Introduction:
Uncertainty remains regarding the most efficient and cost-effective 10-year atherosclerotic cardiovascular disease (ASCVD) risk prediction tool for identifying moderate to high-risk patients for primary prevention statin treatment.
Methods:
We utilized the CVD Policy Model, a computer microsimulation model of ASCVD incidence, prevalence, mortality, and costs, to compare cost-effectiveness of statin treatment at varying 10-year predicted ASCVD risk thresholds for Framingham CVD (FRS-CVD), Reynolds Risk Score (RRS), and Pooled Cohorts Risk Equations over a 10-year time horizon in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort. Cost effectiveness was assessed at predicted 10-year risk ≥ 20.0%, 15.0%, 10.0%, 7.5%, 5.0%, and 2.5%. We restricted the simulation cohort to participants aged 50 to 74 years who were not taking statins at baseline (n = 2,871). Moderate intensity statin treatment effectiveness was parameterized in the model as a 29% low-density lipoprotein cholesterol reduction. Total cost comprised statins ($100/year), side effect costs, and ASCVD event costs. Disability from treatment side effects and ASCVD events were included.
Results:
Average FRS-CVD, RRS, and Pooled Cohorts 10-year predicted ASCVD risks were 18.8%, 11.3%, 12.2%, for men and 8.9%, 4.3%, 6.6%, for women, respectively. At the same predicted risk, FRS-CVD consistently selected the most patients for treatment, and RRS the fewest (
Figure
). Compared with no treatment, treating patients with RRS ≥ 20% was cost saving in men. Subsequent risk threshold strategies with incremental cost effectiveness <$75,000/quality-adjusted life-year (QALY) for men were: FRS-CVD ≥ 20% ($13,046), RRS ≥ 7.5% ($17,774), and RRS ≥ 5.0% ($19,891). For women, the non-dominated thresholds were: Pooled Cohorts ≥ 15% ($27,908) and Pooled Cohorts ≥ 7.5% ($72,377).
Conclusions:
At cost-effectiveness thresholds less than $75,000/QALY, RRS was the highest value tool for men while the Pooled Cohorts Risk Equations performed best for women.
Cost-Effectiveness of Coronary Artery Calcium Testing for Coronary Heart and Cardiovascular Disease Risk Prediction to Guide Statin Allocation: The Multi-Ethnic Study of Atherosclerosis (MESA)