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Estimating the Benefits of Increasing HDL-C

Vivian H. Hamilton, PhD; Francois-Eric Racicot, MSc; Hanna Zowall, MA; Louis Coupal, MSc; Steven A. Grover, MD, MPA, FRCPC

JAMA. 1995;273(13):1032-1038.

Abstract
Objective.
—To evaluate the lifetime cost-effectiveness of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors for treatment of high blood cholesterol levels.

Design.
—We added cost data to a validated coronary heart disease (CHD) prevention computer model that estimates the benefits of lifelong risk factor modification. The updated model takes into account the costs of cholesterol reduction, the savings in CHD health care costs attributable to intervention, the additional non-CHD costs resulting from patients' living longer, and the beneficial effects of reducing CHD risk by reducing total cholesterol and increasing high-density lipoprotein cholesterol (HDL-C).

Patients.
—Men and women aged 30 to 70 years who were free of CHD, had total cholesterol levels equal to the 90th percentile of the US distribution in their age and sex group, had HDL-C levels equal to the mean of the US distribution in their age and sex group, and were either with or without additional CHD risk factors.

Intervention.
—Use of 20 mg of lovastatin per day, which on average reduces total serum cholesterol by 17% and increases HDL-C by 7%.

Main Outcome Measures.
—Cost per year of life saved after discounting benefits and costs by 5% annually.

Results.
—The increase in HDL-C associated with lovastatin lowered cost-effectiveness ratios by approximately 40%, such that the treatment of hypercholesterolemia was relatively cost-effective for men (as low as $20 882 per year of life saved at age 50 years) and women ($36 627 per year of life saved at age 60 years) with additional risk factors. Non-CHD costs resulting from longer life expectancy after intervention added at most 23% to the cost-effectiveness ratios for patients who began treatment at age 70 years, and as little as 3% for patients at age 30 years.

Conclusion.
—The cost-effectiveness of HMG-CoA reductase inhibitors varied widely by age and sex and was sensitive to the presence of non-lipid CHD risk factors. The additional non-CHD costs due to increased life expectancy may be significant for the elderly. Accounting for the drug effects of raising HDL-C levels increased the proportion of the population for which medication treatment was relatively cost-effective.

(JAMA. 1995;273:1032-1038)

Author Affiliations
From the Centre for the Analysis of Cost-Effective Care, the Centre for Cardiovascular Risk Assessment, and the Division of Clinical Epidemiology, the Montreal (Quebec) General Hospital (Drs Hamilton and Grover, Mr Racicot, Ms Zowall, and Mr Coupal); and the Departments of Medicine (Drs Hamilton and Grover), Economics (Dr Hamilton), and Epidemiology and Biostatistics (Dr Grover), McGill University, Montreal, Quebec.

Footnotes
Reprint requests to the Centre for the Analysis of Cost-Effective Care, the Montreal General Hospital, 1650 Cedar Ave, Montreal, Quebec, Canada H3G 1A4 (Dr Grover).

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