FEATURE: A-fib patient management costs strain U.S. healthcare system

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Dr. Michael H. Kim, Northwestern University in Chicago

High rates of re-hospitalization and pharmaceutical expenses for patients with atrial fibrillation are burdening the U.S. healthcare system, according to two studies presented at the American Heart Association's (AHA) 10th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke held last week in Washington, D.C.

Michael H. Kim, from Northwestern University in Chicago, who presented the studies, told Cardiovascular Business News that it was important to quantify the enormity of the total managed costs associated with treating AF patients. "The cost of treating atrial fibrillation is a burden on the patient, as well as the healthcare system," he said.

In one study, Kim and colleagues included a total of 35,255 patients (mean age 64 years, 65 percent men) diagnosed with AF (19,471 with outpatient managed AF, 5,008 with a primary AF diagnosis, 10,776 with a secondary AF diagnosis), and 20,571 controls without AF.

They found that in the 12 months post-hospitalization, for primary AF hospitalization patients, inpatient costs were $11,307 and outpatient costs were $2,827-- for a total cost of more than $14,100). For secondary AF hospitalization patients, incremental AF-related inpatient costs were $5,181 and outpatient costs were $1,376, totaling more than $6,500. For AF patients with outpatient management in 2005, 12-month AF-related costs were $2,177 ($175 for AF hospitalizations and $2,002 for outpatient costs).

"Sadly, I wasn't surprised by the magnitude of the managed care costs," Kim noted. "However, I was quite surprised by the percentage of Medicare patients with AF hitting within the ‘donut hole.' "

The Medicare Part D prescription plan has a coverage gap between $2,250 and $5,100 per year, in which patients pay full drug costs (the ‘donut hole'). At $5,100, patients qualify for catastrophic coverage. In a separate study, Kim and colleagues found that more than half of AF patients aged 65 years or older reached the $2,250 donut hole threshold, and one-fifth reached the $5,100 catastrophic coverage threshold, in 2006. In their study, the authors noted the "impact of this uncovered prescription cost burden on potential discontinuation of AF drugs."

Kim said that anti-arrhythmic drugs were "a minority cost item" compared to the cost burdens associated with the other drugs administered to these patients such as cholesterol and anti-platelet agents.

AF ablation could present an alternative to some of these patients as a first-line treatment, especially for those who are younger and those with no structural heart disease, and "might compare relatively favorably in terms of cost perspective," Kim said.

The success rate for AF ablation, however, is "only intermediate," Kim said. Cost-effectiveness studies would have to examine "sizable upfront costs, which approximately equal the cost of a hospitalization with a few days follow-up, as well as back-end costs such as repeat procedures and complications. Kim added that costs associated with ablation would increase as the patients' acuity and comorbidities increase. 

"A treatment plan for patients with atrial fibrillation should ideally be determined by the individual patient," Kim stated. For example, a "sizeable, number of AF patients can be managed in an outpatient setting--provided they don't have major symptoms."

From a disease management standpoint, Kim et al's study revealed that the largest costs were associated with hospitalization, and a large portion of those costs were related to readmission. "If we could administer safer drugs that would only require outpatient care, it could result in tremendous cost savings," he said.

"Anything that can be done to adequately manage this patient population--from triaging to risk management--to reduce the number of hospitalizations would have a tremendous financial impact to the overall healthcare system," Kim said.