Uso de recursos y costos de hospitalizaciones por insufi ciencia card í aca: un estudio retrospective multic é ntrico en Argentina

Cost-effectiveness in unstable economies: the case of sacubitril/valsartan in heart failure with reduced ejection fraction in Argentina

BACKGROUND

Sacubitril/valsartan (an Angiotensin receptor-neprilysin inhibitor-ARNI) is one of the cornerstones in the management of patients with heart failure with reduced ejection fraction (HFrEF) having demonstrated significant reductions in both mortality and hospitalisations as compared with enalapril. It proved to be a cost-effective treatment in many countries with stable economies. In Argentina, a country with chronic financial instability and a fragmented health care system, the estimation of its cost-effectiveness requires to consider local financial data.

OBJECTIVES

To estimate the cost-effectiveness of sacubitril/valsartan in HFrEF in Argentina.

METHODS

We populated an Excel-based cost-effectiveness model, previously validated, using inputs from the pivotal phase-3 PARADIGM-HF trial and from local sources. As the main problem to consider was the financial instability, we adopted a differential approach to cost discounting based on the opportunity cost of capital. Thus, a discount rate for costs were set at 31.6%, using the BADLAR rate published by the Central Bank of Argentina. Discount for effects were set at 5% as is the current practice. Costs were expressed in Argentinian pesos (ARS). We used the perspective for both the social security and private payers at a 30-year horizon. The primary analysis was the incremental cost-effectiveness ratio (ICER) versus enalapril, the previous standard of care. Alternative scenarios performed included a 5% cost discount rate and 3 a 5-year horizon (as is usually used).

RESULTS

In Argentina the cost-per quality adjusted life-year (QALY) gained for sacubitril/valsartan versus enalapril was 391,158 ARS and 376,665 ARS for a social security and a private payer, respectively, at a 30- year horizon. These ICERs were under the cost- effectiveness threshold of 520,405.79 ARS (1 Gross domestic product (GDP) per capita) suggested by Argentinian health technology assessment bodies. Probabilistic sensitivity analysis showed an acceptability of sacubitril/valsartan as a cost-effective alternative of 86.40% and 88.25% for social security and private payers, respectively.

CONCLUSION

Sacubitril/valsartan is a cost-effective treatment in HFrEF using local inputs that considered the financial instability. For both payers considered the cost per QALY gained are under the cost-effectiveness threshold considered.

Improving the monitoring of chronic heart failure in Argentina: is the implantable pulmonary artery pressure with CardioMEMS Heart Failure System cost-effective?

Background

The CardioMEMS® sensor is a wireless pulmonary artery pressure device used for monitoring symptomatic heart failure (HF). The use of CardioMEMS was associated with a reduction of hospitalizations of HF patients, but the acquisition cost could be high in low-and-middle income countries. Evidence of cost-effectiveness is needed to help decision-makers to allocate resources according to “value for money”. This study is aimed at estimating the cost-effectiveness of CardioMEMS used in HF patients from the third-party payer perspective -Social Security (SS) and Private Sector (PS)- in Argentina.

Methods

A Markov model was developed to estimate the cost-effectiveness of CardioMEMS versus usual medical care over a lifetime horizon. The model was applied to a hypothetical population of patients with HF functional class III with at least one hospitalization in the previous 12 months. The main outcome was the incremental cost-effectiveness ratio (ICER). To populate the model we retrieved clinical, epidemiological and utility parameters from the literature, whilst direct medical costs were estimated through a micro-costing approach (exchange rate USD 1 = ARS 76.95). Uncertainties in all parameters were assessed by deterministic, probabilistic and scenario sensitivity analysis.

Results

Compared with the usual medical care, CardioMEMS increased quality-adjusted life years (QALY) by 0.37 and increased costs per patient by ARS 1,081,703 for SS and ARS 919,051 for PS. The resultant ICER was ARS 2,937,756 per QALY and ARS 2,496,015 per QALY for SS and PS, respectively. ICER was most sensitive to the hazard ratio of HF hospital admission and the acquisition price of CardioMEMS. The probability that CardioMEMS is cost-effective at one (ARS 700,473), three (ARS 2,101,419,) and five (ARS 3,502,363) Gross Domestic Product per capita is 0.6, 17.9 and 64.1% for SS and 5.4, 33.3 and 73.2% for PS.

Conclusions

CardioMEMS was more effective and more costly than usual care in class III HF patients. Since in Argentina there is no current explicit threshold, the final decision to determine its cost-effectiveness will depend on the willingness-to-pay for QALYs in each health subsector.