Heart failure is a major public health concern for all Western countries.1
In the USA and Europe, it is the most common principal diagnosis for adults admitted to hospital aged 65 years and over. In the USA around 2% of the population have heart failure (approximately 5 million people), and each year there are 500 000 new cases diagnosed.2
The estimated prevalence in Sweden is 1.5–2%, approximately 135 000 to 180 000 people.3
Australian data regarding the public health significance and epidemiology of heart failure are currently limited. Estimates rely on information from large-scale population studies conducted in the USA and Europe.1
It is estimated that there are approximately 300 000 Australians living with chronic heart failure, and approximately 30 000 new cases diagnosed each year, with incidence rates and prevalence rising significantly with age.4
In Australia, chronic cardiovascular diseases are associated with healthcare costs of over 5 billion dollars, and estimates put the cost of heart failure at around 1 billion dollars.6
The mortality, morbidity and healthcare costs of heart failure are therefore significant.4
Heart failure is a syndrome with a range of signs and symptoms, diagnosis is based on such signs and symptoms, including dyspnoea and fatigue, and appropriate investigations, such as echocardiogram, which confirm the presence or absence of heart failure and help determine its aetiology.1
Current treatment aims to relieve and stabilise symptoms and prolong survival by stopping, stabilising or reversing the progression of heart failure.7
There are a variety of strategies used in Australia, including non-pharmacological management, pharmacological management, lifestyle changes, and the use of supportive devices, surgery and palliative care.6
The pharmacological approach depends on the type of heart failure and extent of the symptoms.
Despite the availability of strategies to treat and manage the chronic disease, the disability and suffering associated with heart failure is devastating.7
Given this, and the large economic burden, it is reasonable to examine options not currently considered standard therapy. Research examining the use of complementary and alternative medicine (CAM), particularly the use of hawthorn extract, is showing promising results.
Hawthorn extract is a popular herbal medicine used worldwide, particularly for its cardiovascular properties.9
Hawthorn extract has positive inotropic, anti-inflammatory and antioxidative properties; causes peripheral and coronary vasodilation; and protects against ischaemia-induced arrhythmias.9
A recent systematic review concluded that hawthorn extract can provide significant benefits to heart failure patients as an adjunct to conventional treatment and a recent cost-effectiveness study conducted in Germany concluded that hawthorn is a cost-effective treatment option especially in the early stages of heart failure.10–12
Economic evaluation is a structured method for examining the costs and consequences involved with alternative methods of treatments and/or programmes, in order to inform which is the best alternative from a particular viewpoint.13
The goal is to improve the use of healthcare resources and improve patient care.14
When conducted rigorously, such formal analysis allows recommendation to be made with transparency regarding the methods, data sources and assumptions.13
This further allows the process to be replicated, reviewed and even challenged.
Models allow complex situations to be organised into a single coherent form that can be used to make decisions based on comprehensive consideration of the alternative interventions by capturing the essential relationships between the factors included in the model and outcomes.15
Markov models define diseases using clinically relevant and economically important health states, between which patients move based on the natural history of the disease, and to which cost and effectiveness outcomes are ascribed.16
There are numerous examples of cost-effectiveness modelling in heart failure that examine conventional medicine. Pharmacological, behavioural and surgical interventions have all been investigated and many found to be cost-effective.17
Pharmacological agents that have cost-effectiveness evidence include ACE inhibitors (ACEIs), digoxin and β-blockers such as carvedilol and nebivolol. Multidisciplinary heart failure management, in the form of a team, usually made up of a nurse co-ordinator and support from medical staff and allied health including dieticians and physiotherapy, has also shown to be cost-effective through reductions in hopsitalisation and length of stay.17
Surgical options including heart transplant, through intensive education and maximal medical therapy, have demonstrated a range of cost-effectiveness values. Cardiac resynchronisation therapy with or without an implantable cardioverter-defibrillator has shown to be cost-effective from a healthcare perspective.17
Most of the recent evidence involves Markov modelling.
The increasing number of published health economic evaluations is not yet reflected in CAM.21–23
A systematic review examined whether CAM demonstrated cost-effectiveness through economic evaluations.24
There was good evidence for the cost-effectiveness of several therapies in comparison with usual care, acupuncture for migraine, manual therapy for neck pain, spa therapy for Parkinson's, self-administered stress management for cancer patients undergoing chemotherapy, preoperative and postoperative oral nutritional supplementation for lower gastrointestinal tract surgery, biofeedback for patients with ‘functional’ disorders (eg, irritable bowel syndrome), and guided imagery, relaxation therapy and a potassium-rich diet for cardiac patients.24
There remain very few full economic evaluations today. One such evaluation examined therapeutic massage, exercise and lessons in the Alexander technique for treating persistent back pain.25
Massage, lessons in the Alexander technique and an exercise prescription all provided benefits to patients over a 12-month period. Six lessons in the Alexander technique combined with an exercise prescription was the most cost-effective option for the National Health Service.25
Some economic evaluations of CAM have incorporated decision modelling. Recently, the cost-effectiveness of adding acupuncture to usual care for chronic low-back pain was examined, using a Markov model.26
The result was an incremental cost per quality-adjusted life year (QALY) gained of KRW 3 421 394, well below the threshold of South Korean Won (KRW) 20 000 000. Acupuncture plus usual care was more cost-effective than usual care for these patients. The probability of collaborative treatment being cost-effective was 72.3%. Expected value of perfect information (EVPI) analysis suggested that further research was of reasonable value.26
This highlights the need for full economic evaluations in many areas of CAM.
The aim of this study was the construction and application of an economic decision model to evaluate hawthorn treatment as an adjunct to recommended pharmacological treatment versus recommended pharmacological management for chronic heart failure in Australia. The analysis has been conducted using a health sector perspective.