Sorensen Sonja V, Frick Kevin D, Wade Alexander, Simko Robert, Burge Russel
United BioSource Corporation, Bethesda, Maryland 20814, USA.
Clin Ther. 2009 Apr;31(4):862-79. doi: 10.1016/j.clinthera.2009.04.015.
The National Cholesterol Education Program Adult Treatment Panel III guidelines recommend maintaining lipid levels within particular targets to reduce the risk of coronary heart disease (CHD) events.
The objective of this simulation study was to evaluate the cost-effectiveness of following guideline-recommended care compared with current practice or usual care for patients with diabetes mellitus (DM) and mixed dyslipidemia (ie, high low-density lipoprotein cholesterol [LDL-C] and triglyceride [TG] levels).
A simulation model using a US health care payer perspective was designed to predict changes in lipid levels (LDL-C, TG, high-density lipoprotein cholesterol, and total cholesterol) and long-term CHD risk. Data about patients with DM and uncontrolled TG and/or LDL-C were taken from an electronic medical records database to develop the description of current care (eg, statin, fibrate, or no medication) and cholesterol levels. Patients with uncontrolled lipid levels who were not following guideline recommendations were assumed to be receiving combination treatment (ie, coadministration of statin and fibrate) or monotherapy for the uncontrolled lipids under guideline care. Results from a previous study were used to project incremental benefits of combination treatment compared with monotherapy. CHD events were predicted based on risk equations. A 20-year model of direct costs and quality-adjusted life-years (QALYs) was created.
Among patients switched to guideline therapy, the model predicted 72% achieved 2 lipid targets and 44% achieved 3 lipid targets in 1 year. Over 20 years, in a modeled sample of 1000 patients, 176 myocardial infarction and angina events would be avoided by following guideline care. Total present value of costs for drug treatment and medical care for CHD events would be $33,626 per patient for guideline treatment versus $25,264 per patient for current care. The discounted QALY gain would be 0.18 per patient for an incremental cost per QALY of $50,315.
The results of this model simulation suggest that for patients with DM and mixed dyslipidemia, following treatment guidelines rather than current practice (including combination therapy rather than monotherapy) would result in more patients achieving lipid targets, fewer CHD events, and more QALYs gained at a reasonable cost (less than $109,000) per QALY.
美国国家胆固醇教育计划成人治疗小组第三次指南建议将血脂水平维持在特定目标范围内，以降低冠心病（CHD）事件的风险。
本模拟研究的目的是评估遵循指南推荐的治疗方案与糖尿病（DM）合并混合性血脂异常患者（即低密度脂蛋白胆固醇[LDL-C]和甘油三酯[TG]水平高）的当前治疗或常规治疗相比的成本效益。
设计了一个从美国医疗保健支付者角度出发的模拟模型，以预测血脂水平（LDL-C、TG、高密度脂蛋白胆固醇和总胆固醇）的变化以及长期CHD风险。从电子病历数据库中获取有关DM患者以及未控制的TG和/或LDL-C的数据，以描述当前治疗（例如他汀类药物、贝特类药物或不使用药物）和胆固醇水平。假设未遵循指南建议的血脂水平未得到控制的患者在指南治疗下接受联合治疗（即他汀类药物和贝特类药物联合使用）或针对未控制的血脂进行单一疗法。先前一项研究的结果用于预测联合治疗与单一疗法相比的增量益处。基于风险方程预测CHD事件。创建了一个20年的直接成本和质量调整生命年（QALY）模型。
在转而接受指南治疗的患者中，该模型预测1年内72%的患者实现了2个血脂目标，44%的患者实现了3个血脂目标。在20年期间，在1000名患者的模拟样本中，遵循指南治疗可避免176例心肌梗死和心绞痛事件。指南治疗的CHD事件药物治疗和医疗护理的总成本现值为每位患者33,626美元，而当前治疗为每位患者25,264美元。贴现后的QALY增益为每位患者0.18，每QALY的增量成本为50,315美元。
该模型模拟结果表明，对于DM合并混合性血脂异常患者，遵循治疗指南而非当前治疗方案（包括联合治疗而非单一疗法）将使更多患者实现血脂目标，减少CHD事件，并以合理成本（每QALY低于109,000美元）获得更多QALY。
