Cost-effectiveness of 10-Year Risk Thresholds for Initiation of Statin Therapy for Primary Prevention of Cardiovascular Disease.
Cost-effectiveness of 10-Year Risk Thresholds for Initiation of Statin Therapy for Primary Prevention of Cardiovascular Disease.
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DOI：
10.1001/jama.2015.6822
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发表时间：
2015-07-14
期刊：
影响因子：
--
通讯作者：
Gaziano TA
中科院分区：
文献类型：
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作者：
Pandya A;Sy S;Cho S;Weinstein MC;Gaziano TA
美国心脏病学会和美国心脏协会 (ACC/AHA) 胆固醇治疗指南对于使用他汀类药物治疗没有动脉粥样硬化性心血管疾病 (ASCVD) 病史的成年人具有广泛的影响。评估可用于 ACC/AHA 胆固醇治疗指南的各种 10 年 ASCVD 风险阈值的成本效益。微观模拟模型，包括生命周期、美国社会视角、3% 的成本折扣率和健康结果。在该模型中，假设来自 40 至 75 岁美国代表性人群的个体接受了他汀类药物治疗，经历了 ASCVD 事件，并根据 ASCVD 自然史和他汀类药物治疗参数死于 ASCVD 相关或非 ASCVD 相关原因。模型参数的数据来源包括国家健康和营养检查调查、他汀类药物益处和治疗的大型临床试验和荟萃分析以及其他已发表的来源。预计可预防 ASCVD 事件并增加每个质量调整生命年 (QALY) 的成本。在基本情况下，当前 ASCVD 阈值为 7.5% 或更高（估计与 48% 接受他汀类药物治疗的成人相关），与 10% 或更高阈值相比，增量成本效益比 (ICER) 为 37 000 美元/QALY。更宽松的 ASCVD 阈值 4.0% 或更高（接受治疗的成人的 61%）和 3.0% 或更高（接受治疗的成人的 67%）的 ICER 分别为 81 000 美元/QALY 和 140 000 美元/QALY。据估计，从 7.5% 或更高的 ASCVD 风险阈值转变为 3.0% 或更高的 ASCVD 风险阈值可额外避免 161 560 起心血管疾病事件。成本效益结果对与每天服药相关的负效用、他汀类药物价格以及他汀类药物诱发糖尿病的风险的变化敏感。在概率敏感性分析中，使用 100 000 美元/QALY 的成本效益阈值，最佳 ASCVD 阈值为 5.0% 或更低的可能性高于 93%。在这个 45 至 75 岁美国成年人的微观模拟模型中，ACC/AHA 胆固醇治疗指南中使用的当前 10 年 ASCVD 风险阈值（≥7.5% 风险阈值）具有可接受的成本效益概况（ICER，37 000 美元/QALY），但更宽松的 ASCVD 阈值将是最佳的，使用 100 000 美元/QALY（≥4.0% 风险阈值）的成本效益阈值或$150 000/QALY（≥3.0% 风险阈值）。最佳 ASCVD 阈值对患者每天服药的偏好、他汀类药物价格的变化以及他汀类药物诱发糖尿病的风险敏感。
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. To estimate the cost-effectiveness of various 10-year ASCVD risk thresholds that could be used in the ACC/AHA cholesterol treatment guidelines. 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. Estimated ASCVD events prevented and incremental costs per quality-adjusted life-year (QALY) gained. 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. In this microsimulation model of US adults aged 45 to 75 years, 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.