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BACKGROUND: Recent data indicate that more intense lipid lowering reduces recurrent cardiovascular events. We evaluated the cost-effectiveness of such aggressive lipid lowering with 80 mg atorvastatin versus usual care with 20 mg simvastatin for secondary prevention of recurrent cardiovascular events.
METHODS: The study is a cost-effectiveness analysis by decision analytic modeling using the reference-case approach. Primary outcomes were cardiovascular death, MI, unstable angina requiring hospitalization and/or revascularization measured 2 years from randomization. Effectiveness data were from the Pravastatin or Atorvastatin Evaluation and Infection Therapy - Thrombolysis in Myocardial Infarction 22 study that enrolled patients within 10 days of acute MI in stable condition. The relative risk reduction in the primary outcomes was 16% (95% confidence interval: 5%-26%) with aggressive therapy. We assumed that usual care with 20 mg simvastatin is equivalent to 40 mg pravastatin. Life-years were converted into quality-adjusted life-years (QALYs) using established methods. We used published cardiovascular disease cost data and drug costs from the Veterans Health Administration System. All costs are in 2002 US dollars.
RESULTS: The reference-case analysis yields an incremental cost-effectiveness ratio (ICER) for aggressive therapy with atorvastatin of $64,952 per QALY gained. Raising the price of atorvastatin above $1800 for two years of therapy (115% of the reference-case price) makes the ICER >$100,000/QALY. While aggressive therapy is not cost effective below a relative risk reduction of 12%, it is highly cost-effective at higher estimates. The results are not sensitive to change in compliance rates. When the cost of treating coronary heart disease is varied from 50% to 150% of the reference-case, aggressive therapy is not cost effective at price ranges below 70%. Varying the discount rate from 0% to 7.5% yields results consistently in favor of aggressive therapy.
CONCLUSIONS: A strategy of aggressive lipid lowering provides more QALYs at a modest cost. Except when the costs of treating coronary heart disease are low or if the relative risk reduction by aggressive therapy is small, aggressive lipid lowering therapy is substantially better.
See more of Poster Session - CEA: Methods and Applications; Health Services Research
See more of The 26th Annual Meeting of the Society for Medical Decision Making (October 17-20, 2004)