Quantifying the Potential Impact of SGLT-2 Inhibitors in Heart Failure - Episode 4
Expert panel of cardiologists discusses the economic burden and the goals of treatment for patients with heart failure.
Neil Minkoff, MD: I’ll ask 1 of the questions I wanted to bring up, and I’ll address this to Jaime. Diabetes is a particularly complicated and, frankly, expensive disorder for a payer. Heart failure is a difficult and expensive disorder for a payer. Now, you have this beautiful interchange between them, which has its own level of complexity. How does that change the burden to the patient and to society?
Jaime Murillo, MD: Thank you for that question. The reality is, and you can infer this from Dr Desai’s comments, we’re not dealing with separate entities and there’s a lot of pathophysiology we probably still need to find out. I actually work with the UnitedHealth Group R&D [research and development], and we are focusing on research trying to figure out the pathophysiology behind this. In that intersection between heart failure, the metabolic syndromes, and chronic kidney disease, what is common to them that we can address? We’re not just a company that pays for medication. We’re trying to figure out what’s behind this. You mentioned at the beginning of the conference that the population health approach is how you translate those findings from the bench, not just to a clinical practice, but also to the population health side. I think that global view of our patients is what we need to take into account, and that’s exactly how we’re looking at it.
Neil Minkoff, MD: How do you measure that or evaluate the changes? What do you look for to see how your programs are working?
Jaime Murillo, MD: That’s a great question. I’m going to tell you why it’s a great question. That’s where we have a lot of opportunities, not just as a single health plan but, in general, as a society. We’re so used to just paying for a visit, and that leads to—you’ve seen those articles, for instance, about clinical inertia in some other journals. We’re also used to saying, “Let’s work with metrics. Check the box if you have a patient on a statin,” or, “Check the box if you have a patient on the right heart failure medication.” To me, that doesn’t really do the job. The job is, how about if we contract with a health care system or with a provider or whatever institution? How about if the box that we check asks how the outcomes are at 6 or 12 months? Are you keeping people out of the hospital and preventing readmissions? Is their quality of life better? The patient-reported outcomes are also important to mention. We need to take that into account. Am I going to say that we’re there? Not yet. Are we working toward that? You bet.
Neil Minkoff, MD: I couldn’t have asked for a better segue to our next question. That tracks right into what I wanted to move to next, and I’ll ask Nihar to weigh in on this. That gets at, what are the goals? What are we trying to accomplish? There are almost 2 sets of goals if you will: the individual patient and the population of heart failure, and heart failure with patients with diabetes. How do you look at those things?
Nihar Desai, MD, MPH: Neil, the best way to start thinking about the answer to your question is to listen to the patients. The patients we see, whether they’re in the hospital or in the office, say they want to get back to life. They want to feel better and be able to do the things that they have always done and the things that they are hoping to do. That is the challenge we face. How do we get all those patients back to having the lives they want and get back to their world before they got heart failure or a set of other clinical conditions?
There are a number of important things we can do along that front. To Jaime’s point, first and foremost, we have to develop a systematic way to capture symptoms and how people are feeling. Yes, that starts with a clinician during a visit trying to engage with them around that. But being able to systematically incorporate and integrate patient-reported outcome measures, scales, or other standardized assessments is going to be an important element as we think about where we have to go. Relatedly, the clinician and the evidence-based practitioner in me is trying to say, “Of course we want to prevent rehospitalizations. We want to prevent death. We want to prevent ongoing kidney disease.” We want to prevent other downstream utilization in the system. At a population level, we want to try to reduce the burden of disease, improve health, and make sure people are getting the best quality of care in a timely, efficient manner.
Those are all the challenges, whether you’re looking at the individual patient level, or then taking something back to a health system level, a health plan level, or even to a societal level. How do we get people to have the lives that they want so that they can contribute meaningfully to society and we can prevent unnecessary or excess utilization, which is a cost burden for payers or society that we can ill afford.
Steven Nissen, MD: You can summarize this in a couple of ways, and this is actually interesting, because it’s the way the FDA tends to look at drugs for these kinds of conditions. The first is feeling better, and we have therapies that make people feel better but probably don’t make them live any longer. Take the example of a diuretic in heart failure. There has not really been any evidence that furosemide makes people live longer, but they feel better. You decongest them. Then you have the drugs that have been studied that make people live longer. The third arm of that, as you mentioned, Nihar, is keeping people out of the hospital. It is correct that the No. 1 cause for admission to the hospital in Medicare patients, or people over the age of 65 years old, is heart failure. It is the No. 1 reason for admission. For those of us who are old enough to have been in the hospital, it is not a pleasant experience being in a hospital and getting IVs [intravenous treatments] and poked and prodded and all that. Feel-good drugs are really important—can you make people feel better—and then live-longer therapies. In some cases, we have pharmacotherapies that do both, and that’s fantastic. But we can’t expect every therapy will do both. Those that do become very valuable to patients.
It’s interesting because if you look at the labels for most of the drugs we use, they’re about living longer. That’s what people have tried to prove. It’s not as much feeling better, and that’s a deficit. Historically, how we’ve approached drug approval is to emphasize the live-longer and stay-out-of-the-hospital benefits, and not necessarily feeling better as much as we should have. That’s why some of these new metrics around feeling better, which are now appearing in clinical trials, are really important. I suspect we’re going to talk about that later.