This study provides a unique and detailed description of the costs associated with patients with NCCP, AMI and AP from a societal perspective. This has not previously been reported. In the present study, we have calculated the annual societal costs, including direct healthcare costs and indirect costs, due to productivity loss associated with NCCP, compared to costs of AMI and AP. Although the majority of patients with NCCP have no cardiac conditions, many of them believe that they do and they are often treated in cardiac units. Therefore, it is of great interest to compare them with cardiac patients. By comparing them with the more severe cardiac patients who require more and expensive healthcare resources, we can show the extent of the costs incurred by those with NCCP, who have a significantly less severe condition. By highlighting the extent of the costs, we can also emphasize the importance of early diagnostics and treatment for these patients which can have a positive impact on healthcare utilization and costs. This can also lead to better use of resources for those with cardiac conditions.
Patients with NCCP incur large costs for the society, that are similar to or exceed those of AMI and AP, particularly with regard to primary care costs and indirect costs due to sick-leave. On average, patients with NCCP had 54 primary care and out-patient contacts during the study period, incurring higher costs than patients with AMI and AP. This is noteworthy since many of these patients do not have a clear cause and medical diagnosis explaining the pain. The lack of explanation for the chest pain can lead to psychological distress, which may explain these patients’ high number of primary care contacts. According to Eslick , there is a relationship between seeking behavior, symptom severity and higher level of psychological distress.
All 3 groups had significantly more contacts with primary care/out-patient clinics and incurred higher costs in year 2 compared to year 1. This is expected since most treatment and follow-ups after the index admission are carried out within primary care and out-patient clinics. Another reason is that in Sweden, primary care has a strict gatekeeper role and people are advised to initially consult primary care for most symptoms . However, when they experience chest pain, they can seek acute hospital care without referral from primary care.
Patients with NCCP had fewer admissions and shorter length of hospital stay, and thereby lower hospital costs, than those with AMI and AP, which is similar to earlier research [5, 18]. The costs for a hospital admission in the present study was €2602 for 2.4 days for patients with NCCP, to be compared with €884 for about 1 day of hospital admission in a previous study from Sweden , and €3729 for 3.8 days in Ireland . All 3 groups had significantly fewer admissions, and in AMI and AP the length of hospital stays were also shorter year 2 compared to year 1, leading to lower costs in all patient groups. This can partly be explained by the fact that the index admission was included in the first year. However, in patients with AMI and AP, the number of admissions and the length of hospital stay may have decreased after patients had received their diagnoses and treatment for these. Although the mean number of admissions and hospital days was low in all patients, it is recommended that strategies are implemented in order to reduce the number of admissions and hospital days since they represent the greatest part of the cost [16, 18]. In this study, one of the most cost driving units was hospital care, including nursing/caring staff and premises costs. Coodacre & Calvert  recommend short periods of observation with exercise stress testing rather than overnight admission as a reasonably cost-effective treatment of patients with NCCP.
On average, 14%, 18%, and 25% of the patients with NCCP, AMI and AP were on sick-leave annually with a mean length of 103, 54 and 94 days respectively. These percentages were lower than those reported by Eslick & Talley , where 29% of patients with NCCP and 25% with cardiac chest pain were absent from work due to chest pain. The participants in the present study had substantially longer periods of absence from work compared to the 22 days reported by Eslick & Talley. We also found that about 10% of patients with NCCP received a disability pension, which was similar to those with AMI and AP. However, as reported in a previous study , there were some high users in this cohort who contributed to high indirect costs.
The annual societal cost of NCCP per patient was €10,068, which was lower than the costs of patients with AMI and AP, which were €15,989 and €14,737 respectively. To obtain a rough indication of the burden of these patient groups on society, the costs could be extrapolated to a larger context. In 2010, 81,121 patients (2.2% of all patients) were diagnosed with NCCP, 22,836 with AMI and 27,683 with AP in Sweden . Due to the high prevalence of NCCP, the cumulative annual national cost of patients with NCCP would be about €817 million if all patients incurred the same costs as in the present study. The corresponding cost for patients with AMI and AP would then be about €364 million and €408 million respectively.
Strengths and weaknesses
Our results are based on national databases; all healthcare and social insurance utilization over a 2-year period is reported. The study has also identified the most cost driving units in healthcare in connection with patients with NCCP, AMI and AP. This information is of great interest when developing new interventions for these patients in order to support them and reduce societal costs.
All costs associated with the patients’ healthcare utilization and productivity loss were included in the analysis. These also include costs that may have not been related to NCCP, AMI or AP. It should be acknowledged that this fact probably causes a slight over-estimation of the costs. However, including only the costs directly related to the diagnoses was not regarded to be feasible, since many symptoms are indirect consequences of the diagnoses that would then be excluded. Therefore, including only directly related costs would mean a marked under-estimation of the costs.
Data regarding sick-leave periods shorter than 15 days are not registered and are hence not included in the present analysis. Since short-term sick-leave data are unknown, this could mean that the indirect costs are under-estimated.
Not including costs related to an individual due to pain and suffering, or to family members for caring for the individual, or home care services could mean that the total societal costs for these patients are under-estimated.