Medical debate looks at comparing therapies
Patient Joel Thomas, left, of Lincoln discusses his shoulder injury with Dr. Stephen Weber, an orthopedic surgeon. Weber conducted a study using platelet-rich plasma in a group of patients recovering from torn rotator cuffs; he concluded that the treatment didn’t make a difference.
With Tiger Woods and Pittsburgh Steeler Hines Ward providing star-powered proof, demand boomed in recent years for injections of “concentrated” blood rich in platelets to relieve hard-to-heal joint and tendon injuries.
But Dr. Stephen Weber, a Sacramento orthopedic surgeon, was not convinced that the new therapies involving so-called platelet-rich plasma would speed recovery. So he conducted a study.
When he compared the outcomes among patients who used the blood product to help mend torn rotator cuffs and those who didn’t, Weber concluded that it didn’t make a difference and wasn’t worth the extra hundreds of dollars in expense.
“My advice to patients: Be skeptical,” he said.
The country as a whole could use a dose of such skepticism when it comes to expensive new therapies, critics say.
More than $700 billion is spent annually on unproven medicine and procedures, a significant factor in the escalating cost of health care. Patients and doctors rush to adopt the latest and newest medical treatments – often without regard to whether they actually make sense from a cost-benefit standpoint.
Some members of Congress are taking aim at the problem by proposing research centers that could promote less expensive approaches in health care.
Such research centers could serve as libraries of best practices and proven medicine, gathering data that would better inform health care decisions made by physicians and their patients.
The health insurance industry, which blames escalating premiums on the high cost of dispensing medical care, supports the effort – in theory.
“Health plans certainly want this kind of information. Which treatment works best is really crucial information,” said Robert Zirkelbach, spokesman for the group America’s Health Insurance Plans.
In the absence of such scrutiny, he added, “Patients aren’t always getting the best medical treatment.”
Because the proposal for comparative research centers is included in the massive health care bills now before Congress, its fate is uncertain.
If passed, it would build on the $1.1 billion allocated to so-called comparative effectiveness research approved in last year’s economic stimulus package, which will fund programs at existing federal agencies and create a council to provide guidance.
Critics say establishing Comparative Effectiveness Research Centers, as they would be called, could lead to treatment being dictated by nonmedical oversight panels.
They’ve also raised the specter of rationing. Former vice presidential candidate Sarah Palin deepened the controversy last summer by referring to “death panels” that could make life-and-death decisions.
Pharmaceutical companies and medical device companies have been wary of comparative effectiveness panels that, they say, could be automatically dismissive of products deemed too expensive.
Advocates dismiss those concerns, saying the intent is much more benign: Reduce pain and suffering – and wasted expense – by educating doctors and consumers about medical care that is safe and effective.
In some cases, the research centers would weigh in, analyzing data or launching studies of their own.
Supporters say the proposals would in no way undermine the doctor-patient relationship. The House health bill states that it would not “authorize any federal officer or employee to exercise any supervision or control over the practice of medicine.”
The idea, rather, is to provide information that health plans, hospitals and doctors could use to decide which treatments make sense. Health care costs have been steadily escalating and are now estimated at $2.3 trillion annually nationwide.
About a third of this money now goes to pay for health care products and services whose value is unproved, according to estimates by the Congressional Budget Office.
More expensive doesn’t always translate to more effective, according to researchers at the Dartmouth Atlas Project, which for the past two decades has been monitoring what it says are “glaring variations in how medical resources are distributed and used in the United States.”
Regions that spend lots of money on health care don’t necessarily get better results than other areas with lower expenditures, according to the researchers.
While some experts blame the high cost of medicine on expensive new technology, that’s only part of the problem. In general, there are few incentives for doctors and patients to keep costs down – particularly when health insurers are picking up most of the tab.
The U.S. Food and Drug Administration approves pharmaceuticals and medical devices for use, but it does little to inform the public about how truly effective a drug or device is – compared with other drugs or other treatments, said Maribeth Shannon, director of the market and policy monitor program for the California HealthCare Foundation.
“It’s a common American phenomenon to jump on the new thing,” she said. “But it may or may not be better than existing therapies.”
That may be the case when it came to treating joint injuries, said Weber, the orthopedic surgeon.
Weber launched his study last year after noticing the increasing use of platelet-rich plasma therapies in repairing joints and torn tendons.
Some doctors believe that platelet-rich blood, when injected or surgically implanted into wounds, helps the body more quickly repair bone and tissue, particularly in hard-to-treat tendon injuries, such as tennis elbow.
Weber’s small study compared two groups that had undergone rotator cuff surgery, 30 patients in each, who volunteered for the research. They showed no noticeable difference in healing and effectiveness whether or not they were treated with platelet-rich plasma material.
Another study on the use of platelet-rich blood in Achilles’ tendon injuries, published in the Jan. 13 issue of the Journal of the American Medical Association, appears to corroborate Weber’s conclusion that the blood therapy may have little value.
But Dr. Alan Hirahara, another Sacramento orthopedic surgeon, stands by the therapy. He offered a study he conducted himself last year showing improvements in recovery for his patients, 139 of whom received surgery with the platelet-rich blood and 39 who did not.
“There was a big difference in my patient outcomes. We’re saving money; we’re saving the system money,” said Hirahara, who opposes comparative effectiveness panels.
“You should always justify why you’re doing things. If it’s not working, you shouldn’t do it because it’s wasting money,” Hirahara said.
Weber doesn’t quibble with that.
“We want to be the guys in the white hats – the good guys. If physicians aren’t responsible, then the government is going to step in,” said Weber.
He said he supports comparative effectiveness research but is wary of the proposed panels because they could take away decision-making authority from patients and their doctors.
“I prefer to do things that are supported by medical literature,” he said. “You want to be in front of the pack, but at the same time you have to be careful.”
The skeptic, he said, would seek out a second opinion.
In Dr. Stephen Weber’s office, a magnetic resonance image shows a patient’s shoulder. Knowing whether the newest therapy is the best one is a health care challenge.