OP-ED

Heart Failure or System Failure?

Today’s New England Journal of Medicine reports the results of a government-funded study of two potential approaches to giving emergency diuretics to congestive heart failure patients who show up on emergency room doorsteps gasping for breath. Should it be through a continuous drip or periodic injections? Should physicians prescribe high doses or low doses of these fluid dispersal drugs? Cost isn’t an issue since diuretics are generics. The pressing question was whether high doses caused a greater incidence of renal failure, which had been suggested by a number of smaller trials.

This comparative effectiveness study is the kind of research that never receives attention in the press. No new drugs are involved, nor does it involve a high-profile disease. But it merits closer scrutiny because of the patient population. There are more than a million patients who enter hospitals every year with acute episodes of congestive heart failure. The average age in this study was 66, i.e., Medicare was paying the tab. Three quarters had been admitted to the hospital within the past year. More than half had diabetes, and around 40 percent had implanted defibrillators. Most were on two or more drugs for high blood pressure. I searched for data on the average weight of this population, but, alas, that wasn’t included. I think you can guess.

The results were mildly interesting. It didn’t matter what approach physicians took, the outcomes were about the same. Fears of exacerbating renal failure in this vulnerable patient population from high dose diuretics appear to be overblown.

I’m afraid this is going to be the conclusion of much comparative effectiveness research, which received a major shot in the arm through the 2009 stimulus bill and will receive a continuous injection of funds from the Affordable Care Act, presuming the Republicans in Congress aren’t successful in de-funding the bill. Physician and hospital practice will have better evidence about what to do in certain situations, but radical changes in procedures that have a dramatic impact on cost will be elusive.

In an accompanying editorial, Dr. Gregg Fonarow of UCLA Medical Center in Los Angeles comments:

(The study) underscores the dismal prognosis for patients with acute decompensated heart failure. In this well-conducted study, performed at institutions that have highly regarded programs for patients with heart failure, there was an unacceptably high (43%) rate of death, rehospitalization, or emergency department visits within the first 60 days, irrespective of treatment assignment. Clearly, there is a crucial need to develop new agents and effective strategies for this patient population.

We don’t need new agents. Most of these patients had showed up at the hospital before. Nearly half would again within two months. What  we need is better strategies for managing people with multiple chronic conditions BEFORE they show up on hospitals’ doorsteps gasping for breath. The new Patient Centered Outcomes Research Institute funded by the ACA should launch a study that compares the long-term cost of providing patients with congestive heart failure coordinated, hands-on (usually via nurse practitioners) preventive care versus the usual practice of simply releasing them from the hospital with a list of instructions, several prescriptions and a fare thee well. My hypothesis is that these higher upfront costs will pay big dividends for lower Medicare spending down the road.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. His most recent book, “The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs ” (University of California Press, 2004) has won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. You can read more pieces by Merrill at  GoozNews, where this post first appeared.

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  2. Margalit – To follow up on Nate’s most recent comment, I saw an interesting discussion of this recently but I forget where. The point made was that in recent years, most of the additional life years that the healthcare system is able to provide thanks to modern medicine accrues to those who are 65 and older and, for the most part, already retired. Back in the day when infectious diseases were a more significant killer, advances that eliminated or sharply reduced those added many more years of life that accrued to the under 65 population.

    Regarding the productivity issue, if someone becomes disabled and can no longer work, there are plenty of others to take their place, especially in today’s economy. Moreover, suppose someone is forced to quit a job that paid $60K a year to stay home and take care of a spouse or elderly parent who would otherwise have to go into a nursing home that would most likely be paid for by Medicaid. The $60K salary probably generated $20K in annual federal, state and local taxes combined. If the caregiver opts to put the relative into a nursing home instead and goes back to work, we capture $20K in taxes but pay out $75K or more in nursing home costs even at Medicaid rates, at least in our more expensive MSA’s.

    Finally, on healthy lifestyles, there was a study in the Netherlands a couple of years back that showed that smokers, for example, die seven years sooner than non-smokers. On a lifetime medical cost basis, the healthy are more expensive than the smokers because diseases associated with very old age like Alzheimer’s, dementia, cancer, etc. are very expensive to treat. Very few of us die suddenly in our sleep. Even in the case of heart attacks, many more of us pull through and live for years afterward with expensive medical management, stents, etc. than in the past.

  3. ? Margalit those last 20 years are usually spent collecting SS and spending Medicare money.

    People’s productive periods are roughly 25 to 50-55. Most illness catches up to us around 45+. If we where spending all this money so people where more productive between 25 and 50 you might be right. That is not where the money is going and thus why you are so far off.

  4. I don’t know that we can make these calculations so simple, and I don’t think we can look at health care costs in isolation.
    The well managed diabetics that live another 20 years, also work and pay taxes for another 20 years, revenue which would be lost if they died or muddled through the next 20 years in and out of hospitals. And then there is those who have to take care of them, who will also loose productivity.
    Somehow this offset needs to be accounted for, if you look at a national financial sheet.
    It’s easy to calculate that the sooner you die the least expensive you are for the system, but the longer you lead a productive life the more you contribute to the system. So there is a point up to which disease management should be providing system benefits, even if it increases health care costs.

  5. ” How do you define “aggressivly extending life” in this context (not end-of-life)?”

    It is end of life isn’t it? If these actions aren’t taken life will end earlier.

    Spending billions of dollars so the average person lives to 76 instead of 74.5. Personally I think we should redirect our resources to getting young Amercian’s off to a better start, eliminating federal and state debt. Cleaning up the enviromental disasters we have left all over the country. Haveing a more neutural impact on the planet. Only after we have solved all these other problems would I worry about trying to live as long as possible

  6. “Truly preventive care, like immunizations, smoking cessation counseling, diet and exercise advice, or anything that may actually prevent disease, should be able to save money, I think.”

    immunizations usually not, the cost to immunize millions of people against an illness a small percent would get otherwise does not save money, it does greatly improve quality of life though, to a degree most people would say it is worth the additional cost.

    A baby dieing today from measels lets say could not even get close to the lifetime of care they will otherwise receive.

    smoking cessation not even close to saving money.

    diet and exercise advice if you are talking about passive emails they probably do, one on one coaching doesn’t save money.

    “I don’t think we know for sure that, in aggregate, good disease management is more expensive than neglect. Do we?”

    Yes we do. Its pretty simple test of logic. Save them today what will they die of 10 years from now? Usually what kills them down the road will be more expensive then what would have killed them today and when you then factor in 10 more years of treatment and the cost of management there is no question that globably it does not save money,

    Would most people spend 100,000 for another 10 years of good life, surely, that is the fact we need to be discussing, how do we pay for all those extra years of good life, not this obviously BS lie that this will all save us money.

  7. Nate, sorry I didn’t see your post before I replied, but I am curious now. How do you define “aggressivly extending life” in this context (not end-of-life)?

  8. Barry, I do agree that advocates should not disingenuously message people.
    However, not all preventive care is equal and I doubt that disease management can be classified as preventive care since it does not really prevent disease. It may prevent exacerbation, but that’s about it. Is that enough to reduce life-time costs? I don’t know. I would think that for some people it is, and for others it may not be. I don’t think we know for sure that, in aggregate, good disease management is more expensive than neglect. Do we?

    Truly preventive care, like immunizations, smoking cessation counseling, diet and exercise advice, or anything that may actually prevent disease, should be able to save money, I think.

  9. Leave the straw men alone Margalit, no one is wishing or scheduling death. If we are going to propose aggressivly extending life then budget for extending life. We need to find the money to pay SS and Medicare as is which is underfunded, we need to be honest if we are going to increase expected liabilities a couple more trillion and budget to pay it. And budgeting to pay it doesn’t mean leaving our grandkids a drawer of worthless IOUs.

  10. Margalit – I think everyone agrees that good preventive care and aggressive disease management will help people to live longer, healthier lives than they would have without the care. The issue is does it save money for the system in the long term or not? It’s quite likely that it doesn’t and, if it doesn’t, advocates shouldn’t try to sell it by claiming that it does. It’s disingenuous. Sell it by suggesting that it’s the right thing to do even if it costs more and look elsewhere for system savings.

  11. What happens if they stay alive for another 20 years, but with intensive treatments and hospitalizations?
    In other words, are you sure that if you save the $4000 per year, “these people” will oblige and drop dead on schedule?

  12. If you keep a diabetic alive for 20 more years at $4000 per year plus the cost of what ever else eventually kills them there is no way you save money. Dementia and years in a nursing home alone will wipe out any savings from avoided intensive treatments and hospitalizations.

    If we go into this thinking we are saving money we are going to be in for a huge problem when these people are still alive racking up bills 15-20 years later. SS and Medicare are already grossly underfunded and consuming a huge part of GPD, we need to pay for what we already promised.

  13. Merrill – I’m a bit skeptical about whether intensive management of patients with multiple chronic conditions will save money. In the case of CHF, for example, I’ve read that there are 5 million people with that condition in the U.S. of which about 80% are 65 or older. If we provided all of them with aggressive preventive care, how much would it cost and how many hospital admissions are we likely to prevent?

    I saw a program recently about aggressive management of diabetics in Colorado. One of the folks from the clinic stated that the care they provide cost about $4,000 per year per patient. They thought they were preventing hospital admissions down the road but they couldn’t provide any quantification. Their cost, though, is certain and precisely quantifiable. Medicare pilot programs a couple of years ago intended to determine whether disease management could save money or not for patients with multiple chronic conditions produced disappointing results as well.

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