Sodium-Glucose Cotransporter 2 Inhibitor Use Among Individuals Age <65 with Type 2 Diabetes and Heart Failure with Reduced Ejection Fraction: A Cost-Benefit Analysis

Abstract

Background: Type 2 diabetes (T2D) patients face increased risk of heart failure (HF) as they age. Sodium-glucose cotransporter 2 inhibitors (SGLT-2i) have demonstrated effectiveness in reducing HF hospitalizations in patients with T2D and HF with reduced ejection fraction (HFrEF). Diabetes guidelines recommend SGLT-2i therapy for patients with HFrEF; however, SGLT-2i cost is high.

Objective: Study objectives were to assess SGLT-2i utilization and HF hospitalization rates in commercially insured adults (age <65) with T2D and heart failure with reduced ejection fraction (HFrEF) taking metformin with/without SGLT-2i use and conduct a cost-benefit analysis of SGLT-2i use from payer and societal perspectives.

Methods: Economic models included HF hospitalization rates from real-world data (RWD) and hospitalization rate reductions from RWD and SGLT-2i clinical trials. Real-world HF hospitalization rates were obtained from claims data (MarketScan Commercial Database, years 2013-2018). Societal perspective analyses included indirect costs. Sensitivity analyses were conducted on key parameters.

Results: Among adults with T2D and HFrEF age 30-64, SGLT-2i use increased (1.1% to 17.4%) between 2013 and 2018. The HF hospitalization rate without SGLT-2i use vs with was 15.5% vs 11.0% (absolute risk reduction of 4.5%). Base case scenario net-benefit was negative across all payer perspective models, while positive for societal-perspective. Payer perspective overall net-benefit in 30-64 population: -$1,725,758 (-$4106 per person). Societal perspective net-benefit in 30-64 population: $5,996,851 ($14,269 per person). In sensitivity analyses, estimated per person base case societal net-benefit of $14,269 was most sensitive to changes in baseline HF hospitalization rates, post-discharge mortality rates, and readmission rates. Lowering SGLT-2i prescription costs 50% and 80% resulted in per person net-benefit increases of $1737 and $4004, respectively.

Conclusion: SGLT-2i utilization has steadily increased, with lower HF hospitalization rates observed among SGLT-2i users. Societal benefits of SGLT-2i use in this population are substantive; payer benefits are negative unless SGLT-2i cost is drastically reduced.

Keywords: cardiovascular disease; cost benefit; economic impact; heart failure; net benefit; type 2 diabetes.

Figure 1

Base case direct net-benefit results by age category. Net-benefit for base case scenario from health care payer perspective. Real-world (RW) and trial model results are reported for ages 30–64. Real-World – solid black, CANVAS – vertical stripe, DELCARE-TIMI – horizontal strip, EMPA-REG – diagonal stripe.

Figure 2

Base case societal net-benefit results by age category. Net-benefit for base case scenario from societal perspective. Real-world (RW) and trial model results are reported for respective age categories and for ages 30–64 combined. Real-World – Grey, CANVAS – purple, DELCARE-TIMI – pink, EMPA-REG – light blue.

Figure 3

MarketScan ages 30–64 societal net-benefit (per person). Results of the one-way sensitivity analysis for CBA societal perspective model using real-world data.