Would treatment decisions about secondary prevention of CVD based on estimated lifetime benefit rather than 10-year risk reduction be cost-effective?

• Published in: Diagnostic and prognostic research 2020-04, Vol.4 (1), p.4-4, Article 4
• Main Authors: Berkelmans, Gijs F N, Greving, Jacoba P, van der Graaf, Yolanda, Visseren, Frank L J, Dorresteijn, Jannick A N
• Format: Article
• Language: English
• Subjects: Age; Blood pressure; Cardiac arrhythmia; Cardiovascular disease; Cardiovascular diseases; Cost-effectiveness; Costs; Decision making; Diabetes; Disease prevention; Fatalities; Heart attacks; Heart failure; Life expectancy; Lifetime benefit; Lifetime expectancy estimation; Mortality; Patients; PCSK9-mAb; Population; Prevention; Probability; Probability distribution; Risk factors; Stroke; Variables
• ISSN: 2397-7523; 2397-7523
• DOI: 10.1186/s41512-020-00072-5

To test the hypothesis that treatment decisions (treatment with a PCSK9-mAb versus no treatment) are both more effective and more cost-effective when based on estimated lifetime benefit than when based on estimated risk reduction over 10 years. A microsimulation model was constructed for 10,000 patients with stable cardiovascular disease (CVD). Costs and quality-adjusted life years (QALYs) due to recurrent cardiovascular events and (non)vascular death were estimated for lifetime benefit-based compared to 10-year risk-based treatment, with PCSK9 inhibition as an illustration example. Lifetime benefit in months gained and 10-year absolute risk reduction were estimated using the SMART-REACH model, including an individualized treatment effect of PCSK9 inhibitors based on baseline low-density lipoprotein cholesterol. For the different numbers of patients treated (i.e. the 5%, 10%, and 20% of patients with the highest estimated benefit of both strategies), cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER), indicating additional costs per QALY gain. Lifetime benefit-based treatment of 5%, 10%, and 20% of patients with the highest estimated benefit resulted in an ICER of €36,440/QALY, €39,650/QALY, or €41,426/QALY. Ten-year risk-based treatment decisions of 5%, 10%, and 20% of patients with the highest estimated risk reduction resulted in an ICER of €48,187/QALY, €53,368/QALY, or €52,390/QALY. Treatment decisions (treatment with a PCSK9-mAb versus no treatment) are both more effective and more cost-effective when based on estimated lifetime benefit than when based on estimated risk reduction over 10 years.