Heaven have MRSA

10/30/2007 12:40 PM |

Scott Gottlieb tells it like it is via this column in today's edition of The Wall Street Journal ...

Attack of the Superbugs
By SCOTT GOTTLIEB

One of the early morning television news shows recently staged a live feed from a suburban Maryland high-school. It was the latest to close after a student contracted a virulent and drug-resistant bacterium called methicillin-resistant staphylococcus aureus, or MRSA. Pronounced "mersa," it's become this season's equivalent of shark attacks, every day bringing new, terrifying reports, although the dangers of such bacteria are hardly new.

Researchers working at the Centers for Disease Control and Prevention reported this month that nearly 19,000 Americans died in 2005 from MRSA, and about 95,000 were infected. Doctors have been reporting for years that MRSA was cropping up with alarming frequency. The same is true for other bacteria. In Rochester, N.Y., doctors recently reported nine children stricken with a strain of the bacteria that causes ear infections -- streptococcus pneumonia -- that was resistant to all 18 antibiotics commonly used to treat the condition.

The real news isn't that these bugs exist, but how woefully unprepared we are to deal with them. As we make progress in fields like cancer, we are taking a U-turn on bacteria. Despite advances in drug development, the bugs have increased their IQ nearly as fast as research, outwitting our medicines. Efforts have turned to preventing bacterial spread and clamping down on antibiotic prescribing.

There's no question that poor hospital hygiene, overuse -- and sometimes misuse -- of antibiotics contribute to educating bugs at our expense. But preventative efforts alone won't solve our bacterial challenges. What we need most are better diagnostic tests and new medicines.

This is high-stakes science, but the pipeline isn't promising. Since 1998, just 10 new antibiotics have been approved by the the Food and Drug Administration, only two of which work in fundamentally new ways. Only 13 new antibiotics are in development inside big drug companies, compared to an average of 60 more than a decade ago. Since leaving the FDA this year as its deputy commissioner, I've advised a few biopharma firms making antibiotics and the venture investors supporting them. Regrettably, however, many big drug makers have followed the lead of Eli Lilly, a pharmaceutical company that once pioneered antibiotics, only to exit the business entirely.

The problem? There's not a lot of payoff for developing drugs aimed at infections. First, they last only days, or at most weeks, limiting sales. And the better the drug, the more likely doctors and hospitals are to keep it on the shelf as a last resort. Most hospitals require that doctors get special approval to prescribe the best new antibiotics. In that regard, what's good for public health isn't necessarily good for antibiotic development.

Capricious regulation is another problem, adding to uncertainty and, in turn, the cost of development. For drugs targeted to many common bacterial ailments, the FDA historically required so-called non-inferiority trials. This meant a new antibiotic needed to prove it was generally no worse than existing treatments in order to win regulatory approval. Otherwise, conducting trials to prove a new antibiotic was better than a sugar-pill placebo -- or superior to existing drugs -- would require huge trials and, in some cases, was simply unethical if it meant asking patients with potentially serious infections to risk treatment by placebo.

That changed just last year when a handful of FDA reviewers became miffed that companies would get drugs approved through these non-inferiority trials without proving the new drugs were better than older medicines, and then market the new drugs for broad upper respiratory indications. The reviewers brought their complaints to Congress, which has since leaned on the FDA, at one point asking the Government Accountability Office -- staffed with lawyers and policy analysts -- to opine on the nuanced scientific question of non-inferiority trial design. The political intrigue has pushed the FDA to raise its approval bar in some areas, jettisoning the non-inferiority approach for some ailments while leaving a mess of uncertainty for many others.

So how do we surmount these obstacles to get the drugs and diagnostic tests we need to stay ahead of aggressive bacteria like MRSA?

First, we need to recognize that developing drugs aimed at super bugs is not an ordinary pharmaceutical business, and requires unique incentives. If public-health policies compel doctors to hold the best new antibiotics in reserve, we need to compensate with incentives for developing those niche drugs.

One way would be to clarify the rules under the 1983 Orphan Drug Act to include drugs that target resistant bugs. That law provides special incentives for drugs that treat rare diseases, including patent protections and streamlined regulatory review. The FDA needs to create better opportunities for companies to target not only conditions -- such as pneumonia or skin infection -- but also specific bacteria, like multi-drug resistant staph.

The FDA's guidance on other aspects of antibiotic drug development is similarly murky due, in part, to fluid standards. Congress recently had to write into law a demand that the FDA produce guidance on antibiotics for acute exacerbations of chronic bronchitis and acute bacterial sinusitis (finally released yesterday). Merely issuing documents doesn't guarantee clarity, and one of the FDA's recent documents on an aspect of antibiotic development ran several pages, saying little.

The FDA should collaborate with the Infectious Disease Society of America (IDSA) to develop meaningful guidelines that provide clear pathways to new drug development. The IDSA's credible voice could also buttress the FDA against the maneuvering of a handful of staff who take their views to politicians when they lose internal scientific debates.

Finally, we badly need better tools for rapidly detecting resistant infections in blood, even screens for bacterial genes. Today it can sometimes take days to discover that a patient is infected with a resistant bug. If there were better diagnostics -- similar to the "rapid" strep test -- bacterial infections could be distinguished early and doctors could treat patients with confidence. Drug companies could also more easily develop drugs targeted to specific bugs, conducting clinical studies aimed at specific pathogens, and making sure the right patients got the right drug early in the course of their illness, when drugs can make the most difference.

But the diagnostics business has been a lower-margin affair for many years, steering product developers into other fields. There are complicated reasons for this, but Medicare has systematically tried to drive down prices for diagnostic tests, often refusing to pay for new tests altogether. In turn, the big companies that make the tests committed a fundamental mistake early on, by adopting a strategy of charging lower prices for the throw-away test kits and premium prices for the platforms they run on -- a reverse of the old razor-blade model.

The big diagnostic companies figured they would make most of their money off the platforms. They're regretting that now. The strategy may have worked if they had continued to innovate, but now many of the best ideas for new tests are coming out of small firms that have little ability to sell their own big platforms, and a hard time premium pricing diagnostic tests in a market conditioned by the big firms to expect cheap razor blades.

Most existing antibiotics are as old as the earth, screened out of nature where they resided, doing battle with bugs for centuries. We need to accelerate this evolution in our laboratories. Public policy mistakes are partly to blame for creating this inhospitable environment for new development, and it will take a concerted effort to improve it. The only sure way to stay ahead of bacterial evolution is by escalating this arms race.

Dr. Gottlieb, a practicing physician and resident fellow at the American Enterprise Institute, was previously a Deputy Commissioner of the Food and Drug Administration.  Read More & Comment...

When is a medical device not a medical device?

10/30/2007 07:58 AM |

The first thing that needs to be said about medical devices is that we should stop calling them medical devices. They are, in every sense, medical technology.

And technology, as we all know, is what makes the world go ‘round.

That being said, we must take medical technology as seriously as we do pharmaceuticals.

And, as the use of medical technology (from stents to scans) becomes ever more important and more pervasive, so too must we focus on safety.

But we must not fall into the false security of the Precautionary Principle which warns us to do nothing until we know everything. Why is this a bad idea? Because we can never “know everything.” And when it comes to FDA regulated products, be they drugs or devices or combination products – there will always be risk that comes along with benefit.

Can we do a better job regarding medical technology safety? Yes. Must we? Absolutely. Are we?

Here’s what Dan Schultz, director of CDRH had to say in today’s Wall Street Journal on that point:

"Are there ways to identify problems more quickly? I think the answer is yes. But if you require a clinical trial for every design change, what does that do to the ability of bringing new technologies to market?"

What, you mean there's no easy answer? Sorry Senator Grassley.

Here’s a link to the article:

http://online.wsj.com/article/SB119370397918375690.html?mod=hps_us_pageone

Vigilance must not supplant progress. They must advance together and learn from each other.  Read More & Comment...

Thoughts from the John

10/29/2007 08:38 AM |

Seems as though John Edwards must have been absent during the law school lecture on the US Constitution – specifically the part that relates to Freedom of Speech. In a speech the other day he called for, among other things, mandatory FDA approval before drug companies launch major ad campaigns.

Must have tested well in focus groups.

Similar bloviation during debate over FDA reform was quickly dismissed because of some more educated members of Congress familiarity with the First Amendment.

But, as we all know, facts and reality have very little to do with Presidential campaigns.

Further proof of this was Senator Edwards’ remark that drug advertising misleads patients and drives up health care costs.

Neither of these statements is true. As to “misleads patients,” what DTC does do is send patients (aka – consumers) into the offices of their physicians were they have important dialogue about their health. In many of these DTC-initiated visits a previously undiagnosed condition is diagnosed. And earlier diagnosis and treatment decreases health care costs.

As to whether or not DTC increases the cost of medicines, consider this – when you compare the prices of medicines within a given therapeutic category along with their spending on DTC, there is no correlation. Also, when you compare the amount of money spent on DTC versus research and development – they don’t even have the same number of zeroes.

According to Edwards, "The excessive costs of prescription drugs are straining family budgets and contributing to runaway health care costs.”

Another nice sound bite that belies the truth. Only 11.5% of the US health care spend is on pharmaceuticals – the same pharmaceuticals that keep people out of the hospital (over 30% of our health care expense). Proper medication keeps people healthy, at work, and paying taxes.

But that’s not as popular a sound bite in Iowa and New Hampshire (where Senator Edwards shared his comments with primary voters).

"With such aggressive and often misleading drug company marketing, it's too easy for advertising -- instead of doctors or proven results -- to influence families' health decisions," Edwards' campaign quoted him as saying.

Often misleading? Really? Does he even know about “fair balance” and “adequate provision?” Does he even know about the research that shows how few people actually even try to read various brief summaries?

Probably not. And that would explain why the “Edwards Plan” also calls for drug advertising to disclose more information about side effects and comparisons of drugs against placebos and alternatives.

Someone should ask him about this during the next candidate debate. (And speaking of “comparisons,” someone should also ask him about his understanding of comparative effectiveness.)

Further, the Edwards plan would institute a two-year delay on consumer advertising of all new drugs.

So, not only do we not really need Freedom of Speech – we also don’t need new and timely information about new and timely medicines.

Gevalt.  Read More & Comment...

An FDA of One

10/26/2007 12:13 PM |

By now you will have heard about the most recent in a series of FDA leaks. I refer specifically to the Wall Street Journal's "people with knowledge of the matter" -- the matter at hand being Avandia.

I will not speak to the specifics of the leak -- I will not give illegal and unethical behavior one inch of additional space -- nor will I spend any time or energy playing the "I wonder who the leaker is?"game. (Not that I don't have my own suspicions.)

What I do want to address is the growing trend within the FDA of "leaking" internal discussions to the media in order to try to force the agency's hand. If "politicizing" the agency is bad (and it is -- very much so) than it is bad writ large. The ends does not justify the means.

The FDA is an organization of health care professionals. An organization of many. Organizations have hierarchies. And organizations have rules. And rules are meant to be followed. The alternative is chaos -- a state into which the agency mustn't spin. When rogue employees choose to take the law into their own hands -- even when they believe their position is the correct one -- bad things ensue and stakeholder trust erodes. And, yes, one stakeholder is the pharmaceutical industry. Another is the American citizen.

Anonymous leaks are not the acts of whistleblowers -- they are the acts of cowards.

An "FDA of One" is one very bad idea.  Read More & Comment...

Parsing Clinical Trial Data in an Era of Personalized Medicine

10/26/2007 08:26 AM |

Matt Herper and Robert Langreth have a good column about Lilly's hurry up and wait approach to releasing the results of a dosing study about prasugrel, which would not compete with but be an alternative to people who do not respond well to Plavix or aspirin.

Again, it's not the data so much as how it is presented to investors and the clinical community. The rules of the road have changed. People demand more data. And the genetic underpinnings that cause differences in drug response and dose response -- which is what at issue here -- are pretty much like open source software or operating systems.

I don't think anything nefarious is going on. If the science types have control of the process -- and Steve Paul who runs RD at Lilly is a straight shooter -- they are probably retooling and re-examining the data to see which dose works for which groups.

But that is not the end of the matter. Matt and Robert should know that Lilly is likely trying to figure how all this tailored treatment info pans out and whether or not -- in the safety uber alles environment -- even a drug that has diagnostic or gene-specific dosing limits ala warfarin could even get through the FDA these days.


Maybe Lilly is compiling a list of drug safety vigilantes it needs to hire as consultants to ensure they don't trash the drug to the trial attorneys and the media. Drug safety? More like a protection racket.

http://www.forbes.com/2007/10/25/pharmacuticals-prasugrel-lilly-biz-sci-cx_mh_1026lilly1.html?partner=alerts  Read More & Comment...

Isn't It Ironic, Don't Ya Think?

10/26/2007 08:11 AM |

Sometimes life and politics provides their own punchlines... From the KaiserNet's First Edition: these two headlines cluelessly linking a tobacco tax expansion of SCHIP to health plans covering smoking cessation....

TODAY'S NEWS
House Passes Revised SCHIP Bill, Still Lacks Enough Votes To Override President Bush's Threatened Veto
AP/Houston Chronicle

Businesses Pay for Worker Smoking Cessation Programs as Part of Effort To Reduce Health Care Costs
New York Times

http://www.kaisernetwork.org/daily_reports/rep_firstedition.cfm  Read More & Comment...

Should pharma pull the plug on freebies

10/25/2007 04:23 PM |

Seems simple enough. Get rid of samples, pens, pizza. But then let's see just how much information about new medicines flow to doctors and whether that affects patients. Right now the claim that freebies adversely influence prescribing patterns and do not advance patient health is unsubstantiated. And who would decide who gets what information and how? The same group that supports government run comparative effectiveness trials? And the proposal to eliminate all private industry involvement in academic medicine will undermine medical progress. As if academic medicine would be free of bias, conflict, error and devious behavior if money was not involved. Right. See the piece from The Scientist below...

http://www.the-scientist.com/news/home/53709/  Read More & Comment...

All the News that's Fit to Type

10/25/2007 03:03 PM |

I was on a terrific panel this morning (hosted by DTC Perspectives Magazine) on the influence on blogging in pharmaland. Hosted by Pharmalot's Ed Silverman, my fellow panelists were Scott Hensley (of the Wall Street Journal and the Wall Street Journal Health Blog) and Christiane Truelove of MedAd News (or as we like to refer to her because of her pithy Friday blog recaps, "Christiane CliffNotes").

Scott Hensley wins for most thought-provoking soundbite ...

"If we don't post, nothing happens."

Amen brother.  Read More & Comment...

Gray Lady On-Line Letters

10/25/2007 02:50 PM |

In the spirit of full and open dialogue, here are two letters-to-the-editor from today's on-line edition of the New York Times ...

Opinion

LETTERS

Testing New Drugs
Published: October 25, 2007

Re “A Test of Bad Health” (Op-Ed, Oct. 18):

To the Editor:

Peter Pitts’s criticism of the proposed Center for Comparative Effectiveness exemplifies the scare tactics used by the pharmaceutical industry to protect its interests.

While he cites one example of delayed drug approval in Britain, he doesn’t mention the many cases in which comparative effectiveness studies have fostered timely and appropriate decisions to adopt or not adopt new drugs and other medical advances.

The use of government-sponsored studies to inform drug coverage decisions by government agencies is not “an inherent conflict of interest,” but rather the judicious exercise of government resources to serve the public interest.

Sadly, the casualties of President Bush’s veto of the State Children’s Health Insurance Program bill include not only the millions of children left uninsured, but also the hundreds of millions of Americans and their doctors who need better information to make the best possible decisions about their health care.

Alan B. Cohen
Boston, Oct. 18, 2007
The writer is a professor of health policy and management and the executive director of the Boston University Health Policy Institute.

To the Editor:

Peter Pitts warns that a proposed Center for Comparative Effectiveness to test new drugs would be dangerous because “conducting these studies is so tricky, their findings are regularly overturned or modified by further research.” Yet he would have us accept the company’s clinical trials showing the drug to be safe and effective?

One wonders why it is so tricky for the government to do this research, yet so simple for his pharmaceutical financiers to do the same.

Kevin Carlsmith
Hamilton, N.Y., Oct. 18, 2007

After all, everyone's entitled to their opinion.  Read More & Comment...

Getting It Right on Clinical Trials: Honesty is the Best Policy

10/25/2007 12:51 PM |

Sanofi's conduct in the testing of Ketek underscores the importance of trust in shaping perceptions of risk. The relationship between drug companies and consumers must change. It will have to be more honest, more transparent, more individualized and enduring. It can't end after the FDA approves a product either.

According to the WSJ the FDA said it was "unable to find evidence" that the company either fixed the problems or threw the problematic doctors out of the study and told the FDA. The FDA also faulted Aventis for failing to make sure the study was properly conducted and for allowing unqualified investigators to participate in the trial.

These problems are rare and will happen. However when they are detected they should be reported promptly and the unqualified investigators should be barred from participating in clinical trials as a matter of industry policy.

http://online.wsj.com/article/SB119328145497070973.html?mod=googlenews_wsj  Read More & Comment...

Stark Raving Anti-Semite...

10/24/2007 03:17 PM |

Who says sorry seems to be the hardest word? Here's a sample of some a Pete Stark's other gentle musings about those who differ with him on healthcare policy issues... From Jonathan Weisman of the Washington Post (get a look at the photo the WP selected for the article..)


2003: As Stark belittled House Ways and Means Chairman Bill Thomas (R-Calif.), then-Rep. Scott McInnis (R-Colo.) told him to "shut up."

"You think you are big enough to make me, you little wimp?" Stark taunted. "Come on. Come over here and make me, I dare you. You little fruitcake."

2001: At a Ways and Means subcommittee hearing on abstinence promotion, Stark referred to then-Rep. J.C. Watts (R-Okla.) as the "current Republican Conference chairman, whose children were all born out of wedlock."

1995: In a private meeting, Stark called then-Rep. Nancy L. Johnson (R-Conn.) a "whore for the insurance industries."

"He didn't call her a 'whore,' " defended Stark press secretary Caleb Marshall. "He called her a 'whore of the insurance industry.' "

1991: Stark singled out "Jewish colleagues" for blame for the Persian Gulf War, referring to then-Rep. Stephen Solarz (D-N.Y.) as "Field Marshal Solarz in the pro-Israel forces."

1990: Stark called then-Health and Human Services Secretary Louis Sullivan, who is African American, "as close to being a disgrace to his race as anyone I've ever seen."

http://www.washingtonpost.com/wp-dyn/content/article/2007/10/23/AR2007102302165.html  Read More & Comment...

Evidence of an Evidence-Based Double Standard at CMS

10/24/2007 12:48 PM |

Maybe someone can explain the difference between the risks of off-label use of drug-eluting stents -- which CMS will still cover -- and the risks of appropriate ESA use -- which CMS will is banning. In both cases there is no evidence from randomized controlled trials demonstrating safety or quality of life benefit which CMS claims is the standard for reimbursing things these days.

Last time I checked there was no randomized placebo controlled study of aspirin with safety being the primary endpoint. Maybe Medicare should not pay for that either.

http://online.wsj.com/article/SB119318921736669347.html?mod=health_home_stories  Read More & Comment...

People Leak When They Are Losing or it is When They Are Losers?

10/24/2007 11:00 AM |

Gee, I wonder who leaked this to the WSJ...Let's see, when you don't have the science or the facts on your side, presenting the sort of observational data in public to defend your position that you derided as evidence in support of the safety of other drugs and when everyone else in the agency is pretty much responsible...my guess is David Graham and that it is part of a well-orchestrated effort. We know it's not the European Medicine Agency which just tighted prescribing data. Let's hope with better post market data we won't have this hysteria in the future. My guess is, with tort lawyers and web-based interest groups profiting from fear we will see more of this, not less.

http://online.wsj.com/article/SB119318921736669347.html?mod=health_home_stories  Read More & Comment...

Andy's Legacy

10/24/2007 05:18 AM |

Andy von Eschenbach comments on the issue of "legacy drugs" via a letter in today's edition of the New York Times ...

To the Editor:

The Food and Drug Administration thanks you for emphasizing our continued efforts to protect the public and raising consumers’ awareness that certain drugs are marketed without F.D.A. approval. In June 2006, the F.D.A. announced its renewed emphasis on solving the problem that many drugs lack F.D.A. approval, often because they were introduced into the market long before the F.D.A. had its current regulatory authority.

To deal with the unapproved drugs that remain in use, we give highest priority to drugs that have safety concerns, lack evidence of effectiveness or are health frauds. This approach is carried out without imposing undue burdens on health care and is applied uniformly against all companies, large and small, that market these drugs.

The F.D.A. is committed to proactive action to assist companies with finding opportunities to legally market their products. As part of this commitment, the F.D.A. appointed an unapproved drugs coordinator and conducted a full-day workshop in January 2007 to educate companies about the drug approval process, the over-the-counter monograph process and user fee waivers. Our unapproved drugs coordinator consults frequently with companies, and many of them have begun the approval process for their products.

Some refer to these unapproved marketed drugs as “legacy drugs.” A legacy is not a substitute for drug approval. Individual experience, anecdotal evidence and marketing history are insufficient bases for concluding that a drug is safe and effective. In fact, experience demonstrates that unapproved drugs are often unsafe, ineffective, inappropriately labeled and poorly manufactured. This is not the legacy that we want for our families.

I, and the entire F.D.A., remain committed to ensuring that safe and effective drugs are available to protect and promote the health of the American people.

Andrew C. Von Eschenbach, M.D.
Commissioner of Food and Drugs, Food and Drug Administration
Washington, Oct. 22, 2007  Read More & Comment...

FDA Cough Medicine Decision Puts Pediatricians In Silent Mode

10/23/2007 09:18 AM |

Here's the bottom line reason pediatricians love the decision to ban cough medicines: fewer 2 AM phone calls from parents about dosing, less anxiety about lawsuits...

Benjamin Brewer MD who blogs for the WSJ on medicine:

The dose provided some relief — the boy’s sniffles and cough abated long enough for the Brewers to get some shuteye. “I have found that the advice to hold off on a kid’s cold medicine is much easier to give than it is to heed,” Brewer writes.

The crackdown on cold medicines for kids may have an unintended benefit for the doctor. “With infant cold medications off the market, I won’t miss the parents calling in the middle of the night for recommendations on how much to use,” he writes. “I won’t miss meticulously documenting how many tenths of a milliliter I advised a person to give or the liability risks associated with my advice.”

Thanks for the dose of honesty doc.

I just wish the FDA experts were as freaked out about MRSA and diminishing antibiotics to treat them as they were about cough medicines. Ironically, the "safety uber alles" movement has made it likely kids will see fewer antibiotics for killer bugs or coughs. Reminds me of when I was a kid. It would make me feel a little bit better if Mickey Mantle were still batting clean up for the Yankees.

http://blogs.wsj.com/health/2007/10/23/a-taste-of-his-own-medicine/

For those who want to see Mantle's stats as opposed to the number of kids who died from infectious diseases in the 1960s...

http://www.baseball-reference.com/m/mantlmi01.shtml  Read More & Comment...

Bone Débarras

10/23/2007 06:23 AM |

Just in from the Beeb ...

Bone drug rationing 'must end'

Campaigners are appealing against a decision they claim is restricting doctors from prescribing osteoporosis drugs on the NHS.

Currently only one drug - alendronate - is approved by the National Institute for Health and Clinical Excellence. But the drug can cause a severe reaction in a quarter of patients.

The National Osteoporosis Society (NOS) says hundreds of thousands of people are missing out on potentially life-saving treatment as a result. NOS says the decision by NICE to recommend the cheapest drug is a false economy and leaves many patients at increased risk of painful and life-threatening fractures.

Professor Ignac Fogelman of the NOS said: "We are challenging the financial model that was used to look at the cost effectiveness of the various treatments for osteoporosis." GP Rosemary Leonard said: "Alendronate is the one osteoporosis drug which is now off patent so it is a lot cheaper than the others which is why there is this push to prescribe it. "But unfortunately one in four people who are on it can get bad reactions to it, particularly inflammation of the oesophagus.

"There is a choice available but NICE guidelines say that primary care trusts only have an obligation to provide alendronate."

Postcode lottery

In some primary care trusts, this means alendronate is the only drug choice offered, she said.
"We are heading for a postcode lottery."

Professor Tim Spector, a consultant rheumatologist at St Thomas' Hospital, London said: "It is vital for clinicians and patients to have alternative treatments available so we can maximise patient choice, reduce avoidable drug side effects and reduce the risk of osteoporotic fractures."

NICE has not yet released its final guidance.

It said in a statement: "It is disappointing that the appeal will delay final guidance on use of drugs for osteoporosis and delay publication of our clinical guideline which will then set out the best use of drugs and non-drug treatments."

A spokeswoman said NICE would report back in due course once the appeal had been heard.
Osteoporosis literally means "porous bones" and makes it more likely for them to fracture as they lose their density.

Over 1m women in the UK have been diagnosed with the disease, although experts say many more probably suffer from the condition.

Is this what we really want in the US? That's just, well, SiCKO.  Read More & Comment...

March of the Paternalists

10/22/2007 08:19 AM |

Seichel. In Hebrew it means discretion and in Yiddish it means "common sense" or as Joseph Aaron puts it...good sense, street smarts, the kind of wisdom you don’t get from getting a Harvard diploma.

Seichel tells you what’s right and what’s smart better than any book or guide or intellectual.

Or any FDA panel.

Seichel tells you that when millions of parents over 40 years have used cough and cold medicines responsibly they have a better handle of their kids needs than the media seduced know it alls who gathered in Rockville.

Did any of them consider that, because of the ban, parents will simply water down or dose adult cough meds to help their kids stop coughing or sniffling? Or that they will turn to even less effective or untested "natural" remedies that may be even more dangerous?

No, because the panel and the American Academy of Pediatric were not guided by seichel but by the "safety uber alles" principles pushed by the trial lawyers (websites now coming to a computer near you) have pushed medicine past science and common and into the panic room.

The decisions we make out of fear and to eliminate risk completely will always lack common sense and reek of mob rule.  Read More & Comment...

Et tu, Bernie?

10/22/2007 08:00 AM |

The Junior Senator from Ben & Jerry’s, Bernie Sanders, has just introduced a bill that would replace our current patent system for pharmaceuticals with a “Medical Innovation Prize Fund.” Here we go again.

It’s not a new idea. The “prize” model has been used in the past – in the old Soviet Union. It didn’t work. The Soviet experience was characterized by low levels of monetary compensation and poor innovative performance. The US experience isn’t much better. The federal government paid Robert Goddard (“the father of American rocketry”) $1 million as compensation for his basic liquid rocket patents. A fair price? Not when you consider that during the remaining life of those patents, US expenditures on liquid-propelled rockets amounted to around $10 billion.

Certainly not what Schumpeter had in mind when he wrote about “spectacular prizes … thrown to a small minority of winners.” Creative destruction indeed!

Senator Sanders wants to replace a patent system that has allowed the average American lifespan to increase, over the past 50 years, by almost a full decade with a prize program that has a solid record of complete failure.

As Joe DiMasi (Tufts University) and Henry Grabowski (Duke University) have argued, under a prize program, pharmaceutical innovators would lack the incentive to innovate. To quote DiMasi and Grabowski, “The dynamic benefits created by patents on pharmaceuticals can, and almost surely do, swamp in significance their short-run inefficiencies.”

In other words (and to paraphrase Winston Churchill) our pharmaceutical patent system is the worst way to stimulate and support health care innovation – except for every other system. On a list of 100 ideas for ways to improve innovation and access, a prize program shouldn't even on the list.

Who could support such a crackpot idea? Nobody? Wrong! Dangerously wrong. Again, as DiMasi and Grabowski presciently observed in 2004, “The main beneficiaries in the short-term would be private insurers and public sector purchaser of pharmaceuticals … Governments and insurers are focused myopically on managing health care costs. They are not likely to be strong advocates for funding new drug development that can increase individual quality of life and productivity."

Cui bono indeed.

Here is a link to the legislation(courtesy of one of its biggest supporter, Jamie Love):

http://www.keionline.org/misc-docs/SandersRxPrizeFundBill19Oct2007.pdf

Those who support this idea are so blinded by their own propaganda, that they view it as a solution to all the world’s health care ills. Consider some of the following statements:

Merrill Goozner (CSPI), “Research is risky, new drugs are too expensive, and
industry focuses far too much of its effort on drugs of minimal medical significance. The prize fund solves all these problems by disconnecting the incentives for generating breakthroughs from the price that individual patients or their insurers must pay."

Sorry Merrill. Wrong on all counts.

Jamie Love (KEI), “By separating the markets for innovation from the markets for the physical goods, the Prize Fund would ensure that everyone, everywhere, could have access to new medicines at marginal costs.”

Er, Jamie – time for some remedial economics classes.

And the timing of Senator Sanders’ bill is interesting too. It coincides with the upcoming meeting of the WHO’s Intergovernmental Working Group on Public Health, Innovation and Intellectual Property (IGWG in short) whose goal is "to prepare a global strategy and plan of action on essential health research to address conditions affecting developing countries disproportionately.”

As Meir Pugtach (Haifa University) and Helen Disney (Stockholm Network have argued:

After all, how can we expect that an international body will be able to secure the implementation of recommendations, such as "promote the active participation of developing countries in innovation", "provide support for national health research programmes in developing countries through political action and long-term funding", "promote transfer of technology and the production of health products in developing countries" and "monitor the impact of intellectual property rights and other factors on innovation and access to health-care products"?

The truth of the matter is that the promotion of innovation and the creation of new medicines for the sake of developing countries cannot be based on a top-down process. Rather they should be based on bottom-up solutions by the actual players involved in this process - companies, research institutions, and the regulatory and IP authorities.

Clearly Senator Sanders and the Jamie Love-ites do not concur. They want the philosophy of the IGWG to become the law of the land in the United States -- hard facts, economic theory, and historical precedents not withstanding.

Hopefully the US delegation in Geneva will strongly argue against this philosophy and refuse to enter into “consensus.”

A prize in every box does not a Crackerjack idea make.   Read More & Comment...

Comparative Effectiveness Continued

10/19/2007 04:01 PM |

First, I am glad we finally got the posting problem fixed. I do appreciate the comments and criticisms (most of them.)

Second, with respect to Merrill's comments. CMPI is a separate 501 c 3 and we would be happy to send you our 990.

Third, I appreciate Dr. Posen's comments too. I think we are all on common ground...what comparative effectiveness should look like. I would be more than happy to debate/discuss with Merrill you or anyone and provide a forum to do so. Here's our view of comparative effectiveness:

Comparative effectiveness research as currently constructed consists of centralizing coverage decisions for entire groups of people using population-based studies. It looks a single treatment or device in isolation, rather than an integrated focus on personalized, predictive and prospective medicine. Comparative effectiveness only looks at the bottom line of insurers. Tailored treatments rely on combining information about individual differences in genetic and clinical responses to improve wellbeing and measuring outcomes and the value of care to patients, employers and families.

Further, the introduction of the use of “quality adjusted life year” as a bench mark for comparative effectiveness, coverage and reimbursement flows from a method and model of analysis that is similarly outdated and which fails to take into account the value that personalized and targeted therapies provide individuals and their families. In general, the default value of a QALY appears to be $50000 US dollars though that figure has little empirical evidence and was developed to assess the value of dialysis for end stage renal patients in 1979.

CMPI has set up a Patient Centric Health Leadership Forum.

In contrast to the reliance on meta-analyses and large trials that exclude patient variation, we hope to advance the use of individual patient level information from conventional clinical assessments, genomic and biomarker analyses, and, where appropriate, advanced imaging studies.

Such information will be used to increase the adoption of the use of real time updates and refinement of the risk prediction algorithms and health plan strategies that are supported by data-mining techniques, filtered through expert panels at the patient level.

Third, we want to work with policymakers, insurers and government to ensure that value of personalized evidenced, integrated care and targeted medicine is fully articulated at all policy considerations about comparative effectiveness.  Read More & Comment...

Paid Advocate: Look Who's Talking

10/19/2007 12:36 PM |

Let's be clear: Goozner works for Center for Science in the Public Interest. We run Center for Medicine in the Public Interest. Both groups deal with science and medical issues. Both are agenda driven research based organizations. We both get money from different sources that reflect two very different views about the relationship between science, innovation and the private sector.

CSPI gets $16 million a year from a variety of left wing groups and foundations and from a newsletter that over the years has told people that transfats were good (1980s) and that they were bad (2000s) and that wine, soda, popcorn, Chinese food, cookies, and anything other than raw carrots and celery can kill you. It has a vested interest in pumping out bad news and selling it. It has taken money from foundations to promote campaigns against Olestra, antibiotics in agriculture, wine consumption, gelatin, food additives because it causes ADHD, acrylamide (because it "causes" cancer) in bread and social drinking.

We get less then ten percent of that from individuals, foundations, biotech and pharma companies to discuss, promote and develop strategies and approaches to personalize the delivery of medicine. The blog and our oped writing is a small part of who we are and what we do. We blog and write on comparative effectiveness and its limits because no one else is and no one else seems to have the willingness to do so.

In this context simply calling me or Peter a "paid advocate" is tired and intellectually shallow. If we toed the party line and trashed "Big Pharma" no one would care where we got our money from, even if it came from Soros or Chavez or third generation tobacco scions.

This is the last time we will deal this issue because if our critics lack the self awareness and self-honesty to accept that no one group can claim to speak on behalf of the enlightened public interest because of where they get their support. Calling oneself a public interest group is, as Wildavsky noted, not just convenient, it is flattering. " Perhaps getting money from newletters and liberal foundations puts one on a higher moral plane and less conflicted We just think it makes others more...liberal.  Read More & Comment...