Evidence and Access to Biomedical Interventions: The Case of Stem Cell Treatments

The controversy over patients' access to stem cell interventions is familiar to scholars of the drug regulatory system and the politics of evidence-based medicine. What counts as evidence of a biomedical intervention's safety and effectiveness? Who should define and assess safety and effectiveness, and how? In the first section of the paper we describe the types of stem cells that may be therapeutically effective. We then describe how the US Food and Drug Administration asserted regulatory authority over certain stem cell interventions and the legal challenge to the agency's actions. Next, we place the debate about patients' access to stem cell interventions in the broader context of efforts in the US to promote and implement health technology assessment and the debate about standards of evidence. We then review several proposed initiatives to get stem cell and other new biomedical interventions into the clinic faster and consider the extent to which these policies can resolve the underlying conflicts about evidentiary standards for clinical use. Finally, we consider whether efforts to expedite access to biomedical technologies may undermine countervailing efforts to improve the safety and effectiveness of stem cell interventions.

Needed: Global Collaboration for Comparative Research on Cities and Health

Over half of the world's population lives in cities and United Nations (UN) demographers project an increase of 2.5 billion more urban dwellers by 2050. Yet there is too little systematic comparative research on the practice of urban health policy and management (HPAM), particularly in the megacities of middle-income and developing nations. We make a case for creating a global database on cities, population health and healthcare systems. The expenses involved in data collection would be difficult to justify without some review of previous work, some agreement on indicators worth measuring, conceptual and methodological considerations to guide the construction of the global database, and a set of research questions and hypotheses to test. We, therefore, address these issues in a manner that we hope will stimulate further discussion and collaboration.

Medicare and Amyloid PET Imaging: The Battle Over Evidence

We examine a recent dispute regarding the Centers for Medicare and Medicaid Services' (CMS) refusal to unconditionally pay for amyloid positron emission tomography (PET) imaging for Medicare beneficiaries being assessed for Alzheimer's disease. CMS will only pay for amyloid PET imaging when patients are enrolled in clinical trials that meet certain criteria. The dispute reflects CMS's willingness in certain circumstances to require effectiveness evidence that differs from the Food and Drug Administration's standard for pre-market approval of a medical intervention and reveals how stakeholders with differing perspectives about evidentiary standards have played a role in attempting to shape the Medicare program's coverage policies.

Emergency department use: a reflection of poor primary care access?

OBJECTIVES

To determine whether the use of the emergency department (ED) for nonurgent care reflects poor access to community-based primary care providers (PCPs).

STUDY DESIGN

Using a survey of ED patients, insurance claims data, and administrative records identifying demographic factors, we analyzed the use of the ED in an impoverished area of Brooklyn, New York.

METHODS

We examined original survey data to investigate the extent to which residents of northern and central Brooklyn use EDs for nonemergencies and whether these patients have access to PCPs. We used data from health insurers operating in northern and central Brooklyn, and New York state hospital ED visit data to investigate the factors influencing ED visits for ambulatory care-sensitive conditions (ACSCs). Logistic regression was used to identify characteristics that predict ED visits not resulting in admission for ACSCs.

RESULTS

Of 11,546 patients that completed our survey, the presenting complaint was self-described as emergent by 57%, 30% had no PCP, and 19% reported no health insurance coverage. Using health insurance plan encounter data, only 15 % of patients had seen any provider within 1 week of the ED visit. Insurance type, age, gender, race/ethnicity, and socioeconomic status of area of residence influence the likelihood of these ED visits.

CONCLUSIONS

Correlating data from 3 sources, we suggest that the expansion of insurance under the Affordable Care Act may not be sufficient to reduce ED use for nonurgent conditions.

Shanghai rising: health improvements as measured by avoidable mortality since 2000

Over the past two decades, Shanghai, the largest megacity in China, has been coping with unprecedented growth of its economy and population while overcoming previous underinvestment in the health system by the central and local governments. We study the evolution of Shanghai's healthcare system by analyzing "Avoidable Mortality" (AM) - deaths amenable to public health and healthcare interventions, as previously defined in the literature. Based on analysis of mortality data, by cause of death, from the Shanghai Municipal Center for Disease Control and Prevention, we analyze trends over the period 2000-10 and compare Shanghai's experience to other mega-city regions - New York, London and Paris. Population health status attributable to public health and healthcare interventions improved dramatically for Shanghai's population with permanent residency status. The age-adjusted rate of AM, per 1,000 population, dropped from 0.72 to 0.50. The rate of decrease in age-adjusted AM in Shanghai (30%) was comparable to New York City (30%) and Paris (25%), but lower than London (42%). Shanghai's establishment of the Municipal Center for Disease Control and Prevention and its upgrading of public health and health services are likely to have contributed to the large decrease in the number and rate of avoidable deaths, which suggests that investments in public health infrastructure and increasing access to health services in megacities - both in China and worldwide - can produce significant mortality declines. Future analysis in Shanghai should investigate inequalities in avoidable deaths and the extent to which these gains have benefitted the significant population of urban migrants who do not have permanent residency status.

Social vulnerability index for the older people-Hong Kong and New York City as examples

Many world cities have suffered large-scale disasters, causing a significant loss of lives, property damage, and adverse social and economic impact. Those who are most vulnerable during and in the immediate aftermath of disaster crises are the elderly. Therefore, it is imperative to identify them and determine their specific needs in order to support them. Although several Social Vulnerability Indexes (SVIs) have been developed to assess different types of disaster vulnerability across geographic and population levels, few have been tailored to the older population. Building on the research of Gusmano et al., this study modifies and uses an SVI specifically designed to assess the vulnerability of older populations to emergencies and disasters across seven domains, namely, population size, institutionalization, poverty, living alone, disability, communication obstacles, and access to primary care. Moreover, it is acknowledged that availability of data largely depends on the local context and is always a barrier to production of indices across countries. The present study offers suggestions on how modifications can be made for local adaptation such that the SVI can be applied in different cities and localities. The SVI used in this study provides information to stakeholders in emergency preparedness, not only about natural disasters but also about health hazards and emergencies, which few existing SVI address.

Using Comparative Analysis to Address Health System Caricatures

To learn from health care systems abroad, we must move beyond simplistic characterizations and compare different systems with respect to salient performance measures. Despite findings from recent cross-national studies suggesting that many health care systems outperform the United States, claims by U.S. public officials often fail to acknowledge the actual accomplishments of health care systems abroad. We document significant variation among the United States and France, Germany, and England, which provide universal coverage, albeit in different ways. As previously documented, the United States has the highest rate of mortality amenable to health care. We extend this work by adding two indicators: ( a) access to timely and effective primary care as measured by hospital discharges for avoidable hospital conditions; and ( b) use of specialty services as indicated by coronary revascularization (bypass surgery and angioplasty), adjusted for the burden of coronary artery disease. Our findings indicate that: ( a) the United States suffers the gravest consequences of financial barriers to primary care; ( b) in all four countries, older people (65+) receive fewer revascularizations than their younger counterparts once we account for disease burden; and ( c) in France, patients receive the most revascularizations, after adjusting for the burden of disease.

The politics of comparative effectiveness research: lessons from recent history

Efforts to support and use comparative effectiveness research (CER), some more successful than others, have been promulgated at various times over the last forty years. Following a resurgence of interest in CER, recent health care reforms provided substantial support to strengthen its role in US health care. While CER has generally captured bipartisan support, detractors have raised concerns that it will be used to ration services and heighten government control over health care. Such concerns almost derailed the initiative during passage of the health care reform legislation and are still present today. Given recent investments in CER and the debates surrounding its development, the time is ripe to reflect on past efforts to introduce CER in the United States. This article examines previous initiatives, highlighting their prescribed role in US health care, the reasons for their success or failure, and the political lessons learned. Current CER initiatives have corrected for many of the pitfalls experienced by previous efforts. However, past experiences point to a number of issues that must still be addressed to ensure the long-term success and sustainability of CER, including adopting realistic aims about its impact, demonstrating the impact of Patient-Centered Outcomes Research Institute (PCORI) and communicating the benefits of CER, and maintaining strong political and stakeholder support.

Is it reasonable to deny older patients treatment for glioblastoma?

Is it ever fair to limit treatment for diseases like glioblastoma for which prognosis is poor? Because resources are finite and health care spending limits the other possible uses for those resources, limiting access to an intervention that does not generate benefits is ethically sound. Ignoring the balance of benefits and burdens associated with treatment ignores opportunity costs and leads us to treat some lives as more valuable than others. Although it is ethically sound to set limits on medical care, I argue that biological age is a poor criterion for allocating resources.

Introduction: evaluation in analytic theory and political practice

The development of professional policy analysis was driven by a desire to apply "science" to policy decisions, but the vision of apolitical policy analysis is as unattainable today as it was at the inception of the field. While there is powerful evidence that schemes to "get around" politics are futile, they never seem to lose their popularity. The contemporary enthusiasm for health technology assessment and comparative-effectiveness research extends these efforts to find technical, bureaucratic fixes to the problem of health care costs. As the benefits and costs of health care continue to grow, so too will the search for analytic evidence and insights. It is important to recognize that the goal of these efforts should not be to eliminate but rather to enrich political deliberations that govern what societies pay for and get from their health care systems.

Disparities in access to health care in three French regions

OBJECTIVES

This paper compares access to primary and specialty care in three metropolitan regions of France: Ile de France (IDF), Nord-Pas-de-Calais (NPC) and Provence-Alpes-Côte d'Azur (PACA); and identifies the factors that contribute to disparities in access to care within and among these regions.

METHODS

To assess access to primary care, we compare variation among residence-based, age-adjusted hospital discharge rates for ambulatory care sensitive conditions (ASC). To assess access on one dimension of specialty care, we compare residence-based, age-adjusted hospital discharge rates for revascularization - bypass surgery and angioplasty - among patients diagnosed with ischemic heart disease (IHD). In addition, for each region we rely on a multilevel generalized linear mixed effect model to identify a range of individual and area-level factors that affect the discharge rates for ASC and revascularization.

RESULTS

In comparison with other large metropolitan regions, in France, access to primary care is greater in Paris and its surrounding region (IDF) than in NPC but worse than in PACA. With regard to revascularization, after controlling for the burden of IHD, use of services is highest in PACA followed by IDF and NPC. In all three regions, disparities in access are much greater for revascularization than for ASC. Residents of low-income areas and those who are treated in public hospitals have poorer access to primary care and revascularizations. In addition, the odds of hospitalization for ASC and revascularization are higher for men. Finally, people who are treated in public hospitals, have poorer access to primary care and revascularization services than those who are admitted for ASC and revascularization services in private hospitals.

CONCLUSIONS

Within each region, we find significant income disparities among geographic areas in access to primary care as well as revascularization. Even within a national health insurance system that minimizes the financial barriers to health care and has one of the highest rates of spending on health care in Europe, the challenge of minimizing these disparities remains.