A health economic evaluation of the TriageHF Plus clinical care pathway for device-based remote monitoring of heart failure

Abstract Introduction TriageHF Plus is a remote monitoring clinical care pathway designed for people with heart failure (HF) and a compatible implanted cardiac device (CIED), recently endorsed by the National Institute for Health and Care Excellence (NICE, DG61) 1. Continuously monitored physiological parameters feed into the TriageHF algorithm, which calculates risk of ensuing HF hospitalisation. High risk triggers an automated "HF alert" transmission, prompting a telephone-based review and 30-day call by a HF specialist, typically a specialist nurse. The entire pathway is designed to promote disease stability, synergistically optimise guideline-directed medical therapy and prevent avoidable hospitalisations. The pathway has been proven to significantly reduce hospitalisations by up to 58% 2. Purpose To evaluate the cost-effectiveness of TriageHF Plus based on the NICE threshold of £20,000 per quality-adjusted life year gained. Methods This evaluation used data from the TriageHF study which enrolled 758 patients with a compatible CIED over a mean follow-up of 433.6 days across Greater Manchester, UK. A two-state economic model was developed to capture the lifetime cost-effectiveness of TriageHF Plus compared with usual care (device alerts not activated). Intervention costs included infrastructure, staffing, pathway resource use, and health care utilisation. The base-case model assumed a 300-participant centre monitoring all patients with a compatible CIED. A variety of assumptions and scenarios were tested including pre-COVID19 time horizon, HF population only, 1- and 5- year time horizons and device type using both in-trial results, and publicly available reference data. Cost effectiveness relative to usual care was assessed by incremental cost-effectiveness ratio and net monetary benefit (NMB). Results The lifetime cost of managing a patient with the TriageHF Plus pathway (regardless of site size) was £11,563 (CI: £9,629-£13,987), compared with £15,551 (CI: £14,560–£16,619) for usual care, where CI = 95% confidence intervals. The lifetime costs for pathway implementation (£741), infrastructure (£549), and cost of managing HF alerts £192 (CI: £156–£233) were outstripped by cost-savings from avoided hospitalisations (total savings £3,988 per patient). In the base-case model, the probability of cost-effectiveness was 99.4% based on 10,000 lifetime simulations (see Figure 1). NMB per patient was £740 (CI: £337-£1,034) for the first year of monitoring, £2,885 (CI: £1,433-£4,049) for five years, and £4,158 (CI: £1935-£5,781) across a lifetime. In all stated scenarios, TriageHF Plus was dominant (cost saving) over usual care (Table 1). Conclusion TriageHF Plus is a cost-effective and cost-saving option for the remote monitoring of HF in patients with compatible CIEDs. Combined with proven clinical effectiveness, this study provides a strong case for national implementation to improve patient outcomes with effective use of NHS resources.Figure 1:Cost-effectiveness plane Table 1:Additional scenario analyses