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West-German Heart Center, Cardiology, University Hospital Essen Economic burden of patients with various etiologies of chronic systolic heart failure analyzed by resource use and costs J. Biermann1,2, A. Neumann2, C.E. Angermann3, R. Erbel1, B. Maisch4, D. Pittrow5, V. Regitz-Zagrosek6, T. Scheffold7, R. Wachter8, G. Gelbrich9, J. Wasem2, T. Neumann1 on behalf of the German Competence Network Heart Failure 1 Clinic of Cardiology, University Hospital Essen, Essen, Germany | 2 Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany | 3 Department of Internal Medicine I and Comprehensive Heart Failure Center, University Hospital Würzburg, Germany | 4 Department of Internal Medicine, Cardiology, University Hospital Giessen and Marburg, Marburg, Germany | 5 Department for Clinical Pharmacology, Medical Faculty, Carl Gustav Carus, Technical University of Dresden, Germany | 6 Department of Cardiovascular Diseases in Women, Charité University Medicine, Berlin, Germany | 7 Institute for Heart and Circulation Research, University of Witten/Herdecke, Dortmund, Germany | 8 Department of Cardiology and Pneumology, Georg-August University Göttingen, Göttingen, Germany | 9 Clinical Trial Centre Leipzig (KKS), University of Leipzig, Leipzig, Germany Correspondence: Prof. Dr. Till Neumann, Janine Biermann | Clinic of Cardiology, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany | Phone: +49(0)201-723-4806 | Mail: [email protected], [email protected] Purpose Results Chronic heart failure is a major cardiac disease, going along with a high economic burden. Diagnostic and therapy differ depending on etiology of chronic heart failure. The present work analyses disease-related resource use and associated costs of systolic chronic heart failure with respect to the etiology of the disease. The following results are based on 2,710 patients (female 25.2%; 62.9 ± 13.6 years) of the CNHF with systolic CHF (table 1). The mean LVEF in the patient population was 31.3 ± 9.0%. Of all patients, 61.3% had a LVEF between 30 and 50 %, whereas 38.7% had LVEF <30%. The most common cause of heart failure was dilated cardiomyopathy (47.4%), followed by coronary artery disease (33.5%). The majority of patients were in NYHA functional classes II (51.7%) and III (38.1%). During one year, patients had on average 6.1 contacts to their general practitioner, 1.7 contacts to cardiologists and 0.8 hospital stays per year (see table 2). Overall care costs per patient were 3,150€ per year. Costs of inpatient care were the largest component of direct costs (2,622€) thus representing 83%. Costs of medication (290€) and outpatient physician contacts (238€) were significantly lower (see table 3 and figure 1). Over-average costs of heart failure care appeared in patients with hypertrophic cardiomyopathy (4,681€) and dilated cardiomyopathy (3,596€), while patients with heart failure due to coronary artery disease (3,046€) and arterial hypertension (1,039€) exhibited significantly lower resource use and costs per year. Methods From the database of the German Competence Network Heart Failure, 2,710 individuals with systolic chronic heart failure (mean age 62.9 years ± 13.6, 25.2% female, 89.8% NYHA II/III) were included into analyses. Resource use was assessed with regard to outpatient contacts, hospitalizations including rehabilitation, and drug utilization. Table 1. Patient characteristics n (%) DCM CAD 1,285 (47.4) 907 (33.5) HHD HCM NCD Total 117 (4.3) 41 (1.5) 360 (13.3) 2710 (100) Table 3. Annual costs per patient (€) Sex (% female) BMI [kg/m2] 56.5 ± 13.6 69.0 ± 10.3 71.6 ± 10.0 56.5 ± 12.6 67.9 ± 11.1 62.9 ± 13.6 23.2 22.5 41.9 39.0 32.5 25.2 27.6 ± 4.9 27.6 ± 4.8 29.0 ± 5.9 27.3 ± 5.6 27.6 ± 5.1 27.6 ± 5.0 Haemodynamics Systolic BP 119.2 ± 18.0 123.8 ± 19.6 136.2 ± 23.2 123.6 ± 18.6 127.9 ± 21.3 122.7 ± 19.7 Diastolic BP 73.4 ± 11.4 72.3 ± 11.4 77.5 ± 12.4 74.4 ± 10.5 74.7 ± 12.2 73.4 ± 11.6 76.9 ± 16.4 74.3 ± 16.0 80.9 ± 18.4 73.0 ± 16.0 78.1 ± 19.5 76.3 ± 16.9 Heart rate [min-1] NYHA [n (%)] Class I 105 (8.2) 52 (5.7) 3 (2.6) 3 (7.3) 34 (9.4) 197 (7.3) II 666 (51.8) 473 (52.1) 66 (56.4) 19 (46.3) 177 (49.2) 1401 (51.7) III 477 (37.1) 357 (39.4) 44 (37.6) 17 (41.5) 138 (38.3) 1033 (38.1) IV 37 (2.9) 25 (2.8) 4 (3.4) 2 (4.9) 11 (3.1) 79 (2.9) Echocardiography LVEF [%] 28.8 ± 8.8 33.1 ± 8.4 34.4 ± 8.5 36.4 ± 8.8 34.2 ± 8.6 31.3 ± 9.0 LVDD [mm] 66.7 ± 9.5 59.0 ± 9.1 57.1 ± 8.3 53.1 ± 9.5 58.8 ± 8.9 62.4 ± 10.1 All values expressed as mean ± SD. BMI: Body mass index, BP: Blood pressure, CAD: Coronary artery disease, DCM: dilated cardiomyopathy, HCM: hypertrophic cardiomyopathy, HHD: hypertensive heart disease, LVEF: left ventricular ejection fraction, LVDD: left ventricular end-diastolic diameter, NCD: not clearly determined, NYHA: New York Heart Association Functional Classification. CAD HHD HCM NCD Total 265 220 155 429 193 238 General practitioner 119 122 105 154 109 118 Cardiologist 146 98 50 275 85 120 Subtotal Medication 336 258 221 250 232 290 Beta blockers 93 92 69 78 81 90 ACE inhibitors 23 22 21 20 20 23 AT1 receptor antagonists 36 39 46 11 34 37 Aldosterone antagonists 142 84 56 114 70 109 Cardiac glycosides 42 21 28 28 28 32 2,730 2,155 575 3,707 1,638 2,328 Subtotal Physician Hospital (inpatient stays) Rehabilitation (inpatient) ∑ 265 412 88 294 294 294 3,597 3,046 1,039 4,681 2,358 3,150 All costs were adjusted for the year 2009. CAD: coronary artery disease, DCM: dilated cardiomyopathy, HCM: hypertrophic cardiomyopathy, HHD: hypertensive heart disease, NCD: not clearly determined. Table 2. Etiology-related resource use Demographics Age DCM number DCM CAD HHD HCM NCD Total Figure 1. Cost structure 9% Contacts to General Practitioner 8% 9% 0-1 41.5% 35.0% 51.3% 31.7% 39.2% 39.3% 2-4 24.1% 29.0% 17.1% 22.0% 27.2% 25.8% 5-12 21.7% 24.3% 19.7% 31.7% 22.8% 22.8% >12 12.6% 11.8% 12.0% 14.6% 10.8% 12.1% 6.2 ± 8.8 6.3 ± 9.6 5.4 ± 8.0 8.0 ± 9.9 5.6 ± 8.2 6.1 ± 9.0 0-1 50.0% 63.7% 81.2% 34.2% 71.7% 58.5% 2-4 40.9% 31.8% 17.1% 46.3% 22.8% 34.5% Subtotal Physician Subtotal Medication 5-12 8.2% 4.1% 1.7% 14.6% 5.3% 6.2% Hospital (inpatient stays) Rehabilitation (inpatient) >12 0.9% 0.4% 0.0% 4.9% 0.3% 0.7% 2.1 ± 2.8 1.4 ± 2.0 0.7 ± 1.3 4.0 ± 5.2 1.2 ± 1.9 1.7 ± 2.5 Mean ± SD Contacts to Cardiologist Mean ± SD 74% Inpatient Hospital Stays 0 44.6% 54.5% 82.1% 41.5% 59.4% 51.4% 1 32.5% 30.2% 16.2% 26.8% 29.4% 30.6% 2+ 22.9% 15.3% 1.7% 31.7% 11.1% 18.0% 1.0 ± 1.2 0.8 ± 1.3 0.2 ± 0.4 1.3 ± 1.5 0.6 ± 0.9 0.8 ± 1.2 91.4% Mean ± SD Inpatient Rehabilitation Stays 0 91.2% 89.9% 97.4% 90.2% 93.9% 1+ 8.8% 10.1% 2.6% 9.8% 6.1% 8.6% 0.09 ± 0.3 0.14 ± 0.8 0.03 ± 0.2 0.1 ± 0.3 0.1 ± 0.5 0.1 ± 0.5 Mean ± SD All values expressed as mean ± SD. CAD: Coronary artery disease, DCM: dilated cardiomyopathy, HCM: hypertrophic cardiomyopathy, HHD: hypertensive heart disease, NCD: not clearly determined. Conclusions Heart failure is associated with a high economic burden. Patients with non-vascular forms of heart failure require an over-average resource use primarily due to hospital admissions. Efficient treatment strategies have to consider these aspects for optimizing care and to delimitate the economic costs of heart failure care. Declaration of interest No declarations of interest