The American Journal of Managed Care March 2010
Medical Care Costs Among Patients With Established Cardiovascular Disease
The economic burden of providing care to patients with cardiovascular disease, driven by secondary hospitalizations, may be substantially greater than current American Heart Association estimates.
Our results suggest that the societal burden of CVD may be much greater than previously believed. The American Heart Association (AHA)1 estimated that direct medical costs for approximately 21.8 million Americans with prevalent CVD or stroke totaled $131.3 billion in 2008, or about $6000 per person. In our sample, we found medical care costs to be 3 times greater than that, which extrapolates to US-wide direct costs of more than $400 billion. In addition, the AHA1 estimates that patients with CVD or stroke incur another $222 billion in indirect costs from lost productivity because of morbidity and premature death. If that estimate is also low, the total annual costs for these conditions may approach $1 trillion.
Managed care plans are likely already aware that most of their costs are driven by CVD and related conditions such as diabetes and chronic kidney disease. Our results clearly indicate that substantial cost reduction is possible by the avoidance of high-cost CVD events. Preventive medicine also can be expensive: it has been estimated that fully applied prevention activities would increase healthcare costs by approximately $1700 per person per year.12 Nevertheless, this is substantially less than the enormous expense of the secondary hospitalizations we report. Therefore, health plan managers and policy analysts searching for ways to reduce costs, while improving quality, may recognize that much greater prevention efforts seem to be a bargain.
Our findings are consistent with recent studies6,7 that reported costs of $18,000 to $27,000 for patients with acute coronary syndromes; however, those studies did not include patients with other forms of CVD such as MI or stroke. Therefore, to our knowledge, these are the first estimates of per-person medical costs for a heterogeneous population of patients with the full array of CVDs. Although our distribution of costs across inpatient, outpatient, and pharmacy resources was almost identical to that by Menzin et al,6 our cost estimates may be low by comparison. The cited studies included much lower proportions of patients 65 years or older, who are likely to incur higher costs. We also excluded patients who did not survive for at least 6 months following entry into the registry. Given that we found significantly greater costs among patients who subsequently died, the excluded patients were likely to have incurred higher than average costs. Therefore, inclusion of those patients would have increased the mean. Furthermore, 12.9% of our study sample qualified for inclusion by having undergone revascularization procedures. Because these high-cost procedures occurred before follow-up, they were not included in subsequent cost calculations. Indeed, all costs associated with an event that qualified a patient for the CVD registry are excluded. Last, the organizational structure of our study setting is unique. The closed group model that emphasizes low-cost preventive medicine and investment in highly computerized processes that help clinicians coordinate cost-effective care may have led to lower costs than can be achieved in other settings. For all of these reasons, we believe that our cost estimates are conservative. Conversely, annualizing costs could result in overestimation, especially among patients who die. However, sensitivity analyses that excluded various subgroups, including those who died, did not produce different results.
Our findings were also remarkably similar to the results of other studies that have estimated the relative costs of CVD in the presence of other comorbidities. For example, we found that costs were 54% higher among patients with a history of depression relative to those without such a history. Previous studies reported costs that were 47% to 51% higher among older patients with depression13 and 15% to 53% higher among women with versus without depression who had suspected myocardial ischemia.14 We also found that chronic kidney disease, as defined by an eGFR of less than 60 mL/min/1.73 m2, was associated with 81% higher costs, similar to the 76% greater costs seen among patients with stage 3 disease in a previous study15 in this setting. In the present study, diabetes was associated with 58% higher costs, almost identical to the 59% difference found in the same setting using data that were 10 years older4 and similar to a more recent study16 in another setting of managed care patients with and without diabetes and macrovascular disease. Because of the independent contribution of these conditions to cardiovascular risk, secondary prevention of CVD and associated cost reductions may be difficult to achieve. On the other hand, such patients may be more motivated to comply with currently recommended treatment regimens that may provide substantial risk reduction.12,17
A few other limitations warrant discussion. We assessed clinical characteristics at baseline and then observed patients for several years without reassessing those characteristics. Therefore, the extent to which the cost differences we report account for improvements in risk factors cannot be determined. We also required patients to remain enrolled for at least 6 months following registry entry. This requirement generates survival bias that could have affected our results. Finally, as already indicated, the unique structure of KPNW may limit the generalizability of our findings. Kaiser Permanente Northwest has long emphasized preventive medicine and uses various tools, including electronic assists, nonphysician personnel, and physician payment incentives, to maximize quality of care in a cost-containment environment. Nevertheless, the consistency of our results with other published findings is reassuring, suggesting that our data will translate well to other settings.
In conclusion, we found that the total direct medical costs of patients with established CVD were approximately 3 times greater than AHA estimates. The economic burden of providing care to these patients is staggering. Although several comorbid conditions undoubtedly contribute to this burden, avoidance of secondary CVD hospitalization, which in turn drives outpatient and pharmaceutical costs, could substantially reduce healthcare consumption.
Author Affiliations: From the Center for Health Research (GAN, KLP, MO-R), Kaiser Permanente, Portland, OR; and GlaxoSmithKline, Inc (TJB), Research Triangle Park, NC.
Funding Source: Funding provided by GlaxoSmithKline, Inc.
Author Disclosure: Dr Nichols reports receiving grants from GlaxoSmith-Kline, Merck, Novartis, Novo Nordisk, and Takeda. Dr Bell is an employee of GlaxoSmithKline, the funder of this study, and reports owning stock in the company. The other authors (KLP and MO-R) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (GAN); acquisition of data (GAN, KLP, MO-R); analysis and interpretation of data (GAN, TJB, KLP, MO-R); drafting of the manuscript (GAN, MO-R); critical revision of the manuscript for important intellectual content (TJB); statistical analysis (GAN, KLP); obtaining funding (GAN, TJB); and supervision (GAN).
Address correspondence to: Gregory A. Nichols, PhD, Center for Health Research, Kaiser Permanente, 3800 N Interstate Ave, Portland, OR 97227-1098. E-mail: email@example.com.
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