June2007

Drowning in email? Here are some life belts

Jun 22, 2007
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By David Woods (david.woods@rxcomms.com)

76If you feel that emails are inundating you, and you yearn for the days of the quill pen, help is at hand. In her recent book “Life hacker: 88 tech tips to turbocharge your day,” Gina Trapani somewhat paradoxically advises us to use a paper day planner instead of computerised schedules. Her rationale: it can be a great change of pace to wield a pen instead of a mouse. Another of her tips is tougher: “empty your email and keep it empty.”
Mike Song, author of “Hamster revolution: how to manage your email before it manages you,” says: “Certain high-volume users can’t quite help the amount of email they get, but diverting email by creating folders that route lower priority emails to pre-designated folders will help minimise distractions.” For example, he says, “If I don’t want to be interrupted by emails from some organisation that I belong to, I can set it to where those emails will automatically re-route into a folder I’ve designated for that.”

Song believes that most of us receive much more email that we can actually process, and this is fed by mass emails sent to hundreds, or often thousands, of people at once. While one solution to the email deluge is to stop sending so many yourself; another is to make phone calls instead of a quick note. But even phoning can be an endless circuit of voicemails and missed messages, so agree on a mutually agreed-upon time for your call.

Busy computer consultant Jonathan Coopersmith agrees. “My key to managing emails is to set aside a time of day for them. In other words, I schedule them as I would a meeting or a conference call.” He gives an example: “I’ll check my email only at a few predetermined times each day… and then spend 30 minutes sorting, managing, and sending a few quick responses to get them out of the way. For the messages that need more attention, I look at that like scheduling meetings, returning phone calls, or writing letters – some I delegate; others I need to schedule for a later time.”

As Mike Musgrove reports in the Washington Post: “The supposed convenience of electronic mail, like so many other innovations of technology, has become too much for some people. Swamped by an unmanageable number of messages – the volume of email traffic has nearly doubled in the past two years to around six trillion business emails sent in 2006, according to the research firm DYS Analytics – and plagued by annoying spam and viruses, some users are crying ‘Enough.’”

Musgrove says that email overload gives many people the sense that their work is never done, so some people are moving back to the telephone. He quotes Stanford University technology professor Lawrence Lessig as saying that he declared “email bankruptcy” a few years ago after being deluged by thousands of e-messages, noting that “I eventually got to be so far behind that I was either going to spend all my time answering emails or I was going to do my job.” Thereafter, his correspondents received an email saying “Dear person who sent me a yet-unanswered email; I apologise, but I am declaring email bankruptcy.”
One often hears the question: “How did we all manage before emails, cell phones, PDAs, Blackberrys, and laptops?” The answer: we managed to swim along quite nicely, thank you. And with relatively little risk of drowning. But we’re in choppier waters today… and anything we can do to keep afloat is welcome.

ASHE revisited

By Amy Rothman Schonfeld (amy.schonfeld@rxcomms.com)

One year after its first conference, the American Society of Health Economists (ASHE) is clearly thriving. Its membership has grown to more than 800, planning for the next two biennial conferences has begun, an awards competition is in place, and many of the most prominent names in US health economics research have assumed leadership roles.

“There’s been tremendous evidence of a pent-up demand for this kind of association and meeting,” says Richard Arnould, PhD. of the University of Illinois Urbana-Champaign, executive director of ASHE.

More than 500 attendees came to the first ASHE conference held last June in Madison, Wisconsin, USA. The conference offered 330 papers in 107 sessions and 90 posters. Joseph Newhouse and David Cutler of Harvard and B. Douglas Bernheim of Stanford gave keynote presentations. “More than 80% of respondents rated the papers high or very high in quality,” said Arnould. “I believe it is safe to say the inaugural conference was a smashing success.”

The newly instituted ASHE awards generated much excitement. Two awards went to outstanding health economists under age 40 – David Cutler and Jonathan Gruber – and one award went to a doctoral student, Grant Miller.
“One benefit of ASHE compared to an international organisation is that at an international meeting, it would be almost impossible to give an award to a graduate student because doctoral programs differ so much in structure and content around the world,” says Arnould.

Founders of ASHE believe that the association brings other benefits to the health economics community that IHEA does not. In an interview published in the first issue of the Newsletter of the American Society of Health Economists, ASHE president Jody Sindelar, PhD of Yale University writes: “ASHE provides an opportunity to bring together a community of scholars who share an in-depth interest in a similar set of topics. I think you get a better sense of affinity and community with people who share a common set of issues and facts. Some of these issues that are so important to people in the United States are not of interest to people in the international community. IHEA is not interested in some of these topics because they are not as broadly appealing to people in other countries. Health economists from other countries don’t feel a need to learn all about Medicaid or SCHPs, HMOs, PSOs, and other institutions and policies that are specific to the United States.”

ASHE members, however, remain active participants of IHEA. At present, ASHE is under the IHEA umbrella, but by 2010 it will become an independent organisation. Biennial conferences are arranged so that they will not conflict with ASHE conferences scheduled for even-numbered years while IHEA conferences will take place on odd-numbered years. The second biennial ASHE conference will take place June 22–25, 2008 at Duke University. The call for papers will be issued soon after the IHEA meeting in Copenhagen.

Dr. Sindelar outlines some of the future plans for ASHE: “One of the things I’m working on is an ASHE web page. A really informative web page will be of great benefit to ASHE members and students. If someone is going to teach a new course in health economics or healthcare finance, or a newly-minted PhD student wants some help getting started, they can have access to syllabi, some problem sets, and other teaching materials. There can also be links to other material available on the web. The newsletter is also important because in addition to being informative, it will give a sense of community and purpose in the profession.” For more information visit the ASHE website.

ISPOR’s 12th annual international meeting

Jun 22, 2007
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By David Woods (david.woods@rxcomms.com)

75The theme of this year’s international ISPOR meeting – held on May 20–23 in Arlington, Virginia, USA – was “new tools, new audiences for health outcomes research.”

In his valedictory address, retiring ISPOR president Dr Michael Drummond told some of the 1600 registrants to the meeting that the organisation now has more than 3300 members in 80 countries. Forty nine percent of those come from the US and 35% from Europe, while industry accounts for 38% of the membership, he said, with healthcare research and academia each accounting for 28%.

This year’s meeting attracted 64 podium presentations and 524 posters. The organisation’s forward planning strategy – Impetus 2010 – includes research excellence, promoting education, reaching out to decision-makers, and international growth.

In a plenary session titled ‘How should the media convey information about new medical technologies?’ a former JAMA editor Drummond Rennie said that “while the drug industry does exceedingly good trials,” the press is often shrill in its Pharma bashing. Peter Littlejohns of NICE agreed, saying that the press too often sensationalises healthcare issues, takes a personalised angle, quotes from so-called experts, and often presents a negative slant.

Ex-national public radio journalist Snigda Prakash said that in the Vioxx case Merck had hidden adverse cardiovascular data, and, she said, an editor of the New England Journal of Medicine said he’d been ‘hoodwinked’ in connection with the journal’s Vioxx article. A pharmaceutical industry questioner from the floor noted that the media seldom report the great advantages of drugs and the good work done by the pharmaceutical industry. Ms. Prakash said the line between advertising and editorial has become blurred. And Dr. Rennie added that better ways need to be found to educate the public about adverse effects of drugs – a move that would also be helpful to the industry.

In a session on the economics of personalised medicine, a panellist defined this as “doctors customising medical care to a person’s genetic code for better diagnosis, more effective treatment and fewer side effects.” Another panellist spoke of raising the bar – the impact of heightened awareness of the need for health economics data in the absence of regulatory mandates. The managed-care revolution in the US created a demand for evidence-based formulary placement and the need to establish the value of a new medicine, said another. Applying evidence-based criteria to high technology, he said, if the answer is No to the questions of clinical effectiveness, safety, and improved value then the drug or the technology should not be adopted; if the answer is yes, and there is no comparable product, it should be adopted.

In a session on the relevance of cost-effectiveness information for clinicians, Dr. Alan Detsky said there’s a need to teach clinicians how to make decisions based upon rational thinking. Cost-effectiveness analysis is a linear programming technique developed to maximise good health outcomes, he said. Cost consequence analysis, he added, is the cost of the prescription, the cost of effects and the cost of side effects. Those doing such analyses may be biased, he said, and concluded “two economists debating is like watching the passive aggressive Olympics.”

In her inaugural address as ISPOR president, Diana L. Brixner, R.Ph, PhD, executive director of the University of Utah’s Pharmacotherapy Outcomes Research Center, said ISPOR “should glance back, reach outward, and press forward.” She noted the enormous growth, particularly internationally, of the organisation. Founding ISPOR Executive Director Marilyn Dix Smith, Ph.D., said the organisation’s revenue is more than $3 million with a net surplus of $700,000. She said she welcomes ideas for worthwhile projects for the organisation.

ISPOR’s flagship publication Value in Health attracted some 271 submissions in the past year, said its editor Dr Josephine Mauskopf… and the organisation’s website attracts some 1.5 million hits a month.

Next year’s international conference will be held in Toronto.

Observational studies: answering real-life questions about healthcare practice

Jun 17, 2007
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By Ruth Whittington (ruth.whittington@rxcomms.com)

Part 2 – How do observational studies and randomised controlled trials differ?

Last month, I described observational studies and where they fit into the hierarchy of evidence. Randomised controlled trials (RCTs) provide some of the fundamental answers to important questions about a drug’s efficacy and safety, and so are considered top of the hierarchy of medical evidence.

It is easy to be persuaded into thinking (as some of our customers and colleagues do) that RCTs are the be-all and end-all of the evidence needed for a drug. However, looking at one treatment in isolation will not reflect the likely situation in real life clinical practice.

The first major difference between observational studies and RCTs is in how patients are enrolled. For an observational study the question of whether the patient is suitable for enrolment occurs after treatment has been decided, whereas for an RCT it occurs before treatment has been assigned.

Steps in patient recruitment

Randomised controlled trials Observational studies
Step 1: Patient visits doctor Step 1: Patient visits doctor
Step 2: Suitable for trial? Step 2: Doctor assigns treatment
Step 3: Doctor enrols patient in trial Step 3: Suitable for study?
Step 4: Treatment assigned randomly Step 4: Patient enrolled

Once patients have been enrolled in the study, there are a number of ways to differentiate between randomised controlled trials and prospective observational studies. Compare and contrast these in the following table:

Differences between the conduction of a randomised controlled trial and the observational study:

Randomised controlled trials Observational studies
Control groups may include patients on placebo. All study patients are given the treatment that is thought best for them.
The trial design seeks to eliminate bias by keeping the physician and patient out of the treatment
selection process.
The physician selects the treatment physician with the patient’s knowledge and any bias in treatment assignment may be of interest in itself.
Patients who stop taking the treatment are removed from the trial. Patients who stop taking the treatment are asked why and offered alternatives.
Strict criteria applied for recruiting patients, such as age, gender, pre-existing conditions, medical history, etc. The only criteria are that the patient meets the disease definition and receives one of the treatments of interest at the outset of the study.
The population is intentionally homogenous in order to maximise the chance of detecting a possible effect of treatment. The population is more likely to be representative of patients receiving treatment in ordinary clinical practice.
Care protocol may be strict and other drug use is usually limited, to reduce confounding factors and possible drug interactions. Only normal levels of testing and limited interventions are allowed, so cost and resource use will reflect normal practice.
Care is usually provided by specialist clinics and may involve frequent physician visits, resulting in the highest standards of care; extensive patient testing and interventions may be involved. Care is provided by those physicians who would normally treat the patients, resulting in typical standards of care.
Objective clinical end points are measured Outcomes of most relevance to patients and those treating or caring for them are measured.
The trial can demonstrate treatment efficacy. The study can demonstrate overall effectiveness.
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