13th International Congress
THE "NEW FRONTIERS"
OF ARRHYTHMIAS 1998

January 24-31, 1998
Marilleva, Trento, Italy

RT-88

Arrhythmias and health economics

Nina Rehnqvist, Göran Engholm, Lars Nyberg.
The National Board of Health and Welfare, Stockholm, Sweden

Health economics attracts an increasing interest. The topic is difficult and common terminology and means of measurements are not fully accepted. The need for health economic data is obvious, especially in a time when the gaps between available resources and demands on quality on one hand and resources and medical possibilities on the other are increasing. Treatment of arrhythmias has been of interest since long, especially since the introduction of the CCUs in the late sixties. Many problems have been associated with treatment of arrhythmias and the well known adverse effects of antiarrhythmic drug treatment do not need to be stressed.

Sweden has always been a country where, by tradition, antiarrhythmic treatment with drugs has been restrictive. The topic of this paper is to evaluate the proportion of resources devoted to treatment of arrhythmias either in the combination with other heart diseases or alone. In Sweden drug sales due to disorders in the heart and circulatory system constitute 14% of all drug sale costs and is equivalent to 2.736 million SEK (342 million US dollar). The drugs are relatively cheap since 17% of all DDDs are attributable to disorders in the heart and the circulatory system. DDD per 1000 inhabitants and day of antiarrhythmic drugs have slowly declined from 1985 to 1996.

There is a wide variation between different areas in Sweden as well as between countries. For antiarrhythmics drugs there is a two-fold difference between different counties in Sweden. For sotalol there is a 2.5 fold difference and for verapamil a 2.7 fold difference. Verapamil is more often prescribed to women in all age groups except between 15-25 and 60-70 years. The prescription of sotalol is evenly distributed between men and women up to the age of 35. Above that age more men are precribed that drug than women. Antiarrhythmic drug treatment is too rare to merit this kind of comparison.

Pacemaker treatment is less common in Sweden than in some other countries. In the whole country 380 new pacemakers/million inhabitants are implanted. There is also regional variation in pacemaker treatment where the western part of the country has a higher implantation rate. A pacemaker in Sweden costs between 20.000 and 30.000 SEK. The number of implanted generators varies little during the last years and is fairly constant around 2000-2500 per year. Out of these 400 are implanted in patients over 85 years and more than 1500 in patients over the age of 75 years. According to the pacemaker quality register 76% of generators are implanted in patients more than 70 years and 43% in patients aged 80 and over.

Annually any type of cardiac operations are performed in 0.24% of men and 0.11% of women in one year. Cardiac operations constitute about 4% of all in hospital surgical operations. Pacemaker operative activity constitutes 23% of all heart operations ie 1% of all operative activity. The relative use of resources is illustrated by the fact that, in men, annually about 2000 admissions in Sweden are due to pacemaker treatment compared to 17 800 for acute myocardial infarction. The corresponding numbers for women are 1600 pacemaker admissions and 11 000 acute myocardial infarction admissions. The total annual number of procedures is roughly twice the number of admissions, whereas the average number of admissions per patient exceeds only very little 1, ie only few patients need to be admitted more than once a year.

Each year the pulsegenerator is extracted in about 30-40 patients of the 25 000 pacemaker patients.

The complication rate in pacemaker treatment is continuously evaluated in the pacemaker register in Sweden and the complication rate is beeing reduced as time passes.

The annual number of implanted defibrillators has increased from 49 in 1993 to 112 in 1995. Patients in all ages are treated but some 90% of the patients are in ages above 44 years. The oldest patient was 84 years. In about 15 patients the defibrillator has to be exchanged each year. The main costs for treatment are apart from drug costs and costs for devices, the costs for hospitalization. In Sweden the total costs for inhospital somatic care is 57.100 million SEK. Conduction disorders are responsible for about 3400 admissions and there is no great variation over the last years. The mean duration of time in hospital is about 4 days with a median of 3. With an average daily cost in hospital of 2.600 SEK this is corresponding to 46 million SEK ie 0.1% of somatic inhospital costs. Tachyarrhythmias mainly in the form of supraventricular tachycardias are responsible for 26 714 admissions whereof 13 989 are men corresponding to 2% of all male admissions and 12 725 corresponding to 1.4% of female admissions. The mean duration of stay in these disorders is 3.4 days and median 2 days. The total cost is estimated to 139 million SEK (0.2%). Thus treatment for supraventricular arrhythmias is not a heavy burden on hospital costs. Atrial fibrillation and atrial flutter are seldom the main cause for admission but patients with heart failure have atrial fibrillation in 50% of the cases in older ages and in 40 000 admissions atrial fibrillation is the main or contributory cause. There is an even sex distribution in admissions due to atrial fibrillation and flutter. Ventricular fibrillation on the other hand is a much more common disorder in men than in women.

In conclusion, antiarrhythmic problems are fairly common in the population but do not lay a heavy burden on hospital costs. Costs for devices are not negligible but not a heavy burden either. Drug costs for antiarrhythmic treatment are decreasing for pure antiarrhythmic drugs and verapamil but an increase is noted for sotalol. This increase, however, is much less pronounced than for lipidlowering drugs and ACE inhibition. Within the country there is a wide variation between counties with respect to prescription of antiarrhythmic drugs. The highest prescription rate is 2-3 times the lowest rate. There are also variations within the country in pacemaker implantation rate in the order of 50%.

TABLE I - The table shows how the prescription of some drugs of cardiological interest has changed over time

ACEI = ACE-inhibition drugs.