Maximizing the cost-effectiveness of lipid-lowering therapy

The Impact on Cost-Effectiveness of Accounting for Generic Drug Pricing: Four Case Studies

OBJECTIVES

Guidance on the conduct of health technology assessments rarely recommends accounting for anticipated future price declines that can follow loss of marketing exclusivity. This article explores when it is appropriate to account for generic pricing and whether it can influence cost-effectiveness estimates.

METHODS

This article presents 4 case studies. Case study 1 considers a hypothetical drug used by a first patient cohort at branded prices and by subsequent, "downstream" cohorts at generic prices. Case study 2 explores whether statin assessments should account for generic prices for downstream cohorts that gain access after the initial cohort. Case study 3 uses a simplified spreadsheet model to assess the impact of accounting for generic pricing for inclisiran, used when statins insufficiently reduce cholesterol. Case study 4 amends this model for a hypothetical, advanced, follow-on treatment displacing inclisiran.

RESULTS

Assessments should include generic pricing even if the first cohort using a drug pays branded prices and only downstream cohorts pay generic prices (case study 1). Because eventual generic pricing for statins did not depend on decisions for downstream cohorts, assessing reimbursement for those cohorts could safely omit generic pricing (case study 2). For inclisiran (case study 3), including generic pricing notably improved estimated cost-effectiveness. Displacing inclisiran with an advanced therapy (case study 4) modestly affected estimated cost-effectiveness.

CONCLUSIONS

Although this analysis relies on simplified and hypothetical models, it demonstrates that accounting for generic pricing might substantially reduce estimated cost-effectiveness ratios. Doing so when warranted is crucial to improving health technology assessment validity.

Food insecurity and dyslipidemia among adults in the United States

OBJECTIVE

The objective of this study is to estimate the likelihood of dyslipidemia among food insecure men and women.

METHOD

Men, n=2572 and women, n=2977, in the National Health and Nutrition Examination Survey 1999-2002 cholesterol screening sample were included in this study. Gender-stratified descriptive comparisons and logistic regression models were used to study associations between food insecurity and dyslipidemia indicated by abnormal levels of fasting serum triglyceride (TRG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and their ratios.

RESULTS

Food insecurity did not associate with dyslipidemia among men. Among women, the associations between food insecurity and dyslipidemia were not consistent. Compared with the fully food secure, women who were marginally food secure were more likely to have abnormal levels of LDL-C (adjusted OR, 1.85; P=0.045) and TRG/HDL-C ratio (adjusted OR, 1.91; P=0.046). Women who were food insecure without hunger were more likely to have abnormal levels of TRG (adjusted OR, 1.90; P=0.041).

CONCLUSION

Intermediate-level food insecurity associated with some indicators of dyslipidemia among women but not among men. This observation shows food insecure women may be at risk of dyslipidemia.

The relative merits of population-based and targeted prevention strategies

CONTEXT

Preventive medicine has historically favored reducing a risk factor by a small amount in the entire population rather than by a large amount in high-risk individuals. The use of multivariable risk prediction tools, however, may affect the relative merits of this strategy.

METHODS

This study uses risk factor data from the National Health and Nutrition Examination Survey III to simulate a population of more than 100 million Americans aged thirty or older with no history of CV disease. Three strategies that could affect CV events, CV mortality, and quality-adjusted life years were examined: (1) a population-based strategy that treats all individuals with a low- or moderate-intensity intervention (in which the low-intensity intervention represents a public health campaign with no demonstrable adverse effects), (2) a targeted strategy that treats individuals in the top 25 percent based on a single risk factor (LDL), and (3) a risk-targeted strategy that treats individuals in the top 25 percent based on overall CV risk (as predicted by a multivariable prediction tool). The efficiency of each strategy was compared while varying the intervention's intensity and associated adverse effects, and the accuracy of the risk prediction tool.

FINDINGS

The LDL-targeted strategy and the low-intensity population-based strategy were comparable for CV events prevented over five years (0.79 million and 0.75 million, respectively), as were the risk-targeted strategy and moderate-intensity population-based strategy (1.56 million and 1.87 million, respectively). The risk-targeted strategy, however, was more efficient than the moderate-intensity population-based strategy (number needed to treat [NNT] 19 vs. 62). Incorporating a small degree of treatment-related adverse effects greatly magnified the relative advantages of the risk-targeted approach over other strategies. Reducing the accuracy of the prediction tool only modestly decreased this greater efficiency.

CONCLUSIONS

A population-based prevention strategy can be an excellent option if an intervention has almost no adverse effects. But if the intervention has even a small degree of disutility, a targeted approach using multivariable risk prediction can prevent more morbidity and mortality while treating many fewer people.

Economic evaluations of cholesterol-lowering drugs: a critical and systematic review

The wide availability of economic evaluations and their increasing importance for decision making emphasises the need for economic evaluations that are methodologically sound. The aim of this review was to provide users of economic evaluations of cholesterol-lowering drugs with an insight into the quality of these evaluations. By focusing on the most relevant studies, the gap between research and policy making may be narrowed. A systematic review was conducted. All Dutch and English publications on economic evaluations of cholesterol-lowering drugs were identified by searching PubMed, the Centre for Reviews and Dissemination database (CRD), the NHS Economic Evaluation Database (NHS EED), the Health Technology Assessment database (HTA) and the Database of Abstracts of Reviews of Effects (DARE). A search strategy was set up to identify the articles to be included. The quality of these articles was assessed using Drummond's checklists. The scoring was performed by at least two reviewers. When necessary, disagreement between these reviewers was decided upon in a consensus meeting. We calculated an average quality score for the included articles. The search identified 1390 articles, of which 23 were included. Most studies measured the costs per life-year gained. The overall score per study was disappointing and varied between 2.7 and 7.7, with an average of 5.5. Most studies scored high on the measurement of costs and consequences, whereas the establishment of effectiveness left room for improvement. Only two studies included a well performed incremental analysis. This study noted an increase of quality of economic evaluations over time, suggesting the value of cost-effectiveness studies for policy decisions increases over time. In general, piggy-back evaluations tended to score higher on quality and may therefore be more valuable in decision making.

National Cholesterol Education Program risk assessment and potential for risk misclassification

BACKGROUND

The National Cholesterol Education Program Adult Treatment Panel report from 2001 (ATP III) recommends clinicians calculate 10-year coronary risk using multivariable methods only for adults with 2 or more risk factors. We aimed to determine who would be falsely classified as low risk using this approach.

METHODS

We studied 4097 adults aged 20 to 79 years without diagnosed cardiovascular disease or diabetes from the National Health and Nutrition Examination Survey from 1999 to 2002. We determined the proportion with fewer than 2 risk factors who nonetheless had estimated 10-year risk of cardiac death or myocardial infarction > or =10% using multivariable methods.

RESULTS

Among persons with fewer than 2 risk factors, 5.3% (95% confidence interval 4.7 to 6.1%), had a 10-year risk > or =10% using the Framingham Risk Score and would be misclassified using the risk factor counting method (this corresponds to approximately 5,640,000 U.S. adults). Compared to individuals whose classification was unchanged, those misclassified as low risk were older (P<0.001) and more likely male (85.5% vs. 41.2%, P<0.001).

CONCLUSIONS

Relying on the ATP III risk factor counting method rather than determining risk using multivariable methods in all patients resulted in misclassifiying as low risk over 5 million adults with at least moderately high risk of coronary heart disease, most of whom are middle-aged and older men.

Overprescribing of lipid lowering agents

BACKGROUND

Undertreatment of hyperlipidemia has received considerable attention. However, little is known about trends in overprescribing of lipid lowering agents. We examined these trends and their associations with physician, practice, and organisational factors.

METHODS

2034 physicians were surveyed twice: baseline (1996-7) and follow up (1998-9). On each occasion they were asked: "For what percentage of 50 year old men without other cardiac risk factors would you recommend an oral agent for total cholesterol of 240, LDL 150, and HDL 50 after 6 months on a low cholesterol diet?" During the survey period the National Cholesterol Education Program guidelines did not recommend prescribing for these patients. Binomial and multinomial logistic regressions assessed baseline overprescribing and longitudinal changes in overprescribing, accounting for complex sampling.

RESULTS

39% of physicians recommended prescribing at baseline (round 1), increasing at follow up (round 2) to 51% (p < 0.001). Physicians who were more likely to overprescribe at baseline were less likely to be board certified (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.38 to 0.63; p < 0.001), were in solo or two-physician practices (OR 1.88, 95% CI 1.46 to 2.41; p < 0.001), had more revenue from Medicare (OR 1.10, 95% CI 1.03 to 1.17; p = 0.004) or Medicaid (OR 1.09, 95% CI 1.01 to 1.18; p = 0.03), or were family physicians (OR 1.87, 95% CI 1.35 to 2.58; p < 0.001). Physicians with large increases in overprescibing were more likely than those with small increases in overprescribing to be international medical graduates (OR 2.09, 95% CI 1.20 to 3.64; p = 0.011) and to spend more hours in patient care (OR 1.14, 95% CI 1.03 to 1.26; p = 0.016).

CONCLUSIONS

Overprescribing of lipid lowering agents is commonplace and increased. At baseline and longitudinally, overprescribing was primarily associated with physician and practice characteristics and not with organisational factors.

Cost effectiveness of statins in coronary heart disease

INTRODUCTION

Statin therapy reduces the rate of coronary heart disease, but high costs in combination with a large population eligible for treatment ask for priority setting. Although trials agree on the size of the benefit, economic analyses of statins report contradictory results. This article reviewed cost effectiveness analyses of statins and sought to synthesise cost effectiveness ratios for categories of risk of coronary heart disease and age.

METHODS

The review searched for studies comparing statins with no treatment for the prevention of either cardiovascular or coronary heart disease in men and presenting cost per years of life saved as outcome. Estimates were extracted, standardised for calendar year and currency, and stratified by categories of risk, age, and funding source

RESULTS

24 studies were included (from 50 retrieved), yielding 216 cost effectiveness ratios. Estimated ratios increase with decreasing risk. After stratification by risk, heterogeneity of ratios is large varying from savings to $59 000 per life year saved in the highest risk category and from 6500 dollars to 490,000 dollars in the lowest category. The pooled estimates show values of 21571 dollars per life year saved for a 10 year coronary heart disease risk of 20% and 16862 dollars per life year saved for 10 year risk of 30%.

CONCLUSION

Statin therapy is cost effective for high levels of risk, but inconsistencies exist at lower levels. Although the cost effectiveness of statins depends mainly on absolute risk, important heterogeneity remains after adjusting for absolute risk. Economic analyses need to increase their transparency to reduce their vulnerability to bias and increase their reproducibility.

Implications of changing national cholesterol education program goals for the treatment and control of hypercholesterolemia

BACKGROUND

Modifications to the National Cholesterol Education Program (NCEP) guidelines lowered optional low-density lipoprotein cholesterol (LDL-C) treatment goals.

OBJECTIVE

We evaluated the implications of widely adopting these optional goals in clinical practice.

DESIGN AND PARTICIPANTS

We performed a cross-sectional study using 1999 to 2002 data from 3,281 U.S. adults aged 20 to 79 years participating the National Health and Nutrition Examination Survey.

MEASUREMENTS

The primary outcomes were the proportions of adults whose fasting LDL-C levels exceeded NCEP recommended and optional targets from 2001 and 2004. We used survey weights to estimate the size of the U.S. population exceeding targets. We examined outcomes for 4 coronary disease risk subgroups described by the NCEP.

RESULTS

Low-density lipoprotein cholesterol values exceeded 2001 NCEP goals for 30.0% of adults, and 35.8% had levels above optional 2004 goals. An estimated 24,900,000 individuals (14.2%) exceeded 2001 thresholds for drug therapy, 46,200,000 (26.3%) exceeded optional 2001 thresholds for drug therapy, and 56,500,000 (32.2%) were above the optional 2004 thresholds for drug therapy. For lower, moderate, moderately high, and high-risk groups, 13.4%, 44.2%, 58.8%, and 71.8%, respectively, exceeded 2001 NCEP goals; 13.4%, 15.7%, 87.4%, and 96.0% of these groups exceeded optional 2004 thresholds for drug therapy.

CONCLUSIONS

In 1999 to 2002, LDL-C levels commonly exceeded 2001 NCEP goals, especially for moderately high and high-risk individuals, and cholesterol-lowering medications were underused. Optional goals promulgated by the NCEP in 2001 and 2004 moderately increased the number of adults with LDL-C above their goal, and greatly increased the number of low, moderately high, and high-risk adults who exceeded LDL-C thresholds, for cholesterol-lowering medication.

Effectiveness of altering serum cholesterol levels without drugs

Drug therapy with statins and other agents can result in dramatic lipid-lowering effects. Despite the wealth of data supporting the beneficial effects of pharmacologic therapy on cardiovascular risk, patients often express a desire to accomplish similar goals with diet alone. And, except for patients with extreme cholesterol elevations, consensus panels all promote dietary therapy as an initial step in the treatment of hyperlipidemia. This review examines a variety of dietary strategies designed to lower lipid levels, including the American Heart Association diet, the Ornish diet, the Mediterranean diet, exercise, phytosterols, fiber, soy products, and fish oil. Though the declines in low-density lipoprotein cholesterol levels with these methods range from 0% to 37%, cardiovascular risk may be more significantly impacted than would be predicted from these changes alone. Significant benefits can be reaped from nonpharmacologic measures.

Lipids and stroke: the opportunity of lipid-lowering treatment

Dyslipemia is a clear risk factor (RF) for ischemic heart disease and peripheral artery disease, but its relation with ischemic stroke (IS) is not so clear. HMG-CoA reductase inhibitor drugs or statins (simvastatin, atorvastatin, pravastatin) reduce the relative risk of IS by between 18 and 51% in patients with IHD, in patients with high vascular disease risk and in hypertensive patients with other RFs, acute coronary syndrome, and type 2 diabetes mellitus. According to the guidelines for use, statins are indicated in the majority of patients with IS since the risk is equivalent to that of IHD or high vascular disease risk. In view of the existing clinical evidence of benefit, it would not seem unreasonable to proceed with treatment of patients using statins while awaiting specific studies justifying their use. The non-lipid-lowering mechanisms of the statins and results of studies, such as the Heart Protection Study, provide evidence for widening the indications of statins beyond the prevention of dyslipemia, as a new therapeutic approach in the prevention of IS in patients with plasma levels of total cholesterol or low density lipoproteins currently considered within the normal distribution. The neuroprotective role, which these drugs may play in the acute phase of cerebral ischemia, remains to be clarified, but very recent evidence suggests that such patients may also benefit.

Cost-effectiveness of HMG-CoA reductase inhibitors in the treatment of dyslipidemia and prevention of CHD

The recent completion of several clinical trials of lipid-lowering therapy with 3-hydroxy-3-methylglutaryl coenzyme A inhibitors, or statins, was followed by an update in 2004 concerning the Adult Treatment Panel III guidelines issued by the National Cholesterol Education Program. Within this update, individuals considered at very high risk for coronary heart disease-related events were addressed, wherein the role of an aggressive, intensive lowering of lipid levels to new goals was presented. In achieving target cholesterol levels, the statins collectively represent first-line pharmacotherapeutic strategies, although each of the currently marketed agents differ in relative potency, dose, side effects and cost. As such, research concerning the pharmacoeconomics of lipid-lowering therapy may serve to augment clinical, evidence-based approaches to care. Furthermore, identifying and rectifying suboptimal care within healthcare systems may afford optimal outcomes amongst patients for resources consumed.

Cost-effectiveness of fluvastatin following successful first percutaneous coronary intervention

BACKGROUND

In the LIPS (Lescol Intervention Prevention Study), fluvastatin 80 mg/day reduced the risk of major adverse cardiac events (MACE) by 22% versus placebo (p = 0.01) following successful first percutaneous coronary intervention (PCI) in patients with stable or unstable angina or silent ischemia. The cost-effectiveness of such therapy is unknown.

OBJECTIVE

To evaluate the cost-effectiveness of fluvastatin following successful first PCI from a US healthcare system perspective.

METHODS

We used a Markov model to estimate expected outcomes and costs of 2 alternative treatment strategies following successful first PCI in patients with stable or unstable angina or silent ischemia: (1) diet/lifestyle counseling plus immediate fluvastatin 80 mg/day; and (2) diet/lifestyle counseling only, with initiation of fluvastatin 80 mg/day following occurrence of future nonfatal MACE. The model was estimated with data from LIPS and other published sources. Cost-effectiveness was calculated as the ratio of the difference in expected medical-care costs to the expected difference in life-years (LYs) and quality-adjusted life-years (QALYs) alternatively.

RESULTS

Treatment with fluvastatin following successful first PCI was found to increase life expectancy by 0.78 years (QALYs 0.68). Cost-effectiveness of fluvastatin following successful first PCI is 13 505 dollars per LY (15 454 dollar per QALY) saved. Ratios are lower for patients with diabetes (9396 dollar per LY; 10 718 dollar per QALY) and those with multivessel disease (9662 dollar per LY; 11 076 dollar per QALY). Findings were robust with respect to changes in key model parameters and assumptions.

CONCLUSIONS

Fluvastatin therapy following PCI is cost-effective compared with other generally accepted medical interventions.

Achieving greater reductions in cardiovascular risk: lessons from statin therapy on risk measures and risk reduction

Reductions in low-density lipoprotein (LDL) cholesterol with statins have been shown to significantly reduce risk of coronary heart disease (CHD) in the primary- and secondary-prevention settings. Benefit has been observed even in high-risk patients whose baseline LDL cholesterol levels were below the drug initiation levels recommended by current treatment guidelines. Levels of non-high-density lipoprotein cholesterol or total apolipoprotein B more accurately reflect circulating levels of atherogenic particles than does LDL cholesterol concentration, and may provide a surrogate marker that correlates better to CHD event reduction after statin therapy than LDL cholesterol level. More effective lipid-lowering therapy than that currently practiced may be needed in many patients to achieve optimal CHD risk reduction.

Ezetimibe: a novel option for lowering cholesterol

Elevated low-density lipoprotein (LDL)-cholesterol is associated with a significantly increased risk of coronary heart disease but lowering LDL-cholesterol to levels established in current National Cholesterol Education Program (NCEP) guidelines provides significant risk reduction. Nevertheless, many patients receiving lipid-lowering therapy, particularly those at highest coronary heart disease risk, do not reach LDL-cholesterol goals with their current medications. Ezetimibe (Zetia, Merck Schering-Plough) is the first of a new class of lipid-lowering drugs known as cholesterol absorption inhibitors. Ezetimibe has a favorable pharmacokinetic profile, which allows it to be administered once daily and to be given in conjunction with statins. In a series of randomized, controlled, multicenter studies, ezetimibe produced significant improvements in levels of LDL-cholesterol and other lipid parameters when used as monotherapy, with a safety profile comparable with that of placebo. Furthermore, coadministration of ezetimibe with a statin (simvastatin, atorvastatin, lovastatin, or pravastatin) was more effective than statin monotherapy in lowering LDL-cholesterol and improving other lipid parameters. Moreover, coadministration of ezetimibe with a statin allowed a greater percentage of patients to achieve treatment goals established in NCEP guidelines. The safety and side-effect profile of ezetimibe plus statin coadministration therapy was generally comparable with that of statin monotherapy. These studies establish ezetimibe as an effective lipid-lowering agent, which will likely be useful in the management of a broad range of patients with hypercholesterolemia. Ezetimibe can be used in conjunction with a statin at the beginning of therapy, or it can be added if patients do not achieve their LDL-cholesterol goal with statins alone.

Impact of pharmacist-conducted home visits on the outcomes of lipid-lowering drug therapy

OBJECTIVE

To evaluate a pharmacist-conducted educational and monitoring programme, designed to promote dietary and lifestyle modification and compliance with lipid-lowering drug therapy, for patients with dyslipidaemia.

METHODS

This was a prospective, randomized, controlled study. The participants were 94 adults, with 81 completing the study (intervention group: 39; control group: 42), with a cardiovascular-related diagnosis and discharged from hospital, between April and October 2001, on lipid-lowering drug therapy. Patients in the intervention group were visited at home monthly by a pharmacist, who educated the patients on the goals of lipid-lowering treatment and the importance of lifestyle issues in dyslipidaemia and compliance with therapy, assessed patients for drug-related problems, and measured total blood cholesterol levels using point-of-care testing. Patients in the control group received standard medical care. The main outcome measure was total blood cholesterol levels after 6 months, and an evaluation of patient and general practitioner satisfaction with the programme.

RESULTS

There was no significant difference in baseline total blood cholesterol levels between the two groups. The reduction over the course of the study in cholesterol levels within the intervention group was statistically significant (4.9 +/- 0.7 to 4.4 +/- 0.6, P<0.005), whereas there was no change within the control group (P=0.26). At follow-up, 44% of the intervention group patients and 24% of the control group patients had cholesterol levels below 4.0 mmol/L (P=0.06). The reduction in total cholesterol in the intervention group should translate to an expected 21% reduction in cardiovascular mortality risk and a 16% reduction in total mortality risk--more than twice the risk reduction achieved in the control group. In addition, the programme was very well received by the patients and their general practitioners, by satisfaction questionnaire.

CONCLUSION

A pharmacist-conducted educational and monitoring intervention improved the outcomes of lipid-lowering drug therapy.

Cost effectiveness of HMG-CoA reductase inhibitors in the management of coronary artery disease: the problem of under-treatment

HMG-CoA reductase inhibitors significantly reduce the risk of coronary artery disease (CAD) events and CAD-related mortality in patients with and without established CAD. Consequently, HMG-CoA reductase inhibitors have a central role within recommendations for lipid-modifying therapy. However, despite these guidelines, only one-third to one-half of eligible patients receive lipid-lowering therapy and as few as one-third of these patients achieve recommended target serum levels of low density lipoprotein-cholesterol. The underuse of HMG-CoA reductase inhibitors in eligible patients has important implications for mortality, morbidity and cost, given the enormous economic burden associated with CAD; direct healthcare costs, estimated at US $16-53 billion (2000 values) in the US and 1.6 billion pound (1996 values) in the UK alone, are largely driven by inpatient care. Hospitalization costs are reduced by treatment with HMG-CoA reductase inhibitors, particularly in high-risk groups such as patients with CAD and diabetes mellitus in whom net cost savings may be achieved. HMG-CoA reductase inhibitors are underused because of institutional factors and clinician and patient factors. Also, the vast number of patients eligible for treatment means that the use of HMG-CoA reductase inhibitors is undoubtedly limited by budgetary considerations. Secondary prevention in CAD using HMG-CoA reductase inhibitors is certainly cost effective. Primary prevention with HMG-CoA reductase inhibitors is also cost effective in many patients, depending upon CAD risk and drug dosage. As new, more powerful, HMG-CoA reductase inhibitors come to market, and the established HMG-CoA reductase inhibitors come off patent, the identification of the most cost-effective therapy becomes increasingly complex. Research in to the relative cost effectiveness of alternative HMG-CoA reductase inhibitors, taking full account of the institutional, clinician and patient barriers to uptake should be undertaken to identify the most appropriate role for the new therapies.

Pitavastatin alters the expression of thrombotic and fibrinolytic proteins in human vascular cells

In addition to lowering blood lipids, clinical benefits of 3-hydroxy-3-methylglutaryl coenzyme A (HMG Co-A; EC 1.1.1.34) reductase inhibitors may derive from altered vascular function favoring fibrinolysis over thrombosis. We examined effects of pitavastatin (NK-104), a relatively novel and long acting statin, on expression of tissue factor (TF) in human monocytes (U-937), plasminogen activator inhibitor-1 (PAI-1), and tissue-type plasminogen activator (t-PA) in human aortic smooth muscle cells (SMC) and human umbilical vein endothelial cells (HUVEC). In monocytes, pitavastatin reduced expression of TF protein induced by lipopolysaccharide (LPS) and oxidized low-density lipoprotein (OxLDL). Similarly, pitavastatin also reduced expression of TF mRNA induced by LPS. Pitavastatin reduced PAI-1 antigen released from HUVEC under basal, OxLDL-, or tumor necrosis factor-alpha (TNF-alpha)-stimulated conditions. Reductions of PAI-1 mRNA expression correlated with decreased PAI-1 antigen secretion and PAI-1 activity as assessed by fibrin-agarose zymography. In addition, pitavastatin decreased PAI-1 antigen released from OxLDL-treated and untreated SMC. Conversely, pitavastatin enhanced t-PA mRNA expression and t-PA antigen secretion in untreated OxLDL-, and TNF-alpha-treated HUVEC and untreated SMC. Finally, pitavastatin increased t-PA activity as assessed by fibrin-agarose zymography. Our findings demonstrate that pitavastatin may alter arterial homeostasis favoring fibrinolysis over thrombosis, thereby reducing risk for thrombi at sites of unstable plaques.

Measuring the relationship between employees' health risk factors and corporate pharmaceutical expenditures

This study demonstrates the relationship between self-reported health risk factors on a health risk appraisal and pharmaceutical expenditures for a large employer. A total of 3554 employees who were participants in a pharmacy benefit plan for the entire year of 2000 completed a health risk appraisal. As the number of self-reported health risk factors increased from zero to six or more, corporate pharmaceutical costs increased in a stepwise manner: US dollars 345, 443, 526, 567, 750, 754, and 1121 US dollars, respectively. After controlling for age, gender, and the number of self-reported diseases, each additional risk factor was associated with an average annual increase in pharmacy claims costs of 76 US dollars per employee. Specific health risks were associated with significantly higher expenditures. The results provide estimates of incremental expenditures associated with common, potentially modifiable risk factors. Pharmaceutical expenditures should be considered by corporations in their estimates of total health-related costs and in prioritizing disease management initiatives based on health risk appraisal data.

The power of statins: aggressive lipid lowering

A large body of evidence has demonstrated that reductions in low-density lipoprotein cholesterol (LDL-C) decrease the risk of coronary heart disease (CHD) and related adverse events. The greatest reductions in morbidity and mortality are attained in higher-risk patients, suggesting that targeting this group can maximize the cost-effectiveness of statins, since fewer patients need to be treated to prevent one event. High-risk individuals (those with preexisting CHD or CHD risk equivalents) require aggressive lipid lowering to achieve the stringent LDL-C goal levels established by the third report of the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III). The hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statins, have assumed the central role in this setting because of their superior ability to reduce LDL-C across the spectrum of CHD risk. Rosuvastatin, a new agent in this class, reduces LDL-C to a significantly greater degree than atorvastatin, pravastatin, or simvastatin. The more aggressive goals put forward since ATP I (1987) have heightened interest in more efficacious statins. As a result, simvastatin, atorvastatin, and now rosuvastatin have been developed, adding sequentially greater LDL-C-reducing capacity for the physician. Substantially more patients, particularly high-risk patients, are thereby able to achieve NCEP ATP III target LDL-C levels with rosuvastatin. Other cholesterol-lowering drugs (bile acid sequestrants, niacin, plant stanols, and fibrates) are much less effective at lowering LDL-C and are much less well tolerated but may be useful when combined with statins. A novel class of agents, cholesterol transport inhibitors, have recently become available. These and other new agents hold promise to help achieve ATP III goals when used in combination regimens initiated with a statin.

Risks and benefits of continued aggressive statin therapy

The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statins, are a well-tolerated, effective class of medications for the reduction of low-density lipoprotein cholesterol (LDL-C) and total cholesterol levels. Extensive data from clinical trials demonstrate that these agents reduce fatal and nonfatal cardiovascular risk in primary and secondary prevention patients, including women and the elderly. A threshold value for LDL-C reduction below which there is no further clinical benefit has not yet been identified. In the Heart Protection Study (HPS), significant relative risk reduction occurred even among patients with LDL-C levels < 2.6 mmol/l (100 mg/dl). Statin therapy also produced reductions in cardiovascular disease in a wide range of high-risk patients regardless of baseline cholesterol levels. Rhabdomyolysis, typically defined as muscle pain or weakness associated with creatine kinase levels higher than 10 times the upper limit of normal and the presence of myoglobulinuria, is a rare but potentially serious complication of statins. Although dose-dependent transaminase elevations occur in 0.5 to 2% of cases, it has not been determined whether these elevations qualify as true drug-related hepatotoxicity. Management of myopathy and elevated transaminases is addressed in a joint publication from the American College of Cardiology (ACC), the American Heart Association (AHA), and the National Heart, Lung, and Blood Institute (NHLBI). Because statins have significant potential benefits and a low risk for serious adverse effects, aggressive therapy should be considered in patients at high risk for coronary heart disease.

Cost-effectiveness league tables: valuable guidance for decision makers?

This paper asks the question 'are cost-effectiveness league tables a good way to provide information to decision makers about the value of new healthcare interventions?' League tables that rank alternative healthcare interventions based on their incremental cost-effectiveness ratios (ICERs) are seen by economists as a valuable tool to inform decision makers about the allocation of scarce healthcare resources. However, league tables frequently compare ICERs from studies that have computed these ratios using different methods and assumptions including choice of comparator, choice of discount rate, time horizon, and population subgroup. The methodological differences among studies may influence the ranking of the studies and therefore decisions made using the league table. In addition, league tables generally do not include measures of the uncertainty of the cost-effectiveness estimates. In this paper, a reference case approach is proposed for the computation of the incremental cost-effectiveness ratio and an expanded set of measures is proposed for inclusion in the league table. In addition, a central repository for reference case expanded league tables is suggested so that decision makers can use them more effectively and more consistently.

Management of dyslipidemia in the high-risk patient

Lipid-lowering agents have been shown to reduce morbidity and mortality associated with coronary heart disease (CHD), particularly in high-risk patients. The identification and treatment of these patients should therefore be a high priority for clinicians. Guidelines from medical organizations, such as the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP) and the American Diabetes Association (ADA), suggest that patients with low-density lipoprotein cholesterol (LDL-C) levels > or =130 mg/dL, and perhaps even those with levels > or =100 mg/dL, should receive drug therapy. Optimal LDL-C levels have been set at <100 mg/dL and <115 mg/dL for high-risk patients by US and European guidelines, respectively. However, a recent survey shows that only about 20% of high-risk patients currently meet these goals. In order to achieve therapeutic targets for LDL-C, the statins are the foundation of treatment, as they are the most effective and best-tolerated form of lipid-lowering therapy. Other therapeutic options include bile acid sequestrants, niacin, and plant stanols, although seldom as monotherapy. Combination therapy with a statin and one of these other lipid-lowering agents can be useful in patients who are unable to achieve target lipid levels through monotherapy. There remains, however, a need for additional agents. Some of the new options for reducing LDL-C levels that may be available in the near future include 2 new statins, pitavastatin and rosuvastatin. In patients with heterozygous familial hypercholesterolemia, rosuvastatin, which is currently under review by the Food and Drug Administration (FDA), has been shown to produce significantly greater reductions in LDL-C than atorvastatin over its full dose range. In comparative clinical trials, it has also enabled more patients with primary hypercholesterolemia to meet lipid goals than atorvastatin, simvastatin, and pravastatin. Inhibitors of bile acid transport or cholesterol absorption may also have therapeutic value. The first cholesterol absorption inhibitor, ezetimibe, which has just been approved by the FDA, appears to be most effective when combined with a statin. It is anticipated that such new options will allow clinicians to optimize the management of dyslipidemia in high-risk patients, thereby reducing the morbidity and mortality of CHD.

Identification and treatment of individuals at high risk of coronary heart disease

Low-density lipoprotein (LDL) cholesterol reduction remains the cornerstone of coronary heart disease (CHD) prevention. The most dramatic and consistent reductions in LDL cholesterol and CHD risk are achieved with statin therapy. Identification of individuals at high CHD risk is important, not only for initiating appropriate treatment and minimizing morbidity and mortality but also for optimizing the cost-effectiveness of such treatment. A simple method for identifying high-risk individuals is to identify those with preexisting atherosclerotic disease, diabetes, or familial hypercholesterolemia (FH). Treatment options for achieving LDL cholesterol goals in high-risk patients include statins, bile acid sequestrants, niacin, and plant stanols. Statin therapy should be instituted at a dose likely to result in achievement of LDL cholesterol goals based on average response; it should then be aggressively titrated if the goals are not achieved. If LDL cholesterol goals are not achieved with maximal statin therapy, combination with a bile acid sequestrant, niacin, and/or stanols should be considered. Options likely to be available in the near future include more efficacious statins with greater potential for reducing LDL cholesterol in all patients but especially in high-risk patients, such as those with FH, enabling a greater proportion to achieve LDL cholesterol goals. Other options that may soon be available as additive agents to statins to achieve greater LDL cholesterol reductions include bile acid transport inhibitors and cholesterol absorption inhibitors.

Inhibition of geranylgeranyl diphosphate synthase by bisphosphonates and diphosphates: a potential route to new bone antiresorption and antiparasitic agents

We report the inhibition of a human recombinant geranylgeranyl diphosphate synthase (GGPPSase) by 23 bisphosphonates and six azaprenyl diphosphates. The IC50 values range from 140 nM to 690 microM. None of the nitrogen-containing bisphosphonates that inhibit farnesyl diphosphate synthase were effective in inhibiting the GGPPSase enzyme. Using three-dimensional quantitative structure-activity relationship/comparative molecular field analysis (CoMFA) methods, we find a good correlation between experimental and predicted activity: R2 = 0.938, R(cv)2 = 0.900, R(bs)2 = 0.938, and F-test = 86.8. To test the predictive utility of the CoMFA approach, we used three training sets of 25 compounds each to generate models to predict three test sets of three compounds. The rms pIC50 error for the nine predictions was 0.39. We also investigated the pharmacophore of these GGPPSase inhibitors using the Catalyst method. The results demonstrated that Catalyst predicted the pIC50 values for the nine test set compounds with an rms error of 0.28 (R2 between experimental and predicted activity of 0.948).

C-reactive protein, statins, and the primary prevention of atherosclerotic cardiovascular disease

Emerging data implicate inflammation as integral to atherosclerosis and its complications. From a clinical perspective, the inflammatory biomarker C-reactive protein has demonstrated consistent predictive value in the detection of individuals at high risk for cardiovascular disease. Therapy with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) reduces C-reactive protein as well as low-density lipoprotein cholesterol, thus providing a potential additional mechanism for the reduction in cardiovascular events associated with the use of these agents. Evidence from the Air Force/Texas Coronary Atherosclerosis Prevention Study suggests that statin therapy may be effective in reducing incident coronary events among those with elevated levels of C-reactive protein but normal levels of low-density lipoprotein cholesterol. These data, along with accumulating laboratory data, support a potential anti-inflammatory benefit of statins. Large-scale, randomized trials in the primary prevention of acute coronary events among individuals without overt hyperlipidemia but with evidence of elevated C-reactive protein are now needed to directly test this hypothesis.

Atorvastatin: an updated review of its pharmacological properties and use in dyslipidaemia

Atorvastatin is a synthetic hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor. In dosages of 10 to 80 mg/day, atorvastatin reduces levels of total cholesterol, low-density lipoprotein (LDL)-cholesterol, triglyceride and very low-density lipoprotein (VLDL)-cholesterol and increases high-density lipoprotein (HDL)-cholesterol in patients with a wide variety of dyslipidaemias. In large long-term trials in patients with primary hypercholesterolaemia. atorvastatin produced greater reductions in total cholesterol. LDL-cholesterol and triglyceride levels than other HMG-CoA reductase inhibitors. In patients with coronary heart disease (CHD), atorvastatin was more efficacious than lovastatin, pravastatin. fluvastatin and simvastatin in achieving target LDL-cholesterol levels and, in high doses, produced very low LDL-cholesterol levels. Aggressive reduction of serum LDL-cholesterol to 1.9 mmol/L with atorvastatin 80 mg/day for 16 weeks in patients with acute coronary syndromes significantly reduced the incidence of the combined primary end-point events and the secondary end-point of recurrent ischaemic events requiring rehospitalisation in the large. well-designed MIRACL trial. In the AVERT trial, aggressive lipid-lowering therapy with atorvastatin 80 mg/ day for 18 months was at least as effective as coronary angioplasty and usual care in reducing the incidence of ischaemic events in low-risk patients with stable CHD. Long-term studies are currently investigating the effects of atorvastatin on serious cardiac events and mortality in patients with CHD. Pharmacoeconomic studies have shown lipid-lowering with atorvastatin to be cost effective in patients with CHD, men with at least one risk factor for CHD and women with multiple risk factors for CHD. In available studies atorvastatin was more cost effective than most other HMG-CoA reductase inhibitors in achieving target LDL-cholesterol levels. Atorvastatin is well tolerated and adverse events are usually mild and transient. The tolerability profile of atorvastatin is similar to that of other available HMG-CoA reductase inhibitors and to placebo. Elevations of liver transaminases and creatine phosphokinase are infrequent. There have been rare case reports of rhabdomyolysis occurring with concomitant use of atorvastatin and other drugs.

CONCLUSION

Atorvastatin is an appropriate first-line lipid-lowering therapy in numerous groups of patients at low to high risk of CHD. Additionally it has a definite role in treating patients requiring greater decreases in LDL-cholesterol levels. Long-term studies are under way to determine whether achieving very low LDL-cholesterol levels with atorvastatin is likely to show additional benefits on morbidity and mortality in patients with CHD.

Managing dyslipidemia in the high-risk patient

Lipid-lowering agents have been shown to reduce morbidity and mortality associated with coronary artery disease (CAD) in all patients. However, these agents are more cost-effective in high-risk patients whose absolute risk of CAD is greater than that of low-risk patients. Furthermore, from preliminary data, it appears that there is greater risk reduction in those subjects achieving lower low-density lipoprotein cholesterol (LDL-C) levels (ie, lower is better). The identification and aggressive treatment of these patients should therefore be a high priority for clinicians. Guidelines from medical organizations, such as the Adult Treatment Panel (ATP) III of the US National Cholesterol Education Program (NCEP), emphasize that patients with CAD, diabetes, or global risk of CAD >20% over 10 years and LDL-C levels >130 mg/dL should receive drug therapy with a goal of reducing LDL-C levels to <100 mg/dL. The recent results of the United Kingdom's Heart Protection Study (HPS) strongly suggest that even those with CAD or who are at high risk and LDL-C levels >100 mg/dL would benefit from drug therapy. Although optimal LDL-C levels have been set at <100 mg/dL for high-risk patients, recent studies show only about 20% of such patients meet these goals. Thus, a large treatment gap remains that needs to be overcome if we are to continue to make significant inroads into preventing further morbidity and mortality in these high-risk subjects. Of therapeutic options available currently and for the near future, statins remain the most effective and well-tolerated form of lipid-lowering therapy. Other therapies include bile acid sequestrants, niacin, and plant stanols. However, none of these is, in general, sufficiently effective as an initial agent to achieve these more aggressive LDL-C goals in the high-risk patient. However, combination therapy with a statin and 1 of these other lipid-lowering agents is useful in patients who are unable to achieve lipid goals on monotherapy. A number of agents for reducing LDL-C levels currently in development may be available in the near future, including 2 new statins: pitavastatin and rosuvastatin. Rosuvastatin, which is in the later stages of the US Food and Drug Administration (FDA) approval process, has been shown to produce significantly greater reductions in LDL-C levels compared with atorvastatin, simvastatin, and pravastatin, and allows more patients to meet lipid goals. Ezetimibe, the first of an entirely new class of LDL-C-lowering agents that inhibit intestinal cholesterol absorption, also appears to offer significant therapeutic value. It is anticipated that these new options will allow clinicians to optimize the management of dyslipidemia in high-risk patients, thereby further reducing the morbidity and mortality of CAD.

A Comparison of NCEP and Absolute Risk Stratification Methods for Lipid-Lowering Therapy in Middle-Aged Adults: The ARIC Study. The ARIC Investigators

Lipid-lowering therapy has been shown to reduce cardiovascular disease risk in individuals with low-density lipoprotein cholesterol (LDL-C) levels of at or above 130 mg/dL. Several methods have been developed for identifying those at highest risk for treatment. The objective was to compare the 1993 National Cholesterol Education Program guidelines to absolute risk assessment methods similar to those used by recently developed European and British cholesterol treatment guidelines. The design and setting was a population-based, prospective cohort study in four US communities. Among Atherosclerosis Risk in the Communities study participants aged 45-64 years followed for a mean of 7 years, 7314 women and 5762 men were included who had no evidence of clinical cardiovascular disease and were not receiving lipid-lowering drug therapy at entry. Main outcome measures were number meeting criteria for treatment, number of cardiovascular events expected to be prevented with treatment, number needed to treat to prevent one cardiovascular event, and sensitivity of criteria for detecting cases for the entire cohort and for those at or above the LDL-C treatment threshold (within-group). The 1993 National Cholesterol Education Program guidelines identified 16% of participants for treatment: n=2112; events expected to be prevented=77; number needed to treat=27; sensitivity=0.31 (0.28-0.35); sensitivity when LDL-C was greater-than-or-equal160 mg/dL=0.86. Use of a LDL-C treatment threshold of greater-than-or-equal130 mg/dL, a greater-than-or-equal20% 10-year absolute risk cut-point (similar to European guidelines) identified 13% for treatment: n=1701; events expected to be prevented=66; number needed to treat=26; sensitivity=0.29 (0.25-0.32); sensitivity when LDL-C was >130 mg/dL=0.43. A greater-than-or-equal15% risk cut-point (similar to British guidelines) identified 17% for treatment: n=2233; events expected to be prevented=82; number needed to treat=27; sensitivity=0.37 (0.33-0.40); sensitivity when LDL-C was greater-than-or-equal130 mg/dL=0.55. Modified National Cholesterol Education Program guidelines (LDL-C treatment threshold lowered from 160 to 130 mg/dL for those with greater-than-or-equal2 risk factors) identified 30% for treatment: n=3867; events expected to be prevented=120; number needed to treat=32; sensitivity=0.55 (0.52-0.59); sensitivity when LDL-C was 130 mg/dL=0.83. A hybrid strategy using greater-than-or-equal15% risk, or 10% to 14% risk with a parental history of premature coronary heart disease or treated, controlled hypertension, identified 20% for treatment: n=2646; events expected to be prevented=97; number needed to treat=27; sensitivity=0.44 (0.40-0.47); sensitivity when LDL-C was greater-than-or-equal130 mg/dL=0.66. Depending on the priorities of a health care system, higher absolute cut-points can be used for allocating health care resources to those at the highest risk. However, fewer cardiovascular events will be prevented and fewer patients who later experience cardiovascular events will be offered treatment despite acceptable numbers needed to treat to prevent one cardiovascular disease event. A hybrid absolute risk strategy incorporating family history and treated hypertension information appears to be superior to absolute risk strategies that do not include this information. Copyright 2001 CHF, Inc.

Emerging perspectives on lipid management: international approaches and global challenges

The rapid growth in the understanding of the relation between cholesterol and coronary heart disease has introduced new challenges to the contemporary management of lipid disorders. The publication of the trials of the 3-hydroxy-3-methylglutaryl coenzyme-A inhibitors (statins) has invigorated support for the lipid hypothesis, and many advances have been made in understanding the mechanisms underlying atherosclerosis and the potential benefits of the statins. Several international groups have issued guidelines about desirable and undesirable lipid values to help clinical decision making. Despite the availability of such principles, there are many challenges to optimal management of lipid disorders.

Clinically relevant differences between the statins: implications for therapeutic selection

Although the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or statins, share a common lipid-lowering effect, there are differences within this class of drugs. The low-density lipoprotein (LDL) cholesterol-lowering efficacy, pharmacokinetic properties, drug-food interactions, and cost can vary widely, thus influencing the selection of a particular statin as a treatment option. The statins that produce the greatest percentage change in LDL cholesterol levels are atorvastatin and simvastatin. Atorvastatin and fluvastatin are least affected by alterations in renal function. Fewer pharmacokinetic drug interactions are likely to occur with pravastatin and fluvastatin, because they are not metabolized through the cytochrome P450 (3A4) system. The most cost-effective statins, based on cost per percentage change in LDL cholesterol levels, are fluvastatin, cerivastatin, and atorvastatin. Awareness of these differences may assist in the selection or substitution of an appropriate statin for a particular patient.

Developing a clinical strategy for cholesterol management in an era of unanswered questions

Recent clinical trials have supported the use of cholesterol-lowering therapies to reduce cardiovascular events. Despite these results, a number of unanswered questions remain, including the appropriate intensity of lipid-lowering therapy and the role of high-density lipoprotein cholesterol and/or triglycerides in cardiovascular risk assessment and reduction. In addition, the optimal treatment strategies for women, the elderly, and patients with diabetes are more difficult to determine, as these groups have comprised a minority of subjects in prior trials. Studies in progress will provide guidance toward effective treatment of these populations, the appropriate degree of lipid-lowering therapy, and the role of estrogen replacement therapy in postmenopausal women. In the interim, a clinical strategy incorporating the lessons of recent clinical evidence is suggested.

Measurement of C-reactive protein for the targeting of statin therapy in the primary prevention of acute coronary events

BACKGROUND

Elevated levels of C-reactive protein, even in the absence of hyperlipidemia, are associated with an increased risk of coronary events. Statin therapy reduces the level of C-reactive protein independently of its effect on lipid levels. We hypothesized that statins might prevent coronary events in persons with elevated C-reactive protein levels who did not have overt hyperlipidemia.

METHODS

The level of C-reactive protein was measured at base line and after one year in 5742 participants in a five-year randomized trial of lovastatin for the primary prevention of acute coronary events.

RESULTS

The rates of coronary events increased significantly with increases in the base-line levels of C-reactive protein. Lovastatin therapy reduced the C-reactive protein level by 14.8 percent (P<0.001), an effect not explained by lovastatin-induced changes in the lipid profile. As expected, lovastatin was effective in preventing coronary events in participants whose base-line ratio of total cholesterol to high-density lipoprotein (HDL) cholesterol was higher than the median ratio, regardless of the level of C-reactive protein (number needed to treat for five years to prevent 1 event, 47; P=0.005). However, lovastatin was also effective among those with a ratio of total to HDL cholesterol that was lower than the median and a C-reactive protein level higher than the median (number needed to treat, 43; P=0.02). In contrast, lovastatin was ineffective among participants with a ratio of total to HDL cholesterol and a C-reactive protein level that were both lower than the median (number needed to treat, 983; P=0.80).

CONCLUSIONS

Statin therapy may be effective in the primary prevention of coronary events among subjects with relatively low lipid levels but with elevated levels of C-reactive protein.

Assessing the results: phase 1 hyperlipidemia outcomes in 27 health plans

In phase 1 of this hyperlipidemia outcomes management program, characteristics of 7,619 patients treated with statins at 27 US managed care plans were determined. Nearly 40% (3,018 patients) had documented coronary heart disease (CHD). Most (65%) had at least two CHD risk factors. Hyperlipidemia treatment included simvastatin (39%), atorvastatin (25%), fluvastatin (14%), pravastatin (12%), and lovastatin (2%). On-treatment low-density lipoprotein cholesterol (LDL-C) levels were available for 79% of patients; however, only 46% had both baseline and follow-up levels recorded in their charts. Of patients for whom follow-up data were available, 3,779 (63%) achieved their target LDL-C levels as recommended by the National Cholesterol Education Program (NCEP). Target LDL-C levels were reached by 1,381 (87%) of the patients with a goal of 160 mg/dL, 1,326 (65%) of those with a goal of 130 mg/dL, and 1,072 (44%) of those with a goal of 100 mg/dL. Overall, 66% of patients who met their treatment goal and 24% of those who did not required no more than a 25% reduction in LDL-C. In contrast, 8% of patients who achieved goals and 36% of patients who did not required >40% reduction in LDL-C. Phase 1 results did not suggest any substantial difference among statins for achievement of NCEP goals or decrease in LDL-C. These results show that therapy with statins is effective for achievement of NCEP targets in most patients and that there is potential for improvement in the quality and cost-effectiveness of statin therapy with carefully planned interventions.

Clinical context: current concepts of coronary heart disease management

Coronary heart disease (CHD) is the single greatest cause of death among adults in the United States. It is also a major cause of disability and is associated with direct and indirect costs that exceed $118 billion annually. Elevation of serum lipid levels, particularly low-density lipoprotein cholesterol (LDL-C) levels, is closely linked to the development of CHD. Lipid levels that increase the risk of CHD are present in nearly one third of the US population. Large-scale intervention studies have shown that decreasing LDL-C can significantly reduce the risk of cardiovascular mortality, adverse cardiovascular events, and the requirement for revascularization procedures. Statins are now thought the most effective agents for lowering LDL-C, and they also have positive effects on other components of the serum lipid profile. These drugs are also better tolerated than other lipid-lowering agents. Statin therapy significantly decreases the risk of cardiovascular disease and is a cost-effective cardiovascular treatment according to current standards. Because statins vary substantially in acquisition cost, using statins in the most cost-effective manner is important for controlling health-care costs. Optimizing the cost-effectiveness of statin therapy is a particular concern to managed care organizations in light of the large number of patients who are now considered candidates for this treatment.

A means to an end: an overview of a hyperlipidemia outcomes management program

Quality management and improvement are increasingly important to managed care organizations (MCOs) as competition increases. One key area on which quality improvement programs can focus is MCO activity in helping patients remain healthy. Screening for and treatment of hyperlipidemia are important components of the preventive care of patients who are at risk for coronary heart disease (CHD). This article summarizes the methodology of a three-phase hyperlipidemia outcomes management program being implemented by 27 US health plans. Phase 1 identifies inefficiencies in the clinical management of hyperlipidemia by assessing patients' attainment rates of low-density lipoprotein cholesterol (LDL-C) targets. This information is then used to develop a multifactorial intervention program for CHD prevention in phase 2. The interventions for physicians include provision of treatment algorithms for patients with varying degrees of hyperlipidemia, education programs encouraging appropriate treatment of hyperlipidemia, and academic detailing summarizing phase 1 results and providing applicable literature. In phase 3, patient records are reassessed at least 6 months after the educational intervention. This three-phase program has the potential to improve patient care, reduce unnecessary treatment costs, provide a means of quality improvement, and increase plan value to potential purchasers.

Statin therapy: where are we? Where do we go next?

Statin therapy reduces coronary artery disease morbidity and mortality in primary and secondary prevention trials including patients with elevated and average cholesterol levels. The association between reduction of total or low-density lipoprotein cholesterol and preventive benefit is well established. However, additional risk factors for coronary artery disease need to be incorporated into risk assessment to provide an accurate measure of global risk for use in lifestyle intervention and drug therapy guidelines. Assessment of outcomes in the Air Force/Texas Coronary Atherosclerosis Prevention Study primary prevention trial, which involved patients with average cholesterol levels and reduced high-density lipoprotein cholesterol (HDL-C), suggests the importance of on-treatment values of apolipoproteins B and A-I in predicting first major events in such a population. Other data, including trials of fibrate therapy showing reduction in coronary artery disease events, support the importance of triglycerides and HDL-C in coronary artery disease risk. Challenges for future treatment guidelines include incorporation of emerging and novel risk factors into risk assessment, refinement of global risk measurement, and simplification for application to clinical practice.

Current perspectives on lipid lowering with statins to decrease risk of cardiovascular disease

Although guidelines for individual risk factors for cardiovascular disease (CVD) assist the healthcare provider, management of the global risk profile of patients is the optimal means to minimize risk. Regardless of whether patients have one or more risk factors, elevated lipid values are generally considered to be a major contributor to global CVD risk. Therefore, reduction of lipid levels is one of the most effective methods to reduce risk of CVD. The 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitor class of drugs (also known as statins) has documented clinical benefits for reducing the incidence of myocardial infarction, stroke, death from CVD, and total death. Despite widespread acknowledgment of the very favorable benefit-to-risk ratio of the statins, most at-risk patients either are not being treated or are not at the goals defined by the National Cholesterol Education Program.

SSM Health Care clinical collaboratives: improving the value of patient care in a health care system

BACKGROUND

In 1998 SSM Health Care (St Louis) began a series of clinical collaboratives modeled after The Institute of Healthcare Improvement (Boston) Breakthrough Series. There are now four collaboratives, with 46 teams in progress, and four additional collaboratives are scheduled.

COLLABORATIVE TOPICS AND STRUCTURE

Each collaborative consists of three phases: the prework, active, and the continuous improvement phases. The structure of the collaboratives is quite similar to that of the Institute for Healthcare Improvement Breakthrough Series. However, the SSMHC collaboratives include a continuous improvement phase, which was designed to help maintain gains from the projects and to involve entities not originally involved in the collaborative. RESULTS OF COLLABORATIVES IN PROGRESS: Entity teams participating in multiple collaboratives seem to ascend a learning curve and become progressively more skilled in subsequent collaborative work. In Collaborative 1--Improving the Secondary Prevention of Ischemic Heart Disease--the participating entities showed significant improvement in cholesterol screening and treatment. In Collaborative 2--Improving Prescribing Practices--the collaborative teams also showed significant improvement, with a combined cost savings of approximately $450,000 per year. Collaboratives 3--Using Patient Information to Improve Care and Assure Success-and-4--Enhancing Patient Safety Through Safe Systems--are under way.

SUMMARY

The collaboratives accelerate improvement work through sharing of successes and failures and peer influence within a reinforcing environment. Most of the collaborative teams have reached their project goals, and the pace of clinical improvement work has accelerated since the start of the collaboratives. The collaboratives provide an environment for clinicians to constructively participate in improvement of patient care.

Cerivastatin: a review of its pharmacological properties and therapeutic efficacy in the management of hypercholesterolaemia

Cerivastatin is an HMG-CoA reductase inhibitor used for the treatment of patients with hypercholesterolaemia. The lipid-lowering efficacy of cerivastatin has been demonstrated in a number of large multicentre, randomised clinical trials. Earlier studies used cerivastatin at relatively low dosages of < or =0.3mg orally once daily, but more recent studies have focused on dosages of 0.4 or 0.8 mg/day currently recommended by the US Food and Drug Administration (FDA). Along with modest improvements in serum levels of triglycerides and high density lipoprotein (HDL)-cholesterol, cerivastatin 0.4 to 0.8 mg/day achieved marked reductions in serum levels of low density lipoprotein (LDL)-cholesterol (33.4 to 44.0%) and total cholesterol (23.0 to 30.8%). These ranges included results of a pivotal North American trial in almost 1000 patients with hypercholesterolaemia. In this 8-week study, US National Cholesterol Education Program (Adult Treatment Panel II) [NCEP] target levels for LDL-cholesterol were achieved in 84% of patients randomised to receive cerivastatin 0.8 mg/day, 73% of those treated with cerivastatin 0.4 mg/day and <10% of placebo recipients. Among patients with baseline serum LDL-cholesterol levels meeting NCEP guidelines for starting pharmacotherapy, 75% achieved target LDL-cholesterol levels with cerivastatin 0.8 mg/day. In 90% of all patients receiving cerivastatin 0.8 mg/day, LDL-cholesterol levels were reduced by 23.9 to 58.4% (6th to 95th percentile). Various subanalyses of clinical trials with cerivastatin indicate that the greatest lipid-lowering response can be expected in women and elderly patients. Cerivastatin is generally well tolerated and adverse events have usually been mild and transient. The overall incidence and nature of adverse events reported with cerivastatin in clinical trials was similar to that of placebo. The most frequent adverse events associated with cerivastatin were headache, GI disturbances, asthenia, pharyngitis and rhinitis. In the large pivotal trial, significant elevations in serum levels of creatine kinase and transaminases were reported in a small proportion of patients receiving cerivastatin but not in placebo recipients. As with other HMG-CoA reductase inhibitors, rare reports of myopathy and rhabdomyolysis have occurred with cerivastatin, although gemfibrozil or cyclosporin were administered concomitantly in most cases. Postmarketing surveillance studies in the US have been performed. In 3 mandated formulary switch conversion studies, cerivastatin was either equivalent or superior to other HMG-CoA reductase inhibitors, including atorvastatin, in reducing serum LDL-cholesterol levels or achieving NCEP target levels. Pharmacoeconomic data with cerivastatin are limited, but analyses conducted to date in the US and Italy suggest that cerivastatin compares favourably with other available HMG-CoA reductase inhibitors in terms of its cost per life-year gained.

CONCLUSION

Cerivastatin is a well tolerated and effective lipid-lowering agent for patients with hypercholesterolaemia. When given at dosages currently recommended by the FDA in the US, cerivastatin achieves marked reductions in serum levels of LDL-cholesterol, reaching NCEP target levels in the vast majority of patients. Thus, cerivastatin provides a useful (and potentially cost effective) alternative to other currently available HMG-CoA reductase inhibitors as a first-line agent for hypercholesterolaemia.

Standardization of lipoprotein reporting

We wanted to ascertain whether the current format of lipid laboratory reports seemed adequate to promote identification and treatment of patients with dyslipidemia. In a random survey of lipid laboratory reports from 25 laboratories, we found great inconsistencies among reporting formats and contents. Fewer than half the laboratories correctly reported the ranges for cholesterol, only 4 correctly reported ranges for high-density lipoprotein cholesterol, only 2 correctly reported ranges for triglycerides, and none presented low-density lipoprotein cholesterol ranges in terms of risk factors for coronary heart disease. Reports typically were disjointed and difficult to read. The current practice of reporting results for lipid panels is confusing and does not follow the National Cholesterol Education Program (NCEP) guidelines. We recommend that reporting of results be standardized, and a "model" standardized report is presented herein, based on consensus from a team of experts. The standardized report uses current recommendations for ranges, follows the flowcharts of the NCEP guidelines, and takes the patient's clinical condition (the number of risk factors and the presence of coronary heart disease) into consideration. Standardizing lipid reports should decrease confusion and perhaps increase application of the guidelines and patient compliance with treatment.

Cost-effectiveness of statins

The efficacy of lipid-lowering with statins has become clear. Indirect estimations, and direct measurements from long-term randomized trials have also demonstrated cost-effectiveness, both in secondary and primary prevention of coronary heart disease. Targeting care efficiently to high-risk groups by calculating absolute risk is essential. However, it is clear that what would normally be very cost-effective interventions will put substantial strain on health care resources because of the common nature of coronary disease and risk factors.

[Coronary risk and prescription in primary care patients with hypercholesterolemia]

OBJECTIVE

In patients with hypercholesterolaemia determinate the prevalence of high coronary risk (CR), study the lipid lowering treatment applied and determinate if there is any change in CR after a period of treatment.

DESIGN

Cross-sectional.

EMPLACEMENT

Primary care.

PATIENTS

583 patients with hypercholesterolaemia both sex, older than 25 years registered in chronic mobility, randomized selected.

MEASUREMENT AND RESULTS

Applying the Framingham coronary multivariate risk method we estimate high CR > 20%. Patients with a previous history of cardiovascular event, were treated in a 50%, more frequently younger subjects, rising 220 mg/dl of final cholesterol level. Patients without any cardiovascular event known, the 32.5% (28.0-36.7%) have a CR > 20%. Subjects with high CR have 4.9 (3.0-8.2) more probability if receiving treatment than the others with lower risk. The lipid-lowering treatment is explained in a 67% because the high CR and the family history of coronary event. After at least one year period there is a reduction in those with high CR (difference relative of proportions 28.7% [20.4-37.1]).

Current perspectives on statins

Statins (HMG-CoA reductase inhibitors) are used widely for the treatment of hypercholesterolemia. They inhibit HMG-CoA reductase competitively, reduce LDL levels more than other cholesterol-lowering drugs, and lower triglyceride levels in hypertriglyceridemic patients. Statins are well tolerated and have an excellent safety record. Clinical trials in patients with and without coronary heart disease and with and without high cholesterol have demonstrated consistently that statins reduce the relative risk of major coronary events by approximately 30% and produce a greater absolute benefit in patients with higher baseline risk. Proposed mechanisms include favorable effects on plasma lipoproteins, endothelial function, plaque architecture and stability, thrombosis, and inflammation. Mechanisms independent of LDL lowering may play an important role in the clinical benefits conferred by these drugs and may ultimately broaden their indication from lipid-lowering to antiatherogenic agents.

Periodic health examination and screening tests in adults

Whenever a patient presents for the annual health examination, clinicians must choose from a plethora of screening tests and conflicting sets of guidelines. A discussion of the underlying issues leads to practical tips on how select and when to abandon screening tests and when to treat or not treat patients with marginally positive test results.

Cost-effectiveness of stress-echocardiography

Because of constraints on the costs of providing medical care, cardiologists in the future will find themselves challenged to provide care for their patients in the most cost-effective manner possible. Although stress-echocardiography has been shown to compare favorably with other tests in diagnostic accuracy, data on cost-effectiveness are scarce. In this article, general concepts of cost-effectiveness as they relate to stress-echocardiography are reviewed and the available literature is summarized. Although definitive data are lacking, there is evidence to suggest that stress-echocardiography may prove to be cost-effective in several clinical situations.