Cost is a gaping hole in scientific discourse

My perspective on scientific publications has been greatly affected by my experience with this blog and social media in particular.  The ability to serve as author, reviewer, advertiser and marketer can be easily achieved in this space thanks to the power of self-publishing.  But with this new platform comes new responsibilities and for those of us who chose to work with people daily, perhaps none is as great as maintaining the trust of our patient readers.

A recent New England Journal of Medicine opened my eyes to another revelation in scientific reporting where doctors have not been completely honest with our patients.  While few are as enamored with scientific innovation as myself, I find there is a gaping hole in scientific discourse that doctors have not forced to the surface when new innovations arise.

What’s that hole?

Cost.

In an era where scientific discovery has only been eclipsed by price inflation, doctors have not taken responsibility for insisting this cost of any new innovation’s impact on our health care system be disclosed in scientific articles reviewing the medication’s risks and benefits.   We have not insisted that major medical journals reveal which articles are provided free to the public through tacit collusion with their pharmaceutical sponsors.  (While the exact price might not be known at the time of publication of these articles, the estimated cost to our health care system can probably be guessed depending on the novelty of the medication or device and the expected return on investment a manufacturer would hope to achieve.)  To be fair, most reputable journals do require disclosure of manufacturer’s sponsorship of the reported trial, but no where do the journals report the money they receive from those same manufacturers for making favorable articles about a drug or device open access to the public.

Take a recent New England Journal of Medicine. Three articles appear on our new novel oral anticoagulants that lack cost information and disclosure information from the journal regarding if they paid for the article to be open access:

Apixiban for Extended Treatment of Venous Thromboembolism: The article is open access and not a word about the cost of the drug.  Did Bristol-Myers Squibb or Pfizer (or both) pay to be sure this article was open to all?

Extended Use of Dabigatran, Warfarin or Placebo for Venous Thromboembolism: The article is open access and not a word about cost of the drugs.  Did  Boehringer Ingelheim pay to be sure this article was open to all?

Rivaraoxaban for Thromboprophylaxis in Acutely Ill Medical Patients: The article is open access and not a word about the cost of the drugs.  Did Bayer Healthcare Pharmaceuticals and Janssen Research and Development pay to be sure this article was open to all?

Increasingly I find the cost of these novel oral anticoagulants relative to warfarin factors in to conversations I have with patients during their decision about which drug to start.  Granted, it is just one factor, but an important one.  I also find the deluge of pharmaceutical benefit manager denial letters to be a real thorn in my side as I have to constantly justify to payers why one drug has better benefits for an individual patient than another.  Not being armed with cost information puts me at a disadvantage when speaking with these deterrents to care.  The reality is this: we simply HAVE to have honest discussions with our patients about cost these days, especially since more and more costs for care are being shouldered by our patients than ever before and the financial impact of their care has huge psychological implications.  If I have to disclose everything about my relationship with industry thanks to the Sunshine Law, our scientific journals should do the same.

It is for this reason that we should insist on at least relative cost information of new technologies appear in scientific reporting, especially when the cost of new innovations exceed existing innovations by over a factor of 10.  In this era of health care reform and growing cost concerns, patients (and their doctors) deserve disclosure of at least a relative benchmark of price so we can make the best informed medical treatment decisions with our patients that benefits not only their physical well-being, but also their psychological and social well-being too.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • Ian

    With pharmaceutical prices lately, I always just figured that as a general rule if it ends in mab, tran, or ban that it will cost in equivalency to buying somewhere between a used car or a new exotic sports car annually. Where in that range it falls is often dependent on whether the medication is oral, administered in the office, or must be admistered in the hospital.

    That being said, and I do ask someone to correct if I’m wrong as anti-coagulation is not part of my daily life. If in this study of the effectiveness of Apixiban you wanted to consider a cost comparison, woudn’t you have to take into consideration, cost of the drug, lab monitoring, maintenance visits (in office, coumadin clinic etc), and the cost of treating complications? It would seem that there is more to it than drug X costs this compared to drug Y at the pharmacy. While this is an imporant question, this would then change the statistical power needed to answer the clinical questions because now you have additional and different questions to answer. Does it work, and is it cost effective which will likely require completely different patient base to perform an accurate statistical analysis. If you follow this thought process far enough you end up adding additional research costs, delays in development of medications, and additional excuses for pharma to jack up their prices even further.

    I am however sympathetic to this idea for studies whose goal is to show non-inferioirity. Who cares if it’s “just as good” but costs 1000x as much. Personally I would just prefer it if there were less commercials about men being tired and that means their testosterone is low.

  • Satish Raj

    Dr. Wes,
    I enjoy many of your posts.
    In terms of this post, cost (whether it be a drug or a device or a treatment strategy) is a functioning of marketing, and may vary greatly from one jurisdiction to another. This is not controlled, and in many cases not known, by the investigators. In some cases, it is not knowable. The study may have been done in an effort to obtain regulatory approval, while the prices of therapy may only be determined after that time.
    Overall, the point that societal costs (and not just individual costs) are important is well taken. However, I do not think that burden should be on the investigators.
    As you are likely aware, by statute the FDA is not permitted to factor in costs into their approval decisions. This is unlike in other countries where this is factored in such that the combination of effectiveness and cost (an “added value” metric) is used for approval (e.g. NICE in England).
    Even if costs are not included in the approval process, perhaps a more robust system of rating relative costs and benefits of therapy (even if not in a formal “cost-effectiveness” analysis) might be a useful tool for patients, providers, and insurers.