Birds or Pigs; The Swines Have It?

We’ve had a lot of stories the past several days about the swine flu outbreak in Mexico and smaller groupings of confirmed cases in New York, California and elsewhere in the United States.   There has been years of discussion on the H5N1, so called avian flu, pandemic risks.  We all remember the impact of SARS.  And we’ve been rocked, recently, by what some have tagged a ‘depression’ but all of noted as the largest economic downturn since The Great Depression.  The losses associated with this ‘Great Recession’ are still playing out.

But I was wondering — what if the Swine Flu became a pandemic at this time?  All indication (including the CDC site) indicate that aside from some serious implications for Mexico City’s public health, the cases in the United States have been mild, with no hospitalizations.  The 1918 flu pandemic that took 20m lives world-wide, however, is the standard modern example of potential personal and economic costs of a flu pandemic.  Not to minimize the terrible pain and suffering that such a pandemic would cause by putting an economic slant on it– but I was wondering what might be the economic impact to our already tottering United States economy if a pandemic struck.

So I took a look at a study the CDC had commissioned in 1999.  It showed the potential U.S. economic impact of a pandemic.   The CDC used this as a way to assist the public policy discussion in light of strategies regarding flu immunization — i.e., which immunization policy could provide the best net value in the case of flu pandemics of differing severity.   It’s beyond this post (or its author) to analyze the article and it’s conclusions.  But I thought the numbers were notable and summarize the potential economic exposure (without vaccination).  And, of course, this looks at U.S. exposure only.  A pandemic would have a far reach.  Look how quickly in this age of easy travel the virus spread from Mexico to the United States and even potentially exposed the President of the United States during his trip.  From the CDC’s study:

Without large-scale immunization, the estimates of the total economic impact in the United States of an influenza pandemic ranged from $71.3 billion (5th percentile = $35.4 billion; 95th percentile = $107.0 billion) (gross attack rate of 15%) to $166.5 billion (5th percentile = $82.6 billion; 95th percentile = $249.6 billion) (gross attack rate of 35%) (Table 6). At any given attack rate, loss of life accounted for approximately 83% of all economic losses. Outpatients, persons ill but not seeking medical care, and inpatients accounted for approximately 8%, 6%, and 3%, respectively, of all economic losses (Table 6) (Appendix II).

* * * *

If it cost $21 to vaccinate a person and the effective coverage were 40%, net savings to society would result from vaccinating all age and risk groups (Figure 2). However, vaccinating certain age and risk groups rather than others would produce higher net returns. For example, vaccinating patients ages 20 to 64 years of age not at high risk would produce higher net returns than vaccinating patients ages 65 years of age and older who are at high risk (Figure 2). At a cost of $62 per vaccinee and gross attack rates of less than 25%, vaccinating populations at high risk would still generate positive returns (Figure 2). However, vaccinating populations not at high risk would result in a net loss (Figure 2).

via The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention.

There’s also an interesting Congressional Budget Office (CBO) assessment (and see generally the goverment web page)  of possible economic effects of an avian flu pandemic.  That study concludes that a pandemic involving a highly virulent flu strain (such as the one that caused the pandemic in 1918) could produce an impact worldwide similar in depth and duration to an average postwar recession in the United States — but citing studies ranging from a .5% to 6% decrease in GDP.  Query, of course, what impact if such a pandemic hit during an ongoing recession.

Filed under: Comparative Effectiveness Rearch, Health Law, Personal Posts, Pharmacy, Risk Management, Economics, Health Law, Lindedin, Public Health

Factors Influencing Physicians Prescribing NAIDs

In his Healthcare Economist blog, Jason Shafrin, Ph.D. (just recieved – congrats) reported on a recent study in The American Journal of Managed Care concerning the prescribing habits of Nonsteroidal Anti-Inflammatory Drug (NAIDs) among physicians.  The study, entitled Pharmaceutical Company Influence on Nonsteroidal Anti-Inflammatory Drug Prescribing Behaviors, describes, through interviews with academic medical center physicians from a variety of specialities, their prescribing habits in order to elicit the general themes that influence their behavior.  As Jason summarizes from the article, they are mostly influenced by the following:

1. Direct Marketing by pharma detailers.
2. Patient requests for medication, often driven by direct-to-consumer pharmaceutical advertising.
3. Habits formed during medical school. Often, these habits are influenced by drug rep visits while the physician was in medical school.
4. Journals, electronic peer-reviewed literature, and professional meetings.
5. Local physician expert opinion and practice guidelines.
6. The physician’s own experience prescribing drugs to patients.

The purpose of the study was to “describe the taxonomy of methods used by pharmaceutical companies to influence physicians’ nonsteroidal anti-inflammatory drug (NSAID) prescribing behaviors and to elicit physicians’ perceptions of and counterbalances to these influences” since there was a recognized poor adherence to prescribing guidelines for NSAIDs.  The study recognized that physicians describe detailing and direct contact with pharmaceutical representatives, requests from patients inspired by direct-to-consumer advertisements, and marketing during medical school and residency training as primary influences.  The study also reports that physicians described practice guidelines, peer-reviewed evidence, and opinions of local physician experts as important counterweights to pharmaceutical company influence.

The study concludes that the “social and communicative strategies used by pharmaceutical companies can be adapted to improve physicians’ adoption of guidelines for safer NSAID prescribing. Communicative interactions between local experts and other physicians who prescribe NSAIDs may be the critical target for future interventions to promote safer NSAID prescribing.”

Aanand D. Naik, MD and Aaron L. Woofter, MD et al,  (2009) “Pharmaceutical Company Influence on Nonsteroidal Anti-Inflammatory Drug Prescribing Behaviors,” Am J Manag Care. 2009 (published online April 1, 2009 and found online April 18, 2009 at http://www.ajmc.com/web-exclusives/managed-care/AJMC_09Apr_Naik_Exclusiv_e9toe15?utm_source=Listrak&utm_medium=Email&utm_term=%2fweb-exclusives%2fmanaged-care%2fAJMC_09Apr_Naik_Exclusiv_e9toe15&utm_content=jshafrin%40ucsd.edu&utm_campaign=AJMC+e-Table+of+Contents+(April+Web+Exclusive)).

via [AJMC] – American Journal of Managed Care.

Filed under: AKS, Conflicts of Interest, Drug Policy, Health Law, Pharmacy, Conflicts of Interest, Health Law, LinkedIn

Doctors Urge End to Corporate Ties – NYTimes.com

The NY Times Health Blog on April 1 reports that JAMA published a paper in its April 1, 2009 edition.   The paper recommends that medical professional associations adopt stricter conflict-of-interest guidelines.  Mere disclosure of financial ties to drug and medical device companies is not sufficient.  They also advocate barring members industry financial ties from entering leadership positions and participating in influential committees within the association.

The blog further reports that:

The authors are particularly adamant that professional medical associations should neither accept corporate money to underwrite the development of practice guidelines nor allow members with financial ties to industry to serve on committees that develop the guidelines, which are usually widely adopted as the gold standard for medical practice. … “The consensus here was quite clear: You do not want the piper calling the tune,” said David J. Rothman, a professor of social medicine at Columbia University. “We ask that these groups make every effort to get to zero percent and, knowing that it is very difficult to do that, that they move as rapidly as possible to no more than 25 percent,” referring to how much of their support should come from industry.

Commentary from Marjorie Powell, senior assistant general counsel for Pharmaceutical Research and Manufacturers of America was also reported in the blog, reminding of the amount of money that industry provides for necessary research and other support of healthcare providers.

“The vast majority of the research is funded by pharmaceutical companies,” Ms. Powell said. Important decisions regarding practice guidelines might be made, she said, by “very junior people who have no experience.”

via Doctors Urge End to Corporate Ties – NYTimes.com.

Note a similar post in the WSJ Health Blog.

Filed under: Conflicts of Interest, Drug Policy, Health Law, Pharmacy, Reform, Conflicts of Interest, Economics, Finance, Health Law

Authors of Psychiatric Guidelines Get Funding from Drug Makers – Health Blog – WSJ

The WSJ Health Blog reports a significant portion of those writing the APA’s treatment guidelines have financial ties to industry.

[A]mong 20 authors of the guidelines for treatment of depression, dipolar disorder and schizophrenia, 18 had at least one financial tie to a drug maker, and 12 had ties in at least three categories, such as consulting, research grants, speaking fees or stock ownership.The guidelines are a powerful influence on the way doctors treat patients. This week, big-name docs argued in a JAMA paper that medical specialty groups, which put out the guidelines, should tightly limit their funding from industry. (Drug trade group PhRMA responded that industry funding helps doctors obtain important medical information.) Earlier this year, amid news that many heart-disease guidelines aren’t backed up by rigorous scientific testing, an editorial in JAMA argued that guidelines “often have become marketing tools for device and pharmaceutical manufacturers.”

via Authors of Psychiatric Guidelines Get Funding from Drug Makers – Health Blog – WSJ.

In the referenced Boston Globe article one of the authors Dr. Roy Perlis, after noting that the guidelines in his area promote generics and non-pharmeceutical interventions states:

“My job is to find better treatments for my patients. These are awful illnesses. People really suffer,” he said. “And the people who are most responsible for developing new treatments right now are the pharmaceutical companies. What is being lost in all this is that if I didn’t work with them, I couldn’t do my job as a scientist – the part of my job that says we have people who are suffering that need new treatments.”

Filed under: Conflicts of Interest, Health Law, Pharmacy, Reform, Risk Management, Conflicts of Interest, Economics, Health, Health Law

Healthcare Economist · Comparison of Pharmacists and Primary Care Providers as Immunizers

In his Healthcare Economist blog, Jason Shafrin writes about a recent paper he wrote with John Fontanesi, Jan Hirsch, Sarah Lorentz, and Debra Bowers and had published in American Journal of Pharmaceutical Benefits.  The paper (which I have not reviewed) analyzes the efficacy and quality of immunizations as provided in primary care offices and pharmacies in California.  The abstact is below and observes that from a consistency, cost and productivity stand point, pharmacies might be a better alternative. 

This study examines the potential role of “alternative community immunizers,” specifically pharmacists, in providing immunization services. A convenience sampling of almost 700 adults eligible for vaccinations was taken from 15 ambulatory care settings and 11 pharmacies in San Diego, California between 2006 and 2008. The results of the study found that patient characteristics and beliefs were similar between primary care and pharmacies, but pharmacies proved more consistent in following safety protocols; had lower unit costs; and were more efficient, with greater productivity. We conclude that pharmacies combine the best immunization practices of routine scheduled primary care visits and mass influenza vaccination clinics, but gaps still exist in pharmacies’ ability to effectively transmit immunization records securely and provider willingness to embrace these “alternative immunizers.“

via Healthcare Economist · Comparison of Pharmacists and Primary Care Providers as Immunizers.

Filed under: Comparative Effectiveness Rearch, Drug Policy, Health Law, Pharmacy, Primary Care, Quality Reporting, Reform, Risk Management, Economics, Health, Health Law