Cholesterol-reduction intervention study (CRIS): a randomized trial to assess effectiveness and costs in clinical practice

Cardiac rehabilitation with nurse care management and telephonic interactions at a community hospital: program evaluation of participation and lipid outcomes

Cardiac rehabilitation (CR) can help patients with heart disease control some risk factors, limit new coronary artery lesions, and decrease death rates. However, participation rates in CR are low. Using a descriptive design, we evaluated a modified CR program in which nurse care managers used telephonic communication with patients in their homes by comparing it to a traditional CR program in a hospital setting. Using multivariate analysis we compared the patient cohorts eligible for each of the programs, and program participants to the nonparticipants for each program. Compared to traditional CR, the modified CR program with nurse care management was associated with significantly improved participation rates (11% vs. 22%) and the apparent overcoming of several well-described barriers to CR participation (distance from the hospital and domestic isolation). Risk factor management, including testing of serum lipids and achieving goals for lipid reduction, for participants in both CR programs was superior to risk factor management for nonparticipants.

Discontinuation and switching of therapy after initiation of lipid-lowering drugs: the effects of comorbidities and patient characteristics

AIMS

To evaluate the effects of comorbidities and patient characteristics on treatment continuation among patients starting their first course of lipid-lowering drug (LLD) therapy.

METHODS

Within the UK General Practice Research Database (GPRD), we identified 22 408 patients who started LLD therapy due to coronary heart disease, hyperlipidaemia, or other atherosclerotic diseases, and who received > or = two prescriptions for LLD between January 1 1990 and December 31 1997. Differences in potential predictors of treatment continuation between patients who continued, and patients who discontinued/switched lipid-lowering therapy within 1 year after treatment initiation were compared by fitting multivariate logistic regression models. The effects of baseline characteristics on treatment continuation after switching of LLDs were also analysed.

RESULTS

Discontinuation/switching of lipid-lowering therapy was common during the study period, especially among patients who received nonstatin, nonfibrate LLDs (log-rank test P = 0.0001). Statin use, more frequent physician visits, more concurrent cardiovascular medications, diabetes, and fewer noncardiovascular medications were associated with treatment continuation of LLDs. Among patients who switched therapy, prescribing of a statin as the substituted LLD, more concurrent cardiovascular medications, and later treatment switching were related to a higher probability of treatment continuation after switching LLDs.

CONCLUSIONS

Treatment continuation after initiation or switching of lipid-lowering therapy largely increased with concomitant cardiovascular comorbidities, and more health care utilization, and is more common for statins than for other LLDs. Practice guidelines, patient education, and quality of care assessment for lipid-lowering therapy should emphasize factors that predispose patients to discontinuation/switching, in an effort to optimize the choice of therapeutic regimens and to improve patient adherence.

Who receives lipid-lowering drugs: the effects of comorbidities and patient characteristics on treatment initiation

AIMS

Little is known about the effects of comorbidities and patient characteristics on treatment initiation of lipid-lowering drugs (LLDs), which can be helpful in the evaluation of the risks and benefits of LLDs.

METHODS

Baseline characteristics among subjects who received their first ever-recorded LLD prescription in general practice between 1 January 1990 and 31 December 1997, and hyperlipidaemic patients without LLD therapy during the same period were obtained from the UK General Practice Research Database. Differences between patients who received and patients who did not receive LLDs, as well as patients who received different classes of LLDs were compared by fitting multivariate logistic regression models that adjusted for age, sex, body mass index, smoking status, and year of treatment initiation or hyperlipidaemia diagnosis.

RESULTS

We found that there were many differences in the baseline characteristics, such as number of general practitioner visits, diagnosis and severity of cardiovascular diseases, and concurrent medications, between the 25 331 patients who received and the 16 287 patients who did not receive LLDs. We also noted that patients with statin therapy had more prior hospitalization, more recent myocardial infarction/stroke, and more concurrent cardiovascular medications, than those patients who received other LLDs.

CONCLUSIONS

Patients who received LLDs in primary care, especially patients with statin therapy, were more likely to be elderly and to have more concomitant severe cardiovascular comorbidities than those hyperlipidaemic patients who did not receive LLDs. Examining the medical records of individuals eligible for LLD therapy is an important first step in selectively targeting who will experience the greatest benefit to risk ratio for the treatment of hyperlipidaemia, and is an important step in avoiding confounding by indication when designing epidemiological studies comparing the risks and benefits of treatments for hyperlipidaemia.

Lifetime health and economic benefits of weight loss among obese persons

OBJECTIVES

This study estimated the lifetime health and economic benefits of sustained modest weight loss among obese persons.

METHODS

We developed a dynamic model of the relationship between body mass index (BMI) and the risks and costs of 5 obesity-related diseases: hypertension, hypercholesterolemia, type 2 diabetes, coronary heart disease (CHD), and stroke. We then calculated the lifetime health and economic benefits of a sustained 10% reduction in body weight for men and women aged 35 to 64 years with mild, moderate, and severe obesity.

RESULTS

Depending on age, gender, and initial BMI, a sustained 10% weight loss would (1) reduce the expected number of years of life with hypertension, hypercholesterolemia, and type 2 diabetes by 1.2 to 2.9, 0.3 to 0.8, and 0.5 to 1.7, respectively; (2) reduce the expected lifetime incidence of CHD and stroke by 12 to 38 cases per 1000 and 1 to 13 cases per 1000, respectively; (3) increase life expectancy by 2 to 7 months; and (4) reduce expected lifetime medical care costs of these 5 diseases by $2200 to $5300.

CONCLUSIONS

Sustained modest weight loss among obese persons would yield substantial health and economic benefits.

A population-based treat-to-target pharmacoeconomic analysis of HMG-CoA reductase inhibitors in hypercholesterolemia

The 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors have become the drugs of choice for the treatment of patients with hypercholesterolemia. However, one of the major concerns with these drugs is cost. In an attempt to develop a cost-effective treatment strategy for patients referred to our lipid clinic, we conducted a meta-analysis to estimate the lipid-lowering efficacy of the various HMG-CoA reductase inhibitors alone or in combination with niacin or cholestyramine. Based on cholesterol-lowering efficacy estimates derived from a literature-based meta-analysis, we performed a population-based treat-to-target analysis. Fifty-six trials with 101 monotherapy cohorts and 20 trials with 31 combination-therapy cohorts (573 patients) were included in the meta-analysis. Based on reduction in low-density lipoprotein cholesterol (LDL-C), the most effective monotherapy was atorvastatin and the least effective monotherapy was fluvastatin. Combination therapy was more effective in reducing LDL-C than monotherapy with the respective HMG-CoA reductase inhibitor. However, on the basis of dollars spent per percentage of LDL-C reduction, combination therapy was frequently less cost-effective than monotherapy. In addition, combination therapy was associated with a higher rate of noncompliance and a greater risk of drug-drug interactions. As a result, we based our treat-to-target analysis on the use of monotherapy as first-line treatment, with combination therapy reserved for patients failing to achieve the target LDL-C levels of the US National Cholesterol Education Program Adult Treatment Panel II (NCEP ATP-II) with monotherapy. In the population-based treat-to-target analysis, atorvastatin was the most cost-effective drug for high-risk patients (those with coronary heart disease [CHD]), whereas fluvastatin was the most cost-effective agent for low-risk patients (<2 risk factors for CHD) and moderate-risk patients (> or =2 risk factors for CHD). If 1 drug is chosen to treat all patients (i.e., in cases of formulary restriction), atorvastatin would be the most cost-effective agent. In adapting the findings on cholesterol-lowering efficacy from this analysis to our lipid clinic, we concluded that the most cost-effective treatment approach is to individualize the selection of an HMG-CoA reductase inhibitor based on both coronary risk and the LDL-C reduction required to achieve NCEP ATP-II goals. Based on our results, 2 agents--atorvastatin and fluvastatin--should be available on the formulary.

Use of diagnostic cluster methodology for therapeutic costing and drug surveillance of HMG-CoA reductase-inhibitor therapy

Diagnostic cluster methodology groups patients having similar medical conditions according to their International Classification of Diseases, 9th Revision codes. Episodes of care related to the diagnostic cluster can then be tracked from the claims data to determine the total charges associated with patient management. A retrospective claims analysis using an episode registry database was conducted to determine the 1-year (July 1, 1995, to June 30, 1996) covered charge for statin therapy, the overall cost of treating related cardiovascular (CV) disease, and the cost impact of coadministration of drugs that potentially compete for hepatic metabolism. The three statin treatment groups (lovastatin, pravastatin, and simvastatin) were similar with respect to age, gender, mean number of prescription refills, rate of refill compliance, and prevalence of the coadministration of potentially interacting agents. Before adjustment for severity of illness, there were no significant differences between groups in prescription drugs/services (statin Rx/Svc) or total CV charges. After adjustment for severity of illness, the pravastatin group had the lowest statin Rx/Svc and total CV charges. Within the group with the greatest severity of illness, statin Rx/Svc charges were significantly lower with pravastatin than with lovastatin and simvastatin. The statin Rx/Svc charges were not significantly different between lovastatin and simvastatin. Coadministration of a potentially interacting agent significantly increased both the statin Rx/Svc and total CV charges within the simvastatin-treated group but did not significantly influence costs in the lovastatin- or pravastatin-treated groups. The estimates of direct costs derived from this analysis are consistent with findings in the published literature and demonstrate that pravastatin has cost advantages compared with lovastatin and simvastatin. Diagnostic cluster methodology also generated valuable information regarding drug surveillance and the health care cost impact of potential drug-drug interactions with selected statins.

Economic evaluation of cholesterol-related interventions in general practice. An appraisal of the evidence

STUDY OBJECTIVE

To investigate and evaluate published data on cost effectiveness of cholesterol lowering interventions, and how this information could be interpreted in a rational approach of cholesterol management in general practice.

DESIGN

A systematic review of the literature.

SETTING

No restriction on setting.

MATERIALS

Papers reporting on the cost effectiveness or cost utility of prevention of (recurrent) coronary heart disease by reduction of hypercholesterolaemia in adults.

MAIN RESULTS

Thirty nine studies, most cost effectiveness analyses, were included. In 24 studies drug interventions only were analysed. Costs of screening to target cholesterol lowering interventions to persons with hypercholesterolaemia were considered in nine studies. Adjustments of the efficacy of the intervention for community effectiveness were described in seven studies. In four studies life years gained were adjusted for quality of life. Despite large variation in the outcomes, there is a constant tendency towards a less favourable cost effectiveness ratio for intervening in persons without coronary heart disease compared with persons with coronary heart disease and for women compared with men.

CONCLUSIONS

There is lack of data on cost effectiveness of cholesterol lowering interventions in the general practice setting. The cost effectiveness of cholesterol lowering in general practice deteriorates when all relevant costs are taken into account and when efficacy is corrected for community effectiveness. Cholesterol lowering intervention is more cost effective in men compared with women and in patients with coronary heart disease compared with persons without coronary heart disease. Considerations from cost effectiveness analyses should be incorporated into the development and implementation of national cholesterol guidelines for general practitioners. Standardisation of cost effectiveness studies is important for future economic evaluations.

Vitamin supplementation therapy in the elderly

Vitamin supplementation in large dosages is increasingly common in the older population. Often, such supplementation is used in an attempt to improve an individual's health status. There have been claims that the effects of vitamins halt the normal aging process or prevent and cure disease. However, several recent studies have failed to demonstrate the efficacy of vitamin supplementation in preventing several types of cancer. In moderate dosages, supplementation with vitamin E (tocopherols) shows promise as a lipid antioxidant, and may reduce the risk of coronary heart disease. However, before vitamin E becomes an accepted medical therapy, further long term studies must be undertaken to examine the safety and efficacy of such therapy. An adequate intake of vitamins should be ensured by adherence to a well balanced diet. However, the elderly are prone to circumstances that may prevent them from eating a balanced diet. In addition, there are several age-related medical conditions that may predispose individuals to dietary and vitamin deficiencies. To prevent vitamin deficiency diseases and their associated morbidity, modest vitamin supplementation may be necessary. However, supplementation should be reserved for individuals with documented deficiency or who are at risk of developing such deficiencies, especially those who are homebound or institutionalised. Vitamins taken in large dosages should be considered as drugs. These medicines, which are obtainable over-the-counter, should be carefully regulated to prevent toxicity.