Treating asymptomatic hypercholesterolemia
ACP J Club. 1991 Jan-Feb;114:31. doi:10.7326/ACPJC-1991-114-1-031
Toronto Working Group. Efficiency considerations: the cost-effectiveness of treating asymptomatic hypercholesterolemia. J Clin Epidemiol. 1990;43:1093-101.
To evaluate the cost-effectiveness of treating asymptomatic hypercholesterolemia in middle-aged men.
Studies published up to October 1989 were identified through a MEDLINE search using the following keywords: cholesterol and economics. References from published articles were traced, and various workers in the field were consulted.
Of 8 articles identified, 4 met the following selection criteria: sufficient detail was provided to allow an appraisal of study methodology, results were reported for middle-aged men, discounting was applied and results were expressed as costs per life-year saved, and clear evidence was presented for the efficacy of the cholesterol reduction program evaluated.
Studies were reviewed in terms of the groups studied (age/cholesterol levels), the treatment applied, and the basis of determining effectiveness and cost.
Cost-effectiveness ratios were expressed in thousands of 1989 American dollars. A program treating men in their late 40s who had serum cholesterol levels in the top 10% of the American distribution and an average risk profile for coronary heart disease would cost between $100 000 and $200 000 per life-year gained. A sensitivity analysis showed that the cost-effectiveness of programs directed against hypercholesterolemia was most sensitive to the cost of the intervention (for example, drugs), the target group, and the discount rate. It was relatively insensitive to treatment costs for coronary heart disease and other illnesses and to indirect costs and benefits.
A comparison with other interventions to reduce mortality from coronary heart disease showed that treating hypercholesterolemia is relatively inefficient. The costeffectiveness of reducing cholesterol with drugs in middle-aged men is low if applied generally; it approaches the cost-effectiveness of other interventions if only persons with high serum cholesterol levels are treated, and only persons with other, clinically apparent risk factors for coronary heart disease are screened.
Source of funding: Ontario Task Force on the Use and Provision of Medical Services.
Address for article reprint: Not stated.
This article is part of a larger review of clinical policy for the treatment of asymptomatic hypercholesterolemia that appears in the same issue of the Journal of Clinical Epidemiology. There is considerable imprecision in our knowledge of both the efficacy and costs of programs to detect and treat asymptomatic hypercholesterolemia, and estimates of the relation between effects and costs are bound to be uncertain. The methods used to identify and synthesize the studies reviewed by the Toronto Working Group were sound, although more information would have been helpful on the inclusion criteria for studies of alternative interventions with which the treatment programs were compared. Nevertheless, the analysis provided strong evidence that general screening and treatment programs are relatively inefficient ways to reduce mortality associated with coronary heart disease. The cost of $100 000 to $200 000 per life-year gained is also considerably higher than for the treatment of many other conditions (1). These contributions question the wisdom of implementing widespread programs for treating asymptomatic hypercholesterolemia. If implemented, they should be targeted only at high-risk groups.
Jeremiah Hurley, PhD
McMaster University Hamilton, Ontario, Canada