Today’s Managing Health Care Costs Number is 177 million
NNT = number needed to treat; NNH = number needed to harm
This week JAMA published a simulation showing that statin therapy to prevent heart attacks and strokes is more cost-effective than previously thought. An editorialist points out that if the threshold to recommend therapy is a cost per quality adjusted life year (QALY) is $100,000 – we should recommend that even more Americans take statins.
The lay press headlines have been unequivocal:
New York Times “Two Studies Back Guidelines For Wider Use of Statins”
Boston Globe: “Studies May Raise the Use of Statin Drugs”
Boston Globe: “Studies May Raise the Use of Statin Drugs”
LA Times: “Even people with low risk of heart attack, stroke can benefit from taking statins, study says”
There are four indications to be on statins
1) LDL >190
2) Diabetes and LDL>70
3) History of heart attack
4) 10 Year risk of cardiac event over 7.5%
Eight percent of the adult population fits into indications 1-3, and they benefit enormously from statins. The question has been answered – and they should take statins! The benefits are huge. For instance, people who had bypass surgery when I was new in practice very frequently needed redo operations in 10-12 years. That’s rare in the era of statins (and angioplasty).
The study focused on the 92% of American adults who don’t have an iron-clad indication to be on statins. When I use the data from the JAMA article, it appears to me that use of statins for those with 10 year risk of cardiovascular disease of 7.5% will help 1 of 29 people (number needed to treat), and will harm 1 in 100 (number needed to harm). That’s a clear choice.
The researchers and an accompanying editorialist suggest that based on cost effectiveness we should lower the threshold to those at 4% or more 10 year risk of cardiovascular disease – and show that each quality adjusted life year (QALY) would cost just $81,000. These recommendations would mean that 61% of adult Americans (almost 177 million people) would be recommended to take statins.
This might be true for the overall population, but the analysis from the point of view of individual patients is quite different. Changing these recommendations would indeed save many from heart attacks (the researchers say 120,000.) They would also cause additional cases of diabetes. The proposed new recommendations would prevent a cardiovascular event in 1 of 101 new patients on statins (number needed to treat) –but would cause diabetes in 1 of 93 of those newly treated (number needed to ham).
Should we include statins for primary prevention in health insurance plans? Absolutely!
Should individuals with 10 year cardiovascular risk between 4% and 7.5% take statins? Should their doctors offer therapy – or should they be insistent?
I think it’s an individual decision – and that many sensible people would double down on their diets and exercise and not take statins to prevent cardiac disease. I wouldn’t want us to conclude that high rate of statin use among those at relatively low cardiovascular risk was a measure of a physician’s quality.
One more observation. This study once again shows that even inexpensive generic medications are only cost-effective, not cost saving, except for very narrow populations at exceptionally high risk. Drugs save lives, not dollars.
I’ve posted my spreadsheet at this URL. I calculate that the number of Americans who could be saved from a cardiovascular disease by changing the guidelines is 376,000 (not 120,000, which the authors state), and the number of new cases of diabetes would be 405,000. For this post I have used a population of 100,000 since absolute numbers aren’t necessary for NNT and NNH calculations. Please post a reply if you can tie prevented cardiovascular disease numbers to the journal article, or if you find an error in my spreadsheet)
