Heartfelt with Dr Melissa Walton-ShirleyView all posts »
"Auld Lang Syne" for CV medicine: The "Biggest Loser" and winners of 2009Jan 4, 2010 22:55 EST
The entire world celebrates my birthday. Actually, the entire world celebrates "on" my birthday. On each December 31, we herald the beginning of a new year while bidding the previous one a nostalgic goodbye. Some of the largest medical-trial winners in history were born in 2009. Parented by the pharmaceutical world, of course, the impending arrival of dabigatran gets my vote as the top pharmacologic advance for the decade, with dronedarone coming in a distant second. Unfortunately, "comedy and tragedy" are a classic pair, and as fortunate as we've been with new medical advances, we will be equally as devastated as 2009 marks the end of access to American cardiology care as we know it. Thanks to the misguided efforts of the Centers for Medicaid and Medicare Services (CMS) to rein in spending, CV subspecialists already burdened by physician shortages will no longer be able to retain their physician extenders and provide certain services in the office setting. Access to cardiovascular care will become a luxury that will be hard to explain to younger cardiologists, who will just nod their heads with no real understanding or interest when we reminisce ( kind of like teenagers do when their parents talk) about "the good ole days."
I don't think any of us really know how big the dabigatran story was until we've lived it. Though Coumadin monitoring won't completely disappear (there will always be metal valves and second-trimester pregnant women with anticoagulation needs), the ability to anticoagulate patients with less hassle will be huge. No more whining about the monthly or more monitoring treks patients must make to utilize the high-maintenance drug warfarin. No more whining about the piles of charts waiting for us at the end of each day just to manage the prothrombin times. I have a couple of concerns, though. As much as we hate to drag patients in for protime checks, I can't forget how many patients have been helped just because someone noticed how pale they were or because the patient had an opportunity to tell someone "I don't feel well." So many times, patients were found to have poorly controlled rates, bradycardia, anemia, and other issues. I think there might be delays in care just from the lack of face-to-face interaction.
I hope greed won't dampen our celebratory mood. I fear that the market price for dabigatran will hinder access. I'm afraid the sales pitch will include a justification that the "cost of monitoring will be less, so I can charge the heck out of your patient."Please, Boehringer-Ingelheim, pleasantly surprise me by granting my New Year's wish of affordability for your compound. I want to celebrate this new medication every year for the rest of my life, kind of like I do "Dick Clark's New Year's Rockin' Eve." And remember, Bayer is waiting in the wings with rivaroxaban (Xarelto), which might just be a once-daily medication, with a huge trial set for release in the second quarter of 2010, so B-I, be competitive! FDA, punctuate my wish for affordability with speedy approvals!
The "distant second," dronedarone, has won my heart already. Despite the whine that the company didn't have its infrastructure ready for marketing and snarled many a cardiologist's office staff with trying to get the drug approved by the insurance company, I almost forgive them. Insurance companies should be ashamed of the several months of hassle of denying patients access to an FDA-approved drug with a lower side-effect profile and improved safety. It made them look like uncaring uninformed idiots, and they will have to work hard to regain the trust of their patients--if they really ever had it at all. Dronedarone works, is well tolerated, and easy to use in patients without advanced heart failure.
The "Biggest Loser" of 2009 is the CMS. It should have been a really big "duh" moment for the person who came up with the idea of cutting cardiologists' reimbursement, because "cardiovascular expenditures are greater than any other subspecialty in medicine." The "duh" should have come with the realization that more people are dying of cardiovascular illness than any other malady, with more costly chronicity than any other specialty (Like, duh, CHF is our most expensive DRG); therefore, it costs more to treat more people with the worst kind of illness. It's not the "greedy cardiologists" who are driving up the cost of healthcare. It's poor lifestyle choices, medical malpractice, and lack of access to screening and prevention that drive the cost of cardiovascular medicine in America. Destroying the practice of cardiology by making young physicians run away from our profession won't help it. Causing young residents to shy away from long hours because of inability to repay their student loans won't help it. Forcing the early retirement of middle-aged cardiologists won't help it. Breaking practices around the country by allowing the cost of equipment and testing materials to soar while cutting reimbursement won't help it. Our president will need to have an "aha" moment and get behind medical mediation efforts to fix this mess and actually listen to those who practice medicine in the trenches in order to understand it. Prevention and detection must be married to appropriate treatment strategies fostered by a decrease in the fear of litigation in order to rein in spending. Don't reinvent the wheel. Look to the Lone Star State for the best way to manage the malpractice crisis. Make America "smoke-free" and make tons of dollars in a short amount of time to fund and drive prevention measures. Make a plan and execute it immediately!
For cardiologists in the middle or the end of their practice lifetime, we'll sing "Auld Lang Syne" as we mourn the loss of the era when cardiologists made a decent living delivering decent care. However, for patients in need of safer and more effective anticoagulants and an antiarrhythmic with a marked reduction in need for monitoring, with fewer drug interactions and improved tolerability, it's been a banner, life-changing and practice-changing year. The corks should continue to pop (on nonalcoholic champagne, of course!) all around the world for these great medical advances for years to come!
Too bad that in the next decade, there won't be nearly as many physicians around who actually know how to use them.
Auld Lang Syne indeed.