Thursday, July 8, 2010

One Look At Statin Cost Benefit

"In 2001 probably the most momentous publication in medical history occurred. It was momentous not because it was of astounding importance like Einstein’s four papers in 1905, but momentous because it has ended up affecting so many people. The document is the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, produced as part of the National Cholesterol Education Program. The goal of these guidelines is to markedly decrease the incidence of coronary heart disease (CHD). How is this goal to be accomplished? First, by a regimen of low-fat dieting combined with exercise. But if this regimen should fail to lower LDL levels to below 130 mg/dL (more than half of adults over age 35 have LDL levels of 130 mg/dL or higher), then the guidelines recommend treatment with statin drugs to prevent CHD. Readers of this blog know how great the chances are of a low-fat, high-carb diet lowering the LDL to sub 130 mg/dL levels, so these recommendations are tantamount to recommending the use of statins to more than 50% of adults over the age of 35.
I don’t know the exact number of people over age 35 in the United States right now, but I think it would be safe to say that there are at least 100 million. Half that number is 50 million, which would represent the population of adults over 35 with LDL levels of 130 mg/dL or greater. Now, let’s make a big assumption and say that a third of that 50 million can lower their LDL levels with a combination of diet and exercise (highly unlikely, but lets say it just for grins), that leaves us with about 34 million people who–according to the recommendations–should go on statin drugs. Statin drugs cost, depending upon the brand, somewhere between $2.66 and $4.86 a day, so let’s average it out to $3.75 per day. If we multiply $3.75 per day times 365 days per year times 34 million people we end up with $46.537 billion per year, a tidy little sum that will find it’s way into the pockets of Big Pharma should these recommendations be carried out. (Of interest is the fact that in the paper on low LDL and PD that started this post, the average age of the control subjects was 66.7 and 34% of them were taking statins, so the numbers I’m postulating on numbers of people taking statins are pretty much right on the money.)
If you divide this $46+ billion by 453,189 (the number of people who died from CHD in 2004 from the last available statistics) you come up with a cost of $101,923, which would be the cost per year per person saved by statin drugs if those drugs could somehow prevent every single death from CHD. Now multiply this $101,923 times the number of years the average person would have to take these drugs to prevent death, and you come up with some hefty figures. Probably well over a million dollars per person saved. Is it worth it to society to pay that much? Remember, we all pay for this either directly if we take statins or through increased insurance premiums because of others who do. And we really have to ask that question because most of the deaths from heart disease are self inflicted.
Why self inflicted? Because by far the major cause of CHD is smoking with high blood pressure running a close second. I’ve thought back on all the people I know who have had heart attacks and on all the patients I’ve cared for who have had heart attacks, and all of them – 100% – were smokers. I’ve called a couple of colleagues and asked the same question and have gotten the same answer: people who have never smoked and who have heart attacks are scarce as hens teeth. They exist, to be sure, but they are in the minority. Think back about the people you know who have had heart attacks, and I suspect you will realize the same thing. There is a correlation for you. Smoking equals heart disease. Not cholesterol equals heart disease. Michael DeBakey, the Houston heart surgeon who pioneered bypass surgery,once famously remarked that at least half the patients he operated on had low cholesterol levels."

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