Jarmul Jamie, Pletcher Mark J, Hassmiller Lich Kristen, Wheeler Stephanie B, Weinberger Morris, Avery Christy L, Jonas Daniel E, Earnshaw Stephanie, Pignone Michael
Department of Health Policy and Management, Gillings School of Public Health (J.J., K.H.L., S.B.W., M.W.), UNC School of Medicine (J.J., D.E.J.), Department of Epidemiology, Gillings School of Public Health (C.L.A.), Carolina Population Center (C.L.A.), and Cecil G. Sheps Center for Health Services Research (D.E.J.), University of North Carolina-Chapel Hill. Department of Internal Medicine, Dell Medical School, University of Texas-Austin (M.P.). Department of Epidemiology and Biostatistics (M.J.P.) and Department of Medicine (M.J.P.), University of California, San Francisco.
Circ Cardiovasc Qual Outcomes. 2018 Apr;11(4):e004171. doi: 10.1161/CIRCOUTCOMES.117.004171.
It is unclear whether testing for novel risk factors, such as a cardiovascular genetic risk score (cGRS), improves clinical decision making or health outcomes when used for targeting statin initiation in the primary prevention of atherosclerotic cardiovascular disease (ASCVD). Our objective was to estimate the cost-effectiveness of cGRS testing to inform clinical decision making about statin initiation in individuals with low-to-intermediate (2.5%-7.5%) 10-year predicted risk of ASCVD.
We evaluated the cost-effectiveness of testing for a 27-single-nucleotide polymorphism cGRS comparing 4 test/treat strategies: treat all, treat none, test/treat if cGRS is high, and test/treat if cGRS is intermediate or high. We tested a set of clinical scenarios of men and women, aged 45 to 65 years, with 10-year ASCVD risks between 2.5% and 7.5%. Our primary outcome measure was cost per quality-adjusted life-year gained. Under base case assumptions for statin disutility and cost, the preferred strategy is to treat all patients with ASCVD risk >2.5% without cGRS testing. For certain clinical scenarios, such as a 57-year-old man with a 10-year ASCVD risk of 7.5%, cGRS testing can be cost-effective under a limited set of assumptions; for example, when statins cost $15 per month and statin disutility is 0.013 (ie, willing to trade 3 months of life in perfect health to avoid 20 years of statin therapy), the preferred strategy (using a willingness-to-pay threshold of $50 000 per quality-adjusted life-year gained) is to test and treat if cGRS is intermediate or high. Overall, the results were not sensitive to assumptions about statin efficacy and harms.
Testing for a 27-single-nucleotide polymorphism cGRS is generally not a cost-effective approach for targeting statin therapy in the primary prevention of ASCVD for low- to intermediate-risk patients.
在动脉粥样硬化性心血管疾病（ASCVD）一级预防中，将心血管遗传风险评分（cGRS）等新型风险因素检测用于指导他汀类药物起始治疗时，是否能改善临床决策或健康结局尚不清楚。我们的目标是评估cGRS检测在为10年ASCVD预测风险为低至中度（2.5%-7.5%）的个体提供他汀类药物起始治疗的临床决策依据方面的成本效益。
我们评估了检测27个单核苷酸多态性cGRS的成本效益，比较了4种检测/治疗策略：全部治疗、全部不治疗、cGRS高时检测/治疗、cGRS中等或高时检测/治疗。我们测试了一组年龄在45至65岁、10年ASCVD风险在2.5%至7.5%之间的男性和女性的临床场景。我们的主要结局指标是每获得一个质量调整生命年的成本。在他汀类药物负效用和成本的基础案例假设下，首选策略是不进行cGRS检测，对所有ASCVD风险>2.5%的患者进行治疗。对于某些临床场景，如一名10年ASCVD风险为7.5%的57岁男性，在一组有限的假设下，cGRS检测可能具有成本效益；例如，当他汀类药物每月花费15美元且他汀类药物负效用为0.013（即愿意用3个月的完全健康生命来避免20年的他汀类药物治疗）时，首选策略（使用每获得一个质量调整生命年50000美元的支付意愿阈值）是cGRS中等或高时检测并治疗。总体而言，结果对他汀类药物疗效和危害的假设不敏感。
对于低至中度风险患者在ASCVD一级预防中靶向他汀类药物治疗，检测27个单核苷酸多态性cGRS通常不是一种具有成本效益的方法。
