IJCA-13553; No of Pages 4

International Journal of Cardiology xxx (2011) xxx–xxx

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International Journal of Cardiology
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d

Review

Ultrafiltration for acute decompensated heart failure: Financial implications ☆
Amir Kazory a,⁎, Frank B. Bellamy b, Edward A. Ross a
a b

Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, FL, USA Department of Utilization Management, Shands at the University of Florida, Gainesville, FL, USA

a r t i c l e

i n f o

a b s t r a c t
Heart failure is the leading cause of hospitalization in older patients and is considered a public health problem with a significant financial burden on the health care system. Ultrafiltration represents an emerging therapy for patients with heart failure with a number of advantages over the conventional therapy. In this article, a summary of the relevant pathophysiological mechanisms such as removal of inflammatory cytokines are provided that might indeed be associated with a number of financial implications for ultrafiltration. Then practical points such as training of physicians and staff that need to be considered by physicians and medical centers with regards to financial implications of this therapy are reviewed. © 2011 Published by Elsevier Ireland Ltd.

Article history: Received 12 November 2010 Received in revised form 1 April 2011 Accepted 13 May 2011 Available online xxxx Keywords: Ultrafiltration Heart failure LOS DRG Financial

1. Background Heart failure (HF) is the leading cause of hospitalization in patients older than 65 years and is considered a significant financial burden on health care system [1]. Unfortunately, the current therapeutic options for acute decompensated heart failure (ADHF) remain limited with high-dose intravenous diuretics still being the most commonly used medications in this setting. These agents portend a number of serious complications such as worsening renal function, which in turn is known to significantly increase the mortality. Moreover, the efficiency of the current therapeutic strategies is questionable: one third of the patients leave the hospital with unresolved symptoms, and 16–20% of the patients even gain weight during the course of hospitalization [2]. In the absence of an ideal efficient therapeutic modality, extracorporeal ultrafiltration (UF) therapy using the novel portable devices has recently gained much attention as a promising option mainly in an attempt to avoid deleterious effects of diuretics. It has been suggested that early use of UF in this setting might also have additional beneficial effects such as lower rate of re-hospitalization as well as shorter length of stay (LOS). From a financial standpoint, UF represents by far one of the most expensive therapies currently available for refractory HF. While it has been hypothesized that lower rate of re-hospitalization could offset its costs at long term, there are

currently no studies to indicate a cost-saving impact for UF in patients with HF. Moreover, it is conceivable that the beneficial impact of UF therapy might in part depend on variables that are not yet identified such as the etiology of HF or the degree of right ventricular dysfunction and venous congestion. Here we present a number of financially relevant pathophysiological and practical characteristics of UF and discuss their potential implications. 2. Persistence of beneficial effects Several studies have consistently shown that the beneficial effects of UF could extend beyond the period of therapy. Agostoni et al. found that the respiratory parameters (e.g. tidal volume and pulse oxygen) were still improving up to 6 months after UF therapy [3]. In another study by Libetta et al., the anti-inflammatory cytokines decreased after therapy and remained low until one month later [4]. Although the exact mechanisms underlying this phenomenon are not well understood, a number of factors have been proposed. First, it has been shown that UF is more efficient in removal of fluid compared with diuretics [5]. Therefore, patients are more likely to leave the hospital with improved volume status (see later discussion). Moreover, the fluid produced by ultrafiltration (ultrafiltrate) is iso-osmolar and therefore it is capable of removing sodium more efficiently than the hypo-osmolar urine produced by diuretics. Since sodium is the main determinant of extracellular volume, it is then conceivable that relatively lower total body sodium content achieved by UF can help the decongested state persist for a longer period of time. Removal of anti-inflammatory cytokines and myocardial depressant factors by UF are among hypotheses proposed to explain persistence of its beneficial clinical effects on cardiac function. It is noteworthy as well

☆ No specific financial support was obtained for the preparation of this article. The authors have no potential conflicts of interest to declare with respect to this paper. ⁎ Corresponding author at: Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610–0224, USA. Tel.: +1 352 392 4007; fax: +1 352 392 3581. E-mail address: amir.kazory@medicine.ufl.edu (A. Kazory). 0167-5273/$ – see front matter © 2011 Published by Elsevier Ireland Ltd. doi:10.1016/j.ijcard.2011.05.073

Please cite this article as: Kazory A, et al, Ultrafiltration for acute decompensated heart failure: Financial implications , Int J Cardiol (2011), doi:10.1016/j.ijcard.2011.05.073

the subjective part is not as clear. UF. UF-related complications) might also play a role.9]. 6. will potentially help HF patients stay controlled and stable on their outpatient diuretic regimen after termination of UF therapy. Kazory et al. It is also possible that the more frequent and chronic use of this modality in the future could increase the need for more durable blood access with its related costs. Surprisingly.9]. and nesiritide were compared in patients with ADHF [11]. other aspects of the therapy such as water treatment technology (i. It should be noted that in other studies the renal function was not reported to significantly deteriorate with the use of UF.1016/j. in turn. et al. standard care. The frequency for needing indwelling vascular access is of important because of their related cost (e. Training of physicians and staff Training of physicians and staff represents an overlooked financial aspect of UF in the field of cardiology. patients in the UF group were shown to have significantly fewer re-hospitalization days (1. in the UNLOAD trial. it has been suggested that in ADHF. and subjective feeling of improvement reported by the patients. Int J Cardiol (2011).8 vs. Not surprisingly. whereas others did not find any significant difference between diuretics and UF regarding their impact on patients' subjective feeling of improvement [8.g.g. Therefore. Moreover. This might indeed be related to the well-known effect of diuretics on pulmonary vasculature and venous return resulting in improvement in respiratory symptoms unrelated to diuresis and decongestion.g. Currently this cost is surprisingly very high (up to 90 times more expensive compared to equivalent material used in renal replacement therapies).073 . Disposable material Filters and tubing are another financial aspect of UF therapy in patients with HF that can significantly contribute to the increase in cost of this therapy. the LOS was similar in the standard care group and UF group on the first admission where UF was performed. improvement in pulmonary congestion or pedal edema) would therefore act favorably for UF. LOS remains higher in this group.4 vs. Length of stay LOS in patients admitted for ADHF is directly related to disease course and “decongestion” which can be determined by two distinct groups of factors: objective relief of congestion (e. Nevertheless.9. the studies have so far failed to show this. and material).g.2 days for UF compared with 6. In the field of renal replacement therapy.3 days. Besides. although these expenses are hard to quantify on a global basis due to variations in available technologies. the devices used for isolated UF in HF would not need water treatment technology and are not yet available in various models and brands. the UF group showed a trend towards an increase in the LOS compared to the other two groups (mean LOS 7. the larger studies such as UNLOAD failed to report the number of patients that actually needed placement of a central venous access. is capable of faster fluid removal and decreasing patient's weight without increasing the potential complications [8. / International Journal of Cardiology xxx (2011) xxx–xxx that a number of studies have reported on restoration of responsiveness to diuretics in patients undergoing UF [6]. In contrast. Rate of re-hospitalization Interestingly. This. The portable UF devices are intended for use by any physician who has received training in extracorporeal therapies.2 A. which in turn might be related to reduction in the inflammatory cytokines. Ultrafiltration for acute decompensated heart failure: Financial implications .022) [9].979). We have previously discussed several serious potential complications of UF.2 and 4. equipment for placement. 3. brands and contracts. and less costly. In particular.g. symptoms could be related to re-distribution of fluid rather than its accumulation [10]. as compared to diuretics. a number of studies have consistently shown that UF. 5. at 90 days. the great majority of patients with ADHF are admitted because of congestion and fluid retention [2]. The authors hypothesized that lack of sufficient familiarity with this novel modality might have been a reason for the delay in discharging the patients. more biocompatible. Although these new sophisticated technologies are very simple to use.e. Therefore. This phenomenon. and does not require the presence of trained nephrologists or dialysis nurses for its operation. Only a few studies on the use of UF in ADHF have so far evaluated the impact of ultrafiltration on LOS [8. the discrepancy between the subjective and objective findings in patients with ADHF who undergo UF is reflected in the reported LOS in these patients. the advances in the manufacture of the hemofilters and tubings over the past decades have made them more efficient. Therefore. It is important to note that in the UNLOAD trial the LOS for the first hospitalization was similar for patients receiving standard care and those who underwent UF therapy (5.11]. decrease in pulmonary rales) in the absence of potential complications (e. Patients in UF group showed a statistically significant increase in serum creatinine while the changes in the other two groups were not significant. Some studies could show overall improvement in patients' symptoms. This will mandate courses and workshops that will lead to additional costs associated with these therapies. doi:10. 6. which are similar to those associated with other extracorporeal therapies [12]. thus pointing to other not-well-known potential factors. UF was shown to be capable of reducing the number and length of subsequent hospitalizations over the 3 months following a single session of UF by more than 50% [9]. Not surprisingly. trained physicians. and fluid overload. the relief in symptoms after UF can conceivably be disproportionate to the amount of fluid removed. while it was hoped that more rapid removal of fluid with UF would result in a faster improvement in patients' symptoms leading to a shorter LOS. there are problems that can arise from overzealous fluid removal as well as those associated with any blood-pumped extracorporeal therapy (e.ijcard. Moreover.9 days for nesiritide and usual care groups respectively). However. p = 0. poor cardiac output. 3. These studies have used new portable devices with a maximum UF rate of 500 ml/h. Other factors (e. deionizers) and sophisticated computerized dialysis devices comprise a more significant portion of the cost of extracorporeal strategies in this field. The expenses to achieve and maintain competency in performing these procedures would be expected to vary between countries. their efficacy and safety would be optimized by a fully-trained staff. potential catheter-related complications are not only associated with increased morbidity and mortality in these patients. similar to other wasting syndromes and chronic diseases. Patients with HF. but they can also significantly impact the Please cite this article as: Kazory A. the weight loss has been higher in UF group compared with patients who received intravenous diuretics. Yet.05.g. electrolyte abnormalities). 4. It is then expected that a therapeutic strategy with higher rate of fluid removal could potentially result in a faster improvement in signs and symptoms related to congestion and subsequently a shorter length of stay. Interestingly. HF patients generally tend to have compromised peripheral blood vessels due to their advanced age. air embolus or hemolysis). p = 0. while some studies with a limited number of patients have exclusively used peripheral venous catheters. While the objective component of factors influencing the LOS (e. as mentioned earlier. In a recent study by Bartone. the role of disposable materials in determining the cost of this therapy is more prominent. Therefore.2011. can result in impairment in plasma refill rate and susceptibility to complications related to acute contraction of intravascular volume.8 days. It is of note that in these studies. These complications as well as their management strategies should ideally be incorporated in the training of the staff and physicians who intend to deliver such therapies. frequently present with malnutrition–inflammation complex syndrome [7].

nosocomial infections) Reduction in the rate of re-hospitalization Complications related to extracorporeal therapies (e. heparin-induced thrombocytopenia) fewer medications Need for training of physicians and staff Please cite this article as: Kazory A. et al. doi:10. The practitioner needs to be acutely aware of complete and thorough documentation.A. there are a number of considerations with regards to its financial aspects. For example. Alternatively. Epidemiology of acute heart failure syndromes. Physicians and medical centers interested in development of UF programs need to be fully aware of these implications to overcome the associated financial constraints. et al.22:2013–9. Eur Heart J 2005. Ultrafiltration for acute decompensated heart failure: Financial implications . despite a reduction in re-hospitalization rates. Kazory et al. intermediate care units can have twice the cost. 8. [5] Dahle TG.g. UF was very unlikely to result in cost savings from a societal perspective (total cost estimates at 90 days: US $11. especially in the background of longer LOS reported in some of the previous studies. Reassessing treatment of acute heart failure syndromes: the ADHERE Registry. the prospective diagnosis-related group [DRG] approach utilized in the US).g. Management in different levels of care Contrary to traditional renal replacement therapy devices (i. Each facility thus needs to assess the payor mix for this patient population in order to determine the financial implications of strategies that could reduce LOS or increase costs from services rendered. Cardiology 2001. bloodstream infections) Restoration of diuretic responsiveness Anticoagulation-related complications and better control of symptoms with (e. Advantages Disadvantages The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [17]. continuous veno-venous hemofiltration and hemodialysis) that are mainly used in specialized settings such as intensive care unit or hemodialysis center. Zannad F. The wide variation between countries and policies makes this difficult to quantify. Acknowledgement Table 1 Evaluation of ultrafiltration therapy for acute decompensated heart failure from a financial standpoint. References [1] Alla F. and it would be likely for this modality to become financially comparable or even advantageous in this setting [14]. published the findings of their study on the cost-consequences of UF therapy for patients with ADHF [15]. Bradley et al. financial payment to the hospital can vary two to three-folds depending on whether the heart failure is associated with severe concurrent disorders. Compared to a low-acuity medical ward. Facilities will have all their reimbursements (regardless of DRG) decreased by up to 3% if the 30-day HF readmission rate is higher than predicted [16]. 9. in a study by Perencevich et al. $13469 for UF). complications and co-morbidities can be fully captured for billing purposes. The potential advantages and disadvantages of UF therapy for ADHF from a financial standpoint have been summarized in Table 1. so that the subtleties in clinical conditions. and ICUs three to four times higher. Sustained benefit from ultrafiltration in moderate congestive heart failure. UF had a high probability of being cost-saving (total cost estimates at 90 days: US $2820 for diuretics vs.2011. Conclusion While UF has certainly the potential for tremendously changing the current care provided for patients with ADHF. Boyle AJ. there is not even any need for an intermediate care setting. as we have previously discussed. from Medicare and hospital payer perspectives. Large volume ultrafiltration for acute decompensated heart failure using standard peripheral intravenous catheters. need to be put in the perspective of the reimbursement by the insurance company or governmental agency.. Intermittent haemodiafiltration in refractory congestive heart failure: BNP and balance of inflammatory cytokines. Zucchi M. however. This is likely to significantly reduce the costs associated with this therapy. For instance. the “direct” costs will depend on the actual expenses incurred by the services rendered. This study suggested that the payer perspective might be very important in formulating strategies and reimbursement structures to reduce HF hospitalizations. adopting conventional hemodialysis machines for UF allows use of inexpensive supplies but necessitates higher expenses for dialysis nurses and possibly a higher acuity bed [14]. Filippatos G. Sepe V. Olinger CC. whether traditional diuretics and inotropes or new UF techniques.469). air embolus) Reduction in the rate of unscheduled Need for placement of central venous clinic visits or emergency department catheter and possibility of catheteradmissions related complications (e. [4] Libetta C.073 .g. Filippatos G.7(suppl B):B13–9. J Card Fail 2006.ijcard. it is believed that the LOS savings will exceed the high price of those machine's disposable supplies. It is imperative that financial analyses and literature reviews incorporate these wide ranges of expenses and scrutinize how long patients stay at any given level of care. Further complicating financial analyses are new Medicare regulations that will be phased in between 2013 and 2015. Nephrol Dial Transplant 2007. the broad “congestive heart failure” terminology as opposed to “acute systolic heart failure”).000 in 2005 with an average excess LOS of 12 days per episode [13]. The ability of newer portable UF devices to be performed outside the ICU presents a major advantage and cost savings. Ali SS. The financial impact of care on different types of nursing units will be facility-specific and can vary widely. These investigators found that there was a discordance in cost between payer perspective. which can be over US $900/day. Int J Cardiol (2011). many nations have a reimbursement structure based on a single diagnosis-driven global payment (i. it is noteworthy that these calculations have been based on the use of a recently developed UF device as well as proprietary supplies.293 instead of 13.1016/j. Reduction in the length of stay as well as Need for extracorporeal machines and complications related to hospitalization disposable material (e. If conventional devices and hemofilters routinely used by nephrologists for extracorporeal therapies are considered for UF therapy in patients with ADHF.610 for diuretics vs.g. Reportedly. and hospital payer perspectives. Reimbursement The overall costs of the HF patient's care. Apart from the fixed (“indirect”) costs for administering and operating the hospital. the cost of treatment will dramatically decrease (total cost estimates at 90 days for UF: US $11.96:183–9. the facility must invest in mechanisms to meticulously extract from the chart documentation all the appropriate co-morbidities and severity of the HF (i. Blake D. [2] Gheorghiade M. Bunte MC. $6157 for UF). / International Journal of Cardiology xxx (2011) xxx–xxx 3 health care cost. Similarly.e. Heart Fail Rev 2007. 7.05.e. However.12:349–52. Marenzi GC. In 2009. Medicare. The magnitude of those costs and the number of days a patient spends at different levels of care can determine whether UF programs are financially viable in a particular medical center. and relatively few pay per diem or by percent of charges.12:91–5. since these dramatically affect the diagnosis coding and the ultimate reimbursement.e. [3] Agostoni PG. However. catheter-related bloodstream infection could increase the healthcare cost by more than US $18. the novel UF devices can be used on the normal hospital floor. They developed a decision model analysis to evaluate the clinical outcomes and associated costs of UF compared to diuretic therapy from societal.

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