Sir, – Dr Dermot Power correctly summarises many of the issues relating to the reimbursement of newer and safer agents for the prevention of stroke in atrial fibrillation (April 6th).
Atrial fibrillation affects 5 per cent of the population over the age of 65 and results in a third of strokes in Ireland and accounts for 55 per cent of the more severe strokes (Kelly et al, 2011). A stroke due to atrial fibrillation is associated with a 60 per cent risk of disability and 20 per cent mortality.
Stroke is our leading cause of adult disability and third leading cause of death. Most of our acute stroke units are occupied by the devastating and preventable disability due to this disease.
Feely et al previously reported that almost half of older patients with atrial fibrillation did not get appropriate anticoagulation (blood thinning agents) largely due to the complexity and perceived danger of the only available agent until recently, namely warfarin.
Many older people cannot take this drug or attend monitoring clinics, leaving them effectively on non-recommended treatments of little efficacy. Appeals to the HSE to reimburse the newer, safer and more effective drugs, even in these limited circumstances, have until now not been replied to.
As a doctor, one is duty bound to inform and advise patients as to best and internationally recommended treatments and the newer anticoagulation agents have all received favourable recommendations from the National Institute of Clinical Excellence in the UK and the American Stroke Association.
In practice, this currently often leads to an uncomfortable discussion and decision in clinics and bedsides, as to whether patients and their families can pay for this medication themselves or feel disenfranchised by accepting what their physician feels is a second-best strategy.
Health economics, like all economics, is a matter of perspective, “I can’t afford to buy,” says the starving man, “Well then, sell” says the economist. . . ask the 30,000 people living with disability from stroke and those who care for them. – Yours, etc,