Current issues of ACP Journal Club are published in Annals of Internal Medicine


Economics

Cost-effectiveness of pravastatin in the secondary prevention of CAD in men varied with the risk profile of the patient

ACP J Club. 1997 Mar-Apr;126:52. doi:10.7326/ACPJC-1997-126-2-052


Source Citation

Ashraf T, Hay JW, Pitt B, et al. Cost-effectiveness of pravastatin in secondary prevention of coronary artery disease. Am J Cardiol. 1996 Aug 15;78:409-14.


Abstract

Objective

To determine the cost-effectiveness of pravastatin in the secondary prevention of coronary artery disease (CAD).

Design

Cost-effectiveness analysis from a societal perspective using data from two 3-year randomized, placebo-controlled trials on plaque regression. Morbidity and mortality after nonfatal myocardial infarction (MI) were modeled using data from the Framingham Study. A Markov process was used to estimate life-years saved, and decision analysis was used to estimate direct costs. Costs for relevant medical services were taken from the literature and were adjusted to 1995 U.S. dollars.

Setting

United States.

Patients

445 men (mean age 60 y) with CAD and moderately elevated serum low-density lipoprotein (LDL) cholesterol levels (mean LDL cholesterol level 160 mg/dL).

Intervention

Patients treated with pravastatin were compared with patients allocated to placebo.

Main cost and outcome measures

Increase in life expectancy and cost per life-year saved.

Main results

Analysis of the mean discounted gain in life expectancy showed that pravastatin therapy increased life expectancy from 0.11 y/patient in 60-year-old men with CAD and 1 additional risk factor to 0.21 y/patient in men with CAD and ≥ 3 additional risk factors. The overall annual estimated cost of once-daily pravastatin at 36.6 mg (weighted mean dose) was $1055. Incremental costs associated with initiation of therapy and annual follow-up were estimated to be $299 for year 1 and $163 per year thereafter. Incremental dispensing costs were $18 annually. The cost of pravastatin per life-year saved decreased as the number of risk factors increased, from $12 665 per life-year saved for men with CAD and 1 additional risk factor to $7124 per life-year saved for men with CAD and ≥ 3 additional risk factors. The cost-effectiveness ratios varied by 16% when the hospital costs of MI were increased or decreased by 25%, and the cost per life-year saved decreased by 24% when the benefits of pravastatin therapy were projected for 7 additional years.

Conclusion

Depending on coronary risk profiles, the estimated cost per life-year saved with pravastatin for the secondary prevention of coronary artery disease in men varied from $7124 to $12 665.

Source of funding: Bristol-Myers Squibb.

For article reprint: Dr. T. Ashraf, 115 North Third Street, Suite 500, Wilmington, NC 28401, USA. FAX 402-280-4566.


Commentary

This cost-effectiveness analysis by Ashraf and colleagues is based on data from 2 clinical trials that reported a significant decrease in the rate of nonfatal MI among men who had already had an MI and were treated with pravastatin. Because these trials did not provide long-term follow-up data, morbidity and mortality after nonfatal MI were modeled using data from other sources. This study shows that pravastatin has attractive cost-effectiveness ratios for the secondary prevention of CAD in men with hypercholesterolemia. These results are similar to those of a previous cost-effectiveness analysis of lovastatin therapy (1).

It is not surprising that pravastatin therapy is more cost-effective for men who have more coronary risk factors. This finding simply underscores the sound clinical recommendation of the National Cholesterol Education Program expert panel (2) that aggressive cholesterol-lowering therapy is indicated in patients with hypercholesterolemia and CAD, especially in those who have additional coronary risk factors.

Although the usefulness of HMG-CoA reductase inhibitors for the secondary prevention of CAD is well established, the most cost-effective choice among the currently available drugs in this class is less certain. Of interest is that a Canadian cost-effectiveness analysis compared lovastatin, pravastatin, simvastatin, and fluvastatin for the primary prevention of CAD in men (3). Fluvastatin was found to be the most cost-effective initial therapy. The use of lovastatin, pravastatin, and simvastatin, when compared with fluvastatin, added extra life-years but at prohibitive costs. Further studies are needed to determine the incremental cost-effectiveness of various cholesterol-lowering drugs for the secondary prevention of CAD.

Angela M. Cheung, MD
The Toronto HospitalToronto, Ontario, Canada

Angela M. Cheung, MD
The Toronto Hospital
Toronto, Ontario, Canada


References

1. Goldman L, Weinstein MC, Goldman PA, Williams LW. Cost effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of coronary heart disease. JAMA. 1991;265:1145-51.

2. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Summary of the second report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel II). JAMA. 1993;269:3015-23.

3. Martens LL, Guibert R. Cost-effectiveness analysis of lipid-modifying therapy in Canada: comparison of HMG-CoA reductase inhibitors in the primary prevention of coronary heart disease. Clin Ther. 1994; 16:1052-62.