to justify it with a compelling public need or an example of a market failure, but the point of whom to target and how carefully to target them would seem to remain an open question.  

Hospitals Providing Formula

There is an interesting piece in the New York Times about hospitals ending the practice of sending formula home with mothers who are breastfeeding or ending the practice of sending mothers at home with formula at all.  There are a number of interesting economic questions here.

First, what is the role of a sample of formula in determining infant feeding practices.  This is particularly relevant for mothers who have decided to breastfeed at first.  On the one hand, it makes access to formula easier.  Less time required to obtain the first amount of formula that a mother will use to feed a child.  A lower price (zero beyond the hospital costs) than if the sample was not provided.  So, there is an economic logic to the idea that this might change mothers' behavior with respect to how they choose to feed their children.  Perhaps for any mothers who were truly at the margin about their decision to breastfeed, their decision might change.  Or, at the very least, their decision to stop breastfeeding might change to an earlier time than they had otherwise planned if the cost of switching to formula feeding is made lower than it would have been otherwise.

Even if the mother continues to breastfeed, one question would be how to measure the value of having the option of formula feeding readily available.  At least some mothers may assign a value to this even if they never choose to formula feed.  

Second, there is the question about whether it is acceptable to send formula home with mothers who are already formula feeding.  This does not seem like a question of promoting behavior change in this case.  Instead, the issue here is what brand the mother will choose.  Does the mother perceive the type of formula offered as an endorsement from the hospital.  In this case, is the hospital playing a role in essentially marketing a specific type of formula to the mothers.  If they are, is this a reasonable role for the hospital to play?

The biggest question overall may be whether the hospital has a role to play in shaping mothers' behavior rather than letting the mother make a choice for herself with the information she has available.  The hospital arguably has a role in providing information and helping the mother understand tradeoffs that she might need to make but what there is beyond that is uncertain.