0
March 6, 1991, Vol 265, No. 9 >
ARTICLE | March 6, 1991

Cost-effectiveness of HMG-CoA Reductase Inhibition for Primary and Secondary Prevention of Coronary Heart Disease FREE

Lee Goldman, MD, MPH; Milton C. Weinstein, PhD; Paula A. Goldman, MPH; Lawrence W. Williams, MS
[+] Author Affiliations

Reprint requests to Division of Clinical Epidemiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (Dr Goldman).


JAMA. 1991;265(9):1145-1151. doi:10.1001/jama.1991.03460090093039
Text Size: A A A
Published online
Article
References

To determine the cost-effectiveness of HMG-CoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase inhibitors (such as lovastatin) for the primary and secondary prevention of coronary heart disease, we used the Coronary Heart Disease Policy Model, a computer-simulated model that estimates the risk factor-specific annual incidence of coronary heart disease and the risk of recurrent coronary events in persons with prevalent coronary heart disease. When used for secondary prevention, 20 mg/d of lovastatin was estimated to save lives and save costs in younger men with cholesterol levels above 250 mg/dL (6.47 mmol/L) and to have a favorable cost-effectiveness ratio regardless of the cholesterol level except in young women with cholesterol levels below 250 mg/dL (6.47 mmol/L). Doses of 40 mg/d of lovastatin had favorable incremental cost-effectiveness ratios in men with cholesterol levels above 250 mg/dL (6.47 mmol/L). By comparison, primary prevention had favorable cost-effectiveness ratios only in selected subgroups based on cholesterol levels and other established risk factors. We conclude that current national recommendations regarding medication for secondary prevention are not as aggressive as our projections would suggest, while recommendations regarding the use of medications for primary prevention should consider the cost of medication as well as the risk factor profile of the individual patient.

(JAMA. 1991;265:1145-1151)

REFERENCES

1 +
Stamler J, Wentworth D, Neaton JD.  Is the relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? JAMA. 1986;;256:2823-2828.
2 +
 Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results, I: reduction in incidence of coronary heart disease . JAMA. 1984;;251:351-364.
3 +
 Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results, II: the relationship of reduction in incidence of coronary heart disease to cholesterol lowering . JAMA. 1984;;251:365-374.
4 +
Tyroler HA.  Review of lipid-lowering clinical trials in relation to observational epidemiologic studies . Circulation. 1987;;76:515-522.
5 +
McGee D, Gordon T. The results of the Framingham Study applied to four other US-based epidemiologic studies of cardiovascular disease. In: Kannel WB, Gordon T, eds. The Framingham Study: An Epidemiologic Investigation of Cardiovascular Disease. Bethesda, Md: US Government Printing Office; 1976. NIH publication 76-1083.
6 +
Turpeinin O.  Effect of cholesterol-lowering diet on mortality from coronary heart disease and other causes . Circulation. 1979;;59:1-7.
7 +
Hjermann I, Velve Byre K, Holme I, Leren P.  Effect of diet and smoking intervention on the incidence of coronary heart disease . Lancet. 1981;;2:1303-1310.
8 +
Shekelle RB, Shryock AM, Paul O, Lepper M, Stamler J, Liu S.  Diet, serum cholesterol, and death from coronary heart disease . N Engl J Med. 1981;;304:65-70.
9 +
Frick MH, Elo O, Haapa K, et al.  Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia . N Engl J Med. 1987;;317:1237-1245.
10 +
Committee of Principal Investigators.  WHO Clofibrate Trial: a cooperative trial in the primary prevention of ischaemic heart disease using clofibrate . Br Heart J. 1978;;40:1069-1118.
11 +
Dayton S, Pearce ML, Hashimoto S, et al.  A controlled clinical trial of a diet high in unsaturated fat in preventing complications of atherosclerosis . Circulation. 1969;;40( (suppl 2) ):I-63.
12 +
Schucker B, Bailey K, Heimbach JT, et al.  Change in public perspective on cholesterol and heart disease . JAMA. 1987;;258:3527-3531.
13 +
Schucker B, Wittes JT, Cutler JA, et al.  Change in physician perspective on cholesterol and heart disease . JAMA. 1987;;258:3521-3526.
14 +
 The Expert Panel. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults . Arch Intern Med. 1988;; 148:36-69.
15 +
Wilson PWF, Christiansen JC, Anderson KM, Kannel WB.  Impact of national guidelines for cholesterol risk factor screening . JAMA. 1989;;262:41-44.
16 +
Sempos C, Fulwood R, Haines C, et al.  The prevalence of high blood cholesterol levels among adults in the United States . JAMA. 1989;;262:45-52.
17 +
Palumbo PJ.  Cholesterol lowering for all: a closer look . JAMA. 1989;;262:91-92.
18 +
Oster G, Epstein AM.  Cost-effectiveness of antihyperlipemic therapy in the prevention of coronary heart disease . JAMA. 1987;;258:2381-2387.
19 +
Weinstein MC, Stason WB.  Cost-effectiveness of interventions to prevent or treat coronary heart disease . Annu Rev Public Health. 1985;;6:41-63.
20 +
Kinosian BP, Eisenberg JM.  Cutting into cholesterol: cost-effective alternatives for treating hypercholesterolemia . JAMA. 1988;;259:2249-2254.
21 +
Martens LL, Rutten FFH, Erkelens DW,  Ascoop CAPL. Clinical benefits and cost-effectiveness of lowering serum cholesterol levels . Am J Cardiol. 1990;;65:27F-30F.
22 +
Weinstein MC, Coxson PG, Williams LW, Pass TM, Stason WB, Goldman L.  Forecasting coronary heart disease incidence, mortality, and cost . Am J Public Health. 1987;;77:1417-1426.
23 +
Goldman L, Weinstein MC, Williams LW.  Relative impact of targeted versus population-wide cholesterol interventions on the incidence of coronary heart disease . Circulation. 1989;;80:254-260.
24 +
Edelson JT, Weinstein MC, Tosteson ANA, Williams LW, Lee TH, Goldman L.  Long-term efficacy and cost-effectiveness of various initial monotherapies for mild to moderate hypertension . JAMA. 1990;;263:408-413.
25 +
Tosteson ANA, Weinstein MC, Williams LW, Goldman L.  Long-term impact of smoking cessation on the incidence of coronary heart disease . Am J Public Health. 1990;;80:1481-1486.
26 +
Tsevat J, Weinstein MC, Williams LW, Tosteson ANA, Goldman L.  Expected gains in life expectancy from various coronary heart disease risk-factor modifications . Circulation . In press.
27 +
US Bureau of the Census. Estimates of the Civilian Population of the United States by Age, Sex, and Race, 1980-1983: Current Population Reports, Population Estimates and Projections. Series P-25, No. 949. Washington, DC: Government Printing Office; 1984.
28 +
US Bureau of the Census. Preliminary Estimates of the Population of the United States by Age, Sex, and Race, 1970-1981: Current Population Reports, Population Estimates and Projections. Series P-25, No. 917. Washington, DC: Government Printing Office; 1982.
29 +
US Bureau of the Census. Projections of the Population of the United States by Age, Sex, and Race, 1982-2050: Current Population Reports, Population Estimates and Projections. Series P-25, No. 922. Washington, DC: Government Printing Office; 1982.
30 +
The Framingham Study:  An epidemiological investigation of cardiovascular disease . In: US Dept of Health and Human Services. Some Risk Factors Related to the Annual Incidence of Cardiovascular Disease and Death Using Pooled Repeated Biennial Measurements: Framingham Heart Study, 30-Year Follow-up . Bethesda, Md: National Heart, Lung, and Blood Institute; 1987;:section 34. NIH publication 87-2703.
31 +
National Center for Health Statistics. Vital Statistics of the United States, II, Part A: Mortality, 1979-1981. Washington, DC: Government Printing Office; 1981.
32 +
The Framingham Study: an epidemiological investigation of cardiovascular disease. In: US Dept of Health, Education, and Welfare. Some Characteristics Related to the Incidence of Cardiovascular Disease and Death: 18-Year Follow-up. Bethesda, Md: Public Health Service; 1973;:section 30.
33 +
Pell S, Fayerweather WE.  Trends in the incidence of myocardial infarction and in associated mortality and morbidity in a large employed population, 1957-1983 . N Engl J Med. 1985;;312:1005-1011.
34 +
Elveback LR, Connolly DC, Kurland LT.  Coronary heart disease in residents of Rochester, Minnesota, II: mortality, incidence, and survivorship, 1950-1975 . Mayo Clin Proc. 1981;;56:665-672.
35 +
 Prospective Payment Commission . Technical Appendices to the Report and Recommendations to the Secretary . Washington, DC: US Dept of Health and Human Services; 1988;.
36 +
The Lovastatin Study Group II.  Therapeutic response to lovastatin (mevinolin) in nonfamilial hypercholesterolemia . JAMA. 1986;;256:2829-2834.
37 +
Havel RJ, Hunninghake DB, Illingworth DR, et al.  Lovastatin (mevinolin) in the treatment of heterozygous familial hypercholesterolemia . Ann Intern Med. 1987;;107:609-615.
38 +
Illingworth DR.  Mevinolin plus colestipol in therapy for severe heterozygous familial hypercholesterolemia . Ann Intern Med. 1984;;101:598-604.
39 +
Hoeg JM, Maher MB, Zech LA, et al.  Effectiveness of mevinolin on plasma lipoprotein concentrations in type II hyperlipoproteinemia . Am J Cardiol. 1986;;57:933-939.
40 +
Bradford RH, Shear CL, Chremos AN, et al.  Expanded clinical evaluation of lovastatin (Excel) study results . Arch Intern Med. 1991;;151:43-49.
41 +
The Lovastatin Study Group III.  A multicenter comparison of lovastatin and cholestyramine therapy for severe primary hypercholesterolemia . JAMA. 1988;;260:359-366.
42 +
Group of Physicians of the Newcastle upon Tyne Region.  Trial of clofibrate in the treatment of ischaemic heart disease . BMJ. 1971;;4:767-775.
43 +
 Research Committee of the Scottish Society of Physicians. Ischaemic heart disease . BMJ. 1971;;4:775-784.
44 +
Coronary Drug Project Research Group.  Clofibrate and niacin in coronary heart disease . JAMA. 1975;;231:360-381.
45 +
Research Committee to the Medical Research Council.  Low-fat diet in myocardial infarction . Lancet. 1965;;2:501-504.
46 +
Research Committee to the Medical Research Council.  Controlled trial of soya-bean oil in myocardial infarction . Lancet. 1968;;2:693-700.
47 +
Leren P.  The Oslo Diet Heart Study: eleven-year report . Circulation. 1970;;42:935-942.
48 +
Rossouw JE, Lewis B, Rifkind BM.  The value of lowering cholesterol after myocardial infarction . N Engl J Med. 1990;;323:1112-1119.
49 +
Leaverton PE, Sorlie PD, Kleinman JC, et al.  Representativeness of the Framingham risk model for coronary heart disease mortality: a comparison with a national cohort study . J Chronic Dis. 1987;;40:775-784.
50 +
Brown G, Albers JJ, Fisher LD, et al.  Regression of coronary artery disease as a result of intensive lipid-lowering therapy in men with high levels of apolipoprotein B . N Engl J Med. 1990;;323:1289-1298.
51 +
Blankenhorn DH, Nessim SA, Johnson RL, Sanmarco ME, Azen SP, Cashin-Hemphill L.  Beneficial effects of combined colestipol-niacin therapy on coronary atherosclerosis and coronary venous bypass grafts . JAMA. 1987;;257:3233-3240.
52 +
Kannel WB, D'Agostino RB, Stepanians M, D'Agostino LC.  Efficacy and tolerability of lovastatin in a six-month study: analysis by gender, age, and hypertensive status . Am J Cardiol. 1990;; 66:1B-10B.
53 +
Mantell G, Burke T, Staggers J.  Extended clinical safety profile of lovastatin . Am J Cardiol. 1990;;66:11B-15B.
54 +
Kannel WB, Neaton JD, Wentworth D, et al.  Overall and coronary heart disease mortality rates in relation to major risk factors in 325,348 men screened for the MRFIT . Am Heart J. 1986;; 112:825-836.
55 +
 Low cholesterol and increased risk . Lancet. 1989;;1:1423-1425. Editorial.
56 +
Corday E, Ryden L.  Why some physicians have concerns about the Cholesterol Awareness Program . J Am Coll Cardiol. 1989;;13:497-502.
57 +
Himmelstein D, Woolhandler S.  Free care, cholestyramine, and health policy . N Engl J Med. 1984;;311:1511-1514.
58 +
Martens LL, Rutten FFH, Erkelens DW,  Ascoop CAPL. Cost-effectiveness of cholesterol-lowering therapy in the Netherlands: simvastatin versus cholestyramine . Am J Med. 1989;;87:54S-58S.
59 +
Canner PL, Berge KG, Wenger NK, et al.  Fifteen-year mortality in coronary drug project patients . J Am Coll Cardiol. 1986;;8:1245-1255.
60 +
Roberts SD, Maxwell DR, Gross TL.  Cost-effective care of end-stage renal disease: a billion dollar question . Ann Intern Med. 1980;;92:243.
61 +
Garner TI, Dardis R.  Cost-effectiveness analysis of end-stage renal disease treatments . Med Care. 1987;;25:25-34.
62 +
Russell LB.  Some of the tough decisions required by a national health plan . Science. 1989;;246:892-896.
63 +
Drummond MF.  Economic evaluation and the rational diffusion and use of health technology . Health Policy. 1987;;7:309-324.

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 +
Stamler J, Wentworth D, Neaton JD.  Is the relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? JAMA. 1986;;256:2823-2828.
2 +
 Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results, I: reduction in incidence of coronary heart disease . JAMA. 1984;;251:351-364.
3 +
 Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results, II: the relationship of reduction in incidence of coronary heart disease to cholesterol lowering . JAMA. 1984;;251:365-374.
4 +
Tyroler HA.  Review of lipid-lowering clinical trials in relation to observational epidemiologic studies . Circulation. 1987;;76:515-522.
5 +
McGee D, Gordon T. The results of the Framingham Study applied to four other US-based epidemiologic studies of cardiovascular disease. In: Kannel WB, Gordon T, eds. The Framingham Study: An Epidemiologic Investigation of Cardiovascular Disease. Bethesda, Md: US Government Printing Office; 1976. NIH publication 76-1083.
6 +
Turpeinin O.  Effect of cholesterol-lowering diet on mortality from coronary heart disease and other causes . Circulation. 1979;;59:1-7.
7 +
Hjermann I, Velve Byre K, Holme I, Leren P.  Effect of diet and smoking intervention on the incidence of coronary heart disease . Lancet. 1981;;2:1303-1310.
8 +
Shekelle RB, Shryock AM, Paul O, Lepper M, Stamler J, Liu S.  Diet, serum cholesterol, and death from coronary heart disease . N Engl J Med. 1981;;304:65-70.
9 +
Frick MH, Elo O, Haapa K, et al.  Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia . N Engl J Med. 1987;;317:1237-1245.
10 +
Committee of Principal Investigators.  WHO Clofibrate Trial: a cooperative trial in the primary prevention of ischaemic heart disease using clofibrate . Br Heart J. 1978;;40:1069-1118.
11 +
Dayton S, Pearce ML, Hashimoto S, et al.  A controlled clinical trial of a diet high in unsaturated fat in preventing complications of atherosclerosis . Circulation. 1969;;40( (suppl 2) ):I-63.
12 +
Schucker B, Bailey K, Heimbach JT, et al.  Change in public perspective on cholesterol and heart disease . JAMA. 1987;;258:3527-3531.
13 +
Schucker B, Wittes JT, Cutler JA, et al.  Change in physician perspective on cholesterol and heart disease . JAMA. 1987;;258:3521-3526.
14 +
 The Expert Panel. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults . Arch Intern Med. 1988;; 148:36-69.
15 +
Wilson PWF, Christiansen JC, Anderson KM, Kannel WB.  Impact of national guidelines for cholesterol risk factor screening . JAMA. 1989;;262:41-44.
16 +
Sempos C, Fulwood R, Haines C, et al.  The prevalence of high blood cholesterol levels among adults in the United States . JAMA. 1989;;262:45-52.
17 +
Palumbo PJ.  Cholesterol lowering for all: a closer look . JAMA. 1989;;262:91-92.
18 +
Oster G, Epstein AM.  Cost-effectiveness of antihyperlipemic therapy in the prevention of coronary heart disease . JAMA. 1987;;258:2381-2387.
19 +
Weinstein MC, Stason WB.  Cost-effectiveness of interventions to prevent or treat coronary heart disease . Annu Rev Public Health. 1985;;6:41-63.
20 +
Kinosian BP, Eisenberg JM.  Cutting into cholesterol: cost-effective alternatives for treating hypercholesterolemia . JAMA. 1988;;259:2249-2254.
21 +
Martens LL, Rutten FFH, Erkelens DW,  Ascoop CAPL. Clinical benefits and cost-effectiveness of lowering serum cholesterol levels . Am J Cardiol. 1990;;65:27F-30F.
22 +
Weinstein MC, Coxson PG, Williams LW, Pass TM, Stason WB, Goldman L.  Forecasting coronary heart disease incidence, mortality, and cost . Am J Public Health. 1987;;77:1417-1426.
23 +
Goldman L, Weinstein MC, Williams LW.  Relative impact of targeted versus population-wide cholesterol interventions on the incidence of coronary heart disease . Circulation. 1989;;80:254-260.
24 +
Edelson JT, Weinstein MC, Tosteson ANA, Williams LW, Lee TH, Goldman L.  Long-term efficacy and cost-effectiveness of various initial monotherapies for mild to moderate hypertension . JAMA. 1990;;263:408-413.
25 +
Tosteson ANA, Weinstein MC, Williams LW, Goldman L.  Long-term impact of smoking cessation on the incidence of coronary heart disease . Am J Public Health. 1990;;80:1481-1486.
26 +
Tsevat J, Weinstein MC, Williams LW, Tosteson ANA, Goldman L.  Expected gains in life expectancy from various coronary heart disease risk-factor modifications . Circulation . In press.
27 +
US Bureau of the Census. Estimates of the Civilian Population of the United States by Age, Sex, and Race, 1980-1983: Current Population Reports, Population Estimates and Projections. Series P-25, No. 949. Washington, DC: Government Printing Office; 1984.
28 +
US Bureau of the Census. Preliminary Estimates of the Population of the United States by Age, Sex, and Race, 1970-1981: Current Population Reports, Population Estimates and Projections. Series P-25, No. 917. Washington, DC: Government Printing Office; 1982.
29 +
US Bureau of the Census. Projections of the Population of the United States by Age, Sex, and Race, 1982-2050: Current Population Reports, Population Estimates and Projections. Series P-25, No. 922. Washington, DC: Government Printing Office; 1982.
30 +
The Framingham Study:  An epidemiological investigation of cardiovascular disease . In: US Dept of Health and Human Services. Some Risk Factors Related to the Annual Incidence of Cardiovascular Disease and Death Using Pooled Repeated Biennial Measurements: Framingham Heart Study, 30-Year Follow-up . Bethesda, Md: National Heart, Lung, and Blood Institute; 1987;:section 34. NIH publication 87-2703.
31 +
National Center for Health Statistics. Vital Statistics of the United States, II, Part A: Mortality, 1979-1981. Washington, DC: Government Printing Office; 1981.
32 +
The Framingham Study: an epidemiological investigation of cardiovascular disease. In: US Dept of Health, Education, and Welfare. Some Characteristics Related to the Incidence of Cardiovascular Disease and Death: 18-Year Follow-up. Bethesda, Md: Public Health Service; 1973;:section 30.
33 +
Pell S, Fayerweather WE.  Trends in the incidence of myocardial infarction and in associated mortality and morbidity in a large employed population, 1957-1983 . N Engl J Med. 1985;;312:1005-1011.
34 +
Elveback LR, Connolly DC, Kurland LT.  Coronary heart disease in residents of Rochester, Minnesota, II: mortality, incidence, and survivorship, 1950-1975 . Mayo Clin Proc. 1981;;56:665-672.
35 +
 Prospective Payment Commission . Technical Appendices to the Report and Recommendations to the Secretary . Washington, DC: US Dept of Health and Human Services; 1988;.
36 +
The Lovastatin Study Group II.  Therapeutic response to lovastatin (mevinolin) in nonfamilial hypercholesterolemia . JAMA. 1986;;256:2829-2834.
37 +
Havel RJ, Hunninghake DB, Illingworth DR, et al.  Lovastatin (mevinolin) in the treatment of heterozygous familial hypercholesterolemia . Ann Intern Med. 1987;;107:609-615.
38 +
Illingworth DR.  Mevinolin plus colestipol in therapy for severe heterozygous familial hypercholesterolemia . Ann Intern Med. 1984;;101:598-604.
39 +
Hoeg JM, Maher MB, Zech LA, et al.  Effectiveness of mevinolin on plasma lipoprotein concentrations in type II hyperlipoproteinemia . Am J Cardiol. 1986;;57:933-939.
40 +
Bradford RH, Shear CL, Chremos AN, et al.  Expanded clinical evaluation of lovastatin (Excel) study results . Arch Intern Med. 1991;;151:43-49.
41 +
The Lovastatin Study Group III.  A multicenter comparison of lovastatin and cholestyramine therapy for severe primary hypercholesterolemia . JAMA. 1988;;260:359-366.
42 +
Group of Physicians of the Newcastle upon Tyne Region.  Trial of clofibrate in the treatment of ischaemic heart disease . BMJ. 1971;;4:767-775.
43 +
 Research Committee of the Scottish Society of Physicians. Ischaemic heart disease . BMJ. 1971;;4:775-784.
44 +
Coronary Drug Project Research Group.  Clofibrate and niacin in coronary heart disease . JAMA. 1975;;231:360-381.
45 +
Research Committee to the Medical Research Council.  Low-fat diet in myocardial infarction . Lancet. 1965;;2:501-504.
46 +
Research Committee to the Medical Research Council.  Controlled trial of soya-bean oil in myocardial infarction . Lancet. 1968;;2:693-700.
47 +
Leren P.  The Oslo Diet Heart Study: eleven-year report . Circulation. 1970;;42:935-942.
48 +
Rossouw JE, Lewis B, Rifkind BM.  The value of lowering cholesterol after myocardial infarction . N Engl J Med. 1990;;323:1112-1119.
49 +
Leaverton PE, Sorlie PD, Kleinman JC, et al.  Representativeness of the Framingham risk model for coronary heart disease mortality: a comparison with a national cohort study . J Chronic Dis. 1987;;40:775-784.
50 +
Brown G, Albers JJ, Fisher LD, et al.  Regression of coronary artery disease as a result of intensive lipid-lowering therapy in men with high levels of apolipoprotein B . N Engl J Med. 1990;;323:1289-1298.
51 +
Blankenhorn DH, Nessim SA, Johnson RL, Sanmarco ME, Azen SP, Cashin-Hemphill L.  Beneficial effects of combined colestipol-niacin therapy on coronary atherosclerosis and coronary venous bypass grafts . JAMA. 1987;;257:3233-3240.
52 +
Kannel WB, D'Agostino RB, Stepanians M, D'Agostino LC.  Efficacy and tolerability of lovastatin in a six-month study: analysis by gender, age, and hypertensive status . Am J Cardiol. 1990;; 66:1B-10B.
53 +
Mantell G, Burke T, Staggers J.  Extended clinical safety profile of lovastatin . Am J Cardiol. 1990;;66:11B-15B.
54 +
Kannel WB, Neaton JD, Wentworth D, et al.  Overall and coronary heart disease mortality rates in relation to major risk factors in 325,348 men screened for the MRFIT . Am Heart J. 1986;; 112:825-836.
55 +
 Low cholesterol and increased risk . Lancet. 1989;;1:1423-1425. Editorial.
56 +
Corday E, Ryden L.  Why some physicians have concerns about the Cholesterol Awareness Program . J Am Coll Cardiol. 1989;;13:497-502.
57 +
Himmelstein D, Woolhandler S.  Free care, cholestyramine, and health policy . N Engl J Med. 1984;;311:1511-1514.
58 +
Martens LL, Rutten FFH, Erkelens DW,  Ascoop CAPL. Cost-effectiveness of cholesterol-lowering therapy in the Netherlands: simvastatin versus cholestyramine . Am J Med. 1989;;87:54S-58S.
59 +
Canner PL, Berge KG, Wenger NK, et al.  Fifteen-year mortality in coronary drug project patients . J Am Coll Cardiol. 1986;;8:1245-1255.
60 +
Roberts SD, Maxwell DR, Gross TL.  Cost-effective care of end-stage renal disease: a billion dollar question . Ann Intern Med. 1980;;92:243.
61 +
Garner TI, Dardis R.  Cost-effectiveness analysis of end-stage renal disease treatments . Med Care. 1987;;25:25-34.
62 +
Russell LB.  Some of the tough decisions required by a national health plan . Science. 1989;;246:892-896.
63 +
Drummond MF.  Economic evaluation and the rational diffusion and use of health technology . Health Policy. 1987;;7:309-324.

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