Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.
Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
J Formos Med Assoc. 2020 May;119(5):907-916. doi: 10.1016/j.jfma.2020.01.010. Epub 2020 Feb 18.
The recommended target low-density lipoprotein cholesterol (LDL-C) level for coronary artery disease (CAD) patients has been lowered from 100 to 70 mg/dL in several clinical guidelines for secondary prevention. We aimed to assess whether initiating statin treatment in CAD patients with baseline LDL-C 70-100 mg/dL in Taiwan could be cost-effective.
A Markov model was developed to simulate a hypothetical cohort of CAD patients with a baseline LDL-C level of 90 mg/dL. The incidence and recurrence of MI and stroke related to specific LDL-C levels as well as the statin effect, mortality rate, and health state utilities were obtained from the literature. The direct medical costs and rate of fatal events were derived from the national claims database. The incremental cost-effectiveness ratio (ICER) per quality-adjusted life years (QALYs) was calculated, and sensitivity analyses were performed.
Moderate-intensity statin use, a treatment regimen expected to achieve LDL <70 mg/dL in the base case, resulted in a net gain of 562 QALYs but with an additional expenditure of $11.4 million per 10,000 patients over ten years. The ICER was $20,288 per QALY gained. The probabilities of being cost-effective at willingness-to-pay thresholds of one and three gross domestic product per capita ($24,329 in 2017) per QALY were 51.1% and 94.2%, respectively. Annual drug cost was the most influential factor on the ICER.
Lowering the target LDL-C level from 100 to 70 mg/dL among treatment-naïve CAD patients could be cost-effective given the health benefits of preventing cardiovascular events and deaths.
几项二级预防临床指南建议将冠心病（CAD）患者的目标低密度脂蛋白胆固醇（LDL-C）水平从 100 降至 70mg/dL。我们旨在评估在台湾基线 LDL-C 为 70-100mg/dL 的 CAD 患者中开始他汀类药物治疗是否具有成本效益。
开发了一个马尔可夫模型来模拟基线 LDL-C 水平为 90mg/dL 的 CAD 患者的假设队列。MI 和与特定 LDL-C 水平相关的中风的发生率和复发率以及他汀类药物的作用、死亡率和健康状态效用均来自文献。直接医疗成本和致命事件的发生率来自国家索赔数据库。计算了每质量调整生命年（QALY）的增量成本效益比（ICER），并进行了敏感性分析。
中等强度他汀类药物的使用，一种预计在基线时 LDL <70mg/dL 的治疗方案，导致净增益 562QALYs，但在十年内每 10,000 名患者额外支出 1140 万美元。ICER 为每获得一个 QALY 增加 20,288 美元。在愿意支付的阈值为一个和三个人均国内生产总值（2017 年为 24,329 美元）的情况下，具有成本效益的概率分别为 51.1%和 94.2%。每年的药物成本是对 ICER 影响最大的因素。
对于未接受治疗的 CAD 患者，将目标 LDL-C 水平从 100 降至 70mg/dL，考虑到预防心血管事件和死亡的健康获益，可能具有成本效益。
