September 18, 2006

A Time to Be Born, A Time to Die

On September 6, the Food and Drug Administration (FDA) approved the use of the artificial heart. The AbioCor heart, the device that was approved, has been used in 14 people. Their experience formed the basis of the FDA decision. All 14 had very advanced heart failure at the time of the surgery, so advanced they were not expected to live for more than a month. They could scarcely walk without getting short of breath and they were not candidates for a heart transplant (typically because of their age or other medical conditions). All 14 have died: 2 died during surgery, and 6 of the survivors suffered strokes. They lived an average of 5.2 months with the surgery, including one subject who lived for 17 months. However, only one was discharged home. Ten left the hospital only with short passes, and 1 moved to a hotel near the hospital. The cost of the device has been set at $250,000 by AbioMed, its manufacturer. The hospital charge for the insertion (not counting the cost of the prolonged hospital stays that have been required to date) is estimated at $100,000.

A little over a year ago, the scientific advisory panel to the FDA recommended against approving the device. FDA approval is contingent on a device being “safe and effective.” The artificial heart was deemed “effective,” since it prolonged life from an expected one month to an average of 5.2 months. The advisory panel, by a 7:6 vote, concluded they could not consider a device which led to major strokes in 50% of the recipients and which kept almost all patients hospitalized until their deaths “safe.” Usually, the FDA heeds the recommendation of its advisory panel. In this instance, without any engineering modifications since the advisory panel met in June, 2005, the FDA nonetheless approved the device. What happened?

The story of just who put pressure on whom to win approval of the device has yet to be researched. Interestingly, back in 1976, the director of the National Heart, Lung and Blood Institute tried to pull its contracts with 4 firms for designing and manufacturing the total artificial heart on the grounds that the technology was too flawed and too expensive. He didn’t expect anticipate the response from 2 powerful senators, Orrin Hatch of Utah and Edward Kennedy of Massachusetts, in whose states several of the firms were based. At their insistence, the contracts were reinstated—including the one to Abiomed, the Danvers, Massachusetts firm that produces today’s AbioCor heart. (For further insights on the history of the AbioCor heart, see the article by Renee Fox and Judith Swazey, “He Knows That Machine is His Mortality: Old and New Social and Cultural Patterns in the Clinical Trial of the AbioCor Artificial Heart,” Perspectives in Biology and Medicine 2004; 47:74-93).

What we know today is that the FDA decided not to grant full approval, but to allow use of the device under its “humanitarian exception” provision.” The standard in these cases is that the device be “safe and probably beneficial” and that the condition for which it is used afflicts fewer than 4000 individuals per year. The FDA, to be fair, has a tough job. It has to weigh the risks and the benefits of a new device. It has no clear calculus for doing this. In clinical practice, we typically offer treatments that “work” and expect patients to figure out, using their own personal values, whether the potential advantages of the treatment outweigh the disadvantages. When the treatment (whether drug or device) simply doesn’t do what it’s supposed to do, the job is fairly easy. When it does what it’s alleged to do, but there’s a safer alternative, the job of deciding on approval is also fairly straightforward. In the case of the artificial heart, it seems to “work,” if we define working as, on average, prolonging life. But the cost to the individual is enormous. Tom Christenson, the one subject who lived for 18 months after the implant, developed a fever to 107, kidney and liver failure and respiratory problems. He actually made it home for a few months, only to be readmitted to the hospital at which point the decision was made to disconnect the power source of the device and allow him to die.

Just because the FDA has approved use of the device doesn’t mean that it will automatically be paid for by the major health insurers. Medicare, for instance, has a process for making coverage decisions for controversial technologies such as the artificial heart. Medicare is required by law to make available to enrollees in the Medicare program any medical intervention that is “reasonable and necessary,” a phrase even less well-defined than the FDA’s “safe and effective.” Officially, Medicare is not supposed to take cost into consideration. This has become increasingly problematic as more and more expensive and only marginally useful procedures have entered medical practice, such as lung volume reduction surgery (an operation in which parts of the lung are cut out of patients with emphysema), the implantable defibrillator (a device that automatically shocks the heart if it detects a potentially dangerous heart rhythm), and the left ventricular assist device (another device used for patients suffering from very advanced heart failure, one that boosts the function of the heart rather than replacing the heart entirely). As a result, the Centers for Medicare and Medicaid Services has begun setting the price it will pay for certain procedures far below their actual cost—the left ventricular assist device was initially reimbursed at $70,000 even though the device alone cost $65,000 and the surgery to insert it typically cost over $200,000. With the AbioCor Heart, if Medicare does agree to cover the device, it will no doubt employ a similar strategy: it will choose to permit use of the device but pay something like $150,000—roughly what it pays for a heart transplant but less than half the cost of the new procedure—a strategy that will no doubt put a crimp on actual use of the procedure. (See my article, “Medicare Coverage for Technological Intervention: Time for New Criteria? Published in the New England Journal of Medicine 2004; 350: 199-203).

Replacing the human heart has been the American dream since the National Institutes of Health established an Artificial Heart Program in 1965. Originally granted $600,000 and 5 years to achieve its goal, the project has continued for over 40 years. Along the way, it has been critically reviewed multiple times, sometimes with the recommendation that the work continue only if the technology is expected to be cost-effective, or a good “value for the money.” At $350,000 to implant the AbioCor heart—and this figure does not take into account the full cost of hospitalization for these patients (all but 2 of the initial 14 cases spent the rest of their lives in the hospital)—it is surely not a good value. Heart disease is a critically important problem in America, afflicting some 5 million people. Perhaps it’s time to focus on preventing this disease—which we can do, if we do a better job on the prevention of high blood pressure, diabetes, and cigarette smoking. For those patients who do develop heart failure and who are dying of their heart failure, palliative care is an excellent means of addressing their symptoms and supporting them and their families in their final days.

No comments: