Thursday, December 14, 2023

Opining on the "Top."

In the past few days there have been multiple posts in my LinkedIn time line by health care systems celebrating their inclusion in the "Gartner Healthcare Supply Chain Top 25 for 2023."

About five months previously Gartner had a post related to their changing their measurement methodology for this recognition by adding an ESG (environmental, social, and governance) component. At the time I took a quick look at their methodology, and was surprised to find that it did not seem to include any supply chain related KPIs. I commented on the entry, but it did not receive any response at that time and I forgot all about it.

Seeing all the recent entries on this topic reminded me of this, so I went back to view the methodology that was used to come up with the "Top 25" list:

The various components included:
  • Alignment to Quality of Patient Care (20%): This is listed as being based on IBM Watson Health Top 15 Health Systems Study. Further search on Merative (Watson Health had been divested by IBM in 2022 and spun-off to a private equity firm, Francisco Partners, that renamed the company Merative) indicated that the measures used here included: risk-adjusted inpatient mortality, risk-adjusted complications, healthcare associated infections, 30-day mortality, 30-day readmissions, severity-adjusted length of stay, Medicare spending per beneficiary, adjusted inpatient expense per discharge, and overall HCAHPS patient rating.
  • Financial Performance (15%): Here they used S&P bond rating as a proxy.
  • Alignment to Environmental, Social, and Governance (5%): This was measured by the organization belonging to the Healthcare Anchor Network ("a growing nation collaboration of 70+ leading healthcare systems building more inclusive and sustainable local economies"), providing supplier diversity data to the HAN, and signing the HAN Purchasing Impact Commitment. A set of laudable goals no doubt, but not really any measurable results to demonstrate leadership in any ESG areas of focus!
  • Community Opinion (60%): 30% each from a 'Gartner analyst panel' and a 'Peer panel.'

Now while supply chain will have some impact on most of the actual measures used that are listed above and account for 35% of the ranking ratings, these are rather indirect measures of supply chain effectiveness, efficiency, and impact to the organization. Using this logic these measures could as well be used to rank the healthcare systems by their revenue cycle, by clinical staffing, or by a whole host of other inputs!

Additionally, odd for a supply chain ranking, no supply chain-specific measures or KPIs are included. For example none of the twenty-nine 'Health Care Supply Chain Metrics and KPI's' listed by AHRMM are used.

What is left? 60% Opinion. Even if this opinion is all qualified as "expert" (which would seem to be a stretch), it it still opinion! And this is not the strongest foundation to build on; for example it would seem to me to have an inherent bias in favor of much larger systems!

OK, so there are numerous ratings systems in health care, for example the U.S. New and World Report annual ranking, the Leapfrog Group ranking, etc., etc. And, almost always, their methodologies usually start off on the rudimentary side before being 'beefed up' and further developed. Not the case here as this is Gartner's 15th annual listing!

So, who is hurt by this ranking? No one really, so it's not like this is the end of the world. And, truth be told, the organizations listed are all great organizations and they may well be doing amazing things in their supply chains! However, Gartner may be overlooking other (perhaps smaller) supply network exemplars that may be doing great work and should be lauded and emulated. And this ranking provides no benchmarks that others can use to improve themselves, unless of course they sign up as Gartner clients!

P.S. I hope I'm not being petty by pointing out that Gartner actually believes strongly in metrics and KPIs itself, apparently just not in this specific case.

P.P.S. Also odd given the inputs, the Composite Score runs to two decimals!

Tuesday, December 12, 2023

Biological Age Testing II

One's chronological age is how long one has been alive, while one's biological age is the age of your cells and systems based on physiological information. The two ages may be the same or they may also differ, sometimes significantly.  Your biological age is effected by your genetics and by environmental factors such as stress, exercise, diet, sleep, and other factors. Biological age is a better predictor of  possible disease and death than chronological age. 

Biological age determination is now readily available, so I decided to give it a try when I first read about it almost four year ago.  Here are some good introductory articles on biological testing, focused on Elysium Health's process:

Aging clocks aim to predict how long you'll live

I found out my biological age - and was annoyed by the result

A test told me my brain and liver are older than they should be. Should I be worried?

Elysium Health's Index ($299): (link)

When you place an order online they send you a kit that you can use to return a saliva sample. Elysium then extracts your DNA and analyzes DNA methylation across your genome to calculate your overall biological age. They now also determine the biological age of various systems in the body (brain, liver, metabolic, immune, hormone, kidney, heart, inflammation, and blood), and also provide science-based lifestyle recommendations. 

I first did Elysium's Index Jan 2020, followed by repeating testing in July 2022 and September 2023. As you can see the results were internally consistent over the years, with my biological age running at approximately 90% of my chronological age. Initially Elysium only provided the overall biological age; however, they subsequently refined their process and began to also provide the biological age at a system level. Previously I had felt pretty satisfied with my results since I appeared "younger" than my chronological age; however, when I received the additional detail I was taken aback that the picture wasn't that positive, especially the 'brain' result!

My state of mind wasn't helped by running across this article, 'Higher Biological Age May increase Stroke and Dementia Risk' which found:

I posted the Biological Age Testing entry, and resolved to follow some of the (somewhat general) recommendations. I purchased a Whoop 4.0 to track and improve my sleep, as well as to significantly increase my activity and exercise levels. To 'exercise' my brain I now conscientiously do brain puzzles (including the NYT's Wordle, Connections, and Spelling Bee ) every day, and have signed up with Babbel to learn a new language while also brushing up my French, Spanish and German (all very rusty with disuse!).

Biological age testing appears to have come into its own, and there are a multitude of companies offering this service, each touting their methodology (DNA methylation, telomere length, etc.) and scientific expertise. I decided to try two other companies to see if they would validate my Elysium Health estimates. 

Thorne ($99): (link)

Once you purchase the test you first complete an online questionnaire. Then then provide you a lab order that you will have to download and take to a local Quest Diagnostics branch to provide a blood sample. Quest provides you a full blood work-up in a day or two, and a few weeks later you get your results from Thorne. They use "multi-omic testing, artificial intelligence and machine learning to create an in-depth and accurate picture of your biological age." You will receive your overall biological age; your blood, kidney, lipid, liver, and metabolic ages; and information/recommendations related to diet, exercise, lifestyle, and supplements.

MyDNAge ($299): (link)

When you buy the test they send you a kit that you use to send them a (very small) blood sample. Their analysis methodology is based on Dr. Horvath's epigenetic clock - they analyze "DNA methylation patterns of over 2,000 loci on the human genome" and provide your overall biological age,  your epimetabolic index, information on your APOE and MTHFR genes, as well as information that can be used to improve your health and wellness. 



So, how do the results stack up? I have to say that when you compare results for common items (each test yields results for different sets of items!) they're not very consistent at all!  For example, the estimates of my overall biological age range from 58 to 71!  When you consider the granular system numbers, of  systems reported by Elysium and Thorne, they show significant differences for three of four systems. 

OK, these significant variances would seem to undermine the validity of all of these results, so I am unsure how to take this. Unfortunately there seemed to be some concordance related to the brain results -  Elysium's brain age estimate along with the 'Higher Biological Age May Increase Stroke and Dementia Risk' article created some concern about potential dementia and Alzheimer's. This was accentuated by the APOE gene results from MyDNAge  ("Having one APOE e4 gene increases your risk of developing Alzheimer's disease two- to three-fold."

Hmm, I guess time will tell!

Tuesday, October 17, 2023

Whoop - First Look


Amazfit - First Look - Oct 20th, 2020

Due to various issues I decided to move away from the crowd-funded Amazfit X that I had been using as an activity tracker for the past few years. Its sleep tracking (my primary use) suddenly became less accurate and it started to consistently misreport my sleep duration. I would go to bed around 10 pm, falling asleep within a few minutes. Then the next day it would show my sleep starting at 1am or 2 am, etc. Clearly, a very undesirable situation. After checking Google and reading about various trackers, I decide to go ahead and sprang for a year's subscription to Whoop.

Another reason to get a working solution is that I am going to be paying a lot more attention to my activity levels and sleep quality, see Biological Age Testing.

The unboxing photos:

The companion app is downloaded from Google Play:

You need to charge the Whoop, pair it with your phone, and then it starts collecting your information and building a baseline over your first 30 days...  More to come once this has taken place!

Whoop Reviews:
Whoop Band Review (Sleepfoundation)

Whoop YouTube Reviews:

Friday, October 13, 2023

Amazon & One Medical

Amazon's One Medical integration is still in "early days," see Why One Medical's CMO believes Amazon Health can make a big impact tackling chronic diseases.

How they envisage eventually/potentially leveraging One Medical is what I suggested be the value-added part of ๐‡๐š๐ฏ๐ž๐ง - see my Apr 2018 article.

P.S. Note, with Haven their reach would have been ๐ฆ๐ฎ๐œ๐ก ๐›๐ซ๐จ๐š๐๐ž๐ซ.

Thursday, October 12, 2023

Biological Age Testing

I recently took Elysium's ๐ˆ๐ง๐๐ž๐ฑ ๐›๐ข๐จ๐ฅ๐จ๐ ๐ข๐œ๐š๐ฅ ๐š๐ ๐ž ๐ญ๐ž๐ฌ๐ญ - - and just received the results. It started off well - overall my 'biological age' is lower than my chronological age. Then I looked at the system age scores, and ๐˜๐ˆ๐Š๐„๐’!

How concerned should I be about the 'brain' score? Well, enough that I've decided to do more of a few of the recommended follow-up actions:
  • Greatly increase my activity and exercise levels!
  • Try to improve my sleep - levels and quality
  • Learn something new - I've signed up with Babbel to learn a new language. 

I'll redo the Index test in 12 months and report back if any of this has made a difference.

Tuesday, October 3, 2023

Random Thought

๐‘๐š๐ง๐๐จ๐ฆ ๐ญ๐ก๐จ๐ฎ๐ ๐ก๐ญ: Want to sell pharmaceuticals in the U.S.? The government should require that ๐š๐ฅ๐ฅ such entities develop a ‘๐ฆ๐š๐ง๐ฎ๐Ÿ๐š๐œ๐ญ๐ฎ๐ซ๐ข๐ง๐  ๐š๐ง๐ ๐ฌ๐ฎ๐ฉ๐ฉ๐ฅ๐ฒ ๐œ๐ก๐š๐ข๐ง ๐๐ข๐ ๐ข๐ญ๐š๐ฅ ๐ญ๐ฐ๐ข๐ง’ for their operations. A standard model to be developed (in cooperation with pharmaceutical manufacturers, etc.) by NIST who will define the data elements, etc., definitions, metrology/measurement, information collection, reporting, technology used, etc., etc. 

Data from the various manufacturers’ digital twins would regularly (e.g. daily) ‘feed’ a government-controlled ‘๐ฉ๐ก๐š๐ซ๐ฆ๐š ๐ข๐ง๐๐ฎ๐ฌ๐ญ๐ซ๐ฒ ๐ฆ๐š๐ง๐ฎ๐Ÿ๐š๐œ๐ญ๐ฎ๐ซ๐ข๐ง๐  ๐š๐ง๐ ๐ฌ๐ฎ๐ฉ๐ฉ๐ฅ๐ฒ ๐œ๐ก๐š๐ข๐ง ๐๐ข๐ ๐ข๐ญ๐š๐ฅ ๐ญ๐ฐ๐ข๐ง.’ 

This will require enabling legislation e.g. to overcome manufacturer claims of proprietary information, trade secrets, etc. that they historically have used to not provide information. A wide variety of “carrots” and "sticks" will need to be used to gain industry cooperation, for example the government underwriting the costs of development, deployment, and implementation, with the benefits of having such a system accruing to the manufacturers. 

Once the FDA’s QMMP is deployed to manufacturers its data can then also be folded into the digital twin. With the resulting complete transparency and end-to-end visibility across the entire industry now available to the government (manufacturing information, quality information, supply chain information, etc.), the use of AI, ML, and other such tools should support the ability to forecast and anticipate problems, issues, disruptions, etc. so that the appropriate efforts at prevention, mitigation, etc. can be carried out successfully.

6-part article of which the above is a sub-part

Thursday, August 10, 2023

Book Review: The Death of Death


๐•ป๐–Ž๐–ˆ๐–™๐–š๐–—๐–Š ๐•ฎ๐–—๐–Š๐–‰๐–Ž๐–™: ๐•พ๐•น๐–Ž ๐–š๐–˜๐–Ž๐–“๐–Œ '๐•ด๐–’๐–†๐–Œ๐–Š ๐•ฒ๐–Š๐–“๐–Š๐–—๐–†๐–™๐–”๐–— ๐–‡๐–ž ๐•ธ๐–Ž๐–ˆ๐–—๐–”๐–˜๐–”๐–‹๐–™ ๐•ญ๐–Ž๐–“๐–Œ' ๐–Ž๐–“ ๐–™๐–๐–Š ๐–˜๐–™๐–ž๐–‘๐–Š ๐–”๐–‹ ๐•ต๐–”๐–๐–“ ๐•ญ๐–š๐–“๐–ž๐–†๐–“'๐–˜ '๐•ฟ๐–๐–Š ๐•ป๐–Ž๐–‘๐–Œ๐–—๐–Ž๐–’'๐–˜ ๐•ป๐–—๐–”๐–Œ๐–—๐–Š๐–˜๐–˜.'

Here I review “The Death of Death: The Scientific Possibility of Physical Immortality and its Moral Defense”. The authors are Josรฉ Luis Cordeiro and David Wood; and you can scroll to the bottom where (in the interest of complete transparency) I provide some background information on my connection to one of the authors.

From the back cover: “Is death inevitable? Until now, nothing has been more certain... But according to Josรฉ Luis Cordeiro and David Wood, the prospect of death is no longer inevitable... Cordeiro and Wood not only present the major developments, initiatives, and ideas for eternal life, but also share powerful arguments for seeing death for what it is: the last undefeated disease."

The Table of Contents

Preliminary Warning: Even before I get into my review, I would like to preface it with this warning: This is not a quick or light read! A little over two hundred pages, this book is “dense!” Dense in the sense of encyclopedic, as it crams in an incredible amount of data and information from areas as diverse as history, philosophy, theology, geopolitics, and the sciences – general chemistry biology, and physics; cell biology, cryonics, genetics, etc. I read the book over a three-week period, and I’m a “2-3 books every weekend” type of guy! In reality, if a reader were to follow up by reviewing the copious notes (in the form of links) provided at the end of each chapter and dipping into the 9-page bibliography this could easily take several months to get through. 

Suggestion to the authors: perhaps you should talk to someone about turning this into a university course!

Despite having a density approaching that of a black hole, the authors are masterful in pulling off the feat of integrating everything and delivering it with a logical, coherent “flow” that enlightens while not overwhelming the reader. Finish the book and you will have been introduced to concepts and theories as diverse as ‘negligible senescence,’ ‘Malthusian trap,’ ‘longevity escape velocity,’ ‘terror management theory,’ the Pyszczyncki paradox,’ and many, many others. And you may find yourself convinced by the book's message... Or perhaps not.

So, what is in the book? It starts off discussing the possibility of biological immortality, providing examples of this in several lower life forms and speculating if this can be extended to man. This is followed by the scientific study of aging - what it is, what are the factors that affect it, and much more. Next up is a look at a new, developing anti-aging "industry," which traces the ecosystem of groups that have developed. It dives into 'scientific rejuvenation' and highlights eminent researchers/organizations and some of their successes and advancements in various related fields. A quick side trip ventures into the importance of and examples of exponential thinking, providing additional information on investors and different scientific approaches. Next up is a discussion of costs - the existing costs related to aging and death (for example, costs related to the burden of age-related disease); looking at research, etc. costs; and a discussion of the quantification of financial benefits that could theoretically result from a 'longevity dividend.' Then back to the subject of 'the end of death,' looking at many of the objections to this proposition and providing counterpoints. Current medical skepticism on this subject is compared to historical examples where medical thoughts and beliefs that had lasted for decades and centuries were eventually proven incorrect (two examples being medicine's reaction to Semmelweis and his ideas, and the practice of bloodletting, respectively). Next is a brief side trip into the subject of cryopreservation, set up as a Plan B "bridge" to the future. The authors then discuss the path forward, discussing potential obstacles on the 'abolition of aging' pathway. Finally, they conclude that the elimination of aging and death is an idea whose time is now upon us! Their final clarion call? "The future begins today. The future begins here. The future begins with us. The future begins with you today. Who if not you? When if not now? Where if not here? Join the revolution against aging and death! Death to Death!"

Conclusion: I definitely recommend that everyone read this book. You will not regret it. Even if not fully convinced you will still be greatly informed and 'up to speed' on where the world currently stands on this very interesting subject that effects everyone!

As for me, I started out very skeptical, see my tweet of July 13th below:

And now? I remain skeptical regarding 'the death of death.' Somewhat paradoxically, the more I read about the multiple scientific areas being pursued (senolytics, telomeres, stem cells, etc., etc.) the less I felt that the overall proposition was valid. The very multiplicity of approaches merely reinforced in my mind the astounding complexity of the endeavor and the difficulty of attaining the goal! Of course, this could just be an indication of a paucity of imagination on my part!

In the interest of full transparency, here is some ๐›๐š๐œ๐ค๐ ๐ซ๐จ๐ฎ๐ง๐ ๐ข๐ง๐Ÿ๐จ๐ซ๐ฆ๐š๐ญ๐ข๐จ๐ง:

I first met Josรฉ Luis while both of us were attending The Fund for American Studies’ Institute on Comparative Political and Economic Systems summer program. It was what now seems like eons ago (in 1988!) and was held at Georgetown University in Washington, D.C. We struck up a friendship back then that has lasted, even though we are in touch rather infrequently via email, and have only met four or five times over the intervening years. My last email to Jose was probably six plus months ago, and I haven’t see him ‘in the flesh’ for several years. Below is a reference I gave Josรฉ Luis on LinkedIn almost a decade ago, it still describes him to ‘T.” I do not know, and have never met, the co-author, David Wood.

This review is entirely my own, I purchased the book via Amazon when the English edition became available, then read the book.

I'm not exactly sure why, but as I was about to read "The Death of Death" it brought to my mind the tale of Christian in John Bunyan's "The Pilgrim's Progress."

In this case, Mr. and Mrs. Tout-le-Monde are weighed down by great burdens (here their impending old age and death), but seek to shed them and get to life eternal in the Celestial City. I used "Image Creator by Microsoft Bing, powered by DALL-E" to generate some relevant images that I then combined to produce the header picture.

Additionally, the picture also includes some of their travails along the way - their transit of The Slough of Despond; having to choose the correct path, one of three at the Hill of Difficulty (the correct path being the most difficult-looking one, with the easier-looking byways leading to "Danger" and "Destruction"); having to pass on the path between the two lions; and having to defeat Apollyon (a huge demonic creature with fish's scales, the mouth of a lion, feet of a bear, second mouth on his belly, and dragon's wings). I also included a LEV (Longevity Escape Velocity) signpost! Completing the analogy, Josรฉ Luis Cordeiro and David Wood fill the roles of the Evangelist and the Interpreter.

Covers of various editions (English, French, German, Spanish, Chinese, Turkish, Bulgarian)

Monday, July 3, 2023

Drug Shortages - Part IV (Reaction)

Note: This article is the fourth entry of a series of mind maps listing actions that can be taken in various areas, that if/when taken and implemented collectively can contribute to systematically improving the situation.

Framework Needed:

I - Development/Implementation of New Capacity and Capabilities

II - FDA Quality Program

III - Transparency & End-to-End Visibility

IV - Ongoing Oversight and Reaction

V - Overall Coordination of Efforts

VI - Putting It All Together

Wednesday, June 14, 2023

Drug Shortages - Part III (Transparency & End-to-End Visibility)

Note: This article is the third entry of a series of mind maps listing actions that can be taken in various areas, that if/when taken and implemented collectively can contribute to systematically improving the situation.

Framework Needed:

I - Development/Implementation of New Capacity and Capabilities

II - FDA Quality Program

III - Transparency & End-to-End Visibility

Tuesday, June 13, 2023

Drug Shortages - Part II (Quality Program)

Note: This article is the second entry of a series of mind maps listing actions that can be taken in various areas, that if/when taken and implemented collectively can contribute to systematically improving the situation.

Framework Needed:

I - Development/Implementation of New Capacity and Capabilities

II - FDA Quality Program

III - Transparency & End-to-End Visibility

IV - Ongoing Oversight and Reaction

V - Overall Coordination of Efforts

VI - Putting It All Together

Interesting development: Valisure and DoD Signed a Cooperative Research & Development Agreement to Conduct a Pharmaceutical Quality Risk Assessment Pilot Study

Sunday, June 4, 2023

Drug Shortages - Part I (New Capacity and Capability)

Background: Drug shortages are back in the news. This time it is a shortage of some essential cancer-fighting drugs such as cisplatin and carboplatin, see: FDA allows temporary import of unapproved Chinese cancer drug to ease U.S. shortage. Although there are multiple factors that can occur to cause drug shortages (see the list of possible causes I put together in 2002 with contemporaneous examples, republished on my blog in 2011 and on LinkedIn in 2015.), in this case the issue was caused by an Indian manufacturer (Intas) halting production at one manufacturing site following the discovery of quality deficiencies during an FDA inspection. This then snowballed, threatening lives, and leading to the FDA's emergency approval of the import of 'unapproved' versions of the drugs from China. 

According to the New York Times - Drug Shortages Near an All-Time High, Leading to Rationing - "The shortages are so acute that they are commanding the attention of the White House and Congress, which are examining the underlying causes of the faltering generic drug market, which accounts for about 90 percent of domestic prescriptions. The Biden administration has assembled a team to find long-term solutions for shoring up the pharmaceutical supply chain..." Unfortunately, we have heard this many times before. For example in 2018, the FDA (once again) put together a drug shortages task force to produce solutions. I expressed skepticism at the time!

It's long been clear to me that there has been a market failure and that a root cause for many of our drug shortage problems is that the segment of our drugs ("old," long-available, off-patent and generic sterile injectable drugs) that are disproportionately responsible for drug shortages are priced too low. As such, the usual 'article of faith' that is so often served up as a supposed solution to the issue (example from the NYT, 2017) i.e. "Increasing the number of competitors for a given drug in the marketplace will also help prevent and mitigate future shortages" is nonsensical!

The below, from January 2018, is exactly why we just have had the availability issues for cisplatin and carboplatin!

Unfortunately, as I observed, a solution that requires higher prices is not very palatable. The fact is that many (most) people think of drug manufacturers as a monolith, instead of recognizing that there are distinct segments that operate under very divergent conditions. In February 2019 I asked the question: "Drug pricing- is there a topic more fraught with simplism in this day and age?" Unfortunately, the answer was and continues to be "no!"

The bottom line? We will need to eschew simplistic thinking if we are to make any lasting progress in this area. Additionally, looking to the FDA to come up with a solution is flat out wrong. The solution to decreasing the frequency of drug shortages and mitigating their effects is multifactorial and will require a 'Whole of Government' approach that also includes collaboration and partnerships with industry, scientific organizations, public-private partnerships, academic organizations, and non-profits.

Note: This article is the first entry of a series of mind maps listing actions that can be taken in various areas, that if/when taken and implemented collectively can contribute to systematically improving the situation. First up, we need to improve pharmaceutical manufacturing capacity and capability!

Framework Needed:

I - New Capacity & Capability - the development and implementation of needed new capacity (e.g. plant, inventory) and new capabilities (e.g. advanced manufacturing technology) for drug manufacturing:

II - FDA Quality Program

III - Transparency & End-to-End Visibility

IV - Ongoing Oversight and Reaction

V - Overall Coordination of Efforts

VI - Putting It All Together