Treating patients with advanced heart failure in a community-based multidisciplinary team clinic is associated with significant reduction of healthcare utilization and costs

Background/Introduction

Heart failure (HF) care imposes a major economic burden, accounting for 1–3% of healthcare expenditure in developed countries. The greatest proportion of this cost (60%-70%) is accounted for by hospitalizations. A multidisciplinary team (MDT) approach in HF management is a key recommendation in international guidelines, to reduce mortality and HF hospitalization.

Purpose

To investigate whether a community-based MDT in an HF unit (HFU) had an impact on patients' healthcare utilization (HCU), and their associated costs.

Methods

A retrospective cohort study was conducted among members of the country's largest HMO, who visited at least once in a regional community-based HFU, established to provide ambulatory specialist care for patients with advanced HF, emphasizing patients in NYHA functional class III and IV, especially those with recurrent hospitalizations. HCU data were obtained from the HMO's claims data for 12 months before and after first HFU visit.

Results

Our cohort consisted of 962 patients, of whom 843 (87.6%) completed at least 12 months of follow-up, and 119 (12.4%) died during the 12 months following their first HFU visit. Both groups were comparable with regard to sex, socioeconomic status, Charlson comorbidity index, prevalence of IHD and/or carotid artery disease, AF, obesity, and chronic pulmonary disease. Those who died within 12 months were older, had more hypertension, hyperlipidaemia, diabetes, chronic renal disease and malignancy but were less likely to be smokers or to have supplementary health insurance coverage. There was a significant reduction in the total average HCU costs of the entire study population 12 months after the first HFU visit ($12,675 after vs. $13,188 before, p=0.014). However, while a reduction in these costs was observed among patients who completed 12 months of follow-up ($11,955 after vs. $13,112 before, p<0.001), an increase in these costs was observed among patients who died during follow-up ($17,774 after vs. $13,728 before, p=0.015). These opposite trends stem from a decrease ($3,540 after vs. $4,941 before, p<0.001) versus increase ($10,932 after vs. $6,733 before, p=0.002) in hospitalization costs of these groups, respectively, and an increase ($1,272 after vs. $928 before, p<0.001) versus decrease ($799 after vs. $1,116 before, p<0.001) in medication costs of these subgroups, respectively.

Conclusion(s)

Intensification of therapy by a dedicated MDT significantly reduced costs of HCU, predominantly because of a decrease in hospitalizations. This saving was noted even when including patients who died within a year of commencing treatment in our HFU (a group in whom healthcare costs are known to be excessive). A widespread establishment of dedicated community-based units, should be encouraged.

Funding Acknowledgement

Type of funding sources: None.

Effectiveness of etoposide chemomobilization in lymphoma patients undergoing auto-SCT

The effectiveness of stem cell mobilization with G-CSF in lymphoma patients is suboptimal. We reviewed our institutional experience using chemomobilization with etoposide (VP-16; 375 mg/m(2) on days +1 and +2) and G-CSF (5 μg/kg twice daily from day +3 through the final day of collection) in 159 patients with lymphoma. This approach resulted in successful mobilization (>2 × 10(6) CD34+ cells collected) in 94% of patients (83% within 4 apheresis sessions). Fifty-seven percent of patients yielded at least 5 × 10(6) cells in 2 days and were defined as good mobilizers. The regimen was safe with a low rate of rehospitalization. Average costs were $14 923 for good mobilizers and $27 044 for poor mobilizers (P<0.05). Using our data, we performed a 'break-even' analysis that demonstrated that adding two doses of Plerixafor to predicted poor mobilizers at the time of first CD34+ cell count would achieve cost neutrality if the frequency of good mobilizers were to increase by 21%, while the frequency of good mobilizers would need to increase by 25% if three doses of Plerixafor were used. We conclude that chemomobilization with etoposide and G-CSF in patients with lymphoma is effective, with future opportunities for cost-neutral improvement using novel agents.

Usefulness of the hematopoietic cell transplantation-specific comorbidity index (HCT-CI) in predicting outcomes for adolescents and young adults (AYAs) with hematologic malignancies (HM) undergoing allogeneic stem cell transplant (alloSCT)

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Background: The HCT-CI was developed to help predict overall survival (OS) and non-relapse mortality (NRM) in pts undergoing alloSCT, a procedure with significant toxicity. AYAs with cancer (ages 16–40) have been identified by the NCI as a high-risk group, but it is not known whether the HCT-CI is a useful predictor of outcomes in this relatively healthy population. Methods: All pts ages 16–39 at the time of alloSCT from 1992–2008 were included. HCT-CI was retrospectively calculated for pts with complete data available. Univariable Cox regression models were used to examine the association between covariates and OS and NRM. Results: 62 evaluable pts included 38 males and 24 females. 50 (81%) were Caucasian, 9 (15%) African American, and 3 (5%) other. Diseases included AML (23), CML (14), ALL (14), and other (11). All comorbidities had a frequency of <5% in this population except for pulmonary dysfunction (69%), hepatic dysfunction (27%), infection (19%), and psychiatric disturbance (10%). When dichotomized into categories of 0–2 (32) and >3 (30), the HCT-CI was significantly associated with OS (p = 0.0006) and marginally with NRM (p = 0.07). Because pulmonary dysfunction appeared to be the most important contributor to the HCT-CI, the diffusing capacity adjusted for hemoglobin and alveolar volume (DLCO/VA adj) was examined independently. When dichotomized into categories of <80% and >80% of normal, the DLCO/VA adj alone was also significantly associated with OS (p = 0.008), but not with NRM (p = 0.2). Conclusions: AYAs with HM undergoing alloSCT have a limited number of comorbidities in the HCT-CI. Pulmonary dysfunction is most prevalent, and the DLCO/VA adj alone appears to be nearly as predictive for OS as the HCT-CI. The discrepancy between the predictiveness for OS and NRM may reflect pre-treatment or disease status of this population at the time of transplant.

No significant financial relationships to disclose.