European Journal of Heart Failure

European Journal of Heart Failure 2001 3(3):283-291; doi:10.1016/S1388-9842(01)00123-4

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© 2001 European Society of Cardiology

Economics of chronic heart failure

Colin Berry^a,*, David R. Murdoch^b and John J.V. McMurray^b

^a MRC, Clinical Research Initiative in Heart Failure, West Medical Building, University of Glasgow Glasgow G12 8QQ, UK
^b Department of Cardiology, Western Infirmary Dumbarton Road, Glasgow G11 6NT, UK

^* Corresponding author. Tel.: +44-141-330-6588; fax: +44-141-330-6588 E-mail address: colin.berry{at}clinmed.gla.ac.uk (C. Berry).

	Abstract

Top Abstract 1. Introduction 2. Epidemiology of chronic... 3. Component costs of... 4. Studies of healthcare... 5. Emerging healthcare... 6. Conclusions References

 
Chronic heart failure (CHF) is now recognized as a major and escalating public health problem. The costs of this syndrome, both in economic and personal terms, are considerable. The prevalence of CHF is 1–2% and appears to be increasing, in part because of ageing of the population. Economic analyses of CHF should include both direct and indirect costs of care. Healthcare expenditure on CHF in developed countries consumes 1–2% of the total health care budget. The cost of hospitalization represents the greatest proportion of total expenditure. Optimization of drug therapy represents the most effective way of reducing costs. Recent economic analyses in the Netherlands and Sweden suggest the costs of care are rising.

Key Words: Heart failure • Economics • Healthcare expenditure

Received September 13, 1999; Revised October 10, 2000; Accepted November 30, 2000

	1. Introduction

Top Abstract 1. Introduction 2. Epidemiology of chronic... 3. Component costs of... 4. Studies of healthcare... 5. Emerging healthcare... 6. Conclusions References

 
Chronic heart failure is now recognized as a major and escalating public health problem. The costs of this syndrome, both in economic and personal terms, are considerable.

This article attempts to review the current economic burden of heart failure. We have obtained information from a number of sources, namely published reviews on health care economics, cost-effectiveness analyses of drug therapies both in clinical trials and in the community, and also economic analyses of state healthcare expenditure. Firstly, we discuss the epidemiology of chronic heart failure. Secondly, we discuss different methods of economic evaluations. In the next section, we discuss the component costs of healthcare expenditure on chronic heart failure, giving particular attention to the costs of drug therapy. In the fourth section, we review the literature on actual expenditure on CHF in different developed countries. Finally, we consider the future prospects for emerging healthcare interventions that may lead to reduced expenditure in chronic heart failure.

	2. Epidemiology of chronic heart failure

Top Abstract 1. Introduction 2. Epidemiology of chronic... 3. Component costs of... 4. Studies of healthcare... 5. Emerging healthcare... 6. Conclusions References

 
The epidemiology of CHF has been recently reviewed [1]. The magnitude of this public health problem is a determinant of the economic burden of this disease. Early population studies estimated the 6-month population prevalence rate to be 8.8–10 per 1000 (64.9 and 64.7 in those >65 years of age) [2–4]. More recently, a clinical study of 2000 men and women aged 25–74 from an urban population, which used an echocardiographic assessment of left ventricular function, reported a prevalence for left ventricular systolic dysfunction function (defined as a left ventricular ejection fraction 30%) of 2.9% [5]. Symptomatic left ventricular systolic dysfunction (LVSD; heart failure) occurred in 1.5% and asymptomatic LVSD in 1.4% of the study population. The prevalence was greater in men and increased with age to 6.4% in men aged 65–74 years and 4.9% in women in the same age group.

In the Framingham study, the incidence of CHF was estimated to range from 2 per 1000 per annum in individuals aged 45–54, increasing to 40 per 1000 per annum in men aged 85–94 [6,7]. Previous studies have reported similar results [8]. Most recently, however, Cowie et al. reported the incidence of CHF in an urban British population to be 0.02 cases per 1000 population per annum in those aged 25–34 years rising to 11.6 in those aged 85 years and over [9]. The incidence was higher in males than females (age-adjusted incidence ratio 1.75). Although the data of Cowie et al. demonstrate that the current incidence rates are less than previously reported, other studies have predicted that the incidence of CHF may increase. In other countries, e.g. the number of new cases of CHF per annum is predicted to rise by 70% in the Netherlands by the year 2010 [10] and by 52% (65–72 years) and 56% (75 and older) in Australia [11]. Reasons for the rising incidence of CHF include an increased awareness amongst clinicians leading to an increase in the rate of diagnoses and an increase in the rate of survival after an acute myocardial infarction as a result of recent therapeutic developments [12–14].

2.1. Morbidity and mortality
Quality of life is more impaired in CHF than in any other chronic medical condition [15,16]. Hospitalization is an important cause of morbidity. In the US, CHF is the 5th most common reason for hospitalization [17], and the commonest cause of hospitalization in the elderly [18]. In the SOLVD treatment trial, in which 2569 patients were randomized to enalapril or placebo, there were a total number of 5229 hospitalizations during a follow-up period of 41 months [19]. There were fewer hospitalizations in the enalapril group (n=2396) than in the placebo group (n=2833). In the UK, it is estimated that 0.2% of the population are hospitalized for CHF each year, and CHF hospitalizations account for more than 5% of adult general medical admissions [20,21]. The average length of hospitalization for CHF was estimated to be 11.4 days on an acute medical ward and 28.5 days on a geriatric ward in the UK in 1990 [21]. In the United States, the average length of stay was estimated to be between 8 and 11 days in the early 1990s [22]. Although length of stay has decreased in recent years, overall bed usage as a result of CHF remains substantial [21]. Readmission rates are high, particularly in the elderly, where up to one-third of patients may be readmitted within 1 year of discharge [23].

Mortality increases with clinical severity and may be as high as 60% within 1 year for patients with severe (NYHA Class IV) heart failure [7]. Five-year mortality in the Framingham Study was 75% in men and 62% in women [7]. The in-hospital mortality rate for patients hospitalized with CHF is 20–30% [21]. Case-fatality rates in patients hospitalized in Scotland during 1995 were 19% at 30 days, 42% at 1 year [24]. In general, the mortality rate in patients with CHF is 3 to 5 times that of men and women of a similar age without heart failure [25].

	3. Component costs of healthcare expenditure on chronic heart failure

Top Abstract 1. Introduction 2. Epidemiology of chronic... 3. Component costs of... 4. Studies of healthcare... 5. Emerging healthcare... 6. Conclusions References

 
3.1. Methods of cost-effectiveness analysis
Economic evaluations of the cost of care include cost-effectiveness or cost minimization analyses [26]. Cost-effectiveness evaluations typically use universal outcome measures, such as morbidity (e.g. hospitalization rate) and mortality, for the evaluation of a treatment [27]. The assessment may be extended to incorporate quality of life, in the form of quality of life years (QALY), which is a form of cost-utility analysis. Evaluations such as these may be suitable for economic healthcare evaluations, and although QALYs are popular with health policy makers, they have been criticized by clinicians [28–30].

A cost minimization analysis may be used when a new treatment effects similar outcomes when compared with standard therapy. In this case the economic analysis simply evaluates which mode of treatment is cheaper.

3.2. Cost breakdown of heart failure
In developed countries, total expenditure on CHF ranges between 1 and 2% of the total healthcare budget. The cost of treatment increases with both the extent of left ventricular systolic dysfunction [31] and the severity of disease (Table 1) [31,32]. The healthcare costs for patients with NYHA class IV CHF are between 8 and 30 times greater than patients with mild disease (NYHA class II) (Table 1). In the Munich Mild Trial Heart Failure (MHFT) [32], the monthly cost of treatment for patients whose condition remained stable was 218 Deutschmarks (DM; $US1=DM1.42, October 1995), whereas it was DM737 for those whose condition deteriorated. One factor which may limit the cost-savings of effective therapies in CHF is the fact that patients will live longer [33].

View this table: [in this window] [in a new window]   Table 1 Annual cost of CHF according to New York Heart Association (NYHA) class of disease severity [35,36]a

 
3.3. Medical costs: hospitalization and investigation
Health expenditure on CHF includes both direct and indirect costs (Table 2). Studies in the UK, and more recently in Switzerland, have demonstrated that almost two-thirds of total healthcare expenditure on CHF is due to hospitalization [34,35], and increases in relation to the severity of disease (Table 1) [36]. Furthermore, co-morbidity is highly prevalent in heart failure [16]. For example, cardiovascular events, such as stroke and myocardial infarction, and renal failure [37] are common reasons for hospital admission and increased costs in CHF patients [37].

View this table: [in this window] [in a new window]   Table 2 The component costs of health-care expenditure on heart failure

 
The costs of in-patient investigations represent a substantial proportion of expenditure on hospitalization. One estimate of investigation costs (Table 3) quantified the total cost of investigation as £57.4 million in the UK per annum [34]. Costs of hospitalization may be related to differences in care by speciality. In the SUPPORT study, a US-based prospective observational study of procedures and outcomes in patients hospitalized with an exacerbation of chronic heart failure, cost-of in-patient care adjusted for disease-severity was $2100 (42.9%) more expensive for treatment by a cardiologists than by a generalist [38]. It is not clear whether such differences in treatment alter long-term outcomes in these patients.

View this table: [in this window] [in a new window]   Table 3 Investigation of ‘new’ cases of heart failure [34]a

 
3.4. Medical costs: drug therapy
At present, drug therapy represents only a small proportion of the component costs of CHF [34]. Given the high prevalence of CHF in the community, drug therapy, however, represents a substantial source of healthcare expenditure.

3.4.1. Cost savings related to drug therapy
ACE inhibitors reduce both the rate of disease progression and mortality in heart failure [19,39]. In some studies, these treatments have also been shown to improve quality of life [40,41]. Furthermore, ACE inhibitors also reduce CHF-related hospitalizations [19]. In the United States, a reduction in the rate of hospitalization through ACE inhibitor therapy may achieve a net saving of $36 million [42]. As a consequence, ACE inhibitors are an established and cost-effective therapy in heart failure [18,43]. These drugs may be more cost-effective in severe heart failure, where the rate of hospitalization is high. ACE inhibition may also be cost effective in mild-moderate CHF, even when the effect of greater longevity is taken into account [18]. One economic analysis of ACE inhibitor therapy in CHF used the SOLVD study results (follow-up 41.4 months) related to healthcare costs in Switzerland. The results of this study demonstrated that although treatment with enalapril resulted in an additional cost of 2.5 million Swiss Francs, this was balanced by a reduction in total healthcare costs, such that there was a potential net saving of approximately 4.26 million Swiss Francs [44]. A cost-effectiveness analysis of enalapril therapy in CHF in Australia in 1996 based on the SOLVD treatment trial, demonstrated that this drug may confer a net cost saving of, on average, $Aus 117–250 per patient over a 4-year period [45]. Now that this drug is off-patent, and drug costs are therefore less, prescription of enalapril is likely to be even more cost-effective. Furthermore, the cost of ACE inhibitor therapy per life-year gained compares favourably with other healthcare interventions (Table 4).

View this table: [in this window] [in a new window]   Table 4 Incremental cost per life-year gained (LYG) of various healthcare interventions [18]a

 
In the recent US Carvedilol Study Program [46–49] carvedilol combined with standard therapy, reduced mortality by 65% and reduced hospitalization by 27%. In a recent analysis based on French figures, the cost of carvedilol per patient was FF2266. The costs of hospitalization in the carvedilol group were reduced by FF969 such that the cost-effectiveness of carvedilol, or cost per life year saved, ranged from FF4100 to FF4560 [50]. The Cardiac Insufficiency Bisoprolol Study (CIBIS I) compared bisoprolol with placebo in 641 patients with CHF (NYHA III–IV) [51]. One cost effectiveness evaluation of this study demonstrated that the cost of care per patient treated with bisoprolol was reduced by a total of approximately FF4330 per patient [52]. This saving occurred mainly through a reduction in the rate of hospitalization for heart failure. In Germany, a pharmacoeconomic analysis of the CIBIS results demonstrated that per 1000 patient-years, adjuvant bisoprolol therapy resulted in overall cost savings of Deutschmarks (DM) 157 272 [53]. A cost minimization analysis based on the CIBIS data for the UK also suggested that bisoprolol could be a cost-effective additional therapy in CHF [54].

CIBIS II was a multi-centre, randomized, controlled trial of bisoprolol or placebo in 2647 patients with moderate to severe chronic heart failure [55]. In this trial, treatment with bisoprolol was associated with reductions in mortality (hazard ratio 0.66; 95% CI 0.54–0.81; P<0.0001) and readmission to hospital (hazard ratio 0.8; 95% CI 0.56–0.9.0; P=0.0049), compared to treatment with placebo. The cost-effectiveness of bisoprolol therapy in heart failure, as observed in CIBIS I, is now supported by an economic analysis of the cost of adjunctive bisoprolol therapy in CIBIS II [36]. In this study, the cost per patient treated in the placebo and bisoprolol groups was FF35 009 vs. FF31 762 in France, DM 11 563 vs. DM 10 784 in Germany and £4987 vs. £4722 in the UK. Bisoprolol, therefore, increases survival and reduces hospital admissions yet reduces the cost of care. These observations make beta-blockers attractive to both clinicians and healthcare managers.

The Digoxin Investigators Group (DIG) trial was a 5-year trial which compared digoxin with placebo in 7788 patients with CHF who were in sinus rhythm [56]. In this trial, although digoxin therapy had no effect on mortality or quality of life, hospitalization due to worsening CHF was lower in patients treated with digoxin group compared to those treated with placebo (26.8% vs. 34.7%, respectively; risk ratio 0.72; 95% CI 0.66–0.79; P<0.001) in the digoxin group. Overall, 64.3% of the digoxin and 67.1% of the placebo group were hospitalized (risk ratio 0.92; 95% CI 0.87–0.98; P=0.006). An economic evaluation of the effects of the continuation of digoxin therapy from the Prospective Randomized Study of Ventricular Failure and Efficacy of Digoxin (PROVED) [57] and Randomized Assessment of Digoxin and Inhibitors of Angiotensin Converting Enzyme (RADIANCE) [58] calculated a net saving of $406 million per annum (50–75% reduction in costs) [59]. Taken together, the results of these studies suggest that digoxin may be a cost-effective therapy, particularly in patients with non-ischaemic heart failure.

In future, the relative proportion of healthcare expenditure spent on drug therapy in CHF may rise due to polypharmacy and improved prognosis. This may be particularly the case in mild-moderate disease, where rates of hospitalization are low. ‘Furthermore, as drug patents expire, as is already the case for captopril, then cheaper prescriptions of generic drugs may offset some of the future costs of drug therapy.’

Poor compliance can be a problem in heart failure, where patients are increasingly prescribed multiple medications. Underprescription of CHF therapies in the community, such as is the case with ACE inhibitors, is an important clinical problem [60]. If, for example in Sweden, prescription of ACE inhibitors in CHF were to be optimized, then it is estimated that up to 3700 further lives could be saved per annum, with an associated reduction in hospital admissions by approximately 8000 in this time. In this case, there would also be important overall reductions in healthcare expenditure [61]. This problem gains further significance when considered in the light of the ATLAS study [62]. In this study, high dose compared to low dose lisinopril was found to reduce hospitalizations, with a trend toward a reduction in mortality, in patients with NYHA class II–IV heart failure. Furthermore, an economic analysis of these data suggests that high-dose ACE inhibitor therapy may also be more cost-effective (mean difference in cost per patient was £397 lower in the high-dose group [95% CI (high-dose vs. low-dose £1263–£436)] [63].

The costs of surgical intervention in CHF are less than that of hospitalization or drug therapy. In the United Kingdom in 1990/1991, the costs for CABG and cardiac transplantation in CHF patients were estimated at £7.2 and £2.66 million, respectively. This figure represented 2.74% of the total healthcare expenditure on heart failure [34].

3.5. Non-medical costs
The non-medical costs of CHF are difficult to estimate. These costs include those of lost earnings, sickness benefits, hospital transportation and social welfare support. Given that CHF is more common in the elderly, costs related to loss of income may not be as great as might be the case in patients with other chronic diseases. In one German study, only 9.3% of 400 patients studied were working. However, during a 1-year period, eight patients were absent from work for a total of 1058 days, which, based on the average German salary in 1996, equated to an indirect cost of DM415 per patient year [64]. In the SUPPORT study, patients who were consulted by a cardiologist were more likely to have an income of over $11 000 per year, than those treated by a general physician [38]. This observation does suggest that the costs of care may be related to patients’ socio-demographic status and that loss of income can be an important problem in heart failure. Other hidden costs may be considerable. For example in one state in America, the transportation costs of hospital out-patient visits have been estimated to be greater than those spent on drug therapy [42].

	4. Studies of healthcare expenditure on chronic heart failure in different countries

Top Abstract 1. Introduction 2. Epidemiology of chronic... 3. Component costs of... 4. Studies of healthcare... 5. Emerging healthcare... 6. Conclusions References

 
There are now several studies that have quantified the economic impact of CHF on health care expenditure (Tables 5 and 6) [17,32,34,65–72]. These studies differ in a number of ways. Costs have been collected in both state-funded (e.g. the UK National Hearth Service) and private (e.g. US) healthcare systems. Some of these studies have included the cost of operations such as cardiac transplantation (e.g. the UK study), whereas others have not (e.g. the Dutch study). Nursing home and district nurse costs have also been considered in economic analyses (e.g. the US [71], Dutch [68] and Swedish studies [72]; Table 6) but not in others (i.e. the UK study [34]). None of these studies calculated the indirect costs of CHF, such as loss of earnings or pension payments.

View this table: [in this window] [in a new window]   Table 5 The cost of chronic heart failure (CHF) compared with total health care costs in the UK, the Netherlands, France, New Zealand and the USa

 

View this table: [in this window] [in a new window]   Table 6 The economic cost of heart failure in the UK, the Netherlands, the United States and Swedena

 
In the Dutch study [68] healthcare expenditure in 1996 totalled 654 million Dutch guilders (£234.3 million) which represented 9.7% of that country's gross national product. Chronic heart failure accounted for 1.1% of this figure and ranked 29th when costs were compared with those of other chronic diseases. The total costs of healthcare for cardiovascular diseases ranked lower than other conditions such as mental handicap and musculo-skeletal disorders. The data from this study show that expenditure on CHF has increased (over and above the rate of inflation) in the Netherlands since 1994.

The economics of health care expenditure on CHF in Sweden have been recently evaluated by Ryden-Bergsten et al. [72]. This study evaluated both direct treatment costs and those attributable to institutional care. The annual expenditure on CHF was 2.6 billion Swedish Kroner (£12.5 million), or 2% of the total health care budget. Institutional care (hospital and nursing home) represented 64–75% of this total expenditure. The greatest number of hospital days (41%) was provided by district general hospitals. Total ambulatory care (hospital outpatient and primary care) accounted for 15% of total costs. Patients aged 80 years and older represented 50% of all CHF hospital discharges and 75% of nursing home discharges. These figures demonstrate that the economic burden of CHF is a function of the cost of hospitalizations, which occur more frequently in elderly patients.

In one other recent Swedish economic study, a retrospective analysis was undertaken of the total cost of care of all CHF patients (n=108) who were included in a randomized trial of outpatient education. In this study, total costs for one CHF patient were 20 000 SEK (2564 US$, 7.8 SEK=1 US$) for a 6-month period [73].

Despite the considerable variation in healthcare costs between these studies, it seems clear that the direct cost of CHF in developed countries is between 1 and 2% of total healthcare expenditure (Table 6). In the UK, expenditure on CHF represents 10% of total expenditure on diseases of the circulatory system, and is a similar amount to that spent on asthma and stroke [69,74,75]. In the US, expenditure on CHF equals that on hypertension [69]. The overall costs of CHF in the US, including cost due to lost productivity (estimated at $2 billion) and healthcare expenditure, is $US 22.5 billion [17]. Another important point emerges from these studies [32,66–71], namely that healthcare utilization increases with the severity of CHF, and so too does the cost of care.

	5. Emerging healthcare interventions that may reduce costs

Top Abstract 1. Introduction 2. Epidemiology of chronic... 3. Component costs of... 4. Studies of healthcare... 5. Emerging healthcare... 6. Conclusions References

 
5.1. Screening
In a recent study, Davey et al. demonstrated that healthcare costs were higher in patients with asymptomatic left ventricular systolic dysfunction, compared to controls [31]. There is some evidence to suggest that interventions to treat left ventricular dysfunction before the onset of symptomatic CHF may attenuate the progression of disease [76], thereby reducing both the incidence of CHF and the number of hospitalizations. Screening of populations at risk for left ventricular dysfunction, using biochemical markers such as plasma brain natriuretic peptides, is currently under investigation [77]. One Dutch economic study of the cost-effectiveness of captopril for patients with asymptomatic left ventricular dysfunction used a model based on the SAVE trial [78], and found that captopril had a cost-effectiveness ratio of DFL 15799 per life-year gained [79]. Again, this cost may fall as ACE inhibitors come off patent. Ultimately, screening for CHF in high-risk asymptomatic individuals may be a cost-effective practice [78]. As the costs of care are rising, new strategies for the prevention of heart failure need to be explored [80].

5.2. Multi-disciplinary healthcare programmes
Nurse-led community management programmes are one form of non-pharmacological intervention which can lead to both improved compliance and reductions in hospitalizations [81,82]. Other forms of multidisciplinary, integrated management programmes have also been shown to improve clinical outcomes in CHF, whilst also being associated with economic improvements [83–85].

5.3. Emerging drug therapies
The introduction of new therapies in CHF may also lead to future net reductions in expenditure. In the RALES study, treatment of patients (NYHA class IV) with spironolactone conferred a 30% reduction in both the risk of death and the number of hospitalizations by 24 months [86]. This treatment has additional appeal as it is comparatively cheap. A one year supply of spironolactone 25 mg daily would cost approximately £13 8.29 per patient (British National Formulary, 2000).

Vasopeptidase inhibitors are one other class of drugs that are currently undergoing evaluation in clinical trials. ‘These drugs inhibit enzymes involved in the breakdown of the natriuretic peptides, which have beneficial natriuretic and vasodilator effects.’ One such drug is omapatrilat. Preliminary studies with this drug in patients with CHF suggest it may also prove to be clinically useful [87].

	6. Conclusions

Top Abstract 1. Introduction 2. Epidemiology of chronic... 3. Component costs of... 4. Studies of healthcare... 5. Emerging healthcare... 6. Conclusions References

 
Health-care expenditure on CHF in developed countries represents 1–2% of the total health care budget. This figure has risen in recent years, coupled with a rise in the incidence and prevalence of disease. Nursing home and hospital in-patient care represents the bulk of healthcare expenditure on heart failure. These costs are likely to rise unless the rate of hospitalization falls. Optimization of drug therapy, both by increased prescription of ACE inhibitor therapy in CHF and the introduction of other cost-effective treatments such as β-blockers, are potential ways of reducing costs.

In future, the proportional costs of drug therapy are likely to rise. In the longer term, the overall costs of treatment of CHF may fall if and when the impact of drug therapy effects a reduction in hospitalizations. Further studies are required to determine whether screening and prevention programmes might reduce the public health and economic consequences of heart failure.

	References

Top Abstract 1. Introduction 2. Epidemiology of chronic... 3. Component costs of... 4. Studies of healthcare... 5. Emerging healthcare... 6. Conclusions References

 

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