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April 15, 1988, Vol 259, No. 15 >
ARTICLE | April 15, 1988

Cutting Into Cholesterol: Title and subTitle BreakCost-effective AlternatiCost-effective Treating Hypercholesterolemia FREE

Bruce P. Kinosian, MD; John M. Eisenberg, MD, MBA
[+] Author Affiliations

Reprint requests to Division of General Medicine, University of Maryland, 22 S Greene St, Box 151, Baltimore, MD (Dr Kinosian).


JAMA. 1988;259(15):2249-2254. doi:10.1001/jama.1988.03720150025030
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References

We performed an analysis of the cost-effectiveness of treating individuals with significantly elevated levels of total serum cholesterol (>6.85 mmol/L [>265 mg/dL]), comparing treatment with three alternative agents: cholestyramine resin, colestipol, and oat bran (a soluble fiber). We simulated a program for lowering cholesterol levels that was similar to that of the Coronary Primary Prevention Trial, and then used the outcomes of the trial to calculate the incremental cost per year of life saved (YOLS) from the perspective of society. Our findings suggest that the cost per YOLS ranges from $117 17 400 (cholestyramine resin packets) to $70 900 (colestipol packets) and $17 800 (oat bran). Using bulk drug reduces the cost per YOLS to $65 100 (cholestyramine resin) and $63 900 (colestipol). Targeting bulk colestipol treatment only to smokers has a cost per YOLS of $47 010; the incremental cost of treating nonsmokers would be $89 600 per additional YOLS. Although pharmacologic therapy has substantial costs, it may be more cost-effective when low-cost forms are applied to particular high-risk groups, such as smokers. However, a broad public health approach to lowered cholesterol levels by additional dietary modification, such as with soluble fiber, may be preferred to a medically oriented campaign that focuses on drug therapy.

(JAMA 1988;259:2249-2254)

REFERENCES

1 +
 Lowering blood cholesterol to prevent heart disease, CONSENSUS CONFERENCE. JAMA 1985;; 253:2080-2086.
2 +
 Lipid Research Clinics: The Lipid Research Clinics Coronary Primary Prevention Trial results. JAMA 1984;;251:351-364.
3 +
Oster G, Epstein A:  The cost-effectiveness of antihyperlipidemic therapy in the prevention of coronary heart disease: The case of cholestyramine. JAMA 1987;;258:2381-2387.
4 +
Oster G, Epstein A:  Primary prevention and coronary heart disease: The economic benefits of lowering serum cholesterol. Am J Public Health 1986;;76:647-656.
5 +
Weinstein M, Stason W:  Cost-effectiveness of interventions to prevent or treat coronary heart disease. Ann Rev Public Health 1985;;6:41-43.
6 +
Himmelstein D, Woolhandler S:  Free care, cholestyramine, and health policy. N Engl J Med 1984;;311:1511-1514.
7 +
Schaefer E, Levy R:  Pathogenesis and management of lipoprotein disorders. N Engl J Med 1985;;312:1300-1310.
8 +
Hoeg J, Gregg R, Brewer H:  An approach to the management of hyperlipoproteinemia. JAMA 1986;;255:512-521.
9 +
Kirby RW, Anderson JW, Sieling B:  Oat bran intake selectively lowers serum low-density lipoprotein cholesterol concentrations. Am J Clin Nutr 1981;;34:824-829.
10 +
Anderson JW, Story L, Chen W, et al:  Hypocholesterolemic effects of oat bran for hypercholesterolemic men. Am J Clin Nutr 1984;;40:1146-1155.
11 +
Munoz JM, Sandstead H, Jacob RA, et al:  Effects of some cereal brans and textured vegetable protein on plasma lipids. Am J Clin Nutr 1979;;32:580-592.
12 +
Anderson JW, Story L, Sieling B, et al:  Hypocholesterolemic effects of high fibre diets rich in water-soluble plant fibres. J Can Diet Assoc 1984;;45:2-5.
13 +
Behall KM, Lee KH, Moser PB:  Blood lipids and lipoproteins in adult men fed four refined fibers. Am J Clin Nutr 1984;;39:209-214.
14 +
Simons LA, Gayst S, Balasubramaniam S, et al:  Long-term treatment of hypercholesterolemia with a new formulation of guar gum. Atherosclerosis 1982;;45:101-108.
15 +
Zavoral J, Hannan P, Fields D, et al:  The hypolipidemic effect of locust bean gum food products in familial hypercholesterolemic adults and children. Am J Clin Nutr 1983;;38:285-294.
16 +
Vahouny GV, Tombes R, Cassidy M, et al:  Dietary fibers: Binding of bile salts, phospholipids, and cholesterol from mixed micelles by bile acid sequestrants and dietary fibers. Lipids 1980;;15: 1012-1018.
17 +
Falk J, Nagyvary J:  Exploratory studies of lipid-pectin interactions. J Nutr 1982;;112:182-188.
18 +
Hansen WE, Maurer H, Vollmar J, et al:  Guar gum and bile: Effects on postprandial gallbladder contraction and on serum bile acids in man. Hepatogastroenterology 1983;;30:131-133.
19 +
Medicare Directory of Prevailing Charges . Baltimore, Health Care Financing Administration, 1985;.
20 +
Drug Topics Red Book . New York, Hearst Business Publications, 1985;.
21 +
Drug Topics Red Book: 1985 Update . New York, Hearst Business Publications, 1985;.
22 +
Sugden R, Williams A: The Principles of Practical Cost-Benefit Analysis . Oxford, England, Oxford University Press, 1985;.
23 +
 Life tables , in Vital Statistics of the United States, 1980 . National Center for Health Statistics, 1983;, vol 2.
24 +
Levy RI, Brensike JF, Epstein SE, et al:  Results of the NHLBI Type II Coronary Intervention Study. Circulation 1984;;69:325-337.
25 +
Canner PL, Berge KG, Wenger NK, et al:  15-year mortality in coronary drug project patients: Long-term benefit with niacin. J Am Coll Cardiol 1986;;8:1245-1255.
26 +
Weinstein M, Stason W:  Cost-effectiveness of coronary artery bypass surgery. Circulation 1982;;66( (suppl 3) ):56-66.
27 +
Gordon DJ:  Predictive value of the exercise tolerance test for mortality in North American men: The Lipid Research Clinics Mortality Followup Study. Circulation 1986;;74:252-261.
28 +
Eisenberg J, Kitz D:  Savings from outpatient antibiotic therapy for osteomyelitis: Economic analysis of a therapeutic strategy. JAMA 1986;; 255:1584-1588.
29 +
Comparison of the Medicare Federal Prospective Payment System vs the New Jersey Chapter 83 System . Trenton, New Jersey Department of Health, 1986;.
30 +
Hemenway D, Sherman H, Mudge G, et al:  Comparative costs vs symptomatic and employment benefits of medical and surgical treatment of stable angina pectoris. Med Care 1985;;23:113-114.
31 +
Rice D, Hodgson T, Kopstein A:  The economic costs of illness. Health Care Financ Rev 1985;;7:59-60.
32 +
Kannel WB, Sorlie P, McNamara P:  Prognosis after initial myocardial infarction. Am J Cardiol 1979;;44:53-59.
33 +
Shapiro S, Weinblatt E, Frank CW:  Return to work after first myocardial infarction. Arch Environ Health 1972;;24:17-26.
34 +
Hammermeister K, DeRouen T, English M, et al:  Effect of surgical versus medical therapy on return to work in patients with coronary artery disease. Am J Cardiol 1979;;44:105.
35 +
Oberman A, Wayne J, Kouchoukos N, et al:  Employment status after coronary artery bypass surgery. Circulation 1982;;65( (suppl 2) ):2-115.
36 +
Gordon T, Kannel WB:  Multiple risk functions for predicting coronary heart disease: The concept, accuracy, and application. Am J Cardiol 1982;;44: 1031-1039.
37 +
Brittain E:  Probability of coronary heart disease developing. West J Med 1982;;136:86-89.
38 +
Coronary Risk Handbook From the Framingham Study . New York, American Heart Association, 1978;.
39 +
Grundy SM:  Cholesterol and coronary heart disease. JAMA 1986;;256:2849-2858.
40 +
Bloom B, Wierz D, Pauly M:  Cost and price of comparable branded and generic pharmaceuticals. JAMA 1986;;256:2523-2530.
41 +
Russel L: Is Prevention Better Than Cure? Washington, DC, Brookings Institute, 1985;.
42 +
Taylor WC, Pass T, Shepard D, et al:  Cholesterol reduction and life expectancy. Ann Intern Med 1987;;106:605-614.
43 +
Oster G, Huse M, Delea T, et al:  Cost-effectiveness of nicotine gum as an adjunct to physician's advice against cigarette smoking. JAMA 1986;; 256:1315-1318.
44 +
Van Horn LV, Liu K, Parker D, et al:  Serum lipid response to oat product intake with a fat-modified diet. J Am Diet Assoc 1986;;86:759-764.
45 +
Vega GL, Grundy SM:  Treatment of primary moderate hypercholesterolemia with lovastatin (mevinolin) and colestipol. JAMA 1987;;257:33-38.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
 Lowering blood cholesterol to prevent heart disease, CONSENSUS CONFERENCE. JAMA 1985;; 253:2080-2086.
2 +
 Lipid Research Clinics: The Lipid Research Clinics Coronary Primary Prevention Trial results. JAMA 1984;;251:351-364.
3 +
Oster G, Epstein A:  The cost-effectiveness of antihyperlipidemic therapy in the prevention of coronary heart disease: The case of cholestyramine. JAMA 1987;;258:2381-2387.
4 +
Oster G, Epstein A:  Primary prevention and coronary heart disease: The economic benefits of lowering serum cholesterol. Am J Public Health 1986;;76:647-656.
5 +
Weinstein M, Stason W:  Cost-effectiveness of interventions to prevent or treat coronary heart disease. Ann Rev Public Health 1985;;6:41-43.
6 +
Himmelstein D, Woolhandler S:  Free care, cholestyramine, and health policy. N Engl J Med 1984;;311:1511-1514.
7 +
Schaefer E, Levy R:  Pathogenesis and management of lipoprotein disorders. N Engl J Med 1985;;312:1300-1310.
8 +
Hoeg J, Gregg R, Brewer H:  An approach to the management of hyperlipoproteinemia. JAMA 1986;;255:512-521.
9 +
Kirby RW, Anderson JW, Sieling B:  Oat bran intake selectively lowers serum low-density lipoprotein cholesterol concentrations. Am J Clin Nutr 1981;;34:824-829.
10 +
Anderson JW, Story L, Chen W, et al:  Hypocholesterolemic effects of oat bran for hypercholesterolemic men. Am J Clin Nutr 1984;;40:1146-1155.
11 +
Munoz JM, Sandstead H, Jacob RA, et al:  Effects of some cereal brans and textured vegetable protein on plasma lipids. Am J Clin Nutr 1979;;32:580-592.
12 +
Anderson JW, Story L, Sieling B, et al:  Hypocholesterolemic effects of high fibre diets rich in water-soluble plant fibres. J Can Diet Assoc 1984;;45:2-5.
13 +
Behall KM, Lee KH, Moser PB:  Blood lipids and lipoproteins in adult men fed four refined fibers. Am J Clin Nutr 1984;;39:209-214.
14 +
Simons LA, Gayst S, Balasubramaniam S, et al:  Long-term treatment of hypercholesterolemia with a new formulation of guar gum. Atherosclerosis 1982;;45:101-108.
15 +
Zavoral J, Hannan P, Fields D, et al:  The hypolipidemic effect of locust bean gum food products in familial hypercholesterolemic adults and children. Am J Clin Nutr 1983;;38:285-294.
16 +
Vahouny GV, Tombes R, Cassidy M, et al:  Dietary fibers: Binding of bile salts, phospholipids, and cholesterol from mixed micelles by bile acid sequestrants and dietary fibers. Lipids 1980;;15: 1012-1018.
17 +
Falk J, Nagyvary J:  Exploratory studies of lipid-pectin interactions. J Nutr 1982;;112:182-188.
18 +
Hansen WE, Maurer H, Vollmar J, et al:  Guar gum and bile: Effects on postprandial gallbladder contraction and on serum bile acids in man. Hepatogastroenterology 1983;;30:131-133.
19 +
Medicare Directory of Prevailing Charges . Baltimore, Health Care Financing Administration, 1985;.
20 +
Drug Topics Red Book . New York, Hearst Business Publications, 1985;.
21 +
Drug Topics Red Book: 1985 Update . New York, Hearst Business Publications, 1985;.
22 +
Sugden R, Williams A: The Principles of Practical Cost-Benefit Analysis . Oxford, England, Oxford University Press, 1985;.
23 +
 Life tables , in Vital Statistics of the United States, 1980 . National Center for Health Statistics, 1983;, vol 2.
24 +
Levy RI, Brensike JF, Epstein SE, et al:  Results of the NHLBI Type II Coronary Intervention Study. Circulation 1984;;69:325-337.
25 +
Canner PL, Berge KG, Wenger NK, et al:  15-year mortality in coronary drug project patients: Long-term benefit with niacin. J Am Coll Cardiol 1986;;8:1245-1255.
26 +
Weinstein M, Stason W:  Cost-effectiveness of coronary artery bypass surgery. Circulation 1982;;66( (suppl 3) ):56-66.
27 +
Gordon DJ:  Predictive value of the exercise tolerance test for mortality in North American men: The Lipid Research Clinics Mortality Followup Study. Circulation 1986;;74:252-261.
28 +
Eisenberg J, Kitz D:  Savings from outpatient antibiotic therapy for osteomyelitis: Economic analysis of a therapeutic strategy. JAMA 1986;; 255:1584-1588.
29 +
Comparison of the Medicare Federal Prospective Payment System vs the New Jersey Chapter 83 System . Trenton, New Jersey Department of Health, 1986;.
30 +
Hemenway D, Sherman H, Mudge G, et al:  Comparative costs vs symptomatic and employment benefits of medical and surgical treatment of stable angina pectoris. Med Care 1985;;23:113-114.
31 +
Rice D, Hodgson T, Kopstein A:  The economic costs of illness. Health Care Financ Rev 1985;;7:59-60.
32 +
Kannel WB, Sorlie P, McNamara P:  Prognosis after initial myocardial infarction. Am J Cardiol 1979;;44:53-59.
33 +
Shapiro S, Weinblatt E, Frank CW:  Return to work after first myocardial infarction. Arch Environ Health 1972;;24:17-26.
34 +
Hammermeister K, DeRouen T, English M, et al:  Effect of surgical versus medical therapy on return to work in patients with coronary artery disease. Am J Cardiol 1979;;44:105.
35 +
Oberman A, Wayne J, Kouchoukos N, et al:  Employment status after coronary artery bypass surgery. Circulation 1982;;65( (suppl 2) ):2-115.
36 +
Gordon T, Kannel WB:  Multiple risk functions for predicting coronary heart disease: The concept, accuracy, and application. Am J Cardiol 1982;;44: 1031-1039.
37 +
Brittain E:  Probability of coronary heart disease developing. West J Med 1982;;136:86-89.
38 +
Coronary Risk Handbook From the Framingham Study . New York, American Heart Association, 1978;.
39 +
Grundy SM:  Cholesterol and coronary heart disease. JAMA 1986;;256:2849-2858.
40 +
Bloom B, Wierz D, Pauly M:  Cost and price of comparable branded and generic pharmaceuticals. JAMA 1986;;256:2523-2530.
41 +
Russel L: Is Prevention Better Than Cure? Washington, DC, Brookings Institute, 1985;.
42 +
Taylor WC, Pass T, Shepard D, et al:  Cholesterol reduction and life expectancy. Ann Intern Med 1987;;106:605-614.
43 +
Oster G, Huse M, Delea T, et al:  Cost-effectiveness of nicotine gum as an adjunct to physician's advice against cigarette smoking. JAMA 1986;; 256:1315-1318.
44 +
Van Horn LV, Liu K, Parker D, et al:  Serum lipid response to oat product intake with a fat-modified diet. J Am Diet Assoc 1986;;86:759-764.
45 +
Vega GL, Grundy SM:  Treatment of primary moderate hypercholesterolemia with lovastatin (mevinolin) and colestipol. JAMA 1987;;257:33-38.

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