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Cost-effectiveness of screening with B-type natriuretic peptide to identify patients with reduced left ventricular ejection fraction

Paul A. Heidenreich, MD, MS^*,*, Matthew A. Gubens, MS, Gregg C. Fonarow, MD, Marvin A. Konstam, MD, Lynne W. Stevenson, MD^|| and Paul G. Shekelle, MD, PhD^¶

^* VA Palo Alto Health Care System, Palo Alto, California, USA
Stanford University School of Medicine, Stanford, California, USA
University of California at Los Angeles School of Medicine, Los Angeles, California, USA
Tufts-New England Medical Center, Boston, Massachusetts, USA
^|| Brigham and Women's Hospital, Boston, Massachusetts, USA
^¶ Greater Los Angeles VA Healthcare System, Los Angeles, California, USA

View larger version (20K): [in a new window]   Figure 1 State-transition model. Each year a patient can transition between one of four health states. Patients with depressed ejection fraction (EF) may be hospitalized during each year. Transition to heart failure for patients with normal EF is not explicitly modeled, but is accounted for using age-specific medical costs and survival for the general population.

View larger version (14K): [in a new window]   Figure 2 Impact of prevalence of low ejection fraction (EF) (<40%) on the cost-effectiveness (C-E) of screening for men and women using B-type natriuretic peptide (BNP) followed by echocardiography in those with a positive test. The cost-effectiveness ratio drops below $100,000 per quality-adjusted life year (QALY) gained at a prevalence over 0.5% and drops below $50,000 at a prevalence over 1%. For any given prevalence of disease the cost-effectiveness ratio is lower for women because the accuracy of BNP is slightly greater for women then men (9). Open circles = men (BNP vs. no screen); closed circles = women (BNP vs. no screen). LV = left ventricular.

View larger version (13K): [in a new window]   Figure 3 The impact of B-type natriuretic peptide (BNP) test price (base case $32) on the cost-effectiveness (C-E) of screening with BNP followed by echocardiography is shown. At all BNP costs up to $100, screening men with BNP followed by echocardiography costs <$35,000 per quality-adjusted life year (QALY) gained compared to not screening. Circles = men; squares = women.