Schectman G, Wolff N, Byrd J C, Hiatt J G, Hartz A
Department of Medicine, Milwaukee Veterans Affairs Medical Center, Medical College of Wisconsin, USA.
J Gen Intern Med. 1996 May;11(5):277-86. doi: 10.1007/BF02598268.
Treatment of elevated cholesterol levels reduces morbidity and mortality from coronary heart disease in high-risk patients, but can be costly. The purpose of this study was to determine whether physician extenders emphasizing diet modification and, when necessary, effective and inexpensive drug algorithms can provide more cost-effective therapy than conventional care.
Randomized controlled trial.
A Department of Veterans Affairs Medical Center.
Two hundred forty-seven veterans with type IIa hypercholesterolemia.
Patients assigned to either a cholesterol treatment program (CTP) or usual health care provided by general internists (UHC). CTP included intensive dietary therapy administered by a registered dietitian utilizing individual and group counseling and drug therapy initiated by physician extenders for those failing to achieve goal low-density lipoprotein (LDL) levels with diet alone. A drug selection algorithm for CTP subjects utilized niacin as initial therapy followed by bile acid sequestrants and lovastatin. Subjects were followed prospectively for 2 years.
Primary outcome measurements were effectiveness of therapy defined as reductions in LDL cholesterol (LDL-C), and whether goal LDL-C levels were achieved; costs of therapy; and cost-effectiveness defined as the cost per unit reduction in the LDL-C.
Total program costs were higher for CTP patients than for UHC patients ($659 +/- $43 vs $477 +/- $42 per patient, p < .001). However, at 24 months the patients in CTP were more likely to achieve LDL goal levels (65% vs 44%, p < .005), and also achieved greater reductions in LDL-C 27% +/- 2% vs 14% +/- 2% at 24 months, p < .001). Program costs per unit (mmol/L) reduction in the LDL-C, a measure of cost-effectiveness, was significantly lower for CTP ($758 +/- $58 vs $1,058 +/- $70, p = .002).
Although more expensive than usual care, the greater effectiveness of physician extenders implementing cholesterol treatment algorithms resulted in more cost-effective therapy.
降低胆固醇水平可降低高危患者冠心病的发病率和死亡率，但成本可能较高。本研究的目的是确定强调饮食调整的医生助理，以及在必要时采用有效且廉价的药物治疗方案，是否能比传统护理提供更具成本效益的治疗。
随机对照试验。
一家退伍军人事务部医疗中心。
247名患有IIa型高胆固醇血症的退伍军人。
患者被分配到胆固醇治疗项目（CTP）或由普通内科医生提供的常规医疗保健（UHC）。CTP包括由注册营养师进行的强化饮食治疗，采用个体和团体咨询，以及对于仅通过饮食未能达到目标低密度脂蛋白（LDL）水平的患者，由医生助理启动药物治疗。CTP受试者的药物选择方案是以烟酸作为初始治疗，随后使用胆汁酸螯合剂和洛伐他汀。对受试者进行了为期2年的前瞻性随访。
主要结局测量指标包括治疗效果，定义为低密度脂蛋白胆固醇（LDL-C）的降低，以及是否达到目标LDL-C水平；治疗成本；以及成本效益，定义为每降低单位LDL-C的成本。
CTP患者的总项目成本高于UHC患者（每位患者659±43美元对477±42美元，p<.001）。然而，在24个月时，CTP组的患者更有可能达到LDL目标水平（65%对44%，p<.005），并且在24个月时LDL-C的降低幅度也更大（27%±2%对14%±2%，p<.001）。作为成本效益衡量指标的每降低单位（mmol/L）LDL-C的项目成本，CTP组显著更低（758±58美元对1058±70美元，p=.002）。
尽管比常规护理更昂贵，但实施胆固醇治疗方案的医生助理具有更高的有效性，从而产生了更具成本效益的治疗。
