Heart failure affects nearly 5 million Americans and is the leading cause of hospitalization in people over 65. It also is the most expensive cardiovascular illness, costing the nation an estimated $20 billion in 1998.
This money is well spent, say Michael W. Rich, M.D., and Robert F. Nease Jr., Ph.D., both of Washington University School of Medicine in St. Louis. After analyzing the literature, they reported in Archives of Internal Medicine that judicious use of medications and other therapies is the most cost-effective approach to caring for patients with heart failure - people whose hearts pump too little blood. Moreover, certain treatments even save health-care dollars.
"Estimating cost-effectiveness is a unique way to gain insights into the costs and benefits associated with particular medical treatments," Rich says. "Therefore it is a useful guide for medical decision making." Rich is an associate professor of medicine at Washington University School of Medicine in St. Louis and heads the Cardiac Rapid Evaluation Unit at Barnes-Jewish Hospital. Nease, a medical decision analyst, also is an associate professor of medicine at the School of Medicine.
Cost-effectiveness
Many new therapies for heart failure have become available during the past two decades. Therefore, Rich and Nease reviewed cost-effectiveness studies on ACE inhibitors, vasodilators, digoxin and beta-blockers. They also reviewed other types of intervention such as interdisciplinary teams. Most of the studies included only direct costs, such as those associated with medications, diagnostic tests and hospitalization. And the analyses estimated the financial cost of a health benefit rather than identifying the greatest benefit at the lowest cost. A commonly used benchmark is renal dialysis, which is estimated to cost about $40,000 per year of life gained.
"Any new treatment that reduces costs without decreasing effectiveness obviously is cost-effective," Nease says. "But if a new treatment is less costly but less effective or more effective but more costly, cost-effectiveness analysis can evaluate its merit relative to other treatments."
ACE inhibitors improve outcomes for heart failure patients, but are they cost-effective compared with the traditional therapy for heart failure - digoxin plus diuretics? One study reported a 28 percent decline in mortality and a cost of $9,700 per year of life saved with the ACE inhibitor enalapril. A second enalapril study reported a 16 percent decline in mortality, a reduction in hospital admissions and an estimated increase in survival time of nearly two months. Cost estimates ranged from a saving of about $200 per patient or, in the worst-case scenario, a cost of $21,735 per year of life saved.
In a different study, the ACE inhibitor captopril reduced the progression of heart failure by 59 percent, and total costs were almost identical with those incurred using a placebo. In another study, captopril reduced mortality by 19 percent, hospital admissions by 22 percent and heart attacks by 25 percent. Costs ranged from $3,700 to $60,800 per quality-adjusted life year, a measure that accounts for quality of life as well as survival.
Yet another study focused on a combination of hydralazine hydrochloride, a vasodilator, and isosorbide dinitrate, a nitroglycerin preparation. This therapy reduced mortality by 34 percent, and the estimated cost was $5,600 per year of life saved. Digoxin therapy itself saved $338 per patient compared with discontinuing therapy. Two studies showed a 50 percent and 77 percent reduction in the progression of heart failure, and cost-savings were seen regardless of whether patients also were taking an ACE inhibitor.
Three large trials with the beta blocker carvedilol reported a 65 percent reduction in mortality and a 27 percent reduction in cardiovascular-related hospital admissions. Cost-effectiveness ranged from $12,800 to $29,500 per year of life saved.
Several groups have studied the cost-effectiveness of other types of interventions. Rich and colleagues examined the effect of adding a nurse-supervised interdisciplinary team to conventional care. Although operating costs were higher, fewer patients were readmitted to the hospital, resulting in a net cost saving of $460 per patient. Two studies have assessed efforts to increase compliance with drug therapy. In one, home visits by a nurse in a physician-directed program reduced hospital admissions by 74 percent and emergency room visits by 53 percent. In another, hospital admissions were reduced by 35 percent and the projected average saving was $9,800 per patient in six months. "Our analysis suggests that ACE inhibitors, other vasodilators, digoxin, beta blockers and multidisciplinary teams all are cost-effective for managing heart failure," Rich says. "But the most cost-effective option may be a combination of interdisciplinary nonpharmacological measures and maximum medical therapy."
Note: For more information, refer to Rich MW, Nease RF, "Cost-effectiveness Analysis in Clinical Practice. The Case of Heart Failure," Archives of Internal Medicine, 159, pp.1690-1700, Aug. 9/23 1999.
Journal
Archives of Internal Medicine