You've got a cold and you're in the supermarket drug aisle, thinking "This one makes me dizzy, and if I take this, I'll be up for a couple of hours, and this one's expensive. I'd get more relief from some chicken soup, a hot shower, and a few hours of sleep." Wouldn't it be great if your doctor also shopped for a prescription according to what it costs and whether it's really worth it?
Associate professor of medicine Jerry Avorn, M.D. '73, is that doctor. As chief of the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women's Hospital, Avorn's job is to find out not only if drugs work, but whether their outcomes justify the financial cost and the side effects that result from taking them. Part of the answer to that question comes from determining whether a drug reduces future hospitalizations, for instance, or the need for blood transfusions, or any number of tests, procedures, or other outcomes that would indicate whether the drug deals effectively with a given condition.
But there's another important aspect to drug treatment that's much harder to evaluate: how drugs affect quality of life. A 1993 New England Journal of Medicine study by Marcia Testa, lecturer on biostatistics in the Faculty of Public Health, showed that two drugs with equal safety and efficacy ratings may have drastically different side-effect profiles. Finding out what those side effects mean to patients is an important part of Avorn's research. "Part of this is what I bring to the work--my own value system," says Avorn. "I don't want just to run the numbers. I want to factor in pain and suffering and quality of life. Anyone can look up what a drug costs. But we're not just running a business here, we're trying to provide the best possible care of sick people."
Right now, Avorn and his team are taking a hard look at a new class of non-steroidal anti-inflammatory drugs (NSAIDs). These COX-2 inhibitors appear to cause fewer side effects (specifically, gastrointestinal bleeding) than existing NSAIDs like the painkiller ibuprofen--but cost about 20 times as much. Avorn is asking what degree of risk reduction is worth the extra cost, and whether it may be possible to identify patients who would benefit most from the drug.
"This is why drug companies have a love/hate relationship with us," he says. "They would rather have a monopoly on communication with doctors, so they can tell them just what they'd like them to know. But, in an interesting way, they see us as a breath of fresh air, because we're willing to say, 'This drug is expensive, but it's a good buy.' Until we came along, no one was saying that but them."
One example is infliximab. Delivered by intravenous infusion, it can keep people with Crohn's disease out of the operating room by reducing their intestinal inflammation. Avorn says the $1,800 per dose is worth it. Another drug, called Photofrin, costs $4,000 per dose, but it allows lasers to target and kill cancer cells, eliminating some of the risks of surgery while prolonging patients' lives.
Avorn's colleague, instructor in medicine Dan Solomon, M.D., was not so enthusiastic about avcon-L, a gel that purportedly reduces internal scarring from back surgery. Solomon studied intensively the data the manufacturer provided to the Food and Drug Administration, which approved the gel as a device, not a drug. To receive FDA approval, devices need show only evidence of safety, not efficacy, and Solomon concluded that there was no published proof that the $500-per-tube gel works. He and Avorn therefore recommended that the hospital's surgeons avoid using avcon-L. "If the manufacturer were to come up with a good trial that shows that it does help patients, we would look at it again in a millisecond," Avorn says. "But we can't until they provide solid data."
Such examples make one wonder: which drug packs the best bang per buck in medicine today? "In the realm of medical technologies, it's beginning to look like the cholesterol-lowering statins," Avorn replies. "Megastudies involving tens of thousands of people show that these drugs can reduce heart-disease risk in people with both high and low cholesterol, in people who have had heart disease, in the elderly and nonelderly. Every study seems to broaden the population that can benefit."
Then he adds, "There was a time I would have answered that question by saying, 'A conversation with an intelligent, compassionate doctor about lifestyle,' and I still think that's an underrated and scarce commodity."
~ John F. Lauerman