Resource utilization and costs following hospitalization of patients with chronic heart failure in the US

Figures & data

Table 1.  Baseline Characteristics of Chronic HF Patients.

	Chronic HF Patients N = 7814
Age, years (mean ± SD)	73.17 ± 12.98
Age (n,%)
<18 years	2	<0.1%
18–54 years	699	9.0%
55–64 years	1372	17.6%
65–74 years	1555	19.9%
≥75 years	4186	53.6%
Gender (n,%)
Male	4355	55.7%
Female	3459	44.3%
Insurance type (n,%)1
Comprehensive	3182	40.7%
PPO	2836	36.3%
HMO	1283	16.4%
POS	321	4.1%
CDHP	40	0.5%
EPO	10	0.1%
POS with capitation	7	0.1%
Unknown	135	1.7%
Calendar year of initial chronic HF hospitalization (n,%)
2004	741	9.5%
2005	1622	20.8%
2006	1138	14.6%
2007	1569	20.1%
2008	2744	35.1%
Charlson comorbidity index (mean ± SD)2	1.78 ± 1.76
Comorbid conditions (n,%)2
Diabetes mellitus	2046	26.2%
Chronic obstructive pulmonary disease	1441	18.4%
Peripheral vascular disease	635	8.1%
Renal disease	612	7.8%
Connective tissue disease	161	2.1%
Dementia	145	1.9%
Malignant solid tumor	91	1.2%
Malignant lymphoma	72	0.9%
Liver disease	60	0.8%
Ulcer disease	39	0.5%
Hemiplegia	38	0.5%
Leukemia	38	0.5%
AIDS	6	0.1%
Cardiovascular comorbidities (n,%)3
Hypertension	2879	36.8%
Atrial fibrillation	1417	18.1%
Hyperlipidemia	865	11.1%
Cerebrovascular disease	718	9.2%

1. EPO = Exclusive Provider Organization, HMO = Health Maintenance Organization,

POS = Point of Service, PPO = Preferred Provider Organization, CDHP = Consumer-Driven Health Plan

2. Based on a patient's comorbidities, the Charlson comorbidity index predicts the one-year mortality for the patient. The following ICD-9 codes were used for identifying comorbidities: AIDS (042), chronic obstructive pulmonary disease (491, 492, 493.2, 496), connective tissue disease (710, 714), dementia (290, 331.0, 331.1, 331.2), diabetes mellitus (250), hemiplegia (342, 344), leukemia (201.4, 205, 206, 207, 208), malignant lymphoma (200, 201, 202, 203.0, 273.0, 273.3), peripheral vascular disease (440, 441, 442, 437, 437.1, 447.1, 785.4), ulcer disease (531, 532, 533, 534), liver disease (570, 571, 572, 573, 456.0, 456.1, 456.2), renal disease (585, 586, V56, V420, V451), malignant solid tumor (140–171, 174–195, 199, V10)

3. The following ICD-9 codes were used for identifying cardiovascular comorbidities: hypertension (401–405), cerebrovascular disease (430–438), atrial fibrillation (427.31), hyperlipidemia (272.2, 272.4)

Table 2.  Cardiac Diagnostics and Procedures by HF Hospitalization.

	Index hospitalization		First re-hospitalization		Second re-hospitalization		Third re-hospitalization		Fourth re-hospitalization
	Age < 65 N = 2073	Age ≥65 N = 5741	Age <65 N = 514	Age ≥65 N = 1469	Age <65 N = 210	Age ≥65 N = 512	Age <65 N = 93	Age ≥65 N = 200	Age <65 N = 47	Age ≥65 N = 86
Length of stay, days (mean ± SD)	6.8 ± 11.3	6.7 ± 7.2	6.8 ± 7.1	6.6 ± 6.8	7.3 ± 6.4	7.1 ± 7.3	9.7 ± 9.7	7.6 ± 8.7	10.1 ± 11.0	7.2 ± 6.5
Days since previous hospitalization for HF (mean ± SD)	N/A	N/A	209.9 ± 266.1	283.8 ± 285.2	169.0 ± 196.7	238.4 ± 244.2	135.1 ± 205.2	172.3 ± 186.7	141.7 ± 171.8	118.1 ± 129.1
Diagnostics (%)1
Any diagnostic procedure below	91.4%	87.7%	86.0%	81.4%	85.2%	75.6%	81.7%	74.0%	78.7%	76.7%
Chest x-ray	72.8%	71.6%	68.5%	67.3%	68.6%	65.2%	75.3%	60.0%	66.0%	64.0%
Electrocardiogram	52.9%	55.0%	50.2%	49.1%	52.4%	47.3%	57.0%	49.0%	48.9%	48.8%
Echocardiogram	50.6%	49.4%	37.0%	34.3%	33.3%	31.1%	29.0%	32.5%	38.3%	27.9%
Cardiac catheterization	23.8%	11.5%	15.4%	6.0%	17.1%	5.3%	16.1%	4.5%	6.4%	2.3%
Coronary catheterization (angiogram)	20.3%	9.9%	10.1%	4.8%	10.5%	3.5%	10.8%	4.0%	2.1%	1.2%
Nuclear myocardial perfusion scan	7.2%	6.1%	3.5%	2.6%	2.9%	2.7%	2.2%	3.0%	2.1%	1.2%
Multiple gated acquisition scanning of the heart (MUGA)	7.2%	5.9%	3.7%	2.7%	2.4%	2.7%	3.2%	3.5%	2.1%	1.2%
Stress test	7.0%	5.6%	2.5%	2.7%	2.4%	2.7%	1.1%	3.5%	2.1%	2.3%
Blood test for natriuretic peptide	6.0%	0.8%	5.6%	0.7%	4.3%	0.2%	3.2%	1.0%	0.0%	0.0%
Intravascular ultrasound	0.6%	0.5%	0.2%	0.3%	1.0%	0.0%	1.1%	0.0%	0.0%	0.0%
Magnetic resonance imaging (MRI)	0.5%	<0.1%	0.4%	<0.1%	0.0%	0.2%	0.0%	0.0%	0.0%	0.0%
Positron emission tomography (PET) scan	0.2%	<0.1%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Computerized tomography (CT)	0.0%	<0.1%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Cardiac surgeries and procedures (%)1
Any surgery or procedure below	17.8%	12.0%	12.3%	5.4%	11.4%	4.9%	7.5%	3.0%	10.6%	0.0%
Biventricular pacemaker or cardiac resynchronization therapy (CRT)	7.5%	6.7%	2.9%	2.2%	1.9%	1.8%	2.2%	1.5%	4.3%	0.0%
Stent procedure	5.0%	3.1%	5.6%	2.0%	4.8%	1.8%	1.1%	1.0%	2.1%	0.0%
Coronary artery bypass graft (CABG) surgery	3.5%	1.5%	1.9%	0.7%	1.9%	1.2%	1.1%	0.5%	4.3%	0.0%
Valve surgery	1.7%	0.9%	1.6%	0.3%	1.9%	0.6%	2.2%	0.5%	2.1%	0.0%
Implantable cardioverter- defibrillators (ICDs)	0.5%	0.3%	0.6%	0.5%	0.0%	0.2%	1.1%	0.0%	2.1%	0.0%
Angioplasty (PTCA), laser angioplasty, atherectomy	0.4%	0.3%	0.4%	0.2%	1.0%	0.2%	0.0%	0.0%	0.0%	0.0%
Heart transplantation	0.2%	0.0%	0.0%	0.0%	1.9%	0.0%	1.1%	0.0%	0.0%	0.0%
Ventricular assist device (LVAD)	0.1%	0.0%	0.0%	<0.1%	0.5%	0.0%	0.0%	0.0%	2.1%	0.0%

1. The ICD-9, CPT and HCPCS codes for identifying these diagnostics and cardiac surgeries and procedures are specified in Appendix A.

Figure 1.  Hospitalizations over time, by age group.

Table 3.  Outpatient Prescription Patterns for Cardiovascular Medications.

	Baseline period		0–6 months following index hospitalization		6–12 months following index hospitalization		12–18 months following index hospitalization		18–24 months following index hospitalization
	Age <65 N = 2073	Age ≥65 N = 5741	Age <65 N = 2049	Age ≥65 N = 5683	Age <65 N = 1340	Age ≥65 N = 3487	Age <65 N = 890	Age ≥65 N = 2250	Age <65 N = 628	Age ≥65 N = 1550
Medications (n,%)
Beta blockers	53.4%	57.4%	69.2%	59.9%	63.3%	60.7%	62.2%	61.9%	61.0%	61.7%
ACE inhibitors or ARBs	50.8%	52.0%	60.7%	50.8%	55.6%	50.8%	53.8%	51.3%	56.4%	52.3%
- ACE inhibitors	39.7%	37.3%	49.1%	38.4%	43.7%	36.2%	41.6%	36.0%	43.9%	36.6%
- ARBs	13.5%	16.9%	15.8%	14.8%	14.3%	16.1%	14.3%	16.8%	14.2%	17.0%
Loop diuretics	42.0%	52.8%	54.8%	56.9%	47.1%	54.6%	44.9%	54.7%	46.3%	54.8%
Statins	37.6%	43.7%	43.0%	39.7%	41.6%	42.1%	40.8%	41.5%	43.8%	43.1%
Calcium channel blockers	19.2%	24.9%	18.0%	20.1%	16.3%	19.1%	15.8%	18.5%	16.1%	17.9%
Digoxin	14.0%	19.4%	18.9%	20.1%	18.1%	19.6%	19.0%	19.6%	18.8%	19.5%
Thiazide diuretics	11.2%	12.6%	11.2%	9.1%	8.7%	8.7%	8.3%	9.0%	10.5%	8.7%
Potassium sparing diuretics	12.7%	10.2%	19.7%	13.5%	18.0%	11.6%	18.1%	11.7%	18.5%	12.0%
- Aldosterone antagonists	14.1%	10.9%	21.8%	14.4%	20.1%	13.0%	20.3%	13.3%	21.3%	13.9%
- Spironolactone	12.8%	10.3%	20.0%	13.6%	18.3%	11.7%	18.3%	11.9%	18.6%	12.4%
- Eplerenone	1.6%	0.6%	2.0%	0.9%	2.0%	1.3%	2.0%	1.5%	2.7%	1.7%
- Epithelial sodium channel blockers	0.2%	0.3%	<0.1%	0.1%	0.2%	0.1%	0.1%	<0.1%	0.2%	<0.1%
- Amiloride	0.2%	0.3%	<0.1%	0.1%	0.2%	0.1%	0.1%	<0.1%	0.2%	<0.1%
- Triamterene	2.8%	4.1%	1.4%	1.7%	1.2%	1.8%	1.0%	1.4%	0.8%	1.6%
Alpha blockers	6.0%	8.7%	5.8%	7.0%	4.9%	6.2%	5.2%	5.6%	4.1%	5.1%
Vasodilators	3.4%	3.5%	4.9%	5.3%	4.3%	4.2%	4.6%	4.8%	4.6%	4.6%
Aliskiren	0.1%	0.3%	0.1%	0.2%	0.1%	0.2%	0.1%	0.2%	0.2%	0.2%
Medication combinations (n,%)
Aldosterone antagonists and ACE inhibitors	9.2%	4.9%	4.4%	3.1%	3.7%	2.7%	3.9%	2.6%	4.1%	3.4%
ACE inhibitors and ARBs	2.3%	2.2%	4.2%	2.4%	2.5%	1.5%	2.0%	1.4%	1.8%	1.2%
Pharmacy costs per patient per month (mean ± sd)
Cardiovascular drugs
Reimbursement from insurers	$68 ± $69	$162 ± $121	$92 ± $106	$221 ± $464	$80 ± $76	$189 ± $155	$82 ± $77	$185 ± $176	$82 ± $77	$182 ± $129
Patient out-of-pocket	$20 ± $19	N/A	$32 ± $37	N/A	$24 ± $23	N/A	$23 ± $22	N/A	$22 ± $23	N/A
Other drugs
Reimbursement from insurers	$295 ± $472	$447 ± $687	$436 ± $832	$668 ± $2655	$325 ± $534	$492 ± $833	$335 ± $546	$483 ± $808	$386 ± $612	$484 ± $573
Patient out-of-pocket	$50 ± $51	N/A	$82 ± $103	N/A	$56 ± $62	N/A	$55 ± $59	N/A	$59 ± $60	N/A
Total-pharmacy	$398 ± $508	$593 ± $707	$584 ± $869	$848 ± $2715	$452 ± $571	$660 ± $857	$460 ± $587	$649 ± $843	$513 ± $653	$647 ± $597

ACE = Angiotensin-converting enzyme; ARB = Angiotensin II (A-II) receptor blockers

  ICD-9, CPT and HCPCS Codes for Identifying Diagnostics and Cardiac Surgeries and Procedures.

Diagnostic test/Procedure	ICD-9 procedure codes	CPT	HCPCS
Angioplasty (PTCA)/Laser angioplasty/Atherectomy	00.66, 36.03, 36.09	92982, 35481, 35491, 92995	C1885
Biventricular pacemaker or cardiac resynchonization therapy (CRT)	00.50, 00.53, 37.80	33211, 33213, 33214, 33224–33226	C1785, C2619
Blood test (specifically for natriuretic peptide)		83880
Cardiac catheterization	37.21, 37.22, 37.23	93501–93533
Chest x-ray	87.44, 87.49	71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 71090, 0175T
Computerized tomography (CT)	87.41	0144T, 0145T, 0146T, 0147T, 0148T, 0149T, 0150T, 0151T
Coronary artery bypass graft (CABG) surgery	36.10, 36.11, 36.12, 36.13, 36.14, 36.15, 36.16, 36.17, 36.19	33503, 33504, 33505, 33510–33516, 33533–33536, 33548, 33517–33523, 33530	G8158, G8159, G8161, G8162, S2205, S2206, S2207, S2208, S2209
Coronary catheterization		93555
Echocardiogram	37.28, 88.72	93303–93350	G0366, G0367, G0368, G0403, G0404, G0405
Electrocardiogram	89.51, 89.52, 89.54	93000, 93005, 93010, 93040, 93041, 93042
Heart transplantation	37.51	33945
Implantable cardioverter- defibrillators (ICDs)	00.51, 00.54	33216, 33217
Intravascular ultrasound	0.24	37250, 37251, 75945, 92978, 92979
Magnetic resonance imaging (MRI)	88.92	71550, 71551, 71552, 75552–75564
Multiple gated acquisition scanning of the heart (MUGA)	92.05	78472, 78473, 78478, 78483
Nuclear myocardial perfusion scans	92.05	78460, 78461, 78464, 78465, 78491, 78492
Positron emission tomography (PET) scan		78491, 78492, 78459
Stent procedure	00.55, 00.63, 00.64, 00.65, 36.06, 36.07	92980	G0290, C1874, C1875, C1876, C1877
Stress test	89.41, 89.43, 89.44	93015, 93016, 93017, 93018	C8928, C8930
Valve surgery	35.0, 35.1, 35.2	33400–33478
Ventricular assist device	37.65, 37.66	33975, 33976, 33979, 0048T

Figure 2.  Outpatient visits over time, by age group.

Figure 3.  Cost per hospitalization.

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