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Editorial: Angiotensin-Receptor/Neprilysin Inhibitors Deserve Wider Adoption

Key findings

  • A U.S. registry study showed that only 6% of eligible patients received a prescription for an angiotensin-receptor/neprilysin inhibitor (ARNI) at hospital discharge, and at 35% of hospitals, no one received an ARNI
  • Editorialists from Massachusetts General Hospital believe the most likely explanation for low adoption of ARNIs is high prices and the resulting restrictive policies of payers
  • Value-based pricing, in which drug manufacturers demonstrate that a drug's price aligns with its incremental therapeutic value, might improve access to ARNIs
  • For now, physicians should consider that sacubitril/valsartan has been deemed cost-effective, and a cost-effective medication improves value even if it is expensive

Cholesterol treatment guidelines from the American College of Cardiology and the American Heart Association recommend that patients with chronic, symptomatic class II or III heart failure with reduced ejection fraction who tolerate angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers be treated instead with an angiotensin-receptor/neprilysin inhibitor (ARNI), which further reduces the risk of morbidity and mortality.

Nevertheless, adoption of ARNIs for eligible patients has been slow, as confirmed by a registry study from researchers at the University of California—Davis Medical Center and Duke University School of Medicine that was published in the Journal of the American Heart Association. Increasing the use of ARNIs for these patients is a critical public health goal, as it could save lives, according to Kristin E. Bergethon, MD, MBA, resident physician at Massachusetts General Hospital, and Jason H. Wasfy, MD, MPhil, medical director of the Massachusetts General Hospital Physicians Organization and vice chair of the New England Comparative Effectiveness Public Affairs Council (CEPAC).

In an editorial accompanying the new study, Drs. Bergethon and Wasfy explain that value-based pricing should be considered as a way to improve adoption of expensive but mortality-reducing novel therapies.

Quantifying the Adoption of ARNI Therapy

Using data from the Get With The Guidelines®–Heart Failure registry and other sources, a U.S. research team determined that only 6% of eligible patients received a prescription for an ARNI at discharge when hospitalized between October 2015 and December 2016. Worse still, at 35% of hospitals, no eligible patients were prescribed an ARNI.

The researchers propose several explanations for low adoption of ARNIs: therapeutic inertia (reluctance of clinicians and/or patients to switch therapies), drug pricing and barriers to insurance coverage, such as requirements for prior authorization.

While acknowledging that therapeutic inertia may play a role, Drs. Bergethon and Wasfy doubt it explains why so many hospitals failed to prescribe ARNIs at all. The more likely driver, they say, is high drug prices and the resulting restrictive policies of payers.

They call this unfortunate because sacubitril/valsartan was deemed cost-effective in a study funded by the Institute for Clinical and Economic Review.

Hospital Characteristics

The registry study identified certain hospital characteristics that affected prescription of ARNI therapy:

  • Nonprofit hospitals were less likely than for-profit hospitals to discharge an eligible patient on an ARNI
  • Hospitals in the northeast were less likely than those in the west
  • Surprisingly, hospitals with higher quality scores from Hospital Compare were less likely than those with lower scores

The clinicians speculate that completion of prior authorizations might be easier in some hospital systems than in others, or physicians' persistence in securing prior authorizations may be influenced by the clinical culture of a hospital. The geographic differences between hospitals might relate to commercial insurance policies, which vary by state.

Value-based Pricing

Because prior authorizations are often used for expensive medications and may be limiting access to ARNIs, the editorialists discuss how prescription drugs are priced in the United States. They emphasize that the value of a drug—its benefit compared with its cost—is not necessarily considered.

In contrast, the U.K. National Health Service and other single-payer health systems traditionally rely on value-based drug pricing. Coverage of a new drug is determined by whether its price aligns with the incremental therapeutic value it provides, as measured by quality-adjusted life years.

A key advantage of value-based pricing, according to the editorialists, is that insurers and the drug manufacturer can reach evidence-based consensus on how to benchmark the relationship between incremental benefit and cost, which might improve patient access.

For now, Drs. Bergethon and Wasfy urge physicians to consider that a cost-effective medication improves value even if it is expensive. They call for clinicians to redouble their efforts to incorporate novel therapies into practice once they are proven, like ARNIs, to be more effective than older medications for a particular indication.

of eligible patients were not discharged on an ARNI

of hospitals discharged no patients at all on an ARNI

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