Lesson 12: The Risk-Benefit Ratio in Medicine

Healthcare for Policymakers

Very early in my medical training, I learned about the risk-benefit ratio and that became my guiding light in medical decision making. It is a fundamental concept in healthcare. So, what is the risk-benefit ratio?  You calculate that by considering all the risks like side effects or adverse outcomes of a medical intervention and all the potential benefits or positive outcomes and then using that result to decide whether that treatment is a good idea. I used that in all my medical decisions. The risk-benefit ratio calculation must be based on facts, data, and evidence to have the maximum impact. It must be based on established science and knowledge. This is no place for opinion. As American medicine has become more and more expensive, I have expanded this concept to include cost as an important part of the risk-benefit thought process. Cost considerations have become critical as medical expenses strain budgets at every level.

The risk-benefit calculation has become even more important as our knowledge base in scientific medicine has grown. We are learning more and more about aging and chronic diseases and how they are related. That knowledge base is very extensive. To make an informed decision, you must understand that knowledge base and that is the reason that I write. I work to help you understand the risks and benefits of treating chronic diseases so that you can make an informed decision. Remember, the risk-benefit ratio is a dynamic concept. It's crucial to continuously evaluate and adjust treatment plans based on individual patient needs and the latest medical evidence. Open communication and shared decision-making are essential for ensuring that you fully understand the risks, benefits, and costs of your healthcare choices. Medical science is moving very rapidly, and our courses for patient education, clinician education, and policymaker education are living documents. We are updating them continuously so that they reflect the latest developments.

Our current medical information environment is a real problem. Most sources of information that you would use to understand the risks vs. benefits of caring for diabetes or heart artery disease are compromised. They are riddled with conflicts of interest. You see multiple ads for medical treatments and devices on television every day. These are not objective sources of information. These ads are designed to sell more product. They are not designed to help you understand the benefits or risks of the advertised intervention compared to other treatments. For many of the medical products advertised on television and in other media, there is very little in the way of facts, data, and evidence to support their use. Many of these products have no value.  

Most advocacy organizations in medicine also receive the bulk of their support from companies that make drugs or devices. That support influences their recommendations. That is why I decided to write on Substack. My only obligation is to you and others who subscribe to my work. I am working to help you understand the risks and benefits of treating heart artery disease, other artery disease, and risk factors for artery disease like high blood pressure, diabetes, high cholesterol, diet, overweight, and smoking cigarettes. The risk benefit ratio is a cornerstone of evidence-based scientific medicine, but I am adding cost as a factor in the equation. The new calculation must factor in cost if we are to live longer healthier lives and save money. The best care is the least expensive care.

It is important as you think about the risk-benefit-cost equation that you understand that all chronic diseases and the rate of aging are related. The most advanced knowledge in chronic disease management is the relationship between obesity, high blood pressure, high cholesterol, type 2 diabetes, prediabetes, smoking cigarettes, inactivity, heart artery disease, other artery disease, chronic kidney disease, fatty liver and related hepatitis and liver failure, and congestive heart failure. Taken together, these are called cardiometabolic conditions but even that name does not do them justice.

The metabolic part of the name fits. As we age, gain weight, and smoke we change our metabolism and have problems with high uric acid (gout), high blood sugar, high cholesterol, high triglycerides and so on. But the cardio in front of metabolic is too restrictive. As far as I have been able to determine, more rapid aging and earlier chronic disease development always involve increased oxidant production, decreased antioxidant defenses (oxidative stress), and the inflammation that follows. By blocking oxidant formation and inflammation, we don’t just protect the heart. We protect every organ and cell in the body.

It turns out that all chronic diseases are related. Over the last 50 years researchers have developed many powerful precision medications like ace inhibitors (lisinopril) or ARBs (losartan) and aldosterone blockers like spironolactone or eplerenone to treat “risk factors”. These drugs all lower the blood pressure, but they also have powerful antioxidant and anti-inflammatory properties that protect every cell and organ in the body. Statins lower cholesterol and metformin lowers glucose but these drugs also have powerful antioxidant and anti-inflammatory effects. These medicines are all proven, generic, and low in cost. When you combine them, the benefit is far greater in producing the results that matter when compared to the care that most of us receive. There is not a 20% reduction in heart attack. There is a four fold reduction in heart attack. The benefits are far superior and the protocol is designed equally carefully to keep the risks small.  

When you combine these generic, inexpensive, and proven medications lower the target risk factor most effectively while delivering powerful antioxidant and anti-inflammatory effects, you are protecting every organ and cell in the body while incurring the least amount of risk at the lowest possible cost. Make sure that you are getting the best information on risks and benefits when you decide how you will manage your chronic illness.

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