Sick Care
One morning I was setting up a booth at a trade show. I had time to spare so I looked for the coffee. The facility was still preparing everything for breakfast so I slumped back to the booth to wait. A few minutes later I overheard a gentleman ask the conference administrators about coffee and he received the same answer. But now I had a fellow coffee enthusiast! It would be a polite gesture to offer to drive him to Starbucks and no longer just my own indulgence. OK, I probably would have convinced myself to go anyway but by waiting a few minutes I met Paul Grundy, “father” of the Patient Centered Medical Home (PCMH). While there is still much in sick care that PCMH should address, even this effort is a Herculean feat.
Turns out that Dr. Grundy was the keynote speaker at lunch. He used an analogy in that keynote to describe the US “health care” system that still makes me chuckle. According to Paul Grundy, if we wanted to save fish that went over Niagara Falls with the same philosophy as the US “health care” system then we would wait for the fish to go over the falls, send in a rescue helicopter to locate the fish and airlift the fish back to the top of the falls where it would receive all necessary medical attention before releasing it back into the river… so it could go over the falls again and repeat the cycle. Alternatively, we could put a net further upstream to stop the fish. Of course, the net is not covered by insurance… only the helicopter and medical attention.
And this continues to be the frustration for just about everyone it seems. All efforts to improve “sick care” focus almost exclusively on improving a broken process, not promoting health with prevention or cures:
- Reducing hospital readmissions instead of keeping people from needing hospital admission in the first place,
- Decreasing pharmaceutical pricing instead of reducing pharmaceuticals prescribed,
- Bundling payments for episodes of care instead of providing incentives to prevent episodes requiring care,
- Combating the opioid crisis instead of promoting non-pharmacological options, and so on.
Benefits of Lifestyle
It is not news that a healthy lifestyle produces, well…, better health. However, it does seem to be lost in the healthcare debate that a healthy lifestyle can prevent, stop or even reverse many chronic diseases. No need for the helicopter to locate and retrieve the fish.
An Example: Heart Disease in Sick Care & Health Care
Heart disease is the leading cause of death in the US and claims over 600,000 people each year. A standard treatment for heart disease might include statins but an improved and healthy lifestyle (e.g., diet, exercise, relationships, etc.) might be more beneficial and have few (if any) harmful effects. To compare “apples to apples” for statins and lifestyle, we need a common measure. Luckily such an instrument exists and has been around for years (but, surprisingly, not used nearly enough). The measure is the Number Needed to Treat (NNT):
Although we think if a doctor prescribes a treatment it’s going to help, a lot of therapies benefit very few patients. The “number needed to treat” captures this: It’s how many people must get some intervention for a bad thing to be averted in one person. For instance, the NNT for antibiotics curing conjunctivitis within 10 days is about 12: A dozen people with that eye infection need to take the drugs for one person who would otherwise remain infected to become cured. The other 11 either would have gotten better on their own or aren’t helped by the drugs.
Source: What are the odds that your medication will help you get better?
So an NNT of 1 is a perfect therapy. One person undergoes the treatment and that person gets the intended benefit. The higher the NNT the more people who must undergo the treatment in order for at least one person to benefit.
Let’s now use NNT to look at statins vs a lifestyle approach for heart disease.
Statins
Statins, which have become synonymous with “heart-attack-and-stroke-preventing,” have an NNT of 60 for heart attack and 268 for stroke: That’s how many healthy people have to take statins for five years for those respective outcomes to be prevented. In people with heart disease already, the number is smaller: Just 39 must take statins for five years for one non-fatal heart attack to be prevented, while 83 have to do so for one life to be saved. If 125 people with high blood pressure take drugs for five years to lower it, the meds will prevent a fatal stroke or heart attack in only one.
Source: What are the odds that your medication will help you get better?
This means 39 people with heart disease must take statins for five years in order to prevent one fatal heart attack. Stated differently, the statins helped 2.6% (1 / 39) of those people by preventing a repeat heart attack with five years of treatment. None of these people got better… but one avoided a fatal heart attack. This might be success in “sick care” but is a miserable failure in “health care”.
Ornish Lifestyle Medicine
In July 1990 (yes, nearly 30 years ago) Dean Ornish, MD and others published Can Lifestyle Changes Reverse Coronary Heart Disease in The Lancet. In the article the authors highlighted the results of a randomized controlled trial:
Overall, 82% of experimental-group patients had an average change towards regression. Comprehensive lifestyle changes may be able to bring about regression of even severe coronary atherosclerosis after only 1 year, without use of lipid-lowering drugs.
What does this mean for those suffering from heart disease? The Editor’s Choice in the October 2010 BMJ says it best:
80% OF THE PATIENTS ARE CLINICALLY CURED AND PAIN FREE AFTER ONE MONTH (NNT=1)
When the patients understand the association between life-style and health and change the way they think, feel and live, they heal. Ornish has shown us that it really is that simple, also when it comes to the most severe physical diseases like coronary vessel stenosis in the heart and prostate cancer.
It normally takes the heart patients less than a month to reopen an almost closed coronary artery, which is lightening fast! How efficient is his medicine then? Well, according to the published statistics, about 80% of his heart patients are cured by the intervention, both in short term (1-3 month) and in long term (3 years).
Source: BMJ 2010;341:c5715
This was not simply about avoiding a coronary event. The Ornish Lifestyle Medicine therapy was curative… it reopened the coronary artery.
Making the Point
We can plainly see that approaches like Ornish Lifestyle Medicine are effective, based on clinical evidence that has been published for decades (NNT = 1). We know that statins are far less effective through various population studies (NNT = 39). The difference between statins and a lifestyle approach is not just efficacy; rather, even the claimed benefits are dramatically different (avoiding coronary event for statins and reopening coronary artery for Ornish Lifestyle Medicine). However, the topic before the US “sick care” system is not “How do we get more patients off statins and enrolled in lifestyle medicine”? Instead we are debating whether to keep ineffective and dangerous statins or use a new class of drugs that are far more expensive.
Nearly 90 percent of the patients [Johns] Hopkins wants to put on expensive, powerful PCSK9 inhibitors are initially rejected, making heart disease perhaps the central stage in the battle over high U.S. drug prices. In the least, it’s the drug-pricing battle that may matter to the most Americans: Heart disease is the No. 1 cause of death in the country.
Two years after PCSK9 inhibitors from Amgen and Sanofi-Regeneron hit the market, patients are caught in the middle. The injectable drugs — which block a liver protein that prevents the organ from breaking down cholesterol — reduce bad cholesterol as much as 60 percent when combined with statins that have dominated cholesterol-reduction treatment for years. And they work for patients who get poor results from statins or can’t take them because of side effects, Martin said.
Most people with high cholesterol do fine with statin treatment, Ofman said. Those drugs, whose sales peaked at nearly $40 billion but have been battered by generic competition since 2012, are effective in most patients and have few side effects in about 90 percent of cases. In the rest, the most common side effect is muscle pain, which can be severe enough to make patients seek alternatives.
Source: Insurers, doctors battle over new heart disease drugs
We spent $40 Billion on a statins that reduced risk of a fatal heart attack by 2.6%. The statins did not heal anyone, just reduced the risk of a heart attack. And there are known adverse events such as diabetes that may well offset the benefit of a lower risk for heart attack. So then what does this new wonder drug look like?
The estimated cost of treating 74 patients (the number needed to treat (NNT)) for two years with evolocumab [PCSK9 inhibitor] is $2.123.800. That would be the cost of preventing one event (cardiovascular death, myocardial infarction or stroke) over a period of two years.
Source: Evolocumab (Repatha) for Heart Disease – The FOURIER Trial – Success or Failure?
We can prevent one event per 74 patients over a two-year period at a cost of $2,123,800? Again, no one gets cured and, in this case, we have reduced risk of a coronary event by 1.3% (1 / 74).
Only in a “sick care” system can statins vs PCSK9 possibly rise to the level of a debate.
The Question
We have known for three decades that a lifestyle approach is a perfect therapy for heart disease (NNT = 1). We have known for at least 5 years (date of NNT statin study is 2013) that statins are only somewhat effective (NNT=39) and can actually cause harm (i.e., developing diabetes or muscle damage). The US “sick care” system writes scripts for $40 billion to cover “cheap” statins and wants to move to expensive PCSK9 which is still not a cure and seems less effective than statins based on the NNT.
If we truly want to transform from “sick care” to “health care” and provide more health at lower costs, we must answer this question: Why isn’t a funded prescription for several months of lifestyle coaching and products a required first step for EVERY person who faces a chronic illness before escalating to costly and risky pharmaceutical or surgical therapies? I understand lifestyle will not work for some people… they will simply not change and prefer “sick care”. The lifestyle approach is only first step, not a barrier.
Pharmaceuticals and surgeries are wonderful advancements in modern medicine. They have their place. However, that place should not be the first line of defense for chronic diseases… especially where there are evidence-based alternatives than can lead to a reversal of the disease.
Be Well!
-Tim
Tim Perry, MPA, MS, CPHIMS, PCMH CCE, CISSP is the Chief Information Officer of Consumer Health platform HealthCareToo.com. Tim has a deep passion for transforming and improving healthcare that spans two decades. He is blessed with a wonderful wife and two inspiring children. Tim has practiced Tai Chi (Taiji Chuan) for over 15 years and enjoys cooking wholesome (and easy) meals.
Other Articles by Tim
Can You Handle the Truth about Healthcare?
What If We Treated The Whole Person?
“Why Is Health Care So Expensive”–The Wrong Question
Not Value Based Care… But Care Based on Values
Bending the Healthcare Cost Curve
Will We Always Wait Until It’s Too Late?
Why Patient Engagement Is So Hard: and why it won’t change anything
Healthcare Is A Team Sport– an IT Perspective
A Quick History of the US Healthcare System: How Not To Repeat It (written w/ Microsoft Sway)
The Future of Healthcare Is In The Past
When Will The Healthcare Dam Burst?
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