Medical literature key in using value to reduce health costs

Adewole (Ade) Adamson, MD, MPP, talks about increasing the value of health care as his fellow speakers, Joslyn S. Kirby, MD, and Arash Mostaghimi, MD, MPA, MPH, listen.

In a nation divided over the path of health care, there is one fact on which everyone agrees — it all costs too much. Trying to reduce costs seems a Sisyphean task, so a better approach is to get better value.

A Friday session, “Value in Healthcare: Improving Outcomes and Decreasing Waste” (F033), explained how to read dermatology literature to learn more about the comparative effectiveness of treatments. Three speakers tackled questions such as, “Is it worth spending hundreds of dollars a month on a treatment that produces only modestly improved outcomes?” or “Does a patient on this medication need this much monitoring?”

“Cost-effectiveness is not about the money but it is about what you are getting for the money. It is not about the dollar amount and spending less, it is about spending smarter,” said session speaker Adewole (Ade) Adamson, MD, MPP. “We need to understand in what therapeutic and diagnostic situations you can be more cost-effective.”

Value can seem an abstract concept, but session director Joslyn S. Kirby, MD, an associate professor of dermatology at Penn State University, made it more concrete. She said value can be seen as an equation in which the outcome is divided by the cost.

“We need to understand both parts: the numerator and denominator,” she said. “We need to know how to measure or assess outcomes, how to understand what a cost is, and where there is an opportunity to recoup some of the waste. We also need to be able to look at the literature, interpret it confidently, and make changes in our practice.”

As an example, recently published literature calls for reduced monitoring of patients using isotretinoin and spironolactone.

“In the last couple of years, there have been papers coming out showing that the side effects of isotretinoin are probably not as common as we think they are,” Dr. Kirby said. “Side effects to the medication that we monitor for with labs are most often seen at the beginning of treatment, and there are very few changes found later in the course of treatment. So there are opportunities to tailor our monitoring practices to what is seen in the data in the literature.”

Speaker Arash Mostaghimi, MD, MPA, MPH, an assistant professor of dermatology at Harvard Medical School, applied the same approach to spironolactone.

“The routine testing for hyperkalemia among young, healthy women taking spironolactone for acne is an unnecessary practice,” Dr. Mostaghimi said. “Eliminating testing reduces costs and removes barriers to using this  cheap and effective drug.”

“We are going with where the data is leading us, and it is leading us toward the idea that additional testing doesn’t necessarily mean additional safety for the patient. Every time we treat a patient, we need to think about why this test, why this drug, why this patient, and why right now? We need to challenge all of our assumptions.”

Dr. Adamson applied the same approach to the use of combination products for acne. Trials show the effectiveness of these products, but at a great cost over other approaches.

“What a lot of people do not look at in a study are the vehicle arm or the group that is not treated with the combination product or the single product,” said Dr. Adamson, an assistant professor of dermatology at the University of North Carolina School of Medicine. “What you don’t notice is that while there is a difference between combination products and vehicle — benzoyl peroxide in particular — that difference is really small.

“If you look at the price comparing benzoyl peroxide to combination products or monotherapy, there is really only a small difference in how much better people get. You may pay $200, $300, or $500 more to get a 5-10 percent benefit. In practice, that may only be a difference of 4 or 5 pimples at a cost of $500. Is that worth it?” Physicians should use GoodRx to check the prices of medications and look for ways to stay current on their reading, Dr. Adamson said.

“In dermatology, there is no easy resource to be able to determine that. I hope with this discussion that we can create a hub or database where this can be found more quickly.

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