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Not true. I said that the NICE decisionmaking approach -- which takes years -- held patients hostage to a QALY measurment that only took into account what NICE thought was valuable to the NHS, not to the patients themselves. And I said that decision because of its perspective and delay was and will be morally indefensible. I stand by that view and stand by the people who lives are cut short and ruined by NICE.
Innovation is not the problem with health care. Innovation is the solution. Cancer care is a small part of the cost of health care and is often the most effective in terms of reducing expenses and extending life. The question is if we had applied the NICE knife 30 years ago, how many of us, our parents, our siblings, our children would be far worse off (yes -- even dead) because of the absence of products not developed or unavailable due to the cumulative impact of cost trumping care?
The most recent installment of the New York Times series, “The Evidence Gap,” explores NICE and the proposition of balancing cost-based government concerns with patient-centric care.
And ground zero is kidney cancer. According to the Times’ story:
"When Bruce Hardy’s kidney cancer spread to his lung, his doctor recommended an expensive new pill from Pfizer. But Mr. Hardy is British, and the British health authorities refused to buy the medicine. His wife has been distraught."
“Everybody should be allowed to have as much life as they can,” Joy Hardy said in the couple’s modest home outside London. "It’s hard to know that there is something out there that could help but they’re saying you can’t have it because of cost. What price is life?”
Surprisingly the Times’ reporting is a bit old – considering that earlier this week NICE said that their ban on drugs that can give kidney cancer patients many months of extra life is to be lifted. According to the Guardian, “"The move follows British Health Secretary Alan Johnson's decision this month to overhaul the way new medicines are assessed for terminally ill patients. Denying cancer patients access to drugs that are widely available abroad has become a major political issue."
Caveat Baucus.
For more on NICE and the issue of cancer drug denial, see here.
To see how other nations (in this case, Mexico) are developing their own comparative effectiveness protocols, see here.
And consider the words of Professor Atanacio Valencia, of the Mexican Institudo Nacional de Salud Publica who cautioned. “A good economic analysis is not a faultless crystal ball. Don’t make the remedy worse than the disease.”
After reading her analysis, perhaps a better title would have been “Why Not the Best Use of Statistics?”
In addition to entirely discrediting the report’s methodologies, the article (in a series of very disturbing sidebars) shows that the mainstream media was either lazy or complicit (or both) in reporting the story.
Weiss’ full exposé can be found here.
Weiss writes:
“On July 17, 2008, the Commonwealth Fund commission published its second Scorecard report, Why Not the Best?: Results from the national scorecard on U.S. Health System Performance, 2008. Its findings that U.S. health care performance had not improved since 2006 and that access to health care significantly declined were again reported widely in the media and in a way that gave wide credence to the Scorecard’s conclusions (see sidebar). As the New York Times noted, The findings are likely to provide supporting evidence for the political notion that the nation’s health care system needs to be fixed.”
However, the 2008 Scorecard must be interpreted with caution. In attempting to diagnose the ills of America’s healthcare system, the Scorecard suffers from serious flaws that challenge the validity of its conclusions – flaws that were, essentially, ignored by the authors of the study and completely missed by the media coverage. These flaws fall into three categories:
1. The methodology by which the data were collected and the studies were designed to address specific questions.
2. Arbitrary definitions and metrics used to define the concept of “quality” in health care.
3. Sweeping, broad conclusions that are unsubstantiated by the findings of the study.
1. Flawed methodology
The 2008 Scorecard is based upon multiple disparate studies, using various methodologies, non-uniform definitions of “benchmark,” and arbitrary assumptions as to what “logical policy goals” are, and what “adequately insured” actually means. The Scorecard attempts to draw meaningful conclusions based on a summation of individual studies with varying sample sizes, varying performance comparisons, and varying data collection techniques.
In peer-reviewed, scientific literature, it is invalid to lump together the results of multiple studies, using multiple methodologies, in the same charts, graphs, and conclusions, without assigning relative weight to the results of the studies. Adding even more to the confusion, many of the reported data are not directly referenced to published studies, so it is impossible to trace and evaluate the sources of the information. A substantial number of the individual analyses were merely described as “conducted by the authors,” limiting the reader’s ability to evaluate the quality and validity of the studies.
Perhaps more troubling are those data which can be traced back to their source studies, and turn out to be based on patient self-reporting. For example, in its section on “quality,” the Scorecard quantified mistakes made in health care delivery according to patient interpretation and self-reporting! Patients were asked how often they felt mistakes were made in their medical care, such as errors in laboratory testing, or medication errors.
2. Arbitrary metrics used to define “quality”
The entire premise of the Scorecard, is that “quality” in the U.S. Healthcare System can be quantified by assessing mean scores with respect to 37 “indicators” across five “dimensions” of health system performance. The 37 “indicators” across five “dimensions” are modeled after those used in studies of industry, and focus on health care delivery systems performance, which is indeed one component of value and return-on-investment. But it is not the largest determinant of what most Americans would define as “quality.” Assessing the quality of delivery of goods by studying uniformity, for example, is appropriate when evaluating the transformation of undifferentiated inputs into uniform outputs, each machined to be identical to the other.
In other words, the conclusions of the study are dependent on the authors’ assumption that all patients with a given diagnosis, say diabetes, are otherwise identical, and should have no difference in outcomes. This input/output calculation disregards the fact that all inputs, such as patients with diabetes, have other comorbidities, and cannot be expected to have the same outcome or outputs.
3. Unsubstantiated conclusions
The authors of the Scorecard present their results in raw form, and then apply these results to reach broad conclusions, which are several steps removed from the data actually being presented; indeed, the data presented often does not directly support or relate to some of the Scorecard’s conclusions. Because there are so many such examples, it is reasonable to summarize them. In general, the authors conclude that universal health insurance in the U.S. would improve quality at substantial cost-savings, that increased primary care and preventative care always improves outcomes at reduced cost, and that “preventable” hospitalizations and outcomes are preventable entirely by policy changes in health care delivery, in the absence of a drastic culture shift in this country. These conclusions may have some validity, but they are not directly supported by the data presented.
Given the potentially far-reaching implications of publications such as the 2008 Scorecard on policy-making and financing of healthcare, the authors and sponsors of these studies must be held to the same high standards as are physicians and scientists when reporting results of their investigations. This responsibility must be shared by the media, who control the dissemination of information, and must present the results of such studies in as objective and informative a manner as their audience deserves.
As Trevor Butterworth comments in a sidebar:
“Both the Washington Post (“U.S. Health Care Still Ill, Survey Finds”) and Forbes (same headline) ran an article by Healthday News, which simply reported the Scorecard's conclusions and cited Karen Davis, the Commonwealth Fund's president, and Cathy Schoen, the Commonwealth Fund's senior vice president for research and evaluation, to explain the significance:
“‘The United States also lags behind other countries in health-care results, Schoen said. ‘Even where the U.S. average improved, other countries have improved much more rapidly,’ she said. ‘As a result, we are falling further behind the leaders.’”
No other expert opinion was offered in either article, but Post readers were invited to visit the Commonwealth Fund's website “To learn more about health care in the United States.”
A half-truth, as my grandmother used to say, is a whole lie.
Huber discusses, among other things, the current inflection point of innovation vs. cost and how we got to where we are.
Some of his comments to whet your appetite”
“Pharmacology has found better ways to tame smaller shards of hostile life while dodging friendly molecular bystanders. And in scrambling to do all that, it has revealed that we aren't all the same deep down, neither in sickness nor in health.”
But …
“The Fourteenth Amendment doesn't guarantee equal protection at the pharmacy … So the stage is set for a long battle between radically new medical science and a senescent, unscientific vision of how diseases are cured and what the "health-care system" ought somehow to deliver.”
Huber is the first policy wonk (as far as I know) to compare a restrictive formulary to a cheese wheel:
“Charles de Gaulle once wondered how anyone could govern a nation that had 246 different kinds of cheese. Designer medicine could probably stock that many varieties on just the cholesterol shelf of its fromagerie. The simplest fix: fewer cheeses.”
There's a punchline in there somewhere.
According to a report in today’s Guardian, the ban on drugs that can give kidney cancer patients many months of extra life is to be lifted. At least two, and possibly all four, of the medicines that had previously been deemed too expensive to prescribe will be approved by the National Institute for Health and Clinical Excellence (NICE) early next year.
What caused the the reversal? Why evidence, of course.
"A spokeswoman for NICE said the organization was looking again at all the drugs because there was more evidence submitted during a couple of periods of the appraisal process by manufacturers, which needs to be discussed by the [appraisal] committee. We will publish a next draft within four weeks of the committee's meeting in January and issue final guidance in March 2009.”
Couldn't have been anything else, right? Well ...
"The move follows British Health Secretary Alan Johnson's decision this month to overhaul the way new medicines are assessed for terminally ill patients. Denying cancer patients access to drugs that are widely available abroad has become a major political issue."
For more on this issue, see here.
And for the complete Guardian article, see here.
Perhaps HHS Secretary/Healthcare Czar-Designate Daschle should give the Honorable Mr. Johnson a call. And maybe he should conference-in Senator Baucus.
Per the renewed interest in ALLHAT -- and the pros and cons of large scale, government-funded comparative effectiveness trials -- some further comment from Michael Weber, MD -- one of the original ALLHAT investigators (and Chairman of the Center for Medicine in the Public Interest):
Using ALLHAT as an example of an “evidence gap” could be misleading, for the issue is not the information produced by ALLHAT, but rather how it’s interpreted and used.
Most experts, myself included, have concluded that diuretics are highly useful drugs in treating hypertension, and may even be underutilized. But there is no convincing evidence that they are superior to other drug classes.
Admittedly, diuretics are cheap to acquire, though not necessarily cheap to use. Because they cause unwanted changes in such factors as potassium, glucose (which can lead to diabetes) and uric acid ( which can lead to gout), the additional costs of extra laboratory tests, follow-up doctor visits and corrective therapies must be reckoned in.
In fact, the British National Health Service, which is guided in drug selections by its highly cost-sensitive National Institute of Clinical Excellence, favors amlodipine (one of the diuretic’s competitors in ALLHAT) as the usual starting therapy for hypertension. This recommendation is based on the ASCOT study that found that a beta-blocker/diuretic combination (a favored treatment in ALLHAT) was significantly less effective than a combination of newer drugs in reducing fatal and non-fatal cardiovascular events and strokes.
Another powerful study, ACCOMPLISH, was recently presented at the scientific sessions of the
So the claim of an evidence gap is not based on a disregard of evidence, but in fact demonstrates that the opposite is true. Clinicians apparently are aware of the full spectrum of evidence, not just selected portions promoted by a government agency. From the perspective of patients with hypertension, this surely is good news.
(For more on ALLHAT, see here.)
The “internacional” part consisted of myself, Michael Drummond, Professor of Health Economics (University of York), Professor Jacques Lelorier, Chief of the Pharmaco-economics and Pharmaco-epidemiology research unit at the University of Montreal, and Kalipso Chalkidou, Acting Director of Policy Consulting at NICE.
The seminar was designed to debate and discuss Mexico’s new pharmaco-economic guidelines for their national formulary. And there was as much debate as discussion. (The audience was comprised of about 100 members of various Mexican government health authorities – and they were not passive observers.) The opening remarks by Stephano Bertozzi (Instituto Nacional de Salud Publica) set the tone for the event, “We need to spend more and spend more wisely.”
Michael Drummond’s presentation was a primer on the various types of evidence used in healthcare technology assessments. Nothing new – but a valuable view into the soul of HTA. Dr. Drummond’s take-away message was that decisions made via HTA are economic decisions – not necessarily medical ones. He also pointed out that using RCTs as the mainstay of comparative effectiveness measures was a flawed proposition and that other evidence – such as observational studies and real-time outcomes data needed to become part of the broader HTA equation.
I was up next, and the gist of my talk was that decisions should be made on patient-centric rather than cost-based platforms – and that reimbursement choices based on short-term budgetary considerations can have expensive (for the government) and dire (for the patient) consequences. My presentation can be found here.
Third on the agenda was Professor Jacques Lelorier who gave a very provocative presentation on the gaming of the comparator issue in general and by Canadian authorities (CDR) in particular – which does not tell the innovator company what comparator it has chosen and then, once a decision has been made, won’t share the data used in the process. He made the point (echoed by others during the course of the event) that when a particular HTA review finds a product to be outside of the selected cost-effectiveness parameters, “the answer is no,” but when the parameters fall within the selected criteria, “the answer is maybe.”
Kalipso Chalkidou gave an overview of NICE – making a point of the fact that NICE is not a reimbursement agency and does not deny access to pharmaceuticals. She also discussed the pending policy (in the UK) of providing physicians with financial “incentives” if they move patients from on-patent medicines to generic alternatives “Incentive” -- such a nice word when a government uses it. Can you imagine what it would be called if this same technique was used by an innovator company? (Hint – “bribery.”) Dr. Chalkidou also noted this policy is “pending” because it is being challenged in court. She also pointed out (vis-à-vis statins) that if there was “any proof” that an on-patent product was “better” than a generic that NICE would be glad to reconsider its current position on the matter. I will shortly send her a link to the BMJ-published THIN study that shows why switching patients from on-patent atorvastatin (Lipitor) to off-patent simvastatin (generic Zocor) has proven to be very expensive to the British healthcare system because of its disastrous and deleterious impact on patient health. (For more on the THIN study, see here.)
Day Two of the seminar was comprised of Mexican health officials and academics presenting their views on pharmaco-economics and HTA. Some worthwhile and representative remarks:
“Developing guidelines is one thing -- making disastrous implementation mistakes is something else. We must have confidence in the people doing our HTA reviews and understand the relative strengths and weaknesses of the data. We must have clarity about appeal guidelines. A good economic analysis is not a faultless crystal ball. HTA has threats as well as opportunities.” (Atanacio Valencia, Institudo Nacional de Salud Publica)
“HTA isn’t a decision – it is the evidence to assist in making a decision.” (Maria Cristina Gutierrez Delgado, Secretaria de Salud). Her presentation was on a Mexican HTA analysis of the HPV vaccine – an analysis that showed the vaccine not to be cost-efficient. The Health Minister, however, decided to go against that recommendation.
Stephano Bertozzi spoke about the need to create a formalized training program for those who prepare HTA studies as well as for those who will make the final reimbursement decisions.
Octavio Amancio Chassin (Consejo de Salubridad General), made the excellent point that HTA must go “beyond the QALY,” taking into careful consideration a variety of factors such as the financial impact associated with caregivers.
Being able to participate in this event and to view the Mexican public health community discuss and debate how to set up an HTA authority convinces me of five things:
1. HTA can be a valuable tool when the right tools are used the right way;
2. HTA must be a combined and collegial effort of government officials, trained academics, physicians and pharmaceutical companies;
3. A variety of evidence must be considered – from RCTS to observational studies to outcomes data;
4. HTA must be as much a patient-centric proposition as a cost-effectiveness mechanism;
5. All aspects of HTA – from the design to the decision to the appeals process must be open and transparent
As we in the United States begin to think seriously about HTA we absolutely must remember that it’s more than just “comparative effectiveness.” And a good way to start having a serious conversation about the issue would be to convene experts and discuss the right way to move forward.
I respectfully suggest to Senator Baucus and Senator Conrad, before they offer legislation setting up an American comparative effectiveness body (within AHRQ or anywhere else), that they look at the process being used by our NAFTA neighbors to the South and carefully consider the warning of Professor Atanacio Valencia, “Don’t make the remedy worse than the disease.”
CMPI's chairman Michael Weber is quoted:
“There was a feeling there was a political and economic agenda as much as a scientific agenda,” said Dr. Michael Weber, a professor of medicine at the Health Science Center at Brooklyn, part of the State University of New York, who had been an investigator in the study but afterward became one of its leading critics. “They pushed beyond what the data allowed them to say.”
Critics said the rules of the trial had favored the diuretics. If the first drug did not adequately lower blood pressure — as happened in more than 60 percent of cases — a second drug could be added. But that second drug was usually a type that worked better with diuretics than with ACE inhibitors.FDA's Bob Temple says: “This is the largest and best attempt to compare outcomes we are ever going to see,” he said. “And people are extremely doubtful about whether it has shown anything at all.”
So who is in favor of this big trials?
Those who want the government to dictate to doctors what to prescribe based on cost-driven clinical trial designs or think they will spit out precise answers that health plans can use to save money. But in fact such trials themselves have a political edge and often lead by people who themselves have a bias: Which is why Curt Furberg, the man who played fast and loose with the data to claim calcium channel blockers cause cancer, was forced to resign. Actually not the only reason. The other reason: the design of ALLHAT exposed African Americans to an excess risk of stroke and stroke related death. President-Elect Obama and his health advisers should bear that in mind in considering Furberg for any position.
So what's the verdict on comparative effectiveness research? Clinical trials of the size, scope and design of ALLHAT are inconclusive and often outdated, if not politically motivated. So what's the alternative that everyone is seeking to spend billionns on?
"Dr. Clancy (Carolyn Clancy director of the federal Agency for Healthcare Research and Quality) said that her agency was now mainly using insurance records to judge how treatments perform. While clinical trials are the gold standard, she said, they are costly and time-consuming.
And, she added, “You might be answering a question that by the time you are done, no longer feels quite as relevant.”And that's going to save the US health system billions?
Research on how to achieve the best outcomes for patients is possible. But neither the ALLHAT approach or the review of insurance records is the way to do it.
As in "Chicken Little."
I share this because, having just landed in Mexico City for a conference on HTA and pharmacoeconomics, I can attest to the fact that the sky is not falling – notwithstanding a story in today’s Washington Post that the FDA is teetering on the brink.
Consider the opening paragraph:
“Shaken by a series of alarming failures, the FDA desperately needs an infusion of strong leadership, money, technology and personnel -- and perhaps a major restructuring, say former officials, members of Congress, watchdog groups and various government reports.”
First of all, the agency already has some very high caliber leadership – but a new Commissioner with vision, guts and communication skills will absolutely make things better. The FDA is a very hierarchical agency. And it’s very true that more money, personnel and technology are must haves. Particularly technology.
But folks, as Pollyanna-ish as it may sound – the agency that parlor game pundits, some of our elected officials and so-called “watchdog groups” are bemoaning as broken – is actually working pretty well considering withering media attacks, internal score-settling and general hand-wringing by people who mostly have no idea what they’re talking about.
And some who do and should know better.
I am surprised by the comments of my former colleague Bill Hubbard who is quoted in the Post as saying, "FDA is close to being at a tipping point -- the agency is hanging on by its fingertips in protecting us."
If that’s true today, then it must have been true when Bill and I were at Parklawn together. And it wasn’t true then. Bill wants the best for the agency – but tacking to the political winds is bad strategy.
"Everywhere you go, you hear the same chorus: The agency's in trouble," said David A. Kessler, who served as FDA commissioner under Presidents George H.W. Bush and Bill Clinton. "There's a general perception the agency is suffering mightily."
It’s important to read what Dr. Kessler said – that there’s a general “perception” – that’s a lot different from it being true. But minus a smart and robust communications strategy – perception becomes reality. And the FDA has been minus a smart and robust communications strategy for too long.
And then there are those with personal agendas.
"I'm afraid we're going to see more horrible things happen if we don't get our act together on this," said David Ross, who was a drug reviewer at the agency for 10 years.
Funny the article should quote David Ross – who has a chip on his shoulder the size of Gibralter. It’s kind of like asking Hillary Clinton to write a job recommendation for Monica Lewinsky. It’s also poor reporting that Ross’ conflicts weren’t noted.
Sloppy journalism and bad editing.
And then there are those who point out how well the FDA was run when they were running it:
"The agency needs to get back to using science as the basis for its decision-making," said Jane E. Henney, who ran the FDA under Clinton from 1998 to 2001.
Let’s face it -- Jane will not go down in history as one of the great FDA Commissioners. And shame on her for saying the agency isn’t using science, first, last and always as it’s decision-making compass.
The article makes one excellent point that needs to be repeated and repeated and repeated, “While the agency has received some additional money and personnel to help implement new drug safety powers, many say it is overdue for a doubling of its budget.”
That’s change we can believe in – lots of change.
And, according to Mark McClellan – already considered by many to be one of the FDA’s Hall of Fame Commissioners -- "There's broad bipartisan recognition from consumer groups and from industry that the FDA needs more resources. The most important thing is overall effective leadership that leads in a way that establishes public trust."
Amen.
And Happy Thanksgiving.
Last March (March 4th to be exact) drugwonks.com commented on the hypocritical disconnect between what medical journals were writing about medical journalism conflict-of-interest and what they were practicing (“New Realism Redefined”) -- “There seems to be a lot of "do as I say not as I do" going on these days.”
A few months later (August 25th), Steve Usdin of BioCentury weighted in on the same topic. His article, “Sacred vs. Profane,” began as follows:
“Medical journal editorials routinely attack the pharmaceutical industry, alleging drug companies corrupt the practice of medicine through inappropriate and overly aggressive marketing, while also criticizing doctors for allowing themselves to be influenced. The journal publishers themselves, however, play a key role in encouraging the behaviors their editors criticize via advertising, sponsored subscriptions and the promotion of reprints of company-sponsored clinical trials.”
(It should also be noted that both JAMA and NEJM declined Usdin’s requests for interviews.)
So it comes as somewhat of a surprise (Really? No.) that in the current edition of the British Medical Journal (19 November 2008, doi:10.1136/bmj.a2535), much of the same ground is covered – but minus any mention of the sins of medical journals!
Maybe not.
Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.
