Quantifying the ROI of standardized heart failure diagnostics

• Heart failure is a leading driver of healthcare spending, with hospitalizations accounting for the largest share of direct costs

• Many patients with heart failure are not diagnosed until an acute hospital admission, missing opportunities for earlier diagnosis and intervention

• Standardized heart failure diagnostics like NT-proBNP testing offer measurable ROI by improving diagnostic accuracy and enabling earlier treatment

Heart failure (HF) affects more than 64 million people worldwide and is a leading cause of hospitalization and mortality—a burden expected to grow as the global population ages.¹ Beyond its devastating effect on patient health and wellbeing, heart failure places a significant financial pressure on healthcare systems, with an estimated economic burden of USD 284.17 billion across 179 countries in 2021.² 

Early diagnosis is critical, yet the diagnostic pathway for heart failure remains complex and lengthy.^3,4 Classical symptoms, such as shortness of breath, fatigue, reduced exercise tolerance, and ankle edema, are non-specific, making a diagnosis based on clinical assessment alone challenging.^3,4 Because these clinical signs easily overlap with other chronic conditions, structured screening becomes essential, particularly in high-risk populations such as individuals with type 2 diabetes or obesity. Too often, patients receive a diagnosis only during late-stage hospitalization, despite experiencing symptoms for years beforehand.^3,5 The consequences of such late-stage detection include higher mortality rates and increased healthcare costs.^4,5

Healthcare organizations can strengthen the heart failure diagnostic pathway by adopting standardized, protocol-driven biomarker testing. In particular, N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing can help reduce diagnostic uncertainty and support earlier diagnosis. By reducing unnecessary hospital admissions and downstream diagnostic investigations, this standardized approach has the potential to deliver a measurable return on investment (ROI) while improving the efficiency and quality of heart failure care.^3,6,7

Heart failure represents a major global economic burden on healthcare systems. In Europe, it accounts for around 2% of annual healthcare expenditure, totaling EUR 29 billion annually.¹ In the US, the annual cost of HF is projected to reach USD 70 billion by 2030.⁸ But the costs of heart failure extend far beyond these direct costs after factoring in the indirect costs to society, including reduced worker productivity, early retirement, and caregiver costs.^1,2

Although the indirect costs of heart failure are substantial, it’s the inpatient hospitalization that consistently represents the largest contributor to direct healthcare system costs^.1,2,8 In the US, inpatient care accounts for nearly half of all direct heart failure-related healthcare spending.⁸

Much of this cost is preventable through earlier, standardized diagnosis. Delayed diagnosis and diagnoses made only after acute hospital admission are associated with repeat hospitalization, longer inpatient stays, and higher mortality.^3,5,7 Diagnostic uncertainty and the failure to capture early-stage heart failure also delay appropriate triage, postponing timely care that could improve prognosis for some patients while leading to unnecessary investigations and procedures for others, further compounding healthcare costs.⁵ Early diagnosis not only delays disease progression and prolongs quality of life, but also reduces avoidable healthcare expenditure.^3,7

Breathlessness is one of the hallmark symptoms of heart failure, but it is non-specific and may indicate a range of other conditions.^3,9 As a result, relying on traditional clinical assessment alone can delay triage and diagnosis.³ In fact, approximately 22% of patients with acute heart failure are not identified when diagnosis is based solely on clinical assessment, highlighting the need for more accurate diagnostic procedures for heart failure that improve accuracy.⁶

Standardized cardiometabolic blood testing using NT-proBNP helps address this diagnostic uncertainty. As the established biomarker for the diagnosis and prognosis of heart failure, NT-proBNP provides an objective measure of cardiac wall stress that complements clinical evaluation,⁹ supporting clinical decision-making by identifying patients who should be referred for echocardiography to confirm heart failure.^3-5 In acute care, its high sensitivity allows clinicians to confidently rule out acute heart failure, while validated age-specific rule-in thresholds help identify patients who require further cardiac assessment.⁹

Compared with clinical assessment alone, an NT-proBNP-supported diagnostic strategy was shown to increase the probability of a correct diagnosis by 7%.⁷ By improving diagnostic accuracy, NT-proBNP testing helps ensure that patients receive the appropriate investigations and treatment sooner. Most importantly, it serves as an effective gateway to echocardiography, helping healthcare organizations prioritize this valuable and resource-intensive investigation for patients most likely to benefit.^3,10

Given that hospitalization is the largest driver of heart failure healthcare spending, improvements in diagnostic efficiency that enable earlier intervention can deliver measurable financial returns. A recent health economic analysis found that an NT-proBNP-supported diagnostic strategy reduced average inpatient management costs by 10%, generating institutional savings of USD 2,337 per emergency department visit. These savings were driven by lower healthcare resource utilization across the care pathway, including fewer hospital admissions (14%), echocardiograms (31%), and ICU admissions (12%).⁷

Using the NT-proBNP blood test as a standardized gateway to echocardiography can help alleviate workflow bottlenecks and optimize the use of specialist resources by reducing unnecessary imaging.^7,10 The experience at St. George’s Hospital in the United Kingdom demonstrates the value of this approach in practice. The hospital requires NT-proBNP testing before authorizing echocardiography referrals for patients with suspected heart failure in the acute setting. Since implementing this protocol, the hospital has reduced the referral time for inpatients waiting for echocardiography from approximately 5–7 days to just 24 hours, freeing up valuable bed space and specialist capacity.¹¹

Decentralizing NT-proBNP testing into primary care through Point of Care Testing (POCT) offers an opportunity to move diagnosis even earlier in the patient pathway. Using a capillary blood sample, clinicians can obtain laboratory-quality results within minutes, enabling immediate clinical decision-making during the initial consultation rather than waiting days for laboratory testing.¹² This allows general practitioners (GPs) to identify patients who require urgent specialist assessment, decreasing follow-up visits to the GP practice, and to rule out heart failure in lower-risk patients — helping to reduce unnecessary referrals and optimize healthcare resources.^10,13 One study in the UK found that shifting the diagnostic pathway into the community generated longitudinal savings of up to GBP 2,500 per patient over a six-year period for the National Health Service (NHS).⁵ 

Heart failure and metabolic disorders frequently coexist, creating a particularly high-risk patient population.¹⁴ While people with type 2 diabetes mellitus (T2DM) are two to four times more likely to develop heart failure than those without diabetes, the risk trajectory begins much earlier. Elevated heart failure risk is already observed in individuals with prediabetes¹⁵ and obesity.¹⁶ Together, obesity, pre-diabetes, and T2DM form a metabolic continuum¹⁷ that compounds cardiac risk and increases the risk of mortality in both hospitalized and ambulatory patients.^14,18 This underscores the critical need for proactive, early identification of heart failure before disease progression leads to hospitalization. 

For high-risk populations, NT-proBNP is an effective screening tool for identifying patients who require further cardiac assessment. Health economic modeling in Austria and Switzerland evaluated a strategy in which patients with NT-proBNP concentrations above the guideline-recommended threshold of 125 pg/mL were referred for echocardiography. This targeted screening approach was found to be highly cost-effective because it enabled earlier diagnosis and treatment, improving quality of life and extending life expectancy.¹⁸

The economic value of this approach extends beyond individual patient care. The model estimated that NT-proBNP-supported screening generated an additional 0.35 quality-adjusted life years (approximately 4.2 quality-adjusted months) per patient at an incremental cost of just EUR 3,042 per QALY in Austria and CHF 897 per QALY in Switzerland, demonstrating excellent value for healthcare systems. When indirect costs, including lost productivity from employee absenteeism, were incorporated into a scenario analysis, the screening strategy became cost-saving overall, demonstrating how targeted biomarker screening in high-risk populations can deliver both clinical and economic value.¹⁸

To maximize the value of NT-proBNP testing, healthcare systems should adopt validated diagnostic thresholds that balance sensitivity and specificity. In patients with suspected acute heart failure, an NT-proBNP concentration below 300 pg/mL can be used to confidently rule out the condition.⁹ Patients with an NT-proBNP concentration above this threshold should then be assessed using age-specific rule-in thresholds of 450 pg/mL (<55 years), 900 pg/mL (55–75 years), and 1,800 pg/mL (>75 years) to guide further cardiac investigation.⁹

Health economic modelling supports this combined rule-out/rule-in strategy because it improves diagnostic specificity while maintaining high sensitivity. Compared with clinical assessment alone or a rule-out-only strategy, it reduces unnecessary echocardiography and hospital admissions, making it the most cost-effective diagnostic strategy evaluated.⁶ 

Realizing the full value of NT-proBNP testing requires a standardized diagnostic pathway embedded into routine clinical practice. Healthcare organizations can support successful implementation by: 

• Developing standardized diagnostic pathways that define when NT-proBNP testing should be performed and when patients should be referred for echocardiography^9,11

• Integrating age-specific NT-proBNP thresholds into laboratory reports and electronic health records (EHRs) using automated clinical decision support to promote consistent interpretation and timely referral decisions¹⁹ 

• Establishing close collaboration with pathology services to ensure rapid turnaround time (TAT) for NT-proBNP testing in acute care settings, with an ideal TAT of no more than 70 minutes¹¹

• Aligning administrative leaders, cardiologists, emergency clinicians, and central pathology services around a standardized diagnostic pathway¹¹

Together, these implementation strategies help healthcare organizations realize the full clinical and economic value of standardized NT-proBNP testing. By embedding evidence-based diagnostic protocols into routine care, organizations can support early diagnosis and relieve pressure on limited echocardiography resources.

Heart failure represents a significant financial burden on healthcare systems, both as a long-term condition with complex needs and as a common reason for emergency room visits.^1,2,8 Earlier diagnosis has the potential to improve clinical and economic outcomes;^3,5 when integrated into suspected heart failure diagnostic pathways, standardized cardiometabolic blood testing supports faster echocardiography referral, ensuring timely diagnosis and treatment.^7,10,11

Yet despite compelling evidence supporting NT-proBNP testing, uptake remains limited.^3,19 Closing this gap will require healthcare systems to view advanced heart failure diagnostics not simply as laboratory expenses, but as strategic clinical and financial assets that improve diagnostic efficiency and support more sustainable healthcare delivery. 

As healthcare systems face growing demand and constrained resources, investing in standardized, biomarker-driven diagnostic pathways represents an opportunity to improve the quality of heart failure care while delivering measurable ROI.^7,15 By shifting diagnosis earlier in the patient pathway, NT-proBNP testing can help prevent costly acute episodes, repeat hospitalizations, prolonged inpatient stays, and the need for specialist care.^5,7