Medical blogger Dr. Aaron Carroll summarizes a recent research paper:

    The gist of it is that with cardiac surgery, there’s a significant risk of developing acute kidney injury. Up to 30% of patients wind up with it, and there’s not much we can do about it. But there’s a growing belief that “remote ischemic preconditioning” might help. What they do is fool the body into being concerned that ischemia, or periods of no oxygen, are coming. The theory is that this gets the tricked tissues to release certain factors that warn the rest of the body (ie kidneys) to slow down and prepare for badness. Then, when the cardiac surgery comes, the kidneys are better prepared for a hit.

    Basically, doctors place a blood pressure cuff on the upper arm. Then they inflate it to at least 200 mm Hg (which is high) for five minutes. Then they deflate it for five minutes. They do this three times in a row. Then they go ahead and operate normally.

The treatment was effective:

    More than half (52.5%) of the patients who received the placebo developed an acute kidney injury. Much fewer (37.5%) of those that received remote ischemic preconditioning developed one. That’s an absolute risk reduction of 15%... Awesome, right? This costs pretty much NOTHING, and it reduced bad outcomes in a high risk population hugely.

But the doctor predicts that the lack of profit potential and sex appeal means this technique will probably not become widespread. As a critic of public funding, I am sympathetic to the doctor's complaint that NIH won't pursue this treatment because more research would require confirming old results, and NIH looks for "innovation" in its grant guidelines.

But the doctor is skeptical of private forces backing the procedure as well:

    This is too “simple”. It’s tightening a blood pressure cuff. That won’t interest any rich donors to fund it. It won’t interest foundations. And industry won’t fund it—there’s no money in it.

Is the doctor right, that no one cares enough about kidney health to follow up on this? I wouldn't give up on the profit motive. I see hospital advertisements all the time, and being able to claim significantly fewer kidney complications for patients would seem like something to brag about. Even if a hospital does not self-promote, surveys like those by U.S. News should reflect improved patient outcomes.

b_b:

It still costs money to run a trial, even when the treatment itself is inexpensive. The people doing the enrolling need to be paid, the biostatisticians need to be paid, the doctors get paid research comp time, etc. It all adds up to a lot of money. A big trial could run into the millions easily. Hospitals operate on margins that are frighteningly low, 1-2% in many cases, if not at a loss. A doctor can't decide to start doing this procedure to patients on their own without a considerable amount of evidence supporting it as a best practice, even if it seems likely that it is better than the current status quo.

So here's the dilemma. A hospital or consortium invests millions of dollars in a treatment that can't be patented, costs nothing to startup, and can be easily replicated by others. So they've made the investment with the return being spread out among all their competitors. It's a losing proposition, even in the case of hospitals or universities that could afford it. There is simply no for-profit enterprise that would engage in it. Maybe a foundation (Kidney Foundation, for example) would be interested, but typically the budgets of the national foundations are pretty paltry compared to NIH. That is the main reason why a foundation might look away; I disagree with the author that it's about sexiness (and I say this with some authority, as I'm fairly heavily involved in the American Heart Association).

Now, if NIH were to fund a project that can't be directly capitalized on, but whose returns would be spread broadly through the economy, that makes sense, because it's you and I who are putting up the money and reaping the rewards. That's a value proposition. Even if it's ideologically untenable to you that the government fund biomedical research, it's still a pragmatic position to take, given that NIH dollars have a real impact on national health spending--by far our biggest outlay. We can talk about spending all day long, but the conversations will amount to nothing if health and military aren't on the table. Funding NIH is a way to reduce health spending, counterintuitive as it may seem.


posted 3235 days ago