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Guthrie B, Rogers G, Livingstone S, Morales DR, Donnan P, Davis S, Youn JH, Hainsworth R, Thompson A, Payne K. The implications of competing risks and direct treatment disutility in cardiovascular disease and osteoporotic fracture: risk prediction and cost effectiveness analysis. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-275. [PMID: 38420962 DOI: 10.3310/kltr7714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Background Clinical guidelines commonly recommend preventative treatments for people above a risk threshold. Therefore, decision-makers must have faith in risk prediction tools and model-based cost-effectiveness analyses for people at different levels of risk. Two problems that arise are inadequate handling of competing risks of death and failing to account for direct treatment disutility (i.e. the hassle of taking treatments). We explored these issues using two case studies: primary prevention of cardiovascular disease using statins and osteoporotic fracture using bisphosphonates. Objectives Externally validate three risk prediction tools [QRISK®3, QRISK®-Lifetime, QFracture-2012 (ClinRisk Ltd, Leeds, UK)]; derive and internally validate new risk prediction tools for cardiovascular disease [competing mortality risk model with Charlson Comorbidity Index (CRISK-CCI)] and fracture (CFracture), accounting for competing-cause death; quantify direct treatment disutility for statins and bisphosphonates; and examine the effect of competing risks and direct treatment disutility on the cost-effectiveness of preventative treatments. Design, participants, main outcome measures, data sources Discrimination and calibration of risk prediction models (Clinical Practice Research Datalink participants: aged 25-84 years for cardiovascular disease and aged 30-99 years for fractures); direct treatment disutility was elicited in online stated-preference surveys (people with/people without experience of statins/bisphosphonates); costs and quality-adjusted life-years were determined from decision-analytic modelling (updated models used in National Institute for Health and Care Excellence decision-making). Results CRISK-CCI has excellent discrimination, similar to that of QRISK3 (Harrell's c = 0.864 vs. 0.865, respectively, for women; and 0.819 vs. 0.834, respectively, for men). CRISK-CCI has systematically better calibration, although both models overpredict in high-risk subgroups. People recommended for treatment (10-year risk of ≥ 10%) are younger when using QRISK-Lifetime than when using QRISK3, and have fewer observed events in a 10-year follow-up (4.0% vs. 11.9%, respectively, for women; and 4.3% vs. 10.8%, respectively, for men). QFracture-2012 underpredicts fractures, owing to under-ascertainment of events in its derivation. However, there is major overprediction among people aged 85-99 years and/or with multiple long-term conditions. CFracture is better calibrated, although it also overpredicts among older people. In a time trade-off exercise (n = 879), statins exhibited direct treatment disutility of 0.034; for bisphosphonates, it was greater, at 0.067. Inconvenience also influenced preferences in best-worst scaling (n = 631). Updated cost-effectiveness analysis generates more quality-adjusted life-years among people with below-average cardiovascular risk and fewer among people with above-average risk. If people experience disutility when taking statins, the cardiovascular risk threshold at which benefits outweigh harms rises with age (≥ 8% 10-year risk at 40 years of age; ≥ 38% 10-year risk at 80 years of age). Assuming that everyone experiences population-average direct treatment disutility with oral bisphosphonates, treatment is net harmful at all levels of risk. Limitations Treating data as missing at random is a strong assumption in risk prediction model derivation. Disentangling the effect of statins from secular trends in cardiovascular disease in the previous two decades is challenging. Validating lifetime risk prediction is impossible without using very historical data. Respondents to our stated-preference survey may not be representative of the population. There is no consensus on which direct treatment disutilities should be used for cost-effectiveness analyses. Not all the inputs to the cost-effectiveness models could be updated. Conclusions Ignoring competing mortality in risk prediction overestimates the risk of cardiovascular events and fracture, especially among older people and those with multimorbidity. Adjustment for competing risk does not meaningfully alter cost-effectiveness of these preventative interventions, but direct treatment disutility is measurable and has the potential to alter the balance of benefits and harms. We argue that this is best addressed in individual-level shared decision-making. Study registration This study is registered as PROSPERO CRD42021249959. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/12/22) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 4. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Bruce Guthrie
- Advanced Care Research Centre, Centre for Population Health Sciences, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Gabriel Rogers
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Shona Livingstone
- Population Health and Genomics Division, University of Dundee, Dundee, UK
| | - Daniel R Morales
- Population Health and Genomics Division, University of Dundee, Dundee, UK
| | - Peter Donnan
- Population Health and Genomics Division, University of Dundee, Dundee, UK
| | - Sarah Davis
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | - Rob Hainsworth
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Alexander Thompson
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
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Thompson A, Youn JH, Guthrie B, Hainsworth R, Donnan P, Rogers G, Morales D, Payne K. Quantifying the impact of taking medicines for primary prevention: a time-trade off study to elicit direct treatment disutility in the UK. BMJ Open 2023; 13:e063800. [PMID: 37734893 PMCID: PMC10514632 DOI: 10.1136/bmjopen-2022-063800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/03/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Direct treatment disutility (DTD) represents an individual's disutility associated with the inconvenience of taking medicine over a long period of time. OBJECTIVES The main aim of this study was to elicit DTD values for taking a statin or a bisphosphonate for primary prevention. A secondary aim was to understand factors which influence DTD values. METHODS Design: We used a cross-sectional study consisting of time-trade off exercises embedded within online surveys. Respondents were asked to compare a one-off pill ('Medicine A') assumed to have no inconvenience and a daily pill ('Medicine B') over 10 years (statins) or 5 years (bisphosphonates).Setting: Individuals from National Health Service (NHS) primary care and the general population were surveyed using an online panel company.Participants: Two types of participants were recruited. First, a purposive sample of patients with experience of taking a statin (n=260) or bisphosphonate (n=100) were recruited from an NHS sampling frame. Patients needed to be aged over 30, have experience of taking the medicine of interest and have no diagnosis of dementia or of using dementia drugs. Second, a demographically balanced sample of members of the public were recruited for statins (n=376) and bisphosphonates (n=359).Primary and secondary outcome measures: Primary outcome was mean DTD. Regression analysis explored factors which could influence DTD values. RESULTS A total of 879 respondents were included for analysis (514 for statins and 365 for bisphosphonates). The majority of respondents reported a disutility associated with medicine use. Mean DTD for statins was 0.034 and for bisphosphonates 0.067, respectively. Respondent characteristics including age and sex did not influence DTD. Experience of bisphosphonate-use reduced reported disutilities. CONCLUSIONS Statins and bisphosphonates have a quantifiable DTD. The size of estimated disutilities suggest they are likely to be important for cost-effectiveness, particularly in individuals at low-risk when treated for primary prevention.
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Affiliation(s)
- Alexander Thompson
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Ji-Hee Youn
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Advanced Care Research Centre, University of Edinburgh, Edinburgh, UK
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Robert Hainsworth
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Peter Donnan
- Dundee Epidemiology and Biostatistics Unit, University of Dundee, Dundee, UK
| | - Gabriel Rogers
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Daniel Morales
- Division of Population Health Sciences, University of Dundee, Dundee, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
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van den Broek WWA, van Paassen JG, Gimbel ME, Deneer VHM, ten Berg JM, Vreman RA. Cost-effectiveness of clopidogrel vs. ticagrelor in patients of 70 years or older with non-ST-elevation acute coronary syndrome. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 9:76-84. [PMID: 35723240 PMCID: PMC9753095 DOI: 10.1093/ehjcvp/pvac037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/13/2022] [Accepted: 06/15/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The POPular AGE trial showed that clopidogrel significantly reduced bleeding risk compared with ticagrelor without any signs of an increase in thrombotic events. The aim of this analysis was to estimate the long-term cost-effectiveness of clopidogrel compared with ticagrelor in these patients aged 70 years or older with non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS AND RESULTS A 1-year decision tree based on the POPular AGE trial in combination with a lifelong Markov model was developed to compare clopidogrel with ticagrelor in terms of clinical outcomes, costs, and quality-adjusted life years (QALYs) in elderly patients (above 70 year) with NSTE-ACS. Cost-effectiveness was assessed from a Dutch healthcare system perspective. Events rates and utility data observed in the POPular AGE trial were combined with lifetime projections to evaluate costs and effects for a fictional cohort of 1000 patients. Treatment with clopidogrel instead of ticagrelor led to a cost saving of €1484 575 (€1485 per patient) and a decrease of 10.96 QALYs (0.011 QALY per patient) in the fictional cohort. In an alternative base case with equal distribution over health states in the first year, treatment with clopidogrel led to an increase in QALYs. In all scenario analyses, treatment with clopidogrel was cost-saving. CONCLUSION Clopidogrel is a cost-saving alternative to ticagrelor in elderly patients after NSTE-ACS, though regarding overall cost-effectiveness clopidogrel was not superior to ticagrelor, as it resulted in a small negative effect on QALYs. However, based on the results of the alternative base case and clinical outcomes of the POPular AGE trial, clopidogrel could be a reasonable alternative to ticagrelor for elderly NSTE-ACS patients with a higher bleeding risk.
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Affiliation(s)
- Wout W A van den Broek
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Jacqueline G van Paassen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, The Netherlands
| | - Marieke E Gimbel
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Vera H M Deneer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, The Netherlands,Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Centre Utrecht, Heidelberglaan 8, 3584 CS, Utrecht, The Netherlands
| | - Jurriën M ten Berg
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
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Kohli-Lynch CN, Lewsey J, Boyd KA, French DD, Jordan N, Moran AE, Sattar N, Preiss D, Briggs AH. Beyond Ten-Year Risk: A Cost-Effectiveness Analysis of Statins for the Primary Prevention of Cardiovascular Disease. Circulation 2022; 145:1312-1323. [PMID: 35249370 PMCID: PMC9022692 DOI: 10.1161/circulationaha.121.057631] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Cholesterol guidelines typically prioritize primary prevention statin therapy on the basis of 10-year risk of cardiovascular disease. The advent of generic pricing may justify expansion of statin eligibility. Moreover, 10-year risk may not be the optimal approach for statin prioritization. We estimated the cost-effectiveness of expanding preventive statin eligibility and evaluated novel approaches to prioritization from a Scottish health sector perspective.
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Affiliation(s)
- Ciaran N Kohli-Lynch
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois; Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - James Lewsey
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - Kathleen A Boyd
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - Dustin D French
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois; Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Chicago, Illinois; Department of Ophthalmology and Medical Social Science, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Neil Jordan
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois; Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Chicago, Illinois; Departments of Psychiatry & Behavioral Sciences and Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew E Moran
- Division of General Medicine, Columbia University Irving Medical Center, New York City, New York
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - David Preiss
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Andrew H Briggs
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Kohli-Lynch CN, Bellows BK, Zhang Y, Spring B, Kazi DS, Pletcher MJ, Vittinghoff E, Allen NB, Moran AE. Cost-Effectiveness of Lipid-Lowering Treatments in Young Adults. J Am Coll Cardiol 2021; 78:1954-1964. [PMID: 34763772 DOI: 10.1016/j.jacc.2021.08.065] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/09/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Raised low-density lipoprotein cholesterol (LDL-C) in young adulthood (aged 18-39 years) is associated with atherosclerotic cardiovascular disease (ASCVD) later in life. Most young adults with elevated LDL-C do not currently receive lipid-lowering treatment. OBJECTIVES This study aimed to estimate the prevalence of elevated LDL-C in ASCVD-free U.S. young adults and the cost-effectiveness of lipid-lowering strategies for raised LDL-C in young adulthood compared with standard care. METHODS The prevalence of raised LDL-C was examined in the U.S. National Health and Nutrition Examination Survey. The CVD Policy Model projected lifetime quality-adjusted life years (QALYs), health care costs, and incremental cost-effectiveness ratios (ICERs) for lipid-lowering strategies. Standard care was statin treatment for adults aged ≥40 years based on LDL-C, ASCVD risk, or diabetes plus young adults with LDL-C ≥190 mg/dL. Lipid lowering incremental to standard care with moderate-intensity statins or intensive lifestyle interventions was simulated starting when young adult LDL-C was either ≥160 mg/dL or ≥130 mg/dL. RESULTS Approximately 27% of ASCVD-free young adults have LDL-C of ≥130 mg/dL, and 9% have LDL-C of ≥160 mg/dL. The model projected that young adult lipid lowering with statins or lifestyle interventions would prevent lifetime ASCVD events and increase QALYs compared with standard care. ICERs were US$31,000/QALY for statins in young adult men with LDL-C of ≥130 mg/dL and US$106,000/QALY for statins in young adult women with LDL-C of ≥130 mg/dL. Intensive lifestyle intervention was more costly and less effective than statin therapy. CONCLUSIONS Statin treatment for LDL-C of ≥130 mg/dL is highly cost-effective in young adult men and intermediately cost-effective in young adult women.
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Affiliation(s)
- Ciaran N Kohli-Lynch
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York, USA; Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois, USA; Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - Brandon K Bellows
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Yiyi Zhang
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Bonnie Spring
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dhruv S Kazi
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California-San Francisco School of Medicine, San Francisco, California, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California-San Francisco School of Medicine, San Francisco, California, USA
| | - Norrina B Allen
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Andrew E Moran
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York, USA.
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Petersohn S, Grimm SE, Ramaekers BLT, Ten Cate-Hoek AJ, Joore MA. Exploring the Feasibility of Comprehensive Uncertainty Assessment in Health Economic Modeling: A Case Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:983-994. [PMID: 34243842 DOI: 10.1016/j.jval.2021.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/04/2020] [Accepted: 01/06/2021] [Indexed: 05/22/2023]
Abstract
OBJECTIVES Decision makers adopt health technologies based on health economic models that are subject to uncertainty. In an ideal world, these models parameterize all uncertainties and reflect them in the cost-effectiveness probability and risk associated with the adoption. In practice, uncertainty assessment is often incomplete, potentially leading to suboptimal reimbursement recommendations and risk management. This study examines the feasibility of comprehensive uncertainty assessment in health economic models. METHODS A state transition model on peripheral arterial disease treatment was used as a case study. Uncertainties were identified and added to the probabilistic sensitivity analysis if possible. Parameter distributions were obtained by expert elicitation, and structural uncertainties were either parameterized or explored in scenario analyses, which were model averaged. RESULTS A truly comprehensive uncertainty assessment, parameterizing all uncertainty, could not be achieved. Expert elicitation informed 8 effectiveness, utility, and cost parameters. Uncertainties were parameterized or explored in scenario analyses and with model averaging. Barriers included time and resource constraints, also of clinical experts, and lacking guidance regarding some aspects of expert elicitation, evidence aggregation, and handling of structural uncertainty. The team's multidisciplinary expertise and existing literature and tools were facilitators. CONCLUSIONS While comprehensive uncertainty assessment may not be attainable, improvements in uncertainty assessment in general are no doubt desirable. This requires the development of detailed guidance and hands-on tutorials for methods of uncertainty assessment, in particular aspects of expert elicitation, evidence aggregation, and handling of structural uncertainty. The issue of benefits of uncertainty assessment versus time and resources needed remains unclear.
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Affiliation(s)
- Svenja Petersohn
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sabine E Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Bram L T Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Arina J Ten Cate-Hoek
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
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Robles-Zurita JA, Briggs A, Rana D, Quayyum Z, Oldroyd KG, Zeymer U, Desch S, de Waha-Thiele S, Thiele H. Economic evaluation of culprit lesion only PCI vs. immediate multivessel PCI in acute myocardial infarction complicated by cardiogenic shock: the CULPRIT-SHOCK trial. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1197-1209. [PMID: 33029668 PMCID: PMC7561561 DOI: 10.1007/s10198-020-01235-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/16/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The CULPRIT-SHOCK trial compared two treatment strategies for patients with acute myocardial infarction and multivessel coronary artery disease complicated by cardiogenic shock: (a) culprit vessel only percutaneous coronary intervention (CO-PCI), with additional staged revascularisation if indicated, and (b) immediate multivessel PCI (MV-PCI). METHODS A German societal and national health service perspective was considered for three different analyses. The cost utility analysis (CUA) estimated costs and quality adjusted life years (QALYs) based on a pre-trial decision analytic model taking a lifelong time horizon. In addition, a within trial CUA estimated QALYs and costs for 1 year. Finally, the cost effectiveness analysis (CEA) used the composite primary outcome, mortality and renal failure at 30-day follow-up, and the within trial costs. Econometric and survival analysis on the trial data was used for the estimation of the model parameters. Subgroup analysis was performed following an economic protocol. RESULTS The lifelong CUA showed an incremental cost effectiveness ratio (ICER), CO-PCI vs. MV-PCI, of €7010 per QALY and a probability of CO-PCI being the most cost-effective strategy > 64% at a €30,000 threshold. The ICER for the within trial CUA was €14,600 and the incremental cost per case of death/renal failure avoided at 30-day follow-up was €9010. Cost-effectiveness improved with patient age and for those without diabetes. CONCLUSIONS The estimates of cost-effectiveness for CO-PCI vs. MV-PCI have been shown to change depending on the time horizon and type of economic evaluation performed. The results favoured a long-term horizon analysis for avoiding underestimation of QALY gains from the CO-PCI arm.
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Affiliation(s)
- Jose Antonio Robles-Zurita
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Andrew Briggs
- London School of Hygiene & Tropical Medicine, London, UK
| | - Dikshyanta Rana
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Zahidul Quayyum
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Keith G Oldroyd
- West of Scotland Regional Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Uwe Zeymer
- Klinikum Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig, University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Suzanne de Waha-Thiele
- University Heart Center Lübeck, University Hospital Schleswig-Holstein (UKSH), Lübeck, Germany
| | - Holger Thiele
- Heart Center Leipzig, University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
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Petersohn S, Pouwels X, Ramaekers B, ten Cate-Hoek A, Joore M. Rivaroxaban plus aspirin for the prevention of ischaemic events in patients with cardiovascular disease: a cost-effectiveness study. Eur J Prev Cardiol 2020; 27:1354-1365. [PMID: 32223323 PMCID: PMC7457457 DOI: 10.1177/2047487320913380] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/26/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Dual pathway inhibition with 2.5 mg rivaroxaban twice daily plus 100 mg aspirin once daily may be a promising alternative to 100 mg aspirin antiplatelet therapy for the prevention of cardiovascular events in patients with coronary artery disease and/or peripheral arterial disease. However, treatment costs and bleeding risks are higher, and there is another treatment option for peripheral arterial disease, 75 mg clopidogrel. A comprehensive assessment of benefits, risks and costs of dual pathway inhibition versus standard of care is needed. METHODS We used a state transition model including cardiovascular, ischaemic limb and bleeding events to compare dual pathway inhibition to aspirin antiplatelet therapy in coronary artery disease, and additionally to clopidogrel antiplatelet therapy in peripheral arterial disease patients. We calculated the incremental cost-effectiveness ratio from costs and quality-adjusted life-years of lifelong treatment, and the cost-effectiveness probability at a €50,000/quality-adjusted life-year threshold. RESULTS Quality-adjusted life-years and costs of dual pathway inhibition were highest, the incremental cost-effectiveness ratios versus aspirin were €32,109 in coronary artery disease and €26,381 in peripheral arterial disease patients, with 92% and 56% cost-effectiveness probability, respectively (clopidogrel was extendedly dominated). Incremental cost-effectiveness ratios were below €20,000 in comorbid peripheral arterial disease patients and coronary artery disease patients younger than 65 years, incremental cost-effectiveness ratios were above €50,000 in carotid artery disease patients and coronary artery disease patients older than 75 years. CONCLUSION Lifelong preventive treatment of coronary artery disease and peripheral arterial disease patients at risk of cardiovascular events with dual pathway inhibition improves health outcomes and seems overall cost-effective relative to aspirin antiplatelet therapy and also to clopidogrel antiplatelet therapy for peripheral arterial disease, particularly in comorbid patients, but not in older patients and in carotid artery disease patients. These findings may warrant a targeted approach.
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Affiliation(s)
- Svenja Petersohn
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
| | - Xavier Pouwels
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
| | - Arina ten Cate-Hoek
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, The Netherlands
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
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Tran DT, Palfrey D, Lo TKT, Welsh R. Outcome and Cost of Optimal Control of Dyslipidemia in Adults With High Risk for Cardiovascular Disease. Can J Cardiol 2020; 37:66-76. [PMID: 32738207 DOI: 10.1016/j.cjca.2020.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/28/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND We assessed the impact of optimal dyslipidemia control on mortality and costs in adults at high risk for cardiovascular disease (HRCVD). METHODS We linked Alberta health databases to identify patients aged ≥ 18 years with HRCVD between April 2012 and March 2017. The first HRCVD event was considered the index event. Patients were categorized into (1) optimal control and (2) suboptimal control of dyslipidemia based on biomarkers and lipid-lowering therapy during the year post-index event. We measured the association between optimal dyslipidemia control and mortality and health care costs using difference-in-difference and propensity score-matching methods. RESULTS The study included 459,739 patients with HRCVD (43,776 [9.5%] optimal patients). The optimal patients were older (median age = 62 vs 55 years; P < 0.001), included fewer female patients (37.7% vs 52%; P < 0.001), and featured a higher proportion of secondary prevention patients (15.7% vs 1.7%; P < 0.001). Compared with suboptimal patients, the optimal patients had lower adjusted mortality (0.7% vs 1.9% at 1-year and 2.9% vs 5.1% at 3-year post-index event; both P < 0.001), and higher adjusted health care costs (CA$3758 and CA$6844 at 1-year and 3-year post-index event, respectively; both P < 0.001). Among the secondary prevention group, the optimal patients had lower adjusted mortality (2.4% and 5% absolute reduction at 1-year and 3-year post-index event, respectively; both P < 0.001) at no additional costs. The results were robust across 5 definitions of optimal dyslipidemia control. CONCLUSIONS Patients with optimal dyslipidemia control have lower mortality and incur modestly higher costs. However, secondary prevention patients experience lower mortality at no additional costs.
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Affiliation(s)
- Dat T Tran
- Institute of Health Economics, Edmonton, Alberta, Canada; Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada.
| | - Dan Palfrey
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - T K T Lo
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Robert Welsh
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
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10
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Kohli-Lynch CN, Bellows BK, Thanassoulis G, Zhang Y, Pletcher MJ, Vittinghoff E, Pencina MJ, Kazi D, Sniderman AD, Moran AE. Cost-effectiveness of Low-density Lipoprotein Cholesterol Level-Guided Statin Treatment in Patients With Borderline Cardiovascular Risk. JAMA Cardiol 2020; 4:969-977. [PMID: 31461121 DOI: 10.1001/jamacardio.2019.2851] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance American College of Cardiology/American Heart Association cholesterol guidelines prioritize primary prevention statin therapy based on 10-year absolute risk (AR10) of atherosclerotic cardiovascular disease (ASCVD). However, given the same AR10, patients with higher levels of low-density lipoprotein cholesterol (LDL-C) experience greater absolute risk reduction from statin therapy. Objectives To estimate the cost-effectiveness of expanding preventive statin treatment eligibility from standard care to patients at borderline risk (AR10, 5.0%-7.4%) for ASCVD and with high levels of LDL-C and to estimate cost-effectiveness of statin treatment across ranges of age, sex, AR10, and LDL-C levels. Design, Setting, and Participants This study evaluated 100 simulated cohorts, each including 1 million ASCVD-free survey respondents (50% men and 50% women) aged 40 years at baseline. Cohorts were created by probabilistic sampling of the 1999-2014 US National Health and Nutrition Examination Surveys from the perspective of the US health care sector. The CVD Policy Model microsimulation version projected lifetime health and cost outcomes. Probability of first-ever coronary heart disease or stroke event was estimated by analysis of 6 pooled US cohort studies and recalibrated to match contemporary event rates. Other model variables were derived from national surveys, meta-analyses, and published literature. Data were analyzed from May 15, 2018, through June 10, 2019. Exposures Four statin treatment strategies were compared: (1) treat all patients with AR10 of at least 7.5%, diabetes, or LDL-C of at least 190 mg/dL (standard care); (2) add treatment for borderline risk and LDL-C levels of 160 to 189 mg/dL; (3) add treatment for borderline risk and LDL-C levels of 130 to 159 mg/dL; and (4) add treatment for remainder of patients with AR10 of at least 5.0%. Statin treatment was also compared with no statin treatment in age, sex, AR10, and LDL-C strata. Main Outcomes and Measures Lifetime quality-adjusted life-years (QALYs) and costs (2019 US dollars) were projected and discounted 3.0% annually. The primary outcome was the incremental cost-effectiveness ratio. Results In these 100 simulated cohorts, each with 1 million patients aged 40 years at baseline (50% women and 50% men), adding preventive statins to individuals with borderline AR10 and LDL-C levels of 160 to 189 mg/dL would be cost-saving; further treating borderline AR10 and LDL-C levels of 130 to 159 mg/dL would also be cost-saving; and treating all individuals with AR10 of at least 5.0% would be highly cost-effective ($33 558/QALY) and would prevent the most ASCVD events. Within age, AR10, and sex categories, individuals with higher baseline LDL-C levels gained more QALYs from statin therapy. Cost-effectiveness increased with LDL-C level and AR10. Conclusions and Relevance In this study, lifetime statin treatment of patients in a hypothetical cohort with borderline ASCVD risk and LDL-C levels of 160 to 189 mg/dL was found to be cost-saving. Results suggest that treating all patients at borderline risk regardless of LDL-C level would likely be highly cost-effective.
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Affiliation(s)
- Ciaran N Kohli-Lynch
- Division of General Medicine, Columbia University Medical Center, New York, New York.,Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - Brandon K Bellows
- Division of General Medicine, Columbia University Medical Center, New York, New York
| | | | - Yiyi Zhang
- Division of General Medicine, Columbia University Medical Center, New York, New York
| | - Mark J Pletcher
- Department of Epidemiology & Biostatistics, University of California at San Francisco School of Medicine
| | - Eric Vittinghoff
- Department of Epidemiology & Biostatistics, University of California at San Francisco School of Medicine
| | | | - Dhruv Kazi
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Allan D Sniderman
- Division of Cardiology, McGill University, Quebec City, Quebec, Canada
| | - Andrew E Moran
- Division of General Medicine, Columbia University Medical Center, New York, New York
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11
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Impact of China's Low Centralized Medicine Procurement Prices on the Cost-Effectiveness of Statins for the Primary Prevention of Atherosclerotic Cardiovascular Disease. Glob Heart 2020; 15:43. [PMID: 32923337 PMCID: PMC7427664 DOI: 10.5334/gh.830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Statin medications reduce the risk of atherosclerotic cardiovascular disease (ASCVD). China’s new central government medicine procurement policy lowered statin prices by five-fold or more, which may impact the cost-effectiveness of statin therapy. Objective: To explore the impact of China’s 2019 centralized medicine procurement policy on the cost-effectiveness of statins treatment for primary ASCVD prevention. Methods: A microsimulation decision tree analytic model was built using individual participant data from ASCVD-free adults aged 35–64 years (n = 21,265) in the China Multi-provincial Cohort Study. ASCVD incidence, costs (2019 Int$), and quality-adjusted life years (QALYs) over a 10-year period from health-care sector and societal perspectives were estimated. Effect and cost-effectiveness of low-dose statins (equivalent potency regimens of simvastatin 20 mg/day, atorvastatin 10 mg/day, or rosuvastatin 5 mg/day) and moderate-dose (double low dose) statins therapy were simulated. The incremental cost-effectiveness ratio (ICER) of statin treatment was compared with no treatment by category of 10-year ASCVD risk. New lower prices of statins were from the centralized procurement policy bid-winning announcement file. One-way and probabilistic sensitivity analyses quantified model uncertainty. Results: Low-dose statins interventions reduced 10-year ASCVD incidence by 4.1%, 9.7%, and 15.5% among people with low, moderate, and high risk comparing to no treatment. Lowering statin prices to the 2019 central government procurement policy level could lower the ICER of low-dose statins treatment for high-risk people from Int$ 141,000 to Int$ 51,300 per QALY gained from health-care sector perspective. Moderate-dose statin treatment lowered the ICER compared with the low-dose statins treatment in each ASCVD risk category (Int$ 43,100 vs. Int$ 51,300 per QALY gained from the health-care sector perspective for high risk people). Cost-effectiveness improved progressively with increased baseline ASCVD risk. Conclusion: Implementing low central government prices will substantially improve the cost-effectiveness of statins for primary ASCVD prevention in 35–64-year-old Chinese adults.
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12
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Lagerweij GR, Brouwers L, De Wit GA, Moons K, Benschop L, Maas A, Franx A, Wermer M, Roeters van Lennep JE, van Rijn BB, Koffijberg H. Impact of preventive screening and lifestyle interventions in women with a history of preeclampsia: A micro-simulation study. Eur J Prev Cardiol 2020; 27:1389-1399. [PMID: 32054298 DOI: 10.1177/2047487319898021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Preeclampsia is a female-specific risk factor for the development of future cardiovascular disease. Whether early preventive cardiovascular disease risk screenings combined with risk-based lifestyle interventions in women with previous preeclampsia are beneficial and cost-effective is unknown. METHODS A micro-simulation model was developed to assess the life-long impact of preventive cardiovascular screening strategies initiated after women experienced preeclampsia during pregnancy. Screening was started at the age of 30 or 40 years and repeated every five years. Data (initial and follow-up) from women with a history of preeclampsia was used to calculate 10-year cardiovascular disease risk estimates according to Framingham Risk Score. An absolute risk threshold of 2% was evaluated for treatment selection, i.e. lifestyle interventions (e.g. increasing physical activity). Screening benefits were assessed in terms of costs and quality-adjusted-life-years, and incremental cost-effectiveness ratios compared with no screening. RESULTS Expected health outcomes for no screening are 27.35 quality-adjusted-life-years and increase to 27.43 quality-adjusted-life-years (screening at 30 years with 2% threshold). The expected costs for no screening are €9426 and around €13,881 for screening at 30 years (for a 2% threshold). Preventive screening at 40 years with a 2% threshold has the most favourable incremental cost-effectiveness ratio, i.e. €34,996/quality-adjusted-life-year, compared with other screening scenarios and no screening. CONCLUSIONS Early cardiovascular disease risk screening followed by risk-based lifestyle interventions may lead to small long-term health benefits in women with a history of preeclampsia. However, the cost-effectiveness of a lifelong cardiovascular prevention programme starting early after preeclampsia with risk-based lifestyle advice alone is relatively unfavourable. A combination of risk-based lifestyle advice plus medical therapy may be more beneficial.
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Affiliation(s)
- G R Lagerweij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands.,Netherlands Heart Institute, the Netherlands
| | - L Brouwers
- Netherlands Heart Institute, the Netherlands.,Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, the Netherlands
| | - G A De Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands.,Centre for Nutrition, Prevention and Healthcare, National Institute for Public Health and the Environment, the Netherlands
| | - Kgm Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - L Benschop
- Netherlands Heart Institute, the Netherlands.,Department of Obstetrics and Gynecology, Erasmus MC, the Netherlands
| | - Ahem Maas
- Department of Cardiology, Radboud University Medical Center, the Netherlands
| | - A Franx
- Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, the Netherlands
| | - Mjh Wermer
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | | | - B B van Rijn
- Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, the Netherlands
| | - H Koffijberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands.,Department of Health Technology and Services Research, University of Twente, the Netherlands
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13
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Berkelmans GFN, Greving JP, van der Graaf Y, Visseren FLJ, Dorresteijn JAN. Would treatment decisions about secondary prevention of CVD based on estimated lifetime benefit rather than 10-year risk reduction be cost-effective? Diagn Progn Res 2020; 4:4. [PMID: 32318625 PMCID: PMC7161238 DOI: 10.1186/s41512-020-00072-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/13/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To test the hypothesis that treatment decisions (treatment with a PCSK9-mAb versus no treatment) are both more effective and more cost-effective when based on estimated lifetime benefit than when based on estimated risk reduction over 10 years. METHODS A microsimulation model was constructed for 10,000 patients with stable cardiovascular disease (CVD). Costs and quality-adjusted life years (QALYs) due to recurrent cardiovascular events and (non)vascular death were estimated for lifetime benefit-based compared to 10-year risk-based treatment, with PCSK9 inhibition as an illustration example. Lifetime benefit in months gained and 10-year absolute risk reduction were estimated using the SMART-REACH model, including an individualized treatment effect of PCSK9 inhibitors based on baseline low-density lipoprotein cholesterol. For the different numbers of patients treated (i.e. the 5%, 10%, and 20% of patients with the highest estimated benefit of both strategies), cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER), indicating additional costs per QALY gain. RESULTS Lifetime benefit-based treatment of 5%, 10%, and 20% of patients with the highest estimated benefit resulted in an ICER of €36,440/QALY, €39,650/QALY, or €41,426/QALY. Ten-year risk-based treatment decisions of 5%, 10%, and 20% of patients with the highest estimated risk reduction resulted in an ICER of €48,187/QALY, €53,368/QALY, or €52,390/QALY. CONCLUSION Treatment decisions (treatment with a PCSK9-mAb versus no treatment) are both more effective and more cost-effective when based on estimated lifetime benefit than when based on estimated risk reduction over 10 years.
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Affiliation(s)
- Gijs F. N. Berkelmans
- grid.7692.a0000000090126352Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 Utrecht, GA The Netherlands
| | - Jacoba P. Greving
- grid.7692.a0000000090126352Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yolanda van der Graaf
- grid.7692.a0000000090126352Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L. J. Visseren
- grid.7692.a0000000090126352Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 Utrecht, GA The Netherlands
| | - Jannick A. N. Dorresteijn
- grid.7692.a0000000090126352Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 Utrecht, GA The Netherlands
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14
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van Schoonhoven AV, Gout-Zwart JJ, de Vries MJS, van Asselt ADI, Dvortsin E, Vemer P, van Boven JFM, Postma MJ. Costs of clinical events in type 2 diabetes mellitus patients in the Netherlands: A systematic review. PLoS One 2019; 14:e0221856. [PMID: 31490989 PMCID: PMC6730996 DOI: 10.1371/journal.pone.0221856] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 08/18/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is an established risk factor for cardiovascular and nephropathic events. In the Netherlands, prevalence of T2DM is expected to be as high as 8% by 2025. This will result in significant clinical and economic impact, highlighting the need for well-informed reimbursement decisions for new treatments. However, availability and consistent use of costing methodologies is limited. OBJECTIVE We aimed to systematically review recent costing data for T2DM-related cardiovascular and nephropathic events in the Netherlands. METHODS A systematic literature review in PubMed and Embase was conducted to identify available Dutch cost data for T2DM-related events, published in the last decade. Information extracted included costs, source, study population, and costing perspective. Finally, papers were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). RESULTS Out of initially 570 papers, 36 agreed with the inclusion criteria. From these studies, 150 cost estimates for T2DM-related clinical events were identified. In total, 29 cost estimates were reported for myocardial infarction (range: €196-€27,038), 61 for stroke (€495-€54,678), fifteen for heart failure (€325-€16,561), 24 for renal failure (€2,438-€91,503), and seventeen for revascularisation (€3,000-€37,071). Only four estimates for transient ischaemic attack were available, ranging from €587 to €2,470. Adherence to CHEERS was generally high. CONCLUSIONS The most expensive clinical events were related to renal failure, while TIA was the least expensive event. Generally, there was substantial variation in reported cost estimates for T2DM-related events. Costing of clinical events should be improved and preferably standardised, as accurate and consistent results in economic models are desired.
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Affiliation(s)
- Alexander V. van Schoonhoven
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Judith J. Gout-Zwart
- Asc Academics, Groningen, the Netherlands
- Department of Nephrology, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
| | - Marijke J. S. de Vries
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Antoinette D. I. van Asselt
- Department of Epidemiology, University Medical Centre Groningen, Groningen, the Netherlands
- Department of Health Sciences, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
| | | | - Pepijn Vemer
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Job F. M. van Boven
- Department of General Practice & Elderly Care, University of Groningen, University Medical Center Groningen (UMCG), Groningen, the Netherlands
- Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
| | - Maarten J. Postma
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
- Department of Health Sciences, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
- Department of Economics, Econometrics & Finance, University of Groningen, Faculty of Economics & Business, Groningen, The Netherlands
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15
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Rossello X, Dorresteijn JA, Janssen A, Lambrinou E, Scherrenberg M, Bonnefoy-Cudraz E, Cobain M, Piepoli MF, Visseren FL, Dendale P. Risk prediction tools in cardiovascular disease prevention: A report from the ESC Prevention of CVD Programme led by the European Association of Preventive Cardiology (EAPC) in collaboration with the Acute Cardiovascular Care Association (ACCA) and the Association of Cardiovascular Nursing and Allied Professions (ACNAP). EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:522-532. [PMID: 31303009 DOI: 10.1177/2048872619858285] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Risk assessment and risk prediction have become essential in the prevention of cardiovascular disease. Even though risk prediction tools are recommended in the European guidelines, they are not adequately implemented in clinical practice. Risk prediction tools are meant to estimate prognosis in an unbiased and reliable way and to provide objective information on outcome probabilities. They support informed treatment decisions about the initiation or adjustment of preventive medication. Risk prediction tools facilitate risk communication to the patient and their family, and this may increase commitment and motivation to improve their health. Over the years many risk algorithms have been developed to predict 10-year cardiovascular mortality or lifetime risk in different populations, such as in healthy individuals, patients with established cardiovascular disease and patients with diabetes mellitus. Each risk algorithm has its own limitations, so different algorithms should be used in different patient populations. Risk algorithms are made available for use in clinical practice by means of - usually interactive and online available - tools. To help the clinician to choose the right tool for the right patient, a summary of available tools is provided. When choosing a tool, physicians should consider medical history, geographical region, clinical guidelines and additional risk measures among other things. Currently, the U-prevent.com website is the only risk prediction tool providing prediction algorithms for all patient categories, and its implementation in clinical practice is suggested/advised by the European Association of Preventive Cardiology.
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Affiliation(s)
- Xavier Rossello
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Spain
| | | | - Arne Janssen
- Clinical Research Department Cardiology, Heartcentre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Ekaterini Lambrinou
- Clinical Research Department Cardiology, Heartcentre Hasselt, Jessa Hospital, Hasselt, Belgium.,Department of Nursing, Cyprus University of Technology, Cyprus
| | - Martijn Scherrenberg
- Jessa Hospital, Heartcentre Hasselt, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Belgium
| | | | - Mark Cobain
- Department of Cardiovascular Medicine, Imperial College, UK
| | - Massimo F Piepoli
- Heart Failure Unit, Cardiology, G da Saliceto Hospital, Italy, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Frank Lj Visseren
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Paul Dendale
- Jessa Hospital, Heartcentre Hasselt, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Belgium
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16
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Rossello X, Dorresteijn JA, Janssen A, Lambrinou E, Scherrenberg M, Bonnefoy-Cudraz E, Cobain M, Piepoli MF, Visseren FL, Dendale P, This Paper Is A Co-Publication Between European Journal Of Preventive Cardiology European Heart Journal Acute Cardiovascular Care And European Journal Of Cardiovascular Nursing. Risk prediction tools in cardiovascular disease prevention: A report from the ESC Prevention of CVD Programme led by the European Association of Preventive Cardiology (EAPC) in collaboration with the Acute Cardiovascular Care Association (ACCA) and the Association of Cardiovascular Nursing and Allied Professions (ACNAP). Eur J Prev Cardiol 2019; 26:1534-1544. [PMID: 31234648 DOI: 10.1177/2047487319846715] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Risk assessment have become essential in the prevention of cardiovascular disease. Even though risk prediction tools are recommended in the European guidelines, they are not adequately implemented in clinical practice. Risk prediction tools are meant to estimate prognosis in an unbiased and reliable way and to provide objective information on outcome probabilities. They support informed treatment decisions about the initiation or adjustment of preventive medication. Risk prediction tools facilitate risk communication to the patient and their family, and this may increase commitment and motivation to improve their health. Over the years many risk algorithms have been developed to predict 10-year cardiovascular mortality or lifetime risk in different populations, such as in healthy individuals, patients with established cardiovascular disease and patients with diabetes mellitus. Each risk algorithm has its own limitations, so different algorithms should be used in different patient populations. Risk algorithms are made available for use in clinical practice by means of - usually interactive and online available - tools. To help the clinician to choose the right tool for the right patient, a summary of available tools is provided. When choosing a tool, physicians should consider medical history, geographical region, clinical guidelines and additional risk measures among other things. Currently, the U-prevent.com website is the only risk prediction tool providing prediction algorithms for all patient categories, and its implementation in clinical practice is suggested/advised by the European Association of Preventive Cardiology.
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Affiliation(s)
- Xavier Rossello
- 1 Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,2 Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Spain
| | | | - Arne Janssen
- 4 Clinical Research Department Cardiology, Heartcentre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Ekaterini Lambrinou
- 4 Clinical Research Department Cardiology, Heartcentre Hasselt, Jessa Hospital, Hasselt, Belgium.,5 Department of Nursing, Cyprus University of Technology, Cyprus
| | - Martijn Scherrenberg
- 6 Jessa Hospital, Heartcentre Hasselt, Belgium.,7 Faculty of Medicine and Life Sciences, Hasselt University, Belgium
| | | | - Mark Cobain
- 9 Department of Cardiovascular Medicine, Imperial College, UK
| | - Massimo F Piepoli
- 10 Heart Failure Unit, Cardiology, G da Saliceto Hospital, ItalyKeck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Frank Lj Visseren
- 2 Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Paul Dendale
- 6 Jessa Hospital, Heartcentre Hasselt, Belgium.,7 Faculty of Medicine and Life Sciences, Hasselt University, Belgium
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17
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Rossello X, Dorresteijn JAN, Janssen A, Lambrinou E, Scherrenberg M, Bonnefoy-Cudraz E, Cobain M, Piepoli MF, Visseren FLJ, Dendale P. Risk prediction tools in cardiovascular disease prevention: A report from the ESC Prevention of CVD Programme led by the European Association of Preventive Cardiology (EAPC) in collaboration with the Acute Cardiovascular Care Association (ACCA) and the Association of Cardiovascular Nursing and Allied Professions (ACNAP). Eur J Cardiovasc Nurs 2019; 18:534-544. [DOI: 10.1177/1474515119856207] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Risk assessment and risk prediction have become essential in the prevention of cardiovascular disease. Even though risk prediction tools are recommended in the European guidelines, they are not adequately implemented in clinical practice. Risk prediction tools are meant to estimate prognosis in an unbiased and reliable way and to provide objective information on outcome probabilities. They support informed treatment decisions about the initiation or adjustment of preventive medication. Risk prediction tools facilitate risk communication to the patient and their family, and this may increase commitment and motivation to improve their health. Over the years many risk algorithms have been developed to predict 10-year cardiovascular mortality or lifetime risk in different populations, such as in healthy individuals, patients with established cardiovascular disease and patients with diabetes mellitus. Each risk algorithm has its own limitations, so different algorithms should be used in different patient populations. Risk algorithms are made available for use in clinical practice by means of – usually interactive and online available – tools. To help the clinician to choose the right tool for the right patient, a summary of available tools is provided. When choosing a tool, physicians should consider medical history, geographical region, clinical guidelines and additional risk measures among other things. Currently, the U-prevent.com website is the only risk prediction tool providing prediction algorithms for all patient categories, and its implementation in clinical practice is suggested/advised by the European Association of Preventive Cardiology.
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Affiliation(s)
- Xavier Rossello
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Spain
| | | | - Arne Janssen
- Clinical Research Department Cardiology, Heartcentre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Ekaterini Lambrinou
- Clinical Research Department Cardiology, Heartcentre Hasselt, Jessa Hospital, Hasselt, Belgium
- Department of Nursing, Cyprus University of Technology, Cyprus
| | - Martijn Scherrenberg
- Jessa Hospital, Heartcentre Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Belgium
| | | | - Mark Cobain
- Department of Cardiovascular Medicine, Imperial College, UK
| | - Massimo F Piepoli
- Heart Failure Unit, Cardiology, G da Saliceto Hospital, Italy, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Frank LJ Visseren
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Paul Dendale
- Jessa Hospital, Heartcentre Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Belgium
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Bennaghmouch N, de Veer AJWM, Mahmoodi BK, Jofre-Bonet M, Lip GYH, Bode K, Ten Berg JM. Economic evaluation of the use of non-vitamin K oral anticoagulants in patients with atrial fibrillation on antiplatelet therapy: a modelling analysis using the healthcare system in the Netherlands. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 5:127-135. [PMID: 30016398 DOI: 10.1093/ehjqcco/qcy030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 05/20/2018] [Accepted: 07/10/2018] [Indexed: 01/02/2023]
Abstract
AIMS Non-vitamin K oral anticoagulants (NOACs) have consistently demonstrated superior efficacy in terms of stroke prevention and safety in terms of bleeding over vitamin K antagonist (VKA) in patients with non-valvular atrial fibrillation (AF). The potential use of NOACs in AF patients requiring antiplatelet therapy (APT) has only been assessed in small meta-analyses reporting consistent benefits of NOACs over VKAs. However, the prescription costs of NOACs are higher than those of VKAs. The aim of his study was to estimate the cost-effectiveness (CE) of NOACs compared to VKAs in patients with non-valvular AF also requiring APT with the Dutch healthcare system used as a surrogate of many European healthcare systems. METHODS AND RESULTS A decision tree was constructed to analyse the CE of NOACs compared to VKAs in patients with non-valvular AF with an indication for APT over a horizon of 1 year. Beside the base-case analysis, univariate probabilistic sensitivity and two sensitivity analyses were performed: first, we assessed the impact of VKA home monitoring; second, we varied the NOACs price assuming patent expiration. Use of NOACs instead of VKA is associated with a health gain of 0.0171 quality-adjusted life years (QALYs) and with an incremental cost of €357, resulting in an incremental cost-effectiveness ratio of €20 919, which is almost equal to the generally accepted CE threshold of €20 000 used in the Netherlands. The probability that NOACs are cost-effective at a conservative willingness-to-pay threshold of €20 000 per QALY was 50%. Introducing home monitoring increased VKAs costs so much that NOACs became the dominant option (less costly and more effective). Price drops associated to patent expiration of NOACs increased its CE. CONCLUSION This analysis suggests that the use of NOACs is a cost-effective alternative of VKAs in patients with AF needing APT. Our findings in the Netherlands healthcare system are probably consistent with other European populations.
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Affiliation(s)
- Naoual Bennaghmouch
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, CM Nieuwegein, the Netherlands
| | - Anne J W M de Veer
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, CM Nieuwegein, the Netherlands
| | - Bakhtawar K Mahmoodi
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, CM Nieuwegein, the Netherlands
| | - Mireia Jofre-Bonet
- Department of Economics, City University of London, Northampton Square, London, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, City Hospital, Birmingham, UK
| | - Kerstin Bode
- Heart Center, University of Leipzig, Strümpellstraße 39, Leipzig, Germany
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, CM Nieuwegein, the Netherlands
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Lamy A, Lonn E, Tong W, Swaminathan B, Jung H, Gafni A, Bosch J, Yusuf S. The cost implication of primary prevention in the HOPE 3 trial. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 5:266-271. [DOI: 10.1093/ehjqcco/qcz001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 12/17/2018] [Accepted: 01/15/2019] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
The Heart Outcomes Prevention Evaluation-3 (HOPE-3) found that rosuvastatin alone or with candesartan and hydrochlorothiazide (HCT) (in a subgroup with hypertension) significantly lowered cardiovascular events compared with placebo in 12 705 individuals from 21 countries at intermediate risk and without cardiovascular disease. We assessed the costs implications of implementation in primary prevention in countries at different economic levels.
Methods and results
Hospitalizations, procedures, study and non-study medications were documented. We applied country-specific costs to the healthcare resources consumed for each patient. We calculated the average cost per patient in US dollars for the duration of the study (5.6 years). Sensitivity analyses were also performed with cheapest equivalent substitutes. The combination of rosuvastatin with candesartan/HCT reduced total costs and was a cost-saving strategy in United States, Canada, Europe, and Australia. In contrast, the treatments were more expensive in developing countries even when cheapest equivalent substitutes were used. After adjustment for gross domestic product (GDP), the costs of cheapest equivalent substitutes in proportion to the health care costs were higher in developing countries in comparison to developed countries.
Conclusion
Rosuvastatin and candesartan/HCT in primary prevention is a cost-saving approach in developed countries, but not in developing countries as both drugs and their cheapest equivalent substitutes are relatively more expensive despite adjustment by GDP. Reductions in costs of these drugs in developing countries are essential to make statins and blood pressure lowering drugs affordable and ensure their use.
Clinical trial registration
HOPE-3 ClinicalTrials.gov number, NCT00468923.
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Affiliation(s)
- Andre Lamy
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
- Hamilton Health Sciences, 237 Barton St. East, Hamilton, ON, Canada
- McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Eva Lonn
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
- Hamilton Health Sciences, 237 Barton St. East, Hamilton, ON, Canada
- McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Wesley Tong
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
| | - Balakumar Swaminathan
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
| | - Hyejung Jung
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
| | - Amiram Gafni
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
- McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
- McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
- Hamilton Health Sciences, 237 Barton St. East, Hamilton, ON, Canada
- McMaster University, 1280 Main St W, Hamilton, ON, Canada
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Dykun I, Wiefhoff D, Totzeck M, Al-Rashid F, Jánosi RA, Rassaf T, Mahabadi AA. Disconcordance between ESC prevention guidelines and observed lipid profiles in patients with known coronary artery disease. IJC HEART & VASCULATURE 2018; 22:73-77. [PMID: 30603665 PMCID: PMC6310742 DOI: 10.1016/j.ijcha.2018.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 12/16/2018] [Indexed: 12/16/2022]
Abstract
Background We aimed to describe whether updated low-density lipoprotein (LDL)-targets in patients with manifest coronary artery disease (CAD) led to a change in lipid profile over time. Methods We retrospectively included patients with manifest CAD from 2009–2010, 2012–2013, and 2015–2016 (n = 500 each). Lipid levels and medication at the different time-points as well as rate of accordance to guidelines (<100 for 2009–2010, <70 mg/dl for 2012–2013 and 2015–2016) were evaluated. Results Overall, 1500 subjects (mean age: 68.4 ± 11.2 years, 75.8% male) from 813 attending primary care physicians were included. Mean LDL-level was 98.0 ± 35.7 mg/dl, whereas 34.1% reached LDL-targets according to guidelines as applied at each time-point. Reduction of LDL-goals in 2011 lead to an initial decrease in LDL from 98.3 ± 33.4 mg/dl in 2009–2010 to 93.9 ± 36.3 mg/dl in 2012–2013 (p = 0.045). This effect was no longer present in 2015–2016 (101.6 ± 36.6 mg/dl, p = 0.17). The rate of patients meeting recommended LDL-targets decreased over time (2009–2010: 56.6%, 2012–2013: 25.4%, 2015–2016: 20.2%, p < 0.0001 for trend). Likewise, the frequency of statin-intake decreased over time (93.6% in 2009–2010 to 83.7% in 2015-2016, p < 0.0001). While use of medium intensity statins was most frequent (69.4%), only 20.9% of patients with medium intensity statins reached LDL-targets according to guidelines. Conclusion In a large clinical cohort of patients with known coronary artery disease, reduction of LDL-targets in ESC-guidelines in 2011 led to an initial decline in LDL-levels, while this effect was attenuated over time with the majority of patients missing treatment goals. Higher acceptance and compliance of statin therapy is warranted to utilize its effect in secondary prevention in CAD-patients.
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Affiliation(s)
| | | | | | | | | | | | - Amir A. Mahabadi
- Corresponding author at: Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, Hufelandstr. 55, 45147 Essen, Germany.
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Garcia‐Gil M, Comas‐Cufí M, Blanch J, Martí R, Ponjoan A, Alves‐Cabratosa L, Petersen I, Marrugat J, Elosua R, Grau M, Ramos R. Effectiveness of Statins as Primary Prevention in People With Different Cardiovascular Risk: A Population-Based Cohort Study. Clin Pharmacol Ther 2018; 104:719-732. [PMID: 29194590 PMCID: PMC6174924 DOI: 10.1002/cpt.954] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 10/13/2017] [Accepted: 11/12/2017] [Indexed: 01/14/2023]
Abstract
The purpose was to analyze statin effectiveness in a general population with differing levels of coronary heart disease (CHD) risk. Patients (35-74 years) without previous cardiovascular disease were included and stratified according to 10-year CHD risk (<5%, 5-7.4%, 7.5-9.9%, and 10-19.9%). New users were categorized according to their medical possession ratio (MPR). The main outcome was atherosclerotic cardiovascular disease (ASCVD) (myocardial infarction and ischemic stroke). In adherent patients (MPR 70%), statin treatment decreased ASCVD risk across the range of coronary risk (from 16-30%). The 5-year number needed to treat (NNT) was 470 and 204 in the risk categories <5% and 5-7.4%, respectively, and 75 and 62 in the 7.5-9.9% category than in the 10-19.9% category, respectively. Statin therapy should remain a priority in patients at high 10-year CHD risk (10-19.9%). Most patients with intermediate risk could benefit from statin treatment, but the treatment decision should focus on the net benefit, safety, and patient preference, given the higher NNT.
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Affiliation(s)
- Maria Garcia‐Gil
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalonia, Spain; ISV Research Group, Research Unit in Primary CareCataloniaSpain
| | - Marc Comas‐Cufí
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalonia, Spain; ISV Research Group, Research Unit in Primary CareCataloniaSpain
| | - Jordi Blanch
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalonia, Spain; ISV Research Group, Research Unit in Primary CareCataloniaSpain
| | - Ruth Martí
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalonia, Spain; ISV Research Group, Research Unit in Primary CareCataloniaSpain
- Biomedical Research Institute, Girona (IdIBGi), ICSCataloniaSpain
| | - Anna Ponjoan
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalonia, Spain; ISV Research Group, Research Unit in Primary CareCataloniaSpain
- Biomedical Research Institute, Girona (IdIBGi), ICSCataloniaSpain
| | - Lia Alves‐Cabratosa
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalonia, Spain; ISV Research Group, Research Unit in Primary CareCataloniaSpain
| | - Irene Petersen
- Department of Primary Care and Population HealthUniversity College of LondonUK
- Department of Clinical EpidemiologyUniversity of AarhusDenmark
| | - Jaume Marrugat
- Registre Gironí del Cor Research Group (REGICOR) and Cardiovascular, Epidemiology and Genetics Research Group (EGEC), Hospital del Mar Medical Research Institute (IMIM)BarcelonaCataloniaSpain
- CIBER Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | - Roberto Elosua
- Registre Gironí del Cor Research Group (REGICOR) and Cardiovascular, Epidemiology and Genetics Research Group (EGEC), Hospital del Mar Medical Research Institute (IMIM)BarcelonaCataloniaSpain
- CIBER Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | - María Grau
- Registre Gironí del Cor Research Group (REGICOR) and Cardiovascular, Epidemiology and Genetics Research Group (EGEC), Hospital del Mar Medical Research Institute (IMIM)BarcelonaCataloniaSpain
- CIBER Enfermedades Cardiovasculares (CIBERCV)BarcelonaSpain
| | - Rafel Ramos
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalonia, Spain; ISV Research Group, Research Unit in Primary CareCataloniaSpain
- Biomedical Research Institute, Girona (IdIBGi), ICSCataloniaSpain
- Primary Care, Primary Care Services, Girona, Catalan Institute of Health (ICS)CataloniaSpain
- Department of Medical Sciences, School of MedicineUniversity of GironaSpain
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Stam-Slob MC, van der Graaf Y, de Boer A, Greving JP, Visseren FL. Cost-effectiveness of PCSK9 inhibition in addition to standard lipid-lowering therapy in patients at high risk for vascular disease. Int J Cardiol 2018; 253:148-154. [DOI: 10.1016/j.ijcard.2017.10.080] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 10/04/2017] [Accepted: 10/19/2017] [Indexed: 12/28/2022]
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Rolden HJA, Maas AHEM, van der Wilt GJ, Grutters JPC. Uncertainty on the effectiveness and safety of rivaroxaban in premenopausal women with atrial fibrillation: empirical evidence needed. BMC Cardiovasc Disord 2017; 17:260. [PMID: 29029621 PMCID: PMC5640919 DOI: 10.1186/s12872-017-0692-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 10/03/2017] [Indexed: 12/25/2022] Open
Abstract
Background Novel anticoagulations (NOACs) are increasingly prescribed for the prevention of stroke in premenopausal women with atrial fibrillation. Small studies suggest NOACs are associated with a higher risk of abnormal uterine bleeds than vitamin K antagonists (VKAs). Because there is no direct empirical evidence on the benefit/risk profile of rivaroxaban compared to VKAs in this subgroup, we synthesize available indirect evidence, estimate decision uncertainty on the treatments, and assess whether further research in premenopausal women is warranted. Methods A Markov model with annual cycles and a lifetime horizon was developed comparing rivaroxaban (the most frequently prescribed NOAC in this population) and VKAs. Clinical event rates, associated quality adjusted life years, and health care costs were obtained from different sources and adjusted for gender, age, and history of stroke. A Monte Carlo simulation with 10,000 iterations was then performed for a hypothetical cohort of premenopausal women, estimated to be reflective of the population of premenopausal women with AF in The Netherlands. Results In the simulation, rivaroxaban is the better treatment option for the prevention of ischemic strokes in premenopausal women in 61% of the iterations. Similarly, this is 98% for intracranial hemorrhages, 24% for major abnormal uterine bleeds, 1% for minor abnormal uterine bleeds, 9% for other major extracranial hemorrhages, and 23% for other minor extracranial hemorrhages. There is a 78% chance that rivaroxaban offers the most quality-adjusted life years. The expected value of perfect information in The Netherlands equals 122 quality-adjusted life years and 22 million Euros. Conclusions There is a 22% risk that rivaroxaban offers a worse rather than a better benefit/risk profile than vitamin K antagonists in premenopausal women. Although rivaroxaban is preferred over VKAs in this population, further research is warranted, and should preferably take the shape of an internationally coordinated registry study including other NOACs. Electronic supplementary material The online version of this article (10.1186/s12872-017-0692-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Herbert J A Rolden
- Council for Public Health and Society, The Hague, The Netherlands. .,Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert Jan van der Wilt
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P C Grutters
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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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] [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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Pandya A, Sy S, Cho S, Alam S, Weinstein MC, Gaziano TA. Validation of a Cardiovascular Disease Policy Microsimulation Model Using Both Survival and Receiver Operating Characteristic Curves. Med Decis Making 2017; 37:802-814. [PMID: 28490271 DOI: 10.1177/0272989x17706081] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite some advances, cardiovascular disease (CVD) remains the leading cause of death and healthcare costs in the United States. We therefore developed a comprehensive CVD policy simulation model that identifies cost-effective approaches for reducing CVD burden. This paper aims to: 1) describe our model in detail; and 2) perform model validation analyses. METHODS The model simulates 1,000,000 adults (ages 35 to 80 years) using a variety of CVD-related epidemiological data, including previously calibrated Framingham-based risk scores for coronary heart disease and stroke. We validated our microsimulation model using recent National Health and Nutrition Examination Survey (NHANES) data, with baseline values collected in 1999-2000 and cause-specific mortality follow-up through 2011. Model-based (simulated) results were compared to observed all-cause and CVD-specific mortality data (from NHANES) for the same starting population using survival curves and, in a method not typically used for disease model validation, receiver operating characteristic (ROC) curves. RESULTS Observed 10-year all-cause mortality in NHANES v. the simulation model was 11.2% (95% CI, 10.3% to 12.2%) v. 10.9%; corresponding results for CVD mortality were 2.2% (1.8% to 2.7%) v. 2.6%. Areas under the ROC curves for model-predicted 10-year all-cause and CVD mortality risks were 0.83 (0.81 to 0.85) and 0.84 (0.81 to 0.88), respectively; corresponding results for 5-year risks were 0.80 (0.77 to 0.83) and 0.81 (0.75 to 0.87), respectively. LIMITATIONS The model is limited by the uncertainties in the data used to estimate its input parameters. Additionally, our validation analyses did not include non-fatal CVD outcomes due to NHANES data limitations. CONCLUSIONS The simulation model performed well in matching to observed nationally representative longitudinal mortality data. ROC curve analysis, which has been traditionally used for risk prediction models, can also be used to assess discrimination for disease simulation models.
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Affiliation(s)
- Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA (AP, SS, SA, MCW, TAG)
| | - Stephen Sy
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA (AP, SS, SA, MCW, TAG)
| | - Sylvia Cho
- Department of Biomedical Informatics, Columbia University, New York, NY, USA (SC)
| | - Sartaj Alam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA (AP, SS, SA, MCW, TAG)
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA (AP, SS, SA, MCW, TAG)
| | - Thomas A Gaziano
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA (AP, SS, SA, MCW, TAG).,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA (TAG)
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Guthrie B, Thompson A, Dumbreck S, Flynn A, Alderson P, Nairn M, Treweek S, Payne K. Better guidelines for better care: accounting for multimorbidity in clinical guidelines – structured examination of exemplar guidelines and health economic modelling. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05160] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BackgroundMultimorbidity is common but most clinical guidelines focus on single diseases.AimTo test the feasibility of new approaches to developing single-disease guidelines to better account for multimorbidity.DesignLiterature-based and economic modelling project focused on areas where multimorbidity makes guideline application problematic.Methods(1) Examination of accounting for multimorbidity in three exemplar National Institute for Health and Care Excellence guidelines (type 2 diabetes, depression, heart failure); (2) examination of the applicability of evidence in multimorbidity for the exemplar conditions; (3) exploration of methods for comparing absolute benefit of treatment; (4) incorporation of treatment pay-off time and competing risk of death in an exemplar economic model for long-term preventative treatments with slowly accruing benefit; and (5) development of a discrete event simulation model-based cost-effectiveness analysis for people with both depression and coronary heart disease.Results(1) Comorbidity was rarely accounted for in the clinical research questions that framed the development of the exemplar guidelines, and was rarely accounted for in treatment recommendations. Drug–disease interactions were common only for comorbid chronic kidney disease, but potentially serious drug–drug interactions between recommended drugs were common and rarely accounted for in guidelines. (2) For all three conditions, the trials underpinning treatment recommendations largely excluded older, more comorbid and more coprescribed patients. The implications of low applicability varied by condition, with type 2 diabetes having large differences in comorbidity, whereas potentially serious drug–drug interactions were more important for depression. (3) Comparing absolute benefit of treatments for different conditions was shown to be technically feasible, but only if guideline developers are willing to make a number of significant assumptions. (4) The lifetime absolute benefit of statins for primary prevention is highly sensitive to the presence of both the direct treatment disutility of taking a daily tablet and competing risk of death. (5) It was feasible to use a discrete event simulation-based model to represent the relevant care pathways to estimate the relative cost-effectiveness of pharmacological treatments of major depressive disorder in primary care for patients who are also likely to go on and receive treatment for coronary heart disease but the analysis was reliant on eliciting some parameter values from experts, which increases the inherent uncertainty in the results. The key limitation was that real-life use in guideline development was not examined.ConclusionsGuideline developers could feasibly (1) use epidemiological data characterising the guideline population to inform consideration of applicability and interactions; (2) systematically compare the absolute benefit of long-term preventative treatments to inform decision-making in people with multimorbidity and high treatment burden; and (3) modify the output from economic models used in guideline development to examine time to benefit in terms of the pay-off time and varying competing risk of death from other conditions.Future workFurther research is needed to optimise presentation of comparative absolute benefit information to clinicians and patients, to evaluate the use of epidemiological and time-to-benefit data in guideline development, to better quantify direct treatment disutility and to better quantify benefit and harm in people with multimorbidity.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Bruce Guthrie
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Alexander Thompson
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Siobhan Dumbreck
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Angela Flynn
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Phil Alderson
- Centre for Clinical Practice, National Institute for Health and Care Excellence, Manchester, UK
| | - Moray Nairn
- Scottish Intercollegiate Guidelines Network, Edinburgh, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
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Stam-Slob MC, van der Graaf Y, Greving JP, Dorresteijn JAN, Visseren FLJ. Cost-Effectiveness of Intensifying Lipid-Lowering Therapy With Statins Based on Individual Absolute Benefit in Coronary Artery Disease Patients. J Am Heart Assoc 2017; 6:e004648. [PMID: 28214794 PMCID: PMC5523762 DOI: 10.1161/jaha.116.004648] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/20/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND A validated prediction model estimates the absolute benefit of intensive versus standard lipid-lowering therapy (LLT) with statins on next major cardiovascular events for individual patients with coronary artery disease. We aimed to assess whether targeting intensive LLT therapy to coronary artery disease patients with the highest predicted absolute benefit is cost-effective compared to treating all with standard or all with intensive LLT. METHODS AND RESULTS A lifetime Markov model was constructed for coronary artery disease patients (n=10 000) with mean age 61 years. Number of major cardiovascular events, (non) vascular death, costs, and quality-adjusted life years (QALYs) were estimated for the following strategies: (1) standard LLT for all (reference strategy); (2) intensive LLT for those with 5-year absolute major cardiovascular events risk reduction (ARR) ≥3%, ≥2.3%, or ≥1.5% (corresponding to ≥20%, ≥15%, or ≥10% 5-year major cardiovascular events risk); and (3) intensive LLT for all. With intensive LLT for those with ≥3% 5-year ARR (13% of patients), 380 QALYs were gained for €2423/QALY. Using a threshold of ≥2.3% ARR (26% of patients), 630 QALYs were gained for €5653/QALY. Using a threshold of ≥1.5% ARR (56% of patients), 1020 QALYs were gained for €10 960/QALY. By treating all intensively, 1410 QALYs were gained (0.14 QALY per patient) for €17 223/QALY. With benefit-based treatment, 0.16 to 0.17 QALY was gained per treated patient. CONCLUSIONS Intensive LLT with statins for all coronary artery disease patients results in the highest overall QALY gain against acceptable costs. However, the number of QALYs gained with intensive LLT by statins in individual patients can be increased with selective benefit-based treatment. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00327691 and NCT00159835.
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Affiliation(s)
- Manon C Stam-Slob
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yolanda van der Graaf
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
Long-term use of statin therapy is essential to obtain clinical benefits, but adherence is often suboptimal and some patients are also reported to fail because of 'statin resistance'. The identification of PCSK9 as a key factor in the LDL clearance pathway has led to the development of new monoclonal antibodies. Here we critically review the economic evaluations published in Europe and focused on statins. We searched the PubMed database to select the studies published from July 2006 to June 2016 and finally selected 19 articles. Overall, the majority of studies were conducted from a third-party payer's viewpoint and recurred to modelling. Most studies were sponsored by industry and funding seemed to play a pivotal role in the study design. Patients resistant to LDL-C level reduction were considered only in a few studies. The place in therapy of the new class of biologic should be considered a kind of 'third line' for cholesterol-lowering, after patients have failed with restricted dietary regimens and then with current drug therapies. Otherwise they could result in hardly sustainable expenses even for developed countries.
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Affiliation(s)
- Livio Garattini
- CESAV, Centre for Health Economics, IRCCS Institute for Pharmacological Research 'Mario Negri', 24020 Ranica, Italy
| | - Anna Padula
- CESAV, Centre for Health Economics, IRCCS Institute for Pharmacological Research 'Mario Negri', 24020 Ranica, Italy
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Kashef MA, Giugliano G. Legacy effect of statins: 20-year follow up of the West of Scotland Coronary Prevention Study (WOSCOPS). Glob Cardiol Sci Pract 2016; 2016:e201635. [PMID: 28979904 PMCID: PMC5624184 DOI: 10.21542/gcsp.2016.35] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Mohammed Amin Kashef
- Division of Cardiovascular Disease, Baystate Medical Center, Springfield, MA, USA
| | - Gregory Giugliano
- Tufts University School of Medicine, Department of Medicine, Boston, MA, USA
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Stevanović J, de Jong LA, Kappelhoff BS, Dvortsin EP, Voorhaar M, Postma MJ. Dabigatran for the Treatment and Secondary Prevention of Venous Thromboembolism; A Cost-Effectiveness Analysis for the Netherlands. PLoS One 2016; 11:e0163550. [PMID: 27776137 PMCID: PMC5077099 DOI: 10.1371/journal.pone.0163550] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 09/11/2016] [Indexed: 01/31/2023] Open
Abstract
Background Dabigatran was proven to have similar effect on the prevention of recurrence of venous thromboembolism (VTE) and a lower risk of bleeding compared to vitamin K antagonists (VKA). The aim of this study is to assess the cost-effectiveness (CE) of dabigatran for the treatment and secondary prevention in patients with VTE compared to VKAs in the Dutch setting. Methods Previously published Markov model was modified and updated to assess the CE of dabigatran and VKAs for the treatment and secondary prevention in patients with VTE from a societal perspective in the base-case analysis. The model was populated with efficacy and safety data from major dabigatran trials (i.e. RE-COVER, RECOVER II, RE-MEDY and RE-SONATE), Dutch specific costs, and utilities derived from dabigatran trials or other published literature. Univariate, probabilistic sensitivity and a number of scenario analyses evaluating various decision-analytic settings (e.g. the perspective of analysis, use of anticoagulants only for treatment or only for secondary prevention, or comparison to no treatment) were tested on the incremental cost-effectiveness ratio (ICER). Results In the base-case scenario, patients on dabigatran gained an additional 0.034 quality adjusted life year (QALY) while saving €1,598. Results of univariate sensitivity analysis were quite robust. The probability that dabigatran is cost-effective at a willingness-to-pay threshold of €20,000/QALY was 98.1%. From the perspective of healthcare provider, extended anticoagulation with dabigatran compared to VKAs was estimated at €2,158 per QALY gained. The ICER for anticoagulation versus no treatment in patients with equipoise risk of recurrent VTE was estimated at €33,379 per QALY gained. Other scenarios showed dabigatran was cost-saving. Conclusion From a societal perspective, dabigatran is likely to be a cost-effective or even cost-saving strategy for treatment and secondary prevention of VTE compared to VKAs in the Netherlands.
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Affiliation(s)
- J. Stevanović
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, the Netherlands
| | - L. A. de Jong
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, the Netherlands
- * E-mail:
| | | | - E. P. Dvortsin
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, the Netherlands
| | - M. Voorhaar
- Boehringer Ingelheim, Alkmaar, the Netherlands
| | - M. J. Postma
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, the Netherlands
- Institute for Science in Healthy Aging & healthcaRE (SHARE), University Medical Center Groningen (UMCG), University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, UMCG, University of Groningen, Groningen, the Netherlands
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Vasudeva E, Moise N, Huang C, Mason A, Penko J, Goldman L, Coxson PG, Bibbins-Domingo K, Moran AE. Comparative Cost-Effectiveness of Hypertension Treatment in Non-Hispanic Blacks and Whites According to 2014 Guidelines: A Modeling Study. Am J Hypertens 2016; 29:1195-205. [PMID: 27172970 PMCID: PMC5018997 DOI: 10.1093/ajh/hpw047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 03/02/2016] [Accepted: 04/14/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND We compared the cost-effectiveness of hypertension treatment in non-Hispanic blacks and non-Hispanic whites according to 2014 US hypertension treatment guidelines. METHODS The cardiovascular disease (CVD) policy model simulated CVD events, quality-adjusted life years (QALYs), and treatment costs in 35- to 74-year-old adults with untreated hypertension. CVD incidence, mortality, and risk factor levels were obtained from cohort studies, hospital registries, vital statistics, and national surveys. Stage 1 hypertension was defined as blood pressure 140-149/90-99mm Hg; stage 2 hypertension as ≥150/100mm Hg. Probabilistic input distribution sampling informed 95% uncertainty intervals (UIs). Incremental cost-effectiveness ratios (ICERs) < $50,000/QALY gained were considered cost-effective. RESULTS Treating 0.7 million hypertensive non-Hispanic black adults would prevent about 8,000 CVD events annually; treating 3.4 million non-Hispanic whites would prevent about 35,000 events. Overall 2014 guideline implementation would be cost saving in both groups compared with no treatment. For stage 1 hypertension but without diabetes or chronic kidney disease, cost savings extended to non-Hispanic black males ages 35-44 but not same-aged non-Hispanic white males (ICER $57,000/QALY; 95% UI $15,000-$100,000) and cost-effectiveness extended to non-Hispanic black females ages 35-44 (ICER $46,000/QALY; $17,000-$76,000) but not same-aged non-Hispanic white females (ICER $181,000/QALY; $111,000-$235,000). CONCLUSIONS Compared with non-Hispanic whites, cost-effectiveness of implementing hypertension guidelines would extend to a larger proportion of non-Hispanic black hypertensive patients.
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Affiliation(s)
- Eshan Vasudeva
- College of Physicians and Surgeons, Columbia University, New York, USA
| | - Nathalie Moise
- Department of General Medicine, Columbia University Medical Center, New York, USA
| | - Chen Huang
- Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China; National Center for Cardiovascular Diseases, Beijing, China
| | - Antoinette Mason
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Joanne Penko
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Lee Goldman
- College of Physicians and Surgeons, Columbia University, New York, USA
| | - Pamela G Coxson
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Kirsten Bibbins-Domingo
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Andrew E Moran
- College of Physicians and Surgeons, Columbia University, New York, USA; Department of General Medicine, Columbia University Medical Center, New York, USA;
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Mahabadi AA, Möhlenkamp S, Lehmann N, Kälsch H, Dykun I, Pundt N, Moebus S, Jöckel KH, Erbel R. CAC Score Improves Coronary and CV Risk Assessment Above Statin Indication by ESC and AHA/ACC Primary Prevention Guidelines. JACC Cardiovasc Imaging 2016; 10:143-153. [PMID: 27665163 DOI: 10.1016/j.jcmg.2016.03.022] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 02/17/2016] [Accepted: 03/17/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study was to assess the difference in indication for statin therapy by European Society of Cardiology (ESC) versus American Heart Association/American College of Cardiology (AHA/ACC) guidelines and to quantify the potential additional role of coronary artery calcification (CAC) score over updated guidelines in a primary prevention cohort. BACKGROUND Recently, ESC and AHA/ACC updated the guidelines regarding statin therapy in primary prevention. METHODS In 3,745 subjects (59 ± 8 years of age, 47% men) from the population based longitudinal Heinz Nixdorf Recall cohort study without cardiovascular disease or lipid-lowering therapy at baseline CAC score was assessed between 2000 and 2003. Subjects remained unaware of their initial CAC score. Statin indication was determined according to 2012 ESC and 2013 AHA/ACC guidelines based on subjects individual baseline characteristics. RESULTS The frequency of statin recommendation was lower according to ESC compared to AHA/ACC guidelines (34% vs. 56%; p < 0.0001), whereas low CAC score (<100) was common in subjects with statin indication by both guidelines (59% for ESC, 62% for AHA/ACC). During 10.4 ± 2.0 years of follow-up, 131 myocardial infarctions occurred. For ESC recommendations, CAC score differentiated risk for subjects without (1.0 [95% confidence interval (CI): 0.4 to 1.5] vs. 6.5 [95% CI: 4.1 to 8.9] coronary events per 1,000 person-years for CAC 0 vs. ≥100) and with statin indication (2.6 [95% CI: 0.6 to 4.7] vs. 9.9 [95% CI: 7.3 to 12.5] per 1,000 person-years for CAC 0 vs. ≥100). Likewise, CAC score stratified proportions experiencing events subjects with statin indication according to AHA/ACC (2.7 [95% CI: 1.1 to 4.2] vs. 9.1 [95% CI: 7.0 to 11.0] per 1,000 person-years for CAC 0 vs. ≥100), whereas event rate in subjects without statin indication was low (1.1 [95% CI: 0.65 to 1.68] per 1,000 person-years). CONCLUSIONS Current ESC and AHA/ACC guidelines lead to markedly different recommendation regarding statin therapy in a German primary prevention cohort. Quantification of CAC score in addition to the guidelines improves stratification between subjects at high versus low risk for coronary events, indicating that CAC scoring may help to match intensified risk factor modification to atherosclerotic plaque burden as well as actual risk while avoiding therapy in subjects with low coronary atherosclerosis that have low 10-year event rate.
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Affiliation(s)
- Amir A Mahabadi
- Department of Cardiology, West-German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.
| | | | - Nils Lehmann
- Institute for Medical Informatics, Biometry, and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Hagen Kälsch
- Department of Cardiology, West-German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Iryna Dykun
- Department of Cardiology, West-German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Noreen Pundt
- Institute for Medical Informatics, Biometry, and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Susanne Moebus
- Institute for Medical Informatics, Biometry, and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Karl-Heinz Jöckel
- Institute for Medical Informatics, Biometry, and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Raimund Erbel
- Institute for Medical Informatics, Biometry, and Epidemiology, University of Duisburg-Essen, Essen, Germany
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Perera R, McFadden E, McLellan J, Lung T, Clarke P, Pérez T, Fanshawe T, Dalton A, Farmer A, Glasziou P, Takahashi O, Stevens J, Irwig L, Hirst J, Stevens S, Leslie A, Ohde S, Deshpande G, Urayama K, Shine B, Stevens R. Optimal strategies for monitoring lipid levels in patients at risk or with cardiovascular disease: a systematic review with statistical and cost-effectiveness modelling. Health Technol Assess 2016; 19:1-401, vii-viii. [PMID: 26680162 DOI: 10.3310/hta191000] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Various lipid measurements in monitoring/screening programmes can be used, alone or in cardiovascular risk scores, to guide treatment for prevention of cardiovascular disease (CVD). Because some changes in lipids are due to variability rather than true change, the value of lipid-monitoring strategies needs evaluation. OBJECTIVE To determine clinical value and cost-effectiveness of different monitoring intervals and different lipid measures for primary and secondary prevention of CVD. DATA SOURCES We searched databases and clinical trials registers from 2007 (including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Clinical Trials Register, the Current Controlled Trials register, and the Cumulative Index to Nursing and Allied Health Literature) to update and extend previous systematic reviews. Patient-level data from the Clinical Practice Research Datalink and St Luke's Hospital, Japan, were used in statistical modelling. Utilities and health-care costs were drawn from the literature. METHODS In two meta-analyses, we used prospective studies to examine associations of lipids with CVD and mortality, and randomised controlled trials to estimate lipid-lowering effects of atorvastatin doses. Patient-level data were used to estimate progression and variability of lipid measurements over time, and hence to model lipid-monitoring strategies. Results are expressed as rates of true-/false-positive and true-/false-negative tests for high lipid or high CVD risk. We estimated incremental costs per quality-adjusted life-year. RESULTS A total of 115 publications reported strength of association between different lipid measures and CVD events in 138 data sets. The summary adjusted hazard ratio per standard deviation of total cholesterol (TC) to high-density lipoprotein (HDL) cholesterol ratio was 1.25 (95% confidence interval 1.15 to 1.35) for CVD in a primary prevention population but heterogeneity was high (I(2) = 98%); similar results were observed for non-HDL cholesterol, apolipoprotein B and other ratio measures. Associations were smaller for other single lipid measures. Across 10 trials, low-dose atorvastatin (10 and 20 mg) effects ranged from a TC reduction of 0.92 mmol/l to 2.07 mmol/l, and low-density lipoprotein reduction of between 0.88 mmol/l and 1.86 mmol/l. Effects of 40 mg and 80 mg were reported by one trial each. For primary prevention, over a 3-year period, we estimate annual monitoring would unnecessarily treat 9 per 1000 more men (28 vs. 19 per 1000) and 5 per 1000 more women (17 vs. 12 per 1000) than monitoring every 3 years. However, annual monitoring would also undertreat 9 per 1000 fewer men (7 vs. 16 per 1000) and 4 per 1000 fewer women (7 vs. 11 per 1000) than monitoring at 3-year intervals. For secondary prevention, over a 3-year period, annual monitoring would increase unnecessary treatment changes by 66 per 1000 men and 31 per 1000 women, and decrease undertreatment by 29 per 1000 men and 28 per 1000 men, compared with monitoring every 3 years. In cost-effectiveness, strategies with increased screening/monitoring dominate. Exploratory analyses found that any unknown harms of statins would need utility decrements as large as 0.08 (men) to 0.11 (women) per statin user to reverse this finding in primary prevention. LIMITATION Heterogeneity in meta-analyses. CONCLUSIONS While acknowledging known and potential unknown harms of statins, we find that more frequent monitoring strategies are cost-effective compared with others. Regular lipid monitoring in those with and without CVD is likely to be beneficial to patients and to the health service. Future research should include trials of the benefits and harms of atorvastatin 40 and 80 mg, large-scale surveillance of statin safety, and investigation of the effect of monitoring on medication adherence. STUDY REGISTRATION This study is registered as PROSPERO CRD42013003727. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Rafael Perera
- National Institute for Health Research School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emily McFadden
- National Institute for Health Research School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julie McLellan
- National Institute for Health Research School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tom Lung
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Philip Clarke
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Teresa Pérez
- National Institute for Health Research School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Thomas Fanshawe
- National Institute for Health Research School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew Dalton
- National Institute for Health Research School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew Farmer
- National Institute for Health Research School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Osamu Takahashi
- St Luke's International University Center for Clinical Epidemiology, Tokyo, Japan
| | | | - Les Irwig
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Jennifer Hirst
- National Institute for Health Research School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Stevens
- National Institute for Health Research School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Asuka Leslie
- St Luke's International University Center for Clinical Epidemiology, Tokyo, Japan
| | - Sachiko Ohde
- St Luke's International University Center for Clinical Epidemiology, Tokyo, Japan
| | - Gautam Deshpande
- St Luke's International University Center for Clinical Epidemiology, Tokyo, Japan
| | - Kevin Urayama
- St Luke's International University Center for Clinical Epidemiology, Tokyo, Japan
| | - Brian Shine
- Oxford University Hospitals Trust, Oxford, UK
| | - Richard Stevens
- National Institute for Health Research School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Moise N, Huang C, Rodgers A, Kohli-Lynch CN, Tzong KY, Coxson PG, Bibbins-Domingo K, Goldman L, Moran AE. Comparative Cost-Effectiveness of Conservative or Intensive Blood Pressure Treatment Guidelines in Adults Aged 35-74 Years: The Cardiovascular Disease Policy Model. Hypertension 2016; 68:88-96. [PMID: 27181996 PMCID: PMC5027989 DOI: 10.1161/hypertensionaha.115.06814] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 04/15/2016] [Indexed: 11/16/2022]
Abstract
The population health effect and cost-effectiveness of implementing intensive blood pressure goals in high-cardiovascular disease (CVD) risk adults have not been described. Using the CVD Policy Model, CVD events, treatment costs, quality-adjusted life years, and drug and monitoring costs were simulated over 2016 to 2026 for hypertensive patients aged 35 to 74 years. We projected the effectiveness and costs of hypertension treatment according to the 2003 Joint National Committee (JNC)-7 or 2014 JNC8 guidelines, and then for adults aged ≥50 years, we assessed the cost-effectiveness of adding an intensive goal of systolic blood pressure <120 mm Hg for patients with CVD, chronic kidney disease, or 10-year CVD risk ≥15%. Incremental cost-effectiveness ratios <$50 000 per quality-adjusted life years gained were considered cost-effective. JNC7 strategies treat more patients and are more costly to implement compared with JNC8 strategies. Adding intensive systolic blood pressure goals for high-risk patients prevents an estimated 43 000 and 35 000 annual CVD events incremental to JNC8 and JNC7, respectively. Intensive strategies save costs in men and are cost-effective in women compared with JNC8 alone. At a willingness-to-pay threshold of $50 000 per quality-adjusted life years gained, JNC8+intensive had the highest probability of cost-effectiveness in women (82%) and JNC7+intensive the highest probability of cost-effectiveness in men (100%). Assuming higher drug and monitoring costs, adding intensive goals for high-risk patients remained consistently cost-effective in men, but not always in women. Among patients aged 35 to 74 years, adding intensive blood pressure goals for high-risk groups to current national hypertension treatment guidelines prevents additional CVD deaths while saving costs provided that medication costs are controlled.
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Affiliation(s)
- Nathalie Moise
- From the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY (N.M., C.N.K.-L., K.Y.T., A.E.M.); Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China (C.H.); Department of Epidemiology, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medicine Science, Beijing, China (C.H.); George Institute for Global Health, Sydney, New South Wales, Australia (A.R.); Health Economics & Health Technology Assessment, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences and College of Social Sciences, University of Glasgow, Glasgow, United Kingdom (C.N.K.-L.); Division of General Medicine, Department of Medicine, University of California at San Francisco (P.G.C., K.B.-D); and College of Physicians and Surgeons, Columbia University, New York, NY (L.G., A.E.M.)
| | - Chen Huang
- From the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY (N.M., C.N.K.-L., K.Y.T., A.E.M.); Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China (C.H.); Department of Epidemiology, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medicine Science, Beijing, China (C.H.); George Institute for Global Health, Sydney, New South Wales, Australia (A.R.); Health Economics & Health Technology Assessment, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences and College of Social Sciences, University of Glasgow, Glasgow, United Kingdom (C.N.K.-L.); Division of General Medicine, Department of Medicine, University of California at San Francisco (P.G.C., K.B.-D); and College of Physicians and Surgeons, Columbia University, New York, NY (L.G., A.E.M.)
| | - Anthony Rodgers
- From the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY (N.M., C.N.K.-L., K.Y.T., A.E.M.); Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China (C.H.); Department of Epidemiology, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medicine Science, Beijing, China (C.H.); George Institute for Global Health, Sydney, New South Wales, Australia (A.R.); Health Economics & Health Technology Assessment, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences and College of Social Sciences, University of Glasgow, Glasgow, United Kingdom (C.N.K.-L.); Division of General Medicine, Department of Medicine, University of California at San Francisco (P.G.C., K.B.-D); and College of Physicians and Surgeons, Columbia University, New York, NY (L.G., A.E.M.)
| | - Ciaran N Kohli-Lynch
- From the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY (N.M., C.N.K.-L., K.Y.T., A.E.M.); Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China (C.H.); Department of Epidemiology, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medicine Science, Beijing, China (C.H.); George Institute for Global Health, Sydney, New South Wales, Australia (A.R.); Health Economics & Health Technology Assessment, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences and College of Social Sciences, University of Glasgow, Glasgow, United Kingdom (C.N.K.-L.); Division of General Medicine, Department of Medicine, University of California at San Francisco (P.G.C., K.B.-D); and College of Physicians and Surgeons, Columbia University, New York, NY (L.G., A.E.M.)
| | - Keane Y Tzong
- From the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY (N.M., C.N.K.-L., K.Y.T., A.E.M.); Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China (C.H.); Department of Epidemiology, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medicine Science, Beijing, China (C.H.); George Institute for Global Health, Sydney, New South Wales, Australia (A.R.); Health Economics & Health Technology Assessment, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences and College of Social Sciences, University of Glasgow, Glasgow, United Kingdom (C.N.K.-L.); Division of General Medicine, Department of Medicine, University of California at San Francisco (P.G.C., K.B.-D); and College of Physicians and Surgeons, Columbia University, New York, NY (L.G., A.E.M.)
| | - Pamela G Coxson
- From the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY (N.M., C.N.K.-L., K.Y.T., A.E.M.); Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China (C.H.); Department of Epidemiology, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medicine Science, Beijing, China (C.H.); George Institute for Global Health, Sydney, New South Wales, Australia (A.R.); Health Economics & Health Technology Assessment, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences and College of Social Sciences, University of Glasgow, Glasgow, United Kingdom (C.N.K.-L.); Division of General Medicine, Department of Medicine, University of California at San Francisco (P.G.C., K.B.-D); and College of Physicians and Surgeons, Columbia University, New York, NY (L.G., A.E.M.)
| | - Kirsten Bibbins-Domingo
- From the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY (N.M., C.N.K.-L., K.Y.T., A.E.M.); Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China (C.H.); Department of Epidemiology, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medicine Science, Beijing, China (C.H.); George Institute for Global Health, Sydney, New South Wales, Australia (A.R.); Health Economics & Health Technology Assessment, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences and College of Social Sciences, University of Glasgow, Glasgow, United Kingdom (C.N.K.-L.); Division of General Medicine, Department of Medicine, University of California at San Francisco (P.G.C., K.B.-D); and College of Physicians and Surgeons, Columbia University, New York, NY (L.G., A.E.M.)
| | - Lee Goldman
- From the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY (N.M., C.N.K.-L., K.Y.T., A.E.M.); Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China (C.H.); Department of Epidemiology, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medicine Science, Beijing, China (C.H.); George Institute for Global Health, Sydney, New South Wales, Australia (A.R.); Health Economics & Health Technology Assessment, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences and College of Social Sciences, University of Glasgow, Glasgow, United Kingdom (C.N.K.-L.); Division of General Medicine, Department of Medicine, University of California at San Francisco (P.G.C., K.B.-D); and College of Physicians and Surgeons, Columbia University, New York, NY (L.G., A.E.M.)
| | - Andrew E Moran
- From the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY (N.M., C.N.K.-L., K.Y.T., A.E.M.); Department of Evidence Based Medicine, Cardiovascular Institute and Fu Wai Hospital of the Chinese Academy of Medical Sciences, Beijing, China (C.H.); Department of Epidemiology, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medicine Science, Beijing, China (C.H.); George Institute for Global Health, Sydney, New South Wales, Australia (A.R.); Health Economics & Health Technology Assessment, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences and College of Social Sciences, University of Glasgow, Glasgow, United Kingdom (C.N.K.-L.); Division of General Medicine, Department of Medicine, University of California at San Francisco (P.G.C., K.B.-D); and College of Physicians and Surgeons, Columbia University, New York, NY (L.G., A.E.M.).
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Stevanović J, Postma MJ, Le HH. Budget Impact of Increasing Market Share of Patient Self-Testing and Patient Self-Management in Anticoagulation. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:383-390. [PMID: 27325330 DOI: 10.1016/j.jval.2015.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 11/30/2015] [Accepted: 12/22/2015] [Indexed: 06/06/2023]
Abstract
BACKGROUND Patient self-testing (PST) and/or patient self-management (PSM) might provide better coagulation care than monitoring at specialized anticoagulation centers. Yet, it remains an underused strategy in the Netherlands. METHODS Budget-impact analyses of current and new market-share scenarios of PST and/or PSM compared with monitoring at specialized centers were performed for a national cohort of 260,338 patients requiring long-term anticoagulation testing. A health care payer perspective and 1- to 5-year time horizons were applied. The occurrence of thromboembolic and hemorrhagic complications in the aforementioned patient population was assessed in a Markov model. Dutch-specific costs were applied, next to effectiveness data derived from a meta-analysis on PST and/or PSM. Sensitivity and scenario analyses were performed to assess uncertainty on budget-impact analysis results. RESULTS Increasing PST and/or PSM usage in the national cohort from the current 15.4% to 50% resulted in savings ranging from €8 million after the first year to €184 million after 5 years. Further increases in the use of PST and/or PSM produced greater savings. Sensitivity analyses revealed budget-impact model sensitivity to the baseline and relative risks of thromboembolic complications. Unfavorable budget impact was found in scenarios exploring an increase in the use of PST alone as well as an increase in the market share of PST and PSM in patients with atrial fibrillation. CONCLUSIONS Overall study findings indicated that PST and PSM are more favorable alternatives to monitoring at specialized centers in patients without atrial fibrillation.
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Affiliation(s)
| | | | - Hoa H Le
- University of Groningen, Groningen, the Netherlands
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Stevens W, Peneva D, Li JZ, Liu LZ, Liu G, Gao R, Lakdawalla DN. Estimating the future burden of cardiovascular disease and the value of lipid and blood pressure control therapies in China. BMC Health Serv Res 2016; 16:175. [PMID: 27165638 PMCID: PMC4862139 DOI: 10.1186/s12913-016-1420-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 04/30/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Lifestyle and dietary changes reflect an ongoing epidemiological transition in China, with cardiovascular disease (CVD) playing an ever-increasing role in China's disease burden. This study assessed the burden of CVD and the potential value of lipid and blood pressure control strategies in China. METHODS We estimated the likely burden of CVD between 2016 and 2030 and how expanded use of lipid lowering and blood pressure control medication would impact that burden in the next 15 years. Accounting for the costs of drug use, we assessed the net social value of a policy that expands the utilization of lipid and blood pressure lowering therapies in China. RESULTS Rises in prevalence of CVD risk and population aging would likely increase the incidence of acute myocardial infarctions (AMIs) by 75 million and strokes by 118 million, while the number of CVD deaths would rise by 39 million in total between 2016 and 2030. Universal treatment of hypertension and dyslipidemia patients with lipid and blood pressure lowering therapies could avert between 10 and 20 million AMIs, between 8 and 30 million strokes, and between 3 and 10 million CVD deaths during the 2016-2030 period, producing a positive social value net of health care costs as high as $932 billion. CONCLUSIONS In light of its aging population and epidemiological transition, China faces near-certain increases in CVD morbidity and mortality. Preventative measures such as effective lipid and blood pressure management may reduce CVD burden substantially and provide large social value. While the Chinese government is implementing more systematic approaches to health care delivery, prevention of CVD should be high on the agenda.
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Affiliation(s)
| | - Desi Peneva
- Precision Health Economics, Los Angeles, CA, USA
| | | | - Larry Z Liu
- Weill Medical College of Cornell University, New York City, NY, USA
| | - Gordon Liu
- Peking University National School of Development, Beijing, China
| | - Runlin Gao
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China
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Thompson A, Guthrie B, Payne K. Do Pills Have No Ills? Capturing the Impact of Direct Treatment Disutility. PHARMACOECONOMICS 2016; 34:333-336. [PMID: 26645572 DOI: 10.1007/s40273-015-0357-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Model-based economic evaluations should capture the impact on all costs and outcomes relevant to the chosen study perspective and time horizon. This editorial defines what is meant by direct treatment disutility (DTD) and describes why it could be an important harm that those designing model-based evaluations should consider. Some existing estimates of DTD identified from the current literature are summarised in terms of the methods used to elicit the values and the size of the estimated DTD. Model-based studies that include DTDs are also summarised. It was found that the values used within model-based economic evaluations (ranging from 0.00384 to 0.02) were typically smaller than the directly elicited values from the existing literature (0-0.033). Yet even with conservative estimates of DTDs, cost-effectiveness results were sensitive to their inclusion. The editorial concludes by discussing future methodological and empirical research needed to estimate more robust DTD values.
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Affiliation(s)
- Alexander Thompson
- Manchester Centre for Health Economics, The University of Manchester, 4th Floor, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Bruce Guthrie
- Population Health Sciences Division, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, The University of Manchester, 4th Floor, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
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Stevanović J, Pechlivanoglou P, Kampinga MA, Krabbe PFM, Postma MJ. Multivariate Meta-Analysis of Preference-Based Quality of Life Values in Coronary Heart Disease. PLoS One 2016; 11:e0152030. [PMID: 27011260 PMCID: PMC4806923 DOI: 10.1371/journal.pone.0152030] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 03/08/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There are numerous health-related quality of life (HRQol) measurements used in coronary heart disease (CHD) in the literature. However, only values assessed with preference-based instruments can be directly applied in a cost-utility analysis (CUA). OBJECTIVE To summarize and synthesize instrument-specific preference-based values in CHD and the underlying disease-subgroups, stable angina and post-acute coronary syndrome (post-ACS), for developed countries, while accounting for study-level characteristics, and within- and between-study correlation. METHODS A systematic review was conducted to identify studies reporting preference-based values in CHD. A multivariate meta-analysis was applied to synthesize the HRQoL values. Meta-regression analyses examined the effect of study level covariates age, publication year, prevalence of diabetes and gender. RESULTS A total of 40 studies providing preference-based values were detected. Synthesized estimates of HRQoL in post-ACS ranged from 0.64 (Quality of Well-Being) to 0.92 (EuroQol European"tariff"), while in stable angina they ranged from 0.64 (Short form 6D) to 0.89 (Standard Gamble). Similar findings were observed in estimates applying to general CHD. No significant improvement in model fit was found after adjusting for study-level covariates. Large between-study heterogeneity was observed in all the models investigated. CONCLUSIONS The main finding of our study is the presence of large heterogeneity both within and between instrument-specific HRQoL values. Current economic models in CHD ignore this between-study heterogeneity. Multivariate meta-analysis can quantify this heterogeneity and offers the means for uncertainty around HRQoL values to be translated to uncertainty in CUAs.
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Affiliation(s)
- Jelena Stevanović
- University of Groningen, Department of Pharmacy, Unit of Pharmacoepidemiology and Pharmacoeconomics (PE2), Groningen, The Netherlands
| | - Petros Pechlivanoglou
- Toronto Health Economics and Technology Assessment (THETA), Toronto, Canada.,University of Toronto, Faculty of Medicine, Institute of Health Policy, Management and Evaluation, Toronto, Canada
| | - Marthe A Kampinga
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Thorax Center, Groningen, The Netherlands
| | - Paul F M Krabbe
- University of Groningen, University Medical Centre Groningen, Department of Epidemiology, Groningen, The Netherlands
| | - Maarten J Postma
- University of Groningen, Department of Pharmacy, Unit of Pharmacoepidemiology and Pharmacoeconomics (PE2), Groningen, The Netherlands
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Amirsadri M, Hassani A. Cost-effectiveness and cost-utility analysis of OTC use of simvastatin 10 mg for the primary prevention of myocardial infarction in Iranian men. ACTA ACUST UNITED AC 2015; 23:56. [PMID: 26717884 PMCID: PMC4697320 DOI: 10.1186/s40199-015-0129-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 09/11/2015] [Indexed: 11/24/2022]
Abstract
Background Several clinical trials and meta-analyses have shown the advantageous effects of statins in populations with different levels of cardiovascular disease (CVD) risk. Considering the increasing cardiovascular risk among the Iranian population, the cost-effectiveness of the use of simvastatin 10 mg, as an Over-The-Counter (OTC) drug, for the primary prevention of myocardial infarction (MI) was evaluated in this modeling study, from the payer's perspective. The target population is a hypothetical cohort of 45-year CVD healthy men with an average (15 %) 10-year CVD risk. Methods A semi-Markov model with a life-long time horizon was developed to evaluate the Cost-Utility-Analysis (CUA) and Cost-Effectiveness-Analysis (CEA) of the use of OTC simvastatin 10 mg compared to no-drug therapy. Two measures of benefits were used in the model; Quality-Adjusted-Life-Years (QALYs) for the CUA and Life-Years-Gained (LYG) for the CEA. To examine the robustness of the results, one-way sensitivity analysis and probabilistic sensitivity analysis were applied to the model. Results For the base-case scenario with a discount rate of 0 % the estimated ICERs were 1113 USD/QALY and 935USD/LYG per patient (using governmental tariffs). No threshold has been determined in Iran for the cost-effectiveness of health-related interventions. However, according to the recommendation of WHO, this intervention can be considered highly cost-effective as its ICER is far less than the reported GDP per capita for Iran by World bank in 2013 ($4763). Conclusions This modeling study showed that the use of an OTC low dose statin (simvastatin 10 mg) for the primary prevention of myocardial infarction (MI) in 45-year men with a 10-year CVD risk of 15 % could be considered highly cost-effective in Iran, as it meets the WHO threshold of the annual GDP per capita ($4763).
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Affiliation(s)
- Mohammadreza Amirsadri
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Abbas Hassani
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
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Bleakley C, Pumb R, Harbinson M, McVeigh GE. A Reappraisal of the Safety and Cost-Effectiveness of Statin Therapy in Primary Prevention. Can J Cardiol 2015; 31:1411-4. [PMID: 26386731 DOI: 10.1016/j.cjca.2015.03.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 03/24/2015] [Accepted: 03/24/2015] [Indexed: 12/12/2022] Open
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Clinical and Preclinical Use of LOX-1-Specific Antibodies in Diagnostics and Therapeutics. J Cardiovasc Transl Res 2015; 8:458-65. [PMID: 26385009 DOI: 10.1007/s12265-015-9655-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 09/07/2015] [Indexed: 01/01/2023]
Abstract
Lectin-like oxidized low-density lipoprotein receptor-1 (SR-E1, LOX-1, OLR1) was first discovered as a vascular receptor for modified lipoprotein particles nearly 20 years ago. Since then, in vitro and in vivo studies have demonstrated an association between LOX-1, a soluble form (sLOX-1) and a number of diseases including atherosclerosis, arthritis, hypertension and pre-eclampsia. However, converting such discoveries into tools and drugs for routine clinical use is dependent on translational preclinical and clinical studies but such studies have only begun to emerge in the past decade. In this review, we identify the key clinical applications and corresponding criteria that need to be addressed for the effective use of LOX-1-related probes and molecules for patient benefit in different disease states.
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Greving JP, Diener HC, Csiba L, Hacke W, Kappelle LJ, Koudstaal PJ, Leys D, Mas JL, Sacco RL, Sivenius J, Algra A. Individual patient data meta-analysis of antiplatelet regimens after noncardioembolic stroke or TIA: rationale and design. Int J Stroke 2015; 10 Suppl A100:145-50. [DOI: 10.1111/ijs.12581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 06/16/2015] [Indexed: 11/29/2022]
Abstract
Background The Cerebrovascular Antiplatelet Trialists’ Collaborative Group was formed to obtain and analyze individual patient data from the major randomized trials of common antiplatelet regimens after cerebral ischemia. Although the risk of stroke can be reduced by antiplatelet drugs, there continues to be uncertainty about the balance of risk and benefits of different antiplatelet regimens for an individual patient. Aims Our aim is to provide clinicians with a thorough evidence-based answer on these therapeutic alternatives. Methods We have identified six large randomized trials and plan to meta-analyze the data on an individual patient level. In total, these trials have enrolled 46 948 patients with cerebral ischemia. Uniquely, the Cerebrovascular Antiplatelet Trialists’ Collaborative Group has secured access to the individual data of all of these trials, with the participation of key investigators and pharmaceutical companies. Our principal objective includes deriving a reliable estimate of the efficacy of different antiplatelet regimens on key outcomes including serious vascular events, major ischemic events, major bleeding, and intracranial hemorrhage. Results We propose to redefine composite outcome events, if necessary, to achieve comparability. Further, we aim to build and validate prognostic models for the risk of major bleeding and intracranial hemorrhage and to build a decision model that may support evidence-based decision making about which antiplatelet regimen would be most effective in different risk groups of patients. Conclusions This paper outlines inclusion criteria, outcome measures, baseline characteristics, and planned statistical analysis.
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Affiliation(s)
| | - Jacoba P. Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - László Csiba
- Department of Neurology, University of Debrecen Medical and Health Science Center, Debrecen, Hungary
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - L. Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter J. Koudstaal
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Didier Leys
- Department of Neurology, Roger Salengro Hospital, Lille, France
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris Descartes, Paris, France
| | - Ralph L. Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, Coral Gables, FL, USA
| | - Juhani Sivenius
- Department of Neurology, University Hospital of Kuopio and University of Eastern Finland, Kuopio, Finland
| | - Ale Algra
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
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Pandya A, Sy S, Cho S, Weinstein MC, Gaziano TA. Cost-effectiveness of 10-Year Risk Thresholds for Initiation of Statin Therapy for Primary Prevention of Cardiovascular Disease. JAMA 2015; 314:142-50. [PMID: 26172894 PMCID: PMC4797634 DOI: 10.1001/jama.2015.6822] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The American College of Cardiology and the American Heart Association (ACC/AHA) cholesterol treatment guidelines have wide-scale implications for treating adults without history of atherosclerotic cardiovascular disease (ASCVD) with statins. OBJECTIVE To estimate the cost-effectiveness of various 10-year ASCVD risk thresholds that could be used in the ACC/AHA cholesterol treatment guidelines. DESIGN, SETTING, AND PARTICIPANTS Microsimulation model, including lifetime time horizon, US societal perspective, 3% discount rate for costs, and health outcomes. In the model, hypothetical individuals from a representative US population aged 40 to 75 years received statin treatment, experienced ASCVD events, and died from ASCVD-related or non-ASCVD-related causes based on ASCVD natural history and statin treatment parameters. Data sources for model parameters included National Health and Nutrition Examination Surveys, large clinical trials and meta-analyses for statin benefits and treatment, and other published sources. MAIN OUTCOMES AND MEASURES Estimated ASCVD events prevented and incremental costs per quality-adjusted life-year (QALY) gained. RESULTS In the base-case scenario, the current ASCVD threshold of 7.5% or higher, which was estimated to be associated with 48% of adults treated with statins, had an incremental cost-effectiveness ratio (ICER) of $37,000/QALY compared with a 10% or higher threshold. More lenient ASCVD thresholds of 4.0% or higher (61% of adults treated) and 3.0% or higher (67% of adults treated) had ICERs of $81,000/QALY and $140,000/QALY, respectively. Shifting from a 7.5% or higher ASCVD risk threshold to a 3.0% or higher ASCVD risk threshold was estimated to be associated with an additional 161,560 cardiovascular disease events averted. Cost-effectiveness results were sensitive to changes in the disutility associated with taking a pill daily, statin price, and the risk of statin-induced diabetes. In probabilistic sensitivity analysis, there was a higher than 93% chance that the optimal ASCVD threshold was 5.0% or lower using a cost-effectiveness threshold of $100,000/QALY. CONCLUSIONS AND RELEVANCE In this microsimulation model of US adults aged 45 to 75 years [corrected], the current 10-year ASCVD risk threshold (≥7.5% risk threshold) used in the ACC/AHA cholesterol treatment guidelines has an acceptable cost-effectiveness profile (ICER, $37,000/QALY), but more lenient ASCVD thresholds would be optimal using cost-effectiveness thresholds of $100,000/QALY (≥4.0% risk threshold) or $150,000/QALY (≥3.0% risk threshold). The optimal ASCVD threshold was sensitive to patient preferences for taking a pill daily, changes to statin price, and the risk of statin-induced diabetes.
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Affiliation(s)
- Ankur Pandya
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
| | - Stephen Sy
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
| | - Sylvia Cho
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
| | - Thomas A Gaziano
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts2Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Mahmood D, Jahan K, Habibullah K. Primary prevention with statins in cardiovascular diseases: A Saudi Arabian perspective. J Saudi Heart Assoc 2015; 27:179-91. [PMID: 26136632 PMCID: PMC4481463 DOI: 10.1016/j.jsha.2014.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 09/15/2014] [Accepted: 09/22/2014] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular disease (CVD) constitutes one of the major causes of deaths and disabilities, globally claiming 17.3 million lives a year. Incidence of CVD is expected to rise to 25 million by 2030, and Saudi Arabia, already witnessing a rapid rise in CVDs, is no exception. Statins are the drugs of choice in established CVDs. In the recent past, evidence was increasingly suggesting benefits in primary prevention. But over the last decade Saudi Arabia has a witnessed significant rise in CVD-related deaths. Smoking, high-fat, low-fiber dietary intake, lack of exercise, sedentary life, high blood cholesterol and glucose levels were reported as frequent CVD-risk factors among Saudis, who may therefore be considered for primary prevention with statin. The prevalence of dyslipidemia, in particular, indicates that treatment should be directed at reducing the disorder with lipid-modifying agents and therapeutic lifestyle changes. The recent American College of Cardiology (ACC)/American Heart Association (AHA) guidelines has reported lowering the low-density lipoprotein cholesterol (LDL-C) target levels, prescribed by the 2011 European Society of Cardiology (ESC)/the European Atherosclerosis Society (EAS). The new ACC/AHA guidelines have overemphasized the use of statin while ignoring lipid targets, and have recommended primary prevention with moderate-intensity statin to individuals with diabetes aged 40-75 years and with LDL-C 70-189 mg/dL. Treatment with statin was based on estimated 10-year atherosclerotic-CVD (ASCVD) risk in individuals aged 40-75 years with LDL-C 70 to 189 mg/dL and without clinical ASCVD or diabetes. Adoption of the recent ACC/AHA guidelines will lead to inclusion of a large population for primary prevention with statins, and would cause over treatment to some who actually would not need statin therapy but instead should have been recommended lifestyle modifications. Furthermore, adoption of this guideline may potentially increase the incidences of statin intolerance and side-effects. On the other hand, the most widely used lipid management guideline, the 2011 ESC/EAC guidelines, targets lipid levels at different stages of disease activity before recommending statins. Hence, the 2011 ESC/EAC still offers a holistic and pragmatic approach to treating lipid abnormalities in CVD. Therefore, it is the 2011 ESC/EAC guidelines, and not the recent ACC/AHA guidelines, that should be adopted to draw guidance on primary prevention of CVD in Saudi Arabia.
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Affiliation(s)
- D. Mahmood
- Unaizah College of Pharmacy, Qassim University, Saudi Arabia
| | - K. Jahan
- Department of Pharmacology, Faculty of Pharmacy, Hamdard University, Hamdard Nagar, New Delhi 110062, India
| | - K. Habibullah
- Unaizah College of Pharmacy, Qassim University, Saudi Arabia
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Hutchins R, Pignone MP, Sheridan SL, Viera AJ. Quantifying the utility of taking pills for preventing adverse health outcomes: a cross-sectional survey. BMJ Open 2015; 5:e006505. [PMID: 25967985 PMCID: PMC4431138 DOI: 10.1136/bmjopen-2014-006505] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The utility value attributed to taking pills for prevention can have a major effect on the cost-effectiveness of interventions, but few published studies have systematically quantified this value. We sought to quantify the utility value of taking pills used for prevention of cardiovascular disease (CVD). DESIGN Cross-sectional survey. SETTING Central North Carolina. PARTICIPANTS 708 healthcare employees aged 18 years and older. PRIMARY AND SECONDARY OUTCOMES Utility values for taking 1 pill/day, assessed using time trade-off, modified standard gamble and willingness-to-pay methods. RESULTS Mean age of respondents was 43 years (19-74). The majority of the respondents were female (83%) and Caucasian (80%). Most (80%) took at least 2 pills/day. Mean utility values for taking 1 pill/day using the time trade-off method were: 0.9972 (95% CI 0.9962 to 0.9980). Values derived from the standard gamble and willingness-to-pay methods were 0.9967 (0.9954 to 0.9979) and 0.9989 (95% CI 0.9986 to 0.9991), respectively. Utility values varied little across characteristics such as age, sex, race, education level or number of pills taken per day. CONCLUSIONS The utility value of taking pills daily in order to prevent an adverse CVD health outcome is approximately 0.997.
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Affiliation(s)
- Robert Hutchins
- Health Care and Prevention MD-MPH Program, University of North Carolina at Chapel Hill School of Medicine and Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Michael P Pignone
- Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stacey L Sheridan
- Health Care and Prevention MD-MPH Program, University of North Carolina at Chapel Hill School of Medicine and Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anthony J Viera
- Health Care and Prevention MD-MPH Program, University of North Carolina at Chapel Hill School of Medicine and Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Long-term Cost-effectiveness of Statin Treatment for Primary Prevention of Cardiovascular Disease in the Elderly. Cardiovasc Drugs Ther 2015; 29:187-97. [DOI: 10.1007/s10557-015-6584-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rubio-Terrés C, Soria JM, Morange PE, Souto JC, Suchon P, Mateo J, Saut N, Rubio-Rodríguez D, Sala J, Gracia A, Pich S, Salas E. Economic analysis of thrombo inCode, a clinical-genetic function for assessing the risk of venous thromboembolism. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:233-242. [PMID: 25652150 PMCID: PMC4376955 DOI: 10.1007/s40258-015-0153-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Patients with venous thromboembolism (VTE) commonly have an underlying genetic predisposition. However, genetic tests nowadays in use have very low sensitivity for identifying subjects at risk of VTE. Thrombo inCode(®) is a new genetic tool that has demonstrated very good sensitivity, thanks to very good coverage of the genetic variants that modify the function of the coagulation pathway. OBJECTIVE To conduct an economic analysis of risk assessment of VTE from the perspective of the Spanish National Health System with Thrombo inCode(®) (a clinical-genetic function for assessing the risk of VTE) versus the conventional/standard method used to date (factor V Leiden and prothrombin G20210A). METHODS An economic model was created from the National Health System perspective, using a decision tree in patients aged 45 years with a life expectancy of 81 years. The predictive capacity of VTE, based on identification of thrombophilia using Thrombo inCode(®) and using the standard method, was obtained from two case-control studies conducted in two different populations (S. PAU and MARTHA; 1,451 patients in all). Although this is not always the case, patients who were identified as suffering from thrombophilia were subject to preventive treatment of VTE with warfarin, leading to a reduction in the number of VTE events and an increased risk of severe bleeding. The health state utilities (quality-adjusted life-years [QALYs]) and costs (in 2013 EUR values) were obtained from the literature and Spanish sources. RESULTS On the basis of a price of EUR 180 for Thrombo inCode(®), this would be the dominant option (more effective and with lower costs than the standard method) in both populations. The Monte Carlo probabilistic analyses indicate that the dominance would occur in 100 % of the simulations in both populations. The threshold price of Thrombo inCode(®) needed to reach the incremental cost-effectiveness ratio (ICER) generally accepted in Spain (EUR 30,000 per QALY gained) would be between EUR 3,950 (in the MARTHA population) and EUR 11,993 (in the S. PAU population). CONCLUSION According to the economic model, Thrombo inCode(®) is the dominant option in assessing the risk of VTE, compared with the standard method currently used.
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Affiliation(s)
- C. Rubio-Terrés
- Health Value, C/-Virgen de Aránzazu, 21, 5°B, 28034 Madrid, Spain
| | - J. M. Soria
- Unitat de Genòmica de Malalties Complexes, IIB-Sant Pau, Barcelona, Spain
| | - P. E. Morange
- Inserm UMR_S 1062, 13385 Marseille, France
- Aix-Marseille Université, Marseille, France
| | - J. C. Souto
- Unitat d’Hemostasia i Trombosis IIB-Sant Pau, Barcelona, Spain
| | - P. Suchon
- Inserm Unité Mixte de Recherche en Santé (UMR_S) 937, Paris, France
- ICAN Institute for Cardiometabolism and Nutrition, Université Pierre et Marie Curie Paris 6, Paris, France
| | - J. Mateo
- Unitat d’Hemostasia i Trombosis IIB-Sant Pau, Barcelona, Spain
| | - N. Saut
- Inserm Unité Mixte de Recherche en Santé (UMR_S) 937, Paris, France
- ICAN Institute for Cardiometabolism and Nutrition, Université Pierre et Marie Curie Paris 6, Paris, France
| | | | - J. Sala
- Scientific Department, Ferrer inCode, Barcelona, Spain
| | - A. Gracia
- Scientific Department, Ferrer inCode, Barcelona, Spain
| | - S. Pich
- Scientific Department, Gendiag.exe, Barcelona, Spain
| | - E. Salas
- Scientific Department, Gendiag.exe, Barcelona, Spain
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Hutchins R, Viera AJ, Sheridan SL, Pignone MP. Quantifying the Utility of Taking Pills for Cardiovascular Prevention. Circ Cardiovasc Qual Outcomes 2015; 8:155-63. [DOI: 10.1161/circoutcomes.114.001240] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Robert Hutchins
- From the Department of Medicine, Division of General Internal Medicine, University of California San Francisco (R.H.); Health Care and Prevention MD-MPH Program (A.J.V., S.L.S.) and Gillings School of Global Public Health (A.J.V., S.L.S.), University of North Carolina at Chapel Hill School of Medicine; and Department of Family Medicine (A.J.V.) and Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology (S.L.S., M.P.P.), University of North Carolina at Chapel Hill
| | - Anthony J. Viera
- From the Department of Medicine, Division of General Internal Medicine, University of California San Francisco (R.H.); Health Care and Prevention MD-MPH Program (A.J.V., S.L.S.) and Gillings School of Global Public Health (A.J.V., S.L.S.), University of North Carolina at Chapel Hill School of Medicine; and Department of Family Medicine (A.J.V.) and Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology (S.L.S., M.P.P.), University of North Carolina at Chapel Hill
| | - Stacey L. Sheridan
- From the Department of Medicine, Division of General Internal Medicine, University of California San Francisco (R.H.); Health Care and Prevention MD-MPH Program (A.J.V., S.L.S.) and Gillings School of Global Public Health (A.J.V., S.L.S.), University of North Carolina at Chapel Hill School of Medicine; and Department of Family Medicine (A.J.V.) and Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology (S.L.S., M.P.P.), University of North Carolina at Chapel Hill
| | - Michael P. Pignone
- From the Department of Medicine, Division of General Internal Medicine, University of California San Francisco (R.H.); Health Care and Prevention MD-MPH Program (A.J.V., S.L.S.) and Gillings School of Global Public Health (A.J.V., S.L.S.), University of North Carolina at Chapel Hill School of Medicine; and Department of Family Medicine (A.J.V.) and Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology (S.L.S., M.P.P.), University of North Carolina at Chapel Hill
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Lavikainen P, Korhonen MJ, Huupponen R, Helin-Salmivaara A. Accumulation of cardiovascular and diabetes medication among apparently healthy statin initiators. PLoS One 2015; 10:e0117182. [PMID: 25658919 PMCID: PMC4319777 DOI: 10.1371/journal.pone.0117182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 12/20/2014] [Indexed: 11/19/2022] Open
Abstract
Purpose To characterize accumulation of drug-modifiable cardiovascular (CV) risk factors in statin initiators who had no prior medication or hospitalizations for CV disease or diabetes. Methods A cohort of 45-75-year-old statin initiators in Finland with no prior CV diseases, diabetes or medication for these conditions was followed up for 24 months after statin initiation for accumulation of CV and diabetes drugs. The number of drugs was measured semi-annually since the first statin purchase and analyzed by growth mixture modeling. Results Of the 11 948 apparently healthy statin initiators, 34% purchased at least one additional CV or diabetes drug during the subsequent 24 months. Of those, 20% redeemed no other CV or diabetes drugs at statin initiation but started to accumulate them after 18 months of follow-up, receiving on average 1.3 other drugs at 24 months. The majority, 59%, redeemed on average 0.5 drugs at statin initiation and accumulated 1.5 drugs by the end of 24-month follow-up. Seventeen percent received 1 additional drug at statin initiation, accumulating on average 3 drugs. The remaining 4% with an average of 2 CV or diabetes drugs at statin initiation redeemed 3.5 additional drugs during the follow-up. Conclusions Two years after statin initiation, 2 in 3 apparently healthy initiators could still be defined as such as reflected by CV and diabetes medication use.
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Affiliation(s)
- Piia Lavikainen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland
- Drug Research Doctoral Programme, University of Turku, Turku, Finland
- * E-mail:
| | - Maarit Jaana Korhonen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland
- Department of Public Health, University of Turku, Turku, Finland
| | - Risto Huupponen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland
- Department of Clinical Pharmacology, Tykslab, Turku University Hospital, Turku, Finland
| | - Arja Helin-Salmivaara
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland
- Unit of Primary Health Care, Hospital District of Helsinki and Uusimaa, Helsinki, Finland
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Aarnio E, Korhonen MJ, Huupponen R, Martikainen J. Cost-effectiveness of statin treatment for primary prevention in conditions of real-world adherence--estimates from the Finnish prescription register. Atherosclerosis 2015; 239:240-7. [PMID: 25618032 DOI: 10.1016/j.atherosclerosis.2014.12.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/18/2014] [Accepted: 12/24/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of statin therapy for primary prevention of coronary heart disease (CHD) events under real-world adherence. METHODS A cost-effectiveness model was applied to estimate the expected 10-year costs and health outcomes (in terms of quality-adjusted life-years, QALYs) associated with and without statin treatment (at defined adherence levels) among hypothetical cohorts of Finnish men and women who were initially without established CHD. Treatment efficacy, cost, and quality of life estimates were obtained from published sources. Long-term treatment adherence was measured based on data from the national prescription register. RESULTS At an assumed willingness-to-pay threshold of €20,000 per QALY gained, statin treatment with real-world adherence was cost-effective among the older patient groups when the patients' 10-year CHD risk was as high as 20% and did not seem cost-effective in the youngest age groups. Conversely, statin treatment with full adherence was cost-effective for almost all patient groups with a 10-year CHD risk of at least 15%. CONCLUSIONS Even though generic statins are now low-cost drugs, treatment adherence seems to have a major impact on the cost-effectiveness of statin treatment in primary prevention. This finding stresses the importance of making a concerted effort for improving adherence among patients on statin therapy to obtain full benefit of the investment in statins. Therefore, novel cost-effective approaches to improve treatment adherence are warranted.
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Affiliation(s)
- Emma Aarnio
- Department of Clinical Pharmacology, Tykslab, Turku University Hospital, Turku, Finland; Pharmacoeconomics and Outcomes Research Unit (PHORU), School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
| | - Maarit J Korhonen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland.
| | - Risto Huupponen
- Department of Clinical Pharmacology, Tykslab, Turku University Hospital, Turku, Finland; Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland.
| | - Janne Martikainen
- Pharmacoeconomics and Outcomes Research Unit (PHORU), School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
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