Who needs to know? Balancing quality and privacy in health care

Today’s post comes to us from Professor Niek Klazinga, Professor of Social Medicine  at the Academic Medical Center of the University of Amsterdam and contributor to the Health Care Quality Indicator Project, OECD Health Division

... but sharing data can save them

Quality has become a buzzword in health care, as in so many other sectors. Industrialized countries are shifting gradually from governance based on cost-control towards models that also take the quality of the health outcome and process into account.  

This makes sense for many reasons. Judging the “success” of health interventions – whether or not they meet certain quality objectives – is important to any decision on how health care dollars should be spent.  A whole new information industry has sprung up  to produce performance information for governments, patients, health care financers, managers and professionals alike, by measuring different aspects of quality.

Data about quality is needed if we are to improve systems, but collecting it can be controversial since it means keeping track of some aspects of health delivery that we used to consider “private”. The debate around the need to collect data versus the need to protect privacy is only starting.

For good comparisons on surgical complications, for example, we need to know whether the complaint existed at admission  (admission codes indicate this), whether the patient had diabetes or asthma (secondary diagnoses) or whether the patient has also been to another hospital or primary care physician with the same complaint (data linkage via unique patient identifiers).

Gathering this kind of information to improve quality in health care seems justifiable and not  the type of privacy invasion that data protection rules were originally designed for.  Yet the critical attitude towards government and overall concern about privacy currently limit the production of reliable and comparable information on quality and safety.

It is hoped that during the upcoming OECD ministerial conference, countries where these debates are farther along can be inspire those still in the middle of it seeking a balance between the quest for better comparative information and privacy concerns.

Useful links

The OECD Health Care Quality Indicator Project was launched in 2002 to produce reliable, valid and comparable information on the quality of health care in member states.

Results were published in Health at a Glance in 2007 and 2009, covering cancer care, care delivered for cardiovascular diseases, primary care, mental health care and care related to infectious diseases among others.

A working paper on patient safety indicators was published in November 2009.

This won’t hurt a bit…

And remember to clean your teeth with sugar

This week the Insights blog will be focusing on health care issues. In this second post, we introduce evidence-based care.

My grandmother believed that tar fumes stopped kids catching colds, so if she saw road menders at work, she’d march me, my sisters and brothers and our friends over to breathe in the vapours.

We’d then have to huddle around a steaming dollop of bitumen, arms flapping to help the lungs pump the goodness into our ventricles, like a flock of baby seagulls stuck in an oil slick.

A woman who thought that pigs could see the wind probably wasn’t the best source of advice on health (or anything else), and a carcinogenic mixture of 10,000 chemicals, half of them unidentified, probably not the best prophylactic around, but the wisdom of the ancients is not the only knowledge that seems bonkers in retrospect. Mainstream medicine has had its share of dubious treatments too.

Not just dubious. The aptly named To Err is Human report from the US Institute of Medicine in 2000 estimated that medical errors killed more people than traffic accidents in the US.

Of course, with millions going to see the doctor every day, even a tiny fraction of mistakes soon adds up to a startling sum, but the problem isn’t just a slip of the scalpel or an illegible prescription. Another report estimated that up to a third of treatments had no real clinical effectiveness.

To the layperson, this is astonishing. How on Earth were the doctors deciding on treatments? Rolling dice? In fact, they were applying what they’d learned at medical school and best practice as it evolved. (more…)

Health care rationing? NOT NICE

Photo courtesy of Jacques Bron

This week the Insights blog will be focusing on health care issues.

Today’s post comes from guest author Jonathan Wolff, Professor of philosophy and director of the Centre for Philosophy, Justice and Health, University College London.

It is amazing how a single word can distort a debate. Take the word ‘rationing’. What does that mean to you? To me, it conjures up a world of little cardboard booklets, which record whether or not you have been allocated your personal portion of eggs, butter, or flour. A world in which it makes sense to ask whether or not someone has had his or her ration.

In the US debate on health care reform, conservatives warned US citizens that, aside from the horrors of state control, universal health-care would inevitably lead to UK style health rationing. The debate about rationing largely focused on the question of whether it is a lesser evil than a system which, despite pouring much more money into health care per person than any other in the world, still left perhaps as many as 50 million people without health insurance.

I was completely bemused by this debate, and couldn’t understand why ‘progressives’ were prepared to let it be structured this way. For consider. Do we have rationing in the UK or elsewhere in Europe? Where do you keep your ration card? Has your NHS doctor ever refused to see you because you had used up your allocation of appointments? Has a hospital told you that you had already spent your share of nights on the ward?

What we have in England and Wales is the National Institute of Health and Clinical Excellence (NICE) with the job of deciding whether or not a new treatment or intervention is cost-effective. Sometimes, to the fury of patient groups and pharmaceutical companies, it decides that a drug is not worth the price asked for it, and recommends that it is not ‘refunded’ by the National Health Service.

Now, this is bound to cause dispute, and makes excellent news stories. It is easy to find someone who believes that their condition would be massively improved if an excluded drug was made available, and that NICE heartlessly puts a price on life. And indeed, we can argue that NICE may have erred in particular cases, or, more generally goes about its decision-making the wrong way. But it is hard to argue that considerations of cost are never relevant. If a drug cost ten thousand pounds and extended a life by an hour, it would be a difficult to argue that it should be made available at public expense. Sometimes we must put ‘a price on life’, somehow or other. (more…)

Climate Change Ethics: where to start?

This post contributed by John Mutter, Professor of Earth and Environmental Sciences/Professor of International and Public Affairs and Director of PhD in Sustainable Development, Columbia University, NY.


Ethics is the subject of Moral Philosophy.  It concerns itself with what is good and bad, what is right and wrong, what is just and unjust, and what is virtuous.

Climate change per se cannot have an ethical position; only people can do things that are just and unjust, right or wrong.  Climate can’t do right or wrong any more than an earthquake can, even though it might cause enormous death and destruction, or an asteroid hurtling toward us about to wipe out all life as we know it can be said to be doing wrong.   It’s not the climate’s fault.  If there is a wrong being done here, we are doing it.

That being the case it is very tempting to find the wrong doers and chastise them — to name and shame (in the language of human rights advocates) hoping that those named will feel such remorse that they will start to act differently.  There is plenty of that going on; most of which I believe is a huge waste of energy.  None of the wrong doers seem to be listening — why would they, they haven’t listened to any arguments based on the best science or economics; why would they listen to an argument based on ethics.  Perhaps the greatest benefit to identifying the wrong doer is that we, by implication, identify ourselves as being the right-doers and establish a virtuous high ground from which to look down upon others.  Scientists (and I am one of them) tend to indulge in this a lot.  I don’t think this is going to get us anywhere and it is a morally dangerous place to stand.  It may have lead scientists at East Anglia to feel that had the right to suppress data and interfere with the publication of dissenting views – clearly they thought they had right on their side and were justified.  But what they did, in my view was unethical.  And it’s foolish.  Surely the very best way to show that someone doesn’t know what they’re talking about is to let them talk. (more…)

IMF adds to debt warnings

Rising national debt is fast emerging as perhaps the most worrying hangover from the recession. The latest warning comes from the IMF, which says sovereign debt risks triggering a new round of economic woes.

“If the legacy of the present crisis and emerging sovereign risks are not addressed, we run the real risk of undermining the recovery and extending the financial crisis to a new phase,”  said Jose Vinals, director of the IMF’s monetary and capital markets department.

As noted previously on the blog, sovereign debts rose substantially during the crisis as government spent heavily to keep economies afloat. In the OECD area, government debt looks set to equal about 100% of GDP in 2011, up from about 70% before the crisis. That debt, along with government purchases of banks’ bad assets, means that in advanced economies “the biggest threats [to financial stability] have moved from the private to the public sectors”, says the IMF.

There is some good news in the Fund’s latest Global Financial Stability Report: Although banks and financial institutions remain in a “fragile” state, they are – says the IMF – “slowly regaining their health”.

Useful links

OECD Insights: From Crisis to Recovery

OECD work on the crisis

OECD work on economics

GE crops: good for farmers, good for the planet?

What was the 18th century French historian Pierre Jean-Baptiste Legrand d’Aussy talking about when he said : “The pasty taste, the natural insipidity, the unhealthy quality, which is flatulent and indigestible, has caused it to be rejected from refined households and returned to the people, whose coarse palates and stronger stomachs are satisfied with anything capable of appeasing hunger.”

Well done if you recognised the potato, newly introduced into France at the time.

Comments like Legrand d’Aussy’s raise a smile today, but in fact we’re far more conservative about food now than in previous generations (when was the last time you knowingly ate a crow?). For example, over the years, most of the 7000 or so edible plants farmers have cultivated have been marginalised, and a few major crops and animals assure most food supplies.

The big difference is in the variety of ways ingredients are processed by the food industry, and, more recently, in new ways of producing food.

The most controversial of these is genetic engineering, GE. Supporters see it as continuing a long line of technical innovations that have boosted agricultural productivity and contributed to improved food security. Opponents argue that we don’t know enough about the consequences of GE crops and it’s foolish to push ahead, especially when so many other solutions to food security are underused. 

The National Research Council of the National Academies has just published a report on the economic and environmental impacts of GE crops looking at the impacts of GE in the US. (In other OECD countries, notably in Europe, consumer hostility means that GE crops are less widespread than in the US.)

According to the NRC, there are significant environmental benefits.

Insecticide use has declined since GE crops were introduced, and farmers who grow GE crops use fewer insecticides and herbicides that linger in soil and waterways. In addition, farmers who grow herbicide-resistant crops till less often to control weeds and are more likely to practice conservation tillage, which improves soil quality and water filtration and reduces erosion.

There are economic benefits too. In many cases, farmers who have adopted GE crops have either lower production costs or higher yields, or sometimes both, due to more cost-effective weed and insect control and fewer losses from insect damage.

It sounds great, but the report also issues a number of warnings.

Gains aren’t guaranteed. For instance, insect or weed resistance could render genetically engineered crops ineffective and force farmers to resume using more toxic chemicals. The NRC says that more needs to be done to slow the evolution of resistant weeds, such as spraying more than one kind of chemical.

Although farmers have gained economic benefits, more research is needed on the extent to which these advantages will change as pests adapt to GE crops, other countries adopt genetic engineering technology, and more GE traits are incorporated into existing and new crops.

Industry mergers and the dominance of a few players might stifle competition, an issue the Department of Justice is examining.

What do you think?

Useful links

OECD report on Biotechnologies in agriculture and natural resources to 2015

OECD Agriculture homepage

FAO on biotechnology in food and agriculture

20 questions about GM food answered by WHO

Greenpeace says no to genetic engineering

ISAAA says share the benefits of crop biotechnology

Avaaz would like more research, and a ban until it’s done

Bank boom bust in Iceland

Government and regulators in Iceland allowed the country’s banks to grow too big, too fast, paving the way for a financial meltdown, according to an official inquiry.

The Special Investigation Commission  released its report earlier this week. In more than 2,000 pages it paints a picture of reckless expansion in Iceland’s  financial sector. It states that Iceland’s three main banks grew 20-fold in just seven years, a pace that “was not compatible with long-term interests of a strong bank”.

The report heavily criticises regulators and government, accusing them of “extreme negligence”, reports the Financial Times , while regulators were “in general understaffed and lacked experience”, adds the BBC .

But it also contains more than a suggestion of wrongdoing in the banks themselves: “According to all the loan-books from the banks, all the former owners of the three banks had inappropriate loans from the banks,” Sigridur Benediktsdottir, a member of the commission, told the FT.

Iceland wasn’t the only country whose financial sector ran into trouble. Many have wondered if the banks were “unlucky” – could they have avoided collapse if the financial crisis hadn’t hit? The report says no. In a “post mortem” annex , Mark Flannery of the University of Florida comments that the “sub-prime financial crisis surely added pressure on the banks … However, the banks had ignored repeated warnings that their size and rapid expansion exposed them to great risks. It seems likely that they would have come to grief eventually, even without a worldwide financial crisis.”

Useful links

Iceland  at the OECD

OECD Economic Survey of Iceland

Iceland notes from the OECD Economic Outlook (2009)

OECD Insights: From Crisis to Recovery