BACKGROUND: Despite the growing use of statins, many hypercholesterolaemic patients fail to reach their lipid goal and remain at elevated risk of coronary heart disease (CHD). Alternative treatment strategies, such as ezetimibe coadministration and statin titration, can help patients achieve greater lipid control, and thereby lower their CHD risk. But is it cost effective to more aggressively lower cholesterol levels across a broad range of current statin users? METHODS: Using a decision-analytic model based on epidemiological and clinical trials data, we project the lifetime benefit and cost of alternative lipid-lowering treatment strategies for CHD and non-CHD diabetic patients in Germany, Spain and Norway. RESULTS: It is projected that from 40% to 76% of these patients who have failed to reach their lipid goal with their current statin treatment will be able to reach their goal with ezetimibe coadministration; this represents a gain of up to an additional absolute 14% who will be able to reach their goal compared with a 'titrate to goal' strategy where patients are titrated in order to reach their lipid goal (up to the maximum approved dose). For CHD patients, the estimated incremental cost-effectiveness ratio for ezetimibe coadministration is under Euro 18 000 per life-year gained (Euro/LYG) and 26 000 Euro/LYG compared with strategies based on the observed titration rates and the aggressive 'titrate to goal' strategy, respectively; for non-CHD diabetic patients, these ratios are under 26 000 Euro/LYG and 48 000 Euro/LYG for ezetimibe coadministration compared with the two titration strategies. CONCLUSION: Compared with statin titration, ezetimibe coadministration is projected to be cost effective in the populations and countries studied.
To evaluate the lifetime cost-effectiveness of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors for treatment of high blood cholesterol levels.
We added cost data to a validated coronary heart disease (CHD) prevention computer model that estimates the benefits of lifelong risk factor modification. The updated model takes into account the costs of cholesterol reduction, the savings in CHD health care costs attributable to intervention, the additional non-CHD costs resulting from patients' living longer, and the beneficial effects of reducing CHD risk by reducing total cholesterol and increasing high-density lipoprotein cholesterol (HDL-C).
Men and women aged 30 to 70 years who were free of CHD, had total cholesterol levels equal to the 90th percentile of the US distribution in their age and sex group, had HDL-C levels equal to the mean of the US distribution in their age and sex group, and were either with or without additional CHD risk factors.
Use of 20 mg of lovastatin per day, which on average reduces total serum cholesterol by 17% and increases HDL-C by 7%.
Cost per year of life saved after discounting benefits and costs by 5% annually.
The increase in HDL-C associated with lovastatin lowered cost-effectiveness ratios by approximately 40%, such that the treatment of hypercholesterolemia was relatively cost-effective for men (as low as $20,882 per year of life saved at age 50 years) and women ($36,627 per year of life saved at age 60 years) with additional risk factors. Non-CHD costs resulting from longer life expectancy after intervention added at most 23% to the cost-effectiveness ratios for patients who began treatment at age 70 years, and as little as 3% for patients at age 30 years.
The cost-effectiveness of HMG-CoA reductase inhibitors varied widely by age and sex and was sensitive to the presence of non-lipid CHD risk factors. The additional non-CHD costs due to increased life expectancy may be significant for the elderly. Accounting for the drug effects of raising HDL-C levels increased the proportion of the population for which medication treatment was relatively cost-effective.
The Study of Cardiovascular Risk Intervention by Pharmacists, a randomized, controlled trial in over 50 community pharmacies in Alberta and Saskatchewan, Canada, demonstrated that a pharmacist intervention program improved cholesterol risk management in patients at high risk for cardiovascular disease. In a substudy, costs and consequences were analyzed to describe the economic impact of the program. Two perspectives were taken: a government-funded health care system and a pharmacy manager. Costs were reported in 1999 Canadian dollars. Incremental costs to a government payor and community pharmacy manager were $6.40/patient and $21.76/patient, respectively, during the 4-month follow-up period. The community pharmacy manager had an initial investment of $683.50. The change in Framingham risk function for the intervention group from baseline also was reported. The 10-year risk of cardiovascular disease decreased from 17.3% to 16.4% (p
[Effect of medicamentous cholesterol control on resources utilization in public health--significance of the Scandinavian Simvastatin Survival Study (4-S Study) for cost control in Swiss health management conditions].
Upward spiralling health care expenditures have triggered the need to assess the cost-effectiveness of medical interventions. Specifically, interventions in primary and secondary prevention represent an important field of research. A resource utilization analysis was performed on the basis of the recently published Scandinavian Simvastatin Survival Study. It could be shown that treatment with simvastatin compared to placebo leads to a reduction in patient costs of CHF 8.4 million. This represents a reduction of CHF 3770.- per patient. The effective daily treatment costs can thus be calculated at CHF 1.11, which is equivalent to 36% of the actual acquisition cost per day. These results support the notion that secondary coronary prevention is not only justified from a clinical but also from an economic point of view.
Comment In: Schweiz Med Wochenschr. 1998 Jul 21;128(29-30):1150-19715503
This study was designed to analyse the association between adherence to guidelines for rational drug use and surrogate outcome markers for hypertension, diabetes and hypercholesterolaemia.
The study used a cross-sectional ecological design. Data from dispensed prescriptions and medical records were analysed from 24 primary healthcare centres with a combined registered population of 330,000 patients in 2006. Guideline adherence was determined calculating the proportion of the prescribed volume of antidiabetic agents, antihypertensives and lipid-lowering agents representing the 14 different drugs included in the guidelines for these three areas. Patient outcome was assessed using surrogate marker data on HbA1C, blood pressure (BP) and s-cholesterol. The association between the guidelines adherence and outcomes measures was analysed by logistic regression.
The proportion of guideline antidiabetic drugs in relation to all antidiabetic drugs prescribed varied between 80% and 97% among the practices, the ratio of angiotensin converting enzyme (ACE)-inhibitors to all renin-angiotensin drugs 40-77% and the ratio of simvastatin to all statins 58-90%. The proportion of patients reaching targets for HbA1C, BP and s-cholesterol varied between 34% and 66%, 36% and 57% and 46% and 71% respectively. No significant associations were found between adherence to the guidelines and outcome. The expenditures for antihypertensives and lipid-lowering drugs could potentially be reduced by 10% and 50% respectively if all practices adhered to the guidelines as the top performing practices.
A substantial amount of money can be saved in primary care without compromising the quality of care by using recommended first-line drugs for the treatment diabetes, hypertension and hypercholesterolaemia.
Saskatchewan is the only Canadian province that lists ezetimibe for open formulary access even though it is a second-line agent for lowering cholesterol.
A retrospective analysis of ezetimibe use in Saskatchewan between 2002 and 2011 was carried out using provincial health administrative databases. Overall use and costs of ezetimibe were described over time. Among new users of ezetimibe, the percentage who received the drug as first-line monotherapy was estimated. First-line monotherapy was defined as no statin dispensations in the 365 days before and the 60 days after the first ezetimibe dispensation. Potential predictors of first-line monotherapy were assessed using generalized linear mixed-effect models.
In 2004, ezetimibe represented 2.5% of cholesterol-lowering dispensations. In 2011, its use increased to 8.8% of cholesterol-lowering dispensations and 13.2% of the total cost of cholesterol-lowering agents. Overall, ezetimibe was used as first-line monotherapy in 23% of all new users (4024 of 17,475 patients). Approximately half of all cases of first-line monotherapy were prescribed by 10.4% (112 of 1074) of prescribers in the cohort. Patients who had experienced previous acute coronary syndrome or who had undergone coronary revascularization procedures were significantly less likely to receive first-line monotherapy.
A high proportion of ezetimibe's use is not in accordance with evidence-based recommendations. Suboptimal prescribing could partially explain current patterns of use; however, other factors such as medication nonadherence may have played an important role. Restricting ezetimibe use in the provincial formulary in addition to improving prescribers' awareness through academic detailing should be considered.