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Heart Failure Reviews
https://doi.org/10.1007/s10741-018-9710-3

Cost-effectiveness of B-type natriuretic peptide-guided care in patients

with heart failure: a systematic review
Abdosaleh Jafari 1 & Aziz Rezapour 2 & Marjan Hajahmadi 3

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Measuring the level of B-type natriuretic peptide (BNP), as a guide to pharmacotherapy, can increase the survival of patients with
heart failure. This study is aimed at systematically reviewing the studies conducted on the cost-effectiveness of BNP-guided care
in patients with heart failure. Using the systematic review method, we reviewed the published studies on the cost-effectiveness of
BNP-guided care in patients with heart failure during the years 2004 to 2017. The results showed that all studies clearly stated the
time horizon of the study and included direct medical costs in their analysis. In addition, most of the studies used the Markov
model. The quality-adjusted life years (QALYs) were the main outcome used for measuring the effectiveness. The studies
reported various ranges of the incremental cost-effectiveness ratio (ICER); accordingly, the highest ratio was observed in the
USA ($32,748) and the lowest ratio was observed in Canada ($6251). Although the results of the studies were different in terms
of a number of aspects, such as the viewpoint of the study, the study horizons, and the costs of expenditure items, they reached
similar results. Based on the results of the present study, it seems that the use of BNP or N-terminal pro-BNP (NT-pro-BNP) in
patients with heart failure may reduce cost compared to the symptom-based clinical care and increase QALY. In this regard, these
studies were designed and conducted in high-income countries; thus, the application of these results in low- and middle-income
countries will be limited.

Keywords Cost-effectiveness . Heart failure . B-type natriuretic peptide . Economic evaluation

Introduction
Heart failure (HF) is a major cause of morbidity, mortality, and
rehospitalization. Despite modern diagnostic and therapeutic
strategies, HF remains a major health care problem [1–3]. The
incidence of HF increases sharply with age and causes a large
increase in the burden of disease over the next 20 years [4–6]. In
addition, the economic burden of patients with HF has increased
dramatically over the past two decades and global estimates
indicate that total costs for HF in the USA increase from $31
billion in 2012 to $70 billion in 2030 [7]. In the USA, around 20
* Aziz Rezapour
rezapour.a@iums.ac.ir
1
Department of Health Economics, School of Health Management
and Information Sciences, Iran University of Medical Sciences,
Tehran, Iran
2 recommend the use of BNP testing for diagnosing acute HF,
Health Management and Economics Research Center, Iran
University of Medical Sciences, Tehran, Iran
3 guidelines do not uniformly recommend it [22–25].
Cardiovascular Department, Rasoul Akram General Hospital, Iran
University of Medical Sciences, Tehran, Iran
million patients live with HF and this figure is likely to increase
due to the aging population [8, 9]. Various methods such as
BNP, echocardiography, or clinical examinations can be used
to diagnose heart failure; however, these methods are different
in terms of the power of diagnosis of patients. According to
previous studies, the sensitivity (the ability of the test to detect
true positive cases) and the specificity (the ability of the test to
detect true negative cases) of BNP are 50.7 and 70.6% and those
of echocardiography are 80 and 88%, respectively [10, 11].
BNP is a cardiac neurohormone secreted from the ventricles in
response to ventricular volume expansion and pressure over-
load. The presence of a higher level of BNP in the blood indi-
cates a higher risk of heart attack, heart failure, or death [12–16].
Echocardiography is a common and non-invasive method that
uses harmless sound waves to obtain the image of different parts
of the heart and determine the speed of blood flow; this method
can be used to obtain a clear image of the valves and the starting
parts of large arteries [17–21]. Although many clinical studies
there is uncertainty about the cost-effectiveness of BNP and
Furthermore, the cost of interventions and the effectiveness of

diagnosis vary in terms of their effects on the quality of life of
patients [26–28]. Despite the presence of numerous economic
evaluation studies on drug and therapeutic interventions for pa-
tients with heart failure, there are a limited number of studies on
diagnostic methods used for patients with heart failure. Cost-
effectiveness analyses compare the costs and outcomes of an
intervention to help policymakers and clinicians in planning
and resource allocation [29–34]. Due to lack of resources and
increased demand especially in the health system, developing
solutions and implementing cost-effective interventions can im-
prove allocative efficiency and reduce inequality [35–38]. To
date, no known study has systematically reviewed the cost-
effectiveness of BNP-guided care in patients with heart failure.
The results of this review can help decision-makers to finance
cost-effective interventions for patients with heart failure.
Methods
Literature search
Using a systematic review method, this study was conducted
to review published studies on the cost-effectiveness of BNP-
guided care in patients with heart failure during the years from
2004 to 2017. The studies were extracted from the following
databases: Cochrane Library, NHS Economic Evaluation
Database, Medline, PubMed, ScienceDirect, and Scopus.
The following keywords were used to search the relevant
studies: Cost-effectiveness OR cost-utility OR cost-benefit
OR economic evaluation AND heart failure AND BNP-
guided care.
Inclusion and exclusion criteria
The following inclusion criteria were used in this study: orig-
inal studies that performed a full economic evaluation, includ-
ing cost-utility analysis, cost-effectiveness analysis, or cost-
benefit analysis; studies which had measured quality-adjusted
life years (QALYs), life years gained, or rehospitalization as
their outcomes of the study; studies that assessed BNP-guided
care in patients with heart failure; and studies published in
English during the years from 2004 to 2017.
In this research, studies that do not meet the following
criteria were excluded: studies with a partial economic evalu-
ation (such as those evaluating effectiveness, evaluating costs,
and assessing the quality of life), review studies, studies pub-
lished in conferences, case reports, and studies with a low
quality in methodology based on Drummond’s checklist.
Quality assessment of methodology of the studies
The quality of the methodology of the studies was evaluated
using Drummond’s checklist. This checklist contains ten
Heart Fail Rev
questions that assess the design of economic evaluation studies
in terms of the following items: statement of the research ques-
tion; a comprehensive description of competing alternatives,
measurement of effectiveness, appropriate identification, mea-
surement and valuation of costs and consequences; use of the
discount rate, incremental analysis for costs and consequences,
examination of the effect of uncertainty in the estimates of costs
and consequences, and provision of appropriate interpretation
of results [39, 40]. After searching the studies, using
Drummond’s checklist, the selected studies were evaluated by
two researchers in terms of the quality of methodology. Studies
that were poor in methodology were excluded.
Data analysis
The selected studies were fully reviewed, and the required
data were extracted and summarized using designed tables.
Endnote X5 software was used to organize the studies, read
the titles and abstracts, and identify duplicates.
Results
Search results
In the initial search, 188 studies were identified. After screen-
ing the studies using the exclusion criteria, 70 studies were
selected. Then, through thorough reviews of full text of stud-
ies, 59 studies were excluded from the study and four studies
were omitted due to the low quality of methodology checked
using Drummond’s checklist [18, 26–28]. Finally, we selected
and assessed the results of seven studies that carried out a full
economic evaluation of BNP-guided care in patients with
heart failure [41–47]. Figure 1 presents the results of the sys-
tematic review.
Study characteristics
In this study, the characteristics of the studies are summarized
as follows: country setting and year of study, population of the
study, alternative options for comparison, outcome measure
for effectiveness, time horizon, type of model used for data
analysis, viewpoint of the study, included cost, type of sensi-
tivity analysis, the discount rate for costs and outcomes, and
the incremental cost-effectiveness ratio (Table 1).
The reviewed studies have been conducted in the USA,
UK, Canada, and Switzerland. In terms of the model type,
most of the studies used the Markov model and one study
used the decision tree model [47]. All studies except one
[45] included the study perspective. The findings of this re-
view study also show that 60% of the studies used discount
rate and in two studies, as the period of the study was limited,
the discount rate was not used [46, 47]. All the studies clearly
Heart Fail Rev

Fig. 1 Results of systematic Studies excluded based on

literature search Search articles in the following database: study title:
Cochrane library, NHS Economic Evaluations Studies which only
Database Medline, PubMed ,science direct, investigated costs:
Scopus,
(41 articles)
(188 articles)
Studies which only
investigated outcomes:

(54 articles)

Non- comparative studies:

Studies which performed economic (23 articles)

evaluations based on their titles:

(70 articles)

Studies excluded after

complete review of contents:

(59 articles)

Studies met the inclusion criteria:

(11 articles)

Studies not met the qualification

criteria:

(4 articles)

Studies included in the final analysis:

(7 articles)

stated the time horizon of the study. The time horizon of most
studies was lifetime, and one study used a time horizon of
20 years [43]. The quality-adjusted life year (QALY) is the
most common outcome used for measuring the effectiveness
of interventions. Six of seven studies used QALY, one study
focused on the rehospitalization index for measuring the ef-
fectiveness, and two studies applied life years gained in addi-
tion to QALY [42, 46]. Among the reviewed studies, five
studies simultaneously conducted deterministic and probabi-
listic sensitivity analyses [41, 43, 44, 46, 47]. Sensitivity anal-
ysis is used when dealing with the effect of uncertainty in
results and in the generalizability of results [48–56].
Furthermore, the studies reported a wide range of incremental
cost-effectiveness ratio (ICER). In order to compare different
ICER, all of them were inflated by 2017 at an annual rate of
3%. Figure 2 shows that the highest cost and the lowest cost
per QALY were observed in the USA ($32,748) [41] and
Canada ($6251), respectively [43]. The findings of this review
study also indicated that all the studies included direct medical
costs in their analysis. They did not include direct non-medical
costs and indirect costs.
Discussion
The present study, which systematically reviewed the results
of seven valid studies, found use of BNP or N-terminal pro-
brain natriuretic peptide (NT-pro-BNP) in patients with heart
failure may be more cost-effective than the conventional clin-
ical-/symptom-guided care. Moreover, in most studies, the
utility value was obtained on the basis of literature review,
which could lead to an overestimation or underestimation of
QALY. However, different countries reported different ICER
values, varying from $32,748 in the USA [41] to $6251 in
Canada [43]. According to Mohiuddin et al., the ICER value
for BNP in patients aged less than 70 years with heart failure
and reduced ejection fraction was about £9840 per QALY
[44]. As estimated by Sanders-van Wijk et al., the ICER value
for NT-pro-BNP in comparison with symptom-guided therapy
was $5870 per life year gained [46]. Morimoto et al. showed
that the ICER value for the BNP group in comparison with the
clinical group was $3491–7787 per QALY [45]. Various fac-
tors can affect the ICER, such as age and sex, threshold values
in different countries, incidence and prevalence of heart
Table 1 Description of cost-effectiveness study characteristics

Study Country and Study Study population Alternative options for Outcome Time Study Included Sensitivity Discount ICER
Row year of study model comparison measure horizon perspective cost analysis rate for cost
and
effectiveness

1 Mohiuddin UK, 2016 Markov 52,122 BNP-guided versus QALY Lifetime NHS Direct Deterministic 3.5% For patients aged
model symptomatic clinically guided medi- and < 75 years with
patients with care cal probabilis- heart failure and
HF defined by cost tic reduced ejection
age and left fraction, ICER
ventricular was £9840
ejection
fraction
(LVEF) status
BNP measured
during each
90-day period
at the time of
admission
2 Sanders-van Switzerland, No 499 symptomatic N-terminal pro-B-type Life years Third-party Direct Deterministic Costs were ICER of $5870 per
Wijk et al. 2013 model patients aged natriuretic peptide gained, QALY 18 mo- payers medi- and not life year gained
> 60 years (NT-pro-BNP)-gui- nths cal probabilis- discount-
NT-pro-BNP ded versus cost tic ed due to
measured per symptom-guided the
month at the therapy limited
time of follow-up
admission of
18 mont-
hs
3 Moertl Austria and Markov 278 NT-pro-BNP-guided QALY 20 years Payer’s Direct Deterministic 5% ICER for MC
Canada, model asymptomatic intensive patient perspec- medi- and relative to UC
2013 patients management tive cal probabilis- were €3746 and
discharged (BMC) compared cost tic $5554 per QALY
from HF with multidisciplin- gained for
hospitalization ary care (MC) or Austrian and
(index usual care (UC) Canadian costs,
hospitaliza- respectively
tion)
NT-pro-BNP
measured
biweekly at the
time of
discharge
4 Laramée UK, 2012 N/A 6478 Serial measurement of Life years Lifetime UK NHS Direct Probabilistic 3.5% Serial NP
symptomatic natriuretic peptide gained, QALY perspec- medi- measurement by a
patients with (NP) by a specialist, tive cal specialist showing
clinical assessment cost an ICER of £3304
Heart Fail Rev
Table 1 (continued)

Study Country and Study Study population Alternative options for Outcome Time Study Included Sensitivity Discount ICER
Row year of study model comparison measure horizon perspective cost analysis rate for cost
Heart Fail Rev

and
effectiveness

chronic heart by a specialist, and compared with

failure usual care in the clinical
Natriuretic community assessment
peptide
measured
yearly at the
time of
admission
5 Siebert USA, 2006 Decision 599 patients Assessment guided by Urgent care 60 days Provider Direct Deterministic Costs were NT-pro-BNP-guided
tree presenting to NT-pro-BNP com- visits, repeated medi- and not assessment was
the emergency pared to standard ED cal probabilis- discount- associated with
department assessment presentations, cost tic ed due to savings of $474
with dyspnea rehospitalizati- the per patient,
NT-pro-BNP ons limited compared with the
measured once follow-up standard clinical
at the time of assessment
admission
6 Heidenreich USA, 2004 Markov 1000 BNP and QALY Lifetime Societal Direct Deterministic 3% Cost per QALY of
model asymptomatic echocardiography perspec- medi- and $22,300 for men
patients with tive cal probabilis- and $77,700 for
HF cost tic women
BNP measured
per year at the
time of
admission
7 Morimoto USA, 2004 Markov Target population BNP group compared QALY Not Direct Deterministic 3% The incremental
model was 69 to clinical group 18 mo- specified medi- costs would be
symptomatic nths cal $3491–7787 per
CHF patients cost QALY
aged
35–85 years
recently
discharged
from the
hospital
BNP measured
once every
3 months at
the time of
discharge
 Heart Fail Rev

Fig. 2 The cost per QALY for

BNP in patients with heart failure Cost per QALY (USD 2017)
(cost inflated to 2017 at an annual 35000
rate of 3%) 32748

30000

25000

20000

15000 13194

10000
6607 6251
5127 4986
5000

0
USA USA UK UK Switzerland Canada

diseases, methods of measuring costs and outcomes, and the
amount of prices in different countries [57]. The results of this
review study also showed that the target population in the
majority of studies was symptomatic patients with heart fail-
ure. Moreover, in 71% of cases, BNP was measured at the
time of admission. Furthermore, in most studies, cost items
included hospitalization, use of drugs such as ACE inhibitor
and beta-blocker, outpatient visit, and BNP measurements. In
most reviewed studies, BNP was compared with the conven-
tional care and clinical examinations, and in a study, it was
compared with echocardiography [41]. The results of this re-
view revealed that the use of BNP-guided care increased cost
saving. For example, Siebert et al. showed that the use of NT-
pro-BNP reduced the use of echocardiography by 58% and
decreased early hospitalization by 13% [47]. Moertl et al. also
found that the use of NT-pro-BNP reduced costs and increased
QALY, as compared with the usual care and multidisciplinary
care [43]. Laramée et al., in their study in the UK, showed that
the measurement of the level of the natriuretic peptide hor-
mone by a specialist is a cost-effective strategy, but it is not
cost-effective in people aged over 75 years of age [42]. In a
similar study, Mohiuddin et al. showed that the use of BNP in
patients aged less than 70 years with heart failure and reduced
ejection fraction (HFrEF) was more cost-effective than the
clinical care [44]. In a similar study, Morimoto et al. showed
that the use of BNP, as compared with the clinical care, was
more effective in increasing QALY and decreasing costs [45].
Very few studies have been conducted on the economic eval-
uation of the BNP in comparison with other diagnostic
methods in patients with heart failure in developing countries,
while most people with heart diseases are living in countries
with middle and low income [58].
Study limitations
This study had some limitations. First, the effectiveness of
diagnostic methods, including BNP, echocardiography, and
other methods, in patients with heart failure is largely depen-
dent on factors such as the sensitivity and specificity of labo-
ratory tests and imaging devices as well as the history of the
disease and the period of patient follow-up. In addition, the
amount of health expenditure and the opportunity cost vary
from country to country; it can prevent us from generalizing
the results to other settings. Furthermore, in this study, we only
reviewed English studies, which means that studies from other
languages might have been missed.
Conclusion
Based on the results of the reviewed studies in this systematic
review, it seems that the use of BNP or NT-pro-BNP in patients
with heart failure may reduce cost compared to the symptom-
based clinical care and increase QALY. In this regard, these
studies were designed and conducted in high-income countries;
thus, the application of these results in low- and middle-income
countries will be limited. Therefore, if policymakers and clini-
cians decide to use BNP or NT-pro-BNP in their own health care
system, they should design and conduct specialized studies in
their own local settings with the help of specialists and experts in
health economics.
Funding information This study was part of a PhD thesis supported by
the Iran University of Medical Sciences (grant no. IUMS/SHMIS_
9321504001).
Heart Fail Rev
Compliance with ethical standards
The manuscript does not contain clinical studies or patient data.
Conflict of interest The authors declare that they have no conflict of
interest.
References
1. Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K,
Ezekowitz MD, Finkelstein EA, Hong Y, Johnston SC, Khera A
(2011) Forecasting the future of cardiovascular disease in the
United States: a policy statement from the American Heart
Association. Circulation 123(8):933–944. https://doi.org/10.1161/
CIR.0b013e31820a55f5
2. Rathi S, Deedwania PC (2012) The epidemiology and pathophys-
iology of heart failure. Medical Clinics 96(5):881–890. https://doi.
org/10.1016/j.mcna.2012.07.011
3. Stewart S, MacIntyre K, Capewell S, McMurray J (2003) Heart
failure and the aging population: an increasing burden in the 21st
century? Heart 89(1):49–53
4. Chung M, Asher R, Yamada D, Eagle K, Podrid P, Kowey P (2001)
Arrhythmias after cardiac and non-cardiac surgery. Podrid P,
Kowey P Cardiac arrhythmia. 2nd ed Philadelphia: Lippincott
Williams Wilkins:631–638
5. Cook C, Cole G, Asaria P, Jabbour R, Francis DP (2014) The
annual global economic burden of heart failure. Int J Cardiol
171(3):368–376. https://doi.org/10.1016/j.ijcard.2013.12.028
6. Kelly BB, Fuster V (2010) Promoting cardiovascular health in the
developing world: a critical challenge to achieve global health.
National Academies Press,
7. Heidenreich PA, Albert NM, Allen LA, Bluemke DA, Butler J,
Fonarow GC, Ikonomidis JS, Khavjou O, Konstam MA,
Maddox TM (2013) Forecasting the impact of heart failure in
the United States: a policy statement from the American Heart
Association. Circulation: Heart Failure 6(3):606–619. https://
doi.org/10.1161/HHF.0b013e318291329a
8. Friedewald VE, Kornman KS, Beck JD, Genco R, Goldfine A,
Libby P, Offenbacher S, Ridker PM, Van Dyke TE, Roberts WC
(2009) The American Journal of Cardiology and Journal of
Periodontology editors’ consensus: periodontitis and atherosclerot-
ic cardiovascular disease. Am J Cardiol 104:59–68. https://doi.org/
10.1016/j.amjcard.2009.05.002
9. Pearson TA, Mensah GA, Alexander RW, Anderson JL, Cannon
RO, Criqui M, Fadl YY, Fortmann SP, Hong Y, Myers GL (2003)
Markers of inflammation and cardiovascular disease: application
to clinical and public health practice: a statement for healthcare
professionals from the Centers for Disease Control and
Prevention and the American Heart Association. Circulation
107(3):499–511
10. Erbel R, Schweizer P, Krebs W, Meyer J, Effert S (1984) Sensitivity
and specificity of two dimensional echocardiography in detection of
impaired left ventricular function. Eur Heart J 5(6):477–489
11. Sabatasso S, Vaucher P, Augsburger M, Donzé N, Mangin P,
Michaud K (2011) Sensitivity and specificity of NT-proBNP to
detect heart failure at post mortem examination. Int J Legal Med
125(6):849–856. https://doi.org/10.1007/s00414-011-0581-6
12. Dieplinger B, Gegenhuber A, Haltmayer M, Mueller T (2009)
Evaluation of novel biomarkers for the diagnosis of acute
destabilised heart failure in patients with shortness of breath.
Heart 95(18):1508–1513. https://doi.org/10.1136/hrt.2009.
170696
13. Felker GM, Hasselblad V, Hernandez AF, O'connor CM (2009)
Biomarker-guided therapy in chronic heart failure: a meta-analysis
of randomized controlled trials. Am Heart J 158(3):422–430.
https://doi.org/10.1016/j.ahj.2009.06.018
14. Lainchbury JG, Troughton RW, Strangman KM, Frampton CM,
Pilbrow A, Yandle TG, Hamid AK, Nicholls MG, Richards AM
(2009) N-terminal pro–B-type natriuretic peptide-guided treatment
for chronic heart failure: results from the BATTLESCARRED (NT-
proBNP–assisted treatment to lessen serial cardiac readmissions
and death) trial. J Am Coll Cardiol 55(1):53–60. https://doi.org/
10.1016/j.jacc.2009.02.095
15. Pfisterer M, Buser P, Rickli H, Gutmann M, Erne P, Rickenbacher P,
Vuillomenet A, Jeker U, Dubach P, Beer H (2009) BNP-guided vs
symptom-guided heart failure therapy: the Trial of Intensified vs
Standard Medical Therapy in Elderly Patients with Congestive
Heart Failure (TIME-CHF) randomized trial. JAMA 301(4):383–
392. https://doi.org/10.1001/jama.2009.2
16. Porapakkham P, Porapakkham P, Zimmet H, Billah B, Krum H
(2010) B-type natriuretic peptide-guided heart failure therapy: a
meta-analysis. Arch Intern Med 170(6):507–514. https://doi.org/
10.1001/archinternmed.2010.35
17. Cameli M, Lisi M, Mondillo S, Padeletti M, Ballo P, Tsioulpas C,
Bernazzali S, Maccherini M (2010) Left atrial longitudinal strain by
speckle tracking echocardiography correlates well with left ventric-
ular filling pressures in patients with heart failure. Cardiovascular
Ultrasound 8(1):14. https://doi.org/10.1186/1476-7120-8-14
18. Dokainish H, Zoghbi WA, Ambriz E, Lakkis NM, Quinones MA,
Nagueh SF (2006) Comparative cost-effectiveness of B-type natri-
uretic peptide and echocardiography for predicting outcome in pa-
tients with congestive heart failure. Am J Cardiol 97(3):400–403.
https://doi.org/10.1016/j.amjcard.2005.08.060
19. Almahmoud MF, O'Neal WT, Qureshi W, Soliman EZ (2015)
Electrocardiographic versus echocardiographic left ventricular hy-
pertrophy in prediction of congestive heart failure in the elderly.
Clin Cardiol 38(6):365–370. https://doi.org/10.1002/clc.22402
20. Munyandu N (2015) An echocardiography audit to determine and
characterise rheumatic heart disease lesions seen in 2012.
21. Yang H, Marwick TH, Wang Y, Nolan M, Negishi K, Khan F, Okin
PM (2017) Association between electrocardiographic and echocardio-
graphic markers of stage B heart failure and cardiovascular outcome.
ESC Heart Failure 4:417–431. https://doi.org/10.1002/ehf2.12151
22. Tanaray B, Eslami M, Salehi M, Jahanzad I, Emami M (2010)
Relationship of plasma level of NT-ProBNP with development of
AF in CABG patients. Tehran University Medical Sci 68(7):384–390
23. Alimohamadian MRM (2013) NT probnp the newest biomarker in
heart failure. journal of laboratory tests 97(1):1–5
24. Doust J, Lehman R, Glasziou P (2006) The role of BNP testing in
heart failure. Am Fam Physician 74(11):1893–1898
25. kbR MM, sadat H, Namazi M, Safi M, Vakili H (2009) The study of
diagnostic value of NT-proBNP in diagnosis of heart failure in patients
with the main complaint of dyspnea in Modarres hospital in 2007–
2008. J Shahid Behshti University Medical Sci 5(71):241–245
26. Adlbrecht C, Huelsmann M, Berger R, Moertl D, Strunk G,
Oesterle A, Ahmadi R, Szucs T, Pacher R (2011) Cost analysis
and cost-effectiveness of NT-proBNP-guided heart failure special-
ist care in addition to home-based nurse care. Eur J Clin Investig
41(3):315–322. https://doi.org/10.1111/j.1365-2362.2010.02412.x
27. Lim TK, Dwivedi G, Hayat S, Collinson PO, Senior R (2007) Cost
effectiveness of the B type natriuretic peptide, electrocardiography,
and portable echocardiography for the assessment of patients from
the community with suspected heart failure. Echocardiography
24(3):228–236. https://doi.org/10.1111/j.1540-8175.2007.00398.x
28. Sim V, Hampton D, Phillips C, Lo S-N, Vasishta S, Davies J, Penney M
(2003) The use of brain natriuretic peptide as a screening test for left
ventricular systolic dysfunction—cost-effectiveness in relation to open
access echocardiography. Fam Pract 20(5):570–574

29. Gray AM, Clarke PM, Wolstenholme JL, Wordsworth S (2010)
Applied methods of cost-effectiveness analysis in healthcare, vol
3. OUP Oxford,
30. Callahan KP, Bridges JF (2012) Using comparative effectiveness
research to inform decision-making: is there a role of economic
evaluation? J Comparative Effectiveness Res 1(4):299–301.
https://doi.org/10.2217/cer.12.33
31. Eddama O, Coast J (2009) Use of economic evaluation in local
health care decision-making in England: a qualitative investigation.
Health Policy 89(3):261–270. https://doi.org/10.1016/j.healthpol.
2008.06.004
32. Goeree R, Diaby V (2013) Introduction to health economics and
decision-making: is economics relevant for the frontline clinician?
Best Pract Res Clin Gastroenterol 27(6):831–844. https://doi.org/
10.1016/j.bpg.2013.08.016
33. Hutton J (2012) ‘Health economics’ and the evolution of economic
evaluation of health technologies. Health Econ 21(1):13–18. https://
doi.org/10.1002/hec.1818
34. Lessard C, Contandriopoulos A-P, Beaulieu M-D (2010) The
role (or not) of economic evaluation at the micro level: can
Bourdieu’s theory provide a way forward for clinical decision-
making? Soc Sci Med 70(12):1948–1956. https://doi.org/10.
1016/j.socscimed.2010.03.013
35. Almasiankia A, Kavosi Z, Keshtkaran A, Jafari A, Goodarzi S
(2015) Equity in health care financing among Iranian households.
Shiraz E-Medical Journal 16 (11, 12)
36. Jahromi NN, Jafari A, Kavosi Z, Shokrpour N, Sajjadnia Z,
Ravangard R (2016) Demand for dental services in Shiraz,
Iran, 2013. Health Care Manager 35(4):340–349. https://doi.
org/10.1097/HCM.0000000000000136
37. Kavosi Z, Mohammadbeigi A, Ramezani-Doroh V, Hatam N, Jafari
A, Firoozjahantighi A (2015) Horizontal inequity in access to out-
patient services among Shiraz City residents, Iran. J Res Health Sci
15(1):37–41
38. Ravangard R, Hatam N, Teimourizad A, Jafari A (2014)
Factors affecting the technical efficiency of health systems: a
case study of Economic Cooperation Organization (ECO)
countries (2004–10). Int J health Policy Management 3(2):
63–69. https://doi.org/10.15171/ijhpm.2014.60
39. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance
GW (2015) Methods for the economic evaluation of health care
programmes. Oxford university press,
40. Rezapour A, Jafari A, Mirmasoudi K, Talebianpour H (2017) Quality
assessment of published studies in Iranian journals related to economic
evaluation in health care programs based on Drummond’s checklist: a
narrative review. Iranian J Medical Sci 41(2):427–436
41. Heidenreich PA, Gubens MA, Fonarow GC, Konstam MA,
Stevenson LW, Shekelle PG (2004) Cost-effectiveness of screening
with B-type natriuretic peptide to identify patients with reduced left
ventricular ejection fraction. J Am Coll Cardiol 43(6):1019–1026.
https://doi.org/10.1016/j.jacc.2003.10.043
42. Laramée P, Wonderling D, Swain S, Al-Mohammad A, Mant J (2013)
Cost-effectiveness analysis of serial measurement of circulating natri-
uretic peptide concentration in chronic heart failure. Heart 99(4):267–
271. https://doi.org/10.1136/heartjnl-2012-302692
43. Moertl D, Steiner S, Coyle D, Berger R (2013) Cost-utility analysis
of NT-proBNP-guided multidisciplinary care in chronic heart fail-
ure. Int J Technol Assess Health Care 29(1):3–11. https://doi.org/
10.1017/S0266462312000712
44. Mohiuddin S, Reeves B, Pufulete M, Maishman R, Dayer M,
Macleod J, McDonagh T, Purdy S, Rogers C, Hollingworth W
(2016) Model-based cost-effectiveness analysis of B-type natri-
uretic peptide-guided care in patients with heart failure. BMJ
Open 6(12):1–10. https://doi.org/10.1136/bmjopen-2016-
014010
View publication stats
Heart Fail Rev
45. Morimoto T, Hayashino Y, Shimbo T, Izumi T, Fukui T (2004) Is B-
type natriuretic peptide-guided heart failure management cost-ef-
fective? Int J Cardiol 96(2):177–181. https://doi.org/10.1016/j.
ijcard.2003.05.036
46. Sanders-van Wijk S, van Asselt AD, Rickli H, Estlinbaum W,
Erne P, Rickenbacher P, Vuillomenet A, Peter M, Pfisterer ME,
Brunner-La Rocca H-P (2013) Cost-effectiveness of N-
terminal pro-B-type natriuretic-guided therapy in elderly heart
failure patients: results from TIME-CHF (Trial of Intensified
versus Standard Medical Therapy in Elderly Patients with
Congestive Heart Failure). JACC: Heart Failure 1(1):64–71.
https://doi.org/10.1016/j.jchf.2012.08.002
47. Siebert U, Januzzi JL, Beinfeld MT, Cameron R, Gazelle GS
(2006) Cost-effectiveness of using N-terminal pro-brain natri-
uretic peptide to guide the diagnostic assessment and manage-
ment of dyspneic patients in the emergency department. Am J
Cardiol 98(6):800–805. https://doi.org/10.1016/j.amjcard.2006.
06.005
48. Augustovski F, Iglesias C, Manca A, Drummond M, Rubinstein A,
Martií SG (2009) Barriers to generalizability of health economic
evaluations in Latin America and the Caribbean region.
PharmacoEconomics 27(11):919–929. https://doi.org/10.2165/
11313670-000000000-00000
49. Baltussen RM, Hutubessy RC, Evans DB, Murray CJ (2002)
Uncertainty in cost-effectiveness analysis: probabilistic uncertainty
analysis and stochastic league tables. Int J Technol Assess Health
Care 18(1):112–119
50. Drummond M, Manca A, Sculpher M (2005) Increasing the gener-
alizability of economic evaluations: recommendations for the de-
sign, analysis, and reporting of studies. Int J Technol Assess Health
Care 21(2):165–171
51. Ghabri S, Hamers FF, Josselin J-M, Harousseau J-L (2014)
Exploring uncertainty in economic evaluation of medicines: a re-
view of the first manufacturers’ submissions to the French National
Authority for Health (Has). Value Health 17(7):A441–A442.
https://doi.org/10.1016/j.jval.2014.08.1160
52. Limwattananon S (2011) Handling uncertainty of the econom-
ic evaluation result: sensitivity analysis. J Med Assoc Thail
91(6):59
53. Limwattananon S (2014) Sensitivity analysis for handling uncer-
tainty in an economic evaluation. J Medical Assoc Thailand
Chotmaihet Thangphaet 97:S59–S64
54. Ruggeri M, Manca A, Coretti S, Codella P, Iacopino V, Romano F,
Mascia D, Orlando V, Cicchetti A (2015) Investigating the gener-
alizability of economic evaluations conducted in Italy: a critical
review. Value Health 18(5):709–720. https://doi.org/10.1016/j.
jval.2015.03.1795
55. ENd S, Silva MT, Pereira MG (2017) Uncertainty in economic
evaluation studies. Epidemiologia e Serviços de Saúde 26(1):211–
213. https://doi.org/10.5123/S1679-49742017000100022
56. Scalone L, Cortesi PA (2016) About the reliability of the critical
review to investigate the generalizability of economic evaluations
conducted in Italy. Value Health 19(5):697. https://doi.org/10.1016/
j.jval.2016.03.1833
57. Hatam N, Dehghani M, Habibian M, Jafari A (2015) Cost-
utility analysis of IEV drug regimen versus ESHAP drug reg-
imen for the patients with relapsed and refractory Hodgkin and
non-Hodgkin’s lymphoma in Iran. Iranian J Cancer Prevention
8(5):1–8. https://doi.org/10.17795/ijcp-4061
58. Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A
(2010) Growing epidemic of coronary heart disease in low- and
middle-income countries. Curr Probl Cardiol 35(2):72–115.
https://doi.org/10.1016/j.cpcardiol.2009.10.002