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Yang M, Kondo T, Adamson C, Butt JH, Abraham WT, Desai AS, Jering KS, Køber L, Kosiborod MN, Packer M, Rouleau JL, Solomon SD, Vaduganathan M, Zile MR, Jhund PS, McMurray JJV. Impact of comorbidities on health status measured using the Kansas City Cardiomyopathy Questionnaire in patients with heart failure with reduced and preserved ejection fraction. Eur J Heart Fail 2023; 25:1606-1618. [PMID: 37401511 DOI: 10.1002/ejhf.2962] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/18/2023] [Accepted: 06/28/2023] [Indexed: 07/05/2023] Open
Abstract
AIM Patients with heart failure (HF) often suffer from a range of comorbidities, which may affect their health status. The aim of this study was to assess the impact of different comorbidities on health status in patients with HF and reduced (HFrEF) and preserved ejection fraction (HFpEF). METHODS AND RESULTS Using individual patient data from HFrEF (ATMOSPHERE, PARADIGM-HF, DAPA-HF) and HFpEF (TOPCAT, PARAGON-HF) trials, we examined the Kansas City Cardiomyopathy Questionnaire (KCCQ) domain scores and overall summary score (KCCQ-OSS) across a range of cardiorespiratory (angina, atrial fibrillation [AF], stroke, chronic obstructive pulmonary disease [COPD]) and other comorbidities (obesity, diabetes, chronic kidney disease [CKD], anaemia). Of patients with HFrEF (n = 20 159), 36.2% had AF, 33.9% CKD, 33.9% diabetes, 31.4% obesity, 25.5% angina, 12.2% COPD, 8.4% stroke, and 4.4% anaemia; the corresponding proportions in HFpEF (n = 6563) were: 54.0% AF, 48.7% CKD, 43.4% diabetes, 53.3% obesity, 28.6% angina, 14.7% COPD, 10.2% stroke, and 6.5% anaemia. HFpEF patients had lower KCCQ domain scores and KCCQ-OSS (67.8 vs. 71.3) than HFrEF patients. Physical limitations, social limitations and quality of life domains were reduced more than symptom frequency and symptom burden domains. In both HFrEF and HFpEF, COPD, angina, anaemia, and obesity were associated with the lowest scores. An increasing number of comorbidities was associated with decreasing scores (e.g. KCCQ-OSS 0 vs. ≥4 comorbidities: HFrEF 76.8 vs. 66.4; HFpEF 73.7 vs. 65.2). CONCLUSIONS Cardiac and non-cardiac comorbidities are common in both HFrEF and HFpEF patients and most are associated with reductions in health status although the impact varied among comorbidities, by the number of comorbidities, and by HF phenotype. Treating/correcting comorbidity is a therapeutic approach that may improve the health status of patients with HF.
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Affiliation(s)
- Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Carly Adamson
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Karola S Jering
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MS, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Michael R Zile
- RHJ Department of Veterans Affairs Medical Center, Medical University of South Carolina, Charleston, SC, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Zheng J, Parizo JT, Spertus JA, Heidenreich PA, Sandhu AT. Cost-effectiveness of Empagliflozin in Patients With Heart Failure With Preserved Ejection Fraction. JAMA Intern Med 2022; 182:1278-1288. [PMID: 36342696 PMCID: PMC9641590 DOI: 10.1001/jamainternmed.2022.5010] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 09/16/2022] [Indexed: 11/09/2022]
Abstract
Importance In the Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction (EMPEROR-Preserved), empagliflozin significantly reduced hospitalizations for heart failure while improving patient-reported health status compared with placebo. The long-term cost-effectiveness of empagliflozin among patients who have heart failure with preserved ejection fraction (HFpEF) remains unclear. Objective To estimate the cost-effectiveness of empagliflozin in patients with HFpEF. Design, Setting, and Participants This cost-effectiveness analysis performed from October 2021 to April 2022 included a Markov model using estimates of treatment efficacy, event probabilities, and utilities from EMPEROR-Preserved and published literature. Costs were derived from national surveys and pricing data sets. Quality of life was imputed from a heart failure-specific quality-of-life measure. Two analyses were performed, with and without a treatment effect on cardiovascular mortality. Subgroup analyses were based on diabetes status, ejection fraction, and health status impairment due to heart failure. The model reproduced the event rates and risk reduction with empagliflozin observed in EMPEROR-Preserved over 26 months of follow-up; future projections extended across the lifetime of patients. Exposures Empagliflozin or standard of care. Main Outcomes and Measures Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio. Results A total of 5988 patients were included in the analysis, with a mean age of 72 years, New York Heart Association class II to IV heart failure, and left ventricular ejection fraction greater than 40%. At the Federal Supply Schedule price of $327 per month, empagliflozin yielded 0.06 additional QALYs and $26 257 incremental costs compared with standard of care, producing a cost per QALY gained of $437 442. Incremental costs consisted of total drug costs of $29 586 and savings of $3329 from reduced hospitalizations for heart failure. Cost-effectiveness was similar across subgroups. The results were most sensitive to the monthly cost, quality-of-life benefit, and mortality effect of empagliflozin. A price reduction to $153 per month, incremental utility of 0.02, or 8% reduction in cardiovascular mortality would bring empagliflozin to $180 000 per QALY gained, the threshold for intermediate value. Using Medicare Part D monthly pricing of $375 after rebates and $511 before rebates, empagliflozin would remain low value at $509 636 and $710 825 per QALY gained, respectively. Cost-effectiveness estimates were robust to variation in the frequency and disutility of heart failure hospitalizations. Conclusions and Relevance In this economic evaluation, based on current cost-effectiveness benchmarks, empagliflozin provides low economic value compared with standard of care for HFpEF, largely due to its lack of efficacy on mortality and small benefit on quality of life.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, California
| | - Justin T. Parizo
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - John A. Spertus
- St Luke’s Mid America Heart Institute, University of Missouri–Kansas City
| | - Paul A. Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Alexander T. Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
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Parizo JT, Goldhaber-Fiebert JD, Salomon JA, Khush KK, Spertus JA, Heidenreich PA, Sandhu AT. Cost-effectiveness of Dapagliflozin for Treatment of Patients With Heart Failure With Reduced Ejection Fraction. JAMA Cardiol 2021; 6:926-935. [PMID: 34037681 DOI: 10.1001/jamacardio.2021.1437] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial, dapagliflozin was shown to reduce cardiovascular mortality and hospitalizations due to heart failure while improving patient-reported health status. However, the cost-effectiveness of adding dapagliflozin therapy to standard of care (SOC) is unknown. Objective To estimate the cost-effectiveness of dapagliflozin therapy among patients with chronic heart failure with reduced ejection fraction (HFrEF). Design, Setting, and Participants This Markov cohort cost-effectiveness model used estimates of therapy effectiveness, transition probabilities, and utilities from the DAPA-HF trial and other published literature. Costs were derived from published sources. Patients with HFrEF included subgroups based on diabetes status and health status impairment due to heart failure. We compiled parameters from the literature including DAPA-HF, on which our model is based, and many other sources from December 2019 to February 27, 2021. We performed our analysis in February 2021. Exposures Dapagliflozin or SOC. Main Outcomes and Measures Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), costs, and the cost per QALY gained (incremental cost-effectiveness ratio). Results In the model, dapagliflozin therapy yielded a mean of 0.78 additional life-years and 0.46 additional QALYs compared with SOC at an incremental cost of $38 212, resulting in a cost per QALY gained of $83 650. The cost per QALY was similar for patients with or without diabetes and for patients with mild or moderate impairment of health status due to heart failure. The cost-effectiveness was most sensitive to estimates of the effect on mortality and duration of therapy effectiveness. If the cost of dapagliflozin decreased from $474 to $270 (43% decline), the cost per QALY gained would drop below $50 000. Conclusions and Relevance These findings suggest that dapagliflozin provides intermediate value compared with SOC, based on American College of Cardiology/American Heart Association benchmarks. Additional data regarding the magnitude of mortality reduction would improve the precision of cost-effectiveness estimates.
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Affiliation(s)
- Justin T Parizo
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, The Freeman Spogli Institute, Department of Medicine, Stanford University, Stanford, California
| | - Joshua A Salomon
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, The Freeman Spogli Institute, Department of Medicine, Stanford University, Stanford, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - John A Spertus
- St Luke's Mid America Heart Institute, University of Missouri-Kansas City
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California.,Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
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Mondesir FL, Zickmund SL, Yang S, Perry G, Galyean P, Nativi-Nicolau J, Kemeyou L, Spertus JA, Stehlik J. Patient Perspectives on the Completion and Use of Patient-Reported Outcome Surveys in Routine Clinical Care for Heart Failure. Circ Cardiovasc Qual Outcomes 2020; 13:e007027. [PMID: 32862696 DOI: 10.1161/circoutcomes.120.007027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Favel L Mondesir
- Division of Cardiovascular Medicine (F.L.M., J.N.-N., LK., J.S.), University of Utah, Salt Lake City
| | - Susan L Zickmund
- Division of Epidemiology (S.L.Z., S.Y., G.P., P.G.), University of Utah, Salt Lake City.,VA, Salt Lake City, UT (S.L.Z., S.Y., G.P., P.G.)
| | - Serena Yang
- Division of Epidemiology (S.L.Z., S.Y., G.P., P.G.), University of Utah, Salt Lake City.,VA, Salt Lake City, UT (S.L.Z., S.Y., G.P., P.G.)
| | - Grace Perry
- Division of Epidemiology (S.L.Z., S.Y., G.P., P.G.), University of Utah, Salt Lake City.,VA, Salt Lake City, UT (S.L.Z., S.Y., G.P., P.G.)
| | - Patrick Galyean
- Division of Epidemiology (S.L.Z., S.Y., G.P., P.G.), University of Utah, Salt Lake City.,VA, Salt Lake City, UT (S.L.Z., S.Y., G.P., P.G.)
| | - Jose Nativi-Nicolau
- Division of Cardiovascular Medicine (F.L.M., J.N.-N., LK., J.S.), University of Utah, Salt Lake City
| | - Line Kemeyou
- Division of Cardiovascular Medicine (F.L.M., J.N.-N., LK., J.S.), University of Utah, Salt Lake City
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.)
| | - Josef Stehlik
- Division of Cardiovascular Medicine (F.L.M., J.N.-N., LK., J.S.), University of Utah, Salt Lake City
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Gilstrap L, Skinner JS, Gladders B, O'Malley AJ, Barnato AE, Tosteson ANA, Austin AM. Opportunities and Challenges of Claims-Based Quality Assessment: The Case of Postdischarge β-Blocker Treatment in Patients With Heart Failure With Reduced Ejection Fraction. Circ Cardiovasc Qual Outcomes 2020; 13:e006180. [PMID: 32148101 DOI: 10.1161/circoutcomes.119.006180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND To combat the high cost and increasing burden of quality reporting, the Medicare Payment Advisory (MedPAC) has recommended using claims data wherever possible to measure clinical quality. In this article, we use a cohort of Medicare beneficiaries with heart failure with reduced ejection fraction and existing quality metrics to explore the impact of changes in quality metric methodology on measured quality performance, the association with patient outcomes, and hospital rankings. METHODS AND RESULTS We used 100% Medicare Parts A and B and a random 40% sample of Part D from 2008 to 2015 to create (1) a cohort of 295 494 fee-for-service beneficiaries with ≥1 hospitalization for heart failure with reduced ejection fraction and (2) a cohort of 1079 hospitals with ≥11 heart failure with reduced ejection fraction admissions in 2014 and 2015. We used Part D data to calculate β-blocker use after discharge and β-blocker use over time. We then varied the quality metric methodologies to explore the impact on measured performance. We then used multivariable time-to-event analyses to explore the impact of metric methodology on the association between quality performance and patient outcomes and Kendall's Tau to describe impact of quality metric methodology on hospital rankings. We found that quality metric methodology had a significant impact on measured quality performance. The association between quality performance and readmissions was sensitive to changes in methodology but the association with 1-year mortality was not. Changes in quality metric methodology also had a substantial impact on hospital quality rankings. CONCLUSIONS This article highlights how small changes in quality metric methodology can have a significant impact on measured quality performance, the association between quality performance and utilization-based outcomes, and hospital rankings. These findings highlight the need for standardized quality metric methodologies, better case-mix adjustment and cast further doubt on the use of utilization-based outcomes as quality metrics in chronic diseases.
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Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH (L.G., B.G.).,The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH.,Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (L.G.)
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Barbara Gladders
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH (L.G., B.G.)
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH.,Department of Biomedical Data Science (A.J.O.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
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