ACC/AHA 2025 Update on Cost-Effectiveness in Clinical Practice Guidelines
ACC/AHA 2025 Update on Cost-Effectiveness in Clinical Practice Guidelines
Source: ACC and AHA outline calculation of cost-effectiveness in clinical practice guidelines.
Originally published in Circulation, September 25, 2025.
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1. Background
• Healthcare costs continue to rise → new therapies must prove value before adoption.
• First ACC/AHA statement in 2014; 2025 = first major update in over 10 years.
• Update adds:
• New methods in cost-effectiveness analysis (CEA).
• Patient-centered outcomes (what matters to patients, not only survival).
• Health equity focus (fair access across populations).
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2. Historical Context – Before 2014
• Before 2014: ACC/AHA guidelines relied only on Class of Recommendation (COR) and Level of Evidence (LOE).
• Cost/value considerations were sometimes mentioned but without a structured framework.
• 2014 Statement: first formal cost-effectiveness methodology, with value levels (High / Intermediate / Low / Uncertain).
• This marked the start of embedding economic value into cardiology guidelines.
• Important note: Cost-effectiveness analysis (CEA) itself is not new — it has existed since the 1970s (e.g.,Milton C. Weinstein – Harvard professor in health economics and decision sciences, pioneer of cost-effectiveness analysis, NEJM 1977).. What is new is its formal integration into U.S. cardiology guidelines starting in 2014.
3. Why Cost-Effectiveness Matters
• Budgets are finite → funding one therapy means fewer resources for another (opportunity cost).
• Cardiovascular disease costs in the U.S. may quadruple in 30 years.
• Careful allocation is critical to maintain both access and quality.
4. Combining Economics + Clinical Value
• Economic ROI: money saved vs. money spent.
• Clinical ROI: lives saved, fewer hospitalizations, improved quality of life.
• CEA (Cost-Effectiveness Analysis) merges both:
• Uses QALY (Quality-Adjusted Life Year) = one year of life in good health.
• Shows cost required to gain each extra QALY.
5. Thresholds (When Is It “Worth It”?)
• U.S. practice:
• < $50,000/QALY → highly cost-effective.
• $50,000–$150,000/QALY → acceptable.
• $150,000/QALY → usually not cost-effective (unless life-saving).
• UK (NICE): £20–30k/QALY.
• WHO: 1–3 × GDP per capita/QALY.
This shows how societies decide “how much is worth paying for 1 year of good-quality life.”
6. Practical Examples
• High-cost but valuable:
• New HF drug costing thousands per year but prevents deaths & hospitalizations → cost-effective.
• Low-cost but low benefit:
• Cheap test with little impact on treatment → not cost-effective.
• Equity example:
• Effective device but only accessible to wealthy patients → raises fairness concerns.
Update Highlights
• Updated cost-effectiveness thresholds for the U.S. based on latest evidence.
• Explicit focus on equity: ensure disadvantaged groups are included.
• Recommend economic value statements for Class I & IIa therapies.
• Reinforce using U.S.-based cost data for relevance.
7. How CEA Works – Comparing Two Groups:
• Group A (Standard care): patients on usual therapy.
• Group B (New intervention): patients given the new drug/device/procedure.
• Measure difference in outcomes (e.g., death or hospitalization).
• ARR (Absolute Risk Reduction): difference in event rates between groups.
• NNT (Number Needed to Treat): number of patients that must get the new therapy instead of standard care to prevent 1 extra bad outcome (e.g., death or hospitalization).
• ICER (Incremental Cost-Effectiveness Ratio): compares extra cost with extra health gained. Formula = (Cost of new – Cost of old) ÷ (QALYs with new – QALYs with old). This shows how much money is needed for each extra year of good-quality life.
8. Takeaway
• Cost-effectiveness is not just about cutting costs.
• It ensures limited resources produce the maximum health benefit.
• The 2025 update merges economic ROI (cost) with clinical ROI (health outcomes) for fairer, smarter guidelines.
