Characteristics and health care utilization among patients with chronic heart failure: a longitudinal claim database analysis

Definition of Polypharmacy in Heart Failure: A Scoping Review of the Literature

Patients with heart failure (HF) have a high prevalence of polypharmacy, which can lead to drug interactions, cognitive impairment, and medication non-compliance. However, the definition of polypharmacy in these patients is still inconsistent. The aim of this scoping review was to find the most common definition of polypharmacy in HF patients. We conducted a scoping review searching Medline, Embase, CINAHL, and Cochrane using terms including polypharmacy, HF and deprescribing, which resulted in 7,949 articles. Articles without a definition of polypharmacy in HF patients and articles which included patients < 18 years of age were excluded; only 59 articles were included. Of the 59 articles, 49% (n = 29) were retrospective, 20% (n = 12) were prospective, 10% (n = 6) were cross-sectional, and 27% (n = 16) were review articles. Twenty percent (n = 12) of the articles focused on HF with reduced ejection fraction, 10% (n = 6) focused on HF with preserved ejection fraction and 69% (n = 41) articles either focused on both diagnoses or did not clarify the specific type of HF. The most common cutoff for polypharmacy in HF was five medications (59%, n = 35). There was no consensus regarding the inclusion or exclusion of over-the-counter medications, supplements, or vitamins. Some newer studies used a cutoff of 10 medications (14%, n = 8), and this may be a more practical and meaningful definition for HF patients.

Characteristics Associated With Telemonitoring Use Among Patients With Chronic Heart Failure: Retrospective Cohort Study

BACKGROUND

Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption.

OBJECTIVE

We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF.

METHODS

We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use.

RESULTS

Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring.

CONCLUSIONS

The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups.

Living longer in declining health: Factors driving healthcare costs among older people

BACKGROUND

Developed countries are facing challenges in caring for people who are living longer but with a greater morbidity burden. Such people are likely to be regular users of healthcare.

OBJECTIVES

Our analytical aim is to identify factors that explain healthcare costs among: (1) people over 55 years old; (2) the top 5% and 1% high-cost users among this population; (3) those that transition into the top 5% and 1% from one year to the next; (4) those that appear in the top 5% and 1% over multiple years; and (5) those that remain in the top 5% and 1% over consecutive years.

METHODS

The data covered 2011 to 2017 and comprised 1,485,170 observations for a random sample of 224,249 people aged over 55 years in the Catalan region of Spain. We analysed each person's annual healthcare costs across all public healthcare settings related to their age, gender, socio-economic status (SES), whether or not and when they died, and morbidity status, through Adjusted Morbidity Groups.

RESULTS

After controlling for morbidity status, the oldest people did not have the highest costs and were less likely to be among the most costly patients. There was also only a modest impact on costs associated with SES and with dying. Healthcare costs were substantially higher for those with a neoplasm or four or more long term conditions (LTCs), costs rising with the complexity of their conditions. These morbidity indicators were also the most important factors associated with being and remaining in the top 5% or top 1% of costs.

CONCLUSION

Our results suggest that age and proximity to death are poor predictors of higher costs. Rather, healthcare costs are explained mainly by morbidity status, particularly whether someone has neoplasms or multiple LTCs. Morbidity measures should be included in future studies of healthcare costs.

The Effect of Noninvasive Telemonitoring for Chronic Heart Failure on Health Care Utilization: Systematic Review

Background

Chronic heart failure accounts for approximately 1%-2% of health care expenditures in most developed countries. These costs are primarily driven by hospitalizations and comorbidities. Telemonitoring has been proposed to reduce the number of hospitalizations and decrease the cost of treatment for patients with heart failure. However, the effects of telemonitoring on health care utilization remain unclear.

Objective

This systematic review aims to study the effect of telemonitoring programs on health care utilization and costs in patients with chronic heart failure. We assess the effect of telemonitoring on hospitalizations, emergency department visits, length of stay, hospital days, nonemergency department visits, and health care costs.

Methods

We searched PubMed, Embase, and Web of Science for randomized controlled trials and nonrandomized studies on noninvasive telemonitoring and health care utilization. We included studies published between January 2010 and August 2020. For each study, we extracted the reported data on the effect of telemonitoring on health care utilization. We used P<.05 and CIs not including 1.00 to determine whether the effect was statistically significant.

Results

We included 16 randomized controlled trials and 13 nonrandomized studies. Inclusion criteria, population characteristics, and outcome measures differed among the included studies. Most studies showed no effect of telemonitoring on health care utilization. The number of hospitalizations was significantly reduced in 38% (9/24) of studies, whereas emergency department visits were reduced in 13% (1/8) of studies. An increase in nonemergency department visits (6/9, 67% of studies) was reported. Health care costs showed ambiguous results, with 3 studies reporting an increase in health care costs, 3 studies reporting a reduction, and 4 studies reporting no significant differences. Health care cost reductions were realized through a reduction in hospitalizations, whereas increases were caused by the high costs of the telemonitoring program or increased health care utilization.

Conclusions

Most telemonitoring programs do not show clear effects on health care utilization measures, except for an increase in nonemergency outpatient department visits. This may be an unwarranted side effect rather than a prerequisite for effective telemonitoring. The consequences of telemonitoring on nonemergency outpatient visits should receive more attention from regulators, payers, and providers. This review further demonstrates the high clinical and methodological heterogeneity of telemonitoring programs. This should be taken into account in future meta-analyses aimed at identifying the effective components of telemonitoring programs.

Trial of Oral Diuretics Prior to Discharge Is Not Associated With Improved Outcomes in Decompensated Heart Failure

BACKGROUND

Current heart failure guidelines recommend transition of intravenous (IV) diuretics to oral > 24 h prior to hospital discharge. The aim of this study was to determine whether transition to oral diuretics prior to discharge in patients hospitalized with decompensated systolic heart failure (SHF) was associated with improved 30-day events.

METHODS

This was a retrospective cohort study, in which adults admitted to the Loma Linda Medical Center for 3 - 14 days with a primary discharge diagnosis of acute on chronic SHF were included. Mortality data were obtained from the National Death Index, while readmission only to our facility was included. The t-test and Chi-square test were used for analyses.

RESULTS

A total of 314 patients were studied. Patients who were managed with guideline-recommended trial of oral diuretics, and patients who continued to receive IV diuretics on the last full hospital day were overall similar in baseline characteristics. Patients who received oral diuretics on the day prior to discharge had longer length of stay, less weight loss, were discharged on lower diuretic doses (all P < 0.05), and had similar outcomes of 30-day readmission and 30-day hospitalization-free survival.

CONCLUSIONS

The transition to oral diuretics prior to discharge in patients with decompensated SHF was not associated with improved 30-day outcomes. These results require validation in prospective trials but suggest that guideline recommendations regarding transitioning to oral diuretics prior to discharge may deserve re-evaluation.

10 year trends in hospitalization rates due to heart failure and related in-hospital mortality in Poland (2010-2019)

Aims

Heart failure (HF) remains a major public health challenge worldwide. Contemporary epidemiological data on HF hospitalization rates and related in‐hospital mortality are scarce also in Poland. The aim of the study was to determine the trends in hospitalization rates due to HF and related in‐hospital mortality in Poland in the recent decade.

Methods and results

Data on HF hospitalizations and in‐hospital mortality in patients aged >17 years in Poland between 2010 and 2019 were obtained from the central database of the Polish National Health Fund. Hospitalizations with either primary or secondary diagnosis of HF were identified using the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes (I50, I42, J81 with extensions, and R57.0). There were 4 259 698 HF hospitalizations and 608 577 in‐hospital deaths (14% in‐hospital mortality) reported during 2010–2019 in Poland. During this period, there was a steady increase in the number of HF hospitalizations per 1000 inhabitants in subsequent years, being more pronounced in men than in women (in 2019: 16 and 13 HF hospitalizations per 1000 inhabitants in men and women, respectively). The relative risk of HF hospitalization was higher in men than in women, and this gender‐related difference steadily increased from 9% in 2010 to 25% in 2019. During 2010–2019, there was an increase in the number of HF hospitalizations per 1000 inhabitants in subsequent age groups, with a trend being more pronounced in men than in women (129 and 99 HF hospitalizations per 1000 inhabitants in men and women aged ≥80 years, respectively). During this period, there was a slight increase in in‐hospital mortality during HF hospitalization in subsequent years, being more pronounced in women than in men (in 2019: 16% and 14% of in‐hospital mortality in women and men, respectively). The relative risk of in‐hospital mortality during HF hospitalization was higher in women than in men, and this gender‐related difference steadily increased from 8% in 2010 to 18% in 2019. During this period, in‐hospital mortality during HF hospitalization was ~12% for women and men aged 18–29 years, whereas the highest values of in‐hospital mortality reached ~19% for patients aged ≥80 years.

Conclusions

We have observed steady growing trends in HF hospitalization rates and related in‐hospital mortality in Poland over the last decade. Both age and gender have differentiated the reported epidemiological patterns.

Characteristics and health care utilization among patients with chronic heart failure: a longitudinal claim database analysis

AIMS

This study aimed to determine the characteristics of patients with heart failure and high costs (top 1% and top 2-5% highest costs in perspective of the general population) and to explore the longitudinal health care utilization and persistency of high costs.

METHODS AND RESULTS

Longitudinal observational study using claims data from 2006 to 2014 in the Netherlands. We identified all patients that received a hospital treatment for chronic heart failure between 1 January 2008 and 31 December 2010. Of each selected patient, all claims from the Dutch curative health system and with a starting date between 1 January 2006 and 31 December 2014 were extracted. Pharmaceutical and hospital claims were used to establish characteristics and indicators for health care utilization. Descriptive analyses and generalized estimating equation models were used to analyse characteristics, longitudinal health care utilization and to identify factors associated with high costs. Our findings revealed that the difference in costs between top 1%, top 2-5%, and bottom 95% patients with heart failure was mainly driven by hospital costs; and the top 1% group experienced a remarkable increase of mental health costs. Top 1% and top 2-5% patients with heart failure differed from lower cost patients in their higher rate of chronic conditions, excessive polypharmacy, hospital admissions, and heart-related surgeries. Heart-related surgeries contributed to the incidental high costs in 54% of top 1% patients, and the costs of the remaining top 1% patients were driven by mental health and pharmaceuticals use and rates of chronic conditions and multimorbidity. Top 1% patients were relatively young. Anaemia, dementia, diseases of arteries, veins and lymphatic vessels, influenza, and kidney failure were significantly associated with high costs. The end-of-life period was predictive of top 1% and top 5% costs. More than 90% of the population incurred at least one top 5% year during follow-up, and 31.8% incurred at least one top 1% year. Fifty-seven per cent incurred multiple top 5% years whereas only 8.6% incurred multiple top 1% years. Top 5% years were more frequently consecutive than top 1% years.

CONCLUSIONS

Top 1% utilization occurs predominantly incidentally and among less than a third of patients with heart failure, whereas almost all patients with heart failure experience at least one top 5% year, and more than half experience two or more top 5% years. Both medical and psychiatric/psychosocial needs contribute to high costs in heart failure patients. Comprehensive and integrated efforts are needed to further improve quality of care and reduce unnecessary costs.