PERSONALIZED TREATMENT IN HEART FAILURE DISEASE MANAGEMENT IMPROVES OUTCOMES AND REDUCES COSTS

Purpose:   Although several prognostic models have been developed to stratify heart failure (HF) patients into different risk categories, these models are not yet routinely applied in daily clinical practice to guide the selection of therapy. The purpose of this study was to determine to what extent assigning different disease management programs (DMPs) to different risk groups of HF patients could improve outcomes and reduce costs.

Method:   The analysis was conducted alongside the COACH study, a randomized controlled trial in which three DMPs were evaluated: care-as-usual (routine follow-up by a cardiologist); basic additional support by a nurse specialized in HF management; intensive additional support by a nurse specialized in HF management. Subpopulation Treatment Effect Pattern Plot (STEPP) methodology was applied to graphically explore the treatment-mortality risk interaction based on which cut-offs for stratifying patients into different risk categories were selected. Cost-effectiveness analysis was performed within each risk category to determine which of the three DMPs would be preferred in each of these categories. Inverse probability weighting was used to estimate the mean quality-adjusted survival time with the utilities derived from the patients’ SF-36 scores. Total cost was estimated by aggregating the costs for various categories. For each category, resource use was multiplied by unit costs to obtain the total cost for this category.

Result:   The cut-off was selected as 0.17 for patients’ 18-months predicted all-cause mortality to stratify 346 (33.8%) patients into low risk category and 677 (66.2%) patients into high risk category. For low risk patients, intensive support was found to dominate care-as-usual with €653 (95% CI: €-2,283~€3,636) less cost and 19.5 days (95% CI: 3.1~36.2) longer survival. It was found to dominate basic support with €2,084 (95% CI: €-787~€4,942) less cost and 16.9 days (95% CI: 0~33.4) longer survival. For high risk patients, basic support was found to dominate care-as-usual with €704 (95% CI: €-2,067~€3,393) less cost and 10.7 days (95% CI: -12.2~34.6) longer survival. It was found to dominate intensive support with €3,152 (95% CI: €197~€5,994) less cost and 15.5 days (95% CI: -6.7~39.4) longer survival.

Conclusion:   Assigning different DMPs to different risk groups of patients improved outcomes and reduced costs. Applying personalized treatment in daily clinical practice is therefore desired in HF disease management.