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European Journal of Heart Failure 2005 7(4):677-683; doi:10.1016/j.ejheart.2004.10.020
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© 2005 European Society of Cardiology

Economic burden of post-acute myocardial infarction heart failure in the United Kingdom

L. Laceya,* and M. Tabbererb

a Lacey Solutions Ltd. The Beaches, South Strand, Skerries, Dublin, Ireland
b Pfizer Limited Walton on the Hill, UK

* Corresponding author. Tel.: +353 1 8492420; Fax: +353 1 8492420. E-mail address: larrylacey{at}laceysolutions.ie


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Notes
 References
 
Congestive heart failure (CHF) is a major cause of morbidity and mortality. This study was carried out to quantify the burden of CHF, subsequent to acute myocardial infarction (AMI), from the perspective of the UK National Health Service (NHS).

A systematic literature review of publications since 1990 was carried out on the economic burden of heart failure. The economic burden of post-AMI heart failure in the UK for the year 2000 was estimated for two scenarios: (1) Base-case estimate (post-AMI heart failure accounts for 20% of heart failure cases): Direct healthcare costs of £125–181 million (approx. 0.4% of total NHS spend) and nursing home costs of £27 million; (2) Upper estimate (post-AMI heart failure accounts for 50% of the total): Direct healthcare costs of £313–453 million (approx 1.0% of total NHS spend) and nursing home costs of £68 million. In conclusion, post-AMI heart failure imposes a significant direct economic burden on the UK.

Key Words: Economic burden • Heart failure • Post-acute myocardial infarction • Systematic review

Received May 14, 2004; Revised September 8, 2004; Accepted October 20, 2004


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 Notes
 References
 
The objective of this study was to quantify the economic burden of heart failure occurring as a result of acute myocardial infarction (AMI) from the perspective of the UK National Health Service (NHS).

Improvements in the diagnosis and treatment of AMI have led to an increasing number of patients surviving with a damaged myocardium who may subsequently be at risk of developing heart failure. As a consequence, recent studies have identified ischaemic heart disease as a principal aetiology of CHF (36–58%) [1–6]. Historically the principal aetiology of congestive heart failure (CHF) has been identified as hypertension (43–80%) [7–10].

AMI has both immediate and delayed effects [11] on the ventricle. Initial ischaemic damage to the myocardium is usually followed by ventricular remodelling, progressing rapidly in the immediate post-infarction period and more slowly thereafter. Initial wall thinning in the infarct area and ventricular chamber dilatation is followed by compensatory hypertrophy and fibrosis including lengthening of the non-infarcted portion of the myocardium [12]. These changes become maladaptive, causing increased wall stress, oxygen demand and decreased contractility, leading to disease progression and death from heart failure [13].

Following a dramatic increase in the hospital admission rate for heart failure during the 1980s [14], the rate of increase in admissions with heart failure as a primary diagnosis moderated in the 1990s in both England and Scotland [15,16]. However, it has been predicted [17] that heart failure will become more common because:

  1. AMI remains very common, with rates of survival increasing, and heart failure is an inevitable sequel in a significant proportion of survivors.
  2. Heart failure is essentially a disease of the elderly. As the populations of the developed world increasingly age, the incidence and prevalence of heart failure would be expected to increase.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 Notes
 References
 
2.1. Review of the literature
A systematic literature review was carried out on the economic burden of CHF, with a focus on the UK, post-AMI heart failure and left ventricular systolic dysfunction (LVSD). Searches were carried out for references published since 1990 using Medline, PubMed, the Cochrane library, NHS National E-Library for Health, the Heart Failure section of eBMJ, and the British Heart Foundation web site, www.heartstats.org. The searches included the following search terms and keywords: congestive heart failure, myocardial infarction, burden of heart failure, economics of heart failure, cost of heart failure. In addition, references were manually identified from the reference lists of key papers identified from the searches, particularly for relevant older studies published before 1990. Only English language articles were included in the review.

2.2. Estimation of the economic burden of heart failure resulting from AMI
The literature review identified a variety of sources of UK data, from which estimates of the epidemiology and economic burden of heart failure resulting from AMI could be derived. Sources used in the estimation of the economic burden included clinical trials, population-based studies, database analyses and hospital admissions data.

From the epidemiology data, an estimate of the prevalence of post-AMI heart failure was made, based on the prevalence of "all cause" heart failure in the UK. This prevalence estimate was used to calculate the economic burden of post-AMI heart failure, as a proportion of the burden of "all cause" heart failure.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 Notes
 References
 
3.1. Epidemiology of CHF and CHF post-AMI in the UK
The overall incidence rate for CHF is approximately 1–2 per 1000/year of the population in the UK aged 25 years and older [5]. Based on evidence from the CHF clinical trials [18], UK CHF population studies (Table 1), and UK hospital database studies of CHF admissions [1,3], the best estimate for the proportion of patients with post-AMI heart failure in the UK is approximately 20% of all those with CHF, and a proportion of approximately 60% for those with CHF having LVSD [18].


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  		Table 1 Comorbidity of myocardial infarction (MI) in mainly UK population studies of CHF or Left Ventricular Systolic Dysfunction (LVSD)

 
There is some evidence that the proportion of heart failure caused by AMI may be considerably greater than 20% in the UK:
  1. One study [19] (Table 1), involving clinically diagnosed heart failure patients (n=188), found that 53% of the heart failure patients had myocardial infarction as a co-morbidity.
  2. The weighted average incidence of in-hospital heart failure following admission for AMI, obtained from 14 population-based or consecutive hospital admissions studies, was found to be 37% (range 19–51%) [20]. In 2001/2002, there were an estimated 110,000 NHS admissions for AMI [21].

The estimated number of incident cases/episodes of post-AMI heart failure would therefore be approximately 40,000, which is considerable greater than the 10,000–20,000 cases that would be expected if only 20% of heart failures were the result of AMI. This range has been reflected in the estimation of the burden of post-AMI heart failure described below.

3.2. The economic burden of "all cause" heart failure in the UK
Several studies have been conducted to estimate the direct economic burden of CHF on healthcare in the United Kingdom. A prevalence-based approach was used to estimate the economic burden of CHF to the NHS in 1990/1991 [14]. The prevalence rate for CHF in the UK in this study was assumed to be 10 per 1000 based on the Framingham study [7]. Several assumptions were made in the analysis. The number of hospital admissions was limited to those patients with a primary discharge diagnosis of CHF resulting in a conservative estimate of NHS costs in the UK. The total annual direct healthcare cost of heart failure to the NHS in 1990/1991 was estimated to be £360 million. This represented over 1% of the total NHS budget. Costs due to hospital admission accounted for approximately 60% of the total healthcare costs.

The 4th National Survey of Morbidity in General Practice (MSGP4) carried out in 1991–1992 investigated the impact of CHF on primary care services in the UK [15]. This 1-year prospective cohort study of 502,482 patients registered with 60 volunteer general practices in England and Wales examined conditions seen in general practice over a 12-month period. The date, place of contact, reason for each consultation, consultation types and referral types were recorded by the Office of Population Census and Surveys (now the Office for National Statistics) where each diagnosis was assigned an International Classification of Diseases Ninth Revision (ICD9) code. The comparative healthcare resource utilisation were as follows:

  • Patients with CHF had higher general practice consultation rates than patients without heart failure, rate ratio=2.6 (11.6 vs. 4.5 consultations per patient per year). Among CHF patients increasing age was associated with fewer consultations (13.3 for those aged 45–64 years compared to 11.1 consultations per patient per year for those aged ≥75 years).
  • The mean number of home visits increased with age for all patients. Overall, the number of home visits for CHF patients was 4.0 per patient per year, increasing to 4.8 for those aged ≥75 years.
  • Patients with heart failure had higher rates of referral to secondary care compared to patients without heart failure, rate ratio=3.0 (0.5 referrals per patient per year compared to 0.2 for those without CHF).

The Heart of England Screening study [22] estimated the healthcare cost of CHF to the UK NHS in 2000. This prevalence-based screening study used a combination of echocardiography and clinical examination using European Society of Cardiology criteria to diagnose CHF [23]. Hospitalisations for CHF were based on a primary diagnosis. The total cost of CHF to the NHS in the UK was estimated to be approximately £626 million for 2000, of which hospital in-patient care accounted for 61% of the total expenditure (Table 2). The prevalence estimate used for the number of CHF patients in the UK was conservative, limited to those with "definite" heart failure and excluding those with "probable" heart failure. If all those with "definite" and "probable" heart failure were included the estimated total direct costs to the NHS would have been approximately £845 million.


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  		Table 2 A prevalence-based estimate of the healthcare cost to the UK NHS in 2000 (adapted from Ref. [22])

 
The cost of heart failure to the National Health Service in the UK in 1995 and 2000 was extrapolated from contemporary Scottish data [24]. Estimates of prevalence, healthcare utilisation and costs were applied on an age and sex-specific basis to official mid-year population estimates for the UK. Initial analyses calculated the major costs associated with the management of heart failure for the calendar year 1995. Further analysis, using a combination of current and extrapolated data, calculated the cost of heart failure in the calendar year 2000. The results are summarised in Table 3:
  • 1995 direct costs of heart failure were estimated as 1.8% of total NHS expenditure (£716 million, excluding nursing home costs of approximately £106 million).
  • Including the direct costs of hospital admissions with secondary diagnosis of heart failure increases the cost to approximately 3.5% of total expenditure (£1,361 million).
  • The corresponding estimates for 2000 were 1.9% (approximately £905 million) and 3.6% of total NHS expenditure, excluding nursing home costs.

This analysis did not evaluate indirect costs such as those due to premature retirement, time off work, or reduced productivity while at work, as heart failure is primarily a disease of the elderly (≥65 years).


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  		Table 3 Population, prevalence-based estimates of the cost of heart failure to the UK NHS over the period 1995–2000 (adapted from Ref. [24])

 
3.3. Estimating the economic burden of heart failure following AMI in the UK
The economic burden of post-AMI heart failure in the UK in 2000 has been derived from the direct costs to the NHS of "all cause" heart failure [22,24]. Given the uncertainty in the proportion of patients whose heart failure is of AMI aetiology, this has been estimated under two scenarios:
  1. Base-case estimate: approximately 20% of "all cause" heart failure cases in the UK have a post-AMI aetiology.
  2. Upper estimate: approximately 50% of "all cause" heart failure cases in the UK have a post-AMI aetiology.

Base-case estimate (Table 4, Fig. 1):

  • The number of people with post-AMI heart failure in the UK for the year 2000 was estimated to be approximately 130,000 to 202,000 [22,24]. (11,000 to 17,000 in Scotland1 and 119,000 to 185,000 in England and Wales).
  • The estimated direct healthcare costs to the NHS for post-AMI heart failure in the UK for the year 2000 is therefore £125 million to £181 million. (£11–15 million in Scotland and £114–£166 million in England and Wales).
  • If hospital admissions with secondary diagnosis of heart failure were included the total direct costs to the NHS would have been approximately £344 million.
  • The annual direct costs of post-AMI heart failure in the UK were estimated as approximately 0.4% of total NHS healthcare expenditure for the year 2000 (based on hospital admissions with a primary diagnosis of heart failure only).
  • The estimated nursing homes costs would be approximately £27 million in UK for the year 2000. (£2 million in Scotland and £25 million in England and Wales).


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  		Table 4 Summary of the economic burden of post-MI heart failure in the UK in 2000

 


Figure 1
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  		Fig. 1 Estimated disaggregated direct healthcare costs (£ millions) of post-AMI heart failure in UK (2000)-baseline estimate.

 
Upper estimate (Table 4, Fig. 2):
  • The number of people with post-AMI heart failure in the UK for the year 2000 was estimated to be approximately 325,000 to 505,000 [22,24] (28,000 to 43,000 in Scotland and 297,000 to 462,000 in England and Wales).
  • The estimated direct healthcare costs to the NHS for post-AMI heart failure in the UK for the year 2000 is therefore £313 million to £453 million (£27–£39 million in Scotland and £286–£414 million in England and Wales).
  • The annual direct costs of post-AMI heart failure in the UK were estimated to account for approximately 1% of total NHS healthcare expenditure for the year 2000 (based on hospital admissions with a primary diagnosis of heart failure only).
  • The estimated nursing homes costs would be approximately £68 million in UK for the year 2000 (£6 million in Scotland and £62 million in England and Wales).


Figure 2
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  		Fig. 2 Estimated disaggregated direct healthcare costs (£ millions) of post-AMI heart failure in UK (2000)-upper estimate.

 
Estimates for the direct costs of post-AMI heart failure to the NHS and nursing home costs are summarised in Table 4.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
Notes
 References
 
This study has some limitations. The economic burden of post-AMI heart failure has been derived from "all cause" heart failure in the UK. The principal uncertainty in this estimation is therefore the proportion of patients whose heart failure is of AMI aetiology. Most of the evidence would suggest that approximately 20% of heart failure in the UK is of AMI aetiology (Table 1), with approximately 40–60% of heart failure having an aetiology of ischaemic heart disease. However, there is some evidence that the proportion of heart failure caused by AMI may be as high as 50% in the UK.

This uncertainty in the estimate of the proportion of heart failure that is of AMI aetiology has been addressed by providing base-case and upper estimates for the direct costs of post-AMI heart failure to the NHS and nursing home costs. This results in wide ranges for the estimated costs. An alternative approach would be to carry out a UK population-based economic study to quantify the economic burden of post-AMI heart failure directly.

The direct costs of post-AMI heart failure to the NHS for both scenarios investigated are likely to be under-estimates since only hospital admissions with a primary diagnosis of heart failure were included in the estimates. If hospital admissions with a secondary diagnosis of heart failure were included, costs to the NHS would be approximately 90% higher (Figs. 1 and 2, [24]).

These costs are likely to increase over time. The numbers of patients developing post-AMI heart failure in Scotland (and by extrapolation to the UK as a whole) may increase by more than 20% between 2000 and 2020, mainly as a result of the aging of the UK population [24]. It has also been predicted that the numbers of patients developing heart failure will also rise as a result of increasing survival rates after AMI, as heart failure is an inevitable sequel in a significant proportion of survivors [17]. However, two US studies found that the proportion of patients with AMI who developed heart failure during hospitalisation declined between 1975–1995 and 1979–1994, respectively [25,20].

In conclusion, heart failure resulting from AMI is conservatively estimated to have cost the NHS in the UK at least £125–181 million in 2000, with a further £27 million spent on nursing home costs.


   Notes
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Notes
References
 
1 Scottish population estimate is based on a population of 5.1 million, 8.5% of the total UK population of 59.8 million. Back


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

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