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Perceived Economic Burden Linked to HF Mortality Risk, Study Says


Increased perceived economic burden (PEB) was associated with an increased risk of mortality and poorer health status among patients with acute decompensated heart failure (HF).

For patients with acute decompensated heart failure (HF), increased perceived economic burden (PEB) correlated with an increased risk of mortality and poorer health status, according to a new study published in JAMA Network Open. However, PEB was not associated with risk of HF-related rehospitalization.

Cash money stethoscope cost | Image credit: adragan –stock.adobe.com

Patients with severe PEB had a 61% higher risk of 1-year HF mortality compared with those with little PEB | Image credit: adragan – stock.adobe.com

HF affects millions of patients annually in China, leading to significant medical expenses and challenges in accessing health care, which is a concern in both China and the US. PEB, which encompasses factors like income and out-of-pocket expenses, offers a comprehensive view of financial challenges. Previous studies have linked PEB to adverse patient-reported outcomes such as worsened quality of life, well-being, and mental health, but these studies were limited by their size. Despite findings associating financial barriers with rehospitalization post-myocardial infarction, the impact of PEB on clinical events among patients with HF remains unclear.

From August 2016 to May 2018, the prospective, multicenter, hospital-based cohort study was conducted across 52 hospitals in China. The final analysis included 3386 adult patients admitted for acute decompensated HF with a follow-up period of 1 year. The median (IQR) age was 67 (58-75) years and 62.5% of patients were men.

PEB was categorized as severe (cannot undertake expenses), moderate (can almost undertake expenses), or little (can easily undertake expenses). Of the 3386 patients, a clear majority had moderate PEB (59.7%), followed by little PEB, (28.4%), then severe PEB (11.9%). Those with severe PEB had a 61% higher risk of 1-year HF mortality compared with those with little PEB (HR, 1.61; 95% CI, 1.21-2.13; P < .001). However, the 21% higher risk of 1-year HF rehospitalization among those with severe PEB was not deemed significant (HR, 1.21; 95% CI, 0.98-1.49; P = .07).

The researchers found that patients experiencing severe PEB were characterized by demographic and clinical factors. They were more likely to be younger, female, unmarried, covered by the New Cooperative Medical Scheme (NCMS), and had higher New York Heart Association (NYHA) class IV status, lower educational attainment, higher annual out-of-pocket medical expenses, and elevated NT-proBNP levels.

Despite China's universal basic medical insurance coverage, high out-of-pocket costs persist, leading to financial strain, particularly among certain demographics and regions. According to the researchers, disparities in insurance policies across regions and populations contribute to payment discrepancies, emphasizing the need for policy interventions targeting financially vulnerable populations with limited medical insurance protection.

Conversely, patients with severe PEB were less likely to be discharged with angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), or beta-blockers. Additionally, as the severity of PEB increased, patients were more inclined to borrow money from others to cover medical costs and to decline health care due to financial constraints.

Meanwhile, HF-specific health status was measured using the 12-Item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Patients with PEB had significantly lower adjusted KCCQ-12 scores compared with those with little PEB at baseline, with a mean (SD) score of 40 (1.7) vs 50.2 (1.0) points, respectively (P < .001). This trend continued at each monthly visit for a year, with mean scores of 61.5 (1.6) for those with severe PEB and 75.5 (0.9) for those with little PEB (P < .001). This difference amounted to a clinically significant reduction of 11.3 points (95% CI, –14.9 to –7.6; P < .001) in the 1-year KCCQ-12 score for patients reporting severe PEB compared with patients reporting little PEB.

In sensitivity analysis, the relationship between PEB and clinical outcomes in patients with new-onset HF remained consistent with those observed in patients with acute decompensated HF, with no interactions detected between KCCQ-12 scores, PEB, and clinical outcomes.

“The findings suggest that PEB may serve as a convenient tool for risk estimation and as a potential target for quality-improvement interventions for patients with HF,” the researchers said.

The study's limitations include the lack of validation for the construct defining PEB using objective measures of medical expenditures, though PEB severity correlated well with borrowing money for medical expenses. Additionally, potential unmeasured confounders and incomplete KCCQ-12 assessments for some patients pose limitations to the reliability and external validity of these findings.

“National efforts should be expanded to identify pragmatic approaches not only to alleviate the PEB in health care but also to assess its potential consequences for saving lives and improving health status,” the researchers concluded.


Yu Y, Liu J, Zhang L, et al. Perceived economic burden, mortality, and health status in patients with heart failure. JAMA Netw Open. 2024;7(3):e241420. doi:10.1001/jamanetworkopen.2024.1420

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