Too rich for my blood: obesity, palliative care, hepatitis c

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This week: obesity, palliative care, hepatitis c

Learning objectives – Amol, Fahad, and Travis discuss:
1. Understand trends in obesity prevalence in adults and children.
2. Appreciate the effect of early palliative care on quality of life in patients with advanced cancer.
3. Recognize new therapeutic options in chronic Hepatitis C infection and their associated cost implications.

Continuing medical education

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The papers

Cynthia Ogden et al. Prevalence of Childhood and Adult Obesity in the United States, 2011-2012. JAMA 2014 Feb 26;311(8):806-14. (PubMed)

Camilla Zimmerman et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014 Feb 18. pii: S0140-6736(13)62416-2. (PubMed)

Mark Sulkowski et al. Daclatasvir plus Sofosbuvir for Previously Treated or Untreated Chronic HCV Infection. NEJM 2014 Jan 16;370(3):211-21. (PubMed)

Good stuff

Fahad – Slow Ideas, Atul Gawande, The New Yorker, July 29, 2013.

Travis – Are we in a Medical Education Bubble Market, David A. Asch et al., NEJM, Nov. 21, 2013. 

Amol – The blood harvest, Alex Madrigal, The Atlantic, Feb 26, 2014.

Question of the week

Can society afford incredibly expensive drugs for common conditions?

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  • Hans says:

    I believe we (the governments & tax payers) need to carefully consider the idea of ‘pooling’ like the insurance industry does as a way provide people with the best possible care.

  • Amol Verma says:

    Hi MT – thanks for sharing your thoughts! I think diabetes is a fantastic example of a condition in which new/expensive drugs seem to be replacing older/cheaper drugs as first line therapy, with little clinical rationale for this. Next week’s podcast is going to have a whole segment on drug costs/affordability and the role of governments, I hope you will find it interesting! The one question I would ask, from a societal perspective, is whether saving downstream costs (ie. all of those associated with cirrhosis) might actually make the new Hep C drugs cost-effective?

    • andreas laupacis says:

      Hi Amol. Your question was about “incredibly” expensve drugs. Admittedly incredulity is in the eye of the beholder, but i don’t think current drugs for diabetes fall into that category – please corrrect me if I am wrong.

      My answer to your question is “It depends how much better they are than current drugs – they would have to be one hell of a lot better to justify that price.”.

      In the early 1980s Cal Stiller at Western University gave me the opportunity to be involved in a randomized trial of an exceptionally expensive drug for its time – cyclosporine. It turned out cyclosporine was remarkably effective – its use increased the one year kidney graft survival from 64% to 80% (http://www.ncbi.nlm.nih.gov/pubmed/6350878).

      Despite its cost, there was never any question about whether cyclosporine’s cost was worth it – the improvement in patient quality of life and the downstream cost savings associated with people being able to avoid going on dialysis (the equivalent of avoiding cirrhosis in your Hep C example) were huge.

      Unfortunately there aren’t many new drugs that have the impressive clincial benefits that cyclopsoirine did.

  • MT says:

    Hi – great podcast. I wanted to answer the question of the week from my tiny slice of the demographic pie. I’m an RD in a rural community in Northern Ontario and work exclusively in diabetes care (which is becoming almost pandemic, so I’m not sure how much more common it can get). Anyway, I have to say that from my experience the answer is no. Given the current pharmaceutical development structure and government coverage plans, the slice of society that I deal with can’t afford incredibly expensive drugs for common conditions. I would say that I have a conversation about diabetes management and medication adherence just about every day and the discussion is almost always sparked by lack of financial resources to cover the costs of even moderately priced drugs. When a pharm rep comes to my office to tell me about the latest and greatest, or when I’m at a conference where a new therapy is being revealed, my first question is always about its status on the ODB formulary (a system that raises a whole new slew of questions about affordability on a grander scale). Obviously, I’m talking about end-user affordability and not the overall societal cost of expensive drugs – but when I’m satisficing someone’s health with suboptimal pharm therapy and lifestyle modification that’s not quite cutting the mustard, they spend more time costing society, etc.

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