Improving health outcomes without increasing costs: Maximizing the full potential of lipid reduction therapy in the primary and secondary prevention of coronary heart disease

Current Opinion in Lipidology

Volumn 8, Issue 6, 1997, Pages 369-374

  Jacobson, Terry A ^a  

^a EMORY UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ANTILIPEMIC AGENT; HYDROXYMETHYLGLUTARYL COENZYME A REDUCTASE INHIBITOR; PRAVASTATIN; SIMVASTATIN; STATIN;

ATHEROSCLEROSIS; CLINICAL TRIAL; COST CONTROL; COST EFFECTIVENESS ANALYSIS; DRUG EFFICACY; DRUG SAFETY; HIGH RISK POPULATION; HUMAN; ISCHEMIC HEART DISEASE; PRIMARY PREVENTION; PRIORITY JOURNAL; RESOURCE ALLOCATION; SECONDARY PREVENTION; SHORT SURVEY; TREATMENT OUTCOME; TREATMENT PLANNING;

EID: 0030732591     PISSN: 09579672     EISSN: None     Source Type: Journal    
DOI: 10.1097/00041433-199712000-00008     Document Type: Short Survey

References (22)

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2. Wittels EH, Hay JW, Gotto AM Jr: Medical costs of coronary artery disease in the United States. Am J Cardiol 1990, 65:432-440.
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5. Shepherd J, Cobbe SM, Ford I, Isles CG, Lorimer AR, MacFarlane PW, for the West of Scotland Coronary Prevention Study Group: Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med 1995, 333:1301-1307.
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8. Jacobson TA: Preventing CHD in the managed care era: improving the cost-effectiveness of lipid lowering therapy. Am J Man Care 1997, 3(suppl):S29-S41. This study builds on th author's earlier work and suggests a simple algorithm using the statins based on cost effectiveness principles and using cost efficiency frontier analysis. The author used average wholesale prices in the US which may not reflect the true average prices in different managed care plans.
9. Johanneson M, Jonsson B, Kjekshus J, Olsson AG, Pedersen TR, Wedel H, for the Scandinavian Simvastatin Survival Study Group: Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. N Engl J Med 1997, 336:332-336. The full analysis of the Scandinavian Simvastatin Survival Study reveals how cost effective treatment is in secondary prevention when analysed using real prospective data on the benefits of treatment and costs. When analysing indirect costs or those associated with lost job productivity, statin therapy was found in younger patients to actually be cost saving. This cost effectiveness analysis highlights the true value of statin therapy and puts it among the most cost effective interventions in post-myocardial infarction patients.
10. Ashraf T, Hay JW, Pitt B, Wittels E, Crouse J, Davidson M, Furberg CD, Radican L: Cost-effectiveness of pravastatin in secondary prevention of coronary artery disease. Am J Cardiol 1996, 78:409-414. Although not as well designed prospectively as the Scandinavian economic analysis [9••], this study suggests that full dose pravastatin (40 mg) is also very cost effective in secondary prevention when using the risk reductions seen in the two pooled angiographic studies. Pravastatin, Lipids and Atherosclerosis in the Carotid Arteries I and II.
11. Shepherd J, for the West of Scotland Coronary Prevention Study Economic Analysis Group: The cost-effectiveness of preventing initial coronary events with pravastatin. Results of the West of Scotland Coronary Prevention Study Economic Analysis. J Am Coll Cardiol 1997, 29(suppl A):168A.
12. Jacobson TA, Marchman K: Improving the cost-effectiveness of lipid lowering therapy in coronary heart disease prevention. In Multiple risk factors in cardiovascular disease: strategies of prevention of coronary heart disease, cardiac failure, and stroke. Edited by Gotto AM, Lenfant C, Catapano AL, Paoletti R: Dordrecht; Kluwer Academic Publishers; 1997 (in press).
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14. Pyorala K, De Backer G, Graham I, Poole-Wilson P, Wood D, on behalf of the Task Force: Prevention of coronary heart disease in clinical practice. Recommendations of the Task Force of the European Society of Cardiology, European Atherosclerosis Society and European Society of Hypertension. Eur Heart J 1994, 15:1300-1331.
15. Ramsay LE, Haq IU, Jackson PR, Yeo WW, Pickin DM, Payne JN: Targeting lipid lowering drug therapy for primary prevention of coronary disease: an updated Sheffield table. Lancet 1996, 348:387-388. A good reference that suggests that the rates of CHD events in a population can be targeted by using a simple table derived from Framingham and other sources.
16. Haq IU, Ramsey LE, Pickin DM, Yeo WW, Jackson PR, Payne JN: Lipid lowering for prevention of coronary heart disease: what policy now? Clin Sci 1996, 91:399-413. An excellent reference that helps frame the debate about what level of CHD risk to target in the UK population given limited resources. The authors support a very high risk primary prevention approach for the UK population and suggest the targeting CHD rates of 4.5% annually.
17. The West of Scotland Coronary Prevention Study Group. West of Scotland Coronary Prevention Study: Identification of high risk groups in comparison with other cardiovascular intervention trials. Lancet 1996, 348:1339-1342. An excellent subgroup analysis from the West of Scotland group that suggests that certain patients had very high rates of events exceeding 2% per year and could be specifically targeted to reduce the number of individuals needed to be treated to reduce events. This analysis suggests that middle aged males (aged 55 65 years) could be especially targeted for lipid therapy even with one additional risk factor such as smoking, low HDL. diabetes, etc.
18. The West of Scotland Coronary Prevention Study Group: Baseline risk factors and their association with outcome in the East of Scotland Coronary Prevention Study. Am J Cardiol 1997, 79:756-762.
19. Red Book Update. Montvale, NJ: Medical Economics Co. 1997.
20. Jacobson TA: Cost-effectiveness of 3-hydro-3-methylglutarylco-enzyme A HMG-CoA reductase inhibitor therapy in the managed care era. Am J Cardiol 1996, 78(suppl 6A):32-41. The analysis reviews some of the clinical trials to determine the relative efficacy of LDL reductions using different statins and contrasts that with their published costs of therapy. An algorithm of lipid management is suggested based on an intermediate endpoint, Scost/LDL reduction. Although the study was performed before atorvastatin was on the market, it suggested that most patients could be controlled with less than 30% LDL reductions with the least expensive statin, fluvastatin. However, for patients who required LDL reductions greater than 35%, then a more potent statin such as simvastatin was the preferred agent.
21. Tosteson AN, Weinstein MC, Hunink MG, Mittleman MA, Williams LW, Goldman PA, Goldman L: Cost-effectiveness of population educational approaches to reduce serum cholesterol. Circulation 1997, 95:24-30. A population model for Goldman's group that suggests that population approaches can be a very efficient strategy for lowering CHD risk with cost per YOLS estimates of US$3200.
22. Goldman L, Garber AM, Graver SA, Hlatky MA: Task Force 6. Cost effectiveness of assessment and management of risk factors. J Am Coll Cardiol 1996:1020-1030. An excellent primer on what cost effectiveness analysis is, and what the various published cost effectiveness ratios are from common procedures and treatments in cardiovascular medicine.