Cost-Effectiveness of N-Terminal Pro-B-Type Natriuretic-Guided Therapy in Elderly Heart Failure Patients: Results From TIME-CHF (Trial of Intensified versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure)

Study Questions:

How cost-effective is N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided versus symptom-guided therapy in heart failure (HF) patients ≥60 years old?

Methods:

This was a cost-effectiveness analysis of TIME-CHF, a randomized, multicenter trial in which intensified NT-proBNP-guided therapy was compared to standard, symptom-guided therapy in patients ages ≥60 years with New York Heart Association functional class >II HF and left ventricular ejection fraction (LVEF) of ≤45%. The primary outcome measure was incremental costs per life-year gained; the secondary outcome measure was incremental costs per quality-adjusted life-year (QALY) gained.

Results:

A net mean cost reduction of $2,979 USD (2.5%-97.5% confidence interval [CI], $8,758-$3,265; p = 0.24) was achieved with NT-proBNP-guided therapy, compared with symptom-guided therapy, mainly driven by a net savings in residence/nursing home costs (2.5%-97.5% CI: -$7,587 to $208; p = 0.09). The incremental effectiveness of NT-proBNP-guided therapy on life-years was of borderline statistical significance (+0.07; range, 0.00-0.14; p = 0.05). The effect in terms of QALYs was nonsignificant (+0.05; range, -0.02 to 0.11; p = 0.35). The probability of saving 1 life-year or QALY at a cost of $50,000 was 97% and 93%, respectively. Cost-effectiveness was most pronounced in younger patients (<75 years old) and in those with <2 significant comorbidities.

Conclusions:

Compared to symptom-guided therapy in HF patients with a reduced LVEF, NT-proBNP-guided therapy has a high probability of being cost-effective at a threshold of $50,000/life-year gained, particularly in those ages 60-75 years or with <2 comorbidities.

Perspective:

By showing economic benefits to NT-proBNP-guided therapy, the current cost-effectiveness analysis may encourage the use of such therapy in HF patients with reduced LVEF, particularly in relatively younger patients with limited comorbidities. It should be noted that the incremental effectiveness of biomarker-guided therapy was of marginal significance in terms of life-years saved, and of no statistical significance in terms of effect on QALYs. The net cost reduction associated with NT-proBNP-guided therapy was largely driven by a reduction in residence/nursing home costs. It is uncertain why biomarker-guided therapy would reduce such residence costs; it is noteworthy that there was a statistically insignificant difference between baseline residency between treatment groups.

Clinical Topics: Anticoagulation Management, Heart Failure and Cardiomyopathies, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Outcome Assessment (Health Care), Cost-Benefit Analysis, Nursing Homes, Diuretics, Standard of Care, Comorbidity, New York, Natriuretic Peptides, Biological Markers, Flavins, Cardiology, Heart Failure, Peptide Fragments, Stroke Volume, Confidence Intervals


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