Cost-Effectiveness of Cholesterol-Lowering Therapies according to Selected Patient Characteristics

  1. Lisa A. Prosser, MS;
  2. Aaron A. Stinnett, PhD;
  3. Paula A. Goldman, MPH;
  4. Lawrence W. Williams, MSc;
  5. Maria G.M. Hunink, MD, PhD;
  6. Lee Goldman, MD, MPH; and
  7. Milton C. Weinstein, PhD
  1. From Harvard School of Public Health, Boston, Massachusetts; University of Alabama at Birmingham, Birmingham, Alabama; Erasmus University Medical School, Rotterdam, the Netherlands; and University of California, San Francisco, School of Medicine, San Francisco, California.

    Abstract

    Background: The National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II) recommends treatment guidelines based on cholesterol level and number of risk factors.

    Objective: To evaluate how the cost-effectiveness ratios of cholesterol-lowering therapies vary according to different risk factors.

    Design: Cost-effectiveness analysis.

    Data Sources: Published data.

    Target Population: Women and men 35 to 84 years of age with low-density lipoprotein cholesterol levels of 4.1 mmol/L or greater (≥ 160 mg/dL), divided into 240 risk subgroups according to age, sex, and the presence or absence of four coronary heart disease risk factors (smoking status, blood pressure, low-density lipoprotein cholesterol level, and high-density lipoprotein cholesterol level).

    Time Horizon: 30 years.

    Perspective: Societal.

    Interventions: Step I diet, statin therapy, and no preventive treatment for primary and secondary prevention.

    Outcome Measures: Incremental cost-effectiveness ratios.

    Results of Base-Case Analysis: Incremental cost-effectiveness ratios for primary prevention with step I diet ranged from $1900 per quality-adjusted life-year (QALY) gained to $500 000 per QALY depending on risk subgroup characteristics. Primary prevention with a statin compared with diet therapy was $54 000 per QALY to $1 400 000 per QALY. Secondary prevention with a statin cost less than $50 000 per QALY for all risk subgroups.

    Results of Sensitivity Analysis: The inclusion of niacin as a primary prevention option resulted in much less favorable incremental cost-effectiveness ratios for primary prevention with a statin (>$500 000 per QALY).

    Conclusions: Cost-effectiveness of treatment strategies varies significantly when adjusted for age, sex, and the presence or absence of additional risk factors. Primary prevention with a step I diet seems to be cost-effective for most risk subgroups but may not be cost-effective for otherwise healthy young women. Primary prevention with a statin may not be cost-effective for younger men and women with few risk factors, given the option of secondary prevention and of primary prevention in older age ranges. Secondary prevention with a statin seems to be cost-effective for all risk subgroups and is cost-saving in some high-risk subgroups.

    Article and Author Information

    • Disclosure: The Harvard Program on the Economic Evaluation of Medical Technology has received funding from Merck (unrestricted funds, unrelated to cholesterol-lowering drugs). Drs. Weinstein and Goldman were co-investigators for the economic substudy of the CARE study of pravastatin funded by Bristol-Myers Squibb.

    • Grant Support: By grant R01 HS 06258 from the Agency for Healthcare Research and Quality, unrestricted funds from the Harvard Program on the Economic Evaluation of Medical Technology (Ms. Prosser), National Library of Medicine Training Grant 5T15LM07092-08 (Ms. Prosser), and a Faculty Development Award in Pharmacoeconomics from the Pharmaceutical Research and Manufacturers of America Foundation (Dr. Stinnett).

    • Requests for Single Reprints: Milton C. Weinstein, PhD, Harvard Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115-5924.

    • Requests To Purchase Bulk Reprints (minimum, 100 copies): the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints{at}mail.acponline.org.

    • Current Author Addresses: Ms. Prosser: Department of Ambulatory Care and Prevention, Harvard Medical School, 126 Brookline Avenue, Boston, MA 02215.

    • Dr. Stinnett: University of Alabama at Birmingham, 330 RPHB, Birmingham, AL 35294-0022.

    • Ms. Goldman, Mr. Williams, and Dr. Weinstein: Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115-5924.

    • Dr. Hunink: Erasmus Medical Center, Box 1738, 3000 DR Rotterdam, the Netherlands.

    • Dr. Goldman: Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143.

    • Author Contributions: Conception and design: L. Prosser, A.A. Stinnett, M.C. Weinstein.

    • Analysis and interpretation of the data: L. Prosser, P.A. Goldman, M.C. Weinstein.

    • Drafting of the article: L. Prosser.

    • Critical revision of the article for important intellectual content: P.A. Goldman, M.G.M. Hunink, L. Goldman, M.C. Weinstein.

    • Final approval of the article: L. Prosser, A.A. Stinnett, P.A. Goldman, L.W. Williams, M.G.M. Hunink, L. Goldman, M.C. Weinstein.

    • Obtaining of funding: M.C. Weinstein.

    • Administrative, technical, or logistic support: P.A. Goldman, L.W. Williams.

    • Collection and assembly of data: L. Prosser, P.A. Goldman.

    Summary for Patients

    • Summaries for Patients:The Cost Effectiveness of Lowering Cholesterol in Individual Patients Ann Intern Med May 16, 2000 132:769
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    1. Ann Intern Med May 16, 2000 vol. 132 no. 10 769-779
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