Methods: All patients discharged alive after an acute care hospitalization in Ontario,
Canada in fiscal year 2006 were identified. Patients treated at HF clinics were selected based on the presence of a claim by a HF clinic physician in the 1-year after the index hospitalization. The service components at all HF clinics were scored using a 10-item validated instrument. The primary outcome was the cumulative 1-year health care costs post-discharge. Costs included all ambulatory, acute care hospitalizations, emergency room visits, same-day surgeries and HF medication costs. A hierarchical generalized linear model with a logarithmic link and gamma distribution was developed to identify patient and clinic level predictors of cost. The impact of patient and clinic level factors on the variation in costs between clinics was assessed by the proportional change in the variance of the clinic-level random effect.
Results: Of the 16,300 acute care hospitalizations in 2006 for HF, 1,216 patients were seen in HF clinics. There was a 7-fold variation in mean costs by clinic ($14,670-$96,524). The between-clinic variation in costs decreased by 2.5% when patient factors were added to the null model. The variation decreased by a further 67% when clinic-level factors were added. Mean total health care costs were 14% higher for males (rate ratio (RR) 1.14; p=0.037). Chronic atherosclerosis (RR 1.23, p=0.008), valvular heart disease (RR 1.37, p=0.004), diabetes (RR 1.16, p=0.044), and peripheral vascular disease (RR 1.65, p=0.0006) were associated with higher mean costs. A history of CABG was associated with a 48% (p=0.001) reduction in mean costs. Patients seen at HF clinics which placed an emphasis on peer support had lower mean costs (RR 0.75, p=0.018). HF clinic size as reflected by total annual clinic visits was a predictor of costs, with clinics that received a moderate number of visits having a 30% reduction in costs compared to smaller clinics (p=0.037).
Conclusions: HF clinics have a substantial effect on mortality, but health outcomes, including costs vary considerably between clinics. Efforts should focus on ways to standardize care across specialty clinics to ensure effective treatment for patients, while reducing unnecessary health care spending.