Peripheral artery disease (PAD) is one of the most common cardiovascular diseases among adults in the United States. The risk for developing PAD increases as people age and are exposed to specific atherosclerosis risk factors. Previous published research has linked continued tobacco use to an increasing number of heart attacks and strokes, worsened claudication, increased amputations, aneurysms, exposure to costly medical procedures, and death in people with PAD. Tobacco use has been identified as an important preventable cause of PAD and is a major determinant of adverse clinical outcomes.
Taking a Closer Look
Surprisingly, no prior studies have specifically explored the contribution of tobacco use to short-term healthcare utilization and medical costs in PAD. To address this research gap, Sue Duval, PhD, FAHA, and colleagues evaluated this risk in a large, population-based, cross-sectional study published in the Journal of the American College of Cardiology that analyzed 2011 claims data of more than 22,000 people with PAD. “Our study was designed to define the associated immediate health and economic burden of tobacco use in Minnesota and the United States,” says Dr. Duval. “It represents one of the largest measurements of the impact of PAD on health.”
Claims data used in the study were provided by Blue Cross and Blue Shield of Minnesota, the state’s largest health plan. The total study group included individuals with 12 months of continuous enrollment and one or more PAD-related claims. The authors also queried tobacco cessation pharmacotherapy billing codes in a subgroup of patients with pharmacy benefits in order to better identify current smokers. Outcomes assessed in the study included the annual proportion of members hospitalized, the associated primary discharge diagnoses, and total healthcare costs.
Assessing Admissions & Costs
The investigation identified 9% of the more than 22,000 participants with PAD who were tobacco users. Also, a subgroup of more than 9,000 patients with pharmacy benefits included nearly 13% who were identified as tobacco users. The total cohort experienced 22,220 hospital admissions, while the subgroup of patients with pharmacy benefits experienced more than 8,000 admissions.
“Within 1 year, nearly one-half of patients with PAD who used tobacco were hospitalized,” says Dr. Duval. This figure was 35% higher than that of non-tobacco users in the total cohort and 30% higher in the subgroup of patients with pharmacy benefits. In both cohorts, tobacco users were more frequently admitted to the hospital for peripheral or visceral atherosclerosis, heart disease, stroke, pneumonia, and bronchitis.
Observed costs for the total PAD cohort in the first year were $64,041 for tobacco users compared with $45,918 for non-tobacco users, representing a cost difference of nearly $18,000 (Figure). Costs for tobacco users were consistently higher for professional and facility-based care, a finding that persisted even after adjusting for age, sex, comorbidities, and insurance type.
A Devastating Impact
“Our research clearly illustrates the devastating impact smoking can have for those dealing with PAD,” Dr. Duval says. “It’s been well-established that tobacco hurts health, but our study shows how powerfully detrimental smoking can be to patients with PAD. The cost to patients, society, and health payers is gigantic for both the short and long term.” Considering that Minnesota is a state that is known to be “heart healthy,” the study group noted that the implications of their research and the costs of smoking are likely to be even higher in other areas throughout the U.S.
According to Dr. Duval, clinicians, health systems, and insurers need to make much greater and more consistent efforts to assist patients with PAD to quit smoking. “It has been shown by other major research studies, including those involving people with PAD, that physicians who counsel individuals on smoking cessation and provide comprehensive tools to facilitate each quit attempt can make an important impact on empowering patients to quit the habit,” she says. “We should inform patients with PAD that their risks for heart disease are higher if they smoke and let them know that they’re more likely to be hospitalized within a year if they continue to smoke. A discussion about smoking cessation should be routine during every patient encounter in order to reinforce quit efforts.”
It is known that each comprehensive effort to help a patient quit smoking, including both access to behavioral counseling and pharmacotherapy, costs less than $500. “When compared with the nearly $18,000 per year in added healthcare costs, it is much more cost effective to give patients every tool to quit smoking,” Dr. Duval says. “It’s important for clinicians and quality-focused health systems to treat the causes of disease— not just the consequences—and we should think of smoking cessation a first-line therapy for PAD.” She notes that the study results also suggest that immediate provision of tobacco cessation programs may be especially cost effective.
Duval S, Long KH, Roy SS, et al. The contribution of tobacco use to high health care utilization and medical costs in peripheral artery disease: a state-based cohort analysis. J Am Coll Cardiol. 2015;66:1566-1574. Available at: http://content.onlinejacc.org/article.aspx?articleid=2445342&resultClick=3.
Barnes GD, Jackson EA. Tobacco use in peripheral artery disease: an economic drag. J Am Coll Cardiol. 2015;66:1575-1576.
Hennrikus D, Joseph A, Lando HA, Duval S, Kodl M, Ukestad L, Hirsch AT. Effectiveness of a smoking cessation program for peripheral artery disease patients: A randomized controlled trial. J Amer Coll Cardiol 2010 Dec 14;56(25):2105-12.
Rooke TW, Hirsch AT, Misra S, et al; American College of Cardiology Foundation Task Force; American Heart Association Task Force. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:1555-1570.
Hirsch AT, Duval S. The global pandemic of peripheral artery disease. Lancet. 2013;382(9901):1312-1314.