Last month, the American Heart Association (AHA) and the American College of Cardiology (ACA) issued a statement on how new cardiovascular therapy technologies should be evaluated from a cost and value perspective (Kazi et al. 2025). This is an update from their 2014 cost/value methodology (Anderson et al. 2014). What does the AHA/ACC statement say? Here are some highlights in question-and-answer format.
Does the AHA/ACC take a cost-effectiveness-based approach to measuring value?
Yes! Why does it do this?
Because societal resources are limited, resources used to provide one type of health intervention (for example, a new treatment for heart failure) are no longer available to provide other health care interventions (for example, screening for hypertension) or, more broadly, to address other societal priorities beyond health care. The optimal allocation of social resources creates a need to understand trade-offs between alternative uses of available resources, because committing resources to a particular option generates an “opportunity cost” of foregone benefits that would have arisen had resources not been committed to any option.
Does AHA/ACC recommend using QALYs?
Yes, but also life years. Novel measures of effectiveness are also (briefly) discussed.
Economic value statements should include available CEA findings that measure health outcomes in terms of QALYs and life years, and, where available, the equivalent value of life years or health years gained overall. While we recognize that the QALY is an imperfect measure, it provides useful information about the efficiency of resource allocation.
Should health equity be considered in pricing?
Yes!
Health equity is a central and important part of health care quality, and no assessment of value is complete without considering equity implications…For evaluations that result in efficiency-equity trade-offs…[t]This can be done through the use of formal approaches that quantitatively account for the impact of interventions on health disparities (distributive CEA) or catastrophic out-of-pocket expenditures (distributive CEA).
How should the quality of economic evaluation be assessed?
The ACC/AHA recommend using the Criteria for Health Economic Quality Assessment (CHECK) from Kim et al. 2023 “…evaluate the methodological rigor of a health economic study by providing a structured examination of the key structural components of an analysis and helping to define how far the study deviates from a preferred reference case.” They note that although CHECK is a helpful tool, it still requires expert judgment.
Does AHA/ACC take a social approach?
The AHA/ACC guidance cites the Second Panel on Cost-Effectiveness in Health and Medicine (Sanders et al. 2016) that a societal perspective should be used. They also note that “time costs of care, transportation costs, and costs resulting from lost productivity in the labor market, voluntary work, and household production…may be particularly significant for heart disease.” However, they also note that these data points are often not available. Thus, they recommend using a health system (i.e., payer) perspective as a base case and a societal perspective as a sensitivity analysis:
Economic value statements in the ACC/AHA guidelines should be based on CEA that adopt the health care sector perspective, and results from the societal perspective, if available, should be reported in the supporting text… Caregiver time or productivity losses are excluded from CEA that adopt the health care sector perspective but are included in CEA that adopt the societal perspective.
What is the recommended time frame?
Throughout life. At least “an analytical horizon long enough to fully capture health impacts and resource use”. However, since cardiovascular conditions are often long-term, lifetime is preferred as the default.
How should costs be adjusted for inflation?
They do not recommend using the BLS CPI, citing research by Dunn et al. 2018.
Health care cost inputs from older studies should be inflated using the individual health care expenditure deflator developed by the Centers for Medicare and Medicaid Services or the individual consumption expenditure price index developed by the US Bureau for Economic Analysis. 43,44 Note that the medical care component of the Consumer Price Index does not include spending by third-party payers, making it a biased indicator of overall inflation in health care costs, and unsuitable for use in CEA.
What discount rate is recommended?
3%, but researchers should conduct sensitivity analysis changing this value from 2% to 9%
Which cost effectiveness threshold is used?
$120,000/QALY.
They cite research by Van Ness et al. 2021, Phelps 2019, and Pichon-Rivere et al. 2023 to decide. First, AHA/ACC <$50,000 प्रति QALY को उच्च मूल्य के रूप में, $50,000-$150,000/QALY को मध्यवर्ती मूल्य के रूप में, और >Used $150,000/QALY as a lower value.
Will the same cost-effectiveness threshold be used for rare diseases and gene therapy?
…We propose that rare disease drugs and gene therapies be evaluated using the standard cost-effectiveness threshold ($120000 per QALY gained) for the base-case scenario, but with close consideration of relevant factors around disease severity, unmet need, health equity, and access to care.
How will the ACC/AHA format its recommendations?
It has 3 components: 1) category of recommendation; 2) level of certainty; and 3) Recommendation. The first relates to cost effectiveness analysis. The level of certainty is largely based on whether the findings in CEA studies are robust and based on sensitivity analyses. The typical recommendation format combines these two factors and qualitative characteristics and expert opinion. The AHA/ACC has recommended formats throughout the paper.
