Sunday, October 30, 2005

Snippets Oct 30 2005

This Item Re-recommended by Leeza Ozipenka

Building a Better Delivery System: A New Engineering/Health Care Partnership

Proctor P. Reid, W. Dale Compton, Jerome H. Grossman and Gary Fanjiang, Editors

National Academies Press, 2005

Available online at:



“…….The report describes the opportunities and challenges to harnessing the power of systems-engineering tools, information technologies, and complementary knowledge in social sciences, cognitive sciences, and business/management to advance the six IOM quality aims for a twenty-first century health care system.


Commonwealth Fund High Performance Health System Sign-up

The Commonwealth Fund has established the Commission on a High Performance Health System to help move the U.S. toward a health care system that achieves better access, improved quality, and greater efficiency, particularly for those who are vulnerable due to income, race/ethnicity, health, or age.

At a recent Washington, DC briefing cosponsored by the Fund and the Alliance for Health Reform, commission chair James J. Mongan, M.D., president and chief executive officer of Partners HealthCare, called for health system change and the commission released its first chartbook, A Need to Transform the U.S. Health Care System: Improving Access, Quality, and Efficiency.

If you'd like to stay up to date on the commission's activities and publications by receiving e-mail alerts, we invite you to join our new commission mailing list by clicking on the following link to send an e-mail to or visiting our e-mail alert sign-up page

Getting better value for money from Sweden's healthcare system

David Rae
Organisation for Economic Co-operation and Development -
OECD, September 20, 2005

Available online as PDF file [39p.] at:$FILE/JT00189812.PDF

“………This paper reviews the strengths and weaknesses of the Swedish healthcare system and the challenges that it will face in the future.
It discusses ways to improve access to primary care, including different methods for paying GPs, whether access is less equitable
than in other countries and the role of patient fees. The maximum waiting time guarantee for elective surgery is reviewed, along with
ways of reducing regional variations in quality. The extent of decentralisation is questioned, as that may be affecting the quality of care
and value for money in some areas, including elderly and psychiatric care. Mechanisms for improving the hospital sector are also
examined including fee‑for‑service (DRG) payment mechanisms and whether for‑profit hospitals would help.
Finally, it considers ways to make financing more stable and sustainable.

Bridging the Gap: The Use of Research Evidence in Policy Development


Jon D. Brehaut, Don Juzwishin

Health Technology Assessment Unit Alberta Heritage Foundation for Medical Research

Alberta Heritage Foundation for Medical research,  Alberta, Canada – September 2005


          Available online at:


“….Public policy can be a messy business. Bismarck.s famous observation about legislation.and what is legislation but public policy writ large.and sausage making is often quoted (one translation of Bismarck.s observation: …..People who love the law or good sausage should never watch either being made.) because it resonates with our beliefs and experiences.


Policy decisions are difficult to evaluate at the best of times. Is a given decision good or bad? Is it effective or ineffective?
What about unintended consequences? ….


Item from Bobby Milstein : $500,000 MacArthur 'Genius' Grant Awarded to Sue Goldie, Physician and Researcher Who Applies Decision Science to Global Women's Health

One of this year's MacArthur "Genius" Fellowships was awarded to Sue Goldie, a public health researcher at Harvard for her innovative use of computer models in studying policy scenarios.  Below is a brief profile of her work.  Note the rationale given for why her modeling approach is so worthwhile, and its similarities to the sort of models that many of us have been constructing these past few years at CDC and elsewhere.

"The mathematical models she constructs differ from many models used for cost-effectiveness analysis in that they are "biologically-based," hewing closely to the underlying disease process as it unfolds, while remaining consistent with observed epidemiological data. They extend information available from observational studies by extrapolating patterns beyond the time horizon of a single study, and can be used to evaluate strategies in a wide range of settings. In addition to relating biological and clinical information, they can provide quantitative insight into the relative importance of different components of the prevention or treatment process and allow investigation of how results will change if values of key parameters are varied. By identifying the most influential parameters she can identify key information gaps and prioritize and guide data collection efforts." Said HSPH Dean Barry Bloom of Dr. Goldie: "She has a rare ability to go from the most theoretical analysis of decision-making in health care to translating that into the real world of both rich and poor countries in a way that has already made an enormous difference in women's health."
Dr. Goldie's faculty research page is available at:

A feature profile of Dr. Goldie from the Summer 2002 issue of Harvard Public Health Review is available at:
(please note, Dr. Goldie is now an associate professor)

Nanny or Steward? The role of government in public health


Karen Jochelson

The King's Fund, London, UK October 2005


Available online at:


“…..The past year has seen some contentious debates about public health in the United Kingdom, focusing on a ban on smoking in public places, food labelling and food advertising to children. Some people have argued that any government intervention in these areas is ‘nanny statist’ – an unnecessary intrusion into people’s lives and what they do, eat and drink. Others have argued that only the state can effectively reduce the poverty that is so often the root cause of ill health….”


“….This paper suggests that there is a strong argument to be made for government intervention to safeguard public health. Legislation brings about changes that individuals on their own cannot, and sets new standards for the public good. Rather than condemning such activity as nanny statist, it might be more appropriate to view it as a form of ‘stewardship’.


Health Systems Action Network (HSAN)


Concept Note:

The development of a Health Systems Action Network (HSAN) was first proposed at a World Health Organization meeting on “The Montreux Challenge: Making Health Systems Work” in April 2005. It was thought that HSAN could serve as a means to build

·         build on the growing interest and momentum around creating stronger health systems by providing a vehicle through which diverse partners could help maintain attention on health systems

·         improve communication and the flow of credible information about how health system strengthening could be done, and

·         help promote greater coordination and collaboration

The "Montreux Challenge": Making Health Systems Work
Glion sur Montreux, Switzerland, 4-6, April 2005

Background Materials of the meeting available at:


From Knowledge@Wharton Health Economics
After Decades of Malaise, the Vaccine Industry Is Getting an Injection
After decades of decline, the vaccine industry is gaining new interest from drug makers and the federal government in response to last year's flu-shot shortage, concerns about an avian flu pandemic, and the development of potential vaccines targeted at new markets, including cancer. Still, vaccines remain a small piece of the overall drug market -- less than 3% of the global pharmaceutical industry -- and vaccine manufacturers continue to face liability problems and low payments from public-health customers, according to Wharton faculty and other experts. In the face of these obstacles, what will it take to inject some life into the ailing industry?

Implementation Research: A Synthesis of the Literature


National Implementation Research Network (NIRN), University of South Florida, 2005




“….In this report, researchers from the National Implementation Research Network provide a comprehensive view of the current science of implementation and offer practical advice for getting evidence-based practices and programs off the ground successfully. Recommendations gleaned from the authors' analysis of the current literature will help planners make decisions based on the best available knowledge from fields as diverse as medicine and manufacturing…. Sebastien Levesque …”

Download the entire document [5.2mb pdf]

From OECD What is new October 2005 : HEALTH

In Search of Efficiency: Improving Health Care in Hungary: Working Paper

A Series of OECD Policy Briefs on Health: Listing

UK Health Watch Report: The Experience of Health in an unequal society

October 2005


Available online as PDF file [164p.] at:


On the day that the UK government, as part of its EU Presidency, hosts a two day Health Inequalities Summit conference in London, a new report claims that health inequalities have deteriorated as a direct result of government policies.


‘Doing better but feeling worse’ is how UK Health Watch 2005 - an 'alternative UK health report' from the Politics of Health Group - describes health in the UK in 2005. ‘Although average life expectancy in the UK continues to increase, the inequalities between rich and poor people, and the problems faced by socially excluded groups,  have got steadily worse under New Labour. This is confirmed by the Government’s own statistics’, says Dr Alex Scott-Samuel, joint editor of the report and Joint Chair of the Politics of Health Group.


In Case you missed it (Includes Health Stream Session Reports):

The October 2005 issue of the System Dynamics Newsletter is available at Please
take a look! This issue of the newsletter contains a full report on the
Boston Conference, including the President's Address and many articles
submitted by volunteer conference session reporters.


SDList : SD for Malaria Prevention and Control

Posted by  "Jack Homer" <>

See:  James Ritchie Dunham and Jorge Mendez Galvan, "Evalating Epidemic
Intervention Policies with Systems Thinking: A Case Study of Dengue Fever in
Mexico, System Dynamics Review, 15(2), Summer 1999.

Also, pp. 300-323 on modeling disease epidemics, in Sterman's Business
Dynamics book.

Posted by  "Leslie A. Martin" <>
Please see
The paper describes a system dynamics approach taken to evaluate
malaria-control programs in Bolivia.

Sunday, October 16, 2005

Snippets Oct 16 2005

This Lancet item from Roy Greenhalgh

Chronic diseases represent a huge proportion of human illness. They include cardiovascular disease (30% of projected total worldwide deaths in 2005), cancer (13%), chronic respiratory diseases (7%), and diabetes (2%). Two risk factors underlying these conditions are key to any population-wide strategy of control-tobacco use and obesity. These risks and the diseases they engender are not the exclusive preserve of rich nations. Quite the contrary.1 Chronic diseases are a larger problem in low-income settings. Research into chronic diseases in resource-poor nations remains embryonic. But what evidence there is 2,3 shows just how critical it will be to intervene early in the epidemic's course. There is an unusual opportunity before us to act now to prevent the needless deaths of millions. Do we have the insight and resolve to respond?

With a new series of articles, .. The Lancet aims to fill a gap in the global dialogue about disease. It is a surprising and important gap, one that health workers and policymakers can no longer afford to ignore. The call by Kathleen Strong and colleagues4 for the world to set a target to reduce deaths from chronic disease by 2% annually-to prevent 36 million deaths by 2015-deserves to be added to the existing eight MDGs. Without concerted and coordinated political action, the gains achieved in reducing the burden of infectious disease will be washed away as a new wave of preventable illness engulfs those least able to protect themselves. Let this series be part of a new international commitment to deny that outcome.

1 Preventing chronic diseases: how many lives can we save?   Strong K, Mathers C, Leeder S, Beaglehole R   Lancet 2005; published online Oct 5

2 Preventing chronic diseases: taking stepwise action   Epping-Jordan JE, Galea G, Tukuitonga C, Beaglehole R  Lancet 2005; published online Oct 5

3 Responding to the threat of chronic diseases in India   Reddy KS, Shah B, Varghese C, Ramadoss A   Lancet 2005; published online Oct 5

4 Preventing chronic diseases in China   Wang L, Kong L, Wu F, Bai Y, Burton R   Lancet 2005; published online Oct 5

Preventing chronic diseases: a vital investment

World Health Organization, October 2005

This WHO global report makes the case for urgent action to halt and turn back the growing threat of chronic diseases. It presents a state-of-the-art guide to effective and feasible interventions, and provides practical suggestions for how countries can implement these interventions to respond successfully to the growing epidemics.
Part One summarizes the report's main messages.
English [pdf 2.38Mb] | Arabic [pdf 15.92Mb] | Chinese [pdf 7.25Mb] | French [pdf 2.78Mb] | Russian [pdf 7.02Mb] | Spanish [pdf 2.55Mb]

Download full report in English [pdf 7.61Mb]


Snapshots of health systems The state of affairs in 16 countries in summer 2004


Edited by Susanne Grosse-Tebbe and Josep Figueras

The European Observatory on Health Systems and Policies


The Snapshots of health systems - the state of affairs in 16 countries in summer 2004 provide very brief overviews of the organization and fi nancing of the health systems, the provision of health care as well as developments prior to 1 May 2004 in 15 European Union Member States and Israel.


Investing in children’s health: what are the economic benefits?


Paolo C. Belli, Flavia Bustreo, & Alexander Preker

Bulletin of the World Health Organization - Volume 83, Number 10, October 2005, 721–800


Available online as PDF file at:  



This paper argues that investing in children’s health is a sound economic decision for governments to take, even if the moral justifications for such programmes are not considered. The paper also outlines dimensions that are often neglected when public investment decisions are taken. The conclusion that can be drawn from the literature studying the relationship between children’s health and the economy is that children’s health is a potentially valuable economic investment.


The World Disasters Report 2005 focuses on information in disasters

International Federation of Red Cross and Red Crescent Societies, October 2005


People need information as much as water, food, medicine or shelter. Information can save lives, livelihoods and resources. It may be the only form of disaster preparedness that the most vulnerable can afford. The right kind of information leads to a deeper understanding of needs and ways to respond. The wrong information can lead to inappropriate, even dangerous interventions.





CESifo Group: the Center for Economic Studies (CES), the Ifo Institute for Economic Research and the CESifo GmbH (Munich Society for the Promotion of Economic Research


Available online as PDF file [42pp.] at;


“……The UK and the Scandinavian countries are examples of countries where general practitioners (GPs) have a gatekeeping role in the health care system. Patients do not have direct access to secondary care. They need a referral from their (primary care) GP to get access to a hospital or a specialist.1 In the US, several health maintenance organisations (HMOs) also practice gatekeeping. Recently, however, some HMOs have relaxed the restrictions on access to specialists (see, e.g., Ferris et al., 2001).


Disability and Social Safety Nets in Developing Countries


World Bank Social Protection Discussion Paper No.0509, May 2005.

Sophie Mitra, Rutgers University


Please click on the link below to view the paper:


“……This paper deals with how social safety nets may reach the poor with disabilities in developing countries. It presents a framework for analyzing the inclusion of disability in social safety nets. The paper first reviews evidence on the relation between disability and poverty and discusses the roles that safety nets may play with regard to disability.




The Symposium funded by the Department of Health and Human Services, Office of Public Health Emergency Preparedness, the Vaccine Program
Office, and the National Institute of Allergy and Infectious Disease, National Institutes of Health.


The Institute of Medicine (IOM) of the National Academies of Science April 4-5, 2005


Available online at:


Symposium to discuss the current state of the art of research on pandemic influenza and to identify gaps in research. The symposium serves as a first step of discussion towards a combined and coordinated research effort among Department of Health and Human Services agencies, other governmental agencies, international partners and the private sector.


DFID Health Resource Centre Study: Global Health Partnerships: Assessing the Impact, 2004

The DFID Global Health Initiatives and Partnerships team commissioned an extensive study to fill gaps in understanding/knowledge related to increasing GHP impact. The study was broken down into 7 components: finance; effectiveness; governance; commodities; poverty-focus, gender and neglected diseases; and issues of national coordination.

A final synthesis report was written to summarise the findings. A separate but related piece of work subsequently emerged from the GHP study; to map the role and linkages of different agencies and partnerships active in work on TB, malaria and AIDS, along a pathway of investments from product discovery through to access (Study Paper 8).

GHP Study Paper 1: Mapping Global Health Partnerships. What they are, what they do and where they operate View
GHP Study Paper 2: Economic and Financial Aspects of the Global Health Partnerships View
GHP Study Paper 3: Global Health Partnership Impact on Commodity Pricing and Security View
GHP Study Paper 4: Global Health Partnerships and Neglected Diseases View
GHP Study Paper 5: Global Health Partnerships Increasing their Impact by Improved Governance View
GHP Study Paper 6: The Determinants of Effectiveness: Partnerships that Deliver Review of the GHP and ‘Business’ Literature View
GHP Study Paper 7: Assessing the Impact of Global Health Partnerships Country Case Study Report  View
GHP Study Paper 8: The Product Development Pathway View

Assessing the Impact of Global Health Partnerships
Synthesis of findings from the 2004 DFID Studies:

Available online as PDf file at:


Towards a Conceptual Framework for Analysis and Action on the Social Determinants of Health


Discussion paper for the Commission on Social Determinants of Health - CSDH

DRAFT 5 May 2005

WHO Health Equity Team, Office of the Assistant Director-General, Evidence and Information for Policy Cluster


Available as PDF file [35p.] at:


Primary care in the driver's seat?

The John Fry Fellowship Lecture by Professor Richard B. Saltman is now available online at the Nuffield Trust website. 

Monday, October 03, 2005

HPSIG Snippets Oct 4 2005

From The Commonwealth Fund

Despite spending more per capita on health care than any other country, the U.S. health system is fraught with waste and inefficiency, according to a new chartbook released today by the Commonwealth Fund Commission on a High Performance Health System. The chartbook, discussed at a Capitol Hill briefing sponsored by the Fund and the Alliance for Health Reform, paints a stark picture of a fragmented system beset by widespread disparities in access to and quality of care.
A Need to Transform the U.S. Health Care System: Improving Access, Quality, and Efficiency also points to promising opportunities for reforming the health system. These include management of high-cost care, enhancements in care coordination, disease management, and developing networks of high performing providers under Medicare, Medicaid, and private insurance. The Commission on a High Performance Health System will be exploring such opportunities as part of its mission to move the nation toward a health care system providing better access, quality, and efficiency.
Commission chair James J. Mongan, M.D., president and CEO of Partners HealthCare, in his remarks at the Alliance briefing, noted that "the disconnect between people wanting the new things that medical science can produce, yet not being sure that they are willing or able to pay for them." In his presentation, A Tale of Two Health Systems, Mongan said this disconnect "will lead to more of a focus on the value equation in health care, and to more of a focus on a high-performing health system."
The commission's goals are outlined in an essay by Fund president Karen Davis, Ph.D., Toward a High Performance Health System: New Commonwealth Fund Commission, which was published last month in Health Affairs.
A webcast of the commission event, provided by, will be available Tuesday, October 4, on the Alliance for Health Reform Web site.

From The AHRQ Newsletter

In the wake of Hurricanes Katrina and Rita, AHRQ recently released a report titled Development of Models for Emergency Preparedness to help field- and facility-based health care professionals plan for and respond to bioterrorism events or public health emergencies. The evidence-based, best-practice models in this report provide guidance on personal protective equipment, decontamination, isolation/quarantine, and laboratory capacity. Select to download this report. AHRQ has funded a number of emergency preparedness-related tools and resources to help hospitals and health care systems prepare for medical emergencies. More information about these products can be found on our Web site.

Removing user fees for primary care in Africa: the need for careful action

Lucy Gilson, associate professor, Centre for Health Policy University of Witwatersrand, South Africa
Di McIntyre, associate professor, Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa
BMJ  2005;331:762-765 (1 October 2005), doi:10.1136/bmj.331.7519.762

Available online at:

“….Current calls for the removal of user fees respond to evidence of their regressive impacts and their role in enhancing social exclusion—but removal must be carefully managed because this action may have negative impacts on the wider health system …”

Health for Some: Death, Disease and Disparity in a Globalizing Era


Ronald Labonte, Canada Research Chair in Globalization/Health Equity at the Institute of Population Health, University of Ottawa.

Ted Schrecke, senior policy researcher at the Institute of Population Health, University of Ottawa.

Amit Sen Gupta, Secretary of the All India Peoples Science Network, and co-convenor of the Peoples’ Health Movement (India) and member of the Movement’s

International Steering Group.

Centre for Social Justice, Toronto 2005


Available online as PDF file [133p.] at:

“…..The fundamental health challenges inherent in our contemporary global political economy – equity and sustainability — have been central to the struggle for health within countries for the past century. Addressing them requires some form of market-correcting system of wealth redistribution between, as well as within, nations. As Birdsall argues, globalization as we know it today is fundamentally asymmetric. “In its benefits and its risks, it works less well for the currently poor countries and for poor households within developing countries.

Because markets at the national level are asymmetric, modern capitalist economies have social contracts, progressive tax systems, and laws and regulations to manage asymmetries and market failures. At the global level, there is no real equivalent to national governments to manage global markets, though they are bigger, deeper and if anything more asymmetric. They work better for the rich; and their risks and failures hurt the poor more” (Birdsall 2002).

Agenda Setting Workshop on e-infrastructures for social simulation

The ESRC National Centre for e-Social Science ( is organising an Agenda Setting Workshop on e-infrastructures for social simulation (Manchester, U.K. - 26th of October 2005).
The aim of the workshop is to determine what organisational, conceptual and technical infrastructures are required to foster the usage of computational models in the social sciences.
The workshop is divided into four sessions centred on different aspects of the social simulation workflow:
- Sharing Knowledge
- Modelling
- Computing
- Verifying and Validating

Proposals for presentations or demos are welcome.
The (provisional and editable) programme is available on the workshop Wiki at:

Health and Spending of The Future Elderly (RAND Future Elderly microsimulation model)

Health Affairs, 10.1377/hlthaff.w5.r1 – September 26, 2005
Project HOPE

Available online at:

“…This special collection of Health Affairs papers focuses on a topic central to both health policy and public finance: the evolution of Medicare spending as the U.S. population over age sixty-five grows rapidly during the next quarter-century. The papers focus on a set of issues that are key to understanding this evolution: the likely course of disability in successive cohorts of Medicare beneficiaries and the relationships between technological progress and health spending….”

Medical Innovations Will Result In Better Health And Longer Life, But Will Increase, Not Decrease, Elderly SpendingCuring Any One Disease Won’t Dramatically Affect Future Medicare Costs, Although Obesity May Be The Disease Exception To The Rule


BETHESDA, MD — What impact will advances in biomedicine and technology have on health and spending for the elderly in the future? New data, released today by the journal Health Affairs, reveal that many of the most promising medical innovations will result in better health and longer life, but they will increase, not decrease, Medicare spending.

Researchers also predict that curing any one particular disease won’t save Medicare much money, with one important exception: Eliminating obesity could potentially lower costs. “Curing any one disease will make the elderly live longer and in better health—and this has great value to society—but it also means they accumulate more health care spending over a lifetime. That offsets the savings of being healthier,” said Dana P. Goldman, PhD, corporate chair and director of health economics at RAND in Santa Monica, California. Under current projections, Medicare spending will rise from 2.6 percent of gross domestic product (GDP) today to 9.2 percent in 2050. Demographics will have a large impact as the first wave of baby boomers turns 65 in 2010. Goldman led a team of economists and physicians from RAND, Stanford University, and the VA [Department of Veterans Affairs] Greater Los Angeles Healthcare System to explore beyond the established, current projections, and to see how changes in medical technology, disease, and disability would affect future health spending for the elderly. The researchers developed the Future Elderly Model (FEM), a demographic and economic simulation model, to help them predict future costs and health status for the elderly. The data were published today in a series of six articles and seven accompanying Perspectives in a Health Affairs Web Exclusive.“The challenge for policymakers is to understand and manage future Medicare spending. This in-depth analysis will help them chart direction for the future,” said John K. Iglehart, founding editor of Health Affairs.In the lead article, “Consequences of Health Trends and Medical Innovation for the Future Elderly,” Goldman and colleagues looked at advances in cardiovascular disease, cancer and the biology of aging, and neurological disease to assess how innovations affected spending and life years saved over the period 2002–2030. Some technologies would be extremely expensive. For example, expanding the use of implantable cardioverter defibrillators (ICDs) to half of elderly patients with new cases of heart failure or heart attack would result in approximately 550,000 procedures annually in 2030, with total treatment costs of $27 billion measured in 2005 dollars. Other technologies could have modest costs per additional life year, but could increase health care spending substantially. For example, the biomedical research community is actively seeking anti-aging compounds. Such a compound would increase health care spending by 14 percent in 2030 because, if the compound had been taken by healthy beneficiaries starting in 2002, there would be 13 million more Medicare beneficiaries in 2030. However, researchers argue, the cost per additional year of life is well worth it—only $11,000 in 2005 dollars. And if the compound keeps people alive in very poor states of health, total health care spending in 2030 would be 70 percent higher, because there would be more elderly people in poor health, according to Goldman and colleagues. Yet even in this case, the cost per additional life year of $38,000 is still relatively modest.

In an accompanying Perspective, Harvard University’s David M. Cutler takes a more optimistic view for Medicare’s future. Taking into account information technology and other health improvement advances not included in the researchers’ analysis, Cutler writes: “My forecast about medical spending is rosier than the FEM model suggests. The technological changes that the RAND authors consider will likely come to pass, and they will drive up Medicare spending (often with good value). But there is enormous potential for cost savings as well, which we have the capacity to realize. One can be an optimist even when the storm clouds are gathering.”In the article “The Lifetime Burden of Chronic Disease among the Elderly,” economist Geoffrey F. Joyce and colleagues studied seven chronic conditions: stroke, chronic obstructive pulmonary disease (COPD), hypertension, coronary heart disease, cancer, diabetes, and acute myocardial infarction. Cumulative health care spending is only modestly higher for those with chronic diseases at age 65, ranging from about $5,000 to $18,000 (2005 dollars), because the chronically ill live fewer years. Annual Medicare expenses increase by about $750 to $2,000 for people with a serious chronic illness at age 65, while cumulative Medicare expenses increase by $2,500 to $15,000 across the seven chronic conditions studied.

Curing Obesity Could Translate Into Significant Savings For Medicare

Obesity could prove to play a large role in Medicare spending in the future, according to economist Darius N. Lakdawalla and colleagues in the article “The Health and Cost Consequences of Obesity among the Future Elderly.” Using the FEM, the authors contend that if obesity is shown to be responsible for the health differences between those who are obese and those who are not, preventing or curing obesity in any one person would return that person’s health care spending level to that of a person of normal weight. Given the growing number of obese Americans, the resulting savings to Medicare could be substantial.How different are the costs of treating the obese elderly versus the nonobese? An obese 70-year-old incurs $38,000 in additional medical costs in old age compared with costs for a nonobese peer. And although obese 70-year-olds will live as long as those of normal weight, they will spend 40 percent more time disabled than their nonobese counterparts. Lakdawalla and his colleagues argue that the effects of disability from obesity, rather than increased spending, might be the more important component of the social burden of obesity. Medicare will also spend about 34 percent more on an obese person than on someone of normal weight, and obesity may cost Medicare more to treat than other diseases, because higher costs are not offset by reduced longevity, according to the study. Beginning at age 70, an obese person will cost Medicare about $149,000, the highest level of any group. In addition, Medicare spending on an obese person is 20 percent higher than for the next closest group, the overweight, and 35 percent higher than spending on a person of normal weight. Medicare could experience considerable financial burden from the increase in obesity nationwide, spending about $38,000 more over the lifetime of an obese 70-year-old than it will spend on a beneficiary of similar age and normal weight.Three additional articles, in which researchers used the FEM for all or some of their research, round out the Health Affairs Web Exclusive collection.

In “Disability and Health Care Spending among Medicare Beneficiaries,” lead author Michael E. Chernew of the University of Michigan School of Public Health projects that the cost savings associated with improved disability rates will not dramatically slow Medicare spending in the long run. In “Technological Advances in Cancer and Future Spending by the Elderly,” lead author Jayanta Bhattacharya of Stanford University finds that no scenario holds major promise for guaranteeing the future financial health of Medicare. And in “Identifying Potential Health Care Innovations for the Future Elderly,” lead author Paul G. Shekelle evaluated innovations in cardiovascular disease, cancer, the biology of aging, and neurological disease and found that many innovations have the potential to greatly affect the costs and outcomes of health care.This series of articles was funded in part by the National Institute on Aging and the John A. Hartford Foundation.The articles can be read at .

From The Plexus Institute Newsletter

Two Lessons from Fractals and Chaos, by Dr. Liebovitch and Dr. Daniela Scheurle, provides a valuable introduction to fractals and chaos as two examples of nonlinear approaches to understanding complex systems. A fractal, they write, is “an object in space that has an ever larger number of ever smaller pieces.”  Trees, hills, mountain ranges and clouds are examples of fractals, as are the branching patterns in blood vessels, nerve cells and airways in the lungs.  Other fractal biomedical systems include the texture of bone, the surface of cell membranes and the edges of growth of bacterial colonies. Elaborating on the concept of chaos, they note that chaos means that some nonlinear but simple systems can produce very complicated results.  They explain that the unpredictability of such nonlinear systems is the reason the word chaos was chosen to describe them: “These systems have the surprising property that we can completely predict the values of the system over brief time, but we are unable to predict their values over long times.”


Three tutorials prepared by Dr. Liebovitch are available on the website of the Society for Chaos Theory: a tutorial on Chaos,  one on an Introduction to Fractals and More About Fractals and Scaling. The tutorials are composed of sequential illustrative PowerPoint, which range from simple to genuinely formidable. Dr. Liebovitch suggests college level algebra should be sufficient background for a start. These new courses are part of a larger project to build “Resources for Students and Teachers”, where the Tutorials page is currently located on the SCT website.


Taken together, information contained in the book, the article and the online PowerPoint tutorials create an excellent set of learning tools for teachers, students, researchers and curious novices. 

Sunday, September 18, 2005

Snippets Sept 18 2005

Competition In Health Care: It Takes Systems To Pursue Quality And Efficiency

Alain Enthoven is the Marriner S. Eccles Professor of Public and Private Management, Emeritus, at the Stanford University Graduate School of Business in Stanford,
Laura Tollen, senior policy consultant at the Kaiser Permanente Institute for Health Policy in Oakland, California
Health Affairs, 10.1377/hlthaff.w5.420
DOI: 10.1377/hlthaff.w5.420  - Project HOPE–The People-to-People Health Foundation, Posting Date:7 September 2005 

Available online at:

“…….Many stakeholders agree that the current model of U.S. health care competition is not working. Costs continue to rise at double-digit rates, and quality is far from optimal. One proposal for fixing health care markets is to eliminate provider networks and encourage informed, financially responsible consumers to choose the best provider for each condition.

We argue that this "solution" will lead our health care markets toward even greater fragmentation and lack of coordination in the delivery system. Instead, we need markets that encourage integrated delivery systems, with incentives for teams of professionals to provide coordinated, efficient, evidence-based care, supported by state-of-the-art information technology. …..”

In July, The Commonwealth Fund launched its new Commission on a High Performance Health System to help move the nation toward a health system providing better access to care, higher quality, and greater efficiency. In the new issue of Health Affairs, Fund president Karen Davis discusses the rationale behind this major undertaking, the key issues to be addressed, and the range of activities the commission will pursue.
For periodic updates on the Commission's progress, please visit the Fund's
Web site.

Estimating the Contributions of Lifestyle-Related Factors to Preventable Death: A Workshop Summary

Workshop sponsored by the Centers for Disease Control and Prevention

Published on June 2, 2005

Available online at:


Possibility or Utopia? Consumer Choice in Health Care: A Literature Review

Ineke van Beusekom, Silke Tonshoff, Han de Vries, Connor Spreng and Emmett B. Keeler
The research described in this report was prepared for the Bertelsmann Foundation and conducted within RAND Europe

Full Document: PDF [168p.] at:

“…This literature review examines consumer choice in health insurance plans against the background of the German health system to examine models of consumer choice and their effects…’

Widespread Adoption Of Health Information Technology Could Save $162 Billion A Year, Says RAND Study,
But The Federal Government Needs To Help

Study Estimates Up To 2.2 Million Adverse Drug Events Could Be Prevented Annually


Bethesda, MD – Widespread adoption and effective use of electronic medical record systems (EMRs) and other health information technology (HIT) improvements could save the U.S. health system as much as $162 billion annually by greatly improving the way medical care is managed, greatly reducing preventable medical errors, lowering death rates from chronic disease, and reducing employee sick days, says a pair of new RAND Corporation studies released today in the journal Health Affairs.

The studies are the first of their kind to project both the savings and health benefits that could result from nationwide adoption of HIT. Because there is limited direct evidence of the benefits at this early stage of adoption, the RAND team used computer models to show the potential benefits if EMR systems were adopted widely, interconnected, and used effectively.

“The potential savings from HIT is mind-boggling, but it isn’t going to happen overnight,” says lead author Richard Hillestad, senior management scientist for the Santa Monica–based RAND, which has a team devoted to studying the role of HIT in health care. “The federal government will need to step in to speed the diffusion of HIT and remove some major barriers if we are going to reap the tremendous benefits it could have on improving quality, managing diseases, and extending people’s lives,” he says.

Barriers to wider adoption of HIT include the following:

• High initial acquisition and implementation costs
• Slow and uncertain financial payoffs for health care providers
• Disruptive effects on physician practices during implementation
• Payment systems that result in most HIT-enabled savings going to insurers and patients, while most adoption and care improvement costs are borne by providers

To accelerate HIT adoption, Hillestad and the RAND team say that the government will need to act more aggressively in the early stages of adoption to ensure widespread use of

• EMR systems that conform to a national set of standards
• Information-exchange networks sharing approved data among providers and patients
• Programs to measure, report and reward the provision of high-quality, efficient care

RAND’s projections of the value of widespread adoption of EMRs and other HIT improvements come amid a frenzy of activity at the federal level. President Bush has made adoption of EMRs a major domestic initiative designed to assure that nearly every American has an EMR within 10 years, and the Department of Health and Human Services is funding numerous HIT-related projects.

RAND’s findings reinforce the value of staying the course with these and other current federal, state, and private initiatives to promote HIT, says Hillestad. But RAND suggests that the federal government and employer groups also consider adopting a package of policy initiatives designed to accelerate market forces and subsidize change, including laying the foundation for performance-based competition, payment differentials to providers who adopt standards-based EMR systems, and targeted subsidies to help communities create regional information exchange networks. A program to measure and monitor HIT benefits during the rollout should be used supplement the currently weak empirical base and to provide course corrections to government policy during the adoption process.

Curbing Medical Errors and Improving Patient Safety

RAND’s study projects what could happen if EMR systems were adopted widely, interconnected, and used effectively. Under that scenario, the potential safety and cost benefits of standardized EMRs are sizable, according to RAND. For example, one-third to one-half of the eight million adverse drug events (ADEs) per year in ambulatory settings (e.g. doctors’ offices, outpatient clinics) could be prevented. Each avoided ADE saves $1,000 to $2,000 in unnecessary health care costs while improving the quality of patient care, says RAND.

The research team estimates that computerized physician order entry (CPOE) systems, a component of an EMR that can warn physicians about possible drug interactions or suggest alternative courses of action, could eliminate two million ADEs in the ambulatory setting and 200,000 ADEs in the hospital setting. This could save up to $3.5 billion a year in the ambulatory setting and $1 billion a year in hospitals. Medicare would benefit greatly since avoiding ADEs in patients 65 and older account for 60 percent of the hospital savings and 40 percent of the ambulatory savings; about 37 percent of the potential ambulatory savings and error avoidance would come from solo practices, says RAND.

Managing Chronic Diseases

EMRs also can be instrumental in managing high-cost chronic diseases such as asthma, congestive heart failure, chronic obstructive pulmonary disease, and diabetes. RAND says that these programs can generate “savings of several tens of billions of dollars per year” in reduced hospitalizations and emergency room visits by bolstering communication, coordination, measurement, and decision support. Reducing the incidence of chronic disease and hospital visits due to long-term prevention and management could save as much as $147 billion per year. But realizing the benefits of prevention and disease management requires that a substantial portion of providers and consumers participate, says RAND.

Widespread use of HIT also will lead to more short-term preventive care, enabling providers to offer important screening exams or immunizations in a routine manner and remind patients to schedule medical care when they need it. RAND says that the costs of these kinds of measures “are not large compared to the benefits,” projecting, for example, that 13,000 life years would be gained from more routine cervical cancer screening for a cost of $100–$400 million a year.

Removing Barriers

Despite the promise of EMRs and other HIT improvements, the U.S. still has far to go. Most medical records are still stored on paper, and consumers still lack the information they need about costs or quality to make informed decisions about care. The U.S. lags many other countries in its use of standardized EMRs. Only 15–20 percent of U.S. physician offices and 20–25 percent of hospitals have adopted some version of an EMR system, and the majority of these systems can’t effectively interconnect through networks to coordinate care with other health care providers.

RAND estimates that the average yearly cost over a fifteen-year adoption period to get the hospitals and doctors who don’t have an EMR system on board would be about $7.6 billion, much less than the $162 billion per year in possible savings. More specifically, the cost for hospitals to adopt a standardized EMR system would be $98 billion over a fifteen-year adoption period, or $6.5 billion per year, assuming that 20 percent of hospitals now have an EMR. Physician adoption adds $17.2 billion over this adoption period, for an average yearly cost of $1.1 billion, assuming that 90 percent of physicians buy in.

RAND says that moving the U.S. health care system quickly to broad adoption of standards-based EMRs could dramatically reduce national health care spending at costs far below the savings, but the federal government has to help create a pathway.

RAND’s review of the impact of information technology in other industries suggests that the savings could even be larger. “If health care in the U.S. was transformed sufficiently to generate the 1.5 percent annual productivity gains from information technology–enabled efficiencies in the retail and wholesale industries, the annual cost of health care could be reduced by $346 billion or more. But the dramatic transformations and productivity gains seen in other industries resulted from both large investments in information technology and other factors such as deregulation, value-based competition, and system integration,” says RAND, adding that “almost none of these factors are at work in health care.”

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research. Selected articles from the issue are available free on the journal’s Web site,

Key concepts in genetic epidemiology


Paul R Burton , Martin D Tobin, Department of Health Sciences and Department of Genetics, University of Leicester, Leicester, UK
John L Hopper,  Centre for Genetic Epidemiology, University of Melbourne, Melbourne, Victoria, Australia

The Lancet, , Volume 366, Number 9489, 10 September 2005






“…………..This article is the first in a series of seven that will provide an overview of central concepts and topical issues in modern genetic epidemiology. In this article, we provide an overall framework for investigating the role of familial factors, especially genetic determinants, in the causation of complex diseases such as diabetes.


The discrete steps of the framework to be outlined integrate the biological science underlying modern genetics and the population science underpinning mainstream epidemiology. ….”

Analytic Perspective

Historical perspective: the social determinants of disease – some blossoms

Michael Marmot

University College London, Department of Epidemiology & Public Health, London, UK

Epidemiologic Perspectives & Innovations 2005, 2:4     doi:10.1186/1742-5573-2-4


Available online at:

“…… I had two great teachers in epidemiology: Len Syme and Geoffrey Rose. One had his thinking shaped by the insights of Durkheim, a great sociologist; the other by Pickering, a great hypertension specialist. One helped lay the foundations for social epidemiology; the other, if heeded, could change the way we think about public health. Both came to the conclusion that society mattered for health and that one could not understand the social rate of disease simply by studying individuals. …..”

Historical Perspective: The social determinants of disease: some roots of the movement.


S Leonard Syme

University of California, Berkeley, School of Public Health, Berkeley, CA, USA

Epidemiologic Perspectives & Innovations 2005, 2:2     doi:10.1186/1742-5573-2-2


Available online at:


“…..I was asked by the Department of Epidemiology at the Mailman School of Public Health at Columbia University to give a lecture on "The Social Determinants of Disease: The Roots of the Movement". They wanted me to describe the "beginnings" of the field of social epidemiology on the basis of my personal experience. I received many comments following that talk suggesting it might be of interest to record my remarks in published form and that is the purpose of the present paper……”

Historical Perspective: S. Leonard Syme's influence on the development of social epidemiology and where we go from there

Irene H Yen
University of California, San Francisco, USA
Epidemiologic Perspectives & Innovations 2005, 2:3     doi:10.1186/1742-5573-2-3

Available online at:


Interventions Related to Obesity - A State of the Evidence Review


Carmen R. Connolly
The Heart and Stroke Foundation of Canada
, 2005


Available online as PDF file [28p.] at:


“….In this paper, the evidence on interventions related to obesity was grouped into three categories:

• Interventions that have been proven to be effective

• Interventions that have some evidence of promise, but require more research to address evidence gaps

• Interventions that have been proven not to be effective


How Good is Canadian Health Care? 2005 Report

An International Comparison of Health Care Systems


Nadeem Esmail and Michael Walker

The Fraser Institute,  British Columbia, Canada - July 2005


Available online as PDF file [66p.] at:  


“…….Provides answers to a series of questions that are important to resolve if Canada is to make the correct choices as it amends its health care policies.

The study is strictly comparative and examines a wide number of factors for the member countries of the OECD in arriving at the answers to the questions posed. In this study, we primarily compare Canada to other countries that also have universal access, publicly funded, health care systems


Human Development Report 2005

International cooperation at a crossroads: Aid, trade and security in an unequal world


This year’s Human Development Report takes stock of human development, including progress towards the MDGs. Looking beyond statistics, it highlights the human costs of missed targets and broken promises. Extreme inequality between countries and within countries is identified as one of the main barriers to human development—and as a powerful brake on accelerated progress towards the MDGs. 

More Aid, Pro-Poor Trade Reform, and Long-Term Peace-Building Vital to Ending Extreme Poverty
World leaders presented new UNDP Human Development Report in advance of World Summit at UN next week

Press release:

United Nations, 7 September 2005—World leaders today received a stark assessment of the human costs of missing agreed global targets for lifting people out of extreme poverty–costs which would include many millions of preventable deaths over the next 10 years, according to UNDP’s 2005 Human Development Report.

Presented to heads of state and government one week before they meet in New York for a crucial UN summit to review progress towards the Millennium Development Goals (MDGs), the 2005 Human Development Report shows that while there has been substantial overall progress globally, many individual countries are actually falling further behind.

The Report calls for swift and dramatic changes in global aid, trade and security policies to fulfil the promises made by the international community when world leaders gathered here to address these problems five years ago. “




English | Français | Español | Other Languages

 Foreword, Acknowledgements, Contents (207KB)

Overview: International cooperation at a crossroads: aid, trade and security in an unequal world (189KB)

Chapter 1: The state of human development (1,258KB)

Chapter 2: Inequality and human development (684KB)

Chapter 3: Aid for the 21st century (781KB)

Chapter 4: International trade—unlocking the potential for human development (831KB)

Chapter 5: Violent conflict—bringing the real threat into focus (536KB)

Notes, Bibliographic note, Bibliography (356KB)

Human Development Indicators (1,344KB)

Technical Notes (854KB)

Download the complete report (6.3 MB)


Private Health Insurance in Low and Middle-Income Countries

Scope, Limitations, and Policy Responses


Denis Drechsleri and Johannes P. Jüttingii

OECD Development Centre, March, 2005


Available online as PDF file [73p.] at:


“……This paper aims at analyzing characteristics of private health insurance (PHI) in low- and middle income countries and evaluating its significance for national health systems. It yields three major results:

·         First, private health insurance PHI involving pre-payment and risk sharing currently only plays a marginal role in the developing world. Coverage rates are generally below 10 % of the population while private risk sharing programs only have wider significance in a small number of countries (e.g., South Africa, Uruguay, and Lebanon).

·         Secondly, in many countries the importance of private health insurance PHI to finance health care is on a rise. Various factors contribute to this development: growing dissatisfaction with public health care, liberalization of markets and increased international trade in the insurance industry, and overall economic growth allowing higher and more diversified consumer demand. This last aspect in particular is expected to put pressure on the supply side of the system to increase choices and improve the quality of health care coverage.

·         Third, the development of private health insurance PHI presents both opportunities and threats to the health care system of developing countries. If PHI is carefully managed and adapted to local needs and preferences, it can be a valuable tool to complement existing health care financing options. In particular non-profit group-based insurance schemes could become an important pillar of the health care financing system, especially for individuals who would otherwise be left outside of a country’s health insurance system.


Measuring impact: Improving the health and wellbeing of people in mid-life and beyond

Health Development Agency HDA  2005

Measuring impact is the third in a series of publications commissioned by the Health Development Agency from the mid-life programme of work, which seeks to improve the health and wellbeing of people in the mid-life age group and reduce inequalities. The publications Making the case (HDA, 2003) and Taking action (HDA, 2004), and now Measuring impact, aim to support practitioners and policy makers at a local level in implementing and using the evidence of what works to develop mainstream practice and influence policy formulation in this population group.



Measuring impact: Improving the health and wellbeing of people in mid-life and beyond
22 August 2005



Malnutrition: Quantifying the health impact at national and local levels

Environmental burden of diseases series, No. 12


Monika Blössner, Mercedes de Onis

World Health Organization, Nutrition for Health and Development

Protection of the Human Environment, Geneva 2005


Available online as PDF file as PDF file [51p.] at: