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Kuan WC, Sim R, Wong WJ, Dujaili J, Kasim S, Lee KKC, Teoh SL. Economic Evaluations of Guideline-Directed Medical Therapies for Heart Failure With Reduced Ejection Fraction: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1558-1576. [PMID: 37236395 DOI: 10.1016/j.jval.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/13/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVES Decision-analytic models (DAMs) with varying structures and assumptions have been applied in economic evaluations (EEs) to assist decision making for heart failure with reduced ejection fraction (HFrEF) therapeutics. This systematic review aimed to summarize and critically appraise the EEs of guideline-directed medical therapies (GDMTs) for HFrEF. METHODS A systematic search of English articles and gray literature, published from January 2010, was performed on databases including MEDLINE, Embase, Scopus, NHSEED, health technology assessment, Cochrane Library, etc. The included studies were EEs with DAMs that compared the costs and outcomes of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, angiotensin-receptor neprilysin inhibitors, beta-blockers, mineralocorticoid-receptor agonists, and sodium-glucose cotransporter-2 inhibitors. The study quality was evaluated using the Bias in Economic Evaluation (ECOBIAS) 2015 checklist and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklists. RESULTS A total of 59 EEs were included. Markov model, with a lifetime horizon and a monthly cycle length, was most commonly used in evaluating GDMTs for HFrEF. Most EEs conducted in the high-income countries demonstrated that novel GDMTs for HFrEF were cost-effective compared with the standard of care, with the standardized median incremental cost-effectiveness ratio (ICER) of $21 361/quality-adjusted life-year. The key factors influencing ICERs and study conclusions included model structures, input parameters, clinical heterogeneity, and country-specific willingness-to-pay threshold. CONCLUSIONS Novel GDMTs were cost-effective compared with the standard of care. Given the heterogeneity of the DAMs and ICERs, alongside variations in willingness-to-pay thresholds across countries, there is a need to conduct country-specific EEs, particularly in low- and middle-income countries, using model structures that are coherent with the local decision context.
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Affiliation(s)
- Wai-Chee Kuan
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Ruth Sim
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Wei Jin Wong
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Juman Dujaili
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia; Swansea University Medical School, Swansea University, Swansea, Wales, UK
| | - Sazzli Kasim
- Department of Internal Medicine (Cardiology), Universiti Teknologi MARA (UiTM), Sungai Buloh, Selangor, Malaysia
| | | | - Siew Li Teoh
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia.
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Proudfoot C, Gautam R, Cristino J, Agrawal R, Thakur L, Tolley K. Model parameters influencing the cost-effectiveness of sacubitril/valsartan in heart failure: evidence from a systematic literature review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:453-467. [PMID: 35790595 PMCID: PMC10060315 DOI: 10.1007/s10198-022-01485-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 05/25/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To summarize cost-effectiveness (CE) evidence of sacubitril/valsartan for the treatment of heart failure (HF) patients with reduced ejection fraction (HFrEF). The impact of different modeling approaches and parameters on the CE results is also described. METHODS We conducted a systematic literature review using multiple databases: Embase®; MEDLINE®; MEDLINE®-In Process; NIHR CRD database including DARE, NHS EED, and HTA databases; and the Cost Effectiveness Analysis registry. We also reviewed HTA countries' websites to identify CE reports of sacubitril/valsartan, published up to 25-July-2021. Articles published in English as full-texts, conference-abstracts, or HTA reports were included. RESULTS We included 44 CE models [39 from 37 publications (22 full-texts; 15 conference-abstracts) and 5 HTAs; Europe, n = 20; North and South Americas, n = 14; Asia and Australia, n = 10]. Most models adopted a Markov structure with constant transition probabilities of events (n = 27) or a mix of Markov and regression-based models (n = 16), with variations in structural assumptions and chosen parameters. Study authors concluded sacubitril/valsartan to be a cost-effective therapy in 37/41 models in chronic HFrEF patients and 2/3 models in hospitalized patients stabilized after an acute decompensation for HF. CE models showing sacubitril/valsartan not to be a cost-effective treatment generally modeled a shorter time horizon. Effect of sacubitril/valsartan on cardiovascular and all-cause mortality, cost, duration of effect and time horizon was the main model drivers. CONCLUSIONS Most evidence indicated sacubitril/valsartan is cost-effective in HFrEF. The use of a lifetime horizon is recommended in future models as HF is a chronic disease. Data on the CE of sacubitril/valsartan in the inpatient setting were limited and further research is warranted.
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Affiliation(s)
| | - Raju Gautam
- Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | | | | | | | - Keith Tolley
- Tolley Health Economics Ltd., Unit 5, 11-13 Eagle Parade, Buxton, SK17 6EQ, Derbyshire, UK.
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Varghese L, Lin W, Linden S, Lum AL, Sim D. Cost-Effectiveness of Empagliflozin on Top of Standard of Care for Heart Failure With Reduced Ejection Fraction in Singapore. Value Health Reg Issues 2023; 34:108-117. [PMID: 36669346 DOI: 10.1016/j.vhri.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 10/06/2022] [Accepted: 12/13/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVES The prevalence of heart failure (HF) and its risk factors are high in Singapore. The EMPEROR-Reduced trial demonstrated that add-on empagliflozin resulted in a reduction in the risk of cardiovascular death or hospitalization for HF compared with standard of care (SoC). This study aimed to estimate the cost-effectiveness of empagliflozin+SoC versus SoC in patients with HF with reduced ejection fraction from a Singaporean healthcare perspective. METHODS A Markov cohort model simulated progression through health states based on New York Heart Association classes over a lifetime horizon using a cycle length of 1 month. Transition probabilities, and the risk of transient events (hospitalization for HF and cardiovascular/all-cause death) were modeled based on the EMPEROR-Reduced trial. Costs for HF-related events, adverse events, and for monitoring were estimated from a combination of published literature and publicly available fees for public hospitals/polyclinics. RESULTS Empagliflozin+SoC was estimated to be very cost-effective versus SoC alone with an incremental cost-effectiveness ratio of<8000 Singapore Dollars/quality-adjusted life-year gained. The base-case results were robust as evidenced from the consistency of various scenario and sensitivity analyses performed. When using Kansas City Cardiomyopathy Questionnaire - Clinical Summary Score quartiles as the health states, the incremental cost-effectiveness ratio reduced significantly to 4625 Singapore Dollars/quality-adjusted life-year. CONCLUSION The use of empagliflozin on top of SoC represents a highly cost-effective solution for the treatment of patients with HF with reduced ejection fraction in Singapore when considering its efficacy, relative affordability, and the growing economic burden of HF in Singapore.
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Affiliation(s)
| | - Weiqin Lin
- Department of Cardiology, National University Heart Centre Singapore Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Stephan Linden
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - David Sim
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, National University of Singapore, Singapore.
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Hu T, Liu Y, Lou Y. Sacubitril-valsartan versus enalapril for the treatment of acute decompensated heart failure in Chinese settings: A cost-effectiveness analysis. Front Pharmacol 2023; 14:925375. [PMID: 36937882 PMCID: PMC10018029 DOI: 10.3389/fphar.2023.925375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Background: The episode of acute decompensated heart failure (ADHF) is the main cause of hospitalization for heart failure (HF). Sacubitril-valsartan has been proven to be effective in reducing the risks of hospitalization for HF in ADHF. When to initiate sacubitril-valsartan in ADHF to make it the most cost-effective in China remains unclear. Methods: A lifetime Markov model with a 1-month cycle length was developed to evaluate the cost-effectiveness of early or late initiation of sacubitril-valsartan versus enalapril in ADHF. Early initiation of sacubitril-valsartan meant that it was initiated after stabilization from ADHF, and late initiation of sacubitril-valsartan meant that it was initiated after stabilization from HF, which includes no hospitalization for at least three consecutive months. The primary outcome was the incremental cost-effectiveness ratio (ICER), expressed as the ratio of incremental cost to incremental effectiveness. The secondary outcomes were total costs and total effectiveness. Three times of per capita GDP of China in 2021 was set as the willingness-to-pay threshold. One-way sensitivity analysis and probabilistic sensitivity analysis were employed to test the robustness of the results. Results: The early initiation of sacubitril-valsartan treatment resulted in an ICER of 3,662.4 USD per quality-adjusted life year, lower than the willingness-to-pay threshold, and the late initiation of sacubitril-valsartan treatment gained an ICER of 4,444.4 USD/QALY, still lower than the willingness-to-pay threshold. One-way sensitivity analysis showed that our results were robust, and probabilistic sensitivity analysis suggested that early initiation of sacubitril-valsartan in ADHF was cost-effective under a 97.4% circumstance. Conclusion: Early initiation of sacubitril-valsartan after stabilization of ADHF is highly cost-effective compared with the use of enalapril; late initiation of sacubitril-valsartan after stabilization of HF is still cost-effective but not as cost-effective as early initiation of sacubitril-valsartan in ADHF. For Chinese ADHF patients, the time to initiate sacubitril-valsartan should be when the patient is stabilized from ADHF rather than when stabilized from HF, from the perspective of economic evaluation.
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Affiliation(s)
- Tianyang Hu
- Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yiting Liu
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yake Lou
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Yake Lou,
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Lim AH, Abdul Rahim N, Zhao J, Cheung SYA, Lin YW. Cost effectiveness analyses of pharmacological treatments in heart failure. Front Pharmacol 2022; 13:919974. [PMID: 36133814 PMCID: PMC9483981 DOI: 10.3389/fphar.2022.919974] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/08/2022] [Indexed: 12/04/2022] Open
Abstract
In a rapidly growing and aging population, heart failure (HF) has become recognised as a public health concern that imposes high economic and societal costs worldwide. HF management stems from the use of highly cost-effective angiotensin converting enzyme inhibitors (ACEi) and β-blockers to the use of newer drugs such as sodium-glucose cotransporter-2 inhibitors (SGLT2i), ivabradine, and vericiguat. Modelling studies of pharmacological treatments that report on cost effectiveness in HF is important in order to guide clinical decision making. Multiple cost-effectiveness analysis of dapagliflozin for heart failure with reduced ejection fraction (HFrEF) suggests that it is not only cost-effective and has the potential to improve long-term clinical outcomes, but is also likely to meet conventional cost-effectiveness thresholds in many countries. Similar promising results have also been shown for vericiguat while a cost effectiveness analysis (CEA) of empagliflozin has shown cost effectiveness in HF patients with Type 2 diabetes. Despite the recent FDA approval of dapagliflozin and empagliflozin in HF, it might take time for these SGLT2i to be widely used in real-world practice. A recent economic evaluation of vericiguat found it to be cost effective at a higher cost per QALY threshold than SGLT2i. However, there is a lack of clinical or real-world data regarding whether vericiguat would be prescribed on top of newer treatments or in lieu of them. Sacubitril/valsartan has been commonly compared to enalapril in cost effectiveness analysis and has been found to be similar to that of SGLT2i but was not considered a cost-effective treatment for heart failure with reduced ejection fraction in Thailand and Singapore with the current economic evaluation evidences. In order for more precise analysis on cost effectiveness analysis, it is necessary to take into account the income level of various countries as it is certainly easier to allocate more financial resources for the intervention, with greater effectiveness, in high- and middle-income countries than in low-income countries. This review aims to evaluate evidence and cost effectiveness studies in more recent HF drugs i.e., SGLT2i, ARNi, ivabradine, vericiguat and omecamtiv, and gaps in current literature on pharmacoeconomic studies in HF.
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Affiliation(s)
- Audrey Huili Lim
- Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
- *Correspondence: Audrey Huili Lim,
| | - Nusaibah Abdul Rahim
- Malaya Translational and Clinical Pharmacometrics Group, Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Malaya, Kuala Lumpur, Malaysia
| | - Jinxin Zhao
- Infection and Immunity Program and Department of Microbiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | | | - Yu-Wei Lin
- Malaya Translational and Clinical Pharmacometrics Group, Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Malaya, Kuala Lumpur, Malaysia
- Infection and Immunity Program and Department of Microbiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
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Incze A, Kaló Z, Espín J, Kiss É, Kessabi S, Garrison LP. Assessing the Consequences of External Reference Pricing for Global Access to Medicines and Innovation: Economic Analysis and Policy Implications. Front Pharmacol 2022; 13:815029. [PMID: 35462921 PMCID: PMC9019924 DOI: 10.3389/fphar.2022.815029] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 03/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background: External reference pricing (ERP) is used to set pharmaceutical prices to improve affordability, but its application may have negative consequences on patient access—thus, equity—across countries and on global innovation. With the United States contemplating ERP, negative effects could be magnified. Our aim: identify and quantify some major consequences of ERP. Research design, methods: Besides relying on databases and ERP modelling, we developed a heart failure case study. 4-step approach: 1) review ERP policies; 2) establish worldwide “price corridor”; 3) quantify patient access and health outcomes impact by ERP; 4) estimate ERP impact on innovation. Results: Our ERP referencing analysis highlights its perverse effects especially in lower-income countries. As counterstrategies to protect their revenues, manufacturers often implement tight list price corridors or launch avoidance/delays. Consequences include suboptimal patient access—hence, worse outcomes—illustrated by our case study: 500,000 + QALYs health loss. Additionally, the ensuing revenue reduction would likely cause innovation loss by one additional medicine that would have benefitted future patients. Conclusion: This research provides key insights on potential unintentional consequences of medicine price setting by ERP worldwide and under a new proposal for the United States. Our results can inform stakeholder discussions to improve patient access to innovative medicines globally.
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Affiliation(s)
- András Incze
- Department of Healthcare Management, Baden-Wuerttemberg Cooperative State University, Loerrach, Germany.,Akceso Advisors AG, Basel, Switzerland
| | - Zoltán Kaló
- Center for Health Technology Assessment, Semmelweis University/Syreon Research Institute, Budapest, Hungary.,Syreon Research Institute, Budapest, Hungary
| | - Jaime Espín
- Andalusian School of Public Health, Granada, Spain
| | - Éva Kiss
- Akceso Advisors AG, Basel, Switzerland
| | | | - Louis P Garrison
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute Department of Pharmacy, University of Washington, Seattle, WA, United States
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Febrinasari RP, Putra SE, Hafizhan M, Probandari AN. Cost-Effectiveness of Sacubitril-Valsartan Compared to Angiotensin-Converting Enzyme Inhibitors in Patients With Heart Failure With Reduced Ejection Fraction. J Pharm Pract 2022:8971900221087106. [PMID: 35418252 DOI: 10.1177/08971900221087106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The goal of this study was to compare cost-effectiveness of sacubitril/valsartan with angiotensin-converting enzyme (ACE) inhibitors for treating chronic heart failure patients with reduced ejection fraction (HFrEF) from the published articles and explore the methodology applied in the studies. METHODS Systematic research was conducted in February 2021 using PubMed, Cochrane, and EBSCO. A combination of MeSH terms of "cost-effectiveness analysis," "heart failure with reduced ejection fraction," "sacubitril valsartan," and "angiotensin converting enzyme inhibitor" was employed. The review selected for articles published in the last five years in English. RESULTS A total of 15 studies were included in this review. We found that these studies had been conducted in 12 different countries. The United States had the greatest number of publications (5), followed by the Netherlands (2). The study method most used was the Markov decision model (73%). Almost all studies produced ICERs and QALYs that were numerically high. CONCLUSIONS The use of sacubitril/valsartan associates with longer life expectancy and incremental cost-effectiveness ratio than angiotensin-converting enzyme inhibitors.
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Affiliation(s)
- Ratih P Febrinasari
- Department of Pharmacology, Faculty of Medicine, 148007Universitas Sebelas Maret, Surakarta, Indonesia.,Disease Control and Integrated Disease Management Research Group, Faculty of Medicine, 148007Universitas Sebelas Maret, Surakarta, Indonesia
| | - Stefanus E Putra
- Disease Control and Integrated Disease Management Research Group, Faculty of Medicine, 148007Universitas Sebelas Maret, Surakarta, Indonesia
| | - Muhammad Hafizhan
- Disease Control and Integrated Disease Management Research Group, Faculty of Medicine, 148007Universitas Sebelas Maret, Surakarta, Indonesia
| | - Ari N Probandari
- Disease Control and Integrated Disease Management Research Group, Faculty of Medicine, 148007Universitas Sebelas Maret, Surakarta, Indonesia.,Department of Public Health, Faculty of Medicine, 148007Universitas Sebelas Maret, Surakarta, Indonesia
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Liao CT, Yang CT, Kuo FH, Lee MC, Chang WT, Tang HJ, Hua YM, Chang HY, Chen ZC, Strong C, Ou HT, Toh HS. Cost-Effectiveness Evaluation of Add-on Empagliflozin in Patients With Heart Failure and a Reduced Ejection Fraction From the Healthcare System's Perspective in the Asia-Pacific Region. Front Cardiovasc Med 2021; 8:750381. [PMID: 34778407 PMCID: PMC8586201 DOI: 10.3389/fcvm.2021.750381] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/05/2021] [Indexed: 11/22/2022] Open
Abstract
Background: EMPEROR-Reduced trial provides promising evidence on the efficacy of empagliflozin adding to the standard treatment in patients with heart failure and reduced ejection fraction (HFrEF). This study aimed to investigate the cost-effectiveness of add-on empagliflozin vs. standard therapy alone in HFrEF from the perspective of the Asia-Pacific healthcare systems. Methods: A Markov model was constructed to simulate HFrEF patients and to project the lifetime direct medical costs and quality-adjusted life years (QALY) of both therapies. Transitional probabilities were derived from the EMPEROR-Reduced trial. Country-specific costs and utilities were extracted from published resources. Incremental cost-effectiveness ratio (ICER) against willingness to pay (WTP) threshold was used to examine the cost-effectiveness. A series of sensitivity analyses was performed to ensure the robustness of the results. Results: The ICERs of add-on empagliflozin vs. standard therapy alone in HFrEF were US$20,508, US$24,046, US$8,846, US$53,791, US$21,543, and US$20,982 per QALY gained in Taiwan, Japan, South Korea, Singapore, Thailand, and Australia, respectively. Across these countries, the probabilities of being cost-effective for using add-on empagliflozin under the WTP threshold of 3-times country-specific gross domestic product per capita were 93.7% in Taiwan, 95.6% in Japan, 96.3% in South Korea, 94.2% Singapore, 51.9% in Thailand, and 95.9% in Australia. The probabilities were reduced when shortening the time horizon, assuming the same cardiovascular mortality for both treatments, and setting lower WTP thresholds. Conclusion: Adding empagliflozin to HFrEF treatment is expected to be a cost-effective option among the Asia-Pacific countries. The cost-effectiveness is influenced by the WTP thresholds of different countries.
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Affiliation(s)
- Chia-Te Liao
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Electrical Engineer, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Chun-Ting Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Fang-Hsiu Kuo
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Mei-Chuan Lee
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Hsin-Ju Tang
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Yi-Ming Hua
- Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan
| | - Hung-Yu Chang
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Zhih-Cherng Chen
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Carol Strong
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Han Siong Toh
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Health and Nutrition, Chia Nan University of Pharmacy & Science, Tainan, Taiwan
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