Amid Rising Tide of Atherosclerotic CVD, Costs of Treatment Should Spur Policy Makers to Push Prevention

NEW ORLEANS, LA—As the proportion of Americans with atherosclerotic cardiovascular disease (ASCVD) continues to rise, so too do the costs of treatment, even as the number of patients receiving appropriate preventive medicine remains suboptimal, new research shows.

A series of studies looking at US trends in this disease, the costs of treatment, and the use of both statin and nonstatin drugs in this population underscores the message that preventing ASCVD could translate into massive health savings, experts said.

“Prevention efforts should be aimed toward mainly prescription medications and hospitalizations, because [these are] what spike prices,” lead author on one of the studies, Javier Valero-Elizondo, MD (Tecnológico de Monterrey, San Pedro Garza Garcia, Mexico), told TCTMD. He and his team plan to disseminate their findings to policy makers in order to lobby for more funding for prevention efforts. “One of the reasons we started doing research involving economic impact,” he said, “was that the policy makers themselves obviously know that all of these things are important for them and for the whole country, but once you start showing information to them that has a dollar sign, it might be easier for them to understand and to do something about it.”

Valero-Elizondo presented his data during a poster session at the American Heart Association (AHA) Scientific Sessions 2016 earlier this month. The analysis, using figures from the Medical Expenditure Panel Survey, showed that the prevalence of atherosclerotic cardiovascular disease in adults older than 40 years increased from 13% to 16% between 2002 and 2013. Over the same period, direct expenditures related to ASCVD soared from $214 billion to $284 billion per year. Additionally, compared with people without atherosclerotic cardiovascular disease, those with had more than twice the unadjusted mean direct expenditures over the study period ($5,138 vs $14,064).

Once you start showing information to [policy makers] that has a dollar sign, it might be easier for them to understand. Javier Valero-Elizondo

This information, Valero-Elizondo said, “is just one more thing to be able to inform policy makers toward more prevention efforts, especially among modifiable risk factors regarding cardiovascular risk, because [the expenditures are] just going to keep growing.”

A Closer Look at Statins, Nonstatins

Two other studies also presented during AHA 2016 poster sessions zeroed in on expenditures directly related to statin and nonstatin therapy use over the same time period—the former was also published simultaneously in JAMA Cardiology.

Usage of both classes of drugs have increased in adults over the age of 40 since 2002, according to Joseph Salami, MD, MPH (Baptist Health South Florida, Coral Gables), and colleagues. However, statin use—at 27.8% in 2012-2013—is still “suboptimal in high-risk groups,” they say, and “further substitution of branded to generics can yield significant savings.” On the other hand, nonstatins—primarily fibrates and niacin, which were regularly used 1 in 7 adults at the end of this study—are perhaps prescribed too liberally given guideline recommendations, the authors write. As such, nonstatins may be “contributing to significant total healthcare and patient financial burden,” they add. In 2012-2013 the average annual cost per user was approximately $650/year for fibrates and $685/year for niacin, the latter roughly double the cost in 2002-2003. By contrast, the average cost per user for patients taking statins has fallen from $790 in 2002-2003 to $405 in 2012-2013.

Khurram Nasir, MD, MPH (Baptist Health South Florida), a co-author on all three studies, told TCTMD in an email that the statin study specifically has “important public health implications allowing stakeholders to consider pragmatic patient-centered interventions to improve appropriate statin use and manage associated costs.”

The advent of generic statins has had “a pronounced effect on the cost associated with statin use in the last 12 years. While the overall reduction in costs is encouraging, therapeutic substitution from brand to generic statins is of paramount importance in the current climate of cost-containment,” he said. “For example significant nearly $8 billion can be saved if nearly 20% of current brand statin users are substituted to equally efficacious generic versions.”

Working against these cost savings is the fact that only 27.2% of adults over age 40 in the United States were on statins in 2012-2013—up from 17.9% in 2002-2003. This “raises major concerns about missed opportunities for easy optimal management in lowering risk among high risk patients. While statin utilization is a commonly used quality metric to assess optimal care of these high risk patients, future policies should consider also including dose intensity as a quality of care target.”

Nasir also highlighted the “inequalities” of statin use among patient groups such as women, ethnic minorities, and the uninsured. “Equal access to healthcare might not translate to uniform needed evidence-based care,” he said. “These findings should stimulate policy makers and clinicians to pay more attention to these discrepancies and resolve inconsistent adoption of guidelines in these vulnerable populations.”

Good News and Bad

Kirk Garratt, MSc, MD (Christiana Care Health System, Wilmington, DE), who was not involved with any of the studies, told TCTMD that he is confused as to why the prevalence data in the study led by Valero-Elizondo conflicts with what was published in the AHA’s 2016 Heart Disease and Stroke Statistics Update, which showed an 11.7% decrease in cardiovascular disease-related deaths from 2002 to 2013. However, this should not affect the study’s economic findings, he said.

“The likelihood is that the global economic burden of [ASCVD] is going to continue to grow even as the prevalence falls a bit, because the population expands and because some of the therapies that we have to offer for care are coming at increased cost,” Garratt explained. “So something like statins, for example, are going down in cost but the utilization rates are going up much faster than the reductions in cost, so the overall impact on the budget is going to be negative.”

The likelihood is that the global economic burden of [ASCVD] is going to continue to grow even as the prevalence falls. Kirk Garratt

Newer, more expensive classes of drugs, such as PCSK9 inhibitors, will also “move the needle in the wrong direction,” he added.

“The good news is that we’re doing better at keeping people well managed with their disease states,” Garratt concluded. “But the bad news is that this is an expensive endeavor. . . . Our management strategies are proving successful, but they're costly.”