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``A costlier heart drug also proves better", ``Genetech reports strong results for heart-attack drug", ``Rationing a hot issue in health care debate", ``Meeting tall orders: debate grows on treatments for short kids," ``Streak of Streaks" by Stephen Gould.


Read the New York Times article ``A costlier heart drug also proves better" and answer the following questions:

(1) The article you just read reports that the controversy about the relative effectiveness of the two 'clotbusting' drugs Streptokinase and t-PA has finally been settled. Previous studies had not been able to detect any significant difference in effectiveness between Streptokinase, which costs $200per dose, and t-PA, which costs $2,200 per dose. From the data given in the article, it appears that using t-PA instead of Streptokinase reduced the death rate from something like 7.3%to 6.3%, a difference of 1%. Yet the promoters of t-PA describe this as a 14%difference, which sounds a lot more impressive. How do they arrive at this figure? Are they justified in using it?

(2) Of the approximately 20,000 patients who were given t-PA, 7.3%or 146 died and, of the approximately 20,000 patients who were given Streptokinase, 6.3%or 126 died. If there was no difference in the effectiveness of the two drugs, then the 2720 patients who died would be equally likely to have been given each of the drugs. Thus if they are equally effective we can regard the choice of drug given for those that died as the outcome of the toss of a fair coin, heads corresponding to t-PA and tails to Streptokinase. If you toss a fair coin 2720 times and get 1460 heads and 1260 tails, would that be significant evidence that the coin is not fair - i.e. that t-PA is significantly more effective than Streptokinase?

(3) Suppose that using t-PA instead of Streptokinase saves the lives of 1%of patients. What is the extra cost per life saved? If a patient whose life is saved lives an average of 7 extra years, what is the cost per extra year of life? Are these extra years worth the cost?

(4) If you had a heart attack and your insurance plan would only cover the cost of Streptokinase, would you be willing to pay the difference in price in order to `upgrade' from Streptokinase to t-PA? Should Clinton's health plan give full coverage for t-PA?

(5) If you were forced to play Russian Roulette with a gun having a thousand slots only seven of which have bullets would you pay $2,000 to remove one bullet?


Read the other articles handed out and comment record in your journal any questions or comments you have about the class discussion or these articles.


The last journal assignment is to be handed in Tuesday 23 November. At this time we would like you to hand in your complete journal for final review. Your projects will be due at the time of the Chance fair Sunday 5 December. No projects will be accepted after this date except in the case of an official medical excuse.

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