Patients hospitalized with a common form of heart failure could avoid later hospital stays – and dramatically lower health care costs – if they receive the full combination of four medications currently recommended in national treatment guidelines, according to research led by UCLA Health and published in JAMA Cardiology.
Analyzing Medicare-linked data from more than 50,000 patients 65 or older with a condition called heart failure with reduced ejection fraction, or HFrEF, researchers found that full implementation of the recommended drug therapy could dramatically reduce rehospitalizations during the year after discharge. These results could lower hospitalization-related costs by nearly $10,000 per patient annually.
“Heart failure hospitalizations place a significant financial burden on patients, families and the broader health care system – costs that extend well beyond the initial hospital stay. Improving use of guideline-recommended heart failure therapies isn’t just the right clinical move to enhance survival. It may also lower the downstream costs driven by repeat hospitalizations,” said Dr. Gregg Fonarow, director of the Ahmanson-UCLA cardiomyopathy center at UCLA Health, and the paper’s senior author. “Our findings suggest that getting patients on all four key medications could deliver real value for both patients and health systems.”
Randomized clinical trials have shown that therapy using four classes of medications reduces hospitalizations and improves outcomes. Together, the four drugs form the foundation of the current standard of care – called quadruple guideline-directed medical therapy, or GDMT – but the full four-drug approach tends to be underused, the authors said, presenting a persistent challenge to heart failure care.
Heart failure with reduced ejection fraction is a chronic condition in which the heart cannot pump blood effectively enough to meet the body’s needs. It is one of the most common reasons older adults are hospitalized in the U.S., and many patients return to the hospital repeatedly.
In their study, the researchers found that the average one-year total health care cost after hospitalization for heart failure was $41,802 per patient, with $25,172 coming from hospitalizations alone. Based on modeling, they estimated that hospitalization costs would fall by about $9,780 per patient per year with implementation of full four-drug therapy, which was associated with a 61% reduction in all-cause hospitalizations and an 87% reduction in heart failure hospitalizations.
The final analysis weighs hospitalization costs against drug costs, and in this study, some medication combinations resulted in higher net cost, especially when newer or more expensive drugs were used. But many lower-priced or generic versions produced overall savings after accounting for fewer hospitalizations. In fact, using a variety of medication pricing assumptions in their calculations, the investigators found that most scenarios provided net savings when optimal drug therapy was used. And as drug prices evolve and more medications become available in generic form, the balance between medication spending and hospitalization savings may shift even more toward net cost savings.
“Prior cost analyses often focused on individual therapies or relied on trial-based models, but in this study, we used real-world Medicare data to calculate the combined economic impact of implementing all four therapies after a heart failure hospitalization in a contemporary, real-world population,” said Dr. Mohammad Keykhaei, an internal medicine resident at UCLA Health and the paper’s first author.
“Our findings reinforce that patients receiving optimal therapy after hospitalization may be at reduced risk of future hospitalizations and the associated costs,” he said. “For clinicians and health systems, the study highlights the importance of closing treatment gaps, improving medication access, and initiating or optimizing guideline-based therapy before and after hospital discharge.”
The investigators used Medicare-linked data from the American Heart Association’s Get With The Guidelines – Heart Failure registry, including 50,598 Medicare beneficiaries hospitalized with HFrEF between 2016 and 2020. They calculated actual Medicare Part A and Part B health care costs through one year after discharge. Then they used treatment-effect estimates from major clinical trials of guideline medications to model the expected reduction in hospitalizations if eligible patients received optimal therapy with all four drugs. Finally, they combined the projected hospitalization cost reductions with estimated annual medication costs to project the net annual cost impact of optimal quadruple therapy. Depending on different drug pricing assumptions, the net annual impact ranged from $8,556 in savings to $6,347 in costs, with most scenarios resulting in net savings with optimal drug therapy.
The study estimated drug costs under three scenarios including no guideline-directed therapy, partial therapy, and optimal quadruple therapy, which uses four classes of medications: angiotensin receptor-neprilysin inhibitors (ARNIs); beta blockers; mineralocorticoid receptor antagonists (MRAs); and sodium-glucose cotransporter 2 inhibitors (SGLT2i).
“The magnitude of the projected hospitalization cost offset when the therapies were considered together was particularly noteworthy,” Fonarow said. “These findings underscore the importance of ensuring patients with heart failure leave the hospital on the right medications promptly, in line with established treatment guidelines.”
