Modeling the costs and long-term health benefits of screening the general population for risks of cardiovascular disease: a review of methods used in the literature

Cost-effectiveness of applying high-sensitivity troponin I to a score for cardiovascular risk prediction in asymptomatic population

INTRODUCTION

Risk stratification scores such as the European Systematic COronary Risk Evaluation (SCORE) are used to guide individuals on cardiovascular disease (CVD) prevention. Adding high-sensitivity troponin I (hsTnI) to such risk scores has the potential to improve accuracy of CVD prediction. We investigated how applying hsTnI in addition to SCORE may impact management, outcome, and cost-effectiveness.

METHODS

Characteristics of 72,190 apparently healthy individuals from the Biomarker for Cardiovascular Risk Assessment in Europe (BiomarCaRE) project were included into a discrete-event simulation comparing two strategies for assessing CVD risk. The standard strategy reflecting current practice employed SCORE (SCORE); the alternative strategy involved adding hsTnI information for further stratifying SCORE risk categories (S-SCORE). Individuals were followed over ten years from baseline examination to CVD event, death or end of follow-up. The model tracked the occurrence of events and calculated direct costs of screening, prevention, and treatment from a European health system perspective. Cost-effectiveness was expressed as incremental cost-effectiveness ratio (ICER) in € per quality-adjusted life year (QALYs) gained during 10 years of follow-up. Outputs were validated against observed rates, and results were tested in deterministic and probabilistic sensitivity analyses.

RESULTS

S-SCORE yielded a change in management for 10.0% of individuals, and a reduction in CVD events (4.85% vs. 5.38%, p<0.001) and mortality (6.80% vs. 7.04%, p<0.001). S-SCORE led to 23 (95%CI: 20-26) additional event-free years and 7 (95%CI: 5-9) additional QALYs per 1,000 subjects screened, and resulted in a relative risk reduction for CVD of 9.9% (95%CI: 7.3-13.5%) with a number needed to screen to prevent one event of 183 (95%CI: 172 to 203). S-SCORE increased costs per subject by 187€ (95%CI: 177 € to 196 €), leading to an ICER of 27,440€/QALY gained. Sensitivity analysis was performed with eligibility for treatment being the most sensitive.

CONCLUSION

Adding a person's hsTnI value to SCORE can impact clinical decision making and eventually improves QALYs and is cost-effective compared to CVD prevention strategies using SCORE alone. Stratifying SCORE risk classes for hsTnI would likely offer cost-effective alternatives, particularly when targeting higher risk groups.

Optimizing cardiovascular disease risk screening in a low-resource setting: cost-effectiveness of program modifications in Sri Lanka modelled with nationally representative survey data

BACKGROUND

While screening for cardiovascular disease (CVD) risk can help low-resource health systems deliver low-cost, effective prevention, evidence is needed to adapt international screening guidelines for maximal impact in local settings. We aimed to establish how the cost-effectiveness of CVD risk screening in Sri Lanka varies with who is screened, how risk is assessed, and what thresholds are used for prescription of medicines.

METHODS

We used data for people aged 35 years and over from a 2018/19 nationally representative survey in Sri Lanka. We modelled the costs and quality adjusted life years (QALYs) for 128 screening program scenarios distinguished by a) age group screened, b) risk tool used, c) definition of high CVD risk, d) blood pressure threshold for treatment of high-risks, and e) prescription of statins to all diabetics. We used the current program as the base case. We used a Markov model of a one-year screening program with a lifetime horizon and a public health system perspective.

RESULTS

Scenarios that included the WHO-2019 office-based risk tool dominated most others. Switching to this tool and raising the age threshold for screening from 35 to 40 years gave an incremental cost-effectiveness ratio (ICER) of $113/QALY. Lowering the CVD high-risk threshold from 20 to 10% and prescribing antihypertensives at a lower threshold to diabetics and people at high risk of CVD gave an ICER of $1,159/QALY. The findings were sensitive to allowing for disutility of daily medication.

CONCLUSIONS

In Sri Lanka, CVD risk screening scenarios that used the WHO-2019 office-based risk tool, screened people above the age of 40, and lowered risk and blood pressure thresholds would likely be cost-effective, generating an additional QALY at less than half a GDP per capita.

The cost-effectiveness of a uniform versus age-based threshold for one-off screening for prevention of cardiovascular disease

The objective of this article was to assess the cost-effectiveness of screening strategies for cardiovascular diseases (CVD). A decision analytic model was constructed to estimate the costs and benefits of one-off screening strategies differentiated by screening age, sex and the threshold for initiating statin therapy ("uniform" or "age-adjusted") from the Spanish NHS perspective. The age-adjusted thresholds were configured so that the same number of people at high risk would be treated as under the uniform threshold. Health benefit was measured in quality-adjusted life years (QALY). Transition rates were estimated from the European Prospective Investigation into Cancer and Nutrition (EPIC-CVD), a large multicentre nested case-cohort study with 12 years of follow-up. Unit costs of primary care, hospitalizations and CVD care were taken from the Spanish health system. Univariate and probabilistic sensitivity analyses were employed. The comparator was no systematic screening program. The base case model showed that the most efficient one-off strategy is to screen both men and women at 40 years old using a uniform risk threshold for initiating statin treatment (Incremental Cost-Effectiveness Ratio of €3,274/QALY and €6,085/QALY for men and women, respectively). Re-allocating statin treatment towards younger individuals at high risk for their age and sex would not offset the benefit obtained using those same resources to treat older individuals. Results are sensitive to assumptions about CVD incidence rates. To conclude, one-off screening for CVD using a uniform risk threshold appears cost-effective compared with no systematic screening. These results should be evaluated in clinical studies.

A cost-effectiveness analysis of risk-based intervention for prevention of cardiovascular diseases in IraPEN program: A modeling study

Background

IraPEN, a program developed in Iran based on the World Health Organization (WHO) package of essential noncommunicable (PEN) disease interventions for primary healthcare, was launched in 2015. Preventive interventions for cardiovascular diseases (CVDs) are based on the level of risk calculated using the WHO CVD risk chart.

Objective

The main objective of this study was to measure the potential cost-effectiveness (CE) of IraPEN preventive actions for CVD in comparison with the status quo.

Methods

A CE analysis from a healthcare perspective was conducted. Markov models were employed for individuals with and without diabetes separately. Based on the WHO CVD risk chart, four index cohorts were constructed as low (<10%), moderate (10%-19%), high (20%-29%), and very high risk (≥30%). Life years (LY) gained and quality-adjusted life years (QALY) were used as the outcome measures.

Results

The intervention yields an incremental cost-effectiveness ratio (ICER) of $804, $551, and -$44 per QALY for moderate, high, and very high CVD risk in groups without diabetes, respectively. These groups gained 0.69, 0.96, and 1.45 LY, respectively, from the intervention. The results demonstrated an ICER of $711, $630, -$42, and -$71 for low, moderate, high, and very high-risk groups with diabetes, respectively, while they gained 0.46, 1.2, 2.04, and 2.29 years from the intervention.

Conclusion

The IraPEN program was highly cost-effective for all CVD risk groups in the individuals without diabetes except the low-risk group. The intervention was cost-effective for all patients with diabetes regardless of their CVD risk. The results demonstrated that the IraPEN program can likely provide substantial health benefits to Iranian individuals and cost savings to the national healthcare provider.

Regulatory, Legal, and Market Aspects of Smart Wearables for Cardiac Monitoring

In the area of cardiac monitoring, the use of digitally driven technologies is on the rise. While the development of medical products is advancing rapidly, allowing for new use-cases in cardiac monitoring and other areas, regulatory and legal requirements that govern market access are often evolving slowly, sometimes creating market barriers. This article gives a brief overview of the existing clinical studies regarding the use of smart wearables in cardiac monitoring and provides insight into the main regulatory and legal aspects that need to be considered when such products are intended to be used in a health care setting. Based on this brief overview, the article elaborates on the specific requirements in the main areas of authorization/certification and reimbursement/compensation, as well as data protection and data security. Three case studies are presented as examples of specific market access procedures: the USA, Germany, and Belgium. This article concludes that, despite the differences in specific requirements, market access pathways in most countries are characterized by a number of similarities, which should be considered early on in product development. The article also elaborates on how regulatory and legal requirements are currently being adapted for digitally driven wearables and proposes an ongoing evolution of these requirements to facilitate market access for beneficial medical technology in the future.

Estimating the cost-effectiveness of screening a general population for cardiovascular risk with high-sensitivity troponin-I

Aims 

To estimate the cost-effectiveness of using the cardiac specific marker high-sensitivity troponin-I (hsTnI) for assessing cardiovascular disease (CVD) risk in a general population.

Methods and results 

A discrete-event simulation model was developed from a societal perspective of a low-risk (Germany) and a high-risk (Kazakhstan) country. The model compared a Screen&Prevent strategy guided by hsTnI against a do-nothing strategy. Risk functions were derived from published data of a prospective cohort study [Nord-Trøndelag Health (HUNT) Study]. The model assessed the number of CVD events and deaths, healthy life years, direct and indirect costs in PPP 2018 Dollar, and quality-adjusted life years (QALY) over a time horizon of 10 years. Screen&Prevent reduced the number of CVD events per 1000 subjects by 5.1 and 5.0, equal to a number-needed-to-screen of 195 and 191 in Kazakhstan and Germany. Screen&Prevent was cost saving in Kazakhstan and cost-effective in Germany with an incremental-cost-effectiveness ratio of $6755 ($2294; $24 054) per QALY gained at an opportunity-cost based willingness-to-pay threshold of $27 373. Varying input variables in univariate and probabilistic sensitivity analyses confirmed the robustness of the analysis.

Conclusion 

Assessing the cardiovascular risk with hsTnI in a general population and subsequently referring those at high risk to preventive means would very likely be cost-effective or cost-saving by avoiding CVD events and associated direct and indirect costs. This conclusion is retained even if only the direct costs or only the costs for screening and prevention are considered. Future studies should evaluate the incremental cost-effectiveness of hsTnI-guided assessment strategies against established risk algorithms.

Cost-effectiveness of interventions to control cardiovascular diseases and diabetes mellitus in South Asia: a systematic review

OBJECTIVES

More than 80% of cardiovascular diseases (CVD) and diabetes mellitus (DM) burden now lies in low and middle-income countries. Hence, there is an urgent need to identify and implement the most cost-effective interventions, particularly in the resource-constraint South Asian settings. Thus, we aimed to systematically review the cost-effectiveness of individual-level, group-level and population-level interventions to control CVD and DM in South Asia.

METHODS

We searched 14 electronic databases up to August 2016. The search strategy consisted of terms related to 'economic evaluation', 'CVD', 'DM' and 'South Asia'. Per protocol two reviewers assessed the eligibility and methodological quality of studies using standard checklists, and extracted incremental cost-effectiveness ratios of interventions.

RESULTS

Of the 2949 identified studies, 42 met full inclusion criteria. Critical appraisal of studies revealed 15 excellent, 18 good and 9 poor quality studies. Most studies were from India (n=37), followed by Bangladesh (n=3), Pakistan (n=2) and Bhutan (n=1). The economic evaluations were based on observational studies (n=9), randomised trials (n=12) and decision models (n=21). Together, these studies evaluated 301 policy or clinical interventions or combination of both. We found a large number of interventions were cost-effective aimed at primordial prevention (tobacco taxation, salt reduction legislation, food labelling and food advertising regulation), and primary and secondary prevention (multidrug therapy for CVD in high-risk group, lifestyle modification and metformin treatment for diabetes prevention, and screening for diabetes complications every 2-5 years). Significant heterogeneity in analytical framework and outcome measures used in these studies restricted meta-analysis and direct ranking of the interventions by their degree of cost-effectiveness.

CONCLUSIONS

The cost-effectiveness evidence for CVD and DM interventions in South Asia is growing, but most evidence is from India and limited to decision modelled outcomes. There is an urgent need for formal health technology assessment and policy evaluations in South Asia using local research data.

PROSPERO REGISTRATION NUMBER

CRD42013006479.

Cross-sectional analysis of the prevalence and predictors of statin utilisation in Ireland with a focus on primary prevention of cardiovascular disease

OBJECTIVE

To describe the prevalence of statin utilisation by people aged over 50 years in Ireland and the factors associated with the likelihood of using a statin, focusing particularly on those using statins for primary prevention of cardiovascular disease (CVD).

METHODS

This is a cross-sectional analysis of cardiovascular risk and sociodemographic factors associated with statin utilisation from wave 1 of The Irish Longitudinal Study on Ageing. A hierarchy of indications for statin utilisation, consisting of eight mutually exclusive levels of CVD-related diagnoses, was created. Participants were assigned one level of indication. The prevalence of statin utilisation was calculated. The likelihood that an individual was using a statin was estimated using a multivariable logistic regression model, controlling for cardiovascular risk and sociodemographic factors.

RESULTS

In this nationally representative sample (n=5618) of community-dwelling participants aged 50 years and over, 1715 (30.5%) were taking statins. Of these, 65.0% (57.3% of men and 72.7% of women) were doing so for the primary prevention of CVD. Thus, almost two-thirds of those taking statins did so for primary prevention and there was a notable difference between women and men in this regard. We also found that statin utilisation was highest among those with a prior history of CVD and was significantly associated with age (compared with the base category 50-64 years; 65-74 years OR 1.38 (95% CI 1.16 to 1.65); 75+ OR 1.33 (95% CI 1.04 to 1.69)), living with a spouse or partner (compared with the base category living alone; OR 1.35 (95% CI 1.10 to 1.65)), polypharmacy (OR 1.74 (95% CI 1.39 to 2.19)) and frequency of general practitioner visits (compared with the base category 0 visits per year; 1-2 visits OR 2.46 (95% CI 1.80 to 3.35); 3-4 visits OR 3.24 (95% CI 2.34 to 4.47); 5-6 visits OR 2.98 (95% CI 2.08 to 4.26); 7+ visits OR 2.51 (95% CI 1.73 to 3.63)), even after controlling for clinical need. There was no association between using statins and gender, education, income, social class, health insurance status, location or Systematic Coronary Risk Evaluation (SCORE) risk in the multivariable analysis.

CONCLUSION

Statin utilisation among those with no history of CVD accounted for almost two-thirds of all statin use, in part reflecting the high proportion of the population with no history of CVD, although utilisation rates were highest among those with a history of CVD.

Amaranth peptides decreased the activity and expression of cellular tissue factor on LPS activated THP-1 human monocytes

The immunomodulatory activity of amaranth peptides is linked for the first time with their antithrombotic activity. Inhibition of tissue factor expression and the NF-κB pathway was observed after treatment with the peptides.