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Wednesday, 29 July 2015

The statinization of America

Is giving statins to 2/3 of the adult population to maybe extend their lives by six weeks really a good idea?

Anyyone who wants to know why medical costs continue to skyrocket needs only to look at the paper published in the July 14 issue of the Journal of the American Medical Association that examined the "cost-effectiveness" of increasing statin use. The article described a computer simulation that modeled the effects of expanding statin prescriptions by various criteria. Depending on the starting assumptions, the model predicted that it would be "cost-effective" to treat as much as two-thirds of the adult population between 40 and 75 with statins.

Mind you, "cost-effective" does not mean that increasing the number of people eligible for statins would decrease health care costs. All the authors mean by "cost-effective" is that the additional cost per promised additional Quality-Adjusted Life Year would be below some arbitrarily selected value.

And just how much longer would people be living? Table 2 of the JAMA paper gives us the answer. According the authors' model, if we gave statins to everybody judged to have a risk of heart attack or stroke of at least 7.5 percent over the next 10 years (as the American Heart Association currently recommends) as opposed to restricting their use to patients with pre-existing cardiovascular disease, diabetes or severely elevated LDL levels, life expectancy would increase by 43 days.

We don't know that even the meager results demonstrated in clinical trials will be forthcoming in actual clinical practice (the patients in clinical trials are in no way representative of those taking the drug in the real world). We don't know that benefits demonstrated in short-term trials can be extrapolated for the lifetime of the patient (in the absence of data, you just don't know). We do know that in Sweden, as prescriptions for statins tripled in the period 1998-2002, there was no correlation between increased statin prescribing and the rate of heart attacks and deaths.

Moreover, data on the incidence of heart attacks and strokes for the JAMA paper were taken from a 2005 meta-analysis published by the Cholesterol Treatment Trialists' Collaboration, or the CTT. When Dr. John Abramson of Harvard University School of Medicine re-analyzed the CCT's 2012 data, he found that statins conferred no mortality benefits to those whose risk of heart attack or stroke was less than 20 percent.

We're not paying for the medical interventions we're getting now. How can it possibly be "cost-effective" to spend even more money we don't have in the forlorn hope of increasing life expectancy by a few weeks or even less?

We now spend 17 percent of our gross domestic product on health care, more than any other civilization at any time in history. Within the last 50 years, so-called "non-discretionary spending" (mainly Social Security, Medicare and Medicaid) has ballooned to 70 percent of the federal budget, while spending on investment (i.e., education, research and development and infrastructure) has dropped from 20 percent to 10 percent. We are bequeathing to future generations trillions of dollars in debt and trillions of dollars in unfunded liabilities. We are already close to maximum life expectancy, and most of the remaining gap could be closed by lifestyle interventions.

Medical interventions push hundreds of thousands of Americans over the edge to bankruptcy every year and kill hundreds of thousands of Americans every year. If a computer simulation — based on an outdated meta-analysis of studies (mostly bought and paid for by the drug companies) and some indefensible ancillary assumptions — that promises an increased life expectancy measured in a few weeks is anyone's idea of cutting-edge medicine, isn't it time to consider the possibility that we already have picked all the low-lying fruit?

We are a society obsessed with sickness, with death and with tiny or even non-existent reductions in risk. Those of us who (like myself) have passed the half-century mark should ask ourselves: How do we want young people to see us? As elders who are here to protect them, guide them, train them to take our places, and then to die and get the hell out of their way? Or as selfish characters who are here to suck up as many medical resources as we can before finally coding on a respirator in an ICU? At the very least, we ought to have an honest discussion about the magnitude of the promised reductions in risk we are talking about.


1 comment:

Anonymous said...

Do we all want to live forever?
It is the quality of life not quantity that counts.

What a shame we can not get away from the idea of popping pills, but of course the large pharmaceutical companies would not want us to do this (: