Is the Cost of CMR negligible relative to heart failure costs across the full care spectrum? (RF_SA_439)

Heart failure (HF) is a leading cause of morbidity and mortality in the United States and is projected to increase in the next decade despite advancements in therapy.^1,2 Cardiac magnetic resonance (CMR) has been shown to be an important diagnostic and prognostic test in the evaluation of HF. However, uptake has been hampered by the perception of high cost made even more challenging to elucidate due to the complex reimbursement strategies in the United States.^5,6 Our study aims to investigate the cost of CMR as compared to the overall cost of healthcare services provided to individuals with known or suspected HF.

Methods:

Cohort: Participants were sampled from a single-center retrospective cohort of 420 participants >18 years of age referred for CMR from 2009-2019. Patients were categorized into low (LVEF >50% without history of HF), intermediate (LVEF 35-50% or LVEF >50% with history of HF), and high risk (LVEF < 35%) for developing an adverse cardiac event. Chart review was performed to identify patient demographics, cardiovascular disease (CVD) risk factors, therapies, and major adverse outcomes comprising of HF admission, ICD implantation, LVAD implantation, cardiovascular disease-related death, heart transplantation. The primary clinical outcome of interest was a composite variable of major adverse outcomes related to HF detailed above.

Cost: Medication costs, HF management of stable (well), unstable (hospitalized), and HF-related death were obtained from previously published literature.^7-9 Cost of death and management of well patients was heterogeneous requiring estimates from various sources: “Willingness to Pay”, costs at the end of life, CVD management at Kaiser Permanente, and systematic reviews  on mild-HF symptoms.^10-12 Centers for Medicare and Medicaid Services (CMS) reimbursement data based on standardized current procedural terminology (CPT) codes for CMR with and without contrast (CPT 75561) and device implantation (eg, ICD, LVAD, and heart transplantation) was used as a surrogate for cost given the complex reimbursement landscape. Total costs of all services, medications, and devices rendered to patients with known or suspected HF were calculated. Total costs were computed as an aggregate of all cost components, which comprised of costs associated with HF admission, medications, imaging (CMR), medical devices, and death, heart transplantation as well as management of patients with cardiovascular disease who were well.  Per-person costs were also calculated based on the total cost computed divided by the number of individuals within the specified risk group.  All costs were adjusted to US 2022$.¹³

Results:

417 participants were included in the study and stratified by risk group for HF-related outcomes. The cohort included 239 low-risk, 105 intermediate-risk, and 73 high-risk individuals. The most expensive component of HF care was related to management of unstable and stable patients, representing 70-90% of the total cost across the spectrum of disease (Figure 1). On the other hand, the cost of imaging (CMR), $376.09 (2022 US$), represented 0.01% of the overall cost across all risk groups. On a per-person level, the cost of care for a low-risk, intermediate-risk, and high-risk individual (2022$) was $31,032.79, $41,070.33, and $52,512.84, respectively.

Conclusion:

The cost of CMR imaging represents < 1% of the overall cost of HF management across the spectrum of disease. The majority of costs are related to the management of patients at the end of life and those who are “well”.