Bedside Rationing

A fascinating post about the role of clinicians in "bedside rationing" of medical care at Maurice Bernstein's blog, Bioethics Discussion. As I understand it (and I am not an ethicist) bedside rationing means individual docs deciding what care to provide to their patients based on what is cost effective.

In general, doctors are taught that there responsibility is to their individual patients. Therefore, we should do whatever is best for our patient, and not consider, for example, that exorbitant spending will drive up the cost of health care, making it less available and affordable. How costs are controlled is left a bit blurry, but usually it is felt that insurance companies or HMOs will ration care by refusing to pay for certain treatments or at least putting limits on when they'll pay.

I'd like to describe a specific example. Omalizumab (trade name Xolair) is a recently approved treatment for patients with asthma. IgE is the antibody that causes allergies. When you have IgE to something you have reactions like hives, wheezing, etc when you are exposed to that specific thing (technical term is antigen). If you are allergic to peanut, you have IgE that recognizes peanut and when you eat peanut you will get hives, throat tightness, difficulty breathing, etc (anaphylaxis). Reactions to antigens that are found in the environment are generally less severe and triggered by inhaling the offending agent. Examples would be cat dander and ragweed pollen and symptoms might be runny nose and congestion (allergic rhinitis) or wheezing and difficulty breathing (asthma).

Omalizumab is an antibody (an IgG antibody, a different type than IgE) that recognizes human IgE. The idea is that it binds up the IgE you already have and prevents the IgE from causing an allergic reaction. It is now approved in use for patients with moderate to severe persistent asthma (this is per national guidelines and represents pretty hard to control asthma; to the layman moderate persistent asthma would seem severe) who meet certain criteria regarding IgE level and having demostrated allergies. It works, with pretty dramatic reductions in severe exacerbations, ED visits and hospitalizations. It is given as a shot every 2-4 weeks.

The problem is it is incredibly expensive (10-12,000 dollars/year and benefit probably last only as long as you keep taking it) and not cost effective (see Oba and Salzman, J Allergy Clin Immuno 04 114:265). The Oba paper suggests it would be only cost effective in patients who were hospitalized 5 or more times per year or for a total of 20 or more days. While there might be a few such patients out there, no one can identify a group of such patients prospectively.

So what am I, as a practicing allergist to do about using this effective, but expensive medicine?

It would seem I have several options:

1. Not use it at all as it is not cost-effective. It is my job to provide cost-effective care, thereby keeping overall health care costs down, making health insurance as affordable as possible, etc.

2. Use it for my most severe asthmatics, only after trying everything else (other, cheaper medicines, checking on compliance, etc). This is the in-between option. One obvious weakness is that every asthma specialist is likely to have a different approach to who to use it for

3. Use it for everyone who qualifies (there are moderately strict criteria for use, although insurance companies appear to be approving it for more people who don't quite meet the criteria). It is not my job to ration health care. I will do what is best for my patient and it is for someone else to figure out how to make health care more cost effective

I would say I'm between 2 and 3 in my use. I don't give it to just everyone, but I do use it for pateints with pretty bad asthma who aren't responding to other medicines or who have a decreased quality of life, even if they are rarely if ever so sick they need to go to the ED or be hospitalized. In general, I wouldn't prescribe it for those who won't be compliant with inhaled steroids and other less expensive medicines.

Two more scenarios
1. A young woman (say 22) with severe asthma, known cat allergy who refuses to give up her multiple cats and even sleeps with a new kitten here fiancee gave her (must really love her a lot, huh)
2. A similar women with severe asthma who is a smoker.

I said no to #1, but yes to #2. Why? I can't justify it. The women in #1 seemed obnoxious to not even consider trying to get rid of the cats, while the women in #2 wanted to quit smoking (and we are working on this) but was just so addicted. I told a colleague about this, and she was outraged. She felt patient #1 was justified in not wanting to give up her beloved cats, while patient #2 had no particular reason to keep smoking.

I think these two cases illustrate the difficulties in each provider acting to ration care. Based on differences between providers (not surprisingly my outraged colleague is an animal lover and I am not) you will get very different outcomes.

My overall belief is that leaving docs to do what is in their patients interest and someone or something else to ration care is best, but I can't tell you who or what that other entitiy is.