In Heart Failure, Thinking Care Will Be Unaffordable May Mean Poorer Outcomes

How patients with acute decompensated heart failure (HF) perceived the financial challenges of their healthcare played out in their health outcomes, despite receiving life-prolonging medications, a prospective study from China showed.

Among over 3,000 participants hospitalized with HF, those who reported severe perceived economic burden (PEB) were at increased risk for 1-year mortality compared with those who had low PEB (HR 1.61, 95% CI 1.21-2.13, P<0.001), Liwen Li, MD, PhD, of the Guangdong Cardiovascular Institute in China, and colleagues reported in JAMA Network Open.

The mean adjusted 12-Item Kansas City Cardiomyopathy Questionnaire (KCCQ) score was lowest in patients with severe PEB and highest in those with low PEB at baseline (40.0 vs 50.2 on the 100-point scale, P<0.001) and at 12 months (61.5 vs 75.5, P<0.001). The quality-of-life difference between severe and low PEB was considered clinically significant, with a mean 11.3-point difference in KCCQ scores at 1 year (P<0.001).

“Heart failure is a prevalent, deadly chronic condition that requires recurrent examination, indefinite medication use, and even advanced devices. A scenario in which a patient is facing the threat of death with so many available treatment options may pressure physicians to prescribe these options while ignoring their cost,” Li’s group wrote.

“However, our results indicate that these costs might also be toxic by increasing the PEB, which may even completely neutralize the possible effects of these costly interventions,” they added.

Despite China’s universal basic health coverage, there is substantial underinsurance and out-of-pocket expenses, Paul Heidenreich, MD, MS, of the Stanford University School of Medicine in Palo Alto, California, wrote in an accompanying editorial.

In the U.S., so-called “financial toxicity” — which can take the form of avoiding or delaying care, nonadherence to medications, and psychological distress — is common, he noted.

“It was estimated that in 2018, 1 in 7 families in the U.S. with a family member with heart failure spent more than 20% of their income on their care. For low-income families, this ratio was 1 in 4,” Heidenreich noted. “According to the U.S. Gallup Poll, in 2022, roughly 46% of people avoided healthcare due to cost, with 70% of the delayed care being for a very or somewhat serious condition.”

Heidenreich urged a shift in cost-sharing policies.

The large number of available, effective life-prolonging therapies that are cost-effective for society in terms of survival and quality of life, “typically Class I recommendations in clinical guidelines, should be provided without patient copays,” he wrote. “Patient cost-sharing should be reserved for medications where the benefit of therapy is small, uncertain, or does not justify the price.”

The study enrolled 3,386 adult patients hospitalized for acute decompensated HF at 52 hospitals in China from 2016 to 2018. The researchers analyzed 1-year all-cause death and rehospitalization for HF along with HF-specific health status by the KCCQ. The median participant age was 67 years, and 62.5% of participants were men.

PEB was determined by response during the index hospitalization to being asked, “What do you think of the burden of medical expense in the past year?” The 11.9% who said they could not undertake that burden of expenses were classified as having severe PEB, the 59.7% who said they could “almost undertake” the expense were classified as having moderate PEB; and the 28.4% who said they “can undertake easily” the medical bills were classified as having low PEB.

Only a nonsignificant trend emerged for higher 1-year HF rehospitalization with severe versus low PEB (HR 1.21, 95% CI 0.98-1.49, P=0.07).

The authors acknowledged limitations to their study, including its observational design, possible confounders, and that the construct used to define PEB was not validated by actual out-of-pocket medical costs. Also, some 40% of participants did not complete the KCCQ, and the generalizability of the findings to populations outside China is uncertain. They joined the editorialist in recommending further related research.

“National efforts should be expanded to identify pragmatic approaches not only to alleviate the PEB in healthcare but also to assess its potential consequences for saving lives and improving health status,” Li and coauthors advised. “In the face of an emerging heart failure epidemic, describing the association between perceived economic burden and healthcare outcomes is an important step toward more equitable and achievable care.”


The study was supported by grants from the Guangdong Basic and Applied Basic Research Foundation, the Guangzhou City Science and Technology Project of the Ministry of Science and Technology of Guangzhou, and the National Key Technology R&D Program of the Ministry of Science and Technology of China.

Li reported receiving grants from the Ministry of Science and Technology in China during the conduct of the study. Study coauthors and editorialist Heidenreich had no disclosures.

Primary Source

JAMA Network Open

Source Reference: Yu Y, et al “Perceived economic burden, mortality, and health status in patients with heart failure” JAMA Netw Open 2024; DOI: 10.1001/jamanetworkopen.2024.1420.

Secondary Source

JAMA Network Open

Source Reference: Heidenreich P “An underappreciated risk factor for heart failure — financial toxicity” JAMA Netw Open 2024; DOI: 10.1001/jamanetworkopen.2024.1403.


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