Sometimes money buys better health


Category : Medical Rants

An article in today's NY Times led Bob Doherty to write this entry – Is "more care, newer care, and more costly care" better care?

The correct answer is sometimes but not always. Let me provide a couple of examples.  AICD for heart failure with an ejection fraction < 35% decreases mortality.  AICD costs big bucks, but it does save lives.  CABG trumps PCI (percutaneous coronary interventions) for diabetes patients with 3 vessel CAD.  Tolvaptan trumps democlocycline in sodium control, at a much higher cost. 

The problem is not spending money, rather the problem is spending money that does not really help.  This concept explains why we need comparative effectiveness research, so that we know when a higher cost alternative does make a difference.  Let me list a few questions that I would like answered:

  1. In new CHF should I use an ACE-I or an ARB?  Does eplerenone equal spironalactone – and what impact should we attribute to spironalactone side effects?
  2. Should we use low dose statins or high dose statins in various situations?  Do we decrease the muscle complaints with some statins rather than others?
  3. Does lowering the BP from 140/90 to 130/80 help or hurt patients?  Which antihypertensives provide benefits and at what risks?
  4. When should we use expensive antibiotic combinations and when will older generics work just as well?  When should we use vancomycin and when should we switch to linezolid?
  5. How can we decrease the number of CT scans and MRIs?
  6. How can we convince more hospitals to invest in excellent palliative care (which in my experience decreases unnecessary testing and medications)?

Higher spending is not necessarily bad.  We rather must examine what we are buying for that money.  Sometimes money helps. 

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