ABSTRACT
BACKGROUND: Sacubitril/valsartan (an Angiotensin receptor-neprilysin inhibitor-ARNI) is one of the cornerstones in the management of patients with heart failure with reduced ejection fraction (HFrEF) having demonstrated significant reductions in both mortality and hospitalisations as compared with enalapril. It proved to be a cost-effective treatment in many countries with stable economies. In Argentina, a country with chronic financial instability and a fragmented health care system, the estimation of its cost-effectiveness requires to consider local financial data. OBJECTIVES: To estimate the cost-effectiveness of sacubitril/valsartan in HFrEF in Argentina. METHODS: We populated an Excel-based cost-effectiveness model, previously validated, using inputs from the pivotal phase-3 PARADIGM-HF trial and from local sources. As the main problem to consider was the financial instability, we adopted a differential approach to cost discounting based on the opportunity cost of capital. Thus, a discount rate for costs were set at 31.6%, using the BADLAR rate published by the Central Bank of Argentina. Discount for effects were set at 5% as is the current practice. Costs were expressed in Argentinian pesos (ARS). We used the perspective for both the social security and private payers at a 30-year horizon. The primary analysis was the incremental cost-effectiveness ratio (ICER) versus enalapril, the previous standard of care. Alternative scenarios performed included a 5% cost discount rate and 3 a 5-year horizon (as is usually used). RESULTS: In Argentina the cost-per quality adjusted life-year (QALY) gained for sacubitril/valsartan versus enalapril was 391,158 ARS and 376,665 ARS for a social security and a private payer, respectively, at a 30- year horizon. These ICERs were under the cost- effectiveness threshold of 520,405.79 ARS (1 Gross domestic product (GDP) per capita) suggested by Argentinian health technology assessment bodies. Probabilistic sensitivity analysis showed an acceptability of sacubitril/valsartan as a cost-effective alternative of 86.40% and 88.25% for social security and private payers, respectively. CONCLUSION: Sacubitril/valsartan is a cost-effective treatment in HFrEF using local inputs that considered the financial instability. For both payers considered the cost per QALY gained are under the cost-effectiveness threshold considered.
ABSTRACT
OBJECTIVES: The aim of this study was to develop consensus among Argentine cardiologists on a care bundle to reduce readmissions of patients with heart failure (HF). SETTING: Hospitals and cardiology clinics in Argentina that provide in-hospital care for patients with HF. PARTICIPANTS: Twenty-four cardiology experts participated in the two online rounds and 18 (75%) of them participated in the third-round meeting. METHODS: This study used a mixed-method design; it was conducted between August 2019 and January 2020. The development of a care bundle (a set of evidence-based interventions applied to improve clinical outcomes) involved three phases: (1) a literature review to define the list of interventions to be evaluated; (2) a modified Delphi panel to select interventions for the bundle and (3) definition of the HF care bundle. Also, the process included three rounds of scoring. RESULTS: Twenty-six interventions were evaluated. The interventions in the final bundle covered four categories: medication, continuum of care, lifestyle habits, predischarge tests. These were: medication: beta-blockers, angiotensin receptor neprilysin inhibitors or ACE-inhibitors, furosemide and antimineralocorticoids; continuum of care: follow-up appointment, daily weight monitoring; lifestyle habits: smoking cessation counselling and low-sodium diet; predischarge tests: renal function, ionogram, blood pressure control, echocardiogram and determination of decompensating cause. CONCLUSION: Following a systematic mixed-method approach, we have developed a care bundle of interventions that could decrease readmission of patients with HF. The application of this bundle could contribute to scale evidence-based interventions.
