Nightly high dose lactulose infusion could be a cost-effective treatment for hepatic encephalopathy, renal insufficiency and heart failure

Lactulose is an established remedy for hepatic encephalopathy and shows efficacy for chronic renal insufficiency, reducing volume overload, uremia and hyperkalemia. Potentially lactulose could also be used for non-diuretic treatment of congestive heart failure. However, use of lactulose is limited by diarrhea and flatulence. Chronic lactulose administration might be tolerable if it was accomplished by nocturnal infusion through a percutaneous duodenostomy tube, also placing a rectal foley each night following a clearing enema so that large volumes of liquid stool could be passed while patients sleep. Each morning the duodenostomy would be clamped and the foley removed. For acute patients without duodenostomies, a temporary dobhoff feeding tube with accompanying rectal foley could be employed. Patients who did not want a rectal foley could elect to have a permanent colostomy. Clinical trials could establish the relationship between lactulose infusion and clearance of water, salt, potassium, hydrogen, urea and other wastes, and compare efficacy, cost and tolerability with that of peritoneal dialysis and ultrafiltration. Lactulose could potentially allow inexpensive home-based therapy for hepatic encephalopathy, chronic renal failure and congestive heart failure, and might be life-saving in countries where renal replacement in any form is currently unavailable.

Extending the horizon in chronic heart failure: effects of multidisciplinary, home-based intervention relative to usual care

BACKGROUND

The long-term impact of chronic heart failure management programs over the typical life span of affected individuals is unknown.

METHODS AND RESULTS

The effects of a nurse-led, multidisciplinary, home-based intervention (HBI) in a typically elderly cohort of patients with chronic heart failure initially randomized to either HBI (n=149) or usual postdischarge care (UC) (n=148) after a short-term hospitalization were studied for up to 10 years of follow-up (minimum 7.5 years of follow-up). Study end points were all-cause mortality, event-free survival (event was defined as death or unplanned hospitalization), recurrent hospital stay, and cost per life-year gained. Median survival in the HBI cohort was almost twice that of UC (40 versus 22 months; P<0.001), with fewer deaths overall (HBI, 77% versus 89%; adjusted relative risk, 0.74; 95% CI, 0.53 to 0.80; P<0.001). HBI was associated with prolonged event-free survival (median, 7 versus 4 months; P<0.01). HBI patients had more unplanned readmissions (560 versus 550) but took 7 years to overtake UC; the rates of readmission (2.04+/-3.23 versus 3.66+/-7.62 admissions; P<0.05) and related hospital stay (14.8+/-23.0 versus 28.4+/-53.4 days per patient per year; P<0.05) were significantly lower in the HBI group. HBI was associated with 120 more life-years per 100 patients treated compared with UC (405 versus 285 years) at a cost of 1729 dollars per additional life-year gained when we accounted for healthcare costs including the HBI.

CONCLUSIONS

In altering the natural history of chronic heart failure relative to UC (via prolonged survival and reduced frequency of recurrent hospitalization), HBI is a remarkably cost- and time-effective strategy over the longer term.

[The effectiveness of carvedilol in heart failure]

BACKGROUND

The third generation beta-blocker (carvedilol) is effective in reduction of hypertension, and of mortality and morbidity as a supplement to conventional drugs of heart failure therapies (diuretics, ACE inhibitors), based on randomized controlled trials and retrospective analysis.

OBJECTIVE

To analyse the efficacy of carvedilol in the treatment of heart failure with special focused on morbidity, mortality endpoints.

METHODS

We assessed the multicenter, randomised, double-blind studies involving more than 150 patients (1995-2005) from MEDLINE database, in which carvedilol was used in the case of moderate to severe heart failure. We also present the results of health-economic publications (2000-2005).

RESULTS

In U.S. Carvedilol Heart Failure Study (n 1096) the mortality declined by 65% (3.2% vs. 7.8%; p <0.001) with carvedilol vs. placebo, while the cardiovascular hospitalization decline was 27% (14.1% vs. 19.6%; p = 0.036) in heart failure (LVEF < or = 5%) applied together with the basic therapy (diuretic and ACE-inhibitor). In the COPERNICUS trial the efficacy of carvedilol was compared to placebo in the case of severe HF patients (LVEF < 25%, n = 2889). The annual mortality risk declined by 35% (19.7% vs. 12.8%, 95% CI 19-48%, p = 0.00013) while the risk of mortality or any risk of hospitalisation by 24% (p = 0.00004) in the active group. The CAPRICORN study (LVEF < or = 0%, n=1959) showed that carvedilol is efficacious in reduction of total (HR: 0.77; 95% CI 0.60-0.98; p = 0.031) and cardiovascular mortality (HR: 0.75; 95% CI 0.58-0.96; p = 0.024) as far as high-risk patients are concerned.

CONCLUSION

The effectiveness of carvedilol is certified in reduction of mortality and hospitalization in the treatment of moderate-severe heart-failure as part of the combination therapy. The benefits of use of the drug are well measurable not only on the level of patients but on the suppliers and the financer as well, thanks to the decline of resource utilization.

Scale of interest versus scale of estimation: comparing alternative estimators for the incremental costs of a comorbidity

We investigate how the scale of estimation in risk-adjustment models for health-care costs affects the covariate effect, where the scale of interest for the covariate effect may be different from the scale of estimation. As an illustrative example, we use claims data to estimate the incremental costs associated with heart failure within one year subsequent to myocardial infarction. Here, the scale of interest for the effect of heart failure on costs is additive. However, traditional methods for modeling costs use predetermined scale of estimation - for example, ordinary least squares (OLS) regression assumes an additive scale while log-transformed OLS and generalized linear models with log-link assume a multiplicative scale of estimation. We compare these models with a new flexible model that lets the data determine the appropriate scale of estimation. We use a variety of goodness-of-fit measures along with a modified Copas test to assess robustness, lack of fit, and over-fitting properties of the alternative estimators. Biases up to 19% in the scale of interest are observed due to the misrepresentation of the scale of estimation. The new flexible model is found to appropriately represent the scale of estimation and less susceptible to over-fitting despite estimating additional parameters in the link and the variance functions.

Patient-reported economic burden and the health status of heart failure patients

BACKGROUND

Heart failure (HF) guidelines recommend treatment with multiple medications to improve survival, functioning, and quality of life. Yet, HF treatments can be costly, resulting in significant economic burden for some patients. To date, there are few data on the impact of patients' perceived difficulties in affording medical care on their health outcomes.

METHODS AND RESULTS

Comprehensive clinical data, health status, and the perceived economic burden of 539 HF outpatients from 13 centers were assessed at baseline and 1 year later. Health status was quantified with the Kansas City Cardiomyopathy Questionnaire overall summary score. Cross-sectional and longitudinal (1-year) analyses were conducted comparing the health status of patients with and without self-reported economic burden. Patients with economic burden had significantly lower health status scores at both baseline and 1 year later. Although baseline perceptions of economic burden were associated with poorer health status, patients' perceived difficulty affording medical care at 1 year was a more important determinant of lower 1-year health status.

CONCLUSION

HF patients reporting difficulty affording their medical care had lower perceived health status than those reporting little to no economic burden. More research is needed to further evaluate this association and to determine whether addressing perceived economic difficulties affording health care can improve HF patients' health status.

Hospital cost effect of a heart failure disease management program: the Specialized Primary and Networked Care in Heart Failure (SPAN-CHF) trial

BACKGROUND

Determine the effect on hospitalization cost of a heart failure disease management (HFDM) program delivered within a diverse provider network as demonstrated in the SPAN-CHF randomized controlled trial.

METHODS

The SPAN-CHF trial was a prospective randomized assessment of the effectiveness of HFDM delivered for 90 days across a diverse provider network in a heterogeneous population of 200 patients. Baseline clinical and demographic data were obtained on each patient, mortality was monitored, and hospitalizations were tracked for 90 days. Cost estimates for each hospitalization were based on a subsample of patients seen at Tufts-New England Medical Center for whom hospitalization costs were calculated. Heart failure disease management program costs were estimated using a programmatic budget model. Hospital utilization and cost data were combined to estimate medical costs for intervention and control groups.

RESULTS

Heart failure disease management had a favorable effect on heart failure hospitalization, which was partially offset by noncardiac hospitalizations. The relative odds of at least one all-cause hospitalization during the intervention period trended less for the intervention group compared with the control group (0.76 [95% CI 0.38-1.51]). The point estimate of the differential hospitalization cost between control and intervention groups was a reduction in cost of $375 per patient. The net effect including the costs of the program was an increase of $488 per patient for the intervention group compared with the control group. The program would have been cost saving if HFDM costs had been 24% lower.

CONCLUSION

The HFDM intervention, administered over 90 days to patients hospitalized for heart failure, succeeded in reducing the rate of heart failure hospitalizations, although this effect was partially offset by an increase in non-heart failure hospitalizations. The resulting modest reduction in all-cause hospitalization costs was exceeded by the cost of the intervention. Thus, although the reduction in heart failure may be interpreted as an improvement in health status, it could not be considered cost saving.

Routine delivery of myoblasts during coronary artery bypass surgery: why not?

Skeletal myoblast transplantation has now entered the clinical arena as a potential means of restoring function to scarred myocardium. While the current experience derived from phase I trials suggests that cell implantation during coronary artery bypass operations is a straightforward and safe procedure, routine use of myoblast transplantation would certainly be premature. Two major issues have not yet been addressed: firstly, the risk-benefit ratio needs to be assessed, specifically whether the potential proarrhythmic risk associated with myoblast transplantation is supported by the results of an ongoing large, randomized study, and if so, whether this risk is offset by a benefit in terms of improvement of left ventricular function and patient outcome. Secondly, this putative benefit will then have to be weighed against the financial burden inherent to this type of procedure, to assess whether the cost-effectiveness ratio is favorably shifted and supports the expanded indication of myoblast transplantation during coronary artery revascularization in patients with severe ischemic heart failure.

[Cost of heart failure in the Unified Health System]

OBJECTIVE

To describe the direct and indirect costs of ambulatory and in-patient treatments of heart failure during 2002, in the University Hospital Antonio Pedro, Niterói.

METHODS

A cross-sectional and retrospective study on utilization and valuation of resources in 70 patients, consecutively selected, under ambulatory and in-patient treatment. Questionnaires and records of the patients were used for data collection. The resources used were evaluated in Brazilian Reais (2002). The study's point of view was the perspective from society. The data were analyzed in the EPINFO program, 2002 version.

RESULTS

The studied population consisted of 70 patients (39 women), with average age of 60.3 years old. 465 in-patients days (28.5% of the patients) took place. There were 386 ward hospitalizations and 79 in ICUs. The cost with ambulatory appointments was R$ 14.40. The expenses with ambulatory medications amounted R$ 83,430.00 (R$ 1,191.86/patient/year). The cost per hospitalized patient was R$ 4,033.62. The cost with complementary examinations totaled R$ 39,009.50 (R$ 557.28/patient/year). Twenty patients retired due to heart failure, which represented a loss in productivity of R$ 182,000.00. The total cost was R$ 444,445.20. Hospitalization represented 39.7% and the use of medications 38.3% from direct costs.

CONCLUSION

The hospitalization cost and the expenses with medications represented the main components of direct costs. Indirect costs represented economic impacts similar to direct costs.

Advance-practice nursing in heart-failure management: an integrative review

The number of patients with heart failure (HF) is predicted to escalate into the next decade, whereas the number of cardiac specialists who are skilled in evidence-based recommendations in HF practice will struggle to provide available, quality care. The advance-practice nurse, whose focus is HF management, may be an important key to improving access to this growing aggregate. This integrative review indicates the positive cost-to-benefit ratio for the advance-practice nurse's collaboration in HF management. Other measurable nursing outcomes have yet to scratch the surface, thereby inviting studies into areas that will promote the patient's quality of life.

Influence of socioeconomic deprivation on the primary care burden and treatment of patients with a diagnosis of heart failure in general practice in Scotland: population based study

OBJECTIVE

To examine whether there are socioeconomic gradients in the incidence, prevalence, treatment, and follow up of patients with heart failure in primary care.

DESIGN

Population based study.

SETTING

53 general practices (307,741 patients) participating in the Scottish continuous morbidity recording project between 1 April 1999 and 31 March 2000.

PARTICIPANTS

2186 adults with heart failure.

MAIN OUTCOME MEASURES

Comorbid diagnoses, frequency of visits to general practitioner, and prescribed drugs.

RESULTS

2186 patients with heart failure were seen (prevalence 7.1 per 1000 population, incidence 2.0 per 1000 population). The age and sex standardised incidence of heart failure increased with greater socioeconomic deprivation, from 1.8 per 1000 population in the most affluent stratum to 2.6 per 1000 population in the most deprived stratum (odds ratio 1.44, P = 0.0003). On average, patients were seen 2.4 times yearly, but follow up rates were less frequent with increasing socioeconomic deprivation (from 2.6 yearly in the most affluent subgroup to 2.0 yearly in the most deprived subgroup, P = 0.00009). Overall, 812 (80.6%) patients were prescribed diuretics, 396 (39.3%) angiotensin converting enzyme inhibitors, 216 (21.4%) beta blockers, 208 (20.7%) digoxin, and 86 (8.5%) spironolactone. The wide discrepancies in prescribing between different general practices disappeared after adjustment for patient age and sex. Prescribing patterns did not vary by deprivation categories on univariate or multivariate analyses.

CONCLUSIONS

Compared with affluent patients, socioeconomically deprived patients were 44% more likely to develop heart failure but 23% less likely to see their general practitioner on an ongoing basis. Prescribed treatment did not differ across socioeconomic gradients.

[Chronic heart failure: structural and functional deficit of our health policy?]

The problems concerning chronic heart failure can be summarized in 4 paradoxes which concern epidemiology, diagnosis, therapy, and financing respectively. Paradox I: The mortality due to chronic heart failure continues to increase worldwide despite a slow but significant decrease in mortality due to acute coronary syndromes. Paradox II: The clinical manifestations of chronic heart failure correlate poorly with the underlying pathophysiological progression. Paradox III: There is a striking discordance between the perception of evidence-based guidelines by the primary care physician and the actual reality in his/her private medical practice. Paradox IV: The inevitable increase in financial cost contrasts sharply with the many desperate attempts for cost reduction by the government.

SOLUTION

Heart Failure Clinic. Since the introduction of the first heart failure clinics in Sweden in 1990, numerous studies in various countries have emphasized the medical-cardiological and economical benefit of such organizations, mainly as a result of a substantial reduction of more than 40% in hospitalization. Moreover, a more central role is attributed to the primary care general practicioner.

Intravenous levosimendan treatment is cost-effective compared with dobutamine in severe low-output heart failure: an analysis based on the international LIDO trial

BACKGROUND

Levosimendan, a novel calcium sensitiser, improves cardiac performance and symptoms without increasing oxygen consumption, and decreases the mortality of patients with low-output heart failure.

AIMS

To estimate the cost-effectiveness of intravenous treatment with levosimendan compared with dobutamine in patients with severe low-output heart failure.

METHODS

This economic evaluation was based on a European clinical trial (LIDO), in which 203 patients with severe heart failure randomly received a 24 h infusion with either levosimendan or dobutamine. Survival and resource utilisation data were collected for 6 months; survival was extrapolated assuming a mean additional lifetime of 3 years based on data from the Cooperative North Scandinavian Enalapril Survival Study trial. Costs were based on study drug usage and hospitalisation in the 6-month follow-up. A sensitivity analysis on dosage of drug and duration of survival was performed.

RESULTS

The mean survival over 6 months was 157+/-52 days in the levosimendan group and 139+/-64 days in the dobutamine group (P<0.01). When extrapolated up to 3 years, the gain in life expectancy was estimated at 0.35 years (discounted at 3%). Levosimendan increased the mean cost per patient by 1108, which was entirely due to the cost of the study drug. The incremental cost per life-year saved (LYS) was 3205 at the European level; in the individual countries the cost per LYS ranged between 3091 and 3331. The result was robust in the sensitivity analysis.

CONCLUSIONS

Although the patients in the levosimendan group were alive for more days and thus at risk of hospitalisation for longer, there was no increase in hospitalisation or hospitalisation costs with levosimendan treatment. The cost per LYS using levosimendan compares favourably with other cost-effectiveness analyses in cardiology.

Development of a polymer bileaflet valve to realize a low-cost pulsatile blood pump

The final goal of this study is to realize a low-cost pulsatile blood pump especially for patients with acute heart failure or postoperative low cardiac output syndrome. In support of the pump, two types of polymer bileaflet valves with different configuration of the valve seats were developed. Influence of the leaflet thickness on the hydrodynamics of the prototype was preliminarily investigated among 70 microm, 100 microm, and 150 microm. As to the valves with the thinner leaflets, buckling of the leaflets was observed, which induced a large amount of regurgitation at valve closure. However, by thickening the leaflet to 150 microm, the mean flow of the prototype and the second model could be successfully comparable to the Medtronic-Hall valve. Moreover, accelerated fatigue tests showed that reinforcement of the valve seat with the additional spokes in the second model extended the durability by four times as compared with the prototype, equivalent to an in vivo duration of over one month.

Reimbursement claims analysis of outcomes with carvedilol and metoprolol

OBJECTIVE

To compare resource use and costs in heart failure (HF) patients receiving metoprolol, a selective beta1-receptor blocker, with carvedilol, which blocks beta1-, beta2-, and alpha1-adrenergic receptors, by use of a retrospective reimbursement-claims analysis.

METHODS

Resource use and cost data were extracted for patients diagnosed with HF and treated with carvedilol or metoprolol for 6 months after the initiation of the respective therapy, by use of claims submitted to 6 healthcare plans. A modified Charlson index was used to assess comorbidity. Stepwise logistic regression was used to measure the influence of treatment on hospitalization.

RESULTS

Claims from 139 carvedilol and 106 metoprolol patients showed that carvedilol patients experienced significantly fewer total hospitalizations (36.0% vs. 62.3%, respectively; p < 0.001) and emergency department visits (23.7% vs. 42.5%, respectively; p = 0.002) and a trend for fewer HF-related (7.9% vs. 14.2%, respectively; NS) and cardiac-related hospitalizations (15.1% vs. 24.5%, respectively; NS). Treatment with carvedilol was associated with a significant decrease in the risk of any hospitalization (adjusted odds ratio 0.35, 95% CI 0.20 to 0.63; p <0.001). Higher pharmacy costs (mean $1677 vs. $1322; p <0.001) and lower total costs (mean $8100 vs. $14475; p = 0.025) were observed in carvedilol-treated compared with metoprolol-treated patients, respectively.

CONCLUSIONS

Compared with metoprolol, the more comprehensive adrenergic blockade achieved with carvedilol may translate into greater clinical benefits in patients with HF. Despite higher pharmacy costs, lower total costs were observed in carvedilol-treated patients.

Guidelines for management of patients with chronic heart failure in Australia

Chronic heart failure (CHF) affects approximately 1% of people aged 50-59 years, and this high prevalence increases dramatically with age. CHF is a common reason for hospital admission and general practitioner consultation in the elderly. Common causes of CHF are ischaemic heart disease, hypertension and idiopathic dilated cardiomyopathy. Diagnosis of CHF is based on clinical features and objective measurement of ventricular function (eg, echocardiography). Management is directed at prevention, retarding disease progression, relief of symptoms and prolonging survival. Non-pharmacological approaches include exercise, home-based support and risk-factor modification. Angiotensin-converting enzyme (ACE) inhibitors are the cornerstone of pharmacological therapy to prevent disease progression and prolong survival. beta-Blockers prolong survival when added to ACE inhibitors in symptomatic patients. Diuretics provide symptom relief and restoration or maintenance of euvolaemia. Spironolactone, angiotensin II receptor antagonists and digoxin may be useful in some patients. Surgical approaches in highly selected patients may include myocardial revascularisation, insertion of devices and cardiac transplantation.

Cost-effectiveness analysis of long-term moderate exercise training in chronic heart failure

The purpose of this study is to perform a cost-effectiveness analysis of long-term moderate exercise training (ET) in patients with stable chronic heart failure. In particular, the study focuses on the survival analysis and cost savings from the reduction in the hospitalization rate in the exercise group. In the past 10 years, ET has been shown to be beneficial for patients with stable class II and III heart failure in many randomized clinical trials. However, the cost-effectiveness of a long-term ET program has not been addressed for outcomes related to morbidity/mortality end points or health care utilization. We examined the cost-effectiveness of a 14-month long-term training in patients with stable chronic heart failure. The estimated increment cost for the training group, $3,227/patient, was calculated by subtracting the averted hospitalization cost, $1,336/patient, from the cost of ET and wage lost due to ET, estimated at $4,563/patient. For patients receiving ET, the estimated increment in life expectancy was 1.82 years/person in a time period of 15.5 years, compared with patients in the control group. The cost-effectiveness ratio for long-term ET in patients with stable heart failure was thus determined at $1,773/life-year saved, at a 3% discount rate. Long-term ET in patients with stable chronic heart failure is cost-effective and prolongs survival by an additional 1.82 years at a low cost of $1,773 per/life-year saved.

Safety and costs of initiating angiotensin converting enzyme inhibitors for heart failure in primary care: analysis of individual patient data from studies of left ventricular dysfunction

OBJECTIVE

To estimate the costs and consequences of diagnosing symptomatic heart failure with left ventricular systolic dysfunction and initiating angiotensin converting enzyme inhibitors in primary care.

DESIGN

Analysis of individual patient data from studies of left ventricular dysfunction (SOLVD) to identify complications during test dose and titration phases.

SETTING

Two randomised controlled trials in secondary care.

PARTICIPANTS

7487 patients taking a test dose of enalapril at enrolment to the treatment and prevention trials; 2569 patients with clinical signs of heart failure and established left ventricular dysfunction entered the treatment trial.

MAIN OUTCOME MEASURES

Discontinuation during the test dose period. Discontinuation or reduction of dose during the first year of treatment for heart failure. Costs of diagnosis and titration of treatment.

RESULTS

During the test dose phase, 585 patients (7.8%) reported side effects; 136 (1.8%) of these discontinued because of severe side effects. During the titration phase, compared with placebo, enalapril was associated with an increased risk of dose reduction due to hypotension (odds ratio 2.09, 95% confidence interval 1.15 to 3.82). However, overall, there was no difference in the rates of side effects leading to dose reduction or withdrawal between the enalapril and placebo groups. The costs of diagnosing heart failure with left ventricular systolic dysfunction and initiating and titrating an angiotensin converting enzyme inhibitor in primary care are pound300 to pound400.

CONCLUSIONS

Treatment with angiotensin converting enzyme inhibitors can be safely started for patients with heart failure and left ventricular systolic dysfunction in primary care.

Evolution and pathophysiology of chronic systolic heart failure

Understanding of the pathophysiology of chronic systolic heart failure evolved from a purely mechanical model to one in which a cascade of neurohormones and biologically active molecules are thought to be critical in the development, maintenance, and progression of the disease. Two important neurohormonal systems are the sympathetic nervous and renin-angiotensin-aldosterone systems. Initially, increases in norepinephrine concentrations from the sympathetic nervous system and in angiotensin II and aldosterone are beneficial in the short term to maintain cardiac output after an insult to the myocardium. However, long-term exposure to these neurohormones causes alterations of myocytes and interstitial make-up of the heart. These alterations in myocardium lead to progression of heart failure and, eventually, death.

A cost minimisation analysis of cardiac failure treatment in the UK using CIBIS trial data. Cardiac Insufficiency Bisoprolol Study

The clinical benefits of beta-blockers in heart failure are currently subject to intense debate and are being investigated. The economic impact of beta-blockade, however, has largely remained unexplored. The Cardiac Insufficiency Bisoprolol Study (CIBIS), while failing to show statistically significant reduction in mortality over conventional therapy, demonstrates that the administration of bisoprolol adjuvant to standard therapy leads to a significant reduction in hospital admission. The present study is a cost minimisation analysis based on CIBIS data for the UK and is restricted to direct costs only. The costs of bisoprolol medication and inpatient treatment of heart failure are considered. The 'base case' analysis and the sensitivity analyses carried on all cost driver parameters show that administering bisoprolol to heart failure patients adjuvantly to the standard therapy is at least cost neutral. Additional drug costs incurred by bisoprolol are compensated by the inpatient treatment costs of heart failure avoided. All other non-quantifiable clinical benefits such as improvement of New York Heart Association functional class are positive extras to patients and the National Health Service.

A cost-minimization of heart failure therapy with bisoprolol in the French setting: an analysis from CIBIS trial data. Cardiac Insufficiency Bisoprolol Study

Beta-blocker-induced benefit in heart failure is under intense evaluation. Several large-scale mortality trials are currently being performed, with CIBIS II evaluating bisoprolol. The economic impact of beta-blocker therapy in heart failure has not been previously determined. The present study is a cost-effectiveness evaluation of bisoprolol treatment based on CIBIS I data. It considers direct costs, that is, the bisoprolol medication cost and the cost of hospitalization related to heart failure and its complications. Hospitalization costs were calculated from the French system of classification (PMSI), which provides costs according to homogeneous groups of patients (GHM). The cost difference between bisoprolol and placebo in the entire CIBIS population and the trial duration result from an increase in cost caused by bisoprolol treatment (+ 2018 Frs/patient) and a decrease in cost related to reduced hospitalization (6349 Frs/patient). A total savings per patient of about 4330 Frs was produced by bisoprolol. Cost reduction is still more pronounced in patients not having a history of myocardial infarction. We conclude that heart failure therapy with bisoprolol lowers medical healthcare costs, mainly due to the reduced rate of hospital admissions for heart failure.

The heart failure pandemic: changing patterns, costs, and treatment strategies

Heart failure is the most important public health problem in cardiovascular medicine, and is increasing in both prevalence and expense. Programs that use an interdisciplinary team to improve outpatient treatment and prevent hospitalizations will help improve care and control costs. But the most important long-term strategy for dealing with the heart failure pandemic is more aggressive primary and secondary prevention.

Cost of heart failure to the healthcare system

From an economic, mortality, and functional standpoint, heart failure is clearly a disease that needs to be targeted. We can develop a model for heart failure to determine the impact that specific management strategies will have on the overall cost to the system, which by itself can tell us some interesting things because we're currently spending twice as much on transplantation as on digoxin therapy. We can then use this model to assess the impact of different strategies, such as greater use of angiotensin-converting enzyme (ACE) inhibitors or digoxin therapy.

Treatment of endstage heart disease with mechanical circulatory assistance

A great number of patients suffer and die from the sequelae of acute and chronic heart failure each year. Although advances in medical and surgical therapy have benefited many of these patients, the majority suffer from disease refractory to any definitive therapy. For these patients, cardiac transplantation is the only remaining hope. Unfortunately, because of the increasing demand for donor organs in the face of a fixed and limited supply, this option is only available to a small percentage of these patients. Even in patients accepted for transplantation, a significant waiting list mortality has been observed. A variety of ventricular assist devices (VAD) have been developed since the first successful case of mechanical cardiac assistance over 30 years ago. These devices differ in basic mechanical function, method of insertion, and degree of implantability, and thus have different indications and potential applications. While the intra-aortic balloon pump and centrifugal pumps are effective short-term support modalities, extracorporeal and implantable pulsatile devices have been used successfully for long-term support of patients with reversible and non-reversible cardiac failure. These pumps have most commonly been utilized as bridges to transplantation, but increasing clinical experience has supported the notion of long-term mechanical assistance as a definitive therapy for endstage heart disease. While complications, particularly infection and thromboembolism, pose significant challenges and long-term device reliability remains to be fully determined, available implantable devices seem capable of providing effective long-term support. As data is obtained from currently ongoing trials comparing VAD support to medical therapy for endstage heart failure, ethical and economic issues will assume increasing importance.

Heart failure. New treatment options

Heart failure is still not well treated and the published information concerning treatment options has been slow in filtering through to general practitioners. Once a diagnosis of heart failure is made, treatment should begin with an angiotensin converting inhibitor. The dose should be increased relatively quickly. Diuretics and digoxin can be added if there is oedema. If this does not result in adequate improvement, other vasodilators or beta-blockers can be added. Other forms of therapy including antiarrhythmics, anticoagulants and surgery are discussed.

Cost-effective management of heart failure

Heart failure affects more than 2 million Americans, and about 400,000 new cases are diagnosed each year. The direct economic cost is over $10 billion/year. About 75% of this cost is spent on hospitalization, and almost 20% on nursing home care. Drugs such as angiotensin-converting enzyme (ACE) inhibitors reduce mortality and hospitalization and are thus very cost effective in the management of heart failure. Cost-effective strategies should focus on keeping patients out of the hospital. Additional savings can be obtained by more appropriate utilization of tests.

The relationship of emotional and tangible support to psychological well-being among older women with heart failure

The purpose of this study was to determine the relationship between social support, symptom severity, and psychological well-being in older women with heart failure. In-home interviews were conducted with 80 older women following a hospital admission for heart failure. Subjects were asked their perceptions of emotional and tangible support received, symptom severity, and psychological well-being. Greater emotional support was related to greater positive affect and satisfaction with life. Greater tangible support was related to less negative affect. Neither emotional nor tangible support buffered symptom severity. The results indicate that emotional and tangible support may each affect different aspects of psychological well-being in older women with heart failure.