Ankur Pandya1, Stephen Sy1, Sylvia Cho1, Milton C Weinstein1, Thomas A Gaziano2. 1. Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts. 2. Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts2Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Abstract
IMPORTANCE: The American College of Cardiology and the American Heart Association (ACC/AHA) cholesterol treatment guidelines have wide-scale implications for treating adults without history of atherosclerotic cardiovascular disease (ASCVD) with statins. OBJECTIVE: To estimate the cost-effectiveness of various 10-year ASCVD risk thresholds that could be used in the ACC/AHA cholesterol treatment guidelines. DESIGN, SETTING, AND PARTICIPANTS: Microsimulation model, including lifetime time horizon, US societal perspective, 3% discount rate for costs, and health outcomes. In the model, hypothetical individuals from a representative US population aged 40 to 75 years received statin treatment, experienced ASCVD events, and died from ASCVD-related or non-ASCVD-related causes based on ASCVD natural history and statin treatment parameters. Data sources for model parameters included National Health and Nutrition Examination Surveys, large clinical trials and meta-analyses for statin benefits and treatment, and other published sources. MAIN OUTCOMES AND MEASURES: Estimated ASCVD events prevented and incremental costs per quality-adjusted life-year (QALY) gained. RESULTS: In the base-case scenario, the current ASCVD threshold of 7.5% or higher, which was estimated to be associated with 48% of adults treated with statins, had an incremental cost-effectiveness ratio (ICER) of $37,000/QALY compared with a 10% or higher threshold. More lenient ASCVD thresholds of 4.0% or higher (61% of adults treated) and 3.0% or higher (67% of adults treated) had ICERs of $81,000/QALY and $140,000/QALY, respectively. Shifting from a 7.5% or higher ASCVD risk threshold to a 3.0% or higher ASCVD risk threshold was estimated to be associated with an additional 161,560 cardiovascular disease events averted. Cost-effectiveness results were sensitive to changes in the disutility associated with taking a pill daily, statin price, and the risk of statin-induced diabetes. In probabilistic sensitivity analysis, there was a higher than 93% chance that the optimal ASCVD threshold was 5.0% or lower using a cost-effectiveness threshold of $100,000/QALY. CONCLUSIONS AND RELEVANCE: In this microsimulation model of US adults aged 45 to 75 years [corrected], the current 10-year ASCVD risk threshold (≥7.5% risk threshold) used in the ACC/AHA cholesterol treatment guidelines has an acceptable cost-effectiveness profile (ICER, $37,000/QALY), but more lenient ASCVD thresholds would be optimal using cost-effectiveness thresholds of $100,000/QALY (≥4.0% risk threshold) or $150,000/QALY (≥3.0% risk threshold). The optimal ASCVD threshold was sensitive to patient preferences for taking a pill daily, changes to statin price, and the risk of statin-induced diabetes.
IMPORTANCE: The American College of Cardiology and the American Heart Association (ACC/AHA) cholesterol treatment guidelines have wide-scale implications for treating adults without history of atherosclerotic cardiovascular disease (ASCVD) with statins. OBJECTIVE: To estimate the cost-effectiveness of various 10-year ASCVD risk thresholds that could be used in the ACC/AHA cholesterol treatment guidelines. DESIGN, SETTING, AND PARTICIPANTS: Microsimulation model, including lifetime time horizon, US societal perspective, 3% discount rate for costs, and health outcomes. In the model, hypothetical individuals from a representative US population aged 40 to 75 years received statin treatment, experienced ASCVD events, and died from ASCVD-related or non-ASCVD-related causes based on ASCVD natural history and statin treatment parameters. Data sources for model parameters included National Health and Nutrition Examination Surveys, large clinical trials and meta-analyses for statin benefits and treatment, and other published sources. MAIN OUTCOMES AND MEASURES: Estimated ASCVD events prevented and incremental costs per quality-adjusted life-year (QALY) gained. RESULTS: In the base-case scenario, the current ASCVD threshold of 7.5% or higher, which was estimated to be associated with 48% of adults treated with statins, had an incremental cost-effectiveness ratio (ICER) of $37,000/QALY compared with a 10% or higher threshold. More lenient ASCVD thresholds of 4.0% or higher (61% of adults treated) and 3.0% or higher (67% of adults treated) had ICERs of $81,000/QALY and $140,000/QALY, respectively. Shifting from a 7.5% or higher ASCVD risk threshold to a 3.0% or higher ASCVD risk threshold was estimated to be associated with an additional 161,560 cardiovascular disease events averted. Cost-effectiveness results were sensitive to changes in the disutility associated with taking a pill daily, statin price, and the risk of statin-induced diabetes. In probabilistic sensitivity analysis, there was a higher than 93% chance that the optimal ASCVD threshold was 5.0% or lower using a cost-effectiveness threshold of $100,000/QALY. CONCLUSIONS AND RELEVANCE: In this microsimulation model of US adults aged 45 to 75 years [corrected], the current 10-year ASCVD risk threshold (≥7.5% risk threshold) used in the ACC/AHA cholesterol treatment guidelines has an acceptable cost-effectiveness profile (ICER, $37,000/QALY), but more lenient ASCVD thresholds would be optimal using cost-effectiveness thresholds of $100,000/QALY (≥4.0% risk threshold) or $150,000/QALY (≥3.0% risk threshold). The optimal ASCVD threshold was sensitive to patient preferences for taking a pill daily, changes to statin price, and the risk of statin-induced diabetes.
Authors: L A Prosser; A A Stinnett; P A Goldman; L W Williams; M G Hunink; L Goldman; M C Weinstein Journal: Ann Intern Med Date: 2000-05-16 Impact factor: 25.391
Authors: David M Eddy; William Hollingworth; J Jaime Caro; Joel Tsevat; Kathryn M McDonald; John B Wong Journal: Med Decis Making Date: 2012 Sep-Oct Impact factor: 2.583
Authors: Gabriel S Tajeu; John N Booth; Lisandro D Colantonio; Rebecca F Gottesman; George Howard; Daniel T Lackland; Emily C O'Brien; Suzanne Oparil; Joseph Ravenell; Monika M Safford; Samantha R Seals; Daichi Shimbo; Steven Shea; Tanya M Spruill; Rikki M Tanner; Paul Muntner Journal: Circulation Date: 2017-06-20 Impact factor: 29.690
Authors: Ankur Pandya; Stephen Sy; Sylvia Cho; Sartaj Alam; Milton C Weinstein; Thomas A Gaziano Journal: Med Decis Making Date: 2017-05-10 Impact factor: 2.583
Authors: Ravi V Shah; Aferdita Spahillari; Stanford Mwasongwe; J Jeffrey Carr; James G Terry; Robert J Mentz; Daniel Addison; Udo Hoffmann; Jared Reis; Jane E Freedman; Joao A C Lima; Adolfo Correa; Venkatesh L Murthy Journal: JAMA Cardiol Date: 2017-06-01 Impact factor: 14.676
Authors: Junxiu Liu; Dariush Mozaffarian; Tom Gaziano; Renata Micha; Stephen Sy; Yujin Lee; Parke E Wilde; Shafika Abrahams-Gessel Journal: Circ Cardiovasc Qual Outcomes Date: 2020-06-04
Authors: Ciaran N Kohli-Lynch; Brandon K Bellows; George Thanassoulis; Yiyi Zhang; Mark J Pletcher; Eric Vittinghoff; Michael J Pencina; Dhruv Kazi; Allan D Sniderman; Andrew E Moran Journal: JAMA Cardiol Date: 2019-10-01 Impact factor: 14.676