Circ J 2007; 71: 1738 – 1743

Clinical Efficacy and Cost-Benefit Analysis of Nocturnal

Home Oxygen Therapy in Patients With Central
Sleep Apnea Caused by Chronic Heart Failure

Yoshihiko Seino, MD; Hidehiko Imai, MA*; Takaaki Nakamoto, MD**;

Yoshihiko Araki, MD†; Shigetake Sasayama, MD††
for the substudy of CHF-HOT

Background There is increasing evidence that both obstructive and central sleep apnea contribute to the pro-
gression and prognosis in patients with chronic heart failure (CHF). In the main study of nocturnal home oxygen
therapy (HOT) in patients with central sleep apnea because of CHF (CHF-HOT), significant improvements in
oxygen desaturation index, apnea – hypopnea index, left ventricular ejection fraction, and specific activity scale
were reported following 12 weeks of nocturnal HOT in these patients.
Methods and Results The present study is designed to further evaluate the clinical efficacy and cost – benefit
of nocturnal HOT according to the results of a follow-up survey on changes in frequencies of hospitalization,
emergency visits, and regular outpatient visits by 53 patients undergoing nocturnal HOT for more than 6 month
periods. Medical costs were estimated from the DPC-MDC5 charge for hospitalization because of worsening
heart failure (HF), and from the standard model case estimation for emergency and regular outpatient visits for
HF. To reveal the time-saving benefit following nocturnal HOT, the influence on estimated days spent for hospital-
care was also analyzed. The present study revealed significant reduction in frequencies and length of hospitalization
(2.1 to 0.5 times/year, 38.7 to 34.6 days, medical cost: –2,686,267 yen), emergency visit (2.5 to 0.7 times/year,
–15,984 yen), and regular outpatient visit (17.7 to 12.6 times/year, –6,324 yen) as compared with those before
the induction of nocturnal HOT, which resulted in a total medical cost-reduction of 1,854,175 yen/patient/year,
even with the additional charge for nocturnal HOT (854,400 yen/patient/year). Furthermore, nocturnal HOT
produced a remarkable decline in estimated days spent for hospital-care (88.2 to 21.2 days/patient/year).
Conclusion The present analysis calculated a remarkable cost-benefit (1,854,175 yen/patient/year) from the re-
duction in hospitalization and emergency visits, and also time-saving benefits from an increase in expected days
free from hospital-care (67 days/patient/year). (Circ J 2007; 71: 1738 – 1743)
Key Words: Central sleep apnea; Cost-benefit analysis; Heart failure; Home oxygen therapy; Hospitalization;
Quality of life

C
hronic heart failure (CHF) is an increasingly com-
mon disorder in the general population, and is
characterized by poor prognosis and quality of life
(QOL). CHF represents a major health problem in indus-
trialized countries, given an estimated more than 1 million
patients in Japan. Although considerable progress has been
made in the pharmacological treatment of CHF, including
digitalis, diuretics, angiotensin-converting enzyme (ACE)
inhibitors, angiotensin-receptor blockers andβ-blockers, the
mortality and morbidity of this disorder still remain high.
In fact, the mortality rate is comparable with that for malig-
(Received August 18, 2006; revised manuscript received June 14,
2007; accepted July 5, 2007)
Department of Internal Medicine, Cardiovascular Center, Nippon
Medical School Chiba-Hokusoh Hospital, Chiba, *Department of
Economics, Musashi University, Tokyo, **Cardiopulmonary Section,
Dokkyo Medical University Nikko Medical Center, Nikko, †Depart-
ment of Cardiology, Osaka Prefecture Medical Center for Respira-
tory and Allergic Disease, Habikino and ††Heart Bio-Mechanics
Center, Doshisha University, Kyotanabe, Japan
Mailing address: Yoshihiko Seino, MD, Department of Internal Medi-
cine, Cardiovascular Center, Nippon Medical School Chiba-Hokusoh
Hospital, 1715 Kamagari, Imba, Chiba 270-1694, Japan. E-mail:
y-seino@nms.ac.jp
nant disorders, and the severely depressed physical capacity
and frequent hospitalizations for decompensation of CHF
considerably limit not only the patient’s physical activities
but also socioeconomic activities.
There is increasing evidence that sleep-disordered breath-
ing may contribute to the progression and prognosis in
patients with CHF. Coexistence of sleep-disordered breath-
ing, especially central sleep apnea (CSA, also known as
Cheyne-Stokes breathing), has become a focus as one of
the potent predictors for adverse prognosis in patients with
CHF.1–4 The prevalence of CSA has been estimated at
25–50% in patients with CHF, and is related to severity of
CHF, gender, cardiac function, hemodynamic status, and
neurohormoral conditions.5–7
Although nocturnal ventilatory support using continuous
positive airway pressure (CPAP) or bi-level positive airway
pressure has been effectively used for the treatment of ob-
structive sleep apnea, the same efficacy has not been fully
demonstrated in patients with CSA.7–12 Several studies have
reported that nocturnal home oxygen therapy (HOT) for a
relatively short period abolished apnea-related hypoxia and
alleviated sleep apnea, and further decreased nocturnal nor-
epinephrine and N-terminal pro-brain natriuretic peptide
levels.12–17

Circulation Journal Vol.71, November 2007

Cost – Benefit Analysis of Nocturnal HOT in CSA
In the main study of nocturnal HOT in patients with
CSA because of CHF (CHF-HOT), we reported significant
improvements in oxygen desaturation index (ODI), apnea –
hypopnea index (AHI), left ventricular ejection fraction
(LVEF), and specific activity scale (SAS) following 12
weeks of nocturnal HOT in these patients.18 The present
study is designed to further evaluate the clinical efficacy
and cost – benefit of nocturnal HOT, based on changes in
the cost of illness following therapy, which is mainly
consistent with the costs of hospitalization, emergency
visits, and regular outpatient visits per year in patients
undergoing nocturnal HOT for more than 6 months for the
treatment of CSA associated with CHF.
Methods
Patients
Ambulatory patients aged over 20 years with clinical evi-
dence of CHF were enrolled from 20 centers during June
2000 to April 2001, if they met the following criteria: (1)
symptomatic with New York Heart Association (NYHA)
Class II or III despite optimal medication for at least 2 weeks
prior to study entry, (2) LVEF determined by radionuclide
angiography or echocardiography ≤45%, (3) 4% ODI of
≥5 dips/h on pulse oximetry, and (4) at least 5 episodes of
apnea and hypopnea per hour of sleep, of which more than
50% were central on screening polysomnographic exami-
nation. We strictly excluded subjects with predominantly
obstructive sleep apnea, unstable angina, myocardial infarc-
tion within the previous 3 month, significant renal, neuro-
logical or respiratory diseases, or who were pregnant.
Analysis of Sleep Apnea
After written informed consent was given, the patients
who met the inclusion criteria were monitored at home
using a cardiorespiratory monitoring device (Someté,
Compumedics, Australia) to analyze the proportion of cen-
tral and obstructive sleep apnea during sleep. Available
signals include ECG, nasal airflow, thoracic and abdominal
effort, arterial O2 saturation (SpO2), pulse rate, and oximeter
signal quality. Thoracoabdominal movements were recorded
by respiratory inductance plethysmography, and the oxyhe-
moglobin saturation was monitored by a finger pulse
oximetry. The system allows automatic respiratory event
detection (central or obstructive sleep apnea, mixed apnea,
hypopnea), SpO2 desaturation event recording and oxime-
try analysis. The ODI was the number of times per hour of
sleep that the oxyhemoglobin saturation fell by ≥4%. The
AHI was defined as the number of apnea and hypopnea
episodes per hour of sleep. Apnea was defined as complete
cessation of air flow for more than 10 s and hypopnea was
defined as more than 70% attenuation of air flow accompa-
nied with reduction of SpO2 ≥4%. Taken together, CSA was
defined as apnea associated with a lack of thoracoabdominal
movement.
Main Study
Following a baseline study, patients were randomly as-
signed to receive HOT at a rate of 3 L/min through nasal
cannulas during sleep (nocturnal HOT group) or room air
(Control group) for 12 weeks. O2 was delivered via a con-
centrator (TO-90–3N, Teijin Pharma Ltd, Tokyo, Japan).
Patients assigned to the HOT group were instructed to use
nasal O2 inhalation for at least 6 h during sleep.
Circulation Journal Vol.71, November 2007
1739
Table 1 Baseline Characteristics of Patients in the Home-Based
Oxygen Therapy Study
All patients (n=56)
Age (years) [range] 64.1±10.8 [34–81]
M/F (n) [%] 47/9 [83.9/16.1]
Underlying heart disease
26/24/6
(DCM/IHD/Others, n)
Duration of CHF (years) 4.2±4.3
Concomitant medication
31/51/38/35
(Digi/Diur/ACE/β, n)
SAS (Mets) 4.0±1.1
NYHA class (II/III, n) 23/33
LVEF (%) 33.6±9.5
CTR (%) 56.1±6.5
ODI (dips/h) 17.8±10.3
AHI (events/h) 19.3±10.7
ANP (pg/ml) 112.5±103.0
BNP (pg/ml) 291.9±419.8
NE (pg/ml) 606.2±294.4
PaCO2 (mmHg) 39.0±4.6
DCM, dilated cardiomyopathy; IHD, ischemic heart disease; CHF, conges-
tive heart failure; Digi, digitalis; Diur, diuretics; ACE, angiotensin-convert-
ing enzyme inhibitor; β, β-blockers; SAS, specific activity scale; NYHA,
New York Heart Association; LVEF, left ventricular ejection fraction; CTR,
cardiothoracic ratio; ODI, oxygen desaturation index; AHI, apnea-hypopnea
index; ANP, atrial natriuretic peptide; BNP, brain natriuretic peptide; NE,
norepinephine; PaCO2, arterial partial pressure of CO2.
Data are mean ± SD.
Substudy: Follow-up Survey on Morbidity and
Cost – Benefit Analysis
In the present study of CHF-HOT, a questionnaire survey
was conducted to investigate the effects of HOT on mor-
bidity in the study patients who continued HOT for more
than 6 months, including the study periods, and further to
add a cost – benefit analysis of HOT in clinical practice. The
questionnaire survey was sent to 34 physicians at the 20
institutes who participated in the present CHF-HOT study.
Patients from the control group who started nocturnal HOT
after the study period were also included. The following
issues were investigated: (1) frequencies (per year) and
length of hospitalization because of worsening heart failure
(HF), (2) frequency of emergency visits, and (3) regular out-
patient visits immediately before and after using nocturnal
HOT. Medical costs were estimated from the Diagnosis
Procedure Combination (DPC)-MDC5 charge for hospital-
ization for worsening HF and the database of the Social
Insurance Agency in the Ministry of Health and Welfare,
February, 2003, Japan for universal application, and also
from the standard model case estimation (Y.S. and H.I) for
emergency visits and regular outpatient visits for CHF.
Cost – Benefit and Influence on Hospital-Care Days
In the present study, the cost – benefit analysis was based
on changes in the cost of illness following nocturnal HOT,
which was mainly consistent with costs of hospitalization,
emergency visits, and regular outpatients visit per year. The
reduction in the cost of illness following nocturnal HOT per
year per patient was defined as the benefit from treatment.
The charge for the use of nocturnal HOT per year per
patient was defined as the cost. The time-saving benefit was
assessed by analyzing the influence on the estimated days
spent in hospital-care, which was estimated as the sum of
(1) days of hospitalization; incidence of hospitalization
(times/patient/year) multiplied by the mean days for hospi-
talization (day/once), (2) emergency visit days; incidence
1740 SEINO Y et al.

Fig 1. Effect of nocturnal home oxygen therapy (HOT) on incidences of hospitalization (A), regular outpatient visit (B)
and emergency visit (C), and on length of hospitalization (D). Although there was little change in length of hospitaliza-
tion, incidences of all events were remarkably decreased by nocturnal HOT. Mean ± SD (n=53).

Table 2 Cost-Benefit Analysis: Comparison of Medical Costs per Year Before and After HOT

Before HOT After HOT

(1) Hospitalization
(a) Incidence of hospitalization [times/year] 2.1 0.5
(b) Days for one hospitalization [days] 38.7 34.6
(c) Cost per hospitalization* [=¥143,9460 + ¥34,300 /day × ((b) –33days)] ¥1,634,970 ¥1,494,340
(d) Cost per year [=(a) × (c)] ¥3,433,437 ¥747,170
(2) Emergency visit
(a) Incidence of visits [times/year] 2.5 0.7
(b) Cost per visit (including medication) ¥8,880 ¥8,880
(c) Cost per year [=(a) × (b)] ¥22,200 ¥6,216
(3) Regular outpatient visit
(a) Incidence of visits [times/year] 17.7 12.6
(b) Cost per visit (excluding medication) ¥1,240 ¥1,240
(c) Cost for medication, examination and test per year ¥157,130 ¥157,130
(d) Cost per year [=(a) × (b) + (c)] ¥179,078 ¥172,754
(4) Cost for HOT per year ¥0 ¥854,400
(5) Total Cost per year [=(1) + (2) + (3) + (4)] ¥3,634,715 ¥1,780,540
(6) Cost reduction by HOT per year ¥1,854,175

*The cost of hospitalization per day was based on the introduced Diagnosis Procedure Combination MDC5 (#547_0501303 x 99 x
11x) charge for a hospitalization due to worsening heart failure from the database of the Social Insurance Agency in the Ministry of
Health and Welfare, February, 2003, Japan.
HOT, home oxygen therapy.

of emergency visits (time/patient/year), and (3) regular out-
patient visits; incidence of visit (time/patient/year) multi-
plied by 0.25 (quarter day).
The study protocol was approved by the Institutional
Ethics Review Boards, and written informed consent was
given by all patients prior to entry.
Results
Patients Characteristics
A total of 68 patients were enrolled from the 20 centers;
5 patients withdrew or were hospitalized before the start of
nocturnal HOT, and 7 patients dropped out from the study
during the 12-week study period. Thus, 56 patients (Table 1)
were randomly assigned to receive either nocturnal O2 (HOT
group, n=25) or room air (control group, n=31) for 12 weeks.
From these 56 patients, those who continued HOT for more
than 6 months including the study period, and patients from
the control group who started nocturnal HOT after the study
period, or other circumstances, were also included.
Follow-up Survey on Morbidity
The recovery rate of the questionnaire survey from treat-
ing physicians was 85.3%, and data regarding 53 patients
were colleted. After using nocturnal HOT, the mean number
of frequencies of hospitalization and of emergency visits
was remarkably reduced from 2.1 to 0.5 times per year
(76% reduction), and from 2.5 to 0.7 times per year (72%
reduction), respectively. The length of hospitalization
slightly reduced from 38.7 days to 34.6 days per hospitali-
zation. Regular outpatient visits also reduced from 17.7 to
12.6 times per year (29% reduction) (Fig 1).
Cost – Benefit Analysis
As shown in Table 2, hospitalization costs, including
inpatient medical expenses for 1 hospitalization because of
worsening HF, were estimated as 1,634,970 yen/hospitali-
zation on the basis of the charge for uncomplicated HF in
DPC-MDC5 and the mean hospitalization days in the pres-
ent subanalysis group (38.7 days); (50,160 yen/day × 11 days)
plus (40,350 yen/day × 22 days) plus (34,300 yen/day ×
5.7 days). To estimate the standard cost for hospitalization,
we used the cost of uncomplicated HF in DPC-MDC5 and
assumed the adjusting coefficient to be 1.0. Costs for an
emergency visit consisted of outpatient medical fees (includ-
ing overtime charge), outpatient examinations fees, labora-

Circulation Journal Vol.71, November 2007

Cost – Benefit Analysis of Nocturnal HOT in CSA 1741

Fig 2. Comparison of estimated costs per patient per year between Fig 3. Changes in expected days spent for hospital-care per chronic
before and after home oxygen therapy (HOT). Even if the cost for heart failure patient per year by nocturnal home oxygen therapy
HOT was added, the total medical cost remarkably reduced since (HOT). Nocturnal HOT showed increase in expected days free from
nocturnal HOT decreased the incidences of all events. hospital-care issue (67 days/patient/year).

tory tests fees, and medication fees and were estimated as
8,880 yen/emergency visit; 1,300 yen, 3,750 yen, 3,470 yen,
and 360 yen, respectively. Costs for a regular outpatient
visit consisted of outpatient medical fee, basic and internal
medicine dispensing fees, and medication dosage and guid-
ance fee and were estimated as 1,240 yen/regular visit. Pa-
tients received standard medical treatment with diuretics
(91% of the patients), ACE inhibitor (69% of the patients),
β-blockers (63% of the patients), and digitalis (55% of the
patients) during the follow-up period. Thus the costs for
drugs were estimated as 127,750 yen/year; 350 yen/day ×
365 days for standard medical treatment prescribing diu-
retics (furosemide 80 mg/day, 37.8 yen/day), ACE inhibitor
(enarapril 10 mg/day, 195.4 yen), β-blocker (carvedilol
10 mg/day, 102 yen) and digitalis (digoxin 0.25 mg/day,
19.4 yen), and the costs for outpatient examination and
tests were estimated as 29,380 yen/year. We assumed the
following examinations were performed at regular inter-
vals: chest X-ray 1.5 times/year (2,250 yen), 12-lead ECG
1.5 times/year (2,250 yen), echocardiography 1.5 times/year
(12,000 yen), plasma brain natriuretic peptide concentra-
tion 4 times/year (5,800 yen), general blood cell counts
4 times/year (1,080 yen), and biochemical assay (6 items)
6,000 yen.
The cost – benefit analysis calculated a remarkable cost
reduction following nocturnal HOT; namely, cost-reductions
in hospitalization of 2,686,267 yen/patient/year: 3,433,437–
747,170 yen, emergency visits of 15,984 yen/patient/year:
22,200–6,216 yen, and regular outpatient visits of 6,324
yen/patients/year: 179,078–172,754 yen, which would cre-
ate an expected total cost reduction of 1,854,175 yen/year
/patient, even after the added charge for HOT (854,400
yen/patient/year) (Fig 2).
As the costs of hospitalization are a major component of
the costs for the treatment of HF, we performed a sensitivity
analysis according to the hospitalization period. The data-
base of the Central Social Health Insurance Associations in
the Ministry of Health and Welfare, 2003, reported the
mean hospitalization period of uncomplicated HF for DPC
MDC5 was 33 days. The sensitivity analysis revealed the
cost-reduction would be expected for a hospitalization
period exceeding 13 days.
Time-Saving Benefit
Furthermore, nocturnal HOT produced a remarkable
decline in the estimated days spent in hospital-care (88.2 to

Table 3 Changes in Expected Days Spent for Hospital-Care per CHF Patient per Year by HOT

Item Before HOT After HOT

(1) Hospitalization
(a) Incidence of hospitalization [times/patient/year] 2.1 0.5
(b) Mean days for a hospitalization [days/once] 38.7 34.6
(c) Expected days spent for hospital-care [=(a) × (b)] 81.3 17.3
(2) Emergency visit
(a) Incidence of visits [time/patinet/year] 2.5 0.7
(b) Expected days spent for hospital-care [=(a) ×1*] 2.5 0.7
(3) Regular out patient visit
(a) Incidence of visit [time/patient/year] 17.7 12.6
(b) Expected days spent for hospital-care [=(a) × 0.25*] 4.4 3.2
(4) Total expected days spent for hospital-care 88.2 21.2
(5) Increase in expected days free from hospital-care issue 67

*Eestimated as 1 or 5 days spent for emergency and regular outpatient visits, respectively.
Abbreviations see in Tables 1,2.

Circulation Journal Vol.71, November 2007

1742
21.2 days/patient/year), thus the patient, and his or her
family, gained an increase in the expected 67 days free
from hospital-care following the induction of nocturnal
HOT (Table 3, Fig 3).
Discussion
Clinical Efficacy of Nocturnal HOT
The main study of CHF-HOT demonstrated that 12-
week treatment with nocturnal HOT significantly increased
the SAS, together with improvements in AHI and ODI, and
a significant increase in LVEF in patients with CSA because
of CHF. Thus the main study has shown that improvement
in sleep quality associated with improved arterial deoxy-
genation and stabilization of sleep-disordered breathing
increased daytime QOL and, furthermore, improved cardiac
function in these patients.18 The magnitude of the improve-
ment in QOL assessed by the SAS in the present study was
remarkable (1.0 Mets: 4.0±1.2 to 5.0±1.5 Mets vs 0.3 Mets:
4.4±0.2 to 4.7±0.2 Mets) compared with that observed in the
previous trial of Effect of Pimobendan on Chronic Heart
Failure (EPOCH) in Japan, which demonstrated the efficacy
of the long-term treatment with the oral inotropic agent,
pimobendan, on the QOL assessed by SAS in patients with
similar severity of CHF. Furthermore the efficacy of noc-
turnal HOT on mortality and morbidity was prominent
compared with the results of EPOCH, in which reduction
in death and hospitalization because of worsening HF was
34% (10.1% in pimobendan group vs 15.3% patients with
placebo) during a 52-week study period.20 Recent large-scale
randomized trials of β-blockers in CHF also demonstrated
significant reduction in hospitalization because of worsening
HF. In th US-CHF trial, the carvedilol group showed 27%
reduction in hospitalization compared with the placebo
group.21 In the CIBIS-II trial, the bisoprolol group showed
32% reduction in the hospitalization compared with placebo
group.22 The Multicenter carvedilol heart failure dose assess-
ment study in Japan (MUCHA) showed that hospitalization
rates because of worsening HF were significantly lower in
the carvedilol high-dose group (2.6%, 88% reduction) and
carvedilol low-dose group (2.1%, 91% reduction) than in
the placebo group (20.4%).23 The present CHF-HOT sub-
study demonstrated a remarkable reduction in the frequency
of hospitalizations by 76%, from 2.1 to 0.5 times per year
per patient following the introduction of HOT into the stan-
dard medical treatment of CHF. Suppression of worsening
HF following nocturnal HOT was also evidenced in the
remarkable reduction (72%) in emergency visits.
Cost – Benefit and Time-Saving Benefit of Nocturnal HOT
HOT represents a scientifically validated and universally
accepted therapeutic regimen for the treatment of chronic
hypoxemia secondary to chronic obstructive lung disease.
In Japan, HOT has been already used by 124 million pa-
tients with chronic obstructive lung disease, and the benefit
of HOT in these patients was reported to be in the shorten-
ing of hospitalization days (from 38 days to 16 days, 58%),
which resulted in a marked cost – benefit.24,25 In the present
study, the influence of HOT on the length of hospitalization
was not so remarkable, thus if it could be shortened fol-
lowing nocturnal HOT the cost – benefit would be more
increased.
Regarding another nocturnal breathing therapy for sleep
apnea, beneficial effects of CPAP have been documented in
patients with CHF and obstructive sleep apnea; that is,
SEINO Y et al.
nocturnal CPAP markedly reduced obstructive sleep apnea,
day time blood pressure and heart rate, and improved the
LVEF.4,8 However the issue of long-term compliance with
CPAP therapy has been frequently notedut. A recent report
from Canada regarding the use of CPAP for the treatment of
CSA in CHF could not necessarily document an improve-
ment in long-term prognosis, mortality or heart transplan-
tation, frequency of hospitalization, or QOL, even though
beneficial effects were observed in nocturnal oxygen satura-
tion, AHI, LVEF, or 6-min walk test following CPAP appli-
cation.26 In contrast, the CHF-HOT main study showed
beneficial effects of the more convenient nocturnal HOT in
patients with CSA because of CHF,18 and the present study
further demonstrated long-term beneficial effects on mor-
bidity (frequency of hospitalization or emergency visits)
and a cost – benefit following the introduction of nocturnal
HOT. The cost – benefit analysis revealed a remarkable
cost – benefit based on the reduction in frequencies of hos-
pitalization (2.1 to 0.5 /year, 2,686,267 yen), emergency
visits (2.5 to 0.7 /year, –15,984 yen), and regular outpatient
visits (17.7 to 12.6 /year, –6,324 yen) following nocturnal
HOT, which would create an expected cost-reduction of
1,854,175 yen/year/patient, even with the added charge for
nocturnal HOT (854,400 yen/year). Similar analysis was
reported in the study of intermittent milrinone therapy for
patients with refractory HF (NYHA III-IV, LVEF <40%) at
outpatient clinics in the United States. In that study, inter-
mittent milrinone therapy for patients with intractable HF
brought about 55% reduction in hospitalization, 72%
reduction in hospitalization duration, and 52% reduction in
emergency visits after beginning outpatient intermittent
milrinone therapy, which should be a cost – benefit.27 How-
ever, the benefit of milrinone therapy on the long-term
prognosis has not been shown and may instead be deleteri-
ous in patients with ischemic etiology.28
Another significant benefit in the present study was that
nocturnal HOT produced a remarkable decline in the esti-
mated days spent in hospital-care (88.2 to 22.1 days/patient/
year); namely, each patient gained 67 days/year free from
hospital-care, which should be important for time-saving
and QOL for the patients with moderate to severe CHF and
also for their families.
Study Limitations
Whether the beneficial effects of nocturnal HOT con-
tinue persistently for a longer period is not yet clarified. In
the present study, we analyzed the historical comparison
between before vs after the introduction of HOT, and did
not compare between patients on-HOT vs non-HOT groups.
We used a simplified medical cost estimation, according to
the DPC-MDC5 charge for universal application, to avoid
overestimation of hospitalization cost. Furthermore, we
assumed that medical treatment for HF was unchanged dur-
ing the study period in terms of the standardized medi-
cation, which may change during the time course because
of clinical improvement or worsening. Alternation in the
adjusting coefficient, which was assumed to be 1.0 in the
present analysis, would influence the estimation of cost –
benefit. Thus, further analyses on individual and time-
course related cost estimation should be clarified in the real
world of therapy. The longer-term CHF-HOT II compara-
tive study is on-going, and its results remain to be estab-
lished.
Circulation Journal Vol.71, November 2007
Cost – Benefit Analysis of Nocturnal HOT in CSA
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