A reevaluation of the costs of heart failure and its implications for allocation of health resources in the United States

Costs and Healthcare Utilization of Heart Disease by COVID-19 Diagnosis and Race and Ethnicity

Introduction

Heart disease poses a significant health and economic burden in the U.S., with considerable variations in outcomes across different racial and ethnic groups. The COVID-19 pandemic has further highlighted the disparities in healthcare utilization and costs associated with heart disease.

Methods

The authors used the 2021 Merative MarketScan Medicaid claims database to estimate the medical costs and healthcare utilization associated with heart disease by racial and ethnic groups and COVID-19 diagnosis status. This study focused on individuals aged ≥18 years continuously enrolled in a noncapitated insurance plan in 2021. The outcome measures included total medical expenditures and healthcare utilization, including the numbers of emergency department visits and inpatient admissions and length of inpatient stay. The authors employed a generalized linear model with a family of gamma and log links for medical costs, and a negative binomial regression was used for healthcare utilization. Three-way interactions of heart disease, COVID-19 diagnosis, and race and ethnicity categories were implemented after adjusting for age, sex, and comorbidities. The authors reported average marginal effects with 95% CIs.

Results

Among 1,008,166 Medicaid beneficiaries, 8% had heart disease in 2021. The cost associated with heart disease was $10,819 per beneficiary in 2021 (95% CI=10,292; 11,347; p<0.001). The cost was $15,840 (95% CI=14,389; 17,291; p<0.001) for non-Hispanic Black individuals; $9,945 (95% CI=9,172; 10,718; p<0.001) for non-Hispanic White; and $8,511 (95% CI=7,490; 9,531; p<0.001) for Hispanic individuals. Individuals with a COVID-19 diagnosis ($19,638) had $9,541 (95% CI=7,049; 12,032; p<0.001) higher costs associated with heart disease than those without COVID-19 ($10,098) (p<0.001). Individuals with heart disease had higher numbers of emergency department visits (0.937 per beneficiary, 95% CI=0.913; 0.960), inpatient admissions (0.463 per beneficiary, 95% CI=0.455; 0.471), and average length of stay (2.541 days per admission, 95% CI=2.405; 2.677) than those without heart disease.

Conclusions

The study's findings showed that costs and healthcare utilization associated with heart disease are substantial in all racial and ethnic groups and the highest among non-Hispanic Black individuals. Furthermore, individuals with a COVID-19 diagnosis had approximately 2 times higher costs associated with heart disease than individuals without a COVID-19 diagnosis.

Cost Offset of Dapagliflozin in the US Medicare Population with Cardio-Kidney Metabolic Syndrome

INTRODUCTION

Cardiovascular-kidney-metabolic (CKM) syndrome is highly prevalent in the US Medicare population and is projected to increase further. Sodium-glucose co-transporter 2 inhibitors have indications in chronic kidney disease (CKD), heart failure (HF), and type 2 diabetes (T2D), providing protective efficacy across conditions within CKM syndrome. The objective of this study was to develop a model to extrapolate key outcomes observed in pivotal clinical trials to the US Medicare population, and to assess the potential direct cost offsets associated with dapagliflozin therapy.

METHODS

All US 2022 Medicare beneficiaries (≥ 65 years of age) eligible to receive dapagliflozin were estimated according to drug label indication and Medicare enrollment and claims data. Incidence of key outcomes from the dapagliflozin clinical program were modelled over a 4-year time horizon based on patient-level data with CKD, HF, and T2D. Published cost data of relevant clinical outcomes were used to calculate direct medical care cost-offset associated with treatment with dapagliflozin.

RESULTS

In a population of 13.1 million patients with CKM syndrome, treatment with dapagliflozin in addition to historical standard of care (hSoC) versus hSoC alone led to fewer incidents of HF-related events (hospitalization for HF, 613,545; urgent HF visit, 98,896), renal events (kidney failure, 285,041; ≥ 50% sustained decline in kidney function, 375,137), and 450,355 fewer deaths (of which 225,346 and 13,206 incidences of cardiovascular and renal death were avoided). In total this led to medical care cost offsets of $99.3 billion versus treatment with hSoC only (dapagliflozin plus hSoC, $310.3 billion; hSoC, $211.0 billion).

CONCLUSION

By extrapolating data from trials across multiple indications within CKM syndrome, this broader perspective shows that considerable medical care cost offsets may result through attenuated incidence of clinical events in CKD, T2D, and HF populations if treated with dapagliflozin in addition to hSoC over a 4-year time horizon. Graphical abstract available for this article.

Heart Failure and Edema Costs in Patiromer and Sodium Zirconium Cyclosilicate Users

Key Points

Prior research suggests differences in rates of heart failure hospitalization or serious emergency department visits between patients on patiromer versus sodium zirconium cyclosilicate. Total costs of heart failure–related hospitalizations and emergency department visits may be lower in patients on patiromer compared with sodium zirconium cyclosilicate.

Background

Previous work suggested differences between patients taking patiromer or sodium zirconium cyclosilicate (SZC) in real-world risk of heart failure (HF) hospitalizations and edema hospitalizations or emergency department (ED) visits (edema events). We further investigated these differences to assess economic importance. Retrospective study using published event rates and mean costs derived from Optum's deidentified Clinformatics Data Mart Database.

Methods

We designed a model to estimate adjusted economic offsets that combined respective patiromer and SZC HF hospitalization (25.1 and 35.8; difference 10.7 [95% confidence interval (CI)2, 2.6 to 18.8]) and edema event (3.4 and 7.1; difference 3.6 [95% CI, 1.7 to 7.1]) rates/100 person-years from the original published work with costs from our parallel data extract spanning 2019–2021, adjusted to 2021 US dollars.

Results

In a base case of mean HF hospitalization, edema event, and 30-count potassium-binder prescription costs from our data extract, the estimated mean savings with patiromer was $1428 per person per year (95% CI, −$1508 to $4652). Respective costs per person per year for patiromer versus SZC were $8526 versus $12,622 (difference $4096 [95% CI, $116 to $7320]) for HF hospitalization and edema events, and $10,649 versus $7981 (difference −$2668) for potassium binders, totaling $19,175 for patiromer versus $20,603 for SZC.

Conclusions

With differing drug costs, hospitalization and ED costs offset this difference when event rates were numerically small. Model outcomes were driven by HF hospitalization cost and least influenced by edema ED visit cost. A limitation was that the Clinformatics Data Mart data extract may differ from the original work.

Long-Term Outcomes of Heart Failure With Preserved or Mid-Range Ejection Fraction in the United States

Background

Approximately one-half of all heart failure (HF) consists of heart failure with preserved ejection fraction (HFpEF) or heart failure with mid-range ejection fraction (HFmrEF). Although several recent trials have investigated treatments for HFpEF/HFmrEF, there is limited insight on the long-term clinical trajectory of this population.

Objectives

The purpose of this study was to model clinical outcomes in patients with symptomatic (NYHA functional class II-IV) HFpEF/HFmrEF over 10 years.

Methods

We developed a Markov model with stable HF, HF hospitalization, and death states to follow a cohort of patients with HFpEF/HFmrEF treated with standard of care (SoC) recommended by the American Heart Association/American College of Cardiology/Heart Failure Society of America. Population characteristics and clinical event probabilities were derived from recent phase 3 HFpEF/HFmrEF trials. We used weighted averages for control and sodium-glucose cotransporter-2 inhibitor outcomes. SoC was informed by baseline treatments reported in clinical trials.

Results

In a cohort of U.S. patients with HFpEF/HFmrEF treated with SoC, our model estimated 0.53 cumulative HF hospitalizations per patient over 10 years. Overall, 37% had at least 1 HF hospitalization, and 26% experienced cardiovascular death. The model estimated 6.1 years of life expectancy from age 72 and total cost of care over this time of $123,900.

Conclusions

HFpEF/HFmrEF is associated with high rates of HF hospitalization and cardiovascular mortality based on contemporary clinical trials in this population. Furthermore, clinical trial results are likely to be more optimistic than real-world outcomes. Continuing to optimize care and treatment may reduce clinical burden and improve population health.

High ADMA Is Associated with Worse Health Profile in Heart Failure Patients Hospitalized for Episodes of Acute Decompensation

Background and Objectives: episodes of acute decompensation in chronic heart failure (ADHF), a common health problem for the growing elderly population, pose a significant socio-economic burden on the public health systems. Limited knowledge is available on both the endothelial function in and the cardio-metabolic health profile of old adults hospitalized due to ADHF. This study aimed to investigate the connection between asymmetric dimethylarginine (ADMA)-a potent inhibitor of nitric oxide-and key health biomarkers in this category of high-risk patients. Materials and Methods: this pilot study included 83 individuals with a known ADHF history who were admitted to the ICU due to acute cardiac decompensation. Selected cardiovascular, metabolic, haemogram, renal, and liver parameters were measured at admission to the ICU. Key renal function indicators (serum creatinine, sodium, and potassium) were determined again at discharge. These parameters were compared between patients stratified by median ADMA (114 ng/mL). Results: high ADMA patients showed a significantly higher incidence of ischemic cardiomyopathy and longer length of hospital stay compared to those with low ADMA subjects. These individuals exhibited significantly higher urea at admission and creatinine at discharge, indicating poorer renal function. Moreover, their lipid profile was less favorable, with significantly elevated levels of total cholesterol and HDL. However, no significant inter-group differences were observed for the other parameters measured. Conclusions: the present findings disclose multidimensional, adverse ADMA-related changes in the health risk profile of patients with chronic heart failure hospitalized due to recurrent decompensation episodes.

Costs of care and financial hardship among patients with heart failure

With the implementation of new therapies, more patients are living with heart failure (HF) as a chronic condition. Alongside these advances, out-of-pocket (OOP) medical costs have increased, and patients experience significant financial burden. Despite increasing interest in understanding and mitigating financial burdens, there is a relative paucity of data specific to HF. Here, we explore financial hardship in HF from the patient perspective, including estimated OOP costs for guideline-directed medical therapy for HF with reduced ejection fraction, hospitalizations, and total direct medical costs, as well as the consequences of high OOP costs. Studies estimate that high OOP costs are common in HF, and a large proportion are related to prescription drugs. Subsequently, the effects on patients can lead to worsening adherence, delayed care, and poor outcomes, leading to a financial toxicity spiral. Further, we summarize patients' cost preferences and outline future research that is needed to develop evidence-based solutions to reduce costs in HF.

Cardiovascular consequences of financial stress: A systematic review and meta-analysis

BACKGROUND

Cardiovascular diseases (CVD), notably coronary artery disease (CAD) and coronary heart disease (CHD), are predominant contributors to global morbidity and mortality. Financial stress is recognized as a non-traditional risk factor for CVD. The objective of this study is to conduct a systematic review and meta-analysis on the association between financial stress and the incidence of major cardiac outcomes.

METHODS

A literature search was conducted across multiple databases up until September 20, 2023. Primary studies reporting the association between financial stress and the incidence of CAD, CHD, or major cardiovascular outcomes were included. The quality of the incorporated studies was evaluated using the Newcastle-Ottawa Scale. Statistical analysis was performed using R version 4.3, employing a random-effects model.

RESULTS

Out of 2,740 identified studies, seven satisfied the inclusion criteria, displaying a diverse range in design, settings, and participant demographics. A significant association was found between financial stress and major cardiac outcomes, with a combined hazard ratio (HR) of 1.191 (95% CI: 1.00 to 1.47), p<0.001 from five studies. Possible publication bias and variations in definitions and measurements of financial stress were noted among the studies.

CONCLUSION

The available literature substantiates an association between financial stress and the incidence of CAD/CHD or major cardiac outcomes, underscoring an urgent need for standardized definitions and measurements of financial stress. Our findings support the integration of financial stress assessments in patient care and the development of health policies emphasizing economic strains to enhance cardiovascular health outcomes and overall well-being.

Variation in Risk-Standardized Acute Admission Rates Among Patients With Heart Failure in Accountable Care Organizations: Implications for Quality Measurement

Background Accountable care organizations (ACOs) aim to improve health care quality and reduce costs, including among patients with heart failure (HF). However, variation across ACOs in admission rates for patients with HF and associated factors are not well described. Methods and Results We identified Medicare fee-for-service beneficiaries with HF who were assigned to a Medicare Shared Savings Program ACO in 2017 and survived ≥30 days into 2018. We calculated risk-standardized acute admission rates across ACOs, assigned ACOs to 1 of 3 performance categories, and examined associations between ACO characteristics and performance categories. Among 1 232 222 beneficiaries with HF, 283 795 (mean age, 81 years; 54% women; 86% White; 78% urban) were assigned to 1 of 467 Medicare Shared Savings Program ACOs. Across ACOs, the median risk-standardized acute admission rate was 87 admissions per 100 people, ranging from 61 (minimum) to 109 (maximum) admissions per 100 beneficiaries. Compared to the overall average, 13% of ACOs performed better on risk-standardized acute admission rates, 72% were no different, and 14% performed worse. Most ACOs with better performance had fewer Black beneficiaries and were not hospital affiliated. Most ACOs that performed worse than average were large, located in the Northeast, had a hospital affiliation, and had a lower proportion of primary care providers. Conclusions Admissions are common among beneficiaries with HF in ACOs, and there is variation in risk-standardized acute admission rates across ACOs. ACO performance was associated with certain ACO characteristics. Future studies should attempt to elucidate the relationship between ACO structure and characteristics and admission risk.

Financial Toxicity of Medical Management of Heart Failure: JACC Review Topic of the Week

Optimal medical management of heart failure (HF) improves quality of life, decreases mortality, and decreases hospitalizations. Cost may contribute to suboptimal adherence to HF medications, especially angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter-2 inhibitors. Patients' experiences with HF medication cost include financial burden, financial strain, and financial toxicity. Although there has been research studying financial toxicity in patients with some chronic diseases, there are no validated tools for measuring financial toxicity of HF, and very few data on the subjective experiences of patients with HF and financial toxicity. Strategies to decrease HF-associated financial toxicity include making systemic changes to minimize cost sharing, optimizing shared decision-making, implementing policies to lower drug costs, broadening insurance coverage, and using financial navigation services and discount programs. Clinicians may also improve patient financial wellness through various strategies in routine clinical care. Future research is needed to study financial toxicity and associated patient experiences for HF.

A better cost:benefit analysis yields better and fairer results: EPA's lead and copper rule revision

When conducted on a societal level, cost-benefit analysis (CBA) can indicate policies that best allocate scarce public resources. Done incompletely, CBA can produce spurious, biased results. To estimate the potential health benefits of EPA's recent Lead and Copper Drinking Water Rule Revision (LCRR), we used EPA's exposure, compliance, and effect coefficient estimates to monetize 16 of the health endpoints EPA has determined are causally related to lead exposure. In addition, we monetized one health endpoint that EPA has used elsewhere: preterm birth. We estimated that the total annual health benefits of the LCRR greatly exceed EPA's estimated annual costs: $9 billion vs $335 million (2016$). Our benefit estimates greatly exceed EPA's benefit estimates. There are also nonhealth benefits because lead generally contaminates drinking water through the corrosion of plumbing components that contain lead. The LCRR therefore has 2 components: reducing how corrosive the water is and limited replacement of lead pipes. Reducing corrosion damage to drinking water and wastewater infrastructure and residential appliances that use water yields significant annualized material benefits also: $2-8 billion (2016$). Effectively, the health benefits are free. Finally, while actual exposure data are limited, the available data on lead-contaminated drinking water exhibits known risk patterns, disproportionately burdening low-income and minority populations and women. This economic analysis demonstrates that to maximize national benefits and improve equity, the LCRR should be as rigorous as possible.

Challenges and opportunities for increasing patient involvement in heart failure self-care programs and self-care in the post-hospital discharge period

BACKGROUND

People living with heart failure (HF) are particularly vulnerable after hospital discharge. An alliance between patient authors, clinicians, industry, and co-developers of HF programs can represent an effective way to address the unique concerns and obstacles people living with HF face during this period. The aim of this narrative review article is to discuss challenges and opportunities of this approach, with the goal of improving participation and clinical outcomes of people living with HF.

METHODS

This article was co-authored by people living with HF, heart transplant recipients, patient advocacy representatives, cardiologists with expertise in HF care, and industry representatives specializing in patient engagement and cardiovascular medicine, and reviews opportunities and challenges for people living with HF in the post-hospital discharge period to be more integrally involved in their care. A literature search was conducted, and the authors collaborated through two virtual roundtables and via email to develop the content for this review article.

RESULTS

Numerous transitional-care programs exist to ease the transition from the hospital to the home and to provide needed education and support for people living with HF, to avoid rehospitalizations and other adverse outcomes. However, many programs have limitations and do not integrally involve patients in the design and co-development of the intervention. There are thus opportunities for improvement. This can enable patients to better care for themselves with less of the worry and fear that typically accompany the transition from the hospital. We discuss the importance of including people living with HF in the development of such programs and offer suggestions for strategies that can help achieve these goals. An underlying theme of the literature reviewed is that education and engagement of people living with HF after hospitalization are critical. However, while clinical trial evidence on existing approaches to transitions in HF care indicates numerous benefits, such approaches also have limitations.

CONCLUSION

Numerous challenges continue to affect people living with HF in the post-hospital discharge period. Strategies that involve patients are needed, and should be encouraged, to optimally address these challenges.

Mortality and Hospital Readmission Rates for Heart Failure Among Patients of Middle Eastern Ancestry Compared to Non-Middle Eastern Whites in Southeast Michigan

Outcomes after hospital admission for heart failure are likely affected by cultural and ethnic factors. We obtained data from a large health system in Southeast Michigan on all patients admitted for heart failure from 2008 to 2015. Middle Eastern patients were identified through self-identification and a surname algorithm. Multivariate linear, logistic, and Cox regression models were used to evaluate length of stay and readmission rates compared to Caucasian patients. Mortality data was collected from the National Death Index. 7,784 white and 642 Middle Eastern patients were identified. Middle Eastern patients were younger, had higher rates of comorbid conditions, and had a greater mean hospital length of stay (7.96 vs 7.03 days, p = 0.015). Middle Eastern patients had similar thirty-day hospital readmission risk (4.25% vs 4.47%, p = 0.370) but greater ninety-day readmission risk (9.01% vs 8.35%, p = 0.043); after controlling for covariates these differences were not significant. Middle Eastern patients had lower mortality risk (HR = 0.79, p = 0.003). After a hospital admission for heart failure, Middle Eastern patients had longer hospital lengths of stay, similar risk of hospital readmission, but lower all-cause mortality.

The Application of Porous Scaffolds for Cardiovascular Tissues

As the number of arteriosclerotic diseases continues to increase, much improvement is still needed with treatments for cardiovascular diseases. This is mainly due to the limitations of currently existing treatment options, including the limited number of donor organs available or the long-term durability of the artificial organs. Therefore, tissue engineering has attracted significant attention as a tissue regeneration therapy in this area. Porous scaffolds are one of the effective methods for tissue engineering. However, it could be better, and its effectiveness varies depending on the tissue application. This paper will address the challenges presented by various materials and their combinations. We will also describe some of the latest methods for tissue engineering.

Pressure-Controlled Intermittent Coronary Sinus Occlusion: A Novel Approach to Improve Microvascular Flow and Reduce Infarct Size in STEMI

Despite successful primary percutaneous coronary intervention (PCI) for treatment of ST-segment elevation myocardial infarction (STEMI), myocardial salvage is frequently suboptimal resulting in large infarctions with increased rates of heart failure and death. Microvascular dysfunction after the procedure is frequently present and contributes directly to poor outcomes in STEMI. Pressure-controlled intermittent Coronary Sinus Occlusion (PiCSO) is a novel technology designed to mitigate microvascular dysfunction in STEMI. Non-randomized studies have suggested that PiCSO use during primary PCI in STEMI is safe, improves microvascular perfusion and reduces infarct size. Randomized trials are ongoing to investigate the safety and effectiveness of PiCSO in high-risk patients with anterior STEMI undergoing primary PCI.

Cost-effectiveness of Empagliflozin in Patients With Heart Failure With Preserved Ejection Fraction

Importance

In the Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction (EMPEROR-Preserved), empagliflozin significantly reduced hospitalizations for heart failure while improving patient-reported health status compared with placebo. The long-term cost-effectiveness of empagliflozin among patients who have heart failure with preserved ejection fraction (HFpEF) remains unclear.

Objective

To estimate the cost-effectiveness of empagliflozin in patients with HFpEF.

Design, Setting, and Participants

This cost-effectiveness analysis performed from October 2021 to April 2022 included a Markov model using estimates of treatment efficacy, event probabilities, and utilities from EMPEROR-Preserved and published literature. Costs were derived from national surveys and pricing data sets. Quality of life was imputed from a heart failure-specific quality-of-life measure. Two analyses were performed, with and without a treatment effect on cardiovascular mortality. Subgroup analyses were based on diabetes status, ejection fraction, and health status impairment due to heart failure. The model reproduced the event rates and risk reduction with empagliflozin observed in EMPEROR-Preserved over 26 months of follow-up; future projections extended across the lifetime of patients.

Exposures

Empagliflozin or standard of care.

Main Outcomes and Measures

Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio.

Results

A total of 5988 patients were included in the analysis, with a mean age of 72 years, New York Heart Association class II to IV heart failure, and left ventricular ejection fraction greater than 40%. At the Federal Supply Schedule price of $327 per month, empagliflozin yielded 0.06 additional QALYs and $26 257 incremental costs compared with standard of care, producing a cost per QALY gained of $437 442. Incremental costs consisted of total drug costs of $29 586 and savings of $3329 from reduced hospitalizations for heart failure. Cost-effectiveness was similar across subgroups. The results were most sensitive to the monthly cost, quality-of-life benefit, and mortality effect of empagliflozin. A price reduction to $153 per month, incremental utility of 0.02, or 8% reduction in cardiovascular mortality would bring empagliflozin to $180 000 per QALY gained, the threshold for intermediate value. Using Medicare Part D monthly pricing of $375 after rebates and $511 before rebates, empagliflozin would remain low value at $509 636 and $710 825 per QALY gained, respectively. Cost-effectiveness estimates were robust to variation in the frequency and disutility of heart failure hospitalizations.

Conclusions and Relevance

In this economic evaluation, based on current cost-effectiveness benchmarks, empagliflozin provides low economic value compared with standard of care for HFpEF, largely due to its lack of efficacy on mortality and small benefit on quality of life.

Medication Complexity Among Older Adults with HF: How Can We Assess Better?

Medical management of heart failure (HF) has evolved and has achieved significant survival benefits, resulting in highly complex medication regimens. Complex medication regimens create challenges for older adults, including nonadherence and increased adverse drug events, especially associated with cognitive impairment, physical limitations, or lack of social support. However, the association between medication complexity and patients' health outcomes among older adults with HF is unclear. The purpose of this review is to address how the complexity of HF medications has been assessed in the literature and what clinical outcomes are associated with medication regimen complexity in HF. Further, we aimed to explore how older adults were represented in those studies. The Medication Regimen Complexity Index was the most commonly used tool for assessment of medication regimen complexity. Rehospitalization was most frequently assessed as the clinical outcome, and other studies used medication adherence, quality of life, healthcare utilization, healthcare cost, or side effect. However, the studies showed inconsistent results in the association between the medication regimen complexity and clinical outcomes. We also identified an extremely small number of studies that focused on older adults. Notably, current medication regimen complexity tools did not consider a complicated clinical condition of an older adult with multimorbidity, therapeutic competition, drug interactions, or altered tolerance to the usual dose strength of the medications. Furthermore, the outcomes that studies assessed were rarely comprehensive or patient centered. More studies are required to fill the knowledge gap identifying more comprehensive and accurate medication regimen complexity tools and more patient-centered outcome assessment.

Expenditure on Heart Failure in the United States: The Medical Expenditure Panel Survey 2009-2018

BACKGROUND

With rising United States health care expenditure, estimating current spending for patients with heart failure (HF) informs the value of preventative health interventions.

OBJECTIVES

The purpose of this study was to estimate current health care expenditure growth for patients with HF in the United States.

METHODS

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.

RESULTS

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.

CONCLUSIONS

HF is a costly condition for which expenditure is growing faster than that of other chronic conditions.

Comparison of Home-Based vs Center-Based Cardiac Rehabilitation in Hospitalization, Medication Adherence, and Risk Factor Control Among Patients With Cardiovascular Disease

IMPORTANCE

Prior studies have suggested that participation in home-based cardiac rehabilitation (HBCR) vs center-based cardiac rehabilitation (CBCR) results in similar clinical outcomes in patients with low to moderate risk; however, outcome data from demographically diverse populations and patients who are medically complex are lacking.

OBJECTIVE

To compare hospitalizations, medication adherence, and cardiovascular risk factor control between participants in HBCR vs CBCR.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted among patients in Kaiser Permanente Southern California (KPSC), an integrated health care system serving approximately 4.7 million patients, who participated in CR between April 1, 2018, and April 30, 2019, and with follow-up through April 30, 2020. Data were analyzed from January 2021 to January 2022.

EXPOSURES

Participation in 1 or more HBCR or CBCR sessions.

MAIN OUTCOMES AND MEASURES

The primary outcome was 12-month all-cause hospitalization. Secondary outcomes included all-cause hospitalizations at 30 and 90 days; 30-day, 90-day, and 12-month cardiovascular hospitalizations; and medication adherence and cardiovascular risk factor control at 12 months. Logistic regression was used to compare hospitalization, medication adherence, and cardiovascular risk factor control, with inverse probability treatment weighting (IPTW) to adjust for demographic and clinical characteristics.

RESULTS

Of 2556 patients who participated in CR (mean [SD] age, 66.7 [11.2] years; 754 [29.5%] women; 1196 participants [46.8%] with Charlson Comorbidity Index ≥4), there were 289 Asian or Pacific Islander patients (11.3%), 193 Black patients (7.6%), 611 Hispanic patients (23.9%), and 1419 White patients (55.5%). A total of 1241 participants (48.5%) received HBCR and 1315 participants (51.5%) received CBCR. After IPTW, patients who received HBCR had lower odds of hospitalization at 12 months (odds ratio [OR], 0.79; 95% CI, 0.64-0.97) but similar odds of adherence to β-blockers (OR, 1.18; 95% CI, 0.98-1.42) and statins (OR, 1.02; 95% CI, 0.84-1.25) and of control of blood pressure (OR, 0.98; 95% CI, 0.81-1.17), low-density lipoprotein cholesterol (OR, 0.98; 95% CI, 0.81-1.20), and hemoglobin A1c (OR, 0.98; 95% CI, 0.82-1.18) at 12 months compared with patients who received CBCR.

CONCLUSIONS AND RELEVANCE

These findings suggest that HBCR in a demographically diverse population, including patients with high risk who are medically complex, was associated with fewer hospitalizations at 12 months compared with patients who participated in CBCR. This study strengthens the evidence supporting HBCR in previously understudied patient populations.

Sodium-Glucose Cotransporter 2 Inhibitor Use Among Individuals Age <65 with Type 2 Diabetes and Heart Failure with Reduced Ejection Fraction: A Cost-Benefit Analysis

Background

Type 2 diabetes (T2D) patients face increased risk of heart failure (HF) as they age. Sodium-glucose cotransporter 2 inhibitors (SGLT-2i) have demonstrated effectiveness in reducing HF hospitalizations in patients with T2D and HF with reduced ejection fraction (HFrEF). Diabetes guidelines recommend SGLT-2i therapy for patients with HFrEF; however, SGLT-2i cost is high.

Objective

Study objectives were to assess SGLT-2i utilization and HF hospitalization rates in commercially insured adults (age <65) with T2D and heart failure with reduced ejection fraction (HFrEF) taking metformin with/without SGLT-2i use and conduct a cost-benefit analysis of SGLT-2i use from payer and societal perspectives.

Methods

Economic models included HF hospitalization rates from real-world data (RWD) and hospitalization rate reductions from RWD and SGLT-2i clinical trials. Real-world HF hospitalization rates were obtained from claims data (MarketScan Commercial Database, years 2013-2018). Societal perspective analyses included indirect costs. Sensitivity analyses were conducted on key parameters.

Results

Among adults with T2D and HFrEF age 30-64, SGLT-2i use increased (1.1% to 17.4%) between 2013 and 2018. The HF hospitalization rate without SGLT-2i use vs with was 15.5% vs 11.0% (absolute risk reduction of 4.5%). Base case scenario net-benefit was negative across all payer perspective models, while positive for societal-perspective. Payer perspective overall net-benefit in 30-64 population: -$1,725,758 (-$4106 per person). Societal perspective net-benefit in 30-64 population: $5,996,851 ($14,269 per person). In sensitivity analyses, estimated per person base case societal net-benefit of $14,269 was most sensitive to changes in baseline HF hospitalization rates, post-discharge mortality rates, and readmission rates. Lowering SGLT-2i prescription costs 50% and 80% resulted in per person net-benefit increases of $1737 and $4004, respectively.

Conclusion

SGLT-2i utilization has steadily increased, with lower HF hospitalization rates observed among SGLT-2i users. Societal benefits of SGLT-2i use in this population are substantive; payer benefits are negative unless SGLT-2i cost is drastically reduced.

Cost-effectiveness analysis of Ado-trastuzumab emtansine for the treatment of residual invasive HER2-positive breast cancer

Objective

Methods

Results

Conclusion

An Analysis of Epidemiological Factors in Heart Failure Outcomes

Background

Various socioeconomic and demographic factors play a role in determining treatment outcomes across numerous conditions. Different studies have shown that certain demographic factors, such as income status, directly correlate with treatment outcomes. In this study, we analyze the effect of some of these variables, namely, insurance and age, on various endpoints, including length of stay and discharge status, among heart failure patients.

Methodology

The data used in this project were retrieved from the HealthCare Utilization Project. We sorted the data by insurance, age, length of stay, and discharge status. To compare discharge status between different insurance types and age groups, we used Stata to compute odds ratios and 95% confidence intervals. To compare the length of stay among different age groups and insurance types, we conducted an unpaired two-tailed Student’s t-test.

Results

Across all age groups, we found that younger patients with heart failure are more likely to discharge against medical advice compared to older patients. The average length of stay for heart failure patients was the same across all age groups except those 85 and older. Moreover, patients with a lower socioeconomic status, as determined by insurance type, were more likely to discharge against medical advice and less likely to die within hospitals.

Conclusions

Our results speak to the socioeconomic inequalities seen in medicine today. Studies have shown that those with a lower socioeconomic status tend to have worse outcomes across various conditions. Our analysis shows this phenomenon holds true for heart failure as well. In addition, our study helps to determine which groups are at higher risk of making medical decisions, such as discharging against medical advice, that will negatively affect their condition. Identifying these high-risk groups is a key first step to counteracting such behavior.

Burden of hospitalization for heart failure in the United States: a systematic literature review

BACKGROUND: Heart failure (HF) affects approximately 6 million Americans, with prevalence projected to increase by 46% and direct medical costs to reach $53 billion by 2030. Hospitalizations are the largest component of direct costs for HF; however, recent syntheses of the economic and clinical burden of hospitalization for heart failure (HHF) are lacking. OBJECTIVE: To synthesize contemporary estimates of cost and clinical outcomes of HHF in the United States. METHODS: A systematic literature review was conducted using MEDLINE and Embase to identify articles reporting cost or charge per HHF in the United States published between January 2014 and May 2019. Subgroups of interest were those with both HF and renal disease or diabetes, as well as HF with reduced or preserved ejection fraction (HFrEF or HFpEF). RESULTS: 23 studies reporting cost and/or charge per HHF were included. Sample sizes ranged from 989 to approximately 11 million (weighted), mean age from 65 to 83 years, and 39% to 74% were male. Cost per HHF ranged from $7,094 to $9,769 (median) and $10,737 to $17,830 (mean). Charge per HHF ranged from $22,162 to $40,121 (median), and $50,569 to $50,952 (mean). Among patients with renal disease, HHF mean cost ranged from $9,922 to $41,538. For those with HFrEF or HFpEF, mean cost ranged from $11,600 to $17,779 and $7,860 to $10,551, respectively. No eligible studies were identified that reported HHF costs or charges among patients with HF and diabetes. Cost and charge per HHF increased with length of stay, which ranged from 3 to 5 days (median) and 4 to 7 days (mean). CONCLUSIONS: This synthesis demonstrates the substantial economic burden of HHF and the variability in estimates of this burden. Factors contributing to variability in estimates include length of stay, age and sex of the sample, HF severity, and frequencies of comorbidities. Further research into cost drivers of HHF is warranted to understand potential mechanisms to reduce associated costs. DISCLOSURES: This study was funded by Boehringer Ingelheim Pharmaceuticals. Osenenko, Deighton, and Szabo are employees of Broadstreet HEOR, which received funds from Boehringer Ingelheim Pharmaceuticals for this work. Kuti and Pimple are employees of Boehringer Ingelheim Pharmaceuticals. This study was presented in abstract form at the 2020 American Heart Association (AHA) Quality of Care and Outcomes Research (QCOR) 2020 Scientific Sessions (May 15-16, Virtual Meeting).

Butein Inhibits Oxidative Stress Injury in Rats with Chronic Heart Failure via ERK/Nrf2 Signaling

Background

Chronic heart failure (CHF) is a serious heart disease resulting from cardiac dysfunction. Oxidative stress is an important factor in aging and disease. Butein, however, has antioxidant properties. To determine the effect of butein on oxidative stress injury in rats, a CHF rat model was established.

Methods

The CHF rat model was induced by abdominal aortic coarctation (AAC). Rats in CHF+butein and sham+butein group were given 100 mg/kg butein via gavage every day to detect the effect of butein on oxidative stress injury and myocardial dysfunction. The cardiac structural and functional parameters, including the left ventricular end-systolic dimension (LVESD), the left ventricular end-diastolic dimension (LVEDD), the left ventricular ejection fraction (LVEF), and the left ventricular fractional shortening (LVFS), were measured. Oxidative stress was measured through the production of reactive oxygen species (ROS), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), catalase (CAT), and malondialdehyde (MDA). Cardiac injury markers like creatine kinase-MB (CK-MB), lactate dehydrogenase (LDH), and aspartate aminotransferase (AST) were evaluated. Hematoxylin and eosin (H&E) staining was used to observe the myocardial cell morphology. The effect of butein on the extracellular signal-regulated kinase (ERK)/nuclear factor-E2 p45-related factor (Nrf2) signaling was confirmed by Western blot analysis.

Results

Butein had a significant effect on CHF in animal models. In detail, butein inhibited oxidative stress, relieved cardiac injury, and alleviated myocardial dysfunction. Importantly, butein activated the ERK1/2 pathway, which contributed to Nrf2 activation and subsequent heme oxygenase-1 (HO-1) and glutathione cysteine ligase regulatory subunit (GCLC) induction.

Conclusions

In this study, butein inhibits oxidative stress injury in CHF rat model via ERK/Nrf2 signaling pathway.

Readmissions, Death and Its Associated Predictors in Heart Failure With Preserved Versus Reduced Ejection Fraction

Background

Data on rehospitalizations for heart failure (HF) in Asia are scarce. We sought to determine the burden and predictors of HF (first and recurrent) rehospitalizations and all‐cause mortality in patients with HF and preserved versus reduced ejection fraction (preserved EF, ≥50%; reduced EF, <40%), in the multinational ASIAN‐HF (Asian Sudden Cardiac Death in Heart Failure) registry.

Methods and Results

Patients with symptomatic (stage C) chronic HF were followed up for death and recurrent HF hospitalizations for 1 year. Predictors of HF hospitalizations or all‐cause mortality were examined with Cox regression for time to first event and other methods for recurrent events analyses. Among 1666 patients with HF with preserved EF (mean age, 68±12 years; 50% women), and 4479 with HF with reduced EF (mean age, 61±13 years; 22% women), there were 642 and 2302 readmissions, with 28% and 45% attributed to HF, respectively. The 1‐year composite event rate for first HF hospitalization or all‐cause death was 11% and 21%, and for total HF hospitalization and all‐cause death was 17.7 and 38.7 per 100 patient‐years in HF with preserved EF and HF with reduced EF, respectively. In HF with preserved EF, consistent independent predictors of these clinical end points included enrollment as an inpatient, Southeast Asian location, and comorbid chronic kidney disease or atrial fibrillation. The same variables were predictive of outcomes in HF with reduced EF except atrial fibrillation, and also included Northeast Asian location, older age, elevated heart rate, decreased systolic blood pressure, diabetes, smoking, and non‐usage of beta blockers.

Conclusions

One‐year HF rehospitalization and mortality rates were high among Asian patients with HF. Predictors of outcomes identified in this study could aid in risk stratification and timely interventions.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01633398.

Sodium-based osmotherapy for hyponatremia in acute decompensated heart failure

Acute decompensated heart failure (ADHF) accounts for more than 1 million hospital admissions annually and is associated with high morbidity and mortality. Decongestion with removal of increased total body sodium and total body water are goals of treatment. Acute kidney injury (AKI) or chronic kidney disease (CKD) is present in two-thirds of patients with ADHF. The pathophysiology of ADHF and AKI is bidirectional and synergistic. AKI and CKD complicate the management of ADHF by decreasing diuretic efficiency and excretion of sodium and water. Among patients hospitalized with ADHF, hyponatremia is the most common electrolyte abnormality and is classically encountered with volume overload. ADHF represents an additional therapeutic challenge particularly when oligoanuria is present. Predilution continuous venovenous hemofiltration with sodium-based osmotherapy can safely increase plasma sodium concentration without deleteriously increasing total body sodium. We present a detailed methodology that addresses the issue of hypervolemic hyponatremia in patients with ADHF and AKI.

Urinary proteomics combined with home blood pressure telemonitoring for health care reform trial: rational and protocol

BACKGROUND

Hypertension and diabetes cause chronic kidney disease (CKD) and diastolic left ventricular dysfunction (DVD) as forerunners of disability and death. Home blood pressure telemonitoring (HTM) and urinary peptidomic profiling (UPP) are technologies enabling prevention.

METHODS

UPRIGHT-HTM (Urinary Proteomics Combined with Home Blood Pressure Telemonitoring for Health Care Reform [NCT04299529]) is an investigator-initiated 5-year clinical trial with patient-centred design, which will randomise 1148 patients to be recruited in Europe, sub-Saharan Africa and South America. During the whole study, HTM data will be collected and freely accessible for patients and caregivers. The UPP, measured at enrolment only, will be communicated early during follow-up to 50% of patients and their caregivers (intervention), but only at trial closure in 50% (control). The hypothesis is that early knowledge of the UPP risk profile will lead to more rigorous risk factor management and result in benefit. Eligible patients, aged 55-75 years old, are asymptomatic, but have ≥5 CKD- or DVD-related risk factors, preferably including hypertension, type-2 diabetes, or both. The primary endpoint is a composite of new-onset intermediate and hard cardiovascular and renal outcomes. Demonstrating that combining UPP with HTM is feasible in a multicultural context and defining the molecular signatures of early CKD and DVD are secondary endpoints.

EXPECTED OUTCOMES

The expected outcome is that application of UPP on top of HTM will be superior to HTM alone in the prevention of CKD and DVD and associated complications and that UPP allows shifting emphasis from treating to preventing disease, thereby empowering patients.

Trends in Heart Failure Hospitalizations in the US from 2008 to 2018

BACKGROUND

Heart failure (HF) is a major driver of health care costs in the United States and is increasing in prevalence. There is a paucity of contemporary data examining trends among hospitalizations for HF that specifically compare HF with reduced or preserved ejection fraction (HFrEF or HFpEF, respectively).

METHODS AND RESULTS

Using the National Inpatient Sample, we identified 11,692,995 hospitalizations due to HF. Hospitalizations increased from 1,060,540 in 2008 to 1,270,360 in 2018. Over time, the median age of patients hospitalized because of HF decreased from 76.0 to 73.0 years (P < 0.001). There were increases in the proportions of Black patients (18.4% in 2008 to 21.2% in 2018) and of Hispanic patients (7.1% in 2008 to 9.0% in 2018; P < 0.001, all). Over the study period, we saw an increase in comorbid diabetes, sleep apnea and obesity (P < 0.001, all) in the entire cohort with HF as well as in the HFrEF and HFpEF subgroups. Persons admitted because of HFpEF were more likely to be white and older compared to admissions because of HFrEF and also had lower costs. Inpatient mortality decreased from 2008 to 2018 for overall HF (3.3% to 2.6%) and HFpEF (2.4% to 2.1%; P < 0.001, all) but was stable for HFrEF (2.8%, both years). Hospital costs, adjusted for inflation, decreased in all 3 groups across the study period, whereas length of stay was relatively stable over time for all groups.

CONCLUSIONS

The volume of patients hospitalized due to HF has increased over time and across subgroups of ejection fraction. The demographics of HF, HFrEF and HFpEF have become more diverse over time, and hospital inpatient costs have decreased, regardless of HF type. Inpatient mortality rates improved for overall HF and HFpEF admissions but remained stable for HFrEF admissions.

Healthcare Expenditures Associated with Heart Failure in Saudi Arabia: A Cost of Illness Study

Heart failure (HF) is considered to be a global health problem that generates a significant economic burden. Despite the growing prevalence in Saudi Arabia, the economic burden of HF is not well studied. The aim of this study was to estimate the health care expenditures associated with HF in Saudi Arabia from a social perspective. We conducted a multicenter cost of illness (COI) study in two large governmental centers in Riyadh, Saudi Arabia using 369 HF patients. A COI model was developed in order to estimate the direct medical costs associated with HF. The indirect costs of HF were estimated based on a human capital approach. Descriptive and inferential statistics were analyzed. The direct medical cost per HF patient was $9563. Hospitalization costs were the major driver in total spending, followed by medication and diagnostics costs. The cost significantly increased in line with the disease progression, ranging from $3671 in class I to $16,447 in class IV. The indirect costs per working HF patient were $4628 due to absenteeism, and $6388 due to presenteeism. The economic burden of HF is significantly high in Saudi Arabia. Decision makers need to focus on allocating resources towards strategies that prevent frequent hospitalizations and improve HF management and patient outcomes in order to lower the growing economic burden.

Financial burden, distress, and toxicity in cardiovascular disease

Cardiovascular disease (CVD) is a major source of financial burden and distress, which has 3 main domains: (1) psychological distress; (2) cost-related care non-adherence or medical care deferral, and (3) tradeoffs with basic non-medical needs. We propose 4 ways to reduce financial distress in CVD: (1) policymakers can expand insurance coverage and curtail underinsurance; (2) health systems can limit expenditure on low-benefit, high-cost treatments while developing services for high-risk individuals; (3) physicians can engage in shared-decision-making for high-cost interventions, and (4) community-based initiatives can support patients with system navigation and financial coping. Avenues for research include (1) analysis of how healthcare policies affect financial burden; (2) comparative effectiveness studies examining high and low-cost strategies for CVD management; and (3) studying interventions to reduce financial burden, financial coaching, and community health worker integration.

Cost Effectiveness of an Electrocardiographic Deep Learning Algorithm to Detect Asymptomatic Left Ventricular Dysfunction

OBJECTIVE

To evaluate the cost-effectiveness of an artificial intelligence electrocardiogram (AI-ECG) algorithm under various clinical and cost scenarios when used for universal screening at age 65.

PATIENTS AND METHODS

We used decision analytic modeling to perform a cost-effectiveness analysis of the use of AI-ECG to screen for asymptomatic left ventricular dysfunction (ALVD) once at age 65 compared with no screening. This screening consisted of an initial screening decision tree and subsequent construction of a Markov model. One-way sensitivity analysis on various disease and cost parameters to evaluate cost-effectiveness at both $50,000 per quality-adjusted life year (QALY) and $100,000 per QALY willingness-to-pay threshold.

RESULTS

We found that for universal screening at age 65, the novel AI-ECG algorithm would cost $43,351 per QALY gained, test performance, disease characteristics, and testing cost parameters significantly affect cost-effectiveness, and screening at ages 55 and 75 would cost $48,649 and $52,072 per QALY gained, respectively. Overall, under most of the clinical scenarios modeled, coupled with its robust test performance in both testing and validation cohorts, screening with the novel AI-ECG algorithm appears to be cost-effective at a willingness-to-pay threshold of $50,000.

CONCLUSION

Universal screening for ALVD with the novel AI-ECG appears to be cost-effective under most clinical scenarios with a cost of <$50,000 per QALY. Cost-effectiveness is particularly sensitive to both the probability of disease progression and the cost of screening and downstream testing. To improve cost-effectiveness modeling, further study of the natural progression and treatment of ALVD and external validation of AI-ECG should be undertaken.

The cost of non-response to cardiac resynchronization therapy: characterizing heart failure events following cardiac resynchronization therapy

AIMS

The aim of this study is to quantify healthcare resource utilization among non-responders to cardiac resynchronization therapy (CRT-NR) by heart failure (HF) events and influence of comorbidities.

METHODS AND RESULTS

The ADVANCE CRT registry (2013-2015) prospectively identified responders/CRT-NRs 6 months post-implant using the clinical composite score. Heart failure event rates and associated cost, both overall and separated for inpatient hospitalizations, office visits, emergency room visits, and observational stays, were quantified. Costs of events were imputed from payments for similar real-world encounters in subjects with CRT-D/P devices in the MarketScan™ commercial and Medicare Supplemental insurance claims databases. Effects of patient demographics and comorbidities on event rates and cost were evaluated. Of 879 US patients (age 69 ± 11 years, 29% female, ischaemic disease 52%), 310 (35%) were CRT-NR. Among CRT-NRs vs. responders, more patients developed HF (41% vs. 11%, P < 0.001), HF event rate was higher (67.0 ± 21.7 vs. 11.4 ± 3.7/100 pt-year, P < 0.001), and HF readmission within 30 days was more common [hazard ratio 7.06, 95% confidence interval (2.1-43.7)]. Inpatient hospitalization was the most common and most expensive event type in CRT-NR. Comorbid HF was increased by diabetes, hypertension, and pulmonary disorders. Over 2 years, compared to CRT responders, each CRT-NR resulted in excess cost of $6388 ($3859-$10 483) to Medicare (P = 0.015) or $10 197 ($6161-$17 394) to private insurances (P = 0.014).

CONCLUSION

Healthcare expenditures associated with contemporary CRT non-response management are among the highest for any HF patient group. This illustrates an unmet need for interventions to improve HF outcomes and reduce costs among some CRT recipients.

Health expenditures after first hospital admission for heart failure in Nova Scotia, Canada: a retrospective cohort study

BACKGROUND

Although the frequency of heart failure makes it among the costliest of illnesses, there are scant Canadian data on annual costs of treatment or the costs as the condition advances. Our objective was to estimate mean prevalence- and incidence-based direct medical costs among older adults discharged alive after a first hospital admission for heart failure.

METHODS

We conducted a retrospective cohort study using population-based administrative health databases for Nova Scotia. The cohort comprised persons 50 years of age or older with an incident hospital admission for heart failure between 2009 and 2012. We considered the costs (expressed as 2020 Canadian dollars) of hospital admissions, physician visits and, for patients 65 years of age or older, outpatient cardiac medications. We estimated costs for calendar years, longitudinally and in the last 2 years of life. We analyzed costs from the perspective of a third-party public payer.

RESULTS

The cohort consisted of 3327 patients (mean age 77.6 yr; 1605 [48.2%] women). Median survival was 2.5 and 2.2 years among men and women, respectively. Annual prevalence-based costs were about $7100. Mean incidence-based costs ranged between $65 000 and $164 000 in the year after diagnosis and decreased by 90% subsequently. Costs were 4 to 7 times higher in the year before death than in the period from 1 to 2 years before death.

INTERPRETATION

The direct medical costs of treating patients with heart failure in Nova Scotia displayed a reverse J shape, with costs highest after diagnosis, declining subsequently and then increasing during the final year of life. Strategies designed to improve the quality of care immediately after diagnosis and during more advanced stages of disease might reduce these costs.

Cost-impact analysis of baroreflex activation therapy in chronic heart failure patients in the United States

Background

The study evaluated the cost of baroreflex activation therapy plus guideline directed therapy (BAT + GDT) compared to GDT alone for HF patients with reduced ejection fraction and New York Heart Association Class III or II (with a recent history of III). Baroreflex activation therapy (BAT) is delivered by an implantable device that stimulates the baroreceptors through an electrode attached to the outside of the carotid artery, which rebalances the autonomic nervous system to regain cardiovascular (CV) homeostasis. The BeAT-HF trial evaluated the safety and effectiveness of BAT.

Methods

A cost impact model was developed from a U.S. health care payer or integrated delivery network perspective over a 3-year period for BAT + GDT versus GDT alone. Expected costs were calculated by utilizing 6-month data from the BeAT-HF trial and existing literature. HF hospitalization rates were extrapolated based on improvement in NT-proBNP.

Results

At baseline the expected cost of BAT + GDT were $29,526 per patient more than GDT alone due to BAT device and implantation costs. After 3 years, the predicted cost per patient was $9521 less expensive for BAT + GDT versus GDT alone due to lower rates of significant HF hospitalizations, CV non-HF hospitalizations, and resource intensive late-stage procedures (LVADs and heart transplants) among the BAT + GDT group.

Conclusions

BAT + GDT treatment becomes less costly than GDT alone beginning between years 1 and 2 and becomes less costly cumulatively between years 2 and 3, potentially providing significant savings over time. As additional BeAT-HF trial data become available, the model can be updated to show longer term effects.

Short and Mid-Term Economic Impact of Pulmonary Artery Catheter Use in Adult Cardiac Surgery: A Hospital and Integrated Health System Perspective

Objective

A monitoring pulmonary artery catheter (PAC) is utilized in approximately 34% of the US cardiac surgical procedures. Increased use of PAC has been reported to have an association with complication rates: significant decreases in new-onset heart failure (HF) and respiratory failure (RF), but increases in bacteremia and urinary tract infections. We assessed the impact of increasing PAC adoption on hospital costs among cardiac surgery patients for US-based healthcare systems.

Methods

An Excel-based economic model calculated annualized savings for a US hospital with various cardiac surgical volumes and PAC adoption rates. A second model, for an integrated payer-provider health system, analyzed outcomes/costs resulting from the cardiac surgical admission and for the treatment of persistent HF and RF complications in the year following surgery. Model inputs were extracted from published literature, and one-way and probabilistic sensitivity analyses were performed.

Results

For an acute care hospital with 500 procedures/year and 34% PAC adoption, annualized savings equalled $61,806 vs no PAC utilization. An increase in PAC adoption rate led to increased savings of $134,751 for 75% and $170,685 for 95% adoption. Savings ranged from $12,361 to $185,418 at volumes of 100 and 1500 procedures/year, respectively. For an integrated payer-provider health system with the base-case scenario of 3845 procedures/year and 34% PAC adoption, estimated savings were $596,637 for the combined surgical index admission and treatment for related complications over the following year.

Conclusion

PAC utilization in adult cardiac surgery patients results in reduced costs for both acute care hospitals and payer-provider integrated health systems.

Cost-effectiveness of Sacubitril-Valsartan in Hospitalized Patients Who Have Heart Failure With Reduced Ejection Fraction

Importance

Sacubitril-valsartan use reduces mortality and hospitalizations compared with enalapril among patients with chronic heart failure with reduced ejection fraction (HFrEF); however, the cost-effectiveness of these treatments when initiated during hospitalization for HF is unknown.

Objective

To estimate the cost-effectiveness of inpatient initiation of sacubitril-valsartan vs enalapril compared with no initiation or posthospitalization initiation of sacubitril-valsartan among stabilized patients with HFrEF.

Design, Setting, and Participants

This economic evaluation included data on US patients with HFrEF who were eligible for sacubitril-valsartan treatment from December 8, 2009, to May 15, 2018.

Main Outcomes and Measures

A 5-state Markov model with all-cause mortality, HF, and non-HF hospitalization probabilities was used. Quality of life was estimated using Euro-QoL EQ-5D scores. Hospitalization, long-term care, and medication costs for sacubitril-valsartan and enalapril were modeled with a discount rate of 3%. The base-case analysis included a lifetime horizon from a health care and societal perspective.

Results

Modeled patients were a mean (SD) age of 63.8 (11.5) years. Inpatient treatment with sacubitril-valsartan ($5628 per year) was associated with 62 fewer HF-related admissions per 1000 patients compared with outpatient initiation or 116 fewer HF-related admissions compared with continuation of enalapril treatment. From a health care system perspective, initiation of sacubitril-valsartan during hospitalization saved $452 per year compared with continuing enalapril and $811 per year compared with initiation at 2 months after hospitalization and was associated with an incremental cost-effectiveness ratio of $21 532 per quality-adjusted life-year compared with continued enalapril treatment over a lifetime. From a societal perspective, inpatient initiation was estimated to save $460 per year per patient compared with no initiation of sacubitril-valsartan and $813 per year per patient compared with initiation after hospitalization. In a budget analysis, inpatient initiation of sacubitril-valsartan was estimated to save up to $449 per person for 1 year or $2550 per person over 5 years compared with continuation of enalapril.

Conclusions and Relevance

The findings suggest that, for patients with HFrEF, initiation of sacubitril-valsartan during hospitalization may be associated with reduced hospitalizations, increased quality-adjusted life expectancy, and cost savings compared with no initiation or initiation after hospitalization.

Overview of the socio-economic consequences of heart failure

Heart failure (HF) is a frequent cause of morbidity and mortality worldwide. The prevalence of HF increases, and in high-income countries, 1-2% of total healthcare expenditure is spent on HF. This article gives an overview on the impact of HF on health-related quality of life (HRQoL) and the economic burden of HF. Those suffering from HF are associated with a substantial decrease of HRQoL compared to individuals with most other chronic diseases and to individuals without HF. Therapeutic approaches, which decrease risk factors and lead to an improvement of the clinical status of patients, have a positive effect on HRQoL of the patients. Hospitalization rates have been shown to be correlated with disease severity, mortality, and HRQoL. Inpatient treatments of HF patients are cost intensive and the most important component for the economic burden of HF, responsible for at least half of direct cost. Prevention strategies, diagnostic and therapeutic approaches should focus on avoiding need for hospitalizations, and in particular, readmissions. Outpatient care including medication represents the second largest cost component. The cost of HF varies from less than 1,000 USD per patient in low-income countries to between 5,000 and 15,000 EUR in Europe, and between 17,000 and 30,000 USD in the US. There is a lack of study results on indirect costs. All study results on the socio-economic burden of HF clearly underscore the public health relevance of HF, showing a large economic burden for healthcare systems all over the world and a considerable impact on patients' HRQoL. The results on HRQoL are relatively homogeneous, but there are large differences across countries in respect of the economic burden they have to bear. Despite the large number of studies on the socio-economic consequences of HF further research is necessary, especially on indirect cost and for low- and middle-income countries. Future studies would benefit from a greater standardization of methods and presentation of results.

A Failed Cardiac Surgery Program in an Underserved Minority Population County Reimagined: The Power of Partnership

Background

Prince George's County Maryland, historically a medically underserved region, has a population of 909 327 and a high incidence of cardiometabolic syndrome and hypertension. Application of level I evidence practices in such areas requires the availability of highly advanced cardiovascular interventions. Donabedian principles of quality of care were applied to a failing cardiac surgery program. We hypothesized that a multidisciplinary application of this model supported by partnership with a university hospital system could result in improved quality care outcomes.

Methods and Results

A 6‐month assessment and planning process commenced in July 2014. Preoperative, intraoperative, and postoperative protocols were developed before program restart. Staff education and training was conducted via team simulation and rehearsal sessions. A total of 425 patients underwent cardiac surgical procedures. Quality tracking of key performance measures was conducted, and 323 isolated coronary artery bypass grafting procedures were performed from July 2014 to December 2019. Key risk factors in our patient demographic were higher than the Society of Thoracic Surgeons national mean. Risk‐adjusted outcome data yielded a mortality rate of 0.3% versus 2.2% nationally. The overall major complication rate was lower than expected at 7.1% compared with 11.5% nationally. Readmission rate was less than the Society of Thoracic Surgeons mean for isolated coronary artery bypass grafting (4.0% versus 10.1%, P<0.0001). Significant differences in 6 key performance outcomes were noted, leading to a 3‐star Society of Thoracic Surgeons designation in 7 of 8 tracking periods.

Conclusions

Excellent outcomes in cardiac surgery are attainable following program renovation in an underserved region in the setting of low volume. The principles and processes applied have potential broad application for any quality improvement effort.

A Systematic Review of Medical Costs Associated with Heart Failure in the USA (2014-2020)

BACKGROUND

Heart failure presents a growing clinical and economic burden in the USA. Robust cost data on the burden of illness are critical to inform economic evaluations of new therapeutic interventions.

OBJECTIVES

This systematic literature review of heart failure-related costs in the USA aimed to assess the quality of the published evidence and provide a narrative synthesis of current data.

METHODS

Four electronic databases (MEDLINE, EMBASE, EconLit, and the Centre for Reviews and Dissemination York Database, including the NHS Economic Evaluation Database and Health Technology Assessment Database) were searched for journal articles published between January 2014 and March 2020. The review, registered with PROSPERO (CRD42019134201), was restricted to cost-of-illness studies in adults with heart failure events in the USA.

RESULTS

Eighty-seven studies were included, 41 of which allowed a comparison of cost estimates across studies. The annual median total medical costs for heart failure care were estimated at $24,383 per patient, with heart failure-specific hospitalizations driving costs (median $15,879 per patient). Analyses of subgroups revealed that heart failure-related costs are highly sensitive to individual patient characteristics (such as the presence of comorbidities and age) with large variations even within a subgroup. Additionally, differences in study design and a lack of standardized reporting limited the ability to compare cost estimates. The finding that costs are higher for patients with heart failure with reduced ejection fraction compared with patients with preserved ejection fraction highlights the need for differentiating among different heart failure types.

CONCLUSIONS

The review underpins the conclusion drawn in earlier reviews, namely that hospitalization costs are the key driver of heart failure-related costs. Analyses of subgroups provide a clearer understanding of sources of heterogeneity in cost data. While current cost estimates provide useful indications of economic burden, understanding the nuances of the data is critical to support its application.

The burden of heart failure in North America and Western Europe

Background: We depict the burden of heart failure (HF) in North America (NA) and Western Europe (WE), using a cyclical flow diagram of patients from diagnosis/hospitalization until treatment, stabilization and decompensation/death. Materials & methods: We obtained data on HF hospitalizations, prevalence, severity and treatment from national databases and primary/secondary research. Results: In 2020, we estimate 3.6 and 5.2 million HF hospitalizations, and 7.6 and 8.7 million diagnosed prevalent chronic HF (CHF) cases in NA and WE, respectively. All hospitalized HF and 86-88% of prevalent cases are drug-treated. The most widely prescribed drugs for CHF in NA and WE are β-blockers and loop diuretics, respectively. Conclusion: The high burden of HF in NA and WE calls for greater efforts to prevent ischemic heart disease.

Computational characterization of flow and blood damage potential of the new maglev CH-VAD pump versus the HVAD and HeartMate II pumps

Left ventricular assist devices are routinely used to treat patients with advanced heart failure as a bridge to transplant or a destination therapy. However, non-physiological shear stress generated by left ventricular assist devices damages blood cells. The continued development of novel left ventricular assist devices is essential to improve the left ventricular assist device therapy for heart failure patients. The CH-VAD is a new maglev centrifugal left ventricular assist device. In this study, the CH-VAD pump was numerically analyzed and compared with the HVAD and HeartMate II pumps under two clinically relevant conditions (flow: 4.5 L/min, pressure head: normal ~80 and hypertension ~120 mmHg). The velocity and shear stress fields, washout, and hemolysis index of the three pumps were assessed with computational fluid dynamics analysis. Under the same condition, the CH-VAD hemolysis index was two times lower than the HVAD and HeartMate II pumps; the CH-VAD had the least percentage volume with shear stress larger than 100 Pa (i.e. normal condition: 0.4% vs HVAD 1.0%, and HeartMate II 2.9%). Under the normal condition, more than 98% was washed out of the three pumps within 0.4 s. The washout times were slightly shorter under the hypertension condition for the three pumps. No regions inside the CH-VAD or HVAD had extremely long residential time, while areas near the straightener of the HeartMate II pump had long residential time (>4 s) indicating elevated risks of thrombosis. The computational fluid dynamics results suggested that the CH-VAD pump has a better hemolytic biocompatibility than the HVAD and HeartMate II pumps under the normal and hypertension conditions.

The role of health literacy, depression, disease knowledge, and self-efficacy in self-care among adults with heart failure: An updated model

BACKGROUND

Patients with inadequate health literacy and heart failure face high healthcare costs, more hospitalizations, and greater mortality. To address these negative consequences, patients need to improve heart failure self-care. Multiple factors may influence self-care, but the exact model by which they do so is not fully understood.

OBJECTIVES

The objective of this study was to examine a model exploring the contribution of health literacy, depression, disease knowledge, and self-efficacy to the performance of heart failure self-care.

METHODS

Using a cross-sectional design, patients were recruited from a heart failure clinic and completed validated assessments of their cognition, health literacy, depression, knowledge, self-efficacy and self-care. Patients were separated into two groups according to their health literacy level: inadequate/marginal and adequate. Differences between groups were assessed with an independent t-test. Hypothesized paths and mediated relationships were estimated and tested using observed variable path analysis.

RESULTS

Participants (n = 100) were mainly male (67%), white (93%), and at least had a high school education (85%). Health literacy was associated with disease knowledge (path coefficient=0.346, p = 0.002), depression was negatively associated with self-efficacy (path coefficient=-0.211, p = 0.037), self-efficacy was positively associated with self-care (path coefficient=0.402, p<0.0005), and there was evidence that self-efficacy mediated the link between depression and self-care. There was no evidence of: mediation of the link between health literacy and self-care by knowledge or self-efficacy; positive associations between knowledge and self-efficacy or self-care; or mediation of the disease knowledge and self-care relationship by self-efficacy. Further, depression was associated with self-care indirectly rather than also directly as hypothesized.

CONCLUSIONS

Self-efficacy and depression are associated with heart failure self-care. Data generated from the model suggest that healthcare professionals should actively engage all patients to gain self-efficacy and address depression to positively affect heart failure self-care.

Humanistic burden and economic impact of heart failure – a systematic review of the literature

Background: Heart failure (HF) is increasing in prevalence worldwide. This systematic review was conducted to inform understanding of its humanistic and economic burden. Methods: Electronic databases (Embase, MEDLINE®, and Cochrane Library) were searched in May 2017. Data were extracted from studies reporting health-related quality of life (HRQoL) in 200 patients or more (published 2007–2017), or costs and resource use in 100 patients or more (published 2012–2017). Relevant HRQoL studies were those that used the 12- or 36-item Short-Form Health Surveys, EuroQol Group 5-dimensions measure of health status, Minnesota Living with Heart Failure Questionnaire or Kansas City Cardiomyopathy Questionnaire. Results: In total, 124 studies were identified: 54 for HRQoL and 71 for costs and resource use (Europe: 25/15; North America: 24/50; rest of world/multinational: 5/6). Overall, individuals with HF reported worse HRQoL than the general population and patients with other chronic diseases. Some evidence identified supports a correlation between increasing disease severity and worse HRQoL. Patients with HF incurred higher costs and resource use than the general population and patients with other chronic conditions. Inpatient care and hospitalizations were identified as major cost drivers in HF. Conclusions: Our findings indicate that patients with HF experience worse HRQoL and incur higher costs than individuals without HF or patients with other chronic diseases. Early treatment of HF and careful disease management to slow progression and to limit the requirement for hospital admission are likely to reduce both the humanistic burden and economic impact of HF.

Lower Hospitalization and Healthcare Costs With Sacubitril/Valsartan Versus Angiotensin-Converting Enzyme Inhibitor or Angiotensin-Receptor Blocker in a Retrospective Analysis of Patients With Heart Failure

Background

Outcomes data among patients with heart failure (HF) with reduced ejection fraction treated with sacubitril/valsartan (SAC/VAL) are largely limited to clinical trial results. We compared hospitalization and healthcare costs among real‐world patients with HF with reduced ejection fraction treated with SAC/VAL versus angiotensin‐converting enzyme inhibitor or angiotensin‐receptor blocker (ACEI/ARB).

Methods and Results

Using retrospective administrative claims data, stable patients with HF with reduced ejection fraction treated with SAC/VAL or ACEI/ARB from October 2015 to June 2016 were identified. Postindex hospitalization and healthcare costs were assessed in propensity‐matched cohorts using robust variance estimation. Time to first hospitalization was modeled using unadjusted Kaplan–Meier estimates and multivariable models. Postindex all‐cause healthcare costs were modeled using an adjusted multivariable model. Among 279 patients per matched cohort, postindex hospitalization risk was lower for SAC/VAL compared with ACEI/ARB using Kaplan–Meier estimation and unadjusted Cox models. For HF hospitalization, the hazard ratio (95% CI) was 0.56 (0.33–0.94; P=0.030). Adjusted results were similar to unadjusted. Mean (SD) monthly healthcare costs were lower for SAC/VAL versus ACEI/ARB for all categories except pharmacy, with hospital costs being particularly disparate between cohorts: for HF hospitalization, $248 ($1588) for SAC/VAL versus $1122 ($7290) for ACEI/ARB. The adjusted risk of incurring increased all‐cause postindex costs was lower for SAC/VAL versus ACEI/ARB (cost ratio [95% CI] 0.74 [0.59–0.94]; P=0.013).

Conclusions

In clinical practice, patients with HF with reduced ejection fraction treated with SAC/VAL were less likely to be hospitalized than matched patients treated with ACEI/ARB. Despite higher pharmacy costs, SAC/VAL–treated patients incurred lower monthly medical and total healthcare costs.

Impact of the 2016 ASE/EACVI Guidelines on diastolic function reporting in routine clinical practice

OBJECTIVE

To evaluate the impact of 2016 ASE/EACVI guidelines on Diastolic Function (DF) reporting during routine clinical practice.

METHODS

Transthoracic echos performed 9 months before and 18 months after the 2016 guidelines (DF2016) were retrospectively analyzed.

RESULTS

Twenty thousand eight hundred forty three echos performed between July 1, 2015, and September 30, 2017, were analyzed. Quarterly trends showed a stable proportion of normal DF (nDF), diastolic dysfunction (DD), indeterminate DF (DF-I), and nonreported DF (DF-NR) for 3 quarters preceding DF2016. After DF2016 release, reporting of DD decreased by 57% (P < .001), nDF increased by 76% (P < .001), DF-NR increased by 266% (P < .001), and DF-I did not change significantly (P = .40). Grade 1 DD decreased by 64% (P < .001), grade 2 DD decreased by 51% (P < .001), and grade 3 DD did not change significantly (P = .18). Provider level analysis showed increased heterogeneity in grade 1 DD reporting and decreased heterogeneity in DD grades 2 or higher, after DF2016. Systolic dysfunction reporting remained relatively stable (22%→21%→20%) compared to a significant decrease in isolated DD (35%→21%→10%).

CONCLUSION

The 2016 guidelines update has impacted DF reporting patterns significantly. The likelihood of reporting DD decreased significantly, especially for grades 1 and 2. Inter-provider heterogeneity in DF reporting improved for grades 2 and 3 but worsened for grade 1. There was more than threefold increase in failure to report DF, suggesting a decrease in provider confidence.

Cost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure

BACKGROUND

Patients with heart failure (HF) discharged from the hospital are at high risk for death and rehospitalization. Transitional care service interventions attempt to mitigate these risks.

OBJECTIVE

To assess the cost-effectiveness of 3 types of postdischarge HF transitional care services and standard care.

DESIGN

Decision analytic microsimulation model.

DATA SOURCES

Randomized controlled trials, clinical registries, cohort studies, Centers for Disease Control and Prevention life tables, Centers for Medicare & Medicaid Services data, and National Inpatient Sample (Healthcare Cost and Utilization Project) data.

TARGET POPULATION

Patients with HF who were aged 75 years at hospital discharge.

TIME HORIZON

Lifetime.

PERSPECTIVE

Health care sector.

INTERVENTION

Disease management clinics, nurse home visits (NHVs), and nurse case management.

OUTCOME MEASURES

Quality-adjusted life-years (QALYs), costs, net monetary benefits, and incremental cost-effectiveness ratios (ICERs).

RESULTS OF BASE-CASE ANALYSIS

All 3 transitional care interventions examined were more costly and effective than standard care, with NHVs dominating the other 2 interventions. Compared with standard care, NHVs increased QALYs (2.49 vs. 2.25) and costs ($81 327 vs. $76 705), resulting in an ICER of $19 570 per QALY gained.

RESULTS OF SENSITIVITY ANALYSIS

Results were largely insensitive to variations in in-hospital mortality, age at baseline, or costs of rehospitalization. Probabilistic sensitivity analysis confirmed that transitional care services were preferred over standard care in nearly all 10 000 samples, at willingness-to-pay thresholds of $50 000 or more per QALY gained.

LIMITATION

Transitional care service designs and implementations are heterogeneous, leading to uncertainty about intervention effectiveness and costs when applied in particular settings.

CONCLUSION

In older patients with HF, transitional care services are economically attractive, with NHVs being the most cost-effective strategy in many situations. Transitional care services should become the standard of care for postdischarge management of patients with HF.

PRIMARY FUNDING SOURCE

Swiss National Science Foundation, Research Council of Norway, and an Intermountain-Stanford collaboration.

Cost-effectiveness of Canakinumab for Prevention of Recurrent Cardiovascular Events

Importance

In the Canakinumab Anti-inflammatory Thrombosis Outcome Study (CANTOS) trial, the anti-inflammatory monoclonal antibody canakinumab significantly reduced the risk of recurrent cardiovascular events in patients with previous myocardial infarction (MI) and high-sensitivity C-reactive protein (hs-CRP) levels of 2 mg/L or greater.

Objective

To estimate the cost-effectiveness of adding canakinumab to standard of care for the secondary prevention of major cardiovascular events over a range of potential prices.

Design, Setting, and Participants

A state-transition Markov model was constructed to estimate costs and outcomes over a lifetime horizon by projecting rates of recurrent MI, coronary revascularization, infection, and lung cancer with and without canakinumab treatment. We used a US health care sector perspective, and the base case used the current US market price of canakinumab of $73 000 per year. A hypothetical cohort of patients after MI aged 61 years with an hs-CRP level of 2 mg/L or greater was constructed.

Interventions

Canakinumab, 150 mg, administered every 3 months plus standard of care compared with standard of care alone.

Main Outcomes and Measures

Lifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually.

Results

Adding canakinumab to standard of care increased life expectancy from 11.31 to 11.36 years, QALYs from 9.37 to 9.50, and costs from $242 000 to $1 074 000, yielding an incremental cost-effectiveness ratio of $6.4 million per QALY gained. The price would have to be reduced by more than 98% (to $1150 per year or less) to meet the $100 000 per QALY willingness-to-pay threshold. These results were generally robust across alternative assumptions, eg, substantially lower health-related quality of life after recurrent cardiovascular events, lower infection rates while receiving canakinumab, and reduced all-cause mortality while receiving canakinumab. Including a potential beneficial effect of canakinumab on lung cancer incidence improved the incremental cost-effectiveness ratio to $3.5 million per QALY gained. A strategy of continuing canakinumab selectively in patients with reduction in hs-CRP levels to less than 2 mg/L would have a cost-effectiveness ratio of $819 000 per QALY gained.

Conclusions and Relevance

Canakinumab is not cost-effective at current US prices for prevention of recurrent cardiovascular events in patients with a prior MI. Substantial price reductions would be needed for canakinumab to be considered cost-effective.

Healthcare utilization and costs of cardiopulmonary complications following cardiac surgery in the United States

PURPOSE

This study examined postoperative heart failure (HF) and respiratory failure (RF) complications and related healthcare utilization for one year following cardiac surgery.

METHODS

This study identified adult patients undergoing isolated coronary artery bypass graft (CABG) and/or valve procedures from the Cerner Health Facts® database. It included patients experiencing postoperative HF or RF complications. We quantified healthcare utilization using the frequency of inpatient admissions, emergency department (ED) visits with or without hospital admission, and outpatient visits. We then determined direct hospital costs from the determined healthcare utilization. We analyzed trends over time for both HF and RF and evaluated the association between surgery type and HF complication.

RESULTS

Of 10,298 patients with HF complications, 1,714 patients (16.6%) developed persistent HF; of the 10,385 RF patients, 175 (1.7%) developed persistent RF. Healthcare utilization for those with persistent complications over the one-year period following index hospital discharge comprised an average number of the following visit types: Inpatient (1.49 HF; 1.55 RF), Outpatient (2.02, 0.51), ED without hospital admission (0.33, 0.13), ED + Inpatient (0.08, 0.06). Per patient annual costs related to persistent complications of HF and RF were $20,857 and $30,745, respectively. There was a significant association between cardiac surgical type and the incidence of HF, with risk for isolated valve procedures (adjusted OR 2.60; 95% CI: 2.35-2.88) and CABG + valve procedures (adjusted OR 2.38; 95% CI: 2.17-2.61) exceeding risk for isolated CABG procedures.

CONCLUSIONS

This study demonstrates that HF and RF complication rates post cardiac surgery are substantial, and complication-related healthcare utilization over the first year following surgery results in significant incremental costs. Given the need for both payers and providers to focus on healthcare cost reduction, this study fills an important gap in quantifying the mid-term economic impact of postoperative cardiac surgical complications.

Influence of the length of hospitalisation in post-discharge outcomes in patients with acute heart failure: Results of the LOHRCA study

OBJECTIVE

To investigate the relationship between length of hospitalisation (LOH) and post-discharge outcomes in acute heart failure (AHF) patients and to ascertain whether there are different patterns according to department of initial hospitalisation.

METHODS

Consecutive AHF patients hospitalised in 41 Spanish centres were grouped based on the LOH (<6/6-10/11-15/>15 days). Outcomes were defined as 90-day post-discharge all-cause mortality, AHF readmissions, and the combination of both. Hazard ratios (HRs), adjusted by chronic conditions and severity of decompensation, were calculated for groups with LOH >6 days vs. LOH <6 days (reference), and stratified by hospitalisation in cardiology, internal medicine, geriatrics, or short-stay units.

RESULTS

We included 8563 patients (mean age: 80 (SD = 10) years, 55.5% women), with a median LOH of 7 days (IQR 4-11): 2934 (34.3%) had a LOH <6 days, 3184 (37.2%) 6-10 days, 1287 (15.0%) 11-15 days, and 1158 (13.5%) >15 days. The 90-day post-discharge mortality was 11.4%, readmission 32.2%, and combined endpoint 37.4%. Mortality was increased by 36.5% (95%CI = 13.0-64.9) when LOH was 11-15 days, and by 72.0% (95%CI = 42.6-107.5) when >15 days. Conversely, no differences were found in readmission risk, and the combined endpoint only increased 21.6% (95%CI = 8.4-36.4) for LOH >15 days. Stratified analysis by hospitalisation departments rendered similar post-discharge outcomes, with all exhibiting increased mortality for LOH >15 days and no significant increments in readmission risk.

CONCLUSIONS

Short hospitalisations are not associated with worse outcomes. While post-discharge readmissions are not affected by LOH, mortality risk increases as the LOH lengthens. These findings were similar across hospitalisation departments.