Despite advances in left ventricular assist device (LVAD) technology, right ventricular failure (RVF) continues to be a complication after implantation. Most patients undergoing LVAD implantation have underlying right ventricular (RV) dysfunction (either as a result of prolonged LV failure or systemic disorders) that becomes decompensated post-implantation. Additional insults include intra-operative factors or a sudden increase in preload in the setting of increased cardiac output. The current literature estimates post-LVAD RVF from 3.9% to 53% using a diverse set of definitions. A few of the risk factors that have been identified include markers of cardiogenic shock (e.g., dependence on inotropes and Interagency Registry for Mechanically Assisted Circulatory Support profiles) as well as evidence of cardiorenal or cardiohepatic syndromes. Several studies have devised multivariable risk scores; however, their performance has been limited. A new functional assessment of RVF and a novel hepatic marker that describe cholestatic properties of congestive hepatopathy may provide additional predictive value. Furthermore, future studies can help better understand the relationship between pulmonary hypertension and post-LVAD RVF. To achieve our ultimate goal—to prevent and effectively manage RVF post-LVAD—we must start with a better understanding of the risk factors and pathophysiology. Future research on the different etiologies of RVF—ranging from acute post-surgical complication to late-onset RV cardiomyopathy—will help standardize definitions and tailor therapies appropriately.
Background Heart failure (HF) poses a major public health burden in the United States. We examined the burden of out‐of‐pocket healthcare costs on patients with HF and their families. Methods and Results In the Medical Expenditure Panel Survey (MEPS), we identified all families with ≥1 adult member with HF during 2014 – 2018. Total out‐of‐pocket healthcare expenditures included yearly care‐specific costs and insurance premiums. We evaluated two outcomes of financial toxicity: (1) high financial burden – total out‐of‐pocket healthcare expense to post‐subsistence income of >20%, and (2) catastrophic financial burden with the rate of >40% ‐ a bankrupting expense defined by the WHO. There were 788 families in MEPS with a member with HF representing 0.54% (95% CI, 0.48%–0.60%) of all families nationally. The overall mean annual out‐of‐pocket healthcare expenses were $4423 (95% CI, $3908–$4939), with medications and health insurance premiums representing the largest categories of cost. Overall, 14% (95% CI, 11%‐18%) of families experienced a high burden and 5% (95% CI, 3%‐6%) experienced a catastrophic burden. Among the two‐fifths of families considered low‐income, 24% (95% CI, 18%‐30%) experienced a high financial burden, while 10% (95% CI, 6%‐14%) experienced a catastrophic burden. Low‐income families had 4‐fold greater risk‐adjusted odds of high (OR=3.9, 95% CI, 2.3–6.6), and 14‐fold greater risk‐adjusted odds of catastrophic financial burden (OR=14.2, 95% CI, 5.1–39.5) compared with middle/high income families. Conclusions Patients with HF and their families experience large out‐of‐pocket healthcare expenses. A large proportion encounter financial toxicity, with a disproportionate effect on low‐income families.
OBJECTIVE Health-related expenditures resulting from diabetes are rising in the U.S. Medication nonadherence is associated with worse health outcomes among adults with diabetes. We sought to examine the extent of reported cost-related medication nonadherence (CRN) in individuals with diabetes in the U.S. RESEARCH DESIGN AND METHODS We studied adults age ≥18 years with self-reported diabetes from the National Health Interview Survey (NHIS) (2013–2018), a U.S. nationally representative survey. Adults reporting skipping doses, taking less medication, or delaying filling a prescription to save money in the past year were considered to have experienced CRN. The weighted prevalence of CRN was estimated overall and by age subgroups (<65 and ≥65 years). Logistic regression was used to identify sociodemographic characteristics independently associated with CRN. RESULTS Of the 20,326 NHIS participants with diabetes, 17.6% (weighted 2.3 million) of those age <65 years reported CRN, compared with 6.9% (weighted 0.7 million) among those age ≥65 years. Financial hardship from medical bills, lack of insurance, low income, high comorbidity burden, and female sex were independently associated with CRN across age groups. Lack of insurance, duration of diabetes, current smoking, hypertension, and hypercholesterolemia were associated with higher odds of reporting CRN among the nonelderly but not among the elderly. Among the elderly, insulin use significantly increased the odds of reporting CRN (odds ratio 1.51; 95% CI 1.18, 1.92). CONCLUSIONS In the U.S., one in six nonelderly and one in 14 elderly adults with diabetes reported CRN. Removing financial barriers to accessing medications may improve medication adherence among these patients, with the potential to improve their outcomes.
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