The March issue of JAMA has an article about the “mode of death” in patients with heart failure. Yes, Cardiologists lead with “here’s how our patients die.” And yet, no one reads that and thinks, “Wow, cardiologists are terrible at their job.”
To put this in perspective, in 2022, approximately 12% of Medicare fee-for-service (FFS) beneficiaries had a diagnosis of heart failure. In comparison, in 2019, 16% of Medicare beneficiaries had a chronic wound. In other words, chronic ulcers are more prevalent among Medicare patients than chronic heart failure. More than one third of the patients I saw in the wound center had chronic heart failure (CHF) and – incredibly, based on the CMS data from 500 practitioners contributing data to the US Wound Registry (USWR), heart failure may impact HALF of the patients being seen in hospital-based outpatient wound centers. So many of my patients had heart failure that in 2016, when I got my first “Quality and Resource Use Report,” CMS had assumed that I was their primary care doctor (because I provided the plurality of their visits over the year) and penalized me for the hospital readmissions of the heart failure patients seen in the wound center.
I started paying attention to the issue of CHF in my clinic, and one of the things I noticed was that every time one of these patients came into the wound center, they were on some fancy new medication. In fact, one patient who I had placed in comfort care because her ejection fraction was so low that she could not perfuse her feet, returned for her follow-up with a new intravenous drug that was being continuously infused at home. I confess that the thought that went through my mind was, “How is it that heart failure gets so much attention, research, and drug development?”
The answer is, Cardiologists talk very loudly about BAD OUTCOMES of heart failure patients (e.g., reduced life expectancy and death): They tell the world that patients with even mild heart failure and preserved ejection fraction have median life expectancies that are up to 15 years shorter than persons of comparable age. They emphasize the lack of innovation in treatment options. They design trials with very sick people whose outcomes are likely to be bad (e.g., death) and then look at avoiding [bad] endpoints over realistic timeframes (e.g., event free survival) which can be extrapolated to estimate long term benefits. They don’t pretend that everyone “heals,” and they often evaluate cost-effectiveness of their treatments. They talk openly about where gaps exist in treatments for conditions. The publish articles about how their patients DIE. That’s at least part of the reason that new treatments keep being developed for cardiac problems. No cardiologist’s salary is linked to inflated outcome data on heart failure patients, and no cardiology program pretends that every patient gets well, the way that wound centers pretend they have a 95% healing rate.
It’s both funny and sad that a few years ago when I posted the “honest healing rate” of patients under my care, someone on LinkedIn commented on what a lousy wound care doctor I must be. However, if we are going to spend $94 billion a year on wound care (2019 data), we need to stop telling the world we heal everyone. We need to talk about what is not going well in the field of wound care. Otherwise, the incredible amount of money being spent cannot be justified. We also need clinical trials in sick patients with serious problems – if we are ever going to find out what is effective in the real world. Maybe we need to publish a paper called, “Death, amputation and failure to heal among chronic ulcer patients.”
Additional Reading:
- Counting the Cost – and a Roadmap to Survival (Part 5 of 7) – Caroline Fife M.D.
- Counting the Cost – and a Roadmap to Survival (Part 3 of 7) – Caroline Fife M.D.
- Listen to the Interview with Dr. Marissa Carter and Me About Why Chronic Wound Patients Are So Sick – Caroline Fife M.D.
- Sisyphean Mondays – Caroline Fife M.D.
- The “Potemkin Village” of Wound Management and the Wounds with No Name – Caroline Fife M.D.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
