59(SECONDARY PREVENTION Q’s) When should higher intensity statin therapy be considered to improve outcome in people with established CVD?

No 952Study Quality:Cost-effectiveness of high-dose atorvastatin compared with regular dose simvastatin
Author:Lindgren P; Graff J; Olsson AG; Pedersen TJ; Jonsson B;2007
Relevance:secondary prevention for people with stable CAD
Intervention:Atorvastatin 80mg
Comparison:Simvastatin 20–40mg
Population:people with stable CAD enrolled in the IDEAL study
Perspective:THIRD PAYER
Study type:CUA
Methods:RCT, IDEAL study
Health valuations:TTO
Cost components:Direct medical costs relevant to the health payer
Currency:EURO
Cost year:2005
Time horizon:Lifetime
Discount rate:5%
Results cost:Results are presented by country in Euros
Denmark
Atorvastatin7347
Simvastatin5807
Finland
Atorvastatin6333
Simvastatin4289
Norway
Atorvastatin7296
Simvastatin6147
Sweden
Atorvastatin6318
Simvastatin4893
Results effectiveness:Results are presented by country LYG & QALYs gained
Denmark
LY gained0.049
QALY gained0.033
Finland
LY gained0.049
QALY gained0.033
Norway
LY gained0.049
QALY gained0.033
Sweden
LY gained0.049
QALY gained0.033
Results incremental:Results are presented by country Cost/LYG & Cost/QALYs gained
Denmark
LY gained31179
QALY gained41197 ~ £33,000/QALY
Finland
LY gained41381
QALY gained62639 ~ £44,000/QALY
Norway
LY gained23261
QALY gained35210 ~ £25,000/QALY
Sweden
LY gained28847
QALY gained43667 ~ £31,000/QALY
Results Uncertainty:A probabilistic sensitivity analysis was done.
Source Funding:Private
Comments:Atorvastatin was moderately cost-effective using a threshold of Euro 50,000. If this directly translated to what is considered affordable by the NHS, ICERs have to be below Euro 30,000/QALY. This would imply that atorvastatin 80mg is not cost-effective for people with stable CAD at £20,000 threshold
No 951Study Quality: 1+Incremental Benefit and Cost-Effectiveness of High-Dose Statin Therapy in High-Risk Patients With Coronary Artery Disease
Author:Chan PS; Nallamothu BK; Gurm HS; Hayward RA; Vijan S;2007
Relevance:secondary prevention
Intervention:High dose statins
Comparison:Low dose statins
Population:ACS patients and those with stable coronary artery disease
Perspective:SOCIETAL
Study type:CUA
Methods:RCT, For ACSA-Z & PROVE-IT, For stable CAD, IDEAL & TNT
Health valuations:NOT STATED, taken from literature
Cost components:Direct medical costs including drug costs
Currency:US$
Cost year:2005
Time horizon:Lifetime
Discount rate:3%
Results cost:ACS populationCostscost difference
High dose$70581
Conventional$66033$4548 (assuming a cost difference of $1.40)
CAD populationcostcost difference
High dose$67134
Conventional$63920$ 3214
Results effectiveness:Results are shown as discounted life years and QALYs for the different populations
ACS populationLYGQALYSQALY difference
High dose14.32613.589
Conventional14.01713.2370.352
CAD populationLYGQALYSQALY difference
High dose14.46913.770
Results incremental:Using optimistic assumptions on cost difference of $1.40 between high and low dose
ACS population
Duration of treatment effect
For Life$12,900/QALY
5 years then 50%$26,000/QALY
5 years only$49,000/QALY
CAD population
Duration of treatment effect
For Life$33,400/QALY
5 years then 50%$68,200/QALY
5 years only$158,600/QALY
Results Uncertainty:The model is sensitive to statin efficacy and costs which is in agreement with our own model we did for the guideline. Duration of treatment effect also affects the model results for those with CAD. Multivariate analysis showed that 95% of the times the ICERs for ACS will be below $31,000/QALY FOR A $50,000 threshold while in those with stable CAD it will be 76%
Source Funding:Private
Comments:They use a cost difference between high dose and low dose of at most £2 i.e. $3.50. In the UK the cost difference is in the region of about £28 which is approximately $50.00. Given that the analysis is sensitive to the price of drugs, the ICERs will be expected to be worse than the ones reported. However the conclusions do not differ much from our own model conclusions that high dose statins are cost-effective in patients post ACS and not so clear in those with stable CAD. Model results are largely driven by statin effect on mortality.

From: Appendix E, Health Economic Extractions

Cover of Lipid Modification
Lipid Modification: Cardiovascular Risk Assessment and the Modification of Blood Lipids for the Primary and Secondary Prevention of Cardiovascular Disease [Internet].
NICE Clinical Guidelines, No. 67.
National Collaborating Centre for Primary Care (UK).
Copyright © 2008, Royal College of General Practitioners.

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