Associations between Seattle Heart Failure Model scores and health utilities: findings from HF-ACTION

Health State Utilities of Patients with Heart Failure: A Systematic Literature Review

BACKGROUND AND OBJECTIVES

New treatments and interventions are in development to address clinical needs in heart failure. To support decision making on reimbursement, cost-effectiveness analyses are frequently required. A systematic literature review was conducted to identify and summarize heart failure utility values for use in economic evaluations.

METHODS

Databases were searched for articles published until June 2019 that reported health utility values for patients with heart failure. Publications were reviewed with specific attention to study design; reported values were categorized according to the health states, 'chronic heart failure', 'hospitalized', and 'other acute heart failure'. Interquartile limits (25th percentile 'Q1', 75th percentile 'Q3') were calculated for health states and heart failure subgroups where there were sufficient data.

RESULTS

The systematic literature review identified 161 publications based on data from 142 studies. Utility values for chronic heart failure were reported by 128 publications; 39 publications published values for hospitalized and three for other acute heart failure. There was substantial heterogeneity in the specifics of the study populations, methods of elicitation, and summary statistics, which is reflected in the wide range of utility values reported. EQ-5D was the most used instrument; the interquartile limit for mean EQ-5D values for chronic heart failure was 0.64-0.72.

CONCLUSIONS

There is a wealth of published utility values for heart failure to support economic evaluations. Data are heterogenous owing to specificities of the study population and methodology of utility value elicitation and analysis. Choice of value(s) to support economic models must be carefully justified to ensure a robust economic analysis.

Evaluation of a Heart Failure Telemonitoring Program Through a Microsimulation Model: Cost-Utility Analysis

BACKGROUND

Heart failure (HF) is a major public health issue in Canada that is associated with high prevalence, morbidity, and mortality rates and high financial and social burdens. Telemonitoring (TM) has been shown to improve all-cause mortality and hospitalization rates in patients with HF. The Medly program is a TM intervention integrated as standard of care at a large Canadian academic hospital for ambulatory patients with HF that has been found to improve patient outcomes. However, the cost-effectiveness of the Medly program is yet to be determined.

OBJECTIVE

This study aims to conduct a cost-utility analysis of the Medly program compared with the standard of care for HF in Ontario, Canada, from the perspective of the public health care payer.

METHODS

Using a microsimulation model, individual patient data were simulated over a 25-year time horizon to compare the costs and quality-adjusted life years (QALYs) between the Medly program and standard care for patients with HF treated in the ambulatory care setting. Data were sourced from a Medly Program Evaluation study and literature to inform model parameters, such as Medly's effectiveness in reducing mortality and hospitalizations, health care and intervention costs, and model transition probabilities. Scenario analyses were conducted in relation to HF severity and TM deployment models. One-way deterministic effectiveness analysis and probabilistic sensitivity analysis were performed to explore the impact on the results of uncertainty in model parameters.

RESULTS

The Medly program was associated with an average total cost of Can $102,508 (US $77,626) per patient and total QALYs of 5.51 per patient compared with the average cost of Can $97,497 (US $73,831) and QALYs of 4.95 per patient in the Standard Care Group. This led to an incremental cost of Can $5011 (US $3794) and incremental QALY of 0.566, resulting in an incremental cost-effectiveness ratio of Can $8850 (US $6701)/QALY. Cost-effectiveness improved in relation to patients with advanced HF and with deployment models in which patients used their own equipment. Baseline and alternative scenarios consistently showed probabilities of cost-effectiveness greater than 85% at a willingness-to-pay threshold of Can $50,000 (US $37,718). Although the results showed some sensitivity to assumptions about effectiveness parameters, the intervention was found to remain cost-effective.

CONCLUSIONS

The Medly program for patients with HF is cost-effective compared with standard care using commonly reported willingness-to-pay thresholds. This study provides evidence for decision makers on the use of TM for HF, supports the use of a nurse-led model of TM that embeds clinically validated algorithms, and informs the use of economic modeling for future evaluations of early-stage health informatics technology.

Association between quality of life and prognosis of candidate patients for heart transplantation: a cross-sectional study

OBJECTIVE

to verify the association between the prognostic scores and the quality of life of candidates for heart transplantation.

METHOD

a descriptive cross-sectional study with a convenience sample of 32 outpatients applying to heart transplantation. The prognosis was rated by the Heart Failure Survival Score (HFSS) and the Seattle Heart Failure Model (SHFM); and the quality of life by the Minnesota Living With Heart Failure Questionnaire (MLHFQ) and the Kansas City Cardiomyopathy Questionnaire (KCCQ). The Pearson correlation test was applied.

RESULTS

the correlations found between general quality of life scores and prognostic scores were (HFSS/MLHFQ r = 0.21), (SHFM/MLHFQ r = 0.09), (HFSS/KCCQ r = -0.02), (SHFM/KCCQ r = -0.20).

CONCLUSION

the weak correlation between the prognostic and quality of life scores suggests a lack of association between the measures, i.e., worse prognosis does not mean worse quality of life and the same statement is true in the opposite direction.

Micronutrient Deficiency Independently Predicts Time to Event in Patients With Heart Failure

Background Dietary micronutrient deficiencies have been shown to predict event-free survival in other countries but have not been examined in patients with heart failure living in the United States. The purpose of this study was to determine whether number of dietary micronutrient deficiencies in patients with heart failure was associated with shorter event-free survival, defined as a combined end point of all-cause hospitalization and death. Methods and Results Four-day food diaries were collected from 246 patients with heart failure (age: 61.5±12 years; 67% male; 73% white; 45% New York Heart Association [NYHA] class III / IV ) and analyzed using Nutrition Data Systems for Research. Micronutrient deficiencies were determined according to methods recommended by the Institute of Medicine. Patients were followed for 1 year to collect data on all-cause hospitalization or death. Patients were divided according to number of dietary micronutrient deficiencies at a cut point of ≥7 for the high deficiency category versus <7 for the no to moderate deficiency category. In the full sample, 29.8% of patients experienced hospitalization or death during the year, including 44.3% in the high-deficiency group and 25.1% in the no/moderate group. The difference in survival distribution was significant (log rank, P=0.0065). In a Cox regression, micronutrient deficiency category predicted time to event with depression, NYHA classification, comorbidity burden, body mass index, calorie and sodium intake, and prescribed angiotensin-converting enzyme inhibitors, diuretics, or β-blockers included as covariates. Conclusions This study provides additional convincing evidence that diet quality of patients with heart failure plays an important role in heart failure outcomes.

Cost-Effectiveness Analysis of Iodine-123 Meta-Iodobenzylguanidine Imaging for Screening Heart Failure Patients Eligible for an Implantable Cardioverter Defibrillator in the USA

BACKGROUND

Many guideline-eligible heart failure (HF) patients do not receive a survival benefit from implantable cardioverter defibrillators (ICDs). Improved risk stratification may help to reduce costs and improve the cost effectiveness of ICDs.

OBJECTIVE

To estimate the potential outcomes, costs, and cost effectiveness of using iodine-123 meta-iodobenzylguanidine (I-mIBG) to screen HF patients eligible for an ICD.

METHODS

A decision-analytic model was developed to compare screening with I-mIBG imaging and no screening over 2-year and 10-year time horizons from a US payer perspective. Data on I-mIBG imaging and risk stratification were obtained from the ADMIRE-HF/HFX (AdreView Myocardial Imaging for Risk Evaluation in Heart Failure) trial. Data on ICD effectiveness for prevention of sudden cardiac death (SCD) were obtained from a meta-analysis. Costs of ICDs and costs of generator and lead procedures were obtained from the Agency for Healthcare Research and Quality National Inpatient Sample. Age-specific mortality was modeled using US life tables and data from the ACT (Advancements in ICD Therapy) Registry on risks of SCD and non-SCD mortality. Sensitivity analyses were conducted.

RESULTS

In the analysis, screening with I-mIBG imaging was associated with a reduction in ICD utilization of 21 %, resulting in a number needed to screen to prevent 1 ICD implantation of 5. Screening reduced the costs per patient by US$5500 and US$13,431 (in 2013 dollars) over 2 and 10 years, respectively, in comparison with no screening and resulted in losses of 0.001 and 0.040 life-years, respectively, over 2 and 10 years. Screening was decrementally cost effective, with savings of US$5,248,404 and US$513,036 per quality-adjusted life-year lost over 2 and 10 years, respectively. In subgroup analyses, cost savings were greater for patients with an ejection fraction (EF) of 25-35 % than for those with an EF <25 %.

CONCLUSIONS

According to the model, screening of guideline-eligible patients selected for ICDs with I-mIBG imaging may be cost effective and may help reduce costs associated with implantation of ICDs, with a minimal impact on survival.

The utility of biomarker risk prediction score in patients with chronic heart failure

Background

Chronic heart failure (CHF) has been remained a leading cause of cardiovascular morbidity and mortaluty. The risk stratification of CHF individuals based on clinical criteria and biomarkers' models may improve medical care and probably increase efficacy of treatment strategy. However, various predictive models approved for CHF patients appear to be distinguished in their prognostications. The study aim was to evaluate whether biomarker risk prediction score is powerful tool for risk assessment of three-year fatal and non-fatal cardiovascular events in CHF patients.

Methods

It was studied prospectively the incidence of fatal and non-fatal cardiovascular events in a cohort of 388 patients with ischemic-induced CHF within 3 years. Circulating biomarkers were collected at baseline of the study.

Results

Independent predictors of clinical outcomes in patients with CHF were NT-pro-BNP, galectin-3, hs-CRP, osteoprotegerin, CD31⁺/annexin V⁺ endothelail-derived microparticles (EMPs) and CD31⁺/annexin V⁺ EMPs to CD14⁺CD309⁺ monuclear progenitor cells (MPCs) ratio. Index of cardiovascular risk was calculated by mathematical summation of all ranks of independent predictors, which occurred in the patients included in the study. Kaplan-Meier analysis showed that patients with CHF and the magnitude of the risk of less than 4 units have an advantage in survival when compared with patients for whom obtained higher values of cardiovascular risk score ranks.

Conclusion

Biomarker risk score for cumulative cardiovascular events, constructed by measurement of circulating NT-pro-BNP, galectin-3, hs-CRP, osteoprotegerin, CD31+/annexin V+ EMPs and CD31⁺/annexin V⁺ EMPs to CD14⁺CD309⁺ MPCs ratio, allowing reliably predict the probability survival of patients with CHF.

Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model: A Web-based program designed to evaluate the cost-effectiveness of disease management programs in heart failure

BACKGROUND

Heart failure disease management programs can influence medical resource use and quality-adjusted survival. Because projecting long-term costs and survival is challenging, a consistent and valid approach to extrapolating short-term outcomes would be valuable.

METHODS

We developed the Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model, a Web-based simulation tool designed to integrate data on demographic, clinical, and laboratory characteristics; use of evidence-based medications; and costs to generate predicted outcomes. Survival projections are based on a modified Seattle Heart Failure Model. Projections of resource use and quality of life are modeled using relationships with time-varying Seattle Heart Failure Model scores. The model can be used to evaluate parallel-group and single-cohort study designs and hypothetical programs. Simulations consist of 10,000 pairs of virtual cohorts used to generate estimates of resource use, costs, survival, and incremental cost-effectiveness ratios from user inputs.

RESULTS

The model demonstrated acceptable internal and external validity in replicating resource use, costs, and survival estimates from 3 clinical trials. Simulations to evaluate the cost-effectiveness of heart failure disease management programs across 3 scenarios demonstrate how the model can be used to design a program in which short-term improvements in functioning and use of evidence-based treatments are sufficient to demonstrate good long-term value to the health care system.

CONCLUSION

The Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model provides researchers and providers with a tool for conducting long-term cost-effectiveness analyses of disease management programs in heart failure.

The utility of biomarker risk prediction score in patients with chronic heart failure

Chronic heart failure (CHF) remains a leading cause of cardiovascular death worldwide. Current risk models allow better prognosis, however further tools for assessing risk are needed. Thus, this study was aimed to evaluate whether biomarker risk prediction score is powerful tool for risk assessment of three-year fatal and non-fatal cardiovascular events in CHF patients.

METHODS

A prospective study on the incidence of fatal and non-fatal cardiovascular events, as well as the frequency of occurrence of death from any cause in a cohort of 388 patients with CHF during 3 years of observation was performed. Circulating levels of NT-pro brain natriuretic peptide (NT-pro-BNP), galectin-3, high-sensitivity C-reactive protein (hs-CRP), osteoprotegerin and its soluble receptor sRANKL, osteopontin, osteonectin, adiponectin, endothelial apoptotic microparticles (EMPs) and mononuclear progenitor cells (MPCs) were measured at baseline.

RESULTS

Median follow-up of patients included in the study was 2.76 years. There were 285 cardiovascular events determined, including 43 deaths and 242 readmissions. Independent predictors of clinical outcomes in patients with CHF were NT-pro-BNP, galectin-3, hs-CRP, osteoprotegerin, CD31(+)/annexin V(+) EMPs and EMPs/CD14(+)CD309(+) MPCs ratio. Index of cardiovascular risk was calculated by mathematical summation of all ranks of independent predictors, which occurred in the patients included in the study. The findings showed that the average value of the index of cardiovascular risk in patients with CHF was 3.17 points (95% CI = 1.65-5.10 points). Kaplan-Meier analysis showed that patients with CHF and the magnitude of the risk of less than 4 units have an advantage in survival when compared with patients for whom obtained higher values of ranks cardiovascular risk score.

CONCLUSION

Biomarker risk score for cumulative cardiovascular events, constructed by measurement of circulating NT-pro-BNP, galectin-3, hs-CRP, osteoprotegerin, CD31(+)/annexin V(+) EMPs and EMPs/CD14(+)CD309(+) MPCs ratio, reliably predicts the probability survival of patients with CHF, regardless of age, gender, state of the contractile function of the left ventricle and the number of comorbidities.

The clinical course of health status and association with outcomes in patients hospitalized for heart failure: insights from ASCEND-HF

AIMS

A longitudinal and comprehensive analysis of health-related quality of life (HRQOL) was performed during hospitalization for heart failure (HF) or soon after discharge.

METHODS AND RESULTS

A post-hoc analysis was performed of the ASCEND-HF trial. The EuroQOL five dimensions questionnaire (EQ-5D) was administered to study participants at baseline, 24 h, discharge/day 10, and day 30. EQ-5D includes functional dimensions mapped to corresponding utility scores (i.e. 0 = death and 1 = perfect health), and a visual analogue scale (VAS) ranging from 0 (i.e. 'worst imaginable health state') to 100 (i.e. 'best imaginable health state'). The association between baseline and discharge EQ-5D measurements and subsequent clinical outcomes including death and rehospitalization were assessed using multivariable logistic regression and Cox proportional hazards regression. A total of 6943 patients (97%) had complete EQ-5D data at baseline. Mapped utility and VAS scores (mean ± SD) increased over time, respectively, from 0.56 ± 0.23 and 45 ± 22 at baseline to 0.67 ± 0.26 and 58 ± 22 at 24 h and to 0.79 ± 0.20 and 68 ± 22 at discharge, and remained stable at day 30. Lower mapped utility scores at baseline [odds ratio (OR) per 0.1 decrease in utility score 1.03, 95% confidence interval (CI) 1.00-1.06] and discharge (OR 1.10, 95% CI 1.05-1.15) and VAS scores at baseline (OR per 10 point decrease 1.05, 95% CI 1.01-1.09) were significantly associated with increased risk of 30-day all-cause death or HF rehospitalization.

CONCLUSIONS

Patients hospitalized for HF had severely impaired health status at baseline and, although this improved substantially during admission, health status remained abnormal at discharge.

High intensity, interval exercise improves quality of life of patients with chronic heart failure: a randomized controlled trial

BACKGROUND

The aim of this study was to evaluate the effect of high intensity, interval exercise on quality of life (QoL) and depression status, in chronic heart failure (CHF) patients.

METHODS

A randomized controlled trial (phase III). Of the 100 consecutive CHF patients (NYHA classes II-IV, ejection fraction ≤ 50%) that were randomly allocated to exercise intervention (n = 50, high-intensity intermittent endurance training 30 s at 100% of max workload, 30 s at rest, for 45 min/day-by-12 weeks) or no exercise advice (n = 50), 72 (exercise group, n = 33, 63 ± 9 years, 88% men, 70% ischemic CHF and control group, n = 39, 56 ± 11 years, 82% men, 70% ischemic CHF) completed the study. QoL was assessed using the validated and translated Minnesota Living with Heart Failure questionnaire. Depressive symptomatology was evaluated using the validated and translated Zung Depression Rating Scale (ZDRS). Maximal oxygen uptake (VO(2max)) and carbon dioxide production (VCO(2max)) were also measured breath-by-breath.

RESULTS

Data analysis demonstrated that in the intervention group MLHFQ score was reduced by 66% (P = 0.003); 6-min-walk distance increased by 13% (P < 0.05), VO(2max) level increased by 31% (P = 0.001), VCO(2max) level increased by 28% (P = 0.001) and peak power output increased by 25% (P = 0.001), as compared with the control group.

CONCLUSION

High intensity, systematic aerobic training, could be strongly encouraged in CHF patients, since it improves QoL, by favorably modifying their fitness level.