Clinical study
Economic effects of beta-blocker therapy in patients with heart failure

https://doi.org/10.1016/j.amjmed.2003.07.016Get rights and content

Abstract

Background

Studies suggest that beta-blockers improve outcomes in heart failure patients and may be cost saving to society. However, many heart failure patients are not treated with beta-blockers. Economic incentives facing hospitals, physicians, payers, and patients may not encourage treatment adoption. We assessed the economic effects of beta-blocker therapy from various perspectives: societal, Medicare, hospital, physician, and patient.

Methods

A Markov model of heart failure progression over 5 years was developed. Transition probabilities and the effect of beta-blockers on mortality and hospitalization were based on clinical trial data. Estimates of hospital costs and reimbursement were obtained from the Duke University Medical Center. Physician fees were based on the Medicare fee schedule.

Results

Beta-blocker therapy increased survival by 0.3 years per patient and reduced societal costs by $3959 per patient over 5 years. Medicare costs declined by $6064 per patient, due primarily to lower hospitalization rates. Unless heart failure admissions could be replaced with other hospitalizations that generated an equal or greater revenue above variable cost, hospital revenue would be negatively affected. Physician revenue from treating heart failure patients would also decline. Patient costs increased with beta-blocker use ($2113 over 5 years).

Conclusion

Beta-blocker therapy improves the clinical outcomes of heart failure patients and is cost saving to society and Medicare. However, hospitals and physicians have no clear financial incentives to support increased beta-blocker use. Changes in practice patterns could be encouraged by linking reimbursement with evidence-based care and covering patients' medication costs.

Section snippets

Model

We developed a Markov model of heart failure progression based on the natural history of the disease (DATA 3.5; TreeAge Software, Inc., Williamstown, Massachusetts). The model included five health states: four New York Heart Association (NYHA) classes and death. A 5-year time horizon was modeled, with progression through states defined in 6-month cycles (Figure 1). Within each state, the model allowed for inpatient hospitalizations, outpatient service use, and medication use. Following

Modeled survival

Survival estimates produced by the decision model compared well with 4-year survival observed in the Digoxin trial (Figure 2). The maximum absolute difference between the survival curves was 2% (62% vs. 60% at 4 years). This correspondence suggests that the five-state Markov model with time-independent transition probabilities adequately represented disease progression for the study period.

Economic effects: baseline case

The estimated cost to society of treating a patient with heart failure without beta-blockers was $52,999

Discussion

Our results suggest that beta-blocker therapy is both clinically and financially beneficial over the long term from a societal standpoint. Similarly, beta-blockers would likely reduce Medicare expenditures for heart failure patients. The magnitude of savings would depend on the expense associated with increasing treatment adoption and adherence. There are no clear financial incentives for hospitals or providers to increase the use of beta-blockers among heart failure patients. Although patient

Acknowledgements

The authors would like to thank Wendy Gattis, PharmD, and Kevin Anstrom, PhD, for valuable input during model development, and Pamela Hale for editorial assistance.

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    Financial support for this study was provided by grant U18HS10548 (Duke Center for Education and Research on Therapeutics) from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Rockville, Maryland.

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