Monday, November 18, 2013

Week 13: What's it worth?


After an incredibly busy week last week with our trip to our future home in Wisconsin, this week has been mercifully a much more normal one.  Thanks to Nona and Opa, Papa Bear and I were even able to get out on a date.  We had an absolutely delicious meal at Upstairs on the Square, which you should visit soon if you are in the Boston area, as they are closing at the end of this year.  We had gone there way back when we were first dating, so it was fun to take a little stroll down memory lane and see how far we've come in the last five years.

Since nothing of significant note happened in Lemon's life this week, I thought I would devote this week's posting to a topic that has been on my mind a bit over the last few weeks: a medication called palivizumab (which goes by the brand name Synegis).

Synegis is a treatment that can reduce the severity of lung disease caused by respiratory syncycital virus (RSV) in "at risk" babies (babies born prematurely, babies with certain heart conditions, and maybe babies with CF).  Most children in the US have an RSV infection by the time they're two.  RSV infections are usually mild but can occasionally be severe enough to require hospitalization, especially in premature babies or babies with some other condition that compromises their lung health.  Unfortunately, there is currently no vaccine that can protect babies against RSV.  Vaccines act by stimulating the body to produce antibodies against the particular pathogen that causes a disease.  Synegis, which is a man-made injectable antibody against RSV, is effectively a short-cut; instead of getting the body to make its own antibodies, the doctor simply injects the baby with ready-made antibodies.  The idea is that these ready-made antibodies help the baby fight off an RSV infection if it happens.

One of the first things I wondered about when our doctors first recommended that Lemon receive Synegis was how much it really helped.  At the time, Synegis had mostly been studied in premature babies, with relatively little data available for CF babies. There just aren't that many CF babies (only about 1000 per year in the US), so it is hard to get enough of them to do a meaningful clinical study.  A recent review that collected all the published data so far on Synegis in CF babies found that might be beneficial--untreated CF babies had about a 1% chance of being hospitalized for RSV, and treated babies had about an 0.1% chance.  So, as a parent, how do you think about that result?  Do you think that your baby was very unlikely to be hospitalized for something in the first place, and with the treatment he is even less likely?  Or, do you think, "Wow, this treatment reduces the chance of my baby being hospitalized by 10-fold!  Sign me up!"

Next, you might think about the costs of the treatment.  There's the inconvenience of an additional visit to the pediatrician once a month for five months to get the shots.  There are the (very minor) risks associated with receiving the shot, which is overall an extremely safe therapy.  In contrast to what my fellow residents of the blogosphere seem to believe, the shots don't contain any rat DNA, and the recombinant DNA technology used to produce the antibody is very safe.  Then, there is the financial cost.  It's hard to find out exactly, of course, but there is no doubt whatsoever that Synegis is an extremely expensive medicine--about $1500 per shot, or around $7500 for the full treatment course.  It's so expensive, in fact, that the drug company that makes it sends you a nice little gift box once they receive the order for the drug from the pediatrician's office.

We're very fortunate that our insurance company covered Synegis without much fuss, so we didn't have to think about the financial cost at all, nor did our doctors.  But, isn't this exactly what we're told is wrong with healthcare in America?  That both the patient and the provider have no idea how much things cost, so lots of money is spent on treatments or procedures of minimal utility?  By deciding that I wanted Lemon to receive Synegis, even though the actual benefit might be quite small, am I becoming part of the problem?  If I had to pay for Synegis out of pocket, would I do it?

Interestingly enough, I might have the opportunity to answer that question.  The CF center in Wisconsin doesn't seem to think that Synegis is worth it, and the doctor we met there said our new insurance would be very unlikely to cover it, especially since Lemon will have received 3 of the 5 shots by the time we get there.  So, do I cover the remaining two shots out of pocket?  If I do, and he doesn't get RSV, would I feel like it was a waste of $3000?  If I don't, and he does get hospitalized with RSV, would I feel like it was my fault because I wasn't willing to shell out the money? 

Last week, a loyal blog reader pointed out this article from the New Yorker that was published about 8 years ago.  It discusses how different CF centers were getting very different outcomes, despite a supposedly unified set of guidelines for patient treatment.  At one of the centers that was getting the best outcomes, there was a doctor who was absolutely fanatical about maintaining lung function in his patients.  In his view, each day a CF patient had a 0.5% chance of catching a dangerous lung infection (that is, a 99.5% chance of staying healthy).  By being absolutely obsessive about treatment, the patients could reduce that risk to 0.05% per day (a 99.95% chance of staying healthy).  That difference doesn't sound like much, but over a year it is the difference between an 83% chance of getting a lung infection and a 16% chance--which is huge.  There is some evidence that viral infections like RSV can make CF patients more susceptible to the bacterial infections that lead to permanent lung damage.  So, does that mean that Synegis treatment is part of staying in that 99.95% category? If it is, then it's totally worth the cost to me.  I just wish I knew!






1 comment:

  1. If I had the 3k, I'd probably complete the treatment. You talk a lot about probabilities and mathematics, but you forget the psychological effects of peace of mind. If money is not a hardship, just do it, and sleep better at night without having to keep on wondering "what if" and "did I make the right decision or not". People spend 3k on vacations....to obtain peace of mind. People spend 3k on therapists and psychiatrists...to obtain peace of mind. Would you spend 3k to obtain peace of mind even if the reduced infection risk were minimal? I probably would. But then again, Swiss salaries are very generous and 3k would simply mean that I sock no savings that month, not that I have to make any real sacrifices or changes to my lifestyle. Then again, even if minor sacrifices were required, I would think most people would sacrifice a month's salary for peace of mind with regards to the health of their kids. After all, it's not like you're investing 3k on snake oil or some unproven natural remedy. You've researched the science and done your math and the benefits are proven and tangible. But now, how do you value the unquantifiable...your peace of mind? That's the bottom line question, in my view. (shrug).

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