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Original article
Cost-effectiveness of the polypill versus risk assessment for prevention of cardiovascular disease
  1. Bart S Ferket1,2,3,
  2. M G Myriam Hunink2,3,4,
  3. Mohammed Khanji5,
  4. Isha Agarwal6,
  5. Kirsten E Fleischmann7,
  6. Steffen E Petersen5
  1. 1Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  2. 2Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
  3. 3Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
  4. 4Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  5. 5William Harvey Research Institute and NIHR Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK
  6. 6Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  7. 7Division of Cardiology, UCSF Medical Center, San Francisco, California, USA
  1. Correspondence to Dr Steffen E Petersen, National Institute for Health Research Cardiovascular Biomedical Research Unit at Barts, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK; s.e.petersen{at}qmul.ac.uk

Abstract

Objective There is an international trend towards recommending medication to prevent cardiovascular disease (CVD) in individuals at increasingly lower cardiovascular risk. We assessed the cost-effectiveness of a population approach with a polypill including a statin (simvastatin 20 mg) and three antihypertensive agents (amlodipine 2.5 mg, losartan 25 mg and hydrochlorothiazide 12.5 mg) and periodic risk assessment with different risk thresholds.

Methods We developed a microsimulation model for lifetime predictions of CVD events, diabetes, and death in 259 146 asymptomatic UK Biobank participants aged 40–69 years. We assessed incremental costs and quality-adjusted life-years (QALYs) for polypill scenarios with the same combination of agents and doses but differing for starting age, and periodic risk assessment with 10-year CVD risk thresholds of 10% and 20%.

Results Restrictive risk assessment, in which statins and antihypertensives were prescribed when risk exceeded 20%, was the optimal strategy gaining 123 QALYs (95% credible interval (CI) −173 to 387) per 10 000 individuals at an extra cost of £1.45 million (95% CI 0.89 to 1.94) as compared with current practice. Although less restrictive risk assessment and polypill scenarios prevented more CVD events and attained larger survival gains, these benefits were offset by the additional costs and disutility of daily medication use. Lowering the risk threshold for prescription of statins to 10% was economically unattractive, costing £40 000 per QALY gained. Starting the polypill from age 60 onwards became the most cost-effective scenario when annual drug prices were reduced below £240. All polypill scenarios would save costs at prices below £50.

Conclusions Periodic risk assessment using lower risk thresholds is unlikely to be cost-effective. The polypill would become cost-effective if drug prices were reduced.

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Footnotes

  • Contributors BSF, MGMH, MK, IA, KEF, SEP all had substantial contributions to the conception and design of the work, the acquisition, analysis, and interpretation of data for the work, the drafting of the work or revising it critically for important intellectual content. BSF, SEP, and MK searched the literature; BSF and SEP developed the decision model and performed the simulations; BSF, MGMH, MK, and SEP analysed the data. SP is the guarantor.

  • Funding This work was directly funded by the National Institute for Health Research Cardiovascular Biomedical Research Unit at Barts.

  • Competing interests None declared.

  • Ethics approval UK Biobank's protocols were reviewed and approved by the North West Research Ethics Committee (REC Reference Number: 06/MRE08/65).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Statistical codes and patient level data are available to researchers who apply to use the UK Biobank Resource at http://www.ukbiobank.ac.uk/register-apply/ through UK Biobank's Access Procedures, which has a protocol for approving data requests. Because of restrictions based on privacy regulations and informed consent of the participants, data cannot be made freely available in a public repository.

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