Table 2

Presentation of costs and consequences from the use of ACE inhibitors in the treatment of heart failure. Net cost and benefit per patient of ACE inhibitors for heart failure

Assumptions (optimistic or conservative)aOptimisticConservative
aCosts and benefits are shown which arise from the addition of ACE inhibitors to current care. Diagnosis costs are excluded because of the variation in tests performed, the lack of adequate cost data, and because these costs may occur in any case as part of normal care. Costs presented here are overestimates as withdrawal from treatment has not, for simplicity, been included.
bCost per: GP consultation £10 (excluding prescribing cost).29 Outpatient visit £69.30 Costs of additional blood tests are excluded as no adequate cost data were found.
cCalculation based on: Difference in Studies of Left Ventricular Dysfunction (SOLVD) trial treatment and control hospitalisation rates (21.9–15.4%) × 4 years. Inpatient stay of 14.5 days.31 Inpatient day £166.30
d Since patients visit their GPs on average once a year in relation to heart failure, it is not plausible to assume an optimistic reduction in GP visits although treatment does delay disease progression and associated morbidity.
eBased on the placebo controlled findings of the SOLVD treatment trial, improved survival was highly statistically significant (p = 0.0036, stratified log rank test). However, the survival gain calculation (using Irwin's restricted mean) does not provide a useful confidence interval. The point estimate is thus used in optimistic and conservative scenarios. Future costs and benefits are not discounted because of the short four year time frame and because all important costs are distributed along with the benefit in time. Discounting will not substantially alter the cost effectiveness ratios.
fSurvival gains are truncated in the SOLVD trial and it is reasonable to presume that, if treatment stopped, there would be some additional benefit after cessation of therapy. However, this is not modelled since it is probable that treatment would continue and so both costs and benefits would occur after four years.
ACE inhibitor £100/year or £340/year for four years£400£1400
Initiation of therapy by two GP visits or two outpatient visitsb£20£138
Reduced hospitalisation or no reduced hospitalisationc−£626£0
GP visits related to heart failure unchanged or one extra visit/year for four yearsd£0£48
Net cost range−£206£1578
Increased life expectancy (based on placebo comparison)e0.203 years0.203 years
Incremental cost effectiveness of implementing ACE inhibitor therapyfSmall cost saving and health gain£7770 / life year gained