By doing so Clinton and his doctors flouted the conclusion of what the WSJ's Keith Winstein's lovingly calls "a simple concept: Study different medical treatments and figure out which delivers the best results at the cheapest cost, giving patients the most effective care."
That comparative effectiveness research. And Winstein is the muse to those who insist that people like the former POTUS should been given old drugs for 4 months rather than having a stent procedure:
"Even before Congress took up the now-stalled health-care overhaul, it appropriated $1.1 billion to fund these studies. Both the Senate and the House included it in their versions of the bill. President Barack Obama backed it.
Yet, an examination of one of the best-known examples of a comparative-effectiveness analysis shows how complicated such a seemingly straightforward idea can get.
The study, known as "Courage" and published in the New England Journal of Medicine in 2007, shook the world of cardiology. It found that the most common heart surgery—a $15,000 procedure that unclogs arteries using a small scaffold or stent—usually yields no additional benefit when used with a cocktail of generic drugs in patients suffering from chronic chest pain.
The Courage trial was led by William Boden, a Buffalo, N.Y., cardiologist, and funded largely by the Department of Veterans Affairs. It tracked 2,287 patients for five years and found that trying drugs first, and adding stents only if chest pain persisted, didn't affect the rate of deaths and heart attacks, although stents did produce quicker pain relief."
http://online.wsj.com/article/SB10001424052748703652104574652401818092212.html?KEYWORDS=stents
But what did this study really say? And should one study shape how every doctor treats every patient?
Winstein ignores the fact that even the COURAGE study shows that 1 in 4 patients with chest pain need a stent and drugs to survive as long as others who just received drugs. And it ignores the fact that the tools in the study used to identify which patients would benefit most from specific clot busting approaches and medicines -- a PET stress test and gene test for drug response -- are not widely reimbursed yet because they have not undergone the same kind of comparative effectivenesss research your article swoons over. In otherwords, it's ok to use new technologies to make the case not to pay doctors, but not to pay for those technologies when doctors want to use them. That is comparative effectiveness simply put.
Even worse, when quoting Eric Topol in the article Winstein makes it seem that Topol is in favor of the one size fits all approach:
It's certainly remarkable that nothing has been done to put some checks and balances," into the stenting decision after Courage, says Eric Topol, the chief academic officer of Scripps Health, a hospital operator in San Diego. "I have a very strong disagreement with cardiologists who see no reason to do the stress test."
Winstein fails to note what he likely knew if he interview Topol at length, that Topol is also doing gene-testing prior to drug selection for eluting PCI and is a leader in personalized medicine in cardiology.
But that didn't fit the narrative that one study can decide what treatment is good in all cases vs the judgment of doctors and their clinical experience.
Good thing Clinton's doctors didn't drink the COURAGE kool-aid. In the future it would be an act of leadership and consistency for all supporters of CER and its methods to ask their doctors to treat them according what CER studies supported by the government say. Their could even be a health plan for such people. Keith should be the first enrollee.
