With rising United States health care expenditure, estimating current spending for patients with heart failure (HF) informs the value of preventative health interventions.
The purpose of this study ...was to estimate current health care expenditure growth for patients with HF in the United States.
The authors pooled MEPS (Medical Expenditure Panel Survey) data from 2009-2018 to calculate total HF-related expenditure across clinical settings in the United States. A 2-part model adjusted for demographics, comorbidities, and year was used to estimate annual mean and incremental expenditures associated with HF.
In the United States, an average of $28,950 (2018 inflation-adjusted dollars) is spent per year for health care-related expenditure for individuals with HF compared with $5,727 for individuals without HF. After adjusting for demographics and comorbidities, a diagnosis of HF was associated with $3,594 in annual incremental expenditure compared with those without HF. HF-related expenditure increased from $26,864 annual per person in 2009-2010 to $32,955 in 2017-2018, representing a 23% rise over 10 years. In comparison, expenditure on myocardial infarction, type 2 diabetes mellitus, and cancer grew by 16%, 28%, and 16%, respectively. Most of the cost was related to hospitalization: $12,569 per year. Outpatient office-based care and prescription medications saw the greatest growth in cost over the period, 41% and 24%, respectively. Estimated incremental national expenditure for HF per year was $22.3 billion; total annual expenditure for adults with HF was $179.5 billion.
HF is a costly condition for which expenditure is growing faster than that of other chronic conditions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
IMPORTANCE: Heart failure is an established risk factor for postoperative mortality, but how left ventricular ejection fraction and heart failure symptoms affect surgical outcomes is not fully ...described. OBJECTIVES: To determine the risk of postoperative mortality among patients with heart failure at various levels of echocardiographic (left ventricular systolic dysfunction) and clinical (symptoms) severity compared with those without heart failure and to evaluate how risk varies across levels of surgical complexity. DESIGN, SETTING, AND PARTICIPANTS: US multisite retrospective cohort study of all adult patients receiving elective, noncardiac surgery in the Veterans Affairs Surgical Quality Improvement Project database from 2009 through 2016. A total of 609 735 patient records were identified and analyzed with 1 year of follow-up after having surgery (final study follow-up: September 1, 2017). EXPOSURES: Heart failure, left ventricular ejection fraction, and presence of signs or symptoms of heart failure within 30 days of surgery. MAIN OUTCOME AND MEASURE: The primary outcome was postoperative mortality at 90 days. RESULTS: Outcome data from 47 997 patients with heart failure (7.9%; mean SD age, 68.6 10.1 years; 1391 women 2.9%) and 561 738 patients without heart failure (92.1%; mean SD age, 59.4 13.4 years; 50 862 women 9.1%) were analyzed. Compared with patients without heart failure, those with heart failure had a higher risk of 90-day postoperative mortality (2635 vs 6881 90-day deaths; crude mortality risk, 5.49% vs 1.22%; adjusted absolute risk difference RD, 1.03% 95% CI, 0.91%-1.15%; adjusted odds ratio OR, 1.67 95% CI, 1.57-1.76). Compared with patients without heart failure, symptomatic patients with heart failure (n = 5906) had a higher risk (597 deaths 10.11%; adjusted absolute RD, 2.37% 95% CI, 2.06%-2.57%; adjusted OR, 2.37 95% CI, 2.14-2.63). Asymptomatic patients with heart failure (n = 42 091) (2038 deaths crude risk, 4.84%; adjusted absolute RD, 0.74% 95% CI, 0.63%-0.87%; adjusted OR, 1.53 95% CI, 1.44-1.63), including the subset with preserved left ventricular systolic function (1144 deaths 4.42%; adjusted absolute RD, 0.66% 95% CI, 0.54%-0.79%; adjusted OR, 1.46 95% CI, 1.35-1.57), also experienced elevated risk. CONCLUSIONS AND RELEVANCE: Among patients undergoing elective noncardiac surgery, heart failure with or without symptoms was significantly associated with 90-day postoperative mortality. These data may be helpful in preoperative discussions with patients with heart failure undergoing noncardiac surgery.
Coding of systolic function in heart failure is important, but the accuracy is uncertain.
We used data from a chart review of VA heart failure hospitalizations from 2006 to 2013. Trained abstractors ...determined the documented diagnosis of heart failure and the left ventricular ejection fraction (LVEF). We compared this LVEF with the primary and secondary International Classification of Disease, 9th edition, codes for heart failure for the same hospitalization. Among 43,044 hospitalizations for heart failure, the primary discharge diagnosis was coded as systolic heart failure in 18%, diastolic heart failure in 17%, and other heart failure codes in 65%. For an LVEF <40%, a systolic heart failure code had a sensitivity of 29% and a positive predictive value of 76%. The code for systolic heart failure was used more frequently over time, with sensitivity increasing from 16% to 37% but at the expense of the positive predictive value, which decreased from 80% to 74%. The overall area under the receiver operating characteristic curve for the relationship between LVEF and the systolic heart failure code was 0.71. Using LVEF >50% to define diastolic heart failure led to a sensitivity of 29% for a diastolic heart failure code, with a positive predictive value of 78%. In multivariate analysis, a systolic heart failure code had an odds ratio for 1-year mortality of 1.1 (95% confidence interval 1.03–1.17) compared to not having a systolic heart failure code.
Coding for systolic and diastolic heart failure is associated with LVEF, but the accuracy is too poor to substitute for the documented LVEF in performance measurement.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Background The contribution of diabetes to the burden of heart failure (HF) remains largely undescribed. Assessing diabetes temporal trends among US patients hospitalized with HF, and their ...relation with quality measures, in real-world practice can help to define this burden. Methods Using data from the Get With the Guidelines–Heart Failure registry, we assessed temporal trends in diabetes prevalence among patients with HF, and in subgroups with reduced ejection fraction (HFrEF - EF <40%), borderline EF (HFbEF - 40% ≤ EF< 50%), or preserved EF (HFpEF - EF ≥50%), hospitalized between 2005 and 2015. Logistic regression was used to assess whether in-hospital outcomes and HF quality of care were related to trends. Results Among 364,480 HF hospitalizations, 160,171 had diabetes (44.0% overall, 41.8% in HFrEF, 46.7% in HFbEF, 45.5% in HFpEF). There was a temporal increase in diabetes frequency in HF patients (43.2% to 45.8%; Ptrend < 0.0001), including among those with HFrEF (42.0% to 43.6%; Ptrend < 0.0001), HFbEF (46.0% to 49.2%; Ptrend < 0.0001), or HFpEF (43.6% to 46.8%, Ptrend < 0.0001). Diabetic patients had a longer hospital stay (adjusted odds ratio aOR: 1.14, 95%CI: 1.12–1.16), but lower in-hospital mortality (aOR: 0.93 0.89–0.97) compared to those without diabetes, with limited differences in quality measures. Temporal trends in diabetes were not associated with in-hospital mortality or length of stay. There were no temporal interactions of most HF quality measures with diabetes status. Conclusions Approximately 44% of hospitalized HF patients have diabetes, and this proportion has been increasing over the past 10 years, particularly among those patients with new onset HFpEF.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Heart failure with preserved ejection fraction (EF) is a common syndrome, but trends in treatments and outcomes are lacking.
We analyzed data from 275 hospitals in Get With the Guidelines-Heart ...Failure from January 2005 to October 2010. Patients were stratified by EF as reduced EF (EF <40% HF-reduced EF), borderline EF (40%≤EF<50% HF-borderline EF), or preserved (EF ≥50% HF-preserved EF). Using multivariable models, we examined trends in therapies and outcomes. Among 110 621 patients, 50% (55 083) had HF-reduced EF, 14% (15 184) had HF-borderline EF, and 36% (40 354) had HF-preserved EF. From 2005 to 2010, the proportion of hospitalizations for HF-preserved EF increased from 33% to 39% (P<0.0001). In multivariable analyses, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers at discharge decreased in all EF groups, and β-blocker use increased. Patients with HF-preserved EF less frequently achieved blood pressure control (adjusted odds ratio, 0.44 versus HF-reduced EF; P<0.001) and were more likely discharged to skilled nursing (adjusted odds ratio, 1.16 versus HF-reduced EF; P<0.001). In-hospital mortality for HF-preserved EF decreased from 3.32% in 2005 to 2.35% in 2010 (adjusted odds ratio, 0.89 per year; P=0.01) but was stable for patients with HF-reduced EF (3.03%-2.83%; adjusted odds ratio, 0.93 per year; P=0.10).
Hospitalization for HF-preserved EF is increasing relative to HF-reduced EF. Although in-hospital mortality for patients with HF-preserved EF declined over the study period, an important opportunity remains for identifying evidence-based therapies in patients with HF-preserved EF.
The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ...ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.
A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
Early heart failure (HF) recognition can reduce morbidity, yet HF is often initially diagnosed only after a patient clinically worsens. We sought to identify characteristics that predict diagnosis in ...the acute care setting versus the outpatient setting.
We estimated the proportion of incident HF diagnosed in the acute care setting (inpatient hospital or emergency department) versus outpatient setting based on diagnostic codes from a claims database covering commercial insurance and Medicare Advantage between 2003 and 2019. After excluding new-onset HF potentially caused by a concurrent acute cause (eg, acute myocardial infarction), we identified demographic, clinical, and socioeconomic predictors of diagnosis setting. Patients were linked to their primary care clinicians to evaluate diagnosis setting variation across clinicians.
Of 959 438 patients with new HF, 38% were diagnosed in acute care. Of these, 46% had potential HF symptoms in the prior 6 months. Over time, the relative odds of acute care diagnosis increased by 3.2% annually after adjustment for patient characteristics (95% CI, 3.1%-3.3%). Acute care diagnosis setting was more likely for women compared with men (adjusted odds ratio, 1.11 95% CI, 1.10-1.12) and for Black patients compared with White patients (adjusted odds ratio, 1.18 95% CI, 1.16-1.19). The proportion of acute care diagnosis varied substantially (interquartile range: 24%-39%) among clinicians after adjusting for patient-level risk factors.
A large proportion of first HF diagnoses occur in the acute care setting, particularly among women and Black patients, yet many had potential HF symptoms in the months before acute care visits. These results raise concerns that many HF diagnoses are missed in the outpatient setting. Earlier diagnosis could allow for timelier high-value interventions, addressing disparities and reducing the progression of HF.
The economics of heart failure care Wei, Chen; Heidenreich, Paul A.; Sandhu, Alexander T.
Progress in cardiovascular diseases,
January-February 2024, 2024-01-00, Volume:
82
Journal Article
Peer reviewed
Heart failure (HF) poses a significant economic burden in the US, with costs projected to reach $70 billion by 2030. Cost-effectiveness analyses play a pivotal role in assessing the economic value of ...HF therapies. In this review, we overview the cost-effectiveness of HF therapies and discuss ways to improve patient access. Based on current costs, guideline directed medical therapies for HF with reduced ejection fraction provide high economic value except for sodium-glucose cotransporter-2 inhibitors, which provide intermediate economic value. Combining therapy with the four pillars of medical therapy also has intermediate economic value, with incremental cost-effectiveness ratios ranging from $73,000 to $98,500/ quality adjusted life-years. High economic value procedures include cardiac resynchronization devices, implantable cardioverter-defibrillators, and coronary artery bypass surgery. In contrast, advanced HF therapies have previously demonstrated intermediate to low economic value, but newer data appear more favorable. Given the affordability challenges of HF therapies, additional efforts are needed to ensure optimal care for patients. The recent Inflation Reduction Act contains provisions to reform policy pertaining to drug price negotiation and out-of-pocket spending, as well as measures to increase access to existing programs, including the Medicare low-income subsidy. On a patient level, it is also important to encourage patient and physician awareness and discussions surrounding medical costs. Overall, a broad approach to improving available therapies and access to care is needed to reduce the growing clinical and economic morbidity of HF.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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