The social and economic burden of hospitalization for heart failure

Dimitrios FARMAKIS, MD

Heart Failure Unit
Department of Cardiology
Attikon University Hospital
Athens, GREECE

The social and economic burden of hospitalization for heart failure

by D. Farmakis, G. Filippatos,
J. Parissis, and J. Lekakis,

Heart failure (HF) affects 2% of the total population, a prevalence that rises to over 10% in individuals aged over 65 years and is expected to increase continuously over the following years given the aging of the population. HF is the most common reason for hospital admission in the elderly. Hospitalization for HF (HHF) is associated with adverse prognosis with high in-hospital and postdischarge mortality as well as high postdischarge rehospitalization rates. At the same time, HF leads to a huge financial burden that accounts for 2% of the total health care expenditure for all medical conditions. The estimated total cost for HF in the United States in 2012 was $31 billion, and this amount is expected to rise to $70 billion in 2030. Approximately 70% of HF costs result from HHF, the main proportion of which represents ward costs. Interestingly, most of HF readmissions seem to be preventable as it is related to incomplete in-hospital therapy and a poor transition and follow- up plan. Thus, effective management of congestion, careful initiation and titration of evidence-based therapies, and proper planning of follow-up are the keys to prevention of HHF and thus reduction in the social and financial burden of HF.

Medicographia. 2015;37:135-138 (see French abstract on page 138)

Heart failure in numbers

Heart failure (HF) constitutes a major public health problem, affecting a total of 26 million people worldwide.1 The incidence of HF, after 3 decades of marked increase that was perceived as an alert of an upcoming epidemic, currently seems to have reached a plateau.2 In the United States, the incidence of HF in individuals aged 55 years or older is 870 000 new cases per year, reaching 10 per 1000 population after 65 years of age.3 The prevalence of HF in the United States in 2012 was 5.7 million, representing 2.2% of the population.3 As HF is an age-related syndrome, its prevalence increases from less than 1% in individuals aged under 40 years to greater than 10% in those aged over 80 years.3 This increase is even more profound in women, reaching 13.5% after 80 years of age.3 Thus, given the aging of the population as well as the prolongation of patients’ survival by modern drug and device therapy, the overall prevalence of the syndrome is expected to rise. Accordingly, projections show that HF prevalence will increase by 46% up to the year 2030, resulting in more than 8 million adults with HF in the United States at that time.4 In addition, despite advances in therapy, HF is still associated with adverse prognosis, including a high mortality rate. In the United States in 2011, 1 in 9 death certificates mentioned HF and this number was approximately as high as in 1995.3

Hospitalization for HF

Hospitalization for HF (HHF) represents the most common cause of hospital admission in the elderly [acute heart failure chapter], with a total of approximately 1 million admissions per year in the United States and a similar number in Europe.3 Hospital discharges with a diagnosis of HF clearly increased from 1980 to 2000.3 In the subsequent decade, 2000-2010, although hospitalizations with a primary diagnosis of HF declined, those with HF as a secondary diagnosis remained rather stable.5

Hospitalization occurs commonly after the diagnosis of HF. In a population-based cohort, over a period of 5 years following the diagnosis of HF, 83% of patients were hospitalized at least once and 43% of them at least 4 times.6 The majority of patients hospitalized for HF have advanced age, usually above 70 years, and a previous history of HF as de novo HF represents less than one-third or one-fourth of cases.7 Left ventricular ejection fraction is preserved in approximately half of the patients, while the majority suffer from a wide range of cardiovascular and noncardiovascular comorbidities, including arterial hypertension, coronary artery disease, atrial fibrillation, diabetes mellitus, renal disease, chronic obstructive pulmonary disease, anemia, and depression. Comorbid conditions, particularly noncardiovascular ones, affect significantly the prognosis of the syndrome, represent a frequent cause of deterioration and readmission, and have a major impact on patients’ quality of life.8 The median duration of hospitalization ranges between 4 and 11 days.7

Pooled data from a number of acute HF registries carried out in different parts of the world show that HHF carries an ominous prognosis.9-13 In-hospital mortality ranges between 4% and 7%. Following discharge, mortality rates during the first 2 to 3 months are as high as 7% to 11%, and reach 36% within a year after discharge. Postdischarge readmission rates are also high; about 25% to 30% of patients are rehospitalized during the first 2 to 3 months, while 66% are readmitted within a year. Interestingly, those high event rates do not differ between patients with reduced and preserved left ventricular ejection fraction, except for a higher in-hospital mortality rate observed in the former group.14 Postdischarge readmissions seem to follow a 3-phase pattern with an early peak during the first 2 to 3 months, followed by a prolonged plateau phase and a second late peak during the advanced and final stage.15

The financial burden of hospitalization for HF

The cost of HF represents 2% of the total health care expenditure for all medical conditions.16-18 The estimated total cost for HF in the United States in 2012 was $30.7 billion, 68% of which was attributable to direct medical costs.3 As a result of the projected rise in the prevalence of the syndrome, this cost is expected to increase almost by 127% to $69.7 billion in 2030.4 The total health care expenditure that is attributable to HF, excluding the cost related to comorbidities, is expected to be 3-fold higher in 2030, summing a total of $160 billion.4

The huge financial burden associated with HF results from recurrent admissions, multiple-drug therapy, widespread use of device and mechanical modalities—such as implantable cardioverter-defibrillators or ventricular assist devices—combined with prolongation of patients’ survival. Of all those components, the one that contributes the most to the total cost is hospital admissions. In the United Kingdom, the cost related to HHF in 1995 represented 69% of the total HF expenditure.16 The significance of the financial burden resulting from HHF is stressed by the recently introduced Hospital Readmission Reduction Program under President Obama’s Affordable Care Act (Sec. 3025), according to which hospitals with an excessive 30-day readmission rate of Medicare patients face penalties of up to 3% of their total Medicare reimbursement.

A study published in 2014 showed that the mean total cost per patient of an episode of HHF in a Greek tertiary/teaching hospital for a median hospital stay of 7 days reached €3200.18 This amount corresponded to hospitalization in the ward, laboratory investigations, and drug therapy, without taking into account several other costly procedures such as hospitalization in an intensive/cardiac care unit, cardiac catheterization, device implantation or other invasive diagnostic or therapeutic procedures, or the use of mechanical therapies such as circulatory support or renal replacement therapy that increase markedly the total expenditure. In an Irish teaching hospital, the mean cost of HHF (study published in 2000) was estimated to be IR£2146.19

Ward costs appear to represent the greatest proportion of the total HHF cost, while medication contributes much less.17,20 In the aforementioned study from Greece, 79% of the total expenditure was attributed to ward costs, while laboratory investigations and medical treatment accounted for 17% and 4% of the cost, respectively.18 Similarly, in Ireland, ward costs represented 75% of the total HHF cost, while medications accounted for only 3.5%.19 Thus, the length of hospitalization is a key factor that determines the HHF costs.21,22 In addition, the expenditure seems to increase proportionally to the severity of the syndrome, as depicted by the New York Heart Association functional class, the extent of left ventricular systolic dysfunction, and the levels of natriuretic peptides upon admission, all of which represent independent predictors of the HHF cost.17,18

In addition, the presence of comorbid conditions such as renal dysfunction also seems to affect the magnitude of the expenditure resulting from HHF.20

Conclusions and key issues in preventing hospitalization-related HF burden

The increasing prevalence of HF, the constantly high HHF rates, the adverse prognosis associated with HHF, and the huge health care expenditure resulting from HHF are the main features that define the socioeconomic burden of HF. As HHF is the only major contributor to the total HF cost, the prevention of patients’ admission seems to be the key to reduction in costs and use of health care resources, and thus reduction in overall burden of the syndrome. It has been postulated that up to 75% of readmissions are preventable and related to incomplete in-hospital treatment—characterized by residual congestion and poor titration of chronic therapy—as well as to a poor transition and postdischarge follow-up plan. According to recent evidence from the European Society of Cardiology HF Long-term Registry, compliance with guidelines remains suboptimal not only in ambulatory, but also in hospitalized HF patients.23 Proper titration of life-saving HF medications, complete decongestion, treatment and prevention of exacerbating factors, education of patients, delineation of a specific follow-up plan, as well as collaboration with the patient’s attending physician are important measures that may contribute to a reduction in rehospitalization rates and thus help limit the socioeconomic burden of HHF.

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Keywords: cost; expenditure; health care; heart failure; hospitalization