Physician extenders for cost-effective management of hypercholesterolemia.
OBJECTIVE
Treatment of elevated cholesterol levels reduces morbidity and mortality from coronary heart disease in high-risk patients, but can be costly. The purpose of this study was to determine whether physician extenders emphasizing diet modification and, when necessary, effective and inexpensive drug algorithms can provide more cost-effective therapy than conventional care.


METHODS
Randomized controlled trial.


METHODS
A Department of Veterans Affairs Medical Center.


METHODS
Two hundred forty-seven veterans with type IIa hypercholesterolemia.


METHODS
Patients assigned to either a cholesterol treatment program (CTP) or usual health care provided by general internists (UHC). CTP included intensive dietary therapy administered by a registered dietitian utilizing individual and group counseling and drug therapy initiated by physician extenders for those failing to achieve goal low-density lipoprotein (LDL) levels with diet alone. A drug selection algorithm for CTP subjects utilized niacin as initial therapy followed by bile acid sequestrants and lovastatin. Subjects were followed prospectively for 2 years.


METHODS
Primary outcome measurements were effectiveness of therapy defined as reductions in LDL cholesterol (LDL-C), and whether goal LDL-C levels were achieved; costs of therapy; and cost-effectiveness defined as the cost per unit reduction in the LDL-C.


RESULTS
Total program costs were higher for CTP patients than for UHC patients ($659 +/- $43 vs $477 +/- $42 per patient, p < .001). However, at 24 months the patients in CTP were more likely to achieve LDL goal levels (65% vs 44%, p < .005), and also achieved greater reductions in LDL-C 27% +/- 2% vs 14% +/- 2% at 24 months, p < .001). Program costs per unit (mmol/L) reduction in the LDL-C, a measure of cost-effectiveness, was significantly lower for CTP ($758 +/- $58 vs $1,058 +/- $70, p = .002).


CONCLUSIONS
Although more expensive than usual care, the greater effectiveness of physician extenders implementing cholesterol treatment algorithms resulted in more cost-effective therapy.
Schectman
G
G
Department of Medicine, Milwaukee Veterans Affairs Medical Center, Medical College of Wisconsin, USA.
Wolff
N
N
Byrd
J C
JC
Hiatt
J G
JG
Hartz
A
A
D000924:Anticholesteremic Agents / Q000191:economics / Q000627:therapeutic use; D002784:Cholesterol / Q000097:blood; D003362:Cost-Benefit Analysis / Q000191:economics*; D004035:Diet Therapy / Q000191:economics; D005500:Follow-Up Studies; D006801:Humans; D006937:Hypercholesterolemia / Q000097:blood / Q000191:economics* / Q000628:therapy; D008074:Lipoproteins / Q000097:blood / Q000187:drug effects; D008148:Lovastatin / Q000191:economics / Q000627:therapeutic use; D008875:Middle Aged; D010823:Physician Assistants / Q000191:economics*; D011446:Prospective Studies; D016896:Treatment Outcome
D000924:Anticholesteremic Agents; D008074:Lipoproteins; D002784:Cholesterol; D008148:Lovastatin