David A. Latif: Collaborative care and health-care savings
A key part of health-care reform that has not been discussed enough is empowering the patient with enough information to make good decisions.
A recent randomized controlled trial published in the New England Journal of Medicine demonstrated that helping patients participate in the health-care decision making process can save health-care dollars and improve outcomes. It was reported that "collaborative care" (shared decision making) reduced inpatient and outpatient elective surgery by approximately 10 percent. According to George Bennett of Health Dialog, collaborative care may be as important as surgery and pharmaceuticals, and can lower our $38 trillion unfunded Medicare liability by 30 percent.
One area that may have benefited from collaborative care's "shared decision making," and resulted in reduced utilization during the past 15 years, is in the area of cholesterol lowering medications. Pfizer's cholesterol-lowering Lipitor is the best-selling drug of all time. It is estimated that between 1997 and late 2011 (when its patent expired), its total sales exceeded $100 billion.
Such drugs, called statins, are the best-selling class of drugs in history. Yet, empirical research suggests that for many Americans who do not have heart disease and are taking statins for elevated cholesterol levels, the benefits are overstated and may be less than the risks.
A 2010 article in the Archives of Internal Medicine examined the benefit of lipid-lowering therapy for the primary prevention of cardiovascular events such as heart attacks. Researchers performed a meta-analysis of 11 randomized clinical trials that included 65,229 people. The objective was to determine the impact of taking statins on mortality among intermediate and high-risk people with no history of cardiovascular disease. They concluded that there were no significant differences between those taking the drugs and those taking a placebo.
It is quite evident that statins are effective for those with heart disease, or who have had heart attacks. However, these people comprise only a small portion of those on statin therapy. A logical question that must be asked is, "Are statins overprescribed in the United States for those without heart disease?" I believe the answer is "yes" based on the empirical evidence published thus far.
There are several plausible explanations. I will focus on one reason where collaborative care can come into play: Many health-care providers and patients are unaware of the Number Needed to Treat (NNT).
The NNT is a useful number because it tells us the probability of a benefit from a drug. For example, taking Lipitor to lower cholesterol was shown to reduce heart attacks by 36 percent. But you have to give the drug to 100 people to show one heart attack reduction. That means the NNT for Lipitor is 100.
As a comparison, the NNT for an antibiotic cocktail to eradicate the ulcer-causing bacteria H. pylori is 1.1. (The bacteria will be eradicated in 10 of 11 people who take the treatment.)
Statins, with a much lower probability of effectiveness, are not without side effects. An estimated 10 to 15 percent of statin users suffer side effects including muscle pain, cognitive impairments, increased risk of Type 2 diabetes, and sexual dysfunction.
It gets worse. There is reason to believe that the Number Needed to Treat for statins is much greater than 100 for patients without heart disease. That's because the clinical trial for Lipitor was based on selected individuals based on multiple risk factors. Several studies have concluded that the NNT is 250 or greater for lower-risk patients taking statins for up to five years. Stated differently, 250 patients without heart disease would need to take statins every day for five years to prevent one heart attack among them.
If patients knew this information, would fewer decide to take statins for the next decade or longer? It is "information therapy" such as this that empowers patients to make decisions that are right for them that may result in reduced costs and improved health outcomes.
Statins are just one of many examples where collaborative care can be effective. From a health policy standpoint, we optimize our scarce resources. Patients should discuss with their physicians and pharmacists, as well as proactively research the benefits and costs before committing to procedures and therapies that may be of marginal benefit. Patients need to be empowered and need to share in the decision making process regarding their health-care options. Only then, can health-care utilization and outcomes be optimized.
Latif is a professor of health-care management and chairman of Pharmaceutical and Administrative Sciences at the University of Charleston School of Pharmacy.
A key part of health-care reform that has not been discussed enough is empowering the patient with enough information to make good decisions.
A recent randomized controlled trial published in the New England Journal of Medicine demonstrated that helping patients participate in the health-care decision making process can save health-care dollars and improve outcomes. It was reported that "collaborative care" (shared decision making) reduced inpatient and outpatient elective surgery by approximately 10 percent. According to George Bennett of Health Dialog, collaborative care may be as important as surgery and pharmaceuticals, and can lower our $38 trillion unfunded Medicare liability by 30 percent.
One area that may have benefited from collaborative care's "shared decision making," and resulted in reduced utilization during the past 15 years, is in the area of cholesterol lowering medications. Pfizer's cholesterol-lowering Lipitor is the best-selling drug of all time. It is estimated that between 1997 and late 2011 (when its patent expired), its total sales exceeded $100 billion.
Such drugs, called statins, are the best-selling class of drugs in history. Yet, empirical research suggests that for many Americans who do not have heart disease and are taking statins for elevated cholesterol levels, the benefits are overstated and may be less than the risks.
A 2010 article in the Archives of Internal Medicine examined the benefit of lipid-lowering therapy for the primary prevention of cardiovascular events such as heart attacks. Researchers performed a meta-analysis of 11 randomized clinical trials that included 65,229 people. The objective was to determine the impact of taking statins on mortality among intermediate and high-risk people with no history of cardiovascular disease. They concluded that there were no significant differences between those taking the drugs and those taking a placebo.
It is quite evident that statins are effective for those with heart disease, or who have had heart attacks. However, these people comprise only a small portion of those on statin therapy. A logical question that must be asked is, "Are statins overprescribed in the United States for those without heart disease?" I believe the answer is "yes" based on the empirical evidence published thus far.
There are several plausible explanations. I will focus on one reason where collaborative care can come into play: Many health-care providers and patients are unaware of the Number Needed to Treat (NNT).
The NNT is a useful number because it tells us the probability of a benefit from a drug. For example, taking Lipitor to lower cholesterol was shown to reduce heart attacks by 36 percent. But you have to give the drug to 100 people to show one heart attack reduction. That means the NNT for Lipitor is 100.
As a comparison, the NNT for an antibiotic cocktail to eradicate the ulcer-causing bacteria H. pylori is 1.1. (The bacteria will be eradicated in 10 of 11 people who take the treatment.)
Statins, with a much lower probability of effectiveness, are not without side effects. An estimated 10 to 15 percent of statin users suffer side effects including muscle pain, cognitive impairments, increased risk of Type 2 diabetes, and sexual dysfunction.
It gets worse. There is reason to believe that the Number Needed to Treat for statins is much greater than 100 for patients without heart disease. That's because the clinical trial for Lipitor was based on selected individuals based on multiple risk factors. Several studies have concluded that the NNT is 250 or greater for lower-risk patients taking statins for up to five years. Stated differently, 250 patients without heart disease would need to take statins every day for five years to prevent one heart attack among them.
If patients knew this information, would fewer decide to take statins for the next decade or longer? It is "information therapy" such as this that empowers patients to make decisions that are right for them that may result in reduced costs and improved health outcomes.
Statins are just one of many examples where collaborative care can be effective. From a health policy standpoint, we optimize our scarce resources. Patients should discuss with their physicians and pharmacists, as well as proactively research the benefits and costs before committing to procedures and therapies that may be of marginal benefit. Patients need to be empowered and need to share in the decision making process regarding their health-care options. Only then, can health-care utilization and outcomes be optimized.
Latif is a professor of health-care management and chairman of Pharmaceutical and Administrative Sciences at the University of Charleston School of Pharmacy.
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