• Users Online: 260
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 92-97

The cost of heart failure: Principles, processes, prospects, and pitfalls

1 Department of Medicine, University of Ibadan; Department of Medicine, University College Hospital Ibadan, Ibadan, Nigeria
2 Department of Medicine, University College Hospital Ibadan, Ibadan, Nigeria
3 Department of Chemical Pathology, University College Hospital, Ibadan, Nigeria

Date of Submission06-Jul-2020
Date of Decision26-Jul-2020
Date of Acceptance09-Aug-2020
Date of Web Publication13-Nov-2021

Correspondence Address:
Dr. Okechukwu Samuel Ogah
Department of Medicine, University of Ibadan, Oyo
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njc.njc_21_20

Rights and Permissions

Heart failure (HF) is currently a global public health issue. It affects about 37 million people worldwide. The incidence and prevalence of HF increase with age, and it is the most common cause of hospitalizations in people aged 65 years and above based on data from high-income countries of Western Europe, North America, and Japan. HF burden is also projected to increase in countries undergoing demographic and epidemiologic transitions. It is associated with high health-care cost, and this has been supported by data from different parts of the world. The aim of this short review is to present a brief description of the principles, processes, prospects, and pitfalls involved in the estimation or quantification of the economic costs of HF.

Keywords: Cardiac failure, cost, economic burden, economic cost, heart failure

How to cite this article:
Ogah OS, Orimolade OA, Ogah F, Adeyanju T. The cost of heart failure: Principles, processes, prospects, and pitfalls. Nig J Cardiol 2020;17:92-7

How to cite this URL:
Ogah OS, Orimolade OA, Ogah F, Adeyanju T. The cost of heart failure: Principles, processes, prospects, and pitfalls. Nig J Cardiol [serial online] 2020 [cited 2022 Nov 26];17:92-7. Available from: https://www.nigjcardiol.org/text.asp?2020/17/2/92/330422

  Introduction Top

Heart failure (HF) is now recognized as a global public health problem. Data from high-income countries of North America and Western Europe show that it affects about 37 million people worldwide.[1],[2] The prevalence of HF at the population level is between 0.4% and 2.2% based on data from high-income countries of North America and Western Europe.[1],[2] There are between 500,000 and 600,000 incident cases diagnosed in those countries annually. The incidence and prevalence of HF increase with age. It is the most common cause of hospitalizations in people aged 65 years and above.[1] The implication is that HF burden is likely going to increase in countries undergoing demographic and epidemiologic transition.[3] Furthermore, the rate of the global population is rising, and this is projected to increase by 4% in the next 15 years from 12.3% in 2015 to 16.5% in 2030.[1] HF is associated with high health-care cost.[4] This has been supported by data from different parts of the world.[5],[6] The purpose of this paper is to conduct a scoping review of the economic cost of HF with emphasis on the principles, prospects, and pitfalls.

  Global Burden of Heart Failure Top

The global burden of HF is rising. The incidence and prevalence are also high globally.[1] There are over half a million new cases annually in these countries.[1],[7] There are about a million HF admissions annually in advanced countries of Western Europe and North America, and this constitutes about 1%–2% of the total hospital admissions.[1] The length of admission for HF is relatively longer than many other conditions. Readmission is also common.[1] About a quarter are readmitted in 3 months after discharge. HF admission and readmission is a major driver of the total health-care expenditure in many countries.[4],[8] It is responsible for about 2% of the health-care budget in many advanced countries of the world.[4],[8] This has been demonstrated by data from the USA,[9] the United Kingdom,[10],[11],[12] Sweden,[13] The Netherlands,[12],[14] and Nigeria[15] among others.

  Potential Benefits of Cost of Illness Study in Heart Failure Top

Cost of illness (COI) study in HF is principally a descriptive way of assessing the economic burden imposed by HF on the society. It is used to measure and value contributions of relevant components in the care of HF as well as the co-existing medical conditions.

COI study in HF helps to provide the policymakers and the public with the necessary and relevant information on the impact of HF at the population level.[16] It helps to identify the main drivers of HF cost so that resource allocation can be done efficiently and effectively. It can also help in the development of compelling and innovative strategies to counteract the effects of HF. In addition, it helps to improve our understanding of the economic burden HF places on the individual, society, and health-care providers.[16] COI study in HF helps in identifying areas where resources may be allocated in the management of the disease. For example, it has been shown that cost increases with the severity of the disease. Policymakers can therefore allocate more resources to multidisciplinary approach in HF care such as ambulatory HF programs, home-based care by clinical nurses, telehealth programs, and health education.[16]

  Processes of Cost of Illness Studies Top

A good COI study must follow specified processes and follow a standard pattern of data collection and reporting.

  Definition of Illness Top

HF must be properly defined in any cost of HF study. The type, severity, and clinical profile of HF must be well characterized and defined. This must be based on clinical criteria (such as the Framingham criteria)[17],[18],[19] or clinical guidelines (such as the American College of Cardiology Foundation/American Heart Association[20] and the European Society of Cardiology guidelines)[21] or a combination of these. The International Classification of Diseases (ICD) coding system[22] can also be used. The major diagnostic classification of disease and the diseases and disorders of the circulatory system classification may also be used.[23]

Furthermore, HF may be classified into primary and secondary cases. The definition of HF is important as it helps to understand what the cost estimate represents.

  Source of Information Top

Information on HF diagnosis may be obtained from patients' record, HF registry database, health-care database and insurance claim database. Other sources include observational studies, official statistics, cross-sectional data of household surveys and from published studies.

Valuation of cost of HF can be based on national tariff, hospital tariff, health-care claims, health-care database, hospital billing data, expert opinion, and diagnosis-related or group-adjusted valuation.

  Documentation of Severity of Heart Failure Top

It is imperative to document the severity of HF as it has been shown that the cost of HF increases with HF severity. Tools employed include New York Heart Association (NYHA) functional classification, use of echocardiography, use of clinical diagnostic data as well as expert panel review.

  Perspectives in Cost of Heart Failure Studies Top

Various perspectives are used in HF cost studies. The common cost perspectives are the societal perspective, health-care provider perspective, insurance company perspective, and patient-oriented perspective. Health-care system perspective includes only the medical costs. Societal perspective includes medical, nonmedical cost, out-of-pocket payments, and productivity loss costs.

  Epidemiologic Approaches in Heart Failure Cost Estimation Top

Like other disease cost estimation, HF cost evaluation follows two epidemiological approaches: the incidence and prevalence-based approach.

Prevalence approach

Here, the prevalent HF cases who are seen over a specified period usually 1 year are evaluated.[24],[25] The estimate is at certain point in time regardless of the onset of HF. Data obtained can be used to calculate the annual cost of HF per patient as well as cost per hospitalization.

Incidence approach

In this approach, the lifetime costs attributed to HF are focused upon. It measures how cost of HF changes from onset and develops over the progression of the disease. It can be estimated over the person's lifetime after the diagnosis, over a certain period of time, and during the final 2 years of life. One disadvantage is that it can underestimate the cost of HF.[24],[25]

  Resource Quantification Top

Two methods are often employed: person-based approach (bottom-up approach) and the population-based approach (top-down method).[24],[25]

Person-based approach (bottom-up approach)

In this method, costs are assigned to individuals with HF (real-time assignment).[24],[25]

Population-based approach (top-bottom method)

In this approach, part of the aggregated costs is allocated to HF.[24],[25]

  Cost Disaggregation Top

This may be divided into direct and indirect costs. Another method is to disaggregate along the line of:

  • Medical costs: Outpatient cost, inpatient cost, primary health-care services, diagnostic tests, medications, surgery, and procedures
  • Nonmedical cost: Transportation, hospice care, nursing home care, and formal care
  • Societal cost: Productivity loss cost due to the illness incurred by the patient or the caregiver.

  Resource Utilization Top

Inpatient cost

Inpatient cost depends on the length of hospital stay, whether primary or secondary HF (primary HF usually more expensive), use of supportive medication or procedure (which increase cost), the NYHA class (the higher the class, the higher the cost), whether the hospital is urban or rural (urban hospital costs are more than rural), and the presence of comorbidities (which increase HF cost).

Medication cost

This includes the cost of HF medications such as diuretics, ACEI/ARB/sacubitril + valsartan, beta-blockers, nitrates, and digoxin. The more the medications a patient use, the higher the cost.

Diagnostics cost

This includes the cost of hematological, biochemical, microbiological, radiological, electrocardiograph, echocardiogram, and others. The more the diagnostic tests, the higher the cost.

Surgery and procedure cost

These include the cost of coronary artery bypass graft, percutaneous interventions, pacemaker implantations, and ICD and CRT implantations.

Indirect inpatient cost

This includes the cost of productivity loss and costs of informal care. Productivity cost uses the human capital approach based on the annual salary of the subject and the number of days of lost work. Informal care is estimated using the proxy good approach based on the official wage of formal caregiver or the lowest mean hourly wage in three commodities.[24]

Outpatient care

This can also be categorized into direct and indirect costs.

Direct cost includes the cost of outpatient visits, other hospital cares such as surgical visits, nurse visits, and nurse/doctor telephone calls. It also includes physician fee or nurse fee, operational cost, medication cost, diagnostic tests, outpatient surgeries and procedures, and transport cost.[24] Like inpatient cost, indirect outpatient cost includes the cost due to productivity loss and cost of outpatient informal care.

Distribution and driver of heart failure care cost

In many recent and previous studies, the main driver of cost of HF is inpatient cost. It is responsible for 50%–67% of HF care cost.[4],[5] However, in most of these studies, the cost of care is underestimated because most did not capture the cost of indirect. [Table 1] shows the distribution of cost in some HF cost studies.
Table 1: Cost of illness studies in HF: Summary of main study characteristics

Click here to view

Predictors of cost of heart failure

Some of the identified predictors include NYHA functional class, presence of renal dysfunction, increasing age, presence of diabetes, and other comorbidities, for example, coronary artery disease, chronic obstructive pulmonary disease, hypertension, and number of hospitalizations.[29],[30],[31],[32],[33],[34],[37],[40]

Sensitivity analysis in heart failure cost estimation

Because COI study is prone to a lot of uncertainties, a sensitivity analysis is therefore required to test the robustness of the cost estimate to the key variables, and this provides the opportunity to identify the important variables.[24]

Summary of recent studies of heart failure cost

[Figure 1] shows the comparison of recent HF cost using international dollar in different parts of the world.
Figure 1: The cost of heart failure in different parts of the world in international Dollar

Click here to view

Problems and pitfalls in heart failure cost estimation

There is a lot of diversity in the definition of HF in many costs of HF studies. Nondisclosure or lack of clarity on the diagnosis of HF is often a problem in comparing studies. Many studies did not validate their diagnosis with echocardiography. Type of HF is not often reported. Most studies did not disclose the perspective under which their costing was based. Many did not include indirect cost in their estimates. The severity of HF was not included in many studies. Differences in epidemiologic approaches employed by different authors also pose problem in comparing studies.

There is also variation in the study population, for example, inpatients, outpatients, and primary care. There is also variation in cost components used in cost estimation. In some studies, there is a total lack of cost disaggregation. The source of data most often varies.

  Conclusions Top

HF is a growing public health issue worldwide. This is likely going to be worse in the future in view of the growing and aging world population, especially in low- and middle-income countries. It is associated with high economic burden.

Various workers have tried to estimate the cost of HF in different countries and settings. Interpretation and comparison of these data are often difficult because of the variation in methodologies. Nevertheless, robust COI data are needed in order to ensure equitable distribution of resources, especially strategies geared toward reduction of HF-related admission.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Savarese G, Lund LH. Global public health burden of heart failure. Card Fail Rev 2017;3:7-11.  Back to cited text no. 1
Farré N, Vela E, Clèries M, Bustins M, Cainzos-Achirica M, Enjuanes C, et al. Real world heart failure epidemiology and outcome: A population-based analysis of 88,195 patients. PLoS One 2017;12:e0172745.  Back to cited text no. 2
Sibetcheu AT, Agbor VN, Nyaga UF, Bigna JJ, Noubiap JJ. Epidemiology of heart failure in pediatric populations in low- and middle-income countries: A protocol for a systematic review. Syst Rev 2018;7:52.  Back to cited text no. 3
Cook C, Cole G, Asaria P, Jabbour R, Francis DP. The annual global economic burden of heart failure. Int J Cardiol 2014;171:368-76.  Back to cited text no. 4
Lesyuk W, Kriza C, Kolominsky-Rabas P. Cost-of-illness studies in heart failure: A systematic review 2004-2016. BMC Cardiovasc Disord 2018;18:74.  Back to cited text no. 5
Shafie AA, Tan YP, Ng CH. Systematic review of economic burden of heart failure. Heart Fail Rev 2018;23:131-45.  Back to cited text no. 6
Vasan RS, Xanthakis V, Lyass A, Andersson C, Tsao C, Cheng S, et al. Epidemiology of left ventricular systolic dysfunction and heart failure in the framingham study: An echocardiographic study over 3 decades. JACC Cardiovasc Imaging 2018;11:1-1.  Back to cited text no. 7
Berry C, Murdoch DR, McMurray JJ. Economics of chronic heart failure. Eur J Heart Fail 2001;3:283-91.  Back to cited text no. 8
O'Connell JB, Bristow MR. Economic impact of heart failure in the United States: time for a different approach. J Heart Lung Transplant 1994;13:S107-12.  Back to cited text no. 9
Stewart S, Jenkins A, Buchan S, McGuire A, Capewell S, McMurray JJ. The current cost of heart failure to the National Health Service in the UK. Eur J Heart Fail 2002;4:361-71.  Back to cited text no. 10
Cleland JG. Health economic consequences of the pharmacological treatment of heart failure. Eur Heart J 1998;19:P32-9.  Back to cited text no. 11
McMurray 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;6:99.  Back to cited text no. 12
Rydén-Bergsten T, Andersson F. The health care costs of heart failure in Sweden. J Intern Med 1999;246:275-84.  Back to cited text no. 13
Meerding WJ, Bonneux L, Polder JJ, Koopmanschap MA, van der Maas PJ. Demographic and epidemiological determinants of healthcare costs in Netherlands: Cost of illness study. BMJ 1998;317:111-5.  Back to cited text no. 14
Ogah OS, Stewart S, Onwujekwe OE, Falase AO, Adebayo SO, Olunuga T, et al. Economic burden of heart failure: Investigating outpatient and inpatient costs in Abeokuta, Southwest Nigeria. PLoS One 2014;9:e113032.  Back to cited text no. 15
Clabaugh G, Ward MM. Cost-of-illness studies in the United States: A systematic review of methodologies used for direct cost. Value Health 2008;11:13-21.  Back to cited text no. 16
Lloyd-Jones DM. The risk of congestive heart failure: Sobering lessons from the Framingham Heart Study. Curr Cardiol Rep 2001;3:184-90.  Back to cited text no. 17
Jimeno Sainz A, Gil V, Merino J, García M, Jordán A, Guerrero L. Validity of Framingham criteria as a clinical test for systolic heart failure. Rev Clin Esp 2006;206:495-8.  Back to cited text no. 18
McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: The framingham study. N Engl J Med 1971;285:1441-6.  Back to cited text no. 19
Yancy C, Jessup M, Bozkurt B, Butler J, Casey Jr D, Drazner M, et al. 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation. 2013;128:e240.  Back to cited text no. 20
McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The task force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European society of cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012;33:1787-847.  Back to cited text no. 21
Slee VN. The international classification of diseases: Ninth revision (ICD-9) Ann Intern Med 1978;88:424-6.  Back to cited text no. 22
Nakajima H, Yano K, Nagasawa K, Kobayashi E, Yokota K. Examination of the Difference in medical treatment contents according to major diagnostic category of hospital group I and group II using the diagnosis procedure combination survey data. Nihon Eiseigaku Zasshi 2015;70:230-41.  Back to cited text no. 23
Larg A, Moss JR. Cost-of-illness studies: A guide to critical evaluation. Pharmacoeconomics 2011;29:653-71.  Back to cited text no. 24
Evers S, Goossens M, de Vet H, van Tulder M, Ament A. Criteria list for assessment of methodological quality of economic evaluations: Consensus on Health Economic Criteria. Int J Technol Assess Health Care 2005;21:240-5.  Back to cited text no. 25
Stafylas P, Farmakis D, Kourlaba G, Giamouzis G, Tsarouhas K, Maniadakis N, et al. The heart failure pandemic: The clinical and economic burden in Greece. Int J Cardiol 2017;227:923-9.  Back to cited text no. 26
Lee H, Oh SH, Cho H, Cho HJ, Kang HY. Prevalence and socio-economic burden of heart failure in an aging society of South Korea. BMC Cardiovasc Disord 2016;16:215.  Back to cited text no. 27
Murphy TM, Waterhouse DF, James S, Casey C, Fitzgerald E, O'Connell E, et al. A comparison of HFrEF vs HFpEF's clinical workload and cost in the first year following hospitalization and enrollment in a disease management program. Int J Cardiol 2017;232:330-5.  Back to cited text no. 28
Voigt J, Sasha John M, Taylor A, Krucoff M, Reynolds MR, Michael Gibson C. A reevaluation of the costs of heart failure and its implications for allocation of health resources in the United States. Clin Cardiol 2014;37:312-21.  Back to cited text no. 29
Corrao G, Ghirardi A, Ibrahim B, Merlino L, Maggioni AP. Burden of new hospitalization for heart failure: A population-based investigation from Italy. Eur J Heart Fail 2014;16:729-36.  Back to cited text no. 30
Czech M, Opolski G, Zdrojewski T, Dubiel JS, Wizner B, Bolisęga D, et al. The costs of heart failure in Poland from the public payer's perspective. Polish programme assessing diagnostic procedures, treatment and costs in patients with heart failure in randomly selected outpatient clinics and hospitals at different levels of care: POLKARD. Kardiol Pol 2013;71:224-32.  Back to cited text no. 31
Delgado JF, Oliva J, Llano M, Pascual-Figal D, Grillo JJ, Comín-Colet J, et al. Health care and nonhealth care costs in the treatment of patients with symptomatic chronic heart failure in Spain. Rev Esp Cardiol (Engl Ed) 2014;67:643-50.  Back to cited text no. 32
Dunlay SM, Shah ND, Shi Q, Morlan B, VanHouten H, Long KH, et al. Lifetime costs of medical care after heart failure diagnosis. Circ Cardiovasc Qual Outcomes 2011;4:68-75.  Back to cited text no. 33
Bogner HR, Miller SD, de Vries HF, Chhatre S, Jayadevappa R. Assessment of cost and health resource utilization for elderly patients with heart failure and diabetes mellitus. J Card Fail 2010;16:454-60.  Back to cited text no. 34
Zugck C, Müller A, Helms TM, Wildau HJ, Becks T, Hacker J, et al. Health economic impact of heart failure: An analysis of the nationwide German database. Dtsch Med Wochenschr 2010;135:633-8.  Back to cited text no. 35
Neumann T, Biermann J, Erbel R, Neumann A, Wasem J, Ertl G, et al. Heart failure: The commonest reason for hospital admission in Germany: Medical and economic perspectives. Dtsch Arztebl Int 2009;106:269-75.  Back to cited text no. 36
Liao L, Anstrom KJ, Gottdiener JS, Pappas PA, Whellan DJ, Kitzman DW, et al. Long-term costs and resource use in elderly participants with congestive heart failure in the Cardiovascular Health Study. Am Heart J 2007;153:245-52.  Back to cited text no. 37
Agvall B, Borgquist L, Foldevi M, Dahlström U. Cost of heart failure in Swedish primary healthcare. Scand J Prim Health Care 2005;23:227-32.  Back to cited text no. 38
Ory C, Vanderplas A, Dezii C, Chang E. Congestive heart failure: Attributable costs within the managed care setting. J Pharm Financ Econ Policy 2005;14:87.  Back to cited text no. 39
Liao L, Jollis JG, Anstrom KJ, Whellan DJ, Kitzman DW, Aurigemma GP, et al. Costs for heart failure with normal vs reduced ejection fraction. Arch Intern Med 2006;166:112-8.  Back to cited text no. 40


  [Figure 1]

  [Table 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Global Burden of...
Potential Benefi...
Processes of Cos...
Definition of Il...
Source of Inform...
Documentation of...
Perspectives in ...
Epidemiologic Ap...
Resource Quantif...
Cost Disaggregation
Resource Utilization
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded151    
    Comments [Add]    

Recommend this journal