The economic burden of hypertriglyceridemia among US adults with diabetes or atherosclerotic cardiovascular disease on statin therapy

BACKGROUND

Hypertriglyceridemia (HTG) is associated with increased cardiovascular disease (CVD) risk. However, the cost burden of HTG-related CVD in high-risk US adults on statins has not been well characterized.

OBJECTIVE

We estimated the HTG-related health care cost burden among US adults with CVD or diabetes taking statin therapy.

METHODS

We estimated population sizes and annual health care costs among US adults aged ≥45 years with diabetes or CVD taking statin therapy with normal triglycerides (TGs) defined as TG < 150 mg/dL compared with those with HTG defined as TG ≥ 150 mg/dL. Population sizes were estimated from the 2007-2014 National Health and Nutrition Examination Surveys. Adjusted mean total annual health care costs in 2015 US dollars were estimated using the Optum Research Database. The annual total health care cost burden was estimated by multiplying the population size by the mean annual total incremental health care costs overall and within subgroups.

RESULTS

There were 6.2 (95% confidence interval [CI], 5.4 - 7.1) million and 12.0 (95% CI, 11.1 - 12.9) million US adults aged ≥45 years with diabetes and/or CVD on statin therapy with TG ≥ 150 mg/dL and TG < 150 mg/dL, respectively. The mean adjusted incremental total one-year health care costs in adults with TG ≥ 150 mg/dL compared with those with TG < 150 mg/dL was $1730 (95% CI, $1160 - $2320). This leads to a projected annual incremental cost burden associated with HTG in patients with diabetes or CVD on statins of $10.7 billion (95% CI, $6.8 B - $14.6 B).

CONCLUSION

In US adults on statins and at high risk for CVD, the health care costs associated with HTG are substantial.

Increased residual cardiovascular risk in patients with diabetes and high versus normal triglycerides despite statin-controlled LDL cholesterol

AIM

To determine whether high triglycerides (TG) in the presence of statin-controlled LDL-C influence the risk of cardiovascular disease (CVD) among patients with diabetes in real-world clinical practice.

MATERIALS AND METHODS

We identified adults with diabetes from the Southern California and Pacific Northwest regions of Kaiser Permanente. We included patients undergoing statin therapy with LDL-C from 40-100 mg/dL who were not undergoing other lipid-lowering therapies and had a prior diagnosis of atherosclerotic CVD or at least one other CVD risk factor. We grouped patients into high TG (200-499 mg/dL; n = 5542) or normal TG (<150 mg/dL, n = 22 411) from January 2010 through December 2016 to compare incidence rates and rate ratios of first non-fatal myocardial infarction (MI), non-fatal stroke, unstable angina and coronary revascularization. We adjusted multivariable analyses for age, sex, race/ethnicity, smoking status, blood pressure, HbA1c, serum creatinine, presence of ischaemic heart disease and study site.

RESULTS

Adjusted rate ratios for the four outcomes were all statistically significantly different. The incidence rate for non-fatal MI was 30% higher in the high TG group (rate ratio, 1.30; 95% CI, 1.08-1.58; P = 0.006). The rate was 23% higher for non-fatal stroke (1.23, 1.01-1.49, P = 0.037), 21% higher for coronary revascularization (rate ratio, 1.21; 95% CI, 1.02-1.43; P = 0.027) and was, non-significantly, 33% higher for unstable angina (rate ratio, 1.33; 95% CI, 0.87-2.03; P = 0.185).

CONCLUSIONS

Despite statin-controlled LDL-C levels, CV events were greater among patients with diabetes and high TG levels. Because we controlled for cardiometabolic risk factors, it is likely that the difference in TG levels contributed to the excess risk observed in patients with high TGs.

Comparison of Medical Care Utilization and Costs Among Patients With Statin-Controlled Low-Density Lipoprotein Cholesterol With Versus Without Hypertriglyceridemia

High triglyceride (TG) levels are associated with higher medical costs, but the long-term impact of high TG on costs among patients with statin-controlled low-density lipoprotein cholesterol (LDL-C) is unclear. We compared medical utilization and costs over 6.5years between patients with high (200 to 400 mg/dl) versus normal (<150 mg/dl) TG levels, all of whom had established atherosclerotic cardiovascular disease (ASCVD). This was an observational cohort study of 17,183 patients with TG measured in 2010 and followed until death, disenrollment or the end of 2016. All patients had LDL-C levels between 40 and 100 mg/dl and were receiving statin therapy at the time of their TG measurement. We compared annualized medical utilization adjusted for differences between group in age, sex, race, and study site. We also compared annualized medical costs, further adjusting for baseline costs as a proxy for resource-intensive comorbidities. After multivariable adjustment, patients with high TG levels (n=2,702) had a mean of 13% more inpatient admissions per year (p <0.001). Despite adjustment for comorbidities such as diabetes and chronic kidney disease, total outpatient costs were 5% greater (p = 0.035) among those with high TG, including emergency care costs (6% greater) and hospital ambulatory costs (25% greater). The overall difference in annual costs of $964 per patient in the high TG cohort totaled over $2.6million per year in excess annual costs and more than $13.5million over the mean follow-up of 5.2years.

Increased Cardiovascular Risk in Hypertriglyceridemic Patients With Statin-Controlled LDL Cholesterol

CONTEXT

Real-world evidence of the relationship between high triglyceride (TG) levels and cardiovascular (CV) disease (CVD) risk among statin-treated patients with low-density lipoprotein cholesterol (LDL-C) control is lacking.

OBJECTIVE

We aimed to compare CVD and mortality risk between patients with high vs normal TGs.

DESIGN

Longitudinal observational cohort study.

SETTING

Integrated delivery system.

PATIENTS

Patients aged ≥45 years whose TG level was either <150 mg/dL (normal) or between 200 and 499 mg/dL (high) in 2010, were taking only statins, had LDL-C values 40 to 100 mg/dL, and had diagnosed CVD.

OUTCOME MEASURES

Patients were followed through December 2016. Our primary outcomes were a composite of nonfatal myocardial infarction (MI), nonfatal stroke, unstable angina, coronary revascularization, and all-cause mortality and a second composite adding peripheral revascularization and aneurysm repair. We compared multivariable-adjusted incidence rates and rate ratios (RRs) of the outcomes and their components.

RESULTS

A total of 14,481 patients comprised the normal TG group, and 2702 patients were in the high TG group. Multivariable-adjusted incidence of the second composite was 10% greater in the high TG group [50.9/1000 person-years, 95% CI 47.0 to 55.2 vs 46.5, 44.8 to 48.2, RR 1.10, 95% CI 1.00 to 1.20, P = 0.041]. The difference was driven by nonfatal MI (RR 1.20, 95% CI 1.00 to 1.45, P = 0.045), coronary revascularization (RR 1.18, 95% CI 1.00 to 1.40, P = 0.045), and peripheral revascularization (RR 1.56, 95% CI 1.14 to 2.13, P = 0.006).

CONCLUSIONS

CVD risk in high-risk statin-treated patients with atherosclerotic CVD was associated with high TG levels.

Single-dose ampicillin/sulbactam versus ceftriaxone as treatment for uncomplicated gonorrhoea in a Ugandan STD clinic population with a high prevalence of PPNG infection

During the period November 1989 to March 1991 a total of 330 patients (269 males and 61 females) with signs and symptoms of uncomplicated lower genital tract infections with Neisseria gonorrhoeae were treated at a sexually transmitted disease clinic in Kampala, Uganda. Patients were randomized for treatment with either intramuscular ampicillin/sulbactam (1 g ampicillin/0.5 g sulbactam), plus 1 g probenecid orally, or ceftriaxone (250 mg). In those cases where N. gonorrhoeae was isolated and the patients returned for a follow-up visit, 70/74 (95%) of the patients treated with ampicillin/sulbactam and 71/72 (99%) of those treated with ceftriaxone had favourable clinical outcomes. All 24 patients with penicillinase-producing N. gonorrhoeae (PPNG) treated with ampicillin/sulbactam had a favourable clinical outcome compared with 95% (20/21) of those with PPNG treated with ceftriaxone. The infecting pathogen was eradicated in 65/71 (92%) of the evaluable patients treated with ampicillin/sulbactam and in 60/63 (95%) of the ceftriaxone group. Both drug regimens were well tolerated and there were no reports of adverse drug effects. In summary, in a predominantly male group of clinic patients in Kampala, Uganda, ampicillin/sulbactam was as safe and effective as ceftriaxone in treating uncomplicated gonococcal infections of the lower genital tract caused by either PPNG or non-PPNG strains.