Morton Jedidiah I, Liew Danny, Watts Gerald F, Zoungas Sophia, Nicholls Stephen J, Reid Christopher M, Ademi Zanfina
Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.
Diabetes and Population Health, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.
Pharmacoeconomics. 2025 Mar;43(3):331-349. doi: 10.1007/s40273-024-01454-z. Epub 2024 Dec 2.
Current Australian cardiovascular disease (CVD) prevention guidelines calculate 5-year CVD risk and recommend treatment when risk crosses specific thresholds. This may leave risk factors untreated for people with a low short-term (i.e. 5 years), but high long-term (i.e. lifetime), risk of CVD. We aimed to evaluate the cost effectiveness of intervention for risk factor control at age 40 years (regardless of calculated risk) compared to intervention for risk factor control at the age recommended by contemporary Australian CVD prevention guidelines (when the 5-year CVD risk reaches 10%) across a range of individual risk factor profiles.
We used a causal microsimulation model populated with 108 different risk factor profiles, each replicated 10,000 times. Model data were derived from the UK Biobank study and published sources. The primary causal relationships factored in were those of low-density lipoprotein-cholesterol and systolic blood pressure with CVD (defined as myocardial infarction or stroke). The model simulated the ageing of individuals from 40 to 85 years. We calculated years of life lived, quality-adjusted life-years gained, incremental healthcare costs and the incremental cost-effectiveness ratio when low-density lipoprotein-cholesterol and blood pressure were controlled from age 40 years compared to initiation of treatment as recommended by Australian guidelines. The main side effect in the model was an increased risk of type 2 diabetes mellitus from statin use. The trade-off between reduced CVD and increased type 2 diabetes was summarised via quality-adjust life-years. Incremental cost-effectiveness ratios were compared to the Australian willingness-to-pay threshold of AU$28,000 per quality-adjust life-year gained. We adopted a healthcare perspective (2022 AUD) and discounted results at 3% annually.
An earlier intervention meaningfully prevented CVD in all but the lowest risk individuals. Intervention at age 40 years versus age when the 5-year CVD risk reaches 10% led to an increase in quality-adjust life-years for 37/54 female individuals and 44/54 male individuals simulated and an increase in years of life lived (i.e. life expectancy) for 46/54 female individuals and 47/54 male individuals simulated. Earlier intervention was also cost effective in 5/54 female individuals and 17/54 male individuals.
Current guidelines may result in certain individuals with a lower 5-year, but higher lifetime, risk of CVD being overlooked for earlier cost-effective interventions to prevent CVD.
澳大利亚现行的心血管疾病（CVD）预防指南计算5年心血管疾病风险，并在风险超过特定阈值时推荐进行治疗。对于短期（即5年）风险较低但长期（即终生）心血管疾病风险较高的人群，这可能会使风险因素得不到治疗。我们旨在评估与按照当代澳大利亚心血管疾病预防指南推荐的年龄（5年心血管疾病风险达到10%时）进行风险因素控制干预相比，40岁时（无论计算出的风险如何）进行风险因素控制干预的成本效益，涵盖一系列个体风险因素概况。
我们使用了一个因果微观模拟模型，该模型包含108种不同的风险因素概况，每种概况重复模拟10000次。模型数据源自英国生物银行研究及已发表的资料。纳入的主要因果关系是低密度脂蛋白胆固醇和收缩压与心血管疾病（定义为心肌梗死或中风）之间的关系。该模型模拟了个体从40岁到85岁的衰老过程。我们计算了从40岁开始控制低密度脂蛋白胆固醇和血压与按照澳大利亚指南推荐开始治疗相比，获得的生命年数、质量调整生命年数、增量医疗保健成本以及增量成本效益比。模型中的主要副作用是使用他汀类药物导致2型糖尿病风险增加。通过质量调整生命年数总结了降低心血管疾病与增加2型糖尿病之间的权衡。将增量成本效益比与澳大利亚每获得一个质量调整生命年28000澳元的支付意愿阈值进行比较。我们采用医疗保健视角（2022澳元）并按每年3%对结果进行贴现。
除风险最低的个体外，早期干预能有效预防心血管疾病。40岁时进行干预与5年心血管疾病风险达到10%时进行干预相比，在模拟的37/54名女性个体和44/54名男性个体中，质量调整生命年数增加，在模拟的46/54名女性个体和47/54名男性个体中，生命年数（即预期寿命）增加。早期干预在5/54名女性个体和17/54名男性个体中也是具有成本效益的。
现行指南可能会导致某些5年心血管疾病风险较低但终生风险较高的个体被忽视，无法获得早期具有成本效益的心血管疾病预防干预措施。
