• Alexander T Sandhu, Daniel A Ollendorf, Richard H Chapman, Steven D Pearson, and Paul A Heidenreich.
• From Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, and Stanford University School of Medicine, Stanford, California; and Institute for Clinical and Economic Review, Boston, Massachusetts.
• Ann. Intern. Med. 2016 Nov 15; 165 (10): 681-689.

BackgroundSacubitril-valsartan therapy reduces cardiovascular mortality compared with enalapril therapy in patients with heart failure with reduced ejection fraction.ObjectiveTo evaluate the cost-effectiveness of sacubitril-valsartan versus angiotensin-converting enzyme inhibitor therapy in patients with chronic heart failure.DesignMarkov decision model.Data SourcesClinical 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 PopulationPatients at an average age of 64 years, New York Heart Association (NYHA) class II to IV heart failure, and left ventricular ejection fraction of 0.40 or less.Time HorizonLifetime.PerspectiveSocietal.InterventionTreatment with sacubitril-valsartan or lisinopril.Outcome MeasuresLife-years, quality-adjusted life-years (QALYs), costs, heart failure hospitalizations, and incremental cost-effectiveness ratios.Results Of Base Case AnalysisThe 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 AnalysisSacubitril-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.LimitationThe benefit of sacubitril-valsartan is based on a single clinical trial.ConclusionTreatment with sacubitril-valsartan provides reasonable value in reducing cardiovascular mortality and morbidity in patients with NYHA class II to IV heart failure.Primary Funding SourceU.S. Department of Veterans Affairs and Institute for Clinical and Economic Review.

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