Heart failure: enalapril is more cost-effective than hydralazine-isosorbide.

Clinical bottom line (level 1b)

  1. In patients with heart failure, enalapril is more expensive, but saves more lives than hydralazine-isosorbide.
Paul et al: Archives of Internal Medicine 1994; 154: 1143-1149
Expires November 2003

The study

Decision analysis model
Setting: general hospitals, USA

Three randomised trials of patients with congestive heart failure, who were given conventional therapy with placebo or enalapril, isosorbide dinitrate or hydralazine.

  • Viewpoint: societal
  • Benefit assessment: Deaths and hospitalisations occurring over a 10-year period following the initiation of treatment.
  • Resources and costs: Actual costs incurred by the hospital, irrespective of reimbursement from third parties and despite failure to be reimbursed by uninsured patients. On the basis of the Medicare cost report, net revenue-producing cost centres were identified, and a stepdown allocation was done into revenue-producing cost centres by the fiscal affairs department of Massachusetts General Hospital, Boston. The indirect costs and cost-to-charge ratio were incorporated into each component of unit costs by this stepdown allocation. Hospital room costs were determined by the product of the average cost per day on that floor and the length of stay. Average ancillary costs were determined in a similar way. The average total cost was $6750 (1992 US $). The average annual cost per patient for vasodilator agents was determined by a telephone survey of 10 retail pharmacies in the Boston metropolitan area. Enalapril 20 mg/d the cost was $959 and for hydralazine hydrochloride, 300 mg/d plus isosorbide-dinitrate, 160 mg/d, the cost was $437.
  • Sensitivity analysis: Duration of effectiveness of vasodilator therapy, efficacy of vasodilators, congestive heart failure mortality, cost of vasodilators, cost of hospitalisations and discounting.

    • The evidence

    intervention cost
    standard therapy $5429
    ( 4.364 years of life saved )
    standard therapy plus hydralazine hydrochloride-isosorbide dinitrate $5548
    ( 4.386 years of life saved )
    standard therapy plus enalapril $8117
    ( 4.650 years of life saved )

    • Incremental cost-effectiveness ratio for hydralazine-isosorbide was 5600 $/year of life saved.
    • Incremental cost-effectiveness ratio for enalapril was 9700 $/year of life saved.

    Comments

    1. Quality of life and utility were not included in the analysis.

    Citation

    1. Paul SD, Kuntz KM, Eagle KA, et al: Costs and effectiveness of angiotensin converting enzyme inhibition in patients with congestive heart failure. Archives of Internal Medicine 1994; 154: 1143-1149
    Contributor: Clare Wotton and Musab Hayatli, November 1999
    Reviewer:

    Clinical Question.
    Patient congestive heart failure
    Intervention or Exposure angiotensin converting enzyme inhibitors
    Comparison no ACE inhibitors
    Outcome cost-effective