Cost-Effectiveness of Lipid-Lowering Therapies for Cardiovascular Prevention in Germany

Abstract

Purpose Novel pharmaceutical treatments reducing cardiovascular events in dyslipidaemia patients must demonstrate clinical efficacy and cost-effectiveness to promote long-term adoption by patients, physicians, and insurers. Objective To assess the cost-effectiveness of statin monotherapy compared to additive lipid-lowering therapies for primary and secondary cardiovascular prevention from the perspective of Germany’s healthcare system. Methods Transition probabilities and hazard ratios were derived from cardiovascular outcome trials for statin combinations with icosapent ethyl (REDUCE-IT), evolocumab (FOURIER), alirocumab (ODYSSEY), ezetimibe (IMPROVE-IT), and fibrate (ACCORD). Costs and utilities were retrieved from previous literature. The incidence of major adverse cardiovascular events was simulated with a Markov cohort model. The main outcomes were the incremental cost-effectiveness ratios (ICER) per quality adjusted life year (QALY) gained. Results For primary prevention, the addition of icosapent ethyl to statin generated 0.81 QALY and €14,732 costs (ICER: 18,133), whereas fibrates yielded 0.63 QALY and € − 10,516 costs (ICER: − 16,632). For secondary prevention, the addition of ezetimibe to statin provided 0.61 QALY at savings of € − 5,796 (ICER: − 9,555) and icosapent ethyl yielded 0.99 QALY and €14,333 costs (ICER: 14,485). PCSK9 inhibitors offered 0.55 and 0.87 QALY at costs of €62,722 and €87,002 for evolocumab (ICER: 114,639) and alirocumab (ICER: 100,532), respectively. A 95% probability of cost-effectiveness was surpassed at €20,000 for icosapent ethyl (primary and secondary prevention), €119,000 for alirocumab, and €149,000 for evolocumab. Conclusions For primary cardiovascular prevention, a combination therapy of icosapent ethyl plus statin is a cost-effective use of resources compared to statin monotherapy. For secondary prevention, icosapent ethyl, ezetimibe, evolocumab, and alirocumab increase patient benefit at different economic costs.

Cost-Effectiveness of Bivalent, Quadrivalent, and Nonavalent HPV Vaccination in South Africa

“…Transition probabilities used to populate the model can be found in Table 1. Rates, hazard ratios, odd ratios, and probabilities with a different time horizon than 1 year were converted to 1-year probabilities, similar to previous peerreviewed methodologies and cost-effectiveness studies [20,21]. This widely used calculation considers the rate of patients progressing between disease states and the observation's follow-up period [21].…”

Cost-Effectiveness of Icosapent Ethyl, Evolocumab, Alirocumab, Ezetimibe, or Fenofibrate in Combination with Statins Compared to Statin Monotherapy

“…A Markov model simulating the progression of CVD in dyslipidaemia patients was adapted from existing cost-effectiveness studies (Fig. 1) [23]. Patients transitioned between three distinct health states: "Alive without CVD", "Alive with CVD", and "Dead".…”

“…Every year patients were at risk of experiencing acute cardiovascular events (myocardial infarction, stroke, coronary revascularisation, unstable angina pectoris) and dying from CVD or non-CVD causes. Model structure adopted from Michaeli et al [23]. CVD cardiovascular disease…”

“…Therefore, these therapies were only evaluated for secondary cardiovascular prevention setting. Similar to previous studies, baseline transition probabilities were multiplied by + 10% and + 14% annually to model the age-dependent increased risk of non-CVD and CVD events, respectively [23].…”

The potential population health impact of treating REDUCE-IT eligible US adults with Icosapent Ethyl

“…The international Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (REDUCE-IT) showed that icosapent ethyl (IPE) 4 g/day when added to contemporary medical care including statin treatment reduced the risk of time to the first event of the primary composite outcome (cardiovascular death, nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or unstable angina) by 25% (31% in the higher-risk, US subgroup), and reduced the risk of total (first and recurrent) events by 32% [6] , [7] , [8] . Further, IPE added to statin therapy is cost-effective compared with usual care in the US and Germany [ 9 , 10 ].…”