Cost-effectiveness of initial therapy with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors to treat hypercholesterolemia in a primary care setting of a managed-care organization

A Systematic Review of Health Economic Evaluation Studies Using the Patient's Perspective

BACKGROUND

Patient-centered care has become increasingly important and relevant for informed health care decision making.

OBJECTIVE

Our study aimed to perform a systematic review of health economic evaluation studies from the patient's perspective.

METHODS

PubMed, EMBASE, and Cochrane Central databases were searched through May 2014 for cost-effectiveness, cost-utility, and cost-benefit studies using the patient's perspective in their analysis. The reporting quality of the studies was evaluated on the basis of Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

We identified 30 health economic evaluations using the patient's perspective, of which 7 were conducted in the United States, 9 in Europe, and 14 in Asian or other countries. Seventeen of 23 health conditions evaluated were chronic in nature. Among 12 studies that justified the use of the patient's perspective, patient's financial burden associated with medical treatment was the most commonly cited rationale. A total of 29, 17, and 15 studies examined direct medical, direct nonmedical, and indirect costs, respectively. Seventeen studies also included societal, governmental or payer's, and/or provider's perspective(s) in their analyses. Based on Consolidated Health Economic Evaluation Reporting Standards, more than 20% of the reporting items in these studies were either partially satisfied or not satisfied.

CONCLUSIONS

There is a paucity of health economic evaluations conducted from the patient's perspective in the literature. For those studies using the patient's perspective, the true patient costs were not fully explored and study reporting quality was not optimal. With the increasing focus on patient-centered outcomes in health policy research, more frequent use of the patient's perspective in economic studies should be advocated.

Cost effectiveness of statins in coronary heart disease

INTRODUCTION

Statin therapy reduces the rate of coronary heart disease, but high costs in combination with a large population eligible for treatment ask for priority setting. Although trials agree on the size of the benefit, economic analyses of statins report contradictory results. This article reviewed cost effectiveness analyses of statins and sought to synthesise cost effectiveness ratios for categories of risk of coronary heart disease and age.

METHODS

The review searched for studies comparing statins with no treatment for the prevention of either cardiovascular or coronary heart disease in men and presenting cost per years of life saved as outcome. Estimates were extracted, standardised for calendar year and currency, and stratified by categories of risk, age, and funding source

RESULTS

24 studies were included (from 50 retrieved), yielding 216 cost effectiveness ratios. Estimated ratios increase with decreasing risk. After stratification by risk, heterogeneity of ratios is large varying from savings to $59 000 per life year saved in the highest risk category and from 6500 dollars to 490,000 dollars in the lowest category. The pooled estimates show values of 21571 dollars per life year saved for a 10 year coronary heart disease risk of 20% and 16862 dollars per life year saved for 10 year risk of 30%.

CONCLUSION

Statin therapy is cost effective for high levels of risk, but inconsistencies exist at lower levels. Although the cost effectiveness of statins depends mainly on absolute risk, important heterogeneity remains after adjusting for absolute risk. Economic analyses need to increase their transparency to reduce their vulnerability to bias and increase their reproducibility.

Cost effectiveness of HMG-CoA reductase inhibitors in the management of coronary artery disease: the problem of under-treatment

HMG-CoA reductase inhibitors significantly reduce the risk of coronary artery disease (CAD) events and CAD-related mortality in patients with and without established CAD. Consequently, HMG-CoA reductase inhibitors have a central role within recommendations for lipid-modifying therapy. However, despite these guidelines, only one-third to one-half of eligible patients receive lipid-lowering therapy and as few as one-third of these patients achieve recommended target serum levels of low density lipoprotein-cholesterol. The underuse of HMG-CoA reductase inhibitors in eligible patients has important implications for mortality, morbidity and cost, given the enormous economic burden associated with CAD; direct healthcare costs, estimated at US $16-53 billion (2000 values) in the US and 1.6 billion pound (1996 values) in the UK alone, are largely driven by inpatient care. Hospitalization costs are reduced by treatment with HMG-CoA reductase inhibitors, particularly in high-risk groups such as patients with CAD and diabetes mellitus in whom net cost savings may be achieved. HMG-CoA reductase inhibitors are underused because of institutional factors and clinician and patient factors. Also, the vast number of patients eligible for treatment means that the use of HMG-CoA reductase inhibitors is undoubtedly limited by budgetary considerations. Secondary prevention in CAD using HMG-CoA reductase inhibitors is certainly cost effective. Primary prevention with HMG-CoA reductase inhibitors is also cost effective in many patients, depending upon CAD risk and drug dosage. As new, more powerful, HMG-CoA reductase inhibitors come to market, and the established HMG-CoA reductase inhibitors come off patent, the identification of the most cost-effective therapy becomes increasingly complex. Research in to the relative cost effectiveness of alternative HMG-CoA reductase inhibitors, taking full account of the institutional, clinician and patient barriers to uptake should be undertaken to identify the most appropriate role for the new therapies.

Statins do not meet expectations for lowering low-density lipoprotein cholesterol levels when used in clinical practice

BACKGROUND

Statins have become a mainstay in the treatment of hyperlipidemia, based on their potency and favorable side-effect profile. Drug choice is presumed to be guided by the estimated degree of low-density lipoprotein (LDL) cholesterol lowering required in a particular patient and the projected efficacy of any drug-dose combination, as contained in the package inserts for each medication. We investigated whether these expectations were met in a clinical practice.

METHODS

Data were analyzed for 367 hyperlipidemic patients in a preventive cardiology practice who were not taking statins at entry, who were given a standard statin dose at their first visit, and who had at least one follow-up visit on the same drug/dose. Expected LDL cholesterol reductions were calculated for each patient based on guidelines in the package inserts for each drug.

RESULTS

The mean (+/-SD) observed LDL cholesterol reduction of 26% +/- 20% was significantly less than expected (34% +/- 7%, P < 0.001). The ratio of observed to expected reduction was not different for the three statins used (atorvastatin, 0.79 +/- 0.48; simvastatin, 0.88 +/- 0.61; pravastatin, 0.75 +/- 0.69; P = 0.39).

CONCLUSIONS

The use of statins in a clinical practice led to observed reductions in LDL cholesterol level that were significantly less than those projected by package insert guidelines. We believe this gap reflects the reduced patient compliance frequently observed in clinical practice settings, rather than any inherent difference in statin responsiveness of a practice versus a trial population. Physicians should be aware of this disparity when using statins in the clinical setting.

Clinical context: current concepts of coronary heart disease management

Coronary heart disease (CHD) is the single greatest cause of death among adults in the United States. It is also a major cause of disability and is associated with direct and indirect costs that exceed $118 billion annually. Elevation of serum lipid levels, particularly low-density lipoprotein cholesterol (LDL-C) levels, is closely linked to the development of CHD. Lipid levels that increase the risk of CHD are present in nearly one third of the US population. Large-scale intervention studies have shown that decreasing LDL-C can significantly reduce the risk of cardiovascular mortality, adverse cardiovascular events, and the requirement for revascularization procedures. Statins are now thought the most effective agents for lowering LDL-C, and they also have positive effects on other components of the serum lipid profile. These drugs are also better tolerated than other lipid-lowering agents. Statin therapy significantly decreases the risk of cardiovascular disease and is a cost-effective cardiovascular treatment according to current standards. Because statins vary substantially in acquisition cost, using statins in the most cost-effective manner is important for controlling health-care costs. Optimizing the cost-effectiveness of statin therapy is a particular concern to managed care organizations in light of the large number of patients who are now considered candidates for this treatment.

A means to an end: an overview of a hyperlipidemia outcomes management program

Quality management and improvement are increasingly important to managed care organizations (MCOs) as competition increases. One key area on which quality improvement programs can focus is MCO activity in helping patients remain healthy. Screening for and treatment of hyperlipidemia are important components of the preventive care of patients who are at risk for coronary heart disease (CHD). This article summarizes the methodology of a three-phase hyperlipidemia outcomes management program being implemented by 27 US health plans. Phase 1 identifies inefficiencies in the clinical management of hyperlipidemia by assessing patients' attainment rates of low-density lipoprotein cholesterol (LDL-C) targets. This information is then used to develop a multifactorial intervention program for CHD prevention in phase 2. The interventions for physicians include provision of treatment algorithms for patients with varying degrees of hyperlipidemia, education programs encouraging appropriate treatment of hyperlipidemia, and academic detailing summarizing phase 1 results and providing applicable literature. In phase 3, patient records are reassessed at least 6 months after the educational intervention. This three-phase program has the potential to improve patient care, reduce unnecessary treatment costs, provide a means of quality improvement, and increase plan value to potential purchasers.

Lipid-lowering interventions in managed care settings

Effective screening, treatment, and follow-up of patients with elevated serum lipid levels is important because of the very strong association between this condition and coronary heart disease (CHD). Screening of patients with and without CHD for hyperlipidemia is not generally carried out properly by managed care organizations (MCOs) or in other settings. Primary and secondary prevention are inadequate in most patients with this condition; even in patients who are treated, lipid-lowering therapy is often not used to its full potential. These trends have been confirmed by findings in the first of a three-phase hyperlipidemia outcomes management program carried out at 27 US MCOs. The efficacy of lipid-lowering therapy can be enhanced by physician education and comprehensive, integrated quality improvement programs. The cost-effectiveness of such treatment can be improved by individualizing both drug and dose to achieve National Cholesterol Education Program goals at the lowest drug acquisition cost. The quality improvement program described and others like it have the potential to reduce the morbidity and mortality associated with CHD while decreasing the huge economic burden associated with this disease. Several such programs have been undertaken at MCOs, some with more success than others. Interventions and assessments of the type planned in phases 2 and 3 of this program can help to reduce the cost of lipid-lowering therapy without compromising cholesterol goal achievement.

Which statin is most efficient for the treatment of hypercholesterolemia? A cost-effectiveness analysis

A review of the cost-effectiveness literature indicated that the hydroxymethylglutaryl coenzyme A-reductase inhibitor fluvastatin is more cost-effective for achieving minor-to-moderate reductions in low-density lipoprotein cholesterol (LDL-C) levels than 3 other statins: lovastatin, pravastatin, and simvastatin. The main goal of this study was to verify the applicability of these conclusions to Spanish health care costs and patterns of resource consumption related to the treatment of hypercholesterolemia. A stochastic simulation model was used to predict both the costs and effects of treating high-risk hypercholesterolemic patients with fluvastatin, lovastatin, pravastatin, or simvastatin. Epidemiologic data were used to find a suitable theoretic probability distribution model for baseline LDL-C values in high-risk hypercholesterolemic patients. The model was then used to generate 10,000 random observations of baseline LDL-C values; the corresponding LDL-C values after a 2-year treatment period were predicted as a function of the baseline value and the percentage reduction expected with a particular statin and dose, according to the results obtained in 2 meta-analyses. The probability of treatment discontinuation was also taken into account using estimates obtained in usual practice. The effects of treatment were expressed as the rate of success in achieving the goal level of LDL-C, as defined in the current Spanish recommendations for the treatment of hypercholesterolemia. The average costs of treatment were computed from both the social and public-financing perspectives, including the cost of lipid-lowering drugs, physician visits, laboratory tests, and days off work, as appropriate. The occurrence of nonscheduled visits and workdays lost because of side effects were taken into account to compute indirect costs relevant to the social perspective. The potential costs of treating side effects were ignored. A cost-effectiveness analysis was performed to compare the cost-effectiveness ratios obtained with each of the 4 statins considered in this study. Model-based predictions of the effects, total costs, and cost-effectiveness ratios were made. Cost-effectiveness ratios were interpreted as the cost per patient meeting the goal of therapy, according to current Spanish recommendations. The data showed that fluvastatin had the lowest cost-effectiveness ratios when LDL-C levels required reduction to < or =25% of baseline levels. In this situation, fluvastatin was more cost-effective than lovastatin, pravastatin, or simvastatin from public-financing and social perspectives.

Conversion from fluvastatin to simvastatin therapy at a dose ratio of 8 to 1: effect on serum lipid levels and cost

The objective of this study was to assess the effect on serum lipid levels of the substitution of simvastatin for fluvastatin at a dose ratio of 8:1 (fluvastatin to simvastatin). A secondary objective was to determine the number of patients at goal lipid levels before and after this substitution. The study included 60 outpatients with hyperlipidemia who had received a constant dose of fluvastatin for at least 6 weeks. After a baseline 12-hour lipid profile (total cholesterol, triglycerides, high-density lipoprotein, and low-density lipoprotein [LDL]) was obtained, patients were switched from fluvastatin to simvastatin at an 8:1 dose ratio. Patients were instructed to split the simvastatin tablets in half with a pill splitter and to take one half-tablet at bedtime. A repeat lipid profile and liver function testing were performed after 6 to 8 weeks of simvastatin therapy. Lipid components were compared before and during simvastatin therapy using a paired t test. Target LDL levels were based on guidelines issued by the National Cholesterol Education Program. Fifty-six patients completed the study. No change in lipid components was observed, except for a statistically significant decrease in LDL. The majority of patients had a decrease in LDL levels, rather than an increase, after the conversion to simvastatin. Six patients required a dose increase of simvastatin in response to increased LDL levels. Forty-one percent of patients achieved goal LDL levels with simvastatin, compared with 30% with fluvastatin. Four patients withdrew from the study, two because of troublesome side effects and two for failure to complete the protocol. The results show that simvastatin can be substituted for fluvastatin at a dose ratio of 8:1 without loss of lipid control in the majority of patients and that by using this ratio and splitting tablets, significant cost savings can be realized.