Using Stress Testing to Guide Primary Prevention of Coronary Heart Disease Among Intermediate-Risk Patients A Cost-Effectiveness Analysis
OBJECTIVES: Noninvasive stress testing might guide the use of aspirin and statins for primary prevention of coronary heart disease, but it is unclear if such a strategy would be cost effective.
METHODS: We compared the status quo, in which the current national use of aspirin and statins was simulated, with 3 other strategies: (1) full implementation of Adult Treatment Panel III guidelines, (2) a treat-all strategy in which all intermediate-risk persons received statins (men and women) and aspirin (men only), and (3) a test-and-treat strategy in which all persons with an intermediate risk of coronary heart disease underwent stress testing and those with a positive test were treated with high-intensity statins (men and women) and aspirin (men only). Healthcare costs, coronary heart disease events, and quality-adjusted life years from 2011 to 2040 were projected.
RESULTS: Under a variety of assumptions, the treat-all strategy was the most effective and least expensive strategy. Stress electrocardiography was more effective and less expensive than other test-and-treat strategies, but it was less expensive than treat all only if statin cost exceeded $3.16/pill or if testing increased adherence from75%. However, stress electrocardiography could be cost effective in persons initially nonadherent to the treat-all strategy if it raised their adherence to 5% and cost saving if it raised their adherence to 13%.
CONCLUSIONS: When generic high-potency statins are available, noninvasive cardiac stress testing to target preventive medications is not cost effective unless it substantially improves adherence.
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