Economic Evaluation of the 2016 Chinese Guideline and Alternative Risk Thresholds of Initiating Statin Therapy for the Management of Atherosclerotic Cardiovascular Disease

One-size-fits-all versus risk-category-based screening interval strategies for cardiovascular disease prevention in Chinese adults: a prospective cohort study

Background

In non-high-risk individuals, risk-category-based atherosclerotic cardiovascular disease (ASCVD) screening strategies may be more cost-effective than one-size-fits-all approaches. However, current decisions are constrained by a lack of research evidence. We aimed to explore appropriate risk-category-based screening interval strategies for non-high-risk individuals in ASCVD primary prevention in the Chinese population.

Methods

We used data from 28,624 participants in the China Kadoorie Biobank (CKB) who had completed at least two field surveys. The risk assessment tools were the 10-year ASCVD risk prediction models developed based on the CKB cohort. We constructed multistate Markov models to model disease progression and estimate transition probabilities between different risk categories. The total person-years spent unidentified in the high-risk state over a 10-year period were calculated for each screening interval protocol. We also estimated the number of ASCVD events prevented, quality-adjusted life years (QALYs) gained, and costs saved when compared to the 3-yearly screening protocol.

Findings

When compared to the uniform 3-yearly protocol, most risk-category-based screening interval protocols would identify more high-risk individuals timely, thus preventing more ASCVD events and gaining QALYs. A few of them would reduce total health-care costs. The protocol, which used 6-year, 3-year, and 2-year screening intervals for low-risk, intermediate-low-risk, and intermediate-high risk individuals, was optimal, and would reduce the person-years spent unidentified in the high-risk category by 17.9% (95% CI: 13.1%-21.9%), thus preventing an estimated 113 thousand (95% CI: 83-138) hard ASCVD events for Chinese adults aged 30-79 over a 10-year period. When using a lower cost of statin therapy, more screening protocols would gain QALYs while saving costs.

Interpretation

For the primary prevention of ASCVD, risk-category-based screening protocols outperformed the one-size-fits-all approach in the Chinese population.

Funding

This work was supported by National Natural Science Foundation of China (82192904, 82388102, 82192900) and grants (2023YFC2509400) from the National Key R&D Program of China. The CKB baseline survey and the first re-survey were supported by a grant from the Kadoorie Charitable Foundation in Hong Kong. The long-term follow-up is supported by grants from the UK Wellcome Trust (212946/Z/18/Z, 202922/Z/16/Z, 104085/Z/14/Z, 088158/Z/09/Z), grants (2016YFC0900500) from the National Key R&D Program of China, National Natural Science Foundation of China (81390540, 91846303, 81941018), and Chinese Ministry of Science and Technology (2011BAI09B01).

Ten-year Time-trend Analysis of Dyslipidemia Among Adults in Wuhan

OBJECTIVE

Dyslipidemia is associated with an increased risk of cardiovascular disease, the major cause of death in an aging population. This study aimed to estimate the prevalence of dyslipidemia for the past decade among adults in Wuhan, China.

METHODS

We performed a serial cross-sectional study that recruited 705 219 adults from the Health Management Center of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from 2010 to 2019. The diagnosis of dyslipidemia was based on the 2016 Chinese Guidelines for the Management of Dyslipidemia in Adults. Fixed effects and random effects models were applied to adjust the confounding variables (gender and age).

RESULTS

The overall prevalence of dyslipidemia was 33.1% (46.2% in men and 14.7% in women) in 2019. The prevalence of dyslipidemia was significantly increased over 10 years [from 28.6% (95% CI: 28.2%-29.1%) in 2010 to 32.8 % (95% CI:32.6%-33.1%) in 2019;. P-0.001], especially for hypo-high-density lipoprotein cholesterolemia [from 18.4% (95% CI: 18.0%-18.8%) in 2010 to 24.5% (95% CI: 24.3%-24.7%) in 2019; P-0.001]. In 2019, the prevalence of dyslipidemia was higher in participants with comorbidities, including overweight/obesity, hypertension, diabetes, hyperuricemia, or chronic kidney disease, and dyslipidemia was the most significant among participants aged 30-39 years.

CONCLUSION

This study demonstrated that dyslipidemia is on the rise in men, and more emphasis should be provided for the screening of dyslipidemia in young males for the primary prevention of cardiovascular and renal diseases.

Burden of cardiovascular diseases associated with fine particulate matter in Beijing, China: an economic modelling study

Objective

To evaluate the economic and humanistic burden associated with cardiovascular diseases that were attributable to fine particulate matter (≤ 2.5 μg/m³ in aerodynamic diameter; PM_2.5) in Beijing.

Methods

This study used a health economic modelling approach to compare the actual annual average PM_2.5 concentration with the PM_2.5 concentration limit (35 µg/m³) as defined by the Chinese Ambient Air Quality Standard in terms of cardiovascular disease outcomes in Beijing adult population. The outcomes included medical costs, quality-adjusted life-years (QALYs) and net monetary loss (NML). Beijing annual average PM_2.5 concentration was around 105 µg/m³ during 2013–2015. Therefore, we estimated the differences in cardiovascular outcomes of Beijing adults between exposure to the PM_2.5 concentration of 105 µg/m³ and exposure to the concentration of 35 µg/m³. According to WHO estimates, the hazard ratios of coronary heart disease and stroke associated with the increase of PM_2.5 concentration from 35 to 105 µg/m³ were 1.15 and 1.29, respectively.

Results

The total 1-year excess medical costs of cardiovascular diseases associated with PM_2.5 pollution in Beijing was US$147.9 million and the total 1-year QALY loss was 92 574 in 2015, amounting to an NML of US$2281.8 million. The expected lifetime incremental costs for a male Beijing adult and a female Beijing adult were US$237 and US$163, the corresponding QALY loss was 0.14 and 0.12, and the corresponding NML was US$3514 and US$2935.

Conclusions

PM_2.5-related cardiovascular diseases imposed high economic and QALY burden on Beijing society. Continuous and intensive investment on reducing PM_2.5 concentration is warranted even when only cardiovascular benefits are considered.

Impact of China's Low Centralized Medicine Procurement Prices on the Cost-Effectiveness of Statins for the Primary Prevention of Atherosclerotic Cardiovascular Disease

Background:

Statin medications reduce the risk of atherosclerotic cardiovascular disease (ASCVD). China’s new central government medicine procurement policy lowered statin prices by five-fold or more, which may impact the cost-effectiveness of statin therapy.

Objective:

To explore the impact of China’s 2019 centralized medicine procurement policy on the cost-effectiveness of statins treatment for primary ASCVD prevention.

Methods:

A microsimulation decision tree analytic model was built using individual participant data from ASCVD-free adults aged 35–64 years (n = 21,265) in the China Multi-provincial Cohort Study. ASCVD incidence, costs (2019 Int$), and quality-adjusted life years (QALYs) over a 10-year period from health-care sector and societal perspectives were estimated. Effect and cost-effectiveness of low-dose statins (equivalent potency regimens of simvastatin 20 mg/day, atorvastatin 10 mg/day, or rosuvastatin 5 mg/day) and moderate-dose (double low dose) statins therapy were simulated. The incremental cost-effectiveness ratio (ICER) of statin treatment was compared with no treatment by category of 10-year ASCVD risk. New lower prices of statins were from the centralized procurement policy bid-winning announcement file. One-way and probabilistic sensitivity analyses quantified model uncertainty.

Results:

Low-dose statins interventions reduced 10-year ASCVD incidence by 4.1%, 9.7%, and 15.5% among people with low, moderate, and high risk comparing to no treatment. Lowering statin prices to the 2019 central government procurement policy level could lower the ICER of low-dose statins treatment for high-risk people from Int$ 141,000 to Int$ 51,300 per QALY gained from health-care sector perspective. Moderate-dose statin treatment lowered the ICER compared with the low-dose statins treatment in each ASCVD risk category (Int$ 43,100 vs. Int$ 51,300 per QALY gained from the health-care sector perspective for high risk people). Cost-effectiveness improved progressively with increased baseline ASCVD risk.

Conclusion:

Implementing low central government prices will substantially improve the cost-effectiveness of statins for primary ASCVD prevention in 35–64-year-old Chinese adults.