title: Cost-effectiveness of the polypill versus risk assessment for prevention of cardiovascular disease.
abstract: There is an international trend towards recommending medication to prevent cardiovascular disease (CVD) in individuals at increasingly lower cardiovascular risk. We assessed the cost-effectiveness of a population approach with a polypill including a statin (simvastatin 20 mg) and three antihypertensive agents (amlodipine 2.5 mg, losartan 25 mg and hydrochlorothiazide 12.5 mg) and periodic risk assessment with different risk thresholds.
  
  
  
  We developed a microsimulation model for lifetime predictions of CVD events, diabetes, and death in 259 146 asymptomatic UK Biobank participants aged 40-69 years. We assessed incremental costs and quality-adjusted life-years (QALYs) for polypill scenarios with the same combination of agents and doses but differing for starting age, and periodic risk assessment with 10-year CVD risk thresholds of 10% and 20%.
  
  
  
  Restrictive risk assessment, in which statins and antihypertensives were prescribed when risk exceeded 20%, was the optimal strategy gaining 123 QALYs (95% credible interval (CI) -173 to 387) per 10 000 individuals at an extra cost of £1.45 million (95% CI 0.89 to 1.94) as compared with current practice. Although less restrictive risk assessment and polypill scenarios prevented more CVD events and attained larger survival gains, these benefits were offset by the additional costs and disutility of daily medication use. Lowering the risk threshold for prescription of statins to 10% was economically unattractive, costing £40 000 per QALY gained. Starting the polypill from age 60 onwards became the most cost-effective scenario when annual drug prices were reduced below £240. All polypill scenarios would save costs at prices below £50.
  
  
  
  Periodic risk assessment using lower risk thresholds is unlikely to be cost-effective. The polypill would become cost-effective if drug prices were reduced.
authors.affiliation: Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA.|Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.|Department of Radiology, Erasmus MC, Rotterdam, The Netherlands.
authors.forename: Bart S
authors.initials: BS
authors.lastname: Ferket
authors.affiliation: Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.|Department of Radiology, Erasmus MC, Rotterdam, The Netherlands.|Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
authors.forename: M G Myriam
authors.initials: MG
authors.lastname: Hunink
authors.affiliation: William Harvey Research Institute and NIHR Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Khanji
authors.affiliation: Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
authors.forename: Isha
authors.initials: I
authors.lastname: Agarwal
authors.affiliation: Division of Cardiology, UCSF Medical Center, San Francisco, California, USA.
authors.forename: Kirsten E
authors.initials: KE
authors.lastname: Fleischmann
authors.affiliation: William Harvey Research Institute and NIHR Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK.
authors.forename: Steffen E
authors.initials: SE
authors.lastname: Petersen
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000368:Aged; D017311:Amlodipine / Q000191:economics / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D004338:Drug Combinations; D016527:Drug Costs; D050171:Dyslipidemias / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics*; D005260:Female; D006801:Humans; D006852:Hydrochlorothiazide / Q000191:economics / Q000627:therapeutic use; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use*; D006973:Hypertension / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics*; D019808:Losartan / Q000191:economics / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D011322:Primary Prevention / Q000191:economics* / Q000379:methods; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment; D012307:Risk Factors; D019821:Simvastatin / Q000191:economics / Q000627:therapeutic use; D013607:Tablets; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000959:Antihypertensive Agents; D004338:Drug Combinations; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D013607:Tablets; D006852:Hydrochlorothiazide; D017311:Amlodipine; D019821:Simvastatin; D019808:Losartan