One in Six HF Patients Delay or Forego Care, Inflating Costs

One in six patients with heart failure (HF) in the United States forego or delay medical care for their symptoms, significantly driving up later healthcare costs, a new analysis shows. Yet half of those surveyed acknowledged—ironically—that financial concerns had played a key role in their decision to postpone or avoid seeking help in the first place.

In the nationwide analysis, patients who reported skipping appointments or delaying care had annual healthcare expenses more than $8,000 higher than those who didn’t report foregone/postponed care.

Lead author on the paper, Alexander Thomas, MD (Yale University School of Medicine, New Haven, CT), said he was interested in documenting this phenomenon after seeing too many HF patients being hospitalized for serious complications. Oftentimes, he told TCTMD, “they were coming in for a lot of reasons that I thought were very preventable and a lot of it was [due to] missed appointments, missed medications, and sometimes just a lack of understanding about the reasons for needing to go to their appointments. Or [there were], what seemed to me, very overcome-able barriers like transportation or timing . . . that could have prevented them weeks and weeks earlier from having issues and getting hospitalized.”

Prior studies have already linked missed appointments, nonprescribing, and underuse or underdosing of guideline-directed medical therapy to worse outcomes, he noted.

“Though not examined in this study, [we know] that patients that are ending up in the hospital, and patients that are not taking their medications, are not going to have as good outcomes as patients who are going to their outpatient appointments and taking all their prescribed medications and then not getting hospitalized,” Thomas said.

Other research estimates that there are over 1 million preventable HF admissions in the United States annually, representing one-quarter of all HF-related hospital visits, the authors note. What Thomas hopes is that a healthcare utilization and costs analysis can help drive policy solutions by showing that it’s also economically attractive.

By the Numbers

Thomas and colleagues reviewed healthcare expenditures and utilization between 2004 and 2015 in the national Medical Expenditure Survey, which combines a series of cross-sectional surveys collecting information on sociodemographic elements, diagnoses, patient experience, prescriptions, health resource usage, costs, and payment sources.

They found that 16% of patients surveyed said they’d forgone or delayed care. These people were more likely to be under 65, from lower-income households, and to have higher comorbidity burden. The fact that younger patients were more likely to forego or postpone care, said Thomas, may in large part be due to a lack of insurance coverage: 60% of nonelderly and 46% of elderly patients said they deferred care due to financial barriers.

But other factors likely play a role, said Thomas. Younger patients may have more cardiac reserve, so they can tolerate their symptoms more easily, he speculated, but it may also be that younger HF patients have more responsibilities at work and at home that take priority over their own health. “It may be much more difficult to get to those appointments or get to the pharmacy to get your prescriptions, and also to maybe have the extra money available just to get out and do the things that are needed for general maintenance care and heart failure,” said Thomas. “I think a lot of that drives what we saw.” 

Not only was delayed/forgone care associated with higher annual costs, it was also linked with more emergency department visits (43% vs 58%; P < 0.05), $7,548 more in annual inpatient costs and $10,581 more total healthcare costs.

“A lot of this was driven by inpatient hospitalizations, not so much some of the other costs. We didn't see higher rates of hospitalizations, but we saw higher costs per hospitalization,” Thomas said. “I think that there's a lot of room to catch a lot of these things in the outpatient setting before they lead to this long, costly hospitalization, potentially, if someone does need to be hospitalized. When that's caught sooner and it can be a shorter, less intensive hospitalization, it may not require ICU care or as long of a duration to just diurese all the fluid off of them.”

Future Solutions

Commenting on the study for TCTMD, Christopher M. O'Connor, MD (Inova Heart and Vascular Institute, Fairfax, VA), editor-in-chief for JACC: Heart Failure, pointed out that health systems are already stretched to the max; the COVID-19 pandemic has only worsened the financial picture.

“I think this paper is quantifying observations and care that we've all seen, but we didn't know the magnitude of it. When you talk about one in six patients, total annual costs of $10,000, half of the reasons are financial barriers, and ED visits are up significantly in both groups, and hospitalization trends up: this is a big problem,” O’Connor said. “We've got to find better ways to deliver better care and keep patients out of the hospital.”

O’Connor highlighted a point also made to TCTMD by Thomas, that the disproportionate burden of foregone/delayed care for heart failure is born by Black Americans and lower-income families. Recent expansion of Medicaid programs may help to close this gap, O’Connor noted, pointing out that this paper only captures data between 2004 and 2015. “It will be really, really, good work if Dr. Thomas and his team could update this now that Medicaid expansion has gotten legs in the majority of the states,” he said. Other data have hinted that as financial barriers drop, access to heart failure care improves.

On the other hand, COVID-19 is also leaving an indelible impact on heart failure care. Thomas noted that the well-documented trends in hospital avoidance during the pandemic “definitely has impacted heart failure admissions.

“And even though we're not seeing them all the time, the patients that are coming in are definitely much sicker than we’ve seen previously, because they've been at home getting worse when they would have [otherwise] come in weeks or months ago,” he continued, adding that fear of being out in the community even to fill a prescription is also a plausible factor.

But both Thomas and O’Connor pointed out that the rapid expansion of telehealth in response to pandemic conditions has helped physicians to more easily connect with patients facing job, transportation, geographic, or other barriers to care.

“I think one of the silver linings of this tragic pandemic is the familiarization and the quick adoption of telehealth, and I hope that we get a better national coverage policy for telehealth, because some of those have been reverted back to baseline, which is not optimal,” said O’Connor. “I think, particularly for the . . . barriers you saw this paper, telehealth is a reasonable option and alternative and I think it will be one that we will rely on more in this complex population.”

Advances in artificial intelligence and electronic medical records, too, may help catch patients who “fall through the cracks,” O’Connor added. “When a patient misses a visit or misses a prescription, we can use information technology through a multidisciplinary team to collect that, capture that and regain that patient back into the system.”

Certainly COVID-19 has shone a light into some of the darkest disparities in healthcare, Thomas observed. “These kinds of disparities are something that is obviously becoming more and more at the forefront of everyone's minds, and I hope that's going to lead to a lot of changes that need to happen. At this point, having the awareness of it and knowing that these are the patients at higher risk for forgoing or delaying care should maybe give [physicians] a little incentive to spend some additional time with them, to make sure that we're addressing all of the different aspects of the reasons that they may be foregoing or delaying care.”

In an accompanying editorial, Khadijah Breathett, MD (University of Arizona, Tucson), doesn’t mince words, noting that in addition to the COVID-19 pandemic, the “era of social justice” has also revealed the extent to which “underinsured populations and people of color have suffered from disproportionate burden of disease related to bias, racism, and social determinants of health.”

If the cost overruns estimated in this study were applied to the 6.5 million individuals living with heart failure in the United States, “the annual additional cost to the US healthcare system for forgoing or delaying care would exceed $8.3 billion per year,” she notes. “The current US healthcare system is unsustainable. Is it not time to take cost-saving measures that improve quality of life and extend duration of life?”