Statin cost effectiveness in primary prevention: A systematic review of the recent cost-effectiveness literature in the United States

Mitchell, Aaron P.; Simpson, Ross J.

doi:10.1186/1756-0500-5-373

Cited by 38 publications

(26 citation statements)

References 21 publications

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“…Statins, for example, although clearly cost-effective in secondary prevention or high-risk primary prevention patients, become less cost-effective as primary prevention for low-risk patients (34, 35). Overestimation of risk could result in more health care dollars spent, less health gain, and exposure to drug side effects.…”

Section: Discussionmentioning

confidence: 99%

An Analysis of Calibration and Discrimination Among Multiple Cardiovascular Risk Scores in a Modern Multiethnic Cohort

et al. 2015

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Background Accurate risk assessment of atherosclerotic cardiovascular disease (ASCVD) is essential to effectively balance the risks and benefits of therapy for primary prevention. Objective To compare the calibration and discrimination of the new American Heart Association (AHA) and American College of Cardiology (ACC) ASCVD risk score with alternative risk scores and to explore preventive therapy as a cause of the reported risk overestimation using the AHA-ACC-ASCVD score. Design Prospective epidemiologic study of ASCVD. Setting MESA (Multi-Ethnic Study of Atherosclerosis), a community-based, sex-balanced, multiethnic cohort. Patients 4227 MESA participants aged 50 to 74 years and without diabetes at baseline. Measurements Observed and expected events for the AHA-ACC-ASCVD score were compared with 4 commonly used risk scores—and their respective end points—in MESA after a 10.2-year follow-up. Results The new AHA-ACC-ASCVD and 3 older Framingham-based risk scores overestimated cardiovascular events by 37% to 154% in men and 8% to 67% in women. Overestimation was noted throughout the continuum of risk. In contrast, the Reynolds Risk Score overestimated risk by 9% in men but underestimated risk by 21% in women. Aspirin, lipid-lowering or antihypertensive therapy, and interim revascularization did not explain the overestimation. Limitation Comparability of MESA with target populations for primary prevention and possibility of missed events in MESA. Conclusion Of the 5 risk scores, 4, including the new AHA-ACC-ASCVD score, showed overestimation of risk (25% to 115%) in a modern, multiethnic cohort without baseline clinical ASCVD. If validated, overestimation of ASCVD risk may have substantial implications for individual patients and the health care system. Primary Funding Source National Heart, Lung, and Blood Institute.

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Section: Discussionmentioning

confidence: 99%

An Analysis of Calibration and Discrimination Among Multiple Cardiovascular Risk Scores in a Modern Multiethnic Cohort

et al. 2015

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“…27, 36, 37 While $4/month programs available at discount pharmacy outlets should provide access to very low cost statins, most Americans do not avail themselves of these programs, 26 and the costs of even generic statins are substantially higher at retail pharmacies. 27, 36 The decrement in quality of life associated with statin use is similarly hard to parameterize for cost-effectiveness modeling.…”

Section: Discussionmentioning

confidence: 99%

Using the Coronary Artery Calcium Score to Guide Statin Therapy

Pletcher¹,

Pignone²,

Earnshaw

et al. 2014

Circ: Cardiovascular Quality and Outcomes

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Background The coronary artery calcium score (CAC) predicts future coronary heart disease (CHD) events and could be used to guide primary prevention interventions, but CAC measurement has costs and exposes patients to low-dose radiation. Methods and Results We estimated the cost-effectiveness of measuring CAC and prescribing statin therapy based on the resulting score under a range of assumptions using an established model enhanced with CAC distribution and risk estimates from the Multi-Ethnic Study of Atherosclerosis (MESA). Ten years of statin treatment for 10,000 55-year-old women with high cholesterol (10-year CHD risk=7.5%) was projected to prevent 32 myocardial infarctions, cause 70 cases of statin-induced myopathy, and add 1,108 years to total life-expectancy. Measuring CAC and targeting statin treatment to the 2,500 women with CAC>0 would provide 45% of the benefit (+501 life-years), but CAC measurement would cost $2.25 million and cause 9 radiation-induced cancers. Treat All was preferable to CAC screening in this scenario and across a broad range of other scenarios (CHD risk=2.5-15%) when statin assumptions were favorable ($0.13/pill and no quality of life penalty). When statin assumptions were less favorable ($1.00/pill and disutility=0.00384), CAC screening with statin treatment for persons with CAC>0 was cost-effective (<$50,000/quality-adjusted life-year) in this scenario, in 55-year old men with CHD risk=7.5%, and in other intermediate risk scenarios (CHD risk=5-10%). Our results were critically sensitive to statin cost and disutility, and relatively robust to other assumptions. Alternate CAC treatment thresholds (>100 or >300) were generally not cost-effective. Conclusions CAC testing in intermediate risk patients can be cost-effective, but only if statins are costly or significantly impact quality of life.

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“…38,58 Other studies, however, did not 44,59 or only applied a disutility in sensitivity analyses. 60,61 The studies that included a disutility for statin use based this on assumption 58 or on analogy to models in aspirin or warfarin.…”

Section: Scenario Analysesmentioning

confidence: 99%

Improving Adherence to Lipid-Lowering Therapy in a Community Pharmacy Intervention Program: A Cost-Effectiveness Analysis

Vegter

Oosterhof²,

Boven

et al. 2014

JMCP

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BACKGROUND: Pharmaceutical care in community pharmacies has been shown to improve adherence to chronic therapies. Long-term impact on clinical outcomes or medical cost savings, however, remains understudied. OBJECTIVE: To estimate the cost-effectiveness of a pharmaceutical care intervention program in Dutch community pharmacies that improved patients' adherence to lipid-lowering therapy. METHODS: An economic evaluation was performed using a time-dependent Markov model from the health care payer perspective. Participants were patients initiating lipid-lowering therapy for primary prevention (40%) or secondary prevention (60%) of cardiovascular events (CVEs). The intervention was the pharmaceutical care program MeMO (Medication Monitoring and Optimisation) in 9 community pharmacies in the Netherlands, based on continuous monitoring and optimization of lipid-lowering therapy in new patients. The follow-up period of the program was 1 year. The main outcome of the intervention program was discontinuation of lipid-lowering therapy. This outcome was extrapolated in the economic model to lifelong costs, quality of life, reductions in cardiovascular events, and incremental cost-effectiveness ratios. RESULTS: Patients in the MeMO program had a lower risk for therapy discontinuation, RR = 0.49 (0.37 to 0.66); the effectiveness was similar in primary and secondary prevention. In a cohort of 1,000 primary and secondary prevention patients, the MeMO program resulted in a reduction of 7 nonfatal strokes, 2 fatal strokes, 16 nonfatal myocardial infarctions (MIs), 7 fatal MIs, and 16 revascularizations over patients' lifetime. Additional medication, disease management, and intervention costs in the MeMO program were €411,000; the cost savings due to reduced CVEs were €443,000. The MeMO program resulted in 84 quality-adjusted life-years (QALYs) gained and net cost savings of €32,000. Clinical benefits and cost savings were highest in the secondary prevention population. CONCLUSION: Pharmaceutical care in community pharmacies can improve statin therapy adherence, resulting in better prevention of CVEs. The MeMO program resulted in considerable clinical benefits and net cost savings. Programs by community pharmacies targeted at improving adherence may provide good value for money, and health care insurers should consider reimbursing these activities.

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Statin cost effectiveness in primary prevention: A systematic review of the recent cost-effectiveness literature in the United States

Cited by 38 publications

References 21 publications

An Analysis of Calibration and Discrimination Among Multiple Cardiovascular Risk Scores in a Modern Multiethnic Cohort

An Analysis of Calibration and Discrimination Among Multiple Cardiovascular Risk Scores in a Modern Multiethnic Cohort

Using the Coronary Artery Calcium Score to Guide Statin Therapy

Improving Adherence to Lipid-Lowering Therapy in a Community Pharmacy Intervention Program: A Cost-Effectiveness Analysis

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