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2.
Mayo Clin Proc ; 94(9): 1670-1680, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31405751

RESUMO

OBJECTIVE: To retrospectively investigate the real-world impact of elevated triglyceride (TG) levels on cardiovascular (CV) outcomes, medical resource utilization, and medical costs using observational administrative claims data from the Optum Research Database. METHODS: Patients with one or more claims for statin therapy between January 1, 2010, and December 31, 2010, and 6 months or more of baseline data prior to the index date were eligible for inclusion in the study. Patients aged 45 years or older with diabetes and/or atherosclerotic CV disease were included and analyzed in an elevated TG cohort (≥150 mg/dL) vs a comparator cohort with TG levels less than 150 mg/dL and high-density lipoprotein cholesterol (HDL-C) levels greater than 40 mg/dL. RESULTS: In the elevated TG vs propensity-matched comparator cohorts (both N=23,181 patients), the mean age was 62.2 vs 62.6 years, mean follow-up was 41.4 vs 42.5 months, 49.7% (11,518) vs 49.5% (11,467) were female, 83.7% (19,392) vs 84.0% (19,478) had diabetes, and 29.8% (6915) vs 29.3% (6800) had atherosclerotic CV disease. In the elevated TG (N=27,471 patients) vs comparator (N=32,506 patients) cohorts, multivariate analysis revealed significantly greater risk of composite major CV events (hazard ratio [HR], 1.26; 95% CI, 1.19-1.34; P<.001), nonfatal myocardial infarction (HR, 1.32; 95% CI, 1.20-1.45; P<.001), nonfatal stroke (HR, 1.14; 95% CI, 1.04-1.24; P=.004), and need for coronary revascularization (HR, 1.46; 95% CI, 1.33-1.61; P<.001) but not unstable angina (P=.53) or CV death (P=.23). Increased CV risk was maintained with the addition of non-HDL-C to the multivariate model and with high and low HDL-C subgroup analysis. Total direct health care costs (cost ratio, 1.12; 95% CI, 1.08-1.16; P<.001) and inpatient hospital stays (HR, 1.13; 95% CI, 1.10-1.17; P<.001) were significantly higher in the elevated TG cohort vs the comparator cohort. CONCLUSION: Statin-treated patients with TG levels of 150 mg/dL or greater had worse CV and health economic outcomes than those with well-managed TG (<150 mg/dL) and HDL-C (>40 mg/dL) levels.


Assuntos
Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus/epidemiologia , Custos de Medicamentos/estatística & dados numéricos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Hipertrigliceridemia/tratamento farmacológico , Hipertrigliceridemia/epidemiologia , Idoso , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/terapia , Estudos de Casos e Controles , Causas de Morte , Comorbidade , Análise Custo-Benefício , Bases de Dados Factuais , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/tratamento farmacológico , Feminino , Custos de Cuidados de Saúde , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipertrigliceridemia/diagnóstico , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Análise de Sobrevida , Resultado do Tratamento , Triglicerídeos/sangue
3.
Rev Esp Salud Publica ; 932019 Aug 05.
Artigo em Espanhol | MEDLINE | ID: mdl-31378781

RESUMO

OBJECTIVE: The high pharmaceutical consumption requires establishing improvement measures with the collaboration of all the agents involved. The objective of the study was to analyze the pharmaceutical expenditure generated by prescriptions made by physicians working in a primary care area and assess its relationship with the quality indicators of the prescription. METHODS: The prescriptions of 200 family physicians of the Basque Health Service Araba Countyand dispensed by the community pharmacies between 2009 and 2016 were studied. The variables evaluated retrospectively corresponded to the quality indicators of the pharmaceutical prescription included in the Contract-Program of the Basque Department Health of 2016. Prediction models were developed using linear regression and binary logistic regression analysis. RESULTS: The main factors which increased the pharmaceutical expenditure per person were: the use of novel drugs which do not offer therapeutic improvements, the proportion of pensioners, the use of statins and the use of antiulcer the proton pump inhibitors (PPI). On the contrary, the factors that reduced this expense were: the seniority in the medical position, the physician job stability and the prescription quality index. The profile of the doctor who generated the greatest expense of pharmaceutical prescription was mainly that of a professional who was responsible for a high percentage of pensioners, prescribed a high amount of inhibitors of the enzyme angiotensin converting enzyme inhibitors (ACEI), prescribed a high amount of first level non-steroidal anti-inflammatory drugs (NSAIDs) and also showed high use of antiulcer PPI. CONCLUSIONS: There is a statistically significant correlation between physicians who generate lower pharmaceutical expenditure and have a higher quality of prescription. The most influencing factors in the pharmaceutical expenditure are a high percentage of pensioners in the medical quota, the use of novel drugs that do not provide therapeutic improvements and the prescription of statins and anti-ulcer PPI drugs.


Assuntos
Prescrições de Medicamentos/economia , Gastos em Saúde/normas , Atenção Primária à Saúde/normas , Qualidade da Assistência à Saúde , Idoso , Anti-Inflamatórios não Esteroides/economia , Antiulcerosos/economia , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Farmácias , Atenção Primária à Saúde/economia , Inibidores da Bomba de Prótons/economia , Análise de Regressão , Estudos Retrospectivos , Espanha/epidemiologia
4.
J Manag Care Spec Pharm ; 25(5): 544-554, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31039062

RESUMO

BACKGROUND: Statins are effective in helping prevent cardiovascular disease (CVD). However, studies suggest that only 20%-64% of patients taking statins achieve reasonable low-density lipoprotein cholesterol (LDL-C) thresholds. On-treatment levels of LDL-C remain a key predictor of residual CVD event risk. OBJECTIVES: To (a) determine how many patients on statins achieved the therapeutic threshold of LDL-C < 100 mg per dL (general cohort) and < 70 mg per dL (secondary prevention cohort, or subcohort, with preexisting CVD); (b) estimate the number of potentially avoidable CVD events if the threshold were reached; and (c) forecast potential cost savings. METHODS: A retrospective, longitudinal cohort study using electronic health record data from the Indiana Network for Patient Care (INPC) was conducted. The INPC provides comprehensive information about patients in Indiana across health care organizations and care settings. Patients were aged > 45 years and seen between January 1, 2012, and October 31, 2016 (ensuring study of contemporary practice), were statin-naive for 12 months before the index date of initiating statin therapy, and had an LDL-C value recorded 6-18 months after the index date. Subsequent to descriptive cohort analysis, the theoretical CVD risk reduction achievable by reaching the threshold was calculated using Framingham Risk Score and Cholesterol Treatment Trialists' Collaboration formulas. Estimated potential cost savings used published first-year costs of CVD events, adjusted for inflation and discounted to the present day. RESULTS: Of the 89,267 patients initiating statins, 30,083 (33.7%) did not achieve the LDL-C threshold (subcohort: 58.1%). In both groups, not achieving the threshold was associated with patients who were female, black, and those who had reduced medication adherence. Higher levels of preventive aspirin use and antihypertensive treatment were associated with threshold achievement. In both cohorts, approximately 64% of patients above the threshold were within 30 mg per dL of the respective threshold. Adherence to statin therapy regimen, judged by a medication possession ratio of ≥ 80%, was 57.4% in the general cohort and 56.7% in the subcohort. Of the patients who adhered to therapy, 23.7% of the general cohort and 50.5% of the subcohort had LDL-C levels that did not meet the threshold. 10-year CVD event risk in the at-or-above threshold group was 22.78% (SD = 17.24%) in the general cohort and 29.56% (SD = 18.19%) in the subcohort. By reducing LDL-C to the threshold, a potential relative risk reduction of 14.8% in the general cohort could avoid 1,173 CVD events over 10 years (subcohort: 15.7% and 454 events). Given first-year inpatient and follow-up costs of $37,300 per CVD event, this risk reduction could save about $1,455 per patient treated to reach the threshold (subcohort: $1,902; 2017 U.S. dollars) over a 10-year period. CONCLUSIONS: Across multiple health care systems in Indiana, between 34% (general cohort) and 58% (secondary prevention cohort) of patients treated with statins did not achieve therapeutic LDL-C thresholds. Based on current CVD event risk and cost projections, such patients seem to be at increased risk and may represent an important and potentially preventable burden on health care costs. DISCLOSURES: Funding support for this study was provided by Merck (Kenilworth, NJ). Chase and Boggs are employed by Merck. Simpson is a consultant to Merck and Pfizer. The other authors have nothing to disclose.


Assuntos
Doenças Cardiovasculares/prevenção & controle , LDL-Colesterol/sangue , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Hiperlipidemias/tratamento farmacológico , Idoso , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/economia , LDL-Colesterol/efeitos dos fármacos , Redução de Custos/estatística & dados numéricos , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Relação Dose-Resposta a Droga , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Hiperlipidemias/sangue , Hiperlipidemias/economia , Indiana , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
5.
Ann Intern Med ; 170(4): 221-229, 2019 02 19.
Artigo em Inglês | MEDLINE | ID: mdl-30597485

RESUMO

Background: The ODYSSEY Outcomes (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) trial included participants with a recent acute coronary syndrome. Compared with participants receiving statins alone, those receiving a statin plus alirocumab had lower rates of a composite outcome including myocardial infarction (MI), stroke, and death. Objective: To determine the cost-effectiveness of alirocumab in these circumstances. Design: Decision analysis using the Cardiovascular Disease Policy Model. Data Sources: Data sources representative of the United States combined with data from the ODYSSEY Outcomes trial. Target Population: U.S. adults with a recent first MI and a baseline low-density lipoprotein cholesterol level of 1.81 mmol/L (70 mg/dL) or greater. Time Horizon: Lifetime. Perspective: U.S. health system. Intervention: Alirocumab or ezetimibe added to statin therapy. Outcome Measures: Incremental cost-effectiveness ratio in 2018 U.S. dollars per quality-adjusted life-year (QALY) gained. Results of Base-Case Analysis: Compared with a statin alone, the addition of ezetimibe cost $81 000 (95% uncertainty interval [UI], $51 000 to $215 000) per QALY. Compared with a statin alone, the addition of alirocumab cost $308 000 (UI, $197 000 to $678 000) per QALY. Compared with the combination of statin and ezetimibe, replacing ezetimibe with alirocumab cost $997 000 (UI, $254 000 to dominated) per QALY. Results of Sensitivity Analysis: The price of alirocumab would have to decrease from its original cost of $14 560 to $1974 annually to be cost-effective relative to ezetimibe. Limitation: Effectiveness estimates were based on a single randomized trial with a median follow-up of 2.8 years and should not be extrapolated to patients with stable coronary heart disease. Conclusion: The price of alirocumab would have to be reduced considerably to be cost-effective. Because substantial reductions already have occurred, we believe that timely, independent cost-effectiveness analyses can inform clinical and policy discussions of new drugs as they enter the market. Primary Funding Source: University of California, San Francisco, and Institute for Clinical and Economic Review.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Anticorpos Monoclonais Humanizados/economia , Anticolesterolemiantes/economia , Doenças Cardiovasculares/prevenção & controle , Análise Custo-Benefício , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Hipercolesterolemia/tratamento farmacológico , Adulto , Idoso , Angina Instável/prevenção & controle , Anticorpos Monoclonais Humanizados/uso terapêutico , Anticolesterolemiantes/uso terapêutico , Isquemia Encefálica/prevenção & controle , Causas de Morte , Simulação por Computador , Doença das Coronárias/prevenção & controle , Técnicas de Apoio para a Decisão , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/prevenção & controle , Anos de Vida Ajustados por Qualidade de Vida , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
6.
Br J Clin Pharmacol ; 85(1): 227-235, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30402916

RESUMO

AIMS: The aim of this study was to examine the level of and predictors of statin nonadherence and discontinuation among older adults. METHODS: Among 22 340 Australians aged ≥65 years who initiated statin therapy from January 2014 to December 2015, we estimated the first-year nonadherence (proportion of days covered [PDC] <0.80) and discontinuation (≥90 days without statin coverage) rates. Predictors of nonadherence and discontinuation were examined via multivariable logistic regression. Analyses were performed separately for general beneficiaries (with a higher co-payment; n = 4841) and concessional beneficiaries (with a lower co-payment; n = 17 499). RESULTS: During the one-year follow-up, 55.1% were nonadherent (concessional 52.6%; general beneficiaries 64.2%) and 44.7% discontinued statins (concessional 43.1%; general beneficiaries 50.4%). Among concessional beneficiaries, those aged 75-84 years and ≥85 years were more likely to discontinue than people aged 65-74 years (odds ratio 1.11, 95% confidence interval 1.04-1.19 and 1.38, 1.23-1.54, respectively). Diabetes was associated with an increased likelihood of nonadherence and discontinuation, while hypertension, angina and congestive heart failure were associated with a lower likelihood of nonadherence and discontinuation. Anxiety was associated with an increased likelihood of discontinuation, but polypharmacy (concurrent use of five or more drugs) was associated with a lower likelihood of nonadherence and discontinuation. Statin initiation by a general medical practitioner was associated with both increased likelihood of nonadherence and discontinuation. Similar predictors of nonadherence and discontinuation were identified for the general beneficiaries. CONCLUSIONS: Among older adults prescribed statins, first-year nonadherence and discontinuation are high. Specific population subgroups such as people aged ≥85 years, those with diabetes or anxiety may require additional attention to improve statin adherence.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Adesão à Medicação/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Ansiedade/epidemiologia , Austrália , Comorbidade , Diabetes Mellitus/epidemiologia , Prescrições de Medicamentos/estatística & dados numéricos , Honorários Farmacêuticos/estatística & dados numéricos , Feminino , Seguimentos , Gastos em Saúde/estatística & dados numéricos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Masculino , Estudos Retrospectivos , Fatores de Risco , Estados Unidos
7.
Health Serv Res ; 54(1): 187-197, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30284237

RESUMO

OBJECTIVE: To compare medication adherence, cost, and utilization in Medicare beneficiaries attributed to nurse practitioners (NP) and primary care physicians (PCP). DATA: Medicare Part A, B, and D claims and beneficiary summary file data, years 2009-2013. STUDY DESIGN: We used propensity score-weighted analyses combined with logistic regression and generalized estimating equations to test differences in good medication adherence (proportion of days covered (PDC >0.8); office-based and specialty care costs; and ER visits. DATA EXTRACTION: Beneficiaries with prescription claims for anti-diabetics, renin-angiotensin system antagonists (RASA), or statins. PRINCIPAL FINDINGS: There were no differences in good medication adherence (PDC >0.8) between NP and PCP attributed beneficiaries taking anti-diabetics or RASA. Beneficiaries taking statins had a slightly higher probability of good adherence when attributed to PCPs (74.6% vs 75.5%; P < 0.05). NP attributed beneficiaries had lower office-based and specialty care costs and were less likely to experience an ER visit across all three medication cohorts (P < 0.01). CONCLUSIONS: Examining the impact of NP and PCP provided care on outcomes beyond the primary care setting is important to the Medicare program in general but will also help practices seeking to meet benchmarks under alternative payment models that incentivize higher quality and lower costs.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Hipoglicemiantes/economia , Medicare/economia , Adesão à Medicação/estatística & dados numéricos , Profissionais de Enfermagem/economia , Médicos de Atenção Primária/economia , Estudos de Coortes , Feminino , Humanos , Masculino , Estados Unidos
8.
Adv Ther ; 35(12): 2214-2223, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30390239

RESUMO

INTRODUCTION: Statins can reduce the risk of cardiovascular events in patients with diabetes. The objective of this analysis was to evaluate whether primary prevention with statin treatment is cost-effective for newly diagnosed type 2 diabetes mellitus (T2DM) patients in the Chinese context. METHODS: An economic analysis of primary prevention with statin treatment was conducted using the Chinese Outcomes Model for T2DM with a time horizon of a lifetime, which was developed and validated based on the Chinese population. Clinical costs and utility inputs were gathered from published sources. Lifetime discounted quality-adjusted life-years (QALYs), costs, and the incremental cost-effectiveness ratio (ICER) were measured. The uncertainty was evaluated by one-way and probabilistic sensitivity analyses. RESULTS: Statin treatment with atorvastatin 10 mg could add 0.08 QALYs with an additional $1676 compared with that of no statin management (control strategy) over a lifetime horizon, which led to an ICER of $21,924 per QALY gained. At a willingness-to-pay threshold of $27,351 per QALY gained, there was an approximately 80% probability of statin treatment being cost-effective compared with the control strategy. The model outcomes were most sensitive to the length of the expected life and age at the T2DM diagnosis. CONCLUSIONS: Statin treatment with atorvastatin is most likely cost-effective for primary prevention in Chinese patients newly diagnosed with type 2 diabetes. FUNDING: Partially funded by Pfizer Inc.


Assuntos
Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Diabetes Mellitus Tipo 2/epidemiologia , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Prevenção Primária/métodos , Idoso , China/epidemiologia , Análise Custo-Benefício , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Prevenção Primária/economia , Anos de Vida Ajustados por Qualidade de Vida
9.
Cardiovasc Drugs Ther ; 32(6): 601-610, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30446883

RESUMO

PURPOSE: Compare medical expenditures among adults with statin-associated adverse effects (SAAE) and high statin adherence (HSA) following myocardial infarction (MI). METHODS: We analyzed expenditures in 2016 US dollars among Medicare beneficiaries with SAAE (n = 1741) and HSA (n = 55,567) who were ≥ 66 years of age and initiated moderate/high-intensity statins following an MI in 2007-2013. SAAE were identified through a claims-based algorithm, which included down-titrating statins and initiating ezetimibe, switching to ezetimibe monotherapy, having a rhabdomyolysis or antihyperlipidemic adverse event followed by statin down-titration or discontinuation, or switching between ≥ 3 statin types within 365 days following MI. HSA was defined by having a statin available to take for ≥ 80% of the days in the 365 days following MI. RESULTS: Expenditures among beneficiaries with SAAE and HSA were $40,776 (95% CI $38,329-$43,223) and $26,728 ($26,482-$26,974), respectively, in the 365 days following MI, and $34,238 ($31,396-$37,080) and $29,053 ($28,605-$29,500), respectively, for every year after the first 365 days. Multivariable-adjusted ratios comparing expenditures among beneficiaries with SAAE versus HSA in the first 365 days and after the first 365 days following MI were 1.51 (95% CI 1.43-1.59) and 1.23 (1.12-1.34), respectively. Inpatient and outpatient expenditures were higher among beneficiaries with SAAE versus HSA during and after the first 365 days following MI. Compared to beneficiaries with HSA, medication expenditures among those with SAAE were similar in the 365 days following MI, but higher afterwards. Other medical expenditures were higher among beneficiaries with SAAE versus HSA. CONCLUSION: SAAE are associated with increased expenditures following MI compared with HSA.


Assuntos
Custos de Medicamentos , Gastos em Saúde , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Benefícios do Seguro/economia , Medicare/economia , Adesão à Medicação , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/economia , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Substituição de Medicamentos/economia , Feminino , Custos Hospitalares , Humanos , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
10.
Mol Diagn Ther ; 22(6): 641-652, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30218425

RESUMO

We recently conducted two economic evaluations of a hypothetical pharmacogenomic test for statin-induced myopathy (SIM) in patients at high cardiovascular risk. Although the models differed in modeling technique and data inputs, both yielded similar results. We believe our approach to assessing the economic value of a diagnostic test was highly advantageous as it characterized the complete range of false-negative and false-positive test outcomes. We used a broad interpretation of test parameters that reflected physician and patient behavioral responses to the test results and accounted for patient adherence to treatment. Both economic evaluations indicated that a highly accurate pharmacogenomic test for SIM would provide a positive incremental net monetary benefit (INMB) for a provincial payer in Canada. However, the value of the test would depend on its ability to accurately diagnose patients when they experience musculoskeletal pain symptoms and guide patients with a test result indicating no SIM to adhere to treatment. Interestingly, our results indicated that a highly inaccurate test would still yield a positive INMB. We found this surprising result was driven by the imbalance of the risk of cardiovascular events outweighing the risk of rhabdomyolysis in patients at high cardiovascular risk. A highly accurate pharmacogenomic test for SIM in patients at high cardiovascular risk would provide economic value for payers. However, the economic and clinical value of the test would depend on the credibility of the test results and their success in influencing patients without SIM to adhere to therapy.


Assuntos
Doenças Cardiovasculares/tratamento farmacológico , Análise Custo-Benefício , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Doenças Musculares/epidemiologia , Canadá , Doenças Cardiovasculares/economia , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Modelos Cardiovasculares , Doenças Musculares/induzido quimicamente , Doenças Musculares/economia , Farmacogenética/economia , Fatores de Risco
11.
Am J Cardiol ; 122(7): 1128-1132, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-30086877

RESUMO

High triglyceride (TG) levels are associated with higher medical costs, but the long-term impact of high TG on costs among patients with statin-controlled low-density lipoprotein cholesterol (LDL-C) is unclear. We compared medical utilization and costs over 6.5years between patients with high (200 to 400 mg/dl) versus normal (<150 mg/dl) TG levels, all of whom had established atherosclerotic cardiovascular disease (ASCVD). This was an observational cohort study of 17,183 patients with TG measured in 2010 and followed until death, disenrollment or the end of 2016. All patients had LDL-C levels between 40 and 100 mg/dl and were receiving statin therapy at the time of their TG measurement. We compared annualized medical utilization adjusted for differences between group in age, sex, race, and study site. We also compared annualized medical costs, further adjusting for baseline costs as a proxy for resource-intensive comorbidities. After multivariable adjustment, patients with high TG levels (n=2,702) had a mean of 13% more inpatient admissions per year (p <0.001). Despite adjustment for comorbidities such as diabetes and chronic kidney disease, total outpatient costs were 5% greater (p = 0.035) among those with high TG, including emergency care costs (6% greater) and hospital ambulatory costs (25% greater). The overall difference in annual costs of $964 per patient in the high TG cohort totaled over $2.6million per year in excess annual costs and more than $13.5million over the mean follow-up of 5.2years.


Assuntos
LDL-Colesterol/efeitos dos fármacos , Doença da Artéria Coronariana/tratamento farmacológico , Custos de Cuidados de Saúde , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipertrigliceridemia/tratamento farmacológico , Revisão da Utilização de Recursos de Saúde , Idoso , California , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade
12.
J Public Health Policy ; 39(3): 268-282, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30013135

RESUMO

Almost all new treatments being developed for the next influenza pandemic target the virus. During the Ebola crisis in West Africa, patients were treated with an inexpensive generic statin/angiotensin receptor blocker combination that appeared to greatly improve survival. These drugs target the host response, not the virus, and probably reverse endothelial dysfunction. Scientists and health officials have shown little interest in this idea. Yet, during the early months of the next pandemic, vaccines will be unavailable and treatment options will be limited. Physicians should be prepared to undertake clinical trials of widely available generic drugs to determine whether they improve survival in patients with seasonal influenza, other emerging virus diseases, and other forms of acute critical illness. Public health officials should give these studies their strong support. If successful, they will suggest a 'bottom up' approach to patient care that could be implemented worldwide on the first pandemic day.


Assuntos
Medicamentos Genéricos/uso terapêutico , Doença pelo Vírus Ebola/tratamento farmacológico , Influenza Humana/prevenção & controle , Terapia de Alvo Molecular , Pandemias/prevenção & controle , Antagonistas de Receptores de Angiotensina/economia , Antagonistas de Receptores de Angiotensina/uso terapêutico , Ensaios Clínicos como Assunto , Combinação de Medicamentos , Medicamentos Genéricos/economia , Medicamentos Genéricos/provisão & distribução , Saúde Global , Doença pelo Vírus Ebola/epidemiologia , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Influenza Humana/epidemiologia , Análise de Sobrevida
13.
Expert Rev Pharmacoecon Outcomes Res ; 18(6): 655-666, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30014725

RESUMO

BACKGROUND: Prescribing of lipid-lowering agents (LLAs) has increased worldwide including in Scotland with increasing prevalence of coronary heart disease, and higher dose statins have been advocated in recent years. There have also been initiatives to encourage prescribing of generic versus patented statins to save costs without compromising care. There is a need to document these initiatives and outcomes to provide future direction. METHOD: Assessment of utilization (items dispensed) and expenditure of key LLAs (mainly statins) between 2001 and 2015 in Scotland alongside initiatives. RESULTS: Multiple interventions over the years have increased international nonproprietary name prescribing (99% for statins) and preferential prescribing of generic versus patented statins, and reduced inappropriate prescribing of ezetimibe. This resulted in a 50% reduction in expenditure of LLAs between 2001 and 2015 despite a 412% increase in utilization, increased prescribing of higher dose statins (71% in 2015) especially atorvastatin following generic availability, and reduced prescribing of ezetimibe (reduced by 72% between 2010 and 2015). As a result, the quality of prescribing has improved. CONCLUSION: Generic availability coupled with multiple measures has resulted in appreciable shifts in statin prescribing behavior and reduced ezetimibe prescribing, resulting in improvements in both the quality and efficiency of prescribing.


Assuntos
Medicamentos Genéricos/administração & dosagem , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Programas Nacionais de Saúde/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Anticolesterolemiantes/administração & dosagem , Anticolesterolemiantes/economia , Doença das Coronárias/tratamento farmacológico , Doença das Coronárias/epidemiologia , Relação Dose-Resposta a Droga , Custos de Medicamentos , Medicamentos Genéricos/economia , Ezetimiba/administração & dosagem , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Prescrição Inadequada/estatística & dados numéricos , Programas Nacionais de Saúde/economia , Padrões de Prática Médica/normas , Escócia
14.
Rev Esp Cardiol (Engl Ed) ; 71(12): 1027-1035, 2018 12.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29937273

RESUMO

INTRODUCTION AND OBJECTIVES: To analyze the cost-effectiveness ratio and budget impact of treatment with evolocumab (PCSK9 inhibitor) for patients in secondary prevention in the Spanish National Health System. METHODS: A budget impact analysis, decision tree and Markov models were designed under the public health system perspective, based on the only study with morbidity and mortality data (FOURIER). The alternatives compared were evolocumab vs statins, and dual therapy with ezetimibe in 5% of the population. The measure of effectiveness used was the number of cardiovascular events avoided. Univariate and probabilistic sensitivity analyses were performed. RESULTS: The average annual cost of patients receiving evolocumab was 11 134.78€ and 393.83€ for standard treatment (statins plus ezetimibe). The incremental cost-effectiveness ratio was > 600 000 € per avoided cardiovascular event for both assessed outcomes (first: cardiovascular death, myocardial infarction, stroke, and hospitalization due to unstable angina or coronary revascularization; second: includes the first 3 events). To perform the 10-year Markov model, the average cost of standard treatment was 13 948.45€ vs 471 417.37€ with evolocumab. Treatment with evolocumab for patients with familial hypercholesterolemia would cost between 3 and 6.1 million euros, assuming a difference of 2.5 and 5.1 million euros with the standard treatment (2017). This difference would be between 204.3 and 1364.7 million euros (2021) for those with nonfamiliar hypercholesterolemia (secondary prevention). CONCLUSIONS: Treatment with evolocumab is associated with a lower frequency of cardiovascular events, but is inefficient for patients suitable to receive this drug in the Spanish National Health System.


Assuntos
Anticorpos Monoclonais/uso terapêutico , Custos de Medicamentos , Ezetimiba/uso terapêutico , Previsões , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipercolesterolemia/tratamento farmacológico , Anticorpos Monoclonais/economia , Anticorpos Monoclonais Humanizados , Anticolesterolemiantes/economia , Anticolesterolemiantes/uso terapêutico , Análise Custo-Benefício , Ezetimiba/economia , Feminino , Seguimentos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Hipercolesterolemia/economia , Hipercolesterolemia/epidemiologia , Incidência , Masculino , Pessoa de Meia-Idade , Espanha/epidemiologia , Resultado do Tratamento
15.
J Gen Intern Med ; 33(8): 1317-1323, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29855861

RESUMO

BACKGROUND: US Preventive Services Task Force (USPSTF) released new recommendations on statin use for atherosclerotic cardiovascular disease (ASCVD) prevention. The Affordable Care Act (ACA) mandates USPSTF recommendations with an "A" or "B" grade receive insurance coverage without copayment. We assessed the potential impact of these recommendations. OBJECTIVE: To assess the US population meeting criteria for statin use and factors associated with use, and calculate associated costs. DESIGN AND MEASURES: We estimated 10-year ASCVD event risk scores from National Health and Nutrition Examination Survey data using Pooled Cohort Equations from the American College of Cardiology/American Heart Association and applied them to Medical Expenditure Panel Survey data. We estimated the population meeting USPSTF criteria and calculated the number of statin prescription fills and out-of-pocket and total costs. We assessed associations between statin use and sociodemographic and health characteristics and national trends in use from 1996 to 2014. PARTICIPANTS: A nationally representative sample of people aged ≥ 40 years, representing 150 million people living in the USA. KEY RESULTS: Of 26.8 million adults recommended for statins, only 41.8% were taking them. Female sex, Hispanic ethnicity, uninsured status, or living in the South was associated with lower odds of using statins. Under ACA, people with private insurance would avoid out-of-pocket cost of $9 for each generic prescription, resulting in savings of approximately $44 in annual costs. ACA's mandate for insurance coverage would result in a $193 million shift in out-of-pocket cost for statins from patients to private insurers. CONCLUSIONS: New USPSTF recommendations may result in decreased out-of-pocket costs and expanded access to statins. Previous research has shown that eliminating copayments increased adherence and decreased rates of ASCVD events without increasing overall healthcare costs. Future research will determine whether the USPSTF's recommendations will result in similar findings.


Assuntos
Aterosclerose/prevenção & controle , Fidelidade a Diretrizes , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Aterosclerose/epidemiologia , Feminino , Inquéritos Epidemiológicos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Masculino , Pessoa de Meia-Idade , Prevenção Primária/economia , Prevenção Primária/métodos , Fatores de Risco , Estados Unidos/epidemiologia
16.
Int J Cardiol ; 267: 183-187, 2018 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-29731350

RESUMO

BACKGROUND: For patients in whom statins are not tolerated or effective as monotherapy, proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) represent a new class of lipid lowering therapies that may reduce low-density lipoprotein cholesterol (LDL-C) levels by up to 50% and lower cardiovascular events. While an important treatment option, the cost-effectiveness of PCSK9i in Australia remains unknown. This study aimed to determine the cost-effectiveness of PCSK9i compared to placebo in the prevention of atherosclerotic cardiovascular disease (CVD). METHODS AND RESULTS: A Markov cohort state-transition model was developed in Microsoft Excel. A hypothetical sample of 1000 individuals based on subjects in the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) trial populated the model. With each five-year cycle, model subjects could have non-fatal CVD events (myocardial infarction and/or stroke), or die from CVD or other causes. Follow-up was simulated for 25 years. CVD risk reduction, cost and utility data were gathered from published sources. At current acquisition prices (AU$8174 per person per year), the incremental cost effectiveness ratio (ICER) was AU$308,558 per quality-adjusted life year (QALY) saved. Acquisition prices would need to be reduced to approximately AU$1500 per person per annum for PCSK9i to reach the arbitrary cost-effectiveness threshold of AU$50,000 per QALY saved. CONCLUSION(S): PCSK9i are an effective alternative for those with existing CVD or at high risk of CVD in whom statin therapy alone is ineffective, but are not cost-effective to the Australian healthcare system based on current prices.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Hiperlipidemias , Hipolipemiantes , Pró-Proteína Convertase 9/antagonistas & inibidores , Anticorpos Monoclonais/economia , Anticorpos Monoclonais/farmacologia , Austrália , Simulação por Computador , Análise Custo-Benefício , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Inibidores de Hidroximetilglutaril-CoA Redutases/farmacologia , Hiperlipidemias/tratamento farmacológico , Hiperlipidemias/economia , Hipolipemiantes/economia , Hipolipemiantes/farmacologia , Metabolismo dos Lipídeos/efeitos dos fármacos , Cadeias de Markov , Determinação de Necessidades de Cuidados de Saúde , Anos de Vida Ajustados por Qualidade de Vida
17.
Pharmacoeconomics ; 36(9): 1031-1041, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29777433

RESUMO

The objective of this study was to review available health economic evaluations of PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors. These drugs reduce low-density lipid cholesterol levels and cardiovascular risk, but their cost effectiveness has been questioned. We searched Medline and Embase for economic evaluations in any language at any time. Studies were included if they analysed any PCSK9 inhibitor compared with either statin alone or in combination with ezetimibe or any other therapy considered standard prior to the introduction of PCSK9 inhibitors. We found ten full health economic evaluations of PCSK9 inhibitors, two from Europe and eight from the United States (US). Six of the eight from the US were from two different consortia that analysed PCSK9 inhibitors at different stages through the development of evidence. All studies generally reported incremental cost-effectiveness ratios above suggested thresholds for cost effectiveness, except one study from Spain. The results of this review indicate that PCSK9 inhibitors in general are not cost effective at the current prices, but lower prices may change the results.


Assuntos
Anticolesterolemiantes/economia , Análise Custo-Benefício/estatística & dados numéricos , Inibidores Enzimáticos/economia , Hipercolesterolemia/economia , Anticolesterolemiantes/uso terapêutico , Quimioterapia Combinada/economia , Inibidores Enzimáticos/uso terapêutico , Ezetimiba/economia , Ezetimiba/uso terapêutico , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipercolesterolemia/tratamento farmacológico , Pró-Proteína Convertase 9/antagonistas & inibidores , Anos de Vida Ajustados por Qualidade de Vida
18.
Circ Cardiovasc Qual Outcomes ; 11(4): e004171, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29650716

RESUMO

BACKGROUND: It is unclear whether testing for novel risk factors, such as a cardiovascular genetic risk score (cGRS), improves clinical decision making or health outcomes when used for targeting statin initiation in the primary prevention of atherosclerotic cardiovascular disease (ASCVD). Our objective was to estimate the cost-effectiveness of cGRS testing to inform clinical decision making about statin initiation in individuals with low-to-intermediate (2.5%-7.5%) 10-year predicted risk of ASCVD. METHODS AND RESULTS: We evaluated the cost-effectiveness of testing for a 27-single-nucleotide polymorphism cGRS comparing 4 test/treat strategies: treat all, treat none, test/treat if cGRS is high, and test/treat if cGRS is intermediate or high. We tested a set of clinical scenarios of men and women, aged 45 to 65 years, with 10-year ASCVD risks between 2.5% and 7.5%. Our primary outcome measure was cost per quality-adjusted life-year gained. Under base case assumptions for statin disutility and cost, the preferred strategy is to treat all patients with ASCVD risk >2.5% without cGRS testing. For certain clinical scenarios, such as a 57-year-old man with a 10-year ASCVD risk of 7.5%, cGRS testing can be cost-effective under a limited set of assumptions; for example, when statins cost $15 per month and statin disutility is 0.013 (ie, willing to trade 3 months of life in perfect health to avoid 20 years of statin therapy), the preferred strategy (using a willingness-to-pay threshold of $50 000 per quality-adjusted life-year gained) is to test and treat if cGRS is intermediate or high. Overall, the results were not sensitive to assumptions about statin efficacy and harms. CONCLUSIONS: Testing for a 27-single-nucleotide polymorphism cGRS is generally not a cost-effective approach for targeting statin therapy in the primary prevention of ASCVD for low- to intermediate-risk patients.


Assuntos
Aterosclerose/genética , Aterosclerose/prevenção & controle , Dislipidemias/tratamento farmacológico , Dislipidemias/genética , Perfilação da Expressão Gênica/métodos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Lipídeos/sangue , Polimorfismo de Nucleotídeo Único , Prevenção Primária/métodos , Idoso , Aterosclerose/sangue , Aterosclerose/economia , Tomada de Decisão Clínica , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Árvores de Decisões , Custos de Medicamentos , Dislipidemias/sangue , Dislipidemias/economia , Feminino , Perfilação da Expressão Gênica/economia , Estudos de Associação Genética , Marcadores Genéticos , Predisposição Genética para Doença , Nível de Saúde , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Modelos Econômicos , Fenótipo , Valor Preditivo dos Testes , Prevenção Primária/economia , Anos de Vida Ajustados por Qualidade de Vida , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
Mol Diagn Ther ; 22(2): 241-254, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29651791

RESUMO

BACKGROUND: Statin (HMG-CoA reductase inhibitor) therapy is the mainstay dyslipidemia treatment and reduces the risk of a cardiovascular (CV) event (CVE) by up to 35%. However, adherence to statin therapy is poor. One reason patients discontinue statin therapy is musculoskeletal pain and the associated risk of rhabdomyolysis. Research is ongoing to develop a pharmacogenomics (PGx) test for statin-induced myopathy as an alternative to the current diagnosis method, which relies on creatine kinase levels. The potential economic value of a PGx test for statin-induced myopathy is unknown. METHODS: We developed a lifetime discrete event simulation (DES) model for patients 65 years of age initiating a statin after a first CVE consisting of either an acute myocardial infarction (AMI) or a stroke. The model evaluates the potential economic value of a hypothetical PGx test for diagnosing statin-induced myopathy. We have assessed the model over the spectrum of test sensitivity and specificity parameters. RESULTS: Our model showed that a strategy with a perfect PGx test had an incremental cost-utility ratio of 4273 Canadian dollars ($Can) per quality-adjusted life year (QALY). The probabilistic sensitivity analysis shows that when the payer willingness-to-pay per QALY reaches $Can12,000, the PGx strategy is favored in 90% of the model simulations. CONCLUSION: We found that a strategy favoring patients staying on statin therapy is cost effective even if patients maintained on statin are at risk of rhabdomyolysis. Our results are explained by the fact that statins are highly effective in reducing the CV risk in patients at high CV risk, and this benefit largely outweighs the risk of rhabdomyolysis.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Simulação por Computador , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Modelos Cardiovasculares , Doenças Musculares/induzido quimicamente , Farmacogenética/economia , Farmacogenética/métodos , Idoso , Doenças Cardiovasculares/economia , Análise Custo-Benefício , Feminino , Humanos , Masculino , Doenças Musculares/economia
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