Cost-effectiveness of cholesterol-lowering therapy with pravastatin in patients with previous acute coronary syndromes aged 65 to 74 years compared with younger patients: results from the LIPID study

Lifetime effects and cost-effectiveness of statin therapy for older people in the United Kingdom: a modelling study

BACKGROUND

Cardiovascular disease (CVD) risk increases with age. Statins reduce cardiovascular risk but their effects are less certain at older ages. We assessed the long-term effects and cost-effectiveness of statin therapy for older people in the contemporary UK population using a recent meta-analysis of randomised evidence of statin effects in older people and a new validated CVD model.

METHODS

The performance of the CVD microsimulation model, developed using the Cholesterol Treatment Trialists' Collaboration (CTTC) and UK Biobank cohort, was assessed among participants ≥70 years old at (re)surveys in UK Biobank and the Whitehall II studies. The model projected participants' cardiovascular risks, survival, quality-adjusted life years (QALYs) and healthcare costs (2021 UK£) with and without lifetime standard (35%-45% low-density lipoprotein cholesterol reduction) or higher intensity (≥45% reduction) statin therapy. CTTC individual participant data and other meta-analyses informed statins' effects on cardiovascular risks, incident diabetes, myopathy and rhabdomyolysis. Sensitivity of findings to smaller CVD risk reductions and to hypothetical further adverse effects with statins were assessed.

RESULTS

In categories of men and women ≥70 years old without (15,019) and with (5,103) prior CVD, lifetime use of a standard statin increased QALYs by 0.24-0.70 and a higher intensity statin by a further 0.04-0.13 QALYs per person. Statin therapies were cost-effective with an incremental cost per QALY gained below £3502/QALY for standard and below £11778/QALY for higher intensity therapy and with high probability of being cost-effective. In sensitivity analyses, statins remained cost-effective although with larger uncertainty in cost-effectiveness among older people without prior CVD.

CONCLUSIONS

Based on current evidence for the effects of statin therapy and modelling analysis, statin therapy improved health outcomes cost-effectively for men and women ≥70 years old.

Management of high cholesterol levels in older people

The management of hypercholesterolemia in older adults still represents a challenge in clinical medicine. The pathophysiological alterations of cholesterol metabolism associated with aging are still incompletely understood, even if epidemiological evidence suggests that serum cholesterol levels increase with ongoing age, possibly with a plateau after the age of 80 years. Age is also one of the main determinants of cardiovascular disease, according to all cardiovascular risk estimate tools. Cholesterol-lowering treatment, therefore, would be expected to bring significant protection, even in these patients. Unfortunately, direct experimental evidence is extremely limited, particularly in the very old age strata of the population; a clinical benefit still seems to be present, but the risk for drug-related adverse events is clearly higher. At any rate, at the present time, definite guidelines for the correct management of hypercholesterolemia in older patients are not available. Therefore, the decision whether or not a pharmacological treatment should be set up, and the choice of the drug, need to be tailored to the individual patient, and requires accurate clinical judgment. The specific aspects of frailty and disability, along with the actual age of the patients, have to be considered together, with a comprehensive assessment approach. The present review summarizes the evidence regarding the modifications of cholesterol metabolism in older patients, the impact of lipid-lowering drugs on cardiovascular outcomes and focuses on the considerations that can help to define the most appropriate treatment strategy, in view of the individual functional profile. Geriatr Gerontol Int 2019; 19: 375-383.

A systematic literature review of methods of incorporating mortality in cost-effectiveness analyses of lipid-lowering therapies

AIMS

Cost effectiveness analysis (CEA) is a useful tool for estimating the value of an intervention in relation to alternatives. In cardiovascular disease (CVD), CEA is especially important, given the high economic and clinical burden. One key driver of value is CVD mortality prevention. However, data used to inform CEA parameters can be limited, given the difficulty in demonstrating statistically significant mortality benefit in randomized clinical trials (RCTs), due in part to the frequency of fatal events and limited trial durations. This systematic review identifies and summarizes whether published CVD-related CEAs have incorporated mortality benefits, and the methodology among those that did.

MATERIALS AND METHODS

A systematic literature review was conducted of CEAs of lipid-lowering therapies published between 2000-2017. Health technology assessments (HTA) and full-length manuscripts were included, and sources of mortality data and methods of applying mortality benefits were extracted. Results were summarized as proportions of articles to articulate common practices in CEAs of CVD.

RESULTS

This review identified 100 studies for inclusion, comprising 93 full-length manuscripts and seven HTA reviews. Among these, 99% assumed a mortality benefit in the model. However, 87 of these studies that incorporated mortality differences did so despite the trials used to inform model parameters not demonstrating statistically significant differences in mortality. None of the 12 studies that used statistically significant findings from an individual RCT were based on active control studies. In a sub-group analysis considering the 60 CEAs that incorporated a direct mortality benefit, 48 (80%) did not have RCT evidence for statistically significant benefit in CVD mortality.

LIMITATIONS AND CONCLUSIONS

The finding that few CEA models included mortality inputs from individual RCTs of lipid-lowering therapy may be surprising, as one might expect that treatment efficacy should be based on robust clinical evidence. However, regulatory requirements in CVD-related RCTs often lead to insufficient sample sizes and observation periods for detecting a difference in CVD mortality, which results in the use of intermediate outcomes, composite end-points, or meta-analysis to extrapolate long-term mortality benefit in a lifetime CEA.

Influenza vaccine as a coronary intervention for prevention of myocardial infarction

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally. Influenza is one of the leading infectious causes of morbidity and mortality globally, and evidence is accumulating that it can precipitate acute myocardial infarction (AMI). This is thought to be due to a range of factors including inflammatory release of cytokines, disruption of atherosclerotic plaques and thrombogenesis, which may acutely occlude a coronary artery. There is a large body of observational and clinical trial evidence that shows that influenza vaccine protects against AMI. Estimates of the efficacy of influenza vaccine in preventing AMI range from 15% to 45%. This is a similar range of efficacy compared with the accepted routine coronary prevention measures such as smoking cessation (32-43%), statins (19-30%) and antihypertensive therapy (17-25%). Influenza vaccine should be considered as an integral part of CVD management and prevention. While it is recommended in many guidelines for patients with CVD, rates of vaccination in risk groups aged <65 years are very low, in the range of 30%. The incorporation of vaccination into routine CVD prevention in patient care requires a clinical practice paradigm change.

The road not taken: transferability issues in multinational trials

BACKGROUND

National regulatory agencies often have to use cost-effectiveness (CE) data from multinational randomized controlled trials (RCTs) for national decision making on reimbursement of new drugs. We need to make the best use of these patient-level data to obtain estimates of country-specific CE. Several methods, ranging from simple to statistically complex, have existed for years. We investigated which of these methods are used to estimate CE ratios in economic evaluations performed alongside recent, multinational RCTs that enrolled at least 500 patients.

METHODS

In this systematic literature review, studies were classified based on whether resource use, unit costs, health outcomes and utility value sets were obtained from all countries, a subset of countries or one country. We recorded if the study presented trial-wide and country-specific CE results and reported the statistical analyses that were used to estimate them.

RESULTS

We included 21 studies, of which the majority used measurements of health care utilization and health outcomes from all countries to estimate CE. Thirteen studies used a one-country valuation of health care utilization; six used a multi-country valuation. Despite the availability of country-specific utility value sets, none of the studies that presented quality-adjusted life-years (QALYs) used multi-country valuation. Valuation of health care utilization and health outcomes was not always consistent within a study: three studies combined a multi-country valuation of health care utilization, with a one-country valuation of health outcomes. Most studies calculated trial-wide CE estimates, while 11 studies calculated country- or region-specific estimates. Thirteen studies used relatively simple methods, which do not take the possible interaction between the country and treatment effect on health care utilization and health outcomes into account. Eight studies used more advanced statistical methods. Three of them used a fixed-effects modeling approach. Five studies explicitly took the hierarchical structure of the data into account, which leads to more appropriate estimates of population average results and associated standard errors. In this way, they help improve transferability of the published results.

CONCLUSION

Based on this systematic review, we concluded that the uptake of more advanced statistical methods has been relatively slow, while simpler naïve methods are still routinely employed.

Pharmacoeconomics and aging

The aging of the general population in industrialized countries has brought to public attention the increasing incidence of age-related clinical conditions, because the long-term impact of diseases on functional status and on costs are greater in older people than in any other age group. With the aging of the population, it is becoming increasingly important to quantify the burden of illness in the elderly; this will be vital not only in planning for the necessary health services that will be required in coming years, but also in order to measure the benefit to be expected from interventions to prevent disability in older people. The management of multiple and chronic disorders has become a more important issue for healthcare authorities because of increasing requests for medical assistance and healthcare interventions. Among these, pharmacological treatments and drug utilization in older people are pressing issues for healthcare managers and politicians; indeed, a relatively small proportion of the population accounts for a substantial part of public drug costs. Two key sources of pressure are well known: the growing number of elderly persons, who are the highest per-capita users of medicines, and the introduction of new, often more expensive, medicines. On the other hand, the development of strategies for controlling costs, while providing the elderly with equitable access to needed pharmaceuticals, should be based on an evaluation of the economic impact of pharmacological care in older people, taking into account the burden of illness, drug utilization data, drug technology assessment evidence and results. Furthermore, there are major factors affecting pharmacological care in older people: for example inappropriate prescribing, lack of adherence and compliance, and the burden of adverse drug events. The assessment of these factors should be considered a priority in pharmacoeconomic evaluations in the aging population, and the most relevant evidence will be reviewed in this paper with examples referring to particular settings or conditions and diseases, such as the presence of cardiovascular risk factors, diabetes and chronic pain.

Whose Costs and Benefits? Why Economic Evaluations Should Simulate Both Prevalent and All Future Incident Patient Cohorts

Background. Most health technology economic evaluations simulate only the prevalent cohort or the next incident cohort of patients. They therefore do not capture all future patient-related benefits and costs. Objective. We show how to estimate and aggregate the incremental cost-effectiveness ratios (ICERs) for both currently eligible (prevalent) and future (incident) patient cohorts within the same model-based analysis. We show why, and in what circumstances, the prevalent and incident cohort ICERs are likely to differ. Methods. Algebraic expressions were developed to capture all components of the ICER in hypothetical cohorts of all prevalent patients and future incident patients. Numerical examples are used to illustrate the approach. Results. The ICER for the first (i.e., next) incident cohort is equivalent to the ICER for all future incident cohorts only when the discount rates for costs and benefits are the same; otherwise, when the discount rate for benefits is lower than for costs, the ICER for all future incident cohorts is lower than the ICER for the first incident cohort. Separate simulation of prevalent and incident patients treated for a hypothetical progressive chronic disease shows widely different ICERs according to which patient cohorts were included when the discount rates were equal. Conclusions. In many circumstances, both the prevalent cohort and all future incident cohorts should be modeled. The need for this approach will depend on the likely difference in the ICERs for prevalent and incident patients, the relative size of the 2 types of cohort, and whether costs and benefits are discounted at equal rates.

Undertreatment of hypercholesterolemia

Abstract Recent guidelines recommend strict goals for low-density lipoprotein cholesterol (LDL-C) (1.8-2.6 mmol/L; 70-100 mg/dL). However, these goals are not always met and many primary and secondary prevention patients are not optimally controlled. Both the under-prescription of lipid-lowering medication and lack of adherence to prescribed medications could account for this situation. In this issue of the journal, two studies evaluated the under-treatment of hypercholesterolemia in European countries, as well as patient/physician characteristics that are related to poor control of LDL-C. This editorial considers the implications of these findings. While we have come far in recent years in terms of treating hypercholesterolemia, we still have considerable room for improvement and progress towards evidence-based clinical practice.

Atorvastatin and cardiovascular risk in the elderly--patient considerations

Elderly individuals are at increased risk of coronary heart disease (CHD) and account for a majority of CHD deaths. Several clinical trials have assessed the beneficial effects of statins in individuals with, or at risk of developing, CHD. These trials provide evidence that statins reduce risk and improve clinical outcomes even in older patients; however, statin therapy remains under-utilized among the aged. Atorvastatin has been widely investigated among the older subjects and has the greatest magnitude of favorable effects on clinical outcomes of CHD. The pharmacokinetic properties of atorvastatin allow it to be used every other day, a factor which may decrease adverse events and be especially important in the elderly. The purpose of this article is to review the evidence available from randomized clinical trials regarding the safety and efficacy of atorvastatin in primary and secondary prevention of CHD and stroke in older patients and to discuss issues such as drug interactions, patient compliance and cost-effectiveness, which affect prescription of lipid-lowering therapy among older patients.

Gerontology forum: an update on the literature

New treatments and treatment protocols for diseases affecting the elderly are evolving as we strive to meet the needs of an aging society. To help you keep up to date with the latest advances worldwide on all aspects of drug therapy and patient management, this section of the journal brings you information selected from the rapid drug news alerting service Inpharma Weekly. Each issue contains easy-to-read summaries of the most important research and development news, clinical studies, treatment guidelines, and pharmacoeconomic news.