Managed Care - November 2008 - (Page 27)

metabolic syndrome, says Rodgers, and 10 percent of their skinnier contemporaries do. Blood testing helps to pinpoint who is actually at risk. As BMI goes up, so do risk factors BMI 30 Glucose Triglycerides HDL <40 HDL 100 >150 Men Women 11.5% 28.7% 41.89% 6.2% 20.2% 33.7% 10.9% 14.7% 29.0% 11.3% 25.0% 31.5% Similarly, obese people experience lower levels of adiponectin, testosterone (for men), and HDL, and higher levels of ferritin, fasting blood sugar, cholesterol, LDL, triglycerides, and inflammation. But again, not all obese people experience these effects. These biomarkers, says Rodgers, can help identify who is in trouble. And consider inflammation, “the match that starts the disease fire.” Three good indications of inflammation are the biomarkers C-reactive protein (CRP) and interleukins 6 and 8, which are strongly associated with risk for cardiovascular disease. Supporters say biomarkers can tell who has metabolic syndrome and who has or is at risk for diabetes, and of these people, who has the cardiovascular and inflammation profile that puts them most at risk. Once identified, each of these parts can be treated. And biomarkers can also register improvements over time, providing powerful psychological reinforcement for appropriate self-care. Indications for inflammation BMI Glucose >100 CRP>3 30 11.5% 28.7% 41.89% 14.2% 17.0% 44.5% IL-6>12 5.7% 2.1% 10.8% IL-8>75 7.5% 12.2% 20.2% Could the aggressive use of serum biomarkers by health plans save lives and resources? Rodgers concedes that large studies to prove their efficacy have not yet been done, but he thinks the answer may be yes. To illustrate, he cites the year’s most famous early death from heart disease, that of “Meet the Press” host Tim Russert, who collapsed suddenly in June after plaque ruptured in a coronary artery, causing a clot that cut off circulation to part of his heart. His case reminds us that plaque buildup in arteries doesn’t tell the whole story of the risk of sudden heart attack; a rupture in that plaque is often the fatal precipitating event. “There are biomarkers associated with an impending rupture, such as myloperoxidase (MPO), CD-40 ligan, and the matrix matella proteinases,” says Rodgers. “If a broader evaluation of Russert’s biomarkers had been done, it’s possible that medical intervention could have brought down the level of inflammation and prevented the rupture. And I’m not talking about necessarily putting in a stent or doing a bypass; I’m talking about medical therapy.” Rodgers points out that the costs of a thorough blood test would be trifling compared with the tragedy of Russert’s death, or the treatment costs for a similar heart attack patient who survived, but in a vegetative state. Still, Carolyn Langer, MD, medical director of medical management and policy at Harvard Pilgrim Health Care, says the predictive value of biomarkers doesn’t yet have firm science behind it. “Many of these markers promise to assist in stratifying high-risk populations, which may in turn enable clinicians to intervene earlier in the disease process,” she says. “But even for stratification, I don’t feel they are ready for prime time yet.” If their predictive value were now supported by studies, testing for them would be ordered by leading cardiologists, she says. Indeed, her plan consults annually with such specialists to keep abreast of “the emerging standard of care.” And Langer adds a practical concern: From a logistical standpoint, it would be very difficult for the health plans to acquire all of those test results, she says, because plan members don’t always get tested by contracted national labs. “I don’t want to sound pessimistic,” Langer concludes. “To the extent that new biomarkers may someday help us to risk-stratify the population to assist doctors in intervening earlier, that would be a very useful tool for us.” Early cancer detection If biomarkers could be used as a screening device as mammograms are used now to screen breast cancer, there would be few doubters. Between 1990 and 2000, the breast cancer mortality rate decreased 2.3 percent annually because of mass screening that resulted in earlier detection of more cancers. Early detection is a key to saving lives and cost. Though only 25 breast cancers are diagnosed as a result every 10,000 mammograms, the test is NOVEMBER 2008 / MANAGED CARE 27

Table of Contents Feed for the Digital Edition of Managed Care - November 2008

Managed Care - November 2008 Editor’s Memo Contents News and Commentary Legislation & Regulation Letters Medication Management Compensation Monitor Do It Yourself for Less Biomarkers Promise, but Do They Deliver? Oncologists Complain About Drug Payment Consider Blood Pressure Self-Monitoring Q&A: Keep Industry in the Game Formulary Files Plan Watch Tomorrow’s Medicine Outlook Respiratory Syncytial Virus Managed Care Considerations Contents Continuing Education Objectives RSV Disease in the Pediatric Population In the Trenches RSV Infection in the Adult Population Health Plan Medical Director Health Plan Pharmacy Director RSV Issues and Solutions Assessment/Evaluation/Certificate Request Post-Test

Managed Care - November 2008

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