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Although the high morbidity and mortality of heart failure is well known, the impact of high out-of-pocket costs on health is only beginning to be recognized. Although most of the costs of heart failure are spread among health insurance policyholders and taxpayers (such as hospital treatment), a significant portion is borne by patients. These out-of-pocket costs include both insurance premiums and, increasingly, drug costs.1 In 2018, it was estimated that 1 in 7 U.S. households with a family member with heart failure spent more than 20% of their income on heart failure treatment.1 For low-income households, the rate was one in four.1

term economic toxicity Often used to describe the medical effects of financial hardship. Such toxicity can take the form of treatment avoidance or delay, such as lack of compliance, as well as psychological distress. Based on data from the 2017 National Health Interview Survey, more than 137 million Americans (56%) report some form of economic harm from health care.2

Further insight into the economic toxic effects of heart failure is provided by Yu et al.3 writers3 They investigated the perceived economic toxicity and mortality, readmissions, and health outcomes of 3,386 patients with heart failure from 52 hospitals participating in the China Patient-Centered Cardiac Event Assessment Prospective Heart Failure Study. We investigated the relationship with the condition.

Each patient was classified as having severe, moderate, or little financial burden based on their ability to pay for medical care over the past 12 months. Only 38 respondents (1.1%) had no health insurance, while 404 (11.9%) had severe financial burden, and 2021 (59.7%) had moderate financial burden. I was under financial burden.3 The findings show that despite China’s universal healthcare policy, substantial under-insurance and out-of-pocket costs exist.

Yuu and his friends3 In unadjusted analyses, we found an association between perceived economic burden and mortality, readmissions, and poor health outcomes. By 1 year, 129 (13.4%) people with little financial burden had died, compared with 383 (18.9%) with moderate financial burden and 112 (27.7%) with severe financial burden. Met.3 An association between heart failure severity and economic burden was noted with laboratory findings (increased B-type natriuretic peptide levels) or clinical findings (increased New York Heart Association class). Patients with a high economic burden were less likely to use angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, or beta-blockers at discharge, despite having a lower left ventricular ejection fraction; may be partially due to decreased tolerance to these drugs. Worsening health status with greater economic burden was also evident in responses to the Kansas City Cardiomyopathy Questionnaire (KCCQ), a patient-reported outcome specific to heart failure. Those with severe burden had KCCQ scores 11.3 points lower than those with minimal burden. His 5-point change on the KCCQ is considered clinically meaningful for the individual patient.3

The cross-sectional nature of the analysis makes it difficult to be confident in the direction of causality between economic burden and outcomes. Did poor health lead to economic burden or vice versa, or was the causal relationship bidirectional? Since we don’t know which came first (deteriorating health burden or worsening economic burden), Uncertainty remains about the magnitude of the health effects caused by the burden.Fortunately, the authors3 We provide additional data showing that economic toxicity is associated with worse outcomes in heart failure. Researchers found that 261 people (64.6%) who felt severe financial burden reported avoiding medical care due to cost in the previous year, compared to only 44 people who had little financial burden. (4.6%).3

One indicator of economic toxicity is medical debt, which Yu et al were unable to measure.3 however, it may have contributed to the economic burden perceived in the study. U.S. medical debt has been declining slowly (through 2020), but at a slower rate than overall debt, so that average medical debt now exceeds non-medical debt.Four Changes in debt over time vary widely by state, with states that have not expanded Medicaid actually seeing increases in medical debt. The US Gallup poll also found that the proportion of people who said they had postponed treatment (until 2021) due to high costs was stable or slightly decreasing.Five However, in 2022, the number of people postponing treatment increased to 46% (between 26% and 38%).Five This avoidance of medical care due to cost was not limited to elective procedures. According to reports, 70% of his delayed treatments were due to very or moderately serious symptoms.Five One can imagine a vicious cycle between worsening financial burden and worsening health conditions, ultimately leading to death or hospitalization.

What can you do? One solution is to change cost-sharing policies that increasingly shift drug costs onto patients. The degree of cost sharing by patients is usually linked to drug prices when it should be (inversely) linked to benefits and value. Treatment of heart failure is an anomaly, given the large number of life-sustaining treatments that have been proven effective in randomized clinical trials, and which is of reasonable value to society in terms of costs associated with improved survival rates and quality of life. It is. Such treatments are typically Class I recommended by clinical guidelines.6 It should be provided at no out-of-pocket cost to patients. Patient cost-sharing should be reserved for drugs for which the therapeutic benefit is small, uncertain, or price-justified (i.e., low value).

writers3 Prescribing life-sustaining drugs raises the alarming possibility that they may cause economic toxicity that can actually worsen health outcomes. Those involved in the treatment of heart failure are already concerned about patients’ ability to pay for many of the prescription drugs recommended in the guidelines. Now, they must consider that their prescriptions may pose economic harms and negate the benefits of treatment.

There is still much to learn when it comes to financial toxicity. Prospective studies examining outcomes in patients with stable heart failure who experience changes in financial burden are needed. However, thanks in part to the work by Yu et al.3 We know that high out-of-pocket costs are likely to lead to worse heart failure outcomes. Fortunately, this is a toxin that has an antidote.

release date: March 21, 2024. doi:10.1001/jamanetworkopen.2024.1403

Open access: This is an open access article distributed under the terms of the CC-BY license. © 2024 Heidenreich P. JAMA network open.

Corresponding author: Paul Heidenreich, MD, MS, Stanford University School of Medicine, 3801 Miranda Ave, Palo Alto, CA 94303 (heiden@stanford.edu).

Conflict of interest disclosure: There were no reports.

1.

Wang SY, Valero-Elizondo J, Ali HJ, et al. Economic toxicity due to annual out-of-pocket medical costs and medical costs for patients with heart failure in the United States. J. Am Heart Assoc. 2021;10(14):e022164. doi:10.1161/JAHA.121.022164 PubMed Google Scholar Crossref
6.

Heidenreich PA, Bozkurt B, Aguilar D, 2022 AHA/ACC/HFSA Guidelines for the Management of Other Heart Failure: Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Col Cardiol. 2022;79(17):e263-e421. doi:10.1016/j.jacc.2021.12.012 PubMed Google Scholar Crossref

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