Cost/Utility Ratio in Chronic Heart Failure: Comparison Between Heart Failure Management Program Delivered by Day-Hospital and Usual Care - Cost/Utility Ratio in Chronic Heart Failure: Comparison Between Heart Failure Management Program Delivered by Day-Hospital and Usual Care

Description:

The goal of this study was to compare the safety, efficacy and cost/utility ratio between a heart failure (HF) management program delivered by day-hospital (DH) and usual care among outpatients with chronic heart failure. Previous studies have shown that nearly 50% of readmissions for CHF can be prevented by a multidisciplinary approach. However, the performance, effectiveness, and cost/utility ratio of a process of HF outpatient management have not been studied.

Study Design

Study Design:

Drug/Procedures Used:

A total of 234 prospective patients discharged by a HF Unit were randomized to two management strategies: 122 patients to usual community care and 112 patients to a HF management program delivered by the DH. Management (rate of readmissions, therapeutic interventions), functional parameters (New York Heart Association [NYHA] functional class, left ventricular diameters, and ejection fraction, deceleration time of early diastolic mitral flow, peak oxygen uptake, and mitral regurgitation) and hard outcomes (cardiac death and urgent cardiac transplantation) were evaluated. The cost/utility ratios of the two strategies were compared.

Principal Findings:

After 12 ± 3 months of follow-up, the DH subjects were readmitted to the hospital less frequently than were the usual-care group patients (13% vs. 78%, p<0.00001). Patients allocated to usual-care management showed heterogeneous changes in NYHA functional class (13% improved and 16% worsened p = NS); In contrast, the DH group showed significant changes in NYHA functional class (23% improved and 11% worsened, p < 0.009). Hard cardiac events in the one-year follow-up occurred in 25/234 (10.6%) patients; cardiac death occurred in 21/122 (17.2%) of the community group and in 3/112 (2.7%) in the DH group (p < 0.0007). One DH patient underwent urgent transplantation. Comparison of the two managerial models by Cox regression analysis showed that DH management significantly protected against the appearance of hard events (relative risk [RR] 0.17; confidence interval [CI] 0.06 to 0.66). The cost/utility ratio of the two management strategies was similar (usual care $2,409 vs. DH $2,244). The incremental analysis revealed cost savings of $1,068 for each quality-adjusted life year gained. The cost/utility ratio for the integration of DH management of CHF was $19,462 ( 95% CI $13,904 to $34,048).

Interpretation:

Among outpatients with CHF, a heart failure outpatient management program delivered by a DH was associated with a reduction in mortality and morbidity. This management strategy is cost-effective and has an equitable value from a societal point of view. Heart failure (HF) is a major public health problem with significant recent increases in incidence and prevalence and accounts for a major proportion of hospital admissions. This randomized prospective study analyzed cost utility appropriately from a societal perspective and showed that, compared to usual care, a HF management program delivered by a day hospital improves the cost/utility ratio of managing HF. The improvement with the day-hospital strategy is primarily attributable to formalization of the care process and use of evidence based medicine guidelines. More widespread application of this program may result in significant improvement in quality of life of patients with HF and is economically viable.

References:

Capomolla S, Febo O, Ceresa M, et al. Cost/Utility Ratio in Chronic Heart Failure: Comparison Between Heart Failure Management Program Delivered by Day-Hospital and Usual Care. J Am Coll Cardiol 2002;40:1259–66.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Heart Transplant, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Cost-Benefit Analysis, Public Health, Outpatients, Quality of Life, Mitral Valve Insufficiency, Heart Failure, Patient Discharge, Regression Analysis, Evidence-Based Medicine, Quality-Adjusted Life Years, Heart Transplantation


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