“Government Study Debunks Stroke Treatment”

Today’s Managing Health Care Cost Indicator is $20 million

It’s not often you see such a headline in the New York Times.  The paper is reporting on a paper published in JAMA that showed those with history of “prestroke” with proven blocked neck arteries who received surgery to increase brain blood flow had no fewer strokes than those who were treated without surgery.  The study was stopped early when there was not even a trend of improvement among those treated, and far more early strokes.

A JAMA editorial writer wrote that “doctors liked new technology, were paid well to use it and tended to believe in what they were doing, even without data.”

The thing is –the procedure worked!  Those who had the bypass surgery did have greater brain blood flow.  Unfortunately, the intermediate outcome measure (more brain blood flow) was not especially correlated with the desired outcome measure (fewer strokes.)

This is the kind of effectiveness research we need so that we spend precious health care dollars on services that genuinely improve health,  and the kind of research that only the government is likely to fund.  It’s a small investment –since if 24,000 Medicare recipients a year would have been candidates for this operation, the total cost if it was widely adopted would have approached a billion dollars.   But who besides government would spend $20 million to study this?  Alas, funds for the NIH are being cut,  and this kind of important research will be threatened.

There were two reports in the NEJM this past week also reflecting the importance of large, multi-year, government-funded studies of interventions that seem like a good idea, but had never been rigorously studied.  Alas, both also showed little of the financial savings promised by boosters.

RTI reported on the Medicare Health Support trial, which was terminated in 2008 when none of the disease management companies appeared to be on target to save as much money as their interventions cost.   The study is flawed, of course, since the information available to those companies about the “at risk” Medicare beneficiaries was often available far too late.  Still, most of us deeply believed that these programs would be more successful at preventing hospitalizations in the Medicare population, a target-rich environment.   

The other is a commentary about the Physician Group Practice Medicare demonstration project.  The groups improved quality substantially.  However,  high hopes of dramatic declines in health care spending were not realized.  2 of the 10 groups had savings of over 2% at one year, and half had savings of over 2% at five years.  These were all groups with robust infrastructure, committed leadership, and cultures of prudent use of resources.   This shows that creating Accountable Care Organizations from physicians in practices that are currently fragmented and disorganized will be very hard indeed.