Cost-Effectiveness of Sacubitril-Valsartan in Heart Failure

Study Questions:

What is the cost-effectiveness and cost per quality-adjusted life-year (QALY) gained of sacubitril-valsartan relative to enalapril in systolic heart failure (HF)?


The investigators used a Markov model to determine cost-effectiveness for sacubitril-valsartan and enalapril for the treatment of systolic HF. In sensitivity analysis, medication costs were derived from National Average Drug Acquisition Cost data available from the Centers for Medicare and Medicaid Services. The patients were modeled over a lifetime (40 years) from a third-party payer perspective given that patients were 60 years of age at model entry. They derived clinical probabilities from the PARADIGM-HF (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial. They discounted all costs and effects at a 3% annual rate and are presented in 2015 U.S. dollars. The investigators used one-way, two-way, and probabilistic sensitivity analyses to determine the impact of model parameter uncertainty and variability on model outcomes.


The investigators found that cost-effectiveness of sacubitril-valsartan was highly dependent on duration of therapy, ranging from $249,411 per QALY at 3 years to $50,959 per QALY gained over a lifetime. In the base case, sacubitril-valsartan, compared with enalapril, was more costly ($60,391 vs. $21,758) and more effective (6.49 vs. 5.74 QALYs) over a lifetime. The benefits of increased quantity and quality of life may be cost-effective depending on willingness-to-pay threshold (which currently in the United States is considered to be approximately $50,000 per QALY). Average medication and HF hospitalization costs for patients in the sacubitril-valsartan and enalapril groups were $60,391 and $21,758, respectively. At the current price, the use of sacubitril-valsartan to reduce HF hospitalizations is unlikely to be cost saving.


The investigators concluded that sacubitril-valsartan therapy may be a cost-effective option depending on the willingness-to-pay threshold.


Despite the survival advantage of sacubitril-valsartan, adoption of this new combination has been slower than anticipated probably because of cost. As the authors point out, wholesale acquisition cost of sacubitril-valsartan is about $12.50 per day, whereas angiotensin-converting enzyme inhibitors, including enalapril, appear on $4 per 30-day ($0.13 per day) or $10 per 90-day ($0.11 per day) retail prescription drug lists. Currently, health care providers are focusing on maximizing dosing of more established neurohormonal blocking agents rather than adopting more expensive newer therapies such as sacubitril-valsartan because costs can make adhering to therapy more challenging for the patient.

Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Acute Heart Failure, Chronic Heart Failure

Keywords: Angiotensin-Converting Enzyme Inhibitors, Combined Modality Therapy, Cost-Benefit Analysis, Cost Savings, Enalapril, Geriatrics, Heart Failure, Heart Failure, Systolic, Quality-Adjusted Life Years, Quality of Life

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