title: Health Care Costs for Patients with Heart Failure Escalate Nearly 3-Fold in Final Months of Life.
abstract: BACKGROUND
  Heart failure (HF) is a severe chronic disease with growing prevalence and health care burden as well as high mortality. End-of-life cost data for patients with HF may inform disease and medication therapy management.
  
  
  OBJECTIVE
  To (a) characterize a real-world sample of patients with HF who died; (b) estimate health care costs for 6 months and semiannually for 24 months, before death; and (c) examine associations between patient characteristics and predeath health care costs.
  
  
  METHODS
  This was a retrospective study of commercial and Medicare Advantage with Part D (MAPD) enrollees (aged ≥ 18 years), using data from a large national health plan. Included patients had evidence of HF during January 1, 2009-December 31, 2013, based on ≥ 1 inpatient hospitalization or ≥ 2 noninpatient encounters with diagnosis code for HF and evidence of mortality during July 1, 2009-December 31, 2013. Demographic data, comorbidities, guideline-directed HF-related outpatient pharmacotherapy (HFRx), and predeath health care costs (all-cause and HF-related) were described. A generalized linear model examined associations between all-cause health care costs (months 6 and 1 previous to death) and specific patient characteristics.
  
  
  RESULTS
  Of 48,026 identified patients, mean age was 77.9 years; 52.8% were female; 93.0% were MAPD enrolled; 92.5% had Quan-Charlson comor-bidity score ≥ 3; and about one quarter (26.0%) had no evidence of HFRx. Over the last 6 months of life, monthly all-cause total cost increased 3.2-fold for MAPD enrollees and 2.8-fold for commercial enrollees, although pharmacy cost decreased slightly (0.8-fold for both plan types). Cumulative 6-month all-cause medical cost was $37,186 for MAPD enrollees and $143,363 for commercial enrollees (68.8% and 73.2% due to hospitalization, respectively), and cumulative HF-related medical cost was $20,794 for MAPD enrollees and $78,440 for commercial enrollees (88.8% and 95.3% due to hospitaliza-tion, respectively). Over the last 24 months, semiannual all-cause total cost increased 3.2-fold for MAPD enrollees and 4.5-fold for commercial enroll-ees, although pharmacy cost increased only slightly (1.1-fold and 1.3-fold, respectively). Based on multivariable analysis, factors associated with higher risk of incurring a cost increase between month 6 and month 1 before death included older age (75-84 years: cost ratio [CR] = 1.33, P < 0.001; 226585 years: CR = 1.43, P < 0.001), comorbid coronary heart disease (CR = 1.12, P = 0.003), and no evidence of HFRx (CR = 1.48, P < 0.001).
  
  
  CONCLUSIONS
  Patients with HF experienced ≥ 2.8-fold increase in monthly all-cause total cost over the last 6 months of life, which was driven by hospitalization. Although MAPD enrollees incurred greater cost increases, cumulative costs were higher for commercial enrollees. After multivariable adjustment, older age, comorbid coronary heart disease, and no evidence of HFRx were among factors associated with higher risk of cost increase over the last 6 months of life. Study findings provide predeath cost information that should be useful in value assessments of innovative HF interventions and highlight impact of HFRx on predeath health care costs.
authors.affiliation: 1 Institute for Health Outcomes Policy & Economics, Rutgers University, Piscataway, New Jersey, and Health Economics & Outcomes Research, Novartis Pharmaceuticals, East Hanover, New Jersey.
authors.forename: Engels N
authors.initials: EN
authors.lastname: Obi
authors.affiliation: 2 Optum, Eden Prairie, Minnesota.
authors.forename: Jason P
authors.initials: JP
authors.lastname: Swindle
authors.affiliation: 3 Health Economics & Outcomes Research, Novartis Pharmaceuticals, East Hanover, New Jersey.
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Turner
authors.affiliation: 3 Health Economics & Outcomes Research, Novartis Pharmaceuticals, East Hanover, New Jersey.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Russo
authors.affiliation: 2 Optum, Eden Prairie, Minnesota.
authors.forename: Aylin
authors.initials: A
authors.lastname: Altan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D017048:Health Care Costs / Q000639:trends*; D006333:Heart Failure / Q000191:economics* / Q000401:mortality* / Q000628:therapy; D006801:Humans; D007345:Insurance Claim Review / Q000191:economics / Q000639:trends; D007348:Insurance, Health / Q000191:economics / Q000639:trends; D008297:Male; D054524:Medicare Part D / Q000191:economics* / Q000639:trends*; D054539:Medication Therapy Management / Q000191:economics / Q000639:trends; D008875:Middle Aged; D012189:Retrospective Studies; D013727:Terminal Care / Q000191:economics / Q000639:trends; D014481:United States / Q000453:epidemiology; D055815:Young Adult