Although multidisciplinary heart failure (HF) clinics are efficacious, it is not known how patient factors or HF clinic structural indicators and process measures have an impact on the cumulative health care costs.
In this retrospective cohort study using administrative databases in Ontario, Canada, we identified 1216 HF patients discharged alive after an acute care hospitalization in 2006 and treated at a HF clinic. The primary outcome was the cumulative 1-year health care costs. A hierarchical generalized linear model with a logarithmic link and gamma distribution was developed to determine patient-level and clinic-level predictors of cost.
The mean 1-year cost was $27,809 (range, $69 to $343,743). There was a 7-fold variation in the mean costs by clinic, from $14,670 to $96,524. Delays in being seen at a HF clinic were a significant patient-level predictor of costs (rate ratio 1.0015 per day; P<0.001). Being treated at a clinic with >3 physicians was associated with lower costs (rate ratio 0.78; P=0.035). Unmeasured patient-level differences accounted for 97.4% of the between-patient variations in cost. The between-clinic variation in costs decreased by 16.3% when patient-level factors were accounted for; it decreased by a further 49.8% when clinic-level factors were added.
From a policy perspective, the wide spectrum of HF clinic structure translates to inefficient care. Greater guidance as to the type of patient seen at a HF clinic, the timeliness of the initial visit, and the most appropriate structure of the HF clinics may potentially result in more cost-effective care.
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*Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre
†Toronto Health Economics and Technology Assessment (THETA) Collaborative
‡Institute of Health Policy, Management and Evaluation
§Institute for Clinical Evaluative Sciences (ICES)
∥Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
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Supported in part by research funding from the Schulich Heart Center at Sunnybrook Health Sciences Center and the Sunnybrook Research Institute as well as an operating grant from the Canadian Institute for Health Research (CIHR). The Toronto Health Economics and Technology Assessment Collaborative (THETA) and ICES are funded in part by the Ministry of Health and Long Term Care (MOHLTC) of Ontario. H.C.W. is supported by a Distinguished Clinician-Scientist award from the Heart and Stroke Foundation. J.V.T. is supported by a Career Investigator award from the Heart and Stroke Foundation and a Canada Research Chair in Health Services Research. D.T.K. is supported by a New Investigator Award from the CIHR. M.K. holds the F. Norman Hughes Chair in Pharmacoeconomics at the Faculty of Pharmacy, University of Toronto. P.C.A. is supported in part by a Career Investigator Award from the Heart and Stroke Foundation. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.
The authors declare no conflict of interest.
Reprints: Harindra C. Wijeysundera, MD, PhD, 2075 Bayview Avenue, Suite A202, Toronto, ON, Canada M4N3M5. E-mail: firstname.lastname@example.org.