Aaron E. Carroll's Blog, page 5

PEPReC’s FY24 Population-based Workforce Guidelines

With a growing Veteran population and evolving health care demands, the Department of Veterans Affairs (VA) faces critical workforce challenges. In response to the 2022 PACT Act, which primarily expanded care access for Veterans exposed to military toxins like burn pits, VA began assessing staffing levels at VA Medical Centers (VAMCs) nationwide.

To support this congressional requirement, in collaboration with the VA Office of Human Resources and Administration, the Partnered Evidence-based Policy Resource Center (PEPReC) developed population-based workforce guidelines for Fiscal Year 2024 (FY24).

These guidelines offer a data-driven approach to help VAMCs evaluate both current and future staffing needs to ensure timely access to care for Veterans. PEPReC’s supply and demand models incorporate validated metrics, such as new patient clinic work rates and clinic time, to determine how VAMCs can meet preestablished wait time standards. The FY24 guidelines focus on primary care and eight specialty care services that are either high volume or related to military toxic exposure care. Qualitative evaluation was used to refine the guidelines.

For more details on the latest guidelines and workforce planning strategies, read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

The post PEPReC’s FY24 Population-based Workforce Guidelines first appeared on The Incidental Economist.

Medicare Drug Price Negotiations

In most countries, health care systems negotiate drug prices directly with pharmaceutical companies, making crucial drugs more affordable for their citizens. In America, that wasn’t the case until recently. Signed into law in August of 2022, the Inflation Reduction Act made several changes aimed at strengthening the United States Medicare program. One of those changes allowed Medicare, for the very first time, to directly negotiate drug prices.

 



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Can mRNA Vaccines Work for Cancer?

The first mRNA vaccine to gain full FDA approval was for COVID-19, but the future could see more of this type of vaccine – including those for cancer.

 



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Paying to Breathe: Asthma in America

Asthma is one of the most expensive diseases in the United States (US). Despite recent actions from inhaler manufacturers to lower drug prices, there is still much to be done to make asthma treatment affordable.

More than 22 million Americans have asthma. For half of adults and almost 90% of children, it’s caused by allergies. These rates have grown since 1996, likely due to climate change.

To manage asthma, there are two main types of inhalers: controllers for daily maintenance and relievers for flare ups. Based on symptom severity, patients may use both kinds. Patients may also choose to treat their underlying allergies with immunotherapy, antihistamines, and/or by avoiding allergy triggers altogether.

But the expense of some of these asthma treatments puts them out of reach for many patients.

One study of nearly 130,000 participants found that allergic asthma patients have 39% greater annual total health care costs and 79% greater annual asthma-related health care costs than non-allergic asthma patients. They had significantly more pharmacy claims, outpatient visits, and emergency department visits. They also were more likely to have undergone skin and/or blood allergy testing.

All told, the authors calculated that allergic asthma patients paid over $1100 more per year than non-allergic asthma patients. But that didn’t even include the costs of over-the-counter treatments, like antihistamines and nasal sprays, or the costs of immunotherapy (and not just the medicine itself but also weekly copays travel expenses). Nor did their results indicate how well patients’ asthma was controlled, and health care costs are typically higher for patients with poorly controlled asthma.

Further, an investigation by a US Senate Committee found that asthma medications cost significantly more in the US than they do elsewhere. For example, AstraZeneca charges $645 in the US for an inhaler that only costs $49 in the United Kingdom. Similarly, Teva Pharmaceuticals charges $286 in the US for an inhaler that costs $9 in Germany.

To be fair, some drug companies are addressing these high prices.

For example, AstraZeneca and GSK are following the example of major insulin manufacturers and reducing their prices. While these companies are implementing $35 monthly price caps on inhalers, eligibility varies, and patients are still years away from actually seeing the benefits.

Some companies are authorizing generic options for their brand-name inhalers, too. For instance, GSK recently discontinued Flovent, a frequently prescribed maintenance inhaler, because they’re making a cheaper, generic version instead. (It’s worth noting that this abrupt change caused chaos for some patients who had to scramble to find a comparable prescription for the interim.)

Despite these positive changes, the overall system remains flawed. Consider patent protections and Food and Drug Administration-granted exclusivity protections.

With the goal of rewarding innovation, the US Patent and Trade Office allows drug companies to sell new medications for a set period of time without any competition, typically 20 years. The Food and Drug Administration may also give manufacturers a monopoly for different periods and reasons. However, because of these protections, over 50 patents were approved for brand-name inhalers from 1986 to 2020, with only three facing generic competition afterwards. What’s worse, some drug companies partake in practices to extend their market control even longer.

There are ways to remedy this though. The Senate recently passed a bipartisan bill that could prevent product-hopping, one of those unethical practices where manufacturers stop producing a nearly expired product and start selling a new, very similar version, effectively restarting their patent protection. This has been common with Albuterol rescue inhalers, costing payers and patients billions of dollars. If signed into law, this bill could increase the speed at which generics hit the market, ultimately leading to lower prices for patients.

An even more significant change would be if the US moved towards value-based pricing, where prices are based on drug effectiveness and the quality of life improvements patients see. A variety of cost analyses can be utilized to determine fair prices, and this approach has been successful in Europe and Australia with inhalers.

Asthma treatment is expensive, full stop. But asthma sufferers shouldn’t have to worry about how to pay for it. It is possible to minimize costs, but federal policies will need to balance profitability, affordability, and innovation.

Research for this piece was supported by Arnold Ventures.

The post Paying to Breathe: Asthma in America first appeared on The Incidental Economist.

The Impacts of Climate Change on Allergic Asthma

Over 25 million people in the United States (US) have asthma and it’s only becoming more prevalent, as climate change contributes to the climbing allergic asthma rates. But, there are concrete steps the US health care system can take to improve the lives of those impacted.

Half of adults and almost 90% of children with asthma have allergic asthma. Triggered by inhaling allergens such as pollen, dust mites, or pet dander, allergic asthma commonly produces respiratory symptoms like shortness of breath and chest tightness, as well as hives and nose irritation.

The impact of asthma on a person’s quality of life is significant. Asthma is actually one of the top reasons children miss school. In 2013, kids missed almost 14 million days because of asthma alone. (A more recent statistic is not available.) And a fifth of adults with asthma report that workplace exposures make their symptoms worse and negatively affect their productivity. These losses, coupled with related medical costs, make asthma one of the most expensive diseases in the US.

While many asthma cases aren’t preventable, the noted increase in allergic asthma rates is likely due in part to climate change.

First, global warming – due to an increase in greenhouse gases in the atmosphere caused by human activities – impacts the duration and intensity of allergy season.

Warmer temperatures confuse trees into releasing more pollen, and releasing it earlier than they normally do. Think January instead of March. In North America, there is currently almost 20% more pollen than there was in 1990. Historically cooler environments like Norway and Canada are feeling it, too, now that warmer temperatures can support more pollen-producing plants.

Second, global warming causes more frequent, extreme weather events, worsening air quality. For example, wildfires and floods often trigger asthma attacks because the former releases pollutants into the air and the latter promotes indoor mold growth. Even thunderstorms have an effect: Heavy rain and strong winds break up pollen grains into smaller pieces that can travel longer distances.

What’s worse, historically marginalized individuals are hit the hardest by climate change. The data show these populations are 52% more likely to live in areas with higher predicted asthma-related emergency room visits. Higher rates of asthma are also common in low-income households, and Black children are more than seven times as likely to die from asthma than their non-Hispanic White peers.

While daunting, there are ways to reduce the impact of climate change on allergic asthma.

For starters, providers could consider switching the inhalers they prescribe, choosing dry powder inhalers, instead of metered-dose inhalers. Metered-dose inhalers account for almost 90% of the US asthma medication market, prescribed to 144 million patients per year. Yet with every use, they release a greenhouse gas more powerful than carbon dioxide (the most significant contributor to the greenhouse effect) and produce the same amount of emissions as all of the homes in Milwaukee, Wisconsin.

Hospitals could also make environmentally friendly changes. After all, they are major greenhouse gas emitters. The health care system in the US is responsible for 8.5% of all of the country’s carbon emissions, regardless of industry, and 25% of the world’s health care-related emissions. One fix could be to improve energy efficiency in buildings and to substitute fuel powered emergency vehicles with electric ones. Some also recommend reducing single use plastics by switching to reusable isolation gowns, surgical supplies, linens, and other products.

But other sectors have a large role to play, too, and broader scale climate change reform from the federal government could have trickle-down effects.

For example, federal policies could limit how much Americans use fossil fuels. Policymakers could require that large corporations reduce their emissions and enforce a goal of carbon neutrality by 2050 (the year when the damage from climate change will be irreversible). More work can be done on the state and local levels, too, to create and prioritize renewable energy sources like solar, wind, and hydropower.

Asthma won’t ever be gone completely, but rates of allergic asthma could be reduced if global warming is. The health care system and policymakers must work together to protect respiratory health while it’s still possible.

The post The Impacts of Climate Change on Allergic Asthma first appeared on The Incidental Economist.

Incorporating Evidence into Public Policy Requires the Right Tools

In the five years since the implementation of the Foundations for Evidence-based Policymaking Act of 2018 (Evidence Act), a lot has changed. In response to the law’s mandate, cabinet-level federal agencies are developing, expanding, and incorporating evidence building activities into policy and budgetary decision making. As these processes have evolved, so have the tools that make them possible.

TIE contributor, Elsa Pearson Sites, recently wrote about the Evidence Act and the strength of evidence checklist developed by the Partnered Evidence-based Policy Resource Center (PEPReC) and used by the Veterans Health Administration. Earlier this month, PEPReC published a new brief exploring how the checklist has changed since its inception, how it has been deployed, and how it might be used in the future.

For more, read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

The post Incorporating Evidence into Public Policy Requires the Right Tools first appeared on The Incidental Economist.

What Mindfulness Can and Cannot Do

By Kristina Carvalho, MSW, and Austin Frakt, PhD

It’s hard to not be familiar with the term “mindfulness;” it’s spreading across workplaces, classrooms, and friend groups. What’s trickier is knowing what it can and cannot do for one’s health. Although mounting evidence suggests it may have wide utility, there are still unknowns on how far benefits can go.

Academics have discovered over 30 definitions for this Buddhist concept in the literature, but mindfulness is typically defined as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.”

Tracing back millennia in the Eastern world, this awareness can now be nurtured formally through instructor-led mindfulness programs or informally through self-guided personal practice.

The former method often spans months and is facilitated through group training sessions or daylong retreats. The most frequently cited, evidence-based program is Mindfulness-Based Stress Reduction (MBSR). Some of its common exercises include sitting meditation, Hatha yoga, and body scans.

The latter type of mindfulness is individualized, leaving room for a flexible setting and time commitment. Some individuals distinctly set aside time to sharpen this skill with apps like Calm or Healthy Minds, while others find moments to be mindful in their existing daily routine (e.g., while eating, washing the dishes, taking a walk, etc.).

One’s goals for engaging in the practice can also vary; some have a singular aim to achieve, others go into it with no expectations. Some mindfulness interventions have an intended purpose, others are more general.

While mindfulness can sometimes stir up uncomfortable, negative feelings from heightened awareness, these effects are usually mild and to be expected. Research has confirmed that mindfulness based programs are safe and do not come with serious adverse events.

In fact, it can be used to prevent some mental health issues and improve social-emotional skills.

Formal Mindfulness
There are numerous studies that focus on the efficacy of mindfulness programs.

A recent systematic review of randomized controlled trials found evidence that mindfulness based programs can reduce psychological distress for at least six months in a variety of settings. And programs specifically targeting stressed, anxious, or symptomatic adults were more effective at reducing depression and anxiety than generalized programs.

MBSR in particular has been widely cited in clinical literature to reduce symptoms and improve quality of life for healthy individuals and those with a variety of conditions such as post-traumatic stress disorder, multiple sclerosis, chronic pain disorders, and cancer.

By strengthening one’s ability to focus on one thing at time and make more conscious choices, MBSR also encourages self-compassion and promotes positive social behavior. This is precisely why it is sometimes offered by employers! It has been successfully used to improve workplace retention, culture, and productivity.

Informal Mindfulness
General mindfulness practices seemingly produce physical benefits. Research indicates mindfulness practices may reduce cortisol awakening responses, chronic pain, blood pressure, and cardiovascular disease. They may also slow weight gain in women with obesity and improve sleep disorders.

Gaps in Mindfulness Research
There are still plenty of things researchers remain unsure about when it comes to what mindfulness can or cannot do.

For example, it is unclear how mindfulness impacts long-term mental health, and whether any benefits are will last beyond the period of regular practice.

One study did discover potential long-term effects of MSBR on mental health, finding that participants who practiced more days and had higher levels of mindfulness two to five years post-program, had lower levels of anxiety. Though, there was a general decay of benefits after one to two years for those who did not keep up with the practice. While promising, the authors suggest the study should be interpreted with caution due to design limitations.

Another unknown is the difference in effectiveness based on setting. For instance, there’s a lot of room left to investigate nature-based mindfulness and how it compares to practices in more cultivated settings. Preliminarily, one systematic review hints that nature-based mindfulness is superior, and even saw stronger effects for individuals participating in natural outdoor environments (e.g., forest, wild nature) compared to urbanized outdoor environments (e.g., gardens, parks).

Additionally, there’s conflicting preliminary evidence on the neural changes that mindfulness can produce. Some studies have shown that mindfulness programs increase gray matter density in the brain, thus improving working memory capacity and slowing signs of aging. However, a recent review of 25 studies, found that while there are positive neural changes on attention and executive function, there were not significant results for working memory and long-term memory like previous studies had noted.

Some researchers have also expressed ethical concerns. For instance, one study claimed mindfulness programs lack qualified instructors, ethical delivery guidelines, and the capacity to screen for adverse events. To mitigate these concerns, researchers suggest that public health practitioners should establish regulatory bodies, standardized ethical guidelines, appropriate screening procedures, and adequate accreditation and licensing procedures.

Despite the uncertainty of how far the benefits can go, mindfulness remains promising and an inexpensive practice one can explore on one’s own with little to no reported harm.

The post What Mindfulness Can and Cannot Do first appeared on The Incidental Economist.

Sex Testing in Sports: Does it Make Sense?

The issues surrounding sex testing in sports may seem like a new phenomenon, but this has been coming up at least since women were allowed to compete in the Olympics – so, for like the past century or so. There’s a whole lot of concern over who is allowed to compete in women-only sports, and various “solutions” have been aimed at allaying those concerns. But are they effective? Do they make sense?

 



The post Sex Testing in Sports: Does it Make Sense? first appeared on The Incidental Economist.

Using evidence to justify policy and budget decisions

In 2019, the Foundations for Evidence-based Policymaking Act of 2018 (Evidence Act) was signed into law with bipartisan support. The goal of the law is to encourage cabinet-level federal agencies to use evidence to guide, strengthen, and justify their policy- and budget-making decisions. The Department of Veterans Affairs and its administrations, including the Veterans Health Administration (VHA), are required to comply.

The Evidence Act requires certain formal deliverables be submitted to the Office of Management and Budget on routine cadences. However, beyond the law’s formal requirements, VHA developed the strength of evidence checklist to strengthen the legislative and budget proposal processes. The goal is to ensure that VHA offices are using evidence to justify any changes they’re proposing to current law and/or budget lines. VHA considers this the Evidence Act “in action.”

The Partnered Evidence-based Policy Resource Center (PEPReC) spearheaded the checklist’s development and wrote a short policy brief about it. In the policy brief, PEPReC discusses the domains of evidence included in the checklist, how VHA uses it in the legislative and budget proposal process, and the routine improvements made in its early years.

Read the policy brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative, is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

The post Using evidence to justify policy and budget decisions first appeared on The Incidental Economist.

Supplement Madness: Magnesium Edition

Only with considerable effort could I find/figure out all that follows. It’s not that hard, but there seems to be a gap in the (easily accessible) internet. This may help fill it.

As a gentle sleep aid, suppose your doctor recommends you take 200 milligrams of magnesium glycinate. Or, suppose you read a recommendation of just that in a newsletter from a well-known neuroscientist. Following this advice is not as simple as you might think.

First, let’s get straight that, putting aside how it is phrased, this is a perfectly reasonable recommendation. Recommended daily allowances of magnesium for anyone other than young kids is in the hundreds of mg; it is quite common that people do not reach these levels through diet; and servings of foods can include many dozens to about 100mg of magnesium. Daily magnesium supplementation up to a 350mg is considered safe for adults, perhaps higher in consultation with a health care provider.

OK, so what are the problems? In short, there two significant communication issues.

The first is that when someone makes such a recommendation (and the internet is full of them), they almost certainly do not mean what it sounds like they mean. When someone says to take “200mg of magnesium glycinate” they really mean “take 200mg of magnesium in the form of magnesium glycinate.” Or, to be even more precise, they mean “take 200mg of elemental magnesium, delivered as a constituent of the compound magnesium glycinate.”

How do I know they mean this? First, there’s what I wrote three paragraphs above. Recommended daily allowances of magnesium are in the hundreds of mg of magnesium not magnesium glycinate (or some other compound of magnesium). As I will explain below, the difference is large. Only by ignorance or sloppiness can one confuse one with the other.

Second, there are many studies that are clear on this point. They examine magnesium for sleep and discuss doses in the hundreds of mg of elemental magnesium, some taken as magnesium glycinate, others as some other magnesium compound (e.g., magnesium citrate, magnesium oxide).

This is an important distinction. Each magnesium glycinate molecule contains one magnesium atom and two glycine molecules (this is why it is also called magnesium biglycinate, the “bi” meaning two). So, the mass of a number of magnesium atoms is less than the same number of magnesium glycinate molecules, by about a factor of 7. Thus, if you follow the advice “take 200mg of magnesium glycinate” literally (meaning you buy and consume as directed a supplement that offers 200mg of the magnesium glycinate compound per serving), you will be taking less than 30mg of elemental magnesium (200/7 is not quite 30). Based on what I’ve already conveyed above, that’s not enough to do anything. You’re way under-dosing.

(If anything about the preceding paragraph is confusing, think of it this way: imagine a special cherry that has as its pit elemental magnesium. Suppose the pit has a mass of 1 (units irrelevant). The pit is surrounded by cherry fruit composed of biglycinate with a mass of 6. The total mass of a cherry, with pit, is 7. Suppose your doctor said you should eat a mass of 210 of these magnesium-pitted cherries (and to eat the pits too, not spit them out), but she really meant that you should eat 210 magnesium pits. If you follow her instructions, you’d eat 30 cherries (210/7 = 30). In doing so, you’d only get 30 mass units of magnesium (30 pits), a far cry from 210!)

OK, so we’re clear that everyone on the internet, in doctor’s offices, and everywhere else should stop saying “take 200mg of magnesium glycinate” and start saying “take 200mg of magnesium in the form of magnesium glycinate” (or something even clearer than that). Good.

Here’s communication issue number two: The supplement market is not adequately regulated. This allows manufacturers to put all kinds of confusing stuff on their labels. This includes:

Not clearly indicating the mg of elemental magnesium, only writing the mg of the compound of which it is a constituent. So, even if you know you want 200mg of elemental magnesium, you’ve got to do some math to figure out how much of this some supplements deliver.Or, providing the mg of elemental magnesium but mislabeling it as that of the compound.Mixing compounds of magnesium — for example, some kind of blend of magnesium glycinate and magnesium oxide — and only providing the mg of this mix. That makes it even harder to figure out how much elemental magnesium is in it (perhaps impossible, because they usually don’t state the ratio of the mix).Sneaky “serving size” bullshit. When the front label says “500mg magnesium glycinate” in big print and “per serving” in small print and the back label says “4 capsules per serving,” that’s some sneaky bullshit. In addition to increasing the risk of taking the wrong dose, it’s another way it makes it very hard to shop, not just on price but also with an eye toward simplifying your pill burden. Nobody wants to take 4 capsules when they could take 2, say (all else equal).

There are undoubtedly other tricks and sources of confusion, but these are the ones I easily noticed. The best labels indicate the mg of elemental magnesium and the mg of the full compound of which it is a constituent, per serving. The very best labels consider one capsule a serving.

If all labels were written according to these two “Frakt best practices” magnesium shopping would be far less burdensome. And if all advice-givers were clear about what amount of elemental vs compound-bound magnesium they are talking about, that would reduce confusion.

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