Running Head: HEART DISEASE 1

Heart Disease: The Impact of Heart Failure on the US Population

Tawny Nichols
University of San Diego
HEART DISEASE: THE IMPACT OF HEART FAILURE ON THE US POPULATION 2

Abstract
Heart disease is a serious issue that has a significant impact economically and socially upon the

US population. As the leading cause of death in the US and globally, heart disease accounts for

15% of the total US health expenditure. Over the next few decades, heart failure costs are

expected to substantially grow resulting in a higher financial burden and demand for care within

the US healthcare system. The good news is that the majority of studies and research that

incorporate home-based care have shown great potential in treating patients with heart failure

and reducing readmission costs. The best strategies consist of improving care coordination

technology and implementing home-based treatment plans that promote self-management and

guide the patient and family caregivers within their home. It is essential that healthcare address

this chronic condition in light of the long-term burden, and support the family, friends, and

patients living with heart failure.

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Cardiovascular disease, also known as heart disease, plays a significant role in the current

delivery of care within the United States. It is difficult to comprehend the impact of this disease

when discussing such large numbers. According to the American Heart Association (AHA) in

2012, heart disease, including hypertension, congenital heart defect, heart failure, and stroke,

accounted for 15% of the total health expenditures and led the top diagnoses with 108 billion

dollars spent annually (American Heart Association Statistics Committee, 2016). Heart disease

was the leading primary diagnosis for admission into both home health and hospice (American

Heart Association Statistics Committee, 2016). An estimated 43.9% of the US population will

have some form of heart disease by 2030 and is on track to cost over 900 billion dollars

(American Heart Association Statistics Committee, 2016). Globally, heart disease is the leading

cause of death accounting for 17.3 million deaths in 2013 (American Heart Association Statistics

Committee, 2016). The AHA hopes to improve cardiovascular health and reduce deaths by 20%

over the next few years (American Heart Association Statistics Committee, 2016). It is essential

to explore this not merely because of the financial burden but also for the family, friends, and

patients that are living with limitations caused by this disease.

Within the aging US population, heart failure, a subset of heart diseases, is the leading

cause of hospitalization (American Heart Association Advocacy Coordinating Committee,

2013). Since 80% of heart failure patients are older than 65 years of age, management of this

chronic condition is essential (Azad & Lemay, 2014). Heart failure is important because of its

high prevalence, mortality, morbidity, and cost of care (American Heart Association Advocacy

Coordinating Committee, 2013). As the older population ages, patients with heart failure will

increase by 46% by 2030 and is projected to grow in cost from 20.9 billion to 53.1 billion

(American Heart Association Advocacy Coordinating Committee, 2013). Heart failure-related

HEART DISEASE: THE IMPACT OF HEART FAILURE ON THE US POPULATION 4

hospitalizations account for 80% of the financial burden and will increase for people aged 65-79

by 160% (American Heart Association Advocacy Coordinating Committee, 2013). This paper

will explore the potential strategies to improve outcomes and reduce future costs as it relates to

home health management of patients with heart failure.

Recently, there have been discussions that past methods of treatment and an effort to do

as much as possible for the patient may not be the best approach. According to Allen, Maddox,

& Vigen, “for many older patients with progressive heart failure, a more palliative approach

focused on symptom relief, comfort, and support may be preferred (Allen, Maddox, & Vigen,

2012, p. 374).” When a patient has more than five comorbidities, the likelihood of hospital

admission increases from 35% to 72%, and it increases to 94% when more than ten

comorbidities are present (Allen et al., 2012). Chronic heart failure in the older population may

be more complicated than merely treating heart failure but may need to include a comprehensive

treatment plan. To combat the high influx of patients with heart failure, the management of this

community is better assessed and managed within the home than in the hospital.

Background
Heart failure (HF) occurs when the heart is working at a decreased capacity. The

American Heart Association has published a website dedicated to the causes, risks, signs,

symptoms, diagnosis, and treatment in hopes of increasing the dialogue about HF. When the

heart is not pumping enough blood or blood flow is blocked, the heart fails to support proper

oxygen levels. This failure results in fluid building up in the body causing swelling in feet,

ankles, legs or lungs and sometimes weight gain. Signs include shortness of breath, feeling tired,

coughing, and confusion. Comorbidities and complications that are patient-specific make it

complicated to treat with a universal plan (American Heart Association, 2017).

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According to American Heart Association (2017), treatment options consist of four

primary steps: medications, lifestyle changes, cardiac rehabilitation, and devices or surgical

procedures. Drugs may be used to strengthen the heart or remove excess fluid. Medications

include angiotensin-converting enzyme, (ACE) inhibitors or angiotensin receptor blockers,

(ARBs) and –blockers (Fonarow, et al, 2010). When patients change their lifestyle by eating

better, exercising, getting adequate sleep, monitoring their blood pressure, reducing stress,

abstaining from smoking or alcohol and creating a support network, HF symptoms are alleviated

and often slow the disease process. Other effective treatments revolve around rehabilitation that

is designed to improve functionality and stabilize the progression of HF. A physical activity

program is tailored to the patients’ needs while counseling, evaluations, and supervision help the

patient stay on course. Sometimes devices like implantable cardioverter-defibrillator (ICD),

cardiac resynchronization therapy (CRT), and left ventricular assist device (LVAD) are used to

improve heart function. With severe heart failure, corrective surgery like bypasses, angioplasty,

and value replacements are designed to remove a blockage, reroute blood supply or repair a

defect to regulate blood flow. A full heart transplant is required when these options are not viable

(American Heart Association, 2017).

Since the AHA has been funding scientific research on heart diseases for more than 90

years, it is essential to set a context with reports such as the American Heart Association

Statistics Committee (2016). The discussion, based on AHA research is that HF will increase

within the US population and that potential strategies must revolve around reducing re-

hospitalizations. One approach is to use home health or community-based care, and another is to

use hospital-based procedures. With heart disease affecting both the United States and the

world, there are numerous studies that assess treating heart failure in the community setting
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(Freud et al., 2017, Feltner, Jones & Cene, 2014, Fonarow et al, 2010). Other studies focus on

hospital strategies such as research by Bradley et al. (2013) who studied risk standardization to

lower readmission rates. Kielhorn, Kilgore, Maya, Patel, and Sharma (2017) focused

retrospectively on the risk management and payment policies with the cost of federal programs.

The majority of the studies show potential for improving patient conditions and reducing cost.

Social and Economic Impact

Although in most cases HF is treatable, it is the leading cause of death in the US and the

world (Kielhorn et al., 2017). Within the US healthcare system, HF will substantially grow and

have a significant social and economic impact on older Americans. Since HF costs are expected

to rise from 24 billion to 47 billion by 2030, the American Heart Association Statistics

Committee (2016) suggest that this burden ought to produce strategies for reducing future costs

such as care transitions, workforce management, and end-of-life care. A report on Medicare

beneficiaries suggests that hospital stays accounted for 80% of lifetime costs (Kielhorn et al.,

2017). For Medicare, the total cost of a single hospital visit was $14,631 with a mean length of

stay of about 7 ½ days (Kielhorn et al., 2017). Another study showed an average lifetime cost of

nearly $110,000 with hospitalizations costing over $80,000 of the average (Allen et al., 2012).

Healthcare policies must seek to help reduce avoidable hospitalizations.

For the person living with HF, the economic cost is not the only concern. There is a high

level of suffering for both the patient and their family members. After an admission, there is a

substantial decrease in daily living and quality of life (Kielhorn et al., 2017). Many patients

who live with chronic pain, depression, shortness of breath, anxiety, social isolation and feelings

of loss of control say they would trade a year of their lives for improved quality of life (Azad &

Lemay, 2014, Freud et al., 2017). Factors like home environment, addressing caregiver’s issues,

and emergency response systems are crucial for improvement in functional capacity and
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optimization of co-morbid conditions (Azad & Lemay, 2014). Healthcare policies must seek to

improve a patient’s home life.

Emerging Trends in Management

Newer thoughts have paved the way towards patient-centered, timely, and efficient care.

Research by Fonarow et al. (2010) highlighted a gap in conventional evidenced-based care and

pointed out that often, higher risk patients are not receiving therapy because they do not fit the

current guideline-recommended treatment, and these therapies have less applicability to high-risk

patients. Thus, current trends include modifications in the delivery of care that are more

responsive to a patient’s preferences, needs, and values (American Heart Association Statistics

Committee, 2016). According to Azad and Lemay (2014) “The multidisciplinary care is essential

for patient education, promotion of self-management skills, improving medication and dietary

compliance, encouraging daily weight and exercise, assuring close follow up, and introducing

end-of-care issues” (p. 334). Providing evidence-based interventions that incorporate patient

preferences and their unique risk factors will promote engagement and self-management.

Homecare can help reduce hospitalizations and improve the quality of life. In Japan, a

home care unit studied patients with congestive heart failure (CHF). Freud determined that “the

results of this study support the conclusion that a home care intervention program, implemented

by a multidisciplinary team, can reduce healthcare utilization and costs” (p. 8). Another study

found that high-intensity home-visiting program, consisting of 8 planned home visits with the

first visit being within 24 hours of discharge, reduced all-cause readmission and mortality over

three to six months (Feltner et al., 2014). This study also found that if telemonitoring replaced

some of the home visits, the risk for HF readmissions remained unaffected and was not able to

reduce readmissions. In the long run, home-based interventions may not affect mortality, but

they can reduce unplanned hospital or emergency visits and improve daily living.
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In contrast, hospital studies have shown that better integration between primary care and

hospital care can reduce avoidable readmissions. One study examined six strategies that

partnered with physicians, local hospitals, nurses, and discharge practices. According to the

report, previous research had ruled out post-acute options because outpatient care failed to follow

up with discharged patients quickly enough (Bradley et al., 2013). This lack of timeliness is

likely due to the lack of interoperability between hospitals EHRs and other provider’s systems.

Furthermore, over-communicating emergency plans with the patient and family seemed to

reinforce the need to return to the hospital. The research shows that the best strategies involve

electronically linking outpatient medical records to hospitals. Healthcare policies must seek to

promote better care coordination (Bradley et al., 2013).

Federal or State Programs

The Centers for Disease Control and Prevention (CDC) Division for Heart Disease and

Stroke Prevention has set a goal of decreasing ‘recurrences of cardiovascular events’ by

preventing, detecting, identifying, and treating risk factors (Centers for Disease Control and

Prevention, 2014). The program provides funding for states that promote awareness and adopt

their health strategies. For chronic conditions, there are enhanced initiatives for cardiovascular

health such as increases access to healthy food, improvement in health systems, and promotion

of self-management. The program provides toolkits, research, guides, briefs, webinars, and

policy resources in hopes of promoting community-based care (Centers for Disease Control and

Prevention, 2014).

Conclusion
Heart failure is an economic as well as a social concern for the United States. Healthcare

policies should seek to reduce avoidable hospitalizations, improve quality of life by promoting

engagement and self-management, and provide better care coordination (Azad & Lemay, 2014).
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With such a significant increase in demand for care, evidence-based interventions that

incorporate unique risk factors for each patient must become commonplace. Home-based

treatment plans can include all aspects of the patient’s daily living and support them within their

home (Feltner et al., 2014). Home care has the potential to play a significant role in the treatment

of heart failure if taken seriously. The lack of integration between hospitals discharges and post-

acute admissions and perhaps even the quality of outcome within the current home health

industry have left many in the healthcare system wanting more. Therefore, the home health

discussion requires further exploration.

Studies that support older adults with complex heart failure are needed. Specifically,

there is a need for more research with home-based interventions and self-management.

Furthermore, the discussion regarding care coordination and transition of care would bring

needed insight regarding patients during a critical time in recovery. This research will

undoubtedly lead to better care. Perhaps this study can provide relevant clinical suggestions for

healthcare technology.
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References

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