Online Appendix for the following JACC paper
TITLE: Impact of Home versus Clinic-Based Management of Chronic Heart Failure: The
WHICH? (Which Heart Failure Intervention Is Most Cost-Effective & Consumer Friendly in
Reducing Hospital Care) Multicenter, Randomized Trial
AUTHORS: Simon Stewart, PhD, Melinda J. Carrington, PhD, Thomas H. Marwick, MD,
PhD, Patricia M. Davidson, PhD, Peter Macdonald, PhD, John D. Horowitz, PhD, Henry
Krum, PhD, Phillip J. Newton, PhD, Christopher Reid, PhD, Yih Kai Chan, PhD, Paul A.
Scuffham, PhD
APPENDIX
Health expenditure calculations
The use of all health care resources was prospectively measured during the WHICH? Trial and multiplied by the respective unit costs. In general, hospital admissions typically incur higher costs for the initial period when diagnostic tests and surgical procedures are undertaken. Later days of hospital stay are relatively lower cost with little more than hotel costs incurred. The use of Australia-refined Diagnostic Related Groupings (AR-DRGs) allowed us to standardize and categories each hospital readmission into fixed and variable costs. Fixed costs are those that all surviving patients incur irrespective of their length of stay, whilst variable costs are a per diem cost and are dependent on the length of stay. The total costs are the variable costs multiplied by the length of stay plus the fixed cost.
Fixed costs : This included components for the emergency department, pathology, imaging, allied health professional input, pharmacy, critical care, prostheses, operating room procedures and specialist procedure suites.
Per diem costs : The costs for medical staff, nursing staff, non-clinical staff, staff on-costs, supplies, hotel costs (e.g. meals), and depreciation. The WHICH? Trial also collected length of stay in intensive care and critical care units (ICU/CCU), as well overall length of stay.
Accordingly, costs were calculated using fixed costs plus the mean per diem cost for
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ICU/CCU (AU$3356) plus the per diem cost for a general ward (AU$772) multiplied by the lengths of stay in each facility (Table I).
Further, other resources used for community care included the allied health professionals and health services, and was multiplied by the respective unit costs ( Online Table I).
The cost for pharmaceuticals was also estimated from a micro-costing study of communitydwelling people with heart failure ( J of Med Econ, 14(6): 698-704, 2011) . The group in that study had similar characteristics to those in the WHICH? Trial, except they were slightly younger and their survival was greater. In general, their medications typically included ACE inhibitors / angiotensin receptor blockers, loop diuretics, spironolactone, digoxin and beta blockers. The cost per day for that group was reported and used for this study, multiplied by duration of use of the composite of these medications (Table I) .
Online Table I: WHICH? Study health expenditure calculation
Description / cost Source
Total hospital costs
Fixed costs AR-DRG
AR-DRG Version 5.2,
Round 13 (2008-09)
Variable costs
(per diem)
General Unit: $722 per day
(Ave. Z60A, Z60B, Z63A, Z63B)
ICU/CCU: $3356 per day (A06Z)
AR-DRG Version 5.2,
Round 13 (2008-09)
Other community-based costs
Community referrals Pharmacist: $162
Physiotherapist: $167
Podiatrist: $205
Psychologist: $204
Social worker: $138
Occupation therapist: $149
Dietician: $157
Nurse practitioner: $162
Diabetes educators: $205
Cardiology: $314
General Medicine: $295
GP consultation: $33.55
NHCDC cost report, Round
12 (2008-09)
Table 122: Ave cost per occasion of service for Tier
2 non-admitted clinic
Pharmaceuticals CVD: median PBS drug cost $2050 per annum
J of Med Econ, 14(6): 698-
704, 2011
Cost of intervention
Telephone FU Telephone consultation: $0.10 per min Australian Taxation Office
Cost of travel Petrol reimbursement: $0.70 per km Baker IDI Finance office
HF specialist nurse coordinator
Salary scale: 0.8 FTE $70000 RN per annum
Baker IDI Human
Resources
Legend: AR-DRG, Australia-refined diagnostic related grouping; Ave, average; ICU/CCU, intensive care unit/critical care unit; NHCDC, national hospital cost data collection; CVD, cardiovascular disease; PBS, pharmaceutical benefits scheme; FU, follow-up; cost of travel, travel for home-based and clinic-based visits;
FTE: full time equivalent; RN: registered nurse
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Figure 1: Comparison of event-free survival (primary endpoint)
Legend : Independent predictors of the primary endpoint were age (adjusted HR 1.04, 95%
CI 1.02
– 1.07 per year) and length of index hospitalization (adjusted HR 1.04, 95% CI 1.01
– 1.08 per day).
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Figure 2: Comparison of accumulated hospital stay
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