Too Much Blame, Not Enough Credit

FROM THE EDITORS

It's a commonly heard claim: Doctors and patients insist on using the newest and best medical products. Such use has been blamed for everything from soaring healthcare costs to the impending bankruptcy of Medicare.

That's always been an oversimplified argument. Yes, there are devices that are no different from predecessor technologies other than in price. But in many cases, the newer and more expensive technologies make a real difference in terms of patient health. And that often saves money in the long run.

One study in the news makes the point in stark terms. In August, the online journal Circulation published a review by Duke University researchers of 34,000 heart-failure patients who are candidates for cardiac resynchronization therapy (CRT), which shocks hearts back into rhythm. It found that only in 12.4% of cases were CRT devices implanted—this despite earlier studies showing that CRT therapy, when used with drugs and accompanied by lifestyle changes, has tremendous benefits. It is applicable for 30–50% of heart-failure patients. In that patient population, it can reduce deaths by 36% and hospitalizations by 50%.

There are about 5 million people in the United States who suffer from heart failure. That means 1.5 million–2.5 million Americans could benefit from CRT, but only about 620,000 are receiving it. And, according to the Duke researchers, as many as 10% of those who are getting it may not need it. (The American Heart Association recommends CRT for those with a left ventricular ejection fraction of 35% or less.)

The numbers indicate that not enough people who could significantly benefit from the treatment are getting it. Clearly, we have a case where a device is being underused. You won't hear anything about it from those whose idea of healthcare reform is cutting back on new medical technology, though. Where is the outrage over as many as 2 million patients not getting proper care?

The biggest stumbling block, not surprisingly, is short-term cost. CRT devices are priced at about $33,000 apiece. Many hospitals are in a financial crunch, and there is pressure on Medicare and other insurers to cut reimbursements for new technology. So it is easy for hospital administrators to discourage their surgeons from using CRT. Another issue is that there are not enough doctors who have been trained how to implant CRT devices. And it appears that some doctors who could perform the procedure aren't aware of just how beneficial the treatment is.

But if the devices reduce hospitalizations by 50%, isn't the initial cost more than offset by reducing the need for patients to return to the hospital so often? And if they reduce deaths by 36%, isn't that a benefit that should be encouraged, regardless of cost?

“There is a fine balance between appropriate restraint and timely and efficient utilization of new technologies,” cardiologist Jonathan Piccini, a member of the Duke team, told Bloomberg News. “In the case of cardiac resynchronization therapy, there is an abundance of clinical trial data that shows it helps patients.”

This is why blanket reform proclamations are not the way to go. Some devices are overused, but some are underused, so reducing the use of new medical technology should not be the corner­stone of a reform policy. Instead, healthcare stakeholders and policymakers should look at clinical outcomes to determine which treatments help patients and which do nothing more than raise costs.

Erik Swain for The Editors