Intensive medication optimization cost-effective in patients hospitalized with HFrEF
Key takeaways:
- An intensive medication optimization program for patients hospitalized with HF with reduced ejection fraction would be cost-effective.
- A quadruple-therapy program would have the most clinical benefit.
PHILADELPHIA — An intensive medication optimization program for patients hospitalized with HF with reduced ejection fraction would be cost-effective, researchers reported at the American Heart Association Scientific Sessions.
U.S. and European guidelines recommend initiating four classes of drugs for most patients hospitalized for HFrEF: a renin-angiotensin blocker (ACE inhibitor, angiotensin receptor blocker or angiotensin receptor/neprilysin inhibitor [ARNI]), a beta-blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor. As Healio previously reported, the STRONG-HF trial confirmed the clinical benefits of such a strategy, as those assigned to an intensive guideline-directed medical therapy (GDMT) optimization strategy had reduced risk for death or HF hospitalization at 180 days compared with those assigned the usual care.
At the AHA Scientific Sessions, researchers presented an analysis of whether a program such as that featured in STRONG-HF would be cost-effective. The findings were simultaneously published in Circulation: Heart Failure.
“Patients hospitalized with heart failure with reduced ejection fraction have extremely high risk of rehospitalization and mortality. Despite decades of evidence that timely initiation and titration of guideline-directed medical therapy can markedly reduce this risk, pervasive clinical inertia has resulted in gaps, variations and disparities in the use and dosing of GDMT,” Gregg C. Fonarow, MD, FACC, FAHA, FHFSA, Eliot Corday Professor of Cardiovascular Medicine and Science, interim chief of the UCLA division of cardiology, director of the Ahmanson-UCLA Cardiomyopathy Center and co-director of the UCLA Preventive Cardiology Program at the David Geffen School of Medicine at UCLA, told Healio. “The STRONG-HF trial demonstrated the efficacy and safety of rapid GDMT initiation and titration starting during hospitalization and then continuing with a structured outpatient titration of GDMT. Despite the benefits shown in this trial, questions have arisen regarding the feasibility, costs, cost-effectiveness and value of an intensive GDMT titration program. This study was designed to evaluate these important questions from the U.S. health care sector perspective.”
The researchers created two population models to evaluate the cost-effectiveness of an intensive GDMT optimization program, a clinical trial model, based on the STRONG-HF cohort, and a real-world model, based off the Get With The Guidelines-HF Registry of patients admitted with worsening HF. They then modeled in those populations the effect of a triple-therapy optimization program such as that used in STRONG-HF, including an ACE inhibitor or angiotensin receptor blocker instead of an ARNI and not including an SGLT2 inhibitor, and of a quadruple-therapy program such as that recommended in the guidelines, including the ARNI sacubitril/valsartan (Entresto, Novartis) and an SGLT2 inhibitor. Most patients from STRONG-HF were not prescribed SGLT2 inhibitors because evidence for their benefit in HFrEF was not well documented when the trial began.
Mean survival in the clinical trial model was 7.64 years for the usual care, 8.91 years for triple therapy and 10.04 years for quadruple therapy, whereas mean survival in the real-world model was 3.04 years for the usual care, 3.61 years for triple therapy and 4.12 years for quadruple therapy, Fonarow and colleagues found.
The incremental cost-effectiveness ratio (ICER) for triple therapy was $8,000 per quality-adjusted life-year in the clinical trial model and $7,000 per QALY in the real-world model, according to the researchers.
The ICER for quadruple therapy was $60,000 per QALY in the clinical trial model and $54,000 per QALY in the real-world model, and ICERs were higher for the quadruple therapy strategy because of the additional costs of sacubitril/valsartan and SGLT2 inhibitors, the researchers found.
“If ARNI and SGLT2 inhibitor therapy were available at generic pricing in 3 years, the ICERs in the [quadruple-therapy] cohorts decrease to $24,000 and $33,000 in the clinical trial and real-world models, respectively,” the researchers wrote in the simultaneous publication. “If they were available at generic pricing now, then the ICERs drop to $7,000 in both models.”
“This study demonstrates that an intensive GDMT optimization program targeting patients hospitalized with HFrEF would result in substantial gains in clinical outcomes, be extremely cost-effective and provide very high value,” Fonarow told Healio. “These findings were robust across a range of modeling assumptions. The greatest gains in clinical outcomes would occur with the use of optimal quadruple GDMT (ARNI plus beta-blocker plus [mineralocorticoid receptor antagonist] plus SGLT2 inhibitor). The implications of these findings are that clinicians, health systems, payers and policymakers should prioritize implementation of programs to achieve in-hospital and early post-discharge intensive optimization of comprehensive GDMT in all eligible patients hospitalized with HFrEF. If intensive GDMT optimization programs were successfully deployed throughout the U.S. for HFrEF, hundreds of thousands of rehospitalizations and premature cardiovascular deaths could be prevented each year compared to the current usual care being provided in the U.S.”
Reference:
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Dixit NM, et al. Abstract MDP170. Presented at: American Heart Association Scientific Sessions; Nov. 11-13, 2023; Philadelphia.