Long, Kirsten Hall

Background— Heart failure (HF) care constitutes an increasing economic burden on the health care system, and has become a key focus in the health care debate. However, there are limited data on the lifetime health care costs for individuals with HF after initial diagnosis. Methods and Results— Olmsted County residents with incident HF from 1987 to 2006 were identified. Direct medical costs incurred from the time of HF diagnosis until death or last follow-up were obtained using population-based administrative data through 2007. Costs were inflated to 2008 US dollars using the general Consumer Price Index. Inpatient, outpatient, and total costs were estimated using a 2-part model with adjustment for right censoring of data. Predictors of total costs were examined using a similar model. A total of 1054 incident HF patients were identified (mean age, 76.8 years; 46.1% men). After a mean follow-up of 4.6 years, 765 (72.6%) patients had died. The estimated total lifetime costs were $109 541 (95% confidence interval, $100 335 to 118 946) per person, with the majority accumulated during hospitalizations (mean, $83 980 per person). After adjustment for age, year of diagnosis, and comorbidity, diabetes mellitus and preserved ejection fraction (≥50%) were associated with 24.8% ( P =0.003) and 23.6% ( P =0.041) higher lifetime costs, respectively. Higher costs were observed at initial HF diagnosis and in the months immediately before death in those surviving >12 months after diagnosis. Conclusions— HF imposes a significant economic burden, primarily related to hospitalizations. Variations in cost over a lifetime can help identify strategies for efficient management of patients, particularly at the end of life.

Background: Studies have failed to show a survival difference between intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). Comparative cost analyses are limited and fail to control for differences in patient disease severity and comorbid conditions. The authors retrospectively estimated clinical and economic outcomes associated with CRRT and IHD among critically ill patients experiencing acute renal failure (ARF) in 2 tertiary care hospitals in Rochester, Minnesota, between January 1, 2000, and December 12, 2001. Methods: 161 critically ill patients requiring dialysis for ARF were analyzed. Patient demo-graphics, comorbid conditions, ARF etiology, mode of renal replacement therapy (RRT), renal recovery, and survival were abstracted from medical chart. APACHE II scores at dialysis initiation were calculated. Administrative data tracked length of stay (LOS) and direct medical costs from initiation of RRT to death or intensive care unit (ICU) and hospital discharge. Multivariate modeling was used to adjust outcomes for baseline differences. Results: 84 (52%) of the patients received CRRT and 77 (48%) received IHD. CRRT-treated patients were younger (58 vs 65 years), less likely male (58% vs 77%), had higher APACHE II scores (32 vs 27) with a higher incidence of sepsis (46% vs 30%) and respiratory disease (56% vs 39%), and were less likely to have chronic renal insufficiency (32% vs 49%). With adjustment for differences in baseline patient characteristics, the RRT method did not affect the likelihood of renal recovery, in-hospital survival, or survival during follow-up. Mean adjusted ICU LOS was 9.5 days shorter for IHD-treated than CRRT-treated patients ( P < .001), and the adjusted mean difference in hospital and total costs associated with ICU stay was $56 564 and $60 827, in favor of IHD ( P < .001). Mean adjusted total costs through hospital discharge were $93 611 and $140 733 among IHD-treated and CRRT-treated patients, respectively ( P < .001). Conclusions: This observational study suggests that costs may significantly differ by mode of RRT despite similar severity-adjusted patient outcomes. Future prospective comparisons of renal replacement modalities will need to include both clinical and economic outcomes.