When you think about the overall hospital costs of a 5-day admission for an acute condition that often requires ICU care and invasive procedures, you don't necessarily think about the Emergency Department. After all, the patient is usually only in the ED for a few short hours, compared to the several days they will spend as an inpatient. But when it comes to treating acute heart failure, we are beginning to learn that what occurs during those critical initial hours in the Emergency Department has a direct and significant impact on overall treatment outcomes, including the length of stay as an inpatient, the utilization of expensive resources, and the likelihood of readmission to the hospital within the near term. Heart failure is an enormous burden on our healthcare system that is only projected to get worse. Nearly 5 million Americans currently live with heart failure, with more than half a million new cases identified each year. Since it is primarily a disease of the elderly in a country with an aging population, the prevalence of heart failure is only expected to increase. It is also ironic that now that we are better able to help patients survive other cardiovascular diseases like myocardial infarction, more and more of them are living long enough to develop heart failure. The pathophysiology of heart failure begins with a myocardial injury which can result from coronary artery disease, myocardial infarction, long-standing hypertension, cardiomyopathy, valvular disease, and other causes. Left ventricular (LV) dysfunction results from the myocardial injury. The fall in LV performance triggers the activation of several neurohormonal systems in an attempt to compensate in the short term for the fall in cardiac output.

Activation of the Sympathetic Nervous System tries to maintain output with an increase in heart rate, increased myocardial contractility, and peripheral vasoconstriction. Activation of the Renin-Angiotensin-Aldosterone System also results in vasoconstriction (angiotensin) and an increase in blood volume and preload from retention of salt and water (aldosterone). Endothelin, another vasoconstrictor, is also activated.

Natriuretic peptides such as ANP and BNP are also released, which work in counter-regulatory fashion by promoting vasodilation and natriuresis. However, in advanced heart failure, the combined influence of the vasoconstrictive neurohormones overwhelms the counter-regulatory capacity of the natriuretic peptides, and acute decompensation occurs. Acutely decompensated heart failure is not a clearly defined condition. One way to think of it is, in broad functional terms, as the onset of sufficient symptoms of heart failure—typically manifested as shortness of breath or fatigue—to warrant hospitalization for treatment that often involves intravenous administration of diuretics, inotropes, or vasodilators.

A more pathophysiological way to describe decompensation is as the condition that occurs when increased systemic vascular resistance due to excess vasoconstriction is met with insufficient systolic and diastolic myocardial functional reserve, leading to acute afterload mismatch and a redistribution of fluid to the lungs. Acute decompensation is what makes heart failure so costly because it generally requires hospital treatment. The reality is that most patients who have heart failure are going to need hospital care sooner or later, and once they do they are likely to require it again and again. That is why there are now nearly 1 million hospital admissions for heart failure each year. As we see here, out of the more than $20 billion that heart failure represents in direct costs to the healthcare system each year, the majority, or $12.7 billion, goes for hospital care. This high rate of hospitalization makes heart failure the single most expensive Medicare Diagnosis-Related Group, costing the Health Care Financing Administration more than cancer and MI combined. And the cost to HCFA does not reflect the true cost to hospitals, which means that most institutions lose money on heart failure admissions. To make matters worse, if patients are readmitted within 30 days for the same DRG, the hospital does not get paid for that second visit. As this graphic shows, there is a definite hierarchy of expenses for treating heart failure, which tends to be different than for other diseases. The cheapest thing you can do is talk on the phone. Clinic visits are also not very expensive because they are scheduled ahead of time and people aren't kept waiting. Some people will tell you that Emergency Department/Observation care is expensive, but that is not true simply because we get paid for it.

CMS just made an APC code specific for Heart Failure, Chest Pain, and Asthma. Therefore, any care in the ED or Obs Unit where you get paid by code is less expensive than inpatient care, where you get penalized for length of stay that exceeds the capitated amount or for revisits within 30 days. The key is to avoid the most expensive care. A typical ICU bed costs $1500 per night, compared to $850 for a bed on the regular floor. So if you put the patient in ICU you will use up your DRG faster. As we have shown, the Emergency Department is the least-costly form of hospital care. It's also where patients tend to arrive first, as we see from these data from The ADHERE® Registry. Therefore, it makes sense to look at the ED first when thinking about how to save money on treating acute heart failure. So what happens when a patient with decompensated heart failure presents to the ED? Data show that 80% of the time they are admitted as inpatients for an average of 5.3 days. 20% of them are readmitted within 30 days, which Medicare does not pay for, and 4.5% die in the hospital. The high number of admissions for acute heart failure is a problem because hospitals typically lose money on them.

Using the national averages for the year 2002 for DRG-127 you can see that average fully burdened hospital costs per case are $8250. The average amount reimbursed by CMS across the country is $4989. Therefore, the average net revenue for hospitals is a loss of $3261. An LOS of 5 days has been proposed as a rough break-even point financially for most hospitals.

The "lump sum" DRG payment system represents both a challenge and an opportunity for hospitals in relation to heart failure. The challenge is to get patients out in under 5 days. The opportunity lies in the fact that if we do get them out sooner we will actually get paid. That's because, since most heart failure patients are over age 65, they are guaranteed to have medical coverage through CMS, which, as we all know, is something that cannot be said for the general patient population.

So the rules of the game are at least clear, and all we have to do to make sure we don't lose money is become more efficient in how we identify and treat patients. The data I'm about to share with you show that that process has to begin in the Emergency Department. There is a saying that "what gets started in the ED tends to get carried upstairs." This is true not only with respect to specific therapies that get initiated and continued, but also, in a larger sense, to the predicted path a patient will take during their stay. In other words, as we are going to show, the decisions made at the front end in the ED can directly impact the back end of the hospital visit in terms of length of stay and the resources utilized during that stay. Clearly, the best way for hospitals to reduce their losses is to prevent hospitalizations in the first place. This includes the prevention of admissions from the ED as well as readmissions through 30 days. Hospitals can also focus on reducing the highest hospital costs, which occur mainly on days 1 and 2. One way to do that is to use better and more-aggressive therapies that can be administered in less-intensive and less-costly in-hospital settings such as telemetry.

The last bullet point speaks to the Opportunity Cost for hospitals. The prevention of an admission or an ICU stay for an acute heart failure patient means that that bed may be used for a more-expensive DRG diagnosis such as a CABG patient. So how do hospitals end up blowing their DRG on acute heart failure cases?

They lose it on the 12% of patients who are initially misdiagnosed in the ED as having something other than heart failure, which drives up the LOS.

They lose it when the initial treatment decision is to give the patient diuretics and wait to see what happens. This doesn't make any sense because the clock is ticking on the DRG, and you need to get the patients out in 4 days.

They lose it when a drug is given that causes complications. Dobutamine, for example, has a published rate of ventricular tachycardia of 13%. In most hospitals patients with V-tach are sent to the ICU, which eats up cost.

Pharmacy costs for heart failure are 10%. 90% of cost is based on LOS and site of care. So the way you save money on heart failure is not by worrying about what drugs you use or how many tests you run, but by focusing on getting the patients out early and making sure they don't come back. Welcome to our program on Acute Heart Failure: The Emergency Department and the Economics of Care. This is a CME-accredited program that focuses on optimizing treatment strategies in the Emergency Department in order to improve outcomes and reduce overall costs to the hospital.

When you think about the overall hospital costs of a 5-day admission for an acute condition that often requires ICU care and invasive procedures, you don't necessarily think about the Emergency Department. After all, the patient is usually only in the ED for a few short hours, compared to the several days they will spend as an inpatient. But when it comes to treating acute heart failure, we are beginning to learn that what occurs during those critical initial hours in the Emergency Department has a direct and significant impact on overall treatment outcomes, including the length of stay as an inpatient, the utilization of expensive resources, and the likelihood of readmission to the hospital within the near term.