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More effective but not more expensive : the add-on therapy of metoprolol succinate leads to a better treatment in patients with chronic heart failure (CHF) in Germany

An article from the e-journal of the ESC Council for Cardiology Practice

The health economic impact of an additional metoprolol succinate (METsuc) treatment in patients with chronic heart failure (CHF) was analysed for “real life” treatment patterns on the basis of the MERIT-HF trial (Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure). The treatment of CHF with METsuc shows a better clinical outcome and saves money. Further, the life expectancy of a CHF patient is 1.51 years higher in comparison to standard treatment alone.

Heart Failure

Integrated health Care

In times of narrow budgets in the healthcare sector, integrated healthcare is one of the bearers of hope for the German healthcare system.
Additional expenditures in the outpatient sector can lead to savings in the inpatient sector, additional treatment with metoprolol succinate (METsuc) is one example of this. Hence, a moderate investment in one of the sectors may lead to savings in another sector and even in savings for the entire healthcare system.

This analysis is conducted on the basis of the MERIT-HF (Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure) and examines whether data concerning therapeutic intervention in patients with CHF can be associated with economic advantages for the German Healthcare System. For a more detailed description of the methods please refer to Sonntag et al. (8)

MERIT-HF trial

In the MERIT-HF trial 3,991 CHF patients (1,990 in the verum branch and 2,001 in the placebo branch) of the NYHA  functional classes II to IV and a mean age of 64 years received standard medication for the treatment of CHF (ACE-inhibitors, diuretics, digitalis etc.).
As a supplementary medication, the patients either obtained placebo or metoprolol succinate (as retard tablet) in addition to standard treatment.

A highly significant reduction in total mortality - of almost 34% - was observed in the metoprolol succinate treatment arm. Detailed information on MERIT-HF can be found at Hjalmarson et al. (4) and at Hjalmarson and Fagerberg (3).

Real-life conditions

Based on the efficacy data of MERIT-HF, a health economic model was created to simulate the effectiveness of METsuc treatment under real-life conditions.

Missing data for this approach were assessed with the help of a focus group made up of eight general practitioners and cardiologists. Further, the model was validated by the members of the focus group. Outpatient cost data were taken from the doctor’s fee scale (EBM) for the treatment measures as indicated by the focus group.
Drug costs were taken from a current drug price list (IfAP Index Praxis) (10) and were calculated on the basis of a large packsize (N3).
Inpatient costs were acquired on the basis of the Database of the Institute for the Remuneration System in Hospitals (“Institut für das Entgeltsystem im Krankenhaus gGmbH” (InEK), 2004) (5).
The DEALE method (Declining Exponential Approximation of Life Expectancy) (1) was used to calculate the life years gained with METsuc.

The cost analysis was conducted from the perspective of the German Statutory Health Insurance (SHI). Only direct costs were taken into consideration. The base year for the cost analysis is 2004. The period observed was 18 months (six quarters).

A health economic model

An overview of costs used in the model is given in the following table:

Table 1: Overview of costs used in the model

Costs* of

Death  2,104.55 € 2,104.55 €
Adjustment of Therapy 126.03 €  156.63 €
Ambulatory Treatment  69.22 €  103.63 €
Deterioration  118.53 € 118.53 €
No Deterioration 23.08 €   23.08 €
Hospitalisation  2,831.11 €  2,831.11 €

 * The Costs used in the model are provided for a period of 18 months.
Source: own depiction

To revise how sensitive the model is, how it reacts to variations, univariate sensitivity analyses were conducted. For this, all critical parameters such as hospital costs and costs for death were varied from ±5% to ±50 %.

The average costs per patient calculated in the model add up to 1,286.61 Euros with metoprolol succinate and to 1,371.51 Euros with standard treatment. An additional application of metoprolol succinate, compared to standard therapy, for CHF patients (NYHA classes II to IV) did not lead to additional costs from the SHI’s perspective during the observed period.

Model results

The average life expectancy amounts to 8.84 years in the "STANDARD” group and to 10.35 years in the “METsuc” group. The outcome is an average gain in life expectancy of 1.51 years for each patient.

Sensitivity analyses showed the robustness of the results.
Merely an increase of costs in the “METsuc” arm in an outpatient setting of more than 25% as well as a reduction of costs for more than 25% in the “STANDARD” arm would change the result in favor of the standard treatment.

The results of the present analysis are consistent with the results of health economic analyses evaluating the use of the betablockers bisoprolole and carvedilole in the treatment of CHF (9, 10). Treatment within this group of substances not only has a highly clinical benefit but presents an economically favorable treatment approach in CHF.
Finally, the results on life expectancy of CHF patients are comparable with the results of the Framingham Study (6).

On the basis of cost data from 2004 the present analysis shows that no additional costs for the intervention with metoprolol succinate are accounted to the SHI despite improved efficacy.
This turns out to be different from the office based physician’s perspective in an outpatient setting due to additional investments in the metoprolol succinate therapy at the expenses of their drug budget.
Followed by these additional costs, at least for the observation period, less resources are consumed in the inpatient sector. The excess expenditures in the drug area are compensated by this, but no advantage can be demonstrated for the initiator of this, the office based physician.

Under the current regulation, this seems to be more of a disadvantage for physicians as they either have to overdraw their drug budget or have to lower the number of different prescriptions.
However, with regard to the aspects of integrated healthcare, this treatment can be profitable for all persons involved. With a combined budget responsibility for the outpatient as well as the inpatient sector, the sector related perspective will only be of inferior importance.

Eventually, the additional application of metoprolol succinate in CHF patients (NYHA classes II to IV) is justified from a clinical and an economical point of view. This intervention leads to a significant reduction in total mortality and hospitalisations. From the SHI’s perspective, at least for the period considered (18 months), no additional costs accumulate and even tend to result in possible savings.

On the basis of the present analysis the treatment with metoprolol succinate represents an ideal approach for integrated healthcare from a clinical as well as from an economical perspective.

 The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.


1. Beck JR, Kassirer JP, Pauker SG (1982), A convenient approximation of life expectancy (the "DEALE") I, Validation of the method. The American Journal of Medicine 73(6), 883-888.

2. Gilbert EM (2002), Cost-Effectiveness of Beta-Blocker Treatment in Heart Failure, Reviews in Cardiovascular Medicine; 3 (Suppl. 3), 42-47.

3. Hjalmarson A, Fagerberg B (2000), MERIIT-HF mortality and morbidity data, Basic Res Cardiol 95 (Suppl. 1), 98-103.

4. Hjalmarson A, Goldstein S, Fagerberg B et al. (2000), Effects of controlled-release Metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure. The Metoprolol CR/XL randomized intervention trial in congestive heart failure (MERIT-HF), MERIT-HF Study Group. JAMA 283 (10), 1295-1302.

5. Institute for the Remuneration System in Hospitals (Institut für das Entgeltsystem im Krankenhaus gGmbH (InEK)) (2004), G-DRG, German Diagnosis Related Groups, [Status: 2 January 2004].
6. Peeters A, Mamun AA, Willekens F, Bonneux L (2002), A cardiovascular life history, A life course analysis of the original Framingham Heart Study cohort. European Heart Journal 23, 458-466.

7. Service-Institut für Ärzte und Apotheker GmbH, 2004, IfAP Index Praxis, Bad Saarow, (Status 1 October 2004)

8. Sonntag F, Schoeffski O, Hass B (submitted for publication), Führt der Einsatz von Metoprololsuccinat bei der chronischen Herzinsuffizienz zu einer höheren Effektivität der Behandlung, ohne Mehrkosten zu verursachen.

9. Schaedlich PK, Pasch P, Brecht JG (1997), Wirtschaftlichkeit von Bisoprolol bei Herzinsuffizienz, Ökonomische Bewertung der Cardiac Insufficiency Bisoprolol Study (CIBIS) für die Bundesrepublik Deutschland, Med Klin 92, 499-504.

10. Szucs TD, Sokolovic E (2000), Wirtschaftlichkeit von Bisoprolol in der Behandlung der Herzinsuffizienz in Deutschland, Med Klin 9 (12), 663-671.



Vol3 N°41

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.