Uncategorized

WSJ Editorial on Liver Transplants Cherry-Picks the Numbers

Dr. Scott Gottlieb, a resident fellow at the conservative American Enterprise Institute, published an op-ed in the Wall Street Journal last week that returned to the much-exploited story of Nataline Sarkisyan, the 17-year-old Californian who died before receiving a liver transplant. Gottlieb used the story to make the argument that “the U.S. has the best health care in the world.”

Gottlieb is squaring off against John Edwards, who has been suggesting that if Nataline had lived in a European country she might have lived.  Edwards blames CIGNA, her for-profit insurer, for refusing to cover the procedure. Dr.  Gottlieb, who is a former FDA official, responds with a double-barreled argument: “Americans are more likely than Europeans to get an organ transplant, and more likely to survive it too.”  He sounds confident, and at first glance, his argument seems persuasive.

But a closer look reveals that Gottlieb makes his case by carefully culling the numbers that fit his argument, while omitting those that don’t. Unfortunately, too many people involved in the healthcare debate play fast and loose with the facts. Everyone interested in reform should be on the look-out for those who don’t cite solid evidence for their assertions. If they don’t give you their source, it may be because they don’t want you to look it up—and because they realize that they are cherry-picking the numbers.

Before engaging Gottlieb’s argument, I should acknowledge that, as I have said in an earlier post, I think Edwards has picked a bad case to make his argument for healthcare reform. I am not at all certain that the transplant would have helped this particular patient.  And while Edwards puts all of the blame on CIGNA, Nataline’s insurer, I am bothered by the fact that the hospital asked for a $75,000 down payment on the surgery and then refused to go forward without it. As one physician/blogger from the very same hospital where Nataline was treated asked: “Why didn’t the hospital simply perform the surgery and defer payment from the family or CIGNA [Nataline’s insurer] until later? If it was such a great idea, why didn’t they exhibit the outrage and strength of conviction to go ahead regardless of CIGNA’s assessment?”

That said, I agree with Edwards and other proponents of health care reform that, in other countries, decisions about whether or not to pay for expensive procedures like transplants are not based on whether the patient has the money or the insurance to pay for the operation. Instead, in other developed countries, such decisions turn on whether the benefits of the treatment outweigh the risks—and whether the procedure is cost-effective.

After all, in every country (including the U.S), we all pay for high-priced procedures, either in the form of spiraling insurance premiums or steeper taxes.  Thus, it makes sense to ask: “if we go ahead with this procedure, are we wasting resources on a futile treatment, or using money that could be used for the preventive care that would extend other lives?

Following this line of thinking, European countries put more money into preventive care and are less likely to give liver transplants to patients who are seriously ill—or appear close to death.  Gottleib himself points out that a 2004 study published in Liver Transplantation shows that “no transplant patients in the U.K. were in intensive care before transplantation, one marker for how sick patients are, compared with 19.3% of recipients in the U.S. . . . On the whole,” he notes, “the U.S. also performs more transplants per capita, giving patients better odds of getting new organs…In 2002… U.S. doctors performed 18.5 liver transplants per one million Americans. This is significantly more than in the U.K. or in single-payer France, which performed 4.6 per million citizens, or in Canada, which performed 10 per million.”

But– is the fact that we perform more transplants on sicker patients proof that we have a superior healthcare system?

Here, let me acknowledge that Dr. Gottlieb is generally more enthusiastic about experimental, long-odds medical treatments than I am. As the Seattle Times pointed out, when Gottlieb was appointed to  a  high-powered job at the FDA in 2005,  he came to the agency from Wall Street, where he “promoted hot biotech stocks to investors. Now Gottlieb holds the No. 2 job at the federal agency . . . that approves new drugs, oversees their safety and affects the fortunes of companies he once touted. Wall Street likes the appointment of Gottlieb, 33, who believes in faster drug approval and fewer news-release warnings to the public about potential side effects of drug,” the Seattle paper observed. “But some medical experts are shocked by his July 29 appointment, coming at a time when the public is increasingly concerned about the safety of popular medicines.”  (When Gottlieb left the FDA he returned to the American Enterprise Institute and started the Forbes / Gottlieb Medical Technology Report.)

Returning to my question: Is the fact that we perform a greater number of transplants on seriously ill patients reason to claim that U.S. health care is “superior”—or does it simply mean that we are more inclined to experiment on our sickest patients?

It all depends on how well the average patient who is plucked out of the ICU to undergo a liver transplant fares.  If he or she goes on to enjoy several years of high quality life, one would be inclined to say “yes”—our more aggressive care equals better care.   But if too many patients suffer complications and then die in great pain twelve or 15 months later, it would be much harder to argue that “doing more” makes U.S. healthcare “better”—especially when both the money and the liver could have been spent on another patient who had a better chance of surviving.

Gottlieb realizes that everything hinges on outcomes. And so he points to “one recent study” which  “found that patients’ five-year mortality after transplants for acute liver failure, the type from which Ms. Sarkisyan presumably suffered, was about 5% higher in the U.K. and Ireland than the U.S. ”  Moreover, he observes, “the same study also found that in the period right after surgery, death rates were as much as 27% higher in the U.K. and Ireland than in the U.S., although differences in longer-term outcomes equilibrated once patients survived the first year of their transplant.”

Wait a minute—what is he saying in the last part of that final sentence: “differences in longer-term outcomes equilibrated once patients survived the first year?”

“Equilibrated” is a not a verb I would normally choose to use. It’s just one of those very ugly words that fairly bristle on the page; you know there must be a simpler, clearer way to say whatever you are trying to say. And indeed there is. “Equilibrated” means “came into equilibrium” or “canceled each other out.”  In other words, Gottlieb seems to be saying, once patients survived the first year, the differences between outcomes in the U.K. and the U.S. disappeared.

When people use $10 words that are hard on the ear, I become suspicious that they they’re trying to hide behind jargon. I also was bothered that Dr. Gottleib didn’t name the journal where the outcomes study was published.  In the preceding paragraph where he talked about how many more liver transplants the U.S. does, he did cite his source (“a study published in 2004 in the journal Liver Transplantation.”) Why didn’t he name his source when contrasting outcomes?

I decided to do a little research. It turns out that Gottlieb is referring to research that appeared in GUT online, a journal published by BMJ (formerly the British Medical Journal), on March 13, 2007 comparing survival rates for transplant patients in the U.K/Ireland to outcomes for patients in the U.S. (Patients in the two groups were similar in term so age, gender and race and the comparisons adjusted for risk.)

By reading the study I discovered what Gottlieb had left out. First, the researchers looked at how the patients were doing at three points in time: during the 90 days immediately following the transplant, one year after the transplant, and five years after the transplant. Secondly, they followed patients suffering from two types of disease: chronic liver disease and acute liver disease.

Begin with how the patients were faring during the first 90 days. As Gottlieb points out, during this time, mortality rates in the U.S. were lower (regardless of whether patients had originally suffered from acute or chronic liver diseases.) This is, in large part, the article suggests, due to lower nurse/patient ratios in the U.S. and more intensive care during the first weeks following surgery.

But what Gottlieb omits is the crucial fact that, when the researchers went back and  looked at “patients who survived the first post-transplant year,” they discovered that  “patients who had suffered from chronic liver disease in the U.K. and Ireland had a lower overall risk-adjusted mortality” than patients in the U.S.  In other words, survival rates for patients who had a chronic disease before the transplant  were better in the U.K. and Ireland. As for patients suffering from acute liver disease, longer-term survival rates past one year were just as good in the U.K. and Ireland as in the U.S. Moreover, if you checked patients in the interval between 90 days and one year, outcomes were similar in the two health care systems.

So “equilibrated” wasn’t just a dodgy piece of jargon; it was inaccurate. When researchers checked on  patients more than a year after they had the transplant, outcomes in the U.K/Ireland and the U.S. weren’t in perfect balance (or in equilibrium) with results in the U.S.  Outcomes in the U.K./Ireland were just as good for one group and decidedly better for the second —assuming that if you go through the trauma of a liver transplant, the outcome you are hoping for is to live more than a year, rather than just 90 days.

Why is chronic care better in the U.K. in the years following surgery? Because the “primary care infrastructure” is stronger in the U.K. and Ireland, the article explains. Add in the fact that patients have “equal access” to health care and that the cost of care is “lower,” and this helps explain superior long-term results.  As the researchers point out, “the 2002 Commonwealth Fund International Health Policy Survey found that sicker adults in the US are far more likely than those in the UK to forgo medical care and fail to comply with recommended follow-up and treatment because of costs. In the U.S., it seems, outcomes tend to turn on whether the patient has money.

Finally, what about outcomes after five years? What Gottlieb forgot to mention is that survival rates for patients who had originally suffered from chronic liver disease were similar in the two countries, while mortality rates for patients suffering from acute liver disease were higher in the U.K. and Ireland.

But when summing up their findings, the researchers underlined the importance of survival rates during the first 90 days and after one year. “These results highlight interesting differences between two health systems funded by entirely different mechanisms,” one of the report’s authors told Reuters Health. “A predominantly privately funded healthcare system, such as the one in the United States, was demonstrated to have a better short-term outcome for liver transplantation, but a system of universal publicly funded healthcare, as in the U.K. had a better outcome after the first post-transplant year.”

“Our results therefore could have important implications for health policymakers in those countries and beyond,” he concluded.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of  “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

Livongo’s Post Ad Banner 728*90

Categories: Uncategorized

Tagged as: , , ,

12
Leave a Reply

12 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
10 Comment authors
bipinvibhutemaggie maharjmsMaggie MaharPeter Recent comment authors
newest oldest most voted
bipinvibhute
Member

Dr Bipin Vibhute and team offers all kind of liver treatments in all over India. He is currently a senior consultant & Hepato-Pancreatic and Biliary (HPB) Oncosurgeon at the Sahyadri group of hospitals in Pune. He has great experience in liver transplantation. He has performed more than 600 liver transplant in India. Now Dr Bipin Vibhute is providing liver transplant in India. He has 20 years of experience in liver transplant, completed more than 600 liver transplant surgeries across India, completed successfully 250 liver transplant as a primary surgeon, completed more than 100 liver transplant in India in one and… Read more »

jms
Guest
jms

At what age do we say dialysis (or another such effective and proven treatment) should no longer be paid for? It then becomes a financial question of what Medicare can afford (or what taxpayers will support). Inevitably, ethical questions/concerns arise as value judgments are assigned as to what is worthwhile or “cost-effective” and what is not. Should we tell all men: “Don’t bother getting your prostate cancer treated, even though the annual death rate from metastatic prostate cancer is 27,000 per year, and a randomized trial from Scandinavia shows an overall survival benefit of treatment versus observation at 10 years… Read more »

maggie mahar
Guest
maggie mahar

jms–
I think Medicare should refuse to cover ineffective and unproven treatments (except, of course, Medicare should cover unproven treatmetns in clinical trials. But those clnical trials should be being overseen by reserachers who have no financial stake in the outcome.

jms
Guest
jms

Should Medicare engage in rationing healthcare?

Russ Poter
Guest

POLITICS AS MEDICINE ” .. This leads many observers to suspect that the difference might be that they have a better health care system which emphasizes preventive care and offers equal access to all, rich or poor ..” This leads many observers to suspect that politics cognitively frames perception and might be behind theoretical thinking that posits unlimited spending will change people’s behavior and improve their health. It is like those who have their stomachs stapled. Five years later, a significant percentage are still overweight. Of course, people should not excessively eat, drink alcohol, smoke, couch-potato, etc. That is obvious.… Read more »

Maggie Mahar
Guest
Maggie Mahar

First– Thank you all for your comments: Rick and rbaer– I think palliative care really is the answer to many of the grasping-for-straw-after-the–straw procedures that we do. Palliative care specialists are very good at talking to patients and families, compassionately and realistically, about what their options are–and the likely outcomes. They are also very good at talking to surgeons who have been trained to “do everything possible” and who often want to go back in after a surgery (like Nataline’s bone marrow transplant) goes sour. They feel terrible–and want to try to make it right. But that may not be… Read more »

Peter
Guest
Peter

If we do go to a system of cost verse value then how will we administer it? From the doctor level, the hospital level? If you think John Edwards uses improper cases to make a political point then wait until we expect docs and hospitals to make those decisions. I think as long as docs and hospitals make more money with more interventions then they won’t take any chances on public outcry from trying to give grandpa another month with loved ones. If we had a single-pay system with actual budget limits then hosptials would be more likely to try… Read more »

bev M.D.
Guest
bev M.D.

Barry, thanks for finding that CBO paper; it is a great one! I believe it is very well researched and does a good job of considering all the options. I did not come away from it quite as pessimistic as you did, however. It is the prospective randomized clinical trials which will take the longest and cost the most, hence the 10 year benefit estimate. However, there is a great deal of data already out there which could be systematically mined with meta-analysis and other techniques to provide some useful information sooner. Also, one has to start SOMEWHERE, even if… Read more »

Russ Poter
Guest

Once thousands of “academic” studies are read, a hard question is asked —
How the heck is the U.K. like the U.S.?
Population? Weather? Size? MD salaries? MD unions? Any of 100,000,000 other v’bles?
BTW, madam — which medical school did you and Matthew attend?
Was it the medical school with the unlimited amount of taxpayer money?
That medical school with the unlimited amount of taxpayer money should buy advertising here. It would be popular with everyone, I’m sure.

Barry Carol
Guest
Barry Carol

Maggie, If I’m a sick patient who could potentially benefit from a liver transplant, the two most relevant questions in comparing healthcare systems as it relates to this issue are (1) did I get a liver transplant or not and (2) am I alive five years later or not? On both metrics, it appears that I would be better off in the U.S., at least if I have insurance. Whether the cost of the operation was money well spent from the system’s perspective is a separate issue and discussion. On the issue of value or money, including comparative effectiveness research,… Read more »

rbaer
Guest
rbaer

As long as many, if not most US middle- and upper class citizens are overly fascinated by high tech medicine, and also most of them tend to grasp for the straw AFTER the last straw, we will have too many costly high risk procedures without solid benefit. Maybe the AMA should do a campaign: “Even today, we can’t achieve everything and often know sh… about a particular disease”, just to set expectations straight.

Rick
Guest
Rick

What this story reinforces the notion that we don’t do end-of-life care and decision-making very well in the U.S. Scott Gottleib’s assertion that “Americans are more likely than Europeans to get an organ transplant,” certainly appears to be true. What he fails to say is that that might not be a good thing.
If so many of those transplant patients don’t even live a year after the procedure, perhaps palliative care would have been the better choice for them, rather than extending their lives, painfully and unnecessarily, for such a short time.