Taking Cost-Effectiveness to Heart -- Burt's Stent Blog "The Voice in the Ear"


<< To Blog Home >>

"The Stent Blog is a must-read resource"
-- ConcurringOpinions.com

What is
'The Voice
in the Ear'?

Who's Burt?

Archives

« send comment »

Subscribe to
email alerts

RSS Feed

February 11, 2009 -- 12:25pm EST

Taking Cost-Effectiveness to Heart
The current economic environment is forcing many issues into sharper focus. Cost-effective medical therapy is one and it presents the Obama administration with a major challenge, as Alicia Mundy reports in Monday's Wall Street Journal:

The drug and medical-device industries are mobilizing to gut a provision in the stimulus bill that would spend $1.1 billion on research comparing medical treatments, portraying it as the first step to government rationing.... The administration hopes to expand coverage while limiting use of treatments that don't work well.... The House version of the stimulus package sent shudders through the drug and medical-device industry. In a staff report describing the bill, the House said treatments found to be less effective and in some cases more expensive "will no longer be prescribed."

I'm all for expanding medical coverage: it's dis-heartening (sorry!) how many patients write into our Forum, unable to afford critical medications like Plavix because they've lost their insurance -- some have stopped taking it; some have had heart attacks as a result. So to expand coverage to more people, the money is going to have to come from somewhere.

But my immediate reaction to hearing that government might be "comparing medical treatments" to determine which are "effective" is not so much the "I'm not going to let bureaucrats tell me what I can and can't do" stance, as it is the fact that, at least in the field of the treatment of heart disease, there are so many unresolved questions within the medical specialties themselves. And each new study or trial often (not always) adds new and confounding information. I mean we still aren't sure how long Plavix needs to be taken post stenting. Should we use bare-metal or drug-eluting stents, when and in whom -- or no stents at all because the Fractional Flow Reserve is above 80? CT Angiogram or not? Or should we reverse the historical trend and put interventions on the shelf, a la COURAGE, and stay with medical therapy only for most?

If doctors can't agree on the best therapies, how can government agencies do so?

Spencer B. King, III, MD, MACC Where some insight can be found is in The Editor's Page of the current JACC Cardiovascular Interventions. Dr. Spencer B. King, III, a pioneer of coronary angioplasty, discusses the opportunity for medicine in this era of "danger". One thought stood out for me:

Science and technology have been at the heart of interventional cardiovascular medicine and must also drive medical intervention. Through clinical research, we have created an extensive evidence base that is currently being enforced through various mechanisms, but does one-size evidence fit all? It would be ludicrous to put a stent in every patient with angina without clear evidence of what the treatment was to accomplish. On the other hand...the suggestion that everyone with an abnormal C-reactive protein needs massive statin therapy is the one-size-fits-all concept that, along with direct-to-consumer advertising, drives medical costs. Medicine must be personalized in order to be effective and cost-effective...the era of "every therapy for everyone" is over. The opportunity for medicine is to harness the power of technology, medical informatics, genetics and personalized prevention, and therapy for the best outcome for our patients.

Personalized medicine. It's a concept that's been bandied about for a while now, but with new and exciting developments in decoding genetic markers, along with the hard work of physician teams and medical societies who have been authoring Appropriateness Criteria, the idea is being recognized as critical: a variety of available therapies is needed to treat a variety of individuals and physicians need to use the most current data to triage the right patients to the right therapy.

Headlines in the popular press that proclaim "medical therapy trumps stents" or "CT scans are useless and costly" are meaningless, unless applied to specific patients with specific individual clinical situations. Stents or statins can be great for the right patient; not so much so for the wrong one.

So, as someone who has never been able to walk into Macy's and just buy a suit off-the-rack, I sincerely hope the push towards cost-effectiveness does not put much stock in the concept of one-size-fits-all medicine.

« comment » « back to top »

Click here for more information about these