Summary
Background
Very little is known about the costs of mitral regurgitation (MR) in Europe.
Aim
To evaluate the cost of MR from a French National Payer perspective, based on annual costs of surgical and non-surgical patients.
Methods
A 12-month retrospective population-based analysis of patient demographics, outcomes and acute hospital and post-discharge resource utilizations, extracted from the 2009 French Medical Information System.
Results
A total of 19,868 patients with MR were identified. Surgical group ( n = 4099): index hospitalization length of stay (LOS), 17 ± 14.7 days; patients discharged to rehabilitation, 72% (LOS 23 ± 16 days); 12-month rehospitalization rate, 25%; total cost per surgical patient, €24,871 ± 13,940 (ranging from €21,970 ± 11,787 for mitral valve repair [ n = 2567, 62.6%] to €29,732 ± 15,796 for mitral valve replacement). Non-surgical group ( n = 15,769): number of hospitalizations over 12 months, 3.1 ± 1.5 (LOS 23.5 ± 20.4 days); admitted to rehabilitation, 24% (LOS 38.8 ± 37.6 days); total cost per patient, €12,177 ± 10,913 (varying between €9957 ± 9080 and €13,538 ± 11,692 for those without and with heart failure [HF], respectively). The total observed cost for 19,868 MR patients over 12 months was €292.8 million: surgical group, €100.8 million; medical group €192.0 million. Patients with MR and HF who were managed medically consumed 45% (€132.3 million) of the overall annual cost of MR.
Conclusion
The costs of care associated with MR are highly heterogeneous. There are significant differences in costs and resources used between the surgical and medical MR subgroups, with further differences depending on type of surgery and presence of HF.
Résumé
Contexte
La connaissance du coût médico-économique de l’insuffisance mitrale reste très limitée en Europe.
Objectif
Évaluer le coût de l’IM en se basant sur l’étude des coûts annuels rattachés à la prise en charge médicale des patients opérés et non opérés.
Méthodes
Il s’agit d’une étude rétrospective qui a recueilli à partir des données du PMSI de 2009 et un suivi de 12 mois les données démographiques, les événements cliniques, les hospitalisations non programmées et l’utilisation des ressources médicales des patients ayant un diagnostic principal ou secondaire d’insuffisance mitrale.
Résultats
Dix-neuf mille huit cent soixante-huit patients avec IM ont été identifiés. Groupe chirurgical ( n = 4099) : la durée de l’hospitalisation index (LOS) était de 17 ± 14,7 jours ; 72 % des patients étaient ensuite hospitalisés en centre de réadaptation (LOS 23 ± 16 jours) ; le taux de réhospitalisations à 12 mois était de 25 % ; le coût total moyen par patient chirurgical était de 24 871 ± 13 940 €, allant de 21 970 ± 11 787 € pour la réparation valvulaire mitrale ( n = 2567, 62,6 %) à 29 732 ± 15 796 € pour le remplacement valvulaire. Groupe non chirurgical ( n = 15 769) : les patients ont été hospitalisés en moyenne 3,1 ± 1,5 fois sur une période de 12 mois (LOS 23,5 ± 20,4 jours) ; 24 % ont été admis dans un centre de réadaptation (LOS 38,8 ± 37,6 jours) ; le coût total moyen par patient était de 12 177 ± 10 913 €, variant entre 9957 ± 9080 € à 13 538 ± 11 692 € respectivement selon la présence ou l’absence d’insuffisance cardiaque. Le coût total des 19 868 patients avec insuffisance mitrale pendant 12 mois était de 292,8 millions : 100,8 millions € pour le groupe chirurgical et 192,0 millions € pour le groupe médical. Les patient avec IM et insuffisance cardiaque pris en charge médicalement consommaient 45 % (132,3 millions €) du coût total annuel rattaché à l’insuffisance mitrale.
Conclusion
Les coûts médico-économiques et l’utilisation des ressources médicales associés à l’insuffisance mitrale sont très hétérogènes : des différences significatives existent entre les sous-groupes des patients opérés et les patients traités médicalement, avec également des différences selon le type de chirurgie et la présence d’une insuffisance cardiaque.
Background
The exact incidence and prevalence of mitral regurgitation (MR) is unknown, but it probably exceeds five million worldwide ; MR is the second most common type of heart valve disease requiring surgery in Europe . The condition is often associated with heart failure (HF), one of the most common cardiovascular disorders worldwide, and one that poses a significant economic burden . In the USA, the 2010 estimated annual cost of HF was $39.2 billion, approximately 2% of the total USA healthcare budget . The main cost drivers of HF are hospitalization, nursing home, home healthcare and medications . Hospitalizations account for approximately 60% of the total HF cost in the USA, reaching 82% when rehabilitations and long-term hospitalizations are also considered .
In 2009, the therapeutic options available for the treatment of MR included medical management or a surgical approach (repair or replacement). The recent introduction of MitraClip ® , the first percutaneous mitral valve repair device, provides a third therapeutic option for severe MR patients . A growing body of evidence supports the increased uptake of this new therapy . Consequently, the 2012 European Society of Cardiology guidelines suggested the use of percutaneous repair in patients with an indication for valve surgery, but judged inoperable or at unacceptably high surgical risk .
Very little is known about the costs of MR in Europe. As hospital stays account for most of the resources used to manage MR, it is possible to assess the burden of MR from national hospital statistics, based on diagnosis-related groups. Thus, in the context of the development of a percutaneous approach for the treatment of MR and the perspective of a cost-efficacy evaluation, the objective of this study was to assess the hospital costs of MR from a French national payer perspective.
Methods
Direct costs were extracted from the French Medical Information System (programme de médicalisation des systèmes d’information [PMSI]), a national prospective database of the activity of all public and private hospitals. Diagnosis-related groups are derived from standardized discharge reports following hospital stays. Diagnoses are coded using the International Classification of Diseases, 10th revision (ICD-10), as either primary or associated diagnoses (e.g. left ventricular dysfunction [LVD] is coded by a unique code, I501). Therapeutic procedures are extensively coded using the Classification commune des actes médicaux (CCAM), a national standardized medical procedures classification . As a patient may have several hospital stays, each patient is identified using a unique anonymous number calculated from their social security number, date of birth and sex. Because all discharge reports are compulsory and are the basis of hospital funding, the PMSI instrument represents a unique exhaustive database of patients .
Patient identification
Data for MR patients with a follow-up period of 12 months were extracted from the 2009 PMSI database and divided into two groups, defined by their therapeutic management as surgical or non-surgical.
Surgical patients
The population undergoing surgery was extracted based on hospitalization data of patients diagnosed with MR (primary or secondary diagnosis), using five related ICD-10 codes: I340, I348, I349, I511, I390. Thus, this surgical group included all mitral valve surgeries, single or associated with coronary revascularizations or multiple valve repairs or replacements.
Non-surgical patients
The non-surgery population was extracted based on MR hospitalizations identified by the dedicated ICD-10 code (I340). Two subgroups were identified with and without HF or left ventricular failure according to the following five ICD-10 codes: I110, I420, I500, I501 and I509.
As the objective was to capture costs linked to MR as the main diagnosis for hospitalization, patient data were selected on the basis of the following criteria: age > 50 years; no history of mitral valve surgery in the past two years; no surgical management of mitral valve disease during the years of recruitment and follow-up; and a minimum of two hospitalizations during 2009.
Data collection
Data were extracted from 2009 and 2010, and included patient demographics (sex, age, co-morbidities), mortality, discharge location and acute hospital resource utilizations (number of hospitalizations, length of stay [LOS], number of intensive care unit [ICU] days [i.e. ICU itself, resuscitation ward or continuous monitoring] and hospitalization charges). Post-discharge resource utilizations were also collected (rehospitalization rates and charges, rehabilitation rates and charges).
Statistical analysis
Data are expressed as mean ± standard deviation or number (percentage) as appropriate. Unit costs were expressed in Euro-2009 values and were derived according to the French National Payer perspective from published national tariffs from the French National Sick Fund for descriptive statistical analyses, including distribution ranges.
Results
Patient demographics
In total, 19,868 patients with MR were identified: 4099 underwent a surgical mitral valve intervention and 15,769 were treated by non-surgical means.
The surgical group was subdivided according to the surgical intervention (valve repair or valve replacement) ( Table 1 ). Patients were predominantly male (62%), with a mean age of 65 ± 14 years. Co-morbidities included HF (15% of surgical patients), hypertension (35%), diabetes (11%) and renal failure (6%).
| Surgical patients | Repair ( n = 2567) | Replacement ( n = 1532) | Total ( n = 4099) |
|---|---|---|---|
| Men | 68 | 52 | 62 |
| Age (years) | 64 ± 14 | 66 ± 14 | 65 ± 14 |
| Heart failure | 308 (12) | 306 (20) | 614 (15) |
| Hypertension | 878 (34) | 545 (36) | 1423 (35) |
| Diabetes | 207 (8) | 228 (15) | 435 (11) |
| Renal failure | 134 (5) | 129 (8) | 263 (6) |
| Non-surgical patients | With heart failure ( n = 9774) | Without heart failure ( n = 5995) | Total ( n = 15,769) |
|---|---|---|---|
| Men | 54 | 53 | 53 |
| Age (years) | 77 ± 10 | 74 ± 10 | 76 ± 10 |
| LVD | 5269 (54) | 2041 (34) | 7310 (46) |
| Hypertension | 7099 (73) | 4300 (72) | 11,399 (72) |
| Diabetes | 3057 (31) | 1524 (25) | 4581 (29) |
| Renal failure | 3482 (36) | 1021 (17) | 4503 (29) |
The non-surgical group was subdivided depending on the presence of HF, which was reported in 62% of patients ( Table 1 ). Patients were predominantly male (53%), with a mean age of 76 ± 10 years. Co-morbidities included LVD (46% of non-surgical patients), hypertension (72%), diabetes (29%) and renal failure (29%).
Index hospital resource utilization
Over 12 months, the mean LOS in the surgical group was 17 ± 14.7 days and in-hospital mortality reached 6.6% (ranging from 3.4% to 12.0%) ( Table 2 ). In the non-surgical group, the mean number of hospitalizations was 3.1 ± 1.5 (range 2.8 ± 1.2 to 3.3 ± 1.7), with a mean annual LOS of 23.5 ± 20.4 days; in-hospital mortality was 11.4% ( Table 2 ).
| Surgical patients | Repair ( n = 2567) | Replacement ( n = 1532) | Total ( n = 4099) |
|---|---|---|---|
| LOS (days) | 15 ± 12.5 | 21 ± 17.2 | 17 ± 14.7 |
| In-hospital mortality a | 89 (3.4) | 184 (12.0) | 273 (6.6) |
| Costs (€) | 12,749 ± 3846 | 14,849 ± 5132 | 13,534 ± 4487 |
| Additional cost from ICU (€) | 3809 ± 7535 | 6268 ± 9696 | 4728 ± 8490 |
| Additional cost from devices (valves and annulus) (€) | 700 ± 0 | 2600 ± 0 | 1410 ± 0 |
| Total hospitalization cost (€) | 19,158 ± 10,089 | 23,718 ± 13,218 | 19,863 ± 11,571 |
| Non-surgical patients | With heart failure ( n = 9774) | Without heart failure ( n = 5995) | Total ( n = 15,769) |
|---|---|---|---|
| Number of hospitalization stays after 12 months | 3.3 ± 1.7 | 2.8 ± 1.2 | 3.1 ± 1.5 |
| LOS (days) | 28 ± 22.1 | 16.6 ± 15 | 23.5 ± 20.4 |
| Mortality over 12 months | 1474 (15.1) | 339 (5.6) | 1813 (11.4) |
| Total hospitalization cost (€) | 11,430 ± 9394 | 8715 ± 7640 | 10,398 ± 8867 |
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