Stupidity reigns once again. We don't need better blood thinning agents, we need to solve why clotting occurs and stop that. What triggers the clotting? You go after the primary problem, not the secondary problems. Does no one understand cause and effect?
http://medicalxpress.com/news/2014-11-fund-blood-thinning-agents.html
Care gaps are emerging due to disharmony between healthcare
reimbursement policies and evidence-based clinical guideline
recommendations, cautions a group of Canadian physicians. Writing in the
Canadian Journal of Cardiology, they use the example of stroke
prevention in atrial fibrillation (AF) to make a case for engaging with
policy-makers to address the growing barriers to patients' access to
optimal care.
Stroke is a costly disease, imposing a
significant human, societal, and economic burden. AF affects about one
in eight people over age 75 and increases the risk of stroke
five-fold by causing local blood clots in the heart that can break off
and go to the brain. These strokes can be prevented by blood-thinning
drugs ("anticoagulants"). Traditionally, the only effective
blood-thinning available for AF was based on a compound (warfarin) that
inhibits the production in the body of vitamin-K dependent clotting
factors.
Warfarin was originally introduced (and is still employed) as a rat
poison, and requires very careful use and close safety monitoring in
humans. A newer set of compounds, which act directly on clotting factors
(called "Direct Acting AntiCoagulants," or DOACs), has been introduced
over the last few years. DOACs are simpler to use than warfarin and
clinical trials consistently show that they are safer; however, they
cost more. Thus, while national guidelines like those of the Canadian
Cardiovascular Society generally recommend the preferential use of
DOACs, government healthcare funders have been reluctant to provide
patients with unrestricted access based on physician prescription.
Stroke in the setting of AF carries an 80% probability of death or
disability. In Canada, healthcare expenditures are the single largest
category of public expenses with a growth rate that overshadows the rate
of economic growth. A recent Canadian stroke costing study reported the
average overall cost per patient of the first year of stroke as over
CAN$74,000. The initial three months accounted for just over half the
overall cost and was driven primarily by hospitalization and
rehabilitation. Subsequent costs, such as continuing rehabilitation,
homecare, and paid caregivers, contribute substantially to the overall
cost of stroke to society. Thus, any extra costs of paying for DOACs
must be weighed against the overall health expenditure savings that they
produce via their superior value in stroke prevention.
"Although two-thirds of AF-related strokes are preventable with
appropriate anticoagulation drugs, these have historically been
under-prescribed and poorly managed for the Canadian population with
AF," says lead investigator James A. Stone, MD, PhD, Clinical Professor
of Medicine at the University of Calgary. "National and international
guidelines endorse these drugs as first line therapy for this
indication. However, no Canadian province has provided these drugs on an
unrestricted basis. These decisions appear to be founded on silo-based
cost assessment - the drug costs rather than the total system costs -
and thus overlook several important cost-drivers in stroke."
While national guidelines in Canada endorse DOACs (dabigatran,
rivaroxaban, and apixaban) in preference to warfarin for stroke
prevention and reduction of the risk of intracranial bleeding, and hence
the first line therapy for this indication, the Canadian Agency for
Drugs and Therapeutics in Health (CADTH) has recommended that these
agents receive reimbursement only if warfarin cannot be used (e.g., due
to allergy) or after an initial attempt with warfarin therapy has been
unsuccessful.
"This places healthcare providers in an awkward position," says Dr.
Stone. "They are required to treat many patients in a manner that is
discordant with national guidelines and this may have a deleterious
clinical impact given recent evidence of heightened risk of both ischemic stroke and bleeding in the first month of initiating warfarin therapy."
According to the authors, CADTH appears to have considered only
direct costs such as drug acquisition, the cost of anticoagulation level
management itself, treatment costs for bleeding, and avoidable stroke,
rather than a more global assessment that includes the cost of the
outcome to the patient and indirect costs such as costs associated with
undergoing blood clotting assessment, lost productivity due to stroke,
and longer-term expenses of caring for individuals who have experienced
stroke.
"It is within our personal and professional capacity to direct our
efforts at prevention of diseases such as stroke that have such
significant human and economic consequences. Appropriate anticoagulation
of individuals with AF is an extremely effective means of accomplishing
this," notes Dr. Stone.
"Cost containment is essential. However, we must ensure that we
consider a complete assessment of costs when we make policy decisions
and not limit the scope to select budget silos, and ensure that all
stakeholders can understand how and why funding decisions are made. We
have a responsibility to our patients to engage with policy-makers in
addressing and resolving this barrier to optimal patient care. There
needs to be a collaborative approach between funding agencies and
clinical practice guideline groups in an effort to clearly defined
clinical practice strategies, in any preventative or disease treatment
paradigm, that lead to the best cost utility," he concludes.
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