Dr. Utibe Essien: Who Gets Access to Innovative Treatments? (Health & Veritas Ep. 52)

On the Health & Veritas podcast, Yale physician-professors Howard Forman and Harlan Krumholz talk about the latest news and ideas in healthcare and seek out the truth amid the noise. In this episode, Harlan reports on a new study testing the effectiveness of the OCD drug fluvoxamine in treating COVID; Howie reflects on the potential of continuous glucose monitoring for people with diabetes. And they’re joined by Dr. Utibe Essien of the University of Pittsburgh to discuss the barriers preventing people of color from getting innovative new treatments and medications.

Utibe Essien

Utibe Essien
Assistant Professor of Medicine, University of Pittsburgh School of Medicine ; Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
Howard P. Forman
Professor of Radiology and Biomedical Imaging, Economics, Public Health, and Management; Co-founder, Pozen-Commonwealth Fund Fellowship in Health Equity Leadership, MD/MBA Program, and MBA for Executives Program
Harlan M. Krumholz
Harold H. Hines, Jr. Professor of Medicine and Director of the Yale Center for Outcomes Research and Evaluation

October 20, 2022

Listen now:

Links

“Fluvoxamine for Outpatient Treatment of COVID-19: A Decentralized, Placebo-controlled, Randomized, Platform Clinical Trial”

Utibe Essien: “Association of Neighborhood Disadvantage and Anticoagulation for Patients with Atrial Fibrillation in the Veterans Health Administration: the REACH-AF Study”

“Prevalence and Correlates of Patient Rationing of Insulin in the United States: A National Survey”

Harlan Krumholz: “Life Expectancy after Myocardial Infarction by Hospital Performance”

“Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites”

Antiracism in Medicine podcast

“Intermittently Scanned Continuous Glucose Monitoring for Type 1 Diabetes”

Learn more about the MBA for Executives program at Yale SOM.

Email Howie and Harlan comments or questions.

Subscribe to Health & Veritas in Apple Podcasts, Spotify, Google Podcasts, or your favorite podcast player.

TRANSCRIPT

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week, we’ll be speaking with Dr. Utibe Essien. But first, what’s got your attention this week, Harlan?

Harlan Krumholz: Yeah, thanks, Howie. Great to see you again. This week, I wanted to just make a note of this preprint that came out this week. Of course, preprints are articles that have been written being submitted often to journals, but in the period of time when they’re being reviewed are being posted publicly so that people can see them and understand the progress of science. This is on medRxiv, and as you know, it’s a preprint server that I co-founded with Joe Ross and others. I think it’s helped speed science for discussion.

Today, a group called the ACTIV-6 posted an NIH trial on a drug, fluoxetine, that is a drug that’s been used for obsessive-compulsive disorder but found its way into discussions about the treatment of COVID. I bring this up because this is why we do the research. In the midst of a pandemic, but actually in everyday medicine, people are coming in and said, “I’ve heard this works. I’ve heard that works.” People want to try all sorts of different things.

Howard Forman: You have me already so interested in this, because I remember about a year and a half ago, Florida was touting this.

Harlan Krumholz: Oh, my gosh. Yeah. It just came out of nowhere. I mean, people just start saying, “We should take this.” So, people may have heard about SSRI inhibitors. SSRIs are inhibitors of the serotonin reuptake, the “I” is actually “inhibitor.” These have been approved for a wide variety of mental health problems. Like I said, this one for the treatment of obsessive-compulsive disorder and a few psychiatric conditions including social anxiety and depression. But somebody started digging in and saying, “Well, this activates a certain receptor which may decrease inflammation and maybe it down regulates expression of inflammatory genes.”

That’s a whole bunch of language just to say that maybe there’s something here that modulates our defense system that might be useful in patients who are acutely ill with COVID-19. So, there are a whole bunch of activity and proclamations and that there were some smaller studies outside the United States that were maybe trying to look at this and make some determination and even found some promising data. But this NIH study was rigorous and relatively rapid. It was a decentralized study. So, it’s one of these studies where people didn’t need to come into the hospital, but they enrolled, were screened and sent the medications to take once they tested positive. And then they went and saw what happens.

In the end, they had about almost 1,300 people that were 30 years and older with confirmed COVID-19 who were having two or more symptoms of the acute infection within seven days. They wanted to treat them relatively rapidly. So, within a week, they were randomized to receive fluvoxamine 50 milligrams or a placebo twice a day for 10 days. What they wanted to see was, “What was the time to sustained recovery?” That was really three days. They wanted to see how long did it take you to get three days without symptoms, so they went through this. The mean age of people was 48. 57% were women.

Median time to recovery was 13 days. I thought this was interesting in its own right, Howie. So, these are people who got sick, they had the two symptoms, they weren’t feeling well. It took almost two weeks for them to feel better. I actually have people to tell me, “Hey, I’m still feeling sick after week. How normal is that?” If you see in this trial, again, they were looking for people who were symptomatic, but the median time, that means more than half the people took more than two weeks before they actually fully recovered. The bottom line of the trial was... What do you think?

Howard Forman: I’m always a skeptic about everything. So, I would’ve thought it doesn’t work, but I want to say for our audience that when Florida touted this, I did a little research on my own. The few observational studies that were out there were fairly compelling, but they were observational and subject to the same biases that we’ve seen with so many things. I’m skeptical that it works, but I’d love to hear that it does, because it would be a relatively cheap way of preventing it.

Harlan Krumholz: It would be a good and cheap way and hallelujah if it would’ve worked, but the median time to recover was 13 days in the placebo group and 12 days in the fluvoxamine group. That was close enough given the uncertainty around those estimates to say really no evidence of benefit that didn’t work here. So, another touted drug. Lots of people heard about hydroxychloroquine and ivermectin and other things, but in this case, this one also got a lot of attention early on and a lot of people took it, but no real evidence in this trial of benefits. So, kudos to the team. It was run out of Duke and had lots of people from lots of different highfalutin institutions and funded by the NIH. I think it’s one that we can believe is strong evidence.

Howard Forman: I’m really glad they did it. I mean, look, with ivermectin and hydroxychloroquine, we had lots of small trials and lots of epidemiologic studies, but it’s been hard to get these types of large-scale trials going. I’m glad to see they did it and that they published it or are at least in the process of doing so.

Harlan Krumholz: I think we’re learning how to be more rapid-cycle about these trials. There’s a lot of pressure to think how can we be agile and quick and efficient. I think we’re making some progress in that way. We got a long way to go still, but I’m optimistic too and I’m happy that they did it. Okay, Howie, let’s get onto our guest.

Howard Forman: I’m delighted to welcome Dr. Utibe Essien to the podcast. He is an assistant professor of medicine at the University of Pittsburgh and a researcher at the Center for Health Equity Research and Promotion of the VA Pittsburgh Healthcare System. Dr. Essien’s research focuses on racial and ethnic disparities in healthcare, specifically studying the disparities in novel medications, focusing on treatments in cardiovascular diseases. He is passionate about health equity and diversity, serving as the director of the University of Pittsburgh’s Career Education and Enhancement for Healthcare Research Diversity, CEED Medical Student Scholars Program.

He holds many awards, including being recognized in the “30 Leaders under 40 Transforming Healthcare” from Business Insider in 2020 and the Association of American Medical Colleges Herbert W. Nickens Award in 2021. He received his medical degree from the Albert Einstein College of Medicine as a Master of Public Health from Harvard School of Public Health. He completed his residency in internal medicine at the Mass General Hospital in Harvard Medical School. So, first, welcome to the Health & Veritas podcast.

You coined the term pharmacoequity and that was to mean, I’m paraphrasing a tiny bit, all patients, regardless of race, class, or availability of resources should have access to the highest-quality evidence-based medical therapy indicated for their condition. But this is not where we are now. Your research into atrial fibrillation has demonstrated vastly different treatment based on race in a population treated in the VA Healthcare System. Can you tell us a little bit about how this study was carried out and why it is so important to this area?

Utibe Essien: Yeah. Well, first of all, thank you so much, Howie and Harlan, for having me. I’m really excited to be joining you all. Yes, pharmacoequity is really the focus of my work. It has been for the last eight, nine years or so since I was a med student starting down the health equity pathway. You alluded to the condition that I decided to plant my flag in as a general internist was atrial fibrillation, just experiences from patients in clinic as well as in the hospital who are really having a tough time on…at that point when I was in my training, the traditional standard of care medication is warfarin for preventing strokes in that condition. So, atrial fibrillation, for folks who are not as familiar, is an irregular heart rhythm. It can cause strokes, which is the most common negative complication of that condition. It also just has your heart feeling fluttered and funny. So, to prevent strokes, we have a class of medications called blood thinners and warfarin or Coumadin you may have heard of that are referred to as the old-school traditional therapy. But right as I was coming into a residency, there is a new class of medication available called “direct oral anticoagulants,” I’ll call them “DOACs” during our conversation today. Those medications are really changed the game in helping to prevent strokes. They’re easier to use, they’re more effective, but they’re super-expensive.

So, over the last several years, including in our VA study that you alluded to, Howie, I’ve really tried to understand what are some of the drivers of disparities in the use of those medications to really hopefully try and fix disparities and outcomes in patients with atrial fibrillation, which, sadly, we see that Black patients, for example, have about a two times higher risk of stroke and two times higher risk of death if they’re diagnosed with atrial fibrillation. So, in our VA research study, which I’ll share a little bit more on, we found that Black patients were about 15% less likely to get the newer blood thinner medications, those DOAC drugs that I referred to earlier, but this is way beyond the VA.

We saw that finding in a registry that we conducted back in 2018 where the difference in a national U.S.-based study was 25%. We also found it in 2020 in a Medicare study, whereas again, similarly around 25%. We have a new study hot of the presses coming out next week that sadly shows really similar finding. So we have a lot of work to do. As you alluded to, pharmacoequity is not a goal that we’ve achieved and succeeded at. I’m excited to keep exploring this question with my colleagues here.

Harlan Krumholz: You’ve emerged as a real leader in this area, and I say this with great admiration. You’ve done the science, but you’ve also gone and ensured that people hear the message and are spreading the word. It’s a little bit of a variation on the words people have heard before, but it’s an unfortunate same song of these differences. WHO established essential medications. In some countries, even China, they’ve identified medications that they said no one should have to pay for. What about this country? I mean, I see so many situations where there are highly effective medications that are inaccessible to people, that they just require too much of their financial resources and they just can’t stretch to do it.

So, it pains me, because this is truly the structural racism of our society. I mean, we’ve got a situation where we are creating these structural barriers. So, we know the right thing to do. We know that people will do better if they’re on certain regimens, and they simply can’t get there. So, what should we do? How can we start to mount an effort to say for medicines that beyond a shadow of a doubt have been shown to be beneficial, everyone should have a right to access?

Utibe Essien: Yeah, that’s such a great question, Harlan. I mean, first of all, acknowledging the point you made around structural racism, folks might say, “Well, that word is being tossed around so much over the last few years. What does that really mean? Does that really have anything to do with medications? It’s expensive for everyone.” But I think the point is important to emphasize, because here in the U.S. for example, focusing on Black Americans here, Black Americans have 5% of the wealth of White Americans in the U.S. Five percent.

So, you can imagine what that looks like when you have to pay for housing, you have to pay for food, you have to pay for, on top of that, the medications that the three of us are prescribing for our patients to treat diabetes, to treat atrial fibrillation, to treat heart failure. That bill just keeps rising up higher and higher. Again, some patients are having to make this decision of, “Am I going to pay for childcare today or am I going to pay for this drug that my doc said I need to take to help prevent downstream complications of this weird condition he told me that I have?”

So, unless we really acknowledge and deal with this fact that medications are just incredibly too expensive for our patients, we’re really not going to be able to address broadly health equity, which is something, as you alluded to, Howie, I’m really passionate about. So I did want to emphasize that structural racism point. What should we do? There was a study published just this week that showed that incredible amount of Americans, about one in six or so with diabetes are having to ration their insulin. Insulin, I think, is a really important example, because that’s a medication you literally can’t live without when you have diabetes, especially type one diabetes. That study showed that one in four of these individuals who are Black were rationing their medications.

So, we have to put caps on the cost of medications that continue to rise in cost. As you said, Harlan, I think we have to think really deeply about eliminating co-payments for medications. We’ve seen studies that showed that either the elimination or the reduction in the cost of co-payments help to actually improve use and adherence. Until we actually make some bold decisions to do that, unfortunately, we’re going to have the same conversation now we’re having today in 10, 20, 30 years.

Harlan Krumholz: One of the other things I learned from you of in preparation for today was just how much underrepresentation of people of color in clinical trials also affects our ability to achieve pharmacoequity. I wonder if you could speak a little bit about that to our audience and explain why that is the case and why it matters.

Utibe Essien: Yeah, absolutely. So, when I think about pharmacoequity, I do think about the therapeutic continuum, as I like to call it. So, from the first day that genius future Nobel Prize winner discovers a drug in her lab all the way to our grandmother picking up the medication from the pharmacy, that long process includes clinical trials. So, the studying of these newer medications that are just fancy algorithms and names that don’t even have a new name when we pick them up in the pharmacy. So, why does that matter? Why does representation matter? I think first of all, it means that patients are able to have early access to these therapies.

So, in the early stages of clinical trials, patients who have potentially rare, potentially deadly conditions are able to have access to newer discovery, newer therapies that could potentially help them. The more and more patients have access to those therapies, the more they can tell their communion members, their family members, their friends about the drugs that are available and I think have more trust in the science, the phrase that we’ve heard so often over the last two years, “trust the science.” It’s hard to trust it when you’ve never even heard of something until it comes out to you in the pharmacy. So, I think that’s one point.

The second is that a lot of our history here in the U.S. has been based on experimentation around science. Sadly, that experimentation has been experienced by underrepresented racial and ethnic group members. I think the more we encourage, the more we support individuals from underrepresented backgrounds to join in clinical trials and to discover along with us, the more we’re going to be able to move from an experimentation model to actually working together to improve healthcare outcomes and to be able to understand what are some of the barriers to taking complicated medications.

Whether it’s “I can’t come into the office every month to get a monthly injection for X, Y, Z medication because of the life that I lead” or “Twice-a-day pills aren’t really working for me, I actually need a once-a-day pill.” I think understanding some of the social challenges that our patients have and community members have with taking therapies, those are some of the things that we can start to really study in clinical trials.

But if those trials are consistently patients who have money, who can take time off of jobs, who work on a Zoom call like we’re on today, then it’s going to be really hard to be able to have these newer therapies be adherent when our patients take them down the road. So, those are a few of the themes I think about around the clinical trial representation piece.

Harlan Krumholz: Those are very important. Let me break off into another direction, and I want to get your thought about this. This gets back to this issue of structural racism, the way our society’s organized. I mean, let’s just say out loud, race is a social construct. I mean, it’s about identifying a group of individuals based simply on their outward appearance and trying to cluster them. And the biological correlates of this are—and you know this well, I’m just saying this out loud for the podcast—are weak if they exist at all in most people. Yet even when we look at people who have higher incomes, so they have access to resources, there’s still Black and White differences in health outcomes. Now let’s just say people who have more resources do better than people who have fewer resources.

Black Americans have, as you’ve noted, fewer resources, so they get a double whammy. But even when you stratify by income, Black people do worse by health than White people do. There’s no biological reason or explanation. Of course it’s a social construct. So, why would there be for that difference? How do you piece that together? What do you see as the underlying mechanisms and how do we address it? Again, I’m not saying how do we address it for those with means, but I’m just saying, it’s an observation, how pervasive these differences are and they’re not being driven simply by people’s financial situation, although that contributes as you noted, but it’s even more than that. How do we get at this? How do we start to make some progress?

Utibe Essien: Absolutely. Now, this is one of my favorite questions, Harlan. So, I mentioned to you guys over email that I’m giving a talk later today, and it’s a talk I give on this topic of pharmacoequity. Literally, the fourth slide is a paper that you led, Harlan, with Emily Bucholz back in 2016. This is a study that you guys looked at income-based and race-based disparities in patients after they have a heart attack and what their life expectancy is. That study showed that if you’re Black, whether you’re in the highest socioeconomic status or the lowest, you’re still more likely to have a lower life expectancy.

Prior to seeing that study, so 2016, I was just finishing residency, I’d spent so much of my time thinking, “Once we address these social determinants of health, we get patients access to care, I’m a primary care doctor working in a community-based clinic in East Boston. This is what we need. We need to really think about these social factors and get patients the care that they need.” That study rocked me in a way that personally I’m thinking, “Okay, I made it. I’m about to finish my medical training. I’m going to have access to income that I never had before. Why would I not think that I’m going to lead a healthy, long, high quality of life?”

So, personally, that study struck me, but also, I’m thinking about my patients and thinking about the fact that it’s more than just the income. We can’t just pay our way out of these disparities that we’re talking about. We really do have to address these root causes of racism. I think that’s individual-based racism. So, a lot of conversations around patient-provider interactions and how that drives bias in treatment. Really important studies published during that same year in 2016 and PNAS that looked at how false beliefs about Black individuals versus White individuals leads to different treatment in terms of pain, et cetera.

So, I think we have to address those individual biases that still exist in our society, but more importantly, address some of these structures and systems in place, address the fact that if you were Black in Boston at the Brigham and Women’s Hospital and you had heart failure, you were more likely to be admitted to the general medicine wards versus the specialized cardiology wards. What does that mean? Address the fact that we found in our study that if you’re from a underrepresented ethnic background, you’re more likely to have your care in a resident-based clinic versus an attending-based clinic.

So, these structures in place that I think are what cause the disparities that we’re alluding to, whether you have income or high socioeconomic status or not. Other than bias and other than access to care, it’s really thinking about how racism impacts our bodies, our physical bodies, the higher rates of hypertension, the higher rates of anxiety and depression. This is something that has been studied previously. It has not been shouted from the rooftops prior to when we “discovered racism” in 2020, as I sometimes sadly joke, but it’s something that we need to continue to do deep research in science around.

Harlan Krumholz: A lot of the hope that comes out of this is that by illuminating the topic and educating people, we can start to correct some of the disparities in the way we treat different populations. I’m just wondering, because number one, you’re young, you’ve been recently in medical school residency fellowship and a junior faculty member now, but you also are deeply invested in medical education right now. I’m just wondering what type of efforts you’re involved in, and do you have hope when you’re involved in that that we’re going to be able to address it at least partially that way?

Utibe Essien: Yeah, it’s a good question. I definitely have hope. As a pastor’s kid as well as a physician’s kid, I have to lean into faith as something that keeps me going every single day. Otherwise, I just feel very hopeless. It’s a lot of the conversations that we’re having every day. Second, I do have a lot of faith in the future generation. I don’t think that we should put all the pressure and responsibility on the next generation to turn the tide. So, for example, we have a medical education podcast called Antiracism in Medicine podcast. I’ll give a little plug to our other pod for those listening to this one, but it’s a really wonderful series that we have, highlighting some of these themes that we’ve brought up and really diving into the key structural barriers of racism and health.

This was started along with myself by five medical students who decided that enough was enough, that they weren’t getting enough of that level of training in there in their medical school experiences. I think that it’s been really powerful to work with them, to learn from them, to see how they’re pushing the narrative and a narrative that’s not just happening on podcasts but is happening in medical school curricula. I’m here at the University of Pittsburgh, and we not only have an elective Antiracism in Medicine course that I have the opportunity to teach with along with my colleague, Dr. Scrow, but we now have a second-year course that is dedicated to teaching about the impact of race and racism on health.

That is a required course that every student who goes through our institution takes. I think we’re starting to see more of that around the country. Students are voting with their feet about where they’re going to spend their $80,000+ a year depending on what school you go to. The U.S. News and World Report now has a health equity metric on their ranking list around schools. So, I am hopeful not only is the generation going to move us forward, but because of that, institutions are going to have to rebuild their curriculum to really focus on this topic as a key to improving health.

Howard Forman: Just to remind our listeners, it’s called the Antiracism in Medicine podcast, just so they can look it up as well.

Harlan Krumholz: Yeah, I just think as I listen to you, we got to collaborate more. There’s just so much I want to learn from you, and it’d be great to work together. Some of the work that we’ve done recently has been to show that over the last 20 years in the areas of health status and a lot of the access issues and affordability issues, there has been not an iota of progress in going against these disparities. When you look at health status, multiple morbidities, actually, things are getting worse. Not only is the whole population getting sicker over time despite all our investments in healthcare, but the distance between Black and White Americans is actually growing.

The advances that we had made in mortality, there had been some narrowing in mortality earlier in the last two decades, flattened and then worse, and not even counting the pandemic, which led to a great retrenchment. In the course of this time, I mean, look, this has been my career, I consider this a failure. I’ve written so many papers around disparities. I tried to call to action so much, so many of my colleagues, so much of the institutions around us. We are not making progress. I mean Yale New Haven Hospital, Yale University in New Haven, not an iota of progress. So I find this sobering, and I really look to you and wonder, “What do we need to do that we’re not doing now?”

Because what we’ve been doing is not working. It’s just not working. By the way: Obamacare, great. We did get a lot more people insured. It didn’t make a dent in the disparities, and things if anything have gotten worse. I don’t say that’s because of Obamacare, but I’m just saying that policy intervention did not address the disparities. So, what are your thoughts? I mean, what should we do?

Utibe Essien: Yeah, so I’m coming from it as someone earlier in their career, like you mentioned, who at every level hoped that the next big thing would help us get closer. So, as a medical student, I thought I was going to be a dean of students and I figured educating around this topic. One of my mentors, Cristina Gonzalez, teaches around implicit bias training, then at the Albert Einstein, now at NYU. That felt like the path to really teach our way out of this. In residency, I think it was about clinical care, making sure that I was providing along with my colleagues the best care possible to underserved populations out in Chelsea, Massachusetts, especially Spanish-speaking immigrant patients.

And then I came to a research fellowship and thought that studying our way out of this topic was going to be the way. Now, as a faculty member, really thinking about the policy implications and interventions that you just alluded to, Harlan. But I think all of that has been within the lane of healthcare. I go to medical school, go to residency, work in a hospital, and healthcare feels like the way to solve it. I didn’t go through 12 years of training for nothing, but I do think that in a way that that was myopic, that the investments that we’re making in healthcare are huge.

We’re spending billions of dollars every single year to build great hospitals, to increase and improve medical education and for scientific discovery that made it possible for us to have incredible vaccines, to reduce COVID infection, et cetera, amongst other things. But how do we really shift some of those investments outside of the hospital, shift those investments to early education where students in our communities are going to be able to choose careers like medicine, like the three of us, and be able to transform their lives and generations after them?

How do we build the green spaces within our neighborhoods in New Haven, in the Bronx where I spent so much of my career training so that people have healthier lungs, have healthier access to healthier streets where they can run on and stay fit on? Dr. Gina South at Penn is doing a lot of work in that space as well. I firmly believe that shifting some of the resources that we have now in healthcare to outside of healthcare will help us start to create dents, but I do still think that we need to address some of the policies.

So, we improved access to insurance for millions of Americans over the last decade. We didn’t see a huge, huge shift in disparities, but what else could we do? How can we influence and go beyond just access to insurance but to improving actual equitable care? I’m hopeful that this phrase “pharmacoequity,” though it’s not a new idea and a new theme, it’s just one of the ways that we can start to fix that part of the problem.

Harlan Krumholz: Oh, that’s really great. That’s really great.

Howard Forman: You’re an amazing person. You’re educating us, educating our listeners, and having a huge impact on the field. It gives me a lot of optimism and hope for the future. So, thanks very much for joining us on the Health & Veritas podcast.

Harlan Krumholz: Yeah, it’s great to hear you. Great to see you again. I’m going to double down and bugging you about collaborating because I think I want to work with you more if we can.

Utibe Essien: Absolutely. No, thank you both so much for the invitation. Yes, you all heard it here first, Harlan and I have a future paper coming out soon.

Harlan Krumholz: That’d be great. Hey, thanks. So, Howie, that was a great, great interview with Utibe. I really appreciated that and appreciate him, but let’s get to you now. So, what’s been on your mind this week?

Howard Forman: Yeah, so I’m going to bring it right back to our guest in a way because we’ve been talking about diabetes on and off on the podcast several times and we did so again today. We talked about the high cost of insulin, but there’s more than just therapies for diabetes. There’s also the measurement of your glucose. Just to remind our listeners, diabetes is a leading cause of mortality and morbidity. Improving therapies for insulin-dependent diabetics are not the only means of impacting the disease, because accurately measuring blood glucose levels and judiciously using insulin is incredibly important because it avoids high glucose levels, which affect your long-term morbidity and mortality. It also avoids hypoglycemia, where if you go too low, it can be life-threatening.

So, continuous glucose monitors are an important innovation that helps with this, but studies have not always confirmed their benefit. The New England Journal today is reporting a randomized control trial of one type of continuous glucose monitoring device. The results are impressive. The study used is the FreeStyle Libre device to help insulin-dependent diabetics monitor their glucose rather than forcing them to stick their fingers throughout the day. So, why is this such a huge advance, first of all? Because finger sticks only tell you your blood glucose at a specific moment in time. In other words, are you 150 and declining? Are you 150 and rising? Is the decline steep or flat? You don’t really know.

But with continuous glucose monitoring, you not only get hundreds of data points throughout the day, but you also know directionality and the rate of rise or decline. So, what this study found was not only that patients had better control of their blood glucose but also that they avoided events where their glucose could go too low. So, let me put that aside because I think that alone is a really important thing, but I want to then move on to the health equity side of this. It really does concern me. The product they studied is from Abbott. It’s the cheaper and less convenient of the two widely available technologies.

The Dexcom is continuous blood glucose monitoring where you don’t have to do intermittently check it, but even with this cheaper technology, the Abbott one, the FreeStyle Libre, the cost is over $100 for 14 days without insurance. So, over the course of a year, that’s almost $3,000. Insulin and other expenses are not even a factor in the numbers I’m giving you here. So, that adds on a lot more. So, there’s good news out there in that if you look at the technology development in this space, there are abundant companies. I would hesitate to give you an absolute number because it’s not my expertise, but I’m going to guess that there are dozens of companies that are competing to come up with cheaper and cheaper and more efficient blood glucose monitors, continuous ones.

Those are starting to look like they can get down to $3 a day and even less than that, but it comes back to the same issue that Utibe mentioned, which is even if you cap insulin, which is what we’re begging for at $35 a month, that’s still a lot of money for individuals. Even if we were to cap continuous glucose monitoring at another $35 a month, that’s starting to add up. That’s already almost $1,000 a year with insurance, even if you have insurance. So, again, in the same way that he’s looking at pharmacoequity, I think this is another area of pharmacoequity that we’re going to be delving into in the future. I’m hoping to see that technology helps us on this front by driving the price down on its own.

Harlan Krumholz: Well, I’m really glad that you brought this up. I mean, first of all, these devices, I don’t know if you’ve had a chance to use them. I don’t have diabetes, but I’ve been able to test them out because of course my interest in digital health and so forth. They are amazing. I mean, they provide you really interesting and actionable information if you got diabetes. For people without diabetes, you can really see the effect of different meals or diets. You can follow it. We have yet to figure out whether all this data actually can help you make better decisions outside of diabetes. This trial is showing you that you can, within the context of diabetes, actually produce better outcomes. That’s wonderful.

I mean, we’re in the midst of a life sciences revolution. We’re the midst of a data science and technology revolution. Yet we’ve already got these massive disparities, and I just am really appreciative of your point. We’ve got to be thinking hard about how we can be sure that this isn’t going to separate further people who can and cannot afford, people who do and do not have access to these innovations. How about cancer therapies that cost hundreds of thousands of dollars or more?

As we know, Alexion was in our city for a long time as its central headquarters, now just has an office. Well, they were charging $750,000 for their medication. These things are what people would dream about, what they would make in a decade, some people. So, we’ve got to solve this. We’ve got to solve this. I think there’s nothing short of it’s got to be around how we’re going to provide universal access for highly effective treatments and really take this on head-on. But thanks so much for bringing that up.

You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find this on Twitter.

Harlan Krumholz: I’m at @hmkyale. That’s HMK Yale.

Howard Forman: And I’m @TheHowie. That’s @T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu. Aside from Twitter and our podcast, I am fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs or you can check out our website at som.yale.edu/emba.

Harlan Krumholz: Some people wonder if we do this fresh every week or whether or not this is just a boilerplate recording that we just stick in. Hey, this is fresh. This is real. We do this every week.

Howard Forman: We’re getting better.

Harlan Krumholz: We’re getting better. Well, just to prove it to you, just to prove it to you, the Yankees won the fifth game against the Cleveland Guardians, just so people know—

Howard Forman: Thank goodness.

Harlan Krumholz: ... that this is real. We do this every week. Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer, who are terrific. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.

Department: Faculty Viewpoints

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