An opinionated take on NEJM highlights for September 2019

Best care vs. good care

In wealthy countries, the recommended standard of care can often lead to complex medication regimens requiring frequent follow-ups: this can be very challenging for people who though they live in wealthy countries but are poor themselves. In developing countries, efforts have been made to prioritize simplicity and population level impact through one-size fits all polypill interventions, but that has not been tested in the US. Here the authors report on a randomized study including 303 individuals living in poverty and at risk for cardiovascular disease. The active arm was provided with a daily polypill combining a statin and three low-dose antihypertensive agents.  The findings showed high adherence (80%), clear impact on blood pressure and cholesterol vs. usual care, and an implied reduction by 25% of cardiovascular risk. Hopefully, that kind of result will be of interest to Medicaid plans everywhere, because given that all the component drugs are generic, the monetization of this clinical value can only come from healthcare savings.  Polypill for Cardiovascular Disease Prevention in an Underserved Population


Delivery R&D

“Evidence-based medicine” was born out of the realization that many clinical interventions that are perfectly plausible and reasonable do not lead to the expected outcomes. While this has transformed clinical care, health delivery science remains very far behind. NYU Langone is trying to fix that as a system through broad application of rapid-cycle, randomized testing of interventions, completing 10 randomized assessments in just the first year of the program.  My personal favorite was the discovery that the best way to encourage clinicians to talk about smoking cessation was through an EMR pop-up that reminds them that this is a billable service… Doing this on a large scale requires a well-integrated system, tools that plug into the EMR, and an IRB that works with you.  But the pay-off could be significant – NYC is a crowded market that will test the value of this approach in a competitive environment. I hope they win, because in the end, this is the way our delivery systems get better – and that’s just as important as drug R&D.   Creating a Learning Health System through Rapid-Cycle, Randomized Testing


New drugs and mechanisms for Ulcerative Colitis

Inhibition of the TNF pathway with biologics has now long been a mainstay of therapy for individuals with IBD (inflammatory bowel disease) unaddressed by more conservative therapy. Not everyone responds, and other mechanisms have been sought to tamp down on the disease. The journal reports on two positive phase 3 studies of two new therapies that have recently been approved: ustekinumab (Stelara, Janssen) targeting IL-12 and IL-23, and vedolizumab (Entyvio, Takeda) targeting integrin alpha-4 beta-7. Both show clear impact on par with TNF inhibition but the impression one retains is that it’s not much – not more than 30% of patients remain in remission at 1 year. This might be an ideal space for value-based pricing with some risk-sharing. Ustekinumab as Induction and Maintenance Therapy for Ulcerative Colitis; Vedolizumab versus Adalimumab for Moderate-to-Severe Ulcerative Colitis; Biologics beyond Anti-TNF Agents for Ulcerative Colitis — Efficacy, Safety, and Cost?

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 an opinionated perspective on selected highlights that might be of interest to our clients and others.

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