Ballooning Inpatient AF Costs: A $26 Billion Conundrum

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 - Money Balloon

Atrial fibrillation (AF) places a heavy financial burden on the U.S. healthcare system, mainly shouldered by providers, in a trend that is likely to worsen over time. By evaluating costs associated with AF, cardiologists have identified strategies that, if implemented, may help to chip away at these costs. 

The (inpatient) bottom line

Hospitalizations with AF as the primary diagnosis exceed 460,000 each year, and AF is estimated to contribute to more than 80,000 annual deaths (Circulation 2009;119:e21-e181). Because hospitalization is the primary cost driver in the management of the disease—nearly 75 to 80 percent of the costs—the economic burden of AF on the healthcare system is likely to continue to grow. The estimated U.S. costs for AF hospitalization in 2001 were $2.93 billion for patients with AF as their primary discharge diagnosis (Value Health 2006;9[5]:348-356).

Given the demographics and trajectory of the disease state, these numbers are not likely to diminish. “As our population ages we’re seeing more and more cases of atrial fibrillation,” says Michael H. Kim, MD, director of arrhythmia service at the Cardiovascular Institute for Rhode Island Hospital and Miriam Hospital, both in Providence, R.I. “Within the age groups, we’re seeing more comorbidities within the population, including more diabetes, more high blood pressure, more obesity, which are risk factors that translate into more AF cases and worse AF outcomes.”

In the U.S. alone, there has been a 13 percent increase in the incidence of AF over the past two decades, and by 2050, the estimated prevalence is 15.9 million, with more than half of these patients 80 years or older (Circulation 2006;114:119-125). Looking at population epidemiology, this disease state will continue to impact overall societal health, as well as healthcare costs and utilizations.

Kim et al found that the national incremental AF cost is estimated to range from $6 billion to $26 billion, based on 2010 U.S. age- and sex-specific prevalence data (Circ Cardiovasc Qual Outcomes 2011;4:313-320). In the study, they matched 89,066 AF patients to non-AF control subjects. Over one year, 37.5 percent of AF vs. 17.5 percent of control subjects were hospitalized, and 2.1 percent vs. 0.1 percent died during hospitalization. For AF vs. control subjects, the mean annual inpatient costs per patient were $7,841 vs. $2,622; outpatient medical costs were $9,225 vs. $5,629; and outpatient pharmacy costs were $3,605 vs. $3,714. The total incremental cost of AF was $8,705 per patient.

The national incremental cost of AF was $26 billion (AF alone, $6 billion; other cardiovascular [CV], $9.9 billion; non-CV, $10.1 billion). Overall, the researchers estimated that the total direct medical costs were 73 percent higher in AF patients than in matched control subjects, representing a net incremental cost of $8,705 per patient per annum (2008 values).

The cost drivers weren’t specifically focused on the Medicare population, and there was a higher incremental cost of AF in patients in the under-65 age group. Kim et al wrote that this finding was “not unexpected,” given that suspected AF may be investigated more extensively in those under 65 and, once diagnosed, it may be treated more aggressively than in the elderly. 

Also, U.S. patients under 65 years more often have private insurance. In one study of 2 million privately insured individuals in the U.S., direct costs were $15,553 per year (2002 dollars) among enrollees with AF, nearly five times as costly as those without AF (Curr Med Res Opin 2005;21[10]:1693-1699). This study examined the direct (medical and drugs) and indirect (work loss) annual costs associated with AF, not simply the inpatient costs.

Kim says that AF-specific costs out of the total $26 billion finding in his study are probably underestimated. "AF can be embedded into costs associated with heart failure worsened by AF, and even more so, stroke," he says. "We couldn’t really tease that out based on our dataset.” 

Circ Cardiovasc Qual Outcomes 2011;4:313-320 © American Heart Association
Breakdown of National Incremental Costs in Patients with Atrial Fibrillation

 - AF Patient Costs

Stroke prevention

Thromboembolic stroke is the most serious and debilitating of all AF complications, explains Laurence M. Epstein, MD, chief of cardiac arrhythmia service at Brigham and Women’s Hospital in Boston. “To ratchet down the costs associated with AF, we must first ensure that our patients are properly treated for stroke