Published online before print April 23, 2007, doi: 10.1161/CIRCULATIONAHA.106.667683
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(Circulation. 2007;115:2398-2409.)
© 2007 American Heart Association, Inc.
Health Services and Outcomes Research |
Incremental Benefit and Cost-Effectiveness of High-Dose Statin Therapy in High-Risk Patients With Coronary Artery Disease
From the University of Michigan Department of Internal Medicine (P.S.C., B.K.N., H.S.G., R.A.H., S.V.), and Veterans Affairs Ann Arbor Health Services Research & Development Center of Excellence (P.S.C., B.K.N., R.A.H., S.V.), Ann Arbor, Mich.
Reprint requests to Paul Chan, MD, MSc, Veterans Affairs Ann Arbor Health Services Research & Development Center for Excellence, Cardiology (111-A), 2215 Fuller Rd, Ann Arbor, MI 48105. E-mail paulchan{at}umich.edu
Received October 2, 2006; accepted March 15, 2007.
Background— Recent clinical trials found that high-dose statin therapy, compared with conventional-dose statin therapy, reduces the risk of cardiovascular events in patients with acute coronary syndromes (ACS) and stable coronary artery disease (CAD). However, the actual benefit and cost-effectiveness of high-dose statin therapy are unknown.
Methods and Results— We designed a Markov model to compare daily high-dose with conventional-dose statin therapy for hypothetical 60-year-old cohorts with ACS and stable CAD over patient lifetime. Pooled estimates for major clinical end points (all-cause mortality, myocardial infarction, stroke, rehospitalization, and revascularization) from relevant clinical trials were incorporated. Incremental benefit was quantified as quality-adjusted life-years (QALYs). Threshold analyses determined at what price difference high-dose statins would yield incremental cost-effective ratios below $50 000, $100 000, and $150 000 per QALY gained. In ACS patients, a high-dose versus conventional-dose statin strategy resulted in a gain of 0.35 QALYs. In threshold analyses, a high-dose statin strategy consistently yielded incremental cost-effective ratios below $30 000 per QALY even under conservative model assumptions. In stable CAD patients, a high-dose statin strategy yielded a gain of only 0.10 QALYs and was sensitive to model assumptions about statin efficacy. The daily cost difference between a high- and conventional-dose statin would need to be <$1.70, $2.65, and $3.55 to yield incremental cost-effective ratios below $50 000, $100 000, and $150 000 per QALY.
Conclusions— High-dose statin therapy is potentially highly effective and cost-effective in patients with ACS. In patients with stable CAD, however, the cost-effectiveness of high-dose statin therapy is highly sensitive to model assumptions about statin efficacy and cost. Use of high-dose statins can be supported on health economic grounds in patients with ACS, but the case is less clear for patients with stable CAD.
CLINICAL PERSPECTIVE
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