what we can afford

Monday, April 4, 2011

New technology never ceases to amaze and it often takes human guinea pigs to decide what works and what doesn’t. Whether it is a new antibiotic to treat infection or a new type of surgery, benefit has to significantly outweigh the risk before new can become routine. In today’s economic environment, though, a third consideration is added. Can society afford what medicine can do? Medical and political news releases highlight what might become the future. At the same time that a new ways of replacing damaged heart valves was being presented at the American College of Cardiology meetings, the Budget Committee of the House of Representatives proposed major changes to Medicare funding.

The potential for new ways of heart valve replacement may be lost because it was performed on elderly patients who were too ill to survive traditional valve replacement that requires open heart surgery. These patients may be too old, too frail or have a hear t that is too weak to survive the hours of surgery required to open the chest, stop the heart, remove the valve and replace it with a new one. The new procedure is more like a heart catheterization where the new valve is threaded into position through the femoral artery in the groin or through a small incision in the chest wall. There are some significant increased risks with the new procedure including more than double the risk of stroke, but as technique improves with experience, the complication rate should decrease. If it does, then more people would benefit from minimally invasive surgery.

Budgets might get in the way. Is there enough money to operate on people who are old and already have failing hearts? Should that funding be used for prevention to touch more people and who gets to decide a quality of life issue? Aside from the cost of the procedure, the complications can get expensive. A stroke changes the patient’s world. Medical and nursing care, physical and occupational therapy can increase quality and quantity of life but going home requires family commitment that may not be possible.

Compared to watchful waiting, previous studies have shown that the using the valve replacement procedure increases survival at one year and can decrease symptoms increasing quality of life. A critically narrowed aortic valve prevents blood from being pumped by the heart to the rest of the body. Decreased blood flow can cause patients to faint, develop shortness of breath and chest pain because of decreased blood flow in the coronary arteries. As the valve narrows, the heart muscle gets thicker to try to generate more force to push blood through that narrow opening. It becomes a vicious circle; more muscle needs more blood to function but the blood flow isn’t there.

If history repeats, money will be there for the development of newer technologies in the hope that their use will expand to more patients. But new medicine allows people to live longer and demand even more resources to increase the quality of life to match the increased quantity. There is no right answer. The decision to do more for one group of people will ultimately restrict the care given to another, which brings us back to the risk benefit analysis of medical care. The money question may need to be addressed by the physicians and scientists who dream about making life longer and better.

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