Euthanasia in the Netherlands and Belgium, 1990-2015

While parsing the general literature, I found this paper from van der Heide et al. (2017) giving some numbers about end-of-life decisions in the Netherlands these past 25 years. I was wondering if one could see similar evolution in Belgium. And I didn’t have to look very far: van der Heide cited another NEJM paper with Belgian numbers (Chambaere et al., 2015 ; an attentive reader will notice “Belgian” data is “only” about Flanders, not the whole Belgium).

If you put together the data about euthanasia itself (not counting other type of end-of-life assistance), you obtain approximately the same proportion and evolution:

euthanasia_NL_BE

I’m not aware of more recent Belgian data using the same methodology (i.e. physician interviews). The Belgian Commission fédérale de Contrôle et d’Évaluation de l’Euthanasie (CFCEE) presented its last report in October 2016. This report contained numbers for years 2014 and 2015. But these numbers were related to euthanasia that were officially requested (and granted) by the Commission. For instance, the Commission granted 1 928 euthanasia for a total of 104 723 deaths in Belgium in 2014 (i.e. 1.84% ; deaths in Belgium in the Open Data repository). If we focus only on requests written in Flemish, we find 2.59% of euthanasia in 2014 (1 523 euthanasia for a total of 58 858 deaths) (note: Flemish is the language spoken in Flanders – the region targeted by interviews in the Chambaere et al. paper – but requests in Flemish might have originated from other regions). One might have found different numbers if one would have used interviews like van der Heide or Chambaere.

Dataset (note there is more data in a Wikipedia article)

Activity tracker: waist vs. wrist

A few weekends ago, I was challenged by a friend to do more steps than him. Of course, I won 😉 But I noticed he was wearing his activity tracker on his wrist while I was wearing mine on my waist. As I noticed several times before, when I had an activity tracker on my wrist, these devices tend to capture some movements even if you don’t actually walk (while typing energetically on the computer or while driving for instance).

So I took the opportunity of a small trip to wear 2 activity trackers, one Fitbit One on my waist and one Fitbit Charge HR on my wrist. Continue reading “Activity tracker: waist vs. wrist” →

Digitize you charts with Engauge Digitizer

A few words of appreciation for an open source software that can help you a lot in your work, Engauge Digitizer (ED) from Mark Mitchell. ED is a simple, straightforward curve digitizer: it takes images with graphs like the one below and transform them (with a little help) in data you can use later on.

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Continue reading “Digitize you charts with Engauge Digitizer” →

Counting steps is the easiest way to reduce cardiovascular risk

After abandoning my Fitbit device in January because using it didn’t see improvement in my weight (see previous post), I was wondering if I could still measure my risk to develop cardiovascular diseases and other preventable chronic diseases (diabetes e.g.). So, still sitting at my desk (something I do for more than 8 hours a day in theory – probably more in practice), I looked into the ways to monitor my risk for these diseases …

Continue reading “Counting steps is the easiest way to reduce cardiovascular risk” →

Do you gain weight before moving to the USA?

I’ve been using several Fitbit devices since a few years and I decided to stop using them in 2017. My feeling (like many people experienced before) is that wearable devices don’t work. Yes, you’ve read correctly: I was a big supporter of wearables, following the adage “what you can’t measure you can’t manage”, but not anymore.

Why do I write that? What works then? And what does that have to do with the title? Continue reading “Do you gain weight before moving to the USA?” →

Evolution of the number and causes of death in Belgium (2010-2014)

Statbel, the Belgian governmental organisation for data and statistics, just released mortality data for 2014 (press release in French, dataset). The headline of their press release was that, for the first time, tumors were the first cause of death for Belgian men. Diseases of the circulatory system remains the main cause of death in Belgium, for women and for both sex together.

While the death of someone is a bad news in itself, I’m more interested here in the evolution of death causes. I’m interested in the evolution of causes of death because it might be a consequence of the evolution of the Belgian society and, as a proxy, of any (most) developed, occidental countries.

If you look at the data, the number of Belgians dying is stable and natural death is still the main cause (and also stable, around 93%). Note that if we look at data before 2010, it seems that mortality is slightly increasing since around 2005.

Evolution of the number of deaths in Belgium, all causes, 2010-2014

If the total number of deaths seems stable, the press release seemed to indicate that tumors (cancers) are on the rise, especially in men. The breakdown in categories is made following the international classification ICD-10 and, because the names of the different chapters are quite long for graphs, I will use the corresponding chapter numbers instead. Here is the key:

Chapter Header
I Certain infectious and parasitic diseases (A00-B99)
II Neoplasms (C00-D48)
III Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)
IV Endocrine, nutritional and metabolic diseases (E00-E90)
V Mental and behavioural disorders (F00-F99)
VI Diseases of the nervous system (G00-G99)
VII Diseases of the eye and adnexa (H00-H59)
VIII Diseases of the ear and mastoid process (H60-H95)
IX Diseases of the circulatory system (I00-I99)
X Diseases of the respiratory system (J00-J99)
XI Diseases of the digestive system (K00-K93)
XII Diseases of the skin and subcutaneous tissue (L00-L99)
XIII Diseases of the musculoskeletal system and connective tissue (M00-M99)
XIV Diseases of the genitourinary system (N00-N99)
XV Pregnancy, childbirth and the puerperium (O00-O99)
XVI Certain conditions originating in the perinatal period (P00-P96)
XVII Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
XX External causes of morbidity and mortality (V01-Y98)

One thing to notice is that, for chapter IV, Statbel only counts categories E00 to E88 while the WHO includes 2 more, from category E00 to E90 ; I would assume here that it has no important impact. Also note that, below, R ordered the chapters in a strange way – I’ll see how to fix that.

Excluding natural causes, we see that indeed, diseases of the circulatory system (chapter IX) are still the first cause of death, followed by neoplasms (chapter II) and diseases of the respiratory system (chapter X). If we compare the relative ratio of all these causes (second graph below), we also find the same conclusion – but the relative decline in deaths due to diseases of the circulatory system is better shown. And we can see that neoplasms take back approximately the same relative percentage of death, in 2014 (although they returned to the absolute number of deaths of 2012, approximately).

Causes of death in Belgium, 2010-2014

Causes of death in Belgium, 2010-2014, relative numbers

The available data set doesn’t go into more details than numbers by ICD-10 chapters. Therefore we cannot tell from that what kind of neoplasm is the most prevalent or what kind of infectious disease is the most present in Belgium, for instance. The press release however mentions that respiratory, colorectal and breast cancers are the top three killers and that flu was not very present in 2014.

As the cancer occurrence is increasing with age, and as the Belgian population is aging, one of the explanation for a high number of deaths due to neoplasms can be age ; however we don’t see a dramatic increase of neoplasms (fortunately!). Another potential factor is the impact of screening for cancers. Due to a very intelligent political split (sarcasm!), prevention (and therefore screening) is not a federal duty. Therefore regions started different screening programs, at different times, with different results. Screening data and their results are therefore difficult to obtain. The Belgian Cancer Registry doesn’t publish data on screening in oncology – although its latest report (revised version of April 2016) very often mentions screening as a main factor for change in the number of cases diagnosed. In its 2016 report (PDF), the Flemish Center for the Detection of Cancer (Centrum voor kankeropsporing) indicates that they increased the number of women screened for breast cancer by more than 8% between 2011 and 2015 (especially in 2015), with a quality of test between 90% and 95%. They also showed an increase in cancer diagnostics (without linking it directly to the increase in screening).

screening-flanders

This is by no means an exhaustive review of the data. There are other potentially interesting things to look at: the geographical disparities between the three regions, the gender ratio evolution (as some of these diseases are known or by definition affecting more one sex than the other), etc.

It would also be interesting to follow these trends as some changes occurred recently in the Belgian curative landscape. New drugs in cancer immunotherapy were recently authorised and reimbursed, for melanoma, lung – and other indications will follow. These costs have a price (less than what is in the press, however, I may come back on this in a future post) but they delay death (unfortunately they don’t avoid it). However, for some of them, in some indications, their administration and reimbursement is sometimes also linked with screening, testing and prior treatment failure ; that might decrease their impact on overall mortality. New drugs for Hepatitis C also arrived in 2015 and 2016 and the Belgian health minister decided to reimburse these drugs for patients in their early stage 2 of the disease. Studies showed that treating at this stage may prevent hepatitis C from progressing to later stages and, in some cases, studies showed patients cured from the disease. This is an opportunity to see a decline in mortality due to this infectious disease (although it is already quite low – compared to other diseases).

About antibiotic resistance and the price of drugs

Many headlines stated today that UK wants to tax pharmaceutical companies again in order to contribute to a pooled fund against antimicrobial resistance (AMR). The proposed ‘pay or play’ mechanism is a bit more subtle than that. The report (full text here) is also suggesting other financing mechanisms (including the improvement of existing ones) as well as describing potential non-financial measures to reduce these resistances in the first place. Actually, financial measures occupy only about 6% of the report. But headlines need to be catchy. Let’s see a broader picture on tackling antibiotic resistance …

The WHO summarizes well the situation: “Antibiotics are medicines used to prevent and treat bacterial infections. Antibiotic resistance occurs when bacteria change in response to the use of these medicines. Bacteria, not humans, become antibiotic resistant. These bacteria may then infect humans and are harder to treat than non-resistant bacteria. Antibiotic resistance leads to higher medical costs, prolonged hospital stays and increased mortality.”

An illustrative diagram that shows the difference between a drug resistant bacteria and a non-resistant bacteria.

For Belgium, the Joint Programming Initiative on Antimicrobial Resistance displays a long list of governmental bodies and initiatives that study and/or tackle AMR. The Belgian Scientific Institute of Public Health has a dedicated program against AMR. Despite that, a recent study showed that, in 9 European countries, 99% of bacteria Streptococcus pneumoniae taken from nose of people aged 4 or more show antibiotic resistance (S. pneumoniae causes many types of pneumococcal infections like pneumonia or meningitis). The same study showed that Belgium has the worst resistance rate against the antibiotic cefaclor (fortunately authors also show there is little resistance against the most common antibiotics used against S. pneumoniae). A study from last year in 8 European countries (including Belgium) showed that approximately 4 out of 5 Staphylococcus aureus (another bacteria) isolates from individuals without specific health issues were resistant to at least one antibiotic and more than 7% of them are multidrug resistant. And we are talking here about Belgium, a country with a well developed healthcare system, following best practises in antibiotic stewardship and often considered as an example for the reduction of antibiotic consumption outside hospitals.

B0006889 MRSA

Coming back to the UK report, a big part of it advocates more or less what the 2015 WHO country situation analysis on antimicrobial resistance described too: countries need a plan to fight AMR, surveillance and laboratory capacities should be raised (no data = no knowledge of the situation and no capability to measure progression), antimicrobial medicines should be correctly used, public awareness campaigns should be deployed, and the prevention and control of infections allow to tackle the issue at the source.

The question raised in the report is also how to accelerate the discovery of new antimicrobial medicines? The report advocates for a “global innovation fund for early stage and non-commercial R&D”. And it correctly points that there are currently little incentives for companies to invest in research for products that will ultimately be priced very low (also thanks to generics) for a high volume to produce. Because in “normal times” (periods of “usual drug resistance”) competition between existing products drives prices down. However, if resistances become too high (and they will because they are selected over non-resistant bacteria), none of the existing medicine will be effective anymore, the willingness to pay for innovative drugs will be high but the time to develop them will still be in decades (i.e. too late to tackle the resistances).

Intervention 9 of the UK report tackle this issue with a complex reward mechanism (“the carrot”). But then the next section describes a very simple tax in one page (“the stick”). This ‘pay or play’ mechanism that was highlighted in the press and should indeed be the simplest mechanism that can be applied at a country level.

However, another mechanism could be to make the antimicrobial market attractive again. Allow for (moderately) increased prices on existing drugs (even the ones with competition from generics) and pharmaceutical companies will see opportunities to develop new medicines. Yes, they will become richer thanks to these price increases – but these funds are (partially) re-invested in research and development.

Photo credits: What Is Drug Resistance? by NIAID (licence CC-by) and B0006889 MRSA (clusters of methicillin-resistant Staphylococcus aureus (MRSA) bacteria) by Wellcome Images (licence CC-by-nc-nd).

Is it worth buying a coffee machine at work?

As I moved to a new office, I met new colleagues and one of them brought her own coffee machine and placed it on her desk. It’s a bright red Nespresso machine, a kind of statement that the owner doesn’t drink the free coffee offered in kitchenettes on all floors:

IMG_0152b

Given that the company has a professional Nespresso machine downstairs (i.e. similar quality of coffee but with capsules of different shapes), I was wondering if this is really worth buying. The calculation is simple …

On one hand, the “public” Nespresso machine sells 1 capsule at 0.50€ and pours the water (through the capsule) in a cardboard cup.

On the other hand, the cheapest personal Nespresso machine you can buy in Belgium costs 199.00€. The cheapest personal Nespresso capsule you can buy costs 0.35€ (let’s forget for a moment you have to buy them in multiple of 10 and there are savings to be made if you buy large quantities).

Therefore the upfront cost of the personal Nespresso machine tells me it’s more expensive to have my own machine on my desk. But after how many capsules (i.e. cups of coffee) does it become cheaper to have my machine? The equation is easy: 199.00 + 0.35 * x = 0.5 * x (where x is the number of cups of coffee). Solving it tells me I need to consume 1,327 capsules from my machine in order to get my coffee cheaper than on the “public” machine. That is more than 3.6 years if I drink 1 coffee per day – only slightly less than a year if I drink 4 coffees per day (which is a lot).

Of course, this simple calculation doesn’t take into account electricity, water, cleaning cups or the cups themselves ; they are considered free in both situations (which they are, in practice). It doesn’t take into account neither the convenience of not having to stand up, go down a few stairs to the “public” machine. But, for the future, it doesn’t take into account neither the benefit of having moved more during office hours (more than just sitting the whole day).

So, given some assumptions, having my own Nespresso machine on my desk is probably not economically viable at a reasonable time horizon, unless I drink a lot of coffee and if I value the convenience of not losing a few minutes to go down to the “public” machine. But going downstairs for a coffee prevent me from sitting for too long at my desk and it allows me to meet other colleagues downstairs. I’ll keep this habit! 😉

How to redesign a numeric keypad?

In an interesting blog post on Smashing Magazine, C.Y. Gopinath explained the design choices he made to build a new calculator for smartphones (iPhones more specifically). He started with an interesting summary of the reasons and origins of the numerical keypads of phones and calculators (keyboards, ATM, etc.). This is what drove me to read his post. Indeed I posted a photo on Flickr that showed the difference, a few years ago.

3267740436_ae26c899cf_z

While reading the post, I was happy the author of the app did some research on the traditions behind this keyboard layout as well as the reasons and studies that lead to these layout. The article also contains links to further details, if necessary, and interesting comments from Harry Blanchard and Michael Long.

However I think the author mixed several things before re-designing his numerical keypad …

Circular design with numbers already exists in the real world: the analog watch (also mentioned in a comment). I guess most if not all humans above 10 years old are used to this design and the way it starts with “0” (well, “12”) at the top and “6” at the bottom. So when I saw Gopinath’s app screen, I was wondering if there is a reason or if there are research showing the tilt is beneficial and will not confuse for the user.

160111-comp-with-clock
Comparison of C.Y. Gopinath’s calculator app (left) and a regular clock on a smartphone (“HTC Sense – Home” from Cha già José on Flickr, CC-by-sa, right)

Citing research from Bell Laboratories is great: very few apps did this amount of research and still show “revolutionary” user interfaces based only on the gut feeling of a designer on steroids (when there was a designer) (to be fair, some new designs achieve their goals). However the period during which they were conducted (early/mid-last century) has most probably a large role to play in the choices and habits of respondents. One thing in particular is that people most probably would use these numerical keyboards sitting on the table (like phones on table) and use their finger (or fingers but I expect the index being the single most used finger) of one hand.

What could be the response now? Only research would tell. My feeling is to start from habits of smartphone users. My own use would consider the following facts:

  1. so far smartphones are still square / rectangle objects
  2. most smartphones are still small enough to be held with only one hand and one finger on the same hand would be used (the thumb)
  3. if smartphones are too big to be used with only one hand, either you hold it with 2 hands and use your 2 thumbs (text messaging) or you hold it with 1 hand and use one finger from the other hand.

I did not (yet) witness cases where the user types on a smartphone with many fingers, like a typist would use all his/her fingers on a keyboard.

160111-holding-smartphone
Two ways to hold and interact with a smartphone: with one hand on top (from Iriss on Flickr, CC-by-nc) and with two hands below (from Freestocks.org, public domain)

Therefore I would rather see another “radical” design like this one (case phone held with 2 hands, using 2 thumbs to type):

160111-example-calculator-smartphone
My example of mock-up smartphone with digits on the side, reachable by thumbs if placed on the sides (I guess it needs some more research, of course)

I was also wondering why the author added so many gesture and swiping left, right, center. In his assessment of other calculators, it was mentioned that they offered little or no feedback. How these gestures can be intuitive or discovered by the user? I must admit I didn’t install the app but I guess there should be a tutorial for all these gestures. In my opinion, these tutorials are however the admission that these features were not intuitive, that the discoverability principle was forgotten, most probably on the altar of minimalism …

Although I appreciated the author’s research and share most of the author’s comments on current numerical keyboards, I don’t think the current implementation solves the issues of user-friendliness, discoverability and the greater goal of making kids love maths. Ironically, the “Edit History” page of the app shows the standard, old-fashioned numerical keyboard …