Cost-Effectiveness of Lipid-Lowering Treatments in Young Adults

Abstract

Background: Raised low-density lipoprotein cholesterol (LDL-C) in young adulthood (aged 18-39 years) is associated with atherosclerotic cardiovascular disease (ASCVD) later in life. Most young adults with elevated LDL-C do not currently receive lipid-lowering treatment.

Objectives: This study aimed to estimate the prevalence of elevated LDL-C in ASCVD-free U.S. young adults and the cost-effectiveness of lipid-lowering strategies for raised LDL-C in young adulthood compared with standard care.

Methods: The prevalence of raised LDL-C was examined in the U.S. National Health and Nutrition Examination Survey. The CVD Policy Model projected lifetime quality-adjusted life years (QALYs), health care costs, and incremental cost-effectiveness ratios (ICERs) for lipid-lowering strategies. Standard care was statin treatment for adults aged ≥40 years based on LDL-C, ASCVD risk, or diabetes plus young adults with LDL-C ≥190 mg/dL. Lipid lowering incremental to standard care with moderate-intensity statins or intensive lifestyle interventions was simulated starting when young adult LDL-C was either ≥160 mg/dL or ≥130 mg/dL.

Results: Approximately 27% of ASCVD-free young adults have LDL-C of ≥130 mg/dL, and 9% have LDL-C of ≥160 mg/dL. The model projected that young adult lipid lowering with statins or lifestyle interventions would prevent lifetime ASCVD events and increase QALYs compared with standard care. ICERs were US$31,000/QALY for statins in young adult men with LDL-C of ≥130 mg/dL and US$106,000/QALY for statins in young adult women with LDL-C of ≥130 mg/dL. Intensive lifestyle intervention was more costly and less effective than statin therapy.

Conclusions: Statin treatment for LDL-C of ≥130 mg/dL is highly cost-effective in young adult men and intermediately cost-effective in young adult women.

Keywords: cardiovascular disease; cholesterol; cost-effectiveness; statins; young adulthood.

Figure 1.. Distribution of untreated LDL-C in ASCVD-free, U.S. adults.

Analysis conducted in the National Health and Nutrition Examination Survey. LDL-C – low-density lipoprotein cholesterol. Notes: The LDL-C distribution was estimated from the 1999 to 2014 NHANES cycles and projected onto 2020 population estimates (method in Supplemental Methods; Table 2).To convert LDL-C from mg/dL to mmol/L, divide by 38.67.

Figure 2.. Cost-effectiveness plane for lipid-lowering strategies in U.S. young adults.

The transparent points illustrated indicate that the strategy costs more and is less effective than another strategy (i.e., strictly dominated). The solid blue lines represent strategies that are eligible to be considered the preferred treatment (i.e., the cost-effectiveness frontier, which comprises the non-dominated strategies ranked by increasing effectiveness). A strategy is considered cost-effective if the slope of the blue line connecting it to the next least effective strategy (i.e., the incremental cost-effectiveness ratio) is lower than the slope of the cost-effectiveness threshold line. The preferred strategy is defined as the treatment that results in the greatest QALY gains and is cost-effective. LDL-C - low-density lipoprotein cholesterol; QALYs – quality-adjusted life years. To convert LDL-C from mg/dL to mmol/L, divide by 38.67.

Central Illustration.. Conceptual diagram, CVD Policy Model and time-weighted average risk factors.

Panel A (left): Potential LDL-C trajectories for a 20-year-old young adult with raised LDL-C (172 mg/dL) are shown: no treatment (blue), later life statin treatment (green), and lifetime statin treatment (purple). Panel B (right): Results are shown for 100,000 simulations of the three LDL-C trajectories in Panel A while holding other risk factors constant. Mean number of ASCVD events (left axis) was lower and mean ASCVD-free years (right axis) was greater with treatment initiation in young adulthood.