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Sun Z, Ma Y, Yu C, Sun D, Pang Y, Pei P, Yang L, Chen Y, Du H, Zhang H, Yang X, Barnard M, Clarke R, Chen J, Chen Z, Li L, Lv J. One-size-fits-all versus risk-category-based screening interval strategies for cardiovascular disease prevention in Chinese adults: a prospective cohort study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 49:101140. [PMID: 39081880 PMCID: PMC11287009 DOI: 10.1016/j.lanwpc.2024.101140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/06/2024] [Accepted: 06/25/2024] [Indexed: 08/02/2024]
Abstract
Background In non-high-risk individuals, risk-category-based atherosclerotic cardiovascular disease (ASCVD) screening strategies may be more cost-effective than one-size-fits-all approaches. However, current decisions are constrained by a lack of research evidence. We aimed to explore appropriate risk-category-based screening interval strategies for non-high-risk individuals in ASCVD primary prevention in the Chinese population. Methods We used data from 28,624 participants in the China Kadoorie Biobank (CKB) who had completed at least two field surveys. The risk assessment tools were the 10-year ASCVD risk prediction models developed based on the CKB cohort. We constructed multistate Markov models to model disease progression and estimate transition probabilities between different risk categories. The total person-years spent unidentified in the high-risk state over a 10-year period were calculated for each screening interval protocol. We also estimated the number of ASCVD events prevented, quality-adjusted life years (QALYs) gained, and costs saved when compared to the 3-yearly screening protocol. Findings When compared to the uniform 3-yearly protocol, most risk-category-based screening interval protocols would identify more high-risk individuals timely, thus preventing more ASCVD events and gaining QALYs. A few of them would reduce total health-care costs. The protocol, which used 6-year, 3-year, and 2-year screening intervals for low-risk, intermediate-low-risk, and intermediate-high risk individuals, was optimal, and would reduce the person-years spent unidentified in the high-risk category by 17.9% (95% CI: 13.1%-21.9%), thus preventing an estimated 113 thousand (95% CI: 83-138) hard ASCVD events for Chinese adults aged 30-79 over a 10-year period. When using a lower cost of statin therapy, more screening protocols would gain QALYs while saving costs. Interpretation For the primary prevention of ASCVD, risk-category-based screening protocols outperformed the one-size-fits-all approach in the Chinese population. Funding This work was supported by National Natural Science Foundation of China (82192904, 82388102, 82192900) and grants (2023YFC2509400) from the National Key R&D Program of China. The CKB baseline survey and the first re-survey were supported by a grant from the Kadoorie Charitable Foundation in Hong Kong. The long-term follow-up is supported by grants from the UK Wellcome Trust (212946/Z/18/Z, 202922/Z/16/Z, 104085/Z/14/Z, 088158/Z/09/Z), grants (2016YFC0900500) from the National Key R&D Program of China, National Natural Science Foundation of China (81390540, 91846303, 81941018), and Chinese Ministry of Science and Technology (2011BAI09B01).
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Affiliation(s)
- Zhijia Sun
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Beijing, 100191, China
| | - Yu Ma
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Beijing, 100191, China
| | - Canqing Yu
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Beijing, 100191, China
- Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, 100191, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
| | - Dianjianyi Sun
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Beijing, 100191, China
- Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, 100191, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
| | - Yuanjie Pang
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Beijing, 100191, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
| | - Pei Pei
- Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, 100191, China
| | - Ling Yang
- Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Yiping Chen
- Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Huaidong Du
- Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | | | - Xiaoming Yang
- Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Maxim Barnard
- Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Robert Clarke
- Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Junshi Chen
- China National Center for Food Safety Risk Assessment, Beijing, China
| | - Zhengming Chen
- Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Liming Li
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Beijing, 100191, China
- Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, 100191, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
| | - Jun Lv
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Beijing, 100191, China
- Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, 100191, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
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2
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Young RA. Re: Estimating the Cardiovascular Disease Risk Reduction of a Quality Improvement Initiative in Primary Care: Findings from EvidenceNOW. J Am Board Fam Med 2024; 36:1087-1088. [PMID: 38012010 PMCID: PMC10833475 DOI: 10.3122/jabfm.2023.230230r0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Affiliation(s)
- Richard A Young
- Co-Associate Program Director and Director of Research, John Peter Smith Family Medicine Residency Program, Fort Worth, TX
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3
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Meador M, Bay RC, Anderson E, Roy D, Allgood JA, Lewis JH. Using the Practical Robust Implementation and Sustainability Model (PRISM) to Identify and Address Provider-Perceived Barriers to Optimal Statin Prescribing and Use in Community Health Centers. Health Promot Pract 2023; 24:776-787. [PMID: 35603709 PMCID: PMC10336706 DOI: 10.1177/15248399221088592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Statins are an important but underutilized therapy to prevent cardiovascular events, particularly in high-risk patients. To increase use of statin therapy in high-risk patients, the Centers for Disease Control and Prevention funded a project led by the National Association of Community Health Centers to discover reasons for statin underuse in health centers and identify possible leverage points, particularly among vulnerable and underserved patients. The project further sought to develop training and educational materials to improve statin prescribing for and acceptance in eligible high-risk patients. As a first step, investigators implemented a questionnaire to clinical providers (n = 45) at health centers participating in the project to obtain their perspective on barriers to optimal statin use. We used the practical robust implementation and sustainability model (PRISM) domains to frame the overall project and guide the development of our questionnaire. This paper summarizes top perceived barriers to patient and health system/provider statin initiation and sustainment, as well as facilitators to prescribing, using PRISM as an organizing framework. Our questionnaire yielded important suggestions related to public awareness, education materials, health information technology (HIT)/data solutions, and clinical guidelines as key factors in optimizing statin use. It also informed the design of patient education resources and provider training tools. Future directions include using the full application of the PRISM implementation science model to assess how well our educational and training resources help overcome barriers to statin use in high-risk patients, including evaluating how key contextual factors influence successful implementation.
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Affiliation(s)
- Margaret Meador
- National Association of Community Health Centers, Bethesda, MD, USA
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4
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Casiglia E, Tikhonoff V. Cardiovascular prevention with statins: epidemiological considerations. Eur J Prev Cardiol 2022; 29:1827-1829. [PMID: 35767312 DOI: 10.1093/eurjpc/zwac119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Edoardo Casiglia
- Studium Patavinum, University of Padua, Italy.,Department of Medicine, University of Padua, Italy
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5
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Mariano R, Tavares KL, Panhoca R, Sadi M. Influence of statins in metastatic castration-resistant prostate cancer patients treated with new antiandrogen therapies: a systematic review and meta-analysis. EINSTEIN-SAO PAULO 2022; 20:eRW6339. [PMID: 35384986 PMCID: PMC8967314 DOI: 10.31744/einstein_journal/2022rw6339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/24/2021] [Indexed: 11/05/2022] Open
Abstract
Objective To evaluate whether the addition of statins to the new antiandrogens (enzalutamide or abiraterone) affects overall survival in patients with metastatic castration-resistant prostate cancer. Methods We searched studies in English language including the keywords statins, overall survival, and metastatic castration-resistant prostate cancer, at PubMed® (MEDLINE®), Embase and Cochrane databases. Results A total of 195 articles were initially identified, but only four met the inclusion criteria and were selected for the meta-analysis. A total of 955 patients, 632 on the new antiandrogens only group, and 323 on the new antiandrogens + statins group, were analyzed. In all four studies the combination therapy (new antiandrogens + statin) was well tolerated, regardless of which new antiandrogens were used. Neither the type of statin nor the doses and duration of use were well specified in the studies. The combination therapy in metastatic castration-resistant prostate cancer was associated with an overall survival improvement, and a 46% reduction in death (hazard ratio of 0.54; 95%CI 0.34-0.87; p<0.01) in multivariate analysis. Conclusion There seems to be a clinical benefit with the association of statins to the new antiandrogens in patients with metastatic castration-resistant prostate cancer, suggesting longer overall survival with no important collateral effect. However, due to fragility of the studies available in the literature, we are not yet capable of recommending this combination of drugs in the clinical practice. Further randomized prospective studies are warranted to confirm these beneficial outcomes.
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Affiliation(s)
| | - Kevin Lima Tavares
- Hospital do Servidor Púbico Estadual "Francisco Morato de Oliveira", São Paulo, SP, Brazil
| | - Renato Panhoca
- Hospital do Servidor Púbico Estadual "Francisco Morato de Oliveira", São Paulo, SP, Brazil
| | - Marcus Sadi
- Universidade de São Paulo, São Paulo, SP, Brazil
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6
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Husain MJ, Spencer G, Nugent R, Kostova D, Richter P. The Cost-Effectiveness of Hyperlipidemia Medication in Low- and Middle-Income Countries: A Review. Glob Heart 2022; 17:18. [PMID: 35342693 PMCID: PMC8896253 DOI: 10.5334/gh.1097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/26/2022] [Indexed: 01/03/2023] Open
Abstract
Hyperlipidemia is a risk factor for cardiovascular disease - the leading cause of death globally. Increased understanding of the cost-effectiveness of hyperlipidemia treatment in low- and middle-income countries can guide approaches to hyperlipidemia management in resource-limited environments. We conducted a systematic review of the evidence on the cost-effectiveness of hyperlipidemia medication treatment in low- and middle-income countries using studies published between January 2010 and April 2020. We abstracted study details, including study design, treatment setting, intervention type, health metrics, costs standardized to constant 2019 US dollars, and cost-effectiveness measures including average and incremental cost-effectiveness ratios. Comparisons across studies suggested that treatment via polypill is generally more cost-effective than statin-only therapy, and that primary prevention is more cost-effective than secondary prevention. Treating hyperlipidemia at a threshold of 5.7 mmol/l comes at a higher cost per disability-adjusted life-years averted than at a threshold of 6.2 mmol/l. Most pharmacological treatment strategies for hyperlipidemia were found to be cost-effective in most of the examined low- and middle-income countries.
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Affiliation(s)
- Muhammad Jami Husain
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, US
| | - Garrison Spencer
- Center for Global Noncommunicable Diseases, RTI International, Seattle, Washington, US
| | - Rachel Nugent
- Center for Global Noncommunicable Diseases, RTI International, Seattle, Washington, US
| | - Deliana Kostova
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, US
| | - Patricia Richter
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, US
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7
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Mendoza-Herrera K, Pedroza-Tobías A, Hernández-Alcaraz C, Ávila-Burgos L, Aguilar-Salinas CA, Barquera S. Attributable Burden and Expenditure of Cardiovascular Diseases and Associated Risk Factors in Mexico and other Selected Mega-Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4041. [PMID: 31652519 PMCID: PMC6843962 DOI: 10.3390/ijerph16204041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/13/2019] [Accepted: 10/17/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND This paper describes the health and economic burden of cardiovascular diseases (CVD) in Mexico and other mega-countries through a review of literature and datasets. METHODS Mega-countries with a low (Nigeria), middle (India), high (China/Brazil/Mexico), and very high (the U.S.A./Japan) human development index were included. The review was focused on prevalence of dyslipidemias and CVD economic impact and conducted according to the PRISMA statement. Public datasets of CVD indicators were explored. RESULTS Heterogeneity in economic data and limited information on dyslipidemias were found. Hypertriglyceridemia and hypercholesterolemia were higher in Mexico compared with other countries. Higher contribution of dietary risk factors for cardiovascular mortality and greater probability of dying prematurely from CVD were observed in developing countries. From 1990-2016, a greater decrease in cardiovascular mortality in developed countries was registered. In 2015, a CVD expense equivalent to 4% of total health expenditure was reported in Mexico. CVD ranked first in health expenditures in almost all these nations and the economic burden will remain significant for decades to come. CONCLUSIONS Resources should be assured to optimize CVD risk monitoring. Educational and medical models must be improved to enhance CVD diagnosis and the prescription and adherence to treatments. Long-term benefits could be attained by modifying the food system.
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Affiliation(s)
- Kenny Mendoza-Herrera
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico.
| | - Andrea Pedroza-Tobías
- Institute for Global Health Sciences, University of California, San Francisco, CA 94158, USA.
| | - César Hernández-Alcaraz
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico.
| | - Leticia Ávila-Burgos
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico.
| | - Carlos A Aguilar-Salinas
- Unidad de Investigación de Enfermedades Metabolicas, Mexico City 14080, Mexico.
- Departamento de Endocrinología y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City 14080, Mexico.
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey 64710, N.L., Mexico.
| | - Simón Barquera
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico.
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8
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Schleyer T, Hui S, Wang J, Zhang Z, Knapp K, Baker J, Chase M, Boggs R, Simpson RJ. Quantifying Unmet Need in Statin-Treated Hyperlipidemia Patients and the Potential Benefit of Further LDL-C Reduction Through an EHR-Based Retrospective Cohort Study. J Manag Care Spec Pharm 2019; 25:544-554. [PMID: 31039062 PMCID: PMC10397866 DOI: 10.18553/jmcp.2019.25.5.544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Statins are effective in helping prevent cardiovascular disease (CVD). However, studies suggest that only 20%-64% of patients taking statins achieve reasonable low-density lipoprotein cholesterol (LDL-C) thresholds. On-treatment levels of LDL-C remain a key predictor of residual CVD event risk. OBJECTIVES To (a) determine how many patients on statins achieved the therapeutic threshold of LDL-C < 100 mg per dL (general cohort) and < 70 mg per dL (secondary prevention cohort, or subcohort, with preexisting CVD); (b) estimate the number of potentially avoidable CVD events if the threshold were reached; and (c) forecast potential cost savings. METHODS A retrospective, longitudinal cohort study using electronic health record data from the Indiana Network for Patient Care (INPC) was conducted. The INPC provides comprehensive information about patients in Indiana across health care organizations and care settings. Patients were aged > 45 years and seen between January 1, 2012, and October 31, 2016 (ensuring study of contemporary practice), were statin-naive for 12 months before the index date of initiating statin therapy, and had an LDL-C value recorded 6-18 months after the index date. Subsequent to descriptive cohort analysis, the theoretical CVD risk reduction achievable by reaching the threshold was calculated using Framingham Risk Score and Cholesterol Treatment Trialists' Collaboration formulas. Estimated potential cost savings used published first-year costs of CVD events, adjusted for inflation and discounted to the present day. RESULTS Of the 89,267 patients initiating statins, 30,083 (33.7%) did not achieve the LDL-C threshold (subcohort: 58.1%). In both groups, not achieving the threshold was associated with patients who were female, black, and those who had reduced medication adherence. Higher levels of preventive aspirin use and antihypertensive treatment were associated with threshold achievement. In both cohorts, approximately 64% of patients above the threshold were within 30 mg per dL of the respective threshold. Adherence to statin therapy regimen, judged by a medication possession ratio of ≥ 80%, was 57.4% in the general cohort and 56.7% in the subcohort. Of the patients who adhered to therapy, 23.7% of the general cohort and 50.5% of the subcohort had LDL-C levels that did not meet the threshold. 10-year CVD event risk in the at-or-above threshold group was 22.78% (SD = 17.24%) in the general cohort and 29.56% (SD = 18.19%) in the subcohort. By reducing LDL-C to the threshold, a potential relative risk reduction of 14.8% in the general cohort could avoid 1,173 CVD events over 10 years (subcohort: 15.7% and 454 events). Given first-year inpatient and follow-up costs of $37,300 per CVD event, this risk reduction could save about $1,455 per patient treated to reach the threshold (subcohort: $1,902; 2017 U.S. dollars) over a 10-year period. CONCLUSIONS Across multiple health care systems in Indiana, between 34% (general cohort) and 58% (secondary prevention cohort) of patients treated with statins did not achieve therapeutic LDL-C thresholds. Based on current CVD event risk and cost projections, such patients seem to be at increased risk and may represent an important and potentially preventable burden on health care costs. DISCLOSURES Funding support for this study was provided by Merck (Kenilworth, NJ). Chase and Boggs are employed by Merck. Simpson is a consultant to Merck and Pfizer. The other authors have nothing to disclose.
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Affiliation(s)
- Titus Schleyer
- Regenstrief Institute, and Indiana University School of Medicine, Indianapolis
| | - Siu Hui
- Regenstrief Institute, Indianapolis, Indiana
| | - Jane Wang
- Regenstrief Institute, Indianapolis, Indiana
| | - Zuoyi Zhang
- Regenstrief Institute, Indianapolis, Indiana
| | | | - Jarod Baker
- Regenstrief Institute, Indianapolis, Indiana
| | | | | | - Ross J. Simpson
- Division of Cardiology, University of North Carolina at Chapel Hill
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9
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Ngo-Metzger Q, Zuvekas SH, Bierman AS. Estimated Impact of US Preventive Services Task Force Recommendations on Use and Cost of Statins for Cardiovascular Disease Prevention. J Gen Intern Med 2018; 33:1317-1323. [PMID: 29855861 PMCID: PMC6082218 DOI: 10.1007/s11606-018-4497-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 01/26/2018] [Accepted: 05/11/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND US Preventive Services Task Force (USPSTF) released new recommendations on statin use for atherosclerotic cardiovascular disease (ASCVD) prevention. The Affordable Care Act (ACA) mandates USPSTF recommendations with an "A" or "B" grade receive insurance coverage without copayment. We assessed the potential impact of these recommendations. OBJECTIVE To assess the US population meeting criteria for statin use and factors associated with use, and calculate associated costs. DESIGN AND MEASURES We estimated 10-year ASCVD event risk scores from National Health and Nutrition Examination Survey data using Pooled Cohort Equations from the American College of Cardiology/American Heart Association and applied them to Medical Expenditure Panel Survey data. We estimated the population meeting USPSTF criteria and calculated the number of statin prescription fills and out-of-pocket and total costs. We assessed associations between statin use and sociodemographic and health characteristics and national trends in use from 1996 to 2014. PARTICIPANTS A nationally representative sample of people aged ≥ 40 years, representing 150 million people living in the USA. KEY RESULTS Of 26.8 million adults recommended for statins, only 41.8% were taking them. Female sex, Hispanic ethnicity, uninsured status, or living in the South was associated with lower odds of using statins. Under ACA, people with private insurance would avoid out-of-pocket cost of $9 for each generic prescription, resulting in savings of approximately $44 in annual costs. ACA's mandate for insurance coverage would result in a $193 million shift in out-of-pocket cost for statins from patients to private insurers. CONCLUSIONS New USPSTF recommendations may result in decreased out-of-pocket costs and expanded access to statins. Previous research has shown that eliminating copayments increased adherence and decreased rates of ASCVD events without increasing overall healthcare costs. Future research will determine whether the USPSTF's recommendations will result in similar findings.
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Affiliation(s)
- Quyen Ngo-Metzger
- Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Rockville, MD, USA.
| | - Samuel H Zuvekas
- Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Rockville, MD, USA
| | - Arlene S Bierman
- Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Rockville, MD, USA
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10
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Fitzgerald G, Kiernan T. PCSK9 inhibitors and LDL reduction: pharmacology, clinical implications, and future perspectives. Expert Rev Cardiovasc Ther 2018; 16:567-578. [DOI: 10.1080/14779072.2018.1497975] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Gerald Fitzgerald
- Cardiology Department, University Hospital Limerick, Limerick, Ireland
| | - Tom Kiernan
- Cardiology Department, University Hospital Limerick, Limerick, Ireland
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11
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Vanholder R, Van Laecke S, Glorieux G, Verbeke F, Castillo-Rodriguez E, Ortiz A. Deleting Death and Dialysis: Conservative Care of Cardio-Vascular Risk and Kidney Function Loss in Chronic Kidney Disease (CKD). Toxins (Basel) 2018; 10:E237. [PMID: 29895722 PMCID: PMC6024824 DOI: 10.3390/toxins10060237] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023] Open
Abstract
The uremic syndrome, which is the clinical expression of chronic kidney disease (CKD), is a complex amalgam of accelerated aging and organ dysfunctions, whereby cardio-vascular disease plays a capital role. In this narrative review, we offer a summary of the current conservative (medical) treatment options for cardio-vascular and overall morbidity and mortality risk in CKD. Since the progression of CKD is also associated with a higher cardio-vascular risk, we summarize the interventions that may prevent the progression of CKD as well. We pay attention to established therapies, as well as to novel promising options. Approaches that have been considered are not limited to pharmacological approaches but take into account lifestyle measures and diet as well. We took as many randomized controlled hard endpoint outcome trials as possible into account, although observational studies and post hoc analyses were included where appropriate. We also considered health economic aspects. Based on this information, we constructed comprehensive tables summarizing the available therapeutic options and the number and kind of studies (controlled or not, contradictory outcomes or not) with regard to each approach. Our review underscores the scarcity of well-designed large controlled trials in CKD. Nevertheless, based on the controlled and observational data, a therapeutic algorithm can be developed for this complex and multifactorial condition. It is likely that interventions should be aimed at targeting several modifiable factors simultaneously.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Steven Van Laecke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Francis Verbeke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | | | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain.
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12
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Basu S, Sussman JB, Hayward RA. Black-White Cardiovascular Disease Disparities After Target-Based Versus Personalized Benefit-Based Lipid and Blood Pressure Treatment. MDM Policy Pract 2017; 2:2381468317725741. [PMID: 30288429 PMCID: PMC6125055 DOI: 10.1177/2381468317725741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/15/2017] [Indexed: 11/16/2022] Open
Abstract
Background: Cardiovascular disease (CVD) remains the leading cause of black-white morbidity and mortality disparities in the United States. Objectives: We sought to compare black-white CVD morbidity and mortality if lipid and blood pressure treatments were prescribed to achieve targeted lipid and blood pressure levels (treat-to-target [TTT]) or personalized CVD risk and treatment benefit estimates (benefit-based tailored treatment [BTT]). Methods: We utilized a microsimulation model of statin and blood pressure treatment based on a TTT approach (Joint National Commission 7; Adult Treatment Panel III) or a BTT approach (treating those with 10-year CVD risk ≥10%, a modification and extension of recent American College of Cardiology/American Heart Association guidelines). We input data from the National Health and Nutrition Examination Survey, isolating adults 40 to 75 years of age without prior CVD events. Results: We observed that TTT would prevent fewer CVD events (17.0 events prevented per 1,000 whites, 22.2 per 1,000 blacks) than the BTT approach (25.9 events prevented per 1,000 whites, 45.4 per 1,000 blacks). TTT could lower the national black-white CVD event rate disparity from 23.1 excess events per 1,000 blacks to 17.9 excess events (-23%), while BTT could lower the disparity to 3.6 excess events (-84% overall). The inferiority of TTT to BTT remained consistent in sensitivity analyses testing alternative treatment targets and either over- or underestimation of risk by commonly used equations. Conclusions: A BTT approach to lipid and blood pressure treatment would be expected to prevent more CVD events in the overall population and more effectively reduce national black-white CVD disparities than a traditional TTT approach.
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Affiliation(s)
- Sanjay Basu
- Department of Medicine, Stanford University, Stanford, California (SB).,Center for Primary Care, Harvard Medical School, Boston, Massachusetts (SB).,Division of General Medicine, University of Michigan, Ann Arbor, Michigan (JBS, RAH).,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (JBS, RAH)
| | - Jeremy B Sussman
- Department of Medicine, Stanford University, Stanford, California (SB).,Center for Primary Care, Harvard Medical School, Boston, Massachusetts (SB).,Division of General Medicine, University of Michigan, Ann Arbor, Michigan (JBS, RAH).,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (JBS, RAH)
| | - Rodney A Hayward
- Department of Medicine, Stanford University, Stanford, California (SB).,Center for Primary Care, Harvard Medical School, Boston, Massachusetts (SB).,Division of General Medicine, University of Michigan, Ann Arbor, Michigan (JBS, RAH).,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (JBS, RAH)
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Wei CY, Quek RGW, Villa G, Gandra SR, Forbes CA, Ryder S, Armstrong N, Deshpande S, Duffy S, Kleijnen J, Lindgren P. A Systematic Review of Cardiovascular Outcomes-Based Cost-Effectiveness Analyses of Lipid-Lowering Therapies. PHARMACOECONOMICS 2017; 35:297-318. [PMID: 27785772 DOI: 10.1007/s40273-016-0464-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Previous reviews have evaluated economic analyses of lipid-lowering therapies using lipid levels as surrogate markers for cardiovascular disease. However, drug approval and health technology assessment agencies have stressed that surrogates should only be used in the absence of clinical endpoints. OBJECTIVE The aim of this systematic review was to identify and summarise the methodologies, weaknesses and strengths of economic models based on atherosclerotic cardiovascular disease event rates. METHODS Cost-effectiveness evaluations of lipid-lowering therapies using cardiovascular event rates in adults with hyperlipidaemia were sought in Medline, Embase, Medline In-Process, PubMed and NHS EED and conference proceedings. Search results were independently screened, extracted and quality checked by two reviewers. RESULTS Searches until February 2016 retrieved 3443 records, from which 26 studies (29 publications) were selected. Twenty-two studies evaluated secondary prevention (four also assessed primary prevention), two considered only primary prevention and two included mixed primary and secondary prevention populations. Most studies (18) based treatment-effect estimates on single trials, although more recent evaluations deployed meta-analyses (5/10 over the last 10 years). Markov models (14 studies) were most commonly used and only one study employed discrete event simulation. Models varied particularly in terms of health states and treatment-effect duration. No studies used a systematic review to obtain utilities. Most studies took a healthcare perspective (21/26) and sourced resource use from key trials instead of local data. Overall, reporting quality was suboptimal. CONCLUSIONS This review reveals methodological changes over time, but reporting weaknesses remain, particularly with respect to transparency of model reporting.
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Affiliation(s)
- Ching-Yun Wei
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK.
| | | | | | | | - Carol A Forbes
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Steve Ryder
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Nigel Armstrong
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Sohan Deshpande
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Steven Duffy
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Jos Kleijnen
- School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Peter Lindgren
- IHE-Institutet för Hälso-och Sjukvårdsekonomi, Lund, Sweden
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14
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Epstein D, García-Mochón L, Kaptoge S, Thompson SG. Modeling the costs and long-term health benefits of screening the general population for risks of cardiovascular disease: a review of methods used in the literature. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:1041-1053. [PMID: 26682549 PMCID: PMC5047941 DOI: 10.1007/s10198-015-0753-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 11/25/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Strategies for screening and intervening to reduce the risk of cardiovascular disease (CVD) in primary care settings need to be assessed in terms of both their costs and long-term health effects. We undertook a literature review to investigate the methodologies used. METHODS In a framework of developing a new health-economic model for evaluating different screening strategies for primary prevention of CVD in Europe (EPIC-CVD project), we identified seven key modeling issues and reviewed papers published between 2000 and 2013 to assess how they were addressed. RESULTS We found 13 relevant health-economic modeling studies of screening to prevent CVD in primary care. The models varied in their degree of complexity, with between two and 33 health states. Programmes that screen the whole population by a fixed cut-off (e.g., predicted 10-year CVD risk >20 %) identify predominantly elderly people, who may not be those most likely to benefit from long-term treatment. Uncertainty and model validation were generally poorly addressed. Few studies considered the disutility of taking drugs in otherwise healthy individuals or the budget impact of the programme. CONCLUSIONS Model validation, incorporation of parameter uncertainty, and sensitivity analyses for assumptions made are all important components of model building and reporting, and deserve more attention. Complex models may not necessarily give more accurate predictions. Availability of a large enough source dataset to reliably estimate all relevant input parameters is crucial for achieving credible results. Decision criteria should consider budget impact and the medicalization of the population as well as cost-effectiveness thresholds.
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Affiliation(s)
- David Epstein
- Department of Applied Economics, University of Granada, Campus de la Cartuja, 18071, Granada, Spain.
- Escuela Andaluza de Salud Pública, Granada, Spain.
| | | | - Stephen Kaptoge
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Simon G Thompson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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15
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Stevens W, Peneva D, Li JZ, Liu LZ, Liu G, Gao R, Lakdawalla DN. Estimating the future burden of cardiovascular disease and the value of lipid and blood pressure control therapies in China. BMC Health Serv Res 2016; 16:175. [PMID: 27165638 PMCID: PMC4862139 DOI: 10.1186/s12913-016-1420-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 04/30/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Lifestyle and dietary changes reflect an ongoing epidemiological transition in China, with cardiovascular disease (CVD) playing an ever-increasing role in China's disease burden. This study assessed the burden of CVD and the potential value of lipid and blood pressure control strategies in China. METHODS We estimated the likely burden of CVD between 2016 and 2030 and how expanded use of lipid lowering and blood pressure control medication would impact that burden in the next 15 years. Accounting for the costs of drug use, we assessed the net social value of a policy that expands the utilization of lipid and blood pressure lowering therapies in China. RESULTS Rises in prevalence of CVD risk and population aging would likely increase the incidence of acute myocardial infarctions (AMIs) by 75 million and strokes by 118 million, while the number of CVD deaths would rise by 39 million in total between 2016 and 2030. Universal treatment of hypertension and dyslipidemia patients with lipid and blood pressure lowering therapies could avert between 10 and 20 million AMIs, between 8 and 30 million strokes, and between 3 and 10 million CVD deaths during the 2016-2030 period, producing a positive social value net of health care costs as high as $932 billion. CONCLUSIONS In light of its aging population and epidemiological transition, China faces near-certain increases in CVD morbidity and mortality. Preventative measures such as effective lipid and blood pressure management may reduce CVD burden substantially and provide large social value. While the Chinese government is implementing more systematic approaches to health care delivery, prevention of CVD should be high on the agenda.
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Affiliation(s)
| | - Desi Peneva
- Precision Health Economics, Los Angeles, CA, USA
| | | | - Larry Z Liu
- Weill Medical College of Cornell University, New York City, NY, USA
| | - Gordon Liu
- Peking University National School of Development, Beijing, China
| | - Runlin Gao
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China
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16
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Capewell S, McCartney M, Holland W. NHS Health Checks--a naked emperor? J Public Health (Oxf) 2016; 37:187-92. [PMID: 26022810 DOI: 10.1093/pubmed/fdv063] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Simon Capewell
- Department of Public Health and Policy, Institute of Psychology, Health and Society, University of Liverpool, Whelan Building, Quadrangle, Liverpool L69 3GB, UK
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17
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Antiretrovirals for primary HIV prevention: the current status of pre- and post-exposure prophylaxis. Curr HIV/AIDS Rep 2016; 12:127-38. [PMID: 25600106 DOI: 10.1007/s11904-014-0253-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In light of the 2 million HIV infections that occur globally each year, there is a need to optimize strategies that integrate biomedical and behavioral approaches to HIV prevention. Post-exposure prophylaxis (PEP) immediately after acute high-risk exposures and pre-exposure prophylaxis (PrEP) for those who engage in recurrent high-risk behaviors are promising bio-behavioral approaches to decreasing HIV transmission. Guidelines have recommended PEP for occupational and non-occupational exposures for over 15 years, but uptake of PEP has been limited, partly as a result of insufficient awareness of this intervention among persons at highest risk for acquiring HIV. However, since the publication of large randomized clinical trials demonstrating the efficacy of PrEP, and the dissemination of guidelines endorsing its use, there is a renewed focus on bio-behavioral prevention. Numerous studies have recently assessed the acceptability of bio-behavioral prevention programs among diverse populations or described experiences implementing these programs in "real-world" settings. As research and clinical data informing optimal utilization of PEP and PrEP are rapidly accumulating, this review provides a timely summary of recent progress in bio-behavioral prevention. By contextualizing the most noteworthy recent findings regarding PEP and PrEP, this review seeks to inform the successful implementation of these promising prevention approaches.
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18
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Casula M, Tragni E, Piccinelli R, Zambon A, De Fendi L, Scotti L, Corrao G, Gambera M, Catapano AL, Filippi A. A simple informative intervention in primary care increases statin adherence. Eur J Clin Pharmacol 2015; 72:227-34. [PMID: 26563188 DOI: 10.1007/s00228-015-1975-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/30/2015] [Indexed: 02/08/2023]
Abstract
PURPOSE To assess the effectiveness of an informative intervention on general practitioners aimed at improving patients' adherence to statin therapy. METHODS In the local health unit (LHU) of Bergamo, Lombardy (Italy), each general practitioner received a synthetic scientific document on dyslipidaemia and statins and aggregated data on adherence in 2006 for his/her patients compared to the means in the LHU and in his/her working district. Furthermore, a sample of seven districts received also a table of adherence levels for single patients. Patient's level data were retrieved from the health care utilisation databases of the LHU. Adherence parameters (proportion of patients with only one prescription, medication possession ratio [MPR] and proportion of non-persistent patients) were assessed after 1 year of follow-up. RESULTS Overall, 5833 and 4788 new statin users were enrolled before and after the intervention, respectively. The percentage of patients with only one prescription decreased from 28.0 to 23.9 % (p < 0.001). MPR increased from 70.3 to 76.0 % (p < 0.001), and proportion of patients with MPR ≥ 80 % increased from 45.4 to 56.4 % (p < 0.001). The persistence also showed an improvement, both in terms of decreasing proportion of non-persistent (from 51.9 to 41.4 %, p < 0.001) and of increasing duration of continued therapy (from 235 to 264 mean days of persistent therapy, p < 0.001). There were not significant differences between the two types of intervention. CONCLUSIONS This intervention resulted in an overall improvement of the short-term adherence to therapy. This tool can be replicated in other local contexts and with other chronic therapies.
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Affiliation(s)
- Manuela Casula
- Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Via Balzaretti 9, 20133, Milan, Italy.
| | - Elena Tragni
- Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Via Balzaretti 9, 20133, Milan, Italy
| | - Rossana Piccinelli
- Local Pharmaceutical Service, LHU of Bergamo, via Gallicciolli 4, 24121, Bergamo, Italy
| | - Antonella Zambon
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Via Bicocca degli Arcimboldi 8, 20126, Milan, Italy
| | - Luisa De Fendi
- Local Pharmaceutical Service, LHU of Bergamo, via Gallicciolli 4, 24121, Bergamo, Italy
| | - Lorenza Scotti
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Via Bicocca degli Arcimboldi 8, 20126, Milan, Italy
| | - Giovanni Corrao
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Via Bicocca degli Arcimboldi 8, 20126, Milan, Italy
| | - Marco Gambera
- Local Pharmaceutical Service, LHU of Bergamo, via Gallicciolli 4, 24121, Bergamo, Italy
| | - Alberico Luigi Catapano
- Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Via Balzaretti 9, 20133, Milan, Italy.,IRCCS MultiMedica, via Milanese 300, 20099 Sesto S. Giovanni, Milan, Italy
| | - Alessandro Filippi
- Italian Society of General Medicine (SIMG), Via del Pignoncino 9-11, 50142, Florence, Italy
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Deaño RC, Pandya A, Jones EC, Borden WB. A look at statin cost-effectiveness in view of the 2013 ACC/AHA cholesterol management guidelines. Curr Atheroscler Rep 2015; 16:438. [PMID: 25052768 DOI: 10.1007/s11883-014-0438-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The 2013 cholesterol management guidelines presented a major shift in recommendations on which patients at risk of cardiovascular disease should be treated and how to treat them. Implementation of the guidelines is estimated to increase substantially the number of people who would be eligible for statin therapy. As the medical community considers the broad population impact of the new cholesterol guidelines, the issue of cost-effectiveness plays a role. This review covers the basic fundamentals of cost-effectiveness analysis and summarizes the key cost-effectiveness studies that relate to the new cholesterol guidelines.
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Affiliation(s)
- Roderick C Deaño
- Weill Cornell Medicine College, New York-Presbyterian Hospital, 520 East 70th Street, ST 443, New York, NY, 10021, USA
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20
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DeFilippis AP, Young R, Carrubba CJ, McEvoy JW, Budoff MJ, Blumenthal RS, Kronmal RA, McClelland RL, Nasir K, Blaha MJ. An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort. Ann Intern Med 2015; 162:266-75. [PMID: 25686167 PMCID: PMC4414494 DOI: 10.7326/m14-1281] [Citation(s) in RCA: 354] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Accurate risk assessment of atherosclerotic cardiovascular disease (ASCVD) is essential to effectively balance the risks and benefits of therapy for primary prevention. OBJECTIVE To compare the calibration and discrimination of the new American Heart Association (AHA) and American College of Cardiology (ACC) ASCVD risk score with alternative risk scores and to explore preventive therapy as a cause of the reported risk overestimation using the AHA-ACC-ASCVD score. DESIGN Prospective epidemiologic study of ASCVD. SETTING MESA (Multi-Ethnic Study of Atherosclerosis), a community-based, sex-balanced, multiethnic cohort. PATIENTS 4227 MESA participants aged 50 to 74 years and without diabetes at baseline. MEASUREMENTS Observed and expected events for the AHA-ACC-ASCVD score were compared with 4 commonly used risk scores-and their respective end points-in MESA after a 10.2-year follow-up. RESULTS The new AHA-ACC-ASCVD and 3 older Framingham-based risk scores overestimated cardiovascular events by 37% to 154% in men and 8% to 67% in women. Overestimation was noted throughout the continuum of risk. In contrast, the Reynolds Risk Score overestimated risk by 9% in men but underestimated risk by 21% in women. Aspirin, lipid-lowering or antihypertensive therapy, and interim revascularization did not explain the overestimation. LIMITATION Comparability of MESA with target populations for primary prevention and possibility of missed events in MESA. CONCLUSION Of the 5 risk scores, 4, including the new AHA-ACC-ASCVD score, showed overestimation of risk (25% to 115%) in a modern, multiethnic cohort without baseline clinical ASCVD. If validated, overestimation of ASCVD risk may have substantial implications for individual patients and the health care system. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Andrew P. DeFilippis
- From the University of Louisville, Louisville, Kentucky; University of Washington, Seattle, Washington; University of Colorado, Boulder, Colorado; Johns Hopkins Medicine Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California; and Baptist Medical Group, Miami, Florida
| | - Rebekah Young
- From the University of Louisville, Louisville, Kentucky; University of Washington, Seattle, Washington; University of Colorado, Boulder, Colorado; Johns Hopkins Medicine Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California; and Baptist Medical Group, Miami, Florida
| | - Christopher J. Carrubba
- From the University of Louisville, Louisville, Kentucky; University of Washington, Seattle, Washington; University of Colorado, Boulder, Colorado; Johns Hopkins Medicine Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California; and Baptist Medical Group, Miami, Florida
| | - John W. McEvoy
- From the University of Louisville, Louisville, Kentucky; University of Washington, Seattle, Washington; University of Colorado, Boulder, Colorado; Johns Hopkins Medicine Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California; and Baptist Medical Group, Miami, Florida
| | - Matthew J. Budoff
- From the University of Louisville, Louisville, Kentucky; University of Washington, Seattle, Washington; University of Colorado, Boulder, Colorado; Johns Hopkins Medicine Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California; and Baptist Medical Group, Miami, Florida
| | - Roger S. Blumenthal
- From the University of Louisville, Louisville, Kentucky; University of Washington, Seattle, Washington; University of Colorado, Boulder, Colorado; Johns Hopkins Medicine Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California; and Baptist Medical Group, Miami, Florida
| | - Richard A. Kronmal
- From the University of Louisville, Louisville, Kentucky; University of Washington, Seattle, Washington; University of Colorado, Boulder, Colorado; Johns Hopkins Medicine Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California; and Baptist Medical Group, Miami, Florida
| | - Robyn L. McClelland
- From the University of Louisville, Louisville, Kentucky; University of Washington, Seattle, Washington; University of Colorado, Boulder, Colorado; Johns Hopkins Medicine Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California; and Baptist Medical Group, Miami, Florida
| | - Khurram Nasir
- From the University of Louisville, Louisville, Kentucky; University of Washington, Seattle, Washington; University of Colorado, Boulder, Colorado; Johns Hopkins Medicine Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California; and Baptist Medical Group, Miami, Florida
| | - Michael J. Blaha
- From the University of Louisville, Louisville, Kentucky; University of Washington, Seattle, Washington; University of Colorado, Boulder, Colorado; Johns Hopkins Medicine Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California; and Baptist Medical Group, Miami, Florida
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Lavikainen P, Korhonen MJ, Huupponen R, Helin-Salmivaara A. Accumulation of cardiovascular and diabetes medication among apparently healthy statin initiators. PLoS One 2015; 10:e0117182. [PMID: 25658919 PMCID: PMC4319777 DOI: 10.1371/journal.pone.0117182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 12/20/2014] [Indexed: 11/19/2022] Open
Abstract
Purpose To characterize accumulation of drug-modifiable cardiovascular (CV) risk factors in statin initiators who had no prior medication or hospitalizations for CV disease or diabetes. Methods A cohort of 45-75-year-old statin initiators in Finland with no prior CV diseases, diabetes or medication for these conditions was followed up for 24 months after statin initiation for accumulation of CV and diabetes drugs. The number of drugs was measured semi-annually since the first statin purchase and analyzed by growth mixture modeling. Results Of the 11 948 apparently healthy statin initiators, 34% purchased at least one additional CV or diabetes drug during the subsequent 24 months. Of those, 20% redeemed no other CV or diabetes drugs at statin initiation but started to accumulate them after 18 months of follow-up, receiving on average 1.3 other drugs at 24 months. The majority, 59%, redeemed on average 0.5 drugs at statin initiation and accumulated 1.5 drugs by the end of 24-month follow-up. Seventeen percent received 1 additional drug at statin initiation, accumulating on average 3 drugs. The remaining 4% with an average of 2 CV or diabetes drugs at statin initiation redeemed 3.5 additional drugs during the follow-up. Conclusions Two years after statin initiation, 2 in 3 apparently healthy initiators could still be defined as such as reflected by CV and diabetes medication use.
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Affiliation(s)
- Piia Lavikainen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland
- Drug Research Doctoral Programme, University of Turku, Turku, Finland
- * E-mail:
| | - Maarit Jaana Korhonen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland
- Department of Public Health, University of Turku, Turku, Finland
| | - Risto Huupponen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland
- Department of Clinical Pharmacology, Tykslab, Turku University Hospital, Turku, Finland
| | - Arja Helin-Salmivaara
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland
- Unit of Primary Health Care, Hospital District of Helsinki and Uusimaa, Helsinki, Finland
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22
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Aarnio E, Korhonen MJ, Huupponen R, Martikainen J. Cost-effectiveness of statin treatment for primary prevention in conditions of real-world adherence--estimates from the Finnish prescription register. Atherosclerosis 2015; 239:240-7. [PMID: 25618032 DOI: 10.1016/j.atherosclerosis.2014.12.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/18/2014] [Accepted: 12/24/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of statin therapy for primary prevention of coronary heart disease (CHD) events under real-world adherence. METHODS A cost-effectiveness model was applied to estimate the expected 10-year costs and health outcomes (in terms of quality-adjusted life-years, QALYs) associated with and without statin treatment (at defined adherence levels) among hypothetical cohorts of Finnish men and women who were initially without established CHD. Treatment efficacy, cost, and quality of life estimates were obtained from published sources. Long-term treatment adherence was measured based on data from the national prescription register. RESULTS At an assumed willingness-to-pay threshold of €20,000 per QALY gained, statin treatment with real-world adherence was cost-effective among the older patient groups when the patients' 10-year CHD risk was as high as 20% and did not seem cost-effective in the youngest age groups. Conversely, statin treatment with full adherence was cost-effective for almost all patient groups with a 10-year CHD risk of at least 15%. CONCLUSIONS Even though generic statins are now low-cost drugs, treatment adherence seems to have a major impact on the cost-effectiveness of statin treatment in primary prevention. This finding stresses the importance of making a concerted effort for improving adherence among patients on statin therapy to obtain full benefit of the investment in statins. Therefore, novel cost-effective approaches to improve treatment adherence are warranted.
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Affiliation(s)
- Emma Aarnio
- Department of Clinical Pharmacology, Tykslab, Turku University Hospital, Turku, Finland; Pharmacoeconomics and Outcomes Research Unit (PHORU), School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
| | - Maarit J Korhonen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland.
| | - Risto Huupponen
- Department of Clinical Pharmacology, Tykslab, Turku University Hospital, Turku, Finland; Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland.
| | - Janne Martikainen
- Pharmacoeconomics and Outcomes Research Unit (PHORU), School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
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Zoungas S, Curtis AJ, McNeil JJ, Tonkin AM. Treatment of dyslipidemia and cardiovascular outcomes: the journey so far--is this the end for statins? Clin Pharmacol Ther 2014; 96:192-205. [PMID: 24727468 DOI: 10.1038/clpt.2014.86] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 04/07/2014] [Indexed: 01/28/2023]
Abstract
Dyslipidemia is common and is associated with the highest population-attributable risk for cardiovascular disease. Of various cardiovascular preventive therapies, the evidence from randomized controlled trials supporting the importance of aggressive lipid lowering is the most robust, particularly for statins. Despite the use of proven therapies, cardiovascular disease event rates remain relatively high, underpinning the development of novel therapies. In addition to testing new drugs to reduce low-density-lipoprotein cholesterol, there has been a major focus on treatments that can favorably influence high-density-lipoprotein cholesterol and triglyceride levels. This review provides an overview of the important relationship between lipids and cardiovascular disease, the lipid-modifying therapeutic approaches to reducing cardiovascular disease, new guidelines and recommendations, and the challenges ahead for the treatment of dyslipidemia, particularly whether statins will remain at the forefront of recommended therapies.
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Affiliation(s)
- S Zoungas
- 1] School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia [2] The George Institute for Global Health, Sydney, Australia
| | - A J Curtis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - J J McNeil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - A M Tonkin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Albert Fàbregas L, González-Clemente JM. Prevención cardiovascular primaria con estatinas en la diabetes mellitus tipo 2: ¿es hora de cambiar de estrategia? Med Clin (Barc) 2014; 142:358-9. [DOI: 10.1016/j.medcli.2014.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 01/09/2014] [Accepted: 01/16/2014] [Indexed: 10/25/2022]
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Pletcher MJ, Pignone M, Earnshaw S, McDade C, Phillips KA, Auer R, Zablotska L, Greenland P. Using the coronary artery calcium score to guide statin therapy: a cost-effectiveness analysis. Circ Cardiovasc Qual Outcomes 2014; 7:276-84. [PMID: 24619318 PMCID: PMC4156513 DOI: 10.1161/circoutcomes.113.000799] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 01/15/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND The coronary artery calcium (CAC) score predicts future coronary heart disease (CHD) events and could be used to guide primary prevention interventions, but CAC measurement has costs and exposes patients to low-dose radiation. METHODS AND RESULTS We estimated the cost-effectiveness of measuring CAC and prescribing statin therapy based on the resulting score under a range of assumptions using an established model enhanced with CAC distribution and risk estimates from the Multi-Ethnic Study of Atherosclerosis. Ten years of statin treatment for 10,000 55-year-old women with high cholesterol (10-year CHD risk, 7.5%) was projected to prevent 32 myocardial infarctions, cause 70 cases of statin-induced myopathy, and add 1108 years to total life expectancy. Measuring CAC and targeting statin treatment to the 2500 women with CAC>0 would provide 45% of the benefit (+501 life-years), but CAC measurement would cost $2.25 million and cause 9 radiation-induced cancers. Treat all was preferable to CAC screening in this scenario and across a broad range of other scenarios (CHD risk, 2.5%-15%) when statin assumptions were favorable ($0.13 per pill and no quality of life penalty). When statin assumptions were less favorable ($1.00 per pill and disutility=0.00384), CAC screening with statin treatment for persons with CAC>0 was cost-effective (<$50 000 per quality-adjusted life-year) in this scenario, in 55-year-old men with CHD risk 7.5%, and in other intermediate risk scenarios (CHD risk, 5%-10%). Our results were critically sensitive to statin cost and disutility and relatively robust to other assumptions. Alternate CAC treatment thresholds (>100 or >300) were generally not cost-effective. CONCLUSIONS CAC testing in intermediate risk patients can be cost-effective but only if statins are costly or significantly affect quality of life.
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Affiliation(s)
- Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco 185 Berry Street, Suite 5700 San Francisco, CA 94107 Office: (415) 514-8008, Fax: (415) 514-8150,
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
| | | | | | - Cheryl McDade
- RTI Health Solutions, RTI International, Research Triangle Park, NC
| | - Kathryn A. Phillips
- Department of Clinical Pharmacy, UCSF Institute for Health Policy Studies, UCSF Comprehensive Cancer Center, and UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California, San Francisco, CA
| | - Reto Auer
- Department of Epidemiology and Biostatistics, University of California, San Francisco 185 Berry Street, Suite 5700 San Francisco, CA 94107 Office: (415) 514-8008, Fax: (415) 514-8150,
| | - Lydia Zablotska
- Department of Epidemiology and Biostatistics, University of California, San Francisco 185 Berry Street, Suite 5700 San Francisco, CA 94107 Office: (415) 514-8008, Fax: (415) 514-8150,
| | - Philip Greenland
- Departments of Preventive Medicine and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Trends in statin therapy initiation during the period 2000-2010 in Israel. Eur J Clin Pharmacol 2014; 70:557-64. [PMID: 24463538 DOI: 10.1007/s00228-013-1637-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 12/29/2013] [Indexed: 01/14/2023]
Abstract
PURPOSE The aim of this population-based study is to describe trends in the characteristics and treatment patterns of statin initiators over the first decade of the 21st century. METHODS New statin use was studied retrospectively using the database of Maccabi Healthcare Services (MHS), a large Israeli health maintenance organization. Statin initiators were defined as MHS members aged ≥ 30 years who first purchased statins between 2000 and 2010. The starting dose was calculated in simvastatin equivalents based on the World Health Organization's daily defined dose index. Persistence was calculated as the percentage of days covered (PDC) with statins during the first year of therapy. RESULTS Statin initiation peaked in 2005 and decreased from 38.6 to 18.6 per 1,000 in the period 2005-2010. The average age at therapy initiation decreased from 58.9 (± 12.0) to 54.5 (± 11.7) years, and the average (SD) baseline low-density lipoprotein cholesterol (LDL-C) decreased from 4.2 (± 1.1) to 4.0 (± 0.9) mmol/l during the study period. Women were on average 3 years older than men at treatment initiation, with a higher baseline LDL-C. Among statin initiators, the prevalence of ischemic heart disease (IHD) decreased from 17.8 to 6.7 %, and diabetes prevalence increased from 8.6 to 15.7 %, peaking in 2008 (18.0 %). The PDC with statins ranged between 52.9 and 57.7 %. Simvastatin use at initiation increased from 27.5 % in 2000 to >90 % since 2002. Starting dose increased from 18.5 (± 8.9) to 24.3 (± 13.7) mg simvastatin equivalent. CONCLUSIONS Among the study population, statin initiators were increasingly characterized by a lower cardiovascular risk-namely, younger individuals without IHD and with a lower baseline LDL-C. These trends underscore the important shift towards statin initiation for primary prevention, as well as the need to balance between benefits and the potential side effect of statins.
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Saib A, Sabbah L, Perdrix L, Blanchard D, Danchin N, Puymirat E. Evaluation of the impact of the recent controversy over statins in France: The EVANS study. Arch Cardiovasc Dis 2013; 106:511-6. [DOI: 10.1016/j.acvd.2013.06.053] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 05/30/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
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Schuck RN, Mendys PM, Simpson RJ. Beyond statins: lipid management to reduce cardiovascular risk. Pharmacotherapy 2013; 33:754-64. [PMID: 23606278 DOI: 10.1002/phar.1268] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The discovery that elevated total cholesterol levels and the subsequent understanding that low-density lipoprotein cholesterol levels are associated with higher risk for cardiovascular disease (CVD) has led to the development of lipid management strategies that seek to reduce the burden of CVD. Although substantive progress has been made in reducing death and cardiovascular events, questions remain regarding the optimal approach to further reduce CVD-associated death and disability. Based on current evidence, statins are the clear first-line agents for the management of hyperlipidemia in patients at high risk for cardiovascular events. However, due to the failure of recent clinical trials evaluating antihyperlipidemic drugs, the most appropriate lipid management strategy in patients who cannot tolerate statin therapy or who warrant antihyperlipidemic therapies in addition to statins is a major therapeutic controversy. In this review, we summarize the clinical trial evidence evaluating the efficacy of second-line antihyperlipidemic drug classes for reducing cardiovascular risk, provide recommendations for appropriate use of nonstatin lipid-altering drugs, and identify key areas of future research to support evidence-based lipid management. Given the complexity, magnitude, and burden of CVD, opportunities to improve processes of care and identify new therapeutic options clearly exist.
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Affiliation(s)
- Robert N Schuck
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
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Karmali KN, Lloyd-Jones DM. Adding a life-course perspective to cardiovascular-risk communication. Nat Rev Cardiol 2013; 10:111-5. [DOI: 10.1038/nrcardio.2012.185] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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