Response to Letter by Samuelson et al
Dr Samuelson and colleagues raise the important issue of cost in stroke prevention. The American Stroke Association (ASA) guidelines are written on the basis of the evidence for potential benefit or harm to an individual at risk and for use by individual physicians in discussions with patients and families. Although cost is important to all of us in medicine, it is beyond the scope of the guidelines as currently charged to attempt to weigh in a comprehensive and scientific manner the relative contributions to stroke prevention of alternative strategies selected on the basis of cost. In most cases there are few if any data on which to base the “value added” of particular medications or combinations of medications on an ever-changing background of medications for hypertension, diabetes, lipid disorders, and platelet or clotting directed therapies. A large number of variables would have to be considered to do this. These might include the true cost of a specific medication, which may depend on the source of insurance that a patient has and the availability of generic forms of the same drug (as will likely emerge soon with atorvastatin), the effect that a medication such as a statin has on comorbid conditions of significance such as myocardial infarction, and even patient preferences as to how expenditure for stroke reduction compares in importance to other uses of resources that are important to a given patient and their family.
The comparative cost and benefit of competing strategies for prevention of costly conditions such as stroke is of great interest to payers, and there is a need for more rigorous studies in this area. There is a particular need for these entities and companies, as potential beneficiaries of sound data that may allow cost reduction while preserving good outcomes, to do much more to help fund such research. This could perhaps be best accomplished by these groups to contribute substantially to a research funding pool for which disinterested researchers must compete within broad objectives related to cost and clinical outcomes. This will help the science, and those who write guidelines, move beyond evaluating and comparing individual drug trials to a more comprehensive understanding of how the various medications with vascular impact can be used most effectively for the best protection of the individual and wider availability of treatment to all patients at risk by the most rational use of limited resources.