Cost-effectiveness of coronary calcium testing to guide statin therapy: Preliminary Results CVD Risk Biomarker Symposium M...
Goals <ul><li>Compare  Test-and-Treat  strategies against  Treat none  and  Treat all </li></ul><ul><ul><li>For different ...
The CAC version of the model
Key Inputs
Key Inputs <ul><li>CAC relative risks from MESA </li></ul><ul><ul><li>0 ref </li></ul></ul><ul><ul><li>1-100 3.61 </li></u...
Key Inputs <ul><li>Prevalence of CAC, conditional on other CHD risk factors </li></ul><ul><li>Integrate CAC RR’s with prev...
Key Inputs <ul><li>CAC scan cost </li></ul><ul><ul><li>Test itself:  $107.03  (vs. $200 or $300) </li></ul></ul><ul><ul><l...
Other key parameters <ul><li>Statin cost </li></ul><ul><ul><li>Pills $4/month =  $0.13/day  (vs. $1.00/day) </li></ul></ul...
45 yo man with 5% risk Statins = $0.13 / day 10-year horizon Preliminary Results
45 yo man with 5% risk Steeper “slope” (good - depends of CAC RR) Shifted to the right (bad – depends on CAC $) Medium eff...
45 yo man with 5% risk Cost-effectiveness “frontier” (i.e., Non-dominated strategies) Statins = $0.13 / day 10-year horizo...
45 yo man with 5% risk ICER for non-dominated strategies $152,000 $57,000 Statins = $0.13 / day 10-year horizon Preliminar...
45 yo man with 5% risk If willingness to pay <$50,000/QALY,  Preferred strategy = Treat none $152,000 $57,000 Statins = $0...
45 yo man with  15% risk Statins = $0.13 / day 10-year horizon Preliminary Results
45 yo man with  10% risk Statins = $0.13 / day 10-year horizon $25,000/QALY Preliminary Results
45 yo man with  7.5% risk $55,000/QALY $8,000/QALY Preliminary Results
By age/risk <ul><li>Men, statins=$0.13/day, 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Age </li></ul...
By age/risk <ul><li>Men, statins=$0.13/day, 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Age </li></ul...
65  yo man with  7.5% risk $15,000/QALY $8,000/QALY $78,000/QALY Preliminary Results
By age/risk <ul><li>Women , statins=$0.13/day, 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Age </li><...
By age/risk <ul><li>Women , statins=$0.13/day, 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Age </li><...
65  yo  Woman  with  7.5% risk $18,000/QALY $59,000/QALY Preliminary Results
Sensitivity analyses <ul><li>Vary statin price and time horizon </li></ul>
Longer time horizon <ul><li>Women , statins=$0.13/day,  25-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>R...
Short horizon, expensive statins <ul><li>Women , statins =$1.00/day ,  10-year horizon </li></ul><ul><li>WTC >$50,000 </li...
Short horizon, expensive statins (men) <ul><li>Men , statins =$1.00/day ,  10-year horizon </li></ul><ul><li>WTC >$50,000 ...
Results <ul><li>CAC testing is often cost effective! </li></ul>Preliminary Results
Results <ul><li>Under what conditions is it NOT cost-effective for: </li></ul><ul><ul><li>55 yo woman, 10% risk </li></ul>...
By age/risk <ul><li>Women, statins=$0.13/day, 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Age </li></...
By RR/cost <ul><li>55 yo Women, 10% risk </li></ul><ul><li>Statins=$0.13/day, 10-year horizon, WTC >$50,000 </li></ul><ul>...
By RR/cost <ul><li>55 yo Women, 10% risk </li></ul><ul><li>Statins=$0.13/day, 10-year horizon, WTC >$50,000 </li></ul><ul>...
Base Case $16,000/QALY $126,000/QALY Preliminary Results
If cost of scan =  $300 Preliminary Results
If CAC is  half  as useful $24/QALY $37,000/QALY Preliminary Results
Summary <ul><li>CAC testing can be a cost-effective way to target statin therapy </li></ul><ul><ul><li>Depends on the cost...
Big questions <ul><li>How to deal with statin prices? </li></ul><ul><li>What is the right time horizon? </li></ul><ul><li>...
To do: <ul><li>More sensitivity & Monte Carlo analyses </li></ul><ul><li>Radiation-induced cancer from CAC CT </li></ul><u...
Thanks <ul><li>Questions?  Comments? </li></ul>
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Cost-Effectiveness of Coronary Calcium Testing to Guide Statin Therapy

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Presented by Mark Pletcher, MD, MPH, at UCSF's symposium "The Role of Risk Stratification and Biomarkers in Prevention of Cardiovascular Disease" in Jan 2012.

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  • Thanks for the introduction, and thanks for inviting me here today. I’m going to pitch an idea today that I think may be somewhat controversial, but it’s a controversy worthy, at least, of debate. The question is, should we give statins to persons at low short-term cardiovascular risk?
  • Cost-Effectiveness of Coronary Calcium Testing to Guide Statin Therapy

    1. 1. Cost-effectiveness of coronary calcium testing to guide statin therapy: Preliminary Results CVD Risk Biomarker Symposium Mark J. Pletcher, MD, MPH 1/30/2012
    2. 2. Goals <ul><li>Compare Test-and-Treat strategies against Treat none and Treat all </li></ul><ul><ul><li>For different age/sex/risk groups </li></ul></ul><ul><ul><li>Comparing different CAC score thresholds </li></ul></ul><ul><ul><li>Varying key parameters </li></ul></ul><ul><ul><ul><li>Statin price, time horizon, cost of testing </li></ul></ul></ul>
    3. 3. The CAC version of the model
    4. 4. Key Inputs
    5. 5. Key Inputs <ul><li>CAC relative risks from MESA </li></ul><ul><ul><li>0 ref </li></ul></ul><ul><ul><li>1-100 3.61 </li></ul></ul><ul><ul><li>101-300 7.73 </li></ul></ul><ul><ul><li>300+ 9.67 </li></ul></ul>NEJM 2008;358:1336-45
    6. 6. Key Inputs <ul><li>Prevalence of CAC, conditional on other CHD risk factors </li></ul><ul><li>Integrate CAC RR’s with prevalence to get CAC category-specific absolute risk </li></ul>BMC Medicine 2004;2:31
    7. 7. Key Inputs <ul><li>CAC scan cost </li></ul><ul><ul><li>Test itself: $107.03 (vs. $200 or $300) </li></ul></ul><ul><ul><li>Physician visit to discuss results: $71.01 </li></ul></ul><ul><ul><li>Total testing cost = $178.04 </li></ul></ul>
    8. 8. Other key parameters <ul><li>Statin cost </li></ul><ul><ul><li>Pills $4/month = $0.13/day (vs. $1.00/day) </li></ul></ul><ul><ul><li>Extra physician visit/year = $68.97 </li></ul></ul><ul><ul><li>Extra lipid panel/year = $23.44 </li></ul></ul><ul><ul><li>Total annual cost = $140.96 </li></ul></ul><ul><li>Time horizon </li></ul><ul><ul><li>10 years (vs. 25 years) </li></ul></ul><ul><li>Willingness to pay </li></ul><ul><ul><li>$50,000/QALY </li></ul></ul>
    9. 9. 45 yo man with 5% risk Statins = $0.13 / day 10-year horizon Preliminary Results
    10. 10. 45 yo man with 5% risk Steeper “slope” (good - depends of CAC RR) Shifted to the right (bad – depends on CAC $) Medium effectiveness (depends on # treated, prev of CAC) Statins = $0.13 / day 10-year horizon Preliminary Results
    11. 11. 45 yo man with 5% risk Cost-effectiveness “frontier” (i.e., Non-dominated strategies) Statins = $0.13 / day 10-year horizon Preliminary Results
    12. 12. 45 yo man with 5% risk ICER for non-dominated strategies $152,000 $57,000 Statins = $0.13 / day 10-year horizon Preliminary Results
    13. 13. 45 yo man with 5% risk If willingness to pay <$50,000/QALY, Preferred strategy = Treat none $152,000 $57,000 Statins = $0.13 / day 10-year horizon Preliminary Results
    14. 14. 45 yo man with 15% risk Statins = $0.13 / day 10-year horizon Preliminary Results
    15. 15. 45 yo man with 10% risk Statins = $0.13 / day 10-year horizon $25,000/QALY Preliminary Results
    16. 16. 45 yo man with 7.5% risk $55,000/QALY $8,000/QALY Preliminary Results
    17. 17. By age/risk <ul><li>Men, statins=$0.13/day, 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Age </li></ul><ul><li>Risk 35 45 55 65 </li></ul><ul><li>2.5% --- --- --- </li></ul><ul><li>5% --- --- >0 >0 </li></ul><ul><li>7.5% All >0 >0 >0 </li></ul><ul><li>10% All All All All </li></ul><ul><li>15% All All All All </li></ul><ul><li>25% All All All All </li></ul>Preliminary Results
    18. 18. By age/risk <ul><li>Men, statins=$0.13/day, 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Age </li></ul><ul><li>Risk 35 45 55 65 </li></ul><ul><li>2.5% --- --- --- </li></ul><ul><li>5% --- --- >0 >0 </li></ul><ul><li>7.5% All >0 >0 >0 </li></ul><ul><li>10% All All All All </li></ul><ul><li>15% All All All All </li></ul><ul><li>25% All All All All </li></ul>Preliminary Results
    19. 19. 65 yo man with 7.5% risk $15,000/QALY $8,000/QALY $78,000/QALY Preliminary Results
    20. 20. By age/risk <ul><li>Women , statins=$0.13/day, 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Age </li></ul><ul><li>Risk 35 45 55 65 </li></ul><ul><li>2.5% --- --- --- --- </li></ul><ul><li>5% >0 --- --- --- </li></ul><ul><li>7.5% >0 >0 >0 >100 </li></ul><ul><li>10% >0 >0 All </li></ul><ul><li>15% All >0 All </li></ul><ul><li>25% All All All </li></ul>Preliminary Results
    21. 21. By age/risk <ul><li>Women , statins=$0.13/day, 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Age </li></ul><ul><li>Risk 35 45 55 65 </li></ul><ul><li>2.5% --- --- --- --- </li></ul><ul><li>5% >0 --- --- --- </li></ul><ul><li>7.5% >0 >0 >0 >100 </li></ul><ul><li>10% >0 >0 All </li></ul><ul><li>15% All >0 All </li></ul><ul><li>25% All All All </li></ul>Preliminary Results
    22. 22. 65 yo Woman with 7.5% risk $18,000/QALY $59,000/QALY Preliminary Results
    23. 23. Sensitivity analyses <ul><li>Vary statin price and time horizon </li></ul>
    24. 24. Longer time horizon <ul><li>Women , statins=$0.13/day, 25-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Risk 35 45 55 65 </li></ul><ul><li>2.5% >0 >0 >0 >100 </li></ul><ul><li>5% All >0 >0 >0 </li></ul><ul><li>7.5% All All >0 All </li></ul><ul><li>10% All All All </li></ul><ul><li>15% All All All </li></ul><ul><li>25% All All All </li></ul>Preliminary Results
    25. 25. Short horizon, expensive statins <ul><li>Women , statins =$1.00/day , 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Risk 35 45 55 65 </li></ul><ul><li>2.5% --- --- --- --- </li></ul><ul><li>5% --- --- --- --- </li></ul><ul><li>7.5% --- --- --- --- </li></ul><ul><li>10% --- --- --- </li></ul><ul><li>15% >100 >100 >100 </li></ul><ul><li>25% >0 >0 >0 </li></ul>Preliminary Results
    26. 26. Short horizon, expensive statins (men) <ul><li>Men , statins =$1.00/day , 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Risk 35 45 55 65 </li></ul><ul><li>2.5% --- --- --- --- </li></ul><ul><li>5% --- --- --- --- </li></ul><ul><li>7.5% --- --- --- >100 </li></ul><ul><li>10% --- >0 >0 >100 </li></ul><ul><li>15% >0 >0 >0 >0 </li></ul><ul><li>25% >0 >0 >0 </li></ul>Preliminary Results
    27. 27. Results <ul><li>CAC testing is often cost effective! </li></ul>Preliminary Results
    28. 28. Results <ul><li>Under what conditions is it NOT cost-effective for: </li></ul><ul><ul><li>55 yo woman, 10% risk </li></ul></ul><ul><ul><li>Statins = $0.13/day </li></ul></ul><ul><ul><li>Time horizon = 10 years </li></ul></ul>Preliminary Results
    29. 29. By age/risk <ul><li>Women, statins=$0.13/day, 10-year horizon </li></ul><ul><li>WTC >$50,000 </li></ul><ul><li>Age </li></ul><ul><li>Risk 35 45 55 65 </li></ul><ul><li>2.5% --- --- --- --- </li></ul><ul><li>5% >0 --- --- >0 </li></ul><ul><li>7.5% >0 >0 >0 >100 </li></ul><ul><li>10% >0 >0 All </li></ul><ul><li>15% All >0 All </li></ul><ul><li>25% All All All </li></ul>Preliminary Results
    30. 30. By RR/cost <ul><li>55 yo Women, 10% risk </li></ul><ul><li>Statins=$0.13/day, 10-year horizon, WTC >$50,000 </li></ul><ul><li>$/scan </li></ul><ul><li>CAC RR $300 $200 $107.03 (Base case) </li></ul><ul><li>x .50 All All All </li></ul><ul><li>x .75 All All >0 </li></ul><ul><li>Base case All >0 >0 </li></ul>Preliminary Results
    31. 31. By RR/cost <ul><li>55 yo Women, 10% risk </li></ul><ul><li>Statins=$0.13/day, 10-year horizon, WTC >$50,000 </li></ul><ul><li>$/scan </li></ul><ul><li>CAC RR $300 $200 $107.03 (Base case) </li></ul><ul><li>x .50 All All All </li></ul><ul><li>x .75 All All >0 </li></ul><ul><li>Base case All >0 >0 </li></ul>Preliminary Results
    32. 32. Base Case $16,000/QALY $126,000/QALY Preliminary Results
    33. 33. If cost of scan = $300 Preliminary Results
    34. 34. If CAC is half as useful $24/QALY $37,000/QALY Preliminary Results
    35. 35. Summary <ul><li>CAC testing can be a cost-effective way to target statin therapy </li></ul><ul><ul><li>Depends on the cost of the scan </li></ul></ul><ul><ul><li>Testing thresholds depend on statin price </li></ul></ul>Preliminary Results
    36. 36. Big questions <ul><li>How to deal with statin prices? </li></ul><ul><li>What is the right time horizon? </li></ul><ul><li>Statin effectiveness and CAC prediction at the tails of the age-risk distribution </li></ul>
    37. 37. To do: <ul><li>More sensitivity & Monte Carlo analyses </li></ul><ul><li>Radiation-induced cancer from CAC CT </li></ul><ul><li>Other downsides of testing? </li></ul><ul><li>Update CAC prevalence with MESA </li></ul><ul><li>ASA, and ASA+Statins (dif thresholds?) </li></ul><ul><li>Lifetime horizon with delayed treatment </li></ul><ul><li>Online tool… </li></ul>
    38. 38. Thanks <ul><li>Questions? Comments? </li></ul>
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