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Mulligan K, Baid D, Doctor JN, Phelps CE, Lakdawalla DN. Risk preferences over health: Empirical estimates and implications for medical decision-making. J Health Econ 2024; 94:102857. [PMID: 38232447 DOI: 10.1016/j.jhealeco.2024.102857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/19/2024]
Abstract
Mainstream health economic theory implies that an expected gain in health-related quality of life (HRQoL) produces the same value for consumers, regardless of baseline health. Several strands of recent research call this implication into question. Generalized Risk-Adjusted Cost-Effectiveness (GRACE) demonstrates theoretically that baseline health status influences value, so long as consumers are not risk-neutral over health. Prior empirical literature casts doubt on risk-neutral expected utility-maximization in the health domain. We estimate utility over HRQoL in a nationally representative U.S. population and use our estimates to measure risk preferences over health. We find that individuals are risk-seeking at low levels of health, become risk-averse at health equal to 0.485 (measured on a 0-1 scale), and are most risk-averse at perfect health (coefficient of relative risk aversion = 4.51). We develop the resulting implications for medical decision making, cost-effectiveness analyses, and the proper theory of health-related decision making under uncertainty.
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Affiliation(s)
- Karen Mulligan
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA; Schaffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna & Peter Dauterive Hall, Los Angeles, CA, 90089, USA
| | - Drishti Baid
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA
| | - Jason N Doctor
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA; Schaffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna & Peter Dauterive Hall, Los Angeles, CA, 90089, USA
| | - Charles E Phelps
- Department of Economics, University of Rochester, 238 Harkness Hall, 280 Hutchison Road, Box 270156, Rochester, NY, 14627, USA
| | - Darius N Lakdawalla
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA; Schaffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna & Peter Dauterive Hall, Los Angeles, CA, 90089, USA; School of Pharmacy, University of Southern California, 1985 Zonal Ave, Los Angeles, CA, 90089, USA.
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Tunnicliffe DJ, Palmer SC, Cashmore BA, Saglimbene VM, Krishnasamy R, Lambert K, Johnson DW, Craig JC, Strippoli GF. HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis. Cochrane Database Syst Rev 2023; 11:CD007784. [PMID: 38018702 PMCID: PMC10685396 DOI: 10.1002/14651858.cd007784.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND Cardiovascular disease is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), and the absolute risk of cardiovascular events is similar to people with coronary artery disease. This is an update of a review first published in 2009 and updated in 2014, which included 50 studies (45,285 participants). OBJECTIVES To evaluate the benefits and harms of statins compared with placebo, no treatment, standard care or another statin in adults with CKD not requiring dialysis. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 4 October 2023. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. An updated search will be undertaken every three months. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on death, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD (estimated glomerular filtration rate (eGFR) 90 to 15 mL/min/1.73 m2) were included. DATA COLLECTION AND ANALYSIS Two or more authors independently extracted data and assessed the study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous benefits and harms with 95% confidence intervals (CI). The risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 63 studies (50,725 randomised participants); of these, 53 studies (42,752 participants) compared statins with placebo or no treatment. The median duration of follow-up was 12 months (range 2 to 64.8 months), the median dosage of statin was equivalent to 20 mg/day of simvastatin, and participants had a median eGFR of 55 mL/min/1.73 m2. Ten studies (7973 participants) compared two different statin regimens. We were able to meta-analyse 43 studies (41,273 participants). Most studies had limited reporting and hence exhibited unclear risk of bias in most domains. Compared with placebo or standard of care, statins prevent major cardiovascular events (14 studies, 36,156 participants: RR 0.72, 95% CI 0.66 to 0.79; I2 = 39%; high certainty evidence), death (13 studies, 34,978 participants: RR 0.83, 95% CI 0.73 to 0.96; I² = 53%; high certainty evidence), cardiovascular death (8 studies, 19,112 participants: RR 0.77, 95% CI 0.69 to 0.87; I² = 0%; high certainty evidence) and myocardial infarction (10 studies, 9475 participants: RR 0.55, 95% CI 0.42 to 0.73; I² = 0%; moderate certainty evidence). There were too few events to determine if statins made a difference in hospitalisation due to heart failure. Statins probably make little or no difference to stroke (7 studies, 9115 participants: RR 0.64, 95% CI 0.37 to 1.08; I² = 39%; moderate certainty evidence) and kidney failure (3 studies, 6704 participants: RR 0.98, 95% CI 0.91 to 1.05; I² = 0%; moderate certainty evidence) in people with CKD not requiring dialysis. Potential harms from statins were limited by a lack of systematic reporting. Statins compared to placebo may have little or no effect on elevated liver enzymes (7 studies, 7991 participants: RR 0.76, 95% CI 0.39 to 1.50; I² = 0%; low certainty evidence), withdrawal due to adverse events (13 studies, 4219 participants: RR 1.16, 95% CI 0.84 to 1.60; I² = 37%; low certainty evidence), and cancer (2 studies, 5581 participants: RR 1.03, 95% CI 0.82 to 1.30; I² = 0%; low certainty evidence). However, few studies reported rhabdomyolysis or elevated creatinine kinase; hence, we are unable to determine the effect due to very low certainty evidence. Statins reduce the risk of death, major cardiovascular events, and myocardial infarction in people with CKD who did not have cardiovascular disease at baseline (primary prevention). There was insufficient data to determine the benefits and harms of the type of statin therapy. AUTHORS' CONCLUSIONS Statins reduce death and major cardiovascular events by about 20% and probably make no difference to stroke or kidney failure in people with CKD not requiring dialysis. However, due to limited reporting, the effect of statins on elevated creatinine kinase or rhabdomyolysis is unclear. Statins have an important role in the primary prevention of cardiovascular events and death in people who have CKD and do not require dialysis. Editorial note: This is a living systematic review. We will search for new evidence every three months and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Brydee A Cashmore
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Kelly Lambert
- School of Medicine, University of Wollongong, Wollongong, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Mistry H, Enderby J, Court R, Al-Khudairy L, Nduka C, Melendez-Torres GJ, Taylor-Phillips S, Clarke A, Uthman OA. Determining optimal strategies for primary prevention of cardiovascular disease: systematic review of cost-effectiveness analyses in the United Kingdom. Health Technol Assess 2022:10.3310/QOVK6659. [PMID: 36562488 PMCID: PMC10068585 DOI: 10.3310/qovk6659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cardiovascular diseases are the leading cause of morbidity and mortality worldwide. The aim of the study was to guide researchers and commissioners of cardiovascular disease preventative services towards possible cost-effective interventions by reviewing published economic analyses of interventions for the primary prevention of cardiovascular disease, conducted for or within the UK NHS. METHODS In January 2021, electronic searches of MEDLINE and Embase were carried out to find economic evaluations of cardiovascular disease preventative services. We included fully published economic evaluations (including economic models) conducted alongside randomised controlled trials of any form of intervention that was aimed at the primary prevention of cardiovascular disease, including, but not limited to, drugs, diet, physical activity and public health. Full systematic review methods were used with predetermined inclusion/exclusion criteria, data extraction and formal quality appraisal [using the Consolidated Health Economic Evaluation Reporting Standards checklist and the framework for the quality assessment of decision analytic modelling by Philips et al. (Philips Z, Ginnelly L, Sculpher M, Claxton K, Golder S, Riemsma R, et al. Review of guidelines for good practice in decision-analytic modelling in health technology assessment. Health Technol Assess 2004;8(36)]. RESULTS Of 4351 non-duplicate citations, eight articles met the review's inclusion criteria. The eight articles focused on health promotion (n = 3), lipid-lowering medicine (n = 4) and blood pressure-lowering medication (n = 1). The majority of the populations in each study had at least one risk factor for cardiovascular disease or were at high risk of cardiovascular disease. For the primary prevention of cardiovascular disease, all strategies were cost-effective at a threshold of £25,000 per quality-adjusted life-year, except increasing motivational interviewing in addition to other behaviour change strategies. Where the cost per quality-adjusted life-year gained was reported, interventions varied from dominant (i.e. less expensive and more effective than the comparator intervention) to £55,000 per quality-adjusted life-year gained. FUTURE WORK AND LIMITATIONS We found few health economic analyses of interventions for primary cardiovascular disease prevention conducted within the last decade. Future economic assessments should be undertaken and presented in accordance with best practices so that future reviews may make clear recommendations to improve health policy. CONCLUSIONS It is difficult to establish direct comparisons or draw firm conclusions because of the uncertainty and heterogeneity among studies. However, interventions conducted for or within the UK NHS were likely to be cost-effective in people at increased risk of cardiovascular disease when compared with usual care or no intervention. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in Health Technology Assessment. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hema Mistry
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Jodie Enderby
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Chidozie Nduka
- Warwick Medical School, University of Warwick, Coventry, UK
| | - G J Melendez-Torres
- Peninsula Technology Assessment Group (PenTAG), College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Aileen Clarke
- Warwick Medical School, University of Warwick, Coventry, UK
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Keng MJ, Leal J, Mafham M, Bowman L, Armitage J, Mihaylova B. Performance of the UK Prospective Diabetes Study Outcomes Model 2 in a Contemporary UK Type 2 Diabetes Trial Cohort. Value Health 2022; 25:435-442. [PMID: 35227456 PMCID: PMC8881217 DOI: 10.1016/j.jval.2021.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 08/27/2021] [Accepted: 09/06/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The UK Prospective Diabetes Study (UKPDS) Outcomes Model (UKPDS-OM) developed using 30-year (1977-2007) data from the UKPDS is widely used for health outcomes' projections and economic evaluations of therapies for patients with type 2 diabetes (T2D). Nevertheless, its reliability for contemporary UK T2D populations is unclear. We assessed the performance of version 2 of the model (UKPDS-OM2) using data from A Study of Cardiovascular Events in Diabetes (ASCEND), which followed participants with diabetes in the UK between 2005 and 2017. METHODS The UKPDS-OM2 was used to predict the occurrence of myocardial infarction (MI), other ischemic heart disease, stroke, cardiovascular (CV) death, and other death among the 14 569 participants with T2D in ASCEND, all without previous CV disease at study entry. Calibration (comparison of predicted and observed year-on-year cumulative incidence over 10 years) and discrimination (c-statistics) of the model were assessed for each endpoint. The percentage error in event rates at year 7 (mean duration of follow up) was used to quantify model bias. RESULTS The UKPDS-OM2 substantially overpredicted MI, stroke, CV death, and other death over the 10-year follow-up period (by 149%, 42%, 269%, and 52%, respectively, at year 7). Discrimination of the model for MI and other ischemic heart disease (c-statistics 0.58 and 0.60, respectively) was poorer than that for other outcomes (c-statistics ranging from 0.66 to 0.72). CONCLUSIONS The UKPDS-OM2 substantially overpredicted risks of key CV outcomes and death in people with T2D in ASCEND. Appropriate adjustments or a new model may be required for assessments of long-term effects of treatments in contemporary T2D cohorts.
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Affiliation(s)
- Mi Jun Keng
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK; British Heart Foundation Centre of Research Excellence, Oxford, England, UK.
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK
| | - Marion Mafham
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK
| | - Louise Bowman
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK
| | - Jane Armitage
- British Heart Foundation Centre of Research Excellence, Oxford, England, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK; Wolfson Institute of Population Health, Queen Mary University of London, London, England, UK
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Akbarian R, Chamanara M, Rashidian A, Abdollahi A, Ejtemaei Mehr S, Dehpour AR. Atorvastatin prevents the development of diabetic neuropathic nociception by possible involvement of nitrergic system. J Appl Biomed 2021; 19:48-56. [PMID: 34907715 DOI: 10.32725/jab.2021.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 01/28/2021] [Indexed: 11/05/2022] Open
Abstract
AIMS Diabetic neuropathy has been identified as a common complication caused by diabetes. However, its pathophysiological mechanisms are not fully understood yet. Statins, also known as HMG-CoA reductase inhibitors, alleviate the production of cholesterol. Despite this cholesterol-reducing effect of statins, several reports have demonstrated their beneficial properties in neuropathic pain. In this study, we used streptozotocin (STZ)-induced diabetic model to investigate the possible role of nitric oxide (NO) in the antineuropathic-like effect of atorvastatin. METHODS Diabetes was induced by a single injection of STZ. Male rats orally received different doses of atorvastatin for 21 days. To access the neuropathy process, the thermal threshold of rats was assessed using hot plate and tail-flick tests. Moreover, sciatic motor nerve conduction velocity (MNCV) studies were performed. To assess the role of nitric oxide, N(G)-nitro-L-arginine methyl ester (L-NAME), aminoguanidine (AG), and 7-nitroindazole (7NI) were intraperitoneally administered along with some specific doses of atorvastatin. KEY FINDINGS Atorvastatin significantly reduced the hyperalgesia in diabetic rats. L-NAME pretreatment with atorvastatin showed the antihyperalgesic effect, suggesting the possible involvement of the NO pathway in atorvastatin protective action. Furthermore, co-administration of atorvastatin with AG and 7NI resulted in a significant increase in pain threshold in diabetic rats. SIGNIFICANCE Our results reveal that the atorvastatin protective effect on diabetic neuropathy is mediated at least in a part via the nitric oxide system.
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Affiliation(s)
- Reyhaneh Akbarian
- Tehran University of Medical Sciences, Experimental Medicine Research Center, Tehran, Iran.,Tehran University of Medical Sciences, School of Medicine, Department of Pharmacology, Tehran, Iran
| | - Mohsen Chamanara
- Aja University of Medical Sciences, Faculty of Medicine, Department of Pharmacology, Tehran, Iran
| | - Amir Rashidian
- Tehran University of Medical Sciences, Experimental Medicine Research Center, Tehran, Iran.,Tehran University of Medical Sciences, School of Medicine, Department of Pharmacology, Tehran, Iran
| | - Alireza Abdollahi
- Tehran University of Medical Sciences, Imam Hospital complex, Department of Pathology, Tehran, Iran
| | - Shahram Ejtemaei Mehr
- Tehran University of Medical Sciences, Experimental Medicine Research Center, Tehran, Iran.,Tehran University of Medical Sciences, School of Medicine, Department of Pharmacology, Tehran, Iran
| | - Ahmad Reza Dehpour
- Tehran University of Medical Sciences, Experimental Medicine Research Center, Tehran, Iran.,Tehran University of Medical Sciences, School of Medicine, Department of Pharmacology, Tehran, Iran
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Siegel KR, Ali MK, Zhou X, Ng BP, Jawanda S, Proia K, Zhang X, Gregg EW, Albright AL, Zhang P. Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008? Diabetes Care 2020; 43:1557-1592. [PMID: 33534729 DOI: 10.2337/dci20-0017] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/03/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.
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Affiliation(s)
- Karen R Siegel
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Mohammed K Ali
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA.,Hubert Department of Global Health and Department of Family and Preventive Medicine, Emory University, Atlanta, GA
| | - Xilin Zhou
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Boon Peng Ng
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA.,College of Nursing and Disability, Aging and Technology Cluster, University of Central Florida, Orlando, FL
| | - Shawn Jawanda
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Krista Proia
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Xuanping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Edward W Gregg
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ann L Albright
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
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Usman M, Khunti K, Davies MJ, Gillies CL. Cost-effectiveness of intensive interventions compared to standard care in individuals with type 2 diabetes: A systematic review and critical appraisal of decision-analytic models. Diabetes Res Clin Pract 2020; 161:108073. [PMID: 32061637 DOI: 10.1016/j.diabres.2020.108073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/03/2019] [Accepted: 02/10/2020] [Indexed: 01/04/2023]
Abstract
AIMS The objective of this systematic review is to identify and assess the quality of published decision-analytic models evaluating the long-term cost-effectiveness of target-driven intensive interventions for single and multifactorial risk factor control compared to standard care in people with type 2 diabetes. METHODS We searched the electronic databases MEDLINE, the National Health Service Economic Evaluation Database, Web of Science and the Cochrane Library from inception to October 31, 2019. Articles were eligible for inclusion if the studies had used a decision-analytic model evaluating both the long-term costs and benefits associated with intensive interventions for risk factor control compared to standard care in people with type 2 diabetes. Data were extracted using a standardised form, while quality was assessed using the decision-analytic model-specific Philips-criteria. RESULTS Overall, nine articles (11 models) were identified, four models evaluated intensive glycaemic control, three evaluated intensive blood pressure control, two evaluated intensive lipid control, and two evaluated intensive multifactorial interventions. Six reported using discrete-time simulations modelling approach, whereas five reported using a Markov modelling framework. The majority, seven studies, reported that the intensive interventions were dominant or cost-effective, given the assumptions and analytical perspective taken. The methodological and reporting quality of the studies was generally weak, with only four studies fulfilling more than 50% of their applicable Philips-criteria. CONCLUSIONS This is the first systematic review of decision-analytic models of target-driven intensive interventions for single and multifactorial risk factor control in individuals with type 2 diabetes. Identified shortcomings are lack of transparency in data identification and evidence synthesis as well as for the selection of the modelling approaches. Future models should aim to include greater evaluation of the quality of the data sources used and the assessment of uncertainty in the model.
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Affiliation(s)
- Muhammad Usman
- Diabetes Research Centre, University of Leicester, Leicester, UK.
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK; NIHR Applied Research Collaborations - East Midlands (NIHR ARC - EM), Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK; NIHR Leicester Biomedical Research Centre, UK
| | - Clare L Gillies
- Diabetes Research Centre, University of Leicester, Leicester, UK
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Li T, Wan X, Ma J, Wu B. Cost-Effectiveness of Primary Prevention with Statin Treatment for Chinese Patients with Type 2 Diabetes. Adv Ther 2018; 35:2214-23. [PMID: 30390239 DOI: 10.1007/s12325-018-0823-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Statins can reduce the risk of cardiovascular events in patients with diabetes. The objective of this analysis was to evaluate whether primary prevention with statin treatment is cost-effective for newly diagnosed type 2 diabetes mellitus (T2DM) patients in the Chinese context. METHODS An economic analysis of primary prevention with statin treatment was conducted using the Chinese Outcomes Model for T2DM with a time horizon of a lifetime, which was developed and validated based on the Chinese population. Clinical costs and utility inputs were gathered from published sources. Lifetime discounted quality-adjusted life-years (QALYs), costs, and the incremental cost-effectiveness ratio (ICER) were measured. The uncertainty was evaluated by one-way and probabilistic sensitivity analyses. RESULTS Statin treatment with atorvastatin 10 mg could add 0.08 QALYs with an additional $1676 compared with that of no statin management (control strategy) over a lifetime horizon, which led to an ICER of $21,924 per QALY gained. At a willingness-to-pay threshold of $27,351 per QALY gained, there was an approximately 80% probability of statin treatment being cost-effective compared with the control strategy. The model outcomes were most sensitive to the length of the expected life and age at the T2DM diagnosis. CONCLUSIONS Statin treatment with atorvastatin is most likely cost-effective for primary prevention in Chinese patients newly diagnosed with type 2 diabetes. FUNDING Partially funded by Pfizer Inc.
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Groenendyk JW, Mehta NN. Applying the ordinal model of atherosclerosis to imaging science: a brief review. Open Heart 2018; 5:e000861. [PMID: 30094037 PMCID: PMC6074639 DOI: 10.1136/openhrt-2018-000861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 05/30/2018] [Accepted: 07/03/2018] [Indexed: 12/28/2022] Open
Abstract
Atherogenesis has been well demonstrated to proceed in an ordinal fashion. Imaging technologies have advanced substantially in recent decades, enabling early detection of atherosclerosis. Some modalities, such as coronary CT, have seen broad clinical adaptation. In contrast, others, such as flow-mediated dilatation, remain predominantly research-based. Optimal and appropriate usage of these technologies remains an area of active investigation. We hypothesise that investigators ought to consider which stage of atherosclerosis is under investigation when choosing imaging modalities. Additionally, when assessing the efficacy of a particular treatment, some imaging modalities may be more appropriate than others. We review the most important available imaging modalities and suggest stages at which each may or may not be well used. Conceptual application of the classic stages of atherosclerosis model to the variety of modern imaging modalities available will result in more effective investigation and treatment of cardiovascular disease.
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Affiliation(s)
- Jacob W Groenendyk
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Nehal N Mehta
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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Jiao FF, Fung CSC, Wan EYF, Chan AKC, McGhee SM, Kwok RLP, Lam CLK. Five-Year Cost-effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM). Diabetes Care 2018; 41:250-257. [PMID: 29246949 DOI: 10.2337/dc17-1149] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/20/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To estimate the cost-effectiveness of the multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) in primary care patients with type 2 diabetes in comparison with usual primary care in a cohort with 5 years' follow-up. RESEARCH DESIGN AND METHODS We conducted a prospective cohort study among 17,140 propensity score-matched participants in RAMP-DM and those under usual primary care. The effectiveness measures were cumulative incidences of complications and all-cause mortality over 5 years. In a bottom-up approach, we estimated the program costs of RAMP-DM and health service utilization from the public health service provider's perspective. The RAMP-DM program costs included the setup costs, ongoing intervention costs, and central administrative costs. We calculated the incremental cost-effectiveness ratio by dividing the incremental costs by the incremental effectiveness of the RAMP-DM group compared with those of the usual-care group. RESULTS There were significantly lower cumulative incidences of individual on any complications (15.34% vs. 28.65%, P < 0.001) and all-cause mortality (7.96% vs. 21.35%, P < 0.001) in the RAMP-DM group compared with the usual-care group. The mean program cost of RAMP-DM was 157 U.S. dollars (range 66-209) per participant over 5 years. The costs of health service utilization among participants in RAMP-DM group was 7,451 USD less than that of the usual-care group, resulting in a net savings of 7,294 USD per individual. CONCLUSIONS RAMP-DM added to usual primary care was a cost-saving intervention in managing diabetes in patients over 5 years. These findings support the integration of RAMP-DM as part of routine primary care for all patients with diabetes.
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Affiliation(s)
- Fang Fang Jiao
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Colman Siu Cheung Fung
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Anca Ka Chun Chan
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Sarah Morag McGhee
- Li Ka Shing Faculty of Medicine, School of Public Health, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Ruby Lai Ping Kwok
- Primary and Community Services Department, Hospital Authority Head Office, Hong Kong Hospital Authority, Hong Kong, People's Republic of China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
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Ortendahl JD, Harmon AL, Bentley TGK, Broder MS. A systematic literature review of methods of incorporating mortality in cost-effectiveness analyses of lipid-lowering therapies. J Med Econ 2017; 20:767-775. [PMID: 28562126 DOI: 10.1080/13696998.2017.1336449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIMS Cost effectiveness analysis (CEA) is a useful tool for estimating the value of an intervention in relation to alternatives. In cardiovascular disease (CVD), CEA is especially important, given the high economic and clinical burden. One key driver of value is CVD mortality prevention. However, data used to inform CEA parameters can be limited, given the difficulty in demonstrating statistically significant mortality benefit in randomized clinical trials (RCTs), due in part to the frequency of fatal events and limited trial durations. This systematic review identifies and summarizes whether published CVD-related CEAs have incorporated mortality benefits, and the methodology among those that did. MATERIALS AND METHODS A systematic literature review was conducted of CEAs of lipid-lowering therapies published between 2000-2017. Health technology assessments (HTA) and full-length manuscripts were included, and sources of mortality data and methods of applying mortality benefits were extracted. Results were summarized as proportions of articles to articulate common practices in CEAs of CVD. RESULTS This review identified 100 studies for inclusion, comprising 93 full-length manuscripts and seven HTA reviews. Among these, 99% assumed a mortality benefit in the model. However, 87 of these studies that incorporated mortality differences did so despite the trials used to inform model parameters not demonstrating statistically significant differences in mortality. None of the 12 studies that used statistically significant findings from an individual RCT were based on active control studies. In a sub-group analysis considering the 60 CEAs that incorporated a direct mortality benefit, 48 (80%) did not have RCT evidence for statistically significant benefit in CVD mortality. LIMITATIONS AND CONCLUSIONS The finding that few CEA models included mortality inputs from individual RCTs of lipid-lowering therapy may be surprising, as one might expect that treatment efficacy should be based on robust clinical evidence. However, regulatory requirements in CVD-related RCTs often lead to insufficient sample sizes and observation periods for detecting a difference in CVD mortality, which results in the use of intermediate outcomes, composite end-points, or meta-analysis to extrapolate long-term mortality benefit in a lifetime CEA.
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Affiliation(s)
- Jesse D Ortendahl
- a Partnership for Health Analytic Research , Beverly Hills , CA , USA
| | - Amanda L Harmon
- a Partnership for Health Analytic Research , Beverly Hills , CA , USA
| | - Tanya G K Bentley
- a Partnership for Health Analytic Research , Beverly Hills , CA , USA
| | - Michael S Broder
- a Partnership for Health Analytic Research , Beverly Hills , CA , USA
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Ribeiro RA, Duncan BB, Ziegelmann PK, Stella SF, Vieira JLDC, Restelatto LMF, Polanczyk CA. Cost-effectiveness of high, moderate and low-dose statins in the prevention of vascular events in the Brazilian public health system. Arq Bras Cardiol 2014; 104:32-44. [PMID: 25409878 PMCID: PMC4387609 DOI: 10.5935/abc.20140173] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 06/25/2014] [Indexed: 11/20/2022] Open
Abstract
Background Statins have proven efficacy in the reduction of cardiovascular events, but the
financial impact of its widespread use can be substantial. Objective To conduct a cost-effectiveness analysis of three statin dosing schemes in the
Brazilian Unified National Health System (SUS) perspective. Methods We developed a Markov model to evaluate the incremental cost-effectiveness ratios
(ICERs) of low, intermediate and high intensity dose regimens in secondary and
four primary scenarios (5%, 10%, 15% and 20% ten-year risk) of prevention of
cardiovascular events. Regimens with expected low-density lipoprotein cholesterol
reduction below 30% (e.g. simvastatin 10mg) were considered as low dose; between
30-40%, (atorvastatin 10mg, simvastatin 40mg), intermediate dose; and above 40%
(atorvastatin 20-80mg, rosuvastatin 20mg), high-dose statins. Effectiveness data
were obtained from a systematic review with 136,000 patients. National data were
used to estimate utilities and costs (expressed as International Dollars - Int$).
A willingness-to-pay (WTP) threshold equal to the Brazilian gross domestic product
per capita (circa Int$11,770) was applied. Results Low dose was dominated by extension in the primary prevention scenarios. In the
five scenarios, the ICER of intermediate dose was below Int$10,000 per QALY. The
ICER of the high versus intermediate dose comparison was above Int$27,000 per QALY
in all scenarios. In the cost-effectiveness acceptability curves, intermediate
dose had a probability above 50% of being cost-effective with ICERs between Int$
9,000-20,000 per QALY in all scenarios. Conclusions Considering a reasonable WTP threshold, intermediate dose statin therapy is
economically attractive, and should be a priority intervention in prevention of
cardiovascular events in Brazil.
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Affiliation(s)
| | | | | | | | | | | | - Carisi Anne Polanczyk
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul
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Palmer SC, Navaneethan SD, Craig JC, Johnson DW, Perkovic V, Hegbrant J, Strippoli GFM. HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis. Cochrane Database Syst Rev 2014:CD007784. [PMID: 24880031 DOI: 10.1002/14651858.cd007784.pub2] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), for whom the absolute risk of cardiovascular events is similar to people who have existing coronary artery disease. This is an update of a review published in 2009, and includes evidence from 27 new studies (25,068 participants) in addition to the 26 studies (20,324 participants) assessed previously; and excludes three previously included studies (107 participants). This updated review includes 50 studies (45,285 participants); of these 38 (37,274 participants) were meta-analysed. OBJECTIVES To evaluate the benefits (such as reductions in all-cause and cardiovascular mortality, major cardiovascular events, MI and stroke; and slow progression of CKD to end-stage kidney disease (ESKD)) and harms (muscle and liver dysfunction, withdrawal, and cancer) of statins compared with placebo, no treatment, standard care or another statin in adults with CKD who were not on dialysis. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 5 June 2012 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on mortality, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD not on dialysis were the focus of our literature searches. DATA COLLECTION AND ANALYSIS Two or more authors independently extracted data and assessed study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes (lipids, creatinine clearance and proteinuria) and risk ratio (RR) for dichotomous outcomes (major cardiovascular events, all-cause mortality, cardiovascular mortality, fatal or non-fatal myocardial infarction (MI), fatal or non-fatal stroke, ESKD, elevated liver enzymes, rhabdomyolysis, cancer and withdrawal rates) with 95% confidence intervals (CI). MAIN RESULTS We included 50 studies (45,285 participants): 47 studies (39,820 participants) compared statins with placebo or no treatment and three studies (5547 participants) compared two different statin regimens in adults with CKD who were not yet on dialysis. We were able to meta-analyse 38 studies (37,274 participants).The risk of bias in the included studies was high. Seven studies comparing statins with placebo or no treatment had lower risk of bias overall; and were conducted according to published protocols, outcomes were adjudicated by a committee, specified outcomes were reported, and analyses were conducted using intention-to-treat methods. In placebo or no treatment controlled studies, adverse events were reported in 32 studies (68%) and systematically evaluated in 16 studies (34%).Compared with placebo, statin therapy consistently prevented major cardiovascular events (13 studies, 36,033 participants; RR 0.72, 95% CI 0.66 to 0.79), all-cause mortality (10 studies, 28,276 participants; RR 0.79, 95% CI 0.69 to 0.91), cardiovascular death (7 studies, 19,059 participants; RR 0.77, 95% CI 0.69 to 0.87) and MI (8 studies, 9018 participants; RR 0.55, 95% CI 0.42 to 0.72). Statins had uncertain effects on stroke (5 studies, 8658 participants; RR 0.62, 95% CI 0.35 to 1.12).Potential harms from statin therapy were limited by lack of systematic reporting and were uncertain in analyses that had few events: elevated creatine kinase (7 studies, 4514 participants; RR 0.84, 95% CI 0.20 to 3.48), liver function abnormalities (7 studies, RR 0.76, 95% CI 0.39 to 1.50), withdrawal due to adverse events (13 studies, 4219 participants; RR 1.16, 95% CI 0.84 to 1.60), and cancer (2 studies, 5581 participants; RR 1.03, 95% CI 0.82 to 130).Statins had uncertain effects on progression of CKD. Data for relative effects of intensive cholesterol lowering in people with early stages of kidney disease were sparse. Statins clearly reduced risks of death, major cardiovascular events, and MI in people with CKD who did not have CVD at baseline (primary prevention). AUTHORS' CONCLUSIONS Statins consistently lower death and major cardiovascular events by 20% in people with CKD not requiring dialysis. Statin-related effects on stroke and kidney function were found to be uncertain and adverse effects of treatment are incompletely understood. Statins have an important role in primary prevention of cardiovascular events and mortality in people who have CKD.
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Affiliation(s)
- Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, 2 Riccarton Ave, PO Box 4345, Christchurch, New Zealand, 8140
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de Vries FM, Denig P, Visser ST, Hak E, Postma MJ. Cost-effectiveness of statins for primary prevention in patients newly diagnosed with type 2 diabetes in the Netherlands. Value Health 2014; 17:223-230. [PMID: 24636380 DOI: 10.1016/j.jval.2013.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 11/14/2013] [Accepted: 12/20/2013] [Indexed: 06/03/2023]
Abstract
BACKGROUND Statins are lipid-lowering drugs that reduce the risk of cardiovascular events in patients with diabetes. OBJECTIVES The objective of this study was to determine whether statin treatment for primary prevention in newly diagnosed type 2 diabetes is cost-effective, taking nonadherence, baseline risk, and age into account. METHODS A cost-effectiveness analysis was performed by using a Markov model with a time horizon of 10 years. The baseline 10-year cardiovascular risk was estimated in a Dutch population of primary prevention patients with newly diagnosed diabetes from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database, using the United Kingdom Prospective Diabetes Study risk engine. Statin adherence was measured as pill days covered in the IADB.nl pharmacy research database. Cost-effectiveness was measured in costs per quality-adjusted life-year (QALY) from the health care payers' perspective. RESULTS For an average patient aged 60 years, the base case, statin treatment was highly cost-effective at €2245 per QALY. Favorable cost-effectiveness was robust in sensitivity analysis. Differences in age and 10-year cardiovascular risk showed large differences in cost-effectiveness from almost €100,000 per QALY to almost being cost saving. Treating all patients younger than 45 years at diabetes diagnosis was not cost-effective (weighted cost-effectiveness of almost €60,000 per QALY). CONCLUSIONS Despite the nonadherence levels observed in actual practice, statin treatment is cost-effective for primary prevention in patients newly diagnosed with type 2 diabetes. Because of large differences in cost-effectiveness according to different risk and age groups, the efficiency of the treatment could be increased by targeting patients with relatively higher cardiovascular risk and higher ages.
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Affiliation(s)
- Folgerdiena M de Vries
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, The Netherlands.
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sipke T Visser
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, The Netherlands
| | - Eelko Hak
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, The Netherlands
| | - Maarten J Postma
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, The Netherlands
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Nam GE, Han K, Park YG, Choi YS, Kim SM, Ju SY, Ko BJ, Kim YH, Kim EH, Cho KH, Kim DH. Trends in lipid profiles among South Korean adults: 2005, 2008 and 2010 Korea National Health and Nutrition Examination Survey. J Public Health (Oxf) 2014; 37:286-94. [PMID: 24573366 DOI: 10.1093/pubmed/fdu012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND This study aimed to investigate recent trends in the prevalence and parameters of dyslipidemia and rates of lipid-lowering medication use in Korean adults. Trends in lipid profiles in subjects with hypertension, diabetes or obesity were also studied. METHODS Data from the Korea National Health and Nutrition Examination Survey in 2005, 2008 and 2010 were used in this study. A total of 17 009 subjects participated in this study. RESULTS There was a declining trend in the prevalence of dyslipidemia and an increasing trend in the rates of use of lipid-lowering medication among Korean adults. In both men and women, the age-adjusted mean high-density lipoprotein cholesterol level linearly increased. There was a significantly decreasing trend in the age-adjusted mean triglycerides in women and age-adjusted mean lipid-related ratios in both sexes. The age-adjusted mean total cholesterol level showed a slightly increasing trend and the age-adjusted mean low-density lipoprotein cholesterol level was not changed in both sexes. These patterns persisted among subjects not taking lipid-lowering medication. The favorable trends were also observed in subjects with hypertension, diabetes and obesity. CONCLUSIONS Our study showed favorable trends in the prevalence of dyslipidemia and in several lipid profiles among Korean adults.
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Affiliation(s)
- Ga Eun Nam
- Department of Family Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Kyungdo Han
- Department of Biostatistics, Catholic University College of Medicine, Seoul, South Korea
| | - Yong Gyu Park
- Department of Biostatistics, Catholic University College of Medicine, Seoul, South Korea
| | - Youn Seon Choi
- Department of Family Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Seon Mee Kim
- Department of Family Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Sang-Yhun Ju
- Department of Family Medicine, Yeouido St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Byung-Joon Ko
- Department of Family Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Yang Hyun Kim
- Department of Family Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Eun Hye Kim
- Department of Family Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Kyung Hwan Cho
- Department of Family Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Do Hoon Kim
- Department of Family Medicine, Korea University College of Medicine, Seoul, South Korea
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Affiliation(s)
- Bo Kyung Koo
- Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Lee HS, Lee SS, Hwang IY, Park YJ, Yoon SH, Han K, Son JW, Ko SH, Park YG, Yim HW, Lee WC, Park YM. Prevalence, awareness, treatment and control of hypertension in adults with diagnosed diabetes: the Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV). J Hum Hypertens 2013; 27:381-7. [PMID: 23223084 DOI: 10.1038/jhh.2012.56] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We evaluated the prevalence, awareness, treatment and control of hypertension in Korean adults with diagnosed diabetes using nationally representative data. Among subjects aged ≥30 years who participated in the Fourth Korea National Health and Nutrition Examination Survey in 2007 and 2008, a total of 745 subjects (336 men and 409 women) with a previous diagnosis of diabetes mellitus were analyzed. The prevalence of hypertension in adults with diagnosed diabetes was 55.5%. The rates of awareness, treatment and control were 88.0, 94.2, and 30.8%, respectively. Compared with the general population, the prevalence of hypertension in adults with diagnosed diabetes was higher in all age groups in both genders. Factors independently associated with a high prevalence of hypertension included being male, increasing age, single, <9 years of education, the presence of chronic kidney disease risk, hypercholesterolemia (≥240 mg dl(-1)) and high body mass index (≥25 kg m(-2)). Regular medical screening was positively associated with hypertension control, whereas a high triglyceride level (≥150 mg dl(-1)) was inversely associated. A high prevalence and a low control rate of hypertension in adults with diagnosed diabetes suggest that stringent efforts are needed to control blood pressure in diabetic patients.
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Abstract
An ideal biomarker should refine identification of those at risk of disease occurrence or progression, improve prediction of complications of disease, and/or guide and help tailor responses to different therapies. Biomarkers that give insights into disease pathogenesis are also of interest. With this in mind, this review describes biomarker studies relevant to diabetes, focusing on those conducted by the author, his colleagues and collaborators. The review highlights several points. (1) Novel biomarkers may not improve prediction of new-onset diabetes in a meaningful way beyond what can be achieved with simple measures combined with HbA(1c), and a sensible way ahead may be to combine diabetes and cardiovascular disease prediction using HbA(1c) and such measures. (2) In terms of disease pathogenesis, associations do not necessarily infer causality; potential for residual confounding and reverse causality should always be borne in mind. The potential relevance of such issues to understanding the relationship of some topical variables/pathways, namely adiponectin, inflammation and vitamin D, with diabetes will be highlighted. (3) How baseline and serial data on biomarkers arising from the liver have improved our understanding of the role of hepatic fat in diabetes pathogenesis will be explored. (4) Future goals for diabetes biomarker research should focus on predicting complications and determining subgroups who may respond better to particular therapies. (5) All novel biomarker research (regardless of analytical platforms used) needs to be tested against information available from commonly measured variables in clinical practice. Otherwise, many claims of clinical utility can be exaggerated. In summary, biomarker research in diabetes is continuing apace in a number of areas, but it remains to be seen whether the promise of biomarker research to improve the care of our patients becomes a reality.
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Affiliation(s)
- N Sattar
- Faculty of Medicine, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
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Grabner M, Johnson W, Abdulhalim AM, Kuznik A, Mullins CD. The Value of Atorvastatin Over the Product Life Cycle in the United States. Clin Ther 2011; 33:1433-43. [DOI: 10.1016/j.clinthera.2011.08.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 08/25/2011] [Accepted: 08/31/2011] [Indexed: 10/17/2022]
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Wilson AR, Rodin H, Garrett NA, Bargman EP, Harris LA, Pederson MK, Plocher DW. Comparing quality of care between a consumer-directed health plan and a traditional plan: an analysis of HEDIS measures related to management of chronic diseases. Popul Health Manag 2010; 12:61-7. [PMID: 19320605 DOI: 10.1089/pop.2008.0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A cross-sectional, retrospective medical and pharmaceutical claims data analysis was conducted to determine if Healthcare Effectiveness Data and Information Set (HEDIS) measures related to care for chronic conditions differed between enrollees in a traditional comprehensive major medical plan (CMM) and a consumer-directed health plan (CDHP). Eleven HEDIS measures for 2006 were compared for CMM and CDHP enrollees in a health plan. Measures included care for persons with diabetes, asthma, depression, cardiovascular disease, and low back pain, and for persons taking persistent medications for specific conditions. In the CMM population, 1,238,949 members were eligible to be included; 131,763 members in the CDHP population were eligible. Statistical significance testing was performed. As measured by HEDIS, CDHP enrollees received higher quality of care than did CMM enrollees in areas related to low back pain, and eye exams and nephropathy screening for persons with diabetes. No significant differences were found between CDHP enrollees and CMM enrollees for measures describing medication management for persons with depression and asthma, annual monitoring for persons taking persistent medications, cholesterol management for persons with cardiovascular disease, or HbA1c testing and low-density lipoprotein screening for persons with diabetes. Enrollees in CDHPs who have chronic conditions received care at levels of quality equal to or better than CMM enrollees. The potential for increased financial responsibility in the CDHP plan did not appear to deter those enrollees from pursuing necessary care. Future research should control for the demographic factors thought to influence both selection into a plan design and quality of care.
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Affiliation(s)
- Amy R Wilson
- Blue Cross Blue Shield of Minnesota, Eagan, Minnesota 55122, USA.
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Abstract
OBJECTIVE To synthesize the cost-effectiveness (CE) of interventions to prevent and control diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS We conducted a systematic review of literature on the CE of diabetes interventions recommended by the American Diabetes Association (ADA) and published between January 1985 and May 2008. We categorized the strength of evidence about the CE of an intervention as strong, supportive, or uncertain. CEs were classified as cost saving (more health benefit at a lower cost), very cost-effective (<or=$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001 to $50,000 per LYG or QALY), marginally cost-effective ($50,001 to $100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). The CE classification of an intervention was reported separately by country setting (U.S. or other developed countries) if CE varied by where the intervention was implemented. Costs were measured in 2007 U.S. dollars. RESULTS Fifty-six studies from 20 countries met the inclusion criteria. A large majority of the ADA recommended interventions are cost-effective. We found strong evidence to classify the following interventions as cost saving or very cost-effective: (I) Cost saving- 1) ACE inhibitor (ACEI) therapy for intensive hypertension control compared with standard hypertension control; 2) ACEI or angiotensin receptor blocker (ARB) therapy to prevent end-stage renal disease (ESRD) compared with no ACEI or ARB treatment; 3) early irbesartan therapy (at the microalbuminuria stage) to prevent ESRD compared with later treatment (at the macroalbuminuria stage); 4) comprehensive foot care to prevent ulcers compared with usual care; 5) multi-component interventions for diabetic risk factor control and early detection of complications compared with conventional insulin therapy for persons with type 1 diabetes; and 6) multi-component interventions for diabetic risk factor control and early detection of complications compared with standard glycemic control for persons with type 2 diabetes. (II) Very cost-effective- 1) intensive lifestyle interventions to prevent type 2 diabetes among persons with impaired glucose tolerance compared with standard lifestyle recommendations; 2) universal opportunistic screening for undiagnosed type 2 diabetes in African Americans between 45 and 54 years old; 3) intensive glycemic control as implemented in the UK Prospective Diabetes Study in persons with newly diagnosed type 2 diabetes compared with conventional glycemic control; 4) statin therapy for secondary prevention of cardiovascular disease compared with no statin therapy; 5) counseling and treatment for smoking cessation compared with no counseling and treatment; 6) annual screening for diabetic retinopathy and ensuing treatment in persons with type 1 diabetes compared with no screening; 7) annual screening for diabetic retinopathy and ensuing treatment in persons with type 2 diabetes compared with no screening; and 8) immediate vitrectomy to treat diabetic retinopathy compared with deferred vitrectomy. CONCLUSIONS Many interventions intended to prevent/control diabetes are cost saving or very cost-effective and supported by strong evidence. Policy makers should consider giving these interventions a higher priority.
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Affiliation(s)
- Rui Li
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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Annemans L, Marbaix S, Webb K, Van Gaal L, Scheen A. Cost effectiveness of atorvastatin in patients with type 2 diabetes mellitus: a pharmacoeconomic analysis of the collaborative atorvastatin diabetes study in the belgian population. Clin Drug Investig 2010; 30:133-42. [PMID: 20067331 DOI: 10.2165/11531910-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with type 2 diabetes mellitus have a high risk of developing cardiovascular (CV) disease. The clinical benefit of use of statins in patients with type 2 diabetes has been demonstrated in several randomized, controlled trials, including the CARDS clinical trial. Based on the clinical CARDS data, the favourable cost effectiveness of atorvastatin 10 mg in patients with type 2 diabetes has been demonstrated in countries such as the UK and France. This study aimed to estimate the cost effectiveness in the Belgian setting of atorvastatin 10 mg compared with no treatment for the primary prevention of CV events in type 2 diabetes patients without a history of CV disease. METHODS A Markov model with 1-year cycles was developed to simulate the CV event and death risk according to the therapeutic approach initiated. The transition probabilities for CV events in the 'no statin treatment' group were derived from the risk equations reported from the large UKPDS. Risk reductions from the CARDS clinical trial were used to adjust these CV event probabilities in the atorvastatin 10 mg treatment group. The characteristics of type 2 diabetes patients without a CV history were derived from the Belgian OCAPI survey. The public healthcare payers' perspective was taken into account for costing. The direct medical costs of CV events were based on the Public Health Authorities' hospital database for acute care costs and on the literature for the follow-up costs. The impact on the reimbursement system of generic entry to the market was considered in the drug cost. Costs were valued as at year 2009; costs and outcomes were discounted at 3% and 1.5%, respectively. RESULTS Based on a 5-year time horizon, atorvastatin was demonstrated to be cost effective with an incremental cost/quality-adjusted life-year (QALY) of euro 16,681. Over a lifetime horizon (25 years), atorvastatin was demonstrated to be a cost-saving therapeutic intervention. At a threshold of euro 30,000/QALY, atorvastatin had a 98.8% probability of being cost effective. CONCLUSION Compared with 'no treatment', use of atorvastatin 10 mg as a primary prevention intervention in Belgian type 2 diabetes patients not only improves CV outcomes, but also appears to be cost saving over a lifetime horizon.
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Affiliation(s)
- L Annemans
- Department of Public Health, Ghent University, Ghent, Belgium
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Liew D, Park HJ, Ko SK. Results of a Markov model analysis to assess the cost-effectiveness of a single tablet of fixed-dose amlodipine and atorvastatin for the primary prevention of cardiovascular disease in Korea. Clin Ther 2009; 31:2189-203; discussion 2150-1. [DOI: 10.1016/j.clinthera.2009.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2009] [Indexed: 10/20/2022]
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Sorensen SV, Frick KD, Wade A, Simko R, Burge R. Model-based simulation to explore the cost-effectiveness of following practice guidelines for triglyceride and low-density lipoprotein cholesterol control among patients with diabetes mellitus and mixed dyslipidemia. Clin Ther 2009; 31:862-79. [PMID: 19446159 DOI: 10.1016/j.clinthera.2009.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2009] [Indexed: 12/18/2022]
Abstract
BACKGROUND The National Cholesterol Education Program Adult Treatment Panel III guidelines recommend maintaining lipid levels within particular targets to reduce the risk of coronary heart disease (CHD) events. OBJECTIVE The objective of this simulation study was to evaluate the cost-effectiveness of following guideline-recommended care compared with current practice or usual care for patients with diabetes mellitus (DM) and mixed dyslipidemia (ie, high low-density lipoprotein cholesterol [LDL-C] and triglyceride [TG] levels). METHODS A simulation model using a US health care payer perspective was designed to predict changes in lipid levels (LDL-C, TG, high-density lipoprotein cholesterol, and total cholesterol) and long-term CHD risk. Data about patients with DM and uncontrolled TG and/or LDL-C were taken from an electronic medical records database to develop the description of current care (eg, statin, fibrate, or no medication) and cholesterol levels. Patients with uncontrolled lipid levels who were not following guideline recommendations were assumed to be receiving combination treatment (ie, coadministration of statin and fibrate) or monotherapy for the uncontrolled lipids under guideline care. Results from a previous study were used to project incremental benefits of combination treatment compared with monotherapy. CHD events were predicted based on risk equations. A 20-year model of direct costs and quality-adjusted life-years (QALYs) was created. RESULTS Among patients switched to guideline therapy, the model predicted 72% achieved 2 lipid targets and 44% achieved 3 lipid targets in 1 year. Over 20 years, in a modeled sample of 1000 patients, 176 myocardial infarction and angina events would be avoided by following guideline care. Total present value of costs for drug treatment and medical care for CHD events would be $33,626 per patient for guideline treatment versus $25,264 per patient for current care. The discounted QALY gain would be 0.18 per patient for an incremental cost per QALY of $50,315. CONCLUSIONS The results of this model simulation suggest that for patients with DM and mixed dyslipidemia, following treatment guidelines rather than current practice (including combination therapy rather than monotherapy) would result in more patients achieving lipid targets, fewer CHD events, and more QALYs gained at a reasonable cost (less than $109,000) per QALY.
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Khoury H, Wagner M, Merikle E, Johnson SJ, Roberts C. Cost-Effectiveness of Atorvastatin in the Primary Prevention of Major Cardiovascular Events in Patients with Type 2 Diabetes in Canada. Can J Diabetes 2009. [DOI: 10.1016/s1499-2671(09)34006-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Schwarz B, Gouveia M, Chen J, Nocea G, Jameson K, Cook J, Krishnarajah G, Alemao E, Yin D, Sintonen H. Cost-effectiveness of sitagliptin-based treatment regimens in European patients with type 2 diabetes and haemoglobin A1c above target on metformin monotherapy. Diabetes Obes Metab 2008; 10 Suppl 1:43-55. [PMID: 18435673 DOI: 10.1111/j.1463-1326.2008.00886.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Sitagliptin is a novel oral incretin enhancer that acts by inhibiting the dipeptidyl peptidase 4 enzyme and is indicated in Europe as a treatment adjunct to metformin (MF), sulphonylurea (SU), MF plus SU and diet and exercise, in the management of type 2 diabetes mellitus. The objective of the current analysis was to evaluate the cost-effectiveness of adding sitagliptin to the regimens of patients with haemoglobin A1c (HbA1C) above the International Diabetes Federation goal (6.5%) while on MF in six European countries: Austria, Finland, Portugal, Scotland (United Kingdom), Spain and Sweden. METHODS A discrete event simulation model, which employed the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model risk equations for predicting risks of diabetes-related complication, was used. Lifetime costs and benefits were projected for alternative treatment strategies of adding sitagliptin, compared with adding rosiglitazone or a SU to MF in patients not at HbA1C goal on MF monotherapy. Changes in HbA1C as well as side effects associated with these different treatment strategies were based on clinical trial data. Mean baseline values from local epidemiologic studies involving patients with type 2 diabetes not at HbA1C goal on MF monotherapy were included in the current analysis. Costs of medications, side effects and direct costs of diabetes-related complications were based on country-specific data. UKPDS-based disutility weights associated with diabetes complications were incorporated. Disutilities associated with medication side effects were based on published data. All future costs and benefits were discounted according to local guidelines on cost-effectiveness analysis. One-way sensitivity analyses were conducted by varying key input parameters. FINDINGS The discounted incremental cost-effectiveness ratios (ICER) associated with the addition of sitagliptin to MF, compared with adding rosiglitazone, in the different countries analysed ranged from treatment with sitagliptin being dominant (cost saving with improved health outcome) to its being cost-effective [4,766 euros per quality-adjusted life year (QALY)]. Treatment with sitagliptin added to MF was cost-effective compared with adding a SU, with discounted ICER values ranging from 5949 euros/QALY to 20,350 euros/QALY across countries. Sensitivity analyses showed that these results were robust to changes in input parameters, including clinical efficacy, costs and utility weights for both diabetes-related complications and hypoglycaemia. CONCLUSIONS Compared with adding rosiglitazone or a SU to MF, adding sitagliptin to MF is projected to be either cost saving or cost-effective for patients with type 2 diabetes who are not at HbA1C goal on MF.
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Affiliation(s)
- B Schwarz
- Center of Public Health of the Medical University of Vienna (Austria), Karl Landsteiner Institute of Health Economics, Vienna, Austria. bernhard.schwarz@
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Lafuma A, Colin X, Solesse A. Cost-effectiveness of atorvastatin in the prevention of cardiovascular events in diabetic patients: A French adaptation of CARDS. Arch Cardiovasc Dis 2008; 101:327-32. [DOI: 10.1016/j.acvd.2008.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 05/15/2008] [Indexed: 10/20/2022]
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Ramsey SD, Clarke LD, Roberts CS, Sullivan SD, Johnson SJ, Liu LZ. An economic evaluation of atorvastatin for primary prevention of cardiovascular events in type 2 diabetes. Pharmacoeconomics 2008; 26:329-339. [PMID: 18370567 DOI: 10.2165/00019053-200826040-00005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The CARDS trial, a multicentre, randomized, controlled trial, found that atorvastatin 10 mg/day for patients with type 2 diabetes mellitus and normal low-density lipoprotein (LDL)-cholesterol significantly reduced cardiovascular (CV) events, including stroke. We estimated the cost effectiveness of atorvastatin as primary prevention against CV disease from the short-term and lifetime US payer perspectives. RESEARCH DESIGN AND METHODS We constructed a decision analytic (Markov) model to evaluate long-term costs and outcomes for atorvastatin 10 mg/day versus no HMG-CoA reductase inhibitor (statin) therapy for patients with type 2 diabetes and no history of a CV event. CV event rates and survival were based on risk equations calibrated to CARDS and applied to a US type 2 diabetes population; the atorvastatin effect on CV events was based on hazard ratios from CARDS; direct medical care costs were based on US treatment patterns and published costs analyses of patients with diabetes. Costs were valued in $US, year 2005 values; costs and benefits were discounted at 3% per annum. RESULTS Within the time horizon of the trial (5 years), the cost effectiveness of atorvastatin was $US137 276 per QALY. At 10 years, the incremental cost per QALY improved to $US3640 per QALY. At 25 years, overall costs were lower and QALYs higher in the atorvastatin arm. Costs of managing CV events were lower after 5 years for patients treated with atorvastatin. CONCLUSIONS For patients with type 2 diabetes and one additional risk factor for CV disease, normal LDL-cholesterol and no history of a CV event, primary prevention with atorvastatin appears to be cost saving and improve outcomes over 25 years, although it is costly from a short-term US payer perspective. From both a medical and an economic viewpoint, primary prevention is desirable in this patient population.
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Affiliation(s)
- Scott D Ramsey
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USAUniversity of Washington, Seattle, WA 98109, USA.
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Abstract
A systematic review was undertaken to analyse pharmaco-economic issues in diabetes, with evidence selected on the basis of relevance and immediacy. Pharmaco-economics in diabetes primarily relates to making choices about antidiabetic pharmaceuticals, and this is being influenced by global trends. Trends include increasing numbers of patients with diabetes, with increasing costs of caring for people with diabetes, and an ever-present focus on the costs of pharmaceuticals which are predicted to increase as the pace of development of new medications parallels the increasing incidence of the condition. These developments have influenced the demand for health care in diabetes in the last decade, and will continue to determine this in the coming decade. Recent national experiences are cited to illustrate current issues and to focus specifically upon the challenges facing a raft of new diabetes treatment options now hitting the marketplace, although supported by fewer completed long-term trials. It can be anticipated that these newer agents will be appraised for their cost-effectiveness or value for money. Economic analyses for some of the new technologies are summarized; in general, the peer-reviewed publications using well-accepted and validated models have reported that these technologies are cost-effective. Endorsement of any technology in a national setting is not awarded simply because the incremental cost-effectiveness ratio (ICER) falls below the threshold regarded as value for money. In most national observations the reviewers expressed concerns about assumptions used in economic modelling which resulted in the ICERs being deemed optimistic at best, generally highly uncertain, and resulting in the cost-effectiveness appearing better than it really would be in clinical practice. This has often led to the authorities concluding that the price advantage of new technologies over comparators could not be justified, essentially leading to restrictions in use compared to their licence. In general, a paucity of robust evidence on longer-term outcome data together with a lack of health-related quality of life (HRQOL) data collected in a reliable manner in appropriate patients and amenable to utility (and hence quality adjusted life year or QALY) estimation have resulted in problems for these new drugs at the so-called fourth (cost-effectiveness) hurdle. In the light of these findings, the implications for generating credible fit-for-purpose cost-effectiveness analyses of new technologies in diabetes are discussed. Throughout this chapter, the interested reader is referred to a number of excellent review articles for further details.
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Affiliation(s)
- Julia M Bottomley
- Amygdala Ltd, The Warren, Willian Road, Letchworth Garden City, Hertfordshire SG6 2AA, UK.
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Plosker GL, Lyseng-Williamson KA. Atorvastatin: a pharmacoeconomic review of its use in the primary and secondary prevention of cardiovascular events. Pharmacoeconomics 2007; 25:1031-1053. [PMID: 18047388 DOI: 10.2165/00019053-200725120-00005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Atorvastatin is a lipid-lowering agent that has been evaluated in a number of primary and secondary intervention studies. In the primary prevention trials ASCOT-LLA and CARDS, atorvastatin 10 mg/day significantly reduced cardiovascular events compared with placebo. A prospectively conducted economic analysis of the 3.3-year ASCOT-LLA trial showed that atorvastatin was associated with incremental cost-effectiveness ratios (ICERs) of euro11,693 (UK) and euro12,673 (Sweden) per event avoided (2002 values). Longer-term modelled analyses using data from CARDS showed ICERs of euro8046 (Spain) and 6471pound (UK) per QALY gained (2003/2004 values), and a US analysis showed atorvastatin was dominant versus no statin when modelled over the lifetime of a representative US diabetic primary prevention population. In a modelled analysis based on results of the IDEAL trial, which showed significant reductions in cardiovascular endpoints with high-dose atorvastatin (80 mg/day) compared with conventional-dose simvastatin in patients with stable coronary heart disease, ICER values were below the commonly used cost-effectiveness threshold of euro50,000 per QALY gained in Norway, Sweden and Denmark, but were above this threshold in Finland (2005 values). A modelled US analysis that also included data from IDEAL and other sources showed an ICER of $US33,400 per QALY gained, assuming the incremental difference in acquisition cost between high-dose atorvastatin and conventional-dose simvastatin was $US1.40/day (2005 value). Most cost-effectiveness analyses with atorvastatin in patients with acute coronary syndrome used data from the 16-week MIRACL study, which showed a significant reduction in cardiovascular events with high-dose atorvastatin compared with placebo. Analyses were conducted in North America and Europe and showed that 31-86% of the acquisition cost of high-dose atorvastatin was offset by reductions in costs associated with cardiovascular events. Across five countries, ICER values ranged from approximate $US850 to $US4100 per event avoided (2000/2001 values). Another analysis conducted in the US used longer-term data and showed that high-dose atorvastatin versus conventional-dose statin was associated with an ICER of $US12,900 per QALY gained, assuming the daily difference in acquisition cost was $US1.40 (2005 value). In conclusion, atorvastatin has demonstrated beneficial effects on various cardiovascular endpoints in large, well designed primary and secondary intervention trials. These benefits in moderate- to high-risk patients were achieved at a relatively low incremental cost and, across the economic analyses, a substantial proportion of atorvastatin acquisition costs was offset by reductions in healthcare resource use associated with cardiovascular events. Cost-effectiveness analyses based on major clinical trials comparing atorvastatin with placebo, usual medical care, simvastatin or pravastatin have generally shown that atorvastatin is associated with favourable ICER values, often well below commonly used cost-effectiveness thresholds. These modelled analyses have the inherent limitation that projecting long-term outcomes beyond the time period of a clinical trial imparts a degree of uncertainty to the results. Nevertheless, while some findings were sensitive to changes in model assumptions, such as the long-term benefits of statin therapy, most sensitivity analyses showed that results of the base-case analyses were robust to plausible changes in key parameters. Although a clear pattern is not evident from available data, intuitively, the value of atorvastatin would be expected to increase with the patient's risk for serious cardiovascular events.
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