A commenter (I believe a physician) on one of my posts wrote the following:
I can prevent heart attacks and strokes (caused by atherosclerosis – “blockage”) in people (minimal cost) who have NO symptoms. If I wait for their heart attack or stroke – it costs a WHOLE lot more.
The implication is that screening and treating high cholesterol saves money in the long run. Unfortunately, the truth is the opposite. This is an extremely common misconception among most people in healthcare, physicians included. Therefore the American people believe the same thing.
If I give a person a pneumonia shot and that person lives the rest of her life never catching pneumonia, then there is a fair chance I prevented a case of pneumonia. On the other hand, she may not have ever gotten pneumonia any way, therefore the shot was useless. There’s no way to sort that out, but classifying a vaccine as preventing a disease is certainly fair.
What is a person with high cholesterol who doesn’t eat ideally, doesn’t take his medicine consistently, and never exercises most likely to die from? A heart attack.
What is a person with high cholesterol who eats lots of fruits and vegetables, never misses a dose of his cholesterol medicine, and has 30-60 minutes of vigorous exercise every day most likely to die of? A heart attack.
A lot of the screening/prevention work family physicians do add a few healthy months or years of life to their patients, at a cost. We don’t really save lives when we prescribe statins, we just push back the moment of injury (nonfatal angina or heart attack) or death a little. One could argue that the overall death rate from cardiovascular disease is reduced with statin treatment. That’s true. But the effect is not huge, and it just means people will die of other expensive diseases such as cancer and Alzheimer’s.
These realities drive the findings of the cost-effectiveness studies on statin treatment that calculate to extend a low-risk person’s life with a statin costs over a million dollars per year of life extended. That’s the net cost of doctor’s visits, lab tests, and drugs, minus any future savings from fewer heart attacks and hospitalizations.
If I see a very sick patient in my office, diagnose him as having a severe kidney and blood infection, admit and care for him in the hospital, and he survives this infection, I saved his life. If I treat a low- to moderate-risk risk patient who has high cholesterol with a statin drug, I know statistically her life expectancy has now increased by a few weeks. I believe it is hyperbole to say I saved her life. A much more humble and realistic assessment is that I extended her life. I delayed her death, on average, by a few weeks.
Here are links for two of the classic papers on statin cost-effectiveness if you’d like to read more.
To be very clear, I’m not suggesting that prescribing statins is a useless waste of our time. I am saying that the bang for the buck isn’t that great in many cases. (Just to confuse the issue, I also have my doubts that the risk/benefit balance of drug therapy has solid evidence behind it for low-risk patients).
My final position on this issue is that I really don’t care if the American people want me to screen and treat everyone for high cholesterol, only the high-risk patients, or none at all. It’s their money, time, and hassle. I just want them to be sure they know that as they expect more aggressive screening and treatment, their healthcare costs will rise. I can practice medicine at whatever point they want to draw the line. They just need to keep in mind that for most technology-driven preventive services, an ounce of prevention costs a ton of money.