This Week in Managed Care: November 22, 2019

Stents may offer no more value than drugs for some heart patients, a ban on flavored tobacco products gains momentum, and most American families struggle with social factors that impact health.

Welcome to This Week in Managed Care, I’m Laura Joszt.

Use of Stents in Heart Disease

Patients with stable heart disease may do just as well with medication as they do with stents or bypass surgery, a landmark study has found. The $100 million ISCHEMIA study, presented last weekend at the American Heart Association (AHA) Scientific Sessions in Philadelphia, found that medication offered a slight benefit over the first six months, while invasive therapy showed a benefit at the 4-year mark.

Without this trial, said Alice Jacobs, MD, of Boston University School of Medicine, “The data are conflicting, and there is equipoise in the community, but I think there is a nagging undertow of concern about not withholding the invasive strategy in patients with moderate to severe ischemia, because of the fear of exposing them to adverse outcomes.”

Invasive procedures would still be preferred if there is frequent angina, based on patient-reported outcomes.

Other major announcements at AHA include:

• Interim results from the EVAPORATE study suggest that the effect of Vascepa on coronary plaques could explain why the purified fish oil pill prevents heart attacks. The FDA will soon decide whether to expand the drug’s label.
• The SGLT2 inhibitor dapagliflozin improved quality-of-life scores and was just as effective among seniors with heart failure as it was among young patients.

View full coverage from AHA.

Measures Address Vaping

Measures to curb the teen vaping epidemic passed the House Energy and Commerce committee this week, with the lawmakers taking steps that go beyond President Trump’s proposed flavor ban.

The House bill would do the following:

• Ban all flavored tobacco products
• Increase the legal buying age to 21
• Ban online sales

The vote came the same day the American Medical Association (AMA) called for a complete ban on electronic cigarettes and vaping devices, in light of lawsuits against Juul for targeting teenagers.

Said AMA President Patrice Harris, MD: “It’s simple. We must keep nicotine products out of the hands of young people.”

Social Factors of Health Impact Majority of American Families

Most US families struggle with at least 1 social factor that affects their health, according to a new survey.

Sixty-five percent of parents with a child under age 18 have barriers to optimal health, said the report commissioned by Nemours Children’s Health System. Like most health systems, Nemours is calling for changes to payment systems so that health systems are rewarded for actions that improve health rather than treat disease.

Nemours President and Chief Executive Officer R. Lawrence Moss, MD, FACS, FAAP, wrote in the report: “We are paid for volume and complexity of service delivered. This misalignment of incentives means that keeping children healthy and out of the hospital is financially unsustainable.”

Dollars must be shifted to give parents resources to raise healthy children, he said. The survey found:

• 32% skipped a medical appointment because they couldn’t afford it or had no transportation
• 30% had trouble paying for medicine
• 23% worried about running out of food
• 17% had trouble finding affordable child care

Educating on Purpose of Precision Medicine Trials

A new study finds that both families and healthcare professionals need more education on the benefits and limits of precision medicine trials. The study in the Journal of Clinical Oncology discussed how children can sometimes benefit from complex treatments, but their parents may have little understanding of genomics and not grasp what the trial is designed to do.

The authors wrote: “Parents often have high expectations regarding the potential therapeutic benefit for their child. These high expectations may be misconstrued as misunderstanding the trial’s primary objective but often are associated with parents’ hope of tumor response. Even when parents know that their child is unlikely to benefit, they may still hope that an effective treatment will be identified.”

Authors interviewed parents involved in the TARGET pilot study to treat pediatric tumors. In two-thirds of the cases, the children who had taken part in the trial had died at the time of these interviews. And the interviews made it clear that the most parents still had minimal understanding of the purpose of the trial.

The authors concluded: “Supporting families to better understand the benefits and limitations of precision medicine will be critical to enhance satisfaction with their child’s care and reduce potential negative psychological outcomes. Easy-to-understand educational resources in multiple languages explaining the main concepts of precision medicine trials are needed.”

Debating Value Assessment

Finally, this month’s issue of The American Journal of Managed Care^® (AJMC^®) features a lively debate over the issue of value assessment:

Authors led by Anirban Basu, PhD, of the CHOICE Institute, ask how heterogeneity in populations can be better reflected in value assessments, while Steve Pearson, MD, of the Institute of Clinical and Economic Review, responds that the nature of these assessments means that they can never account for all population differences.

Check out the full issue.

For all of us at AJMC^®, I’m Laura Joszt.