Heroes Not Zombies

A recent paper in the BMJ has argued that we should focus on the concept of “value” when making decisions about health care and health care spending.

“Value” is a simple concept to describe: useful outcomes divided by the cost of achieving those outcomes

This paper makes a couple of interesting points – not least that “useful outcomes” must be outcomes which are useful to the patient.

Value emphasises the importance of doing whatever we do efficiently. It also highlights the importance of viewing health and disease along a continuum of prevention; of early diagnosis followed by proactive intervention in long term conditions; and of linking healthcare to social care and public health. Most of all it emphasises that what matters to patients and population is not healthcare in itself but health. Healthcare is often a means to health, but it is not the only means. This highlights the importance of establishing a quality numerator in the value equation that truly describes outcomes that matter to patients. We think that quality should encompass clinical outcomes, outcomes reported by patients, and patients’ experiences, measured along whole pathways of care.

Whilst I support this argument and particularly appreciate the emphases on patient reported outcomes and patients’ experiences (which are almost entirely neglected by RCTs based on measurement of a narrow range of biological quantities), I think there’s a crucial missing part of their proposed spectrum of “prevention; of early diagnosis followed by proactive intervention in long term conditions” – health.

If we only start by considering disease and its prevention we will be caught up in an endless pursuit of moving targets. It’s important to be able to reduce the risks of preventable diseases, and it’s also important to treat disease, acute or chronic, but we’re only going to improve the health of the population and reduce the burden of disease if we understand what “health” is, and seek to create the conditions for optimal health.

Value in health care, therefore, has to include policies and processes consciously created to support and develop health, not just to try to prevent or treat disease.

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Pharmageddon – interesting title captured on the BBC News site.

It’s been coined in relation to a veritable epidemic of addiction to prescription drugs – I’ll say that again PRESCRIPTION DRUGS.

I believe I can safely say that over 80% of the inmates in the Pike County regional detention centre are in there for something dealing with their addiction to prescription drugs,” said Dan Smoot, director of law enforcement

80%?!

the average age at which users first abuse prescription pills is 11. It’s a statistic that makes him angry. “We have basically robbed our children of a childhood.” The pill crisis, which some are calling pharmageddon, is only now receiving national attention.

There are just too many drugs being prescribed. Too many, too carelessly, and too easily. Add to this the toll from Adverse Drug Reactions, and the rapidly escalating drugs bills of all health services, and isn’t it about time we came up with a radically different health care strategy? One which emphasised health and non-pharmacological interventions as much as possible and reduced drug interventions to only where really necessary?

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Strangely, a letter to the Lancet from a group of scientists, and an early day motion in Parliament calling for more human-based as opposed to animal-based testing of drugs, has gone fairly unn0ticed in the news. If I hadn’t just stumbled onto Sky News yesterday, I think I’d have missed it entirely.

The call is based on some pretty disturbing statistics –

Adverse drug reactions have reached epidemic proportions and are increasing at twice the rate of prescriptions.The European Commission estimated in 2008 that adverse reactions kill 197 000 EU citizens annually, at a cost of €79 billion. The cost of new medicines is rising unsustainably, creating an ever-increasing burden on the National Health Service (NHS). Meanwhile, many increasingly prevalent diseases, such as Alzheimer’s disease, diabetes, many cancers, and stroke, remain without adequate treatments. The major reason for the rising cost of new drugs is the fact that more than 90% of them fail in clinical trials

In our collective zeal to summarise, we have too often ignored the fact that a vast and growing proportion of those original studies are industry sponsored, which means that they tend to exaggerate benefits and play down harms. Summarising that bias doesn’t make it go away. Medicine’s prized evidence base has become debased.

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