1
|
Marquina C, Morton JI, Lloyd M, Abushanab D, Baek Y, Abebe T, Livori A, Dahal P, Watts GF, Ademi Z. Cost-Effectiveness of Screening Strategies for Familial Hypercholesterolaemia: An Updated Systematic Review. PHARMACOECONOMICS 2024; 42:373-392. [PMID: 38265575 PMCID: PMC10937756 DOI: 10.1007/s40273-023-01347-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND OBJECTIVE: This study aimed to systematically synthesise the cost-effectiveness of screening strategies to detect heterozygous familial hypercholesterolemia (FH). METHODS We searched seven databases from inception to 2 February , 2023, for eligible cost-effective analysis (CEA) that evaluated screening strategies for FH versus the standard care for FH detection. Independent reviewers performed the screening, data extraction and quality evaluation. Cost results were adapted to 2022 US dollars (US$) to facilitate comparisons between studies using the same screening strategies. Cost-effectiveness thresholds were based on the original study criteria. RESULTS A total of 21 studies evaluating 62 strategies were included in this review, most of the studies (95%) adopted a healthcare perspective in the base case, and majority were set in high-income countries. Strategies analysed included cascade screening (23 strategies), opportunistic screening (13 strategies), systematic screening (11 strategies) and population-wide screening (15 strategies). Most of the strategies relied on genetic diagnosis for case ascertainment. The most common comparator was no screening, but some studies compared the proposed strategy versus current screening strategies or versus the best next alternative. Six studies evaluated screening in children while the remaining were targeted at adults. From a healthcare perspective, cascade screening was cost-effective in 78% of the studies [cost-adapted incremental cost-effectiveness ratios (ICERs) ranged from dominant to 2022 US$ 104,877], opportunistic screening in 85% (ICERs from US$4959 to US$41,705), systematic screening in 80% (ICERs from US$2763 to US$69,969) and population-wide screening in 60% (ICERs from US$1484 to US$223,240). The most common driver of ICER identified in the sensitivity analysis was the long-term cost of lipid-lowering treatment. CONCLUSIONS Based on reported willingness to pay thresholds for each setting, most CEA studies concluded that screening for FH compared with no screening was cost-effective, regardless of the screening strategy. Cascade screening resulted in the largest health benefits per person tested.
Collapse
Affiliation(s)
- Clara Marquina
- Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Jedidiah I Morton
- Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Melanie Lloyd
- Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Dina Abushanab
- Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Yeji Baek
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tamrat Abebe
- Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Adam Livori
- Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Grampians Health, Ballarat, Australia
| | - Padam Dahal
- School of Health, Medical and Applied Sciences, Central Queensland University, Sydney Campus, Sydney, Australia
| | - Gerald F Watts
- School of Health, Medical and Applied Sciences, Central Queensland University, Sydney Campus, Sydney, Australia
- School of Medicine, University of Western Australia, Perth, Australia
- Cardiometabolic Service, Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
| | - Zanfina Ademi
- Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia.
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| |
Collapse
|
2
|
Meng R, Wei Q, Zhou J, Zhang B, Li C, Shen M. A systematic review of cost-effectiveness analysis of different screening strategies for familial hypercholesterolemia. J Clin Lipidol 2024; 18:e21-e32. [PMID: 37980172 DOI: 10.1016/j.jacl.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/07/2023] [Accepted: 11/02/2023] [Indexed: 11/20/2023]
Abstract
AIMS Diagnosis rate of familial hypercholesterolemia (FH) remained less than 10 % globally and the economic evaluation results of different FH screening strategies varied. This study aimed to systematically review the methodology and results of cost effectiveness analysis (CEA) of FH screening, which will provide evidence support for health-related decision-making. METHODS The Medline/PubMed, Embase, Cochrane Library, Web of science, National Health Service Economic Evaluation Database (NHSEED) and CEA Registry databases were electronically searched to collect full economic evaluation from the establishment of the databases to June 30, 2022. The quality of included studies was evaluated by the Consolidated Health Economic Evaluation Reporting Standards statement 2022 (CHEERS 2022) checklist. RESULTS Among 232 retrieved studies, 18 economic evaluations were included and all of them are from developed countries, with an average quality score of 0.73. The decision tree model and/or Markov model were constructed by thirteen articles (72 %). Twelve studies (67 %) adopted the healthcare perspective and the lifetime horizon to compare the costs and health outcome of different screening strategies. The results of eight studies indicated that cascade screening was a cost-effective strategy compared with no screening, which was more pronounced in younger adults. Universal screening in young adults aged 16 years or 18-40 years (n=3) and in children aged 1-2 years combined with reverse cascade screening (n=3) are both cost-effective. The probability of being cost-effective for cascade screening (n=6) and universal screening (n=1) of young aged 18-40 years were greater than 95 %. CONCLUSIONS Our review demonstrated the economic advantages of cascade screening, universal screening of young adults, and universal screening of newborns combined with reverse cascade screening. Further health economic evaluation is needed in children and in low- and middle-income countries.
Collapse
Affiliation(s)
- Rui Meng
- China-Australia Joint Research Center for Infectious Diseases (Drs Meng, Shen), School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, PR China
| | - Qiran Wei
- School of International Pharmaceutical Business (Drs Wei, Zhou), China Pharmaceutical University, Nanjing, Jiangsu 211198, China
| | - Jiting Zhou
- School of International Pharmaceutical Business (Drs Wei, Zhou), China Pharmaceutical University, Nanjing, Jiangsu 211198, China
| | - Baoming Zhang
- College of Stomatology (Dr Zhang), Xi'an Jiaotong University, Xi'an, Shaanxi 710004, PR China; Key laboratory of Shaanxi Province for Craniofacial Precision Medicine Research (Dr Zhang), College of Stomatology, Xi'an Jiaotong University, Xi'an, Shaanxi 710004, PR China; School of Public Health (Drs Zhang, Li), Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, PR China
| | - Chao Li
- School of Public Health (Drs Zhang, Li), Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, PR China
| | - Mingwang Shen
- China-Australia Joint Research Center for Infectious Diseases (Drs Meng, Shen), School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, PR China; Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province (Dr Shen), Xi'an, Shaanxi 710061, PR China.
| |
Collapse
|
3
|
Lin TK, Dispenza TC. Cholesterol Screening in Children: Is a Universal Approach Working? Curr Atheroscler Rep 2023; 25:579-590. [PMID: 37594601 DOI: 10.1007/s11883-023-01129-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE OF REVIEW Ample evidence supports that an individual's lifetime risk of atherosclerotic cardiovascular disease correlates to long-term, cumulative exposure to circulating cholesterol levels, beginning in childhood. Selective screening strategies based on family history fail to identify many children with hypercholesterolemia. Universal cholesterol screening in childhood is a worthwhile goal. However, cholesterol screening rates through childhood remain low. RECENT FINDINGS Mounting evidence clarifies the barriers to cholesterol screening in children. Specific strategies to foster universal screening in childhood have been proposed. SUMMARY We present an overview of the present state of childhood cholesterol screening, summarizing historical and contemporary guidelines and collating evidence of low adherence to current guidelines. We contend that novel approaches to universal cholesterol screening in childhood are warranted, and we present potential opportunities for improvement. We call for new and universal pediatric cholesterol screening guidelines.
Collapse
Affiliation(s)
- Tracie K Lin
- Penn State Health Children's Hospital, Division of Pediatric Cardiology, 600 University Drive, Hershey, PA, 17033, USA
| | - Thomas C Dispenza
- Penn State Health Children's Hospital, Division of Pediatric Cardiology, 600 University Drive, Hershey, PA, 17033, USA.
| |
Collapse
|
4
|
Xi Q, Jin S, Morris S. Economic evaluations of predictive genetic testing: A scoping review. PLoS One 2023; 18:e0276572. [PMID: 37531363 PMCID: PMC10395838 DOI: 10.1371/journal.pone.0276572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/03/2023] [Indexed: 08/04/2023] Open
Abstract
Predictive genetic testing can provide information about whether or not someone will develop or is likely to develop a specific condition at a later stage in life. Economic evaluation can assess the value of money for such testing. Studies on the economic evaluation of predictive genetic testing have been carried out in a variety of settings, and this research aims to conduct a scoping review of findings from these studies. We searched the PubMed, Web of Science, Embase, and Cochrane databases with combined search terms, from 2019 to 2022. Relevant studies from 2013 to 2019 in a previous systematic review were also included. The study followed the recommended stages for undertaking a scoping review. A total of 53 studies were included, including 33 studies from the previous review and 20 studies from the search of databases. A significant number of studies focused on the US, UK, and Australia (34%, 23%, and 11%). The most frequently included health conditions were cancer and cardiovascular diseases (68% and 19%). Over half of the studies compared predictive genetic testing with no genetic testing, and the majority of them concluded that at least some type of genetic testing was cost-effective compared to no testing (94%). Some studies stated that predictive genetic testing is becoming more cost-effective with the trend of lowering genetic testing costs. Studies on predictive genetic testing covered various health conditions, particularly cancer and cardiovascular diseases. Most studies indicated that predictive genetic testing is cost-effective compared to no testing.
Collapse
Affiliation(s)
- Qin Xi
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Shihan Jin
- Department of Pharmaceutical and Health Economics, Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, University of Southern California, Los Angeles, California, United States of America
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
5
|
Dikilitas O, Sherafati A, Saadatagah S, Satterfield BA, Kochan DC, Anderson KC, Chung WK, Hebbring SJ, Salvati ZM, Sharp RR, Sturm AC, Gibbs RA, Rowley R, Venner E, Linder JE, Jones LK, Perez EF, Peterson JF, Jarvik GP, Rehm HL, Zouk H, Roden DM, Williams MS, Manolio TA, Kullo IJ. Familial Hypercholesterolemia in the Electronic Medical Records and Genomics Network: Prevalence, Penetrance, Cardiovascular Risk, and Outcomes After Return of Results. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2023; 16:e003816. [PMID: 37071725 PMCID: PMC10113961 DOI: 10.1161/circgen.122.003816] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 01/03/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The implications of secondary findings detected in large-scale sequencing projects remain uncertain. We assessed prevalence and penetrance of pathogenic familial hypercholesterolemia (FH) variants, their association with coronary heart disease (CHD), and 1-year outcomes following return of results in phase III of the electronic medical records and genomics network. METHODS Adult participants (n=18 544) at 7 sites were enrolled in a prospective cohort study to assess the clinical impact of returning results from targeted sequencing of 68 actionable genes, including LDLR, APOB, and PCSK9. FH variant prevalence and penetrance (defined as low-density lipoprotein cholesterol >155 mg/dL) were estimated after excluding participants enrolled on the basis of hypercholesterolemia. Multivariable logistic regression was used to estimate the odds of CHD compared to age- and sex-matched controls without FH-associated variants. Process (eg, referral to a specialist or ordering new tests), intermediate (eg, new diagnosis of FH), and clinical (eg, treatment modification) outcomes within 1 year after return of results were ascertained by electronic health record review. RESULTS The prevalence of FH-associated pathogenic variants was 1 in 188 (69 of 13,019 unselected participants). Penetrance was 87.5%. The presence of an FH variant was associated with CHD (odds ratio, 3.02 [2.00-4.53]) and premature CHD (odds ratio, 3.68 [2.34-5.78]). At least 1 outcome occurred in 92% of participants; 44% received a new diagnosis of FH and 26% had treatment modified following return of results. CONCLUSIONS In a multisite cohort of electronic health record-linked biobanks, monogenic FH was prevalent, penetrant, and associated with presence of CHD. Nearly half of participants with an FH-associated variant received a new diagnosis of FH and a quarter had treatment modified after return of results. These results highlight the potential utility of sequencing electronic health record-linked biobanks to detect FH.
Collapse
Affiliation(s)
- Ozan Dikilitas
- Department of Internal Medicine (O.D.), Mayo Clinic, Rochester, MN
- Department of Cardiovascular Medicine (O.D., A.S., S.S., B.A.S., D.C.K., I.J.K.), Mayo Clinic, Rochester, MN
| | - Alborz Sherafati
- Department of Cardiovascular Medicine (O.D., A.S., S.S., B.A.S., D.C.K., I.J.K.), Mayo Clinic, Rochester, MN
| | - Seyedmohammad Saadatagah
- Department of Cardiovascular Medicine (O.D., A.S., S.S., B.A.S., D.C.K., I.J.K.), Mayo Clinic, Rochester, MN
| | - Benjamin A Satterfield
- Department of Cardiovascular Medicine (O.D., A.S., S.S., B.A.S., D.C.K., I.J.K.), Mayo Clinic, Rochester, MN
| | - David C Kochan
- Department of Cardiovascular Medicine (O.D., A.S., S.S., B.A.S., D.C.K., I.J.K.), Mayo Clinic, Rochester, MN
| | - Katherine C Anderson
- Department of Medicine (K.C.A., J.E.L., J.F.P.), Vanderbilt University Medical Center, Nashville, TN
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University Irving Medical Center, New York (W.K.C.)
| | | | - Zachary M Salvati
- Genomic Medicine Institute, Geisinger, Danville, PA (Z.M.S., A.C.S., L.K.J., M.S.W.)
| | - Richard R Sharp
- Biomedical Ethics Research Program (R.R.S.), Mayo Clinic, Rochester, MN
| | - Amy C Sturm
- Genomic Medicine Institute, Geisinger, Danville, PA (Z.M.S., A.C.S., L.K.J., M.S.W.)
| | - Richard A Gibbs
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX (R.A.G., E.V.)
| | - Robb Rowley
- National Human Genome Research Institute, Bethesda, MD (R.R., T.A.M.)
| | - Eric Venner
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX (R.A.G., E.V.)
| | - Jodell E Linder
- Department of Medicine (K.C.A., J.E.L., J.F.P.), Vanderbilt University Medical Center, Nashville, TN
| | - Laney K Jones
- Genomic Medicine Institute, Geisinger, Danville, PA (Z.M.S., A.C.S., L.K.J., M.S.W.)
| | - Emma F Perez
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA (E.F.P.)
| | - Josh F Peterson
- Department of Medicine (K.C.A., J.E.L., J.F.P.), Vanderbilt University Medical Center, Nashville, TN
| | - Gail P Jarvik
- Departments of Medicine (Medical Genetics) and Genome Sciences, University of Washington Medical Center, Seattle (G.P.J.)
| | - Heidi L Rehm
- Laboratory for Molecular Medicine, Partners Healthcare Personalized Medicine, Cambridge (H.L.R., H.Z.)
| | - Hana Zouk
- Laboratory for Molecular Medicine, Partners Healthcare Personalized Medicine, Cambridge (H.L.R., H.Z.)
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston (H.Z.)
| | - Dan M Roden
- Departments of Medicine, Pharmacology, and Biomedical Informatics (D.M.R.), Vanderbilt University Medical Center, Nashville, TN
| | - Marc S Williams
- Genomic Medicine Institute, Geisinger, Danville, PA (Z.M.S., A.C.S., L.K.J., M.S.W.)
| | - Teri A Manolio
- National Human Genome Research Institute, Bethesda, MD (R.R., T.A.M.)
| | - Iftikhar J Kullo
- Department of Cardiovascular Medicine (O.D., A.S., S.S., B.A.S., D.C.K., I.J.K.), Mayo Clinic, Rochester, MN
- Gonda Vascular Ctr (I.J.K.), Mayo Clinic, Rochester, MN
| |
Collapse
|
6
|
Jahn B, Santamaria J, Dieplinger H, Binder CJ, Ebenbichler C, Scholl-Bürgi S, Conrads-Frank A, Rochau U, Kühne F, Stojkov I, Todorovic J, James L, Siebert U. Familial hypercholesterolemia: A systematic review of modeling studies on screening interventions. Atherosclerosis 2022; 355:15-29. [DOI: 10.1016/j.atherosclerosis.2022.06.1011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/26/2022]
|
7
|
Johnson K, Saylor KW, Guynn I, Hicklin K, Berg JS, Lich KH. A systematic review of the methodological quality of economic evaluations in genetic screening and testing for monogenic disorders. Genet Med 2022; 24:262-288. [PMID: 34906467 PMCID: PMC8900524 DOI: 10.1016/j.gim.2021.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Understanding the value of genetic screening and testing for monogenic disorders requires high-quality, methodologically robust economic evaluations. This systematic review sought to assess the methodological quality among such studies and examined opportunities for improvement. METHODS We searched PubMed, Cochrane, Embase, and Web of Science for economic evaluations of genetic screening/testing (2013-2019). Methodological rigor and adherence to best practices were systematically assessed using the British Medical Journal checklist. RESULTS Across the 47 identified studies, there were substantial variations in modeling approaches, reporting detail, and sophistication. Models ranged from simple decision trees to individual-level microsimulations that compared between 2 and >20 alternative interventions. Many studies failed to report sufficient detail to enable replication or did not justify modeling assumptions, especially for costing methods and utility values. Meta-analyses, systematic reviews, or calibration were rarely used to derive parameter estimates. Nearly all studies conducted some sensitivity analysis, and more sophisticated studies implemented probabilistic sensitivity/uncertainty analysis, threshold analysis, and value of information analysis. CONCLUSION We describe a heterogeneous body of work and present recommendations and exemplar studies across the methodological domains of (1) perspective, scope, and parameter selection; (2) use of uncertainty/sensitivity analyses; and (3) reporting transparency for improvement in the economic evaluation of genetic screening/testing.
Collapse
Affiliation(s)
- Karl Johnson
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katherine W Saylor
- Department of Public Policy, College of Arts and Sciences, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Isabella Guynn
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Karen Hicklin
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jonathan S Berg
- Department of Genetics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC.
| |
Collapse
|
8
|
Spencer SJ, Jones LK, Guzauskas GF, Hao J, Williams MS, Peterson JF, Veenstra DL. Cost-effectiveness of population-wide genomic screening for familial hypercholesterolemia in the United States. J Clin Lipidol 2022; 16:667-675. [PMID: 35961838 PMCID: PMC9926472 DOI: 10.1016/j.jacl.2022.07.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/13/2022] [Accepted: 07/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Population genomic screening for familial hypercholesterolemia (FH) in unselected individuals can prevent premature cardiovascular disease. OBJECTIVE To estimate the clinical and economic outcomes of population-wide FH genomic screening versus no genomic screening. METHODS We developed a decision tree plus 10-state Markov model evaluating the identification of patients with an FH variant, statin treatment status, LDL-C levels, MI, and stroke to compare the costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness of population-wide FH genomic screening. FH variant prevalence (0.4%) was estimated from the Geisinger MyCode Community Health Initiative (MyCode). Genomic test costs were assumed to be $200. Age and sex-based estimates of MI, recurrent MI, stroke, and recurrent stroke were obtained from Framingham risk equations. Additional outcomes independently associated with FH variants were derived from a retrospective analysis of 26,025 participants screened for FH. Sensitivity and threshold analyses were conducted to evaluate model assumptions and uncertainty. RESULTS FH screening was most effective at younger ages; screening unselected 20-year-olds lead to 111 QALYs gained per 100,000 individuals screened at an incremental cost of $20 M. The incremental cost-effectiveness ratio (ICER) for 20-year-olds was $181,000 per QALY, and there was a 38% probability of cost-effectiveness at a $100,000 per QALY willingness-to-pay threshold. If genomic testing cost falls to $100, the ICER would be $91,000 per QALY. CONCLUSION Population FH screening is not cost-effective at current willingness to pay thresholds. However, reducing test costs, testing at younger ages, or including FH within broader multiplex screening panels may improve clinical and economic value.
Collapse
Affiliation(s)
- Scott J. Spencer
- Institute for Public Health Genetics, University of Washington; Seattle, WA
| | | | - Gregory F. Guzauskas
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington; Seattle, WA
| | - Jing Hao
- Department of Population Health Sciences, Geisinger; Danville, PA, USA (Dr Hao).
| | | | - Josh F. Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center; Nashville, TN
| | - David L Veenstra
- Institute for Public Health Genetics, University of Washington; Seattle, WA, USA (Drs Spencer and Veenstra); The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington; Seattle, WA, USA (Drs Guzauskas and Veenstra).
| |
Collapse
|
9
|
Izar MCDO, Giraldez VZR, Bertolami A, Santos Filho RDD, Lottenberg AM, Assad MHV, Saraiva JFK, Chacra APM, Martinez TLR, Bahia LR, Fonseca FAH, Faludi AA, Sposito AC, Chagas ACP, Jannes CE, Amaral CK, Araújo DBD, Cintra DE, Coutinho EDR, Cesena F, Xavier HT, Mota ICP, Giuliano IDCB, Faria Neto JR, Kato JT, Bertolami MC, Miname MH, Castelo MHCG, Lavrador MSF, Machado RM, Souza PGD, Alves RJ, Machado VA, Salgado Filho W. Update of the Brazilian Guideline for Familial Hypercholesterolemia - 2021. Arq Bras Cardiol 2021; 117:782-844. [PMID: 34709306 PMCID: PMC8528358 DOI: 10.36660/abc.20210788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
| | - Viviane Zorzanelli Rocha Giraldez
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Grupo Fleury, São Paulo, SP - Brasil
| | | | | | - Ana Maria Lottenberg
- Hospital Israelita Albert Einstein (HIAE) - Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo, Laboratório de Lípides (LIM10), São Paulo, São Paulo, SP - Brasil
| | | | | | - Ana Paula M Chacra
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Andrei C Sposito
- Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | - Cinthia Elim Jannes
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Fernando Cesena
- Hospital Israelita Albert Einstein (HIAE), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - Marcio Hiroshi Miname
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Maria Helane Costa Gurgel Castelo
- Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
- Hospital do Coração de Messejana, Fortaleza, CE - Brasil
- Professora da Faculdade Unichristus, Fortaleza, CE - Brasil
| | - Maria Sílvia Ferrari Lavrador
- Hospital Israelita Albert Einstein (HIAE) - Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), São Paulo, SP - Brasil
| | - Roberta Marcondes Machado
- Faculdade de Medicina da Universidade de São Paulo, Laboratório de Lípides (LIM10), São Paulo, São Paulo, SP - Brasil
| | - Patrícia Guedes de Souza
- Hospital Universitário Professor Edgard Santos da Universidade Federal da Bahia (UFBA), Salvador, BA - Brasil
| | | | | | - Wilson Salgado Filho
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| |
Collapse
|
10
|
Jackson CL, Huschka T, Borah B, Agre K, Zordok M, Farwati M, Moriarty J, Kullo IJ. Cost-effectiveness of cascade genetic testing for familial hypercholesterolemia in the United States: A simulation analysis. Am J Prev Cardiol 2021; 8:100245. [PMID: 34485965 PMCID: PMC8403726 DOI: 10.1016/j.ajpc.2021.100245] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/02/2021] [Accepted: 08/13/2021] [Indexed: 11/20/2022] Open
Abstract
Objective There is no coordinated cascade testing program for familial hypercholesterolemia (FH) in the U.S. We evaluated the contemporary cost-effectiveness of cascade genetic testing relatives of FH probands with a pathogenic variant. Methods A simulation model was created to simulate multiple family trees starting with progenitor individuals carrying a pathogenic variant for FH who were followed through several generations. This approach allowed us to examine a family tree that had grown sufficiently to have large numbers of relatives across multiple degrees of relatedness. The model estimated costs and life years gained (LYG) when cascade genetic testing was implemented for relatives of FH probands identified through standard care who were at or older than designated age thresholds (5, 10, 15, 20, 25, 30, 35, 40). Costs were valued in 2018 U.S. dollars. Future costs and LYG projected by the model were discounted at an annual rate of 3%. Results For 1st degree relatives, cascade testing at every age threshold resulted in a positive number of average LYG per person, though this number decreased as testing was started at higher age thresholds. Testing was not cost-effective if initiated at an age threshold of 40 and older but was cost-effective at younger age thresholds, with a discounted cost per LYG per person of less than $50,000. For 2nd degree relatives, testing was cost-effective with a screening age threshold of 10 but no longer cost-effective at a threshold of 15 or higher. In more distant relatives, cascade genetic testing was not beneficial or cost-effective. Conclusions Based on our simulation model, cascade genetic testing for FH in the U.S. is cost-effective if started before age 40 in 1st degree relatives and before age 15 in 2nd degree relatives.
Collapse
Affiliation(s)
| | - Todd Huschka
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Bijan Borah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States.,Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, United States
| | - Katherine Agre
- Clinical Genomics, Mayo Clinic, Rochester, MN, United States
| | - Magdi Zordok
- Department of Cardiovascular Medicine and the Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States
| | - Medhat Farwati
- Department of Cardiovascular Medicine and the Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States
| | - James Moriarty
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Iftikhar J Kullo
- Department of Cardiovascular Medicine and the Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States.,Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
11
|
Camacho OFC, Molina GP, Catalá CFM, Reali JR, Cruz RM, Zenteno JC. Familial Hypercholesterolemia: Update and Review. Endocr Metab Immune Disord Drug Targets 2021; 22:198-211. [PMID: 33563162 DOI: 10.2174/1871530321666210208212148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/28/2020] [Accepted: 12/28/2020] [Indexed: 11/22/2022]
Abstract
Knowledge of epidemiology, genetic etiopathogenesis, diagnostic criteria, and management of familial hypercholesterolemia have increased in the last two decades. Several population studies have shown that familial hypercholesterolemia is more frequent than previously thought, making this entity the most common metabolic disease with monogenic inheritence in the world. Identification of causal heterozygous pathogenic variants in LDLR, APOB, and PCSK9 genes have increased diagnostic accuracy of classical criteria (extreme hypercholesterolemia, personal / family history of premature coronary artery disease or other cardiovascular disease). Genetic screening has been recently introduced in many European countries to detect patients with familial hypercholesterolemia, mainly affected pediatric subjects, asymptomatic or those at the beggining of their disease, with the purpose of increasing surveillance and avoiding complications such as cardiovascular diseases. Cholesterol-lowering drugs should be started as soon as the diagnosis is made. Various combinations between drugs can be used when the goal is not achieved. New therapies, including small interference ribonucleic acids (siRNA) are being tested in different clinical trials.
Collapse
Affiliation(s)
| | - Glustein Pozo Molina
- Carrera de Médico Cirujano, Facultad de Estudios Superiores Iztacala, Universidad Nacional Autónoma de México, Tlalnepantla, . Mexico
| | - Claudia Fabiola Méndez Catalá
- Carrera de Médico Cirujano, Facultad de Estudios Superiores Iztacala, Universidad Nacional Autónoma de México, Tlalnepantla, . Mexico
| | - Julia Reyes Reali
- Carrera de Médico Cirujano, Facultad de Estudios Superiores Iztacala, Universidad Nacional Autónoma de México, Tlalnepantla, . Mexico
| | - René Méndez Cruz
- Carrera de Médico Cirujano, Facultad de Estudios Superiores Iztacala, Universidad Nacional Autónoma de México, Tlalnepantla, . Mexico
| | - Juan Carlos Zenteno
- Biochemistry Department, Faculty Medicine, National Autonomous University of Mexico, Mexico City,. Mexico
| |
Collapse
|
12
|
Health economic evaluation of screening and treating children with familial hypercholesterolemia early in life: Many happy returns on investment? Atherosclerosis 2020; 304:1-8. [DOI: 10.1016/j.atherosclerosis.2020.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/25/2020] [Accepted: 05/08/2020] [Indexed: 11/20/2022]
|
13
|
Ara R, Hill H, Lloyd A, Woods HB, Brazier J. Are Current Reporting Standards Used to Describe Health State Utilities in Cost-Effectiveness Models Satisfactory? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:397-405. [PMID: 32197736 DOI: 10.1016/j.jval.2019.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 11/15/2019] [Accepted: 12/29/2019] [Indexed: 05/13/2023]
Abstract
OBJECTIVE The aims of this study were to examine current reporting standards of health state utilities (HSU) using a review of published cost-effectiveness analyses in cardiovascular disease and to explore the impact of variation in model inputs used in these on estimated quality-adjusted life-years (QALYs) and cost-effectiveness. METHODS Key health/economics bibliographic databases were searched to identify relevant articles published after 2014. Any narrative or values relating to the HSU used in the model were extracted and reviewed. The HSUs were systematically applied to an existing model to explore the influence of different values on QALYs and the incremental cost-effectiveness ratio. RESULTS Twenty-four peer-reviewed articles were identified. Only 2 studies referred to a literature review for the HSUs. Most (18 of 24) referenced previously published economic studies (as opposed to the original source) for at least 1 of the HSUs. Only 4 studies referenced the original sources and reported all of the HSUs accurately, and several did not provide all the HSUs. Little information was provided on the methods used to calculate QALYs, for example, the duration of time for acute HSUs, what the baseline HSU was, the method that was used to assign HSUs for subsequent different events, or how constant HSUs for clinical events were combined with age-adjusted baseline values. The huge differences in HSUs used in the studies produced substantial variations in the QALYs and incremental cost-effectiveness ratios generated from the cost-effectiveness model. CONCLUSION Current standards are poor, and there is a need for greater transparency in reporting the HSUs used in cost-effectiveness models.
Collapse
Affiliation(s)
- Roberta Ara
- Health Economics and Decision Science, University of Sheffield, Sheffield, England, UK
| | - Harry Hill
- Health Economics and Decision Science, University of Sheffield, Sheffield, England, UK
| | - Andrew Lloyd
- Acaster Lloyd Consulting Ltd, London, England, UK
| | - Helen Buckley Woods
- Health Economics and Decision Science, University of Sheffield, Sheffield, England, UK
| | - John Brazier
- Health Economics and Decision Science, University of Sheffield, Sheffield, England, UK.
| |
Collapse
|
14
|
Page MM, Bell DA, Watts GF. Widening the spectrum of genetic testing in familial hypercholesterolaemia: Will it translate into better patient and population outcomes? Clin Genet 2019; 97:543-555. [PMID: 31833051 DOI: 10.1111/cge.13685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/25/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022]
Abstract
Familial hypercholesterolaemia (FH) is caused by pathogenic variants in LDLR, APOB or PCSK9. Impaired low-density lipoprotein (LDL) receptor function leads to decreased LDL catabolism and premature atherosclerotic cardiovascular disease (ASCVD). Thousands of LDLR variants are known, but assignation of pathogenicity requires accurate phenotyping, family studies and assessment of LDL receptor function. Precise, genetic diagnosis of FH using targeted next generation sequencing allows for optimal treatment, distinguishing FH from pathogenically distinct disorders requiring different treatment. Polygenic hypercholesterolaemia resulting from an accumulation of LDL cholesterol-raising single nucleotide polymorphisms (SNPs) could also be suspected by this approach. Similarly, ASCVD risk could be estimated by broader sequencing of cholesterol and non-cholesterol-related genes. Both of these areas require further research. The clinical management of FH, focusing on the primary or secondary prevention of ASCVD, has been boosted by PCSK9 inhibitor therapy. The efficacy of PCSK9 inhibitors in homozygous FH may be partly predicted by the LDLR variants. While expanded genetic testing in FH is clinically useful in providing an accurate diagnosis and enabling cost-effective testing of relatives, further research is needed to establish its value in improving clinical outcomes.
Collapse
Affiliation(s)
- Michael M Page
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Department of Clinical Biochemistry, Western Diagnostic Pathology, Perth, Australia
| | - Damon A Bell
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital and Royal Perth Hospital, Perth, Australia.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia.,Department of Clinical Biochemistry, Clinipath Pathology, Perth, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia
| |
Collapse
|
15
|
|
16
|
Akioyamen LE, Genest J, Shan SD, Inibhunu H, Chu A, Tu JV. Anxiety, depression, and health-related quality of life in heterozygous familial hypercholesterolemia: A systematic review and meta-analysis. J Psychosom Res 2018; 109:32-43. [PMID: 29773150 DOI: 10.1016/j.jpsychores.2018.03.170] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/24/2018] [Accepted: 03/24/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Heterozygous familial hypercholesterolemia (FH) is a common genetic disease predisposing affected individuals to a high risk of cardiovascular disease. Yet, considerable uncertainty exists regarding its impact on psychosocial wellbeing. OBJECTIVES We performed a systematic review and meta-analysis of the association between FH and symptoms of anxiety and depression, and health-related quality of life (HRQL). METHODS We searched MEDLINE, EMBASE, Global Health, the Cochrane Library, PsycINFO, and PubMed for peer-reviewed literature published in English between January 1, 1990 and January 1, 2018. Quantitative and qualitative studies were eligible if they included patients with confirmed FH and evaluated its association with symptoms of anxiety or depression, or HRQL. We performed a narrative synthesis of studies, including thematic analysis of qualitative studies, and where data permitted, random-effects meta-analysis reporting standardized mean differences (SMD) and 95% confidence intervals. RESULTS We found 10 eligible studies measuring HRQL, depression and anxiety. Random-effects meta-analysis of 4 (n = 4293) and 5 studies (n = 5098), respectively, showed that patients with FH had slightly lower symptoms of anxiety (SMD: -0.29 [95% CI: -0.53, -0.04]) and mental HRQL (SMD: -0.10 [95% -0.20, -0.00]) relative to general population controls. No significant differences existed in depressive symptoms (SMD: 0.04 [95% CI: -0.12, 0.19]) or physical HRQL scores (SMD: 0.02 [95% CI: -0.09, 0.12]). CONCLUSIONS Our systematic review suggests that patients with FH may report small but measurable differences in anxiety symptoms and mental HRQL.
Collapse
Affiliation(s)
- Leo E Akioyamen
- Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON M4N 3M5, Canada.
| | - Jacques Genest
- Faculty of Medicine, McGill University, Montreal, QC H3G 2M1, Canada; McGill University Health Centre, Royal Victoria Hospital, Montreal, QC H3A 1A1, Canada.
| | - Shubham D Shan
- Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON M4N 3M5, Canada.
| | - Happy Inibhunu
- Faculty of Science, University of Ontario Institute of Technology, Oshawa, ON L1H 7K4, Canada.
| | - Anna Chu
- Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON M4N 3M5, Canada.
| | - Jack V Tu
- Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON M4N 3M5, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada.
| |
Collapse
|
17
|
Kerr M, Pears R, Miedzybrodzka Z, Haralambos K, Cather M, Watson M, Humphries SE. Cost effectiveness of cascade testing for familial hypercholesterolaemia, based on data from familial hypercholesterolaemia services in the UK. Eur Heart J 2018; 38:1832-1839. [PMID: 28387827 PMCID: PMC5837803 DOI: 10.1093/eurheartj/ehx111] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 02/28/2017] [Indexed: 01/14/2023] Open
Abstract
Aims Familial hypercholesterolaemia (FH) is a vastly under-diagnosed genetic disorder, associated with early development of coronary heart disease and premature mortality which can be substantially reduced by effective treatment. Patents have recently expired on high-intensity statins, reducing FH treatment costs. We build a model using UK data to estimate the cost effectiveness of DNA testing of relatives of those with monogenic FH. Methods and Results A Markov model was used to estimate the cost effectiveness of cascade testing, using data from UK cascade services. The estimated incremental cost effectiveness ratio (ICER) was £5806 and the net marginal lifetime cost per relative tested was £2781. More than 80% of lifetime costs were diagnosis-related and incurred in the 1st year. In UK services, 23% of 6396 index cases were mutation-positive. For each mutation-positive index case, 1.33 relatives were tested, resulting overall in a rate of 0.31 tested relatives per tested index case. If the number of relatives tested per tested index case rose to 3.2 (projected by National Institute for Health and Care Excellence in 2008) the ICER would reduce to £2280 and lifetime costs to £1092. Conclusion Cascade testing of relatives of those with suspected FH is highly cost effective. The current Europe-wide high levels of undiagnosed FH, and associated morbidity and mortality, mean adoption of cascade services should yield substantial quality of life and survival gains.
Collapse
Affiliation(s)
- Marion Kerr
- Economics Department, Insight Health Economics Ltd., 16 Cambrian Road, Richmond, Surrey TW10 6JQ, UK
| | - Robert Pears
- Public Health Department, Hampshire County Council, Elizabeth II Court South, Winchester SO23 8UJ, UK
| | - Zofia Miedzybrodzka
- Department of Medical Genetics, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Kate Haralambos
- Wales Heart Research Institute, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | - Moyra Cather
- Northern Ireland Regional Genetics Centre, Regional Genetics Laboratories, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, UK
| | - Melanie Watson
- Wessex Clinical Genetics Service, University Hospital Southampton NHS Foundation Trust, Princess Anne Hospital, Coxford Road, Southampton SO16 5YA, UK
| | - Steve E Humphries
- Centre for Cardiovascular Genetics, Institute of Cardiovascular Science, University College London, 5 University Street, London WC1E 6JJ, UK
| |
Collapse
|
18
|
Pelczarska A, Jakubczyk M, Jakubiak-Lasocka J, Banach M, Myśliwiec M, Gruchała M, Niewada M. The cost-effectiveness of screening strategies for familial hypercholesterolaemia in Poland. Atherosclerosis 2018; 270:132-138. [PMID: 29407882 DOI: 10.1016/j.atherosclerosis.2018.01.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/26/2017] [Accepted: 01/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolaemia (FH) elevates the cholesterol level and increases the risk of coronary events and death. Early detection and treatment reduce this risk. We aimed to determine the cost-effectiveness of FH screening in Poland in children, first job takers, and after an acute coronary syndrome (ACS) event, each followed by a cascade screening in the relatives of the positively-diagnosed subjects. METHODS A decision tree was constructed to model the diagnosis process. We considered scenarios with and without genetic testing. A life-time Markov was built to investigate the effectiveness (life years gained, LYG; and quality-adjusted life years, QALY) and cost (public payer perspective) of treatment in FH-affected subjects. The clinical benefits result from early treatment reducing the risk of coronary heart disease (and death, in result). Model parameters were based on published data and experts' opinions. The costs (patients visits, tests, drugs) were estimated from the National Health Fund data and other publicly-available sources. RESULTS Screening ACS patients below 55/65 years of age in men/women is the most cost-effective strategy: the cost of one LYG (QALY) amounts to 100 EUR (110 EUR). Removing the age limit or using genetic tests reduced cost-effectiveness; nonetheless, all strategies remained cost effective: the cost of one LYG or QALY was <5040 EUR, much lower than the official threshold of ca. 29,800 EUR/QALY. CONCLUSIONS Screening for FH is highly cost-effective in Poland. The strategies are complementary, and using a combination thereof is recommended.
Collapse
Affiliation(s)
| | - Michał Jakubczyk
- Decision Analysis and Support Unit, SGH Warsaw School of Economics, Poland
| | | | - Maciej Banach
- Department of Hypertension, Medical University of Łódź, Poland
| | - Małgorzata Myśliwiec
- Chair and Clinics of Paediatrics, Diabetology and Endocrinology, Medical University of Gdańsk, Poland
| | - Marcin Gruchała
- Department of Cardiology I, Medical University of Gdańsk, Poland
| | - Maciej Niewada
- Department of Clinical and Experimental Pharmacology, Medical University of Warsaw, Poland.
| |
Collapse
|
19
|
Akioyamen LE, Genest J, Shan SD, Reel RL, Albaum JM, Chu A, Tu JV. Estimating the prevalence of heterozygous familial hypercholesterolaemia: a systematic review and meta-analysis. BMJ Open 2017; 7:e016461. [PMID: 28864697 PMCID: PMC5588988 DOI: 10.1136/bmjopen-2017-016461] [Citation(s) in RCA: 214] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Heterozygous familial hypercholesterolaemia (FH) confers a significant risk for premature cardiovascular disease (CVD). However, the estimated prevalence of FH varies substantially among studies. We aimed to provide a summary estimate of FH prevalence in the general population and assess variations in frequency across different sociodemographic characteristics. SETTING, PARTICIPANTS AND OUTCOME MEASURES We searched MEDLINE, EMBASE, Global Health, the Cochrane Library, PsycINFO and PubMed for peer-reviewed literature using validated strategies. Results were limited to studies published in English between January 1990 and January 2017. Studies were eligible if they determined FH prevalence using clinical criteria or DNA-based analyses. We determined a pooled point prevalence of FH in adults and children and assessed the variation of the pooled frequency by age, sex, geographical location, diagnostic method, study quality and year of publication. Estimates were pooled using random-effects meta-analysis. Differences by study-level characteristics were investigated through subgroups, meta-regression and sensitivity analyses. RESULTS The pooled prevalence of FH from 19 studies including 2 458 456 unique individuals was 0.40% (95% CI 0.29% to 0.52%) which corresponds to a frequency of 1 in 250 individuals. FH prevalence was found to vary by age and geographical location but not by any other covariates. Results were consistent in sensitivity analyses. CONCLUSIONS Our systematic review suggests that FH is a common disorder, affecting 1 in 250 individuals. These findings underscore the need for early detection and management to decrease CVD risk.
Collapse
Affiliation(s)
- Leo E Akioyamen
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Jacques Genest
- Faculty of Medicine, McGill University, Montreal, Canada
- MGill University Health Centre, Royal Victoria Hospital, Montreal, Canada
| | - Shubham D Shan
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Rachel L Reel
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Anna Chu
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Jack V Tu
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| |
Collapse
|
20
|
Hopkins PN, Lane SR. Genotype-guided diagnosis in familial hypercholesterolemia: clinical management and concerns. Curr Opin Lipidol 2017; 28:144-151. [PMID: 28157722 DOI: 10.1097/mol.0000000000000397] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW In this review, we examine benefits and concerns associated with genetic testing in the clinical management of familial hypercholesterolemia (FH). RECENT FINDINGS Application of next-generation sequencing and other advances provide improved yield of causal mutations compared with older methods and help disclose underlying pathophysiology in many instances. Concerns regarding clinical application of genetic testing remain. SUMMARY More widespread application of genetic testing for FH in the USA may be forthcoming. When a genetic cause of FH can be identified or is known for the family, test results can provide more accurate individual diagnosis of FH, clarification of underlying pathophysiology, and greater clinical insight. However, several concerns persist, particularly cost to FH patients, potential discrimination, and inappropriate denial of clinically indicated therapies for patients without definitive genetic testing results.
Collapse
Affiliation(s)
- Paul N Hopkins
- aCardiovascular Genetics Research Program, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah bThe FH Foundation, Pasadena, California, USA
| | | |
Collapse
|
21
|
Abul-Husn NS, Manickam K, Jones LK, Wright EA, Hartzel DN, Gonzaga-Jauregui C, O’Dushlaine C, Leader JB, Lester Kirchner H, Lindbuchler DM, Barr ML, Giovanni MA, Ritchie MD, Overton JD, Reid JG, Metpally RPR, Wardeh AH, Borecki IB, Yancopoulos GD, Baras A, Shuldiner AR, Gottesman O, Ledbetter DH, Carey DJ, Dewey FE, Murray MF. Genetic identification of familial hypercholesterolemia within a single U.S. health care system. Science 2016; 354:354/6319/aaf7000. [DOI: 10.1126/science.aaf7000] [Citation(s) in RCA: 264] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 11/16/2016] [Indexed: 12/12/2022]
|
22
|
Norman R, Watts GF, Weintraub W, Gidding SS. Challenges in the health economics of familial hypercholesterolemia. Curr Opin Lipidol 2016; 27:563-569. [PMID: 27798488 DOI: 10.1097/mol.0000000000000365] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Implementation of effective interventions often requires evidence regarding value, that is, whether they are worth what we pay for them. This review explores recent evidence concerning cost-effectiveness in familial hypercholesterolemia, and discusses the cause of, and likelihood of solutions to, the paucity of such evidence. RECENT FINDINGS Cost-effectiveness analysis in familial hypercholesterolemia has been limited almost exclusively to adult populations. However, there is growing evidence that childhood intervention offers substantial benefit in terms of downstream health gains. Statin therapy in adults has been demonstrated to be cost-effective, but the range of novel agents that might be used will require de novo economic evaluation alongside exploration of their effect and safety profile. SUMMARY The familial hypercholesterolemia field has limited evidence regarding cost-effectiveness, which limits optimum allocation of resources. Economic evaluations are necessary to appraise new agents and optimal timing of management approaches. Evaluations often have substantial data demands; consequentially, their applicability to medical decision-making or policy will be partly determined by the availability of data, particularly those providing information about the long-term trajectory of health benefit from familial hypercholesterolemia treatment.
Collapse
Affiliation(s)
- Richard Norman
- aSchool of Public Health, Curtin University, Bentley bCardiometabolic Service, Department of Cardiology, Royal Perth Hospital cSchool of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia dChristiana Care Health System eNemours Cardiac Center, Alfred I. Dupont Hospital for Children, Wilmington, Delaware USA
| | | | | | | |
Collapse
|
23
|
Pajak A, Szafraniec K, Polak M, Drygas W, Piotrowski W, Zdrojewski T, Jankowski P. Prevalence of familial hypercholesterolemia: a meta-analysis of six large, observational, population-based studies in Poland. Arch Med Sci 2016; 12:687-96. [PMID: 27478447 PMCID: PMC4947614 DOI: 10.5114/aoms.2016.59700] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 02/27/2016] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Familial hypercholesterolemia (FH) is a severely underdiagnosed and undertreated genetic disorder. Little is known about regional variation in the prevalence of FH, and information for Central and Eastern Europe (CEE) is scarce. This paper assesses the prevalence of FH and related cardiovascular disease (CVD) risk factors in Poland. MATERIAL AND METHODS We performed a meta-analysis of six population-based studies in Poland. The FH was assessed using the Dutch Lipids Clinics Network (DLCN) criteria. The categories "definite" (> 8 points) and "probable" (6-8 points) were combined into "potential FH". Combined estimates of proportions across studies were pooled by meta-analysis with a random effects model. RESULTS A total of 37,889 persons aged 20-79 years were included in the analysis. The distribution of DLCN scores was skewed, and there were only 7 cases of definite FH. Prevalence of potential FH was 404/100,000 people (95% CI = 277-531/100,000). Familial hypercholesterolemia was more prevalent in women than in men, and the prevalence was the highest in the age group 45-54 years in men and 55-64 years in women. After adjustment for age and sex, compared to participants with normal cholesterol, persons with potential FH had twice the prevalence of hypertension (p < 0.01); smoking was more prevalent by about 80% (p < 0.01) and hypertriglyceridemia was nine times more frequent (p < 0.001). There was no difference in the prevalence of low high-density lipoprotein (HDL)-cholesterol or diabetes. CONCLUSIONS We believe that our study might facilitate the planning of a strategy to manage the disease at a population level, i.e. to develop a national strategy for the detection, diagnosis, and treatment of FH.
Collapse
Affiliation(s)
- Andrzej Pajak
- Department of Epidemiology and Population Studies, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Krystyna Szafraniec
- Department of Epidemiology and Population Studies, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej Polak
- Department of Epidemiology and Population Studies, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Drygas
- Department of Epidemiology, Cardiovascular Disease Prevention and Health Promotion, Institute of Cardiology, Warsaw, Poland
- Department of Preventive Medicine, Medical University of Lodz, Lodz, Poland
| | - Walerian Piotrowski
- Department of Epidemiology, Cardiovascular Disease Prevention and Health Promotion, Institute of Cardiology, Warsaw, Poland
| | - Tomasz Zdrojewski
- Department of Prevention and Medical Education, Medical University of Gdansk, Gdansk, Poland
| | - Piotr Jankowski
- Department of Intensive Electrotherapy and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| |
Collapse
|
24
|
Pang J, Lansberg PJ, Watts GF. International Developments in the Care of Familial Hypercholesterolemia: Where Now and Where to Next? J Atheroscler Thromb 2016; 23:505-19. [DOI: 10.5551/jat.34108] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jing Pang
- School of Medicine and Pharmacology, University of Western Australia
| | - Peter J Lansberg
- Center for Translational Molecular Medicine - Translational Research Infrastructure (CTMM-TraIT)
- Department of Vascular Medicine, Academic Medical Center
| | - Gerald F Watts
- School of Medicine and Pharmacology, University of Western Australia
- Lipid Disorders Clinic, Cardiometabolic Service, Department of Cardiology, Royal Perth Hospital
| |
Collapse
|
25
|
Santos RD, Frauches TS, Chacra APM. Cascade Screening in Familial Hypercholesterolemia: Advancing Forward. J Atheroscler Thromb 2015. [PMID: 26194978 DOI: 10.5551/jat.31237] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Familial hypercholesterolemia is a genetic disorder associated with elevated LDL-cholesterol and high lifetime cardiovascular risk. Both clinical and molecular cascade screening programs have been implemented to increase early definition and treatment. In this systematic review, we discuss the main issues found in 65 different articles related to cascade screening and familial hypercholesterolemia, covering a range of topics including different types/strategies, considerations both positive and negative regarding cascade screening in general and associated with the different strategies, cost and coverage consideration, direct and indirect contact with patients, public policy around life insurance and doctor-patient confidentiality, the "right to know," and public health concerns regarding familial hypercholesterolemia.
Collapse
Affiliation(s)
- Raul D Santos
- Lipid Clinic, Heart Institute (InCor), University of São Paulo Medical School Hospital
| | | | | |
Collapse
|
26
|
Wiegman A, Gidding SS, Watts GF, Chapman MJ, Ginsberg HN, Cuchel M, Ose L, Averna M, Boileau C, Borén J, Bruckert E, Catapano AL, Defesche JC, Descamps OS, Hegele RA, Hovingh GK, Humphries SE, Kovanen PT, Kuivenhoven JA, Masana L, Nordestgaard BG, Pajukanta P, Parhofer KG, Raal FJ, Ray KK, Santos RD, Stalenhoef AFH, Steinhagen-Thiessen E, Stroes ES, Taskinen MR, Tybjærg-Hansen A, Wiklund O. Familial hypercholesterolaemia in children and adolescents: gaining decades of life by optimizing detection and treatment. Eur Heart J 2015; 36:2425-37. [PMID: 26009596 PMCID: PMC4576143 DOI: 10.1093/eurheartj/ehv157] [Citation(s) in RCA: 546] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/19/2015] [Indexed: 12/27/2022] Open
Abstract
Familial hypercholesterolaemia (FH) is a common genetic cause of premature coronary heart disease (CHD). Globally, one baby is born with FH every minute. If diagnosed and treated early in childhood, individuals with FH can have normal life expectancy. This consensus paper aims to improve awareness of the need for early detection and management of FH children. Familial hypercholesterolaemia is diagnosed either on phenotypic criteria, i.e. an elevated low-density lipoprotein cholesterol (LDL-C) level plus a family history of elevated LDL-C, premature coronary artery disease and/or genetic diagnosis, or positive genetic testing. Childhood is the optimal period for discrimination between FH and non-FH using LDL-C screening. An LDL-C ≥5 mmol/L (190 mg/dL), or an LDL-C ≥4 mmol/L (160 mg/dL) with family history of premature CHD and/or high baseline cholesterol in one parent, make the phenotypic diagnosis. If a parent has a genetic defect, the LDL-C cut-off for the child is ≥3.5 mmol/L (130 mg/dL). We recommend cascade screening of families using a combined phenotypic and genotypic strategy. In children, testing is recommended from age 5 years, or earlier if homozygous FH is suspected. A healthy lifestyle and statin treatment (from age 8 to 10 years) are the cornerstones of management of heterozygous FH. Target LDL-C is <3.5 mmol/L (130 mg/dL) if >10 years, or ideally 50% reduction from baseline if 8–10 years, especially with very high LDL-C, elevated lipoprotein(a), a family history of premature CHD or other cardiovascular risk factors, balanced against the long-term risk of treatment side effects. Identifying FH early and optimally lowering LDL-C over the lifespan reduces cumulative LDL-C burden and offers health and socioeconomic benefits. To drive policy change for timely detection and management, we call for further studies in the young. Increased awareness, early identification, and optimal treatment from childhood are critical to adding decades of healthy life for children and adolescents with FH.
Collapse
Affiliation(s)
- Albert Wiegman
- Department of Paediatrics, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Samuel S Gidding
- Nemours Cardiac Center, A. I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Gerald F Watts
- School of Medicine and Pharmacology, Royal Perth Hospital Unit, The University of Western Australia, Western Australia, Australia
| | - M John Chapman
- Pierre and Marie Curie University, Paris, France National Institute for Health and Medical Research (INSERM), Pitié-Salpêtrière University Hospital, Paris, France
| | - Henry N Ginsberg
- Columbia University College of Physicians and Surgeons, New York, NY, USA Irving Institute for Clinical and Translational Research, Columbia University Medical Center, New York, USA
| | - Marina Cuchel
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Leiv Ose
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway Lipid Clinic, Oslo University Hospital, Oslo, Norway
| | - Maurizio Averna
- Department of Internal Medicine, University of Palermo, Italy
| | - Catherine Boileau
- Diderot Medical School, University Paris 7, Paris, France Genetics Department, Bichat University Hospital, Paris, France INSERM U698, Paris, France
| | - Jan Borén
- Department of Medicine, Sahlgrenska Academy, Göteborg University, Gothenburg, Sweden Wallenberg Laboratory for Cardiovascular Research, Gothenburg, Sweden
| | - Eric Bruckert
- Department of Endocrinology and Prevention of Cardiovascular Disease, University Hospital Pitié-Salpêtrière, Paris, France
| | - Alberico L Catapano
- Department of Pharmacology, Faculty of Pharmacy, University of Milano, Milan, Italy Multimedica IRCSS, Milan, Italy
| | - Joep C Defesche
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
| | | | - Robert A Hegele
- Robarts Research Institute, University of Western Ontario, London, ON, Canada
| | - G Kees Hovingh
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Steve E Humphries
- Centre for Cardiovascular Genetics, University College London, Institute of Cardiovascular Sciences, London, UK
| | | | - Jan Albert Kuivenhoven
- Department of Pediatrics, Section Molecular Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Luis Masana
- Vascular Medicine and Metabolic Unit, Department of Medicine and Surgery, University Rovira and Virgili, Reus-Tarragona, Spain
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev Hospital, Copenhagen University Hospital, Herlev, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Päivi Pajukanta
- Department of Human Genetics, Center for Metabolic Disease Prevention, University of California, Los Angeles, USA
| | - Klaus G Parhofer
- Department of Endocrinology and Metabolism, University of Munich, Munich, Germany
| | - Frederick J Raal
- Carbohydrate & Lipid Metabolism Research Unit; and Division of Endocrinology & Metabolism, University of the Witwatersrand, Johannesburg, South Africa
| | - Kausik K Ray
- Department of Primary Care and Public Health, School of Public Health, Imperial College, London, UK
| | - Raul D Santos
- Lipid Clinic of the Heart Institute (InCor), University of São Paulo, São Paulo, Brazil Department of Cardiology, University of São Paulo Medical School, São Paulo, Brazil
| | - Anton F H Stalenhoef
- Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Erik S Stroes
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Marja-Riitta Taskinen
- Research Programs Unit, Diabetes & Obesity, University of Helsinki and Heart & Lung Centre, Helsinki University Hospital, Helsinki, Finland
| | - Anne Tybjærg-Hansen
- Department of Clinical Biochemistry, Section for Molecular Genetics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Olov Wiklund
- Department of Experimental and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | |
Collapse
|