Tagged Emergency Medicine

Hospitals Slashed Use Of Two Heart Drugs After Huge Price Hikes

Even before media reports and a congressional hearing vilified Valeant Pharmaceuticals International for raising prices on a pair of lifesaving heart drugs, Dr. Umesh Khot knew something was very wrong.

Khot is a cardiologist at the Cleveland Clinic, which prides itself on outstanding heart care. The health system’s pharmacists had alerted doctors about the skyrocketing cost of the drugs, nitroprusside and isoproterenol. But these two older drugs, frequently used in emergency and intensive care situations, have no direct alternatives.

“If we are having concerns, what is happening nationally?” Khot wondered.

As it turned out, a lot was happening.

Following major price increases, use of the two cardiac medicines has dramatically decreased at 47 hospitals, according to a research letter Khot and two others published Wednesday in the New England Journal of Medicine.

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The number of patients getting nitroprusside, which is given intravenously when a patient’s blood pressure is dangerously high, decreased 53 percent from 2012 to 2015. At the same time, its price per 50 milligrams jumped thirtyfold, from $27.46 in 2012 to $880.88 in 2015.

The use of isoproterenol, key in monitoring and treating heart-rhythm problems during surgery, decreased 35 percent as the price per milligram rose from $26.20 to $1,790.11.

The drugs, which are off patent, have long been go-to medicines for doctors.

“This isn’t like a cholesterol medicine, these are really, very specialized drugs,” said Khot, who is lead author on the peer-reviewed research letter. When patients get the drugs, “they are either sick beyond sick in intensive care or they’re under anesthesia [during] a procedure.”

Valeant bought the drugs in early 2015 from Marathon Pharmaceuticals. Last year, Valeant announced a rebate program to lower the price hospitals paid for the drugs. And Valeant’s Lainie Keller, a vice president of communications, said the company is committed to limiting price increases.

“The current management team is committed to ensuring that past decisions with respect to product pricing are not repeated,” Keller wrote.

Erin Fox, who directs drug information at the University of Utah Health Care, said the letter reveals “exactly what a lot of pharmacists have been talking about. When prices are unsustainable, you have to stop using the drug whenever you can. You just can’t afford it.”

Fox said her Utah health system removed isoproterenol from its bright-red crash carts, which are stocked for emergencies like heart attacks. Nitroprusside is more difficult to replace.

“It is one if you need it, you need it,” Fox said. “That’s exactly why the usage has not gone down to zero even with the huge price increases.”

Cleveland Clinic leaders spent months investigating each drug’s use and potential alternatives, Khot said.

“We’re not going to ration or restrict this drug in any way that would negatively impact these patients,” Khot said, adding that he hopes to do more research on how the decreased use of both drugs affected patients.

Dr. Richard Fogel, a cardiologist and electrophysiologist at Ascension, a large nonprofit hospital chain with facilities in 22 states and the District of Columbia, told a Senate committee last year that the cost of the two drugs alone drove a nearly $12 million increase in Ascension’s spending over one year.

“While we understand a steady, rational increase in prices, it is the sudden, unfounded price explosions in select older drugs that hinder us in caring for patients,” Fogel said.

The NEJM letter also analyzed two other drugs — nitroglycerin and dobutamine — that remained stable in price as a control group. The number of patients treated with nitroglycerin, a drug used for chest pain and heart failure, increased by 89 percent, but Khot warned that the drugs can’t always be used as substitutes.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Categories: Cost and Quality, Pharmaceuticals

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EMS Delays In Rural Areas Leave First-Aid Gap For Bystanders To Fill

Better hope that you aren’t in a rural area if you are seriously hurt and need an ambulance. The wait could be dangerous.

Response times for emergency medical services are more than twice as long in rural areas than urban locations, according to a recent research letter in JAMA Surgery.

Median response times were 13 minutes out in the country compared with six in both city and suburban locations, researchers found after reviewing records of nearly 1.8 million EMS runs across the U.S. in 2015.

That’s not the worst of it. In rural areas, one in 10 EMS units did not reach an emergency scene for nearly half an hour after the 911 call came in, the study reported.

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“There are just some things that just can’t wait,” said Dr. Howard Mell, the study’s lead author. “When someone’s heart is not beating … when someone’s not breathing, any delay in care, even a minute — it’s proven to be detrimental.”

The researchers point out in their letter that they looked into the time differences to help inform the debate about improving first aid campaigns. They said their data suggest that bystanders can provide valuable assistance to the sick and injured persons before EMS arrives.

The JAMA letter put it this way: “Recognizing that ‘you are the help until help arrives’ may be lifesaving.”

Mell, whose 25 years in emergency medicine also includes stints as a firefighter and a paramedic, said he cannot recall an instance when a trained bystander at an emergency scene would not have helped before EMS’ arrival. He is the attending emergency physician for CEP-America at Presence Mercy Medical Center in Aurora, Ill., and a spokesperson for the American College of Emergency Physicians.

Caring for the sick and injured is EMS’ workers’ job, but according to Mell’s study, family, friends and bystanders are the first link in the chain of survival. Beneficiaries are not always strangers.

People who get first aid and CPR training will likely use it to save friends and family members one day, Mell said. “It’s extremely rare that you get a patient who is truly alone.”

The researchers’ message is at the center of a public education campaign called “Until Help Arrives,” which is affiliated with the Federal Emergency Management Agency and other government agencies. The campaign provides web-based resources to teach basic life-saving skills.

An accompanying editorial endorsed the researchers’ viewpoint and said their study “reinforces the importance of bystanders as immediate responders.” It pointed to the need for more emphasis on teaching people how to control bleeding.

Thirty-two states have adopted legislation requiring high school students be trained in CPR and the use of  automatic electric defibrillators before graduation. Students should also learn how to control bleeding, the editorial said.

Categories: Cost and Quality

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