**1. Highlights**

We previously reported a reduced risk for mortality and major cardiovascular events when older hospitalized patients with chronic heart failure and malnutrition received individualized nutritional interventions compared with similar patients who consumed only a usual hospital diet. In this study, we developed a Markov model of healthcare–state transitions and costs to identify the cost-savings and incremental cost-effectiveness ratios

**Citation:** Schuetz, P.; Sulo, S.; Walzer, S.; Krenberger, S.; Stagna, Z.; Gomes, F.; Mueller, B.; Brunton, C. Economic Evaluation of Individualized Nutritional Support for Hospitalized Patients with Chronic Heart Failure. *Nutrients* **2022**, *14*, 1703. https:// doi.org/10.3390/nu14091703

Academic Editors: Omorogieva Ojo and Amanda R. Amorim Adegboye

Received: 18 March 2022 Accepted: 18 April 2022 Published: 20 April 2022

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(ICER) of nutritional intervention. With an additional 5.77 life days, the overall ICER for nutritional support vs. no nutritional support was 2625 Swiss francs per life day gained.

#### **2. Introduction**

Chronic heart failure (CHF) has high clinical and economic costs worldwide given adverse health outcomes and increased healthcare resource utilization. Globally, HF cases exceed 60 million and account for nearly 10 million life-years lost to disability, with yearly costs estimated at nearly USD 350 billion [1,2]. The annual medical cost for a person with HF was estimated at more than USD 24,000 in the United States, although costs vary widely among individuals and are highest among those who are oldest and have co-morbidities [3]. Since HF imposes the greatest burden on older adults [1], the incidence is increasing as the population grows and ages [4].

Poor nutritional status is common among older people with HF because of multiple negative prognostic factors, such as decreased appetite and weight loss [5], impaired intestinal function [6], the presence of other comorbidities, and catabolic metabolism due to HF-related inflammation [7,8]. Malnutrition with consequent loss of muscle mass and physical functionality has been associated with increased morbidity, poorer quality of life, and worsening of CHF [9]. Nutritional strategies have long been recommended as part of treatment for CHF, but clinical studies often focus on restricting sodium intake and following specific dietary patterns for long-term cardiac health benefits, e.g., the Mediterranean and DASH diets [10,11].

Currently, many HF patients urgently need supportive nutrition care to address nutritional shortfalls and subsequent adverse consequences. Studies have reported improved health outcomes when patients with poor nutritional status receive nutritional interventions. In fact, quality improvement programs can be used across the continuum of care to enhance outcomes for people who have evidence of poor nutritional status in home-care settings, in residential nursing care [12], and during hospital admission [13–17]. An early review by Tappendan et al. found that hospital care with a focus on nutrition can reduce complication rates, length of hospital stays, readmission rates, and mortality [17]. Further, the results of a systematic review and meta-analysis of studies on hospitalized patients with malnutrition showed that nutritional interventions can significantly improve nutritional intake and reduce the risk of mortality [18]. Beyond health benefits, individualized nutritional support during and after hospitalization is also recognized as cost-saving because it spares healthcare resource utilization due to excess hospital lengths of stay, readmissions, and need for intensive care unit (ICU) admission [19–22]. In fact, the added cost of providing nutritional support is considered low, especially relative to the resultant lowered costs of hospitalization and medical treatments [20].

We previously reported results of beneficial health outcomes of nutritional intervention for at-risk patients in Swiss hospitals—a study known as Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial (EFFORT) [23]. In this study of more than 2000 medical inpatients, we found that nutritional interventions helped poorly nourished participants meet calorie and protein goals better than usual hospital food, significantly enhancing survival. When we focused the analysis on a subpopulation of EFFORT patients with CHF, we similarly found better health outcomes for the patients who were given supportive, individualized nutritional care [24]. Specifically, CHF patients at high nutritional risk had significantly reduced risk for mortality and major cardiovascular events when they received individualized nutritional interventions rather than standard hospital food [24]. In our current economic analysis of results from these vulnerable CHF patients in EFFORT, we applied a Markov model of health outcomes to predict how nutritional support would affect costs of healthcare utilization.
