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Cost-Effectiveness of Coronary Calcium Testing to Guide Statin Therapy

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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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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