- Kenny Lin, MD
A recent systematic review and meta-analysis from the Cochrane Collaboration broke new ground in evaluating not one intervention or group of interventions for a single health condition, but the more general question of whether new treatments are more effective than established ones. The authors analyzed data from four cohorts of publicly funded trials of cancer treatments, treatments for neurological problems, and treatments for mixed diseases. In this sample, they found that slightly more than half of new treatments turned out to be better than old ones, but not by much: primary outcomes were just 9 percent better with the new treatments, and mortality fell by only 5 percent.
To make it easier for family physicians to compare new treatments to old ones, AFP publishes the STEPS (Safety, Tolerability, Effectiveness, Price, and Simplicity) series of new drug reviews. The October 15th issue includes a STEPS review of rivaroxaban (Xarelto), a new oral anticoagulant that is indicated to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation. Under Effectiveness, the review notes: "Rivaroxaban was as effective as warfarin at preventing stroke and systemic embolism, and reduced annual stroke rates to 2.1 percent, compared with 2.4 percent for warfarin. No trials have compared rivaroxaban with dabigatran (Pradaxa), a direct thrombin inhibitor, or with fondaparinux (Arixtra), an injectable factor Xa inhibitor." Rivaroxaban does not require laboratory INR monitoring like warfarin, but costs more than 40 times as much. Family physicians and patients will need to decide whether this relatively small benefit is worth the increased cost of this new drug compared to the old.
Thursday, October 18, 2012
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New treatments also fail for the purpose of primary care delivery.
ReplyDeleteThe "old treatment" of family medicine yields 25 Standard Primary Care Years per graduate over a career, 6 rural SPCYRs, and 13 SPCYRs outside of current workforce concentrations. A single FM graduate results in 4 - 6 times more primary care per graduate compared to newest "treatments" such as NP and PA.
Generic primary care expanded to 29,000 annual grads (NP 9000, IM 7400, PA 6800, FM 3000, PD 3000, MPD 400) yields less than 7 Standard Primary Care Years and less than 3 Outside SPCYRs of primary care delivery where needed for 65% of the population in 30,000 zip codes outside of concentrations.
Dilute solutions such as generic advanced nursing (the most dilute) are promoted despite just 2 - 3 Standard Primary Care Years over a career.
Specific highest yield per graduate solutions such as family medicine residency graduates have been ignored for 30 years, remaining at just 3000 annual graduates.
New, innovative, and reorganized treatments all fail compared to the original with most primary care result per graduate, least cost of training per Standard Primary Care Year, and best results for the majority of Americans left behind.
I for one tend to wait a year or two for aftermarket experience with "new" treatments, as it seems often the risk of previously unexpected side effects lead to harm. Old is better when there is no proven benefit of new in these cases.
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