High dose lisinopril in heart failure:: Economic considerations

Background and Objectives. In Switzerland, heart failure (HF) is one of the ten most common causes of hospitalization in patients older than 65 and the second most common in those over 80 years. 17% of the population in Switzerland is in this age class. The expenditures associated with HF are thus considerable. High doses of the angiotensin-converting enzyme (ACE) inhibitor lisinopril in patients with heart failure have been shown to significantly reduce the risk of death or hospitalization for heart failure and for any reason. The objective of the present study was to analyze the economic implications of using high doses of lisinopril in the Swiss health care system setting, both from the societal perspective and from that of the Swiss health insurers. Patients and Methods. Using published data from the ATLAS Trial, we computed the monthly probability of death and of hospital admission for heart failure, ischemic events, other cardiovascular causes and any reason per patient for both arms of the trial. Swiss resource use patterns and Swiss unit costs were used to calculate expected monthly expenditures per patient from the third party payer perspective and from the societal viewpoint. Extensive sensitivity analyses were performed to test the robustness of our results. Results. Expected monthly expenditures from the third party payer perspective are EUR 347 per patient in the low dose group and EUR 319 in the high dose group. This represents expected savings of EUR 28 per patient monthly. Because the public sector pays more than 50% of hospital costs, the savings from the societal viewpoint are greater. Expected monthly costs from the societal perspective are EUR 762 in the low dose group and EUR 670 in the high dose group per patient. This results in expected monthly savings of EUR 92. Sensitivity analysis shows that the use of high doses of ACE inhibitor lisinopril does not result in higher health care expenditures for the whole system or even savings through a wide variety of practice patterns and unit costs. Conclusions. Based on the results of the ATLAS study, high doses of lisinopril are associated with a reduction in the number of hospitalizations for HF and for any reason and with a statistically non-significant reduction in mortality. The additional expenditures incurred because of prescription of high doses are offset by the savings in hospital costs. These are important considerations, given the increasing number of people aged 65 and older in Switzerland, and the prevalence of heart failure in this age group.