title: Comparing the cost-effectiveness of four novel risk markers for screening asymptomatic individuals to prevent cardiovascular disease (CVD) in the US population.
abstract: BACKGROUND
  High sensitivity CRP (hsCRP), coronary artery calcification on CT (CT calcium), carotid artery intima media thickness on ultrasound (cIMT) and ankle-brachial index (ABI) improve prediction of cardiovascular disease (CVD) risk, but the benefit of screening with these novel risk markers in the U.S. population is unclear.
  
  
  RESULTS
  A microsimulation model evaluating lifelong cost-effectiveness for individuals aged 40-85 at intermediate risk of CVD, using 2003-2004 NHANES-III (N=3736), Framingham Heart Study, U.S. Vital Statistics, meta-analyses of independent predictive effects of the four novel risk markers and treatment effects was constructed. Using both an intention-to-treat (assumes adherence <100% and incorporates disutility from taking daily medications) and an as-treated (100% adherence and no disutility) analysis, quality adjusted life years (QALYs), lifetime costs (2014 US $), and incremental cost-effectiveness ratios (ICER in $/QALY gained) of screening with hsCRP, CT coronary calcium, cIMT and ABI were established compared with current practice, full adherence to current guidelines, and ubiquitous statin therapy. In the intention-to-treat analysis in men, screening with CT calcium was cost effective ($32,900/QALY) compared with current practice. In women, screening with hsCRP was cost effective ($32,467/QALY). In the as-treated analysis, statin therapy was both more effective and less costly than all other strategies for both men and women.
  
  
  CONCLUSIONS
  When a substantial disutility from taking daily medication is assumed, screening men with CT coronary calcium is likely to be cost-effective whereas screening with hsCRP has value in women. The individual perceived disutility for taking daily medication should play a key role in the decision.
authors.affiliation: Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands; Department of Radiology, Erasmus MC, Rotterdam, The Netherlands.
authors.forename: Bob J H
authors.initials: BJ
authors.lastname: van Kempen
authors.affiliation: Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, USA.
authors.forename: Bart S
authors.initials: BS
authors.lastname: Ferket
authors.affiliation: Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.affiliation: Institute for Health & Aging and Department of Social and Behavioral Sciences, University of California, San Francisco, CA, USA.
authors.forename: Wendy
authors.initials: W
authors.lastname: Max
authors.affiliation: Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands; Department of Radiology, Erasmus MC, Rotterdam, The Netherlands; Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA. Electronic address: m.hunink@erasmusmc.nl.
authors.forename: M G
authors.initials: MG
authors.lastname: Myriam Hunink
authors.affiliation: Department of Medicine, The University of California, San Francisco, CA, USA.
authors.forename: Kirsten E
authors.initials: KE
authors.lastname: Fleischmann
mesh_terms: D055109:Ankle Brachial Index / Q000191:economics; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000191:economics* / Q000378:metabolism; D002114:Calcinosis / Q000175:diagnosis* / Q000191:economics* / Q000517:prevention & control; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000191:economics; D059168:Carotid Intima-Media Thickness / Q000191:economics; D003324:Coronary Artery Disease / Q000097:blood / Q000175:diagnosis* / Q000191:economics* / Q000517:prevention & control; D003362:Cost-Benefit Analysis / Q000191:economics; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics; D011237:Predictive Value of Tests; D012307:Risk Factors; D012680:Sensitivity and Specificity; D014481:United States
chemical_list: D015415:Biomarkers; D002097:C-Reactive Protein
keywords: Comparative effectiveness; Cost-effectiveness; Long-term prognosis; Novel biomarkers; Primary prevention