Monday, November 10, 2008

With Prevention, The Sky's the Limit

Jupiter (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin), Astra-Zeneca's tour de force cholesterol-treatment trial, was released at the American Heart Association's national meeting yesterday and simultaneously published online yesterday. It's the talk of the town.

Especially in Boston.

That's where the study's lead investigator and the Brigham and Women's Hospital that holds patents on the c-reactive protein tests used to screen the 89,000-plus people for the 17,800 people enrolled in the trial are from. They're lovin' life right now.

Imagine inventing a test can be applied as a "screening test" on about 30 billion million people to find the 6 billionmillion or so people annually who would be benefitted by the prevention measure. Imagine making $1250 per year per person on the sale of your statin. Imagine that twenty five such individuals will have to be treated for five years with the statin to prevent one cardiovascular event.


This is not to say that the results of the trial are not impressive. To demonstrate a near 50 percent reduction in cardiovascular events in a carefully selected low-risk population for cardiovascular events is impressive. Really.

But at what price comes such preventative measures to our health care system?

If we assume that a 20-mg daily rosuvastatin (Crestor) tablet costs $107 per month to treat the average patient, and that twenty five patients have to be treated for five years to prevent one cardiovascular complication (and this does not include the annual liver function tests, the cholesterol tests, the C-reactive protein checks, etc), we begin to focus on an inevitable realization: that prevention is a remarkably expensive way to deal with our exploding health care costs.

For instance, if we assume that 25 people would have to be treated with Crestor for five years to prevent one cardiovacular event (as the study suggests), we can estimate the following back-of-the-envelope costs:
  • Lipid level evaluation ($150 per test x 5 years) = $750
  • C-reactive protein level $20 per year x 5 years = $100
  • Annual liver function tests: $250 per test per year x 5 years = $1250
  • Annual Crestor costs ($107 per month x 12 months per year x 5 years) = $6420
  • Number of people needing to be treated over 5 years to prevent one cardiovascular event: 25
Applying these costs to the population that is thought to be at "risk" (some 6 to 10 billion million people), if every person were given this therapy, the cost to our health care system would implement this single prevention measure would amount to a whopping $51.12 trillion billion dollars over five years.*

Hey, if I owned stock in Astra Zeneca, I'd be "all in," too. But my simple calculations lead me to wonder if such prevention measures are the way to fix our current health care cost crisis.

I don't think so.


*$213,000 per 25 people treated = $8,520 dollars per person treated over 5 years.
6 billion million people treated for five years x $8,520 dollars per person = $51,120,000,000.

Addendum 13:25 CST - Calculation corrections made. Thanks to Yoni and anony 12:18 who pointed out my error.


rlbates said...

Thanks for doing the math. Helps put things in perspective.

Yoni said...

kick me if i'm wrong, but I think you're off by a factor of 1000. The at risk population should be 6-30 *million*.
That puts the cost at 51 Billion. Still a tidy sum, but at least its within the AIG range :)

Anonymous said...

Hard to imagine the potential risk pool being 6-10 billion people since there are only 6 billion or so people in the entire world. So the final value of $51 trillion is wrong tremendously but the cost per event prevented of $213,000 is correct. Whcih greatly exceeds the generally accepted price limits. Especially since this is cardiac events, not cardiac deaths or all-cause mortality.

DrWes said...

anony 12:18 -
Point well-taken. Irrespective, the numbers are astromonical and well beyond Jupiter...

Anonymous said...

Wonder where the cost would come out if you use a generic statin and skip the CRP test (which is so nonspecific as to be valueless) and just aim for a lower target LDL. I think the patients ended up with a mean LDL level of 55 mg/dL which is very low, so maybe it suggests that the current targets are too high.

Anonymous said...

dr wes,

don't forget all the extra dr visits for all that prescribing. and testing. and counseling. and dealing with dose changes. and side effects.

(and making visits that would have already happened anyway more complex and thus more expensive.)

Margaret Polaneczky, MD (aka TBTAM) said...

Brilliant post.

Anonymous said...

They stopped a 5 year trial, 3 years early.

Hmmmmmmmm. Wonder why?

Anonymous said...

anon 10:00 CST-

I'm guessing the DSMB (not the company) stopped the trial early because the interventional arm had a 50% lower cardiac event rate. It is unethical to continue an RCT when one arm is clearly superior to another.

The whole basis of human subject participation in clinical research is (right or wrong) informed consent. At the time subjects were consented, there was genuine uncertainty as to whether or not otherwise healthy subjects with elevated CRP benefited from CRP lowering by a statin. Once it became clear that this was almost certainly true, it became difficult for a DSMB to ethically justify continuing the trial and pretending this was not the case.

Not everything about big pharma is completely corrupt.

Anonymous said...

Just curious, but how much does an average admission for one of the 'cardiac events' run these days? I'm assuming a fair number end up in the unit which isn't cheap .....

Anonymous said...

Just curious, but how much does an average admission for one of the 'cardiac events' run these days? I'm assuming a fair number end up in the unit which isn't cheap .....

Ever heard about NNT? Sure admissions aren't cheap, but admitting 1 person may still be cheaper than treating many, don't you think?

#1 Dinosaur said...

I'm not sure I agree with some of your numbers, so I re-crunched them here.

Anonymous said...

Nice post.

I still think "cholesterol" is one of the biggest scams ever in the history of modern medicine, right up there with "bleeding" patients of their bad blood.

I seem to recall that nearly half of all heart attacks happen to people with normal LDL/HDL levels.

C-RP and triglycerides make a lot more sense as warning signals, although as I understand it they are more strongly associated with general vasculitis. (Speaking as a medical dabbler.)

Since statins seems to universally place burdens on the liver, I wonder what would have happened if they had recorded incidence of effects like cirrhosis along with heart trauma.

Prevention is great, but not if it is expensive and simply shifts the risk of death around.