Monday, 12 May 2014

Back to Sutton’s Law

Last week we saw the status quo bias starting from the article "Assessing Value in Health Care Programs". Remember that this bias is due to the human tendency to keep doing things as usual, without questioning too much the meaning of what is being done.

But in this post I want to talk about exactly the opposite innovative attitude and the difficulties inherent to the changes in an environment as segmented and as regulated as the health system. For this reason I have chosen three examples that illustrate the obstacles that many professionals must overcome when they are eager to change routines or adopt a new drug they know is supported by scientific evidence. But the problem is that to adopt the novelty, investments are required, or simply more budget because the new drug is more expensive. So the question is: who pays for the novelty when we were told that we can not spend more?

Example 1 - Adherence to treatment

Let’s consider a program that may improve adherence to treatment, which barely reaches 45%, after myocardial infarction (Volpp 2012). Let’s imagine that a new program foresees increasing this adherence to up to 70% and as a result there would be a 10% reduction in readmissions both for new myocardial infarction and for stroke or revascularization, with a cost reduction that could collect savings for the association of $2,000 per case per year. Does this mean that the program should not be approved if its cost would be $3,000 per case and year?

In this situation, it’s clear that the calculated return of investment for the program would be negative, as it would cost more than it would save. But even being more expensive, would not it be better to invest in it than allowing the consequences of poor adherence to treatment to happen? The article's authors remind us that mortality from myocardial infarction is higher in readmissions within 30 days, and that many patients when they relapse in heart attack die before reaching the hospital. In this innovation, the only winners would be the patients (with less cardiovascular complications), as both the association and the hospital would lose.

Example 2 - Dabigatran versus Warfarin

Warfarin is an oral anticoagulant that acts by inhibiting factors dependent on vitamin K. It’s a drug that is used primarily in patients with auricular fibrillation to prevent remote embolization and to avoid brain strokes. The millions of elderly worldwide taking Warfarin need regular blood tests to ensure that the level of anticoagulation is appropriate in order to avoid the adverse effect of the onset of haemorrhages.

Dabigatran is a new oral anticoagulant that acts by directly inhibiting thrombin. This new molecule has appeared in the world of preventive anticoagulation with the intent to overthrow Warfarin. Its credentials are: bigger effectiveness in preventing stroke and lower risk of suffering haemorrhages. The reality is that the new drug is causing a collapse in the world of clinical management, and I'll say it bluntly: it’s 60 times more expensive, but in return it promises not to require controls.

Studies of cost-effectiveness of Dabigatran versus Warfarin are contradictory; there are Canadians in favour of the new molecule and English against it. No wonder it’s not easy to calculate the actual cost of Warfarin use, regardless of the price of the drug, with the structures that the health systems are equipped with to perform millions of checks that are required in addition to the costs of periodic mobilization of millions of elderly patients. If the change of drug is approved, patients will gain, but the price to be paid will be a reform of the sector, with obvious drawbacks.

Example 3 - The Program of All Care for the Elderly (PACE)

PACE is a Medicare and Medicaid program (U.S. only) that provides the entirety of the health and social services for people over 55 with chronic conditions and elements of frailty, avoiding however, the range of special needs and end of life. PACE strives to choose patients for those that can be kept away from health institutions through prevention and health promotion and therefore preventive controls, physical exercise, diets, etc. are encouraged.

The program is organized through ”PACE Centres” that operate as day centres, doctors' offices, nursing services, physical therapy and social services. Today, after 40 years, there are 35 PACE programs throughout the United States. Their results are controversial and their cost/effectiveness have not been clearly demonstrated. It's evident that while PACE reduces hospitalizations and admissions in “nursing homes”, however the program costs are high. But the question that interests us in this post is that PACE programs that have attempted to reduce costs based on reducing care teams have failed in reducing hospitalizations.

Discussion: back again with Sutton's Law

The thought of take away the resources of unconvincing performances in order to invest them into new programs with better results is OK, but do not forget that Willie Sutton had to refine his ingenuity a lot in order to bypass the security measures of the banks he was robbing. The archive says he was the best, but even so, in the end he got caught. Therefore, let’s be ingenious and not be caught by the status quo.

Jordi Varela

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