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The ethical issues that arise in the practice of EBM in managed care are not unique. Like other large health care organizations, MCOs must grapple with the combined ethical difficulties involved in identifying and rationing effective care. MCOs should develop guidelines that simultaneously steer effective care for their population as a whole and include permissible strategies for the individual provider to negotiate satisfactory patient-centered care.

On the other hand, MCOs are in a uniquely strong position to generate evidence. Hence, MCOs have a responsibility to realize that the nature of the evidence they generate can have a profound impact on medical practice. They should seek to generate evidence that promotes population health, attempts to fill the gaps in needed data, particularly for understudied segments of the population, incorporates patient utilities, and avoids undue influence from those who are marketing innovations, or from those who wish to cut costs without concern for good patient outcomes.

Involvement of the sympathetic nervous system in congestive heart failure is characterized by a vicious circle, where reduced cardiac output results in neurohumoral activation. The hyperadrenergic state in turn causes desensitization and downregulation of cardiac β-adrenergic receptors and alterations of postsynaptic signal transduction, which further impair myocardial performance. Alterations of presynaptic cardiac sympathetic innervation are also involved in this pathophysiologic process. Reduction of presynaptic catecholamine reuptake increases overexposure to catecholamines further and thereby contributes to disease progression.

The ethical issues that arise in the practice of EBM in managed care are not unique. Like other large health care organizations, MCOs must grapple with the combined ethical difficulties involved in identifying and rationing effective care. MCOs should develop guidelines that simultaneously steer effective care for their population as a whole and include permissible strategies for the individual provider to negotiate satisfactory patient-centered care.

On the other hand, MCOs are in a uniquely strong position to generate evidence. Hence, MCOs have a responsibility to realize that the nature of the evidence they generate can have a profound impact on medical practice. They should seek to generate evidence that promotes population health, attempts to fill the gaps in needed data, particularly for understudied segments of the population, incorporates patient utilities, and avoids undue influence from those who are marketing innovations, or from those who wish to cut costs without concern for good patient outcomes.

The ethical issues that arise in the practice of EBM in managed care are not unique. Like other large health care organizations, MCOs must grapple with the combined ethical difficulties involved in identifying and rationing effective care. MCOs should develop guidelines that simultaneously steer effective care for their population as a whole and include permissible strategies for the individual provider to negotiate satisfactory patient-centered care.

On the other hand, MCOs are in a uniquely strong position to generate evidence. Hence, MCOs have a responsibility to realize that the nature of the evidence they generate can have a profound impact on medical practice. They should seek to generate evidence that promotes population health, attempts to fill the gaps in needed data, particularly for understudied segments of the population, incorporates patient utilities, and avoids undue influence from those who are marketing innovations, or from those who wish to cut costs without concern for good patient outcomes.

The ethical issues that arise in the practice of EBM in managed care are not unique. Like other large health care organizations, MCOs must grapple with the combined ethical difficulties involved in identifying and rationing effective care. MCOs should develop guidelines that simultaneously steer effective care for their population as a whole and include permissible strategies for the individual provider to negotiate satisfactory patient-centered care.

On the other hand, MCOs are in a uniquely strong position to generate evidence. Hence, MCOs have a responsibility to realize that the nature of the evidence they generate can have a profound impact on medical practice. They should seek to generate evidence that promotes population health, attempts to fill the gaps in needed data, particularly for understudied segments of the population, incorporates patient utilities, and avoids undue influence from those who are marketing innovations, or from those who wish to cut costs without concern for good patient outcomes.

The ethical issues that arise in the practice of EBM in managed care are not unique. Like other large health care organizations, MCOs must grapple with the combined ethical difficulties involved in identifying and rationing effective care. MCOs should develop guidelines that simultaneously steer effective care for their population as a whole and include permissible strategies for the individual provider to negotiate satisfactory patient-centered care.

On the other hand, MCOs are in a uniquely strong position to generate evidence. Hence, MCOs have a responsibility to realize that the nature of the evidence they generate can have a profound impact on medical practice. They should seek to generate evidence that promotes population health, attempts to fill the gaps in needed data, particularly for understudied segments of the population, incorporates patient utilities, and avoids undue influence from those who are marketing innovations, or from those who wish to cut costs without concern for good patient outcomes.

The ethical issues that arise in the practice of EBM in managed care are not unique. Like other large health care organizations, MCOs must grapple with the combined ethical difficulties involved in identifying and rationing effective care. MCOs should develop guidelines that simultaneously steer effective care for their population as a whole and include permissible strategies for the individual provider to negotiate satisfactory patient-centered care.

On the other hand, MCOs are in a uniquely strong position to generate evidence. Hence, MCOs have a responsibility to realize that the nature of the evidence they generate can have a profound impact on medical practice. They should seek to generate evidence that promotes population health, attempts to fill the gaps in needed data, particularly for understudied segments of the population, incorporates patient utilities, and avoids undue influence from those who are marketing innovations, or from those who wish to cut costs without concern for good patient outcomes.

Involvement of the sympathetic nervous system in congestive heart failure is characterized by a vicious circle, where reduced cardiac output results in neurohumoral activation. The hyperadrenergic state in turn causes desensitization and downregulation of cardiac β-adrenergic receptors and alterations of postsynaptic signal transduction, which further impair myocardial performance. Alterations of presynaptic cardiac sympathetic innervation are also involved in this pathophysiologic process. Reduction of presynaptic catecholamine reuptake increases overexposure to catecholamines further and thereby contributes to disease progression.