Article Figures & Data
Tables
Parameter Value Sensitivity Rangea Source Aspirin for primary prevention of CVD and colorectal cancer Colorectal cancer incidence >10 y, RR 0.60 0.76/0.47 Chubak27,28 Cardiovascular disease death, RR 1.00 1.00/0.97 Guirguis-Blake29,30 Gastrointestinal bleed, RR 1.58 1.95/1.29 Whitlock31,32 Hemorrhagic stroke, RR 1.27 1.68/1.00 Whitlock31,32 Ischemic stroke, nonfatal, RR 0.86 0.98/0.76 Guirguis-Blake29,30 Myocardial infarction, nonfatal, RR 0.83 0.94/0.74 Guirguis-Blake29,30 Cost per screening, $ 29.23 ± 25% See text Treatment cost, annual, $ 18.23 ± 25% See text Cholesterol screening High-density lipoprotein, median treatment efficacy, mg/dL +1.6 Not considered 4S,33 Downs,34 Holdaas,32 Sever,33 Knopp,37 MRC/BHF,38 LIPID,39 Shepherd40,41 Low-density lipoprotein, median treatment efficacy, mg/dL −49.9 Not considered 4S,33 Downs,34 Holdaas,32 Sever,33 Knopp,37 MRC/BHF,38 LIPID,39 Shepherd40,41 Cost per screening, $ 55.56 ± 25% See text Treatment and management cost, annual, $ 528.00 ± 25% See text Hypertension screening Systolic blood pressure, median treatment efficacy, mm Hg −6.5 Not considered Liu,42 Beckett,43 MRC,44 MRC,45 PROGRESS,46 SHEP,47 Dahlof,48 Liu,49 Staessen50 Cost per screening, $ 29.23 ± 25% See text Treatment and management annual cost, $ 278.52 ± 25% See text All services Aspirin use rate, primary/secondary prevention, % 77/86 ± 10% points NHIS51 Blood pressure and lipid medication use rates, primary/secondary prevention, % Age 18–39 y 62/77 ± 10% points NHANES52–56 Age 40–64 y 84/89 ± 10% points NHANES52–56 Age >65 y 94/97 ± 10% points NHANES52–56 Myocardial infarction cost, 1st y/ongoing, $ 37,095/2,490 ± 25% AHRQ/MEPS57 Myocardial infarction QALY decrement, 1st y/ongoing 0.3 (3 mo)/0.0 ± 0.1 QALY Maciosek58 Screening and counseling acceptance rate, % 90 ± 10% points Assumed Stroke cost, 1st y/ongoing, $ 18,192/5,389 ± 25% AHRQ/MEPS57 Stroke QALY decrement, 1st y/ongoing 0.4/0.4 ± 0.1 QALY Maciosek58 Treatment effectiveness, % 70 ± 10% points Calibrated assumption 4S = Scandinavian Simvastatin Survival Study; AHRQ = Agency for Healthcare Research and Quality; CVD = cardiovascular disease; MEPS = Medical Expenditure Panel Survey; NCEP = National Cholesterol Education Program; NCHS = National Center for Health Statistics; NHANES = National Health and Nutrition Examination Survey; QALY = quality-adjusted life years; RR = relative risk; SHEP = Systolic Hypertension in the Elderly Program.
↵a The sensivity range indicates the lower and upper bounds (ie, worst case/best case) used in the deterministic sensitivity analysis.
Variable Total, % Men, % Women, % Non-Hispanic White, % Non-Hispanic Black, % Hispanic % Hypertension ModelHealth: CVD 29.2 30.0 28.4 26.1 45.0 27.5 NHANES (2007–2010)72 29.6 30.5 28.6 28.6 41.3 27.7 Elevated lipid levels (LDL ≥130) ModelHealth: CVD 29.8 27.8 31.6 29.6 29.9 30.2 NHANES (2009–2012)5 31.7 31.0 32.0 30.7 32.2 35.3 Coronary heart disease ModelHealth: CVD 6.5 8.6 4.7 6.3 7.2 6.7 BRFSS (2010)73 6.0 7.8 4.6 5.8 6.5 6.1 Stroke ModelHealth: CVD 2.5 2.6 2.4 2.3 4.1 2.3 BRFSS (2010)74 2.6 2.7 2.6 2.4 3.9 2.5 BRFSS = Behavioral Risk Factor Surveillance System; CVD = cardiovascular disease; LDL = low-density lipoprotein; NHANES = National Health and Nutrition Examination Survey.
Note: Risk factor and event prevalence rates are age-adjusted. ModelHealth: CVD data are generated from a birth cohort starting at age 18 years.
- Table 3
Predicted Lifetime Health and Cost Outcomes of CVD Clinical Preventive Services in US Population Groups
Preventive Service US Adults Men Women Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic White Non-Hispanic Black Hispanic Aspirin for primary prevention Health impact, QALY 2,200 2,700 6,800 2,300 300 5,000 100 Cost-effectiveness, $ 31 saved pp 50 saved pp 166 saved pp 47 saved pp 16,700/QALY 14 saved pp 60,200/QALY CVD events, No. −530 −750 −2,030 −840 −20 −530 −20 MI events −300 −470 −930 −530 −20 −190 −10 Stroke events −100 −110 −420 −110 Longevitya −240 −10 CVD deaths −80 −110 −340 −150 −10 −100 −10 CRC cases, No. −280 −370 −860 −390 −80 −370 −20 Persons treated for primary prevention, No. 15,600 22,000 39,200 27,500 2,300 21,000 2,200 Total costs, $ million −3.1 −5.0 −16.6 −4.7 0.8 −1.4 1.1 Disease costs −5.5 −7.9 −21.7 −8.3 −0.3 −4.8 −0.2 Screening costs 1.1 1.1 1.1 1.3 0.8 1.1 1.1 Treatment costs 1.4 1.8 4.0 2.3 0.2 2.3 0.2 Cholesterol screening Health impact, QALY 14,300 17,500 25,600 19,700 7,900 14,200 9,100 Cost-effectiveness, $/QALY 33,800 29,400 22,900 25,600 56,500 42,100 48,900 CVD events, No. −3,960 −5,090 −6,630 −5,320 −2,150 −3,520 −2,940 MI events −1,500 −2,150 −2,860 −2,070 −700 −960 −930 Stroke events −40 −150 Longevitya −40 Longevitya −130 −20 CVD deaths −1,010 −1,120 −1,450 −1,220 −820 −1,120 −630 Persons treated for primary prevention, No. 40,100 43,300 51,400 45,500 32,500 43,100 36,000 Total costs, $ million 80.1 89.0 106.4 90.1 61.3 90.9 65.1 Disease costs −36.3 −51.5 −76.4 −58.8 −12.1 −22.6 −21.9 Screening costs 16.1 17.7 18.6 18.5 13.1 18.2 14.4 Treatment and management costs 100.3 122.8 164.3 130.3 60.2 95.4 72.5 Hypertension screening Health impact, QALY 15,600 11,800 17,000 14,900 16,500 24,700 16,300 Cost-effectiveness, $/QALY 48,500 52,200 60,600 40,800 48,300 42,100 49,500 CVD events, No. −4,000 −3,460 −3,740 −4,060 −3,920 −5,930 −4,610 MI events −750 −880 −970 −860 −600 −630 −690 Stroke events −1,020 −680 −860 −720 −1,100 −2,250 −1,180 CVD deaths −1,010 −780 −1,080 −1,040 −1,070 −1,480 −1,080 Persons treated for primary prevention, No. 53,400 46,200 58,900 47,900 56,700 64,700 59,000 Total costs, $ million 122.9 105.7 184.6 102.7 119.7 176.4 121.6 Disease costs −34.8 −33.6 −37.5 −31.6 −30.7 −58.2 −38.0 Screening costs 33.8 34.2 27.4 34.4 35.4 28.8 34.9 Treatment and management costs 124.0 105.1 194.7 99.9 115.0 205.9 124.8 CRC = colorectal cancer; CVD = cardiovascular disease; MI = myocardial infarction; pp = per person; QALY = quality-adjusted life year.
Note: All outcomes are standardized for comparison purposes to reflect the lifetime of a 100,000 person US-representative birth cohort within each respective group starting at age 18 years. Cost-effectiveness is expressed in terms of incremental costs per QALY, unless a preventive service is cost-saving overall, in which case, it is expressed in terms of costs saved per person. All costs are expressed in 2012 US dollars.
↵a Population rates in the outcome are projected to stay the same or increase slightly due to increases in life expectancy attributable to the clinical preventive service.
- Table 4
Relative Value of Clinical Preventive Services for CVD, by Outcome, for US Population Group
Outcome US Adults Men Women Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic White Non-Hispanic Black Hispanic Largest health impact (QALY) Hypertensiona (15,600) Cholesterol (17,500) Cholesterol (25,600) Cholesterol (19,700) Hypertension (16,500) Hypertension (24,700) Hypertension (16,300) Cholesterolb (14,300) Hypertension (11,800) Hypertension (17,000) Hypertension (14,900) Cholesterol (7,900) Cholesterol (14,200) Cholesterol (9,100) Aspirinc (2,200) Aspirin (2,700) Aspirin (6,800) Aspirin (2,300) Aspirin (300) Aspirin (5,000) Aspirin (100) Highest cost-effectiveness ($ saved pp, or $ per QALY) Aspirin (31 pp) Aspirin (50 pp) Aspirin (166 pp) Aspirin (47 pp) Aspirin (16,700/QALY) Aspirin (14 pp) Cholesterol (48,900/QALY) Cholesterol (33,800/QALY) Cholesterol (29,400/QALY) Cholesterol (22,900/QALY) Cholesterol (25,600/QALY) Hypertension (48,300/QALY) Cholesterol (42,100/QALY) Hypertension (49,500/QALY) Hypertension (48,500/QALY) Hypertension (52,200/QALY) Hypertension (60,600/QALY) Hypertension (40,800/QALY) Cholesterol (56,500/QALY) Hypertension (42,100/QALY) Aspirin (60,200/QALY) Most prevented myocardial infarctions (No.) Cholesterol (1,500) Cholesterol (2,150) Cholesterol (2,860) Cholesterol (2,070) Cholesterol (700) Cholesterol (960) Cholesterol (930) Hypertension (750) Hypertension (880) Hypertension (970) Hypertension (860) Hypertension (600) Hypertension (630) Hypertension (690) Aspirin (300) Aspirin (470) Aspirin (930) Aspirin (530) Aspirin (20) Aspirin (190) Aspirin (10) Most prevented strokes (No.) Hypertension (1,020) Hypertension (680) Hypertension (860) Hypertension (720) Hypertension (860) Hypertension (2,250) Hypertension (1,180) Aspirin (100) Cholesterol (150) Aspirin (420) Aspirin (110) Aspirin (longevityd) Aspirin (240) Cholesterol (20) Cholesterol (40) Aspirin (110) Cholesterol (longevityd) Cholesterol (40) Cholesterol (longevityd) Cholesterol (130) Aspirin (10) CVD = cardiovascular disease; pp = per person; QALY = quality-adjusted life year.
Note: Preventive services are aspirin counseling, hypertension screening, and cholesterol screening. All outcomes are for the lifetime of a 100,000-person US-representative birth cohort within each respective group starting at age 18 years. Cost-effectiveness is expressed in terms of incremental costs per QALY, unless a preventive service is cost saving overall, in which case, it is expressed in terms of costs saved per person. All costs expressed in 2012 US dollars.
↵a Hypertension screening and management in adults.
↵b Lipid disorder screening and management in adults.
↵c Aspirin for the primary prevention of cardiovascular disease and colorectal cancer.
↵d Population rates in the outcome are projected to stay the same or increase slightly because of increases in life expectancy attributable to the clinical preventive service.
Parameter Health Impact QALY Cost-Effectiveness $ Cardiovascular Disease Event, No. Total Cost $ Million Aspirin for primary prevention Base case 2,200 31 saved pp −530 −3.1 Treatment efficacy Low 200 91,700/QALY −50 2.5 High 4,000 68 saved pp −910 −6.8 Treatment effectiveness −10% (60% effectiveness) 1,800 18 saved pp −370 −1.8 +10% (80% effectiveness) 2,600 45 saved pp −720 −4.5 Disease costs −25% 2,200 17 saved pp −530 −1.7 +25% 2,200 45 saved pp −530 −4.5 Screening and medication costs Screening (clinic) costs, −25% 2,200 32 saved pp −530 −3.2 Screening (clinic) costs, +25% 2,200 30 saved pp −530 −3.0 Bulk aspirin (−35%), $11.93/y 2,200 36 saved pp −530 −3.6 Name brand aspirin (+32%), $24.04/y 2,200 27 saved pp −530 −2.7 No patient time cost 2,200 37 saved pp −530 −3.7 QALY decrements −0.10 QALY 2,100 31 saved pp −530 −3.1 +0.10 QALY 2,300 31 saved pp −530 −3.1 Cholesterol screening Base case 14,300 33,800/QALY −3,960 80.1 Treatment effectiveness −10% (60% effectiveness) 12,400 35,100/QALY −3,510 71.8 +10% (80% effectiveness) 18,300 27,200/QALY −5,140 81.9 Disease costs −25% 14,300 37,600/QALY −3,960 89.2 +25% 14,300 30,000/QALY −3,960 71.0 Screening, management, and medication costs Screening and management (clinic) costs, −25% 14,300 30,800/QALY −3,960 73.0 Screening and management (clinic) costs, +25% 14,300 36,800/QALY −3,960 87.2 Discount generic medications (−91%), $36.70/y 14,300 5,300/QALY −3,960 12.6 Name brand medications (+804%), $3,818.73/y 14,300 284,800/QALY −3,960 675.1 No patient time cost 14,300 28,000/QALY −3,960 66.4 QALY decrements −0.10 QALY 13,400 37,400/QALY −3,960 80.1 +0.10 QALY 15,000 31,400/QALY −3,960 80.1 Hypertension screening Base case 15,600 48,500/QALY −4,000 122.9 Treatment effectiveness −10% (60% effectiveness) 11,800 60,300/QALY −3,060 115.7 +10% (80% effectiveness) 19,800 39,700/QALY −5,100 127.1 Disease costs −25% 15,600 52,000/QALY −4,000 131.6 +25% 15,600 45,100/QALY −4,000 114.2 Screening, management, and medication costs Screening and management (clinic) costs, −25% 15,600 44,400/QALY −4,000 112.5 Screening and management (clinic) costs, +25% 15,600 52,500/QALY −4,000 133.1 Discount generic medications (−82%), $36.70/y 15,600 26,200/QALY −4,000 66.5 Name brand medications (+1,973%), $4,216.16/y 15,600 584,600/QALY −4,000 1,481.0 No patient time cost 15,600 34,200/QALY −4,000 86.6 QALY decrements −0.10 QALY 14,900 52,300/QALY −4,000 122.9 +0.10 QALY 15,700 46,800/QALY −4,000 122.9 CE = cost-effectiveness; CVD = cardiovascular disease; pp = per person; QALY = quality-adjusted life years.
Note: Cost-effectiveness is expressed in terms of incremental costs per QALY, unless a preventive service is cost-saving overall, in which case, it is expressed in terms of costs saved per person. Sources for the sensitivity ranges for medication costs are described in the Supplemental Appendix (Supplemental Appendix http://www.annfammed.org/content/15/1/23/suppl/DC1). All costs are expressed in 2012 US dollars.
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The Article in Brief
Health Benefits and Cost-Effectiveness of Asymptomatic Screening for Hypertension and High Cholesterol and Aspirin Counseling for Primary Prevention
Steven P. Dehmer , and colleagues
Background Cardiovascular disease (CVD) is the leading cause of death and one of the greatest causes of illness in the United States today. Total direct and indirect costs are estimated to exceed $300 billion annually and total direct medical costs are projected to triple by 2030. This study updates estimates of the health and economic impact of three services recommended for preventing CVD: cholesterol screening, lipid screening, and aspirin counseling.
What This Study Found All three services continue to rank highly among recommended preventive services for U.S. adults in primary care. Health impact is highest for hypertension screening and treatment, closely followed by cholesterol screening and treatment. Aspirin counseling has lower health impact but is cost saving. Outcomes for subgroups of the population sometimes diverge in meaningful ways from the population average. For example, findings favor hypertension over cholesterol screening for women, and opportunities to reduce disease burden across all services are greatest for the non-Hispanic black population.
Implications
- Clinical services to prevent CVD can avert substantial disease burden and save costs. Such services should remain among the top prevention priorities for adults in primary care.
- Individual priorities should be tailored by taking a patient's demographic characteristics and clinical objectives into account.
