Biopharma should choose targets using a baseball-style draft

All opinions my own and do not necessarily reflect those of Novo Nordisk

I was sitting around last evening checking out how the end of my fantasy baseball season is working out (for the record, first out of ten in one league and fourth in the league I wrote about here) and I starting thinking again about the parallels between baseball and drug development (which I previously wrote about here and here for example, and also Stewart Lyman has a nice piece on a similar theme here). And it hit me that there’s another way in which biopharma could take a  page from baseball: fantasy and Major League Baseball both.

Biopharma could institute a draft for drug targets.  And to explore this I’m going to employ the time-honored, not to mention trite and artificial, format of a series of questions and answers.

Continue reading

Premature testification is not a laughing matter

All opinions are my own and do not necessarily reflect those of Novo Nordisk.

“These studies, once validated, open an opportunity for creating tests that an expectant mother can take to see if she is producing these autoantibodies. ”

I wrote this statement back in July as part of a post describing the report that maternal autoantibodies to specific neural proteins correlated with the appearance of autism symptoms in the children of those mothers.  Little did I suspect that plans to create a test were already in the works.  Science recently reported (paywall) that researchers behind this study are teaming up with a testing company to develop and market a diagnostic test for maternal autoantibodies.

On the one hand I am much in favor of prognostic tests that will help us anticipate health problems.  I believe in many cases early knowledge and interventions can be helpful, even when there is no “cure.”  One of the hopes for the wave of genomic biomedical research going on now is that it will allow us to better estimate who will and will not come down with specific diseases based on clues in individuals’ DNA.  But on the other hand, it can be problematic when tests are created and released before the underlying biomedical hypothesis has been strongly vetted and supported. Continue reading

Transparency and the invisible hand in hospital and healthcare costs

All opinions are my own and do not necessarily reflect those of Novo Nordisk

One of the things that sometimes seems to get lost when people talk about the power of the market to create efficiency is that a free market requires that information be shared and freely available and understandable by everyone.  When information is withheld by one side or the other of a transaction, or when different customers for a service or product are unable to compare prices, the metaphor of the invisible hand breaks down.

You can see, this, interestingly enough, in sports as it relates to both the trading of players under contract and the signing of free agents.  Since I’m a baseball fan, let me link here to a discussion of research that’s been done looking at Major League Baseball.  The studies looked at players traded or signed by a different team as a free agent and how those players performed in subsequent years versus players whose original team re-signed them.  It turns out that players who switched teams did, indeed, perform more poorly relative to projections than players who stayed.  This suggests that the original teams have proprietary information that allows them to make better decisions about which players to retain.  Thus the market for baseball players isn’t quite free and efficient because of information asymmetry.

And unfortunately, information asymmetry is also rampant in other industries such as healthcare. Continue reading

Fear versus fear: understanding vaccination rates

All opinions are my own and do not necessarily reflect those of Novo Nordisk.

h/t to @edyong209 for the heads up on the study.

If it seems like plagues from bygone years are coming back, well, you’re right!  Due to growing objections within the United States to vaccination efforts, we are seeing a number of infectious diseases arising that even ten years ago we might have said were eradicated in the US.   The problem may seem larger than it is simply because we get so much more news so much more quickly and easily than we used to.  However, so far there have been 159 cases of measles, which is the highest yearly count since the mid-90s.  And there are still 3.5 months to go in 2013.  Texas has been in the news quite a bit recently for clusters of measles and whooping cough–both diseases with good vaccines that prevent infection when used correctly.

There are a number of reasons why parents choose not to vaccinate their children and one of these seems to be a lack of familiarity with these preventable diseases.  Once almost everyone got the measles and kids got really sick; some died.  Now, the idea of infectious diseases might seem quaint, distant and nonthreatening to parents with no frame of reference.  And of course, once a child gets a disease it’s too late.  A particularly scary report suggests even some younger doctors feel that infectious diseases aren’t such a big deal.

So you might think that this recent study, and others like it showing that the Human Papilloma Virus (HPV) vaccine is clearly reducing HPV infections throughout the body should be promoted even more strongly by public health officials.  Why?  Because HPV is known to cause cancer.  And if there’s anything that evokes the immediacy of fear in the area of health issues, it’s cancer.  That may not be the correct path however, and I’ll get to that in a minute, but first I just want to talk about the research.

The research study was a double-blinded clinical trial in which  7,466 women were inoculated at random with either an HPV vaccine or a control vaccine to hepatitis A.  At the end of the trial, the women were checked for evidence of oral HPV infections.  The vaccine had an estimated vaccine efficacy of about 93%, meaning it reduced infection rates about 14-15 fold.  This study is the first to demonstrate that HPV vaccinations can prevent oral HPV infections in addition to those at the cervix and other locations, as has been shown previously in other research.

That HPV infection is linked causally to the development of some cancers has been shown repeatedly.  Oral HPV infections contribute to the majority of oropharyngeal cancers. When these vaccines were developed, this was the basic argument:  that giving this vaccine to women would result in a decrease in HPV infections and subsequently a decrease in various cancers.  However, as has happened with many vaccines such as the Measles-Mumps-Rubella (MMR) shot, the scientific rationale became overshadowed by a number of other, unanticipated societal factors.

With the HPV vaccine, as Beth Skwarecki (@BethSkw) astutely pointed out on PLOS Blogs, maybe the key issue that wasn’t given enough attention in planning the vaccine rollout is that they way you get HPV is by having sex, and the age at which you should ideally give a person a vaccine is when they are 11 to 12 years old.  Or, to think about it another way, just when girls are starting to begin the maturation process into young women and parents have to face the reality that there is a good chance their child will be having sex sometime in the next 5-10 years.

And that’s scary.  Scarier than the possibility that your child might get cancer 20, 30 years down the road because he or she did not get vaccinated for HPV.  Beth also helpfully links to writing by David Ropeik about how fear can trump common sense with respect to things like, for example, vaccines.

It’s already known that people are lousy about understanding probability, and when you add an element of fear to this misunderstanding, one can see how vaccination campaigns even for something as straightforward as HPV face an uphill battle.

I mean, cancer!  If you can’t get people behind a preventative measure for cancer, what can you do?

And that is the question.  It’s not enough to just say that vaccinations should be mandated.  Sure government could do that, but the consequences could be quite large in terms of anger and pushback.  Would it have helped if in the beginning Merck had not pressed so strongly for every girl to be vaccinated?  Maybe, as some analyses after the fact suggest Merck involvement increased suspicion that all this was just some Pharma boondoggle.  That’s a post-hoc justification though, which I tend to distrust.

Ultimately it seems the answer will have to come from some combination of using subtler methods for incentivizing parents and better understanding of what people are afraid of.  Because right now it seems like even the fear of cancer isn’t enough.

Priming the pump: Biopharma contributions and prescribing patterns

All opinions are my own and do not necessarily reflect those of Novo Nordisk.

How in control are we of the decisions we make every day?  How sure are we of our judgement, how we feel, what we believe?  I think many people would say they feel very in control and very certain.  I suspect many people are wrong.  Studies in behavioral psychology have begun identifying the effect of priming–how a subtle stimulus can affect how people, behave or think.  The field of priming is not without ongoing controversy, but at the same time the effect of priming has been seen in many studies (like this one) and appears to be a real phenomenon, albeit one that is still very challenging to clearly describe, test and validate.

Its in this context that a recent report describing physician prescribing patterns is particularly interesting.  And disturbing.  The study by Joseph Engelberg, Christopher Parsons and Nathan Tefft looked at the effect of Biopharma payments to what drugs doctors prescribe.  To quote from their introduction for some context:  “While such rent-seeking behavior [such as pushing more expensive merchandise by salespeople] might not surprise many people…that financial conflicts of interest could influence their doctor’s advice might be both less expected and more worrisome…intrinsic motivation is thought to be important in medicine, with the goal of optimizing patient health being a paramount objective.”  The null hypothesis would be that prescribing patterns would be related solely to health condition, general information about drug efficacy, and price to the patient.  That’s not what was found. Continue reading