Treating heart failure with angiotensin-converting enzyme (ACE) inhibitors, beta-blockers and aldosterone antagonists provided the largest gains in quality-adjusted life years compared with treatments that did not include all three agents. Treatment according to guidelines resulted in an incremental cost-effectiveness ratio of less than $1,500 per quality-adjusted life year, based on a study that aimed to quantify the incremental cost-effectiveness of various heart failure therapies.
Heart failure accounts for more than 1 million hospital admissions per year and the costs of heart failure are estimated at $39.2 billion per year (Circulation 2010;121:e46-e210). ACE inhibitors, beta blockers and aldosterone antagonists have become the guideline-directed treatments of choice for heart failure, and the use of these drug therapies has significantly reduced morbidity and mortality.
Many of these treatments are now available in generic formulations. Gaurav Banka, MD, of Ahmanson-UCLA Cardiomyopathy Center in Los Angeles, and colleagues designed a study to determine the cost-effectiveness of guideline-directed medical treatment of heart failure compared to treatment with diuretics alone and to treatment with some, but not all, of the guideline-directed treatments.
The researchers created a Markov model of hypothetical patients in the U.S. with New York Heart Association class II or class III heart failure with reduced ejection fraction who were treated with ACE inhibitors, beta blockers and aldosterone antagonists. The model simulated costs, quality-adjusted life years and the incremental cost-effectiveness of treatment.
Patients in the Study of Left Ventricular Dysfunction (SOLVD), a cohort of heart failure patients with ejection fractions of 35 percent of less who received oral loop diuretics, were used as the base population in Banka et al’s study. The researchers compared this group of patients to patients receiving:
- ACE inhibitors only;
- ACE inhibitors plus beta blockers; and
- ACE inhibitors, beta blockers and aldosterone antagonists in accord with guidelines.
They calculated rates of hospitalization for each group, and costs (which included heart failure-related hospitalization, medications and medication monitoring, and ambulatory care). To determine mortality for the diuretic only and ACE inhibitor only groups, the researchers used data from the SOLVD trial. They used data from the MERIT-HF study to calculate mortality for the ACE inhibitor plus beta blockers group, and data from EMPHASIS-HF trial to determine mortality among the ACE inhibitor plus beta-blockers plus aldosterone antagonists group.
The researchers found that patients receiving only diuretics had higher costs and lower quality of life years than patients receiving medical therapies. Patients in the diuretic-only cohort had costs of $12,742; cost savings were $444 in the ACE inhibitor cohort and $33 in the cohort that received ACE inhibitors plus beta-blockers. Patients receiving ACE inhibitors plus beta blockers plus aldosterone antagonists had additional costs of $47, but when the reduction in mortality and hospitalization was extended over five years, there was a cost savings of $356. When extended to 15 years, patients receiving the three guideline-directed treatments realized no “cost savings but [the treatment] was highly cost effective with an incremental cost-effectiveness ratio of $623 per life year ($799 per quality-of-life year),” they wrote.
The researchers noted that dialysis for patients with chronic renal failure has an estimated cost-effectiveness of $50,000 per quality of life year, and opined that this “implies a societal judgment that treatments with a lower cost/quality of life year ratio are cost effective and should be provided.”
They suggested that their findings support investment in systems to ensure that heart failure patients receive guideline-directed medical therapies and assistance in adhering to their prescribed regimen. “Our study suggests that $3,000 to $14,000 per patient could be spent to ensure adherence to these therapies and still maintain an attractive incremental cost-effectiveness ratio of $25,000 per life-year gained,” they concluded.
Banka et al acknowledged the limitation associated with the modeling process and its assumptions. They specifically noted that they assumed mortality and hospitalization rates would be identical to those observed in clinical trials, that they were unable to model end-of-life