Cost-effectiveness of pravastatin in secondary prevention of coronary heart disease: comparison between Belgium and the United States of a projected risk model
Introduction
Detection, evaluation and treatment of high blood cholesterol have both health and economic implications [1]. Primary and secondary prevention trials have demonstrated that clinical events and arteriographic progression can be reduced with lipid-lowering therapy 2, 3, 4. Cost-effectiveness analyses among diverse populations in North America and Europe have been widely applied in the evaluation of alternative strategies for lowering cholesterol 5, 6, 7, 8, 9. In general, cholesterol-lowering treatment has been shown to be most cost-effective when targeted towards individuals at high-risk for coronary heart disease (CHD) 8, 10. Differences in methodology have, however, often precluded comparisons of findings between studies and variations in health care regulations among countries have limited their use in other populations. The authors have, therefore, applied a projected risk model, designed to determine the economic value in the United States of pravastatin in the secondary prevention of CHD, to the Belgian situation, using local data on costs and utilization of health care resources. The model has used the results of the 3-year, double-blind, placebo-controlled, randomized clinical trials pravastatin limitation of atherosclerosis in the coronary arteries (PLAC I) [11]and pravastatin, lipids and atherosclerosis in the carotid arteries (PLAC II) [12]and utilized Framingham data to project the risk of mortality 10 years post-myocardial infarction. In the United States, this model estimated the cost per life year gained (LYG) with pravastatin monotherapy for 3 years in secondary prevention of CHD to range from US$ 7124 to 12 665, depending upon the patient risk profile [13].
Section snippets
Data sources
Two clinical trials, PLAC I [11]and PLAC II [12], provided the basis for the projected risk model. These 3-year studies have been carried out according to a similar double-blind, placebo-controlled, randomized design in patients with established CHD. Along with assessing the primary endpoint of atherosclerotic plaque regression in the coronary (PLAC I) or carotid (PLAC II) arteries, both studies also evaluated four clinical outcomes: non-fatal myocardial infarction (NFMI); fatal MI; CHD death;
Costs
Costs of medical care for cardiovascular events in Belgium are listed in Table 1. Estimates of average hospitalization costs for MI, angina, CHF and stroke include surgical and diagnostic procedures, medical therapies and overall hospitalization costs. Annual incremental costs for the follow-up of MI and subsequent events comprise expenditures for physician office visits, drug therapies and diagnostic procedures such as exercise tests, laboratory tests, chest X-rays and cardiovascular
Discussion
The present cost-effectiveness analysis of pravastatin treatment for a 3-year period in the secondary prevention of CHD has applied health care costs in Belgium to a projected risk model based on morbidity and mortality rates as well as on life tables from the United States [13]. The model has used pooled data from the randomized, controlled PLAC I and II trials and has evaluated male patients, aged 60. Results of this analysis should, therefore, not be extrapolated to other age ranges or to
Acknowledgements
We are indebted to Talat Ashraf, Joel Hay and co-workers for their development of the US model, to Daniel Pettitt for his helpful comments and to Eva Lauwers. This work was supported by a grant from Bristol-Myers Squibb Belgium.
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