[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 34.232.62.209. Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Views 3,237
Citations 0
Original Investigation
May 13, 2020

Cost-effectiveness of Contemporary Statin Use Guidelines With or Without Coronary Artery Calcium Assessment in African American Individuals

Author Affiliations
  • 1Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
  • 2Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 3Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
  • 4Department of Epidemiology and Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands
  • 5Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
  • 6Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
  • 7Vanderbilt Translational and Clinical Cardiovascular Research Center, Department of Radiology, Vanderbilt University, Nashville, Tennessee
  • 8National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, National Institutes of Health, Bethesda, Maryland
  • 9Field Center, Jackson Heart Study, Jackson State University, Jackson, Mississippi
  • 10Duke Clinical Research Institute, Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
  • 11Duke Clinical Research Institute, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
  • 12Department of Medicine, University of Mississippi Medical Center, Jackson
  • 13Cardiovascular Medicine Division, Department of Medicine, University of Michigan, Ann Arbor
  • 14Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
JAMA Cardiol. Published online May 13, 2020. doi:10.1001/jamacardio.2020.1240
Key Points

Question  What is the cost-effectiveness of statin therapy guidelines with and without use of coronary artery calcium assessment in African American individuals at intermediate risk for atherosclerotic cardiovascular disease?

Findings  In a model-based economic evaluation informed in part by follow-up data from 472 individuals, use of the 2018 American College of Cardiology/American Heart Association guideline strategy with coronary artery calcium assessment appeared to be cost-effective in most cases. The 2013 guidelines, which do not include coronary artery calcium assessment, provided a greater quality-adjusted life expectancy at a higher cost ($428.97) compared with the 2018 guideline strategy; results appeared to be sensitive to the patient’s preference to avoid use of daily medication therapy.

Meaning  The results of this study suggest that the 2018 American College of Cardiology/American Heart Association statin allocation guidelines with coronary artery calcium assessment appear to be cost-effective for the primary prevention of atherosclerotic cardiovascular disease in African American individuals.

Abstract

Importance  Clinical and economic consequences of statin treatment guidelines supplemented by targeted coronary artery calcium (CAC) assessment have not been evaluated in African American individuals, who are at increased risk for atherosclerotic cardiovascular disease and less likely than non–African American individuals to receive statin therapy.

Objective  To evaluate the cost-effectiveness of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline without a recommendation for CAC assessment vs the 2018 ACC/AHA guideline recommendation for use of a non-0 CAC score measured on one occasion to target generic-formulation, moderate-intensity statin treatment in African American individuals at risk for atherosclerotic cardiovascular disease.

Design, Setting, and Participants  A microsimulation model was designed to estimate life expectancy, quality of life, costs, and health outcomes over a lifetime horizon. African American–specific data from 472 participants in the Jackson Heart Study (JHS) at intermediate risk for atherosclerotic cardiovascular disease and other US population-specific data on individuals from published sources were used. Data analysis was conducted from November 11, 2018, to November 1, 2019.

Main Outcomes and Measures  Lifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually.

Results  In a model-based economic evaluation informed in part by follow-up data, the analysis was focused on 472 individuals in the JHS at intermediate risk for atherosclerotic cardiovascular disease; mean (SD) age was 63 (6.7) years. The sample included 243 women (51.5%) and 229 men (48.5%). Of these, 178 of 304 participants (58.6%) who underwent CAC assessment had a non-0 CAC score. In the base-case scenario, implementation of 2013 ACC/AHA guidelines without CAC assessment provided a greater quality-adjusted life expectancy (0.0027 QALY) at a higher cost ($428.97) compared with the 2018 ACC/AHA guideline strategy with CAC assessment, yielding an incremental cost-effectiveness ratio of $158 325/QALY, which is considered to represent low-value care by the ACC/AHA definition. The 2018 ACC/AHA guideline strategy with CAC assessment provided greater quality-adjusted life expectancy at a lower cost compared with the 2013 ACC/AHA guidelines without CAC assessment when there was a strong patient preference to avoid use of daily medication therapy. In probability sensitivity analyses, the 2018 ACC/AHA guideline strategy with CAC assessment was cost-effective compared with the 2013 ACC/AHA guidelines without CAC assessment in 76% of simulations at a willingness-to-pay value of $100 000/QALY when there was a preference to lose 2 weeks of perfect health to avoid 1 decade of daily therapy.

Conclusions and Relevance  A CAC assessment-guided strategy for statin therapy appears to be cost-effective compared with initiating statin therapy in all African American individuals at intermediate risk for atherosclerotic cardiovascular disease and may provide greater quality-adjusted life expectancy at a lower cost than a non-CAC assessment-guided strategy when there is a strong patient preference to avoid the need for daily medication. Coronary artery calcium testing may play a role in shared decision-making regarding statin use.

×