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Comparison of an Aggressive (U.S.) and a Less Aggressive (Canadian) Policy for Cholesterol Screening and Treatment

Murray Krahn, MD; C. David Naylor, MD, DPhil; Antoni S. Basinski, MD, PhD; and Allan S. Detsky, MD, PhD
[+] Article, Author, and Disclosure Information

Grant Support: Dr. Naylor is supported by an Ontario Ministry of Health Career Scientist Award 02377. Dr. Basinski is a Research Scholar, Department of Family and Community Medicine, University of Toronto. Dr. Detsky is supported by National Health Research Scholar award 6606-2849-48 from Health and Welfare Canada.

Requests for Reprints: Murray Krahn, MD, Toronto Hospital, Western Division, WW1-810, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.

Current Author Addresses: Dr. Krahn: Toronto Western Hospital, WW1-810, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.

Drs. Naylor and Basinski: Sunny brook Health Science Centre, 2075 Bayview Avenue, A433, Toronto, Ontario M4N 3M5, Canada.

Dr. Detsky: Toronto General Hospital, 200 Elizabeth Street, ENG 246, Toronto, Ontario M5G 2C4, Canada.

© 1991 American College of PhysiciansAmerican College of Physicians

Ann Intern Med. 1991;115(4):248-255. doi:10.7326/0003-4819-115-4-248
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Objective: To determine the point at which adverse quality-of-life effects engendered by an aggressive cholesterol-lowering strategy dictate the use of a less aggressive approach.

Design: Decision analysis was used to compare the effects of the National Cholesterol Education Program (NCEP) guidelines, an aggressive program, with those of the Canadian Task Force on the Periodic Health Examination (CTF) guidelines, a more conservative program. Quality-adjusted life expectancy was calculated for a theoretical cohort of middle-aged men treated according to each program using Markov cohort analysis.

Measurements: Guidelines were applied to the population of the Lipid Research Clinics Coronary Primary Prevention Trial (LRC-CPPT), under the assumption that cholesterol levels had the distribution of the ageand sex-matched general population. Outcomes were calculated using a three-state (health, coronary heart disease, and death) Markov model. State transition probabilities were calculated using bivariate (age and cholesterol) proportional hazards and logistic regression functions.

Main Results: The result was a "toss-up"; the number of expected quality-adjusted life years was similar for both programs at all time intervals, although the conservative program was consistently slightly favored. The result was very sensitive to the disutility of dietary therapy (threshold value, 0.0014 compared with the baseline estimate of 0.02) but was also affected by the time frame of the analysis and the rate at which adverse effects of treatment decline.

Conclusions: Even small disutilities associated with treatment may outweigh the benefits of aggressive cholesterol-lowering strategies. Research should be directed toward measuring these disutilities and finding ways to reduce their size. Incorporation of the disutility of treatment into policy formulation may result in less interventionist and less costly policies.





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