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American Journal of Critical Care. 2002;11: 474-478
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Outpatient Costs of Medications for Patients with Chronic Heart Failure

By Leslie C. Hussey, RN, PhD, Sonya Hardin, RN, PhD and Christopher Blanchette, BS. From the Department of Adult Health Nursing, School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte.


   Abstract
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 Abstract
Objective
 Methods
 Results
 Discussion
 References
 
• Background The outpatient costs of medications prescribed for chronic heart failure are high and are often borne by individual patients. Lack of financial resources may force noncompliance with use of medications.

• Objective To compare the outpatient costs of medications for patients with different New York Heart Association classifications of chronic heart failure.

• Methods The charts of 138 patients with chronic heart failure were reviewed retrospectively. Outpatient costs of medications were obtained from the Web sites of commercial pharmacies. Medications were classified by type according to the system of the American Heart Association. A mean cost for each classification of medication was used for analysis.

• Results The overall mean monthly cost of medications for chronic heart failure was $438. Patients with class II and class III chronic heart failure had the highest costs: $541 and $514, respectively. Analysis of variance indicated that the differences in monthly costs of medications between the patients with the 4 stages of chronic heart failure were significant (F = 4.86, P = .003). A post hoc Scheffé test revealed significant differences in costs between patients with class I and patients with class II heart failure (P=.02) and between patients with class I and those with class III heart failure (P=.02).

• Conclusions The outpatient costs of medications for chronic heart failure are significant. Ability to pay for prescribed medications must be determined. Healthcare professionals must maintain an awareness of the costs of medications and patients’ ability to pay.

Chronic heart failure (CHF) is a major public health problem. This progressive and chronic disease limits patients’ functional status and severely lowers quality of life. Among persons more than 65 years old, almost 10 per 1000 have CHF, making it the most common diagnosis upon hospital discharge for this age group. Degree of severity of CHF is classified according to the New York Heart Association (NYHA) system (Table 1Go).1


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  		Table 1 New York Heart Association functional classification of heart failure

 
CHF is newly diagnosed in approximately 550 000 persons in the United States each year.2 Although significant advances have been made in determining both the pathophysiology of and therapy for CHF, mortality rates have changed little during the past 4 decades.3 The 5-year mortality rate for patients with symptomatic heart failure is almost 50%, and up to 40% of these deaths are sudden.2,4

Diagnosis of a chronic disease, such as CHF, is an important determinant of personal drug expenditures. In one study,5 mean monthly pharmaceutical expenditures for elderly patients were $196 for patients with a single chronic condition and $519 for those with 3 or more chronic conditions. Prescription drug costs for elderly patients with diabetes, emphysema, and heart disease were higher than this average, ranging from $520 to $557.

Currently, according to the American Heart Association,2 the direct costs of CHF are $19.4 billion per year. When indirect costs such as lost productivity, morbidity, and mortality are included, the cost totals increase to $21 billion. Costs of medication and other medical durables alone are $1.6 billion per year.

A high proportion of costs of medications prescribed for CHF and other diseases are often borne by the individual patient. Persons more than 65 years old who have Medicare as their only health insurance plan have no outpatient coverage for medications, and many of the supplemental plans are too costly for individual consumers. Persons who qualify for Medicaid have limited coverage for medications. Supplemental insurance plans vary in the type and amount of coverage for medications.

Lack of financial resources to pay for medications may force a patient with CHF into noncompliance. For example, a patient may alter the dosing of the medications to decrease cost. This practice can predispose patients to an acute exacerbation and result in a costly hospitalization.

Available data6,7 indicate that approximately 30% to 50% of hospital readmissions for CHF, particularly those that occur within 90 days of initial discharge, are preventable. Successful management of chronic heart failure often includes long-term lifestyle adjustments by patients and patients’ families. Lifestyle adjustments focus on modifications in diet and activities, the need to monitor signs and symptoms, and adherence to a complex medication regimen.8 Successful adherence to a complex medication regimen requires adequate knowledge of the medications and their use as well as the availability of financial resources to pay for the medications.


   Objective
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 Abstract
 Objective
Methods
 Results
 Discussion
 References
 
The purpose of this study was to compare the out-patient costs of medications for patients with different NYHA classes of chronic heart failure.


   Methods
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 Abstract
 Objective
 Methods
Results
 Discussion
 References
 
Approval for the study was obtained from two institutional review boards at the participating institutions. The sample was all patients who had a diagnosis of CHF and were being cared for by a physician specializing in internal medicine at a medical center in North Carolina. The charts of 138 patients were reviewed retrospectively. Data were gathered and reviewed by the coinvestigators and the research assistant to ensure consistency. Demographic data collected included age, sex, comorbid conditions, medications, and stage of CHF. Each patient’s heart failure was classified according to the NYHA classification system.

Costs of medications were obtained from the Web sites of 3 commercial pharmacies. Each medication was placed into its appropriate category according to the classification of medications of the American Heart Association.9 For example, furosemide was classified as a diuretic. The mean monthly cost of each medication classification was calculated. Mean medication costs were calculated for patients according to the patients’ NYHA class. Medication costs were also calculated for patients who had CHF plus other noncardiovascular conditions and were analyzed according to the patients’ NYHA class of heart failure. Analysis of variance was used to test for significant differences between the data sets.


   Results
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 Results
Discussion
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The mean age of the subjects was 72.8 years. Of the 138 subjects, 87 (63%) were men and 51 (37%) were women. Forty-three patients were classified as NYHA class I, 25 as class II, 36 as class III, and 34 as class IV. Thirty-four patients (25%) reported they were currently smoking, 33 (24%) were nonsmokers, and 55 (40%) had quit smoking in the preceding 2 years. Demographic data by NYHA class are given in Table 2Go.


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  		Table 2 Demographic data, by New York Heart Association classification of heart failure

 
The mean number of medications taken daily by each patient was 10.53. The mean numbers of daily medications by NYHA class were 8.36 for class I, 13 for class II, and 11 each for classes III and IV.

Medications for each subject were grouped by functional classification. The 10 most commonly prescribed medication categories for each NYHA class were determined. Overall, diuretics were prescribed most often for the patients in this study. The other 9 categories most often prescribed were blood thinners, agents (inhalers) for treatment of chronic obstructive pulmonary disease (COPD), angiotensin-converting enzyme inhibitors, vasodilators, digitalis, cholesterol-lowering agents, potassium supplements, calcium supplements, and vitamin E. Other commonly prescribed medications included calcium supplements and ß-blockers.

Some patients were prescribed more than a single medication in a category. For example, of the patients with class I CHF, 27 (62.8%) were prescribed diuretics; 21 (48.8%) were taking 1 diuretic and 6 (14%) were taking 2 or more diuretics. Figure 1Go illustrates the top 4 categories of medications prescribed according to NYHA class and the number of each medication taken within the category.



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  		Figure 1 Top 4 medication categories, by New York Heart Association class of heart failure, prescribed for patients with chronic heart failure.

 
The overall mean monthly cost of prescribed medications per patient was $438. Patients with class II heart failure had the highest mean monthly cost: $541. Mean monthly costs for patients in the other classes were $514 for class III, $438 for class IV, and $314 for class I. The differences in costs between the 4 groups were significant (F = 4.86, P = .003). A post hoc Scheffé test revealed significant differences in mean costs between patients with class I and class II heart failure (P = .02) and between patients with class I and class III heart failure (P = .02).

Further analysis was done to more closely determine the source of the costs of medications for patients with CHF. A number of patients had coexisting diseases. The 2 most common noncardiovascular comorbid conditions were COPD and diabetes mellitus. Of the 138 patients, 16% had COPD and CHF; 21% had diabetes mellitus and CHF; and 16% had chronic heart failure, COPD, and diabetes mellitus. The mean monthly costs of outpatient medications were calculated for these 3 groups of patients and for patients who had CHF only. The mean costs were $340 for patients with CHF only; $308 for patients with CHF and diabetes mellitus; $600 for patients with CHF and COPD; and $730 for patients with CHF, COPD, and diabetes mellitus. Analysis of variance indicated a significant difference between costs for these groups (F=4.519, P=.005). A post hoc Scheffé test indicated significant differences between patients with CHF only and patients with CHF and COPD (P = .002) and between patients with CHF only and patients with CHF, COPD, and diabetes mellitus (P<.001). The mean monthly costs of medications were calculated for patients with CHF only; CHF and COPD; CHF and diabetes mellitus; and CHF, COPD, and diabetes mellitus according to NYHA stages (Figure 2Go). No significant differences between these groups of patients were detected.



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  		Figure 2 Mean monthly cost of medications, by New York Heart Association class of heart failure for patients with chronic heart failure (CHF) only and patients with CHF plus other noncardiovascular conditions

 

   Discussion
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 Abstract
 Objective
 Methods
 Results
 Discussion
References
 
The cost of outpatient medications is a significant factor in the lives of patients living with CHF. The mean age of the patients in our study was more than 65 years. Many persons older than 65 have Medicare as their sole source of insurance coverage. Therefore, the financial burden of outpatient medication costs is fairly significant for patients in all NYHA classes of CHF. The costs increase for patients who have CHF and comorbid conditions.

Our results indicate that the cost of medications for patients with CHF is significant and that it increases as the severity of the disease advances to class II and class III heart failure. The types of medications by NYHA class indicate the complexity of the prescribed regimens. Some patients are taking more than a single type of medication in a drug classification. Of note, the mean monthly cost of medications decreased for patients with class IV CHF. The reason for this decrease is unclear. Perhaps the therapeutic regimen for patients with the final stages of CHF is not as aggressive as that for patients in the earlier stages of the disease or perhaps complications from comorbid conditions and interactions between medications limit choices of medication. A study tracking the progression of CHF and medication needs and choices might provide further insight into the cost differences.

Limitations of our study include a small sample size and using data on the patients of only one physician. A larger sample and inclusion of patients from multiple practices and geographic regions are needed to determine differences in the cost of medications for CHF among the general population.

Although limited in scope, our results do indicate what medication costs may be for patients with a chronic illness such as CHF. Healthcare professionals in acute care facilities focus on providing the best care in a prescribed length of stay and then discharge the patient. Many healthcare professionals may not fully consider the high costs of medications for patients with CHF and the implication for compliance or adherence, especially in patients with CHF and comorbid conditions.

Costs and ability to pay for the medication regimen must be included in any teaching plan. Many patients will not volunteer information about their personal finances. Discharge planning from an acute care facility should include a plan for paying for medications. Consultation with an appropriate healthcare professional such as a social worker may assist patients in securing services that deal with financial need. Healthcare professionals who provide care in community settings must maintain an awareness of the costs of medications and should discuss patients’ ability to pay for the medications crucial to treatment and survival.


   ACKNOWLEDGMENTS
 
The study was funded by a grant from the University of North Carolina at Charlotte.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809–2273 or (949) 362–2050 (ext 532); fax, (949) 362–2049; e-mail, reprints{at}aacn.org.


   REFERENCES
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 Abstract
 Objective
 Methods
 Results
 Discussion
 References
 

  1. Halm MA, Penque S. Heart failure in women. Prog Cardiovasc Nurs. 2000;15:121–133.[Medline]
  2. American Heart Association. 2001 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2000.
  3. Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Frmingham Study. J Am Coll Cardiol. 1993;22(suppl A):6A–13A.[Medline]
  4. O’Connell JB. The economic burden of heart failure. Clin Cardiol. 2000;23(suppl III):III6–III10.[Medline]
  5. Mueller C, Schur C, O’Connell J. Prescription drug spending: the impact of age and chronic disease status. Am J Public Health. 1997;87:1626–1629.[Abstract/Free Full Text]
  6. Kornowski R, Zeeli D, Auerbuch M, et al. Intensive home-care surveillance prevents hospitalization and improves morbidity rates among elderly patients with severe congestive heart failure. Am Heart J. 1995;129:762–766.[Medline]
  7. Rich M, Beckham V, Wittenberg C, Leven C, Freedland K, Carney R. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333:1190–1195.[Abstract/Free Full Text]
  8. Dunbar SB, Jacobson LH, Deaton C. Heart failure: strategies to enhance patient self-management. AACN Clin Issues. 1998;9:244–256.[Medline]
  9. American Heart Association. Common classifications of cardiovascular diseases. Available at: www.americanheart.org/presenter2002.jhtml?identifier=689. Accessed July 15, 2002.



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This Article
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Right arrow Articles by Hussey, L. C.
Right arrow Articles by Blanchette, C.

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