Economic evaluation of new blood pressure target for hypertensive patients in Taiwan according to the 2022 hypertension clinical practice guidelines of the Taiwan society of cardiology: a simulation modeling study.

With the promising cardiovascular benefits in the STEP and SPRINT trials, the 2022 Taiwan's hypertension guidelines redefined the hypertension threshold as 130/80 mmHg and a universal blood-pressure target of <130/80 mmHg. This study's objective was to examine the cost-effectiveness of the intensive blood-pressure target for hypertensive patients using estimated lifetime medical costs and quality-adjusted life years (QALY) from the Taiwan national payer's perspective. We developed a lifetime Markov model comparing the intensive and conservative blood-pressure targets. Incremental cost-effectiveness ratio (ICER) against the willing-to-pay thresholds at the one-time [US$34,000(NT$1,020,000)] and three-time [US$100,000(NT$3,000,000)] gross domestic product per capita were defined as very cost-effect and only cost-effective. The cost-effectiveness in different age stratifications and cardiovascular risks treated with a more intensive target (120 mmHg) were examined in the subgroup analyses. The new blood-pressure treatment target produced more lifetime medical costs [US$31,589(NT$947,670) versus US$26,788(NT$803,640)] and QALYs (12.54 versus 12.25), and the ICER was US$16,589(NT$497,670), which was 99.1% and 100% probability of a very cost-effective and cost-effective strategy. The ICERs in all age stratifications had more than a 90% probability of being very cost-effective, and ICERs decreased with age. More intensive control in patients with high cardiovascular risks produced a lower ICER [US$14,547(NT$436,410)]. In conclusion, Taiwan's new blood-pressure treatment target can prevent more cardiovascular events with acceptable costs per QALY below the willing-to-pay thresholds. The cost-effectiveness of intensive control is consistent across different ages and more pronounced with the increase in age and cardiovascular risk.

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.

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.

Cost-effectiveness evaluation of add-on dapagliflozin for heart failure with reduced ejection fraction from perspective of healthcare systems in Asia-Pacific region.

BACKGROUND: With emerging evidence on the efficacy of adding dapagliflozin to standard care for patients with heart failure with reduced ejection fraction (HFrEF), this study assessed the cost-effectiveness of add-on dapagliflozin to standard care versus standard care alone for HFrEF from the perspective of healthcare systems in the Asia-Pacific region. METHODS: A Markov model was applied to project the outcomes of treatment in terms of lifetime medical cost and quality-adjusted life-years. The transition probabilities between health states in the model were obtained from the Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction trial. Country-specific costs and utilities were extracted for modeling. The incremental cost-effectiveness ratio against a country-specific willingness-to-pay threshold was applied to determine the cost-effectiveness of treatment. A series of sensitivity analyses were performed to ensure the robustness of the study results. Costs are presented in 2020 United States dollars. RESULTS: The incremental cost-effectiveness ratios for add-on dapagliflozin versus standard care alone were $5277, $9980, $12,305, $16,705, and $23,227 per quality-adjusted life-year gained in Korea, Australia, Taiwan, Japan, and Singapore, respectively. When using add-on dapagliflozin to standard care versus standard care alone, ~ 100% of simulations were cost-effective at a willingness-to-pay threshold of one gross domestic product per capita of the given Asia-Pacific country; however, the probability of being cost-effective for using add-on dapagliflozin decreased when the time horizon for simulation was restricted to 18 months and when the cardiovascular mortality for the two treatments (43.8% and 33.0%, respectively) was assumed to be the same. The cost-effectiveness results were most sensitive to cardiovascular mortality of treatment. CONCLUSIONS: Adding dapagliflozin to standard care is cost-effective for HFrEF in healthcare systems in the Asia-Pacific region, which supports the rational use of dapagliflozin for HFrEF in this region.

The evolution of guideline-directed medical therapy among decompensated HFrEF patients in sacubitril/valsartan era: Medical expenses and clinical effectiveness.

BACKGROUND: Over recent years, new evolution in guideline-directed medical therapy (GDMT) contributes to clinical benefits in patients with heart failure and reduced ejection fraction (HFrEF). The additional medical expenditure may be a concern due to the current financial constraint. This study aimed to investigate the medical costs and clinical effectiveness of contemporary GDMT in recently hospitalized HFrEF patients. METHODS: Acutely decompensated hospitalized HFrEF patients from two multicenter cohorts of different periods were retrospectively analyzed. A propensity score matching was performed to adjust the baseline characteristics. Annual medication costs, risks of mortality, and recurrent heart failure hospitalizations (HFH) were compared. RESULTS: Following 1:2 propensity score matching, there were 426 patients from the 2017-2018 cohort using sacubitril/valsartan, while 852 patients from 2013 to 2014 did not use so at discharge. Baseline characteristics were similar, whereas the sacubitril/valsartan users were more likely to receive beta-blockers, ivabradine and mineralocorticoid receptor antagonists at discharge (79.3% vs 60.4%, 23.2% vs 0%, and 64.1% vs 49.8%, p < 0.001). The 2017-2018 cohort produced more medication costs by 1277 United States dollar (USD) per person per year, while it resulted in lower rates of HFH and all-cause mortality (10.3 vs 20.3 and 48.8 vs 79.9 per 100 person-year, p < 0.001). Costs of preventing a mortality event and a HFH event with contemporary treatments were 15 758 USD (95% confidence interval [CI] 10 436-29 244) and 5317 USD (95% CI 3388-10 098), respectively. CONCLUSION: The higher adoption of GDMT was associated with greater medical expenses but better clinical outcomes in recently decompensated HFrEF patients.

Educational intervention in CKD retards disease progression and reduces medical costs for patients with stage 5 CKD.

BACKGROUND: Nephrologist-based multidisciplinary care (MDC) has a positive impact on slowing chronic kidney disease (CKD) progression. However, the benefits of MDC in patients with stage 5 CKD remain unclear. METHODS: Stage 5 CKD patients who visited the Chang Gung Memorial Hospital, Chiayi, Taiwan during the period of 2002-2008 were enrolled. The incident dialysis and medical cost were compared between MDC recipients and nonrecipients. The MDC recipients were divided into two groups by educational duration to observe the clinical renal outcome and medical care expenses. The effect of MDC on renal disease progression was also compared in MDC recipients with and without diabetes. RESULTS: Out of 307 patients, 171 received MDC. For MDC recipients, the temporary usage of catheter was reduced (54.7% vs. 79.4%, p < 0.001), the hospital stay was shorter (18.64 ± 1.20 vs. 24.63 ± 1.22 months, p = 0.001), and the total medical cost was lower [New Taiwan dollars (NTD) 105,948.54 ± 9,967.22 vs. NTD 160,388.61 ± 16,373.97, p = 0.005] than for nonrecipients. Out of the 171 MDC recipients, those with MDC for more than 1 year had slower renal disease progression (0.76 ± 0.27 mL/min per 1.73 m(2) per year) and had an estimated per- capita annual cost savings of about NTD 336,500.66. MDC recipients with diabetes had a higher risk of requiring dialysis than those without diabetes. CONCLUSIONS: MDC could significantly reduce temporary use of the catheter, hospital stay, and total medical costs in patients with stage 5 CKD. Furthermore, longer (>1 year) MDC could preserve renal function and deliver annual medical cost savings.

Prognostic value of acute physiology and chronic health evaluation II and organ system failure in patients with acute renal failure requiring dialysis.

BACKGROUND: Despite advances in modern technology of dialysis, prognosis of patients with acute renal failure (ARF) remains poor. To give the clinicians the most useful information, a model that accurately predicts outcome early in the course of ARF is required. However, because ARF is a heterogeneous syndrome and occurs in patients with diverse etiologies and some coexisting diseases, predicting outcome early is hard. The aim of this study is to evaluate prospectively the Acute Physiology and Chronic Health Evaluation (APACHE II) and organ system failure (OSF) models, evaluated prior to dialysis, in predicting hospital mortality. METHODS: From June 2002 to March 2004, ARF patients requiring dialysis at Chang Gung Memorial Hospital, Chiayi, were prospectively recruited for this study. The worst clinical and laboratory data in the 24 hours before initiation of dialysis were prospectively evaluated, and the patients' APACHE II score and OSF number were assessed. RESULTS: A total of 61 patients (40 male and 21 female) were enrolled, of whom 38 (62.3%) died before discharge. By multivariate logistic regression, the APACHE II score (odds ratio 1.3 per increase in one score; P<0.001), or OSF number (odds ratio 1.9 per increase in one OSF; P<0.01) and oliguria (odds ratio 4.2; P=0.04), were found to be statistically significant prognostic factors for hospital mortality. Mortality increased progressively and significantly as OSF number (chi-square for trend; P=0.001) or the APACHE II score (chi-square for trend; P < 0.001) increased. By using Youden's index, the best cut-off value for APACHE II was 24, with 63% sensitivity and 96% specificity. The best cut-off value for OSF number was 2, with a sensitivity of 81.6% and a specificity of 60.9%. The areas under the receiver operating characteristic curves for APACHE II and OSF number were 0.847 (95% confidence interval (CI)=0.752-0.942; P<0.01) and 0.769 (95% CI=0.646-892; P<0.001), respectively, indicating good model discrimination. CONCLUSIONS: This study concludes that APACHE II and OSF number measured prior to initiation of dialysis reliably predict outcomes of ARF patients requiring dialysis. The mortality rates increase as the APACHE II score or OSF number increases. For predicting mortality, the APACHE II score > or = 24 was found to have 63% sensitivity and 96% specificity, and OSF number> or = 2 had 81.6% sensitivity and 60.9% specificity.

An outbreak of methicillin-resistant Staphylococcus aureus infections related to central venous catheters for hemodialysis.

OBJECTIVES: To determine risk factors for hemodialysis catheter-related bloodstream infections (HCRBSIs) and investigate whether use of maximal sterile barrier precautions would prevent HCRBSIs. SETTING: Tertiary-care medical center hemodialysis unit. DESIGN: Open trial with historical comparison and case-control study of risk factors for HCRBSIs. METHODS: Prospective surveillance was used to compare HCRBSI rates for 1 year before and after implementation of maximal sterile barrier precautions. A case-control study compared 50 case-patients with HCRBSI with 51 randomly selected control-patients. RESULTS: The HCRBSI rate was 1.6% per 100 dialysis runs (CI95, 1.1%-2.3%) in the first year and 0.77% (CI95, 0.5%-1.1%) in the second year (P = .0106). The most frequent cause of HCRBSI was MRSA in the first year (15 of 32) and MSSA in the second year (13 of 18). Ten MRSA blood isolates in the first year were identical by PFGE. Diabetes mellitus was a risk factor for HCRBSI. Age, gender, site of hemodialysis central venous catheter (CVC), other underlying diseases, coma score, APACHE II score, serum albumin level, and cholesterol level were not associated with HCRBSI and did not change between the 2 years. Hospital stay was prolonged for case-patients (32.78 +/- 20.96 days) versus control-patients (22.75 +/- 17.33 days), but mortality did not differ. CONCLUSIONS: Use of maximal sterile barrier precautions during the insertion of CVCs reduced HCRBSIs in dialysis patients and seemed cost-effective. Diabetes mellitus was associated with HCRBSI. An outbreak of MRSA in the first year was likely caused by cross-infection via medical personnel.