Pharmaceutical Cost-Effectiveness and Diet

I saw an interesting short piece in the Washington Post discussing the discovery that the number of drugs with important interactions with grapefruit has increased substantially since an initial report on the matter 20 years ago and particularly since 2008.

I will refer interested readers to the article for the details, but the short description of the issue is that grapefruit (but not all citrus fruit and not regular oranges) contain a chemical that interacts with some pharmaceutical products and substantially increases the bioavailability of the product.  In this case, more is not necessarily better.  In fact, more can be toxic, particularly to the kidneys.

This raises an interesting question that was probably not considered when any cost-effectiveness analysis related to the drugs is conducted.  Essentially, how does the cost-effectiveness change when you have this type of potential interaction.  It is not a typical drug-drug interaction.  It is not an adverse event due solely to the drug.  It is an event that is purely avoidable by properly reading the packaging or listening to a physician or pharmacist and then following up on what a person has been told.  Sounds simple enough.

I suppose if people were constantly have drug-grapefruit interactions, it would make the news and we would all become aware.  It is probably in the category of "things that sound scary but really are pretty rare" even though an article without additional information about the incidence of such events may make it sound very scary.

If this were a big issue, it would not seem too hard to provide better education at a fairly low cost and prevent events. If it is not a big issue, then while the increasing number of drugs that have this characteristic is interesting but probably not worth more than the short article that I saw.  I'd be intrigued to know more--such as whether anyone has personal knowledge of this issue for themselves or someone they know.

It does point to a larger issue of how we might evaluate the economic importance of better counseling about the interaction between drugs and diet more generally.  

Changing Medical Practice

In today's newsfeed from the Johns Hopkins Bloomberg School of Public Health there is a link to a blog entry about a study that asked medical care leaders why studies that seem to provide strong evidence of the relative effectiveness make such a small impact on the practice of medicine.  THe blog entry can be found here.

A key message from this blog entry seems to be--because the incentives don't point in the direction of adopting things that are less expensive.  The examples of studies with little impact tended to be things that would cost less money than the current approach to care.

We all hear from political leaders that we, in the United States, are spending too much on medical care.  We hear the same thing from business leaders.  We hear very similar things from insurance companies.  And, many individuals chime in with the same type of comment.

What we forget is two groups who aren't complaining--those who make the pharmaceutical products and devices on which we spend so much money and the physicians who prescribe their use.  Even with everyone else calling for reducing expenditures, the manufacturers do not have a strong incentive to save money.  The system right now pays in a way that bears at least some relationship to what is charged.  As such, companies that manufacture more expensive products that can be sold at a higher margin make more profits.

Physicians have only limited time to sort through the literature and to decide how to change their practice.  They listen to the way things are presented by manufacturers.  And they do not, at present, have to respond to incentives to provide care at a lower cost.

This is why I worry so much about the perspective of the cost-effectiveness or comparative effectiveness analyses.  The cost savings come from the societal perspective.  They may even characterize numerous other perspectives.  However, when all is said and done, if the economics don't work for the manufacturers and providers, change is unlikely to occur.  And, in a poor use of scarce resources, the manufacturer will spend money marketing (i.e., trying to convince people) that their products should continue to be used despite evidence to the contrary.

Unfortunately, that does not characterize an efficient system.  And changing the incentives in the first place may be much harder than changing practice patterns at any point.    

Flu Shots

First, an admission.  I have done research on flu shots.  I have helped a student of mine write a dissertation on the timing of flu shots.  However, neither I nor anyone in my family has ever had a flu shot.  Why was that our health economic decision?  We have never thought that the risk was all that large and we have never felt that the time costs were sufficiently low (even with minimal monetary costs) to warrant getting flu shots.

Now, to share an interesting piece of information.  In yesterday's Johns Hopkins Bloomberg School of Public Health news feed there was a link to a piece about a report on flu shot effectiveness.  The report that the blog had written about concluded that there was surprisingly little randomized trial evidence (the gold standard) of the effectiveness of flu shots--for almost any population and even for preventing excess transmission in hospital settings when hospital workers get vaccinated.  The blog points out the history of how we ended up with influenza vaccination being recommended for the older adult population and how difficult it would be to ever go back and rethink policy.  In short, the Surgeon General in 1960 made the recommendation and ever since then it has been considered unethical to withhold a recommended vaccine.  The author of the linked blog entry calls flu shots a sales job.

Here is where economics and ethics may come together.  Maybe if we could realize how many resources we may be over-utilizing, we could ask how it could be ethical to continue to use the resources without asking if it is efficient.  In other words, is a known inefficiency unethical?  Is a potential inefficiency unethical?  Is acting like a supposition is fact without high quality data on the facts unethical?  In any case, this would require some consultation with bioethicists and likely a new cost-effectiveness study based on the latest report showing the lack of data on the effectiveness of flu shots.  Then we could use that to motivate a new study.

It is not a common use of a cost-effectiveness study but it would be extremely useful in this case.