Financial aspects of heart failure programs of care

Paying for disease management

Disease Management (DM) first appeared in the United States in the early 1990s. Since then its incorporation into health plans has increased dramatically, yet proof of its effectiveness in terms of quality improvement and cost reduction remains to be seen. The following review provides an exploratory analysis of the basic principles of DM, its evolution and differences from traditional managed care, the ways in which programs are currently being used in the private and public sectors, and the challenges to determining a payment structure for incorporating DM into the current health insurance system.

Two-year outcome of a prospective, controlled study of a disease management programme for elderly patients with heart failure

OBJECTIVE

Elderly heart failure patients are at high risk of events. Available studies and systematic reviews suggest that elderly patients benefit from disease management programmes (DMPs). However, important questions remain open, including the optimal follow-up intensity and duration and whether such interventions are cost-effective during long-term follow-up and in different healthcare systems. The aim of this study was to determine the long-term efficacy of a hybrid DMP in consecutive older outpatients.

METHODS

Intervention consisted in combined hospital-based (cardiologists and nurse-coordinators from two heart failure clinics) and home-based (patient's general practitioner visits) care. The components of the DMP were the following: discharge planning, education, therapy optimisation, improved communication, early attention to signs and symptoms. Intensive follow-up was based on scheduled hospital visits (starting within 14 days of discharge), nurse's phone call and home general practitioner visits.

RESULTS

A group of 173 patients aged > or =70 years (mean age 77 +/- 6 years, 48% women) was randomly assigned to DMP (n = 86) or usual care (n = 87). At 2-year follow-up, a 36% reduction in all-cause death and heart failure hospital admissions was observed in DMP vs. usual care. All-cause and heart failure admissions as well as the length of hospital stay were also reduced. DMP patients reported, compared to baseline, significant improvements in functional status, quality of life and beta-blocker prescription rate. The intervention was cost-effective with a mean saving of euro 982.04 per patient enrolled.

CONCLUSIONS

A hybrid DMP for elderly heart failure patients improves outcomes and is cost-effective over a long-term follow-up.

Extending the horizon in chronic heart failure: effects of multidisciplinary, home-based intervention relative to usual care

BACKGROUND

The long-term impact of chronic heart failure management programs over the typical life span of affected individuals is unknown.

METHODS AND RESULTS

The effects of a nurse-led, multidisciplinary, home-based intervention (HBI) in a typically elderly cohort of patients with chronic heart failure initially randomized to either HBI (n=149) or usual postdischarge care (UC) (n=148) after a short-term hospitalization were studied for up to 10 years of follow-up (minimum 7.5 years of follow-up). Study end points were all-cause mortality, event-free survival (event was defined as death or unplanned hospitalization), recurrent hospital stay, and cost per life-year gained. Median survival in the HBI cohort was almost twice that of UC (40 versus 22 months; P<0.001), with fewer deaths overall (HBI, 77% versus 89%; adjusted relative risk, 0.74; 95% CI, 0.53 to 0.80; P<0.001). HBI was associated with prolonged event-free survival (median, 7 versus 4 months; P<0.01). HBI patients had more unplanned readmissions (560 versus 550) but took 7 years to overtake UC; the rates of readmission (2.04+/-3.23 versus 3.66+/-7.62 admissions; P<0.05) and related hospital stay (14.8+/-23.0 versus 28.4+/-53.4 days per patient per year; P<0.05) were significantly lower in the HBI group. HBI was associated with 120 more life-years per 100 patients treated compared with UC (405 versus 285 years) at a cost of 1729 dollars per additional life-year gained when we accounted for healthcare costs including the HBI.

CONCLUSIONS

In altering the natural history of chronic heart failure relative to UC (via prolonged survival and reduced frequency of recurrent hospitalization), HBI is a remarkably cost- and time-effective strategy over the longer term.

Creation of standardized tools for therapeutic education specifically dedicated to chronic heart failure patients: The French I-CARE project

AIM

To develop educational programs in chronic heart failure (CHF), creation of standardized tools for therapeutic education specifically dedicated to CHF patients was performed as a part of the French I-CARE project.

METHODS AND RESULTS

A working group was constituted of cardiologists, nurses and dieticians, specialized in both therapeutic education and CHF. The personal patient's document consisted of a ring binder with dividers containing index cards for 5 units. The unit "Educational diagnosis" comprised a guide for the user and an auto-questionnaire for the patient. The unit "Knowledge of the disease" comprised a whiteboard for explaining cardiovascular physiology, a 3D-model of heart, and a glossary. The unit "Diet control" was composed of posters, a food-card game with a game mat figuring the different meals of a day, a low-salt recipe book, and 1-g salt spoons. The unit "Physical activity and daily life" comprised recommendations for physical activity and questionable real-life situations, and a card game for evaluation. The unit "Medical treatment" consisted of index cards for different cardiovascular drugs.

CONCLUSION

These educational tools should help multidisciplinary teams to develop therapeutic education dedicated to CHF in order to improve self-management, morbidity and quality of life in CHF patients.

Cost-effectiveness of cardiac resynchronization therapy: results from the CARE-HF trial

AIMS

Whilst the CArdiac REsynchronization in Heart Failure (CARE-HF) trial has shown that cardiac resynchronization therapy (CRT) leads to reduced morbidity and mortality, the cost-effectiveness of this therapy remains uncertain. The aim of this study was to evaluate the incremental cost per quality adjusted life year (QALY) gained and incremental cost per life year gained of CRT plus medical therapy compared to medical therapy alone.

METHODS AND RESULTS

This prospective analysis based on intention to treat data from all patients enrolled in the CARE-HF trial at 82 clinical centres in 12 European countries. A total of 813 patients with New York Heart Association class III or IV heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony were randomized to CRT plus medical therapy (n = 409) vs. medical therapy alone (n = 404). During a mean follow-up of 29.4 months CRT was associated with increased costs (4316, 95% CI: 1327-7485), survival (0.10 years, 95% CI: -0.01-0.21), and QALYs (0.22, 95% CI: 0.13-0.32). The incremental cost-effectiveness ratio was 19 319 per QALY gained (95% CI: 5482-45 402) and 43 596 per life-year gained (95% CI: -146 236-223 849). These results were sensitive to the costs of the device, procedure, and hospitalization.

CONCLUSION

Treatment with CRT appears cost-effective at the notional willingness to pay threshold of 29 400 (20,000 pounds sterlings) per QALY gained.