Author + information
- Miguel Cainzos-Achirica, MD, MPH∗ (, )
- Marta Trapero-Bertran, MSc, PhD,
- Usama Bilal, MD, MPH, PhD,
- Xavier Corbella, MD, MBA, PhD and
- Josep Comin-Colet, MD, PhD
- ↵∗Hospital Universitari de Bellvitge, Department of Cardiology, 19th Floor, Feixa Llarga, Hospitalet de Llobregat, Barcelona 08907, Spain
We have read the recent study by Wadhera et al. (1) with great interest. Rising direct health care costs associated with pandemic conditions such as chronic heart failure (CHF) are becoming major threats to the sustainability of health care systems in most Western countries. This concern has boosted the development of a number of initiatives aimed at reducing hospitalizations and other key sources of health care costs associated with these patients.
Among the available cost-reduction approaches, recent research has shown that policies and interventions focused on cutting specific costs and using penalties may be associated with worsened health outcomes, which are the worst costs that patients and societies could face. A landmark example of this is the recent evaluation by Gupta et al. (2) in Medicare patients with CHF, in which a program implemented in 2010 that was aimed at reducing readmissions through financial penalties to hospitals was followed by concerning increases in 30-day mortality rates.
CHF is a complex, challenging condition, requiring multidimensional in-hospital, transitional, and long-term management approaches (3). In this context, population-based studies evaluating programs aimed at improving the holistic care of these patients have shown strong associations between program implementation and subsequent reductions in mortality and hospitalizations (4). Similarly, evidence from small randomized trials supports the benefits of comprehensive disease management programs in CHF in terms of hospitalization and death (5).
Current evidence, therefore, suggests that interventions with an emphasis on increasing quality of care rather than on reducing specific sources of health care costs may be the pathway to improving CHF health outcomes. Nevertheless, the implications, in terms of costs, of holistic management programs are currently less understood. Although improved quality is expected to reduce costs through, for example, minimizing preventable readmissions, paradoxically, longer survival would also be expected to yield higher long-term health care resource use and costs.
In this context, the study by Wadhera et al. (1) provides some valuable insights on the in-hospital or early post-discharge phase of the process. Optimal in-hospital CHF management involves a number of interventions, including a detailed etiological assessment, complete relief of congestive signs and symptoms, initiation of evidence-based pharmacotherapies, use of invasive procedures when appropriate, pre-discharge assessment by multidisciplinary teams, and careful design of the transitional and long-term care management plan of each patient. Because most of these are costly interventions, improving quality requires investments. Consistent with this, Wadhera et al. (1) observed that centers with higher odds of performing cardiac catheterizations, performing coronary revascularization procedures, more frequently discharging patients to skilled nursing facilities, and more frequently providing home care on discharge had higher CHF inpatient costs.
Unfortunately, Wadhera et al. (1) could not quantify the potential long-term implications of improving in-hospital and post-discharge quality and outcomes, and further research is needed. Specifically, comprehensive, long-term health economics evaluations are mandatory, accounting simultaneously for clinical outcomes, costs, efficiency, and the value of money. Such evaluations would provide nuanced insights on the long-term implications of different CHF management programs, thereby aiding the design of the most effective, efficient interventions.
Please note: Dr. Cainzos-Achirica has reported that he collaborates with RTI Health Solutions, an independent nonprofit research organization that does work for government agencies and pharmaceutical companies. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- Wadhera R.K.,
- Joynt Maddox K.E.,
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- Gupta A.,
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- Yancy C.W.,
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- American College of Cardiology Foundation,
- American Heart Association Task Force on Practice Guidelines
- Comín-Colet J.,
- Verdú-Rotellar J.M.,
- Vela E.,
- et al.,
- Working Group of the Integrated Program for Heart Failure Management of the Barcelona Litoral Mar Integrated Health Care Area, Spain