Cost-Effectiveness of Lipid-Lowering Treatments in Young Adults

Ciaran N. Kohli-Lynch, PHD; Brandon K. Bellows, PHARMD; Yiyi Zhang, PHD; Bonnie Spring, PHD; Dhruv S. Kazi, MD; Mark J. Pletcher, MD; Eric Vittinghoff, PHD; Norrina B. Allen, PHD; Andrew E. Moran, MD

Disclosures

J Am Coll Cardiol. 2021;78(20):1954-1964. 

In This Article

Results

Number of Treatment-eligible Young Adults

An estimated 26.3 million (27%) U.S. young adults without ASCVD have an LDL-C level of ≥130 mg/dL, and more than 8.5 million (9%) have an LDL-C level of ≥160 mg/dL (Figure 1, Table 2). Approximately one-half (51%) of young adults have had their cholesterol checked. In comparison, 86% of adults aged 40–74 years have had their cholesterol checked.

Figure 1.

Distribution of Untreated LDL-C in ASCVD-Free U.S. Adults
Analysis conducted in the National Health and Nutrition Examination Survey. The LDL-C distribution was estimated from the 1999 to 2014 National Health and Nutrition Examination Survey cycles and projected onto 2020 population estimates (Supplemental Methods, Table 2). To convert LDL-C from mg/dL to mmol/L, divide by 38.67. ASCVD = atherosclerotic cardiovascular disease; LDL-C = low-density lipoprotein cholesterol.

Main Cost-effectiveness Analysis

The baseline characteristics of the simulation cohorts are provided in Supplemental Table 10. Compared to women, on average, men had a higher mean LDL-C, lower mean HDL-C, higher mean SBP, and higher smoking rates.

For both men and women, the model projected that adding statin treatment for young adults with an LDL-C of ≥130 mg/dL to standard care would prevent the most ASCVD events and gain the most QALYs in the population (Table 3, Figure 2, Supplemental Table 11).

Figure 2.

Cost-Effectiveness Plane for Lipid-Lowering Strategies in U.S. Young Adults
The transparent points illustrated indicate that the strategy costs more and is less effective than another strategy (ie, strictly dominated). The solid blue lines represent strategies that are eligible to be considered the preferred treatment (ie, the cost-effectiveness frontier, which comprises the nondominated strategies ranked by increasing effectiveness). A strategy is considered cost-effective if the slope of the blue line connecting it to the next least effective strategy (ie, the incremental cost-effectiveness ratio) is lower than the slope of the cost-effectiveness threshold line. The preferred strategy is defined as the treatment that results in the greatest QALY gains and is cost-effective. Red dotted line is cost-effectiveness threshold of $50,000/QALY. Red dashed line is cost-effectiveness threshold of $150,000/QALY. To convert LDL-C from mg/dL to mmol/L, divide by 38.67. LDL-C = low-density lipoprotein cholesterol; QALY = quality-adjusted life year.

For young adult men with an LDL-C of ≥160 mg/dL, statin therapy was estimated to produce an ICER of US$13,200/QALY compared to standard care. Further expanding statin eligibility to young adult men with an LDL-C of ≥130 mg/dL was estimated to produce an ICER of US$31,000/QALY compared with statins for an LDL-C of ≥160 mg/dL. For young adult women with an LDL-C of ≥160 mg/dL, the model projected that statins would produce an ICER of US$51,500/QALY compared to standard care. Further expanding statin eligibility to young adult women with an LDL-C of ≥130 mg/dL produced an ICER of US$106,000/QALY. Young adult lifestyle treatment strategies were all predicted to be more costly and less effective than statin treatment strategies (ie, strictly dominated).

For men, statin therapy for individuals with an LDL-C of ≥130 mg/dL was projected to be the preferred strategy in 72% of probabilistic simulations at a cost-effectiveness threshold of US$50,000/QALY. At a cost-effectiveness threshold of US$50,000/QALY, standard care had the highest probability (51%) of being the preferred strategy for women (Supplemental Figure 4). At a higher cost-effectiveness threshold of US$150,000/QALY, however, statin therapy with an LDL-C of ≥130 mg/dL was projected to be the preferred treatment strategy for both men (95%) and women (59%).

In the secondary analysis, the model projected that statins plus intensive lifestyle intervention for young adults with an LDL-C of ≥160 mg/dL had a higher ICER and less QALYs gained than statin therapy alone for both men and women (ie, statins plus intensive lifestyle strategies were extendedly dominated) (Supplemental Table 12). Statins plus intensive lifestyle intervention for young adults with an LDL-C of ≥160 mg/dL were projected to produce ICERs of US$59,300/QALY and US$185,000/QALY compared to statin therapy alone for men and women, respectively.

Sensitivity Analysis

In sensitivity analyses, the cost-effectiveness of statin strategies was most sensitive to changes in the discount rate, statin efficacy, and magnitude of effect of cumulative exposure to LDL-C on CHD risk (Supplemental Figure 5). The cost-effectiveness of statin therapy could be improved for men and women by using low-price statin formulations, improving patient adherence, reducing the required check-up visits for persistent statin users, and averting patient pill-taking disutility. Results for the intensive lifestyle intervention strategies were sensitive to changes in the effect of such interventions on young adult LDL-C, discount rate, and the number of behavioral visits required in years subsequent to treatment initiation.

All treatments were projected to become more effective compared to standard care as the duration of the treatment effect increased (Supplemental Figure 6). Even when treatment effects were sustained for ≥10 years, statin treatment strategies were more cost-effective than intensive lifestyle interventions (Supplemental Figure 7).

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