Friday, September 24, 2010


I must say that I am troubled by some of the innovations are new therapies presented to the medical community by the US medical industry last week. Three items in particular merits attention and will certainly drive up the cost of healthcare ( in my opinion ). I am waiting to see how NICE of UK will view it.

1. Last week, we saw the FDA approving the use of Dabigatran for the prevention of strokes in patients with atrial fibrillation. Atrial fibrillation ( quite a common arrhythmia in the elderly ). In these patients, the heart beat becomes irregularly, irregular, and make them prone to strokes, especially if they also have diabetes , hypertension. Currently, I treat them using drugs to control the rate ( so that it does no beat too fast ) and anti-coagulate them with warfarin ( rat poison ). It is true that warfarin has a narrow therapeutic index and close monitoring is required, with regular blood test ( RM20 per test ). A complaint patient helps in the monitoring of side effects ( which includes life threatening bleed ). It has served my patients well for so long. Warfarin cost a few cents a tablet. Now, some clinical trial data has come out in support of a new anti-thrombotic agent call Dabigatraned ( by Boeringher-Ingelheim ) which has been proven to reduce strokes in patients with atrial fibrillation. This new drug does not require meticulous monitoring ( easier to use ), but cost RM 20 per tablet and you need 2 tablet a day. Since atrial fibrillation is usually chronic, patient may need it life-long. Can you imagine RM 40 daily for one drug? I am concern that with shrewed marketing, it may become the norm, and so healthcare cost will go up. I am also concern as to what longterm adverse effects this drug will have?

2. I also read that at the ongoing TCT meeting ( this Transcatheter Therapeutic meeting is probably the largest interventional cardiology meeting in the world currently and is use as a show piece to showpiece all the latest innovations in interventional cardiology ) in Washington, some US investigators have presented some positive results in the use of a percutaneously inserted valve that can be used as a valve replacement in patients too sick to undergo. The trial is called the PARTNER trial, and it showed that the percutaneously inserted, implanted aortic valve helped patients who would otherwise only have medical therapy. There are too issues with this trial. Firstly, this percutaneously valve system, cause about RM 100,000 each. Secondly, it is very difficult to use and should only be used by people who have substantial training. The indication for the use of this percutaneously inserted valve is also very vague. Patients unfit for surgery, can be interpreted in so many ways. Those who are unfit, in a vigorously audited medical system, may be entirely different from " unfit " in another self conflicted, unaudited medical system. I have heard it been said like this, " now we can put in an artificial valve without the need for operation. Your father is too weak for surgery ". Whatever it is, it is bound to be abuse. Maybe any patient age 70 yrs and above maybe offered this percutaneous valve, under the pretext that age makes one not fit for surgery. This will definitely raise the cost of healthcare.

3. I also read that at this same TCT meeting in Washington, our US colleagues have started experimenting the use of robotics in angioplasty. It saves the physician from too much radiation, and the procedure is suppose to be faster with the use of less contrast dye. I am sure also at added cost. I have no experience with robotics angioplasty. I can only say that nowadays, we interventionist are quite good and have learned to do cases quite fast and safe. I am very worried that robotic systems ( these can be purchase by any businessmen ), put in a cath lab with any physician with little training and used on patients. I am sure this cannot be cheap. I do not think that this is good for the patient.

This brings up the next question. It what is innovated by the Americans good for patient care? How do we decide that matured treatment techniques, is good enough and we do not need expensive toys to do what an able bodied physician can do? I am very concern that what the Americans can do is good and we must follow them? How then can we contain healthcare cost?

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