NEJM Highlights December 2015: providing effective healthcare is hard and expensive – but ineffective care can be even more expensive – and defining what expensive means in healthcare is hard

By

A new focus on the diagnostic reliability of clinicians

Two perspectives highlighting the recent report from the National Academy of Medicine (formerly IOM) entitled “Improving Diagnosis in Health Care”.  Diagnostic error has long been the invisible side of poor medicine compared to medication errors, or a towel forgotten inside the patient and the like.  But the growth of health IT is both exposing diagnostic error and bearing the seeds of a solution, initially through rule-based automated checks and reminders, but likely eventually through a much more guideline driven practice of medicine with clinical decision support tools.   Reducing Diagnostic Errors — Why Now?Improving Diagnosis in Health Care — The Next Imperative for Patient Safety (subscriber access)

 

The tale of a homeless mentally ill patient

A fascinating clinical conference discussing the management of what many would call “a crazy street person”. Quoting the primary physician from the article:  My primary goal during the first encounter was to earn her trust and not to turn her visit to the shelter into a formal medical encounter. Instead, I soaked her feet and trimmed her toenails… At the 33rd visit, the patient agreed to start low-dose olanzapine [an antipsychotic]. Throughout, this article surfaces the long and difficult process of establishing a trusted well-coordinated medical home for complex patients. It is clear that the upside is tremendous, not only for the patient, but also from a cost perspective as care in acute settings could easily have ballooned to seven figures. Still, one wonders if the saintliness (in this case the term seems appropriate) that drives the front line care givers is something that can be systematized, or will it always be the luck of the draw? Case 40-2015 — A 40-Year-Old Homeless Woman with Headache, Hypertension, and Psychosis (subscriber access)

 

Gilead hits it out of the park for Hep C, again

After the success of Harvoni (sofosbuvir/ledispavir), Gilead comes up with a new combination with velpatasvir replacing ledispavir. Once again, stellar results but now across an even broader spectrum of HCV genotypes (Harvoni was particularly targeted to type 1 genotype), of patients post prior treatment failure, and of patients with advanced liver disease.  As before questions about cost and access continue to roil the waters as the NEJM editorial considers the burden on the healthcare system from paying for this highly effective therapy.  Simple, Effective, but Out of Reach? Public Health Implications of HCV Drugs; Sofosbuvir and Velpatasvir for HCV Genotype 1, 2, 4, 5, and 6 Infection (free access); Sofosbuvir and Velpatasvir for HCV Genotype 2 and 3 Infection; Sofosbuvir and Velpatasvir for HCV in Patients with Decompensated Cirrhosis (subscriber access)

 

 

Valuing care and drugs

In the context of recent uproars over drug pricing in the US, a pair of perspective articles giving an overview of the current high level of effort to quantify the value of therapies – with a heavy emphasis on cancer drugs, although as we are reminded, these represent a very small fraction of healthcare costs.  Among all initiatives, two stand out because they actually bite the bullet of directly linking cost vs. health benefit via the use of QALYs: ICER and Sloan Kettering. Others, ASCO or NCNN notably, shy away from making that translation preferring to quantify benefit in points rather than dollars.  As those effort become more prominent, it is worth recalling these are difficult quantifications to make: (1) clinical data are never complete and require assumptions to fill the gaps; (2) as the standard of care evolves with new approaches, the incremental value of a given therapy will change; (3) the value of a therapy depends on the population that is covered – e.g. all other things being equal, a diabetic patient population will benefit more from a cholesterol lowering medication than a non-diabetic population. Value-Based Cancer Care; Measuring the Value of Prescription Drugs (free access)

 

The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer a brief overview of highlights that might be of interest to our clients and others.