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Cost-Effectiveness of Medical Therapy for Heart Failure With Mildly Reduced and Preserved Ejection Fraction
Neal M Dixit1, Katie P Truong2, Muthiah Vaduganathan3
1Division of Cardiovascular Medicine, Department of Medicine, University of California, Davis, Sacramento, California, USA.
Insights
Mineralocorticoid receptor antagonists (MRA) offer high value for heart failure patients. Increased use of MRA and sodium glucose co-transporter 2 inhibitors (SGLT2i) is recommended, alongside efforts to reduce SGLT2i and ARNI costs.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Pharmacoeconomics
Background:
- Guideline-recommended treatments for heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) include three medication classes.
- The cost-effectiveness of combining these agents for HFmrEF/HFpEF remains to be established.
Purpose of the Study:
- To determine the cost-effectiveness of mineralocorticoid receptor antagonists (MRA), angiotensin receptor-neprilysin inhibitors (ARNIs), and sodium glucose co-transporter 2 inhibitors (SGLT2is) in patients with HFmrEF/HFpEF.
- To evaluate the cost-effectiveness of single-drug, two-drug, and three-drug combinations of these therapies.
Main Methods:
- A 3-state Markov model was utilized to simulate cohorts of 1,000 patients with HFmrEF and HFpEF.
- Cost-effectiveness was assessed from a United States health care sector perspective over a 30-year time horizon.
- Incremental cost-effectiveness ratios (ICERs) were calculated in 2023 United States dollars.
Main Results:
- MRA monotherapy increased life years by 1.04 (HFmrEF) and 0.99 (HFpEF) versus placebo, with an ICER of $10,000/QALY.
- Combination therapy with MRA+SGLT2i yielded higher life year gains (1.58 HFmrEF, 1.54 HFpEF) but with ICERs of $113,000/QALY (HFmrEF) and $141,000/QALY (HFpEF).
- Adding ARNI therapy resulted in ICERs >$250,000/QALY; however, generic pricing for SGLT2i and ARNI reduced ICERs to <$10,000/QALY.
Conclusions:
- Mineralocorticoid receptor antagonists (MRA) represent high value, SGLT2 inhibitors (SGLT2i) intermediate value, and ARNIs low value for HFmrEF/HFpEF patients.
- Increased utilization of MRA and SGLT2i therapies is recommended for HFmrEF/HFpEF.
- Reducing the costs of SGLT2i and ARNI therapies is crucial to improve cost-effectiveness.
Background:
Three medications are now guideline-recommended treatments for heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF), however, the cost-effectiveness of these agents in combination has yet to be established.
Objectives:
The purpose of this study was to determine the cost-effectiveness of mineralocorticoid receptor antagonists (MRA), angiotensin receptor-neprilysin inhibitors (ARNIs), and sodium glucose co-transporter 2 inhibitors (SGLT2is) in individuals with HFmrEF/HFpEF.
Methods:
Using a 3-state Markov model, we performed a cost-effectiveness study using simulated cohorts of 1,000 patients with HFmrEF and HFpEF. Treatment with 1-, 2-, and 3-drug combinations was modeled. Based on a United States health care sector perspective, outcome data was used to calculate incremental cost-effectiveness ratios (ICERs) in 2023 United States dollars based on a 30-year time horizon.
Results:
Treatment with MRA, MRA+SGLT2i, and MRA+SGLT2i+ARNI therapy resulted in an increase in life years of 1.04, 1.58, and 1.80 in the HFmrEF subgroup, respectively, and 0.99, 1.54, and 1.77 in the HFpEF subgroup, respectively, compared with placebo. At a yearly cost of $18, MRA therapy resulted in ICERs of $10,000 per quality-adjusted life year (QALY) in both subgroups. The ICER for the addition of SGLT2i therapy ($4,962 per year) was $113,000 per QALY in the HFmrEF subgroup and $141,000 in the HFpEF subgroup. The addition of ARNI therapy ($5,504 per year) resulted in ICERs >$250,000 per QALY in both subgroups. If SGLT2i and ARNI were available at generic pricing the ICERs become <$10,000 per QALY in both EF subgroups. Outcomes were highly sensitive to assumed benefit in cardiovascular death.
Conclusions:
For patients with heart failure, MRA was of high value, SGLT2i was of intermediate value, and ARNI was of low value in both HFmrEF and HFpEF subgroups. For patients with HFmrEF/HFpEF increased use of MRA and SGLT2i therapies should be encouraged and be accompanied with efforts to lower the cost of SGLT2i and ARNI therapies.
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