Map of life expectancy at birth from Global Education Project.

Thursday, March 18, 2010

Roundup of NEJM commentaries

The New England Journal of Medicine makes something like a million dollars a year off of drug advertising but they still hide most of their content from the public. I think that's a major scandal. The least I can do is let you in on some of the interesting observations.

This week, Wafaa M. El-Sadr, Kenneth Mayer (with whom I am acquainted) and Sally Hodder discuss the HIV epidemic in the United States. Remember that? It seems that most people don't, and it's mostly because of the people who are most at risk. The prevalence of HIV among Black men in Washington DC, for example, and among men who have sex with men in various places, is higher than the prevalence in South Africa, Kenya and other places in sub-Saharan African which attract much more attention, even in the U.S. High risk for HIV in the U.S. is largely confined to isolated social networks -- poor communities with low social mobility. Even among men who have sex with men, it is African American and Latino men, and those of low and moderate socioeconomic status, who are at highest risk. Now that we no longer have a high incidence of perinatal HIV in the U.S. (thanks to pharmaceutical prophylaxis) or risk from blood transfusions, it's "those other people" who have a problem. But in fact, we still have more than 50,000 new HIV infections every year here in the U.S.

Eminence gris Victor Fuchs weighs in with a fairly basic essay on health care spending. I say it's basic but it's basic stuff that politicians and "reporters" don't seem to understand. We can project future spending but that's largely guesswork. A lot can happen in 10 years that will affect how much we spend on the medical industry regardless of the policy decisions we make. However, the long-term phenomenon for at least 70 years is clear: medical advances largely drive increased medical spending. Some innovations can be cost saving, but most cost more. It might be worth it, but that's a separate question. It's a question we have to ask, as a society, and we stubbornly refuse to confront it. How much is it worth spending for a given incremental benefit in population or individual health? Screaming about "death panels" is just a fairly deranged way of sticking your fingers in your ears.

And so, Jordan VanLare and colleagues discuss the sort of comparative effectiveness research program we need. Of course, they won't go so far as to talk about cost effectiveness. Oh no, that would be rationing. Nevertheless the Institute of Medicine proposes that public participation -- including patients and caregivers -- is fundamental. (Notice they didn't say drug companies, but unfortunately we know what is likely to happen given the political conditions in this country.); that priorities for CER need to be established and made transparent; that we need to a coordinating body for CER; that we need to push for innovation in CER methodology; that we need to develop large-scale data networks to support CER; and we need a way to promote rapid adoption of recommendations coming from the CER enterprise.

Will this happen? We'll see after the November elections. One more reason to get out the vote.

No comments: