Cost-effectiveness and Return on Investment of a Nationwide Case-Finding Program for Familial Hypercholesterolemia in Children in the Netherlands

Improving Preteen Lipid Screening Rates at Well-Child Visits Through Quality Improvement Methods

BACKGROUND

Universal lipid screening is recommended for all pediatric patients aged 9 to 11 years based on 2011 guidelines; however, current screening rates remain low. Our aim was to increase universal lipid screening rates in patients aged 9 to 11 years at our pediatric primary care practices from 5% to 50%.

METHODS

Baseline screening rates were obtained from May 2019 to April 2021. Provider education and electronic medical record (EMR) clinical decision support (CDS) were introduced in May 2021. Point-of-care (POC) testing was implemented at 1 site in May 2021 and 2 additional sites in May 2022. Provider feedback was performed at 1 site in February 2022, followed by ongoing quarterly provider feedback for all 3 sites in July 2022. Data were collected through April 2023. Rates were plotted on monthly statistical process control charts. Lipid results were analyzed to determine the number of abnormal test results and compared before and after POC testing introduction using χ2 tests.

RESULTS

Baseline testing rates ranged from 1% to 10%, which increased to 18% to 60% at completion of the study period. POC testing and provider feedback were the interventions with the most significant impact, whereas education and EMR CDS alone did not lead to a meaningful increase in screening rates. The proportion of eligible visits with abnormal lipids identified increased from 1.3% to 4.2% after introduction of POC testing.

CONCLUSION

POC testing and provider feedback are effective strategies to improve universal lipid screening rates and increase the identification of children with abnormal lipids.

Perspectives on early health economic evaluations of RNA therapies targeted at lipoprotein(a)

PURPOSE OF REVIEW

Early health economic evaluations of new medications are useful, as they consider the implications for health services.We reviewed recent literature on expected clinical outcomes of lowering of elevated plasma lipoprotein(a) [Lp(a)] in secondary prevention, which is essential information on effectiveness for economic evaluations.We reviewed a recent early economic evaluation of RNA therapies targeted at Lp(a).

RECENT FINDINGS

RNA-based therapies, if approved, would likely be used initially in adults with established atherosclerotic cardiovascular disease (ASCVD) and very high Lp(a). Adults with ASCVD have high absolute risk of recurrent events and elevated Lp(a) serves as a risk-enhancing factor.Potent lowering of Lp(a) in secondary prevention may be associated with significant relative risk reductions of coronary heart disease or ASCVD events; this needs confirmation in currently ongoing and future clinical trials.One economic evaluation has estimated the value of olpasiran and pelacarsen, at various willingness-to-pay thresholds, compared with standard-of-care secondary prevention.

SUMMARY

Early economic evaluations estimate longer-term clinical benefits and cost consequences associated with new medications.Existing casual evidence of Lp(a) and cardiovascular disease can be used in early economic evaluations as best available evidence, while awaiting results from major cardiovascular outcomes trials.

Life Course Approach for Managing Familial Hypercholesterolemia

Treatment of familial hypercholesterolemia is directed toward the moment of the medical encounter. However, risk for heart disease as a consequence of having familial hypercholesterolemia is related to lifelong exposure to elevated low-density lipoprotein cholesterol, rather than low-density lipoprotein cholesterol level at a specific time point. The purpose of this review is to reassess contemporary research on treatment of familial hypercholesterolemia and current evidence-based guidelines, to present an approach that emphasizes treatment across the life course, and to recognize the importance of family experiences to care. To accomplish this, we review the changing treatment needs that emerge across the life course, from birth through childhood, adolescence, young adulthood, peripregnancy, middle age, and late in life. Special attention is paid to improving adherence to treatment, the potential role of monitoring atherosclerosis in a lifelong model of care, and medical issues related to care transitions: from pediatric to internal medicine care, peripregnancy, after a cardiac event, and care after age 70 years in the absence of a cardiac event. Novel considerations related to treatment of homozygous familial hypercholesterolemia are discussed. The summary identifies research gaps that need to be closed to move from the current point-of-care model to one that considers treatment over the life course.

Early health technology assessment of gene silencing therapies for lowering lipoprotein(a) in the secondary prevention of coronary heart disease

BACKGROUND

Olpasiran and pelacarsen are gene-silencing therapies that lower lipoprotein(a). Cardiovascular outcome trials are ongoing. Mendelian randomization studies estimated clinical benefits from lipoprotein(a) lowering.

OBJECTIVE

Our study estimated prices at which olpasiran and pelacarsen, in addition to standard-of-care, would be deemed cost-effective in reducing risk of recurrent coronary heart disease (CHD) events in the Australian healthcare system.

METHODS

We developed a decision tree and lifetime Markov model. For olpasiran, participants had CHD and lipoprotein(a) 260 nmol/L at baseline and three-monthly injections, profiled on OCEAN(a) Outcomes trial (NCT05581303). Baseline risks of CHD, costs and utilities were obtained from published sources. Clinical trial data were used to derive reductions in lipoprotein(a) from treatment. Mendelian randomization study data were used to estimate downstream clinical benefits. Annual discounting was 5%. For pelacarsen, participants had CHD and lipoprotein(a) 226 nmol/L at baseline and one-monthly injections, profiled on Lp(a) HORIZON (NCT04023552) trial.

RESULTS

Olpasiran in addition to standard-of-care saved 0.87 discounted quality-adjusted life years (QALYs) per person. Olpasiran in addition to standard-of-care would be cost-effective at annual prices of AU$1867 (AU$467 per dose) at threshold AU$28,000 per QALY. Pelacarsen would be cost-effective at annual prices of AU$984 (AU$82 per dose). For incremental cost-effectiveness ratio (ICER) threshold AU$50,000 per QALY, olpasiran and pelacarsen would be cost-effective at annual prices AU$4207 and AU$2464, respectively.

CONCLUSION

This early health technology assessment model used inclusion criteria from clinical trials. Olpasiran and pelacarsen would be cost-effective if annual treatment prices were AU$1867 and AU$984, respectively, from the Australian healthcare perspective.

Synthesized economic evidence on the cost-effectiveness of screening familial hypercholesterolemia

BACKGROUND

Familial hypercholesterolemia (FH) is a prevalent genetic disorder with global implications for severe cardiovascular diseases. Motivated by the growing recognition of the need for early diagnosis and treatment of FH to mitigate its severe consequences, alongside the gaps in understanding the economic implications and equity impacts of FH screening, this study aims to synthesize the economic evidence on the cost-effectiveness of FH screening and to analyze the impact of FH screening on health inequality.

METHODS

We conducted a systematic review on the economic evaluations of FH screening and extracted information from the included studies using a pre-determined form for evidence synthesis. We synthesized the cost-effectiveness components involving the calculation of synthesized incremental cost-effectiveness ratios (ICERs) and net health benefit (NHB) of different FH screening strategies. Additionally, we applied an aggregate distributional cost-effectiveness analysis (DCEA) to assess the impact of FH screening on health inequality.

RESULTS

Among the 19 studies included, over half utilized Markov models, and 84% concluded that FH screening was potentially cost-effective. Based on the synthesized evidence, cascade screening was likely to be cost-effective, with an ICER of $49,630 per quality-adjusted life year (QALY). The ICER for universal screening was $20,860 per QALY as per evidence synthesis. The aggregate DCEA for six eligible studies presented that the incremental equally distributed equivalent health (EDEH) exceeded the NHB. The difference between EDEH and NHB across the six studies were 325, 137, 556, 36, 50, and 31 QALYs, respectively, with an average positive difference of 189 QALYs.

CONCLUSIONS

Our research offered valuable insights into the economic evaluations of FH screening strategies, highlighting significant heterogeneity in methods and outcomes across different contexts. Most studies indicated that FH screening is cost-effective and contributes to improving overall population health while potentially reducing health inequality. These findings offer implications that policies should promote the implementation of FH screening programs, particularly among younger population. Optimizing screening strategies based on economic evidence can help identify the most effective measures for improving health outcomes and maximizing cost-effectiveness.

Familial hypercholesterolemia in children and the importance of early treatment

PURPOSE OF REVIEW

Familial hypercholesterolemia leads to elevated levels of low-density lipoprotein cholesterol (LDL-C) from birth onwards due to a pathogenetic variation in genes in cholesterol metabolism. Early screening to identify and subsequently treat children with familial hypercholesterolemia is crucial to reduce the risk of premature atherosclerotic cardiovascular disease (ASCVD). This review focuses on recent insights in the field of pediatric familial hypercholesterolemia.

RECENT FINDINGS

Screening in childhood and early initiation of optimal lipid-lowering therapy (LLT) have shown promising outcomes in the prevention of ASCVD. In addition, cost-effectiveness research has demonstrated highly favorable results. With the availability of novel therapies, familial hypercholesterolemia has become a well treatable disease.

SUMMARY

Children with familial hypercholesterolemia benefit from early detection and optimal treatment of their elevated LDL-C levels.

Health economics of detection and treatment of children with familial hypercholesterolemia: to screen or not to screen is no longer the question

PURPOSE OF REVIEW

Heterozygous familial hypercholesterolemia (HeFH) is one of the most common monogenic disorders and is safely treatable with lipid-lowering medication. However, most individuals with HeFH remain untreated and undetected, especially in paediatric populations where the potential for long-term therapeutic benefit is higher. Here, we review the recent literature on health economic outcomes for the detection and management of FH in children.

RECENT FINDINGS

A targeted literature review identified eight studies evaluating detection and management strategies for paediatric FH populations in the last 25 years. Most studies conducted modelled cost-effectiveness analyses to understand the long-term impact of these strategies on health outcomes and the financial impact on the healthcare system. All studies reported that detection and management of HeFH in paediatric populations was cost-effective, regardless of the age of the children. However, cost-effectiveness varied depending on the method of case ascertainment - targeted screening was generally cheaper overall, but less effective, than whole-of-population screening, although both methods were generally cost-effective.

SUMMARY

Detection and management of HeFH in paediatric populations is a cost-effective way to significantly lower the burden of disease later in life for these individuals. These strategies should be implemented across healthcare systems.

Cost-Effectiveness of Screening Strategies for Familial Hypercholesterolaemia: An Updated Systematic Review

BACKGROUND

OBJECTIVE: This study aimed to systematically synthesise the cost-effectiveness of screening strategies to detect heterozygous familial hypercholesterolemia (FH).

METHODS

We searched seven databases from inception to 2 February , 2023, for eligible cost-effective analysis (CEA) that evaluated screening strategies for FH versus the standard care for FH detection. Independent reviewers performed the screening, data extraction and quality evaluation. Cost results were adapted to 2022 US dollars (US$) to facilitate comparisons between studies using the same screening strategies. Cost-effectiveness thresholds were based on the original study criteria.

RESULTS

A total of 21 studies evaluating 62 strategies were included in this review, most of the studies (95%) adopted a healthcare perspective in the base case, and majority were set in high-income countries. Strategies analysed included cascade screening (23 strategies), opportunistic screening (13 strategies), systematic screening (11 strategies) and population-wide screening (15 strategies). Most of the strategies relied on genetic diagnosis for case ascertainment. The most common comparator was no screening, but some studies compared the proposed strategy versus current screening strategies or versus the best next alternative. Six studies evaluated screening in children while the remaining were targeted at adults. From a healthcare perspective, cascade screening was cost-effective in 78% of the studies [cost-adapted incremental cost-effectiveness ratios (ICERs) ranged from dominant to 2022 US$ 104,877], opportunistic screening in 85% (ICERs from US$4959 to US$41,705), systematic screening in 80% (ICERs from US$2763 to US$69,969) and population-wide screening in 60% (ICERs from US$1484 to US$223,240). The most common driver of ICER identified in the sensitivity analysis was the long-term cost of lipid-lowering treatment.

CONCLUSIONS

Based on reported willingness to pay thresholds for each setting, most CEA studies concluded that screening for FH compared with no screening was cost-effective, regardless of the screening strategy. Cascade screening resulted in the largest health benefits per person tested.

Current and emerging monoclonal antibodies for treating familial hypercholesterolemia in children

INTRODUCTION

Heterozygous familial hypercholesterolemia (HeFH) is a common genetic disorder caused by pathogenic variants in the LDL-C metabolism. Lifelong exposure to elevated LDL-C levels leads to a high risk of premature cardiovascular disease. To reduce that risk, children with HeFH should be identified and treated with lipid-lowering therapy. The cornerstone consists of statins and ezetimibe, but not in all patients this lowers the LDL-C levels to treatment targets. For these patients, more intensive lipid-lowering therapy is needed.

AREAS COVERED

In this review, we provide an overview of the monoclonal antibodies which are currently available or being tested for treating HeFH in childhood.

EXPERT OPINION

Monoclonal antibodies that inhibit PCSK9 are first in line lipid-lowering treatment options if oral statin and ezetimibe therapy are insufficient, due to intolerance or very high baseline LDL-C levels. Both evolocumab and alirocumab have been shown to be safe and effective in children with HeFH. For children, evolocumab has been registered from the age of 10 years old and alirocumab from the age of 8 years old. The costs of these new agents are much higher than oral therapy, which makes it important to only use them in a selected patient population.

Childhood Screening for Familial Hypercholesterolemia: JACC Review Topic of the Week

Screening for familial hypercholesterolemia (FH) in childhood remains controversial. Existing guidelines offer practitioners conflicting advice despite generally agreeing on the evidence and areas in which evidence is lacking, including a lack of long-term clinical trials demonstrating coronary event reduction as a result of screening and long-term data on statin side effects. A limitation of existing evidence-based frameworks is reliance on 1 evidence grading system to determine recommendations. However, rigorous evidence evaluation alternatives relevant to FH exist. FH is considered a tier 1 genetic condition, meaning that identification and treatment will improve health outcomes among those affected. Elevated low-density lipoprotein cholesterol, the primary consequence of FH, can be considered causal for atherosclerosis and coronary heart disease. Incorporating these concepts into existing evidence pathways allows the inclusion of surrogate clinical trial outcomes (low-density lipoprotein cholesterol reduction and atherosclerosis regression) and observational data on medication safety, strengthening the evidence for pediatric screening for FH.

Recent advances in the management and implementation of care for familial hypercholesterolaemia

Familial hypercholesterolaemia (FH) is a common autosomal semi-dominant and highly penetrant disorder of the low-density lipoprotein (LDL) receptor pathway, characterised by lifelong elevated levels of low-density lipoprotein cholesterol (LDL-C) and increased risk of atherosclerotic cardiovascular disease (ASCVD). However, many patients with FH are not diagnosed and do not attain recommended LDL-C goals despite maximally tolerated doses of potent statin and ezetimibe. Over the past decade, several cholesterol-lowering therapies such as those targeting proprotein convertase subtilisin/kexin type 9 (PCSK9) or angiopoietin-like 3 (ANGPTL3) with monoclonal antibody or ribonucleic acid (RNA) approaches have been developed that promise to close the treatment gap. The availability of new therapies with complementary modes of action of lipid metabolism has enabled many patients with FH to attain guideline-recommended LDL-C goals. Emerging therapies for FH include liver-directed gene transfer of the LDLR, vaccines targeting key proteins involved in cholesterol metabolism, and CRISPR-based gene editing of PCSK9 and ANGPTL3, but further clinical trials are required. In this review, current and emerging treatment strategies for lowering LDL-C, and ASCVD risk-stratification, as well as implementation strategies for the care of patients with FH are reviewed.