© 2004 by European Society of Cardiology
Reduction in hospitalization rates following cardiac resynchronisation therapy in cardiac failure: experience from a single centre
Regional Cardiology Centre, Belfast City Hospital Northern Ireland
Manuscript submitted 12 February 2004. Accepted after revision 2 August 2004.
*Corresponding author. Coronary Care Unit, 1 North, Craigavon Area Hospital, Craigavon, Northern Ireland. Tel.: +44 28 38 334444; fax: +44 28 38 613693. Email address: l.dixon{at}qub.ac.uk (L.J. Dixon).
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Abstract |
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AIMS: Frequent, lengthy hospital admissions for congestive cardiac failure (CCF) result in excessive health care costs. Cardiac resynchronisation therapy (CRT) is a novel treatment option for patients with CCF and associated cardiac conduction defects. We investigated whether CRT resulted in significant improvements in New York Heart Association (NYHA) symptom class, exercise tolerance, and hospitalization rates in such patients.
METHODS: Twenty-seven patients who underwent CRT in a single centre were studied, with NYHA symptom class, exercise tolerance and hospitalization rates noted in the 12 months prior to and following CRT.
RESULTS: Following 12 months of CRT, NYHA symptom class improved from 3.3 ± 0.5 to 2.1 ± 0.4 (P < 0.05). Exercise tolerance, assessed by 6 min hall walk test increased by 64% from 195 ± 114 m to 320 ± 85 m (P = 0.007). Days in hospital for stabilisation of cardiac failure decreased by 98% from 472 to 9 days (P < 0.001). Significant hospitalization cost savings of 201 684 euros were calculated, with an overall saving of 12 420 euros.
CONCLUSIONS: These data demonstrate that CRT results in significant improvement in clinical parameters, and considerable reductions in hospital admissions, and costs in patients with CCF.
Key Words: cardiac failure, cardiac conduction defects, cardiac resynchronisation therapy, hospitalizations, cost-effectiveness
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Introduction |
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Despite significant advances in the pharmacological management of CCF [1,
2], congestive cardiac failure (CCF) remains a condition with exceptionally high rates of morbidity and mortality [3,4]. For a population of CCF patients remaining refractory to conventional drug treatment, access to therapies such as heart transplantation and implantable assist devices remains restricted [5]. These patients have frequent, lengthy hospitalizations. The high and increasing incidence of CCF, in combination with high hospitalization rates result in significant healthcare costs, with 75% of these attributable to hospital care [6].
Cardiac resynchronisation therapy (CRT) is a novel therapy for the estimated 30% of patients CCF who have associated intra- and inter-ventricular conduction defects [7–9]. These conduction defects, usually but not always, characterised on the surface ECG as prolongation of the PR interval and left bundle branch block, result in an inefficient in-coordinate cardiac contraction, and correlate with increased mortality [10–14]. Early studies suggest that CRT enhances functional capacity and quality of life [15–20]. Braunschweig et al. demonstrated a reduction in hospitalization following CRT [21] and the COMPANION trial suggested a reduction in all-cause mortality and all-cause hospitalization following CRT [22]. Reports to date have been from multicentre trials. We report results from a single centre, examining whether CRT results in clinical improvement in addition to a reduction in hospitalization rates and costs.
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Methods |
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Patients with dilated or ischaemic cardiomyopathy, QRS duration of greater than 130 ms, NYHA symptom class III or IV, and ejection fraction of less than 30% were recruited from the Belfast City Hospital Heart Failure clinic. Patients were excluded if they had acute coronary syndrome, needed revascularisation, or if percutaneous transluminal angioplasty, or coronary artery bypass surgery had been performed in the previous 6 months. NYHA symptom class, six-minute hall walk test, ECG and echocardiogram were documented at baseline. Study approval was obtained from the local ethics committee, and written informed consent was obtained from all participants. A single cardiologist performed all implantations. There were no pacemaker related complications. Patients were reviewed at month 1, and thereafter at 3 monthly intervals post-procedure, with study parameters recorded at each review. The number and duration of hospitalizations, and the reason for admission were also recorded. We used average European costings of an average cost per day for hospitalization of 588 euro, CRT implantation procedure 483 euro, pacemaker and leads 4800 euro, and pacemaker follow-up 460 euro to perform a simple cost analysis to determine cost savings in the 12 months prior to CRT (including hospital stay, CRT procedure, device, and follow-up costs), compared with the 12 months following CRT.
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Results |
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Results are reported as mean ± standard deviation, unless otherwise stated. Paired Student t-tests were used for statistical analysis.
Twenty-four males, three females, mean age 64 ± 9 years were included. Fourteen were of ischaemic, and 13 of dilated aetiology and mean symptom duration was 4.5 years. Twenty-four patients were in normal sinus rhythm, with a mean PR interval of 186 ± 47 ms. Mean left ventricular end diastolic dimension prior to CRT was 6.6 ± 0.2 cm. Mean QRS duration prior to CRT was 177 ± 21 ms, reducing to 158 ± 25 ms at 1 month post-CRT, a reduction which was maintained at 12-months follow-up. Mean NYHA functional class at baseline was 3.3 ± 0.5, which improved to 2.3 ± 0.5 at month 1 (P = 0.02). This significant improvement persisted at 3 (2.1 ± 0.3), 6 (2.1 ± 0.3) and 12 months (2.1 ± 0.4). Distance covered during a 6 min walk test was 195 ± 114 m prior to CRT, improving by 30% to 254 ± 115 m at month 1 (P = 0.003), by 51% at month 3 (294 ± 120 m) (P = 0.002), 71% at month 6 (334 ± 104 m) (P = 0.0007), 85% at month 9 (360 ± 76 m) (P = 0.0006) and by 64% at month 12 (320 ± 85 m) (P = 0.002). One patient died during the follow-up period from biliary carcinoma. There were no pacemaker related complications, and no cardiac related deaths. Total days in hospital, for all causes decreased by 71% from a total of 483 days to 140 days (P < 0.001). Days in hospital for stabilisation of cardiac failure decreased substantially by a dramatic 98%, from 472 to 9 days (P < 0.001). The mean duration of stay for heart failure was reduced by 61% from 11.5 days to 4.5 (P < 0.001). Total number of admissions for heart failure decreased considerably, by 95%, from 41 prior to pacing to 2 following pacing (P < 0.001). The estimated costs for hospital care, pacemaker device and implantation and follow-up are shown in Table 1, and demonstrate a reduction in hospitalization costs of 201 684 euro, (7470 euro per patient), and an overall reduction of 46 623 euro (1727 euro per patient).
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Discussion |
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This study demonstrates that in patients with CCF and cardiac conduction abnormalities, CRT improves NYHA symptom class and exercise tolerance, benefits which were apparent after only one month of treatment and sustained for 12 months. In parallel with the improvement in clinical parameters, the reduction in hospital admissions for CCF was substantial (98% from 472 to 9 days), and also duration of stay was reduced from 11.5 to 4.5 days. The observed reduction in hospitalization rates resulted in significant cost savings, with a saving of 201 684 euros for hospitalization costs, and an overall saving of 46 623 euros when CRT implantation, device and follow-up were taken into account. These cost–benefits will obviously be extended if device costs fall with increased use and availability of CRT and, furthermore, if these benefits are maintained long-term, the savings may be substantial, both in economic terms and patient well-being. These findings are obviously of considerable consequence to the Health Care System, where CCF represents an increasing and substantial economic burden.
These data reflect the findings of Braunschweig et al. [21], however, the patient group is from a single centre, is larger, and the follow-up period longer in the present study.
An interesting and surprising finding in the present study was that in spite of the severe nature of the cardiac condition prior to CRT, the cardiac mortality was zero.
The interpretation of these results is limited by the uncontrolled nature of the study, and the small number of participants. However, as the patients post-CRT are being compared with their pre-CRT state, an element of control exists.
In conclusion, our results strongly support the therapeutic value of CRT in patients with CCF and associated evidence of cardiac asynchrony. It is a safe procedure, which significantly improves symptoms, exercise tolerance, reduces hospitalization rates and provides significant cost savings. Despite the absence of strong data on mortality benefits, this study provides further evidence to validate CRT as a valuable intervention on the basis of symptoms, days in hospital and cost. Further controlled studies are currently underway to investigate the long-term clinical benefits of this promising treatment.
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