The break-even point: when medical advances are less important than improving the fidelity with which they are delivered

Abstract

Society invests billions of dollars in the development of new drugs and technologies but comparatively little in the fidelity of health care, that is, improving systems to ensure the delivery of care to all patients in need. Using mathematical arguments and a nomogram, we demonstrate that technological advances must yield dramatic, often unrealistic increases in efficacy to do more good than could be accomplished by improving fidelity. In 2 examples (the development of anti-platelet agents and statins), we show that enhanced efficacy failed to achieve the health gains that would have occurred by delivering older agents to all eligible patients. Society's huge investment in technological innovations that only modestly improve efficacy, by consuming resources needed for improved delivery of care, may cost more lives than it saves. The misalignment of priorities is driven partly by the commercial interests of industry and by the public's appetite for technological breakthroughs, but health outcomes ultimately suffer. Health, economic, and moral arguments make the case for spending less on technological advances and more on improving systems for delivering care.

Figure 1.

“The Break-even Point” (for a drug that reduces mortality by 20%). Triangle A. If 100,000 patients are destined to die from a disease, a drug that reduces death rates by 20% (relative risk reduction [RRR] = 0.20) will save 16,000 lives (A1) if delivered to 80% of eligible patients. Increasing delivery to 100% would save 4,000 more lives (A2). To save as many lives with without improving upon the delivery rate of 80% (A3), the RRR of the drug must be increased to at least 25% (‘break-even point”). Triangle B. Delivering the drug to only 60% of patients would save only 12,000 lives (B1), and improving delivery to 100% would save 8,000 additional lives. To save 8,000 additional lives without improving upon the delivery rate of 60% (B2), the RRR of the drug must be increased to at least 33.3% (“break-even point”). Developing a more efficacious drug is more beneficial than improving access only if the new relative risk reduction (RRR) exceeds the existing RRR divided by the proportion of the population exposed to treatment. The complete nomogram from which the figure derives is provided by the Annals in an online appendix available at http://www.annfammed.org/cgi/content/full/3/6/545/DC1.