OBJECTIVES: To assess the incremental cost-effectiveness of sacubitril/valsartan compared with an ACE inhibitor (ACEI), enalapril, in the treatment of chronic heart failure with reduced ejection fraction (HFrEF) in Singapore.

METHODS: Previously developed UK cost-effectiveness model based on PARADIGM-HF trial was adapted using Singapore specific epidemiologic and economic data to assess the impact of sacubitril/valsartan compared with enalapril. A regression-based cohort model was developed, incorporating hospitalizations, adverse events and deaths. Utilities were calculated as functions of these events as well as of patient characteristics, time from randomization and treatment. UK EQ-5D tariff was used to generate utility values. Efficacy and safety data for sacubitril/valsartan were based on the pivotal Phase III study PARADIGM-HF. A lifetime time horizon (30 years) was applied in the model.

RESULTS: Base-case results suggest that compared with enalapril, sacubitril/valsartan is associated with incremental costs of SGD 21,903 and 0.59 QALYs gained, resulting in an incremental cost-effectiveness ratio of SGD 37,199 per QALY gained (USD 27,869). Increased costs of pharmacological therapy were offset by reductions in hospitalization costs. Expected survival is estimated to increase from 6.63 years for those receiving an ACEi to 7.35 years for patients receiving sacubitril/valsartan. Overall, the results were not sensitive to changes in the model parameters, being mostly sensitive to the coefficients in the statistical model of CV mortality; the treatment effect of sacubitril/valsartan, the impact of age on the risk of CV mortality, and the baseline CV mortality hazard itself.

CONCLUSIONS: The Singapore adapted model suggest that sacubitril/valsartan represents a cost-effective intervention in the treatment of HFrEF (NYHA Class II-IV) versus an ACEi, assuming the WHO willingness-to-pay threshold of less than one GDP per capita (assumed as SGD 79,000 in 2017) as very cost-effective and between two and three times the GDP per capita as cost-effective.