Chagas' cardiomyopathy: The economic burden of an expensive and neglected disease

https://doi.org/10.1016/j.ijcard.2013.01.262Get rights and content

Abstract

Background

Chagas' cardiomyopathy (CC) is a rising etiology for heart failure (HF) that previously was restricted to some countries of Latin America. The chronic CC cases cause now a profound socio-economic impact. However this issue has not been well studied if compared to other causes of HF. The objective of this study was to assess the cost burden of CC during acute decompensated HF admissions (ADHF), and compare this cost to the other etiologies of HF.

Methods and results

By the end of 2006 we started a five year follow-up of 577 consecutive adult patients admitted at a high complexity cardiology university hospital in the city of Sao Paulo, Brazil. This study shows the data of the first admission of each patient of this follow-up. Patients were divided in two groups: CC (58 patients) and non-chagasic (NC) (519 patients). Mortality was different among groups, 19/58 (32.8%) in CC vs 113/519 (21.8%) in NC (p = 0.046). The prevalence of signs of inadequate perfusion was higher in the CC group at admission, but in a multivariated analysis chagasic etiology and presence of diabetes were independent predictors of higher costs per day of hospitalization adjusted by mortality. Median costs per day were US$ 308 (277–542) vs US$ 467 (323–815) for NC and CC respectively (p < 0.001).

Conclusion

Treating ADHF patients with CC etiology was more expensive and mortality was higher in this population at the first admission of this follow-up. This could be explained by the severity of Chagas' cardiomyopathy disease.

Introduction

In times of economic crises around the world, the cost of disease knowledge is of utmost importance in order to plan healthcare actions. The importance of heart failure (HF) is that this disease continues to be among the most prevalent high mortality and morbidity diseases around world. Besides that, the need of resources for treating this disease requires significant proportion of overall healthcare budget in a lot of countries [1], [2], [3], [4], [5]. The so called “industrialized world” is more frequently used to dealing with an elderly population of patients whose diseases are mainly resulted from ischemic and hypertensive etiologies for HF [6]. Chagas' cardiomyopathy (CC) is a rising etiology for HF that previously was restricted to some countries of Latin America [7]. This disease results from a long term, chronic, systemic, parasitic infection caused by the protozoan Trypanosoma cruzi. It affects about 18 million people in Latin America [7]. Although it can be severe, acute cardiac form of the disease is not usually seen. The major problem happens in about 20–35% of the infected patients who develop the chronic disease that can primarily damage heart, digestive system, or both many years after the infection [8], [9]. Other complications are seen due to heart failure, mural thrombus, left ventricular apical aneurysm, and several types of cardiac arrhythmias, causing stroke [10]. Certainly, the cardiomyopathy, that evolutes to congestive heart failure is the worst condition and leads to high level of disabling sequelae. Early diagnose of the cardiac disease may not change the chronic evolution of the disease because at this phase drugs against the protozoan are not proven yet as effective to prevent the development of heart failure and/or arrhythmias. The world health organization (WHO) considers it a neglected tropical diseases according to the definition “…Chronically endemic and epidemic-prone tropical diseases, which have a very significant negative impact on the lives of poor populations [and] remain critically neglected in the global public health agenda” [11].

Due to national health authorities' control activities, the domestic and peridomestic cycles of transmission involving vectors, animal reservoirs and human in countries like Argentina, Chile, Brazil, and Uruguay were almost finished [7]. In the past, the lack of screening in blood banks was also an important form of contamination. However, many countries totally interrupted this kind of transmission in Latin America [7], [8].

Nowadays, the main reason for the spread of Chagas' disease is immigration that brought the parasite to North America and Europe [12], [13]. As the other neglected diseases, Chagas' disease has become an international health problem [11]. It needs to be cared for, not only in poor areas where basic health could prevent the epidemics but also in rich places where very sick patients demand for highly complex medical treatments [13], [14]. An example of this paradox is seen in many Sao Paulo cardiology centers that are located at a rich area of Brazil.

Nowadays, even with the reduction of cases described above, the chronic CC cases may cause a profound socio-economic impact. The reason for that is because many of the numerous infected people still may develop the disease. However the burden of this disease has not been well studied if compared to other causes of HF. Thus, we decided to focus on in-patients because the major part of resources to treat this disease is spent during these admissions. Our objective was to assess the cost burden of CC during acute decompensated HF (ADHF) admissions, and compare this cost to the other etiologies of HF.

Section snippets

Methods

By the end of 2006, after Ethical Commission Board approval (and complying with the Declaration of Helsinki) we started a five year follow-up of 577 consecutive adult patients admitted at a high complexity cardiology university hospital in the city of Sao Paulo, Brazil.

Patients with diagnosis of symptomatic heart failure due to either systolic or diastolic dysfunction that needed emergency or urgency care were enrolled in this study. All of the 577 records had the ADHF diagnosis confirmed, 58

Results

Non-chagasic patients were older and had more non-cardiac co-morbidities. Diabetes and renal dysfunction were more frequent in non-chagasic patients. Although coronary disease was more frequent in non-chagasic group, around 8% of the CC patients had history of coronary disease too. The prevalence of previous stroke was similar in both groups, but CC patients had more documented left ventricular clots. Comorbidity Charlson Index was higher in non-chagasic group. Regarding cardiac history, CC

Discussion

Our investigation provides data from a “real world” found in a university hospital in São Paulo, but may be taken as similar in many other cities in Brazil. High complexity is also a feature of this heart hospital. The reason for evaluating ADHF patients is because those admissions correspond to the main part of the resources used to treat HF patients.

The main attribute of our population is the severity of its sickness. The high rates of mortality in this population could be explained by the

References (32)

  • K. Dickstein et al.

    ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008

    Eur Heart J

    (2008)
  • D.M. Lloyed-Jones et al.

    Lifetime risk for developing congestive heart failure. The Framingham Heart Study

    Circulation

    (2002)
  • T. Neumann et al.

    Heart failure: the commonest reason for hospital admission in Germany medical and economic perspectives

    Dtsch Arztebl Int

    (2009)
  • G. Ertl et al.

    Heart failure in the 21st century: is it a coronary artery disease problem or hypertension problem?

    Cardiol Clin

    (2007)
  • A. Moncayo et al.

    Current epidemiological trends for Chagas disease in Latin America and future challenges in epidemiology, surveillance and health policy

    Mem Inst Oswaldo Cruz

    (2009)
  • J.A. Rassi et al.

    Chagas disease

    Lancet

    (2010)
  • Cited by (0)

    1

    Heart Failure Department, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.

    2

    This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

    3

    New Technologies Evaluation Department, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.

    4

    Information Technology Department, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.

    View full text