I'm not really all that mysterious

ever heard of opportunity cost?

This article in the Washington Post tries to argue that prevention is more expensive than intervention. The only problem is that they deliberately ignore two preventative measures that have clearly been demonstrated to decrease costs: immunizations, and colon cancer screening.

But even the idea that tight control of LDL using a statin is more expensive than performing urgent/emergent PCI or CABG is suspect. The argument is that giving people statins will cost approximately $160k/year of life in men and $240k/year of life, if you count lab tests and physician’s visits, and according to an old article in JAMA, the number needed to treat in order to prevent one death is somewhere between 163-639/year, depending on which statin and which dose you actually use. (For a back of the envelope calculation, we can use data from A month supply of simvastatin 40 mg costs $27.99. A month supply of pravastatin 40 mg is $20.99. [These are the prices for the generic formulations.] So we’re really talking about somewhere between $41,056/year to $214,627/year to save a life, which, if you put it that way, doesn’t really sound like much, now, does it? I mean, I’d like to think that a life is worth more than $214k, you know?) And, in theory, you really don’t need to see your physician more often than normal. It makes no sense to check lipids more than every 6 months—and certainly no more frequently than every 3 months at the most. And you only really need to check LFTs a couple of times before you know whether or not they’re going to cause transaminitis. Once you’re stabilized and at goal, you can let it ride, pretty much.

Now compare this to an emergent ambulance transport to the emergency room, the activation of the cath lab, the GpIIb-IIIa receptor blockers, the fluoro time, and, God help you, the clopidogrel (a 30 day supply costs $135.99, and if you end up with a drug-eluting stent, we’re talking at least one year of this stuff, and sometimes, we’re talking a lifetime of Plavix.) Or maybe you need to get CABGed, so we’re talking about OR time, bypass time, probable ICU time ± balloon pump, and I’m thinking that we’re easily talking about comparable costs, particularly when you add in the incidence of complications. And it’s a hell of a lot less convenient to have an MI than it is to take a pill for the rest of your life, if you ask me.

But we’re not even looking at opportunity cost: think about all the productivity that gets lost when someone has an MI in their 50s. I mean, we’re talking possibly up to a decade and a half of reduced productivity (and maybe more if we keep pushing the retirement age back.)

So, yeah, it’s going to be pretty damn hard to get me to believe that intervention is more expensive than prevention. Sure, we shouldn’t just put beta-blockers and SSRIs in the water to prevent MIs and major depression. You’ve still got to rationally target your preventions. And if you add in the cost to society in terms of opportunity cost, you’re bound to eventually start coming out ahead.

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