Rapid Responses to:

LETTERS: Gerd Assmann, Paul Cullen, and Helmut Schulte "Polypill" to fight cardiovascular disease: Interpretation of trial data is optimistic BMJ 2003; 327: 808-b [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Polypill and Public Policy

Gerhard B. Holt   (1 May 2006)

Polypill and Public Policy 1 May 2006
Gerhard B. Holt, Medical Student University of Sydney 2006 Send response to journal: Re: Polypill and Public Policy	The polypill for primary prevention has its critics. Some suggest that (1) the reductions in IHD and stroke may be overly optimistic. Others suggest that (2) the cost effectiveness of such a primary prevention approach has not been fully established. (3) Others even wonder whether anyone has enough of an economic interest in the polypill to develop such a program to fruition - since its components are off-patent. (1) Ward and Law suggest an 88 % reduction in IHD and an 80 % reduction in stroke. Even if these rates are overestimated by a factor of 4 - a 22 % potential reduction in IHD and a 20 % potential reduction in stroke strongly merit immediate further investigation. (2) The human costs of IHD and stroke clearly demand further investigation of the polypill. But even from a purely economic analysis, stroke and IHD are enormously expensive to society - not only in direct costs of care, but in terms of years of reduced or lost productivity - not only for the patient, but also for the patient's family and friends. A proper economic analysis would have to take these factors into account (although it is likely that even the (much lower) direct cost savings would be quite substantial). (3) While pharmaceutical companies might not have a direct economic interest in developing the polypill, several key players do. These include : . (1) government payers (such as medicare), . (2) large health insurers and HMOs, . (3) large employers with health care obligations, . (4) regional governments in areas with a high density of persons over 55. . (5) regional governments who are responsible for paying for hospital services. . (6) Large non-profit organizations like A.A.R.P. Some Polypill Policy Approaches : Governments and other heath care players could actively encourage GPs to schedule a special visit with their patients when they turn 55 (or if they are already over 55). GPs could be actively encouraged to consider a polypill as a DEFAULT choice - with the burden being on the GP to justify why a patient would NOT benefit from the polypill. GPs could be encouraged and incentivized to consider the polypill with all patients over 55 - just as they are encouraged to promote vaccination in children. Protocols could be established for dealing with the more common significant side effects or commonly occuring counterindications. For example, a version of the Polypill could be made with substitute ingredients for people with asthma, or Type II diabetes. Large generic manufacturing of polypills could also readily create Polypill - 1 (six varieties), and Polypill - 2 (fifteen varieties) without losing (massive) economies of scale. These could be used in patients who had significant adverse reactions to one or two of the components. (Such patients could then take for example a Polypill-1 (minus the ACE Inhibitor) if they had a persistent dry cough. Their GP could then decide whether or not to substitute the absent components with other medications). Large scale manufacturing of these 24 pills could be done very efficiently by a utility-like pharmaceutical manufacturer to ensure quality and to maximize gain from economies of scale. It is a mistake to make a "fixed resource pie" assumption when the potential benefits are so substantial. If necessary, new resources can be allocated to INVEST in such dramatic (and efficient) improvements. In the longer run, substantial gains from having a more healthy elderly population may dramatically outweigh the initial required investments. Conclusion : According to Wald and Law, the polypill would add 11 years of life free of stroke or IHD in one third of people over 55. In total years of life gained to society, this represents millions of lifetimes. If countries were threatened by a war that would kill and cruelly disable millions of their citizens - you would not be hearing all this waffling. The citizenry of free nations would DEMAND that their governments spend the resources needed to protect them - after all, that's why governments exist. Competing interests: None declared