title: Use of low density lipoprotein particle number levels as an aid in statin treatment decisions for intermediate risk patients: a cost-effectiveness analysis.
abstract: The 2013 ACC/AHA guideline recommended either no statin therapy or moderate-intensity statin therapy (MST) for intermediate risk patients-those with 5-7.5% 10-year risk and without cardiovascular disease (CVD), hypercholesterolemia or diabetes. The guideline further suggested that the therapy choice be based on patient-clinician discussions of risks and benefits. Since low-density lipoprotein particle (LDL-P) levels were reported to be associated with CVD independently of traditional risk factors in intermediate and low risk patients, we investigated the cost-effectiveness of using LDL-P levels to identify intermediate risk patients likely to benefit from initiating or intensifying statin therapy.
  
  
  
  We evaluated 5 care strategies for intermediate risk patients. These included the strategies suggested by the guideline: no-statin therapy and MST. We compared each of these strategies to a related strategy that incorporated LDL-P testing. No-statin therapy was compared with the strategy of MST for those with high LDL-P levels and no statin therapy for all other patients (test-and-MST). MST was compared with the strategy of high-intensity statin therapy (HST) for those with high LDL-P levels and MST for all other patients (test-and-HST). We also evaluated the strategy of HST for all. Costs (payer perspective) and utilities were assessed over a 5-year time horizon in a Markov model of 100,000 hypothetical intermediate risk patients.
  
  
  
  HST dominated all other strategies, costing less and-despite causing 739 more cases of diabetes than did MST-resulting in more quality adjusted life-years (QALYs). For patient-clinician discussions that would otherwise lead to the MST strategy, we found the test-and-HST strategy reduced costs by $4.67 MM and resulted in 134 fewer CVD events and 115 additional QALYs. For patient-clinician discussions that would otherwise lead to no statin therapy, we found that the test-and-MST strategy reduced costs by $3.25 MM, resulted in 97 fewer CVD events and 44 additional QALYs.
  
  
  
  The HST strategy was cost saving and improved outcomes in intermediate risk patients. For patient and clinicians concerned about the adverse events associated with HST, using LDL-P levels to target intensified statin therapy could improve outcomes and reduce costs.
authors.affiliation: Quest Diagnostics, Nichols Institute, 33608 Ortega Highway, 92675, San Juan Capistrano, CA, USA. dov.shiffman@questdiagnostics.com.
authors.forename: Dov
authors.initials: D
authors.lastname: Shiffman
authors.affiliation: Quest Diagnostics, Nichols Institute, 33608 Ortega Highway, 92675, San Juan Capistrano, CA, USA.
authors.forename: Andre R
authors.initials: AR
authors.lastname: Arellano
authors.affiliation: Quest Diagnostics, Nichols Institute, 33608 Ortega Highway, 92675, San Juan Capistrano, CA, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Caulfield
authors.affiliation: Quest Diagnostics, Nichols Institute, 33608 Ortega Highway, 92675, San Juan Capistrano, CA, USA.
authors.forename: Judy Z
authors.initials: JZ
authors.lastname: Louie
authors.affiliation: Quest Diagnostics, Nichols Institute, 33608 Ortega Highway, 92675, San Juan Capistrano, CA, USA.
authors.forename: Lance A
authors.initials: LA
authors.lastname: Bare
authors.affiliation: Quest Diagnostics, Nichols Institute, 33608 Ortega Highway, 92675, San Juan Capistrano, CA, USA.
authors.forename: James J
authors.initials: JJ
authors.lastname: Devlin
authors.affiliation: Department of Clinical Sciences, Lund University, Malmö, Sweden.|Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden.
authors.forename: Olle
authors.initials: O
authors.lastname: Melander
mesh_terms: D000328:Adult; D000368:Aged; D008078:Cholesterol, LDL / Q000097:blood*; D003362:Cost-Benefit Analysis; D003657:Decision Making; D005260:Female; D005544:Forecasting; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D006937:Hypercholesterolemia / Q000097:blood / Q000188:drug therapy / Q000191:economics*; D008297:Male; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D012307:Risk Factors
chemical_list: D008078:Cholesterol, LDL; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors
keywords: Cost-effectiveness analysis; LDL-P test; Primary prevention