Cost and Value in Contemporary Heart Failure Clinical Guidance Documents

John W. Ostrominski, MD; Sameer Hirji, MD, MPH; Ankeet S. Bhatt, MD, MBA; Javed Butler, MD, MPH, MBA; Mona Fiuzat, PHARMD; Gregg C. Fonarow, MD; Paul A. Heidenreich, MD, MS; James L. Januzzi, JR, MD; Carolyn S.P. Lam, MBBS, PHD; Thomas M. Maddox, MD, MS; Christopher M. O'Connor, MD; Muthiah Vaduganathan, MD, MPH


JACC Heart Fail. 2022;10(1):1-11. 

In This Article

Abstract and Introduction


Objectives: This study sought to evaluate the frequency and nature of cost/value statements in contemporary heart failure (HF) clinical guidance documents (CGDs).

Background: In an era of rising health care costs and expanding therapeutic options, there is an increasing need for formal consideration of cost and value in the development of HF CGDs.

Methods: HF CGDs published by major professional cardiovascular organizations between January 2010 and February 2021 were reviewed for the inclusion of cost/value statements.

Results: Overall, 33 documents were identified, including 5 (15%) appropriate use criteria, 7 (21%) clinical practice guidelines, and 21 (64%) expert consensus documents. Most CGDs (27 of 33; 82%) included at least 1 cost/value statement, and 20 (61%) CGDs included at least 1 cost/value-related citation. Most of these statements were found in expert consensus documents (77.7%). Three (9%) documents reported estimated costs of recommended interventions, but only 1 estimated out-of-pocket cost. Of 179 cost/value-related statements observed, 116 (64.8%) highlighted the economic impact of HF or HF-related care, 6 (3.4%) advocated for cost/value issues, 15 (8.4%) reported gaps in cost/value evidence, and 42 (23.5%) supported clinical guidance recommendations. Over time, patterns of inclusion of statements and citations of cost/value have been largely stable.

Conclusions: Although most contemporary HF CGDs contain at least 1 cost/value statement, most CGDs focus on the high economic impact of HF and its related care; explicit inclusion of cost/value to support clinical guidance recommendations remains infrequent. These results highlight key opportunities for the integration of formalized cost/value considerations in future HF-focused CGDs.


The increasing societal and patient-level costs associated with heart failure (HF) are among the most pressing issues facing cardiovascular medicine in the modern era.[1,2] In 2012, the estimated global economic burden of HF was $108 billion per annum, of which expenditures in the United States constituted more than 28%, and these costs are expected to increase over the next several decades.[3] By 2030, total cost of HF in the United States is projected to approach $70 billion, at which time >8 million patients with HF will be exposed to increasing levels of cost sharing, treatment-related expenses, and other indirect costs.[4–6] Although poised to diminish the morbidity and mortality associated with HF significantly, the expanding choices of pharmacological and device-based interventions come with financial complexity. On average, patients with chronic HF take 7 prescription medications per day,[7] and novel HF therapies often lack less costly generic options. Further, more than 80% of patients with HF have at least 2 additional major comorbid conditions, such as diabetes or chronic kidney disease, that engender additional direct and indirect costs.[8] Complicating these concerns remains the issue that the highest HF burden—and therein the greatest need—lies in lower- to middle-income regions of the world, where resource scarcity is a key barrier.[9,10] Ultimately, these considerations call for greater awareness of, competency regarding, and sensitivity to cost/value-related issues in the cardiovascular community.

Given their potential to influence clinician behaviors, clinical guidance documents (CGDs) are well positioned to effectuate efforts to maximize the value of HF-related care. However, the extent to which contemporary HF CGDs consider cost and value remains poorly defined. In this study, we sought to ascertain the frequency with which existing contemporary HF CGDs include considerations of cost and value, as well as to assess the nature of these considerations.