© 2003 European Society of Cardiology
Is multidisciplinary care of heart failure cost-beneficial when combined with optimal medical care?
a Heart Failure Unit, St Vincent's University Hospital Elm Park, Dublin 4, Ireland
b National Centre for Pharmacoeconomics, St James's Hospital Dublin 8, Ireland
* Corresponding author. Tel.: +353-1-2094147; fax: +353-1-2094149. E-mail address: kenneth.mcdonald{at}ucd.ie
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Abstract |
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 Top Abstract 1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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Background: Multidisciplinary care (MDC) of heart failure (HF) can significantly reduce rates of unplanned hospitalisation, the major cost component of HF care.
Aims: This prospective, randomised, controlled study examines the cost-benefits of MDC of HF in the setting of optimal medical care.
Methods: 98 NYHA class IV HF patients (mean age 70.8±10.5 years) were randomised to MDC (n=51) or routine care (RC; n=47) of HF. A direct intervention cost was calculated from contact time (scheduled and unscheduled) spent by the MDC team. Unplanned hospitalisation costs for HF were calculated at a daily rate of 
242. Outcomes were determined in monetary terms, i.e. the cost of the service per hospitalisation prevented and net costs/savings at 3 months.
Results: The direct intervention cost of the MDC team was 5860, with an average cost per patient of 113 (95% Cl: 97–128). At 3 months, there were a total of 12 unplanned HF readmissions in the RC group (25.5% rate, 195 days) compared to 2 in the MDC group (3.9% rate, 17 days). The number needed to treat to prevent one hospitalisation for HF was 6 over 3 months. The cost of the service per hospitalisation prevented was 586. The intervention produced a net cost saving of 37,216 for 51 patients treated over 3 months. Sensitivity analyses using 50% variation in costs and lower relative risk reductions confirmed the cost-benefits of the intervention.
Conclusion: MDC of HF remains cost-beneficial when combined with optimal, medical care. The significant clinical and cost-benefits suggest that this intensive approach to MDC and medical management should become the standard of care for HF.
Key Words: Heart failure • Multidisciplinary care • Health economic evaluation
Received January 3, 2002; Revised September 9, 2002; Accepted October 14, 2002
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1. Introduction |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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The developed world is currently experiencing a heart failure (HF) epidemic, with prevalence rising dramatically as a result of ageing populations, poorly controlled cardiovascular disease such as hypertension and increased survival rates from acute myocardial events. Current estimates suggest that Northern Europe has 14,000 cases of HF per million of population, with up to 3 times this total figure likely when asymptomatic LVSD and HF with normal systolic function are taken into account [1].
Competing demands on limited healthcare resources have heightened the importance of health economic evaluations. New pharmacological and healthcare interventions are increasingly being examined for cost as well as clinical benefits, to help healthcare providers optimise healthcare provision and rationalise choices. While much has been done to improve the pharmacological treatment of HF in recent years, and much of this is considered cost-effective, this condition continues to be associated with frequent, and often prolonged, hospitalisations. Not surprisingly, HF morbidity is a major drain on healthcare spend and accounted for 2% of the entire US healthcare budget in 1992 [2]. Recent estimates from the UK suggest that the figure may be closer to 4% of the NHS budget [3].
A growing body of data shows that the practice of Multidisciplinary care (MDC) of HF in specialised clinics can produce significant reductions in re-hospitalisation rates [4–7]. This involves co-ordinating the care process between the patient and different healthcare professionals and has resulted in significant reductions in hospitalisation rates. However, in the reported care programmes to date, optimal medical care has not been a stated component and changes in medical care may account for some of the benefits achieved. It is therefore unproven whether the benefit of MDC of HF derives from the education and support provided by the multidisciplinary team or from the differences in medical therapy. By applying intensive, optimal medical therapy in both intervention and control groups, our study is the first to focus on the intrinsic benefit of regular patient education and support delivered as part of a MDC programme for HF [7].
This may have implications for the costs of the service since the intervention is both labour intensive and costly, particularly because of the need for ongoing clinical follow-up. The purpose of this health economic study is to determine whether intensive hospital based MDC is still cost-beneficial when combined with optimal medical care.
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2. Methods |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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2.1. Patient screening and recruitment
This prospective, randomised, controlled investigation conforms with the principles outlined in the Declaration of Helsinki and was approved by the St Vincent's University Hospital Ethics Committee. All patients over 18 years admitted to St Vincent's University Hospital through casualty with a diagnosis of HF were screened. Diagnosis of HF was confirmed or refuted by a cardiologist based on the following four criteria: history and examination compatible with HF, chest X-ray appearance of congestion, echocardiography evidenced left ventricular systolic and/or diastolic dysfunction and response to initial therapy. Patients presenting with HF in the setting of myocardial infarction or unstable angina, or where HF was not thought to be the primary problem were excluded. Those with illnesses that could compromise survival over the duration of the study or with cognitive impairment were also excluded. Once stable and when written informed consent had been obtained, all eligible patients were randomised to RC or MDC, directly under the supervision of the cardiology service.
2.2. Study procedure
2.2.1. Routine care (control) group
Patients underwent HF investigations including echocardiography and right and left heart catheterization, where indicated. Optimal medical therapy was administered (see below). Ancillary services such as dietary and social work consultations were provided as requested by the attending cardiologist. Clinical stability criteria outlined below had to be fulfilled before discharge.
Following discharge, patients were referred back to their primary care physician with a letter explaining their participation in the study and that routine management of their condition was to be general practice based. Review by the hospital cardiology service was available, if required. Both the patient and their physician were asked to inform the study centre if admission to any hospital occurred during the 3-month follow-up period. All patients were reviewed at 3 months at the HF clinic.
2.2.2. Multidisciplinary care (intervention) group
Patients underwent similar investigation and treatment as outlined for the RC group. In addition, patients systematically received specialist nurse-led education and dietetic consultations on three or more occasions. All additional patient contact time provided as part of MDC was recorded by the care team. The education programme focused on daily weight monitoring, disease and medication understanding and salt restriction. Similar advice was given to the patient's carer/next of kin where applicable. As in the RC group, stability criteria had to be fulfilled before discharge.
Patients were discharged from hospital with a letter to the referring physician explaining the nature of the study and that management of HF-related issues should be referred to the clinic. Telephone contact was made with the patient 3 days following discharge and weekly thereafter until 12 weeks, with the exception of week 2 and week 6, when patients and their next of kin attended the HF outpatient clinic to check clinical status and revise key education issues. The purpose of the phone call was to re-enforce education points such as the importance of daily weight monitoring, disease and medication understanding and salt restriction. Patients were also asked to contact the HF clinic if they noticed any clinical deterioration, in which case a full clinical review was undertaken. The patient was also advised to contact the clinic for an out-of-hospital increase in diuretic dose (by 40 mg of frusemide or equivalent), if weight-gain of 2 kg or more occurred over 1–3 days in the absence of clinical deterioration. The patient was then asked to attend the HF outpatient clinic for assessment of urea and electrolytes. Failure of this approach to bring body weight back to baseline, resulted in a full clinical review by the physician and nurse, with the option of using intravenous frusemide at the clinic to regain clinical stability. As during the in-hospital phase of the study, all direct patient contact time with the MDC team (scheduled and unscheduled) was recorded.
2.2.3. Optimal medical care
Both RC and MDC groups received optimal medical care as previously reported [7,8]. We define ‘optimal medical care’ as involving specialist management of HF during the in-hospital phase, optimal application of medical therapy, including target dose or high dose ACE inhibition where appropriate and fulfilment of specific stability criteria before discharge. The stability criteria required that patients be symptomatically improved and stable, off all IV therapy for 2 days, have stable oral therapy with no dose change for 2 days and have stable dry weight (no change >1 kg) for 2 days.
2.3. Criteria for admission
2.3.1. Routine care group
The decision to admit a patient was the responsibility of the physicians in charge of care and was not influenced by the study personnel.
Charts were subsequently reviewed and the confirmed admitting diagnosis was accepted, but in the case of HF this had to include chest X-ray evidence of pulmonary venous congestion, independently reported by a consultant radiologist.
2.3.2. Multidisciplinary care group
The decision to readmit a patient was made by the MDC physician according to specific, pre-defined criteria. These were: NYHA class IV, potassium <2.8 or >6.0 meq/L, failure of the tiered medical response (augmentation of oral diuretic, clinical review and use of intravenous diuretic on one occasion) to manage clinical deterioration and/or weight gain.
2.4. Measurement of costs
All costs were taken from the perspective of the healthcare provider. The total cumulative cost of the MDC intervention was measured as direct scheduled and unscheduled patient contact time with the specialist nurses and dieticians using a ‘microcosting’ approach [9]. Costs were calculated based on an average annual salary for these positions of 31,750. Physician staff costs were calculated on the basis of an annual registrar salary of 50,000. The National Centre for Pharmacoeconomics in Ireland has calculated a daily cost for HF hospitalisation in an Irish teaching hospital to be 242 [10]. This comprises the components presented in Table 1, of which the major cost (74.8%) is hospital ward cost. No indirect costs (e.g. patient travel, attendance time, lost earnings) are included in the data analysis because there is substantial data in the literature demonstrating that the major cost of HF care is hospitalisations.
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2.5. Endpoints and data analysis
In this cost-benefit analysis both costs and consequences were valued in monetary units (
). We determined the net benefit of the MDC intervention for HF. Sensitivity analyses on cost-benefit calculations were carried out based on a 50% variation in costs (4 scenarios). The large variation in costs was chosen to account for the use of direct hospitalisation cost data based on general medical ward costs. Further sensitivity analyses were carried out based on lower relative risk reductions (40–60%) than those observed in the study.
Data were analysed by intention to treat using unpaired Student's t-test (normal distribution) and 
2-analysis (with calculation of odds ratio and 95% confidence interval) for discrete variables.
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3. Results |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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Between November 1998 and April 2000, 337 patients were admitted to St Vincent's University Hospital through Accident and Emergency with a presumed diagnosis of HF. Two hundred and fourteen patients had a confirmed diagnosis of primary HF, 116 of whom were excluded for reasons outlined in Table 2, leaving a study population of 98.
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The characteristics of the patient population are presented in Table 3. While within the age range of published reports on MDC of HF programmes, this population (age 70.8±10.5 years) may be more representative of community HF than the majority of large-scale HF trials. Furthermore, this was an at risk population as more than half the patients had a known history of HF and of these 85% had previously been admitted for this condition. Moreover, 38% of these had been admitted for HF in the 3 months prior to this index admission.
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Only one patient did not fulfil stability criteria before discharge and 98% of patients in both groups with LV systolic dysfunction tolerated ACE inhibitor therapy. All of these tolerated target (4 mg o.d.) or high dose therapy (>4 mg o.d.) prior to discharge with perindopril, with the exception of one patient in the multidisciplinary arm.
At 3 months there was no difference between the groups in terms of daily perindopril dose (MDC: 4.5±3.3 mg vs. RC: 4.7±3.0 mg), frusemide dose (MDC: 44.4 mg±25.2 mg vs. RC: 39.6±27.0 mg) or digoxin dose (0.107±0.099 mg vs. RC: 0.154±0.106 mg), with all P>0.05. This justifies the decision to exclude cost differences arising from medication prescribed for the treatment of HF.
The additional time spent by the MDC team in providing the scheduled MDC service is presented in Tables 4 and 5 (in-hospital and clinic visits) and Fig. 1 (out-patient telephone contact). The mean nurse time spent during an average of 6.6 visits was 188 (95% Cl: 160–216) min per patient. The mean nurse time spent during 11 scheduled phone calls was 63 (95% Cl: 51–76) min giving a total average specialist nursing time spent per patient of 251 (95% Cl: 214–287) min or 4.2 (95% Cl: 3.6–4.8) h. There was a trend towards reduced phone call duration during the 3-month study period. The longest phone call was the first call post discharge (day 3), taking 7.6±6.3 min and the average duration of the phone calls reduced during the course of the study to a low of 4.7±5.2 min at 10 weeks. The average specialist dietician time spent was 132 (95% Cl: 110–154) min or 2.2 h (95% Cl: 1.8–2.6) over an average of 3.7 visits.
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There were a total of 26 unscheduled contacts made to the service over the 3-month study period. Ten of these were initiated directly by the patients over the telephone. Six of these required outpatient clinic follow-up and 4 required no follow-up. A further 16 unscheduled contacts were initiated by the specialist nurse during the scheduled phone calls as a result of concern about the patient's clinical status and included outpatient clinic visits. In total, the unscheduled contacts resulted in 14 out of hospital increases in diuretic dose. Two patients were admitted during the 3-month period. The unscheduled contacts took 3.8% of the total time of the service and the majority of this was nursing input.
A full time working year has 110,400 min and the total nursing time spent was 12,798 min (112 h). Therefore the cost of the nursing intervention was 11.6% of the total specialist nurse salary of 31,750, which is 3680. The total dietician time was 6740 min (112 h). The cost of the diet intervention was, therefore, 6.1% of the total salary of 31,750, which is 1938. A further cost of 241 was associated with unscheduled contacts, including 22 separate outpatient clinical reviews over 12.1 h (nurse and physician). Therefore, the total intervention cost of the MDC team, or service cost, measured as direct patient contact, was calculated as 5860, or 113 (95% Cl: 97–128) per patient treated over 3 months.
On discharge, there were significantly better scores for patients in the MDC intervention group for knowledge of HF (16.3±2.7 out of 20 vs. 13.1±2.2 out of 20, P<0.01) and knowledge of diet (8.3±2.1 out of 20 vs. 6.6±1.9 out of 20, P<0.01), which reflects the impact of the specialist nursing and dietician input.
At 3 months, there were 12 unplanned HF readmissions in the RC group (25.5% rate per number of participants) compared to 2 in the MDC group (3.9% rate per number of participants, P<0.01). There were a total of 17 days of hospitalisation in the MDC group vs. 195 days of hospitalisation in the RC group in 3 months. There were 2 out of hospital deaths in each group and one patient in each group died during a hospital admission for HF. There was a trend towards improved quality of life score (Minnesota living with HF Score) in the MDC group compared to the RC group (29±19 vs. 40±23, P=0.10).
Since the number of hospitalisations in the RC and MDC groups were 12 and 2, respectively, there was an absolute reduction of 10 hospitalisations as a result of the intervention. Dividing the absolute intervention cost by the absolute reduction in hospitalisations gives a service cost of 586 per hospitalisation prevented.
The overall costs and savings are presented graphically in Fig. 2. The total hospitalisation costs of the RC group were 47,190 whereas those for the MDC group were 4,114. Since the MDC intervention cost 5860, there was a net cost saving during the study of 37,216. Therefore, in addition, to the clinical benefits produced by the intervention, there was a net cost saving of 729 per patient treated.
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The results of cost-benefit sensitivity analyses are presented in Table 6. Four scenarios are presented based on 50% variation in the main direct costs (service costs and hospitalisation costs). A further 3 scenarios based on lower relative risk reductions (40–60%) are presented. The results show that even allowing for such variation, the absolute cost-benefit of the programme ranges from
8,634 to 65,798.
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4. Discussion |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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This study shows that even when medical therapy is optimised and event rates are consequently low, MDC of HF is cost-beneficial.
HF is one of the few cardiovascular diseases, which, under certain circumstances, can produce cost savings while saving lives. In its severest form, the condition is associated with frequent and expensive hospitalisations. These are the major treatment cost in HF, accounting for up to 70% of the direct costs of disease management. Several well-established medical therapies, such as ACE inhibitors, diuretics and beta-blockers, which reduce morbidity in HF, are also considered cost-effective largely through the reduction in hospitalisation costs [11–15]. However, despite advances in the medical care of HF, the condition causes substantial morbidity and the associated costs continue to drain healthcare budgets.
Recently, MDC of HF has been shown to significantly reduce re-hospitalisation rates in elderly patients with severe HF, from a range of 37–46% for the RC groups over 3 months to a range of 17–35% over 3 months for the MDC groups [4–7]. Some of these studies have shown the programmes to be cost effective [5,6]. However, in the reported work so far, optimised medical care, according to our definition above, has not been a stated component of the protocols. Since differences in medical therapy, stability at discharge and specialist care can independently alter hospitalisations [16–20], our study is the first to focus on the benefit of MDC independent of optimal medical care [7].
Furthermore, because all patients in this study were cared for by the cardiology service, fulfilled stability criteria before discharge and had optimal medical therapy, the event rates for HF are the lowest reported for this elderly, NYHA class IV, HF population. The out of hospital death and/or readmission for HF rate was 7.8% in the MDC group over 3 months [7].
In the context of this optimal medical care with lower event rates, there may be more limited scope for cost savings. Additionally, there had been concern that the care programme might not prove cost-effective, given the requirement to provide frequent clinic and phone communication with the patient over the course of the study.
The service or intervention cost per hospitalisation prevented was 586. Furthermore, the number needed to treat in order to prevent one hospitalisation for HF is 6 over 3 months. This compares very favourably with commonly used pharmacological therapies in HF [20].
The MDC intervention with optimal medical care produces a large net cost-saving based on direct service costs and hospitalisation costs alone. It is likely that inclusion of indirect costs would increase the cost differences between the two groups. The saving achieved over the course of the study was calculated as 37,216 and underlines the cost effectiveness of the MDC service, which underpins the clinical benefits.
There were no differences between the two groups in terms of demographics or medication at 3 months. This justified the exclusion of medicine costs from our cost-benefit analysis. The recorded differences, which explain the reduction in hospitalisations, are the intensive education and contact (scheduled and unscheduled) provided by the MDC service. In particular, the 14 out of hospital increases in diuretic dosage and the review of MDC patients by an experienced team when problems arose, resulted in more aggressive out-patient management of this group. This may have allowed intervention in early stages of de-compensation, preventing situations that in less experienced hands would have resulted in hospital admission. The stipulated admission criteria served to prevent over-aggressive out-patient management by the MDC team.
The average nurse specialist time spent per patient was 4.2 h covering an average of 6.6 visits over a 3-month period. The average specialist dietician time per patient was 2.2 h over 3.7 visits in the same period. The average call time was only 6.3 min per patient per call and tended to decrease during the course of the study as patients became more familiar with the education and advice provided by the service. Furthermore, the unscheduled contacts required less than 4% of the total service time. Despite concerns about the intensive nature of the clinic and telephone follow-up, this study demonstrates that the additional specialist nurse and dietician time required to produce the significant morbidity and cost-benefits in this patient cohort was in the order of 25% full time equivalent specialist nurse and 10% full time equivalent specialist dietician per 100 patients treated.
No study of MDC to date has accounted for direct patient contact times with the level of detail reported here. This ‘microcosting’ approach to health economic evaluations is the preferred method of our unit given that our nursing, paramedical and medical staff have multiple functions and spend a minority of their time providing the MDC intervention described above. However, in applying these data to other institutions, certain caveats must be borne in mind. Firstly, in setting up a new service, staff costs which will generally be fixed at half-time or full-time equivalents. Unless the patient throughput is sufficiently high, or other duties are performed, the ‘microcosting’ approach presented here may over-estimate the cost-benefit of the service. Secondly, the detailed time evaluations forming the basis of the ‘microcosting’ approach used in this study should serve as a guide only for other hospital units with existing staff in place should they wish to introduce the service. As with most health economic evaluations we have not attempted to quantify the training and re-organisation costs that would be incurred in the set-up phase.
The data can give projected cost savings if the programme were to be introduced nationally in Ireland. Government data on medical admissions in Ireland show that 20,249 patients were admitted to Irish public hospitals in 1999 with HF related illness. Based on our data, even if optimal medical care were applied in hospital, there would be 5,163 emergency readmissions for HF within a three-month period at a cost to the healthcare system of 21,242,600. However, if MDC was additionally applied, there would be only 1721 3-month re-admissions at a cost of 3,248,800. This would translate into a net saving of at least 17,993,800 and would greatly exceed the estimated 2,318,200, which would be required to provide the service.
There are several limitations to this work, which must be acknowledged. Firstly, the hospitalisation costs applied in the present study are based on work carried out in a separate study. However, both studies were carried out in Dublin teaching hospitals and involved HF patients with similar age and demographic profiles. Furthermore, the sensitivity analyses show that the programme remains cost effective with large variation in this figure and in the context of lower risk reductions than those observed. Secondly, the decision to exclude indirect costs associated with the care of HF means that the data here represent, at best, an underestimation of the cost-benefits of the programme. Finally, while the data provide a compelling argument for benefit of the programme over 3 months, it is not known from this study whether the benefits of the three month education and support programme can be sustained beyond this time period. It would be of interest, in this regard, to know whether any sustained benefit requires ongoing service provision and, if so, can the service be effectively provided in a community setting, where the vast majority of HF patients are treated.
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5. Conclusion |
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TopAbstract1. Introduction2. Methods3. Results4. Discussion5. ConclusionReferences |
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MDC of HF remains cost-effective and cost-beneficial when combined with optimal medical care. The cost per HF hospitalisation prevented is
586. The service cost is 113 (95% CI: 97–128) per patient over 3 months and there is a net cost saving per patient treated of 729. The intervention requires 25% full-time equivalent specialist nurse and 10% specialist dietician per 100 patients treated. The significant clinical and cost-benefits suggest that this intensive approach to MDC and medical management should become the standard of care for HF. |
Acknowledgements |
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This work was supported in part by unrestricted grants from the Irish Heart Foundation and Servier Laboratories, Ireland.
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References |
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