Statin treatment for primary prevention of vascular disease: whom to treat? Cost-effectiveness analysis
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1672 (Published 30 March 2011) Cite this as: BMJ 2011;342:d1672All rapid responses
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Greving et al present important cost-effectiveness modeling showing
that even at a yearly cost of 9Euros statins 'seemed' not cost-effective-
for the healthcare payer-when used for primary prevention over 10 years.
Interestingly, their generic statin represented only 6% of the cost
of this pharmacological intervention. This cost did not include that of
the burden to the patient of up to 40 doctor's visits, pharmacy visits and
10 yearly blood tests.
As in all modeling, assumptions have to be made and, here, the
authors assume a reduced post-event mortality rate, even after referencing
to 4 reviews not finding such effect. Moreover, the authors mention the
n=17,802 JUPITER trial where no cardiovascular mortality benefit was found
(p=0.37) from rosuvastatin [Crestor] and where, tellingly, the ONLY
'statistically' significant benefit in women was a reduction in
revascularizations after about 6500 patient-years.(1)
The authors should have concluded that in primary prevention statins
ARE not cost-effective rather than SEEMED not to be so. In primary
prevention [at least] statins are not life-savers and patients must be
told. vos{at}health-heart.org
1. Vos E, Rose CP, Biron P. Circulation. 2010 Dec 7;122(23):e576
http://www.ncbi.nlm.nih.gov/pubmed/21135369
Competing interests: No competing interests
In terms of the cost elements there are significantly cheaper ways of
doing things.
Cardiovascular risk assessment with say QRISK2 can be performed by a nurse
and requires only a lipid blood test. BMI/BP etc can be established in the
assessment.
At this assessment it can easily be projected when in the future the
patient will reach 20% risk in 10 years and enter the present program.
If Simvastatin 10mg is used no further blood tests or monitoring is
required.
Many of the patients prescribed a statin will have to pay for their
prescriptions. If 6 months are issued at a time what the patient pays will
cover the drug and prescribing costs.
The lower dose of Simvastatin will cause fewer side effects (hopefully
resulting in better compliance) It will have two thirds of the effect on
lowering lipids of Simvastatin 40mg.
I would very much like to know the cost per QUALY at different
age/risk levels calculated on this basis.
Competing interests: No competing interests
Statin treatment for primary prevention of vascular disease: whom to treat? Cost-effectiveness analysis
Dear Sir,
We thank Drs Vos and Smith for their interest in our study.
Dr Vos
questions the assumptions made in our analysis, in particular regarding
mortality rate and costs of statin treatment. As stated in our methods, we
assigned survivors of a first myocardial infarction or stroke a two-fold
increased risk for death. Thus, we did not assume a reduced post event
mortality rate. With regard to costs of statin treatment, these costs
include those incurred by the drug, laboratory tests, doctors' visits, and
pharmacists' fee. This implies that our conclusion is justified: statins
ARE cost-effective for high risk primary prevention populations, but
seemed not to be cost-effective for low risk prevention populations.
Dr Smith questions the cost-effectiveness of statins with alternative cost
assumptions. The suggested alternative assumptions will probably lead to
more favourable cost-effectiveness. However, until now there is not enough
evidence to justify these alternative assumptions. Our cost-effectiveness
analysis is based on how statin treatment should be provided according to
current cardiovascular risk management guidelines in The Netherlands.
Dr Jacoba P Greving, senior research fellow in clinical epidemiology;
Prof Dr Frank LJ Visseren, internist and professor of vascular medicine;
Dr G Ardine de Wit, associate professor of health technology assessment;
Prof Dr Ale Algra, professor of clinical
epidemiology
Competing interests: No competing interests