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Cost-effectiveness of coronary artery calcium testing for coronary heart and cardiovascular disease risk prediction to guide statin allocation: the Multi-Ethnic Study of Atherosclerosis (MESA).

Roberts ET, Horne A, Martin SS, Blaha MJ, Blankstein R, Budoff MJ, Sibley C, Polak JF, Frick KD, Blumenthal RS, Nasir K - PLoS ONE (2015)

Bottom Line: We project that it is both cost-saving and more effective to scan intermediate-risk patients for CAC and to treat those with CAC≥1, compared to treatment based on established risk-assessment guidelines.Treating patients with CAC≥100 is also preferred to existing guidelines when we account for statin side effects and the disutility of statin use.Compared to the alternatives we assessed, CAC testing is both effective and cost saving as a risk-stratification tool, particularly if there are adverse effects of long-term statin use.

View Article: PubMed Central - PubMed

Affiliation: Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland, United States of America.

ABSTRACT

Background: The Multi-Ethnic Study of Atherosclerosis (MESA) showed that the addition of coronary artery calcium (CAC) to traditional risk factors improves risk classification, particularly in intermediate risk asymptomatic patients with LDL cholesterol levels <160 mg/dL. However, the cost-effectiveness of incorporating CAC into treatment decision rules has yet to be clearly delineated.

Objective: To model the cost-effectiveness of CAC for cardiovascular risk stratification in asymptomatic, intermediate risk patients not taking a statin. Treatment based on CAC was compared to (1) treatment of all intermediate-risk patients, and (2) treatment on the basis of United States guidelines.

Methods: We developed a Markov model of first coronary heart disease (CHD) and cardiovascular disease (CVD) events. We modeled statin treatment in intermediate risk patients with CAC≥1 and CAC≥100, with different intensities of statins based on the CAC score. We compared these CAC-based treatment strategies to a "treat all" strategy and to treatment according to the Adult Treatment Panel III (ATP III) guidelines. Clinical and economic outcomes were modeled over both five- and ten-year time horizons. Outcomes consisted of CHD and CVD events and Quality-Adjusted Life Years (QALYs). Sensitivity analyses considered the effect of higher event rates, different CAC and statin costs, indirect costs, and re-scanning patients with incidentalomas.

Results: We project that it is both cost-saving and more effective to scan intermediate-risk patients for CAC and to treat those with CAC≥1, compared to treatment based on established risk-assessment guidelines. Treating patients with CAC≥100 is also preferred to existing guidelines when we account for statin side effects and the disutility of statin use.

Conclusion: Compared to the alternatives we assessed, CAC testing is both effective and cost saving as a risk-stratification tool, particularly if there are adverse effects of long-term statin use. CAC may enable providers to better tailor preventive therapy to patients' risks of CVD.

No MeSH data available.


Related in: MedlinePlus

Cost-Effectiveness Acceptability Curves.Panel (a): 10-Year CVD Events, Treat CAC ≥ 1. Panel (b): 10-Year CVD Events, Treat CAC ≥ 100. Note: The cost-effectiveness acceptability curves show the proportion of simulations (vertical axis) that are cost-effective at a given willingness-to-pay threshold (horizontal axis). A mean CAC scanning cost of $100 and a mean statin cost of $180 is assumed in both plots (indirect costs and costs associated with incidentalomas are not included). The vertical intercept of each cost-effectiveness acceptability curve includes simulations that are cost saving and which result in a loss of fewer QALYs compared to the alternative scenarios. The intercept can be interpreted as the probability that a strategy would be accepted at a willingness-to-pay threshold of $0/QALY. For example, approximately 75% of simulations in both CAC strategies would be accepted at the $0/QALY threshold.
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pone.0116377.g002: Cost-Effectiveness Acceptability Curves.Panel (a): 10-Year CVD Events, Treat CAC ≥ 1. Panel (b): 10-Year CVD Events, Treat CAC ≥ 100. Note: The cost-effectiveness acceptability curves show the proportion of simulations (vertical axis) that are cost-effective at a given willingness-to-pay threshold (horizontal axis). A mean CAC scanning cost of $100 and a mean statin cost of $180 is assumed in both plots (indirect costs and costs associated with incidentalomas are not included). The vertical intercept of each cost-effectiveness acceptability curve includes simulations that are cost saving and which result in a loss of fewer QALYs compared to the alternative scenarios. The intercept can be interpreted as the probability that a strategy would be accepted at a willingness-to-pay threshold of $0/QALY. For example, approximately 75% of simulations in both CAC strategies would be accepted at the $0/QALY threshold.

Mentions: Fig. 2 plots the cost-effectiveness acceptability curves for each risk assessment and treatment strategy, for the prevention of CVD events over a ten-year horizon, when outcomes are valued as QALYs. The figure summarizes the distribution of the simulated results, based on the proportion of simulations that are cost-effective (measured on the vertical axis) at different willingness-to-pay thresholds (horizontal axis). The intercept of each curve with the vertical axis represents the proportion of simulations for a given strategy that would be accepted at a willingness-to-pay threshold of $0/QALY; the intercept includes simulations for which a strategy is both cost saving and more effective than the two other alternatives. The figure demonstrates that approximately 75% of the CAC simulations are cost-effective at the $0/QALY threshold, compared to the treat-all and ATP III strategies. CAC remains favored in a majority of simulations at positive willingness-to-pay thresholds.


Cost-effectiveness of coronary artery calcium testing for coronary heart and cardiovascular disease risk prediction to guide statin allocation: the Multi-Ethnic Study of Atherosclerosis (MESA).

Roberts ET, Horne A, Martin SS, Blaha MJ, Blankstein R, Budoff MJ, Sibley C, Polak JF, Frick KD, Blumenthal RS, Nasir K - PLoS ONE (2015)

Cost-Effectiveness Acceptability Curves.Panel (a): 10-Year CVD Events, Treat CAC ≥ 1. Panel (b): 10-Year CVD Events, Treat CAC ≥ 100. Note: The cost-effectiveness acceptability curves show the proportion of simulations (vertical axis) that are cost-effective at a given willingness-to-pay threshold (horizontal axis). A mean CAC scanning cost of $100 and a mean statin cost of $180 is assumed in both plots (indirect costs and costs associated with incidentalomas are not included). The vertical intercept of each cost-effectiveness acceptability curve includes simulations that are cost saving and which result in a loss of fewer QALYs compared to the alternative scenarios. The intercept can be interpreted as the probability that a strategy would be accepted at a willingness-to-pay threshold of $0/QALY. For example, approximately 75% of simulations in both CAC strategies would be accepted at the $0/QALY threshold.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4364761&req=5

pone.0116377.g002: Cost-Effectiveness Acceptability Curves.Panel (a): 10-Year CVD Events, Treat CAC ≥ 1. Panel (b): 10-Year CVD Events, Treat CAC ≥ 100. Note: The cost-effectiveness acceptability curves show the proportion of simulations (vertical axis) that are cost-effective at a given willingness-to-pay threshold (horizontal axis). A mean CAC scanning cost of $100 and a mean statin cost of $180 is assumed in both plots (indirect costs and costs associated with incidentalomas are not included). The vertical intercept of each cost-effectiveness acceptability curve includes simulations that are cost saving and which result in a loss of fewer QALYs compared to the alternative scenarios. The intercept can be interpreted as the probability that a strategy would be accepted at a willingness-to-pay threshold of $0/QALY. For example, approximately 75% of simulations in both CAC strategies would be accepted at the $0/QALY threshold.
Mentions: Fig. 2 plots the cost-effectiveness acceptability curves for each risk assessment and treatment strategy, for the prevention of CVD events over a ten-year horizon, when outcomes are valued as QALYs. The figure summarizes the distribution of the simulated results, based on the proportion of simulations that are cost-effective (measured on the vertical axis) at different willingness-to-pay thresholds (horizontal axis). The intercept of each curve with the vertical axis represents the proportion of simulations for a given strategy that would be accepted at a willingness-to-pay threshold of $0/QALY; the intercept includes simulations for which a strategy is both cost saving and more effective than the two other alternatives. The figure demonstrates that approximately 75% of the CAC simulations are cost-effective at the $0/QALY threshold, compared to the treat-all and ATP III strategies. CAC remains favored in a majority of simulations at positive willingness-to-pay thresholds.

Bottom Line: We project that it is both cost-saving and more effective to scan intermediate-risk patients for CAC and to treat those with CAC≥1, compared to treatment based on established risk-assessment guidelines.Treating patients with CAC≥100 is also preferred to existing guidelines when we account for statin side effects and the disutility of statin use.Compared to the alternatives we assessed, CAC testing is both effective and cost saving as a risk-stratification tool, particularly if there are adverse effects of long-term statin use.

View Article: PubMed Central - PubMed

Affiliation: Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland, United States of America.

ABSTRACT

Background: The Multi-Ethnic Study of Atherosclerosis (MESA) showed that the addition of coronary artery calcium (CAC) to traditional risk factors improves risk classification, particularly in intermediate risk asymptomatic patients with LDL cholesterol levels <160 mg/dL. However, the cost-effectiveness of incorporating CAC into treatment decision rules has yet to be clearly delineated.

Objective: To model the cost-effectiveness of CAC for cardiovascular risk stratification in asymptomatic, intermediate risk patients not taking a statin. Treatment based on CAC was compared to (1) treatment of all intermediate-risk patients, and (2) treatment on the basis of United States guidelines.

Methods: We developed a Markov model of first coronary heart disease (CHD) and cardiovascular disease (CVD) events. We modeled statin treatment in intermediate risk patients with CAC≥1 and CAC≥100, with different intensities of statins based on the CAC score. We compared these CAC-based treatment strategies to a "treat all" strategy and to treatment according to the Adult Treatment Panel III (ATP III) guidelines. Clinical and economic outcomes were modeled over both five- and ten-year time horizons. Outcomes consisted of CHD and CVD events and Quality-Adjusted Life Years (QALYs). Sensitivity analyses considered the effect of higher event rates, different CAC and statin costs, indirect costs, and re-scanning patients with incidentalomas.

Results: We project that it is both cost-saving and more effective to scan intermediate-risk patients for CAC and to treat those with CAC≥1, compared to treatment based on established risk-assessment guidelines. Treating patients with CAC≥100 is also preferred to existing guidelines when we account for statin side effects and the disutility of statin use.

Conclusion: Compared to the alternatives we assessed, CAC testing is both effective and cost saving as a risk-stratification tool, particularly if there are adverse effects of long-term statin use. CAC may enable providers to better tailor preventive therapy to patients' risks of CVD.

No MeSH data available.


Related in: MedlinePlus