Hostname: page-component-78c5997874-lj6df Total loading time: 0 Render date: 2024-11-10T13:03:33.605Z Has data issue: false hasContentIssue false
  • English
  • Français

Cost of lipid lowering in patients with coronary artery disease by Case Method Learning

Published online by Cambridge University Press:  26 April 2005

Anna Kiessling ,
Niklas Zethraeus  and
Peter Henriksson
Anna Kiessling
Affiliation:
Karolinska Institute and Danderyd University Hospital
Niklas Zethraeus
Affiliation:
University of Stockholm
Peter Henriksson
Affiliation:
Karolinska Institute and Danderyd University Hospital
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives: This investigation was undertaken to study the costs of a Case Method Learning (CML) -supported lipid-lowering strategy in secondary prevention of coronary artery disease (CAD) in primary care.

Methods: This prospective randomized controlled trial in primary care with an additional external specialist control group in Södertälje, Stockholm County, Sweden, included 255 consecutive patients with CAD. Guidelines were mailed to all general practitioners (GPs; n=54) and presented at a common lecture. GPs who were randomized to the intervention group participated in recurrent CML dialogues at their primary health-care centers during a 2-year period. A locally well-known cardiologist served as a facilitator. Assessment of low-density lipoprotein (LDL) cholesterol was performed at baseline and after 2 years. Analysis according to intention-to-treat—intervention and control groups (n=88)—was based on group affiliation at baseline. The marginal cost of lipid lowering comprised increased cost of lipid-lowering drugs in the intervention group compared with the primary care control group, cost of attendance of the GP's in the intervention group, and cost of time for preparation, travel, and seminars of the facilitator. Costs are as of 2002 with an exchange rate 1 US$=9.5 SEK (Swedish Crowns).

Results: Patients in the primary care intervention group had their LDL cholesterol reduced by 0.5 (confidence interval [CI], 0.1–0.9) mmol/L compared with the primary care control group (p<.05). No change occurred in controls. LDL cholesterol in the external specialist control group decreased by 0.6 (CI, 0.4–0.8) mmol/L. The cost of the educational intervention represented only 2 percent of the drug cost. The cost of lipid lowering in the intervention group, including the cost of the educational intervention, was actually lower than that of patients treated at the specialist clinic—106 US$ per mmol decrease in LDL cholesterol in the intervention group and 153 US$ per mmol decrease in LDL cholesterol in the specialist group. EuroQol 5D Index, which gives an estimate of global health-related quality of life, was 0.80 (CI, 0.75–0.85) in the present cohort.

Conclusions: The additional cost of CML was only 2 percent of the drug cost. Assuming the same gain in life expectancy per millimole decrease in LDL cholesterol as in the 4S-study gives a cost per gained quality-adjusted life year of US$ 24,000. This finding indicates that the CML-supported lipid-lowering strategy is cost-effective. The low cost of CML in primary care should probably warrant its use in the improvement of the quality of care in other major chronic diseases.

Keywords

Coronary artery diseaseLipidsAntilipemic agentsHealth-care costsEducationMedicalContinuingQuality of life
Type
GENERAL ESSAYS
Information
International Journal of Technology Assessment in Health Care , Volume 21 , Issue 2 , April 2005 , pp. 180 - 186
Copyright
© 2005 Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Clinical reality of coronary prevention guidelines: A comparison of EUROASPIRE I and II in nine countries. 2001; EUROASPIRE I and II Group. European action on secondary prevention by intervention to reduce events. Lancet. 357: 995– 1001.
Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). 1994; Lancet. 344: 1383– 1389.
Bjork S, Norinder A. 1999; The weighting exercise for the Swedish version of the EuroQol. Health Econ. 8: 117– 126.Google Scholar
Brooks R. 1996; EuroQol: The current state of play. Health Policy. 37: 53– 72.Google Scholar
Cabana MD, Rand CS, Powe NR, et al. 1999; Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 282: 1458– 1465.Google Scholar
Dolan P. 1997; Modeling valuations for EuroQol health states. Med Care. 35: 1095– 1108.Google Scholar
Ekman M, Zethraeus N, Dahlstrom U, et al. 2002; [Cost-effectiveness of bisoprolol in chronic heart failure]. Lakartidningen. 99: 646– 650.Google Scholar
Fairhurst K, Huby G. 1998; From trial data to practical knowledge: Qualitative study of how general practitioners have accessed and used evidence about statin drugs in their management of hypercholesterolaemia. BMJ. 317: 1130– 1134.Google Scholar
Fuat A, Hungin AP, Murphy JJ. 2003; Barriers to accurate diagnosis and effective management of heart failure in primary care: Qualitative study. BMJ. 326: 196.Google Scholar
Hirth RA, Chernew ME, Miller E, et al. 2000; Willingness to pay for a quality-adjusted life year: In search of a standard. Med Decis Making. 20: 332– 342.Google Scholar
Johannesson M. 2001; At what coronary risk level is it cost-effective to initiate cholesterol lowering drug treatment in primary prevention? Eur Heart J. 22: 919– 925.Google Scholar
Johannesson M, Jonsson B, Kjekshus J, et al. 1997; Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. Scandinavian Simvastatin Survival Study Group. N Engl J Med. 336: 332– 336.Google Scholar
Jonsson B, Johannesson M, Kjekshus J, et al. 1996; Cost-effectiveness of cholesterol lowering. Results from the Scandinavian Simvastatin Survival Study (4S). Eur Heart J. 17: 1001– 1007.Google Scholar
Kiessling A, Henriksson P. 2002; Efficacy of case method learning in general practice for secondary prevention in patients with coronary artery disease: Randomised controlled study. BMJ. 325: 877– 880.Google Scholar
Meltzer D. 1997; Accounting for future costs in medical cost-effectiveness analysis. J Health Econ. 16: 33– 64.Google Scholar
Pickin DM, McCabe CJ, Ramsay LE, et al. 1999; Cost effectiveness of HMG-CoA reductase inhibitor (statin) treatment related to the risk of coronary heart disease and cost of drug treatment. Heart. 82: 325– 332.Google Scholar
Rabin R, de Charro F. 2001; EQ-5D: A measure of health status from the EuroQol Group. Ann Med. 33: 337– 343.Google Scholar
Sacks FM, Pfeffer MA, Moye LA, et al. 1996; The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med. 335: 1001– 1009.Google Scholar
Salkeld G, Phongsavan P, Oldenburg B, et al. 1997; The cost-effectiveness of a cardiovascular risk reduction program in general practice. Health Policy. 41: 105– 119.Google Scholar
Simes J, Furberg CD, Braunwald E, et al. 2002; Effects of pravastatin on mortality in patients with and without coronary heart disease across a broad range of cholesterol levels. The Prospective Pravastatin Pooling project. Eur Heart J. 23: 207– 215.Google Scholar
WHO. 1983 Proposal for the multinational monitoring of trends and determinants in cardiovascular disease (MONICA) project and protocol. Geneva: Cardiovascular Disease Unit, World Health Organisation.