Long-term costs and resource use in elderly participants with congestive heart failure in the Cardiovascular Health Study

doi:10.1016/j.ahj.2006.11.010

American Heart Journal

Volume 153, Issue 2, February 2007, Pages 245-252

https://doi.org/10.1016/j.ahj.2006.11.010 Get rights and content

Background

Although heart failure (HF) afflicts nearly 5 million Americans, the long-term cost of HF care has not been described previously. In a prospective, longitudinal cohort of community-dwelling elderly from 4 regions, we examined the long-term costs and resource use of elderly patients with HF.

Methods

We linked 4860 elderly participants in the National Heart, Lung, and Blood Institute Cardiovascular Health Study to Medicare part A and part B claims from 1992 to 2003. Costs were calculated from Medicare payments and discounted at 3% annually. We applied nonparametric estimators to calculate mean costs and resource use per patient for a 10-year period. To describe the relationship between patient characteristics and long-term costs, we constructed censoring-adjusted regression models.

Results

There were 343 participants (84.8% white; 50.1% men; mean age, 78.2 years) with prevalent HF and 4517 participants without HF at study entry. Mean follow-up was 6.7 years (median, 6.4 years). The 10-year survival rates were 33% and 63% for the prevalent HF and nonprevalent HF groups (P < .001), respectively. The mean 10-year medical costs were significantly higher for the prevalent HF cohort ($54,704 vs $41,780, P < .001). The higher costs associated with HF were also reflected in greater resource use with more hospitalizations (P < .05) and more intensive care unit days (P < .05). Participants with HF had more physician visits (P < .05), with most of these encounters involving noncardiology physicians. However, in multivariate models, prevalent HF was not an independent predictor of higher costs.

Conclusion

Patients with HF consume substantially more health care resources than their elderly peers, and these higher costs persist through 10 years of follow-up. Many of these costs may be related to other comorbid conditions.

Section snippets

Methods

We assembled a study population from the participants of the National Heart, Lung, and Blood Institute CHS. The CHS is a prospective, community-based, epidemiologic, observational study of 5888 men and women aged 65 years or older from 4 geographically dispersed communities (Sacramento County, CA; Washington County, MD; Forsyth County, NC; and Allegheny County, PA).5, 6 The original cohort of 5201 participants was enrolled in 1989 to 1990 with a supplemental cohort of 687 mostly African

Results

There were 343 participants with prevalent HF at study entry (in 1992, the beginning of claims data) and 4517 participants without HF at study entry. Participants with HF were older (mean age, 78.2 vs 75.6 years; P < .0001) and more likely to be male (50.1% vs 41.2% in the nonprevalent HF group; P < .001) (Table I). As a group, the HF cohort had greater comorbid illness with significantly higher rates of hypertension (93.0% vs 67.8%; P < .05), diabetes (31.8% vs 17.2%; P < .05), and COPD (16.9%

Discussion

This is the first study to examine the longitudinal inpatient and outpatient costs of prevalent HF in the elderly. As expected, study participants with HF have higher costs and greater resource use during the 10-year study period. These differences are accentuated after adjusting for the worse survival of HF participants. However, after accounting for age, sex, and comorbidities, most of the greater costs seen with HF appeared to be explained by these comorbid conditions. In particular,

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Cost-effectiveness of dapagliflozin and empagliflozin for treatment of heart failure with reduced ejection fraction
2023, International Journal of Cardiology
The differences in cost and efficacy between dapagliflozin and empagliflozin in combination with standard of care (SoC) raise the question of which regimen would be cost-effective in treating heart failure with reduced ejection fraction (HFrEF). This study evaluates the cost-effectiveness of dapagliflozin plus SoC (dapagliflozin-SoC) versus empagliflozin plus SoC (empagliflozin-SoC) or SoC alone for treatment of HFrEF.
We developed a Markov model to estimate the cost-effectiveness of dapagliflozin-SoC, empagliflozin-SoC, and SoC alone from the healthcare system perspective over a lifetime horizon. Data on efficacy of dapagliflozin-SoC, empagliflozin-SoC, and SoC were obtained from randomized controlled trials. Costs were measured in 2022 US dollars, and effectiveness was measured in quality-adjusted life years (QALYs).
Among three strategies, dapagliflozin-SoC was the most cost-effective strategy and dominated empagliflozin-SoC in an extended sense. Compared with SoC alone, dapagliflozin-SoC and empagliflozin-SoC had incremental cost-effectiveness ratios (ICER) of $56,782 and $89,258 per QALY, respectively. Dapagliflozin-SoC cost more $5524 but yielded more 0.20 QALYs than empagliflozin-SoC, with the ICER of $27,861 per QALY. The cost-effectiveness of dapagliflozin-SoC, empagliflozin-SoC, and SoC alone did not depend on diabetic status. However, empagliflozin-SoC was no longer cost-effective versus SoC alone in HFrEF patients without CKD, and dapagliflozin-SoC was not cost-effective versus empagliflozin-SoC in HFrEF patients with CKD.
Dapagliflozin-SoC was cost-effective versus empagliflozin-SoC or SoC alone for treatment of HFrEF.
Expenditure on Heart Failure in the United States: The Medical Expenditure Panel Survey 2009-2018
2022, JACC: Heart Failure
With rising United States health care expenditure, estimating current spending for patients with heart failure (HF) informs the value of preventative health interventions.
The purpose of this study was to estimate current health care expenditure growth for patients with HF in the United States.
The authors pooled MEPS (Medical Expenditure Panel Survey) data from 2009-2018 to calculate total HF-related expenditure across clinical settings in the United States. A 2-part model adjusted for demographics, comorbidities, and year was used to estimate annual mean and incremental expenditures associated with HF.
In the United States, an average of $28,950 (2018 inflation-adjusted dollars) is spent per year for health care–related expenditure for individuals with HF compared with $5,727 for individuals without HF. After adjusting for demographics and comorbidities, a diagnosis of HF was associated with $3,594 in annual incremental expenditure compared with those without HF. HF-related expenditure increased from $26,864 annual per person in 2009-2010 to $32,955 in 2017-2018, representing a 23% rise over 10 years. In comparison, expenditure on myocardial infarction, type 2 diabetes mellitus, and cancer grew by 16%, 28%, and 16%, respectively. Most of the cost was related to hospitalization: $12,569 per year. Outpatient office-based care and prescription medications saw the greatest growth in cost over the period, 41% and 24%, respectively. Estimated incremental national expenditure for HF per year was $22.3 billion; total annual expenditure for adults with HF was $179.5 billion.
HF is a costly condition for which expenditure is growing faster than that of other chronic conditions.
Healthcare cost variation in patients with heart failure: a nationwide study
2022, Public Health
Citation Excerpt :
This study is a nationwide study investigating the healthcare cost system in Denmark and may not be directly applicable globally. Our analysis did not stratify by subtype or severity of HF, which potentially could have contributed with interesting findings as former studies have shown that the cost of HF increases with NYHA classes.18,26,27,29 Registry studies have inherent limitations associated with the data accuracy, but a registry validation study found a positive prediction value for HF is 81–84%, and the negative prediction value is 90% in the Danish registries.55,56
Heart failure (HF) imposes a major economic burden; however, the individual management for patients varies, potentially leading to large cost heterogeneity. The aim of this study was to investigate the spectrum of health cost by patients with HF and factors associated with high direct health cost.
This was a nationwide, retrospective longitudinal study.
Using Danish nationwide registries from 2012 to 2015, we identified all patients aged >18 years with a first-time diagnosis of HF. Total health costs were investigated using two perspectives—at index and during 3 years of follow-up. Patients were investigated by decile cost groups. A multivariable logistic regression was used to identify variables associated with being in the highest cost decile compared with the rest (90%).
A total of 11,170 patients with HF were included, and those in the highest cost decile (n = 1117, 10%) were younger (69 vs. 75 years), fewer were females (34% vs. 43%), and more were inpatients (83% vs. 70%) compared with the rest of the patients with HF (n = 10,053, 90%). Patients in the highest cost decile (10%) incurred a 30 times higher cost with a mean total health cost in index year of €86,607 compared with €2893 for patients in lowest cost decile (10%). The results were similar for 3 years aggregated (€139,473 vs. €4086), corresponding to a 34 times higher cost.
In patients with HF, a large total health cost heterogeneity exists with younger age, inpatient admittance, male sex, and comorbidities being associated with a higher likelihood of belonging to the highest cost group.
Trends in health care expenditure among US adults with heart failure: The Medical Expenditure Panel Survey 2002-2011
2017, American Heart Journal
Citation Excerpt :
Our findings of increasing HF costs are in agreement with other reports that have examined the medical cost of HFs over time. Indeed, in the prospective Cardiovascular Health study (CHS,) the mean 10-year medical costs were significantly higher for the prevalent HF cohort ($54,704 vs $41,780) compared with those without HF.33 Also, a study of the lifetime costs of HF showed that comorbidities such as diabetes mellitus significantly influence the expenditures.34
Population-based national data on the trends in expenditures related to heart failure (HF) are scarce. Assessing the time trends in health care expenditures for HF in the United States can help to better define the burden of this condition.
Using 10-year data (2002-2011) from the national Medical Expenditure Panel Survey (weighted sample of 188,708,194 US adults aged ≥18 years) and a 2-part model (adjusting for demographics, comorbidities, and time); we estimated adjusted mean and incremental medical expenditures by HF status. The costs were direct total health care expenditures (out-of-pocket payments and payments by private insurance, Medicaid, Medicare, and other sources) from various sources (office-based visits, hospital outpatient, emergency department, inpatient hospital, pharmacy, home health care, and other medical expenditures).
Compared with expenditures for individuals without HF ($5511 [95% CI 5405-5617]), individuals with HF had a 4-fold higher mean expenditures of ($23,854 [95% CI 21,733-25,975]). Individuals with HF had $3446 (95% CI 2592-4299) higher direct incremental expenditures compared with those without HF, after adjusting for demographics and comorbidities. Among those with HF, costs continuously increased by $5836 (28% relative increase), from $21,316 (95% CI 18,359-24,272) in 2002/2003 to $27,152 (95% CI 20,066-34,237) in 2010/2011, and inpatient costs ($11,318 over the whole period) were the single largest component of total medical expenditure. The estimated unadjusted total direct medical expenditures for US adults with HF were $30 billion/y and the adjusted total incremental expenditure was $5.8 billion/y.
Heart failure is costly and over a recent 10-year period, and direct expenditure related to HF increased markedly, mainly driven by inpatient costs.
An Intervention to Enhance Goals-of-Care Communication Between Heart Failure Patients and Heart Failure Providers
2016, Journal of Pain and Symptom Management
Heart failure patients contend with a markedly impaired quality of life, experiencing emotional distress and severe physical discomfort that increases in frequency in the last months of life. Improving communication between patients and providers about goals of care has the potential to improve patient-provider communication and patient outcomes.
To determine the effects of a goals-of-care (GoC) intervention compared to usual care on the number of GoC conversations, quality of communication between patients and providers, referrals to palliative care services and completion of advance care directives.
A two-group randomized study (n = 40/group) compared a GoC intervention to usual care, conducted in an academic heart failure (HF) clinic. The GoC intervention was a previsit patient activation-education, telephone-based intervention delivered by a nurse. The primary outcome of the study was number of GoC conversations between HF patients and HF providers. Secondary outcomes were quality of communication, number of referrals to palliative care, and completion of advance directives.
Patients averaged 58.15 ± 11.26 years of age, with mean left ventricular ejection fraction = 30.31 ± 9.72% and Seattle Heart Failure Model scores = 95.1 ± 1.60. There was a significant increase in goals-of-care conversations (58% vs. 2.6%, P < 0.001) and quality of end-of-life communication (P = 0.03) in the GoC group compared to usual care after the intervention. There were no differences between groups on the other outcomes.
The GoC intervention resulted in more GoC conversations and higher quality communication between HF patients and providers without increased anxiety or depression. Further studies are needed to assess impact on longer term quality of care and patient outcomes.
Palliative Care in Heart Failure
2016, Progress in Cardiovascular Diseases
Citation Excerpt :
The cost of nearly half of the hospitalizations for HF exceeds Medicare reimbursement, which places a significant financial burden on hospitals and healthcare systems.4 When compared to all hospitalized patients, those with HF incur greater health care costs through increased physician visits, hospital admissions, and twice as many days in intensive care units.4 End-stage HF as defined by ACC/AHA guidelines5 includes a subset of patients with HF who continue to have significant symptoms despite maximum goal directed medical therapy (GDMT).
Heart failure (HF) is a leading cause of morbidity and mortality worldwide, with limited curative options. Palliative care is a holistic, symptom based approach to patients that has been proven to improve the quality of life for both patients and their caregivers. In this review we will summarize the epidemiology of end stage HF and the data supporting the use of palliative care in this patient population. We will also review basic principles of palliative care as they apply to caring for end stage patients.

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^☆: The Cardiovascular Health Study was funded by contracts NO1-HC-85079-85086 and NO1-HC-15103 from the National Heart, Lung and Blood Institute. This work was supported by a grant from the American Heart Association.

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Clinical InvestigationCongestive Heart FailureLong-term costs and resource use in elderly participants with congestive heart failure in the Cardiovascular Health Study☆

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Am Heart J

Am Heart J

Ann Epidemiol

Ann Epidemiol

Ann Epidemiol

Am J Cardiol

Am Heart J

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Heart Lung

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J Am Coll Cardiol

Clinical Investigation
Congestive Heart Failure
Long-term costs and resource use in elderly participants with congestive heart failure in the Cardiovascular Health Study☆