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Economic Evaluation of Sacubitril/Valsartan for HF
Quick Takes
- Across a broad population of patients with chronic HF, sacubitril/valsartan provides high economic value in patients with EF ≤50%, and intermediate economic value in patients with EF ≤60%.
- Among a narrower range of patients with EF of 45-60%, sacubitril/valsartan provides intermediate economic value.
- The cost-effectiveness of sacubitril/valsartan is improved when the drug cost is reduced.
Study Questions:
What is the cost-effectiveness of sacubitril/valsartan compared with renin-angiotensin system (RAS) inhibitors across the range of ejection fractions (EFs) in patients with heart failure (HF)?
Methods:
The investigators created a statistical model to estimate the cost-effectiveness of sacubitril/valsartan versus RAS inhibitors using pooled data from the PARADIGM-HF and PARAGON-HF randomized clinical trials. Using event rates and hazard ratios from those studies, risk estimates for mortality and hospitalization were determined across the spectrum of EF up to 60%, and applied to the US population distribution of EFs in HF patients. For the base case scenario, investigators predicted the lifetime HF-related health care costs and quality-adjusted life-years (QALYs) with sacubitril/valsartan versus enalapril or valsartan. The incremental cost-effectiveness ratio (ICER) was the primary endpoint. In addition, several sensitivity analyses were performed varying the cost of sacubitril/valsartan, the cost of hospitalization, and utility gains related to quality of life. Various willingness-to-pay thresholds were applied. Confidence intervals were calculated using a probabilistic sensitivity analysis. In addition, cost-effectiveness was evaluated across various upper-level EF cutoffs.
Results:
For the base case scenario, treatment with sacubitril/valsartan was projected to produce 7.67 QALYs at a lifetime cost of $143,317 compared with 7.14 QALYs at a lifetime cost of $102,425 for RAS inhibitors. The net benefit of sacubitril/valsartan versus RAS inhibitor was 0.53 QALYs at an incremental lifetime cost of $40,892, and the ICER was $76,852 per QALY gained. Sensitivity analyses demonstrated that the cost of sacubitril/valsartan was the strongest driver of cost-effectiveness. With a cost at or below $338 annually, sacubitril/valsartan would be cost-saving. At a cost of $3,673 annually, sacubitril/valsartan met the threshold of high economic value (ICER <$60,000). At a cost of $10,242 annually, sacubitril/valsartan would be of at least intermediate economic value (ICER < $180,000).
Among patients with EF ≤45%, the ICER was $56,786 per QALY gained; with EF ≤50%, it was $59,614, and with EF ≤55%, ICER was $67,331. ICER was $84,291 among patients with EF 45-50%, $100,388 for those with EF 45-55%, and $127,172 for those with EF 45-60%.
Conclusions:
Sacubitril/valsartan provides high economic value (defined as ICER <$60,000 per QALY) for the patients with HF and EF ≤50%, intermediate economic value (defined as ICER <$180,000) for patients with HF and EF ≤60%, and intermediate economic value for patients with HF and EF in the range of 45-60%. At its current cost (using an undiscounted wholesale acquisition cost of $7,091 per year), sacubitril/valsartan provides at least intermediate value across a broad population of patients with HF and EF ≤60%.
Perspective:
A previous study found that sacubitril/valsartan has high economic value in patients with HF and EF ≤40% (JAMA Cardiol 2016;1:666-72). The current study evaluates the cost-effectiveness of sacubitril/valsartan in patients with EF ≤60%, and finds high economic value in patients with EF ≤50% and intermediate economic value with EF ≤60%.
Clinical Topics: Heart Failure and Cardiomyopathies
Keywords: Economics, Pharmaceutical, Renin-Angiotensin System, Valsartan
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