Bad medicine

Two reports in the NEJM cast doubt on just how well the market works in U.S. healthcare.

In the first (free full text!) the popularity of nesiritide, a treatment of heart failure is questioned:

How can a drug that is associated with higher rates of both renal dysfunction and death than placebo — and that costs 50 times as much as standard therapies and for which there are no meaningful data on relevant clinical end points — be given to more than 600,000 patients and be promoted throughout the United States for serial outpatient use, an indication not listed on the label?

The answer, unfortunately is a marketing campaign combined with a strategy that make provision of the drug financially advantageous for the doctor's who prescribe it:

an aggressive marketing campaign by the manufacturer, Scios, which is encouraging physicians to start their own "infusion centers" for whose services they can bill Medicare as if they were providing chemotherapy

In the second, we learn how Guidant, maker of implantable defibrillators, failed to warn physicians and patients when it learned that one of its products was prone to short-circuiting, leaving patients unprotected and leading to unnecessary deaths. While the risk was arguably small, the company seems to have covered up the data for finanacial reasons:

Guidant, the second-largest manufacturer of implantable defibrillators, had identified the electrical flaws in the Prizm 2 DR in February 2002 and had made manufacturing changes, on April 16 and November 13 of that year, in an effort to prevent this rare but unpredictable and catastrophic type of failure. To date, there have been no reports of failures of such devices built after the April 2002 change. Guidant, however, continued to sell devices that had been manufactured before that change was made and issued no public statements about the problem or the corrections. The company’s first announcement came on May 23, 2005 — more than three years after Guidant had become aware of the problem and hours before the New York Times published an article about Oukrop’s death.

The problem in health care is too often the incentives are in the wrong place. Nesiritide is lucrative for physicians who prescribe it and the company that makes it, but at best an unnecessary expense for the system as a whole (and a danger to patients in the worst case). While society benefits from the knowledge that some of Guidant's products are defective, Guidant (who has the information) doesn't and is actually hurt by it's disclosure.