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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Short FilmMargalit Gur-ArieHeart Failure or System Failure? | patr7apittNate OgdenBarry Carol Recent comment authors
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While I was surfing yesterday I saw a great article about

Barry Carol
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Barry Carol

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… Read more »

Nate Ogden
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Nate Ogden

? 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.

Margalit Gur-Arie
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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… Read more »

Nate Ogden
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Nate Ogden

” 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… Read more »

Nate Ogden
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Nate Ogden

“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… Read more »

Margalit Gur-Arie
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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)?

Margalit Gur-Arie
Guest

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… Read more »

Nate Ogden
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Nate Ogden

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.

Barry Carol
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Barry Carol

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.

Margalit Gur-Arie
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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?

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Nate Ogden
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Nate Ogden

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… Read more »

Barry Carol
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Barry Carol

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… Read more »