Mark J. Pletcher, MD, MPH; Lawrence Lazar, MD; Kirsten Bibbins-Domingo, PhD, MD; Andrew Moran, MD, MPH; Nicolas Rodondi, MD, MAS; Pamela Coxson, PhD; James Lightwood, PhD; Lawrence Williams, MSc; Lee Goldman, MD, MPH
Lipid-lowering therapy is costly but effective at reducing coronary heart disease (CHD) risk.
To assess the cost-effectiveness and public health impact of Adult Treatment Panel III (ATP III) guidelines and compare with a range of risk- and age-based alternative strategies.
The CHD Policy Model, a Markov-type cost-effectiveness model.
National surveys (1999 to 2004), vital statistics (2000), the Framingham Heart Study (1948 to 2000), other published data, and a direct survey of statin costs (2008).
U.S. population age 35 to 85 years.
2010 to 2040.
Health care system.
Lowering of low-density lipoprotein cholesterol with HMG-CoA reductase inhibitors (statins).
Full adherence to ATP III primary prevention guidelines would require starting (9.7 million) or intensifying (1.4 million) statin therapy for 11.1 million adults and would prevent 20Â 000 myocardial infarctions and 10Â 000 CHD deaths per year at an annual net cost of $3.6 billion ($42Â 000/QALY) if low-intensity statins cost $2.11 per pill. The ATP III guidelines would be preferred over alternative strategies if society is willing to pay $50Â 000/QALY and statins cost $1.54 to $2.21 per pill. At higher statin costs, ATP III is not cost-effective; at lower costs, more liberal statin-prescribing strategies would be preferred; and at costs less than $0.10 per pill, treating all persons with low-density lipoprotein cholesterol levels greater than 3.4 mmol/L (>130 mg/dL) would yield net cost savings.
Results are sensitive to the assumptions that LDL cholesterol becomes less important as a risk factor with increasing age and that little disutility results from taking a pill every day.
Randomized trial evidence for statin effectiveness is not available for all subgroups.
The ATP III guidelines are relatively cost-effective and would have a large public health impact if implemented fully in the United States. Alternate strategies may be preferred, however, depending on the cost of statins and how much society is willing to pay for better health outcomes.
Flight Attendants' Medical Research Institute and the Swanson Family Fund. The Framingham Heart Study and Framingham Offspring Study are conducted and supported by the National Heart, Lung, and Blood Institute.
Pletcher MJ, Lazar L, Bibbins-Domingo K, Moran A, Rodondi N, Coxson P, et al. Comparing Impact and Cost-Effectiveness of Primary Prevention Strategies for Lipid-Lowering. Ann Intern Med. ;150:243–254. doi: 10.7326/0003-4819-150-4-200902170-00005
Download citation file:
Published: Ann Intern Med. 2009;150(4):243-254.
Cardiology, Coronary Risk Factors, Dyslipidemia, High Value Care, Prevention/Screening.
Copyright © 2018 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use