Journal of Internal Medicine 1999; 246: 275±284
The health care costs of heart failure in Sweden
T. RYDEÂ N-BERGSTEN & F. ANDERSSON
1 2
1 2
From the Department of Health Economics, AstraZeneca R&D, MoÈlndal; Sweden; and the Department of Health Economics & Quality of Life,
AstraZeneca R&D, Lund
Abstract. RydeÂn-Bergsten T, Andersson F (Astra-
Zeneca R&D, Lund; and AstraZeneca R&D, MoÈlndal;
Sweden). The health care costs of heart failure in
Sweden. J Intern Med 1999; 246: 275±284.
Aim. Heart failure is a common and serious
condition requiring extensive health care resources.
The aim of this study is to estimate the total
treatment costs of heart failure in Sweden.
Methods and results. The study is a prevalence-
based cost-of-illness study. It includes costs of
institutional care (hospitals and nursing homes),
outpatient care, surgery and drugs. The costs are
estimated based on official Swedish statistics, and on
various clinical and epidemiological studies. The
results are expressed in 1996 prices. The total
Introduction
Heart failure is a common condition with a serious
prognosis. The prevalence is estimated at approxi-
mately 1±2%, indicating that there are between
100 000 and 200 000 sufferers in Sweden as a
whole [1]. The condition demands extensive re-
sources, which is reflected by the fact that it is one of
the most common reasons for hospital care [1, 2].
Although the prevalence is increasing, the health
care costs are predicted to increase even faster. This
is mainly due to the development of more advanced,
but also more costly, diagnostic investigations, and
more effective methods of treatment, which are now
being used to an increasing extent [1]. Currently,
the development of carefully planned management
programmes as a means of improving the care of
heart failure patients is receiving much attention [3±
5]. Well-planned, carefully evaluated management
programmes would also be beneficial from a health
economic point of view. Such programmes may help
existing resources to be used as efficiently as
# 1999 Blackwell Science Ltd
annual treatment costs for heart failure are approxi-
mately Swedish kronor (SEK) 2000±2600 million,
or nearly 2% of the Swedish health care budget.
Institutional care is the single largest component,
amounting to SEK 1300±1900 million, or about
65±75% of the costs of heart failure treatment.
Conclusions. The results from this study indicate
that heart failure is a costly condition. Efforts to
develop effective management programmes that can
reduce the need for expensive institutional care,
without a negative impact on quality of life,
morbidity and mortality, should be given high
priority.
Keywords: cost-of-illness, heart failure, total treat-
ment costs.
possible, with the aim of achieving maximum benefit
for a given cost.
In order to develop cost-effective management
programmes, it is important to identify the key areas
in which the costs involved in treating heart failure
arise. The aim of this study is to calculate treatment
costs which, apart from hospital care, include care
in nursing homes, surgery, outpatient care and the
cost of drugs. A secondary aim is to identify areas
requiring more detailed study in the future regard-
ing the economic and clinical consequences of
various management programmes for heart failure.
Methods
This study is a prevalence-based cost-of-illness study
of treatment costs for heart failure in Sweden in
1996. It is based on the total number of cases of
varying degrees of heart failure within a given year,
and estimates the cost of all resources used to treat
these patients during that period of time. The study
includes costs of institutional care (hospitals and
nursing homes), outpatient care, surgery and drugs.
275
276 T . R Y D EÂ N - B E R G S T E N & F . A N D E R S S O N
Data have been gathered from official statistics and
medical publications (see below). Prices for 1995
and earlier have been adjusted upwards to 1996
prices using the consumer price index.
Categories of costs taken into account
Data pertaining to hospital care (i.e. number of
discharges and bed-days) have been taken from the
National In-patient Registry for 1995 [6]. This data
base encompasses data on all inpatient bed-days and
all discharges in Sweden as per International
Classification of Diseases (ICD-9) codes. Data sets
are compiled annually, and quality assessments and
correction of the data are performed. The proportion
of missing data is approximately 1% or less for most
variables. One limitation, however, is the lack of
information on the diagnostic accuracy of the
register.
This study covers all discharges and all bed-days
during 1995 for which heart failure (ICD-9 code
428A congestive heart failure; 428B left heart
failure; and 428X heart failure, unspecified) was
listed as the primary diagnosis. Heart failure is a
common complication of myocardial infarction (MI),
and MI patients who develop this complication may
require prolonged hospital care as compared with
patients without a secondary diagnosis of heart
failure. The marginal difference in length of stay has
been taken into account in our estimates. MI was
considered the only diagnosis for which heart failure
is likely to affect the length of hospital stay (personal
communication, Dr Peter Held, Astra HaÈssle AB,
MoÈlndal, Sweden).
Apart from institutional care administered by the
county councils, there are also costs for long-term
care in nursing homes, which were transferred to
municipal authorities in conjunction with parlia-
mentary reforms in 1992 (A È delreformen 1992). As
no statistics are available after 1991, the extent and
the cost of municipal nursing home care have been
calculated using data on number of bed-days from
the National In-patient Registry for 1991 [7]. All
discharges and bed-days during 1991 for which
heart failure (ICD-9 code 428A±X) was listed as the
primary diagnosis have been included in the
calculations. The calculations are based on the
assumption that no change took place in the
number of bed-days between 1991 and 1995. In
nursing homes, however, a patient's heart failure
# 1999 Blackwell Science Ltd Journal of Internal Medicine 246: 275±284
may sometimes be the cause of death even though
another illness may have been the original reason
that care was needed. To take this uncertainty into
account, the number of bed-days and the costs for
nursing home care have been estimated for different
subgroups of heart failure patients. These subgroups
include patients with heart failure as the sole
diagnosis, or heart failure with either a secondary
diagnosis of coronary-related diseases (ICD-9 codes
401±429, 440±459) or diabetes (ICD-9 code 250).
We have assumed that, if any of these secondary
diagnoses was present, this suggested that heart
failure was a significant reason for nursing home
care.
Costs were calculated at the departmental level for
each hospital category using information from
LandstingsfoÈrbundet (the Federation of Swedish
County Councils) on the average cost per bed-day
at different types of hospitals and departments [8].
Costs of hospital care also include costs of diagnostic
tests, drugs used by inpatients and costs of
personnel, including physicians [8]. Details about
the average cost per bed-day at nursing homes were
taken from a recently published study [9].
Details of the number and nature of operations for
which heart failure was the main diagnosis have
been taken from the 1995 surgical records of the
Swedish Board of Health and Welfare [6]. Costs of
surgical procedures are based on diagnosis related
groups (DRG) data from 1996 [10].
Data on drug utilization patterns for drugs
prescribed for heart failure patients in ambulatory
care have been obtained from the National Survey
on Diagnosis and Prescriptions 96/97 [11]. These
data have been combined with sales statistics for
ambulatory care from Apoteksbolaget (the National
Corporation of Swedish Pharmacies) [12].
The National Survey on Diagnosis and Prescrip-
tions is a continuous statistical survey sampling 6%
of all Swedish physicians. The survey provides
details about the medications prescribed for given
diagnoses (ICD-9 codes) in ambulatory care. In
addition, this survey also provides information about
prescriptions according to diagnosis, i.e. diagnostic
profiles of drugs. Hence, for each drug used for heart
failure, it is possible to identify the proportion of the
total number of prescriptions that are specifically
prescribed for heart failure. The code available for
reporting prescriptions with heart failure as the
main diagnosis is 428.9, unspecified heart failure.
 COSTS OF HEART FAILURE IN SWEDEN
The National Survey on Diagnosis and Prescrip-
tions also provides information on ambulatory care
with respect to the total number of outpatient
consultations per ICD-9 code, as well as the
distribution of these consultations between general
practitioners and hospital outpatient departments.
These figures have been combined with the average
costs for both types of consultation based on the
calculations of the Federation of County Councils
[8]. Consultation costs also include costs of any
examinations that patients may have undergone
during their visits.
Results
The total treatment costs for heart failure amount to
SEK 2579 million, distributed as shown in Table 1.
Based on prevalence data from the Framingham
study [13], it is also estimated that approximately
101 000 individuals older than 50 years of age
were diagnosed as suffering from heart failure in
Sweden in 1996, and thus the average annual cost
per patient was just over SEK 25 000. Table 2
presents the distribution of costs according to the
number of contributing patients in each category.
These data show that costs are not normally
distributed, since approximately 30% of the patients,
i.e. those discharged from nursing homes and those
discharged from hospitals, contributed nearly three-
quarters of the costs. Furthermore, of the patients
discharged from hospitals, 25% had been hospita-
lized twice or more.
Institutional care in hospitals and nursing homes
Based on data from 1995 for all reasons for
institutional care indicated at the time of hospital
discharge, heart failure was the fourth most
Table 1 Total direct treatment costs for heart failure in Sweden. All costs are in 1996 Swedish kronor (SEK)
Resources
Hospital care ± county councils
Nursing homes ± municipal authorities
Surgery
Hospital outpatient departments
General practitioners
Drugs
Total
$1 = approximately SEK 6.80 (December 1996) and SEK 7.80 (June 1998).
# 1999 Blackwell Science Ltd Journal of Internal Medicine 246: 275±284
277
common reason for hospital care, and the most
common reason in the 65+ age group. Furthermore,
heart failure accounted for 14% of all instances of
hospital care associated with diseases of the circu-
latory system. Added to this, the large number of
bed-days in nursing homes made institutional care
the single most costly item at SEK 1891 million. The
municipalities paid almost 60% of the total costs for
institutional care (Table 3).
In 1995 there were 37 085 hospital discharges
that were coded with the primary diagnosis of heart
failure (Table 3). Most of the care was provided by
district hospitals, i.e. local hospitals serving 30 000±
100 000 inhabitants. Differentiating hospital costs
by type of department shows that general internal
medicine accounted for approximately 75%,
whereas long-term care departments accounted for
an additional 13% of the cost of hospital care. The
age distributions for the hospital and nursing home
heart failure populations are shown in Table 4.
These data indicate that, in nearly 50% of all cases,
the patients were 80 years of age or older. In
nursing homes this figure was even higher (. 70%).
The data in Table 5 indicate that heart failure is a
rapidly expanding problem. In the period between
1989 and 1995 the number of discharges increased
by almost 40%. The average length of stay,
however, remained largely constant during this
period.
Long-term care at municipal nursing homes,
where heart failure is the main diagnosis, accounts
for the single highest cost (Table 1). Analysis of
different subgroups indicates that, for at least 45% of
the bed-days, heart failure was the sole diagnosis or
it was listed with a secondary diagnosis of a
cardiovascular disease or diabetes. These data
indicate that the true cost of heart failure in nursing
homes may be less than SEK 1104 million, the lower
Costs (million SEK) Share (%)
787 31
1104 43
2 <1
231 9
162 6
294 11
2579 100
278 T . R Y D EÂ N - B E R G S T E N & F . A N D E R S S O N

Table 2 Distribution of costs according to severity of disease

No. contributing Costs Cost/patient

Location patients % (million SEK) % (SEK)

Nursing homesa 4116 4 1104 (500) 43 268 000 (121 000)

Hospitalsb 27 073 27 787 30 29 000
Remaining itemsc 69 980 69 (100) 694 27 10 000 (7000)
Total 101 169 100 2579 100 25 495
a
Twelve per cent of the patients were admitted on two or more occasions, bringing their share of the admissions up to 26%. bTwenty-four
per cent of the patients were admitted twice or more, bringing their share of the admissions up to 45%. cThe averages above should be taken
with some caution. The number of items (outpatient visits, drugs and surgery) is not necessarily equal to the number of patients. Some
patients may have required more than one item. Since most patients in nursing homes and hospitals also consume drugs and have
outpatient visits, the value within brackets indicates the true cost per patient based on the estimated total number of heart failure patients.

limit being approximately SEK 500 million, which is
equal to 45% of the total cost of nursing home care.
Surgery
Costs for operations when heart failure was the
main diagnosis were only approximately SEK 2
million, or well below 1% of the total expenditure.
SEK 0.6 million can be attributed to heart trans-
plants, and the rest to coronary artery bypass
grafting (CABG) and percutaneous transluminal
coronary angioplasty (PTCA), the other two types
of surgery included in the analysis.
Ambulatory care
Altogether, costs for ambulatory care constituted
approximately 15% of total treatment costs. A large
proportion (46%) of the visits were to outpatient
hospital departments, which involved greater costs
(Table 6). This may be compared, for example, with
the proportion of hospital visits for patients suffering
from hypertension (18%), angina pectoris (33%)
and atrial fibrillation (37%) during the same period
[11].
Drugs
Drugs accounted for around 11% (SEK 294 million)
of the total costs, i.e. a slightly lower proportion than
for ambulatory care. Table 7 shows that, on
average, patients are prescribed approximately 1.4
drugs specifically for heart failure. Loop diuretics
were the most commonly prescribed diuretic pre-

Table 3 Institutional care distributed according to the different types of institutions. All costs are in 1996 Swedish kronor (SEK)

Care category Total costs Discharges Bed-days Average length

(million SEK) (No.) (No.) of stay (days)

County councils
Regional hospitals 151 6635 45 000 6.8
County hospitals 230 11 351 85 204 7.5
District hospitals 324 16 622 137 604 8.3
Nursing homes* 53 2477 31 245 12.6
Total 787** 37 085 299 053 8.1

Municipal authorities
Nursing homes*** 1104 4895 1 031 507 211

$1 = approximately SEK 6.80 (December 1996) and SEK 7.80 (June 1998). *Nursing homes managed by the County councils. **Including
costs for additional bed-days (SEK 30 million) in connection with myocardial infarction where heart failure was the secondary diagnosis. In
1995 there were 5883 such discharges reported. The average length of hospital stay for these patients was 2 days longer than for
È delreformen); average cost per bed-day = SEK
myocardial infarction patients without this secondary diagnosis. ***Data from 1991 (before A
1070.

# 1999 Blackwell Science Ltd Journal of Internal Medicine 246: 275±284

 COSTS OF HEART FAILURE IN SWEDEN 279

Table 4 Number of hospital and nursing home discharges and consultations in ambulatory care with heart failure as the primary
diagnosis, according to age

Age group Hospital Nursing home Age groups Consultations

(years) discharges (%) discharges (%) (years) (%)

0±59 1674 (5) 54 (1) 0±54 15 308 (4)

60±65 1855 (5) 89 (2) 55±64 26 789 (7)
66±69 2408 (6) 164 (3) 65± 304 603 (89)
70±75 6622 (18) 456 (10)
76±79 6052 (16) 639 (13)
80± 18 473 (50) 3499 (71)
Total 37 085 (100) 4895 (100) Total 382 700 (100)

parations, accounting for some 75% of all costs for in other countries [5, 16±21]. In one United States
diuretics. With respect to other groups of substances, cost-of-illness study, the total health care cost for
24% of all patients received angiotensin-converting heart failure was estimated at more than $10 000
enzyme (ACE) inhibitors. million in 1990 [5]. In another more detailed United
States cost-of-illness study, the estimate was found
to be even higher. In the latter study, the total
Discussion health care cost for heart failure was estimated at
$38 100 million in 1991, which was 5.4% of the
The overall results total health care expenditure [16]. The cost of
hospital care ($23 100 million) accounted for 61%
The overall picture indicates that considerable of the total costs, whilst the remaining 39%
financial resources are being spent on heart failure. ($14 700 million) was spent on ambulatory care.
The cost of treating individuals with heart failure in Less than 1% of the total costs of heart failure was
1996 was approximately SEK 2600 million in spent on surgery. The average length of hospital
Sweden, an average of about SEK 25 000 per stay was 7.7 days in that study, close to the
patient. These costs constitute 1.8% of the total 8.1 days found in the present study.
health care budget, and around 15% of costs In the United Kingdom, the cost of heart failure to
associated with diseases affecting the circulatory the National Health Service (NHS) was estimated at
system. It is interesting to make a comparison with almost £359 million ($600 million), or over 1% of
other chronic disabling diseases such as angina the total NHS budget in 1991 [18]. Hospital care
pectoris and stroke. In 1991 the cost of stroke in and investigations were estimated to account for
Sweden was approximately SEK 4600 million and in approximately 75% of this total. Drug treatment and
1994 the cost of angina pectoris was estimated to be ambulatory care accounted for only 8% and 14%,
SEK 3700 million [14, 15]. respectively. Just under 3% was spent on surgery. In
The extent of the public health care problem the Netherlands, the estimated total cost of heart
associated with heart failure is similar to that found failure in 1988 was estimated at approximately NL
Guilders 444 million ($278 million), which is about
Table 5 Hospital care (discharges/100 000 inhabitants) related to
heart failure for different age groups [22]
Table 6 Cost of ambulatory care
Age Average length of Average length of
(years) 1989 1995 stay 1989 (days) stay 1995 (days) Type of No. of Share of Cost (million
visit visits visits (%) SEK)
0±59 17 24 6.7 6.4
60±69 413 534 7.2 6.8 General practitioner 206 658 54 162
70±79 1315 1742 7.9 7.6 Hospital outpatient 176 042 46 231
80± 3230 4390 8.3 8.8 department
Average 300 419 7.9 8.1 National total 382 700 100 393

# 1999 Blackwell Science Ltd Journal of Internal Medicine 246: 275±284

280 T . R Y D EÂ N - B E R G S T E N & F . A N D E R S S O N
Table 7 Drug costs for heart failure and drug profiles, i.e. the
share of patients (as a percentage) with a diagnosis of heart failure
for whom the following classes of drugs were prescribed. All costs
are in 1996 Swedish kronor (SEK)
Drug class Share of treated Cost (million
(ATC* code) patients (%) SEK)
Diuretics 78 108
ACE inhibitors 24 150
Cardiac glycosides 20 11
Nitrates and nitrites 2 4
Potassium 6 4
Beta-blockers 3 8
Antithrombotic drugs 3 2
Calcium antagonists 1 7
Total ± 294
$1 = approximately SEK 6.80 (December 1996) and SEK 7.80
(June 1998). *Anatomical therapeutic chemical classification
system.
1.2% of the total health care expenditure. The total
cost was distributed over hospital care (67%),
nursing home care (23%), drugs (6%), ambulatory
care (4%), and surgery (, 1%) [17]. In France, the
cost of heart failure in 1990 was fr. 11 400 million
($2 300 million), which accounted for nearly 2% of
the total health care costs that year [21]. Hospital
care was the single largest expenditure (64%).
In the present analysis, hospital care and nursing
home care accounted jointly for 74% of the total
cost. However, in the small number of similar
studies conducted, the cost relating to nursing home
care was in most cases not estimated
[16, 18, 20, 21]. If the cost of nursing home care
is excluded from the present estimate of the total
health care cost of heart failure, hospital care (SEK
787 million) accounts for 53% of the remaining
total cost of SEK 1475 million. The average length of
hospital stay is an important determinant of the
costs. In Sweden, the average length of stay is less
than the 14.5 and 11.6 days, respectively, reported
in two other European surveys [18, 19]. This may
explain in part why the cost of hospital care
accounts for a higher proportion of the total cost
in these countries.
As the nature of the data sources, the definitions
of heart failure as per selection of ICD-9 codes
included, the length of hospital stay, the costing
methods, etc., differ amongst these analyses, it is
difficult to make direct comparisons of the results
reported. For example, in the United Kingdom study
# 1999 Blackwell Science Ltd Journal of Internal Medicine 246: 275±284
the selection criteria for discharges related to heart
failure were broad, and were based on ICD-9 code
428, as well as the ICD-9 codes for hypertensive
heart failure and cardiomyopathy [18]. In the
United States study, all discharges with a primary
or secondary diagnosis of heart failure as per ICD-9
code 428 were included [16].
In 1989, an early Swedish cost-of-illness study
estimated the expenditure for heart failure based on
the costs of hospital care, drugs and ambulatory care
at SEK 800 million [1]. The difference between the
1989 and 1996 estimates is due to a number of
factors. Our study is more comprehensive in that it
includes more items and is based on more detailed
estimates of these items. Furthermore, the rate of
hospitalization has increased considerably in the
period between these two years (excluding nursing
homes), as is also the case with the rate of inflation
(36%).
The increasing cost of inpatient care is a rapidly
expanding problem
Although different methodological approaches lead
to varying estimates of costs, it is clear that
institutional care is the single largest component of
expenditures for heart failure. This pattern is
consistent across countries [16±21].
A comparison of our 1995 data on hospitalization
with data from an early Swedish epidemiological
study, surveying the rate of hospitalization in 1989
owing to heart failure, indicates that hospital care
requirements have increased in Sweden since 1989
[22]. In this context, it is important to note that the
average length of hospital stay has remained largely
unchanged in the period between these two years.
Increasing hospitalization rates have been reported
in other countries [20, 23, 24]. A survey of Scottish
hospitals showed that the number of instances of
hospitalization had increased by 63% between 1980
and 1990 [23]. In New Zealand the hospital
admissions for heart failure increased by 37%
between 1980 and 1992 [20]. However, another
study of the hospitalization rates owing to heart
failure in New Zealand between 1988 and 1991,
with a slightly different definition of heart failure, did
not demonstrate temporal trends in hospital admis-
sions [25]. This was explained by the authors as
being due to too short a study period to allow for the
reliable detection of such trends. In the United
 COSTS OF HEART FAILURE IN SWEDEN
States, there was a fourfold increase in the number
of hospitalizations between 1971 and 1991 [24].
Furthermore, the present study indicates that, in
50% and 95% of all discharges with the diagnosis of
heart failure, the patients were older than 80 and
65 years of age, respectively. This is consistent with
findings in other studies [16, 20].
The increase in hospital admissions is consistent
with the changing epidemiological features of heart
failure [24]. The prevalence of the illness is on the
increase, mainly owing to the increasing number of
elderly people in the population and because the
predisposing conditions are palliated but not cured,
and also because more and more patients are
surviving the acute stage of a heart attack [24].
Because of the high prevalence of heart failure
and the high costs involved in caring for these
patients, improvements in the management patterns
could have a tremendous impact on the costs as well
as the outcomes. Bearing in mind the great
significance of hospital costs, it is essential to find
ways of treating heart failure that reduce the need
for this type of care. In this context, it is interesting
to note that international studies have shown that
treatment programmes covering such disparate
areas as medication, diet, exercise and education of
patients and their relatives with respect to home
care can reduce the need for hospital care and
shorten the number of days per hospitalization,
whilst also improving the patient's functional status
and quality of life [3, 4, 26, 27]. There is also
increasing interest in Sweden in the development of
this kind of structured care programme [28].
Continued low share of ACE inhibitor prescriptions
As for medication, the study shows that heart failure
patients are primarily treated using diuretics, ACE
inhibitors and cardiac glycosides. In a recent survey
of Italian heart failure patients admitted to hospital
cardiology units, details of drug treatment patterns
were reported [19]. In this cohort the same types of
drug classes were used. With the exception of
diuretics, the Italian share of treated patients within
the drug classes was higher, as was the average
number of drugs prescribed [19]. It is, however,
difficult to compare our data with data from other
published sources, such as the Italian study, or with
data on drug therapy at baseline reported in
mortality studies of ACE inhibitors in patients with
# 1999 Blackwell Science Ltd Journal of Internal Medicine 246: 275±284
281
heart failure [19, 29]. These sources report the
overall drug treatment pattern and consumption,
including drugs prescribed for other comorbidities
related to heart failure, whereas our data account
only for drugs prescribed specifically for the diag-
nosis of heart failure alone.
Compared with findings in a Swedish study in
1992, the prescription of cardiac glycosides has
decreased slightly (30% in 1992) [1]. The use of
diuretics remains largely unchanged (84% in 1992)
[1]. By contrast, the prescription of ACE inhibitors
has increased (9% in 1992) [1]. However, only
around a quarter of all heart failure patients in
Sweden are prescribed this latter treatment, despite
the fact that these are the most effective prepara-
tions against mortality and morbidity [29, 30]. A
British research team analysing the use of ACE
inhibitors also reached the same conclusion [31].
Only 36% of the patients had been on ACE inhibitors
on admission, and, of those, only 17% were taking a
dose that had been proven in clinical trials to have a
positive effect on mortality. One factor that may
account for this is the high average age of the
patients (76 years), which is higher than that of
patients included in the major studies of ACE
inhibitors [29, 30].
On the whole, it seems as if ACE inhibitors are not
being optimally used in the treatment of heart
failure, since too few patients are being prescribed
the treatment and many patients are being pre-
scribed too low a dose. Furthermore, the use of ACE
inhibitors in the treatment of heart failure has been
shown to be highly cost-effective [17, 20, 32±35].
Given the increased budgetary pressures, every effort
should be made to obtain the greatest possible value
from health care spending. This means that efforts
should be made to increase the use of cost-effective
treatments such as ACE inhibitors.
Areas for further research
It has been shown that relatively few patients are in
New York Heart Association (NYHA) class IV, and
that these patients are 8±30 times more expensive
than patients in NYHA class II [36]. Therefore, it
seems essential to develop management strategies
that prevent patients with mild disease from
progressing to severe and hence very costly heart
failure. Although our study provides no detailed
information on the use of resources and costs
282 T . R Y D EÂ N - B E R G S T E N & F . A N D E R S S O N
associated with the varying severity of heart failure,
our findings that a small number of patients
contribute to nearly 75% of the costs are in line
with this. A different study method, based on a
systematic review of patient records, would be
necessary to obtain such information. However,
the primary aim was to provide a general picture of
the overall cost situation for heart failure in Sweden.
The method that has been applied is well suited to
conditions requiring frequent hospital care. How-
ever, the results do suggest that continued studies,
including data abstraction from patient records,
would certainly be useful when planning pro-
grammes to render heart failure treatment more
cost-effective.
In addition to providing information about the
overall healthcare costs according to NYHA class,
such systematic analyses might, for example, be
used to quantify the extent of costs for diagnostic
investigations of heart failure, as well as to study
how and on what grounds diagnostic investigations
are applied. A wide range of diagnostic methods are
now available, and the question is whether they are
being used in the most efficient way, regarding both
the choice of method and the clinical criteria, which
would warrant a more advanced diagnostic exam-
ination.
Review of patient records might also be used to
monitor the utilization pattern of ACE inhibitors
with the aim of identifying the reasons for use and
the clinical and human effects associated with the
under-prescribing of ACE inhibitors, as well as the
economic consequences.
Some limitations
The prevalence calculations in this study were based
on the Framingham data, and almost certainly
underestimate the actual number of individuals
suffering from heart failure. It is difficult for several
reasons to obtain a reliable estimate of the pre-
valence of heart failure in Sweden. First, there is no
simple, clear definition of exactly what constitutes
heart failure [37]. Owing in part to this problem,
existing Swedish epidemiological data have certain
limitations [38, 39]. Secondly, the clinical criteria
used as the definition of heart failure in the
Framingham study principally estimates the occur-
rence of advanced heart failure. However, most
other epidemiological studies have used clinical
# 1999 Blackwell Science Ltd Journal of Internal Medicine 246: 275±284
criteria to diagnose heart failure, and no objective
evidence of left ventricular function has been
obtained [13, 38±41]. If the number of individuals
suffering from heart failure according to the
Framingham estimate (101 000 individuals) is
related to the estimated number of outpatient visits
(382 700), this corresponds to about 3.8 visits per
patient per year. Finally, since heart failure is still
difficult to diagnose, the recognition of milder forms
of the syndrome may go undetected in clinical
practice. These observations lend further support to
the use of the Framingham data in the calculation of
prevalence.
Another possibility would have been to use
prevalence data from a recent Scottish study in
which individuals from the general population were
screened for evidence of impaired left ventricular
systolic function [42]. In this cohort, the prevalence
of symptomatic heart failure was found to be 1.5%.
The Scottish study, however, included only indivi-
duals aged 25±74 years. It is evident from the
Framingham data that the prevalence of heart
failure increases considerably after the age of 74
[13].
There is also a certain degree of uncertainty in the
interpretation of nursing home data, which may
result in an overestimation of the costs relating to
heart failure in these institutions. Since the transfer
of budget responsibility in 1992, a number of
cheaper means of care have been established.
Consequently, there is uncertainty concerning the
frequency of admissions, the duration, and the
distribution of different means of care for the elderly.
As for the relevance of using the 1991 figures, they
are considered fairly representative of earlier and
later years (personal communication, Per Carlsson,
the Swedish Council on Technology Assessment in
Healthcare). We have therefore estimated a lower
limit of SEK 500 million for this cost parameter,
providing a total cost for heart failure of slightly less
than SEK 2000 million. However, there might also
be a risk of underestimating the costs of nursing
home care owing to the length of the average care
period. The statistics include only patients who have
been discharged from the institution during the
course of the year. They do not therefore include
bed-days for patients who have been cared for
during the year but who have not been discharged
before the end of the year. However, this should not
affect heart failure figures to too great an extent,
 COSTS OF HEART FAILURE IN SWEDEN
since a 1-year survival period for patients with
advanced forms of heart failure is rare, in some cases
less than 50% [43]. Regardless of the proportion of
nursing home care costs attributed to heart failure,
the ultimate conclusion that institutional care
constitutes the single most costly area is not affected.
Finally, this is probably quite a conservative
calculation, as the study does not include direct
nonmedical costs and indirect costs. Such costs
include home care, private services and transporta-
tion (direct nonmedical costs), lost productivity
owing to sick leave, sickness pension, early retire-
ment pension and informal care provided by family
and friends. Some of these costs may be quite
considerable, since many of the patients suffering
from heart failure are severely disabled and thus
need a substantial amount of assistance during long
periods of time. For most of these costs there are no
national data, and it is almost impossible to make
reliable estimates. Hence these costs have been
omitted from this analysis, and it should be
remembered that the true societal costs of heart
failure may be higher than the estimate presented in
this analysis.
Conclusion
The results of this study indicate that the total
annual expenditure for heart failure amounts to
approximately SEK 2000±2600 million, which
corresponds to nearly 2% of the Swedish health
care budget. Hospital and nursing home care jointly
account for up to 75% of the total costs. Efforts to
develop effective treatment strategies that can
reduce the need for expensive institutional care,
without having a negative impact on patients'
quality of life, morbidity and mortality, should be
given high priority. Furthermore, a key area in
which future detailed studies are required concerns
the under-prescribing of ACE inhibitors, regarding
reasons and costs as well as utilization patterns
based on subject characteristics. Utilization patterns
and costs of diagnostic procedures in patients with
varying severity of heart failure are other important
areas for research.
Acknowledgements
The authors acknowledge the helpful comments of
Associate Professor Henry Eriksson, Sahlgren's
# 1999 Blackwell Science Ltd Journal of Internal Medicine 246: 275±284
283
Hospital, Gothenburg, Sweden, and Professor Lars
RydeÂn, Karolinska Hospital, Stockholm, Sweden. We
are grateful to Leif Forsberg, the National Swedish
Board of Health and Welfare, Epidemiological
Centre, Stockholm, Sweden, for his valuable re-
search assistance.
This study received financial support from HaÈssle
LaÈkemedel AB, MoÈlndal, Sweden.
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Received 13 March 1998; accepted 29 December 1998.
Correspondence: Tina RydeÂn-Bergsten MSc, Health Economics
Manager, Health Economics, AstraZeneca R&D MoÈlndal,
S-431 83 MoÈlndal, Sweden (fax: +46 31 776 38 05; e-mail:
tina.ryden-bergsten@hassle.se.astra.com).