Prevention of coronary heart disease
http://www.100md.com
《英国医生杂志》
EDITOR—Correspondents responding to my article on bmj.com raise several interesting issues.1 Nevertheless no correspondent disputes either the approach (incremental cost effectiveness analysis) or the fundamental findings: that aspirin and antihypertensive treatment with bendrofluazide and atenolol are markedly more cost effective than statins and clopidogrel.
Conradi et al and O'Donnell indicate that statins may have more side effects than is generally appreciated. Mann doubts the effectiveness of clopidogrel in primary prevention.1 Both points strengthen the paper's conclusions. I agree with Mann's suggestion that individuals need information on the risk reduction with treatment in order to decide if it is worth while.
Cooke says that the development of further drugs to prevent coronary heart disease may not be cost effective. It is very efficient to prevent coronary disease by using existing, low cost treatments.
If, as Jacobs says, treatment effects are not independent, second and third treatments may be even less cost effective than the analysis shows.1 Under current criteria, 80% of those eligible for one preventive treatment are eligible for at least two and 53% are eligible for all three.
Das and Vos suggest oily fish as an intervention.1 Wide confidence intervals around the estimated effectiveness of dietary oily fish meant it was excluded from the published paper, however it is probably more cost effective than a statin.
Mihaylova et al suggest further refinements to the model including cost savings from heart disease prevented. They acknowledge that these refinements are unlikely to affect the rankings or overall message.1 As the purpose of economic evaluation is to improve decision making it is not clear how further complexity can be justified in terms of better decisions. My analysis includes sufficient information to improve decision making dramatically within preventive cardiology. Complex analysis is not always well understood.2
Several correspondents refer to an imminent fall in the price of simvastatin. At ￡4.45 a pack (containing 28 tablets), simvastatin becomes the third most cost effective intervention. Under these circumstances a rational policy would offer aspirin at 5% coronary risk, bendrofluazide and atenolol at 7.5%, and simvastatin at 15%. A third antihypertensive drug would never be offered, obviating the need to "treat to target" (table) The onus is now on pharmaceutical manufacturers to provide simvastatin at this cost.
Cost effectiveness of preventive treatments (￡) in patients at different degrees of risk if price of simvastatin falls by 85%
Tom Marshall, clinical lecturer
Department of Public Health and Epidemiology, University of Birmingham, Birmingham B15 2TT T.P.Marshall@bham.ac.uk
Competing interests: None declared
References
Electronic responses. Coronary heart disease prevention. bmj.com 2003. bmj.bmjjournals.com/cgi/eletters/327/7426/1264 (accessed 20 Jan 2004). http://bmj.bmjjournals.com/cgi/content/full/327/7426/1264 (accessed 1 Feb 2004).
Burls A, Sandercock J. How to make a compelling submission to NICE: tips for sponsoring organisations. BMJ 2003;327: 1446-8.
Conradi et al and O'Donnell indicate that statins may have more side effects than is generally appreciated. Mann doubts the effectiveness of clopidogrel in primary prevention.1 Both points strengthen the paper's conclusions. I agree with Mann's suggestion that individuals need information on the risk reduction with treatment in order to decide if it is worth while.
Cooke says that the development of further drugs to prevent coronary heart disease may not be cost effective. It is very efficient to prevent coronary disease by using existing, low cost treatments.
If, as Jacobs says, treatment effects are not independent, second and third treatments may be even less cost effective than the analysis shows.1 Under current criteria, 80% of those eligible for one preventive treatment are eligible for at least two and 53% are eligible for all three.
Das and Vos suggest oily fish as an intervention.1 Wide confidence intervals around the estimated effectiveness of dietary oily fish meant it was excluded from the published paper, however it is probably more cost effective than a statin.
Mihaylova et al suggest further refinements to the model including cost savings from heart disease prevented. They acknowledge that these refinements are unlikely to affect the rankings or overall message.1 As the purpose of economic evaluation is to improve decision making it is not clear how further complexity can be justified in terms of better decisions. My analysis includes sufficient information to improve decision making dramatically within preventive cardiology. Complex analysis is not always well understood.2
Several correspondents refer to an imminent fall in the price of simvastatin. At ￡4.45 a pack (containing 28 tablets), simvastatin becomes the third most cost effective intervention. Under these circumstances a rational policy would offer aspirin at 5% coronary risk, bendrofluazide and atenolol at 7.5%, and simvastatin at 15%. A third antihypertensive drug would never be offered, obviating the need to "treat to target" (table) The onus is now on pharmaceutical manufacturers to provide simvastatin at this cost.
Cost effectiveness of preventive treatments (￡) in patients at different degrees of risk if price of simvastatin falls by 85%
Tom Marshall, clinical lecturer
Department of Public Health and Epidemiology, University of Birmingham, Birmingham B15 2TT T.P.Marshall@bham.ac.uk
Competing interests: None declared
References
Electronic responses. Coronary heart disease prevention. bmj.com 2003. bmj.bmjjournals.com/cgi/eletters/327/7426/1264 (accessed 20 Jan 2004). http://bmj.bmjjournals.com/cgi/content/full/327/7426/1264 (accessed 1 Feb 2004).
Burls A, Sandercock J. How to make a compelling submission to NICE: tips for sponsoring organisations. BMJ 2003;327: 1446-8.