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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 593] [Impact Index Per Article: 296.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary. J Am Coll Cardiol 2022; 79:1757-1780. [DOI: 10.1016/j.jacc.2021.12.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 674] [Impact Index Per Article: 337.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e876-e894. [PMID: 35363500 DOI: 10.1161/cir.0000000000001062] [Citation(s) in RCA: 126] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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Heidenreich PAULA, BOZKURT BIYKEM, AGUILAR DAVID, ALLEN LARRYA, BYUN JONIJ, COLVIN MONICAM, DESWAL ANITA, DRAZNER MARKH, DUNLAY SHANNONM, EVERS LINDAR, FANG JAMESC, FEDSON SAVITRIE, FONAROW GREGGC, HAYEK SALIMS, HERNANDEZ ADRIANF, KHAZANIE PRATEETI, KITTLESON MICHELLEM, LEE CHRISTOPHERS, LINK MARKS, MILANO CARMELOA, NNACHETA LORRAINEC, SANDHU ALEXANDERT, STEVENSON LYNNEWARNER, VARDENY ORLY, VEST AMANDAR, YANCY CLYDEW. 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America Guideline for the Management of Heart Failure: Executive Summary. J Card Fail 2022; 28:810-830. [DOI: 10.1016/j.cardfail.2022.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GFM, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Marinella Ruospo
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Patrizia Natale
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Robert R Quinn
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Paul E Ronksley
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical CenterDepartment of Medicine3459 Fifth AvenuePittsburghPAUSA15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of OtagoDepartment of Medicine, NephrologistChristchurchNew Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Pietro Ravani
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
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Di Tanna GL, Bychenkova A, O'Neill F, Wirtz HS, Miller P, Ó Hartaigh B, Globe G. Evaluating Cost-Effectiveness Models for Pharmacologic Interventions in Adults with Heart Failure: A Systematic Literature Review. PHARMACOECONOMICS 2019; 37:359-389. [PMID: 30596210 PMCID: PMC6386015 DOI: 10.1007/s40273-018-0755-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Heart failure (HF) is a well-recognized public health concern and imposes high economic and societal costs. Decision analytic models exist for evaluating the economic ramifications associated with HF. Despite this, studies that appraise these modelling approaches for augmenting best-practice decisions remain scarce. OBJECTIVE Our objective was to conduct a systematic literature review (SLR) of published economic models for the management of HF and describe their general and methodological features. METHODS This SLR employed a combination of relevant search terms associated with HF, which were used in a number of databases, including MEDLINE, Embase, the National Health Service Economic Evaluation Database, Cost-Effectiveness Analysis Registry, ScHARR Health Utilities Database and Cochrane Library Database. A number of model features (i.e. model structure, specification, outcomes assessed, scenario and sensitivity analysis, key model drivers) were extracted and subsequently summarized. RESULTS Of 64 publications retained, a selection of modelling approaches were identified, including Markov (n = 28), trial-based analytic (n = 22), discrete-event simulation (n = 6), survival analytic (n = 7) and decision-tree modelling (n = 1) approaches. The bulk of publications employed either a cost-utility (n = 27) or cost-effectiveness (n = 36) analysis and evaluated more than one study outcome, which typically included overall costs (n = 59), incremental cost-effectiveness ratios (n = 55), life-years gained (n = 48) and willingness-to-pay thresholds (n = 37). Most publications focused on patients with chronic HF (n = 40) and used New York Heart Association (NYHA) disease classifications to categorize patients and determine disease severity. Few (n = 19) publications documented the use of hospitalization states for modelling patient outcomes and associated costs. A quality assessment of the included publications revealed most articles demonstrated reasonable methodological value. CONCLUSIONS We identified numerous decision analytic modelling approaches for evaluating the cost effectiveness of pharmacologic treatments in HF. A Markov cohort model approach was most commonly used, and most models relied on NYHA classes as a proxy of HF severity, disease progression and prognosis.
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Affiliation(s)
- Gian Luca Di Tanna
- Economic Modelling Centre of Excellence, Amgen (Europe) GmbH, Rotkreuz, Switzerland
| | | | | | - Heidi S Wirtz
- Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320-1799, USA
| | - Paul Miller
- Miller Economics Ltd, Biohub Alderley Park, Alderley Edge, UK
| | | | - Gary Globe
- Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320-1799, USA.
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Romero M, Arango CH. Análisis de costo efectividad del uso de metoprolol succinato en el tratamiento de la hipertensión arterial y la falla cardiaca en Colombia. REVISTA COLOMBIANA DE CARDIOLOGÍA 2012. [DOI: 10.1016/s0120-5633(12)70125-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Menzin J, Boulanger L, Tang S, Thakker K, Nissen SE. Cost analysis of amlodipine versus enalapril in patients with coronary artery disease and normal blood pressure: findings from the CAMELOT economic substudy. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2008; 6:157-162. [PMID: 19231908 DOI: 10.1007/bf03256130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES To analyse 2-year hospitalization and cost data collected during a prospective, double-blind, randomized, controlled trial comparing amlodipine, enalapril and placebo in normotensive patients with coronary artery disease (CAD). METHODS All patients who were enrolled in the CAMELOT study were included in this economic substudy. Patients with CAD and normal blood pressure were randomized to amlodipine, enalapril or placebo, and followed up for 24 months (between 1999 and 2004). Data on hospitalizations and medication use were obtained from the clinical trial. Costs were assigned from secondary sources. Total costs ($US, year 2004 values) were estimated as the sum of costs associated with cardiovascular hospitalizations, study medications and concomitant cardiovascular medications. Costs and resource use were analysed by treatment arm overall and for selected patient subgroups. Cost differences were evaluated using nonparametric bootstrap techniques. RESULTS Of 1991 patients enrolled, 663 were treated with amlodipine, 673 were treated with enalapril and 655 were treated with placebo. Significantly fewer patients were hospitalized for cardiovascular reasons in the amlodipine group (16.4%) than in the placebo group (22.7%; p < 0.01), but not compared with the enalapril group (20.1%; p = 0.09). The amlodipine group also had numerically fewer days in hospital per patient (1.1) than the enalapril (1.3) and placebo (1.5) groups. Mean 2-year per-patient costs in the amlodipine group were estimated to be $US 609 and $US 717 lower than for the placebo and enalapril groups, respectively. CONCLUSIONS These results suggest that use of amlodipine may reduce costs of care among CAD patients with normal blood pressure.
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Affiliation(s)
- Joseph Menzin
- Boston Health Economics, Inc., Waltham, Massachusetts, USA.
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Ho YL, Hsu TP, Chen CP, Lee CY, Lin YH, Hsu RB, Wu YW, Chou NK, Lee CM, Wang SS, Ting HT, Chen MF. Improved cost-effectiveness for management of chronic heart failure by combined home-based intervention with clinical nursing specialists. J Formos Med Assoc 2007; 106:313-9. [PMID: 17475609 DOI: 10.1016/s0929-6646(09)60258-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND/PURPOSE The influence of home- and clinic-based caring system on the economic burden of heart failure remains unknown. METHODS Between January 2004 and December 2004, chronic heart failure patients who were followed up by specialist nurse-led telephone visiting regularly were enrolled. Clinical and economic data half a year before enrollment were collected as control. RESULTS A total of 247 patients (168 males, 79 females; mean age, 60 +/- 17 years) were enrolled. The mean follow-up period was 139 +/- 96 days. The mean left ventricular ejection fraction was 35%. There were 1618 times of specialist nurse-led telephone visiting (average 8 +/- 6 times/patient). The mortality rate was 5.7%. Before enrollment, the total hospitalization fees were 624,020 US dollars. After enrollment, the cost was reduced to 362,722 US dollars (41.8% reduction). The mean functional class (New York Heart Association) also improved from 2.27 +/- 0.80 to 1.9 6 +/- 0.90 (p < 0.001). The mean duration of hospital stay due to heart failure was reduced by 5.3 days (26.2% decrement). The total numbers of admission were reduced to 36 times (33.0% decrement). The readmission rate due to etiologies other than heart failure (such as infection, gastrointestinal bleeding, etc.) was reduced from 15.9% to 7.7%. The total fees of visiting emergency station were reduced from 6528 US dollars to 6101 US dollars (6.5% decrement). On the other hand, the frequency of visiting the outpatient department (OPD) increased from 5.2 +/- 3.2 to 6.6 +/- 4.1 times/patient (p < 0.001). The total fees of visiting OPD increased from 90,783 US dollars to 94,855 US dollars(4.4% increment). CONCLUSION The home- and clinic-based caring system is capable of decreasing adverse outcomes, most notably hospitalization and length of stay, and could trigger significant cost savings in the management of heart failure.
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Affiliation(s)
- Yi-Lwun Ho
- Graduate Institute of Clinical Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Heidenreich PA, Gholami P, Sahay A, Massie B, Goldstein MK. Clinical Reminders Attached to Echocardiography Reports of Patients With Reduced Left Ventricular Ejection Fraction Increase Use of β-Blockers. Circulation 2007; 115:2829-34. [PMID: 17515459 DOI: 10.1161/circulationaha.106.684753] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Although β-blockers are known to prolong survival for patients with reduced left ventricular ejection fraction, they are often underused. We hypothesized that a reminder attached to the echocardiography report would increase the use of β-blockers for patients with reduced left ventricular ejection fraction.
Methods and Results—
We randomized 1546 consecutive patients with a left ventricular ejection fraction <45% found on echocardiography at 1 of 3 laboratories to a reminder for use of β-blockers or no reminder. Patients were excluded from analysis if they died within 30 days of randomization (n=89), did not receive medications through the Veterans Affairs system after 30 days (n=180), or underwent echocardiography at >1 laboratory (n=6). The primary outcome was a prescription for an oral β-blocker between 1 and 9 months after randomization. The mean age of the 1271 included patients was 69 years; 60% had a history of heart failure, and 51% were receiving treatment with β-blockers at the time of echocardiography. More patients randomized to the reminder had a subsequent β-blocker prescription (74%, 458 of 621) compared with those randomized to no reminder (66%, 428 of 650;
P
=0.002). The effect of the reminder was not significantly different for subgroups based on patient location (inpatient versus outpatient) or prior use of β-blockers.
Conclusions—
A reminder attached to the echocardiography report increased the use of β-blockers in patients with depressed left ventricular systolic function.
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Affiliation(s)
- Paul A Heidenreich
- Palo Alto VA Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304, USA.
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Caro JJ, Migliaccio-Walle K, O'Brien JA, Nova W, Kim J, Hauch O, Hillson E, Wedel H, Hjalmarson A, Gottlieb S, Deedwania PC, Wikstrand J. Economic Implications of Extended-Release Metoprolol Succinate for Heart Failure in the MERIT-HF Trial: A US Perspective of the MERIT-HF Trial. J Card Fail 2005; 11:647-56. [PMID: 16360958 DOI: 10.1016/j.cardfail.2005.06.433] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2004] [Revised: 05/09/2005] [Accepted: 06/09/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND The MERIT-HF trial demonstrated improved survival and fewer hospitalizations for worsening heart failure with extended-release (ER) metoprolol succinate in patients with heart failure. This study sought to estimate the economic implications of this trial from a US perspective. METHODS AND RESULTS A discrete event simulation was developed to examine the course of patients with heart failure. Characteristics of the population modeled, probabilities of hospitalization and death with standard therapy, and risk reductions with ER metoprolol succinate were obtained from Metoprolol CR/XL Randomized Intervention Trial in Chronic Heart Failure (MERIT-HF) and evaluated in weekly cycles. Direct medical costs were estimated from US databases in 2001 US dollars. Uncertainty in inputs was incorporated and analyses were carried out to estimate events prevented total and net costs. The model predicts that ER metoprolol succinate will prevent approximately 7 deaths and 15 hospitalizations from heart failure per 100 patients over 2 years. Compared with standard therapy alone, this translates to a cost reduction between $395 and $1112 per patient, depending on whether the costs of hospitalizations for other causes are included. Savings were maintained in 90% of the simulations. CONCLUSION This analysis predicts that the positive effect of ER metoprolol succinate on mortality and morbidity demonstrated in MERIT-HF leads to substantial savings.
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Affiliation(s)
- J Jamie Caro
- Caro Research Institute, Concord, Massachusetts 01742, USA
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Howard PA, Shireman TI. Heart Failure Drug Utilization Patterns for Medicaid Patients Before and After a Heart Failure-Related Hospitalization. ACTA ACUST UNITED AC 2005; 11:124-8. [PMID: 15947532 DOI: 10.1111/j.1527-5299.2005.03872.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The authors examined heart failure (HF) drug utilization patterns in Medicaid patients before and after a HF-related hospitalization. This was a retrospective claims analysis of Kansas Medicaid beneficiaries hospitalized for HF between July 1, 2000, and March 31, 2001. HF drugs were tracked 6 months prior and 6 months following the admission. Angiotensin-converting enzyme (ACE) inhibitor doses were compared with target ranges. The cohort of 135 patients had a mean age of 53.6 years and was predominantly female (66.7%) and Caucasian (70.4%) with a high prevalence of cardiovascular comorbidities. Before hospitalization, less than one third of patients were receiving ACE inhibitors, angiotensin receptor blockers, beta blockers, digoxin, or vasodilators. Following hospitalization, increased utilization was observed for beta blockers, digoxin, and angiotensin receptor blockers, but overall usage remained low. ACE inhibitors and vasodilator use remained constant. ACE-inhibitor doses were below target ranges before and after hospitalization. In this Medicaid cohort, HF-related hospitalizations did not lead to improved HF therapy.
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Affiliation(s)
- Patricia A Howard
- Department of Pharmacy Practice, University of Kansas School of Pharmacy, University Medical Center, 3901 Rainbow Boulevard, Lawrence, KS 66160-7231, USA.
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Díez Manglano J. [Congestive heart failure in Spain: cost-effectiveness and cost-benefit analyses of treatment with beta-blockers]. Rev Clin Esp 2005; 205:149-56. [PMID: 15860185 DOI: 10.1157/13074160] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Beta-blockers (BB) have proven to be effective in the treatment of congestive heart failure (CHF). This study is an economic analysis for the addition of BB to standard treatment of CHF. PATIENTS AND METHOD Randomized, double-blinded controlled studies are included, with 1,647 patients treated with bisoprolol, 3,034 treated with carvedilol, 2,432 treated with metoprolol, and 6,807 treated with placebo. Direct costs of BB treatment and of every hospitalization episode are assessed. Cost-effectiveness is assessed as cost in euros by prevented death, and cost-benefit as the difference between hospitalization costs and BB costs. The study is conducted from the perspective of a third-party payer. RESULTS Two studies with bisoprolol, six with carvedilol, and five with metoprolol are included, with an average follow-up of 13.5 months. Carvedilol prevents 5.07% of deaths per year of treatment and is more effective than bisoprolol (3.82% of avoided deaths) and metoprolol (3.03%). Cost-effectiveness ratio (cost for every prevented death and year) was 10,832 euros for bisoprolol, 17,516 euros for carvedilol and 16,664 euros for metoprolol. Incremental cost-effectiveness ratio for carvedilol ranges between 12,631 euros and 86,610 euros for life saved. All BB generate costs saving for hospitalization but only bisoprolol provides a net profit. Benefit-cost index is 1.13 for bisoprolol, 0.26 for carvedilol and 0.59 for metoprolol. CONCLUSIONS Use of BB in the treatment of CHF is an effective and cost-effective alternative. Carvedilol is the most effective alternative, and bisoprolol the most cost-effective alternative and the drug with greater benefit-cost index.
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Stewart S, McMurray JJV, Hebborn A, Coats AJS, Packer M. Carvedilol reduces the costs of medical care in severe heart failure: An economic analysis of the COPERNICUS study applied to the United Kingdom. Int J Cardiol 2005; 100:143-9. [PMID: 15820297 DOI: 10.1016/j.ijcard.2004.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2004] [Revised: 10/27/2004] [Accepted: 12/30/2004] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to determine the effects of carvedilol on the costs related to the treatment of severe chronic heart failure (CHF). METHODS Costs for the treatment for heart failure within the National Health Service (NHS) in the United Kingdom (UK) were applied to resource utilisation data prospectively collected in all patients randomized into the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Study. Unit-specific, per diem (hospital bed day) costs were used to calculate expenditures due to hospitalizations. We also included costs of carvedilol treatment, general practitioner surgery/office visits, hospital out-patient clinic visits and nursing home care based on estimates derived from validated patterns of clinical practice in the UK. RESULTS The estimated cost of carvedilol therapy and related ambulatory care for the 1156 patients assigned to active treatment was pound530,771 ( pound44.89 per patient/month of follow-up). However, patients assigned to carvedilol were hospitalised less often and accumulated fewer and less expensive days of admission. Consequently, the total estimated cost of hospital care was pound3.49 million in the carvedilol group compared with pound4.24 million for the 1133 patients in the placebo arm. The cost of post-discharge care was also less in the carvedilol than in the placebo group ( pound479,200 vs. pound548,300). Overall, the cost per patient treated in the carvedilol group was pound3948 compared to pound4279 in the placebo group. This equated to a cost of pound385.98 vs. pound434.18, respectively, per patient/month of follow-up: an 11.1% reduction in health care costs in favour of carvedilol. CONCLUSIONS These findings suggest that not only can carvedilol treatment increase survival and reduce hospital admissions in patients with severe CHF but that it can also cut costs in the process.
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Affiliation(s)
- Simon Stewart
- Division of Health Sciences, University of South Australia, City East Campus, Adelaide 5000, Australia
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Goldfarb N, Weston C, Hartmann CW, Sikirica M, Crawford A, He H, Howell J, Maio V, Clarke J, Nuthulaganti B, Cobb N. Impact of appropriate pharmaceutical therapy for chronic conditions on direct medical costs and workplace productivity: a review of the literature. ACTA ACUST UNITED AC 2004; 7:61-75. [PMID: 15035834 DOI: 10.1089/109350704322919005] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This paper presents the findings of a literature review investigating the economic impact of appropriate pharmaceutical therapy in treating four prevalent chronic conditions - asthma, diabetes, heart failure, and migraine. The goal of the review was to identify high-quality studies examining the extent to which appropriate pharmaceutical therapy impacts overall medical expenditure (direct costs) and workplace productivity (indirect costs). The working hypothesis in conducting the review was that the costs of pharmaceuticals for the selected chronic conditions are offset by savings in direct and indirect costs in other areas. The literature provides evidence that appropriate drug therapy improves the health status and quality of life of individuals with chronic illnesses while reducing costs associated with utilization of emergency room, inpatient, and other medical services. A growing body of evidence also suggests that workers whose chronic conditions are effectively controlled with medications are more productive. For employers, the evidence translates into potential direct and indirect cost savings. The findings also confirm the importance of pharmaceutical management as a cornerstone of disease management.
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Affiliation(s)
- Neil Goldfarb
- Department of Helath Policy, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA.
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Cowper PA, DeLong ER, Whellan DJ, Allen LaPointe NM, Califf RM. Economic effects of beta-blocker therapy in patients with heart failure. Am J Med 2004; 116:104-11. [PMID: 14715324 DOI: 10.1016/j.amjmed.2003.07.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Studies suggest that beta-blockers improve outcomes in heart failure patients and may be cost saving to society. However, many heart failure patients are not treated with beta-blockers. Economic incentives facing hospitals, physicians, payers, and patients may not encourage treatment adoption. We assessed the economic effects of beta-blocker therapy from various perspectives: societal, Medicare, hospital, physician, and patient. METHODS A Markov model of heart failure progression over 5 years was developed. Transition probabilities and the effect of beta-blockers on mortality and hospitalization were based on clinical trial data. Estimates of hospital costs and reimbursement were obtained from the Duke University Medical Center. Physician fees were based on the Medicare fee schedule. RESULTS Beta-blocker therapy increased survival by 0.3 years per patient and reduced societal costs by US dollars 3959 per patient over 5 years. Medicare costs declined by US dollars 6064 per patient, due primarily to lower hospitalization rates. Unless heart failure admissions could be replaced with other hospitalizations that generated an equal or greater revenue above variable cost, hospital revenue would be negatively affected. Physician revenue from treating heart failure patients would also decline. Patient costs increased with beta-blocker use (US dollars 2113 over 5 years). CONCLUSION Beta-blocker therapy improves the clinical outcomes of heart failure patients and is cost saving to society and Medicare. However, hospitals and physicians have no clear financial incentives to support increased beta-blocker use. Changes in practice patterns could be encouraged by linking reimbursement with evidence-based care and covering patients' medication costs.
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Affiliation(s)
- Patricia A Cowper
- Outcomes Research and Assessment Group, Durham, North Carolina 27715, USA.
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Abstract
Carvedilol (Dilatrend) blocks beta(1)-, beta(2)- and alpha(1)-adrenoceptors, and has antioxidant and antiproliferative effects. Carvedilol improved left ventricular ejection fraction (LVEF) in patients with chronic heart failure (CHF) in numerous studies. Moreover, significantly greater increases from baseline in LVEF were seen with carvedilol than with metoprolol in a double-blind, randomised study and in a meta-analysis. Carvedilol also reversed or attenuated left ventricular remodelling in patients with CHF and in those with left ventricular dysfunction after acute myocardial infarction (MI). Combined analysis of studies in the US Carvedilol Heart Failure Trials Program (patients had varying severities of CHF; n = 1094) revealed that mortality was significantly lower in carvedilol than in placebo recipients. In addition, the risk of hospitalisation for any cardiovascular cause was significantly lower with carvedilol than with placebo. Mortality was significantly lower with carvedilol than with metoprolol in patients with mild to severe CHF in the Carvedilol Or Metoprolol European Trial (COMET) [n = 3029]. The Carvedilol Prospective Randomised Cumulative Survival (COPERNICUS) trial (n = 2289) demonstrated that compared with placebo, carvedilol was associated with significant reductions in all-cause mortality and the combined endpoint of death or hospitalisation for any reason in severe CHF. All-cause mortality was reduced in patients who received carvedilol in addition to conventional therapy compared with those who received placebo plus conventional therapy in the Carvedilol Post-Infarct Survival Control in LV Dysfunction (CAPRICORN) trial (enrolling 1959 patients with left ventricular dysfunction following acute MI). Carvedilol was generally well tolerated in patients with CHF. Adverse events associated with the alpha- and beta-blocking effects of the drug occurred more commonly with carvedilol than with placebo, whereas placebo recipients were more likely to experience worsening heart failure. In conclusion, carvedilol blocks beta(1)-, beta(2)- and alpha(1)-adrenoceptors and has a unique pharmacological profile. It is thought that additional properties of carvedilol (e.g. antioxidant and antiproliferative effects) contribute to its beneficial effects in CHF. Carvedilol improves ventricular function and reduces mortality and morbidity in patients with mild to severe CHF, and should be considered a standard treatment option in this setting. Administering carvedilol in addition to conventional therapy reduces mortality and attenuates myocardial remodelling in patients with left ventricular dysfunction following acute MI. Moreover, mortality was significantly lower with carvedilol than with metoprolol in patients with mild to severe CHF, suggesting that carvedilol may be the preferred beta-blocker.
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Abstract
Chronic heart failure continues to exact a heavy burden on society due to high morbidity and mortality, in spite of advances in management. Beta-adrenergic blockade, by the suppression of sympathetic activity, attenuates the adverse ventricular remodeling seen in heart failure, and decreases mortality and hospitalization rates. Recently reported trials, meta-analyses, and sub-analyses extend the benefit of beta-blockade to severe heart failure, women, elderly patients, and African Americans. In addition, recent data also indicate the cost-effectiveness of beta-blockade in combating this deadly disease. These data indicate the strength of evidence for the use of beta-blockade for most patients with chronic heart failure.
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Affiliation(s)
- Georges Chahoud
- Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System, Little Rock 72205, USA
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20
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Patterson JH, Rodgers JE. Expanding role of beta-blockade in the management of chronic heart failure. Pharmacotherapy 2003; 23:451-9. [PMID: 12680475 DOI: 10.1592/phco.23.4.451.32116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Although recent advances have been made in the treatment of heart failure, this disease continues to result in significant morbidity and mortality. Among the negative effects associated with progression of heart failure are decline in myocardial reserve, decreased exercise tolerance, decreased contractile function, and altered cardiac gene expression. Guidelines recommend neurohormonal antagonists for treatment and stress the importance of angiotensin-converting enzyme inhibition and beta-blockade in reversing the cardiac remodeling process. beta-Blockade slows or reverses the adverse effects resulting from chronic adrenergic stimulation. Traditionally, beta-blockers were reserved for mild-to-moderate heart failure, based on evidence from large, randomized clinical trials showing their positive effects on myocardial function and clinical outcomes. More recently, clinical data reveal that the agents can be expanded to patients with severe heart failure and those with left ventricular systolic dysfunction after myocardial infarction. Individual beta-blocking agents vary in their pharmacology and dosing requirements. These variations may influence treatment decisions and affect clinical measurements of left ventricular function and ventricular remodeling.
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Affiliation(s)
- J Herbert Patterson
- School of Pharmacy, University of North Carolina, CB #7360 Beard Hall, Chapel Hill, NC 27599-7360, USA.
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Luzier AB, Antell LA, Chang LL, Xuan J, Roth DA. Reimbursement claims analysis of outcomes with carvedilol and metoprolol. Ann Pharmacother 2002; 36:386-91. [PMID: 11895048 DOI: 10.1345/aph.1a146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To compare resource use and costs in heart failure (HF) patients receiving metoprolol, a selective beta1-receptor blocker, with carvedilol, which blocks beta1-, beta2-, and alpha1-adrenergic receptors, by use of a retrospective reimbursement-claims analysis. METHODS Resource use and cost data were extracted for patients diagnosed with HF and treated with carvedilol or metoprolol for 6 months after the initiation of the respective therapy, by use of claims submitted to 6 healthcare plans. A modified Charlson index was used to assess comorbidity. Stepwise logistic regression was used to measure the influence of treatment on hospitalization. RESULTS Claims from 139 carvedilol and 106 metoprolol patients showed that carvedilol patients experienced significantly fewer total hospitalizations (36.0% vs. 62.3%, respectively; p < 0.001) and emergency department visits (23.7% vs. 42.5%, respectively; p = 0.002) and a trend for fewer HF-related (7.9% vs. 14.2%, respectively; NS) and cardiac-related hospitalizations (15.1% vs. 24.5%, respectively; NS). Treatment with carvedilol was associated with a significant decrease in the risk of any hospitalization (adjusted odds ratio 0.35, 95% CI 0.20 to 0.63; p <0.001). Higher pharmacy costs (mean $1677 vs. $1322; p <0.001) and lower total costs (mean $8100 vs. $14475; p = 0.025) were observed in carvedilol-treated compared with metoprolol-treated patients, respectively. CONCLUSIONS Compared with metoprolol, the more comprehensive adrenergic blockade achieved with carvedilol may translate into greater clinical benefits in patients with HF. Despite higher pharmacy costs, lower total costs were observed in carvedilol-treated patients.
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Affiliation(s)
- Aileen B Luzier
- School of Pharmacy, University of Buffalo, NY 14260-1200, USA.
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