Cost Effectiveness of AtherosclerosisCost Effectiveness of AtherosclerosisScreeningScreening

Daniel B. Mark, MDDaniel B. Mark, MDDuke Clinical Research InstituteDuke Clinical Research Institute

No relationships to discloseNo relationships to disclose

The 4 Major Attitudes About Screening for Atherosclerosis:The 4 Major Attitudes About Screening for Atherosclerosis:The Cardiac Imaging ExpertThe Cardiac Imaging Expert

The 4 Major Attitudes About Screening for Atherosclerosis:The 4 Major Attitudes About Screening for Atherosclerosis:The Practicing MDThe Practicing MD

The 4 Major Attitudes About Screening for Atherosclerosis:The 4 Major Attitudes About Screening for Atherosclerosis:The PatientThe Patient

The 4 Major Attitudes About Screening for Atherosclerosis: The 4 Major Attitudes About Screening for Atherosclerosis: The Academic Professor The Academic Professor

Assessing the Economics of Screening for AtheroscerosisAssessing the Economics of Screening for AtheroscerosisThe Two Key QuestionsThe Two Key Questions

• Is the test strategy good value for $ ? Is the test strategy good value for $ ? (Cost effectiveness)(Cost effectiveness)

• Do we have the money to provide it Do we have the money to provide it for our pts? ($ in health care budget)for our pts? ($ in health care budget)

Cost Brings Discipline to the Practice of MedicineCost Brings Discipline to the Practice of Medicine

Choosing the Right Tool for the TaskChoosing the Right Tool for the Task

Impact of EBT on CV Risk Profile:Impact of EBT on CV Risk Profile:Uniformed Services (Army) RCTUniformed Services (Army) RCT

• 450 consecutive Army personnel, age 39-45450 consecutive Army personnel, age 39-45

• Randomized to EBT & case management Randomized to EBT & case management (2 X 2 factorial)(2 X 2 factorial)

• 15% had coronary calcium, mean 10 yr 15% had coronary calcium, mean 10 yr Framingham risk 6%Framingham risk 6%

• Over 1 yr, EBT arm showed no change in Over 1 yr, EBT arm showed no change in FRS relative to controlFRS relative to control

O’Malley P et al.O’Malley P et al.JAMA 5/03JAMA 5/03

Uncoupling of Dx Testing and Outcome:Uncoupling of Dx Testing and Outcome:How and Why?How and Why?

• Test provides “significant” new info that Test provides “significant” new info that does not alter MD decisiondoes not alter MD decision

• MDs do not agree on how to use test MDs do not agree on how to use test resultsresults

• Indicated therapy not sufficiently effectiveIndicated therapy not sufficiently effective

• Indicated therapy not applied effectivelyIndicated therapy not applied effectively

RCTs of Prevention with Statin Therapy:RCTs of Prevention with Statin Therapy:Overview of 5-year Benefits and CostsOverview of 5-year Benefits and Costs

11º Preventionº Prevention

WOSCOPSWOSCOPS

AFCAPSAFCAPS

2º Prevention2º Prevention

CARECARE

4S4S

DeathsDeaths

55

44

1111

3232

MIsMIs

1919

2626

1818

4747

RevascsRevascs

88

3131

4747

5959

RxRx

$3700$3700

$4654$4654

$5550$5550

$4680$4680

OffsetOffset

$100$100

$524$524

$1660$1660

$3900$3900

NetNet

$3600$3600

$4130$4130

$3890$3890

$780$780

per 1000 ptsper 1000 pts Costs per ptCosts per pt

Mark DB et al.Mark DB et al.Circ 08/02Circ 08/02

Atherosclerosis Imaging in Preventive Cardiology:Atherosclerosis Imaging in Preventive Cardiology:Will It Break the Bank?Will It Break the Bank?

• If each farmer grazes If each farmer grazes a few cattle, plenty of a few cattle, plenty of grass for allgrass for all

• If each farmer grazes If each farmer grazes as many cattle as as many cattle as possible, grass possible, grass rapidly depletedrapidly depleted

The Tragedy of the Medical CommonsThe Tragedy of the Medical Commons

Screening for Atherosclerosis:Screening for Atherosclerosis:The Ultimate ParadoxThe Ultimate Paradox

““Everyone wants to go toEveryone wants to go to

heaven but no one wantsheaven but no one wants

to die.” to die.”

Identifying High Risk of Sudden Cardiac Death:Identifying High Risk of Sudden Cardiac Death:A Screening ParadoxA Screening Paradox

0.2%1.5%

5.0%

20.0%

25.0%

0%

5%

10%

15%

20%

25%

30%300,000

200,000

150,000

100,000

30,000

0

75000

150000

225000

300000

375000

Gen H-Risk Hx of EF<30% OutptGen H-Risk Hx of EF<30% Outpt Gen H-Risk Hx of Gen H-Risk Hx of EF<30% OutptEF<30% Outpt Pop CAD MI CHF SCD sur Pop CAD MI CHF SCD sur Pop CAD MI CHF SCD sur Pop CAD MI CHF SCD sur

Incidence of SCD/yearIncidence of SCD/year Total events/yearTotal events/year