Heart failure: digoxin continuation was cost effective.

Clinical bottom line (level 2b)

  1. In patients with heart failure, the continuation of digoxin therapy decreased the cost and increases the health benefits, when compared with withdrawal of the treatment.
Ward et al: Journal of the American College of Cardiology 1995; 26: 93-101
Expires November 2003

The study

Decision analysis
Setting: general hospitals, USA

Two previous trials- Prospective Randomized Study of Ventricular Failure and Efficacy of Digoxin (PROVED) and Randomized Assessment of Digoxin and Inhibitors of Angiotensin-Converting Enzyme (RADIANCE).

  • Viewpoint: Health care system
  • Benefit assessment: Treatment failures, causes of digoxin toxicity and health care costs.
  • Resources and costs: Estimates from Henry Ford Hospital and the Health Care Finance Administration were used to calculate costs (in 1991 dollars). Assumed that digoxin therapy costs $60/year, serum digoxin concentration monitoring costs $50/year, each clinic visit for heart failure costs $100 and that each emergency visit for heart failure costs $363. It was also assumed that heart failure hospital admission cost $3,844 and that the average cost to treat an episode of digoxin toxicity was $1,000.
  • Sensitivity analysis: One-way sensitivity analysis for % heart failure patients meeting criteria, relative risk of therapy failure without ACE inhibitor in week 1-12, prevalence in the USA, baseline annual risk of hospitalisation effectiveness during weeks 13-52 relative to weeks 1-12, relative risk of therapy failure with ACE inhibitor in weeks 1-12, cost of hospitalisation , proportion of patients on ACE inhibitors, cost of digoxin therapy per patient per year, cost of digoxin serum level monitoring per patient per year, cost of physician visit, annual incidence of digoxin toxicity, cost to treat average episode of digoxin toxicity, baseline emergency visits as % of admissions, baseline clinic visits per year as % of admissions and cost of heart failure emergency department visits.
    • Epidemiologic assumptions were derived from published reports and expert opinion.

    The evidence

    intervention cost
    withdrawal of digoxin $1,094 million per year
    continuation of digoxin $688 million per year

    • Continuation of digoxin therapy results in a saving of $406 million/year

    Citation

    1. Ward RE, Gheorghiade M, Young JB, et al: Economic outcomes of withdrawal of digoxin therapy in adult patients with stable congestive heart failure. Journal of the American College of Cardiology 1995; 26: 93-101
    Contributor: Clare Wotton and Musab Hayatli, November 1999
    Reviewer:

    Clinical Question.
    Patient stable congestive heart failure
    Intervention or Exposure withdrawal of digoxin therapy
    Comparison not withdrawing
    Outcome economic outcomes