Map of life expectancy at birth from Global Education Project.

Friday, February 26, 2010

I got an excuse

Sorry for no post yesterday, I had to finish both a paper and a conference abstract. It's hard work -- sometimes even harder than watching war on TV. And I also heard a talk by Michael Drummond, DPhil, who is the chairman of a death panel.

At least that's how he introduced himself. He's the chair of one of four committees of the UK's National Institute for Health and Clinical Excellence, abbreviated NICE because the H would just mess it up, and he was here to give us all the latest on how NICE works and the politics of death panelling in the land of bangers and mash.

The only way we're going to get health care in this country that serves everybody well and fairly is if we develop some kind of equivalent to NICE. As long as we have multiple payers, it's going to be difficult, but it's not impossible with a sufficiently strong regulation. There are a lot of moving parts in this discussion so I refer you to my series beginning December 14 and concluding on January 5 if you need to a primer. So today I'll just talk about NICE.

Drugs and medical devices get licensed in the UK pretty much on the same basis they do here: they have to show reasonable evidence of being safe and effective, but not necessarily more effective or more safe than existing and probably cheaper alternatives. So Dr. Drummond and his fellow death panelists decide in a separate step whether the National Health Service will pay for them. They can rule that a drug can be used freely as per license; used only in specific circumstances; or not used routinely meaning that a physician would have to ask special permission to have it paid for. Note that the license means the doctor can prescribe it, it's just that you will have to pay for it out of your inheritance.

The hard part is that these decisions are about what the NHS will pay for and that means cost is part of the calculation. Before we get to cost, of course, we have to measure benefit, and NICE uses Quality Adjusted Life Years, with further discussion here. This way of looking at things seems a bit odd to Americans whose values seem to include infinite entitlement. It's not just the obvious consequence that NHS won't spend 100,000 pounds to extend your life by one month.

Dr. Drummond's panel considered the application by Glaxo to approve zanamivir (Relenza) for the flu. It's not very expensive. But they turned it down. Glaxo's application just said that the benefit was that, if taken within 48 hours of the onset of symptoms, it shortened the average duration of symptoms from 6 days to 5. Dr. Drummond said, "What's the benefit of that? When I have the flu, once I start feeling better, my wife starts asking me to do things around the house." That's just not enough of a clinical benefit for the NHS to pay for it at almost any price, because the QALY's it buys you are infinitesimal. One day of not having the tail-end symptoms of a bout with the flu just doesn't compute. In order for Glaxo to get it approved, they had to go back to the drawing board and try to show that it reduces the risk of severe complications, hospitalization or death in high risk people or makes a big difference after severe complications have developed. (So far, I believe, they haven't done that.) In the mean time, it's licensed in the UK, if any of Her Majesty's subjects want to buy it themselves, they are free to do so with a doctor's prescription, but Her Majesty's exchequer won't pay for it.

How that is contrary to freedom I do not know, but Sarah Palin says it is.

Next: How NICE operates.

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