Charles M. Clark, MD
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Clark C.; Cost-Effectiveness Analyses. Ann Intern Med. 2001;135:382. doi: 10.7326/0003-4819-135-5-200109040-00021
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Published: Ann Intern Med. 2001;135(5):382.
TO THE EDITOR:
Cost-effectiveness analyses, such as those published in the 16 May 2000 issue (1, 2), perform an important clinical and policy function. I am, however, puzzled by the lack of distinction in such analyses between the cost-effectiveness of the decision to initiate therapy and the cost-effectiveness of setting goals after therapy is initiated. Modern pharmacologic treatments for the major risk factors for cardiovascular disease (hypertension, hyperlipidemia, and diabetes), while expensive, are effective and safe and have little negative effect on quality of life. Currently, cost-effectiveness analyses focus on the cost of these drugs and try to define where on the “S”-shaped risk curve they become cost-effective. The more sophisticated analyses add to the risk analysis clinical or biochemical data that shape this curve, such as the presence of comorbid conditions or a clinical history of a cardiovascular event. We end up, then, with a dollar value per quality-adjusted life-year of initiating, for example, cholesterol-lowering therapy at various levels of high-density lipoprotein cholesterol. However, I hold that a second analysis is needed once the decision to initiate therapy has been made. That analysis needs to take into account the incremental cost-effectiveness of setting various goals. Taking again cholesterol-lowering therapy, increasing the dose of a statin to achieve a high-density lipoprotein cholesterol level of 2.20 mmol/L (85 mg/dL) rather than 3.36 mmol/L (130 mg/dL) or 2.59 mmol/L (100 mg/dL) is associated with little additional risk or cost. One could say the same about treating to achieve a blood pressure of 130/80 mm Hg or a hemoglobin A1c level of 0.065 (6.5%) in the absence of hypoglycemia. I would like to see a discussion of the value and difficulties of analyzing the incremental cost-effectiveness of decreasing cardiovascular risk factors to minimal risk levels, once it is established that therapy is necessary. Such analyses seem warranted both scientifically and clinically.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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