The impact of different perspectives on the cost-effectiveness of remote patient monitoring for patients with heart failure in different European countries.

BACKGROUND AND OBJECTIVE: Heart failure (HF) is a complex clinical syndrome with high mortality and hospitalization rates. Non-invasive remote patient monitoring (RPM) interventions have the potential to prevent disease worsening. However, the long-term cost-effectiveness of RPM remains unclear. This study aimed to assess the cost-effectiveness of RPM in the Netherlands (NL), the United Kingdom (UK), and Germany (DE) highlighting the differences between cost-effectiveness from a societal and healthcare perspective. METHODS: We developed a Markov model with a lifetime horizon to assess the cost-effectiveness of RPM compared with usual care. We included HF-related hospitalization and non-hospitalization costs, intervention costs, other medical costs, informal care costs, and costs of non-medical consumption. A probabilistic sensitivity analysis and scenario analyses were performed. RESULTS: RPM led to reductions in HF-related hospitalization costs, but total lifetime costs were higher in all three countries compared to usual care. The estimated incremental cost-effectiveness ratios (ICERs), from a societal perspective, were €27,921, €32,263, and €35,258 in NL, UK, and DE respectively. The lower ICER in the Netherlands was mainly explained by lower costs of non-medical consumption and HF-related costs outside of the hospital. ICERs, from a healthcare perspective, were €12,977, €11,432, and €11,546 in NL, the UK, and DE, respectively. The ICER was most sensitive to the effectiveness of RPM and utility values. CONCLUSIONS: This study demonstrates that RPM for HF can be cost-effective from both healthcare and societal perspective. Including costs of living longer, such as informal care and non-medical consumption during life years gained, increased the ICER.

Cost-effectiveness of remote haemodynamic monitoring by an implantable pulmonary artery pressure monitoring sensor (CardioMEMS-HF system) in chronic heart failure in the Netherlands.

AIMS: Remote haemodynamic monitoring with an implantable pulmonary artery (PA) sensor has been shown to reduce heart failure (HF) hospitalizations and improve quality of life. Cost-effectiveness analyses studying the value of remote haemodynamic monitoring in a European healthcare system with a contemporary standard care group are lacking. METHODS AND RESULTS: A Markov model was developed to estimate the cost-effectiveness of PA-guided therapy compared to the standard of care based upon patient-level data of the MONITOR-HF trial performed in the Netherlands in patients with chronic HF (New York Heart Association class III and at least one previous HF hospitalization). Cost-effectiveness was measured as the incremental cost per quality-adjusted life year (QALY) gained from the Dutch societal perspective with a lifetime horizon which encompasses a wide variety of costs including costs of hospitalizations, monitoring time, telephone contacts, laboratory assessments, and drug changes in both treatment groups. In the base-case analysis, PA-guided therapy increased costs compared to standard of care by €12 121. The QALYs per patient for PA-guided therapy and standard of care was 4.07 and 3.481, respectively, reflecting a gain of 0.58 QALYs. The resulting incremental cost-effectiveness ratio was €20 753 per QALY, which is below the Dutch willingness-to-pay threshold of €50 000 per QALY gained for HF. CONCLUSIONS: The current cost-effectiveness study suggests that remote haemodynamic monitoring with PA-guided therapy on top of standard care is likely to be cost-effective for patients with symptomatic moderate-to-severe HF in the Netherlands.

The CardioMEMS Heart Failure System for chronic heart failure - a European perspective.

INTRODUCTION: Chronic heart failure (HF) is characterized by high hospital admission rates. The CardioMEMSTM HF System is a pulmonary artery pressure sensor developed for remote hemodynamic monitoring to reduce HF hospitalizations. The device is FDA approved and CE marked, but clinical evidence for the CardioMEMS system is mainly based upon U.S. studies. Because of structural differences in HF care between the U.S. and Europe, it is important to study CardioMEMS efficacy in European setting on top of usual HF care and contemporary therapy. Several observational studies have been performed in Europe, but there is an unmet need for randomized clinical trials. AREAS COVERED: This review focuses on safety and efficacy data for CardioMEMS remote hemodynamic monitoring in European HF setting, and discusses important upcoming studies. EXPERT OPINION: For safety, data from European studies are in line with U.S. studies. Efficacy with regard to reduction of HF hospitalizations seems promising, but is merely based upon observational studies comparing pre- and post-implantation event rates. The first European randomized clinical trial (MONITOR HF) will provide efficacy data compared to actual standard care in a high-quality healthcare system with contemporary HF treatment and will provide important generalizable information to other European countries.

Future medical and non-medical costs and their impact on the cost-effectiveness of life-prolonging interventions: a comparison of five European countries.

When healthcare interventions prolong life, people consume medical and non-medical goods during the years of life they gain. It has been argued that the costs for medical consumption should be included in cost-effectiveness analyses from both a healthcare and societal perspective, and the costs for non-medical consumption should additionally be included when a societal perspective is applied. Standardized estimates of these so-called future costs are available in only a few countries and the impact of inclusion of these costs is likely to differ between countries. In this paper we present and compare future costs for five European countries and estimate the impact of including these costs on the cost-effectiveness of life-prolonging interventions. As countries differ in the availability of data, we illustrate how both individual- and aggregate-level data sources can be used to construct standardized estimates of future costs. Results show a large variation in costs between countries. The medical costs for the Netherlands, Germany, and the United Kingdom are large compared to Spain and Greece. Non-medical costs are higher in Germany, Spain, and the United Kingdom than in Greece. The impact of including future costs on the ICER similarly varied between countries, ranging from €1000 to €35,000 per QALY gained. The variation between countries in impact on the ICER is largest when considering medical costs and indicate differences in both structure and level of healthcare financing in these countries. Case study analyses were performed in which we highlight the large impact of including future costs on ICER relative to willingness-to-pay thresholds.

Estimating Quality of Life Decrements in Oncology Using Time to Death.

OBJECTIVES: The estimation of lifetime quality-adjusted life-years (QALYs) requires the extrapolation of both length and quality of life (QoL). The extrapolation of QoL has received little attention in the literature. Here we explore the predictive value of "time to death" (TTD) for extrapolating QoL in oncology. METHODS: We used QoL and survival data from the Patient Reported Outcomes Following Initial Treatment and Long-Term Evaluation of Survivorship registry, which is linked to The Netherlands Cancer Registry. QoL was assessed with EQ-5D and SF-6D. We tested the relationship between TTD and QoL using linear, 2-part, and beta regression models. Incremental QALYs were compared using the TTD approach and an annual age-related disutility approach using artificial survival data with varying mortality rates. RESULTS: A total of 6 samples with >100 patients each were used for the analysis. A declining pattern in QoL was observed when patients were closer to death, confirming the predictive value of TTD for QoL. The declining pattern in QoL was most pronounced when QoL was measured with SF-6D. Proximity to death had a larger impact on QoL than age. Incremental QALYs were higher using the TTD approach than annual age-related disutility, ranging from +0.139 to +0.00003 depending on mortality rates. CONCLUSIONS: TTD is a predictor variable for QoL. Using TTD allows cost-effectiveness models that lack QoL data to extrapolate morbidity using overall survival estimates. The TTD approach generates more incremental QALYs than an annual age-related disutility, most notably for longer survival periods.