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1.
PLoS One ; 14(12): e0226750, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31856265

RESUMEN

PURPOSE: This study examined postoperative heart failure (HF) and respiratory failure (RF) complications and related healthcare utilization for one year following cardiac surgery. METHODS: This study identified adult patients undergoing isolated coronary artery bypass graft (CABG) and/or valve procedures from the Cerner Health Facts® database. It included patients experiencing postoperative HF or RF complications. We quantified healthcare utilization using the frequency of inpatient admissions, emergency department (ED) visits with or without hospital admission, and outpatient visits. We then determined direct hospital costs from the determined healthcare utilization. We analyzed trends over time for both HF and RF and evaluated the association between surgery type and HF complication. RESULTS: Of 10,298 patients with HF complications, 1,714 patients (16.6%) developed persistent HF; of the 10,385 RF patients, 175 (1.7%) developed persistent RF. Healthcare utilization for those with persistent complications over the one-year period following index hospital discharge comprised an average number of the following visit types: Inpatient (1.49 HF; 1.55 RF), Outpatient (2.02, 0.51), ED without hospital admission (0.33, 0.13), ED + Inpatient (0.08, 0.06). Per patient annual costs related to persistent complications of HF and RF were $20,857 and $30,745, respectively. There was a significant association between cardiac surgical type and the incidence of HF, with risk for isolated valve procedures (adjusted OR 2.60; 95% CI: 2.35-2.88) and CABG + valve procedures (adjusted OR 2.38; 95% CI: 2.17-2.61) exceeding risk for isolated CABG procedures. CONCLUSIONS: This study demonstrates that HF and RF complication rates post cardiac surgery are substantial, and complication-related healthcare utilization over the first year following surgery results in significant incremental costs. Given the need for both payers and providers to focus on healthcare cost reduction, this study fills an important gap in quantifying the mid-term economic impact of postoperative cardiac surgical complications.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Costos y Análisis de Costo , Insuficiencia Cardíaca/epidemiología , Complicaciones Posoperatorias/epidemiología , Utilización de Procedimientos y Técnicas/estadística & datos numéricos , Insuficiencia Respiratoria/epidemiología , Adolescente , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos/economía , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Femenino , Insuficiencia Cardíaca/economía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/economía , Utilización de Procedimientos y Técnicas/economía , Insuficiencia Respiratoria/economía , Estados Unidos
2.
Adv Exp Med Biol ; 1193: 89-106, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31368099

RESUMEN

Heart failure (HF) is a structural or functional cardiac abnormal syndrome characterized with series of symptoms and signs such as breathlessness, fatigue, pulmonary crackles, and peripheral edema. Being a terminal phase of most myocardial lesions, HF has become a leading cause of mobility and mortality worldwide, associated with heavy clinical burden and economic costs affecting over 23 million people [14]. There is an increase to 5.5% with systolic dysfunction and an increase to 36.0% with diastolic dysfunction in people 60 years or older [85]. The costs accompanied with heart failure stand 2-3% of the total healthcare system expenditure in high-income countries and are expected to increase >2-fold in the next 2 decades [34].


Asunto(s)
Aldehído Deshidrogenasa/genética , Insuficiencia Cardíaca/genética , Costos de la Atención en Salud , Insuficiencia Cardíaca/economía , Humanos
3.
PLoS One ; 14(6): e0217696, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31216301

RESUMEN

BACKGROUND: Approximately 28% of adults have ≥3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress. METHODS AND FINDINGS: To determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, 'other'). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R2 = 0.36) in claims paid/beneficiary. CONCLUSIONS: Identifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.


Asunto(s)
Diabetes Mellitus/epidemiología , Insuficiencia Cardíaca/epidemiología , Enfermedades Renales/epidemiología , Medicare/economía , Afecciones Crónicas Múltiples/epidemiología , Organizaciones Responsables por la Atención/economía , Anciano , Diabetes Mellitus/economía , Femenino , Costos de la Atención en Salud , Insuficiencia Cardíaca/economía , Humanos , Enfermedades Renales/economía , Masculino , Persona de Mediana Edad , Afecciones Crónicas Múltiples/economía , Estados Unidos
4.
J Manag Care Spec Pharm ; 25(6): 705-713, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31134861

RESUMEN

BACKGROUND: Evidence suggests that cost sharing adversely affects appropriate prescription drug use for chronic disorders. However, few studies have evaluated this effect in heart failure (HF), the most common cause of hospitalization in Medicare. OBJECTIVE: To determine whether spending on HF pharmacotherapy by Medicare Part D enrollees was associated with prescription refill adherence. METHODS: This correlational study used pooled data from the 2010-2012 Medicare Current Beneficiary Survey (MCBS). The analysis sample consisted of community-dwelling MCBS participants with self-reported HF and continuous Part D coverage during the year of participation. 3 drug classes were analyzed independently: beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs). 1,448 weighted participant-year records (derived from 964 individuals) met the inclusion criteria, of which 846 (58%) were included for beta-blockers, 633 (44%) for ACE inhibitors, and 229 (16%) for ARBs. Spending was measured by average out-of-pocket payment for the relevant prescription, standardized to a 30-day supply, as a percentage of average monthly income. Adherence was measured by the medication possession ratio (MPR): total days supplied for all but the last refill divided by number of days between the first and last fills of the year. RESULTS: Accounting for sampling weights, the median (interquartile range) monthly income was $1,472 ($949-$2,466), and average percentage of monthly income spent on a 30-day medication supply was 0.22% for beta-blockers, 0.19% for ACE inhibitors, and 0.90% for ARBs. Mean MPR was 88.9% for beta-blockers, 88.5% for ACE inhibitors, and 90.4% for ARBs. Risk-adjusted models showed that percentage of income spent on a beta-blocker prescription was directly associated with odds of nonadherence (MPR < 80%), odds ratio = 1.38, 95% CI = 1.01-1.89, P = 0.045, and inversely associated with beta-blocker MPR, B = -4.17, SE = 1.23, P = 0.001. No such association was observed for ACE inhibitors or ARBs. CONCLUSIONS: Price sensitivity was evident for beta-blockers but not for antiangiotensin drugs, despite very low out-of-pocket costs and high adherence. This study is relevant to value-based pricing of HF management drugs in Part D plans. DISCLOSURES: No outside funding supported this study. Butler has served as a paid consultant or advisor on unrelated projects for Amgen, Array, Astra Zeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, CVRx, G3, Innolife, Janssen, Medtronic, Merck, Novartis, Relypsa, Stealth Peptide, SC Pharma, Vifor, and ZS Pharma. The other authors have no potential conflicts of interest to declare. An early version of this paper was presented as a poster at Sigma Theta Tau International's 28th Nursing Research Congress; July 27-31, 2017; Dublin, Ireland.


Asunto(s)
Gastos en Salud/estadística & datos numéricos , Insuficiencia Cardíaca/tratamiento farmacológico , Medicare Part D/economía , Cumplimiento de la Medicación/estadística & datos numéricos , Medicamentos bajo Prescripción/economía , Anciano , Anciano de 80 o más Años , Seguro de Costos Compartidos/economía , Seguro de Costos Compartidos/estadística & datos numéricos , Femenino , Insuficiencia Cardíaca/economía , Humanos , Masculino , Medicare Part D/estadística & datos numéricos , Medicamentos bajo Prescripción/uso terapéutico , Estados Unidos
5.
J Med Econ ; 22(8): 814-817, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31038380

RESUMEN

Aims: This study aimed to examine the long-term clinical and economic burden of adults with congenital heart disease (ACHD) in Hong Kong. Methods: It retrospectively analyzed 336 consecutive ACHD patients who attended the Adult Congenital Heart Clinic between January 1, 2009 and December 31, 2014. Direct medical costs and clinical outcomes over the 5 years were calculated and documented. The economic evaluation was from the hospital's perspective. Results: The median age of ACHD patients was 47 (31-62) years old, with female predominance (61.5%). Ventricular and atrial septal defects accounted for 70% and severe ACHD for 10% of the study cohort. The prevalence of arrhythmia and heart failure increased with the complexity of CHD. The total mean annual cost for managing each ACHD patient was USD 2,913. The annual cost of management of simple ACHD was USD 2,638 vs complex ACHD (USD 6,425) (p = 0.013). Conclusions: This study demonstrated severe ACHD patients accounted for higher cardiovascular morbidities in arrhythmias and heart failure with a higher cost of management.


Asunto(s)
Cardiopatías Congénitas/epidemiología , Insuficiencia Cardíaca/economía , Adulto , Anciano , Arritmias Cardíacas/epidemiología , Costo de Enfermedad , Femenino , Gastos en Salud/estadística & datos numéricos , Recursos en Salud/economía , Recursos en Salud/estadística & datos numéricos , Servicios de Salud/economía , Servicios de Salud/estadística & datos numéricos , Cardiopatías Congénitas/economía , Cardiopatías Congénitas/fisiopatología , Insuficiencia Cardíaca/epidemiología , Hong Kong , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores Socioeconómicos
6.
Eur Heart J Acute Cardiovasc Care ; 8(7): 660-666, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-30977391

RESUMEN

AIMS: Registries have reported large inter-hospital differences in intensive care unit admission rates for patients with acute heart failure, but little is known about the potential economic impact of over-admission of low-risk patients with heart failure to higher cost intensive care units. We described the variability in intensive care unit admission practices, the provision of critical care therapies, and estimated the potential national cost savings if all hospitals adopted low intensive care unit admission practices for patients admitted with heart failure. METHODS: Using a national population health dataset, we identified 349,693 heart failure admission hospitalisations with a primary diagnosis of heart failure between 2007 and 2016. Hospitals were categorised as low (first quartile), medium (second and third quartile) and high (fourth quartiles) intensive care unit utilisation. RESULTS: The mean intensive care unit admission rate was 16.4% (inter-hospital range 0.3-51%) including 5.4% in low, 14.5% in medium and 30% in high utilisation hospitals. Intensive care unit therapies in low, medium and high intensive care unit utilisation hospitals were 54.5%, 45.1% and 24.1% (P<0.001), respectively and the inhospital mortality rate was not significantly different. The proportion of hospital costs incurred by intensive care unit care was 7.8% in low, 19.8% in medium and 28.2% in high (P<0.001) admission hospitals. The potential cost savings of altering intensive care unit utilisation practices for patients with heart failure was CAN$234.8m over the study period. CONCLUSIONS: In a national cohort of patients hospitalised with heart failure, we observed that low intensive care unit utilisation centres had lower hospital costs with no differences in mortality rates. The development of standardised admission criteria for high-cost and high acuity intensive care unit beds could reduce costs to the healthcare system.


Asunto(s)
Cuidados Críticos/economía , Costos de la Atención en Salud/tendencias , Insuficiencia Cardíaca/economía , Hospitalización/economía , Aceptación de la Atención de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Canadá/epidemiología , Femenino , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/terapia , Humanos , Masculino , Morbilidad/tendencias , Estudios Retrospectivos
7.
J Am Coll Cardiol ; 73(9): 1004-1012, 2019 03 12.
Artículo en Inglés | MEDLINE | ID: mdl-30846093

RESUMEN

BACKGROUND: The Medicare Hospital Readmissions Reduction Program has led to fewer readmissions following hospitalizations with a principal diagnosis of heart failure (HF). Patients with HF are frequently hospitalized for other causes. OBJECTIVES: This study sought to compare trends in Medicare risk-adjusted, 30-day readmissions following principal HF hospitalizations and other hospitalizations with HF. METHODS: This was a retrospective study of 12,973,853 Medicare hospitalizations with a principal or secondary diagnosis of HF between January 2008 and June 2015. Hospitalizations were categorized as follows: principal HF hospitalizations; principal acute myocardial infarction or pneumonia hospitalizations with secondary HF; and other hospitalizations with secondary HF. The study examined trends in risk-adjusted, 30-day, all-cause readmission rates for each cohort and trends in differences in readmission rates among cohorts by using linear spline regression models. RESULTS: Before passage of the Affordable Care Act in March 2010, risk-adjusted, 30-day readmission rates were stable for all 3 cohorts, with mean monthly rates of 26.1%, 24.9%, and 24.4%, respectively. Risk-adjusted readmission rates started declining after passage of the Affordable Care Act by 1.09% (95% confidence interval [CI]: 0.51% to 1.68%), 1.24% (95% CI: 0.92% to 1.57%), and 1.05% (95% CI: 0.52% to 1.58%) per year, respectively, until implementation of the Hospital Readmissions Reduction Program in October 2012 and then stabilized for all 3 cohorts. CONCLUSIONS: Patients with HF are often hospitalized for other causes, and these hospitalizations have high readmission rates. Policy changes led to decreases in readmission rates for both principal and secondary HF hospitalizations. Readmission rates in both groups remain high, suggesting that initiatives targeting all hospitalized patients with HF continue to be warranted.


Asunto(s)
Insuficiencia Cardíaca/terapia , Medicare/estadística & datos numéricos , Readmisión del Paciente/tendencias , Anciano de 80 o más Años , Causas de Muerte/tendencias , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/epidemiología , Humanos , Masculino , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiología
8.
Recenti Prog Med ; 110(1): 23-32, 2019 Jan.
Artículo en Italiano | MEDLINE | ID: mdl-30720014

RESUMEN

BACKGROUND: Heart failure (HF) is commonly reported, it is estimated to affect 10% of subjects aged over 70 years. Objectives of this study were to describe clinical and demographic characteristics of patients with HF diagnosis, to analyze therapeutic pathways and to estimate healthcare resources consumption. METHODS: Data on patients aged ≥18 years with a hospitalization discharge diagnosis of HF between 01/01/2010 and 31/12/2014 and in treatment with HF-related drugs were extracted from the administrative databases of the Italian Local Health Unit of Barletta-Andria-Trani (BT). We described the pharmacological treatment prescribed and the use of drugs in combination both at the beginning and at the end of the 12-month follow-up period. The costs analysis was conducted with the perspective of the Italian National Health System. RESULTS: A total of 2 669 patients with HF were enrolled in the study, 1 960 as primary and 709 as secondary diagnosis (average age 77.0±10.4/76.5±11.1 years respectively, 49% and 55% were male, respectively). Mortality during 12 months of follow-up was 46% and 43% respectively. Mostly prescribed pharmacological treatments were diuretics (90.4% of patients with primary HF diagnosis and 79.4% of patients with secondary HF diagnosis), beta-blockers (53.7% and 58.8%, respectively) and aldosterone antagonists (57.5% and 42.5%, respectively); moreover, during the follow-up period, half of the patients presented a switch from the original therapy and 10% of the patients required an add-on. Healthcare resource consumption for patients discharged alive was € 11 872.4 for patients with primary diagnosis and € 12 493.7 for patients with secondary diagnosis of HF. Cost for hospitalizations during follow-up was around € 3 800 (32.3% of total costs) and € 3 600 (29.0% of total costs), respectively. CONCLUSIONS: Our findings are in accordance with what already published, both in a National and International context, on mortality rates in HF patients and related costs for the National Healthcare System. Results from the present study highlight the under-prescriptions of ACEi/ARBs, aldosterone antagonists and beta-blockers in HF patients.


Asunto(s)
Costos de la Atención en Salud/estadística & datos numéricos , Insuficiencia Cardíaca/tratamiento farmacológico , Hospitalización/estadística & datos numéricos , Antagonistas Adrenérgicos beta/uso terapéutico , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Diuréticos/uso terapéutico , Femenino , Estudios de Seguimiento , Recursos en Salud/economía , Recursos en Salud/estadística & datos numéricos , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/mortalidad , Hospitalización/economía , Humanos , Italia , Masculino , Persona de Mediana Edad , Antagonistas de Receptores de Mineralocorticoides/uso terapéutico
9.
Card Electrophysiol Clin ; 11(1): 1-9, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30717841

RESUMEN

"Heart failure is a global pandemic that is becoming an increasingly common diagnosis due to aging of the population and increased longevity. Understanding the scope and costs of current heart failure management will lead to improved health economic decision making. Interventions to reduce spending in heart failure care have been centered on reduction of readmissions, improvement in transitions of care, and innovations in technology that have further improved quality of life. Technological advancements in outpatient monitoring offers the hope of further reducing morbidity, mortality, and cost in heart failure."


Asunto(s)
Análisis Costo-Beneficio , Insuficiencia Cardíaca , Enfermedad Crónica , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/terapia , Humanos , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida
10.
Expert Rev Pharmacoecon Outcomes Res ; 19(4): 397-408, 2019 08.
Artículo en Inglés | MEDLINE | ID: mdl-30747011

RESUMEN

INTRODUCTION: Unlike the adult heart failure (HF) patient population, there is scarce information on the overall burden of HF in the pediatric population across geographies and within different age groups. AREAS COVERED: A systematic review aims to describe and quantify the economic, humanistic, and societal burden of pediatric (age <18 years) HF on patients and caregivers. Eighteen published studies over a period of 10 years (1 January 2006-20 May 2016) were identified through Embase, Medline, Cochrane Library and selected congresses. Studies from the US reported higher HF-related hospitalization-rates in infants aged <1 year (49.3%-63.9%) versus children aged 1-12 years (18.7%-30.9%) in HF diagnosed patients. Across the studies, the average length of hospital stay was 15 days, increasing to 26 days for infants. Average annual hospital charges were higher for infants (US$176,000) versus children aged 1-10 years (US$132,000) in the US. In Germany, diagnosis-related group (DRG)-based hospital-allowances per HF-case increased from €3,498 in 1995 to €4,250 in 2009. EXPERT OPINION: To our knowledge, this is the first systematic review, which provides valuable insights into the burden of HF in children and adolescents, and strengthens current knowledge of pediatric HF. However, there is a need for larger population-based studies with wider geographical coverage.


Asunto(s)
Costo de Enfermedad , Insuficiencia Cardíaca/epidemiología , Hospitalización/estadística & datos numéricos , Adolescente , Factores de Edad , Cuidadores/estadística & datos numéricos , Niño , Preescolar , Insuficiencia Cardíaca/economía , Costos de Hospital/estadística & datos numéricos , Hospitalización/economía , Humanos , Lactante , Recién Nacido , Tiempo de Internación/estadística & datos numéricos
11.
Circ Heart Fail ; 12(1): e005171, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30630340

RESUMEN

BACKGROUND: Hospitalizations for acute heart failure (HF) are significant events with downstream implications for patients, as well as healthcare systems and payers. However, from anecdotal experience, both hospitalization and postdischarge courses vary significantly based on severity of presenting decompensation. METHODS AND RESULTS: We compared patient and hospitalization characteristics, resource utilization, and associated outcomes, among modern era acute HF patients enrolled in the GWTG-HF (Get With the Guidelines-Heart Failure) registry between 2011 and 2016, by varying severity of their acute HF. Among over 165 000 hospitalizations included in our analysis, 2% were considered high-risk and 32% intermediate-risk for in-hospital mortality, similar to findings from 15 years prior. Further, the 1-year mortality rate was 40% among Medicare beneficiaries in GWTG-HF who survived to hospital discharge. CONCLUSIONS: The long-term outcomes among acute HF survivors remain poor and, in the context of an increasing HF burden, warrant further study of postdischarge management strategies including inpatient-to-clinic transitions and ambulatory HF systems-based care.


Asunto(s)
Recursos en Salud , Insuficiencia Cardíaca/terapia , Hospitalización , Anciano , Anciano de 80 o más Años , Femenino , Recursos en Salud/economía , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/mortalidad , Costos de Hospital , Mortalidad Hospitalaria , Hospitalización/economía , Humanos , Masculino , Persona de Mediana Edad , Admisión del Paciente , Alta del Paciente , Readmisión del Paciente , Pronóstico , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Estados Unidos
12.
ESC Heart Fail ; 6(2): 254-261, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30620150

RESUMEN

AIMS: Heart failure (HF) is a clinical syndrome with significant social and economic burden. We aimed to estimate the burden of HF in mainland Portugal over a 22-year time horizon, between 2014 and 2036. METHODS AND RESULTS: Heart failure burden was measured in disability-adjusted life years (DALYs), resulting from the sum of years of life lost (YLL) due to premature death and years lost due to disability (YLD). YLL were estimated based on the Portuguese mortality rates reported by the European Detailed Mortality Database. For YLD, disease duration and the overall incidence were estimated using an epidemiological model developed by the World Health Organization (DISMOD II). Disability weights were retrieved from published literature. The impact of ageing was estimated with a shift-share analysis using official demographic projections. In 2014, 4688 deaths were attributed to HF, corresponding to 4.7% of the total deaths in mainland Portugal. DALYs totalled 21 162, 53.9% due to premature death (YLL: 11 398) and 46.1% due to disability (YLD: 9765). Considering only population ageing over a 22-year horizon, the deaths and burden of HF are expected to increase by 73.0% and 27.9%, respectively, reaching 8112 deaths and 27 059 DALYs lost due to HF in 2036. DALY's growth is mainly driven by the increase of YLL, whose contribution to overall burden will increase to 62.0%. CONCLUSIONS: Heart failure is an emerging and growing health problem where significant health gains may be obtained. The projected significant increase of HF burden highlights the need to set HF as a priority for healthcare system.


Asunto(s)
Costo de Enfermedad , Personas con Discapacidad/estadística & datos numéricos , Predicción , Insuficiencia Cardíaca/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/economía , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Mortalidad Prematura/tendencias , Portugal/epidemiología , Años de Vida Ajustados por Calidad de Vida , Estudios Retrospectivos
13.
J Card Fail ; 25(1): 27-35, 2019 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-30485789

RESUMEN

BACKGROUND: Merging United Network for Organ Sharing (UNOS) and Pediatric Health Information Systems databases has enabled a more granular analysis of pediatric heart transplant outcomes and resource utilization. We evaluated whether transplant indication at time of transplantation was associated with mortality, resource utilization, and inpatient costs during the first year after transplantation. METHODS AND RESULTS: We analyzed transplant outcomes and resource utilization from 2004 to 2015. Patients were categorized as congenital (CHD), myocarditis, or cardiomyopathy based on UNOS-defined primary indication. CHD complexity subgroup analyses (single-ventricle, complex, and simple biventricular CHD) were also performed. Of 2251 transplants (49% CHD, 5% myocarditis, 46% cardiomyopathy), CHD recipients were younger (2 [IQR 0-10], 6 [IQR 0-12], and 7 [IQR 1-14] years, respectively; P < .001) and less likely to have a ventricular assist device (VAD) at transplantation (3%, 27%, and 13%, respectively; P < .001). Patients with single-ventricle CHD had the longest time on the waitlist and were least likely to receive a VAD before transplantation. After adjusting for patient-level factors, transplant recipients with single-ventricle CHD had the greatest mortality during transplantation admission and within 1 year (odds ratio [OR] 11.8 [95% confidence interval (CI) 5.9-23.6] and OR 6.0 [95% CI 3.6-10.2], respectively, vs cardiomyopathy). Mortality was similar between patients with myocarditis and cardiomyopathy. Post-transplantation length of stay (LOS) was longer in transplant recipients with CHD than myocarditis or cardiomyopathy (25 [interquartile range [IQR] 15-45] vs 21 [IQR 12-35] vs 16 [IQR 12-25] days; P < .001), related in part to longer duration of intensive care unit-level care (ICU LOS 8 [IQR 4-20] vs 6 [IQR 4-13] vs 5 [IQR 3-8] days; P < .001). Similarly, patients with CHD had higher median post-transplantation costs than myocarditis or cardiomyopathy ($415K [IQR $201K-503K] vs $354K [IQR $179K-390K] vs $284K [IQR $145K-319K]; P < .001) that persisted after adjusting for patient-level factors (adjusted cost ratio 1.4 [95% CI 1.4-1.5], CHD vs cardiomyopathy) and was primarily driven by longer LOS. More than 50% were readmitted during the first year after transplantation, although readmission rates were similar across transplant indications (P = .42). CONCLUSIONS: Children with CHD, particularly single-ventricle patients, require substantially greater hospital resource utilization and have significantly worse outcomes during the first year after heart transplantation compared with other indications. Further work is aimed at identifying modifiable pre-transplantation risk factors, such as pre-transplantation conditioning with VAD support and cardiac rehabilitation, to improve post-transplantation outcomes and reduce resource utilization in this complex population.


Asunto(s)
Bases de Datos Factuales , Sistemas de Información en Salud , Insuficiencia Cardíaca/mortalidad , Trasplante de Corazón/mortalidad , Costos de Hospital , Aceptación de la Atención de Salud , Adolescente , Niño , Preescolar , Análisis de Datos , Bases de Datos Factuales/economía , Bases de Datos Factuales/tendencias , Femenino , Sistemas de Información en Salud/economía , Sistemas de Información en Salud/tendencias , Recursos en Salud/economía , Recursos en Salud/tendencias , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/terapia , Trasplante de Corazón/economía , Trasplante de Corazón/tendencias , Costos de Hospital/tendencias , Hospitalización/economía , Humanos , Lactante , Masculino , Mortalidad/tendencias , Estudios Retrospectivos
14.
Am J Cardiol ; 123(3): 355-360, 2019 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-30502047

RESUMEN

The PIONEER AF-PCI trial demonstrated that in atrial fibrillation patients who underwent intracoronary stenting, either rivaroxaban 15 mg daily plus P2Y12 inhibitor monotherapy (Group 1) or 2.5 mg rivaroxaban twice daily plus dual antiplatelet therapy (DAPT) (Group 2) was associated with fewer recurrent hospitalizations, primarily for bleeding and cardiovascular events, compared with standard-of-care vitamin K antagonist and DAPT (Group 3). Associated costs are unknown. This study estimates costs associated with rivaroxaban strategies compared with vitamin K antagonist and DAPT. Medication costs were estimated using wholesale acquisition costs, medication discontinuation rates, and costs of monitoring. Using a large US healthcare claims database, the mean adjusted increase in 1-year cost of care for individuals with atrial fibrillation and percutaneous coronary intervention (PCI) rehospitalized for bleeding, cardiovascular, and other events was compared with those not rehospitalized. Using adjudicated rehospitalization rates from PIONEER AF-PCI, cost differences were estimated. Rates of rehospitalization for bleeding were 6.5%, 5.4%, 10.5%, and 20.3%, 20.3%, 28.4% for cardiovascular events in Groups 1, 2, and 3. Medication and monitoring costs were $3,942, $4,115, and $1,703. One-year costs for all recurrent hospitalization costs and/or patient for the groups were $24,535, $20,205, and $29,756. One-year cost increase associated with bleeding rehospitalizations and/or patient was $4,160, $3,212, and $6,876 and was $13,264, $11,545, and $17,220 for cardiovascular rehospitalizations and/or patient. Overall estimated cost per patient was $28,476, $24,320, and $31,458. Compared with warfarin, both rivaroxaban treatment strategies had higher medication costs, but these were more than accounted for by fewer hospitalizations.


Asunto(s)
Anticoagulantes/economía , Anticoagulantes/uso terapéutico , Fibrilación Atrial/terapia , Readmisión del Paciente/economía , Anciano , Monitoreo de Drogas/economía , Quimioterapia Combinada , Femenino , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/epidemiología , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Humanos , Relación Normalizada Internacional , Masculino , Readmisión del Paciente/estadística & datos numéricos , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria/economía , Inhibidores de Agregación Plaquetaria/uso terapéutico , Rivaroxabán/economía , Rivaroxabán/uso terapéutico , Warfarina/economía , Warfarina/uso terapéutico
15.
Eur J Health Econ ; 20(3): 475-482, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30374630

RESUMEN

OBJECTIVES: We sought to explore to what extent the use of Subpopulation Treatment Effect Pattern Plot (STEPP) may help to identify efficient treatment allocation strategy. METHODS: The analysis was based on data from the COACH study, in which 1023 patients with heart failure were randomly assigned to three treatments: care-as-usual, basic support, and intensive support. First, using predicted 18-month mortality risk as the stratification basis, a suitable strategy for assigning different treatments to different risk groups of patients was developed. To that end, a graphical exploration of the difference in net monetary benefit (NMB) across treatment regimens and baseline risk was used. Next, the efficiency gains resulting from this proposed subgroup strategy were quantified by computing the difference in NMB between our stratified approach and the best performing population-wide strategy. RESULTS: The analysis using STEPPs suggested that a differentiated approach, based on offering intensive support to low-risk patients (18-month mortality risk ≤ 0.16) and basic support to intermediate- to high-risk patients (18-month mortality risk > 0.16) would be an economically efficient treatment allocation strategy. This was confirmed in the subsequent cost-effectiveness analysis, where the average gain in NMB resulting from the proposed stratified approach compared to basic support for all was found to be €1312 (95% CI €390-€2346) per patient. CONCLUSIONS: STEPP provides a systematic approach to assess the interaction between baseline risk and the difference in NMB between competing interventions and to identify cutoffs to stratify patients in a health economically optimal manner.


Asunto(s)
Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/mortalidad , Medición de Riesgo/métodos , Gráficos por Computador , Análisis Costo-Beneficio/métodos , Sistemas de Apoyo a Decisiones Clínicas , Técnicas de Apoyo para la Decisión , Economía Médica , Humanos , Factores de Riesgo
16.
Int J Cardiol ; 277: 250-257, 2019 Feb 15.
Artículo en Inglés | MEDLINE | ID: mdl-30413306

RESUMEN

BACKGROUND: To evaluate the associations between individual income, all-cause mortality and use of healthcare resources in a very large population of chronic heart failure (CHF) patients living in Catalonia (Spain), where access to public healthcare is granted by law. METHODS AND RESULTS: We used 2016 data from the Catalan Health Surveillance System, a large, exhaustive, administrative healthcare database which includes information on medical diagnoses, healthcare resource use, and individual income for all Catalan residents (N = 7,638,524). Individual annual income was categorized as high (>100,000€), medium (18,000-100,000€), low (<18,000€), and very low (welfare support). Among 155,883 CHF patients, lower individual income was associated with a shorter life expectancy at age 50 (life expectancy for high income patients 22.2 years, for very low income patients 12.8), and were independently associated with higher all-cause mortality adjusting for age, sex, comorbidities, and duration of the CHF diagnosis (odds ratio very low vs. medium income 1.21 [95% CI 1.11, 1.33]). Also, in patients with lower income levels the burden of public healthcare resource use was displaced towards urgent hospitalizations and frequent emergency department visits, as opposed to regular, specialized CHF ambulatory-based care. CONCLUSION: In a very large population of CHF patients with access to universal healthcare, lower income was independently associated with higher mortality and with lower use of ambulatory-based healthcare resources. Our findings suggest that CHF patients may benefit from systematic assessment of their socioeconomic status, as this may aid the identification of vulnerable subgroups who may benefit from tailored health education and management.


Asunto(s)
Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/mortalidad , Renta , Aceptación de la Atención de Salud , Vigilancia de la Población , Cobertura Universal del Seguro de Salud/economía , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Femenino , Insuficiencia Cardíaca/terapia , Humanos , Renta/tendencias , Masculino , Persona de Mediana Edad , España/epidemiología , Cobertura Universal del Seguro de Salud/tendencias
17.
Eur J Heart Fail ; 21(3): 311-318, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30549171

RESUMEN

AIMS: We aimed to identify a 'frequent admitter' phenotype among patients admitted for acute decompensated heart failure (HF). METHODS AND RESULTS: We studied 10 363 patients in a population-based prospective HF registry (2008-2012), segregated into clusters based on their 3-year HF readmission frequency trajectories. Using receiver-operating characteristic analysis, we identified the index year readmission frequency threshold that most accurately predicts HF admission frequency clusters. Two clusters of HF patients were identified: a high frequency cluster (90.9%, mean 2.35 ± 3.68 admissions/year) and a low frequency cluster (9.1%, mean 0.50 ± 0.81 admission/year). An index year threshold of two admissions was optimal for distinguishing between clusters. Based on this threshold, 'frequent admitters', defined as patients with ≥ 2 HF admissions in the index year (n = 2587), were of younger age (68 ± 13 vs 69 ± 13 years), more often male (58% vs. 54%), smokers (38.4% vs. 34.4%) and had lower left ventricular ejection fraction (37 ± 17 vs. 41 ± 17%) compared to 'non-frequent admitters' (< 2 HF admissions in the index year; n = 7776) (all P < 0.001). Despite similar rates of advanced care utilization, frequent admitters had longer length of stay (median 4.3 vs. 4.0 days), higher annual inpatient costs (€ 7015 vs. € 2967) and higher all-cause mortality at 3 years compared to the non-frequent admitters (adjusted odds ratio 2.33, 95% confidence interval 2.11-2.58; P < 0.001). CONCLUSION: 'Frequent admitters' have distinct clinical characteristics and worse outcomes compared to non-frequent admitters. This study may provide a means of anticipating the HF readmission burden and thereby aid in healthcare resource distribution relative to the HF admission frequency phenotype.


Asunto(s)
Costo de Enfermedad , Insuficiencia Cardíaca , Readmisión del Paciente/estadística & datos numéricos , Anciano , Análisis por Conglomerados , Femenino , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/terapia , Hospitalización/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Uso Excesivo de los Servicios de Salud/estadística & datos numéricos , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Factores Sexuales
18.
ESC Heart Fail ; 6(1): 111-121, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30338668

RESUMEN

AIMS: There are indications that economic crises can affect public health. The aim of this study was to describe characteristics, health status, and socio-economic status of outpatient heart failure (HF) patients several years after a national economic crisis and to assess whether socio-economic factors were associated with patient-reported outcome measures (PROMs). METHODS AND RESULTS: In this cross-sectional survey, PROMs were measured with seven validated instruments, as follows: self-care (the 12-item European Heart Failure Self-Care Behaviour scale), HF-related knowledge (Dutch Heart Failure Knowledge Scale), symptoms (Edmonton Symptom Assessment System), sense of security (Sense of Security in Care-'Patients' evaluation'), health status (EQ-5D visual analogue scale), health-related quality of life (HRQoL) (Kansas City Cardiomyopathy Questionnaire), and anxiety and depression (Hospital Anxiety and Depression Scale). Additional data were collected on access and use of health care, household income, demographics, and clinical status. The patients' (n = 124, mean age 73 ± 14.9, 69% male) self-care was low for exercising (53%) and weight monitoring (50%) but optimal for taking medication (100%). HF-specific knowledge was high (correct answers 12 out of 15), but only 38% knew what to do when symptoms worsened suddenly. Patients' sense of security was high (>70% had a mean score of 5 or 6, scale 1-6). The most common symptom was tiredness (82%); 12% reported symptoms of anxiety, and 18% had symptoms of depression. Patients rated their overall health (EQ-5D) on average at 65.5 (scale 0-100), and 33% had poor or very bad HRQoL. The monthly income per household was <€3900 for 84% of the patients. A total of 22% had difficulties making appointments with a general practitioner (GP), and 5% had no GP. On average, patients paid for six health care-related items, and >90% paid for medications, primary care, and visits to hospital and private clinics out of their own pocket. The cost of health care had changed for 71% of the patients since the 2008 economic crisis, and increased out-of-pocket costs were most often explained by a greater need for health care services and medication expenses. There was no significant difference in PROMs related to changes in out-of-pocket expenses after the crisis, income, or whether patients lived alone or with others. CONCLUSIONS: This Icelandic patient population reported similar health-related outcomes as have been previously reported in international studies. This study indicates that even after a financial crisis, most of the patients have managed to prioritize and protect their health even though a large proportion of patients have a low income, use many health care resources, and have insufficient access to care. It is imperative that access and affordable health care services are secured for this vulnerable patient population.


Asunto(s)
Recesión Económica , Estado de Salud , Insuficiencia Cardíaca/epidemiología , Calidad de Vida , Sistema de Registros , Autoinforme , Anciano , Instituciones de Atención Ambulatoria/estadística & datos numéricos , Estudios Transversales , Femenino , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/terapia , Humanos , Islandia/epidemiología , Masculino , Morbilidad/tendencias , Estudios Retrospectivos , Encuestas y Cuestionarios
19.
Ann Thorac Surg ; 107(2): 527-532, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30316859

RESUMEN

BACKGROUND: We evaluated the effects of hospital ownership, classified into three tiers (nonfederal government, not-for-profit, and for-profit hospitals), on in-hospital outcomes after implantation of continuous-flow left ventricular assist devices (LVADs) in the United States from 2009 to 2014. METHODS: Data from the National Inpatient Sample were used to calculate annual national estimates in utilization, in-hospital mortality, major complications, lengths of stay, cost of hospitalization, and disposition at discharge for years 2009 to 2014. Complications were calculated using patient safety indicators and International Classification of Diseases, Ninth Revision, Clinical Modification codes. RESULTS: Of the 3,571 patients (weighted, 17,547) with LVAD implants in the United States between 2009 and 2014, 82.1% were in not-for-profit hospitals, 15.6% in nonfederal government hospitals, and 2.3% in for-profit hospitals. In-hospital mortality significantly decreased over time only in not-for-profit hospitals by average annual change of -7.4% (p = 0.001) and was higher in for-profit hospitals than other tiers of hospital ownership. Our analysis did not suggest any differences in postoperative complications among different hospital ownership types. LVAD implantation in nonfederal government hospitals was associated with the highest cost ($227,930; interquartile range [IQR], $173,259 to $301,566) and implantation in for-profit hospitals was associated with lower cost ($148,406; IQR, $133,149 to $199,317; p = 0.03). The length of stay was similar across the three tiers of hospital ownership. Nonroutine discharge was significantly more frequent in not-for-profit hospitals (73.6%; IQR 69.5% to 77.7%) compared with nonfederal government (48.8%; IQR, 42.4% to 55.1%) and for-profit (59.8%; IQR, 43.0% to 76.6%) hospitals (p < 0.001). CONCLUSIONS: Disparities in in-hospital mortality, cost, and disposition exist between various hospital ownerships during admission for LVAD implant.


Asunto(s)
Insuficiencia Cardíaca/cirugía , Corazón Auxiliar , Costos de Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Hospitales Privados/organización & administración , Propiedad , Complicaciones Posoperatorias/epidemiología , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/economía , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Pacientes Internos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos/epidemiología
20.
J Cardiovasc Pharmacol Ther ; 24(2): 113-119, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30081658

RESUMEN

OBJECTIVES: In the follow-up of patients in a trial of intracoronary sodium nitrite given during primary percutaneous coronary intervention (PCI) after acute myocardial infarction (AMI), we found a reduction in the incidence of major adverse cardiac events (MACEs). Specifically, MACE rates were 5.2% versus 25.0% with placebo at 3 years ( P = .013). Such MACE reductions should also be associated with economic benefit. Thus, we assessed the cost utility of sodium nitrite therapy versus standard primary PCI only. METHODS AND RESULTS: We developed a model to simulate costs and quality-adjusted life years (QALYs) over the first 36 months after ST-Segment Elevation Myocardial Infarction (STEMI). Decision tree analysis was used to assess different potential cardiovascular outcomes after STEMI for patients in both treatment groups. Model inputs were derived from the NITRITE-AMI study. Cost of comparative treatments and follow-up in relation to cardiovascular events was calculated from the United Kingdom National Health Service perspective. Higher procedural costs for nitrite treatment were offset by lower costs for repeat revascularization, myocardial infarction, and hospitalization for heart failure compared to primary PCI plus placebo. Nitrite treatment was associated with higher utility values (0.91 ± 0.19 vs 0.82 ± 0.30, P = .041). The calculated incremental cost-effectiveness ratio of £2177 per QALY indicates a cost-effective strategy. Furthermore, positive results were maintained when input parameters varied, indicating the robustness of our model. In fact, based on the difference in utility values, the cost of nitrite could increase by 4-fold (£2006 per vial) and remain cost-effective. CONCLUSION: This first analysis of sodium nitrite as a cardioprotective treatment demonstrates cost-effectiveness. Although more comparative analysis and assessment of longer follow-up times are required, our data indicate the considerable potential of nitrite-mediated cardioprotection.


Asunto(s)
Costos de los Medicamentos , Infarto del Miocardio/economía , Infarto del Miocardio/prevención & control , Daño por Reperfusión Miocárdica/economía , Daño por Reperfusión Miocárdica/prevención & control , Intervención Coronaria Percutánea/economía , Infarto del Miocardio con Elevación del ST/economía , Infarto del Miocardio con Elevación del ST/terapia , Nitrito de Sodio/administración & dosificación , Nitrito de Sodio/economía , Vasodilatadores/administración & dosificación , Vasodilatadores/economía , Toma de Decisiones Clínicas , Ahorro de Costo , Análisis Costo-Beneficio , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/terapia , Costos de Hospital , Humanos , Modelos Económicos , Infarto del Miocardio/etiología , Daño por Reperfusión Miocárdica/etiología , Intervención Coronaria Percutánea/efectos adversos , Supervivencia sin Progresión , Años de Vida Ajustados por Calidad de Vida , Retratamiento/economía , Nitrito de Sodio/efectos adversos , Medicina Estatal/economía , Factores de Tiempo , Reino Unido , Vasodilatadores/efectos adversos
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