HE之06/07最佳论文摘要

Therapeutic non-adherence: a rational behavior revealing patient preferences? Karine Lamiraud^1,*,  Pierre-Yves Geoffard^1,2,3   Article first published online: 15 FEB 2007

这篇得了06/07年HE最佳的论文让我一头雾水，好量化啊，题目叫"治疗非依附性：这是一种揭示病人偏好的理性行为吗？"我决定翻一下其摘要：

文章基于病人是否遵从他们接受的处方来提供一种对病人福祉的间接测评手段。依附行为(Adherence behavior)被认为是可揭示病人对某种治疗的主观评价。我们写了一段简单的病人依附行为的理论模型—其反应了可知成本(perceived costs)和可知疗效(observed regimen efficacy)之间的权衡。一个离散选择框架(discrete choice framework)被用来进行估计，如两种药物摄入治疗所产生受益的比较。所以实证分析是基于对"与依附性相关的病人特征和药物特征"之间的识别。经济计量方法是通过一个联合分析"与依附性、病人对治疗反应相关的影响因素"的双变量面板双方程模拟系统进行研究的。数据来自1999-2001在法国进行的一个比较两种HIV 三疗法(tritherapy)的随机临床试验。

理论和实证结果都认为，对于可比较的临床疗效和毒理级别而言，更高的依附性和更好的病人福祉是相关的，因此研究为仅仅是生物统计分析产生的结论增加了更有价值的参考信息。所以从病人感知来说，依附性增加(adherence-enhancing)的药物必定是受偏爱的。我们基于面板数据的结果还认为，无法观测的病人特征是解释病人对药物评价的主要因素，而且治疗过程中病人对药物的评价是会改变的。另外我们提供了对依附性数据分析的一个新框架。这个微观计量框架强调非依附性是内生行为，这为改进依附性提出了新的途径。

Abstract

This paper offers an indirect measure of patient welfare based on whether patients comply with the prescription they receive. Adherence behavior is supposed to reveal patients' subjective valuations of particular therapies. We write a simple theoretical model of patient adherence behavior, that reflects the trade-off between perceived costs and observed regimen efficacy. A discrete choice framework is then used for the estimation, i.e. the comparison of the incremental benefit of drug intake between two regimens. Consequently, the empirical analysis is based on the identification of patient and drug characteristics associated with adherence. The econometric approach is implemented through a bivariate panel two-equation simultaneous system studying jointly the factors associated with adherence and response to treatment. The data come from a randomized clinical trial conducted in France between 1999 and 2001 and comparing the efficacy of two tritherapy strategies in HIV disease.

Both the theoretical and empirical results suggest that, for comparable clinical efficacy and toxicity levels, a higher adherence level is associated with higher patient welfare, thus adding valuable information to conclusions drawn by a mere biostatistical analysis. Therefore, from the perspective of the patient, the adherence-enhancing drug must be favored. Our results based on panel data also stress that unobserved patient characteristics account substantially for drug valuation and that the assessment evolves during the course of the treatment. Furthermore, we provide a new framework for the analysis of adherence data. The microeconometric framework highlights that non-adherence is an endogenous behavior, thus suggesting new ways for improving adherence.

Keywords: drug valuation method; revealed preferences; endogenous adherence behavior; panel bivariate probit estimation; HIV

本月HA精粹2011-4

这个月的HA有几篇专注 医疗事故成本 的文章，Jason有系统摘录。

The Ongoing Quality Improvement Journey: Next Stop, High Reliability这篇文章系统回顾了US的医疗卫生服务的质量改进的进程，并提出一个未来的改进框架（虽然我觉得框架很烂），但作为质量改进历史和文献综述看看不错。

The Trade-Off Among Quality, Quantity, And Cost: How To Make It—If We Must 宾大的大牛Mark Pauly认为ACA给医疗服务市场的质量改进无数的政策压力，但事实效果却未必尽然。更好的策略莫过于熊彼特的"破坏性创新disruptive innovation"--市场的力量！例如对医疗服务市场PCP的一个替代品retail clinic零售诊所 -- to provide limited services by nonphysician professionals in a more convenient and lower-cost setting，虽然是由护士或其他非医生专业服务者代理，但消费者或许会认同牺牲一点质量但可换来的方便性和低成本。Pauly虽然1968年就发表了医保产生道德损害的经典论文，但多年研究和经验反而让他更愿意支持market power。

Variations In Efficiency And The Relationship To Quality Of Care In The Veterans Health System一个NY Albany的经济PhD的文献，这群作者开始担心促进医院效率提高会影响质量（以前我看过一篇JAMA的文献就讲这个意思），但是他们对VA军队医院系统的实证模型发现1VA的效率挺高的（我在想CCVA呢？），2是效率高反而质量高，效率低的质量也低。我看到他们模型里用的测量指标真爽，要是大陆也有一半的测量指标系统就好了。

另：他们的Hospital Cost And Efficiency Model也就是随机前沿分析

Rosko MD, Mutter RL. Stochastic frontier analysis of hospital inefficiency: a review of empirical issues and an assessment of robustness. Med Care Res Rev. 2008;65(2):131–66.

The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors 一群精算师测算的US一年可供测评的且可预防的医疗事故给病人造成的成本(annual cost of measurable preventable medical errors that harm patients)是17.1billion。作者说文章只关乎直接医疗成本direct medical costs，如malpractice insurance premiums(medical malpractice settlements, malpractice insurance costs, and other medical professional liability costs)等间接成本不关此题。Medical errors跟Medical malpractice差不多吧？Chandra就有篇National Costs Of The Medical Liability System美国医疗责任事故系统的国家成本的文章，Reinhardt还在econmix上很有好评呢。

Financial Incentives And Measurement Improved Physicians' Quality Of Care In The Philippines则更绝，他们觉得以前用财务激励改进临床质量的研究和政策都很薄弱，干脆用菲律宾30家医院及其医生来做个试验。他们先测量了临床绩效clinical performance，然后检查了modest bonuses（=5%的薪水）和医院层面的收入增长（即医院收入带来的医生收入增加激励）等两项是否产生医疗服务质量改进。结果两项都提高了10%（他们用的自己的质量评估系统），并认为认真测评是能发现财务激励对质量的效果的--也就是说以前很多研究不严谨，匆忙否定财务和经济激励对医疗质量的影响（并以此强调医疗服务的特殊性）。

weblinks 2011-4-12

来自Austin Frakt的文献检视--医院的服务量和质量的关系--是双向影响还是单向呢？

A recent paper in Health Economics by David Barker, Gary Rosenthal, and Peter Cram (ungated working paper available) provides one route to an answer and includes a literature review that provides others. They examine the relationship between volume and mortality for cardiac revascularization in specialty hospitals versus general hospitals. After controlling for the simultaneity of volume and mortality, they conclude that "specialty hospitals do not have an advantage over general hospitals in mortality rates after cardiac revascularization." Moreover, they find that mortality rates do influence volume. Therefore, efforts to increase volume may not themselves increase the quality of outcomes. Volume isn't exogenous.

一个医生、一个律师、一个经理人，创立了Open Health Market--一个在线的医疗服务匹配市场。在这里，雇主可以递交所需医疗服务的申请（团购或个体），然后对面则有Health care providers进行竞价。就好像那些卖餐饮的团购网站一样，什么"好评网"啊之类的，各家商店推出一批服务，而online medical则是购买者需求主导。 ---http://hosted.ap.org/dynamic/stories/U/US_BIDDING_ON_HEALTH?SITE=TXDAM&SECTION=HOME&TEMPLATE=DEFAULT

一个前NHS的主任死于她的手术被4次取消--因为队排得太长了，她居然也叫Margaret，撒切尔肯定会比较郁闷的。虽然是反讽，但还是同情一下吧。A former NHS director died after waiting for nine months for an operation - at her own hospital. Margaret Hutchon, a former mayor, had been waiting since last June for a follow-up stomach operation at Broomfield Hospital in Chelmsford, Essex.

J Wennberg的故事 之二

Dartmouth Atlas团队传统的观点是认为Medicare的花费有地区集中性。且之前的研究Fisher et al. 2003;Center for the Evaluative Clinical Services 2007) 有认为这些差异是由供给诱导需求产生的。但Reschovsky 的研究在控制了个人层面的健康状况后，认为不是供给诱导产生的费用差异。

另外高花费并不联系到高质量的医疗服务也受到挑战，这里面的地区差异也被认为是过度夸张了。Zuckerman et al. (2010) 也认为基线健康状况、人口特征等的调整能解释29%的地区费用差异，而地区层面的医疗资源供给差异并不能深入减少高低花费地区间的可观察差异。那么由于疾病负担本身产生的费用地区差异，而不是执业结构（诊断结构差异），则试图从医生的诊断层面进行改变的政策就将没有意义了。

Source：http://healthcare-economist.com/2011/04/04/regional-differences-in-medicare-spending-and-health-status/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+HealthcareEconomist+%28Healthcare+Economist%29

http://healthcare-economist.com/2011/03/30/is-there-really-large-differences-in-medicare-spending-across-states/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+HealthcareEconomist+%28Healthcare+Economist%29