Strategies for reducing coronary risk factors in primary care: which is most cost effective?

BMJ 1995;310:1109-1112 (29 April)

General practice

Strategies for reducing coronary risk factors in primary care: which is most cost effective?

K Field, senior lecturer,^a M Thorogood, senior lecturer,^b C Silagy, C Normand, professor of health policy,^b C O'Neill, nurse facilitator,^c J Muir, senior research fellow ^c

^a Gwent College of Higher Education, Newport Business School, PO Box 180, Newport NP9 5XR, ^b Public Health and Policy Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, ^c Imperial Cancer Research Fund General Practice Research Group, University of Oxford, Radcliffe Infirmary, Oxford OX2 6HE

Department of General Practice, School of Medicine, Flinders University of South Australia, Adelaide 5001, Australia Chris Silagy, professor. Correspondence to: Dr Thorogood.

Abstract

Objective: To examine the relative cost effectiveness of a rangeof screening and intervention strategies for preventing coronaryheart disease in primary care.
Subjects: 7840 patients aged 35-64 years who were participantsin a trial of modifying coronary heart disease risk factorsin primary care.
Design: Effectiveness of interventions assumed and the potentialyears of life gained estimated from a risk equation calculatedfrom Framingham study data.
Main outcome measure: The cost per year of life gained.
Results: The most cost effective strategy was minimal screeningof blood pressure and personal history of vascular disease,which cost pounds sterling310-pounds sterling930 per year oflife gained for men and pounds sterling1100-pounds sterling3460for women excluding treatment of raised blood pressure. Theextra cost per life year gained by adding smoking history tothe screening was pounds sterling400-pounds sterling6300 inmen. All strategies were more cost effective in men than inwomen and more cost effective in older age groups. Lipid loweringdrugs accounted for at least 70% of the estimated costs of allstrategies. Cost effectiveness was greatest when drug treatmentwas limited to those with cholesterol concentrations above 9.5mmol/l.
Conclusions: Universal screening and intervention strategiesare an inefficient approach to reducing the coronary heart diseaseburden. A basic strategy for screening and intervention, targetedat older men with raised blood pressure and limiting the useof cholesterol lowering drugs to those with very high cholesterolconcentrations would be most cost effective.

Key messages

Key messages
The most cost effective strategy is to target patients with raised blood pressure or a history of coronary heart disease
Extending the strategy to include other factors increases the cost by variable amounts
All prevention strategies are more cost effective in men than in women and in older than younger age groups
Drug treatment for patients with high cholesterol concentrations is cost effective, but the incremental cost of extending treatment to lower cholesterol concentrations is high

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