Health Care Spending After Initiating Sacubitril-Valsartan vs Renin-Angiotensin System Blockers for Heart Failure Treatment

Abstract

Importance: For patients with heart failure with reduced ejection fraction (HFrEF), treatment with sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor, has become increasingly preferred over angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin II receptor blockers (ARBs). However, sacubitril-valsartan is much more expensive than generic ACE-I/ARBs. It is unknown whether the high cost of sacubitril-valsartan is offset by lower spending on hospitalizations and other treatments. Objective: To compare total and out-of-pocket health care spending among Medicare beneficiaries initiating sacubitril-valsartan vs ACE-I/ARBs for HFrEF. Design, Setting, and Participants: This was a cohort study using data from Medicare fee-for-service claims with propensity score matching of Medicare beneficiaries with HFrEF. Data analysis was performed from November 2022 to December 2023. Exposure: Initiation of sacubitril-valsartan or an ACE-I/ARB. Patients were matched by propensity score based on 104 covariates, including demographic characteristics, comorbidities, baseline annual spending, and baseline use of health care services. Main Outcomes and Measures: Mean total and out-of-pocket health care expenditures during the 365 days after initiating sacubitril-valsartan or an ACE-I/ARB. Censoring for incomplete follow-up was addressed using Kaplan-Meier probability weighting. Cost differences, cost ratios, and 95% CIs were calculated using a nonparametric bootstrapping method with 500 samples drawn with replacement. Results: Among 13755 matched pairs of Medicare patients with HFrEF (mean [SD] age, 77.5 [7.5] years; 5138 [39%] 80 years or older; 9949 females [36%] and 17 561 males [64%]), mean annual total health care spending per person was similar for sacubitril-valsartan initiators and ACE-I/ARB initiators (difference, $701; 95% CI, -$132 to $1593). Sacubitril-valsartan initiators had higher prescription drug costs (difference, $1911; 95% CI, $1704 to $2113), lower inpatient costs (difference, -$790; 95% CI, -$1468 to -$72), lower outpatient costs (difference, -$330; 95% CI, -$664 to -$11), and higher annual out-of-pocket spending (difference, $109; 95% CI, $13 to $208). Conclusions and Relevance: This cohort study found that Medicare beneficiaries initiating sacubitril-valsartan to treat HFrEF had similar total health care spending as those initiating ACE-I/ARBs; higher prescription drug spending was offset by lower inpatient and outpatient spending. However, sacubitril-valsartan use was associated with higher patient out-of-pocket costs, which may exacerbate health disparities and limit access and affordability.