Pharmacotherapy sequencing strategies for patients with heart failure with reduced ejection fraction: a cost–utility analysis

Figures

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  Figure 1:. State transition diagram for the microsimulation model of pharmacotherapy initiation and titration in patients with heart failure with reduced ejection fraction (HFrEF). Solid arrows represent transitions between primary health states occurring between cycles. Dashed arrows denote transitions within each cycle while the patient remains in the “HF stable” state. Orange arrows indicate transitions affected by HFrEF medications. Note: HF = heart failure. See Related Content tab for accessible version.

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  Figure 2:. Pharmacotherapy sequencing strategy profiles used in the model. The figure provides a visual representation of each profile through sequencing steps and walks. Each walk represents 1 week in practice and 1 cycle in the model, with each step corresponding to each initiation or titration. Thus, each adjustment visit (i.e., step) occurs every 2 weeks/walks for version a, and every week/walk for version b. The number of up-titration visits required to achieve the target dose for each medication is as follows: ACEI/ARB/ARNI = 3 visits (ARNI = 2 visits for those previously on ACEI/ARB); BB = 4 visits; MRA = 2 visits; SGLT2I = 1 visit. Note: ACEI = angiotensin-converting enzyme inhibitor, ARB = angiotensin receptor blocker, ARNI = angiotensin receptor–neprilysin inhibitor, BB = β-blocker, MRA = mineralocorticoid receptor antagonist, SGLT2I = sodium–glucose cotransporter-2 inhibitor. See Related Content tab for accessible version.

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  Figure 3. Cost-effectiveness acceptability curve showing the results of the 5000 simulations conducted in the probabilistic analysis. The x-axis indicates the willingness-to-pay range ($0–$100 000/QALY), and the y-axis represents the proportion (%) of simulations a strategy has the highest net monetary benefit, indicating the probability of 1 strategy being the most cost-effective strategy at that particular willingness-to-pay threshold. The strategy that is most likely to be cost-effective at a certain willingness-to-pay threshold will have its curve on top of the others. Legends for strategies are ordered from the highest to lowest probability of being cost-effective at a willingness-to-pay threshold of $50 000.

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  Figure 4:. Tornado diagram showing the results of a 1-way deterministic sensitivity analysis of the net monetary benefit (NMB) for a willingness-to-pay threshold of $50 000/QALY. Variables tested in the 1-way sensitivity analysis are displayed on the y-axis, and the x-axis represents the NMB. Variables are followed by the values of their range considered in the analysis. Variables with the greatest impact on the result are shown with a wider line at the top. The most relevant variables in the model were the discount rate, the mortality rate during follow-up and in-trial periods, and heart failure (HF) hospital admission rate. The expected NMB of the best comparator (profile 6a) at the base value is represented by expected value. Rates’ values are reported as per 100 person-years.