European Journal of Heart Failure

European Journal of Heart Failure 2002 4(3):361-371; doi:10.1016/S1388-9842(01)00198-2

This Article Abstract FREE Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to citation manager Request Permissions Disclaimer Google Scholar Articles by Stewart, S. Articles by McMurray, J. J.J.V. Search for Related Content PubMed PubMed Citation Articles by Stewart, S. Articles by McMurray, J. J.J.V. Social Bookmarking          What's this?

© 2002 European Society of Cardiology

The current cost of heart failure to the National Health Service in the UK

Simon Stewart^a,b,1, Andrew Jenkins^c, Scot Buchan^c, Alistair McGuire^d, Simon Capewell^e and John J.J.V. McMurray^a,*

^a CRI in Heart Failure, Wolfson Building University of Glasgow, Glasgow G12 8QQ, UK
^b Department of Public Health The University of Glasgow, Glasgow, UK
^c Strategen Ltd Herriard, UK
^d Department of Economics City University, London, UK
^e Department of Public Health University of Liverpool, Liverpool, UK

^* Corresponding author. Tel./fax: +44-141-330-6588. E-mail address: j.mcmurray{at}bio.gla.ac.uk

	Abstract

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
We have recently shown that heart failure admission rates continue to increase in the UK — particularly in older age groups. As hospital activity represents the major cost component of healthcare expenditure related to heart failure, this study evaluated the current cost of this syndrome to the National Health Service (NHS) in the UK. We applied contemporary estimates of healthcare activity associated with heart failure to the whole UK population on an age and sex-specific basis to calculate its cost to the NHS for the year 1995. Direct components of healthcare included in these estimates were hospital admissions associated with a principal diagnosis of heart failure, associated outpatient consultations, general practice consultations and prescribed drug therapy. We also calculated the cost of nursing-home care following a primary heart failure admission and the cost of hospitalisations associated with a secondary diagnosis of heart failure. Adjusting for probable increases in hospital activity and the progressive ageing of the UK population, we have also projected the cost of heart failure to the NHS for the year 2000. We estimated that there were 988000 individuals requiring treatment for heart failure in the UK during 1995. The ‘direct’ cost of healthcare for these patients was estimated to be £716 million, or 1.83% of total NHS expenditure. Hospitalisations and drug prescriptions accounted for 69 and 18% of this expenditure, respectively. The additional costs associated with long-term nursing home care and secondary heart failure admissions accounted for a further £751 million (2.0% of total NHS expenditure). By the year 2000, we estimated that the combined total direct cost of heart failure would have risen to £905 million — equivalent to 1.91% of total NHS expenditure. Using well-validated sets of data, these findings re-confirm the importance of heart failure as a major public health problem in the UK. The annual direct cost of heart failure to the NHS in 2000 is likely to be of the order of 1.9% of total expenditure — the predominant cost component being hospitalisation.

Key Words: Heart failure • Cost evaluation • Morbidity • Hospitalisation

Received March 21, 2001; Revised August 7, 2001; Accepted August 10, 2001

	1. Introduction

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
In recent years, heart failure has been recognised as a major and increasing public health problem [1,2]. Although associated with a short survival time, [3,4] heart failure still causes considerable disability and morbidity. This in turn is very costly because of the need for complex pharmacotherapy, community care, and most of all, frequent admission to hospital [5,6], An earlier study, conducted in 1990/1991, estimated that heart failure accounted for 1.2% of National Health Service (NHS) expenditure in the United Kingdom (UK) [7]. Subsequent studies in other countries reached similar conclusions [8–12].

In the decade since our 1990/1991 analysis was conducted, there have been major changes in the treatment of heart failure, changes in the practice of medicine generally and in the overall demography of the UK population (possibly leading to an increase in the prevalence of heart failure). There has also been an improvement in the quantity and quality of epidemiological and cost data available on heart failure and a better understanding of economic analysis in medicine. Specifically, the use of angiotensin-converting enzyme (ACE) inhibitors, in its infancy in 1990/1991, has become more widespread. This type of treatment improves symptoms, reduces the risk of hospital admission and prolongs life [13]. Beta-blockers [14] and spironolactone [15], which have similar benefits, are also starting to be used. The length of hospital stay (a major driver of cost) has been falling in most conditions, including heart failure [5,6]. Major epidemiological studies of heart failure have been undertaken in the past decade, including up-to-date analyses of hospitalisation rates [6,16,17].

The aim of this study was, therefore, to re-examine the cost of heart failure in the UK, using more contemporary and detailed information than previously available and taking into account components of cost that could not be evaluated previously, including nursing-home care.

	2. Methods

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
In this study, a prevalence-based approach was used to estimate the economic burden of heart failure. In the majority of cases, estimates of prevalence, healthcare utilisation and costs were obtained from contemporary Scottish data and applied on an age and sex-specific basis to official mid-year population estimates for the UK [18]. The major analysis involved the use of such data to calculate the predominant costs associated with the management of heart failure in the calendar year 1995. A further analysis was performed, using a combination of current and extrapolated data, to calculate the cost of heart failure in the calendar year 2000. Where a range of estimates was available, we have used the most conservative alternative.

2.1. Community-based healthcare
2.1.1. Patient population
We applied age and sex-specific estimates of the population prevalence of individuals with symptomatic left-ventricular systolic dysfunction from two comparable, cross-sectional studies performed by McDonagh and colleagues (Scottish data involving 1640 individuals aged 45–75 years) [16] and Morgan and colleagues (English data involving 817 individuals aged 70–84 years) to construct a conservative estimate of the total UK population of heart failure patients [17]. Both studies were performed in the 1990s and used echocardiography to determine the presence/absence of left-ventricular systolic dysfunction, as well as recording each individual's symptomatic status. Importantly, the reported prevalence of heart failure among individuals aged 70–74 years (the only overlap with respect to the age of the two study cohorts) was similar. Many recent studies have suggested that one-third to one-half of patients with symptomatic chronic heart failure have preserved left-systolic dysfunction [19], and importantly, that these patients experience comparable rates of hospital admission to those with impaired systolic function [19,20]. Consequently, we have inflated the estimated number of cases of symptomatic systolic dysfunction by one-third.

2.1.2. General practitioner consultations
Age and sex-specific rates of general practitioner (GP) consultations per 1000 population were obtained from the Information and Statistics Division of the NHS in Scotland. This Division routinely collates data from a number of GP practices (74 at the time of this study) serving a representative sample of the Scottish population. These data are used to compile the Scottish Continuous Morbidity Record. All GPs involved in this scheme routinely collect information on each patient consultation, providing a list of diagnoses (including heart failure) relevant to that particular consultation. The information recorded is regularly audited and validated before official entry into the data set [21]. As the current data set only provides the major cause of consultation, we applied age and sex-specific ratios to calculate the additional number GP consultations where heart failure was likely to be a contributory factor based on the observed proportion of hospitalisations associated with a principal or secondary diagnosis of heart failure. Consistent with UK Government data [22], we adopted a conservative assumption that one in 10 consultations occurred in the patient's home.

2.1.3. General practice referrals to outpatient clinic
There are limited data concerning GP referral to specialist outpatient clinics. However, based on our previous report and a more recent survey of the diagnosis and treatment of heart failure patients in primary care, we have estimated that one-third of heart failure patients will be referred per annum for further investigation, such as echocardiography and chest X-ray, and will attend, on average, two outpatient clinics as a result [7,23–25].

2.1.4. Drug prescriptions
The total number of prescriptions associated with the community-based, pharmacological management of heart failure was calculated from a number of data sources. As described above, we firstly estimated the total number of UK patients being treated for heart failure. We then used data from a contemporary, community-based study of heart failure [24], in addition to data from IMS Health (UK), which monitors the prescribing patterns of 500 GPs from around the UK using the World Health Organisation International Classification of Diseases [26] to estimate the proportion of patients prescribed the major classes of drugs used to treat heart failure, including diuretics and ACE inhibitors. Additional information came from a further survey of the primary care management of heart failure [25]. Based on these three data sources, we assumed a rate of seven prescriptions per patient per annum.

2.2. Hospital-based healthcare
2.2.1. Hospital admissions
Rates of hospitalisation for heart failure, both as a primary and secondary diagnosis of discharge in the calendar year 1995, were directly obtained from the Information and Statistics Division of the National Health Service in Scotland. This department collects and collates data on all hospital discharges via the Scottish Morbidity Record Scheme [3,21,27]. In 1995, information from patient case records was routinely used to code up to six diagnoses at the time of hospital discharge according to the 9th revision of the World Health Organisation International Classification of Diseases (ICD9) [28]. The following ICD9 codes were used to determine the presence of heart failure: 402 (hypertensive heart failure); 425.4 (primary cardiomyopathy); 425.5 (alcoholic cardiomyopathy); 425.9 (secondary cardiomyopathy); 428.0 (congestive heart failure); 428.1 (left heart failure/acute pulmonary oedema); and 428.9 (heart failure, unspecified). Regular auditing of ICD coding of each hospital admission in Scotland suggests that diagnostic data are essentially 100% complete and more than 90% accurate [29].

The term ‘discharge’ includes both live discharges and deaths. For those discharged alive, subsequent hospitalisations can be identified for an individual patient using this linked database. These data are also linked to information held by the General Register Office for Scotland relating to all deaths within the United Kingdom. Consequently, any admission (and readmission) or death can be identified on an individual basis. This data set also provides information on the length of hospital stay (including those on speciality units) and the destination of live discharges, for instance to the patient's home or to a nursing home.

All these Scottish hospitalisation data were analysed and stratified by age and sex and applied to the overall UK population on this same basis.

2.2.2. Post-discharge outpatient clinic visits
We assumed that each ‘live’ discharge after hospitalisation with a principal diagnosis of heart failure, and not requiring subsequent long-term care, would be followed by an average of three post-discharge visits to an outpatient clinic and that these visits would be specific to the unit from which the patient was discharged, such as a cardiology or geriatric. These estimates were derived from a contemporary Scottish cohort of hospitalised heart-failure patients [30] and are also consistent with those used in the previous report. [7]

2.3. Long-term care
2.3.1. Post-discharge nursing-home care
There is a paucity of data on discharge to long-term care facilities. In this study, we estimated the total number of days of admission to nursing-home care, following a hospitalisation associated with a principal diagnosis of heart failure, from the reported proportion of patients directly discharged to such care per annum. A rolling average of the percentage of patients discharged to nursing home-care each month and duration of stay, with adjustment for subsequent days of hospitalisation and death, was calculated for the calendar year 1995.

2.4. Information on costs related to heart failure in 1995
The components of healthcare expenditure listed below were calculated and summed to estimate the overall cost of the management of heart failure in the UK during the year 1995. This cost was then compared to official estimates of total NHS-related healthcare expenditure for that year [31].

2.4.1. Community-based healthcare
The average cost of a GP consultation was obtained from a formal estimate made in the year 1995 [32]. These costs were stratified according to whether a consultation occurred as a result of a clinic appointment, or alternatively, as part of a home visit. Moreover, they encompassed the cost of routine investigations and non-drug therapy. The average cost of a GP-referred, hospital outpatient visit was obtained from an official audit of Scottish healthcare provision costs for the financial year 1995/1996 (see below) [32]. The average cost of a prescription specific to each of the major classes of drug used to treat heart failure in the UK was obtained from IMS Health (UK). They record the number and cost of sales of pharmacological agents to retail pharmacies from wholesalers within the UK [26]. In order to account for the cost of dispensing, we added 10% to the total cost of drug prescriptions.

2.4.2. Hospital-based healthcare
The costs associated with hospital admissions and post-discharge outpatient clinic visits were obtained from an audit of Scottish healthcare provision costs for the financial year 1995/1996, published by the Information and Statistics Division of the NHS in Scotland [32]. This report provided healthcare expenditure data for the whole of the NHS in Scotland and on a hospital-specific basis. The hospital activity associated with medical and geriatric units closely mirrored the overall distribution of hospital activity occurring within Scotland (a mixture of urban vs. rural and tertiary vs. non-tertiary referral hospitals). We therefore applied the overall, average cost of each day of hospitalisation for this type of hospital stay. As the majority of hospitalisations involving specialist intensive or coronary care-unit stay predominantly occurred in tertiary referral hospitals, we applied data from these types of institutions alone. Hospital expenditure associated with length of stay was stratified by age and sex and according to the type of unit in which the hospital stay occurred. Average costs applied to admission to geriatric, general medical and coronary/intensive care units in 1995 were £113, £192 and £909 per day, respectively. These cost estimates are inclusive of all healthcare expenditure associated with a hospitalisation. We have, therefore, not calculated inpatient pharmacotherapy and procedural (e.g. angioplasty, transplantation) costs as separate components of expenditure.

2.4.3. Long-term care
The average cost per week of nursing home stay was also obtained from a contemporary UK-based report [33].

2.5. Projected cost of heart failure in the year 2000
As the majority of the above cost components were calculated on an age and sex-specific basis, we were able to project the probable cost of heart failure to the NHS for the calendar year 2000. In order to calculate the largest component of healthcare expenditure (hospital stay), we assumed that the trends observed for hospitalisation rates between 1990 and 1995 (and their associated inpatient case–fatality rates) would continue essentially unchanged for the period 1995–2000. Our estimates for the year 2000 are therefore based on a direct and constant extrapolation (e.g. a rate increase of 10% every 5 years) of hospitalisation and survival rates observed between 1990 and 1995 and applied to the population structure projected for the UK [18]. Where other data were unavailable for the year 2000, we applied a constant ratio of events per hospitalisation (e.g. three outpatient visits per live discharge). All such healthcare activity was costed at 1995 levels and the overall total increased by a factor of 1.21 to incorporate underlying inflation rate increases in the UK during this period [34].

	3. Results

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
3.1. Cost of community-based healthcare
3.1.1. Number of patients
Based on contemporary age- and sex-specific prevalence data, we estimated that there were approximately 356 000 men and 387 000 women within the UK population in 1995 who had symptomatic left-ventricular systolic dysfunction (the principal form of chronic heart failure) requiring medical treatment. Using a conservative estimate of an additional one-third of patients with other forms of heart failure, particularly that associated with preserved left-ventricular systolic dysfunction, we estimated that in 1995 there were a further 117 000 men and 128 000 women with chronic heart failure in the UK. In total, therefore, there were an estimated 988 000 such individuals in the UK.

3.1.2. General practitioner consultations
Data from the Scottish Continuous Morbidity Record Scheme suggested that the rate of GP consultations primarily for heart failure ranged from less than one visit per 1000 population per annum, in men aged less than 45 years, compared to just under 300 visits in those aged 85 years and over. In women, the equivalent figures ranged from less than one to just over 200 visits per 1000 head of population per annum, respectively. With the addition of GP consultations where heart failure is likely to contribute to such a consultation, but not be recorded as the principal cause, we estimated that there were approximately 1.1 million male and 1.3 million female consultations of this type in 1995. This represents a ratio of 2.3 and 2.5 GP consultations per male and female patient, respectively. At an average cost of £15 per ‘surgery’ consultation (estimated to be 90% of such activity) and £52 per domiciliary consultation (the residual 10% of such activity) [31], the total expenditure for GP consultations in the year 1995 was estimated to be £44.9 million.

3.1.3. General practitioner referrals to outpatient clinic
Assuming that one-third of heart failure patients, approximately 326 000, attended for an average of two hospital outpatient visits (at a cost of £54 per visit) for further investigation/specialist management [32], this component of healthcare expenditure totalled an additional £35.2 million.

3.1.4. Drug prescriptions
Table 1 shows the estimated number of cases and cost of community-based, pharmacological management of heart failure according to the major classes of drugs used to treat this syndrome. Based on costing data provided by Intercontinental Medical Statistics Ltd [26] and a 10% adjustment to account for additional dispensing costs, we estimate that community-based drug therapy for heart failure would have cost the NHS £128.6 million.

View this table: [in this window] [in a new window]   Table 1 Estimated number and cost of UK prescriptions for chronic heart failure in the UK during 1995

 
3.2. Cost of hospital-based care
3.2.1. Hospital admissions (principal diagnosis)
Using accurate age- and sex-specific data relating to the whole of Scotland and applied to the whole of the UK, we estimated that in 1995 there were approximately 66 000 male hospitalisations, involving 54 000 individuals, which comprised a total of 986 000 bed-days associated with a primary diagnosis of heart failure. For women, the equivalent figures were approximately 69 000 hospitalisations involving 59 000 individuals that comprised a total of 1.37 million bed-days. Fig. 1 shows the number of male and female patients who contributed to these hospitalisations, the majority of which were associated with acute pulmonary oedema (ICD 428.1), indicative of acute decompensated heart failure, and their associated outcome. Stratifying costs according to the proportion of bed-days spent in different types of wards (general or speciality — see Table 2), we calculated that the total expenditure for male and female heart failure admissions in the UK during 1995 was £216.2 million and £273.4 million, respectively: a total of £489.7 million.

View larger version (31K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 1 Profile of hospitalisations associated with a principal diagnosis of heart failure in 1995 and subsequent outcomes.

 

View this table: [in this window] [in a new window]   Table 2 Distribution of hospital activity and cost according to type of hospital unit and diagnostic position of heart failure (1995)

 
Table 3 shows the estimated cost of hospital admissions associated with a principal diagnosis of heart failure, on an age-specific basis, for men and women separately. The greatest concentration of expenditure was associated with women aged 75 years or more. For men, the greatest expenditure occurred in those aged between 75 and 84 years.

View this table: [in this window] [in a new window]   Table 3 Age and sex-specific cost of hospitalization for heart failure (principal diagnosis) in 1995

 
3.2.2. Post-discharge outpatient visits
Based on the estimated number of ‘live’ male (49 500) and female (50 000) hospital discharges associated with a principal diagnosis of heart failure (not resulting in subsequent admission to long-term care) and the assumption of an average of three follow-up outpatient visits per admission (with an average cost per visit ranging from £54 for a general medical assessment to £79 for a geriatric assessment [32]), total expenditure for this component of healthcare was calculated to be £17.3 million (comprising £8.6 and £8.7 million for male and female consultations, respectively).

3.2.3. Additional hospital admissions (secondary diagnosis)
In addition to those hospital admissions associated with a principal diagnosis of heart failure, we estimated that there were a further 90 000 male hospitalisations associated with a secondary diagnosis of heart failure (almost exclusively in the second and third diagnostic positions for the purpose of coding). These involved 77 000 individuals and comprising a total of 1.4 million bed-days. In women, the equivalent figures were approximately 86 000 hospitalisations involving 76 000 individuals that comprised a total of 1.9 million bed-days. The total cost of such admissions to the NHS in 1995 was £645.6 million (£275.9 and £369.7 million for male and female admissions, respectively).

3.3. Long-term nursing-home care
Approximately 4200 men and 4900 women were directly discharged to a nursing home following a hospital admission associated with a principal diagnosis of heart failure in 1995. With adjustment for time spent in hospital and duration of survival, we estimate that such patients accumulated a total of 2.7 million days of residential/nursing-home care in 1995. At a conservative cost estimate of £272 per week [33], the total cost of this component of healthcare expenditure was £41.5 million for men and £64.2 million for women (a total of £105.7 million).

3.4. Total heart failure-related healthcare expenditure in 1995
Based on the above (conservative) estimates, we have calculated that heart failure accounted for a total of £715.7 million of healthcare expenditure in the UK for 1995 (excluding hospitalisations with a secondary heart-failure coding and nursing-home care). In the same year, the cost of healthcare provided by the NHS for the whole of the UK was £39 118 million [31]. Heart failure was, therefore, estimated to account for 1.83% of this expenditure. The major component of such expenditure was hospital admissions (1.25% of the total NHS budget). This was, however, likely to underestimate the true cost of heart failure hospitalisations because of the many other admissions associated with heart failure coded as a secondary diagnosis (see above). Fig. 2 shows the relative contribution of the various components of the expenditure (excluding secondary heart-failure admissions and nursing-home care). It demonstrates that hospital admissions account for approximately 69% of total expenditure, the second largest component of cost being drug treatment (18%). If nursing home visits are included, hospitalisation still accounts for 60% of overall expenditure.

View larger version (21K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 2 Components of healthcare expenditure related to heart failure in the UK in 1995 (excluding secondary admissions and long-term nursing-home care).

 
3.5. Projected cost of heart failure in 2000
3.5.1. Community-based care
Based on demographic changes in the UK population, we estimated that there would be an additional 23 000 individuals with chronic heart failure (both with and without associated left-ventricular systolic dysfunction) in the year 2000 — a total of 1.01 million cases. The number of GP consultations and GP-referred outpatient visits was estimated to increase accordingly and to cost £56.8 million and £44 million, respectively. Similarly, based on contemporary data provided by IMS Health (UK) [26], we estimated that the cost of drug prescriptions would increase to £176.2 million. Of this, £27 million would relate to increased prescriptions for beta-blockers, angiotensin-II receptor blockers and spironolactone.

3.5.2. Hospital-based care
Assuming a consistent rate of increase in heart failure-related hospital activity during the period 1995–2000, we estimated that there would be approximately 140 000 male and female hospitalisations (involving 118 000 individual patients and comprising just over 2.4 million days of admission) associated with a principal diagnosis of heart failure in UK during the year 2000. Adjusting for underlying inflation rate increases in the UK, we calculated that this component of healthcare would increase to £606.2 million (£270.9 and £335.3 million for male and female admissions, respectively): a rise of 24% relative to that of 1995. Post-discharge outpatient visits following these hospitalisations were correspondingly estimated to cost an additional £22.1 million. Assuming an even greater rate of increase in hospitalisation associated with a secondary diagnosis of heart failure, we estimated that such hospital activity would account for £812.6 million in healthcare expenditure in the year 2000.

3.5.3. Long-term nursing-home care
With a parallel increase in the number of patients discharged alive, we estimated that the cost of nursing-home care following a primary heart-failure admission would be £136.9 million in the year 2000.

3.5.4. Total heart failure-related expenditure in 2000
On the basis of the above, we calculated that total healthcare expenditure associated with heart failure in the UK in the year 2000 would be approximately £905.3 million — a 26% increase, including 5% over and above that of inflation, compared to 1995, and consistently excluding hospitalisations with a secondary heart-failure coding and nursing-home costs. Despite a marked, parallel increase in healthcare expenditure in the UK to £52 billion in the year 2000 [31], and not accounting for the increased resources (and therefore increased costs) directed towards heart failure, we calculated that this component of healthcare alone would account for 1.73% of total NHS expenditure. Based on 1995 levels of funded healthcare activity (the basis on which the 2000 estimates were calculated), this equates to 1.91% of NHS expenditure. The incremental cost of secondary heart failure admissions to the NHS was estimated to be 1.6% (or 1.8% on the basis of 1995 levels of funded activity) in the year 2000.

3.6. Potential economic impact of changes in clinical practice
As expected, hospital stay represented the major cost-component of expenditure related to the overall management of heart failure. We examined a number of ways in which such costs could be curtailed and therefore deliver considerable cost-savings to the NHS.

3.6.1. Specialist care
Based on recent trends, we estimated that 16% of male and 11% of female admissions associated with a principal diagnosis of heart failure resulted in some form of specialist care in a coronary (the majority) or intensive care unit in the year 2000. Typically, such patients are admitted with acute pulmonary oedema secondary to acute decompensated heart failure. Importantly, although the number of days of admission to such units are small in comparison to the overall length of stay associated with heart failure (being 1–2% of male and 1–3% of female days of admission), this particular component of care still accounts for 13% of male and 11% of female expenditure in relation to hospital care. If, on average, 1 day of admission to a coronary care unit was replaced by a day on a medical unit (an average cost saving of £717 per day), this would result in a saving of £13.4 million in relation to principal admissions in the year 2000.

3.6.2. Length of stay
Even greater cost savings might be achieved if it were possible to reduce average length of stay without provoking increasing readmission rates (see below). For example, a 1-day reduction in average length of stay in those admissions with a principal diagnosis of heart failure might reduce costs by approximately £36.3 million in the year 2000.

3.6.3. Readmissions
The greatest cost savings might be achieved through a significant reduction in hospital readmissions. If, for example, 50% of second admissions within a calendar year associated with a principal diagnosis of heart failure had been avoided in 2000, savings equivalent to £56.4 million would have resulted. A 30% reduction in recurrent admissions might save £28.2 million.

	4. Discussion

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
Heart failure continues to consume almost 2% of the entire NHS budget. We have calculated this using comparable methods to our original analysis in 1990/1991, but using better-validated data than previously available [7]. The present estimate is 1.8% in 1995 and 1.9% in 2000. Furthermore, this excludes the substantial costs related to nursing-home care and hospitalisations with heart failure coded as a secondary diagnosis. These high costs continue, despite complex and opposing changes in the factors influencing heart failure expenditure. Although drug therapy has become more complicated and expensive, newer treatments reduce hospital admission rates [14,15,35], the major driver of overall costs. These treatments also prolong survival and, as a consequence of this and other factors, the overall prevalence of heart failure may have increased. The total number of hospital admissions and population admission rates have certainly increased in recent years, potentially reflecting increased prevalence and changed admission thresholds. As these rates now appear to be levelling off, it is possible that effective therapies are now beginning to impact upon heart failure-related morbidity [6]. Average length of stay has definitely decreased dramatically in the past decade [5,6].

Although better data are available on heart failure epidemiology and resource utilisation, they do not significantly alter the assumptions made in 1990/1991 [7]. They do, however, allow us to extend our analysis to include areas that were previously unaccountable. Our original analysis used only hospitalisations with heart failure as the first coded diagnosis. A hospitalisation with atrial fibrillation coded first and heart failure second, for example, was not included. It is impossible to know how much of the cost of hospitalisations with heart failure as a secondary coding is actually due to heart failure. Interestingly, however, the duration of those hospitalisations is very similar to those with heart failure as the principal discharge coding, suggesting that heart failure may be the major determinant of length of hospital stay. This is further supported by the fact that heart failure is predominantly coded in the second or third position for the purpose of diagnostic coding in these cases [6]. Because secondary heart failure admissions outnumber primary ones, the associated extra costs related to these are potentially enormous — approximately £813 million in the year 2000 (1.6% of NHS expenditure). Any assessment of NHS costs of heart failure relying solely on discharges with heart failure as the primary coding, should, therefore, be regarded as very conservative.

We were also previously unable to assess the contribution of nursing-home care to the overall cost of heart failure. Now, knowing the number of individuals discharged to such care, and sex- and age-specific survival rates, we were able to estimate that it represented an additional £106 million of expenditure during 1995. Importantly, this estimate was conservative and did not include nursing-home care following a secondary admission for heart failure.

To place this total heart-failure expenditure of £716 million expenditure in perspective, contemporary reports of healthcare expenditure in the UK associated with disease states such as stroke, diabetes and epilepsy have been estimated to be £949 million [37], £748 million [38] and £156 million [39] (1995 cost equivalents), respectively. Furthermore, this comparison excludes the cost of over £750 million for secondary hospitalisations and nursing-home care for heart failure.

Taking a conservative estimate of overall direct NHS and nursing-home costs (total £1 billion in the year 2000) and a reasonable estimate of heart failure prevalence (approximately 1 million individuals), the annual cost per patient with heart failure is approximately £1000. However, this varies markedly with age. In 73 000 men aged 45–54 years, we estimated that the annual cost per patient was approximately £500, compared to £1200 in a man aged 75–84 (an estimated 174 000 cases). The equivalent figures for women were £300 and £1500 per patient per annum, respectively.

The main contributor to the overall cost of heart failure is hospitalisation, as reported previously [7] and confirmed in other industrialised countries [8–12]. Fig. 3 summarises the respective cost burden of heart failure on the community and hospital sectors. This highlights the potential economic benefit of reducing hospital admission rates and duration of hospital stay, especially in more expensive types of wards. Reducing length of stay by an average of 1 day, or reducing readmissions by half in relation to all heart failure-related admissions, could result in annual savings of £50–120 million.

View larger version (31K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 3 Summary of the overall burden of heart failure in the UK in 1995.

 
Any study of this type must have a number of limitations. In particular, a large component of the data was derived from Scottish data and applied on a UK-wide basis, while other estimates were derived from limited information. However, we believe these estimates are consistent with UK clinical experience. Most importantly, we believe the data concerning hospitalisation, the greatest single component of expenditure for heart failure, are accurate. Furthermore, these data are consistent with our previous report [7], with comparable reports from other industrialised countries suggesting that heart failure contributes 1–2% of total healthcare expenditure [8–12] and with a recent report from Sweden, where additional components of healthcare expenditure, including nursing-home care, substantially increased the costs of heart failure [36].

In conclusion, we believe that our data represent a realistic estimate of the cost of heart failure to the NHS in the UK. They re-confirm the importance of heart failure as a major public health problem in the UK and comparable industrialised countries. The annual direct cost of heart failure to the NHS in 2000 estimated to be 1.9% of total expenditure, while secondary heart failure admissions and long-term nursing-home care were estimated to consume an additional 2.0% of expenditure — a combined total of almost 4% of healthcare expenditure in the UK. Clearly, there is an urgent need to curtail this enormous expenditure, with heart failure-related hospital stay representing the most obvious target.

	Acknowledgments

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
This study was partially funded by Orion Pharma UK Ltd. We are indebted to Peter Stephens and Lindsey Harkins from IMS Health (UK) and the Information and Statistics Division of the National Health Service in Scotland, respectively, for their invaluable assistance in providing data.

	Notes

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 
¹ Simon Stewart is a recipient of a National Heart Foundation of Australia Overseas Post-Doctoral Medical Research Scholarship.

	References

Top Notes Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Acknowledgments References

 

1. Garg R., Packer M., Pitt B., Yusuf S. Heart failure in the 1990s: evolution of a major public health problem in cardiovascular medicine. J Am Coll Cardiol (1993) 22(Suppl_A):3A–5A.[Medline]
2. Bonneux L., Barendregt M.A., Meeter K., Bonsel G.J., van der Maas P.J. Estimating clinical morbidity due to ischemic heart disease and congestive heart failure: the future rise of heart failure. Am J Public Health (1994) 84:20–28.[Abstract/Free Full Text]
3. MacIntyre K., Capewell S., Stewart S., et al. Evidence of improving prognosis in heart failure: trends in case–fatality in 66 547 patients hospitalised between 1986 and 1995. Circulation (2000) 102:1126–1131.[Abstract/Free Full Text]
4. Stewart S., MacIntyre K., Hole D.A., Capewell S., McMurray J.J. More malignant than cancer? Five-year survival following a first admission for heart failure in Scotland. Eur J Heart Failure (2001) 3:315–322.[Abstract/Free Full Text]
5. Haldeman G.A., Croft J.B., Giles W.H., Rashidee A. Hospitalization of patients with heart failure: national hospital discharge survey 1985–1995. Am Heart J (1999) 137:352–360.[CrossRef][Web of Science][Medline]
6. Stewart S., MacIntyre K., McCleod M.E., Bailey A.E., Capewell S., McMurray J.J. Trends in heart failure hospitalisations in Scotland, 1990–1996: an epidemic that has reached its peak? Eur Heart J (2001) 22:209–217.[Abstract/Free Full Text]
7. McMurray J.J., Hart W., Rhodes G. An evaluation of the cost of heart failure to the National Health Service in the UK. Br J Med Econ (1993) 6:91–98.
8. Rodriguez-Artalejo F., Guallar-Castillon P., Banegas Banegas J.R., del Rey Calero J. Trends in hospitalization and mortality for heart failure in Spain, 1980–1993. Eur Heart J (1997) 18:1771–1779.[Abstract/Free Full Text]
9. Ghali J.K., Cooper R., Ford E. Trends in hospitalisation rates for heart failure in the United States 1973–1986: evidence for screening population prevalence. Arch Intern Med (1992) 150:769–773.
10. Eriksson H., Wilhelmsen L., Caidahl K., Svardsudd K. Epidemiology and prognosis of heart failure. Z Kardiol (1991) 80:1–6.[Web of Science][Medline]
11. Doughty R., Yee T., Sharpe N., et al. Hospital admissions and deaths due to congestive heart failure in New Zealand, 1988–1991. NZ Med J (1995) 108:473–475.[Web of Science][Medline]
12. Reitsma J.B., Mosterd A., de Craen A.J.M., et al. Increase in hospital admission rates for heart failure in the Netherlands, 1980–1993. Heart (1996) 76:388–392.[Abstract/Free Full Text]
13. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med (1991) 325:293–302.[Abstract]
14. MERIT Investigators. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (Merit-HF). Lancet (1999) 353:2001–2007.[CrossRef][Web of Science][Medline]
15. Pitt B., Zannad F., Remme W.J., et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med (1999) 341:709–717.[Abstract/Free Full Text]
16. McDonagh T.A., Morrison C.E., Lawrence A., et al. Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population. Lancet (1997) 350:829–833.[CrossRef][Web of Science][Medline]
17. Morgan S., Smith H., Simpson I., et al. Prevalence and clinical characteristics of left ventricular dysfunction among elderly patients in general practice setting: cross sectional survey. Br Med J (1999) 318:368–372.[Abstract/Free Full Text]
18. Department of Health. Health and Personal Social Services and Statistics (UK). London: Government Statistical Service, 2000.
19. Vasan R.S., Benjamin E.J., Levy D. Prevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective. J Am Coll Cardiol (1995) 26:1565–1574.[Abstract]
20. Senni M., Tribouilloy C.M., Rodeheffer R.J., et al. Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation (1998) 98:2282–2289.[Abstract/Free Full Text]
21. http://www.show.scot.nhs.uk/isd/primary_care.
22. Royal College of General Practitioners, Office of Population Censuses and Surveys, Department of Health. Morbidity Statistics from General Practice: Fourth National Study 1991–1992. London: HMSO, 1995.
23. Mair F.S., Crowley T.S., Bundred P.E. Prevalence, aetiology and management of heart failure in general practice. Br J Gen Pract (1996) 46:77–79.[Web of Science][Medline]
24. Lip G., Sawar S., Ahmed I., et al. A survey of heart failure in general practice. Eur J Gen Pract (1997) 3:85–89.
25. Clarke K.W., Gray D., Hampton J.R. How common is heart failure? Evidence from PACT (Prescribing Analysis and Cost) data in Nottingham. J Public Health Med (1995) 17:459–464.[Abstract/Free Full Text]
26. IMS Health (UK). Congestive Heart Failure, 2000.
27. Kendrick S., Clarke J. The Scottish record linkage system. Health Bull (1993) 51:72–79.
28. WHO. Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death (1977) 9th revision.
29. Harley K., Jones C. Quality of Scottish Morbidity Record (SMR) data. Health Bull (1996) 54:410–417.
30. Stewart S., Blue L., Capewell S., Horowitz J.D., McMurray J.J. Poles apart, but are they the same? A comparative study of Australian and Scottish patients with chronic heart failure. Eur J Heart Failure (2001) 3:249–255.[Abstract/Free Full Text]
31. Office of Health Economics. 10th Compendium of Health Statistics. London: Office of Health Economics, 1997.
32. National Health Service in Scotland. Scottish Health Service Costs. Edinburgh: Information and Statistics Division, 1996.
33. Community Care Costs. PSSRU, University of Kent, 1998.
34. http://www.bankofengland.co.uk/inflationreport/index.htm.
35. Packer M., Poole-Wilson P.A., Armstrong P.W., et al. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. Circulation (1999) 100:2312–2318.[Abstract/Free Full Text]
36. Rydén-Bergsten T., Andersson F. The healthcare costs of heart failure in Sweden. J Intern Med (1999) 246:275–284.[CrossRef][Web of Science][Medline]
37. Dale S. Stroke (1989) London: Office of Health Economics.
38. Laing W. The cost of diet-related disease. In: Preventative Nutrition—Turner M., ed. (1989) London: Academic Press.
39. Griffin J., Wyles M. Epilepsy: Towards Tomorrow (1991) London: Office of Health Economics.

CiteULike    Connotea    Del.icio.us    What's this?

This article has been cited by other articles:

				M. J. Carrington, S. Stewart, and on behalf of the NIL-CHF Study Investigators Bridging the gap in heart failure prevention: rationale and design of the Nurse-led Intervention for Less Chronic Heart Failure (NIL-CHF) Study Eur J Heart Fail, November 18, 2009; (2009) hfp161v1. [Abstract] [Full Text] [PDF]

				V. Tibaldi, G. Isaia, C. Scarafiotti, F. Gariglio, M. Zanocchi, M. Bo, S. Bergerone, and N. A. Ricauda Hospital at Home for Elderly Patients With Acute Decompensation of Chronic Heart Failure: A Prospective Randomized Controlled Trial Arch Intern Med, September 28, 2009; 169(17): 1569 - 1575. [Abstract] [Full Text] [PDF]

				M. T. Kearney Chronic heart failure: A missing component of the metabolic syndrome? Diabetes and Vascular Disease Research, July 1, 2009; 6(3): 145 - 145. [PDF]

				F D R. Hobbs Delivering quality and value in heart failure BMJ, April 30, 2009; 338(apr30_1): b1672 - b1672. [Full Text]

				R. Willenheimer The current role of beta-blockers in chronic heart failure: with special emphasis on the CIBIS III trial Eur. Heart J. Suppl., March 1, 2009; 11(suppl_A): A15 - A20. [Abstract] [Full Text] [PDF]

				P. S. Jhund, K. MacIntyre, C. R. Simpson, J. D. Lewsey, S. Stewart, A. Redpath, J. W.T. Chalmers, S. Capewell, and J. J.V. McMurray Long-Term Trends in First Hospitalization for Heart Failure and Subsequent Survival Between 1986 and 2003: A Population Study of 5.1 Million People Circulation, February 3, 2009; 119(4): 515 - 523. [Abstract] [Full Text] [PDF]

				P. de Groote, R. Isnard, P. Clerson, G. Jondeau, M. Galinier, P. Assyag, N. Demil, A. Ducardonnet, J.-F. Thebaut, and M. Komajda Improvement in the management of chronic heart failure since the publication of the updated guidelines of the European Society of Cardiology: The Impact-Reco Programme Eur J Heart Fail, January 1, 2009; 11(1): 85 - 91. [Abstract] [Full Text] [PDF]

				J. McMurray, M. Petrie, K. Swedberg, M. Komajda, S. Anker, and R. Gardner CHAPTER 23 Heart Failure ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]

				Authors/Task Force Members, K. Dickstein, A. Cohen-Solal, G. Filippatos, J. J.V. McMurray, P. Ponikowski, P. A. Poole-Wilson, A. Stromberg, D. J. van Veldhuisen, D. Atar, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM) Eur. Heart J., October 1, 2008; 29(19): 2388 - 2442. [Full Text] [PDF]

				K. Dickstein, A. Cohen-Solal, G. Filippatos, J. J.V. McMurray, P. Ponikowski, P. A. Poole-Wilson, A. Stromberg, D. J. van Veldhuisen, D. Atar, A. W. Hoes, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM) Eur J Heart Fail, October 1, 2008; 10(10): 933 - 989. [Full Text] [PDF]

				M. Ryder, N. F. Murphy, D. McCaffrey, C. O'Loughlin, M. Ledwidge, and K. McDonald Outpatient intravenous diuretic therapy; potential for marked reduction in hospitalisations for acute decompensated heart failure Eur J Heart Fail, March 1, 2008; 10(3): 267 - 272. [Abstract] [Full Text] [PDF]

				M. Yacoub and R. Nerem Introduction. Bioengineering the heart Phil Trans R Soc B, August 29, 2007; 362(1484): 1253 - 1255. [Full Text] [PDF]

				L. Selman, R. Harding, T. Beynon, F. Hodson, C. Hazeldine, E. Coady, L. Gibbs, and I. J. Higginson Modelling services to meet the palliative care needs of chronic heart failure patients and their families: current practice in the UK Palliative Medicine, July 1, 2007; 21(5): 385 - 390. [Abstract] [PDF]

				M. C. van der Wel, R. W.M.M. Jansen, J. C. Bakx, H. H.J. Bor, M. G.M. OldeRikkert, and C. van Weel Non-cardiovascular co-morbidity in elderly patients with heart failure outnumbers cardiovascular co-morbidity Eur J Heart Fail, June 1, 2007; 9(6-7): 709 - 715. [Abstract] [Full Text] [PDF]

				F. Najafi, A. J. Dobson, and K. Jamrozik Recent changes in heart failure hospitalisations in Australia Eur J Heart Fail, March 1, 2007; 9(3): 228 - 233. [Abstract] [Full Text] [PDF]

				S. Jeyaseelan, B. M. Goudie, S. D. Pringle, P. T. Donnan, F. M. Sullivan, and A. D. Struthers A critical re-appraisal of different ways of selecting ambulatory patients with suspected heart failure for echocardiography Eur J Heart Fail, January 1, 2007; 9(1): 55 - 61. [Abstract] [Full Text] [PDF]

				I. Chung and G. Y.H. Lip Platelets and heart failure Eur. Heart J., November 2, 2006; 27(22): 2623 - 2631. [Abstract] [Full Text] [PDF]

				J. J.V. McMurray, F. L. Andersson, S. Stewart, K. Svensson, A. C. Solal, R. Dietz, J. Vanhaecke, D. J. van Veldhuisen, J. Ostergren, C. B. Granger, et al. Resource utilization and costs in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme. Eur. Heart J., June 1, 2006; 27(12): 1447 - 1458. [Abstract] [Full Text] [PDF]

				J. G.F. Cleland, H. Loh, J. Windram, K. Goode, and A. L. Clark Threats, opportunities, and statins in the modern management of heart failure Eur. Heart J., March 2, 2006; 27(6): 641 - 643. [Full Text] [PDF]

				R J Shelton, A S Rigby, J G F Cleland, and A L Clark Effect of a community heart failure clinic on uptake of {beta} blockers by patients with obstructive airways disease and heart failure Heart, March 1, 2006; 92(3): 331 - 336. [Abstract] [Full Text] [PDF]

				S Ellery, L Williams, and M Frenneaux Role of resynchronisation therapy and implantable cardioverter defibrillators in heart failure Postgrad. Med. J., January 1, 2006; 82(963): 16 - 23. [Abstract] [Full Text] [PDF]

				M C Shibata, J Collinson, A K Taneja, A Bakhai, and M D Flather Long term prognosis of heart failure after acute coronary syndromes without ST elevation Postgrad. Med. J., January 1, 2006; 82(963): 55 - 59. [Abstract] [Full Text] [PDF]

				W. J. Remme, J. J.V. McMurray, B. Rauch, F. Zannad, K. Keukelaar, A. Cohen-Solal, J. Lopez-Sendon, F.D. R. Hobbs, D. E. Grobbee, A. Boccanelli, et al. Public awareness of heart failure in Europe: first results from SHAPE Eur. Heart J., November 2, 2005; 26(22): 2413 - 2421. [Abstract] [Full Text] [PDF]

				F. A. Masoudi, C. A. Baillie, Y. Wang, W. D. Bradford, J. F. Steiner, E. P. Havranek, J. M. Foody, and H. M. Krumholz The Complexity and Cost of Drug Regimens of Older Patients Hospitalized With Heart Failure in the United States, 1998-2001 Arch Intern Med, October 10, 2005; 165(18): 2069 - 2076. [Abstract] [Full Text] [PDF]

				C.-M. Yu, L. Wang, E. Chau, R. H.-W. Chan, S.-L. Kong, M.-O. Tang, J. Christensen, R. W. Stadler, and C.-P. Lau Intrathoracic Impedance Monitoring in Patients With Heart Failure: Correlation With Fluid Status and Feasibility of Early Warning Preceding Hospitalization Circulation, August 9, 2005; 112(6): 841 - 848. [Abstract] [Full Text] [PDF]

				M. Komajda, P. Lapuerta, N. Hermans, J. R. Gonzalez-Juanatey, D. J. van Veldhuisen, E. Erdmann, L. Tavazzi, P. Poole-Wilson, and C. Le Pen Adherence to guidelines is a predictor of outcome in chronic heart failure: the MAHLER survey Eur. Heart J., August 2, 2005; 26(16): 1653 - 1659. [Abstract] [Full Text] [PDF]

				A. U. Khand, M. Shaw, I. Gemmel, and J. G.F. Cleland Do discharge codes underestimate hospitalisation due to heart failure? Validation study of hospital discharge coding for heart failure Eur J Heart Fail, August 1, 2005; 7(5): 792 - 797. [Abstract] [Full Text] [PDF]

				R Holland, J Battersby, I Harvey, E Lenaghan, J Smith, and L Hay Systematic review of multidisciplinary interventions in heart failure Heart, July 1, 2005; 91(7): 899 - 906. [Abstract] [Full Text] [PDF]

				S. Stewart Recognising the "other half" of the heart failure equation: are we doing enough for family caregivers? Eur J Heart Fail, June 1, 2005; 7(4): 590 - 591. [Full Text] [PDF]

				L. Lacey and M. Tabberer Economic burden of post-acute myocardial infarction heart failure in the United Kingdom Eur J Heart Fail, June 1, 2005; 7(4): 677 - 683. [Abstract] [Full Text] [PDF]

				D. R. Thompson, A. Roebuck, and S. Stewart Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure Eur J Heart Fail, March 16, 2005; 7(3): 377 - 384. [Abstract] [Full Text] [PDF]

				S. Stewart Financial aspects of heart failure programs of care Eur J Heart Fail, March 16, 2005; 7(3): 423 - 428. [Abstract] [Full Text] [PDF]

				F. Lloyd-Williams, S. Beaton, P. Goldstein, F. Mair, C. May, and S. Capewell Patients' and nurses' views of nurse-led heart failure clinics in general practice: a qualitative study Chronic Illness, March 1, 2005; 1(1): 39 - 47. [Abstract] [PDF]

				M. D. Flather, M. C. Shibata, A. J.S. Coats, D. J. Van Veldhuisen, A. Parkhomenko, J. Borbola, A. Cohen-Solal, D. Dumitrascu, R. Ferrari, P. Lechat, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS) Eur. Heart J., February 1, 2005; 26(3): 215 - 225. [Abstract] [Full Text] [PDF]

				B. Unal, J. A. Critchley, D. Fidan, and S. Capewell Life-Years Gained From Modern Cardiological Treatments and Population Risk Factor Changes in England and Wales, 1981-2000 Am J Public Health, January 1, 2005; 95(1): 103 - 108. [Abstract] [Full Text] [PDF]

				M. D. Sosin, G. S. Bhatia, R. C. Davis, and G. Y.H. Lip Heart failure--the importance of ethnicity Eur J Heart Fail, December 1, 2004; 6(7): 831 - 843. [Abstract] [Full Text] [PDF]

				M. Di Bari, C. Pozzi, M. C. Cavallini, F. Innocenti, G. Baldereschi, W. De Alfieri, E. Antonini, R. Pini, G. Masotti, and N. Marchionni The diagnosis of heart failure in the community: Comparative validation of four sets of criteria in unselected older adults: the ICARe Dicomano Study J. Am. Coll. Cardiol., October 19, 2004; 44(8): 1601 - 1608. [Abstract] [Full Text] [PDF]

				J. Gonseth, P. Guallar-Castillon, J. R. Banegas, and F. Rodriguez-Artalejo The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports Eur. Heart J., September 2, 2004; 25(18): 1570 - 1595. [Abstract] [Full Text] [PDF]

				F. A. McAlister, S. Stewart, S. Ferrua, and J. J.J.V. McMurray Multidisciplinary strategies for the management of heart failure patients at high risk for admission: A systematic review of randomized trials J. Am. Coll. Cardiol., August 18, 2004; 44(4): 810 - 819. [Abstract] [Full Text] [PDF]

				F A McAlister, N F Murphy, C R Simpson, S Stewart, K MacIntyre, M Kirkpatrick, J Chalmers, A Redpath, S Capewell, and J J V McMurray 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 BMJ, May 8, 2004; 328(7448): 1110. [Abstract] [Full Text] [PDF]

				S Stewart, N Murphy, A Walker, A McGuire, and J J V McMurray Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK Heart, March 1, 2004; 90(3): 286 - 292. [Abstract] [Full Text] [PDF]

				B A Groenning, I Raymond, P R Hildebrandt, J C Nilsson, M Baumann, and F Pedersen Diagnostic and prognostic evaluation of left ventricular systolic heart failure by plasma N-terminal pro-brain natriuretic peptide concentrations in a large sample of the general population Heart, March 1, 2004; 90(3): 297 - 303. [Abstract] [Full Text] [PDF]

				M. Tendera The epidemiology of heart failure Journal of Renin-Angiotensin-Aldosterone System, March 1, 2004; 5(1_suppl): S2 - S6. [Abstract] [PDF]

				R Senior, G Galasko, J V McMurray, and J Mayet Screening for left ventricular dysfunction in the community: role of hand held echocardiography and brain natriuretic peptides Heart, November 1, 2003; 89(90003): iii24 - 28. [Full Text] [PDF]

				S Stewart, N Murphy, A Walker, A McGuire, and J J V McMurray The current cost of angina pectoris to the National Health Service in the UK Heart, August 1, 2003; 89(8): 848 - 853. [Abstract] [Full Text] [PDF]

				R. J. O'Brien, I. B. Squire, B. Demme, J. E. Davies, and L. L. Ng Pre-discharge, but not admission, levels of NT-proBNP predict adverse prognosis following acute LVF Eur J Heart Fail, August 1, 2003; 5(4): 499 - 506. [Abstract] [Full Text] [PDF]

				J.G.F Cleland, K Swedberg, F Follath, M Komajda, A Cohen-Solal, J.C Aguilar, R Dietz, A Gavazzi, R Hobbs, J Korewicki, et al. The EuroHeart Failure survey programme--a survey on the quality of care among patients with heart failure in Europe: Part 1: patient characteristics and diagnosis Eur. Heart J., March 1, 2003; 24(5): 442 - 463. [Abstract] [Full Text] [PDF]

				J.G.F. Cleland, A. Takala, M. Apajasalo, N. Zethraeus, and G. Kobelt Intravenous levosimendan treatment is cost-effective compared with dobutamine in severe low-output heart failure: an analysis based on the international LIDO trial Eur J Heart Fail, January 1, 2003; 5(1): 101 - 108. [Abstract] [Full Text] [PDF]

				S. Stewart and J. J V McMurray Palliative care for heart failure BMJ, October 26, 2002; 325(7370): 915 - 916. [Full Text] [PDF]

This Article Abstract FREE Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to citation manager Request Permissions Disclaimer Google Scholar Articles by Stewart, S. Articles by McMurray, J. J.J.V. Search for Related Content PubMed PubMed Citation Articles by Stewart, S. Articles by McMurray, J. J.J.V. Social Bookmarking          What's this?

Online ISSN 1879-0844 - Print ISSN 1388-9842

Copyright © 2009 European Society of Cardiology

Oxford Journals Oxford University Press

• Site Map
• Privacy Policy
• Frequently Asked Questions

Other Oxford University Press sites: Oxford University Press Oxford Journals China Oxford Journals Japan American National Biography Booksellers' Information Service Children's Fiction and Poetry Children's Reference Corporate & Special Sales Dictionaries Dictionary of National Biography Digital Reference English Language Teaching Higher Education Textbooks Humanities International Education Unit Law Medicine Music Online Products Oxford English Dictionary Reference Rights and Permissions Science School Books Social Sciences Very Short Introductions World's Classics