Pharmaceutical policies: effects of regulating drug insurance schemes

BACKGROUND

Drug insurance schemes are systems that provide access to medicines on a prepaid basis and could potentially improve access to essential medicines and reduce out-of-pocket payments for vulnerable populations.

OBJECTIVES

To assess the effects on drug use, drug expenditure, healthcare utilisation and healthcare outcomes of alternative policies for regulating drug insurance schemes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers between November 2014 and September 2020, including a citation search for included studies on 15 September 2021 using Web of Science. We screened reference lists of all the relevant reports that we retrieved and reports from the Background section. Authors of relevant papers, relevant organisations, and discussion lists were contacted to identify additional studies, including unpublished and ongoing studies.

SELECTION CRITERIA

We planned to include randomised trials, non-randomised trials, interrupted time-series studies (including controlled ITS [CITS] and repeated measures [RM] studies), and controlled before-after (CBA) studies. Two review authors independently assessed the search results and reference lists of relevant reports, retrieved the full text of potentially relevant references and independently applied the inclusion criteria to those studies. We resolved disagreements by discussion, and when necessary by including a third review author. We excluded studies of the following pharmaceutical policies covered in other Cochrane Reviews: those that determined how decisions were made about which conditions or drugs were covered; those that placed restrictions on reimbursement for drugs that were covered; and those that regulated out-of-pocket payments for drugs.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies and assessed risk of bias for each study, with disagreements being resolved by consensus. We used the criteria suggested by  Cochrane Effective Practice and Organisation of Care (EPOC)  to assess the risk of bias of included studies. For randomised trials, non-randomised trials and controlled before-after studies, we planned to report relative effects. For dichotomous outcomes, we reported the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For interrupted time series and controlled interrupted time-series studies, we computed changes along two dimensions: change in level; and change in slope. We undertook a structured synthesis following the EPOC guidance on this topic, describing the range of effects found in the studies for each category of outcomes.

MAIN RESULTS

We identified 58 studies that met the inclusion criteria (25 interrupted time-series studies and 33 controlled before-after studies). Most of the studies (54) assessed a single policy implemented in the United States (US) healthcare system: Medicare Part D. The other four assessed other drug insurance schemes from Canada and the US, but only one of them provided analysable data for inclusion in the quantitative synthesis. The introduction of drug insurance schemes may increase prescription drug use (low-certainty evidence). On the other hand, Medicare Part D may decrease drug expenditure measured as both out-of-pocket spending and total drug spending (low-certainty evidence). Regarding healthcare utilisation, drug insurance policies (such as Medicare Part D) may lead to a small increase in visits to the emergency department. However, it is uncertain whether this type of policy increases or decreases hospital admissions or outpatient visits by beneficiaries of the scheme because the certainty of the evidence was very low. Likewise, it is uncertain if the policy increases or reduces health outcomes such as mortality because the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

The introduction of drug insurance schemes such as Medicare Part D in the US health system may increase prescription drug use and may decrease out-of-pocket payments by the beneficiaries of the scheme and total drug expenditures. It may also lead to a small increase in visits to the emergency department by the beneficiaries of the policy. Its effects on other healthcare utilisation outcomes and on health outcomes are uncertain because of the very low certainty of the evidence. The applicability of this evidence to settings outside US healthcare is limited.

[Sustainable Development Goals: impact of lack of financial protection in health in Latin American and Caribbean countriesObjetivos de Desenvolvimento Sustentável: impacto da falta de proteção financeira em saúde nos países da América Latina e do Caribe]

Objetivo.

Determinar el impacto del gasto de bolsillo en salud en los hogares, los niveles de protección financiera y su desigualdad según variables relevantes en países de la Región. Se indaga su evolución y relación con el uso de servicios del sistema de salud.

Métodos.

Se recopila información descriptiva comparada acerca del gasto de bolsillo, su incidencia en la población, y su peso y composición en el consumo de los hogares. Se presentan indicadores de protección financiera en el nivel nacional y su distribución por quintiles de consumo total de hogares y por género. Se contrastan con un indicador de cobertura de servicios.

Resultados.

Los indicadores de gasto de bolsillo y protección financiera son deficientes pero diferenciados entre los países. Se identifica la composición del gasto en salud para un subgrupo de ellos y existen gradientes significativos cuando se estudian las desigualdades. Para algunos casos, se muestran cambios en el tiempo y posibles asociaciones con los niveles de cobertura de servicios.

Discusión.

La desprotección financiera afecta a una gran parte de la población, se configuran grupos de países con dificultades mayores que otros, con preponderancia de gasto en medicamentos y exposición mayor de grupos en situaciones de vulnerabilidad, como los más pobres y las mujeres, lo que denota una gran inequidad. Se identifican políticas de algunos países que pueden asociarse con la evolución de la protección financiera. Para reemplazar el gasto de bolsillo, barrera para el acceso, los países necesitan aumentar el gasto público mediante el financiamiento de los sistemas de salud en transformación hacia la salud universal.

National Health Insurance: A conceptual framework from conflicting typologies

In the path to universal health coverage, policymakers discuss different alternative health system's financing schemes. Classical typologies have been posited, including models such as National Health Service, Social Health Insurance and Private Health Insurance. More recently, National Health Insurance (NHI) has been suggested as a separate model. Nevertheless, there are discrepancies regarding what defines an NHI model. The purpose of this article is to propose a comprehensive definition of an NHI model, aimed to disentangle the current discrepancies in the conceptualization and the scope of this type of arrangement. Based on the previous literature we identified some common characteristics across NHI definitions, namely universal coverage, pooling in a single fund and a purchasing function based on a single-payer financing mechanism. Areas of controversy were also identified. While some authors emphasized the importance of an effective separation between the purchaser and provider functions, others highlighted the relative importance of privately-owned provision to define a system like NHI-type. Based on empirical data, we suggest that the ownership is not a critical variable to distinguish an NHI from other models, and instead, suggest that a pivotal characteristic of the NHI is the single payer mechanism that is not integrated with the health providers.

El desafío de la sostenibilidad de los programas ampliados de inmunizaciones

Objetivo. Analizar la sostenibilidad y la integración de los programas prioritarios en el marco de la Estrategia para el acceso universal a la salud y la cobertura universal de salud (Salud Universal) de la Organización Panamericana de la Salud de 2014.

Métodos. Se llevó a cabo una revisión no sistemática de la bibliografía reciente enfocada al análisis de la integración y la sostenibilidad.

Resultados. El principal resultado que se extrae de la bibliografía revisada es la necesidad de abordar la sostenibilidad de tal modo que se superen los límites de cualquier análisis restringido a la sostenibilidad financiera. Aunque la integración y la sostenibilidad no se interpretan de forma homogénea, sobresale un abordaje que contempla la integración como un factor facilitador del proceso de sostenibilidad del PAI.

Conclusiones. La efectividad de las estrategias de integración del PAI depende en buena medida de que se consideren la presencia, el fortalecimiento y la transformación de las estructuras organizativas e institucionales que faciliten la participación de los actores con capacidad técnica y política para garantizar sus procesos de implementación. De esta forma, se podrán ponderar los procesos políticos que legitiman una agenda de inclusión del PAI en la Estrategia de salud universal y, por tanto, como parte integrante del fortalecimiento de los sistemas de salud.

[The pending health reform in Chile: reflections on a proposal to transform the systemA inacabada reforma da saúde no Chile: reflexões sobre proposta de transformação do sistema]

Chile maintains a health system segmented by risks and income. A Presidential Commission convened in 2014 presented two scenarios for its health system in accordance with a timeline of expected results. For the long term, it proposed a vision for the direction of the Chilean health system that would converge in a single public insurance. For the short term, it proposed a transition that consisted of regulating pension health institutions to function under social security rules and principles. The central approaches were based on international evidence of systems that have achieved success in offering universal health access and coverage to the population, through appropriate transformations and regulations. The analysis carried out by the Commission signaled the beginning of a new paradigm for health policies in Chile. This points out that the strategy used previously-to promote greater competition and freedom of choice in health insurance markets-has not yielded results, and that in order to advance towards equitable access to health it is necessary to focus on the right to health and the principles of solidarity and equity, as well as assessing progress in the world, recognizing that the Chilean scheme moves away from the best practices in terms of the design of health systems. The proposal has not been implemented yet, and it will be necessary to propose an accelerated implementation plan for its longterm vision. Chile's experience is relevant for other countries in the Region of the Americas that discuss the problems of health segmentation.

[Hospital performance in a segmented and unequal health system: Chile 2001-2010]

Objective:

To analyze the differences in health outcomes by hospital characteristics, focusing on ownership: public, private not-for-profit (PNFP) and private for-profit (PFP).

Materials and methods:

We used a discharged patient dataset of Chilean hospitals for the period 2001-2010 with a total of 16 205 314 discharges in 20 public, six PNFP and 15 PFP hospitals.We selected a subsample of two medical conditions: myocardial infarction and stroke.We used probit regression analyses with mortality rates as dependent variable, ownership status as the key explanatory variable, and control variables which included patients' health status and socioeconomic level, and hospital characteristics.

Results:

Private hospitals showed lower risk of death relative to public hospitals: 1.3% in PNFP, 0.7% in PFP and 3.5% in public hospitals.

Conclusions:

The analysis shows the inequities that exist between public hospitals and the private sector.

[Assessing the economic impact of cancer in Chile: a direct and indirect cost measurement based on 2009 registries]

PURPOSE

This paper aims to determine the economic impact that cancer represents to Chile, exploring the share of costs for the most important cancers and the differences between the public and private sector.

METHODS

We used the cost of illness methodology, through the assessment of the direct and indirect costs associated with cancer treatment. Data was obtained from 2009 registries of the Chilean Ministry of Health and the Superintendence of Health. Indirect costs were calculated by days of job absenteeism and potential years of life lost.

RESULTS

Over US$ 2.1 billion were spent on cancer in 2009, which represents almost 1% of Chile’s Gross Domestic Product. The direct per capita cost was US$ 47. Indirect costs were 1.92 times more than direct costs. The three types of cancer that embody the highest share of costs were gastric cancer (17.6%), breast cancer (7%) and prostate cancer (4.2%) in the public sector, and breast cancer (14%), lung cancer (7.5%) and prostate cancer (4.1%) in the private sector. On average men spent 30.33% more than women.

CONCLUSION

There are few studies of this kind in Chile and the region. The country can be classified as having a cancer economic impact below the average of those in European Union countries. We expect that this information can be used to develop access policies and resource allocation decision making, and as a first step into further cancer-costing studies in Chile and the Latin American and Caribbean region.

A snapshot of cancer in Chile: analytical frameworks for developing a cancer policy

INTRODUCTION

The South American country Chile now boasts a life expectancy of over 80 years. As a consequence, Chile now faces the increasing social and economic burden of cancer and must implement political policy to deliver equitable cancer care. Hindering the development of a national cancer policy is the lack of comprehensive analysis of cancer infrastructure and economic impact.

OBJECTIVES

Evaluate existing cancer policy, the extent of national investigation and the socio-economic impact of cancer to deliver guidelines for the framing of an equitable national cancer policy.

METHODS

Burden, research and care-policy systems were assessed by triangulating objective system metrics--epidemiological, economic, etc.--with political and policy analysis. Analysis of the literature and governmental databases was performed. The oncology community was interviewed and surveyed.

RESULTS

Chile utilizes 1% of its gross domestic product on cancer care and treatment. We estimate that the economic impact as measured in Disability Adjusted Life Years to be US$ 3.5 billion. Persistent inequalities still occur in cancer distribution and treatment. A high quality cancer research community is expanding, however, insufficient funding is directed towards disproportionally prevalent stomach, lung and gallbladder cancers.

CONCLUSIONS

Chile has a rapidly ageing population wherein 40% smoke, 67% are overweight and 18% abuse alcohol, and thus the corresponding burden of cancer will have a negative impact on an affordable health care system. We conclude that the Chilean government must develop a national cancer strategy, which the authors outline herein and believe is essential to permit equitable cancer care for the country.

Anti-heat shock protein 90β antibodies are detected in patients with multiple sclerosis during remission

Antibodies against heat shock protein 90beta (Hsp90beta) recognize the antigen on the surface of oligodendrocyte precursor cells and induce a decrease in the oligodendrocyte population of cell cultures. This study investigated the presence of anti-Hsp90beta antibodies in patients with multiple sclerosis (MS) during remission. Anti-Hsp90beta antibodies were detected in the cerebrospinal fluid (CSF) of patients with a specific and sensitive western blot procedure using Hsp90beta from cell membrane fraction. The number of patients with anti-Hsp90beta antibodies detected in the CSF was significantly greater in MS patients than in control patients with other neurological diseases, which included patients with other inflammatory neurological diseases. CSF anti-Hsp90beta antibody levels were significantly higher in MS patients than in control patients. The presence of anti-Hsp90beta antibodies in the CSF of MS patients during remission could suggest a potential pathogenic role for these autoantibodies in MS.

Detection of anti-heat shock protein 90 beta (Hsp90beta) antibodies in cerebrospinal fluid

Antibodies against heat shock protein 90 beta (Hsp90beta) recognize the antigen on the cell surface of the oligodendrocyte precursor cells and cause a decrease of oligodendrocyte population in cell cultures. These antibodies have been found in patients with multiple sclerosis (MS). This report describes an original and sensitive method to detect anti-Hsp90beta antibodies in cerebrospinal fluid (CSF) using a western blot procedure. We have developed the method for autoantibody detection using Hsp90beta from cell membrane fraction instead of commercial Hsp90beta as antigen. The presence of anti-Hsp90beta antibodies in CSF of MS patients may play a pathogenic role in MS, and a large-scale study is needed to establish a possible diagnostic value of these antibodies in MS patients.

Caspase inhibitors protect against neuronal apoptosis induced by cerebrospinal fluid from multiple sclerosis patients

Neuronal apoptosis has recently been implicated in multiple sclerosis (MS). Apoptotic cell death of neurons is induced in cultures exposed to cerebrospinal fluid (CSF) from MS patients. Since caspases are essential in the regulation of apoptosis, direct evidence was sought linking caspases to CSF-induced neuronal death. Caspase activity was measured in cell extracts from MS CSF-treated cultured neurons by the cleavage of caspase-1 and caspase-3 substrates. Caspase-3 activity, but not caspase-1, was induced in neuronal cultures in response to MS CSF treatment. This caspase-3 activity was inhibited in vitro by Ac-YVAD-cmk and Ac-DEVD-cmk caspase inhibitors. Treatment of MS CSF-incubated neuronal cells with these caspase inhibitors completely preserved neuronal survival and largely attenuated DNA fragmentation detected in situ. These findings show that neuronal cells are rescued from MS CSF-induced death by caspase inhibitors and suggest ways to treat MS.

Influence of water pressure on the final quality of arabica espresso coffee. Application of multivariate analysis

Water pressure is one of the most important factors which influence the final quality of espresso coffee (EC). However, few studies dealing with this issue have been found. The aim of this work was to study the effect of water pressure on the final quality of Arabica ECs as well as to classify ECs prepared at different pressures (7, 9, and 11 atm) according to their physicochemical and sensory characteristics, key odorants, by means of multivariate analysis. Statistically, principal component 1 (PC1) separated ECs prepared at 7 and 9 atm from ECs prepared at 11 atm and included the main foam and taste characteristics as well as some key odorants and flavor compounds. ECs prepared at 7 and 9 atm were separated by principal component 2 (PC2). Coffees prepared at 9 atm showed consistency of foam and a high percentage of key odorants related to freshness and fruity, malty, and buttery flavors. A simple discriminate function was obtained by discriminate analysis, allowing the classification of ECs prepared at three pressures into their respective groups with a success rate of 100%.

[The effect of cerebrospinal fluid on neurone culture: implications in the pathogenesis of multiple sclerosis]

In vitro studies have shown that the cerebrospinal fluid of patients with multiple sclerosis transports compounds which may affect the function or viability of central nervous system cell function. The presence of nerve ion channel blockers and other molecules, as yet unidentified, which may cause the death of nerve cells or oligodendrocytes has been shown, although their relevance and clinical correlation is still not clear. If their usefulness is proved, these methods may be useful in the search for inhibitors of the noxious effects of the substances mentioned.

Characterization of espresso coffee aroma by static headspace GC-MS and sensory flavor profile

The aromas of three espresso coffee (EC) samples from different botanical varieties and types of roast (Arabica coffee, Robusta natural blend, and Robusta Torrefacto blend (special roast by adding sugar)) were studied by static headspace GC-MS and sensory flavor profile analysis. Seventy-seven compounds were identified in all of the EC samples. Among them, 13 key odorants have been quantified and correlated with their flavor notes by applying multivariate statistical methods. Some correlations have been found in the EC samples: some aldehydes with fruity flavors, diones with buttery flavors, and pyrazines with earthy/musty, roasty/burnt, and woody/papery flavors. By applying principal component analysis (PCA), Arabica and Robusta samples were separated successfully by principal component 1 (60.7% of variance), and Torrefacto and Natural Robusta EC samples were separated by principal component 2 (28.1% of total variance). With PCA, the aroma characterization of each EC sample could be observed. A very simple discriminant function using some key odorants was obtained by discriminant analysis, allowing the classification of each EC sample into its respective group with a success rate of 100%.

Multivariate methods for characterization and classification of espresso coffees from different botanical varieties and types of roast by foam, taste, and mouthfeel

Three espresso coffee (EC) samples of different botanical varieties and types of roast were prepared in standard conditions using an experimental EC prototype: Arabica coffee, Robusta Natural blend, and Robusta Torrefacto blend (a special roast by adding sugar). The ECs were characterized with regard to the physical parameters, amount of total solids, total solids on filtrate, lipids, caffeine, trigonelline, and chlorogenic acids by HPLC, and sensory descriptive analysis related to foam appearance, taste, and mouthfeel. Principal component analysis (PCA) was applied to differentiate the EC samples. Arabica and Robusta samples were separated successfully by principal component 1 (55.3% of variance) including physicochemical and sensory parameters related to foam and taste of ECs. Torrefacto and Robusta Natural EC samples were separated by principal component 2 (20.7% of total variance) including mouthfeel and other attributes of color foam. Some interesting correlations among sensory and physicochemical variables were found. A very simple discriminate function was obtained by discriminate analysis allowing the classification of each EC sample into its respective group with a success rate of 100%.

Optimizing headspace temperature and time sampling for identification of volatile compounds in ground roasted Arabica coffee

Equilibration time and temperature were the factors studied to choose the best conditions for analyzing volatiles in roasted ground Arabica coffee by a static headspace sampling extraction method. Three temperatures of equilibration were studied: 60, 80, and 90 degrees C. A larger quantity of volatile compounds was extracted at 90 degrees C than at 80 or 60 degrees C, although the same qualitative profile was found for each. The extraction of the volatile compounds was studied at seven different equilibration times: 30, 45, 60, 80, 100, 120, and 150 min. The best time of equilibration for headspace analysis of roasted ground Arabica coffee should be selected depending on the chemical class or compound studied. One hundred and twenty-two volatile compounds were identified, including 26 furans, 20 ketones, 20 pyrazines, 9 alcohols, 9 aldehydes, 8 esters, 6 pyrroles, 6 thiophenes, 4 sulfur compounds, 3 benzenic compounds, 2 phenolic compounds, 2 pyridines, 2 thiazoles, 1 oxazole, 1 lactone, 1 alkane, 1 alkene, and 1 acid.

A homogeneous method to measure aminoacyl-tRNA synthetase aminoacylation activity using scintillation proximity assay technology

A new method to measure the aminoacylation of tRNA based upon the use of the scintillation proximity assay (SPA) technology has been developed. The assay detects incorporation of radiolabeled amino acids into cognate tRNA, catalyzed by a specific aminoacyl-tRNA synthetase (aaRS). Under acidic conditions, uncoated yttrium silicate SPA beads were found to bind tRNA aggregates, while the radiolabeled amino acid substrate remains in solution, resulting in good signal discrimination of these two species in the absence of any separation steps. The usefulness of this approach was demonstrated by measurement of steady-state kinetic constants and inhibitor binding constants for a range of aaRS enzymes in comparison with data from standard, trichloroacetic acid-precipitation-based assays. In all cases, the data were quantitatively comparable. Although the radioisotopic counting efficiency of the SPA method was less than that of standard liquid scintillation counting, the statistical performance (i.e., signal to background, variability, stability) of the SPA assays was at least equivalent to the separation-based methods. The assay was also shown to work well in miniaturized 384-well microtiter plate formats, resulting in considerable reagent savings. In summary, a new method to characterize aaRS activity is described that is faster and more amenable to high-throughput screening than traditional methods.

[Treatment of transformed refractory migraine with intravenous dihydroergotamine]

In this work we present our experience with a seven-day protocol of i.v. dihydroergotamine (DHE) in the treatment of 6 patients (7 treatments) suffering from intractable transformed migraine. All of them were admitted to hospital and treated for one week with a protocol which included DHE doses between 0.5-1 mg/8 h. One patient did not respond. The remaining 6 became free of pain in under 48 hours after the beginning of treatment. This positive effect remained for between 15 days and 3 months. All patients experienced adverse events; however, these were slight and ceased when the DHE dose was reduced. DHE is an effective and quick option for the short-term treatment of patients with severe transformed migraine resistant to other medications.

Design of a modified uniform redundant-array mask for portable gamma cameras

Uniform redundant-array masks have been reported as good lenses to form the image of gamma sources, with the correlation between the mask-aperture matrix and the shadows projected on a static position-sensitive detector. We present a modified uniform redundant-array configuration suitable for portable and small-size gamma cameras; its ability to reconstruct the image of several sources is analyzed. We have carried out a Montecarlo simulation of the gamma interactions in the mask, defining the expected response of the correlation process and comparing it with that achieved with the usual uniform redundant-array configurations.

Anaphylactic reaction after atropine

A 38-year-old woman developed symptoms of anaphylactic shock after intravenous atropine and required adrenaline to maintain perfusion pressure. A strongly positive response was obtained on intradermal testing. The Prausnitz-Kuestner test was also positive, which indicated the presence of drug specific IgE antibodies. No response was obtained after hyoscine.

Direct communication between the right pulmonary artery and the left atrium

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