Merrill Goozner
First published 3/3/11 on Gooz News
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 is an independent health care journalist. When not writing for others, he writes at Gooz News.
Care And Cost 
Hello Merrill,
You are right. We don’t need new agents. Actually the multiple chronic condition issue begins decades before these people show up in the emergency room. As much as 80% of the cases of CHF in the United States come from patients who did not have their blood pressure adequately controlled. A large proportion of the remainder come from patients who have had a heart attack and did not receive ACE inhibitors or B-blockers in the aftermath. For the overwhelming majority of patients this is an ailment that can be prevented and the treatment on the outpatient side can be much more effective. Most of the heavy lifting can be done with generic drugs. We just do too little too late. Sad business.