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What drives the costs of heart failure care in Germany? A health services cost analysis



Heart failure (HF) represents an increasing burden on health-care systems because of the aging population. The aim of this study was to explore its costs of care in Germany from the payer perspective and to identify the main drivers.

Subjects and methods

As part of a trial, primary care physicians (PCPs) enrolled eligible patients and documented actual clinical and 12-month retrospective ambulatory health-care utilisation data related to HF [PCP and cardiologist contacts, and cardiovascular (CV) medication] and provided the doctors’ reports of hospitalisations during 2004 and 2005, enabling the collection and calculation of costs. Furthermore, each hospitalisation was classified according to the cause of admission into HF, CV or other hospitalisation.


Thirty-seven physicians enrolled 168 patients with complete data of 159 patients (95 %). Patients (mean age 68 ± 10 years, 73 % male, 47 % ischaemic aetiology) had ascertained systolic HF (mean ejection fraction 33 ± 7 %) with NYHA class II/III in 53/45 %. Mean (SD; median) annual costs of 96 hospitalisations, CV medication, and 337 cardiologist and 3,037 PCP practice contacts were 3,545 (8,065; 0), 854 (835; 638), 117 (105; 106) and 269 (190; 233) euros, respectively, totalling 4,792 (8249;1341) euros. Fourteen per cent of all patients incurred 50 % of total costs. Twenty-five HF, 49 CV and 22 other hospitalisations incurred 13, 73 and 14 % of hospital care costs, respectively.


These secondary outcome data might indicate a trend that neither HF ambulatory care nor hospitalisation but rather interventional cardiology is the main cost driver. Planning interventions aimed at reduced hospitalisation and costs should include further clarification of the mechanisms of CV hospitalisation and reimbursement.

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  • Al Khatib SM, Hellkamp A, Curtis J et al (2011) Non-evidence-based ICD implantations in the United States. JAMA 305:43–49

    Article  PubMed  CAS  Google Scholar 

  • Clabaugh G, Ward MM (2008) Cost-of-illness studies in the United States: a systematic review of methodologies used for direct cost. Value Health 11:13–21

    Article  PubMed  Google Scholar 

  • Dickstein K, Cohen-Solal A, Filippatos G et al (2008) ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail 10:933–989

    Article  PubMed  Google Scholar 

  • Graf von der Schulenburg JM, Greiner W, Jost F et al (2008) German recommendations on health economic evaluation: third and updated version of the Hanover Consensus. Value Health 11:539–544

    Article  PubMed  Google Scholar 

  • Jaarsma T, van der Wal MHL, Lesman-Leegte I et al (2008) Effect of moderate or intensive disease management program on outcome in patients with heart failure: coordinating study evaluating outcomes of advising and counseling in heart failure (COACH). Arch Intern Med 168:316–324

    Article  PubMed  Google Scholar 

  • Krauth C, Hessel F, Hansmeier T, Wasem J, Seitz R, Schweikert B (2005) Empirical standard costs for health economic evaluation in Germany—a proposal by the working group methods in health economic evaluation. Gesundheitswesen 67:736–746

    Article  PubMed  CAS  Google Scholar 

  • McMurray JJ, Stewart S (2000) Epidemiology, aetiology, and prognosis of heart failure. Heart 83:596–602

    Article  PubMed  CAS  Google Scholar 

  • Mosterd A, Hoes AW (2002) Reducing hospitalizations for heart failure. Eur Heart J 23:842–845

    Article  PubMed  CAS  Google Scholar 

  • Neumann T, Biermann J, Erbel R et al (2009) Heart failure: the commonest reason for hospital admission in Germany: medical and economic perspectives. Dtsch Arztebl Int 106:269–275

    PubMed  Google Scholar 

  • Peters-Klimm F, Muller-Tasch T, Remppis A et al (2008) Improved guideline adherence to pharmacotherapy of chronic systolic heart failure in general practice—results from a cluster-randomized controlled trial of implementation of a clinical practice guideline. J Eval Clin Pract 14:823–829

    Article  PubMed  Google Scholar 

  • Peters-Klimm F, Campbell S, Müller-Tasch T et al (2009) Primary care-based multifaceted, interdisciplinary medical educational intervention for patients with systolic heart failure: lessons learned from a cluster randomised controlled trial. Trials 10:68

    Article  PubMed  Google Scholar 

  • Peters-Klimm F, Laux G, Campbell S et al (2012) Physician and patient predictors of evidence-based prescribing in heart failure: a multilevel study. PLoS One 7:e31082

    Article  PubMed  CAS  Google Scholar 

  • Rickham PP (1964) Human experimentation. Code of ethics of the World Medical Association. Declaration of Helsinki. Br Med J 2:177

    Article  PubMed  CAS  Google Scholar 

  • Solomon SD, Dobson J, Pocock S et al (2007) Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure. Circulation 116:1482–1487

    Article  PubMed  Google Scholar 

  • Taylor S, Bestall J, Cotter S et al. (2005) Clinical service organisation for heart failure. Cochrane Database Syst Rev: CD002752

  • Young JB, Dunlap ME, Pfeffer MA et al (2004) Mortality and morbidity reduction with Candesartan in patients with chronic heart failure and left ventricular systolic dysfunction: results of the CHARM low-left ventricular ejection fraction trials. Circulation 110:2618–2626

    Article  PubMed  CAS  Google Scholar 

  • Zugck C, Muller A, Helms TM et al (2010) Health economic impact of heart failure: An analysis of the nationwide German database. Dtsch Med Wochenschr 135:633–638

    Article  PubMed  CAS  Google Scholar 

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We thank all study participants and participating PCPs for their additional participation in the cost of care study.

Conflict of interest

The authors declare that they have no conflict of interest.


The parental trial was supported by the Competence Network Heart Failure, funded by the German Ministry of Education and Research (BMBF), grant no. 01GI0205.

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Correspondence to Frank Peters-Klimm.

Additional information

The study was supported by the Competence Network of Heart Failure, funded by the German Ministry of Education and Research (BMBF).

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Peters-Klimm, F., Halmer, A., Flessa, S. et al. What drives the costs of heart failure care in Germany? A health services cost analysis. J Public Health 20, 653–660 (2012).

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Key words

  • Heart failure
  • Hospitalisation
  • Hospital admission
  • Cost of illness
  • Germany