( By Dr Ramesh Kapadia )

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Appendix A

As part of his efforts to focus establishment attention on the cost implications of not addressing the underlying causes of heart disease, Dean Ornish had met First Lady Hillary Rodham Clinton. He is a member of the office of Alternative Medicine at the National Institute of Health. The following is an excerpt from a letter Dr. Ornish wrote to Ms. Clinton.

Dear Ms. Clinton,
Please accept sincere and heartfelt appreciation for the opportunity to meet with you on Thursday morning. Thank you for making health care such a high priority in your administration.

In a series of clinical trials conducted during the past sixteen years, funded in part by the National Heart, Lung and Blood Institute of the National Institutes of Health, we have demonstrated that the course of even severe coronary heart disease often can be reversed by a program of comprehensive lifestyle changes without bypass surgery, angioplasty or a lifetime of cholesterol lowering drugs. These lifestyle changes include a very low-fat vegetarian diet, mind-body stress management techniques, moderate exercise, smoking cessation, and psychosocial support.

Comprehensive lifestyle changes may be not only medically effective but also cost-effective in significantly reducing health care expenditures. These choices are most clearly seen in the arena of cardiology, for in no other area are costs so high and the benefits of less costly lifestyle inverventions as well-documented. In the past, lifestyle interventions have been viewed as increasing costs in the short run for a possible savings years later. In this new model, you do not have to wait five years to see a benefit; the reduction in costs is immediate.

Providing lifestyle changes as a direct alternative for patients who otherwise would receive coronary bypass surgery or coronary angioplasty would result in an immediate and substantial cost savings. Last year, over $ 14 billion were spent on coronary bypass surgery in the US at an average cost of at least $ 40,000 per operation, much more when complications occurred. Over $ 5 billion were spent on coronary angioplasty at an average cost of over $ 15,000 per operation. Intensive lifestyle modification is much less costly. For every patient who decides to change his or her lifestyle rather than undergoing bypass surgery, at least $ 40,000 are saved that would have been spent. Providing lifestyle changes as a direct alternative for patients who otherwise would receive coronary bypass surgery or coronary angioplasty may result in significant long-term cost savings. Despite the tremendous expense of bypass surgery and angioplasty, up to one-half of bypass grafts become blocked after only five years and one third to one-half of angioplastied arteries clog up again after only four to six months regardless of the method used. When this occurs, coronary bypass surgery or coronary angioplasty is often repeated, thereby incurring additional costs. Rather than the usual course of getting worse and worse over time, many heart patients can get better and better if they make comprehensive lifestyle changes. Within a few weeks, the patients in our research reported a 91 percent average reduction in the frequency of angina (Chest Pain). Most of the patients became essentially pain-free, including those who had been unable to work or engage in daily activities due to severe chest pain. Within a month, we measured increased blood flow to the heart and improvements in the heart's ability to pump. And within a year, even severely blocked coronary arteries began to improve in 82 percent of the patients. They demonstrated even more reversal of heart disease after four years than after one year. Our findings are giving many people new hope and new choices.

Our work is based on the premise that addressing the underlying causes of a problem is ultimately more effective than addressing only its symptoms. Efforts to contain medical costs that do not address the more fundamental causes that determine why people become sick - rather than literally or figiratively bypassing them - will inevitably result in painful choices. This is as true for individual patients as it is with the health care system in general. There is a better alternative.

Our program is now considered a valid alternative, and to a growing number physicians a clinically preferable alternative to bypass surgery, angioplasty and/ or a lifetime of cholesterol lowering drugs for many patients with moderate to severe coronary heart disease. This approach can provide a third alternative to rationing of continued spiraling costs.

Besides the growing costs, access to bypass surgery is not equitable. Last year over 90 percent of bypass surgery was performed on white upper middle-class males, despite evidence that heart disease is actually declining in this group whereas it is increasing in women, minorities, and lower socieeconomic groups. One-half of women are destined to die from heart and blood vessel diseases. Bypass surgery and angioplasty do not work as well in women as in men. Times times as many women as men die in the hospital; following an angioplasty and women have twice the mortality rate as men following bypass surgery. In contrast, women in our research showed even more reversal of their heart disease than did men. In other words, our program can most benefit those who are most likely to develop heart disease and who have the least access to conventional medical therapies.

My colleagues and I are in the process of training other hospitals in our program, including Beth Israel Hospital in New Hork and Immanuel Hospital in Omaha. Reimbursement for this program at hospitals that we have trained will enable them to serve those who most need it.

In summary, our research can serve as a model of a "third alternative" in addressing the dilemma of how to significantly lower health care costs and improve access without compromising the quality of health. Clearly, a program that can reverse coronary heart disease would help prevent it for most people. In this context, all Americans may benefit either directly or indirectly. I admire you greatly and look forward with pleasure to meeting you. With best wishes and warm personal regards.

Dean Ornish

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