Background:Sacubitril–valsartan therapy reduces cardiovascular mortality compared with enalapril therapy in patients with heart failure with reduced ejection fraction. Objective:To evaluate the cost-effectiveness of sacubitril–valsartan versus angiotensin-converting enzyme inhibitor therapy in patients with chronic heart failure. Design:Markov decision model. Data Sources:Clinical trials, observational analyses, reimbursement data from the Centers for Medicare & Medicaid Services, drug pricing databases, and Centers for Disease Control and Prevention life tables. Target Population:Patients with an average age of 64 years, New York Heart Association (NYHA) class II to IV heart failure, and a left ventricular ejection fraction of 0.40 or less. Time Horizon:Lifetime. Perspective:Societal. Intervention:Treatment with sacubitril–valsartan or lisinopril. Outcome Measures:Life-years, quality-adjusted life-years (QALYs), costs, heart failure hospitalizations, and incremental cost-effectiveness ratios. Results of Base-Case Analysis:The sacubitril–valsartan group experienced 0.08 fewer heart failure hospitalization, 0.69 additional life-year, 0.62 additional QALY, and $29 203 in incremental costs, equating to a cost per QALY gained of $47 053. The cost per QALY gained was $44 531 in patients with NYHA class II heart failure and $58 194 in those with class III or IV heart failure. Results of Sensitivity Analysis:Sacubitril–valsartan treatment was most sensitive to the duration of improved outcomes, with a cost per QALY gained of $120 623 if the duration was limited to the length of the trial (median, 27 months). No variations in other parameters caused the cost to exceed $100 000 per QALY gained. Limitation:The benefit of sacubitril–valsartan is based on a single clinical trial. Conclusion:Treatment with sacubitril–valsartan provides reasonable value in reducing cardiovascular mortality and morbidity in patients with NYHA class II to IV heart failure. Primary Funding Source:U.S. Department of Veterans Affairs and Institute for Clinical and Economic Review.
Ann Intern Med. Published online 30 August 2016 doi:10.7326/M16-0057