Congestive heart failure has long been one of the most serious medical conditions in the United States; in fact, in the United States alone, heart failure accounts for 6.5 million days of hospitalization each year. One important goal of heart-failure therapy is to inhibit the progression of congestive heart failure through pharmacologic and device-based therapies. Therefore, there have been efforts to develop device-based therapies aimed at improving cardiac reserve and optimizing pump function to meet metabolic requirements. The course of congestive heart failure is often worsened by other conditions, including new-onset arrhythmias, ischemia and infarction, valvulopathy, decompensation, end-organ damage, and therapeutic refractoriness, that have an impact on outcomes. The onset of such conditions is sometimes heralded by subtle pathophysiologic changes, and the timely identification of these changes may promote the use of preventive measures. Consequently, device-based methods could in the future have an important role in the timely identification of the subtle pathophysiologic changes associated with congestive heart failure.
We report the case of a patient who had chronic anthracycline-induced cardiomyopathy that was reversed after treatment with a left ventricular assist device. A 29-year-old woman had undergone anthracycline-based chemotherapy as a teenager in 1991 and 1992 and received a diagnosis of dilated cardiomyopathy 10 years later. Optimal medical therapy had initially controlled the symptoms of heart failure. However, in June 2006, the symptoms worsened to New York Heart Association functional class IV status. We implanted a continuous-flow left ventricular assist device as a bridge to cardiac transplantation; of note, a left ventricular core biopsy at that time showed no replacement fibrosis. The patient's clinical status improved thereafter, enabling left ventricular assist device ex-plantation after 17 months. To our knowledge, this is the first report of the use of left ventricular assist device support to reverse chronic anthracycline-induced heart failure.
Background: The MOMENTUM 3 trial compares the centrifugal HeartMate 3 (HM3) with the axial HeartMate II (HMII) continuous-flow left ventricular assist system in patients with advanced heart failure, irrespective of the intended goal of therapy. The trial’s 2-year clinical outcome (n=366) demonstrated superiority of the HM3 for the primary end point (survival free of a disabling stroke or reoperation to replace or remove a malfunctioning pump). This analysis evaluates health resource use and cost implications of the observed differences between the 2 devices while patients were enrolled in the trial. Methods: We analyzed all hospitalizations and their associated costs occurring after discharge from the implant hospitalization until censoring (study withdrawal, heart transplantation, and pump exchange with a nonstudy device or death). Each adjudicated episode of hospital-based care was used to calculate costs (device-attributable and non–device-attributable event costs), estimated by using trial data and payer administrative claims databases. Cost savings stratified by subgroups (study outcome [transplant, death, or ongoing on device], intended goal of therapy, type of insurance, or sex) were also assessed. Results: In 366 randomly assigned patients, 361 comprised the as-treated group (189 in the HM3 group and 172 in the HMII group), of whom 337 (177 in the HM3 group and 160 in the HMII group) were successfully discharged following implantation. The HM3 arm experienced fewer total hospitalizations per patient-year (HM3: 2.1±0.2 versus HMII: 2.7±0.2; P =0.015) and 8.3 fewer hospital days per patient-year on average (HM3: 17.1 days versus HMII: 25.5 days; P =0.003). These differences were driven by patients hospitalized for suspected pump thrombosis (HM3: 0.6% versus HMII: 12.5%; P <0.001) and stroke (HM3: 2.8% versus HMII: 11.3%; P =0.002). Controlled for time spent in the study (average cumulative cost per patient-year), postdischarge HM3 arm costs were 51% lower than with the HMII (HM3: $37 685±4251 versus HMII: $76 599±11 889, P <0.001) and similar in either bridge to transplant or destination therapy intent. Conclusions: In this 2-year outcome economic analysis of the MOMENTUM 3 trial, the HM3 demonstrated a reduction in rehospitalizations, hospital days spent during rehospitalizations, and a significant cost savings following discharge in comparison with the HMII left ventricular assist system, irrespective of the intended goal of therapy. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02224755.
Whether we are in academic medicine or private practice, a for-profit or a nonprofit institution, the treatment of heart failure is a business. In 2009, the estimated direct and indirect cost of treating heart-failure patients in the United States was more than $37 billion.1 Hospitals receive slightly more than $6,000 from Medicare for each admission, and the average stay lasts about 5.8 days.2 In this country, however, as many as 25% of heart-failure patients are readmitted within 30 days of discharge.3,4 For patients who are readmitted during this time span, Medicare does not reimburse the hospital, so the cost burden is shifted to the healthcare facility.
The following measures can help to ensure that left ventricular assist device (LVAD) therapy is affordable and accessible for future patients.
Communicating with Administrators Effectively. As heart-failure specialists, it is our duty to inform administrators about the importance of advanced therapies to a hospital's cost structure. We must show them that they will make an overall profit—maybe not per se from the patients who receive advanced therapies, but from the larger pool of patients who come to our centers because of the availability of these therapies.
Evaluating Our Heart-Failure Programs from a Business Standpoint. We need to evaluate our individual heart-failure programs from a business standpoint, so that we can speak the same language as our administrators. What strategies and assumptions underlie the everyday care of our patients? How do we incorporate advanced therapies into our program? What are our program's particular strengths and weaknesses? Can our program provide an adequate return on the hospital's investment in advanced therapies and the personnel required to implement them?
Fostering an Alliance between Institutions and Physicians. A crucial factor in incorporating these advanced therapies is an alliance between institutions and physicians. As a consequence of recent Medicare cuts, more and more cardiovascular care is being performed in integrated healthcare systems. For example, because diagnostic testing is reimbursed at a higher rate if performed in a hospital facility (rather than in a cardiologist's private office), some nonacademic hospital systems are now hiring physicians either directly or through a nonprofit organization that is supported by the hospital but governed by a separate board. This alignment of physicians and hospitals can promote the development of advanced cardiovascular programs that will provide a profit margin for the hospital and financial security for the physicians.
Some programs have a mixture of academic faculty members and private practitioners, rendering such alliances problematic in terms of their overall profitability. However, what we are marketing is not just advanced therapy but continuity of care for heart-failure patients. Hospital administrators need to be aware of the big picture: heart-failure clinics increase patient volume, generating substantial profit from diagnostic testing; this can offset the expense of one long hospitalization for a recipient of advanced therapies.
Selecting Patients Carefully. Patient selection is important, because well-chosen patients have a shorter length of stay, impose a lower cost burden, and may even generate a profit. Each medical review board is responsible for selecting patients likely to have the best outcomes. Those at too high a level of risk for advanced therapies may benefit from disease management and palliative care. Rather than use an expensive, fully implantable LVAD for high-risk patients in cardiogenic shock, it might be wiser to use a temporary device, which will allow time to reassess these patients and evaluate their neurologic and psychological status.
Enhancing Nutritional Care and Postoperative Discharge Planning. Malnutrition, a common finding in advanced heart-failure patients, is associated with an increased risk of infection and death in patients who receive mechanical circulatory support. To achieve optimal long-term outcomes in mechanical circulatory support patients, an interdisciplinary approach that incorporates a nutrition-support team is vital.
Long hospital stays can lead to a substantial deficit in even the most profitable mechanical circulatory support programs. Ideally, one nurse should focus on postimplantation discharge planning—examining each patient daily and asking what can be done that day to facilitate discharge. To help decrease the length of stay, some implant centers have developed partnerships with long-term acute-care facilities that have personnel specifically trained in LVAD therapy.
Using Reimbursement Specialists. Round-table sessions on the subject of reimbursement are another important resource. By doing a chart analysis, reimbursement specialists can identify major coding errors that prevent adequate reimbursement for supplies and clinical care. For instance, some programs make costly errors in billing for LVAD batteries: they bill for HeartMate® XVE batteries rather than HeartMate® II batteries, decreasing insurance reimbursement by $3,000 per patient; or they fail to bill for the LVAD pump, thereby absorbing the cost. Reimbursement resources are readily available, but most programs use them infrequently because of time constraints and lack of personnel to oversee coding and billing.
