Cost effective? Bah Humbug

NYTimes article tries to figure out why docs order expensive medicines (and leaves out the real reason for so much testing: Lawyers), althoug they mention why sometimes we don't follow the experts "guidelines": Too many tests not available for those of us in rural practice. But another reason is that too often the cases mix up apples and organges. Let's take this snippet:

For example, one study found that generic diuretic pills that cost pennies a day worked better for patients with high blood pressure than newer drugs that could be as much as 20 times as expensive. Because hypertension affects tens of millions of Americans, this finding had the potential to save the health care system billions of dollars. But the finding never really took hold; the percentage of patients taking the cheaper diuretics barely increased.

Not mentioned: They mainly work in populations that retain fluid (e.g. the black population), they often dehydrate our patients and make them low potassium and weak, and the really important fact: That ten to twenty percent of our men get sexual dysfunction from the pills.

Similarly, the "pril" drugs can cause a nasty cough (an allergy that gives you a "tickle in the throat") in ten percent of the patients.. So a doc with a patient who is not too good at giving you history or keeping appointments might prefer to prescribe a "sartan" drug that has the same advantages without the cough, but costs three times as much.

Finally, if you live in an area where you can't keep an eye on the potassium, you might want to use the medicine with the least side effects: the "pine" pills (amlodipine, nifedipine). That is why I spend the extra money to send Sister Euphrasia in Africa this pill instead of the cheaper ones: I can't monitor her potassium or her BUN, and I don't have to worry she will collapse from dehydration in the heat.

One more item on the population: When I worked with Native Americans, most of our high blood pressure was diabetes related. So a "pril" (or "sartan") type drug was preferred, since these medicines slow the rate of renal deterioration from diabetes.