Cost-effectiveness and budget-impact analysis of Acetazolamide in decompensated heart failure patients with volume overload in the German health care system

Acute decompensated heart failure (ADHF) represents a major clinical and economic burden in Germany, primarily due to the frequent need for hospitalizations and high rehospitalization rates. Acetazolamide, a carbonic anhydrase inhibitor, has been shown in the ADVOR trial to improve early decongestion when added to loop diuretics. However, its economic impact within the German healthcare system has not yet been evaluated.

We developed a decision-analytic cost-effectiveness model using a 3-month time horizon to evaluate the addition of acetazolamide to standard diuretic therapy in hospitalized ADHF patients, based on data from the ADVOR trial. The analysis was conducted from the perspective of the German statutory health insurance (GKV). Model inputs included clinical probabilities, utilities from German heart failure populations, and healthcare costs (2025 values). Both deterministic and probabilistic sensitivity analyses were performed. A complementary budget impact analysis (BIA) estimated national-level financial implications under various adoption scenarios. In the base-case analysis, acetazolamide was technically dominant, incurring lower cost (4495€ vs. 4959€ per patient) and slightly higher quality-adjusted life years (QALYs: 0.132287 vs. 0.127710, difference 0.00458 ≈ 1.7 quality-adjusted days over 3 months) resulting in an ICER of −101 449€ per QALY. In a scenario using arm-specific outcomes from ADVOR, acetazolamide remained cost-saving with a minimal QALY decrement (−0.00024). The BIA estimated annual savings of €11–217 million depending on uptake and patient eligibility, with €39 million under full uptake when ADVOR exclusion criteria are applied.

Acetazolamide appears to be a cost-effective and potentially cost-saving adjunct to standard care in patients hospitalized with ADHF in Germany. Broad adoption of acetazolamide could reduce inpatient costs for ADHF, with potential annual savings ranging from tens to hundreds of millions of euros depending on eligibility and uptake.