Why do patients use emergency rooms rather than primary care?

Good post from the DMCB summarizing a recent study on why patients use emergency rooms rather than primary care for medical treatment, despite the vastly higher costs of emergency room care:

64 hospitalized patients with low socioeconomic status were approached to participate in a "qualitative" research interview (here's one example of how it's done). The patients were selected because they had been hospitalized via the ER multiple times, were between the ages of 18-64 years, were uninsured or on Medicaid, lived in a poor ZIP-code region of the city... 

Two themes emerged:

1) Convenience/Access: Even if they have access to primary care, the emergency room and inpatient setting remains the more convenient option.  That's because walk-in is available 24/7 and all testing as well as specialty care is available during a one-time visit.  Zero dollar primary care co-pays don't make up for the hassle, time and expense of calling ahead for appointments, arranging transportation (even if vouchers through Medicaid are available) or being referred for separate testing as well as specialty consultation.

2) Technology: Based on personal experience with their primary care docs, the emergency rooms and hospitals were perceived to have more technically proficient providers who were better able to achieve the correct diagnosis and render the correct treatment in a timely fashion.

There are more interesting observations in the full blog post.

Where is corruption improving?

Rwanda, Sudan, South Sudan, Azerbaijan, Belgium, Cambodia, Fiji, Georgia, Philippines, Serbia, Taiwan.  

What do these countries have in common? 

They are the only countries where people -- on the whole -- believe that corruption has decreased over the past two years, according to Transparency International's 2013 Global Corruption Perceptions report.  

It is an interesting list, in that there is not much to tie the countries together.  Rwanda, Cambodia, Georgia and the Philippines have experienced very good GDP growth over the past few years.  But GDP fell by 11% in Sudan in 2012 and by 4.5% in 2011.  In South Sudan, GDP supposedly fell by a stunning 55% in 2013.  Meanwhile, Azerbaijan achieved solid, but unspectacular growth over the past two years, and Belgium and Serbia were stagnant.  

These countries range across continents and regions as well.  Rwanda and the Sudans are the only African countries represented.  Belgium is the only OECD country on this list.  No Latin American countries made the list.  

Georgia was likely helped by a surprisingly smooth and peaceful transition of power.  

Why are obesity rates falling?

EpiAnalysis reports on a recent briefing from RWJF which suggests that childhood obesity may be declining in several locations across the U.S. 

Interesting to note that these improvements took place in a wide range of communities, from wealthy Eastern Massachusetts and New York City to poorer regions such as Mississippi and West Virginia. 

EpiAnalysis discusses some follow-up questions to the study: 

(1) First, if these changes are meaningfully large and sustained, are there clear contrasts in policy we can use as “natural experiments” to analyze what changes might have occurred? 

It's a nice thought, but it seems unlikely that there would be a natural experiment that helps to understand these declines in obesity rates.  In fact, I would venture that there are few single policies that have the capacity to affect obesity rates.  More likely, these shifts are the result of a cultural shift.  We have become more cognizant of the problem of obesity and (slightly) more aware of the ways in which it can be combatted.  I would guess that shows like the Biggest Loser have more effect on obesity rates than school lunch programs or sugar taxes.  

My views on this topic have shifted a lot in recent years and will continue to shift, but I'm increasingly skeptical of paternalistic policies to prevent obesity.  Not because I'm politically or ethically against such policies, but because I don't think we know enough about the causes of obesity to allow us to design precise and effective prevention policies.  Once we have a better scientific understanding of obesity, I will welcome the introduction of better and more targeted prevention policies.  

From oil subsidies to cash transfers in Libya

Rolling back the (oil) subsidies is a tricky business, but it can and must be done. Some countries, such as Jordan and Yemen, have already taken painful measures and so far survived the consequences. Libya, too, has been surprisingly bold for a country where petrol has been cheaper than water for a generation. Its current budget provides for sharply higher petrol and electricity prices and a shift in the subsidies to monthly cash transfers of about $500 per citizen. “It sounds like a lot, but this will actually save the government a ton of money,” says Faisal Gergab, chief economist at the Libyan Investment Authority.

That is buried deep within the Economist's special report on the Arab Spring, but it's an impressive and exciting policy reform.  If the measure succeeds, perhaps other other developing countries will follow suit.  This would be a very positive development, both economically and environmentally.  

Book Review: Getting Health Reform Right

Getting Health Reform Right: A Guide to Improving Performance and Equity by Roberts, Hsiao, Berman and Reich

This was one of the better policy books I've ever read. It was a bit dry, but it was nevertheless interesting, balanced and original throughout. The wealth of knowledge and expertise was outstanding; the authors offer useful examples of health reforms from different countries on every page.

They manage to provide both analysis that is dispassionate and balanced, but also useful policy recommendations. Each chapter has several well-reasoned policy recommendations.

It is interesting throughout, a rarity for policy books. The second half of the book might actually be better and more useful than the first. I particularly enjoyed the chapters on Financing, Payment and Behavior.

Highly recommended for anyone interested in health policymaking. All that being said, this is more toolkit than interesting for its own sake; I would only recommend it to someone interesting in health policymaking.

I will bring it with me to Abidjan.  

The legacy of Felix Houphouet-Boigny

A good article from ThinkAfrica on the legacy of Felix Houphouet-Boigny, father of independence in the Cote d'Ivoire: 

(Africa's) fathers’ didn’t actually sire independence. Rather, they were themselves the progeny of overbearing historical circumstances, and fairly predictable ‘midnight’s children’ to boot...

There is one notable exception: Félix Houphouët-Boigny, Ivory Coast’s first president. Arguably, he led his people where he wanted them to go and, to the extent possible, steered his own course through history. However, though he made history, he did not make it into history, at least not as gloriously as Nkrumah, Nyerere, Sékou Touré or Patrice Lumumba. Houphouët-Boigny is generally overlooked, or else dismissed as ‘a lackey of the French’. Yet, best comparable perhaps to Kenya’s Jomo Kenyatta, Houphouët-Boigny wrote his own ticket and delivered a powerful message that, 50 years later, might still nurture African realpolitik... 

Really interesting stuff throughout.  I'd always wondered about the disconnect between his communist background and capitalist policies implemented while in office.  I had no idea that he hadn't actually been a communist, but rather had joined the party as a part of a strategic plan to build a broader coalition for independence.  Economic and social ideology, unsurprisingly, were quite secondary to the goal of independence at this point.  

His pro-French attitude is very interesting as well, particularly for the contrast with so many post-independence leaders: 

Houphouët-Boigny had staunchly opposed colonial inequality. Now that he was convinced that France and its sub-Saharan colonies were en route for a common future, he coined the neologismla Françafrique and vowed to serve the cause of a “Franco-African community” with unsparing loyalty. Neither the Franco-British attempt to seize the Suez Canal in 1956, nor the colonial war in Algeria and hijacking of a plane to arrest the leadership of the Algerian liberation movement altered his public support of the French authorities. He was paid back in kind: in 1957, he became the first African ever to reach full ministerial rank. At one point, he was France’s Minister of Health, pushing through parliament a reform of the medical system. 

 And here's some interesting analysis of "the wager" between Houphouet-Boigny and Ghana's Kwame Nkrumah: 

This was to be called “the wager”, as Houphouët-Boigny went on to conclude: “So let us meet up again in ten years to see who among us has chosen the best approach for his people.”

Ten years later, toppled by a coup d’état, Nkrumah was living in exile in Guinea, the state run by his francophone alter ego, Ahmed Sékou Touré, who had said no to Charles de Gaulle’s proposal of a Franco-African community, preferring “freedom in poverty to riches in slavery”.

For his part, Houphouët-Boigny had become, at Ivory Coast’s independence in 1960, the president of a country well on its way to superseding Ghana as the world’s most important cocoa producer – and overall to turning into an economic “miracle” – while Ghana sank amid instability and mismanagement. Houphouët-Boigny’s warning against merely “nominal independence” – that is, a political flag of convenience flying proudly above a poorer-than-ever land – had been vindicated. 

Who won the wager? Strictly speaking, within the bet’s ten-year limit, Houphouët-Boigny carried the day. Yet, inasmuch as the only way to learn how to play the harp is to play the harp, Ghana at least made its own mistakes and, since the 1990s, seems to have learned from them. This is small comfort for the generation of Ghanaians after independence which grew up in misery and chaos, without much schooling and healthcare or a functioning state.

But it is also little comfort for the Ivorian youth of the past 20 years – years marred by a putsch, a civil war, and an outbreak of xenophobia in the name of ivoirité (“Ivorianness”) – to know that their parents had enjoyed a better life before. Houphouët-Boigny’s state was eviscerated by corruption abetted by the president himself (“when you’re roasting peanuts for others, no-one should look into your mouth”); land tenure was a mess he had created (“the land belongs to who is tilling it”); and his generous open-door immigration policy left almost a third of the population in doubt as to whether they were still immigrants or already Ivorian citizens. 

Where we stand in the battle to eliminate malaria

Jenny Liu and colleagues, writing in the Lancet, report some significant good news in the battle to eradicate malaria: 

The malaria map is rapidly shrinking. In 1900, endemic malaria was present in almost every country. Nowadays, the disease has been eliminated in 111 countries and 34 countries are advancing towards elimination.1 Elimination is defined as the absence of transmission in a defined geography—typically a country.2 Successful malaria control programmes in the remaining 64 countries with ongoing transmission have helped to reduce global incidence by 17% and mortality by 26% since 2000.3 For the 34 eliminating countries, the reductions were 85% in incidence and 87% in mortality.1 This progress is encouraging, but is worldwide eradication of human malaria possible? If so, is it a worthwhile goal and should we commit to it?

There is plenty of bad news as well, however: 

First, despite progress, the burden of malaria is still great and it is widespread. In 2010, an estimated 219 million cases of malaria were reported and 660 000 people died in 98 countries.3 Second, drug and insecticide resistance are on the rise. In Burma, Cambodia, China, Thailand, and Vietnam, resistance of Plasmodium falciparum, the major human malarial parasite species, to artemisinin, the most widely used first-line drug, has been detected and could be spreading despite efforts to contain it.3, 4 Resistance to pyrethroid insecticides can happen quickly and has emerged after large-scale distributions of bednets in several regions.5 Although new drugs and insecticides are being sought, none are expected to be available in the near future. Third, increased mobility of people not only makes containment of resistance difficult, but also threatens the introduction or reintroduction of malaria parasites to receptive areas. Fourth, outside sub-Saharan Africa, Plasmodium vivax, the second major human malarial parasite species, is the main challenge. P vivax is much less researched than is P falciparum. P vivax is harder to diagnose and failure to successfully treat its dormant liver stage results in relapses that can fuel onward transmission. Furthermore, in Borneo and neighbouring regions, evidence now exists of human infection by a monkey parasite species, Plasmodium knowlesi. Zoonotic reservoirs challenge all campaigns for eradication of human infection. Fifth, extreme events, such as wars or natural disasters, greatly disrupt malaria control and elimination activities, and can lead to substantial resurgence. When accompanied by large population movements, these events can introduce malaria into previously malaria-free areas. Sixth, as malaria becomes rare, persuasion of governments to allocate finances to maintain effective elimination or post-elimination programmes is increasingly difficult. Since 1930, 75 resurgences of malaria have been recorded and nearly all are linked to the scaling back of programmes.

Policy recommendations here: 

The practical policy option, and the one that will be less costly in the long term, is to pursue a global policy of progressive elimination, aggressive control in the high-burden areas, and eventual eradication. This policy is even more appealing in consideration of recent evidence showing that malaria elimination could be an inherently stable state, unlike sustained control.7, 8 No-one can know when malaria will be eradicated. Our estimate is perhaps 2050 or 2060. The last battles will likely be waged in wet, tropical, and poor areas: against P falciparum in sub-Saharan Africa and P vivax in Melanesia. Continued vigilance will be needed against zoonotic malaria arising from close human—macaque contact in Borneo and neighbouring areas.9 Special measures will need to be designed and implemented to control such malaria.

And then there is this bold claim: 

Of the ten leading causes of death in the developing world, malaria is the only one with a real prospect for eradication.