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Lost Therapeutic Benefit of Delayed Low-Density Lipoprotein Cholesterol Control in Statin-Treated Patients and
Clara Marquina1, Jedidiah Morton2, Ella Zomer3
1Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
Insights
Delaying lipid-lowering treatment intensification in patients with high cholesterol leads to more coronary heart disease events and wasted healthcare resources. Promptly achieving low-density lipoprotein cholesterol (LDL-C) goals is crucial for better patient outcomes and economic efficiency.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Pharmacoeconomics
Background:
- Suboptimal attainment of therapeutic low-density lipoprotein cholesterol (LDL-C) goals is common in patients receiving statin therapy.
- The health economic impact of delayed lipid-lowering treatment intensification in Australia is not fully quantified.
Purpose of the Study:
- To quantify the health economic impact of delayed lipid-lowering intensification in statin-treated patients with uncontrolled LDL-C from an Australian perspective.
- To compare the outcomes of no delay versus a 5-year delay in achieving LDL-C goals.
Main Methods:
- A lifetime Markov cohort model (n=1000) was developed to estimate the impact on coronary heart disease (CHD) of intensifying lipid-lowering treatment.
- Intensification strategies included high-intensity statins or statins + ezetimibe, compared with standard of care (no intensification).
- Outcomes included CHD events, quality-adjusted life-years (QALYs), healthcare and productivity costs, and incremental cost-effectiveness ratios (ICERs).
Main Results:
- Compared to standard care, no delay in treatment intensification with high-intensity statins prevented 29 CHD events and gained 30 QALYs (ICER AU$13,205/QALY).
- A 5-year delay with high-intensity statins prevented 22 CHD events and gained 16 QALYs (ICER AU$20,270/QALY).
- No delay with statins + ezetimibe prevented 53 CHD events and gained 45 QALYs (ICER AU$37,271/QALY), versus 40 CHD events and 29 QALYs (ICER AU$44,218/QALY) with a 5-year delay.
Conclusions:
- Delaying the attainment of LDL-C goals results in significant loss of therapeutic benefit.
- Delayed intensification leads to a waste of healthcare resources and reduced patient quality-adjusted life-years.
- Urgent policy interventions are necessary to improve LDL-C goal attainment in statin-treated patients.
Objectives:
Attainment of low-density lipoprotein cholesterol (LDL-C) therapeutic goals in statin-treated patients remains suboptimal. We quantified the health economic impact of delayed lipid-lowering intensification from an Australian healthcare and societal perspective.
Methods:
A lifetime Markov cohort model (n = 1000) estimating the impact on coronary heart disease (CHD) of intensifying lipid-lowering treatment in statin-treated patients with uncontrolled LDL-C, at moderate to high risk of CHD with no delay or after a 5-year delay, compared with standard of care (no intensification), starting at age 40 years. Intensification was tested with high-intensity statins or statins + ezetimibe. LDL-C levels were extracted from a primary care cohort. CHD risk was estimated using the pooled cohort equation. The effect of cumulative exposure to LDL-C on CHD risk was derived from Mendelian randomization data. Outcomes included CHD events, quality-adjusted life-years (QALYs), healthcare and productivity costs, and incremental cost-effectiveness ratios (ICERs). All outcomes were discounted annually by 5%.
Results:
Over the lifetime horizon, compared with standard of care, achieving LDL-C control with no delay with high-intensity statins prevented 29 CHD events and yielded 30 extra QALYs (ICERs AU$13 205/QALY) versus 22 CHD events and 16 QALYs (ICER AU$20 270/QALY) with a 5-year delay. For statins + ezetimibe, no delay prevented 53 CHD events and gave 45 extra QALYs (ICER AU$37 271/QALY) versus 40 CHD events and 29 QALYs (ICER of AU$44 218/QALY) after a 5-year delay.
Conclusions:
Delaying attainment of LDL-C goals translates into lost therapeutic benefit and a waste of resources. Urgent policies are needed to improve LDL-C goal attainment in statin-treated patients.
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