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 Table of Contents  
REVIEW ARTICLE
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
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njc.njc_21_20

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  Abstract 


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 2021 Nov 29];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

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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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  In this article
Abstract
Introduction
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
Conclusions
References
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