Comparing Impact and Cost-Effectiveness of Primary Prevention Strategies for Lipid-Lowering

  1. Mark J. Pletcher, MD, MPH;
  2. Lawrence Lazar, MD;
  3. Kirsten Bibbins-Domingo, PhD, MD;
  4. Andrew Moran, MD, MPH;
  5. Nicolas Rodondi, MD, MAS;
  6. Pamela Coxson, PhD;
  7. James Lightwood, PhD;
  8. Lawrence Williams, MSc; and
  9. Lee Goldman, MD, MPH
  1. From the University of California, San Francisco, San Francisco, California; Columbia University, New York, New York; University of Lausanne, Lausanne, Switzerland; and Brigham and Women's Hospital, Boston, Massachusetts.

    Abstract

    Background: Lipid-lowering therapy is costly but effective at reducing coronary heart disease (CHD) risk.

    Objective: To assess the cost-effectiveness and public health impact of Adult Treatment Panel III (ATP III) guidelines and compare with a range of risk- and age-based alternative strategies.

    Design: The CHD Policy Model, a Markov-type cost-effectiveness model.

    Data Sources: National surveys (1999 to 2004), vital statistics (2000), the Framingham Heart Study (1948 to 2000), other published data, and a direct survey of statin costs (2008).

    Target Population: U.S. population age 35 to 85 years.

    Time Horizon: 2010 to 2040.

    Perspective: Health care system.

    Intervention: Lowering of low-density lipoprotein cholesterol with HMG-CoA reductase inhibitors (statins).

    Outcome Measure: Incremental cost-effectiveness.

    Results of Base-Case Analysis: Full adherence to ATP III primary prevention guidelines would require starting (9.7 million) or intensifying (1.4 million) statin therapy for 11.1 million adults and would prevent 20 000 myocardial infarctions and 10 000 CHD deaths per year at an annual net cost of $3.6 billion ($42 000/QALY) if low-intensity statins cost $2.11 per pill. The ATP III guidelines would be preferred over alternative strategies if society is willing to pay $50 000/QALY and statins cost $1.54 to $2.21 per pill. At higher statin costs, ATP III is not cost-effective; at lower costs, more liberal statin-prescribing strategies would be preferred; and at costs less than $0.10 per pill, treating all persons with low-density lipoprotein cholesterol levels greater than 3.4 mmol/L (>130 mg/dL) would yield net cost savings.

    Results of Sensitivity Analysis: Results are sensitive to the assumptions that LDL cholesterol becomes less important as a risk factor with increasing age and that little disutility results from taking a pill every day.

    Limitation: Randomized trial evidence for statin effectiveness is not available for all subgroups.

    Conclusion: The ATP III guidelines are relatively cost-effective and would have a large public health impact if implemented fully in the United States. Alternate strategies may be preferred, however, depending on the cost of statins and how much society is willing to pay for better health outcomes.

    Funding: Flight Attendants' Medical Research Institute and the Swanson Family Fund. The Framingham Heart Study and Framingham Offspring Study are conducted and supported by the National Heart, Lung, and Blood Institute.

    Article and Author Information

    • Note: Preliminary results were presented at the 47th Annual Conference on Cardiovascular Disease Epidemiology and Prevention in Orlando, Florida, 28 February–3 March 2007.

    • Disclaimer: The manuscript was prepared by using a limited-access data set obtained by the National Heart, Lung, and Blood Institute and does not necessarily reflect the opinions or views of the Framingham Heart Study; Framingham Offspring Study; or the National Heart, Lung, and Blood Institute.

    • Acknowledgment: The authors thank Dr. Stephanie Earnshaw for her help with cost inputs and Dr. David Fairley for help developing the Monte Carlo simulation program for the CHD Policy Model.

    • Grant Support: By the Flight Attendants' Medical Research Institute and a grant from the Swanson Family Fund to the University of California (Dr. Goldman). The Framingham Heart Study and Framingham Offspring Study are conducted and supported by the National Heart, Lung, and Blood Institute in collaboration with the Framingham Heart Study and Framingham Offspring Study investigators.

    • Reproducible Research Statement: The CHD Policy Model is owned by an Intellectual Property Commons, currently led by Columbia University and formerly led by the University of California and Harvard University, both of which remain part of the Commons. To guarantee the reliability and integrity of the model, collaborating investigators and their institutions become part of this Commons by agreeing to 1) help maintain and improve the model and 2) have any of their uses of the model (e.g., requests for extramural funding or potential publications) reviewed for accuracy and approval by the Commons before any dissemination. Since its establishment, the Commons has included a number of funded projects, none from for-profit entities. Several investigators, including some from outside the United States, recently joined the Commons, and new members are always welcome but rarely solicited. In all decisions, maintaining the integrity, reliability, and impartiality of the model remains the primary goal. Persons who are interested in joining the Commons and are committed to improving the model and using it for scientific purposes should contact Dr. Goldman.

    • Potential Financial Conflicts of Interest: Consultancies: N. Rodondi (Pfizer). Honoraria: N. Rodondi (Pfizer, AstraZeneca, Merck & Co., Schering-Plough).

    • Requests for Single Reprints: Mark J. Pletcher, MD, MPH, University of California, San Francisco, 185 Berry Street, Suite 5700, San Francisco, CA 94107; e-mail, mpletcher{at}epi.ucsf.edu.

    • Current Author Addresses: Dr. Pletcher: University of California, San Francisco, 185 Berry Street, Suite 5700, San Francisco, CA 94107.

    • Dr. Lazar: 2732 Derbyshire Road, Cleveland Heights, OH 44106.

    • Dr. Bibbins-Domingo: University of California, San Francisco, Box 1364, San Francisco, CA 94143.

    • Dr. Moran: Columbia University, 622 West 168th Street, New York, NY 10032.

    • Dr. Rodondi: Department of Ambulatory Care and Community Medicine, University of Lausanne, Bugnon 44, Lausanne 1011, Switzerland.

    • Dr. Coxson: Department of General Internal Medicine, San Francisco General Hospital, Building 10, Third Floor, 1001 Potrero Avenue, San Francisco, CA 94110.

    • Dr. Lightwood: Department of Clinical Pharmacology, University of California, San Francisco, 3333 California Street, Suite 420, San Francisco, CA 94118.

    • Dr. Williams: Partners HealthCare System, 93 Worcester Street, Suite 201, Wellesley, MA 02481.

    • Dr. Goldman: Columbia University Medical Center, College of Physicians and Surgeons, 630 West 168th Street, Suite 2-401, New York, NY 10032.

    • Author Contributions: Conception and design: M.J. Pletcher, K. Bibbins-Domingo, A. Moran, P. Coxson, L. Goldman.

    • Analysis and interpretation of the data: M.J. Pletcher, L. Lazar, K. Bibbins-Domingo, N. Rodondi, P. Coxson, J. Lightwood, L. Goldman.

    • Drafting of the article: M.J. Pletcher, P. Coxson.

    • Critical revision of the article for important intellectual content: M.J. Pletcher, K. Bibbins-Domingo, A. Moran, N. Rodondi, P. Coxson, L. Goldman.

    • Final approval of the article: M.J. Pletcher, A. Moran, N. Rodondi, P. Coxson, J. Lightwood, L. Goldman.

    • Statistical expertise: N. Rodondi, L. Williams.

    • Obtaining of funding: L. Goldman.

    • Administrative, technical, or logistic support: K. Bibbins-Domingo, L. Goldman.

    • Collection and assembly of data: M.J. Pletcher, L. Lazar, L. Williams.

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    1. Ann Intern Med February 17, 2009 vol. 150 no. 4 243-254
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