Evidence-based medicine requires that we treat patients with medications and procedures that have been proven to be safe and efficacious. Drug A might be indicated to treat an illness, for example, if it reduces the mortality of that condition over some period of time studied.
The efficacy of a drug is often determined by trials which statistically compare patients' outcomes using that drug, to outcomes in similar patients either treated with a different drug or with a placebo, a tablet or injection which has no drug in it at all.
Some drugs show such statistical superiority that their use is considered to be the "standard of care" in treating certain conditions. Recently, doctors have even been offered "bonuses" by Medicare, if they document the use of some of these agents in certain disease states, in a system called the Physician Quality Reporting Initiative (PQRI).
For example, Measure #6 in the PQRI determines what percentage of patients I treat with coronary artery disease are taking a drug that inhibits platelets from clumping together. Most commonly, this would be a prescription medication called clopidogrel (Plavix), or nonprescription aspirin. For years I have told my patients with coronary artery disease to take an aspirin daily, as a cheap and easy way to prevent future heart attacks or strokes. For the individual patient, it is a good decision, and the economic cost to that individual is minimal.
However, when we begin to look at the finances of healthcare delivery, as we debate the administration's evolving plans for healthcare reform, we have to consider the implications and costs of such a recommendation to the healthcare system. In 2002, a study by Gaspoz and his colleagues estimated the cost, based upon improvements in mortality with aspirin treatment, at $11,000 per quality-adjusted year of life gained by therapy. Using clopidogrel instead of aspirin, by the way, was estimated to cost $130,000 per quality-adjusted year gained.
Similar estimates have been generated for cardiology procedures. Parmley, et al, estimated in 1999 that performing an angioplasty in the setting of a heart attack costs $12,000 per quality-adjusted life year. Wong, et al, estimated in 1990 that angioplasty costs $6,400 to $8,800 per life year saved in patients with severe angina, but $28,000 to $132,000 per life year saved in patients with mild angina. Placing a stent in an artery, as opposed to angioplasty alone, was estimated by Cohen, et al, in 1993 to add another $32,000 per life year saved for patients with single vessel coronary artery disease.
It is difficult, if not impossible, to place a value on a year of a person's life, particularly if that person is your patient, or a family member, or yourself. On the other hand, if we, as a society, are going to pay for the health care costs of our fellow citizens, what costs are we willing to bear?
And what about promoting less expensive life-style changes, as well? What is the cost of throwing away our cigarettes? It might even save us enough to pay for our prescriptions. What is the cost of a healthier diet, to decrease our growing problems of obesity and to help control our elevated cholesterol levels and our diabetes? What is the cost of taking a walk each day to improve our physical conditioning, our blood pressure control, our good HDL cholesterol levels, and our muscle and joint health?
That daily aspirin may help us prevent our second heart attack. But the effect would be even more striking, if we took it on the way out of the house for our daily walk.