Heart failure and the cost-of-living crisis

The cost-of-living crisis being experienced around the world is not just about energy and food prices. It also encompasses access to healthcare and affordability of therapies. According to findings presented at the recent ADA Scientific Sessions, these costs are hitting people with heart failure hard, particularly those in lower socioeconomic classes, who are already disproportionately affected by the condition. Dr Susan Aldridge reports.

The social determinants of health are extremely important and are tied to outcomes. This is as true in heart failure as in other chronic conditions. Speaking at the American Diabetes Association’s (ADA) conference this summer, Dr Shahzeb Khan, Duke University School of Medicine, pointed to a study of hospitalisation for heart failure (HHF) in young adults from 2004 to 2018, which showed an increase over this time. “Of particular interest is that 50% of these hospitalisations occurred in households in the lowest quartile of household income,” he says.

There was also a relationship between living in a ‘food desert’ and recurrent HHF and all-cause hospitalisations. A food desert is a low-income area with limited access to healthy foods. Another study showed that 63% of choices about healthy food and beverages are mediated by expenditure, so a healthy lifestyle is seen by many as a privilege.

Many health conditions are disproportionately clustered in poorer regions, Shahzeb says. But when it comes to healthcare, patients of lower socioeconomic status are more likely to face health inequalities and to have comorbidities. They have fewer interactions with primary care and are more likely to ‘end up’ in secondary care.   

Socioeconomic status and heart failure

A study looking at more than 40,000 patients from the Swedish Heart Failure Registry found that Class 4 heart failure was twice as common in the lowest compared with the highest socioeconomic class.

“What was even more worrisome is that patients of lower socioeconomic class had a 15% lower use of heart failure devices and medical therapies,” says Shahzeb. “They also had a higher comorbidity burden, including diabetes. And, although they were more likely to have heart failure, they were less likely to be admitted to hospital with it and receive an implantable cardiac defibrillator or anticoagulants.”

He was involved in another study on differences between rural and urban regions in mortality from heart failure, ischaemic heart disease and stroke, using the Centers for Disease Control and Prevention database. “Our study showed that people from rural areas had a much higher mortality from heart failure compared with people from metropolitan areas,” he says. “This can be linked to multiple factors, including access to healthcare, financial constraints and lower levels of health education.”  

There has been a very recent study of the global disparities in prescription of guideline-recommended drugs for heart failure with reduced ejection fraction. It covered more than 8000 patients hospitalised for acute heart failure in 44 countries. A lower proportion of patients in lower- and middle-income countries were on guideline-recommended therapy and, to make matters worse, they were also on lower doses. “This study clearly shows that that improved access to medicines, globally, is direly needed,” says Shahzeb.

Turning to heart failure in the USA, one study showed that one in six patients forgo or delay care, with more than half of these saying they do so because of cost. These patients are, unsurprisingly, more likely to appear in an emergency room and actually end up with higher annual inpatient and total healthcare costs. There are very similar findings for atherosclerotic cardiovascular disease, where one in two families of non-elderly patients with the condition have difficulty in paying medical bills.

Financial toxicity

Shahzeb went on to describe a study of healthcare spending by families with large employer coverage between 2003 and 2018. “This shows that out-of-pocket spending is rising steadily and has increased by 67% over that period. Patients with heart failure and their families are experiencing very large out-of-pocket healthcare expenses.” The study found that one in seven families with a member who has heart failure – and as many as one in four low-income families with a member who has heart failure – experience so-called ‘financial toxicity’. This means spending over 20% of their post-subsistence income on healthcare expenses per year. The main contributors to this out-of-pocket spending are insurance premiums and medications costs. “Therefore, financial toxicity represents an additional challenge for families of patients with heart failure, especially those on low incomes,” Shahzeb concludes.

“There is a huge difference in the best therapy available and the best therapy actually being delivered,” he continues. A US study on sacubitril/valsartan, which is now recommended for management of patients with heart failure found that, despite FDA approval, less than 3% of heart failure patients were taking it within the first 18 months. This may be associated with out-of-pocket costs, for this drug costs far more than other heart failure medications. 

Meeting the challenge  

“Now that we know that socioeconomic status has a huge impact on heart failure outcomes, we need to assess cardiologists’ knowledge, attitudes and practices on cost discussions and cost-conscious care,” says Shahzeb. “There is a lack of evidence on the quality of cost discussions between patients and physicians and, even in the guidelines, there is very little on how to conduct these discussions.”

He has some pilot study-based descriptive data on patients’ views and goals on cost discussions for heart failure treatment and says: “They may feel uncomfortable discussing costs with their physicians. We have very little information on patient perspectives on how to conduct such complex discussions.”

He is therefore working on the development and validation of a heart failure-related financial navigation programme for recently diagnosed patients. This includes one-to-one discussions, financial education, budget worksheets and appropriate counselling. There will also be research on financial toxicity and, ultimately, Shahzeb hopes that patient contributions to high-value therapies can be minimised. Addressing the socioeconomic aspects of heart failure, including costs, should hopefully improve outcomes.

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.