European Journal of Heart Failure

European Journal of Heart Failure 2005 7(3):423-428; doi:10.1016/j.ejheart.2005.01.001

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© 2005 European Society of Cardiology

Financial aspects of heart failure programs of care

Simon Stewart^*

Division of Health Sciences, University of South Australia Adelaide, Australia
Faculty of Health Sciences, University of Queensland Brisbane, Australia

^* School of Nursing and Midwifery, City East Campus, University of South Australia, North Terrace, Adelaide, 5000, Australia. Tel.: +61 8 8302 1115; fax: +61 8 8302 1806. E-mail address: simon.stewart{at}unisa.edu.au

	Abstract

Top Abstract 1. Introduction 2. The economic burden... 3. Effect of heart... 4. Financial implications of... 5. Further considerations 6. Conclusions References

 
As suggested by studies that have examined the economic burden imposed by heart failure and, more specifically where the greatest expenditure occurs, the key to cost-effectively minimising the impact of a sustained heart failure epidemic is to minimise recurrent hospital use—even at the expense of increasing levels of community-based care and prescribed pharmacotherapy [Mark DB. Economics of treating heart failure. Am J Cardiol 1997;80:33H–38H; Weintraub WS, Cole J, Tooley JF. Cost and cost-effectiveness studies in heart failure research. Am Heart J 2002;143:565–76]. This paper examines the potential cost–benefits of applying specialist heart failure programs of care and the range of financial issues that need to be considered when establishing a formal heart failure service.

Key Words: Chronic heart failure • Programs of care • Cost

Received May 18, 2004; Revised December 20, 2004; Accepted January 4, 2005

	1. Introduction

Top Abstract 1. Introduction 2. The economic burden... 3. Effect of heart... 4. Financial implications of... 5. Further considerations 6. Conclusions References

 
As suggested by studies that have examined the economic burden imposed by heart failure and, more specifically where the greatest expenditure occurs, the key to cost-effectively minimising the impact of a sustained heart failure epidemic is to minimise recurrent hospital use—even at the expense of increasing levels of community-based care and prescribed pharmacotherapy [1,2]. This paper examines the potential cost–benefits of applying specialist heart failure programs of care and the range of financial issues that need to be considered when establishing a formal heart failure service.

	2. The economic burden of chronic heart failure

Top Abstract 1. Introduction 2. The economic burden... 3. Effect of heart... 4. Financial implications of... 5. Further considerations 6. Conclusions References

 
The full financial impact of an epidemic of heart failure was first unveiled by a series of studies undertaken in the 1990s. These studies revealed that the overall cost of managing heart failure consumed at least 1–2% of total health-care expenditure in a diverse range of developed countries [3–9]. Importantly, hospitalisations represented the costliest (more than two thirds) component of such expenditure. Moreover, there was a strong suspicion that the true burden imposed by heart failure was being underestimated due to a steady increase in heart failure-related hospital admissions—particularly where it was coded as a contributory (secondary) rather than primary diagnosis but was the major reason for that hospital admission [10–13].

Two related studies emanating from the UK were the first to comprehensively document the rising cost of heart failure over time. Initially, in 1990, heart failure was estimated to cost 1.3% of health care expenditure in that country [9]. A follow-up study using a similar methodology (i.e. using a per diem analysis based on official health care utilisation costs) found that in the year 2000, heart failure consumed approximately 2.1% of expenditure (based on 1990 equivalent expenditure levels). When the cost of hospitalisation associated with a secondary diagnosis of heart failure was considered, this figure rose markedly to 4% [14]. It is reasonable to assume, therefore, that the cost of heart failure has increased by two- to three-fold in the past decade in most countries. With forecasts of a sustained epidemic [15] the financial burden imposed by heart failure is likely to rise further in all countries where hospitalizations have been documented to account for more than two thirds of heart failure-related expenditure (e.g. The Netherlands, UK, Sweden, Spain, USA and New Zealand). The most cost-effective strategies for minimising the burden of heart failure, beyond preventative interventions, target "high risk/high cost" individuals with heart failure (representing around 25% of those admitted with heart failure in any one year [9]) who consume a disproportionate amount of health care resources and expenditure through recurrent hospitalizations in the final stages of this deadly syndrome.

	3. Effect of heart failure programs on recurrent hospital use

Top Abstract 1. Introduction 2. The economic burden... 3. Effect of heart... 4. Financial implications of... 5. Further considerations 6. Conclusions References

 
It is largely based on the cost dynamics of the heart failure epidemic, combined with increasing evidence that a large proportion of costly heart failure-related readmissions could be avoided via better management [16,17], that there has been growing interest in applying cost-effective models of care for high risk patients with this syndrome. An increasing number of randomised studies of predominantly nurse-led programs of care have demonstrated that optimising the post-discharge management of older patients with chronic heart failure can reduce the frequency of recurrent hospital use, improve quality of life and even prolong survival in the process [18,19]. Such benefits have been confirmed by meta-analyses involving thousands of randomised patients and have proven to be independent of gold-standard pharmacotherapy [20–22]. It is estimated that the "numbers needed to treat" via a multidisciplinary team in the community or via a specialised clinic, to avoid a heart failure admission, all-cause admission or all-cause death are 11 (combined relative risk reduction of 0.74, 95% CI 0.63 to 0.87), 10 (RR 0.81, 95% CI 0.72 to 0.91) and 17 (RR 0.75, 95% CI 0.59 to 0.96), respectively, relative to usual care [21]. In comparison, the equivalent figures for avoiding heart failure admission or all-cause death associated with ACE inhibitor therapy in similar patient populations are 16 and 19, respectively [23].

Fig. 1 shows the impact of predominantly nurse-led, post-discharge, specialist heart failure management programs on recurrent hospital use, relative to standard post-discharge care, within 12 months of index hospitalisation in 10 randomised studies from a range of developed countries [24–33]. These data are consistent with the results of 20 more randomised studies examining the potential benefits of optimising the post-discharge management of chronic heart failure. A recent meta-analysis demonstrated that programs of care that typically provide additional support in the form of specialist heart failure clinic and/or a coordinated program of multidisciplinary home-based management are likely to reduce all-cause recurrent hospital stay by 40–60% relative to usual care and have the lowest numbers needed to treat (as above) to prevent major morbid and fatal events [21]. Significantly, the majority of appropriately powered studies of multidisciplinary management programs that have included quality of life as a study end-point, have also shown improved health-related quality of life scores relative to usual care in patients exposed to this form of intervention [24,26–28,34–38]. These programs, therefore, appear to provide both individual and societal benefits overall; although it must be acknowledged that the true impact of these programs on carers and families (many of whom play a key role in optimising therapy) is under-researched and appreciated [39].

View larger version (21K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 1 Comparison of the effect of heart failure management programs on recurrent hospital use within 3–12 months relative to usual post-discharge care. Percentage values shown are for the percentage reduction in recurrent hospital use. [24–33].

 
As can be appreciated, given the cost dynamics of the heart failure burden and the preponderance of expenditure associated with hospital episodes and outpatient and primary care visits usually associated with usual post-discharge care, such programs are likely to be extremely cost-effective if applied on a formal basis [40]. Despite residual concerns that despite improvements in the quality of care, chronic disease management programs overall may not be cost-effective in a "managed care" environment, such as that common to the USA [41] and potential difficulties in applying heart failure programs widely [22], there is strong evidence from pre-established programs of care that "promised" health care benefits can be delivered when sufficient resources are provided to establish the key principles of such management [42].

	4. Financial implications of applying a post-discharge heart failure service

Top Abstract 1. Introduction 2. The economic burden... 3. Effect of heart... 4. Financial implications of... 5. Further considerations 6. Conclusions References

 
Directly projecting the potential cost impact of specialist heart failure programs from research studies to the wider health care system without adjusting for additional expenses and a range of effects on health care utilisation rates, however, is too simplistic and will lead to an over-estimation of potential cost–benefits [18]. Few programs of care cost less than first budgeted for. Most programs, therefore, are under-resourced and unable to provide the type of service first envisioned.

The following list outlines some of the more important components of expenditure that should be considered when establishing a formal heart failure service.

A program coordinator.

Administrative personnel and office space and equipment.

Specialist heart failure nurses (with coverage of sickness and annual leave) at a ratio 1:200–250 nurses: patients per annum.

Cardiologists and other key health care professionals within a multidisciplinary team.

Staff training (e.g. a four-week induction program and on-going educational activities).

Clinic space and equipment.

Transport (e.g. car plus ongoing travel costs).

Communication (e.g. phone, paperwork and computing).

Monitoring equipment and investigational costs (e.g. weigh machines and venepuncture equipment).

Data management (e.g. electronic database).

Additional investigations (for example, electrolyte and renal function tests).

Auditing of key outcomes (e.g. prescription of gold-standard therapy, morbidity and mortality).

Patient booklets.

Importantly, there are a number of flow-on costs that may need to be considered when implementing a program of care. These include:

Incremental pharmacotherapy—particularly if current guidelines (e.g. introducing a beta-blocker and/or increasing the dose of prescribed therapy) are used to address sub-optimal prescription patterns.

Referral to other health care professionals (e.g. dietician, social worker and pharmacist).

An initial increase in general practitioner visits to address important clinical issues identified during the process of patient evaluation and management.

Clearly, therefore, there are substantial up-front costs associated with the establishment of a specialist heart failure service. The exact cost will depend on a number of factors including the type of intervention chosen (i.e. telephonic support versus specialist heart failure clinic), the number of patients to be managed (e.g. if the service includes patients with preserved systolic function the case load is likely to be high), the expertise of staff (e.g. use of specialist heart failure nurse versus advanced nurse practitioner) and local variations in health care costs. There is some evidence that the approximate cost of applying clinic-based management is similar to that of applying a home-based approach—at least from the perspective of a universal health provider that pays for both hospital and community-based health care costs. For example, in the UK, we estimated that a national heart failure service would cost approximately £70 million per annum in the year 2000 [40]. This cost was reasonably consistent when applying a clinic or community-based approach (cost variation £2–3 million per annum). The key assumptions used to derive the cost of applying a clinic-based heart failure service for a UK population area of 1 million people in the year 2000 are summarised in Table 1. As such it shows that each formal service providing specialist heart failure care for a populated area of one million is likely to cost around £1.4 million. Importantly, the cost considerations and dynamics used to derive this estimate are likely to be similar in other developed countries.

View this table: [in this window] [in a new window]   Table 1 Summary of the estimated cost components of establishing a formal heart failure service in the UK

 
Given the substantial cost of applying heart failure services on a formal basis it is vitally important to establish specific targets for reducing other health care costs and undertake audits to ensure they are being achieved [42]. For example, in building an economic argument for establishing a UK-wide heart failure service based on our previous study of the burden of heart failure in that country (i.e. using official cost-estimates and a per diem analysis of hospital data [14]), we estimated that each 10% reduction in recurrent hospital use associated with optimal heart failure management would produce nominal "cost-savings" of £18 million per annum in a case-load of 120,000 patients per annum. These saving comprised both reductions in hospital bed utilisation and post-discharge care in the community [40].

Fig. 2 summarises the results of this study. As such, it demonstrates that if a heart failure service were able to reduce recurrent hospital utilisation by 40% per annum it would produce cost-savings equivalent to its annual running costs (£70 million per annum). If the cost of correcting the under-utilisation of gold-standard pharmacotherapy were subtracted from the heart failure service budget, this key target would fall to 30% ((£70 million per annum) [40]. Importantly, when a continuous case load of patients is considered, as opposed to a static cohort followed for a specific time period, the overall effect of these programs on recurrent hospital use over a one year period is magnified rather than reduced; this reflects the fact that risk of readmission is greatest within the first 3 months post index hospitalisation. Essentially, this means that reaching a target of a 40–50% reduction in recurrent hospital use over 12 months in a service continually turning-over patients (usually maintaining a ratio of 150–200 patients per specialist nurse/coordinator) is achievable even when a "point" analysis of readmission data (i.e. a 25% reduction in recurrent hospital use) indicates otherwise.

View larger version (18K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 2 Summary of the expected cost–benefits of a UK-wide heart failure service. This graph shows the approximate savings achieved via a 20% to 50% reduction in the typical pattern of recurrent hospital stay seen in patients with heart failure in the UK. The black dotted line shows the cost of applying optimal heart failure management through a formal heart failure service (equivalent to £70 million per annum and a 40% reduction in recurrent hospital stay) and the grey dotted line shows that if the cost of gold-standard pharmacology is deducted from this calculation, given that it should be applied regardless of the presence or absence of a service, this figure falls to £60 million per annum and a 30% reduction in recurrent hospital stay.

 

	5. Further considerations

Top Abstract 1. Introduction 2. The economic burden... 3. Effect of heart... 4. Financial implications of... 5. Further considerations 6. Conclusions References

 
It is important to consider the future application of technological support (i.e. telemonitoring [43]) to further optimise the management of heart failure. This approach is likely to alter the cost dynamics of providing heart failure services in the future and, pending a formal cost analysis of this type of approach based on a number of randomised studies, it is not clear whether they will assist pre-existing strategies to become more cost-effective or simply elevate costs with limited improvements in health outcomes. It is also important to note that with one notable exception [44] there are few data examining the long-term cost impact of better heart failure management. For example, there is a small possibility that heart failure programs simply delay the inevitable (i.e. recurrent hospitalisation) and provide only short-term benefits that do not lead to substantive cost-savings in the longer-term. This was certainly not the case in the only randomised study with more than 3 years study follow-up [44]. Finally, the notion of actual "cost savings" is meaningless given that a hospital bed will still be utilised even if a patient with heart failure does not use it. However, the potential to reduce surgical waiting lists, improve the efficiency of the health care system overall by limiting the number of complex cases and, potentially, limit the need for expanding hospitals to cope with an increasing number of old and fragile patients with heart failure cannot be overstated.

	6. Conclusions

Top Abstract 1. Introduction 2. The economic burden... 3. Effect of heart... 4. Financial implications of... 5. Further considerations 6. Conclusions References

 
The data supporting the widespread introduction of services based on the expert management applied by specialist heart failure programs of care are compelling-both on the basis of individual benefits to the patient and their caregivers and on a financial basis [20–22]. National heart failure services based on the expertise of specialist heart failure nurses have the potential to deliver significant cost-savings and enable the incumbent health care system to operate more efficiently.

	References

Top Abstract 1. Introduction 2. The economic burden... 3. Effect of heart... 4. Financial implications of... 5. Further considerations 6. Conclusions References

 

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