Comparing impact and cost-effectiveness of primary prevention strategies for lipid-lowering.
BACKGROUND
Lipid-lowering therapy is costly but effective at reducing coronary heart disease (CHD) risk.


OBJECTIVE
To assess the cost-effectiveness and public health impact of Adult Treatment Panel III (ATP III) guidelines and compare with a range of risk- and age-based alternative strategies.


METHODS
The CHD Policy Model, a Markov-type cost-effectiveness model.


METHODS
National surveys (1999 to 2004), vital statistics (2000), the Framingham Heart Study (1948 to 2000), other published data, and a direct survey of statin costs (2008).


METHODS
U.S. population age 35 to 85 years.


METHODS
2010 to 2040.


CONCLUSIONS
Health care system.


METHODS
Lowering of low-density lipoprotein cholesterol with HMG-CoA reductase inhibitors (statins).


METHODS
Incremental cost-effectiveness.


RESULTS
Full adherence to ATP III primary prevention guidelines would require starting (9.7 million) or intensifying (1.4 million) statin therapy for 11.1 million adults and would prevent 20,000 myocardial infarctions and 10,000 CHD deaths per year at an annual net cost of $3.6 billion ($42,000/QALY) if low-intensity statins cost $2.11 per pill. The ATP III guidelines would be preferred over alternative strategies if society is willing to pay $50,000/QALY and statins cost $1.54 to $2.21 per pill. At higher statin costs, ATP III is not cost-effective; at lower costs, more liberal statin-prescribing strategies would be preferred; and at costs less than $0.10 per pill, treating all persons with low-density lipoprotein cholesterol levels greater than 3.4 mmol/L (>130 mg/dL) would yield net cost savings.


RESULTS
Results are sensitive to the assumptions that LDL cholesterol becomes less important as a risk factor with increasing age and that little disutility results from taking a pill every day.


CONCLUSIONS
Randomized trial evidence for statin effectiveness is not available for all subgroups.


CONCLUSIONS
The ATP III guidelines are relatively cost-effective and would have a large public health impact if implemented fully in the United States. Alternate strategies may be preferred, however, depending on the cost of statins and how much society is willing to pay for better health outcomes.


BACKGROUND
Flight Attendants' Medical Research Institute and the Swanson Family Fund. The Framingham Heart Study and Framingham Offspring Study are conducted and supported by the National Heart, Lung, and Blood Institute.
Pletcher
Mark J
MJ
University of California, San Francisco, San Francisco, California 94107, USA. mpletcher@epi.ucsf.edu
Lazar
Lawrence
L
Bibbins-Domingo
Kirsten
K
Moran
Andrew
A
Rodondi
Nicolas
N
Coxson
Pamela
P
Lightwood
James
J
Williams
Lawrence
L
Goldman
Lee
L
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D008078:Cholesterol, LDL / Q000097:blood*; D003198:Computer Simulation; D003327:Coronary Disease / Q000453:epidemiology / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D019983:Guideline Adherence; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000191:economics* / Q000627:therapeutic use; D008390:Markov Chains; D008875:Middle Aged; D009010:Monte Carlo Method; D017410:Practice Guidelines as Topic; D011322:Primary Prevention / Q000191:economics*; D019057:Quality-Adjusted Life Years; D012307:Risk Factors
D008078:Cholesterol, LDL; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors