Division of Cardiovascular Medicine, Department of Medicine, University of California, Davis, Sacramento (N.M.D.).
School of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles (N.U.P.).
Circ Heart Fail. 2023 Dec;16(12):e011218. doi: 10.1161/CIRCHEARTFAILURE.123.011218. Epub 2023 Nov 6.
The STRONG-HF trial (Safety, Tolerability and Efficacy of Up-Titration of Guideline-Directed Medical Therapies for Acute Heart Failure) demonstrated substantial reductions in the composite of mortality and morbidity over 6 months among hospitalized patients with heart failure (HF) who were randomized to intensive guideline-directed medical therapy (GDMT) optimization compared with usual care. Whether an intensive GDMT optimization program would be cost-effective for patients with HF with reduced ejection fraction is unknown.
Using a 2-state Markov model, we evaluated the effect of an intensive GDMT optimization program on hospitalized patients with HF with reduced ejection fraction. Two population models were created to simulate this intervention, a clinical trial model, based on the participants in the STRONG-HF trial, and a real-world model, based on the Get With The Guidelines-HF registry of patients admitted with worsening HF. We then modeled the effect of a 6-month intensive triple therapy GDMT optimization program comprised of cardiologists, clinical pharmacists, and registered nurses. Hazard ratios from the intervention arm of the STRONG-HF trial were applied to both population models to simulate clinical and financial outcomes of an intensive GDMT optimization program from a US health care sector perspective with a lifetime time horizon. Optimal quadruple GDMT use was also modeled.
An intensive GDMT optimization program was extremely cost-effective with incremental cost-effectiveness ratios <$10 000 per quality-adjusted life-year in both models. Optimal quadruple GDMT implementation resulted in the most gains in life-years with incremental cost-effectiveness ratios of $60 000 and $54 000 in the clinical trial and real-world models, respectively.
An intensive GDMT optimization program for patients hospitalized with HF with reduced ejection fraction would be cost-effective and result in substantial gains in clinical outcomes, especially with the use of optimal quadruple GDMT. Clinicians, payers, and policymakers should prioritize the creation of such programs.
STRONG-HF 试验（急性心力衰竭患者指南指导的药物治疗升级的安全性、耐受性和疗效）表明，与常规治疗相比，接受强化指南指导的药物治疗（GDMT）优化的住院心力衰竭（HF）患者的死亡率和发病率复合终点在 6 个月时显著降低。对于射血分数降低的 HF 患者，强化 GDMT 优化方案是否具有成本效益尚不清楚。
使用 2 状态马尔可夫模型，我们评估了强化 GDMT 优化方案对射血分数降低的 HF 住院患者的影响。创建了两种人群模型来模拟这种干预，一种是基于 STRONG-HF 试验参与者的临床试验模型，另一种是基于 Get With The Guidelines-HF 登记的因 HF 恶化而入院的患者的真实世界模型。然后，我们对包含心脏病专家、临床药师和注册护士的 6 个月强化三联 GDMT 优化方案进行建模。将 STRONG-HF 试验干预组的风险比应用于这两种人群模型，以从美国医疗保健部门的角度模拟强化 GDMT 优化方案的临床和财务结果，采用终生时间范围。还对最佳四重 GDMT 使用进行了建模。
在这两种模型中，强化 GDMT 优化方案具有极高的成本效益，增量成本效益比均低于每质量调整生命年 10000 美元。最佳四重 GDMT 实施在临床试验和真实世界模型中分别导致生命年的最大获益，增量成本效益比分别为 60000 美元和 54000 美元。
对于因射血分数降低的 HF 而住院的患者，强化 GDMT 优化方案具有成本效益，并可显著改善临床结局，尤其是使用最佳四重 GDMT。临床医生、支付者和政策制定者应优先制定此类方案。
