The implications of competing risks and direct treatment disutility in cardiovascular disease and osteoporotic fracture: risk prediction and cost effectiveness analysis
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View abstract on PubMed
Summary
This summary is machine-generated.Predictive models for preventative treatments must account for competing mortality and treatment disutility. Incorporating these factors, particularly treatment inconvenience, can significantly alter the cost-effectiveness of interventions like statins and bisphosphonates.
Area Of Science
- Health economics and outcomes research
- Clinical decision-making and risk prediction modeling
- Preventative medicine and public health interventions
Background
- Clinical guidelines recommend preventative treatments based on risk thresholds, necessitating reliable risk prediction tools and cost-effectiveness analyses.
- Existing models often inadequately handle competing risks of death and the disutility associated with treatments (e.g., hassle factor).
- This study addresses these limitations using primary prevention of cardiovascular disease with statins and osteoporotic fracture with bisphosphonates as case studies.
Purpose Of The Study
- To externally validate existing risk prediction tools (QRISK®3, QRISK®-Lifetime, QFracture-2012) and develop new ones (CRISK-CCI, CFracture) accounting for competing mortality.
- To quantify the direct treatment disutility for statins and bisphosphonates.
- To examine the impact of competing risks and treatment disutility on the cost-effectiveness of preventative treatments.
Main Methods
- Risk prediction models were validated using data from the Clinical Practice Research Datalink.
- Direct treatment disutility was measured using online stated-preference surveys (time trade-off and best-worst scaling).
- Cost-effectiveness was analyzed using decision-analytic modeling, incorporating updated models used by the National Institute for Health and Care Excellence.
Main Results
- New models (CRISK-CCI, CFracture) demonstrated good discrimination and calibration, outperforming some existing tools, especially in specific subgroups.
- Statins had a direct treatment disutility of 0.034, and bisphosphonates 0.067, with inconvenience influencing preferences.
- Accounting for disutility increased the risk threshold for statin benefits and indicated bisphosphonate treatment could be net harmful at all risk levels.
Conclusions
- Ignoring competing mortality overestimates event risk, particularly in older individuals and those with multimorbidity.
- While competing risk adjustment minimally impacts cost-effectiveness, direct treatment disutility is a measurable factor that can shift the benefit-harm balance.
- Individual-level shared decision-making is recommended to address the impact of treatment disutility in preventative care.
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