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DLM: Self-Management and Individualized Counseling (2001)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

This meta-analysis study explored the cost-effectiveness of primary and secondary prevention with cholesterol-lowering therapies to determine how cost-effectiveness varies with individual patient characteristics.

Inclusion Criteria:
Exclusion Criteria:
Description of Study Protocol:
  • Validated computer simulation model: The Coronary Heart Disease Policy Model was used to estimate the effects and costs of each cholesterol-lowering strategy in each risk group
  • Base-case analysis evaluated the cost-effectiveness of primary and secondary prevention over a 30-year period in persons with low-density lipoprotein cholesterol (LDL) cholesterol over 4.1mmol per L, divided into 240 risk sub-groups by:
    • Age (35 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84)
    • Gender
    • Smoking status
    • Diastolic blood pressure (less than 95mmHg or more than 95mmHg)
    • High-density lipoprotein (HDL) cholesterol (less than 0.9mmol per L; 0.9mmol to 1.3mmol per L; more than 1.3mmol per L)
    • LDL cholesterol of 4.2mmol to 4.9mmol per L or more than 4.9mmol per L.
  • Studies used in analysis:
    • Five studies on the Step I diet were pooled for primary prevention
    • Three long-term studies with 40mg pravastatin used to evaluate primary prevention with a statin.
  • One study to evaluate secondary prevention with a statin (Scandinavian Simvastatin Survival Study)
  • Cost estimates: Sum of intervention costs, costs of coronary heart disease (CHD) care and costs of non-CHD care
    • Intervention costs: Medications, physician visits (and patient time), lab tests
    • Assumptions made: Step I diet, $108 per year (diet therapy by MD plus lab); 1° prevention, $1,512 in the first year and $1,318 in subsequent years (statin medication plus lab plus MD visits); 2° prevention with statin, $1,329 per year.
Data Collection Summary:
Outcome measures: Incremental cost-effectiveness ratios.
Description of Actual Data Sample:
Summary of Results:
  • Step I diet as primary prevention: Incremental cost-effectiveness ratios ranged from $1,900 per quality-adjusted life-year (QALY) for men 75 to 84 years of age with four risk factors to $500,000 per QALY for women 35 to 44 years of age with no risk factors
  • Statin as primary prevention: $150,000 per QALY for women 65 to 74 years of age and $730,000 per QALY for women 35 to 44 years of age. For men, the range of cost-effectiveness was $54,000 to $420,000.
  • Statin as secondary prevention: Under $50,000 per QALY for all risk subgroups and less than $10,000 per QALY for most risk sub-groups
  • Cost-effectiveness of treatment strategies varies significantly when adjusted for age, sex and the presence or absence of additional risk factors. Primary prevention with a Step I diet seems to be cost-effective for most risk sub-groups, but may not be cost-effective for otherwise healthy young women. Primary prevention with a statin may not be cost-effective for younger men and women with few risk factors, given the option of secondary prevention and of primary prevention in older ages. Secondary prevention with a statin seems to be cost-effective for all risk sub-groups and is cost-saving in some high-risk sub-groups.
Author Conclusion:
Step I diet is the diet recommended for most Americans (US Dietary Goals). The cost of intervention would be primarily physician visits and serum lipids.
Funding Source:
Government: Agency for Healthcare Research and Quality, National Library of Medicine Training
Not-for-profit
1
Reviewer Comments:
Quality Criteria Checklist: Review Articles
Relevance Questions
  1. Will the answer if true, have a direct bearing on the health of patients? Yes
  2. Is the outcome or topic something that patients/clients/population groups would care about? Yes
  3. Is the problem addressed in the review one that is relevant to dietetics practice? Yes
  4. Will the information, if true, require a change in practice? Yes
 
Validity Questions
  1. Was the question for the review clearly focused and appropriate? Yes
  2. Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? No
  3. Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? No
  4. Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? No
  5. Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? Yes
  6. Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? Yes
  7. Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? No
  8. Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? No
  9. Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? Yes
  10. Was bias due to the review's funding or sponsorship unlikely? Yes