Thursday, January 29, 2009

[EQ] Value In Health Care

Value In Health Care

Health Affairs, doi: 10.1377/hlthaff.28.2.w205  by Project HOPE 
27 January 2009 

From The Editor Susan Dentzer

“……..A paramount topic at the moment is value in health care: What should we pay for and how much? Resources aren’t unlimited, and desires or demands for health care should be balanced against various realities--including the effectiveness of care or the desire for other goods and services. Especially in a depressed economy, questions about value in health care may well be at the center of coming health reform debates.

Value discussions raise other issues, including efficiency, measurement, the influence of the payment system, and the locus of accountability for quality. The papers in this volume take up these and other aspects of the value equation. …………”

Building Organizational Capacity: A Cornerstone Of Health System Reform
Janet Corrigan and Dwight McNeill

Payment Reform Alone Will Not Transform Health Care Delivery - Charles N. Kahn III

Fostering Accountable Health Care: Moving Forward In Medicare
Elliott S. Fisher, Mark B. McClellan, John Bertko, Steven M. Lieberman,
Julie J. Lee, Julie L. Lewis, and Jonathan S. Skinner

Medicare: The Place To Start Delivery System Reform - Francis J. Crosson

A Consumer Perspective On Physician Payment Reform - John Rother

Using Medicare Payment Policy To Transform The Health System: A Framework For Improving Performance
Stuart Guterman, Karen Davis, Stephen Schoenbaum, and Anthony Shih

Measuring Outcomes And Efficiency In Medicare Value-Based Purchasing
Christopher P. Tompkins, Aparna R. HIggins, and Grant A. Ritter

Payment Reform Options: Episode Payment Is A Good Place To Start
Robert E. Mechanic and Stuart H. Altman

Consumer-Driven Health Care: Promise And Performance
James C. Robinson and Paul B. Ginsburg

Costs And Benefits Of Health Information Technology: New Trends From The Literature
Caroline Lubick Goldzweig, Ali Towfigh, Margaret Maglione, and Paul G. Shekelle

Measuring, Monitoring, And Managing Quality In Germany's Hospitals
Reinhard Busse, Ulrike Nimptsch, and Thomas Mansky

 

 

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[EQ] Health and Medical Research in Spain

Health and Medical Research in Spain

Health Research Observatory

 

Fragiskos Archontakis
RAND Europe’s Health Research Observatory 2008
Documented Briefing series, funded by the UK Department of Health

Available online PDF [66p.] at: http://www.rand.org/pubs/documented_briefings/2009/RAND_DB566.pdf

This report provides an overview of health and medical research in Spain. The report is part of a series of country-specific reports available from RAND Europe's Health Research Observatory. The report describes the structure of Spain's health research system, the processes and performance of the Spain health research system, and an outlook which considers current and emerging health research issues in Spain.

Summary: Key Points

- Key funders of health R&D in Spain are industry, central government, and the local governments of the autonomous communities

- Important role of Carlos III Health Institute as a funds manager and of the Spanish National Research Council as a research driver

- R&D funding in Spain has increased year on year, and health R&D funding is also increasing as a percentage of total funding

- The INGENIO 2010 initiative includes a series of policies and strategic actions

- Research productivity (as measured by publications) has been increasing in biomedical sciences

Content:

Summary
Introduction
Structure of the Spanish Health Research System
Processes and Performance of the Spanish Health Research System
Outlook
Reference List.

See Also: Free, downloadable PDF file(s) full text, available online.

Australia

Canada

Japan

New Zealand

Sweden

United Kingdom

United States

Guiding Good Research

 

 

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This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
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Information Technology - Virtual libraries; Research & Science issues.  [DD/ KMC Area]

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[EQ] Exchange in Int J Epidemiology on individualistic fallacy,ecological fallacy, and the importance of history & societal context

fyi: an exchange just published in the International Journal of Epidemiology (advanced access)

 

-- the 1st article critiques the individualistic fallacy of the classic paper on ecologic fallacy by Robinson (1950), provides new evidence regarding a contributing source of the documented ecologic fallacy, and does so by bringing in historical and societal context, including the impact of Jim Crow (legalized segregation) on population outcomes

 

-- the additional 4 articles include the original Robinson paper, two commentaries, and a response to the commentaries

 

Below is a list of the article titles, followed by the article titles + abstracts (or excerpts)

 

 

ARTICLE TITLES

 

1)      Revisiting Robinson: The perils of individualistic and ecologic fallacy


S V Subramanian, Kelvyn Jones, Afamia Kaddour, and Nancy Krieger

1 Department of Society, Human Development and Health, Harvard School of Public Health, Boston, USA.

2 School of Geographical Sciences, University of Bristol, Bristol, UK.

3 Department of Global Health and Population, Harvard School of Public Health, Boston MA

IJE Advance Access published on January 28, 2009.

doi:10.1093/ije/dyn359  http://ije.oxfordjournals.org/cgi/content/abstract/dyn359

 

 

Background W S Robinson made a seminal contribution by demonstrating that correlations for the same two variables can be different at the individual and ecologic level. This study reanalyzes and historically situates Robinson's influential study that laid the foundation for the primacy of analyzing data at only the individual level.

 

Methods

We applied a binomial multilevel logistic model to analyse variation in illiteracy as enumerated by the 1930 US. Census (the same data as used by Robinson). The outcome was log odds of being illiterate, while predictors were race/nativity (‘native whites’, ‘foreign-born whites’ and ‘negroes’) at the individual-level, and presence of Jim Crow segregation laws for education at the state-level. We conducted historical research to identify the social and scientific context within which Robinson's study was produced and favourably received.

 

Results Empirically, the substantial state variations in illiteracy could not be accounted by the states' race/nativity composition. Different approaches to modelling state-effects yielded considerably attenuated associations at the individual-level between illiteracy and race/nativity. Furthermore, state variation in illiteracy was different across the race/nativity groups, with state variation being largest for whites and least for foreign-born whites. Strong effects of Jim Crow education laws on illiteracy were observed with the effect being strongest for blacks. Historically, Robinson's study was consonant with the post-World War II ascendancy of methodological individualism.

 

Conclusion Applying a historically informed multilevel perspective to Robinson's profoundly influential study, we demonstrate that meaningful analysis of individual-level relationships requires attention to substantial heterogeneity in state characteristics. The implication is that perils are posed by not only ecological fallacy but also individualistic fallacy. Multilevel thinking, grounded in historical and spatiotemporal context, is thus a necessity, not an option.

 

 

2) Reprints and Reiterations

    WS Robinson

    Ecological Correlations and the Behavior of Individuals

    IJE Advance Access published on January 28, 2009.

    doi:10.1093/ije/dyn357 http://ije.oxfordjournals.org/cgi/content/extract/dyn357

 

 

AN INDIVIDUAL CORRELATION is a correlation in which the statistical object or thing described is indivisible. The correlation between color and illiteracy for persons in the United States, shown later in Table I, is an individual correlation, because the kind of thing described is an indivisible unit, a person. In an individual correlation the variables are descriptive properties of individuals, such as height, income, eye color, or race, and not descriptive statistical constants such as rates or means.

 

In an ecological correlation the statistical object is a group of persons. The correlation between the percentage of the population which is Negro and the percentage of the population which is illiterate for the 48 states, shown later as Figure 2, is an ecological correlation. The thing described is the population of a state, and not a single individual. The variables are percentages, descriptive properties of groups, and not descriptive properties . . .

 

 

 

3) Glenn Firebaugh

    Commentary: ‘Is the Social World Flat? W.S. Robinson and the Ecologic Fallacy’

    IJE Advance Access published on January 28, 2009.

    doi:10.1093/ije/dyn355  http://ije.oxfordjournals.org/cgi/content/extract/dyn355

 

If the social world were ‘flat’ in the sense that it did not matter where you lived or with whom you associated-no place effects, no context effects, no contagion effects-then single-level analysis would do. The message of Subramanian, Jones, Kaddour and Krieger1 is that the social world usually is not flat, so multilevel analysis usually is called for. The idea that single-level analysis is problematic when there are multilevel effects is quite consistent with Robinson's classic warning about the ecologic fallacy.2 In fact, I suspect that Robinson himself would have embraced multilevel analysis had it existed in his day.

 

 

4) J Michael Oakes

    Commentary: Individual, ecological and multilevel fallacies

    IJE Advance Access originally published on January 27, 2009. This version published January 28, 2009.

    doi:10.1093/ije/dyn356 URL:
http://ije.oxfordjournals.org/cgi/content/full/dyn356v2?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&author1=J+Michael+Oakes&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

 

The new paper by Drs Subramanian, Jones, Kaddour and Krieger (hereinafter Authors) contains many important and subtle insights about the fallacies of single-level research, be it at the individual or ecological level.1 The Authors urge epidemiologists to consider contexts and multilevel phenomena when investigating and explaining population health. They also criticize the late William S. Robinson and his classic 1950 paper, and methodological individualism (MI) as a research paradigm.2 Support comes from historical anecdotes, theory and a re-analysis of Robinson's data.

 

Assuming I understood it properly, I am in full agreement with the primary aim of the new paper. Epidemiologists, especially those interested in the effect of social forces on health, should consider contexts and multilevel phenomena. And as a general proposition, I also agree that critical examination of a scientist's culture, history and personal motivation can be enlightening. The Authors’ scholarship on these matters merits careful study.

 

 

5) SV Subramanian, Kelvyn Jones, Afamia Kaddour, and Nancy Krieger

     Response: The value of a historically informed multilevel analysis of Robinson's data

     IJE Advance Access published on January 28, 2009.

     doi:10.1093/ije/dyn354 http://ije.oxfordjournals.org/cgi/content/extract/dyn354

 

“….Our story begins where Robinson's classic study ended.1 Could a study of relationship between two variables measured only at the individual-level-emblematic of most epidemiologic and social science research when individual data are available-lead to an impoverished description of the relationship?


Using the same data on illiteracy and race that Robinson employed and supplementing it with relevant ecologic data that would have been available at that time, we showed that, in this particular case, studying solely the ‘behavior of individuals’, while ignoring their historical and ecological state context, was both limiting and misleading.2 The comments of the two discussants,3,4 whom we thank for their efforts, underscore the importance of a multilevel approach to scientific research. Neither of their commentaries, importantly, alters the central tenets and conclusions of our study and instead serves only to bolster them….”

 

 

 

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