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Cost Offset With SGLT2 Inhibitors After HF Hospitalization
Quick Takes
- Mean health care costs 1-year post-discharge from hospitalization for HF were found to be $40,557 and primarily driven by hospitalizations.
- A meta-analysis of five SGLT2i trials estimated an 11% and 29% reduction in all-cause and HF hospitalizations, respectively.
- Implementation of SGLT2i therapy in eligible HF patients was projected to reduce costs by $1,439 to $2,668 per patient over 1-year post-discharge, depending on LVEF and excluding drug costs.
Study Questions:
What is the forecasted cost offset that could be realized with optimal implementation of sodium glucose co-transporter 2 inhibitor (SGLT2i) therapy for patients with heart failure (HF) with left ventricular ejection fraction (LVEF) ≤40% and >40%?
Methods:
This study linked the Get With The Guidelines–Heart Failure (GWTG-HF) registry with Medicare claims data to compare total and cause-specific costs among patients hospitalized with HF between January 1, 2016 and December 31, 2020, subdivided by LVEF ≤40% and >40%. A trial-level meta-analysis of five SGLT2i trials (DAPA-HF, EMPEROR-Reduced, EMPEROR-Preserved, SOLOIST-WHF, and DELIVER) was used to estimate the effect of SGLT2i on total all-cause and HF hospitalizations, which were then used to estimate the cost offset if SGLT2i were initiated for the SGLT2i-eligible GTWG-HF cohort.
Patients were included if they were admitted to a participating hospital with a primary HF diagnosis with continuous Medicare part A and B coverage for ≥1-year post-discharge or until death. Patients were excluded if they were missing sex, age, or LVEF values; died during the index hospitalization; received advanced HF therapies; discharged to hospice care or against medical advice; or transferred to another acute care facility. Patients with estimated glomerular filtration rate <20 mL/min/1.73 m2, type 1 diabetes, and chronic or in-hospital dialysis were excluded for the estimated cost offset with the SGLT2i-eligible cohort.
Results:
A total of 146,003 HF patients were included for overall cost analysis with more patients with LVEF >40% (65.3%) compared to LVEF ≤40%. Patients with LVEF >40% were more likely to be older, female, White, and have higher systolic blood pressure and body mass index, lower natriuretic peptides, and higher costs attributed to non-HF and non-cardiovascular (CV) hospitalizations and skilled nursing facilities. Patients with LVEF ≤40% were more likely to have higher costs attributed to all-cause hospitalizations and HF or CV hospitalizations. The mean total health care costs through 1-year post-discharge were $40,557 and were similar across LVEF groups (p = 0.48) with the largest contributor to cost being all-cause hospitalization.
This trial level meta-analysis of HF outcome trials demonstrated that SGLT2i significantly reduced the rate of all-cause hospitalizations (rate ratio [RR], 0.89; 95% confidence interval [CI], 0.84-0.93) and total HF hospitalizations (RR, 0.71; 95% CI, 0.66-0.76) with no evidence of heterogeneity across trials. A total of 133,914 SGLT2i-eligible patients were included for the cost-offset analysis. Applying the relative risk reduction of SGLT2i to all-cause hospitalization resulted in an anticipated mean hospitalization cost offset of $2,668 and $2,410 per patient with LVEF ≤40% and >40%, respectively. The projected mean hospitalization cost reduction for HF hospitalizations was $2,451 (LVEF ≤40%) compared to $1,439 (LVEF <40%) per patient. Using the annual US costs of SGLTi (range $2,892 to $7,428) resulted in a projected annual net cost ranging from cost excess of $5,018 to cost savings of $2,092, depending on LVEF and actual drug cost.
Conclusions:
This large cohort of older adults hospitalized for HF demonstrated different cause-specific costs of care between patients with LVEF ≤40% and >40%. SGLT2i significantly reduced the rate of HF and all-cause hospitalizations irrespective of LVEF in clinical trials, and optimal implementation of SGLT2i is projected to reduce costs by $1,439 to $2,668 per patient over 1-year post-discharge.
Perspective:
This large cohort of older adults with Medicare found high overall health care costs for HF with recurrent hospitalization confirmed as a significant driver of health care costs, affirming the importance of reduction efforts. The pooled findings from five major trials of SGLT2i in patients with HF found they reduced the relative rate of both all-cause and HF hospitalizations with no heterogeneity despite trial variance in including patients with LVEF ≤40% and >40%. This study also highlights the importance of accounting for the competing risk of death in data for health care costs, as seen by the 35.2% of patients (more with LVEF ≤40%) who died within 1-year post-discharge, as this exerted a downward pressure on total costs. Of note, the patients in the GWTG-HF registry had low prescribing rates for mineralocorticoid receptor antagonists (27.2% vs. 12% for LVEF ≤40% and >40%, respectively), which also impact hospitalizations and mortality.
A significant limitation of this trial is the lack of accounting for drug costs in projecting hospitalization cost reduction, as affordability of these agents often poses a challenge. Providers should explore cost-savings programs with patients eligible for manufacturer patient assistance programs, grants, or co-pay assistance cards (non–government-sponsored insurance) to minimize patient costs for SGLT2i when possible.
Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure, Cardiovascular Care Team
Keywords: Costs and Cost Analysis, Heart Failure, Sodium-Glucose Transporter 2 Inhibitors
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