Using Stress Testing to Guide Primary Prevention of Coronary Heart Disease among Intermediate-Risk Patients: A Cost-effectiveness Analysis
Background—Non-invasive stress testing might guide the use of aspirin and statins for primary prevention of coronary heart disease (CHD), but it is unclear if such a strategy would be cost-effective.
Methods and Results—We compared the status quo, in which the current national use of aspirin and statins was simulated, with three other strategies; 1) full implementation of Adult Treatment Panel (ATP III) guidelines, 2) a “treat-all” strategy in which all intermediate-risk persons received statins (men and women) and aspirin (men only) and 3) a "test and treat strategy" in which all persons with an intermediate-risk of CHD underwent stress testing and those with a positive test were treated with high-intensity statins (men and women) and aspirin (men only). Healthcare costs, CHD events, and quality-adjusted life years from 2011 to 2040 were projected. Under a variety of assumptions, the “treat-all” strategy was the most effective and least expensive strategy. Stress electrocardiography was more effective and less expensive than other "test and treat" strategies, but it was less expensive than “treat all” only if statin cost exceeded $3.16/pill or if testing increased adherence from below 22% to above 75%. However, stress electrocardiography could be cost-effective in persons initially non-adherent to the “treat all” strategy if it raised their adherence to 5% and cost-saving if it raised their adherence to 13%.
Conclusions—When generic high-potency statins are available, non-invasive cardiac stress testing to target preventive medications is not cost-effective unless it substantially improves adherence.
- Received May 2, 2011.
- Accepted November 17, 2011.
- Copyright © 2011, American Heart Association, Inc. All rights reserved. Unauthorized use prohibited