Cost-effectiveness of statins

Rosuvastatin is Cost-Effective in Treating Patients to Low-Density Lipoprotein-Cholesterol Goals Compared with Atorvastatin, Pravastatin and Simvastatin: Analysis of the Stellar Trial

Background

Rosuvastatin calcium (CRESTOR®) has demonstrated superior efficacy in reducing low-density lipoprotein cholesterol (LDL-C). However, healthcare providers and authorities require information on its cost-effectiveness in the treatment of dyslipidaemia.

Design

A retrospective pharmacoeconomic analysis was performed using data from the Statin Therapies for Elevated Lipid Levels compared Across doses to Rosuvastatin (STELLAR) trial. The cost-effectiveness of rosuvastatin 10-40 mg was compared with atorvastatin 10-80 mg, pravastatin 10-40 mg and both branded and generic simvastatin 10-80 mg in achieving Third Joint European Task Force LDL-C goals in patients with hypercholesterolaemia.

Methods

The analysis was conducted from the perspective of the UK National Health Service, using clinical data from the STELLAR trial and drug acquisition costs. Cost-effectiveness was compared using incremental cost-effectiveness ratios (ICERs), with sensitivity analyses applied to both efficacy and cost parameters.

Results

In terms of patients achieving goal, rosuvastatin 10 mg dominated (was more effective at equal or lower cost) atorvastatin 10 and 20 mg, pravastatin 20 and 40 mg, branded simvastatin 10-80 mg and generic simvastatin 40 and 80 mg. Where rosuvastatin 10 mg did not dominate, ICERs ranged from £36 to £162 per extra patient to goal. Rosuvastatin 20 and 40 mg were cost-effective compared with milligram-equivalent and higher doses of other branded statins. Sensitivity analyses showed that the results were robust to variations in both statin efficacy and price.

Conclusion

In patients with hypercholesterolaemia, rosuvastatin is a cost-effective statin option in treating to LDL-C goals. Eur J Cardiovasc Prev Rehabil 12:18-28 © 2005 The European Society of Cardiology

Cost-effectiveness analysis of alternative screening and treatment strategies for heterozygous familial hypercholesterolemia in the United States

BACKGROUND/OBJECTIVES

Familial hypercholesterolemia (FH) is a genetic disorder that leads to premature heart disease or stroke if untreated. Statins are effective for individuals with FH but less than 20% of actual cases are diagnosed in the US and many people are not adherent to treatment. Using new knowledge regarding mutations responsible for FH, some European countries have developed genetic FH screening strategies, many of which have been shown to be cost-effective. This study evaluates the cost-effectiveness of genetic screening and lipid-based screening with statin adherence measures compared to lipid-based screening alone in the US.

METHODS

A decision tree was used to estimate disease detection with the three screening strategies, while a Markov model was used to model disease progression until death, quality-adjusted life years (QALYs) and costs from a US societal perspective.

RESULTS

The results showed that Genetic Screening cost $15,594 for 18.29 QALYs per person and Lipid Screening with adherence measures cost $16,385 for 18.77 QALYs compared with $10,396 for 18.28 QALYs for Lipid Screening alone. The incremental cost-effectiveness ratio (ICER) of Genetic Screening versus Lipid Screening was $519,813/QALY and that of Lipid Screening with adherence measures versus Lipid Screening alone was $12,223/QALY. At a US willingness-to-pay threshold of $150,000/QALY Genetic Screening is not cost-effective compared with Lipid Screening. Sensitivity analyses showed that results were robust to reasonable variations in model parameters.

CONCLUSIONS

Although genetic screening is currently not a cost-effective option in the US, health outcomes for FH individuals could benefit from adherence measures encouraging statin use.

Do different methods of modeling statin treatment effectiveness influence the optimal decision?

PURPOSE

Modeling studies that evaluate statin treatment for the prevention of cardiovascular disease (CVD) use different methods to model the effect of statins. The aim of this study was to evaluate the impact of using different modeling methods on the optimal decision found in such studies.

METHODS

We used a previously developed and validated Monte Carlo-Markov model based on the Rotterdam study (RISC model). The RISC model simulates coronary heart disease (CHD), stroke, cardiovascular death, and death due to other causes. Transition probabilities were based on 5-year risks predicted by Cox regression equations, including (among others) total and high-density lipoprotein (HDL) cholesterol as covariates. In a cost-effectiveness analysis of implementing the ATP-III guidelines, we evaluated the impact of using 3 different modeling methods of statin effectiveness: 1) through lipid level modification: statins lower total cholesterol and increase HDL cholesterol, which through the covariates in the Cox regression equations leads to a lower incidence of CHD and stroke events; 2) fixed risk reduction of CVD events: statins decrease the odds of CHD and stroke with an associated odds ratio that is assumed to be the same for each individual; 3) risk reduction of CVD events proportional to individual change in low-density lipoprotein (LDL) cholesterol: the relative risk reduction with statin therapy on the incidence of CHD and stroke was assumed to be proportional to the absolute reduction in LDL cholesterol levels for each individual. The probability that the ATP-III strategy was cost-effective, compared to usual care as observed in the Rotterdam study, was calculated for each of the 3 modeling methods for varying willingness-to-pay thresholds.

RESULTS

Incremental cost-effectiveness ratios for the ATP-III strategy compared with the reference strategy were €56,642/quality-adjusted life year (QALY), €21,369/QALY, and €22,131/QALY for modeling methods 1, 2, and 3, respectively. At a willingness-to-pay threshold of €50,000/QALY, the probability that the ATP-III strategy was cost-effective was about 40% for modeling method 1 and more than 90% for both methods 2 and 3. Differences in results between the modeling methods were sensitive to both the time horizon modeled and age distribution of the target

POPULATION

CONCLUSIONS

Modeling the effect of statins on CVD through the modification of lipid levels produced different results and associated uncertainty than modeling it directly through a risk reduction of events. This was partly attributable to the modeled effect of cholesterol on the incidence of stroke.

The effectiveness and cost of single and multi-factorial cardiovascular risk factor modification to guideline targets in type 2 diabetes

AIMS

Cardiovascular disease is the main cause of morbidity and mortality in type 2 diabetes (T2DM), at huge cost to the NHS. We investigated the potential effect on population cardiovascular risk and associated costs of single and multi-factorial intervention, to target levels, in individuals with T2DM.

METHODS

Baseline population means and proportions for cardiovascular risk factors were calculated for 159 patients with T2DM from 3 general practices. Predicted 10year cardiovascular risk, and associated costs were calculated using the LIP2687 risk calculator, based on Framingham and UKPDS equations. Systolic blood pressure, HbA(1C), total cholesterol and HDL-cholesterol were altered to NICE and SIGN target levels and the model run again. The difference in outcomes was observed.

RESULTS

45%, 76% and 38% of patients met NICE targets for cholesterol, systolic blood pressure and HbA1c, respectively. As expected, comparing the two guidelines, fewer patients met the 'stricter' targets (P=0.0001). Treatment-to-target produced no significant difference in cardiovascular risk or costs, although greater reductions in outcomes were seen with multi-factorial intervention.

CONCLUSION

This small study suggests that intervention in only those patients with the highest cardiovascular risk brings little reduction in population cardiovascular risk and associated health costs. Multi-factorial intervention in all patients with T2DM, regardless of baseline values, is likely to bring greater reductions. This raises the question as to whether the current emphasis on treatment to target should be modified to encourage multi-factorial intervention in all patients with T2DM, even those with baseline values below target levels.

Economic evaluation of high-dose (80 mg/day) atorvastatin treatment compared with standard-dose (20 mg/day to 40 mg/day) simvastatin treatment in Canada based on the Incremental Decrease in End-Points Through Aggressive Lipid-Lowering (IDEAL) trial

BACKGROUND

The Incremental Decrease in End-Points Through Aggressive Lipid-Lowering (IDEAL) trial demonstrated incremental cardiovascular benefit of treatment with high-dose atorvastatin (80 mg/ day) versus standard-dose simvastatin (20 mg/day to 40 mg/day) in 8888 patients with a previous myocardial infarction (MI) over a median follow-up period of 4.8 years.

OBJECTIVES

To assess the cost-effectiveness of high-dose atorvastatin versus standard-dose simvastatin treatment in patients with a history of MI from a Canadian societal perspective.

METHODS

In a within-trial analysis, end point-related events, resources used and productivity losses occurring during the IDEAL trial were aggregated by treatment arm on an intention-to-treat basis to calculate the incremental cost per event avoided. Additionally, quality-adjusted survival was projected using a lifetime Markov model. Transition probabilities, workdays lost, use of study medication and cardiovascular hospitalization rates were based on IDEAL trial data. Hospitalization, study medication and productivity costs were included. Probabilistic and deterministic sensitivity analyses were performed.

RESULTS

Compared with standard-dose simvastatin, atorvastatin 80 mg led to 0.099 fewer events per patient and cost savings over 4.8 years of treatment. Over a lifetime horizon, atorvastatin 80 mg led to 0.023 qualityadjusted life years (QALYs) gained per patient at an incremental cost of $26,795/QALY gained. The incremental cost-effectiveness ratio remained below $50,000/QALY in 78% of 1000 simulations. Exclusion of indirect costs resulted in an incremental cost-effectiveness ratio of $38,834/QALY. Results were relatively sensitive to baseline age, but robust with respect to sex, baseline low-density lipoprotein cholesterol levels, diabetes status and hospitalization costs.

CONCLUSION

From a Canadian societal perspective, high-dose atorvastatin is cost-effective compared with standard-dose simvastatin in patients with a previous MI.

Cost-effectiveness of rosuvastatin in the prevention of ischemic heart disease in Portugal

OBJECTIVE

To assess the cost-effectiveness of rosuvastatin in the treatment of hypercholesterolemia and the prevention of ischemic heart disease (IHD) in Portugal.

METHODS

A probabilistic Markov model was constructed to analyze the costs and consequences of lifetime treatment with rosuvastatin, atorvastatin, pravastatin, and simvastatin. For this purpose, the results from randomized head-to-head trials evaluating low-density lipoprotein (LDL) changes were combined with the results from a meta-analysis defining the relationship between LDL levels and fatal and nonfatal IHD events. The incidence of myocardial infarction (MI) was derived from a 9-year Portuguese observational study. The eligible population was defined as untreated individuals aged more than 35 years with LDL levels above 115 mg/dl. Death rates due to IHD and other causes were obtained from official data. Resource use in the treatment of MI was estimated by a Delphi panel of eight Portuguese cardiologists with at least 15 years of clinical practice. Costs were calculated from the payers' perspective.

RESULTS

Rosuvastatin increases life expectancy between 5.5 and 12.1 days per patient. It is cost-saving when compared to atorvastatin, but it increases costs when assessed against pravastatin and simvastatin (euro1,004 and euro684 per patient, respectively). Therefore, rosuvastatin is a dominant alternative compared to atorvastatin, having an incremental cost-effectiveness ratio of euro30,350 to pravastatin and euro39,340 to simvastatin. In the probabilistic sensitivity analysis, performed rosuvastatin always dominates atorvastatin and is associated with a cost per life-year gained inferior to euro50,000 in 95.7% of the cases when compared to pravastatin and in 67.0% simulations when assessed against simvastatin.

CONCLUSIONS

Rosuvastatin is a cost-effective alternative in the prevention of IHD in Portugal.

The economic consequences of noncompliance in cardiovascular disease and related conditions: a literature review

OBJECTIVES

To review studies on the cost consequences of compliance and/or persistence in cardiovascular disease (CVD) and related conditions (hypertension, dyslipidaemia, diabetes and heart failure) published since 1995, and to evaluate the effects of noncompliance on healthcare expenditure and the cost-effectiveness of pharmaceutical interventions.

METHODS

English language papers published between January 1995 and February 2007 that examined compliance/persistence with medication for CVD or related conditions, provided an economic evaluation of pharmacological interventions or cost analysis, and quantified the cost consequences of noncompliance, were identified through database searches. The cost consequences of noncompliance were compared across studies descriptively.

RESULTS

Of the 23 studies identified, 10 focused on hypertension, seven on diabetes, one on dyslipidaemia, one on coronary heart disease, one on heart failure and three covered multiple diseases. In studies assessing drug costs only, increased compliance/persistence led to increased drug costs. However, increased compliance/persistence increased the effectiveness of treatment, leading to a decrease in medical events and non-drug costs. This offset the higher drug costs, leading to savings in overall treatment costs. In studies evaluating the effect of compliance/persistence on the cost-effectiveness of pharmacological interventions, increased compliance/persistence appeared to reduce cost-effectiveness ratios, but the extent of this effect was not quantified.

CONCLUSIONS

Noncompliance with cardiovascular and antidiabetic medication is a significant problem. Increased compliance/persistence leads to increased drug costs, but these are offset by reduced non-drug costs, leading to overall cost savings. The effect of noncompliance on the cost-effectiveness of pharmacological interventions is inconclusive and further research is needed to resolve the issue.

Atorvastatin and cardiovascular risk in the elderly--patient considerations

Elderly individuals are at increased risk of coronary heart disease (CHD) and account for a majority of CHD deaths. Several clinical trials have assessed the beneficial effects of statins in individuals with, or at risk of developing, CHD. These trials provide evidence that statins reduce risk and improve clinical outcomes even in older patients; however, statin therapy remains under-utilized among the aged. Atorvastatin has been widely investigated among the older subjects and has the greatest magnitude of favorable effects on clinical outcomes of CHD. The pharmacokinetic properties of atorvastatin allow it to be used every other day, a factor which may decrease adverse events and be especially important in the elderly. The purpose of this article is to review the evidence available from randomized clinical trials regarding the safety and efficacy of atorvastatin in primary and secondary prevention of CHD and stroke in older patients and to discuss issues such as drug interactions, patient compliance and cost-effectiveness, which affect prescription of lipid-lowering therapy among older patients.

The cost-effectiveness of fluvastatin in Hungary following successful percutaneous coronary intervention

BACKGROUND

The Lescol Intervention Prevention Study (LIPS) showed substantial gains in health outcomes from statins following PCI. That study was a randomized double-blind placebo-controlled trial undertaken in 77 centres, predominantly in Europe, of patients with moderate hypercholesterolemia who had undergone their first PCI. The evidence on cost-effectiveness has been established for the UK, USA and the Netherlands, but due to different health system cost structures, the results may not be applicable to other European countries. The aim of this study was to estimate the cost-effectiveness of fluvastatin used following first PCI in Hungary.

MATERIALS AND METHODS

A deterministic Markov model was used to estimate the incremental costs per quality-adjusted life year gained, with cost data drawn from the Hungarian National Health Insurance Fund. Effectiveness data on fluvastatin was derived directly from LIPS and utility weights from previous studies on heart disease. Sensitivity analyses were conducted around key parameters and analyses were conducted for subgroups identified in LIPS.

RESULTS

Treatment with fluvastatin cost an additional 1,704 euro and resulted in an additional 0.107 QALYs per patient discounted over 10-years compared with controls. The incremental cost per quality-adjusted life year gained was 15,910 euro. The key determinants of cost-effectiveness were the effectiveness of fluvastatin, utility weights, cost of fluvastatin, and the time horizon evaluated. Fluvastatin was substantially more cost-effective in patients with diabetes, renal disease, multi-vessel disease or LDL-cholesterol >3.4 mmol/l.

CONCLUSIONS

Fluvastatin is an economically efficient pharmaceutical for reducing heart disease in Hungary and other European countries in patients following PCI.

A Model for Assessing the Cost-Effectiveness of Atorvastatin and Simvastatin in Achieving Canadian Low-Density Lipoprotein Cholesterol Targets

BACKGROUND

Elevated low-density lipoprotein cholesterol (LDL-C) is an important modifiable risk factor for cardiovascular (CV) disease. Statins differ in their LDL-C-lowering effects and acquisition costs. Atorvastatin and simvastatin are the 2 most commonly used statins in Canada.

OBJECTIVE

This analysis compared the cost-effectiveness of atorvastatin and generic simvastatin in terms of annual drug cost per patient treated to Canadian LDL-C targets. It was conducted from the perspective of the Canadian provincial drug-reimbursement plans.

METHODS

A hypothetical cohort of 1000 dyslipidemic patients was assigned baseline LDL-C serum concentrations and levels of risk for CV disease based on Canadian population data. Canadian data on statin dosing were combined with efficacy data from a published meta-analysis to determine the proportion of patients who would be expected to achieve LDL-C targets after treatment with atorvastatin or generic simvastatin. Statin acquisition costs were obtained from Ontario and Quebec and reported in 2005 Canadian dollars. The sensitivity of the model to changes in drug costs, effectiveness, and persistence with treatment was tested.

RESULTS

The model predicted that more patients would reach the LDL-C target with atorvastatin than with simvastatin (73% vs 57%, respectively). The mean annual drug cost per patient treated to target was $54 higher with atorvastatin ($905 vs $851). The incremental cost-effectiveness ratio, measured as annual drug cost per additional patient treated to target with atorvastatin, was $1088. The model was sensitive to drug cost and effectiveness assumptions. Incorporating real-life rates of adherence into the model had no significant impact on the results.

CONCLUSION

In this hypothetical cohort of dyslipidemic patients, treatment with atorvastatin would allow achievement of LDL-C targets in more patients than treatment with simvastatin, at an annual incremental cost of $1088 per additional patient treated to target.

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

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

A review of health care models for coronary heart disease interventions

This article reviews models for the treatment of coronary heart disease (CHD). Whereas most of the models described were developed to assess the cost effectiveness of different treatment strategies, other models have also been used to extrapolate clinical trials, for capacity and resource planning, or to predict the future population with heart disease. In this paper we investigate the use of modelling techniques in relation to different types of health intervention, and we discuss the assumptions and limitations of these approaches. Many of the models reviewed in this paper use decision tree models for acute or short term interventions, and Markov or state transition models for chronic or long term interventions. Discrete event simulation has, however, been used for more complex whole system models, and for modelling resource-constrained interventions and operational planning. Nearly all of the studies in our review used cohort-based models rather than population based models, and therefore few models could estimate the likely total costs and benefits for a population group. Most studies used de novo purpose built models consisting of only a small number of health states. Models of the whole disease system were less common. The model descriptions were often incomplete. We recommend that the reporting of model structure, assumptions and input parameters is more explicit, to reduce the risk of biased reporting and ensure greater confidence in the model results.

Effectiveness calculation in economic analysis: the case of statins for cardiovascular disease prevention

OBJECTIVES

This report aimed to evaluate the calculation of estimates of effectiveness in cost effectiveness analyses of statins for cardiovascular disease prevention.

METHODS

Methodological aspects were reviewed of seven primary studies (based on trial results) and 12 secondary modelling studies (extrapolated) on the cost effectiveness of statin treatment, published between 1995 and 2002. Estimates of life years gained were extracted and compared with estimates calculated using the Dutch male life table of 1996-2000.

RESULTS

Of the seven primary modelling analyses, six showed all the essential data. They estimated that 3 to 5.6 years (average 4.6 years) of statin treatment resulted in 0.15 to 0.41 years (average 0.3 years) saved over a lifetime time horizon. In contrast none of the 12 secondary modelling studies provided transparent results. They assumed lifelong treatment, leading to life table estimations of 2.4 and 2.0 (undiscounted) years saved for 40 and 60 year olds, with peak savings at around the mean age of death: 75-80 years. With 5% discounting, these effects reduced to 0.4 and 0.8 years respectively.

CONCLUSION

Reporting of essential data and assumptions on statin treatment was poor for secondary modelling analyses and satisfactory for primary modelling studies. Secondary modeling studies made assumptions on long term effectiveness that were hard to justify with the available evidence, and that led to the majority of life years saved at high ages. Further standardisation in economic analyses is important to guarantee transparency and reproducibility of results.

Impact of rosuvastatin use on costs and outcomes in patients at high risk for cardiovascular disease in US managed care and medicare populations: A data analysis

BACKGROUND

High blood cholesterol is a major modifiable risk factor for coronary heart disease (CHD) and stroke.

OBJECTIVE

The aim of this study was to estimate the economic impact of rosuvastatin calcium use in patients at high risk for CHD and stroke, according to the National Cholesterol Education Program Adult Treatment Panel (ATP) III guidelines.

METHODS

An economic simulation model was developed that used a Markov process to project the number of cardiovascular events and associated costs in a high-risk population in various treatment scenarios. According to the ATP III, high-risk patients are those with CHD, atherosclerosis of peripheral and/or cerebral arteries, diabetes, and/or multiple other risk factors conferring a risk of at least 20% within 10 years. Data on population characteristics and costs of cardiovascular disease (CVD) were obtained from claims data sets from employer-funded commercial and Medicare health plans in the United States. Treatment of lipid disorders was translated into CVD risk reduction based on results from the Heart Protection Study. The estimated efficacies of individual lipid-lowering drugs were based on data published in package inserts. The model generated costs at the health plan level of lipid-lowering therapy in high-risk patients and the number and total costs of cardiovascular events. Estimates were compared for scenarios representing the mix of treatments used before and after the introduction of rosuvastatin. Estimates were generated separately for commercial and Medicare health plans.

RESULTS

For every 1 million members of a commercial health plan, an estimated 44,457 met ATP III criteria for high-risk status. Use of rosuvastatin in place of other 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors ("statins") by 11 % of these patients over a period of 5 years was estimated to result in 36 fewer cardiovascular events and a net savings of US 4.03 million dollars. A Medicare plan of 1 million members with an estimated 433,268 high-risk patients and 7% rosuvastatin use was estimated to avoid 727 events and save US 34.32 million dollars.

CONCLUSIONS

The results of this data analysis suggest that increasing the use of rosuvastatin can result in cardiovascular event reduction and cost savings. Because the impact of lipid-modifying therapy on cardiovascular risk has not been thoroughly documented in controlled clinical studies, our model assumed that incremental lipid changes had effects in proportion to the magnitude of change.

Cost effectiveness of statins in coronary heart disease

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cost effectiveness of adding ezetimibe to atorvastatin therapy in patients not at cholesterol treatment goal in Canada

INTRODUCTION

This analysis compared the cost effectiveness of adding ezetimibe to atorvastatin therapy versus atorvastatin titration or adding cholestyramine (a resin) for patients at high risk of a coronary artery disease (CAD) event who did not reach target cholesterol levels on their current atorvastatin dosage. The primary analysis focused on 65-year-old patients with low-density lipoprotein cholesterol (LDL-C) levels of 3.1 or 3.6 mmol/L with a treatment goal of <2.5 mmol/L, classified as very high risk according to the 2000 Canadian Guidelines for Management and Treatment of Hyperlipidaemia.

METHODS

A previously developed Markov model was utilised to capture the cost and clinical consequences of lipid-lowering therapy in primary and secondary prevention of CAD. Comparisons between treatment strategies were made using ICERs (cost per QALY) from a Canadian Ministry of Health perspective. The effects of lipid-lowering therapies were based on clinical trial data. The risks of CAD events were estimated using Framingham Heart Study risk equations. Treatment costs and the costs of acute and long-term care for CAD events were included in the analysis. Costs (Canadian dollar, 2002 values) and outcomes were discounted at 5% per annum.

RESULTS

Ezetimibe added to atorvastatin therapy compared with treatment with the most common fixed atorvastatin daily dosage (10 mg) or with common atorvastatin titration strategies (up to 20 mg daily; up to 40 mg daily) resulted in cost per QALY estimates ranging from 25,344 to 44,332 Canadian dollars. The addition of ezetimibe to atorvastatin therapy was less costly and more effective than the addition of cholestyramine (dominant).

CONCLUSION

Our analysis suggests that adding ezetimibe to atorvastatin for patients not achieving treatment goals with their current atorvastatin dose produces greater clinical benefits than treatment with a fixed-dose atorvastatin or atorvastatin titration at an increased overall cost. The cost-effectiveness ratios provide strong evidence for the adoption of ezetimibe within the Canadian healthcare system.

Efficacy of a Low Dose of Pitavastatin Compared with Atorvastatin in Primary Hyperlipidemia: Results of a 12-week, open label study

BACKGROUND

Pitavastatin has a potent cholesterol-lowering action. The clinical efficacy and safety of a low dose, 1 mg, of pitavastatin were examined.

METHODS

The effect of 12 weeks' treatment with pitavastatin 1 mg in an open label, non-randomized trial involving 137 patients with hypercholesterolemia as compared with treatment with atorvastatin 10 mg.

RESULTS

Total cholesterol, low-density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol and triglyceride (TG) levels at baseline did not differ between the two groups. At follow-up, there were no significant differences in total cholesterol, LDL cholesterol and HDL cholesterol levels between the groups. The TG levels at follow-up were higher in the pitavastatin group than atorvastatin group (p < 0.01). In patients with hyperlipidemia type IIa, TG levels at follow-up were lower in the atorvastatin subgroup (p < 0.01). However, there was no significant difference in TG levels at follow-up between the two subgroups in patients with hyperlipidemia type IIb.

CONCLUSION

Pitavastatin 1 mg daily was safe and efficacious in reducing LDL cholesterol levels as compared with atorvastatin 10 mg daily. Further randomized comparative studies are needed to clarify the effect of a low dose of pitavastatin.

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

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

Rosuvastatin is cost-effective compared with atorvastatin in reaching cholesterol goals

BACKGROUND

Lowering low-density lipoprotein cholesterol (LDL-C) levels reduces the risk of coronary heart disease. The introduction of a highly efficacious new statin, rosuvastatin, may enable more patients to be treated to LDL-C goal within a fixed budget.

OBJECTIVES

To compare the cost-effectiveness of rosuvastatin 10 mg and atorvastatin 10 mg in lowering LDL-C and achieving guideline goals after 12 weeks of treatment. The LDL-C goals were those recommended by the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP) III and the Third Joint European Task Force.

METHODS

The analysis was performed on pooled data from three clinical trials. Efficacy was measured as the percent reduction in LDL-C and the proportion of patients who reached guideline LDL-C goals following the first 12 weeks of treatment, prior to dose titration. Costs comprised drug acquisition costs only. The cost-effectiveness measures were cost per 1% reduction in LDL-C and cost per patient treated to their LDL-C goal.

RESULTS

Treatment with rosuvastatin 10 mg costs 1.85 per 1% reduction in LDL-C, compared with 2.37 per 1% reduction with atorvastatin 10 mg. The average costs per patient treated to the European LDL-C goals were 130.18 for rosuvastatin 10 mg and 242.44 for atorvastatin 10 mg. Treating to NCEP ATP III goals costs 115 per patient treated with rosuvastatin 10 mg vs. 163 per patient treated with atorvastatin 10 mg.

CONCLUSIONS

Rosuvastatin has the same acquisition costs as and is more efficacious than atorvastatin in lowering LDL-C and treating patients to target LDL-C levels.

Cost effectiveness of rosuvastatin in treating patients to low-density lipoprotein cholesterol goals compared with atorvastatin, pravastatin, and simvastatin (a US Analysis of the STELLAR Trial)

Statin therapy decreases low-density lipoprotein cholesterol levels and the risk of coronary heart disease but has a considerable short-term effect on health care budgets. The cost effectiveness of rosuvastatin (Crestor) has been compared with those of atorvastatin, pravastatin, and simvastatin in lowering low-density lipoprotein cholesterol levels and achieving National Cholesterol Education Program Adult Treatment Panel III low-density lipoprotein cholesterol goals. The analysis was conducted from the perspective of health care payers in the United States. Clinical data were obtained from the Statin Therapies for Elevated Lipid Levels Compared Across Doses to Rosuvastatin (STELLAR) trial. Drug costs were based on wholesale acquisition costs. Cost effectiveness was assessed with the net monetary benefit approach and a 1-year time horizon. Rosuvastatin at 10 mg, the recommended starting dose, was the most cost-effective statin over a large range of "willingness-to-pay" values for a unit of clinical effect (i.e., a 1% decrease in low-density lipoprotein cholesterol or a patient achieving the goal).

Economic effects of prolonged clopidogrel therapy after percutaneous coronary intervention

OBJECTIVES

This study examined the incremental cost-effectiveness of extending clopidogrel therapy from one month to one year after percutaneous coronary intervention (PCI) in an unselected, heterogeneous patient population.

BACKGROUND

Clinical trials suggest that prolonging clopidogrel therapy for up to one year after PCI reduces downstream cardiac events. However, clopidogrel therapy is costly and may increase bleeding risk.

METHODS

Using decision analysis, we compared the outcomes and cost of prolonging clopidogrel treatment from one month to one year after PCI with the alternative strategy of discontinuing therapy one month after the procedure. Event rates were based on 3,976 PCI patients who were treated between January 1999 and December 2001 at the Duke Medical Center and received no more than one month of clopidogrel after the procedure. Baseline characteristics and event rates were obtained from Duke clinical information systems. The effect of prolonged clopidogrel therapy on event rates was based on the Clopidogrel for the Reduction of Events During Observation (CREDO) trial per-protocol data. Unit costs and the effect of myocardial infarction (MI) on life expectancy were based on published sources.

RESULTS

Extending clopidogrel therapy from one month to one year after PCI cost USD 879 per patient and reduced the risk of MI by 2.6%. Assuming MI decreases life expectancy by two years, prolonged therapy would cost USD 15,696 per year of life saved. Economic attractiveness of therapy varied with baseline risk, the effect of prolonged therapy on MI risk, and the price of clopidogrel.

CONCLUSIONS

Prolonging clopidogrel therapy for one year after PCI is economically attractive, particularly in high-risk patients.

Pharmacoeconomic impact of non-compliance with statins

There are numerous studies examining the pharmacoeconomic impact of HMG-CoA reductase inhibitor (statin) therapy on healthcare costs and outcomes. A recently published review demonstrated that the cost-benefit of these agents depends primarily on the risk of developing a coronary event. That is, as the risk of a coronary event increases, the cost-effectiveness ratio decreases. The typical cost per life-year saved (LYS) ranged from USD 1800 to USD 40,000 in patients with pre-existing coronary artery disease (CAD) and from USD 15,000 to > USD 1 million per LYS in patients without pre-existing CAD. The literature is sparse on the pharmacoeconomics of medication non-compliance in patients taking statin medications. Data from two studies suggest that >75% compliance results in decreased coronary events such as myocardial infarction. However, retrospective database analyses indicate that the average compliance rate hovers around the 65% mark. Many of the studies discuss medication non-compliance as a factor, but do not independently analyse compliance pharmacoeconomically. We examined the pharmacoeconomic impact of non-compliance using published studies that contained pharmacoeconomic data and/or compliance data. In general, we used the placebo arm of these published studies as the surrogate marker for complete non-compliance. The results suggest that for almost 100% compliance versus initial non-compliance, the cost effectiveness of statin medications ranges from USD 4500 to over USD 250,000 per LYS depending on patient age, presence or absence of risk factors and whether the statin is being used for primary or secondary prevention. Alternate-day or weekly dosing studies were also used to examine the impact of compliance on cost and health outcomes. Alternate-day dosing represented 50% compliance and weekly dosing 29% compliance. Less than full compliance had the expected effect of worse health outcomes and lower drug costs. However, the studies were small and not designed as true pharmacoeconomic studies looking at the relationship between medication compliance and cost. The results of this review suggest that there needs to be further examination of the relationship between compliance with statins and cost effectiveness, and studies need to include compliance in their data collection and analysis.

A pharmacoeconomic evaluation of statins in the treatment of hypercholesterolaemia in the primary care setting in Spain

BACKGROUND

Cardiovascular disease is one of the leading causes of death and it has been shown that primary prevention with the HMG-CoA reductase inhibitor (statin) lipid-lowering drugs can reduce cardiovascular events. Acquisition costs vary between statins and this may be an important consideration in the overall cost effectiveness (CE) of different options.

OBJECTIVE

To perform a CE study of the main statins used in Spain for primary prevention of cardiovascular disease in patients with high cholesterol levels [corrected]

STUDY DESIGN

The CE analysis was based on an open-label, prospective, naturalistic, randomised intervention study under usual care conditions in primary care settings in patients with high cholesterol levels (total cholesterol [TC] >240 mg/dL, low-density lipoprotein cholesterol [LDL-C] >160 mg/dL) and one or more cardiovascular risk factors. The analysis was conducted from the perspective of the Spanish National Health System; the year of costing was 2001.

PATIENTS

A total of 161 patients (49.7% males), mean age 65 +/- 10.3 years, without evidence of cardiovascular disease were included in the study. Of those, 82.1% were hypertensive, 37.1% had diabetes mellitus and 17.9% were smokers.

INTERVENTIONS

Forty-eight patients received oral atorvastatin 10 mg/day, 32 received fluvastatin 40 mg/day, 44 received simvastatin 20 mg/day and 37 patients received pravastatin 20 mg/day for 6 months.

MAIN MEASUREMENTS AND RESULTS

After 6 months, the therapeutic goals of LDL-C control, according to the recommendations of the Spanish Society of Arteriosclerosis--Consensus-2000, were reached in 62.5%, 43.8%, 45.5% and 40.5% of patients treated with atorvastatin, fluvastatin, simvastatin and pravastatin, respectively. The average CE ratio, expressed as the cost in euros (euro) per patient achieving the therapeutic goals, was euros 424.3 for atorvastatin, euros 503.5 for fluvastatin, euros 527.0 for simvastatin and euros 683.4 for pravastatin. The incremental CE ratios for atorvastatin versus fluvastatin and simvastatin were euros 238.9 and euros 149.5, respectively, per additional patient reaching therapeutic goals. Atorvastatin, fluvastatin and simvastatin all dominated pravastatin.

CONCLUSIONS

All the statins studied have been shown to be effective for reducing both TC and LDL-C levels. In this study, atorvastatin was the most efficient drug, with the best CE ratio (cost per patient reaching therapeutic goals). Atorvastatin was more effective and less costly than pravastatin, and when compared with fluvastatin or simvastatin the additional cost per additional patient achieving therapeutic goals was <euros 250.

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

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

An economic evaluation of fluvastatin used for the prevention of cardiac events following successful first percutaneous coronary intervention in the UK

AIMS

To estimate the costs, benefits and cost effectiveness, from the UK NHS perspective, of fluvastatin (relative to no HMG-CoA reductase inhibitor [statin]) for the secondary prevention of major adverse cardiac events following a successful first percutaneous coronary intervention (PCI).

METHODS

A cost-effectiveness analysis was undertaken using efficacy data from the Lescol Intervention Prevention Study (LIPS). LIPS was a randomised, double-blind, placebo-controlled trial undertaken in 77 centres (predominantly in Europe). Patients included in the trial had moderate hypercholesterolaemia and had successfully undergone their first PCI. Fluvastatin (Lescol) 40 mg twice daily plus dietary counselling was given to the intervention group for up to 4 years; the control group received dietary counselling only. A Markov model was used to estimate the incremental costs per QALY gained over a 10-year period, with cost data drawn from the UK NHS (2002 values). Monte Carlo simulations and multivariate analysis were used to assess uncertainty. Costs were discounted at 6% per annum, and health outcomes at 1.5% per annum.

RESULTS

On average, treatment with fluvastatin cost an additional pound 300 (SD pound 303) [euro 423; SD euro 428] per patient and resulted in an additional 0.092 (SD 0.06) QALYs per patient over 10 years compared with controls. The incremental cost per QALY gained with fluvastatin versus the control group was pound 3207 (SD pound 5,497) [euro 4,527; SD euro 7,759]. Fluvastatin was dominant (better outcomes and lower costs) in 15.9% of the simulations and was dominated in 2.9%. The key determinants of cost effectiveness were: the effectiveness of fluvastatin in reducing acute myocardial infarction, subsequent PCI, coronary artery bypass graft and cardiac deaths; the utility weight associated with a subsequent post-PCI state; the cost of fluvastatin; and the time horizon evaluated.

CONCLUSIONS

Fluvastatin is the only statin which has proven effective in preventing major coronary adverse events in new PCI patients; other statins lack this evidence. This Markov model, with its underlying assumptions and data, suggests that fluvastatin is a viable and economically efficient pharmaceutical (relative to no statin) to reduce heart disease in the UK when given routinely to all patients following PCI.

Potential cost-effectiveness of C-reactive protein screening followed by targeted statin therapy for the primary prevention of cardiovascular disease among patients without overt hyperlipidemia

BACKGROUND

Evidence suggests that statin therapy reduces the rate of cardiovascular events among patients with low lipid levels but elevated C-reactive protein levels. However, no cost-effectiveness analyses have been performed to assist in determining whether large-scale randomized trials are merited to test this hypothesis.

METHODS

We used a Markov model to estimate the benefits, costs, and incremental cost-effectiveness of C-reactive protein screening followed by targeted statin therapy for elevated C-reactive protein levels, compared with dietary counseling alone, for the primary prevention of cardiovascular events among patients with low-density lipoprotein cholesterol levels <149 mg/dL. All costs were in 2000 U.S. dollars.

RESULTS

The potential incremental cost-effectiveness ratio for screening followed by statin therapy compared with no screening and no statin therapy was $48,100 per quality-adjusted life-year (QALY) for 58-year-old men and $94,400 per QALY for 58-year-old women. Screening was most cost-effective for 65-year-old men ($42,600 per QALY) and least cost-effective for 35-year-old women ($207,300 per QALY). Our results were most sensitive to the baseline risk of coronary heart disease, the cost of statin therapy, and the efficacy of statin therapy for preventing myocardial infarction in patients with high C-reactive protein levels. If a 58-year-old man who smokes and is hypertensive was considered, screening for C-reactive protein followed by statin therapy would be cost saving if the cost of statin therapy was reduced to $500 per year. If the cost of statin therapy was reduced to $1 per day, the cost-effectiveness of screening would be $4900 per QALY for 58-year-old men and $19,600 per QALY for women of the same age. If the costs associated with elective revascularization (percutaneous coronary intervention or coronary artery bypass surgery) were included in the base case analyses, the incremental cost-effectiveness ratios for screening would be $40,100 per QALY for 58-year-old men and $87,300 per QALY for women.

CONCLUSION

A strategy involving C-reactive protein screening to target statin therapy for the primary prevention of cardiovascular disease among middle-aged patients without overt hyperlipidemia could be relatively cost-effective and, in some cases, cost saving.

Treatment of patients with lipid disorders in the primary care setting: new treatment guidelines and their implications

Coronary heart disease (CHD) remains a major cause of morbidity and mortality throughout North America. The role played by lipid abnormalities is now well established, and primary care physicians can play a major role in reversing the increasing prevalence of CHD by following the recommended guidelines of the National Cholesterol Expert Panel (NCEP ATP-III). While many physicians are aware of the importance of lowering lipid levels, a large number of patients still fail to reach their treatment goals. It is therefore important to identify patients at risk of developing coronary events due to abnormal lipid profiles and to quickly implement effective prevention programs. Although diet and other lifestyle modifications should form the basis of lipid management, the addition of lipid-modifying drugs is often necessary. Several lipid-modifying agents are available, but the proven efficacy and good tolerability of statins has increasingly made them the drugs of choice.

A pharmacoeconomic evaluation of the Myocardial Ischaemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study in the United Kingdom

OBJECTIVE

To determine the short-term healthcare costs associated with intensive lipid lowering with atorvastatin initiated within 24-96 hours of the occurrence of acute coronary syndrome (ACS) in patients in the UK.

METHODS

Patient-level clinical outcome data from the Myocardial Ischaemia Reduction with Aggressive Cholesterol Lowering (MIRACL) trial and standard cost data were used to compare the total expected 16-week cost per patient on atorvastatin 80 mg/day versus placebo. Clinical outcomes assessed included the following: death; cardiac arrest with resuscitation; nonfatal myocardial infarction; worsening angina pectoris with objective evidence of myocardial ischaemia requiring rehospitalisation; surgical or percutaneous coronary revascularisation; nonfatal stroke; hospitalisation for angina without objective evidence of myocardial ischaemia; and new or worsening congestive heart failure requiring rehospitalisation. All relevant direct medical costs from the perspective of the NHS were considered.

RESULTS

The total expected cost was pound 784.05 per patient in the placebo cohort and pound 851.59 per patient in the atorvastatin cohort, resulting in an incremental cost of pound 67.54 per patient in the atorvastatin group. The cost per event avoided was pound 1762.04. A third of the cost of atorvastatin treatment was offset within 16 weeks by the cost savings resulting from the reduction in the number of events in the atorvastatin cohort compared with the placebo cohort.

CONCLUSION

The clinical benefits of short-term intensive atorvastatin treatment administered after ACS is attainable through a marginal increase in 'upfront' costs.

Do HEDIS measures reflect cost-effective practices?

PURPOSE

Whether the Health Plan Employer Data and Information Set (HEDIS) performance measures for managed care plans encourage a cost-effective use of society's resources has not been quantified. Our study objectives were to examine the cost-effectiveness evidence for the clinical practices underlying HEDIS 2000 measures and to develop a list of practices not reflected in HEDIS that have evidence of cost effectiveness.

DATA SOURCES

Two databases of economic evaluations (Harvard School of Public Health Cost-Utility Registry and the Health Economics Evaluation Database) and two published lists of cost-effectiveness ratios in health and medicine.

STUDY SELECTION

For each of the 15 "effectiveness of care" measures in HEDIS 2000, we searched the data through 1998 for cost-effectiveness ratios of similar interventions and target populations. We also searched for important interventions with evidence of cost-effectiveness (<$20,000 per life-year [LY] or quality-adjusted life year [QALY] gained), which are not included in HEDIS. All ratios were standardized to 1998 dollars. The data were collected and analyzed during fall 2000 to summer 2001.

DATA EXTRACTION

Cost-effectiveness ratios reporting outcomes in terms of cost/LY or cost/QALY gained were included if they matched the intervention and population covered by the HEDIS measure.

DATA SYNTHESIS

Evidence was available for 11 of the 15 HEDIS measures. Cost-effectiveness ranges from cost saving to $660,000/LY gained. There are numerous non-HEDIS interventions with some evidence of cost effectiveness, particularly interventions to promote healthy behaviors.

CONCLUSIONS

HEDIS measures generally reflect cost-effective practices; however, in a number of cases, practices may not be cost effective for certain subgroups. Data quality and availability as well as study perspective remain key challenges in judging cost effectiveness. Opportunities exist to refine existing measures and to develop additional measures, which may promote a more efficient use of societal resources, although more research is needed on whether these measures would also satisfy other desirable attributes of HEDIS.

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

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

CONCLUSION

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

Treatment with atorvastatin to the National Cholesterol Educational Program goal versus 'usual' care in secondary coronary heart disease prevention. The GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) study

BACKGROUND

Atorvastatin is very effective in reducing plasma low-density lipoprotein cholesterol (LDL-C) levels. However, there is no long-term survival study that evaluated this statin.

PATIENTS-METHODS

To assess the effect of atorvastatin on morbidity and mortality (total and coronary) of patients with established coronary heart disease (CHD), 1600 consecutive patients were randomised either to atorvastatin or to 'usual' medical care. The dose of atorvastatin was titrated from 10 to 80 mg/day, in order to reach the National Cholesterol Education Program (NCEP) goal of LDL-C <100 mg/dl (2.6 mmol/l). All patients were followed up for a mean period of 3 years.

MAIN OUTCOME MEASURES

Primary endpoints of the study were defined as death, non-fatal myocardial infarction, unstable angina, congestive heart failure, revascularisation (coronary morbidity) and stroke. Secondary endpoints were the safety and efficacy of the hypolipidaemic drugs as well as the cost-effectiveness of atorvastatin.

RESULTS

The mean dosage of atorvastatin was 24 mg/day. This statin reduced total chlesterol by 36%, LDL-C by 46%, triglycerides by 31%, and non-high-density lipoprotein cholesterol (non-HDL-C) by 44%, while it increased HDL-C by 7%; all these changes were significant. The NCEP LDL-C and non-HDL-C treatment goals were reached by 95% (n = 759) and 97% (n = 776), respectively, of patients on atorvastatin. Only 14% of the 'usual' care patients received any hypolipidaemic drugs throughout the study and 3% of them reached the NCEP LDL-C treatment goal. The cost per quaility-adjusted life-year gained with atorvastatin was estimated at $US 8350. During this study 196 (24.5%) CHD patients on 'usual' care had a CHD recurrent event or died vs. 96 (12%) CHD patients on atorvastatin; risk ratio (RR) 0.49, confidence interval (CI) 0.27-0.73, p < 0.0001. In detail, atorvastatin reduced, in comparison to 'usual' care, total mortality (RR 0.57, CI 0.39-0.78, p = 0.0021), coronary mortality (RR 0.53, CI 0.29-0.74, p = 0.0017), coronary morbidity (RR 0.46, CI 0.25-0.71, p < 0.0001), and stroke (RR 0.53, CI 0.30-0.82, p = 0.034). All subgroups of patients (women, those with diabetes mellitus, arterial hypertension, age 60 to 75 years, congestive heart failure, recent unstable angina or prior revascularisation) benefited from treatment with atorvastatin. Withdrawal of patients because of side-effects from the atorvastatin group was low (0.75%) and similar to that of the 'usual' care group (0.4%).

CONCLUSIONS

Long-term treatment of CHD patients with atorvastatin to achieve NCEP lipid targets significantly reduces total and coronary mortality, coronary morbidity and stroke, in comparison to patients receiving 'usual' medical care. Treatment with atorvastatin is well tolerated and cost-effective.

Development of predictive models for long-term cardiovascular risk associated with systolic and diastolic blood pressure

Most existing risk prediction models have not considered the joint contribution of systolic and diastolic blood pressure to cardiovascular risk, and some suggest that there are thresholds below which further reductions of blood pressure yield no additional benefit. We developed multivariate risk prediction models that quantify the risk associated with both systolic and diastolic blood pressure and that can be used to infer the benefits of antihypertensive therapy in populations. Two large clinical trial cohorts, the Physicians' Health Study, composed of 22 071 males (mean age, 53.2 years; median follow-up, 13.0 years), and the Women's Health Study, composed of 39 876 females (mean age, 53.8 years; median follow-up, 6.2 years), were used to develop gender-specific predictive models via Cox regression. End points included myocardial infarction, stroke, coronary artery bypass, angioplasty, and cardiovascular death. Risk reduction estimates were derived by computing reductions associated with incremental lowering of systolic and diastolic blood pressures. In both populations, lower levels of blood pressure predicted lower event rates, with no evidence of a plateau or a J-shaped curve. In males, both systolic and diastolic blood pressures were significantly associated with events (P<0.001), whereas in females, only systolic blood pressure (P<0.001) predicted outcome after multivariate adjustment. Correction for measurement error in blood pressure increased risk estimates by approximately 50%. Differences in systolic blood pressure yielded greater relative risk reductions than did differences in diastolic blood pressure in a combined population of males and females. These predictive models may be useful for risk estimation associated with hypertension in similar populations and may also be used to infer the benefits of antihypertensive therapy.

Atorvastatin

Atorvastatin (Lipitor, Pfizer) is a safe and effective 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase inhibitor (statin). It is the most potent currently available statin in terms of lowering low-density lipoprotein (LDL) and total cholesterol levels. It was the first statin shown to lower triglycerides in patients with isolated hypertriglyceridaemia. It has a good safety profile. In common with other statins, it has non-lipid-lowering effects including improving endothelial function, antiproliferative actions on smooth muscle and reducing platelet aggregation. It also has anti-inflammatory effects and may reduce plasma glucose levels. Clinical trial evidence with this statin is currently limited. It did slightly reduce events in the AVERT trial comparing patients receiving coronary angioplasty with those receiving high-dose atorvastatin therapy and in the MIRACL study reduced ischemia in patients with acute coronary syndromes. Other end point trials are in progress.

[Cost-effectiveness of atorvastatin against simvastatin as hypolipemic treatment in hypercholesterolemic patients in primary care]

OBJECTIVE

To perform an economics evaluation of lipid-lowering therapy with atorvastatin and simvastatin in patients with hypercholesterolemia in primary care setting.

DESIGN

Cost-effectiveness analysis (CEA) has been carried out by means of an open, random, prospective, "real world" study, with hypercholesterolemic patients (total cholesterol [TC] > 240 mg/dl and cLDL > 160 mg/dl).

PATIENTS

A total of 92 patients were included (44.8% males), with a mean age of 64.9 +/- 9.4 years old (mean +/- standard deviation). 41.4% were diabetics, 62.1% hypertensives and 16.1% smokers.

INTERVENTIONS

Patients were allocated to simvastatin 20 mg/day (44) and atorvastatin. 10 mg/day (48) for 6 months. ASSESSMENT AND MAIN RESULTS: Both therapies reduced significantly cLDL, TC and triglycerides at the end of the study. Atorvastatin reduced lipids faster than simvastatin at 3 months (p < 0.05), but significant differences could not be observed at 6 months. Atorvastatin reduced cLDL levels by 21.5 +/- 13.2% and 23.8 +/- 13.9% at 3 and 6 months, respectively, versus 16.4 +/- 14.2% and 22.8 +/- 10.8% with simvastatin. By these reductions, 54.2% of patients treated with atorvastatin and 50.0% of those allocated to simvastatin reached therapeutic goals of cLDL control. Atorvastatin 10 mg was more cost-effective than simvastatin 20 mg; 95,406 versus 101,335 pts per patient reaching therapeutic goals, respectively, which means that simvastatin need an extra cost of 24,833 pts per patient reaching therapeutic goals to be as efficient as atorvastatin. Sensitivity analysis to control for uncertainty confirmed the results of cost-effectiveness analysis.

CONCLUSIONS

Both statins were effective as lipid-lowering agents. However, atorvastatin 10 mg was more efficient than simvastatin 20 mg due to a better cost-effectiveness ratio.

If LDL-C is the answer...what was the question? What do the data really show?

The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors are frequently utilized in the treatment of hypercholesterolemia. With recently completed statin clinical cardiovascular outcomes data available, the purpose of this review is to analyze the relative benefits of each molecule and to determine whether "lower is better" is a correct hypothesis for secondary prevention. Twenty-one clinical studies, each with a duration of statin therapy of 6 months or longer, were reviewed, and the pharmacologic effects of these agents on cardiovascular outcomes was examined. As evaluated by study drug, statistical event reduction was achieved in seven of nine pravastatin studies, one of three simvastatin studies, one of six lovastatin studies, zero of two fluvastatin studies, and zero of one atorvastatin study. Pravastatin was the only statin proven statistically to reduce events in both primary and secondary prevention. Thus, all of the statins do not appear to be the same in terms of their ability to reduce cardiovascular events. Until head-to-head trials have been completed, these clinical outcomes data suggest that in patients with severe hypercholesterolemia who require high-dose statin therapy, simvastatin 80 mg each evening would appear to be the agent of choice. However, pravastatin 40 mg daily at bedtime appears to be a unique molecule, with the strongest evidence for event reduction in the majority of patients with moderate hypercholesterolemia with, or who are at risk for, coronary heart disease.

Cost per millimeter of mercury lowering is a measure of economic value for antihypertensive agents

The use of pharmacoeconomic analyses to evaluate the appropriateness of treatment regimens is increasing rapidly. Trials that study the efficacy of antihypertensive agents do not often measure long-term cardiovascular morbidity and mortality, so complementary methods are needed to evaluate the cost-effectiveness of these agents. One method is to compare agents on the basis of their costs and blood pressure-lowering efficacy, producing a ratio of cost per millimeter of mercury lowering, or cost/mm Hg. This provides a simple, transparent method with which to evaluate the cost-effectiveness of antihypertensive agents. It also allows the cost-effectiveness of a blood pressure treatment to be assessed in terms of ambulatory blood pressure data. The use of cost/mm Hg requires assumptions that tolerability of agents is comparable and that blood pressure lowering is a valid surrogate for cardiovascular risk reduction. Given the emergence of new treatments that have differences in blood pressure efficacy, cost/mm Hg is likely to become increasingly used as an indicator of economic value.

Cost-effectiveness of statins

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

Debate: at what level of coronary heart disease risk should a statin be prescribed?

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are effective treatments for the primary and secondary prevention of coronary heart disease, but an outstanding issue is determining who should have such treatment. The benefit from treatment with statins appears to be proportional to the underlying risk of coronary heart disease and independent of the factors increasing risk. Most benefit will therefore be achieved by treating people at increased risk of coronary heart disease. Statins reduce coronary morbidity even when the risk of coronary heart disease is relatively low (6% over 10 years), but reduction in all-cause mortality, the true measure of safety has been shown only when the risk of a major coronary heart disease event is 15% over 10 years or greater. At this level of risk patients appear willing to take treatment to gain the benefit expected from statin treatment, and the cost effectiveness of statin treatment is within the range accepted for other treatments. The major impediments to the systematic introduction of statin treatment at this level of risk are the very high overall cost and the large workload in countries like Britain, where the population risk of coronary heart disease is high. For this reason, recent British guidelines correctly advise statin treatment for secondary prevention and primary prevention when the 10 year coronary heart disease risk is 30% or greater as the first priority, moving to a lower coronary heart disease threshold for primary prevention only when resources permit.

Benefits of lipid-lowering agents in stroke and coronary heart disease: pharmacoeconomics

Coronary heart disease remains the leading cause of death in the United States. Although coronary heart disease and stroke entail very expensive therapies and extensive hospital utilization, the cost of preventive measures is also quite expensive. In this review, the factors that determine the cost-effectiveness of statin therapy for the primary and secondary prevention of coronary heart disease are discussed. A risk-based strategy for the selection of patients seems to provide cost-effective utilization of this potent treatment strategy. Appropriate patient selection should be accompanied by aggressive measures to improve utilization and compliance through improved physician and patient education.

Cost-effectiveness of stress-echocardiography

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