Carvedilol reduces the costs of medical care in severe heart failure: an economic analysis of the COPERNICUS study applied to the United Kingdom

BACKGROUND: The aim of this study was to determine the effects of carvedilol on the costs related to the treatment of severe chronic heart failure (CHF). METHODS: Costs for the treatment for heart failure within the National Health Service (NHS) in the United Kingdom (UK) were applied to resource utilisation data prospectively collected in all patients randomized into the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Study. Unit-specific, per diem (hospital bed day) costs were used to calculate expenditures due to hospitalizations. We also included costs of carvedilol treatment, general practitioner surgery/office visits, hospital out-patient clinic visits and nursing home care based on estimates derived from validated patterns of clinical practice in the UK. RESULTS: The estimated cost of carvedilol therapy and related ambulatory care for the 1156 patients assigned to active treatment was pound530,771 ( pound44.89 per patient/month of follow-up). However, patients assigned to carvedilol were hospitalised less often and accumulated fewer and less expensive days of admission. Consequently, the total estimated cost of hospital care was pound3.49 million in the carvedilol group compared with pound4.24 million for the 1133 patients in the placebo arm. The cost of post-discharge care was also less in the carvedilol than in the placebo group ( pound479,200 vs. pound548,300). Overall, the cost per patient treated in the carvedilol group was pound3948 compared to pound4279 in the placebo group. This equated to a cost of pound385.98 vs. pound434.18, respectively, per patient/month of follow-up: an 11.1% reduction in health care costs in favour of carvedilol. CONCLUSIONS: These findings suggest that not only can carvedilol treatment increase survival and reduce hospital admissions in patients with severe CHF but that it can also cut costs in the process.     

The economic burden of asthma: direct and indirect costs in Switzerland.

Asthma mortality increased in Switzerland between 1980 and 1994. This study aimed to assess the economic burden of asthma in this country. Chart reviews were conducted for the last five patients seen for asthma in physician practices in 1996 and 1997. Direct expenditures and indirect costs for asthma-related morbidity were determined. A total of 589 patient charts were completely analysed, including 117 children's charts, obtained from 120 office-based physicians. The annual direct medical costs were CHF 1,778 and the mean annual indirect costs were CHF 1,019 per patient for all patients. The total estimated cost of asthma in Switzerland in 1997 was nearly CHF 1,252 million. Direct medical expenditures approached CHF 762 million, or 61% of the total. In 1997, the indirect costs for asthma were estimated to have exceeded CHF 490 million. Of these costs CHF 123 million (25%) was associated with morbidity and nearly CHF 368 million (75%) was associated with looking after asthmatic patients who had to be cared for at home. This study provides evidence that asthma is a major healthcare cost factor in Switzerland, amounting to approximately CHF 1,200 million per year. The data suggest that cost savings can be achieved by improving primary care for asthma in an ambulatory setting.     

The burden of overweight and obesity-related ill health in the UK

This paper reviews previous cost studies of overweight and obesity in the UK. It proposes a method for estimating the economic and health costs of overweight and obesity in the UK which could also be used in other countries. Costs of obesity studies were identified via a systematic search of electronic databases. Information from the WHO Burden of Disease Project was used to calculate the mortality and morbidity cost of overweight and obesity. Population attributable fractions for diseases attributable to overweight and obesity were applied to National Health Service (NHS) cost data to estimate direct financial costs. We estimate the direct cost of overweight and obesity to the NHS at pound 3.2 billion. Other estimates of the cost of obesity range between pound 480 million in 1998 and pound 1.1 billion in 2004 [Correction added after online publication 11 June 2007: 'of the cost of obesity' added after 'Other estimates']. There is wide variation in methods and estimates for the cost of overweight and obesity to the health systems of developed countries. The method presented here could be used to calculate the costs of overweight and obesity in other countries. Public health initiatives are required to address the increasing prevalence of overweight and obesity and reduce associated healthcare costs.     

The annual global economic burden of heart failure

Background

Heart failure (HF) imposes both direct costs to healthcare systems and indirect costs to society through morbidity, unpaid care costs, premature mortality and lost productivity. The global economic burden of HF is not known.

Methods

We estimated the overall cost of heart failure in 2012, in both direct and indirect terms, across the globe. Existing country-specific heart failure costs analyses were expressed as a proportion of gross domestic product and total healthcare spend. Using World Bank data, these proportional values were used to interpolate the economic cost of HF for countries of the world where no published data exists. Countries were categorized according to their level of economic development to investigate global patterns of spending.

Results

197 countries were included in the analysis, covering 98.7% of the world's population. The overall economic cost of HF in 2012 was estimated at $108 billion per annum. Direct costs accounted for ~ 60% ($65 billion) and indirect costs accounted for ~ 40% ($43 billion) of the overall spend. Heart failure spending varied widely between high-income and middle and low-income countries. High-income countries spend a greater proportion on direct costs: a pattern reversed for middle and low-income countries.

Conclusions

Heart failure imposes a huge economic burden, estimated at $108 billion per annum. With an aging, rapidly expanding and industrializing global population this value will continue to rise.     

The health care costs of diabetic nephropathy in the United States and the United Kingdom

PROBLEM: Diabetic nephropathy (DN) is a common microvascular complication of diabetes and can result in end-stage renal disease (ESRD) necessitating long-term dialysis or kidney transplantation. The costs of these complications are relatively high. The aim of this study was to quantify and compare the rates and annual costs of DN in the USA and the UK. METHODS: A cost of illness model was used to estimate the numbers of people with DN (microalbuminuria, overt nephropathy, and ESRD) or a previous kidney transplant at a given point in time and the numbers of new kidney transplants during a year. All costs were estimated in 2001 currencies. A sensitivity analysis assessed the robustness of the national annual cost estimates. RESULTS: In the USA, the total annual medical costs incurred by all payers in managing DN were US dollars 1.9 billion for Type 1 diabetes (range: US dollars 1.0-2.8 billion), US dollars 15.0 billion for Type 2 diabetes (range: US dollars 7.6-22.4 billion), and US dollars 16.8 billion for all diabetes (range: US dollars 8.5-25.2 billion). In the UK, the total annual costs to the National Health Service (NHS) of managing DN were US dollars 231 million ( pound 152 million) for Type 1 diabetes (range: US dollars 190-350 million [ pound 125-230 million]), US dollars 933 million (pound 614 million) for Type 2 diabetes (range: US dollars 809 million-US dollars 1.4 billion [pound 532-927 million]), and US dollars 1.2 billion ( pound 765 million) for all diabetes (range: US dollars 999 million-US dollars 1.8 billion [pound 657 million- pound 1.2 billion]). CONCLUSIONS: The total annual cost of DN is 13 times greater in the USA than in the UK. Controlling for the substantially higher number of people at risk, the total cost per person with DN and/or a kidney transplant is 40% higher: US dollars 3735 in the USA and US dollars 2672 (pound 1758) in the UK.     

The impact of diabetes-related complications on healthcare costs: results from the United Kingdom Prospective Diabetes Study (UKPDS Study No. 65).

AIMS: To develop a model for estimating the immediate and long-term healthcare costs associated with seven diabetes-related complications in patients with Type 2 diabetes participating in the UK Prospective Diabetes Study (UKPDS). METHODS: The costs associated with some major complications were estimated using data on 5102 UKPDS patients (mean age 52.4 years at diagnosis). In-patient and out-patient costs were estimated using multiple regression analysis based on costs calculated from the length of admission multiplied by the average specialty cost and a survey of 3488 UKPDS patients' healthcare usage conducted in 1996-1997. RESULTS: Using the model, the estimate of the cost of first complications were as follows: amputation pound 8459 (95% confidence interval pound 5295, pound 13 200); non-fatal myocardial infarction pound 4070 ( pound 3580, pound 4722); fatal myocardial infarction pound 1152 ( pound 941, pound 1396); fatal stroke pound 3383 ( pound 1935, pound 5431); non-fatal stroke pound 2367 ( pound 1599, pound 3274); ischaemic heart disease pound 1959 ( pound 1467, pound 2541); heart failure pound 2221 ( pound 1690, pound 2896); cataract extraction pound 1553 ( pound 1320, pound 1855); and blindness in one eye pound 872 ( pound 526, pound 1299). The annual average in-patient cost of events in subsequent years ranged from pound 631 ( pound 403, pound 896) for heart failure to pound 105 ( pound 80, pound 142) for cataract extraction. Non-in-patient costs for macrovascular complications were pound 315 ( pound 247, pound 394) and for microvascular complications were pound 273 ( pound 215, pound 343) in the year of the event. In each subsequent year the costs were, respectively, pound 258 ( pound 228, pound 297) and pound 204 ( pound 181, pound 255). CONCLUSIONS: These results provide estimates of the immediate and long-term healthcare costs associated with seven diabetes-related complications.     

Economic Impact of Hyperhomocysteinemia in Switzerland

Summary Since more than 20 years elevated homocysteine plasma levels have been associated with an elevated cardiovascular risk. It can be assumed that approx. 5–7% of the Swiss population suffers from hyperhomocysteinemia. These people have an odds ratio of 1.7 (95% confidence interval: 1.5–1.9) to develop a myocardial infarction and an odds ratio of 2.5 (95% confidence interval 2–3) of developing a stroke. These significant cardiovascular endpoints have monetary implications and lead to a loss in life years. The cost consequences and total life years lost were determined with an incidence-based epidemiological model utilizing a Swiss third party payer perspective. We could demonstrate that hyperhomocysteinemia-related sequelae (myocardial infarction and stroke) amount to 41.1–110.2 million CHF. In addition it can be estimated that 6′941–18′478 life years may be lost. Comparing these data with the total costs for cardiovascular disease in Switzerland of CHF 987 million, we estimate the share of the economic burden of hyperhomocysteinemia at approximately 10%. Preventive measures could thus yield a positive impact on total health care expenditure in the Swiss healthcare system and warrants further research.     

Cost-effectiveness of left ventricular assist devices (LVADs) for patients with advanced heart failure: Analysis of the British NHS bridge to transplant (BTT) program

Background

A previous cost-effectiveness analysis showed that bridge to transplant (BTT) with early design left ventricular assist devices (LVADs) for advanced heart failure was more expensive than medical management while appearing less beneficial.Older LVADs were pulsatile, but current second and third generation LVADs are continuous flow pumps. This study aimed to estimate comparative cost-effectiveness of BTT with durable implantable continuous flow LVADs compared to medical management in the British NHS.

Methods and results

A semi-Markov multi-state economic model was built using NHS costs data and patient data in the British NHS Blood and Transplant Database (BTDB). Quality-adjusted life years (QALYs) and incremental costs per QALY were calculated for patients receiving LVADs compared to those receiving inotrope supported medical management. LVADs cost £80,569 ($127,887) at 2011 prices and delivered greater benefit than medical management. The estimated probabilistic incremental cost-effectiveness ratio (ICER) was £53,527 ($84,963)/QALY (95%CI: £31,802–£94,853; $50,479–$150,560) (over a lifetime horizon). Estimates were sensitive to choice of comparator population, relative likelihood of receiving a heart transplant, time to transplant, and LVAD costs. Reducing the device cost by 15% decreased the ICER to £50,106 ($79,533)/QALY.

Conclusions

Durable implantable continuous flow LVADs deliver greater benefits at higher costs than medical management in Britain. At the current UK threshold of £20,000 to £30,000/QALY LVADs are not cost effective but the ICER now begins to approach that of an intervention for end of life care recently recommended by the British NHS. Cost-effectiveness estimates are hampered by the lack of randomized trials.     

Excess morbidity and cost of failure to achieve targets for blood pressure control in Europe

Aim: To estimate the burden of failing to achieve targets for blood pressure (BP) control in France, Germany, Italy, Sweden and the UK. Methods: A cost of illness model was constructed to estimate the impact of uncontrolled hypertension to each national healthcare system. Prevalence of uncontrolled hypertension was taken from published data. Relationships between achieved BP and the cardiovascular events of symptomatic acute myocardial infarction, congestive heart failure and stroke were estimated from the HOT study. Costs were taken from public sources. The acute medical costs of these events were estimated at current prevalence of uncontrolled hypertension and if BP were treated to target. Results: The model estimated that 29 million adults in the five countries (13% population) have BP levels above 160/95 mmHg, and an additional 46 million (21% population) have BP in the range 140/90-160/95 mmHg. The model estimated that healthcare system costs of 1.26 billion euros could be avoided if hypertension management did achieve BP targets. This does not consider the cost of interventions required to reduce the risk of cardiovascular disease. Conclusions: Failing to achieve BP targets contributes substantially to healthcare system costs and preventable events in the countries studies.     

The economic burden of smoking and secondhand smoke exposure in rural South-West China

Objective: To estimate the direct and indirect costs of chronic diseases attributed to smoking and exposure to secondhand smoke (SHS) in a given year (2011) in rural southwest China. Methods: A prevalence-based, disease-specific attributable-risk approach was used to estimate the economic burden of chronic diseases attributable to both smoking and exposure to secondhand smoke (SHS). A cross-sectional questionnaire survey of 17?158 consenting adults aged ≥18 years was used to derive prevalence of smoking and exposure to SHS, as well as direct and indirect costs of chronic diseases. Results: In the study population, the prevalence rates of smoking and exposure to SHS are 73.1 and 38.2% for males and 1.4 and 43.4% for females, respectively. The total costs of illness are $25.85 million for COPD, $18.80 million for asthma, $37.25 million for CHD, $17.91 million for stroke, $264.35 million for hypertension and $17.11 million for peptic ulcer. The estimated costs attributable to smoking and exposure to SHS are $95.51 million and $79.35 million, accounting for 7.15 and 5.94% of local healthcare costs, respectively. Of the total costs of tobacco, direct costs and indirect costs are $94.66 million and Objective: To estimate the direct and indirect costs of chronic diseases attributed to smoking and exposure to secondhand smoke (SHS) in a given year (2011) in rural southwest China. Methods: A prevalence-based, disease-specific attributable-risk approach was used to estimate the economic burden of chronic diseases attributable to both smoking and exposure to secondhand smoke (SHS). A cross-sectional questionnaire survey of 17?158 consenting adults aged ≥18 years was used to derive prevalence of smoking and exposure to SHS, as well as direct and indirect costs of chronic diseases. Results: In the study population, the prevalence rates of smoking and exposure to SHS are 73.1 and 38.2% for males and 1.4 and 43.4% for females, respectively. The total costs of illness are $25.85 million for COPD, $18.80 million for asthma, $37.25 million for CHD, $17.91 million for stroke, $264.35 million for hypertension and $17.11 million for peptic ulcer. The estimated costs attributable to smoking and exposure to SHS are $95.51 million and $79.35 million, accounting for 7.15 and 5.94% of local healthcare costs, respectively. Of the total costs of tobacco, direct costs and indirect costs are $94.66 million and $0.85 million for smoking, and $78.22 million and $1.36 million for exposure to SHS. Smoking contributes more cost of illness than exposure to SHS in men, whereas exposure to SHS contributes more cost of illness than smoking in women. Conclusions: Smoking and exposure to SHS produce substantial economic burden as well as have a considerable public health impact in rural southwest China.     

Cost of stroke in the United Kingdom

Introduction: this study aims to quantify the annual cost ofillness of stroke to the UK economy. Methods: we estimate the cost of stroke from a societal perspective.Direct care costs include diagnosis, inpatient care and outpatientcare. Income loss and social benefit payments to stroke patientsare accounted for in the indirect cost calculations. Data fromSouth London Stroke Register and a number of other nationalsources are used. Sensitivity analysis was carried out to accountfor the variability in the data used. Results: the treatment of and productivity loss arising fromstroke results in total societal costs of £8.9 billiona year, with treatment costs accounting for approximately 5%of total UK NHS costs. Direct care accounts for approximately50% of the total, informal care costs 27% and the indirect costs24%. Sensitivity analysis did not alter the estimate of totalcosts significantly for most of the variables except using ofdiffering prevalence rates. Conclusions: stroke incurs considerable societal costs. Ourcalculations show a high sensitivity to the underlying prevalencerates used. The findings highlight a need for further economicevaluations to ensure that there is an efficient use of resourcesdevoted to the treatment of this disease.     

Developing and applying a costing tool for hypertension and related cardiovascular disease: Attributable costs to salt/sodium consumption

This paper proposes a costing tool for hypertension and cardiovascular disease by adapting cost‐of‐illness methodologies to estimate the attributable burden of excessive salt intake on cardiovascular disease. The methodology estimates the changes in blood pressure that result from each gram change in salt intake and links diet to the direct and indirect costs of cardiovascular diseases (CVD), such as coronary heart disease, stroke, hypertensive disease, aortic aneurysm, heart failure, pulmonary embolism, and rheumatic heart, using the relative risks of disease and the prevalence of salt consumption in the population. The methodology includes (a) identifying major diseases and conditions related to excessive salt intake and relevant economic cost data available, (b) quantifying the relationship between the prevalence of excessive salt intake and the associated risk of disease morbidity and mortality using population attributable risks (PAR), (c) using PARs to estimate the share of total costs directly attributed to excessive salt intake, and (d) undertaking a sensitivity analysis of key epidemiological and economic parameters. The costing tool has estimated that, in 2013, US$ 102.0 million (95% uncertainty interval—UI: US$ 96.2‐107.8 million) in public hospitalizations could be saved if the average salt intake of Brazilians were reduced to 5 g/d, corresponding to 9.4% (95% UI: 8.9%‐9.9%) of the total hospital costs by CVDs. This methodology of cost of illness associated with salt consumption can be adapted to estimate the burden of other dietary risk factors and support prevention and control policies in Brazil and in other countries.     

The cost of pressure ulcers in the UK

OBJECTIVE: To estimate the annual cost of treating pressure ulcers in the UK. DESIGN: Costs were derived from a bottom-up methodology, based on the daily resources required to deliver protocols of care reflecting good clinical practice. SETTING: Health and social care system in the UK. SUBJECTS: Patients developing a pressure ulcer. METHODS: A bottom-up costing approach is used to estimate treatment cost per episode of care and per patient for ulcers of different grades and level of complications. Also, total treatment cost to the health and social care system in the UK. RESULTS: The cost of treating a pressure ulcer varies from pound 1,064 (Grade 1) to pound 10,551 (Grade 4). Costs increase with ulcer grade because the time to heal is longer and because the incidence of complications is higher in more severe cases. The total cost in the UK is pound 1.4- pound 2.1 billion annually (4% of total NHS expenditure). Most of this cost is nurse time. CONCLUSIONS: Pressure ulcers represent a very significant cost burden in the UK. Without concerted effort this cost is likely to increase in the future as the population ages. To the extent that pressure ulcers are avoidable, pressure damage may be indicative of clinical negligence and there is evidence that litigation could soon become a significant threat to healthcare providers in the UK, as it is in the USA.     

National economic impact of tirofiban for unstable angina and myocardial infarction without ST elevation; example from the United Kingdom

BACKGROUND: Acute coronary syndromes without ST elevation are a major health and economic burden. Treatments such as glycoprotein IIb/IIIa antagonists like tirofiban reduce the risk of complications but the cost impact of these agents including cost offsets of avoiding complications are needed particularly in Europe. METHODS: We used treatment patterns from the Prospective Registry of Acute Ischemic Syndromes in the UK, risk reductions derived from the PRISM-PLUS trial and cost estimates from the CHKS database to estimate the impact of tirofiban on PRAIS-UK patients with and without complications and subgroups at higher risk of complications. These subgroups (and proportions) were patients: (1) aged 60 or over with abnormal electrocardiograms (58%), (2) with ST depression or bundle branch block on admission (30%) and (3) with ST depression, bundle branch block or MI on admission (37%). RESULTS: Total cost of care in the UK at 6 months for the estimated 87339 acute coronary syndromes admissions annually was pound 213 million, which would increase by pound 33 million (15.7%) if tirofiban were given to all patients, avoiding 2422 complications at a mean cost per event avoided of pound 13388. Among the subgroups, the mean cost per event avoided ranges from pound 10856 for subgroup 1 to pound 5953 for subgroup 3. Treating the latter subgroup, would avoid 1977 events at a cost of pound 12 million (5.5%). CONCLUSION: The use of tirofiban in the UK to treat acute coronary syndromes patients without ST elevation provides an important therapeutic advantage at modest proportional increase in cost, particularly if targeted to higher risk subgroups as recommended in the European guidelines.     

Cost of disorders of the brain in Switzerland with a focus on mental disorders

QUESTIONS UNDER STUDY: This study aims at estimating the costs of disorders of the brain in Switzerland based on the published epidemiological and economic evidence. Methods: the data presented for Switzerland are derived from the "cost of disorders of the brain in Europe" study of the European Brain Counsil (EBC). Available Swiss data were integrated. RESULTS: There are an estimated 2 million people currently living with a brain disorder in Switzerland. This number amounts to about 25% of all people living in Switzerland. The total annual costs are estimated to amount to 8.9 billion Euros corresponding to 1200 Euros per inhabitant and per year. Direct medical expenditure accounts for 33% of all expenditure, while indirect costs add up to 49%. Mental disorders account for approximately 2/3 of the total costs of brain disorders, ie, 5.6 billion Euros. This cost estimate comes very close to the current expenses for mental health in Switzerland with 5.3 billion Euros constituting 16% of total health care costs. : The present study probably underestimates the full economic burden of brain and especially mental disorders in Switzerland. In order to better understand the impact of brain disorders on Swiss society prospective field studies are needed in all disorders of the brain.     

Economic impact of using clodronate in the management of patients with multiple myeloma

The economic impact of using prophylactic clodronate as an adjunct to chemotherapy in the management of multiple myeloma for the first 4 years following diagnosis was established from the perspective of the National Health Service (NHS). A state-transition model of the course of multiple myeloma was constructed using the MRC VI myelomatosis trial results and information on patient management obtained retrospectively from clinical trialists. Data were collected on resource use and corresponding costs for standard management and managing severe hypercalcaemia, vertebral and non-vertebral fractures. Managing patients with prophylactic clodronate cost the NHS a mean 22 934 pound silver per patient; comprising 16 697 pounds silver for standard management, 4862 pound silver for clodronate therapy and 1376 pound silver for adverse events. Managing patients without prophylactic clodronate cost a mean 19 557 pound silver (16 697 pound silver and 2860 pound silver for standard management and adverse events respectively). Therefore prophylactic clodronate therapy increased the cost by 3377 pound silver, or 17% per patient. Hospitalization accounted for 32% of the total cost, whereas chemotherapy accounted for 5%. The results were robust to sensitivity analyses (range 2605 pound silver-4150 pound silver). Further studies are required to assess the impact of prophylactic clodronate on quality of life to enable the clinical benefits and additional cost of this treatment to be compared with other healthcare interventions.     

Costs of viral hepatitis B in the Republic of Korea, 2002‐2015

The Republic of Korea has a high prevalence of hepatitis B virus (HBV) infection, and the policies concerning costly antiviral medication have been revised recently. However, in the past 10 years, no related research on costs has been conducted. The objective of this study was to estimate the economic burden of viral hepatitis B and determine the trend of changes in its costs between 2002 and 2015. Claims data from the National Health Insurance Service were used. To identify viral hepatitis B cases, the ICD‐10th code B16, B17.0, B18.0 and B18.1 were used based on a primary diagnosis. This study was conducted from a societal perspective regarding both direct and indirect costs. Annual costs were adjusted for inflation by calculations based on the 2015 costs. The number of patients with viral hepatitis B increased from 213 758 in 2002 to 342 672 in 2015. The total socio‐economic costs increased from 127.1 million USD in 2002 to 459.1 million USD in 2015, mainly due to the increase in pharmaceutical costs, which accounted for the largest proportion of total costs since 2009—220.5 million USD in 2015, which was ~15 times higher than that in 2002. The healthcare costs for viral hepatitis B accounted for 0.13% of the national health expenditure in 2002, increasing to 0.31% in 2015. The economic burden of viral hepatitis B has increased in the Republic of Korea. It is therefore essential to reduce the healthcare costs of HBV infection by establishing an effective management policy.