title: Model-based cost-effectiveness analysis of B-type natriuretic peptide-guided care in patients with heart failure.
abstract: Monitoring B-type natriuretic peptide (BNP) to guide pharmacotherapy might improve survival in patients with heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). However, the cost-effectiveness of BNP-guided care is uncertain and guidelines do not uniformly recommend it. We assessed the cost-effectiveness of BNP-guided care in patient subgroups defined by age and ejection fraction.
  
  
  
  We used a Markov model with a 3-month cycle length to estimate the lifetime health service costs, quality-adjusted life years (QALYs) and incremental net monetary benefits (iNMBs) of BNP-guided versus clinically guided care in 3 patient subgroups: (1) HFrEF patients <75 years; (2) HFpEF patients <75 years; and (3) HFrEF patients ≥75 years. There is no evidence of benefit in patients with HFpEF aged ≥75 years. We used individual patient data meta-analyses and linked primary care, hospital and mortality data to inform the key model parameters. We performed probabilistic analysis to assess the uncertainty in model results.
  
  
  
  In younger patients (<75 years) with HFrEF, the mean QALYs (5.57 vs 5.02) and costs (£63 527 vs £58 139) were higher with BNP-guided care. At the willingness-to-pay threshold of £20 000 per QALY, the positive iNMB (£5424 (95% CI £987 to £9469)) indicates that BNP-guided care is cost-effective in this subgroup. The evidence of cost-effectiveness of BNP-guided care is less strong for younger patients with HFpEF (£3155 (-£10 307 to £11 613)) and older patients (≥75 years) with HFrEF (£2267 (-£1524 to £6074)). BNP-guided care remained cost-effective in the sensitivity analyses, albeit the results were sensitive to assumptions on its sustained effect.
  
  
  
  We found strong evidence that BNP-guided care is a cost-effective alternative to clinically guided care in younger patients with HFrEF. It is potentially cost-effective in younger patients with HFpEF and older patients with HFrEF, but more evidence is required, particularly with respect to the frequency, duration and BNP target for monitoring. Cost-effectiveness results from trials in specialist settings cannot be generalised to primary care.
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Syed
authors.initials: S
authors.lastname: Mohiuddin
authors.affiliation: School of Clinical Sciences, University of Bristol, Bristol, UK.
authors.forename: Barnaby
authors.initials: B
authors.lastname: Reeves
authors.affiliation: School of Clinical Sciences, University of Bristol, Bristol, UK.
authors.forename: Maria
authors.initials: M
authors.lastname: Pufulete
authors.affiliation: School of Clinical Sciences, University of Bristol, Bristol, UK.
authors.forename: Rachel
authors.initials: R
authors.lastname: Maishman
authors.affiliation: NHS Practice, Taunton and Somerset NHS Trust, Somerset, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Dayer
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: John
authors.initials: J
authors.lastname: Macleod
authors.affiliation: Faculty of Life Sciences and Medicine, King's College London, London, UK.
authors.forename: Theresa
authors.initials: T
authors.lastname: McDonagh
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Purdy
authors.affiliation: School of Clinical Sciences, University of Bristol, Bristol, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Rogers
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: William
authors.initials: W
authors.lastname: Hollingworth
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006333:Heart Failure / Q000188:drug therapy* / Q000191:economics / Q000378:metabolism / Q000503:physiopathology; D006760:Hospitalization; D006801:Humans; D008297:Male; D008390:Markov Chains; D020097:Natriuretic Peptide, Brain / Q000378:metabolism*; D005791:Patient Care / Q000191:economics / Q000379:methods*; D011320:Primary Health Care; D019057:Quality-Adjusted Life Years; D013318:Stroke Volume
chemical_list: D002317:Cardiovascular Agents; D020097:Natriuretic Peptide, Brain
keywords: B-type natriuretic peptide; Cost-effectiveness; Markov model; Survival analysis