Lim S S, Vos T, Peeters A, Liew D, McNeil J J
Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC.
Med J Aust. 2001 Nov 5;175(9):459-64. doi: 10.5694/j.1326-5377.2001.tb143676.x.
(i) To analyse how well Pharmaceutical Benefits Scheme (PBS) criteria for prescribing lipid-lowering therapy identify people most at risk of coronary heart disease (CHD); and (ii) to determine the cost-effectiveness of primary prevention therapy with pravastatin according to these criteria in Australia.
(i) Analysis of targeting of CHD risk according to PBS criteria; (ii) cost-effectiveness analysis for pravastatin as primary preventive therapy (40 mg/day), with a 20-year projection from 1999.
(i) Men and women aged 25-69 years from the 1989 National Heart Foundation Risk Factor Prevalence Survey; (ii) Australian men and women, aged 25-85 years, excluding those with diabetes and existing CHD.
(i) Proportion eligible for lipid lowering treatment according to PBS criteria within 15-year risk of CHD mortality groups; (ii) average net cost in Australian dollars ($) per year of life saved (YOLS), with 80% uncertainty ranges (UR).
(i) PBS criteria do not adequately identify those most at risk of CHD, as only 61% of Australians (aged 25-69 years) with a greater than 10% 15-year risk of CHD mortality were eligible for treatment; and 11% of those at low risk of CHD mortality (< 2.5% over 15 years) were eligible for treatment. (ii) Cost-effectiveness of treatment according to PBS criteria was estimated at $110,000 (80% UR, $96,000-$150,000) per YOLS for men and $87,000 (80% UR, $80,000-$130,000) per YOLS for women. As an indicator of the likely recurrent annual costs, total first-year treatment costs (excluding the costs of non-compliers) were estimated at $940 million. Assuming compliance of 50%, cost-effectiveness of treatment was markedly improved using 32.5% 15-year risk of CHD mortality as a cut-off, with ratios of $31,000 (80% UR, $27,000-$40,000) per YOLS for men and $39,000 (80% UR, $33,000-$53,000) per YOLS for women. First-year treatment costs of $940 million were the same as treating according to PBS criteria, but absolute health impact in terms of deaths averted and years of life saved was more than doubled.
While PBS criteria do target patients at risk of CHD, there is room for improvement in identifying those most at risk of CHD, and treatment according to PBS criteria is not likely to be the most cost-effective. For optimal cost-effectiveness, targeting of therapy for primary CHD prevention needs to be based on population-specific, multivariable risk.
（i）分析药品福利计划（PBS）的降脂治疗处方标准在识别冠心病（CHD）高危人群方面的效果；（ii）根据这些标准确定澳大利亚使用普伐他汀进行一级预防治疗的成本效益。
（i）根据PBS标准对CHD风险的靶向性分析；（ii）对普伐他汀作为一级预防治疗（40毫克/天）的成本效益分析，预测期为从1999年起的20年。
（i）来自1989年国家心脏基金会风险因素患病率调查的25 - 69岁男性和女性；（ii）年龄在25 - 85岁的澳大利亚男性和女性，不包括患有糖尿病和现有CHD的人群。
（i）在CHD死亡风险15年分组中，根据PBS标准符合降脂治疗条件的比例；（ii）每年挽救的每生命年（YOLS）的平均净成本（澳元），不确定性范围（UR）为80%。
（i）PBS标准未能充分识别CHD高危人群，因为在CHD死亡风险超过10%的15年风险的澳大利亚人（25 - 69岁）中，只有61%符合治疗条件；而在CHD死亡低风险人群（15年内<2.5%）中，有11%符合治疗条件。（ii）根据PBS标准进行治疗的成本效益估计为男性每YOLS 110,000澳元（80% UR，96,000 - 150,000澳元），女性每YOLS 87,000澳元（80% UR，80,000 - 130,000澳元）。作为可能的年度重复成本指标，第一年的总治疗成本（不包括未依从者的成本）估计为9.4亿澳元。假设依从率为50%，以CHD死亡风险15年为32.5%作为临界值，治疗的成本效益显著提高，男性每YOLS为31,000澳元（80% UR，27,000 - 40,000澳元），女性每YOLS为39,000澳元（80% UR，33,000 - 53,000澳元）。9.4亿澳元的第一年治疗成本与根据PBS标准进行治疗的成本相同，但在避免死亡和挽救生命年方面的绝对健康影响增加了一倍多。
虽然PBS标准确实针对CHD高危患者，但在识别CHD最高危人群方面仍有改进空间，并且根据PBS标准进行治疗不太可能是最具成本效益的。为了实现最佳成本效益。冠心病一级预防治疗的靶向性需要基于特定人群的多变量风险。
