Cost-effectiveness of Low-density Lipoprotein Cholesterol Level-Guided Statin Treatment in Patients With Borderline Cardiovascular Risk
Cost-effectiveness of Low-density Lipoprotein Cholesterol Level-Guided Statin Treatment in Patients With Borderline Cardiovascular Risk
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DOI：
10.1001/jamacardio.2019.2851
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发表时间：
2019-10-01
期刊：
影响因子：
24
通讯作者：
Moran, Andrew E.
中科院分区：
文献类型：
--
作者：
Kohli-Lynch, Ciaran N.;Bellows, Brandon K.;Moran, Andrew E.
美国心脏病学会/美国心脏协会胆固醇指南根据动脉粥样硬化性心血管疾病（ASCVD）的10年绝对风险（AR（10））优先考虑一级预防他汀类药物治疗。然而，给定相同的AR（10），具有较高水平的低密度脂蛋白胆固醇（LDL-C）的患者经历他汀类药物治疗的更大的绝对风险降低。5.0%-7.4%），并评估他汀类药物治疗在不同年龄、性别、AR（10）和LDL-C水平范围内的成本效益。每项研究包括100万名基线年龄为40岁的无ASCVD调查受访者（50%男性和50%女性）。从美国医疗保健部门的角度，通过1999-2014年美国国家健康和营养检查调查的概率抽样创建了队列。CVD政策模型微观模拟版本预测了生命周期健康和成本结果。通过分析6项汇总的美国队列研究估计首次冠心病或卒中事件的概率，并重新校准以匹配当代事件发生率。其他模型变量来自国家调查、荟萃分析和已发表的文献。分析了2018年5月15日至2019年6月10日的数据。暴露比较了四种他汀类药物治疗策略：（1）治疗所有AR（10）至少为7.5%、糖尿病或LDL-C至少为190 mg/dL的患者（2）增加对临界风险和160至189 mg/dL的LDL-C水平的治疗;（3）增加对临界风险和130至159 mg/dL的LDL-C水平的治疗;和（4）对其余AR（10）至少为5.0%的患者增加治疗。他汀类药物治疗与非他汀类药物治疗在年龄、性别、AR（10）和LDL-C分层方面也进行了比较。主要结果和指标：预测并贴现了生命质量调整生命年（Qs）和成本（2019年美元）每年3.0%。结果在这100个模拟队列中，每个队列有100万基线年龄为40岁的患者（50%女性和50%男性），向边缘AR（10）和LDL-C水平为160至189 mg/dL的个体添加预防性他汀类药物将节省成本;进一步治疗临界AR（10）和LDL-C水平为130至159 mg/dL也将节省成本;治疗AR（10）至少为5.0%的所有个体将具有高度成本效益（33558美元/QALY），并将预防大多数ASCVD事件。在年龄、AR（10）和性别类别中，基线LDL-C水平较高的个体从他汀类药物治疗中获得的QOL更多。成本效益随着LDL-C水平和AR的增加而增加（10）.结论和相关性在这项研究中，在具有临界ASCVD风险和LDL-C水平为160至189 mg/dL的假设队列中，发现终生他汀类药物治疗患者可以节省成本。结果表明，治疗所有处于临界风险的患者，无论LDL-C水平如何，都可能具有很高的成本效益。
IMPORTANCE American College of Cardiology/American Heart Association cholesterol guidelines prioritize primary prevention statin therapy based on 10-year absolute risk (AR(10)) of atherosclerotic cardiovascular disease (ASCVD). However, given the same AR(10), patients with higher levels of low-density lipoprotein cholesterol (LDL-C) experience greater absolute risk reduction from statin therapy.OBJECTIVES To estimate the cost-effectiveness of expanding preventive statin treatment eligibility from standard care to patients at borderline risk (AR(10), 5.0%-7.4%) for ASCVD and with high levels of LDL-C and to estimate cost-effectiveness of statin treatment across ranges of age, sex, AR(10), and LDL-C levels.DESIGN, SETTING, AND PARTICIPANTS This study evaluated 100 simulated cohorts, each including 1 million ASCVD-free survey respondents (50% men and 50% women) aged 40 years at baseline. Cohorts were created by probabilistic sampling of the 1999-2014 US National Health and Nutrition Examination Surveys from the perspective of the US health care sector. The CVD Policy Model microsimulation version projected lifetime health and cost outcomes. Probability of first-ever coronary heart disease or stroke event was estimated by analysis of 6 pooled US cohort studies and recalibrated to match contemporary event rates. Other model variables were derived from national surveys, meta-analyses, and published literature. Data were analyzed from May 15, 2018, through June 10, 2019.EXPOSURES Four statin treatment strategies were compared: (1) treat all patients with AR(10) of at least 7.5%, diabetes, or LDL-C of at least 190 mg/dL (standard care); (2) add treatment for borderline risk and LDL-C levels of 160 to 189 mg/dL; (3) add treatment for borderline risk and LDL-C levels of 130 to 159 mg/dL; and (4) add treatment for remainder of patients with AR(10) of at least 5.0%. Statin treatment was also compared with no statin treatment in age, sex, AR(10), and LDL-C strata.MAIN OUTCOMES AND MEASURES Lifetime quality-adjusted life-years (QALYs) and costs (2019 US dollars) were projected and discounted 3.0% annually. The primary outcome was the incremental cost-effectiveness ratio.RESULTS In these 100 simulated cohorts, each with 1 million patients aged 40 years at baseline (50% women and 50% men), adding preventive statins to individuals with borderline AR(10) and LDL-C levels of 160 to 189 mg/dL would be cost-saving; further treating borderline AR(10) and LDL-C levels of 130 to 159 mg/dL would also be cost-saving; and treating all individuals with AR(10) of at least 5.0% would be highly cost-effective ($33558/QALY) and would prevent the most ASCVD events. Within age, AR(10), and sex categories, individuals with higher baseline LDL-C levels gained more QALYs from statin therapy. Cost-effectiveness increased with LDL-C level and AR(10).CONCLUSIONS AND RELEVANCE In this study, lifetime statin treatment of patients in a hypothetical cohort with borderline ASCVD risk and LDL-C levels of 160 to 189 mg/dL was found to be cost-saving. Results suggest that treating all patients at borderline risk regardless of LDL-C level would likely be highly cost-effective.