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Sunday, August 17, 2014

Economics always trumps evidence

One of the basic tenants of economics is that people respond to incentives. One of the most powerful incentives are monetary ones. As my oldest child describes this, "We are coin operated. "

Which brings me to a recent study published in JAMA - “Effect of Flexible Sigmoidoscopy Screening on Colorectal Cancer Incidence and Mortality“. This study demonstrated that screening patients with flexible signmoidoscopy decreases the incidence of colon cancer and death from colon cancer. It was a large study involving tens of thousands of people in Norway. This was the fourth study which showed similar effects. They were not huge in terms of absolute numbers, lowering the mortality from 4/1000 to 3/1000 over the 11 year interval in which patients were studied.

In the accompanying commentary by Allan Brett, the author points out that while flexible sigmoidoscopy demonstrates this benefit, the same has not been shown for colonoscopy, the more difficult, expensive, and risky approach to screening. Yet, colonoscopy has all but completely replaced the use of flexible sigmoidoscopy. Will this new information cause the pendulum to swing back toward use of the flexible sigmoidoscopy? I doubt it since the economics are so compelling.

As Dr. Brett notes in his commentary, patients are nudged by AGA guidelines identifying that the colonoscopy approach is the "preferred" strategy. Attempts to have a more nuanced discussion are really not feasible (likely true) and why not drive patients to the procedure that creates this highest margins? One does not need to be in the pocket of drug companies in order to be financially conflicted. You just need to be practicing medicine.

Perhaps it is not fair to single out the gastroenterologists,  since this type of thinking is absolutely rampant within current medical practice. It just seems that the economic underpinnings of this particular specialty may become unraveled rather quickly. As noted by Dr. Brett and in a cited piece by Stacey Butterfield in the ACP internist (Changes in colon cancer screening), next generation stool DNA testing may replace an expensive and cumbersome test with a simple stool test. I am sure that this will not happen without a real fight because as noted by David Lieberman, MD who was quoted in the ACP piece, "Colonoscopy has been really good to the specialty. It has been the goose that laid the golden egg".

I guess gooses don't live forever. The question is whether we should be working toward goose immortality.

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