Cost-Effectiveness and Population Impact of Statins for Primary Prevention in Adults Aged 75 Years or Older in the United States
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Abstract
Background:
Evidence to guide primary prevention in adults aged 75 years or older is limited.
Objective:
To project the population impact and cost-effectiveness of statin therapy in adults aged 75 years or older.
Design:
Forecasting study using the Cardiovascular Disease Policy Model, a Markov model.
Data Sources:
Trial, cohort, and nationally representative data sources.
Target Population:
U.S. adults aged 75 to 94 years.
Time Horizon:
10 years.
Perspective:
Health care system.
Intervention:
Statins for primary prevention based on low-density lipoprotein cholesterol threshold of 4.91 mmol/L (190 mg/dL), 4.14 mmol/L (160 mg/dL), or 3.36 mmol/L (130 mg/dL); presence of diabetes; or 10-year risk score of at least 7.5%.
Outcome Measures:
Myocardial infarction (MI), coronary heart disease (CHD) death, disability-adjusted life-years, and costs.
Results of Base-Case Analysis:
All adults aged 75 years or older in the National Health and Nutrition Examination Survey have a 10-year risk score greater than 7.5%. If statins had no effect on functional limitation or cognitive impairment, all primary prevention strategies would prevent MIs and CHD deaths and be cost-effective. Treatment of all adults aged 75 to 94 years would result in 8 million additional users and prevent 105 000 (4.3%) incident MIs and 68 000 (2.3%) CHD deaths at an incremental cost per disability-adjusted life-year of $25 200.
Results of Sensitivity Analysis:
An increased relative risk for functional limitation or mild cognitive impairment of 1.10 to 1.29 could offset the cardiovascular benefits.
Limitation:
Limited trial evidence targeting primary prevention in adults aged 75 years or older.
Conclusion:
At effectiveness similar to that in trials, statins are projected to be cost-effective for primary prevention; however, even a small increase in geriatric-specific adverse effects could offset the cardiovascular benefit. Improved data on the potential benefits and harms of statins are needed to inform decision making.
Primary Funding Source:
American Heart Association Western States Affiliate, National Institute on Aging, and the National Institute for Diabetes on Digestive and Kidney Diseases.
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Published In
Annals of Internal Medicine
Volume 162 • Number 8 • 21 April 2015
Pages: 533 - 541
History
Published online: 21 April 2015
Published in issue: 21 April 2015
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© 2015 American College of Physicians.
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Cost-Effectiveness and Population Impact of Statins for Primary Prevention in Adults Aged 75 Years or Older in the United States. Ann Intern Med.2015;162:533-541. [Epub 21 April 2015]. doi:10.7326/M14-1430
Cost-Effectiveness and Population Impact of Statins for Primary Prevention in Adults Aged 75 Years or Older in the United States. Ann Intern Med.2015;162:533-541. [Epub 21 April 2015]. doi:10.7326/M14-1430
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Comment
In addition the authors misrepresent the inclusiveness of their analysis by referring repeatedly to cardiovascular disease reduction, and failing to mention the lack of the inclusion of stroke as a serious limitation. The term cardiovascular disease includes stroke as well as CHD.
While it is encouraging that statins for the primary prevention of CHD after age 75 are cost-effective at $25,200 per disability adjusted life year, the full potential for cost-effectiveness, or potentially cost-savings, cannot be evaluated without considering the full benefits of statins for preventing both stroke and CHD.
Improving the ASCVD risk calculation and primary prevention
If Odden, et al, stratified their subjects by alcohol intake, diet, and physical activity as well as by family history (5,6), those with better lifestyles and good family histories would have less absolute benefit from statins than the average and those with worse would have more. A discussion individualized for a patient about ASCVD risk reduction requires knowledge of the likely risk reduction for a specific patient based on all the lifestyle factors of Akesson (3) and family history in addition to the factors in the current risk calculator (http://tools.cardiosource.org/ASCVD-Risk-Estimator/ ). One should not focus on statins and neglect change in modifiable lifestyle factors because they can make such a large difference in prognosis.
If these additional lifestyle factors and family history were added to the ASCVD risk calculator, a more personalized risk assessment could be made and a more relevant comprehensive discussion about primary prevention could be held.
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