title: Incremental cost-effectiveness of guideline-directed medical therapies for heart failure.
abstract: OBJECTIVE
  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.
authors: Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA 90095, USA.
authors: Gaurav
authors: G
authors: Banka
authors: Paul A
authors: PA
authors: Heidenreich
authors: Gregg C
authors: GC
authors: Fonarow
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000191:economics / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000191:economics / Q000627:therapeutic use*; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination; D006333:Heart Failure / Q000188:drug therapy* / Q000191:economics*; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008390:Markov Chains; D000451:Mineralocorticoid Receptor Antagonists / Q000191:economics / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D019057:Quality-Adjusted Life Years
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000451:Mineralocorticoid Receptor Antagonists