Issue 31 / 17 August 2015

AM I the only one who sees some irony here? While researching this article, the state premiers were meeting with the Prime Minister in Canberra to shore up funding for health and education. A hike in the GST was being considered.
Around the same time, in the MJA there was an editorial calling for a dramatic reorganisation of hospital resources to accommodate neurointervention for stroke: specifically, urgent endovascular therapy in addition to systemic thrombolysis. 
The editorial notes that this would present an insurmountable workload to the current population of interventional radiologists, and suggests that, like cardiologists and gastroenterologists, neurologists now become proceduralists.
Let’s look at what is being proposed. 
We already know that systemic thrombolysis for stroke is problematic: only a small proportion of stroke patients qualify, the treatment is time-dependent, and we don’t know which patients will be harmed by the treatment. 
In Australia in 2012, only 5%‒7% of stroke patients were eligible for thrombolysis (met clinical criteria and accessed treatment). Clinical improvement is modest, and is greatest in patients with the mildest strokes. 
Significantly, we can’t predict with any certainty which patients will suffer fatal intracerebral bleeds as a result of therapy.
More recent studies (published as recently as June 2015) compare combined endovascular therapy and systemic thrombolysis with thrombolysis alone. 
There are no placebo arms — although we know that systemic thrombolysis is associated with more early deaths
Newer approaches emphasise patient selection with estimation of thrombus location and size, and the volume of irreversibly infarcted brain tissue. New technology and skills are also required, as well as careful timing. 
Despite all this, and the prediction that only about 10% of stroke patients will be eligible (and those with the mildest strokes will benefit most), there are international calls for the hospital system to be reorganised around the delivery of such care.
There is good reason for neurologists to want to implement effective treatment for their patients who suffer the potentially devastating effects of stroke. Stories of dramatic recovery are inspiring. Unfortunately, these are rare, and often spontaneous. And systemic thrombolysis can kill.
Some signs are promising. It seems centres offering endovascular thrombectomy are getting closer to optimal patient selection, although fatal haemorrhages still occur. 
However, the reorganisation required to offer this therapy would require an enormous shift of resources, with potential to benefit few.
So, how do we continue to fund new technology advances in the health system — higher income tax, higher Medicare levy, increased GST? 
Or do we wait for more evidence before we rush towards expensive and potentially exclusive new therapies?
Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She is also a member of the Friends of Science in Medicine executive.

3 thoughts on “Sue Ieraci: Costly treatment

  1. SA Health Library Network says:

    In SA that reorganisation is already underway. There will be one interventional stroke centre for the state. That’s actually a decrease from the current two. As to the other issues, they don’t appear to matter ……

  2. Ian Relf says:

    A balanced real world view; true perspective of the risks and which patient group benefits. Excellent article.   

  3. Department of Health Victoria Clinicians Health Channel says:

    Excellent article. Enormous cost to benefit very few patients.

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