Paying Physicians, Patients to Lower LDL-C Is Cost-effective

Debra L Beck

October 04, 2018

Financially incentivizing patients and physicians to control low-density-lipoprotein cholesterol (LDL-C) is cost-effective, a new model-based economic evaluation suggests.

"Our model allowed us to take a clinical trial scenario, which offered behavioral and financial incentives for only 12 months, and look at it over the lifetime because patients and payers aren't interested in just what happens during a trial, they want to avert events for a lifetime," explained senior author Thomas A. Gaziano, MD, MSc, Harvard T.H. Chan School of Public Health, Boston, in an interview.

"What we found is that it is cost-effective to offer these financial incentives even for just one year."

Their findings were published online September 14 in JAMA Network Open.

The analysis was a planned follow-on to a 4-group randomized clinical trial published in 2015 that showed financial incentives shared between physicians and patients were better at reducing LDL-C compared with no financial incentives, or incentives aimed at either physicians or patients alone.

Strategies for physician- or patient-only incentives were associated with greater costs and lower quality-adjusted life years (QALYs), compared with the shared-incentives strategy, which had an incremental cost-effectiveness ratio (ICER) of $60,000/QALY.

QALYs are the standard measure of effect in cost-effectiveness analysis and account for both the quantity and quality of life, whereas ICERs measure the difference in cost divided by the difference in health for an intervention compared with its alternative. A lower ICER suggests better value for money than a higher one.

"Even if we say the benefits trail off after 10 years and people don't remain vigilant about taking their medications, it was still cost-effective to invest in that year of incentives with a cost per QALY of about $60,000," said Gaziano.

When the duration of LDL-C level reduction was assumed to last only 5 years with linear waning, the ICER went up to $130,000 per QALY. But on the flip side, if no waning of effect was assumed, the shared-incentives strategy had a very affordable ICER of just $5900 per QALY.

Mean age, LDL-C levels, and 10-year coronary heart disease risk were similar in the modeled population (n = 1,000,000) and the observed trial population. To this, the investigators added a "virtual usual-care" control group that received no intervention at all.

This virtual usual-care strategy was associated with higher lifetime costs and lower QALYs compared to all other strategies, even assuming a 10-year waning in effect from the trial's interventions.

"Even the control group in the trial, who only used the electronic pill bottle but weren't given any financial incentives whatsoever, they still saw significant cholesterol lowering," Gaziano said. "So, just knowing that someone knew every time you didn't twist open your pill bottle helped people change their behaviour, and was cost-effective compared to usual care."

Gaziano is a cardiologist at Brigham & Women's Hospital and a health policy researcher involved in the development of decision analytic models to assess the cost-effectiveness of various screening, prevention and management decisions. Ankur Pandya, PhD, also from Harvard T.H. Chan School of Public Health, was the first author on the study.

A Wellness Initiative With Data

Commenting on these findings for theheart.org | Medscape Cardiology, Lauren G. Gilstrap, MD, MPH, also a cardiologist and health policy researcher, Dartmouth University, Lebanon, New Hampshire, called the analysis "sophisticated" and "rigorous."

"This study was very thoughtfully performed with an eye toward providing something relevant to insurers, payers, and employers — the entities we see who are looking for out-of-the-box ways to help individuals improve their overall health and who are taking up a number of these wellness initiatives," said Gilstrap.

"This is much more than most wellness initiatives have prior to implementation," she added.

"With this analysis, they have some real empirical data on which to base a decision of whether or not they want to invest in something similar to this, rather than just saying, 'oh, that sounds good, it should probably work.'"

She felt the base-case assumption of a 10-year waning in effect on LDL-C was "on the conservative end of the spectrum."

"It's patient specific, but I think that by and large when people tolerate their medicines well and don't have a lot of side effects, and the vast majority of people do really well on statins, and the drugs are generically priced, I think the vast majority of patients will keep taking them," said Gilstrap.

Pay-4-Performance Initiative That Worked

In the original 2015 randomized trial on which this cost-effectiveness analysis was based, 344 primary care physicians and 1503 patients cared for by those physicians were enrolled. Patients were eligible if they had a 10-year Framingham Risk Score (FRS) of 20% or greater, had coronary artery disease equivalents with LDL-C levels of 120 mg/dL or greater, or had an FRS of 10% to 20% with LDL-C levels of 140 mg/dL or greater.

Patients in all four groups of the trial were given electronic pill bottles (Vitality GlowCap) that, when opened, wirelessly transmitted a signal to a web platform accessible by study staff.

Physicians in the physician-incentive group and patients in the patient-incentive group could "earn" just over $1000 annually in incentive payouts. In the shared-incentives intervention, that amount was split between the physician and patient.

Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation and the electronic pill bottle.

The trial made innovative use of principles of behaviour economics, including leveraging loss aversion — the tendency to strongly prefer avoiding losses over acquiring similarly sized gains.

At 1 year, patients in the shared incentives group had achieved a mean reduction in LDL-C of 33.6 mg/dL, significantly greater than the 25.1 mg/dL reduction seen in the control group (= .002).

Mean reductions in LDL-C in the physician incentives group (27.9 mg/dL) and patient incentives group (25.1 mg/dL) did not differ significantly from those seen in the control group.

"The effect seen with just the electronic pill bottle is consistent with prior literature," said Gilstrap. "We know from a whole host of prior studies...that directly observed therapy, pill counts, and things like that, dramatically improve adherence, so it would make sense that some form of accountability would have an impact."

This study was funded by grants from the National Institute on Aging and the National Heart, Lung, and Blood Institute. Gaziano reported receiving funds through a grant from Novartis, multiple grants from the National Institute of Health, and advisory board with Takeda and Teva. Gilstrap disclosed no relevant financial relationships.  

JAMA Network Open. Published online September 14, 2018. Abstract

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