Clinical Research
Heart Failure
Incremental Cost-Effectiveness of Guideline-Directed Medical Therapies for Heart Failure

https://doi.org/10.1016/j.jacc.2012.12.022Get rights and content
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Objectives

This study sought to quantify the incremental cost-effectiveness ratios (ICER) of angiotensin-converting enzyme inhibitor (ACEI), beta-blocker (BB), and aldosterone antagonist (AldA) therapies for patients with heart failure with reduced ejection fraction (HFrEF).

Background

There are evidence-based, guideline-directed medical therapies for patients with HFrEF, but the incremental cost-effectiveness of these therapies has not been well studied using contemporary data.

Methods

A Markov model with lifetime horizon and two states, dead or alive, was created. We compared HFrEF patients treated with diuretic agents alone to three treatment arms: 1) ACEI therapy alone; 2) ACEI+BB; and 3) ACEI+BB+AldA. Sequential therapy was also analyzed. HF hospitalizations and mortality rates were based on representative studies. Costs of medications and inpatient and outpatient care were accounted for.

Results

Treatment with ACEI and ACEI+BB strictly dominated treatment with diuretics only (cost-saving). The greatest gains in quality-adjusted life-years occurred when all 3 guideline-directed medications were provided. The incremental cost-effectiveness ratio (ICER) of ACEI+BB+AldA versus ACEI+BB and ACEI+BB versus ACEI was <$1,500 per quality-adjusted life-year. The cost-savings in the ACEI and ACEI+BB cohorts compared to that with diuretics alone were $444 and $33, respectively. Assuming lower treatment costs and lower hospitalization rates in the ACEI+BB+AldA arm resulted in greater cost-savings. Even in the most unfavorable situations, the ICER was <$10,000 per life-year gained.

Conclusions

Our analysis demonstrates that medical treatment of HFrEF is highly cost-effective and may even result in cost-savings. Greater efforts to ensure optimal adherence to guideline-directed medical therapy for HFrEF are warranted.

Key Words

cost-effectiveness
heart failure
medications

Abbreviations and Acronyms

ACEI
angiotensin-converting enzyme inhibitor
AldA
aldosterone antagonists
BB
beta-blocker
HF
heart failure
HFrEF
heart failure with reduced ejection fraction
ICER
incremental cost-effectiveness ratio
QALY
quality-adjusted life-year

Cited by (0)

Dr. Fonarow holds the Eliot Corday Chair in Cardiovascular Medicine and Science and is supported by the Ahmanson Foundation; has research funding from the Agency for Healthcare Research and Quality (AHRQ); and is a consultant with Medtronic, Novartis, and Gambro. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.