Effects of medical research on health care and economy

Global Academic Productivity in the Field of Internal Medicine and Its Correlation to National Economic Indicators: A Bibliometric Analysis of 24 Years

BACKGROUND

Previous studies have demonstrated a correlation between national economic indicators and academic productivity. However, such a relationship has not been studied in the field of internal medicine (IM).

METHODS

The number of documents published, number of citable documents, number of citations, citations per document and the h index between 1996 and 2019 in the field of IM among the Organisation for Economic Co-operation and Development (OECD) countries were analysed. Data were derived from the The Scimago Journal and Country rank source. We analysed the correlation between these indicators to the gross domestic product (GDP) per capita, health spending as percent of GDP and gross domestic expenditure on research and development as percent of GDP (GERD). Economic data were collected from the OECD websites.

RESULTS

A significant correlation was found between health expenditure and h index (r = 0.75, P < 0.001), number of citations (r = 0.72, P < 0.001), number of documents (r = 0.62, P < 0.001) and number of citable documents (r = 0.61, P < 0.001); between GERD and number of citations (r = 0.6, P < 0.001), h index (r = 0.6, P < 0.001), number of documents published (r = 0.53, P = 0.001) and citable documents (r = 0.51, P = 0.001); between the GDP per capita and number of citations (r = 0.46, P = 0.005), citations per document (r = 0.54, P = 0.001) and h index (r = 0.5, P = 0.002).

CONCLUSIONS

This study demonstrated a positive correlation between academic productivity in the field of IM and economic indicators of the OECD countries, mainly health expenditure, implying the advantage of domestic investment in health.

Neural Prosthetics:A Review of Empirical vs. Systems Engineering Strategies

Implantable electrical interfaces with the nervous system were first enabled by cardiac pacemaker technology over 50 years ago and have since diverged into almost all of the physiological functions controlled by the nervous system. There have been a few major clinical and commercial successes, many contentious claims, and some outright failures. These tend to be reviewed within each clinical subspecialty, obscuring the many commonalities of neural control, biophysics, interface materials, electronic technologies, and medical device regulation that they share. This review cites a selection of foundational and recent journal articles and reviews for all major applications of neural prosthetic interfaces in clinical use, trials, or development. The hard-won knowledge and experience across all of these fields can now be amalgamated and distilled into more systematic processes for development of clinical products instead of the often empirical (trial and error) approaches to date. These include a frank assessment of a specific clinical problem, the state of its underlying science, the identification of feasible targets, the availability of suitable technologies, and the path to regulatory and reimbursement approval. Increasing commercial interest and investment facilitates this systematic approach, but it also motivates projects and products whose claims are dubious.

Living Long With Short Bowel Syndrome: A Historical Case of Twenty-Nine Years of Living With Home Parenteral Nutrition

BACKGROUND

This paper traces the 29-year survival of Robert Thomas, who received home parenteral nutrition (PN), and contrasts his oral narrative with the clinical history of PN.

METHODS

Interviews, chart review, review of the literature, and historical analysis.

RESULTS

Bobby Thomas was part of an early group of patients scattered throughout the country who, with their medical team, provided the foundation for more successful survival with home PN. They learned together and taught numerous nutrition support clinicians the intricacies of patient management. The importance of the patient to the teaching function of new and experienced practitioners is highly critical. Patients like Robert Thomas gave practitioners firsthand evidence of both the tenacity of the human spirit and the complexity and difficulties of chronic illness and its treatments.

CONCLUSIONS

While Bobby struggled with the complications and difficulties that came with the disease and the treatment keeping him alive, his own experiences over 29 years, as told to his medical team during his treatment and to informed interviewers before he died, tell a story that is both intersecting and parallel to the medical history. Pioneering patients like Bobby Thomas confirm the possibility of survival. They also, through their own negotiations to maintain a sense of control, can live lives they themselves help define.

Medicare Cost Effects of Recent U.S. Disability Trends in the Elderly

Objective: The authors examine how trends in disability prevalence and in inflation-adjusted per capita, per annum Medicare costs, 1982 to 1999 and 1989 to 1999, affected total Medicare costs projected to 2004 and 2009. Method: To describe disability trends, the authors applied grade of membership analyses to 27 measures of disability from the 1982 to 1999 National Long Term Care Surveys (NLTCS). This identified seven disability profiles for which individual scores were calculated. These were used to calculate sample weighted Medicare costs and cost trends. Results: Significant declines (up to 19%) in Medicare costs were found in 2004 and 2009 assuming continuation of the 1982 to 1999 disability declines and Medicare cost trends. In addition to declines in disability prevalence, inflation-adjusted per capita, per annum Medicare costs declined for nondisabled persons aged 65 to 84. Discussion: Preserving health in the growing nondisabled population did not require increased health care expenditures.

Health sector employment growth calls for improvements in labor productivity

While rising costs of healthcare have put increased fiscal pressure on public finance, job growth in the health sector has had a stabilizing force on overall employment levels - not least in times of economic crises. In 2014 EU-15 countries employed 21 million people in the health and social care sector. Between 2000 and 2014 the share of employed persons in this sector rose from 9.5% to 12.5% of the total labor force in EU-15 countries. Over time labor input growth has shifted towards residential care activities and social work while labor in human health activities including hospitals and ambulatory care still comprises the major share. About half of the human health labor force works in hospital. Variation of health and social care employment is large even in countries with generally comparable institutional structures. While standard measures of productivity in health and social care are not yet comparable across countries, we argue that labor productivity of a growing health work force needs more attention. The long-term stability of the health system will require care delivery models that better utilize a growing health work force in concert with smart investments in digital infrastructure to support this transition. In light of this, more research is needed to explain variations in health and social care labor endowments, to identify effective policy measures of labor productivity enhancement including enhanced efforts to develop comparable productivity indicators in these areas.

Medical cost trajectories and onsets of cancer and noncancer diseases in US elderly population

Time trajectories of medical costs-associated with onset of twelve aging-related cancer and chronic noncancer diseases were analyzed using the National Long-Term Care Survey data linked to Medicare Service Use files. A special procedure for selecting individuals with onset of each disease was developed and used for identification of the date at disease onset. Medical cost trajectories were found to be represented by a parametric model with four easily interpretable parameters reflecting: (i) prediagnosis cost (associated with initial comorbidity), (ii) cost of the disease onset, (iii) population recovery representing reduction of the medical expenses associated with a disease since diagnosis was made, and (iv) acquired comorbidity representing the difference between post- and pre diagnosis medical cost levels. These parameters were evaluated for the entire US population as well as for the subpopulation conditional on age, disability and comorbidity states, and survival (2.5 years after the date of onset). The developed approach results in a family of new forecasting models with covariates.

Long-term economic growth stimulus of human capital preservation in the elderly

Health care is a crucial factor in US economic growth, because growing health care costs have made US corporations less competitive than their counterparts in countries where central governments assume most of those costs. In this paper we illustrate a second, possibly more powerful, effect of health care expenditures on the long term pace of US economic growth, i.e., that such investments in aging populations helps preserve human capital to later ages. In addition, as current investment in health care improves health and functional status, the future demand for health care as well as future health care costs will be constrained. These are crucial factors in countries experiencing rapid population aging. US labor force projections do not directly represent the effects of health care investment on the health of the future labor force, and federal health cost projections do not reflect the trajectory of health changes. Health dynamic projections suggest the effects of health care investment are large and growth stimulating. Projections done for the time period used by the Congressional Budget Office in budget mark-ups (2010-2020) are presented in the supporting information.

Reductions in disability prevalence among the highest income groups of older Brazilians

OBJECTIVES

We sought to identify the income-disability prevalence relationship among older Brazilians.

METHODS

Data were from 63,985 individuals 60 years and older from the 1998 and 2003 Brazilian National Household Surveys. Generalized additive logistic models with cubic regression splines were used to estimate the disability-income relationships.

RESULTS

There was a strong linear relationship between increased income and reduced disability prevalence for most of the income distribution. Benefits were still present above the 90th percentile of income but were more modest. Because incomes among the wealthiest few are disproportionately large, odds ratios of disability nevertheless showed marked improvements, even across the very highest income groups.

CONCLUSIONS

Among older Brazilians, reduced disability is associated with higher income, and these associations are present even above the 90th percentile of income. In addition to understanding mechanisms of disability reduction among impoverished individuals, work is needed to understand these mechanisms in middle- and high-income groups.

Chronic disease and severe disability among working-age populations

BACKGROUND

Recent work has shown that rates of severe disability, measured by the inability to perform basic activities of daily living, have been rising in working age populations. At the same time, the prevalence of important chronic diseases has been rising, while others falling, among working age populations. Chronically ill individuals are more likely than others to have activity of daily living limitations.

OBJECTIVE

We examine the extent to which chronic disease trends can explain these disability trends.

DATA

We use nationally representative survey data from the 1984-1996 National Interview Survey, which posed a consistent set of questions regarding limitations in activities of daily living over that period.

METHODS

We decompose trends in disability into 2 parts-1 part due to trends in the prevalence of chronic disease and the other due to trends in disability prevalence among those with chronic disease.

RESULTS

: Our primary findings are that for working age populations between 1984 and 1996: (1) disability prevalence fell dramatically among the nonchronically ill; (2) rising obesity prevalence explains about 40% of the rise in disability attributable to trends chronic illness; and (3) rising disability prevalence among the chronically ill explains about 60% of the rise in disability attributable to trends in chronic illness.

CONCLUSIONS

Disability prevention efforts in working age populations should focus on reductions in obesity prevalence and limiting disability among chronically ill populations. Given the rise in disability among these population subgroups, it is unclear whether further substantial declines in elderly disability can be expected.

Labor force participation and human capital increases in an aging population and implications for U.S. research investment

The proportion of the United States labor force >/=65 years of age is projected to increase between 2004 and 2014 by the passing of age 65 of the large post-World War II baby boom cohorts starting in 2010 and their greater longevity, income, education, and health [Toossi M (2005) Mon Labor Rev 128(11):25-44]. The aging of the U.S. labor force will continue to at least 2034, when the largest of the baby boom cohorts reaches age 70. Thus, the average health and functional capacity of persons age 65+ must improve for sufficient numbers of elderly persons to be physically and cognitively capable of work. This will require greater investments in research, public health, and health care. We examine how disability declines and improved health may increase human capital at later ages and stimulate the growth of gross domestic product and national wealth.

Percutaneous valve interventions

PURPOSE OF REVIEW

Open heart surgery has long been considered the gold standard for treatment of patients with valvular heart disease. Although results are excellent, this technique requires the use of cardiopulmonary bypass and is associated with protracted recovery and attendant risks of open surgery. The field of percutaneous valve interventions has emerged as a closed-chest alternative for all patients, but particularly those who otherwise would be considered too high risk for open surgery.

RECENT FINDINGS

Several devices are currently being evaluated in the clinical realm for each heart valve, particularly for the aortic and mitral positions. Early results are promising, but longer follow-up is necessary to determine durability of the procedures.

SUMMARY

Although only in its infancy, percutaneous valve therapies offer heart valve interventions without the use of cardiopulmonary bypass. This creates many new possibilities for patients, especially those who are deemed either high risk or inoperable by the usual surgical standards. Newer device iterations and longer term follow-up will be necessary as the field moves forward.

Role of islet amyloid in type 2 diabetes mellitus

Diabetes mellitus is one of the most common metabolic diseases worldwide and its prevalence is rapidly increasing. Due to its chronic nature (diabetes mellitus can be treated but as yet not cured) and its serious complications, it is one of the most expensive diseases with regard to total health care costs per patient. The elevated blood glucose levels in diabetes mellitus are caused by a defect in production and/or secretion of the polypeptide hormone insulin, which normally promotes glucose-uptake in cells. Insulin is produced by the pancreatic 'beta-cells' in the 'islets of Langerhans', which lie distributed within the exocrine pancreatic tissue. In type 2 diabetes mellitus, the initial defect in the pathogenesis of the disease in most of the patients is believed to be 'insulin resistance'. Hyperglycemia (clinically overt diabetes mellitus) will not develop as long as the body is able to produce enough insulin to compensate for the reduced insulin action. When this compensation fails ('beta-cell failure') blood glucose levels will become too high. In this review, we discuss one of the mechanisms that have been implicated in the development of beta-cell failure, i.e. amyloid formation in the pancreatic islets. This islet amyloid is a characteristic histopathological feature of type 2 diabetes mellitus and both in vitro and in vivo studies have revealed that its formation causes death of islet beta-cells. Being a common pathogenic factor in an otherwise heterogeneous disease, islet amyloidosis is an attractive novel target for therapeutic intervention in type 2 diabetes mellitus.

Technological advances in cancer and future spending by the elderly

This paper forecasts the consequences of scientific progress in cancer for total Medicare spending between 2005 and 2030. Because technological advance is uncertain, widely varying scenarios are modeled. A baseline scenario assumes that year 2000 technology stays frozen. A second scenario incorporates recent cancer treatment advances and their attendant discomfort. Optimistic scenarios analyzed include the discovery of an inexpensive cure, a vaccine that prevents cancer, and vastly improved screening techniques. Applying the Future Elderly Model, we find that no scenario holds major promise for guaranteeing the future financial health of Medicare.

From progress to regression: biomedical research funding

Despite great advances in health-related research and health care, major challenges remain regarding the causes and cures of many diseases; these may be overcome with further research. Our society is enthusiastic about fostering such investigations. However, available federal funds limit many such projects. Previously there have been sizable increases in the NIH budget, but because of the escalating cost of scientific investigation and the pressures of financing other much-needed governmental programs, recent growth in biomedical research funding has barely kept up with inflation. This article focuses on select attempts to sustain the record of scientific achievement enabled in the past by continued increasing investment and also suggests some solutions.

Proposed methods for reviewing the outcomes of health research: the impact of funding by the UK's 'Arthritis Research Campaign'

Background

External and internal factors are increasingly encouraging research funding bodies to demonstrate the outcomes of their research. Traditional methods of assessing research are still important, but can be merged into broader multi-dimensional categorisations of research benefits. The onus has hitherto been on public sector funding bodies, but in the UK the role of medical charities in funding research is particularly important and the Arthritis Research Campaign, the leading medical charity in its field in the UK, commissioned a study to identify the outcomes from research that it funds. This article describes the methods to be used.

Methods

A case study approach will enable narratives to be told, illuminating how research funded in the early 1990s was (or was not) translated into practice. Each study will be organised using a common structure, which, with careful selection of cases, should enable cross-case analysis to illustrate the strengths of different modes and categories of research. Three main interdependent methods will be used: documentary and literature review; semi-structured interviews; and bibliometric analysis. The evaluative framework for organising the studies was previously used for assessing the benefits from health services research. Here, it has been specifically amended for a medical charity that funds a wide range of research and is concerned to develop the careers of researchers. It was further refined in three pilot studies. The framework has two main elements. First, a multi-dimensional categorisation of benefits going from the knowledge produced in peer reviewed journal articles through to the health and potential economic gain. The second element is a logic model, which, with various stages, should provide a way of organising the studies. The stock of knowledge is important: much research, especially basic, will feed into it and influence further research rather than directly lead to health gains. The cross-case analysis will look for factors associated with outcomes.

Conclusions

The pilots confirmed the applicability of the methods for a full study which should assist the Arthritis Research Campaign to demonstrate the outcomes from its funding, and provide it with evidence to inform its own policies.

From immune system to health systems--challenges for health research

There are many similarities between the immune system and health systems. Both are knowledge-based learning systems with an ultimate common objective of maintaining the health of individuals and populations, respectively. The immune system learns from the environment, and knowledge and discovery are key drivers of health systems improvement and improving health status. But discovery goes well beyond immunology, virology and genomics, for example, in the quest to develop new drugs, vaccines and diagnostic tests. New ways must also be discovered to make sure that these products reach the people who need it most. We must discover ways for knowledge to be turned into effective policies, to inform the practice of healthcare and to inform the public and society at large. Only if discovery is seen in its broadest perspective will we be able to reach the goal of health for all.

Vasopressin-induced cytoplasmic and nuclear calcium signaling in embryonic cortical astrocytes: dynamics of calcium and calcium-dependent kinase translocation

The present study sought to determine the downstream consequences of V1a vasopressin receptor (V1aR) activation of Ca2+ signaling in cortical astrocytes. Results of these analyses demonstrated that V1aR activation led to a marked increase in both cytoplasmic and nuclear Ca2+. We also investigated V1aR activation of Ca2+-activated signaling kinases, protein kinase C (PKC), Ca2+/calmodulin-dependent protein kinase II (CaMKII), and the mitogen-activated protein (MAP) kinases [MAPK and extracellular signal-regulated kinases 1 and 2 (ERK1/2)], their localization within cytoplasmic and nuclear compartments, and activation of their downstream nuclear target, the transcription factor cAMP response element-binding protein (CREB). Results of these analyses demonstrated that V1aR activation led to a significant rise in PKC, CaMKII, and ERK1/2 activation, with CaMKII and ERK1/2 demonstrating dynamic transport between cytoplasmic and nuclear compartments. Although no evidence of PKC translocation was apparent, PKC and CaMKs were required for activation and nuclear translocation of ERK1/2. Subsequent to CaMKII and ERK1/2 translocation to the nucleus, CREB activation occurred and was found to be dependent on upstream activation of ERK1/2 and CaMKs. These data provide the first systematic analysis of the V1aR-induced Ca2+ signaling cascade in cortical astrocytes. In addition, results of this study introduce a heretofore unknown effect of vasopressin, dynamic Ca2+ signaling between the cytoplasm and nucleus that leads to comparable dynamics of kinase activation and shuttling between cytoplasmic and nuclear compartments. Implications for development and regeneration induced by V1aR activation of CREB-regulated gene expression in cortical astrocytes are discussed.

Role of islet amyloid in type 2 diabetes mellitus: consequence or cause?

Type 2 diabetes mellitus (DM2) is characterized metabolically by defects in both insulin secretion and insulin action, resulting in hyperglycemia. Histopathologically, DM2 is characterized by depositions of protein in the pancreatic islets. This 'islet amyloid' is present in >90% of patients with DM2, as well as in monkeys and cats with DM2. The pathogenesis of DM2 is heterogeneous and multifactorial, although insulin resistance seems to be the predominant initiating factor for development of the disease. In the longer term, an insulin secretion defect is also revealed (referred to as 'beta-cell failure'), resulting in clinically manifest diabetes. Recent data, particularly from transgenic mouse studies, indicate that islet amyloidosis is a diabetogenic factor, which is both consequence (of insulin resistance) and cause (of beta-cell failure) of DM2. Available transgenic mouse models with islet amyloid formation in vivo will provide the opportunity to assess the effectiveness of novel anti-amyloidogenic therapies, for which promising results are emerging.

Perspectives on Palliative Care: A Chair of Medicine Viewpoint

Palliative care should integrate well into academic medicine. The diversity of patients served and the attraction of the sickest of patients mandate palliative care as well as disease directed therapy. The themes of coping, caring and symptom management are daily needs at a university hospital. A chair of medicine with a background as a hospice medical director can provide valuable support to physicians as well as to the patients. Research and new models of palliative care can be developed, often in conjunction with the community. The provision of longitudinal care and symptom management are not incongruous with the mission of research. They are inseparable.

Quality of care in mental health: the case of schizophrenia

Scientific evidence supporting the efficacy of a range of treatments for persons with schizophrenia set the stage for the recent development of evidence-based quality-of-care indicators for this disorder. On the heels of these quality indicators, research has found that treatment services for many persons with schizophrenia are inadequate. Because most of these patients receive their care under public auspices (Medicaid, Medicare, and Veterans Affairs), public health policy can exert considerable influence to address these quality-of-care problems. Publicly funded managed care could promote evidence-based care. It also could coordinate specialty and primary care to improve early detection and general medical care for persons with schizophrenia.

Cardiac markers: present and future

In the early twentieth century, acute myocardial infarction secondary to acute thrombotic coronary occlusion was considered a rare, fatal condition. Acute myocardial infarction is now one of the most-commmon serious illnesses in the industrialized world. Laboratory medicine now plays a crucial role in identifying risk factors, early events, and conditions triggering plaque rupture in coronary ischemic disease. However, the greatest progress in laboratory research has resulted from the discovery of new and more-promising biochemical markers of myocardial damage. The discovery of cardiac troponins, in particular, has heralded a new age in the diagnosis and treatment or management of a broad spectrum of diseases, grouped together under the heading of acute coronary syndrome, and including stable and unstable angina, and non-Q wave infarction to Q-wave infarction. Cardiac troponins, which are selectively released by damaged myocardiocytes, have a specificity that has not only allowed an improvement in the diagnosis of acute cardiac ischemic disorders, but has also enabled us to make a more-reliable stratification of risk and prediction of outcome. It is generally agreed that two biochemical markers should be used: an early marker (and we recommed myoglobin for this) and a definitive marker, which is cardiac troponin (I or T). Future research is likely to include the standardization of methods for measuring current markers, troponin I in particular, the assessment of rapid bedside tests, and the investigation of the relationship between cardiac markers and emerging immunological and coagulation parameters. Thrombogenesis is now recognized as important in the final process of coronary atherosclerosis, and new markers of thrombogenesis should be used to evaluate the risk of plaque rupture and to monitor the outcome of thrombolytic therapy. Moreover, recent vascular biology studies have provided information on the developmental stages of atherosclerosis and emphasized the importance of the endothelium as a modulator of vascular reactivity, atherogenesis, and plaque stability. The different types of laboratory test (biochemical, immunological, and coagulative) now available, should soon allow improvement in the diagnosis and therapy of ischemic coronary diseases.