Estimated annual healthcare costs after acute pulmonary embolism: results from a prospective multicentre cohort study

Abstract

Aims: Patients surviving acute pulmonary embolism (PE) necessitate long-term treatment and follow-up. We estimated, the chronic economic impact of PE on the German healthcare system.

Methods and results: We calculated the direct cost of illness during the first year after discharge for the index PE, analysing data from a multicentre prospective cohort study in Germany. Main and accompanying readmission diagnoses were used to calculate DRG-based hospital reimbursements; anticoagulation costs were estimated from the exact treatment duration and each drug's unique national identifier; and outpatient post-PE care costs from guidelines-recommended algorithms and national reimbursement catalogues. Of 1017 patients enrolled at 17 centres, 958 (94%) completed ≥3-month follow-up; of those, 24% were rehospitalized (0.34 [95% CI 0.30-0.39] readmissions per PE survivor). Age, coronary artery, pulmonary and kidney disease, diabetes, and (in the sensitivity analysis of 837 patients with complete 12-month follow-up) cancer, but not recurrent PE, were independent cost predictors by hurdle gamma regression accounting for zero readmissions. The estimated rehospitalization cost was €1138 (95% CI 896-1420) per patient. Anticoagulation duration was 329 (IQR 142-365) days, with estimated average per-patient costs of €1050 (median 972; IQR 458-1197); costs of scheduled ambulatory follow-up visits amounted to €181. Total estimated direct per-patient costs during the first year after PE ranged from €2369 (primary analysis) to €2542 (sensitivity analysis).

Conclusion: By estimating per-patient costs and identifying cost drivers of post-PE care, our study may inform decisions concerning implementation and reimbursement of follow-up programmes aiming at improved cardiovascular prevention.

Keywords: Anticoagulation; Cost of illness; Economic burden; Long-term care; Pulmonary embolism; Readmission.

Graphical Abstract

Figure 1

Kaplan-Meier estimator of the cumulative incidence of readmissions in the entire FOCUS population of survivors of acute pulmonary embolism, stratified by sex (left panel; same-colour shaded areas surrounding each curve denote the corresponding 95% confidence interval) and by age group (right panel). Differences between subgroups were analysed with Gray's test.²⁶ FOCUS: FOllow-up after aCUte pulmonary emboliSm study.

Figure 2

Decision tree-based outpatient follow-up visits and tests after acute pulmonary embolism (green boxes), with the respective reimbursement in euros (red boxes). The sequence of visits and tests correspond to the pulmonary embolism follow-up algorithm recommended by current European guidelines.^, The standard outpatient follow-up visit includes clinical examination, an electrocardiogram, and a 6-min walking test, followed by specific functional, imaging and/or laboratory tests as indicated. Numbers in green indicate the probability of needing a specific visit or test based on the findings at the previous visit or test as documented in the FOCUS study population. The amounts in euros below each visit/test are based on the current ambulatory healthcare services reimbursement catalogue of the National Association of Statutory Health Insurance Physicians (Einheitlicher Bewertungsmaßstab der Kassenärztlichen Bundesvereinigung) in Germany. The indicated echocardiogram reimbursement is for a test performed by a board-certified cardiologist. BNP, brain natriuretic peptide; CPET, cardiopulmonary exercise testing (spiroergometry); CTEPH, chronic thromboembolic pulmonary hypertension; Echo, outpatient transthoracic echocardiogram including Doppler examination; FOCUS: FOllow-up after aCUte pulmonary emboliSm study; FU, follow-up; interm. PH probab., intermediate echocardiographic probability for (chronic) pulmonary hypertension as defined by the 2022 European Guidelines on Pulmonary Hypertension; low PH probab., low echocardiographic probability for (chronic) pulmonary hypertension; NT-proBNP, N-terminal pro brain natriuretic peptide; PE, pulmonary embolism; PE survivors, all patients who survived the acute phase of the index PE event and were discharged alive; PH, pulmonary hypertension; pos, positive; rf, risk factor(s); RH cath., right heart catheterization; V/Q scan, ventilation-perfusion lung scintigraphy.