Elsevier

American Heart Journal

Volume 169, Issue 2, February 2015, Pages 282-289.e15
American Heart Journal

Clinical Investigations
Outcomes, Health Policy and Managed Care
Factors associated with variations in hospital expenditures for acute heart failure in the United States

https://doi.org/10.1016/j.ahj.2014.11.007Get rights and content

Background

Relatively little contemporary data are available that describe differences in acute heart failure (AHF) hospitalization expenditures as a function of patient and hospital characteristics, especially from a population-based investigation. This study aimed to evaluate factors associated with variations in hospital expenditures for AHF in the United States.

Methods

A cross-sectional analysis using discharge data from the 2011 Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, was conducted. Discharges with primary International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes for AHF in adults were included. Costs were estimated by converting Nationwide Inpatient Sample charge data using the Healthcare Cost and Utilization Project Cost-to-Charge Ratio File. Discharges with highest (≥80th percentile) versus lowest (≤20th percentile) costs were compared for patient characteristics, hospital characteristics, utilization of procedures, and outcomes.

Results

Of the estimated 1 million AHF hospital discharges, the mean cost estimates were $10,775 per episode. Younger age, higher percentage of obesity, atrial fibrillation, pulmonary disease, fluid/electrolyte disturbances, renal insufficiency, and greater number of cardiac/noncardiac procedures were observed in stays with highest versus lowest costs. Highest-cost discharges were more likely to be observed in urban and teaching hospitals. Highest-cost AHF discharges also had 5 times longer length of stay, were 9 times more costly, and had higher in-hospital mortality (5.6% vs 3.5%) compared with discharges with lowest costs (all P < .001).

Conclusions

Acute heart failure hospitalizations are costly. Expenditures vary markedly among AHF hospitalizations in the United States, with substantial differences in patient and hospital characteristics, procedures, and in-hospital outcomes among discharges with highest compared with lowest costs.

Section snippets

Data sources

The NIS is sponsored by the Agency for Healthcare Research and Quality through HCUP and is the largest all-payer inpatient database available publically in the United States containing discharge data from about 1,000 hospitals across 46 states in 2011. The database includes charge information regardless of payer or insurance status, as well as clinical and resource use information included in a typical discharge abstract. Approximately 8 million hospitalizations per year are selected from a 20%

Results

The NIS data set for 2011 includes 8 million discharges. There were 217,449 discharges with a primary diagnosis of AHF for patients >18 years of age. After weighting, we estimated that there were approximately 1 million AHF discharges in the United States in 2011 (Figure 1). The mean national cost estimates for AHF were $10,775 per AHF hospitalization episode, which was about one-third the amount of mean hospital charges. Inpatient costs for 2011 AHF hospitalizations were right-skewed, with a

Discussion

Hospital expenditures varied substantially among patients in the United States hospitalized with AHF in 2011, with highest-cost AHF inpatient stays having approximately 9-fold higher expenditures and 5 times longer length of stay compared with lowest-cost stays. Substantial differences were found in patient and hospital characteristics, procedures, and in-hospital outcomes among AHF hospitalizations with highest versus lowest costs. In-hospital mortality was higher for highest-cost compared

Limitations

The NIS data set unit is based on hospitalizations and lacks individual patient identifiers; consequently, readmissions are not identified. Rehospitalization rates are estimated to approach 30% for HF.12 We are therefore not able to distinguish variation in costs between AHF hospitalizations and AHF rehospitalizations. We only included hospitalizations with a primary discharge diagnosis for AHF and not secondary diagnoses, and the degree of variation in expenditures and associated factors may

Conclusions

This study provides insights into the high cost and variation in hospital expenditures among AHF hospitalizations in the United States and identifies factors associated with higher and lower expenditures. Select demographic factors and comorbidities are independently associated with variations in hospital expenditures, as are certain in-hospital procedures. Expenditures also vary by hospital characteristics, including geographic location. These findings may assist in further understanding

Author disclosures

Boback Ziaeian: no relationships to disclose.

Puza P. Sharma: Novartis Pharmaceuticals Corporation employee and stockholder.

Tzy-Chyi Yu: Novartis Pharmaceuticals Corporation employee and stockholder.

Katherine Waltman Johnson: Novartis Pharmaceuticals Corporation employee and stockholder (significant).

Gregg C. Fonarow: Research AHRQ (significant), NHLBI (significant); Consultant Bayer (modest), Gambro (modest), Medtronic (modest), Novartis (significant), Boston Scientific (modest), Medicines

Acknowledgements

The authors developed the manuscript, and all authors significantly edited the first draft for intellectual content. All authors approved the final manuscript that is submitted for publication.

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    Financial support: Novartis Pharmaceuticals (East Hanover, NJ) provided funding and review of manuscript prior to submission.

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