Strategies for reducing coronary risk factors in primary care: which is most cost effective?

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Abstract
Objective: To examine the relative cost effectiveness of a range of screening and intervention strategies for preventing coronary heart disease in primary care. Subjects: 7840 patients aged 35-64 years who were participants in a trial of modifying coronary heart disease risk factors in primary care. Design: Effectiveness of interventions assumed and the potential years of life gained estimated from a risk equation calculated from Framingham study data. Main outcome measure: The cost per year of life gained. Results: The most cost effective strategy was minimal screening of blood pressure and personal history of vascular disease, which cost pounds sterling310-pounds sterling930 per year of life gained for men and pounds sterling1100-pounds sterling3460 for women excluding treatment of raised blood pressure. The extra cost per life year gained by adding smoking history to the screening was pounds sterling400-pounds sterling6300 in men. All strategies were more cost effective in men than in women and more cost effective in older age groups. Lipid lowering drugs accounted for at least 70% of the estimated costs of all strategies. Cost effectiveness was greatest when drug treatment was limited to those with cholesterol concentrations above 9.5 mmol/l. Conclusions: Universal screening and intervention strategies are an inefficient approach to reducing the coronary heart disease burden. A basic strategy for screening and intervention, targeted at older men with raised blood pressure and limiting the use of cholesterol lowering drugs to those with very high cholesterol concentrations would be most cost effective. Key messages The most cost effective strategy is to target patients with raised blood pressure or a history of coronary heart disease Extending the strategy to include other factors increases the cost by variable amounts All prevention strategies are more cost effective in men than in women and in older than younger age groups Drug treatment for patients with high cholesterol concentrations is cost effective, but the incremental cost of extending treatment to lower cholesterol concentrations is high

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