QJM Advance Access originally published online on April 21, 2007
QJM 2007 100(5):277-289; doi:10.1093/qjmed/hcm020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Economic analysis of treatments reducing coronary heart disease mortality in England and Wales, 2000–2010
1From the Division of Public Health, University of Liverpool, 2Department of Public Health, Dokuz Eylul University School of Medicine, 35340 Izmir, Turkey, 3International Health Research Group, Liverpool School of Tropical Medicine, Liverpool, UK
Address correspondence to Professor S. Capewell, Department of Public Health, University of Liverpool, Whelan Building, Quadrangle, Liverpool L69 3GB. email: capewell{at}liverpool.ac.uk
Received 26 June 2006 and in revised form 15 October 2006
 |
Summary |
|---|
 Top Summary IntroductionMethodsResultsDiscussionAppendix 1Appendix 2AcknowledgementsReferencesReferences for Appendix II |
|---|
Background: Coronary heart disease (CHD) in the UK affects
3 million people, with >100 000 deaths annually. Mortality rates have halved since the 1980s, but annual NHS treatment costs for CHD exceed £2 billion. Aim: To examine the cost-effectiveness of specific CHD treatments in England and Wales.
Methods: The IMPACT CHD model was used to calculate the number of life-years gained (LYG) from specific cardiological interventions from 2000 to 2010. Cost-effectiveness ratios (costs per LYG) were generated for each specific intervention, stratified by age and sex. The robustness of the results was tested using sensitivity analyses.
Results: In 2000, medical and surgical treatments together prevented or postponed approximately 25 888 deaths in CHD patients aged 25–84 years, thus generating 194 929 extra life-years between 2000 and 2010 (range 143 131–260 167). Aspirin and beta-blockers for secondary prevention following myocardial infarction or revascularisation, for angina and heart failure were highly cost-effective (<£1000 per LYG). Other secondary prevention therapies, including cardiac rehabilitation, ACE inhibitors and statins, were reasonably cost-effective (£1957, £3398 and £4246 per LYG, respectively), as were CABG surgery (£3239–£4601 per LYG) and angioplasty (£3845–£5889 per LYG). Primary angioplasty for myocardial infarction was intermediate (£6054–£12 057 per LYG, according to age), and statins in primary prevention were much less cost-effective (£27 828 per LYG, reaching £69 373 per LYG in men aged 35–44). Results were relatively consistent across a wide range of sensitivity analyses.
Discussion: The cost-effectiveness ratios for standard CHD treatments varied by over 100-fold. Large amounts of NHS funding are being spent on relatively less cost-effective interventions, such as statins for primary prevention, angioplasty and CABG surgery. This merits debate.
|
Introduction |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAppendix 1Appendix 2AcknowledgementsReferencesReferences for Appendix II |
|---|
Coronary heart disease (CHD) generates a major disease burden in the UK, chronically affecting over 2.6 million individuals, and causing over 100 000 deaths annually.1 However, CHD mortality in the UK has halved since the 1980s, as in most developed countries. Studies using a range of methodologies consistently suggest that some 40–50% of this fall can be attributed to medical treatments.2–6
NHS costs for CHD are rapidly rising, and now exceed £2 billion annually,7 having increased from £1.73 billion in 1999.8 Hospital in-patient care now accounts for over £1 billion and drug treatment over £750 million, with some two-thirds going to patients aged >65 years.7,8 The 1998 CHD National Service Framework has led to a dramatic spending increase on revascularization, statins and other expensive medications, together exceeding £700 million.9 In 2005, the statin bill alone exceeded £840 million.10 Inevitably, these escalating costs have increased concerns about the most cost-effective use of limited NHS resources.7,11
Many economic evaluations of CHD interventions have been published.12–16 However, much of the available economic evidence now appears restricted in focus or increasingly dated. It is therefore difficult for planners and policy makers to make valid comparisons across the wide range of available cardiac interventions. In fact, very few economic studies have used consistent methodology and assumptions to evaluate more than a handful of therapies simultaneously. The most recent comprehensive European analysis, in 1996,12 suggested substantial variations in cost-effectiveness ratios across different technologies, from £50 per life-year gained (LYG) for aspirin as secondary prevention, to £8240 per LYG for statins in primary prevention.12 However, since then, most costs have increased substantially while statin costs have fallen dramatically, making the previous findings obsolete. Furthermore, the 1996 analysis did not consider potentially costly revascularization procedures. Earlier UK and US studies had suggested that the cost effectiveness of coronary artery bypass graft (CABG) surgery for chronic angina might vary between £2000 and £20 000 per LYG (or QALY), depending on patient selection and disease severity.14,15 Studies have consistently suggested that angioplasty is less cost-effective than CABG, generally exceeding £5000 per LYG.14,17
CABG surgery and angioplasty rates in Britain have trebled since the mid 1990s, and now dominate local and national CHD budgets.9 Meanwhile, commentators increasingly suggest that scarce NHS resources should be directed to those interventions offering best value for money, to maximize the allocative efficiency of the health system.7,11,18 This is equally true for decision-makers at local or national levels, whether working in the National Institute for Health and Clinical Excellence (NICE) or in a Primary Care Trust (PCT). Hence there is a pressing need for a standardized approach to facilitate valid comparisons across the very wide range of interventions now potentially available to treat CHD patients.
This study therefore aimed to use a consistent methodology to examine the cost-effectiveness of all the principal CHD treatments given in England and Wales in 2000.
|
Methods |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAppendix 1Appendix 2AcknowledgementsReferencesReferences for Appendix II |
|---|
To capture all the important CHD treatments given in England and Wales in 2000, we identified and analysed 36 condition-treatment scenarios. The principal conditions were: acute myocardial infarction (AMI), secondary prevention after AMI or revascularization, unstable angina, chronic angina, heart failure in hospital and in the community, plus primary prevention using statins.
The specific therapies considered included aspirin, thrombolysis, beta-blockers, ACE inhibitors, statins, cardiac rehabilitation, warfarin, heparin, glycoprotein IIb/IIIa inhibitors, CABG surgery and angioplasty. Lifestyle interventions such as smoking cessation and diet will be considered in a separate study.
The IMPACT model
This large cell-based mortality model, previously validated in Scotland, New Zealand and Finland, has been described in detail elsewhere.3–5,19–22 In brief, the model uses large MS Excel spreadsheets to synthesize data from: CHD patient numbers, uptake of specific medical and surgical treatments, effectiveness of specific treatments, and median survival in patients with and without CHD. The model was developed using data from a range of sources describing England and Wales in the year 2000.3 The complete IMPACT model also includes the mortality consequences of population trends in major risk factors; these will be studied in a separate analysis. The effectiveness estimates for each therapy were based on recent meta-analyses and large randomized controlled trials. The included trials are listed in Appendix 2.
For the purpose of this study, the current IMPACT model was extended to follow each cohort of patients who received specific treatments for up to 10 years from the year 2000 through to 2010. Age-specific mortality rates, age-specific incidence rates, disease fatality and treatment efficacy (quantified as relative risk reduction) were used to calculate the number of deaths prevented or postponed in each patient group attributable to that treatment.3,20 Life-years gained (LYG) were calculated by applying median survival values for each group to the deaths prevented or postponed.23 These LYG estimates were then used to calculate cost-effectiveness ratios, as detailed below. Results were stratified by age and sex.
Costing methodology
The perspective adopted for the study was that of the NHS. Only drug costs and intervention costs were included in this analysis. Cost-effectiveness ratios were calculated in terms of cost per LYG.
Unit costs for health technologies were estimated using a range of sources, including NHS Reference Costs, British National Formulary (BNF), Prescription Cost Analysis (PCA) data, published literature, NICE Guidance documents and grey literature.18,24–28 The costs used in base-case analysis and the assumptions are summarized in Table 1.
|
For drugs, the unit costs were derived from the BNF for 2000,26 using the doses reported in the major trials (Appendix 2). Costs were adjusted for under-dosing where data were available.
There was considerable variation in costs across different formulations within the same class of drugs. For example, the annual cost of treatment with beta-blockers varied between £22 (atenolol) and £357 (carvedilol), depending on the drug of choice. For the base case estimates, weighted average costs were therefore calculated reflecting each drug's share in the UK drug prescription total. The breakdown of NHS expenditure according to each formulation was obtained from PCA data, which provide an accurate estimate of the drugs prescribed in the community settings. As there were few reliable data on hospital prescription patterns, we assumed similar drug use patterns in in-patient settings.
Costs for CABG surgery and angioplasty were taken from NHS Reference Costs for 2000.25 Where possible, the data from routine cost sources were confirmed using other published sources, grey literature and policy documents. Costs of glycoprotein IIb/IIIa inhibitors and thrombolysis were taken from NICE reviews that used a rigorous costing methodology.27 Cost of cardiac rehabilitation was taken from the published literature.28 One-off costs were calculated for surgical procedures, cardiac rehabilitation, thrombolysis and glycoprotein IIIa/IIb inhibitors.25–27
Wherever possible, the actual 2000 prices were used in the analysis. When the 2000 prices were not available, the prices were converted using the NHS Pay and Prices Index. When wide variations between drug doses and unit costs were encountered, the impact of cost variations on the cost-effectiveness ratios was examined using sensitivity analyses.
All costs and treatment effects were estimated for 10-year age bands and for both men and women. The very small number of patients aged <35 years were excluded from the analysis, as were those aged >85 years.3
Time frame
Interventions for acute myocardial infarction and acute coronary syndrome were evaluated over a one-year scenario. Cardiac rehabilitation benefits were assumed to last for two years.24
Cost-effectiveness ratios were calculated on the basis of a 10-year time horizon for continuous drug interventions, in all chronic conditions except heart failure. Given the severely reduced life expectancy in heart failure, costs and treatment benefits were calculated over 2 years for patients admitted to hospital, and over 5 years for heart failure patients treated only in the community.23
A discount rate of 3.5% was applied to both costs and benefits, as recommended by the National Institute for Clinical Excellence.29 ‘Discount rates’ can be defined as rates of discount used to convert future healthcare costs and benefits into equivalent present values. The impact of the discount rates on the results was tested in sensitivity analyses.
Sensitivity analyses
Sensitivity analyses are commonly used methods for assessing the robustness of an economic model by examining the changes in results of the analysis when key variables are varied over a specified range. Our sensitivity analyses were performed using a standard one-way methodology.30 This addressed the uncertainties surrounding the key variables (treatment costs, patient numbers, treatment uptake, treatment efficiency, median survival and the overlap between different treatment categories). The reported base-case cost-effectiveness ratios were calculated using the best estimates for costs and effectiveness. The minimum and maximum plausible values for each variable (Table 1 and 2) were then used to generate minimum and maximum estimates of cost per LYG (Appendix 1).
|
|
Results |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAppendix 1Appendix 2AcknowledgementsReferencesReferences for Appendix II |
|---|
CHD medical and surgical treatments in 2000: deaths prevented or postponed and life years gained through to 2010
Specific medical and surgical treatments for CHD patients prevented or postponed approximately 25 888 deaths in England and Wales in the year 2000. The combined effect of all the relevant treatments generated a total of 194 929 additional life-years (minimum estimate 143 131, maximum 260 167 life-years).23 The largest contributions came from secondary prevention following myocardial infarction or revascularization, heart failure treatments and initial treatments for acute myocardial infarction (Table 2).
Cost-effectiveness ratios
Acute myocardial infarction
All initial treatments had very favourable cost-effectiveness ratios across all age groups (Figure 1). Base-case cost-effectiveness ratios were £408 per LYG for cardiopulmonary resuscitation (ranging from £192 in patients aged 45–54 years, to £1281 in patients aged >75 years), £1498 per LYG for thrombolysis (£1185–£1708 per LYG), and £268 per LYG for ACE inhibitors (£189–£560 per LYG). The least favourable cost-effectiveness was £7571 per LYG for primary angioplasty (£6054–£12 057 per LYG) (Figure 1 and Table 3).
|
|
Secondary prevention
Cost-effectiveness was also very favourable for all secondary prevention treatments in patients following myocardial infarction or revascularization. Discounted base-case cost-effectiveness ratios for aspirin, beta blockers and warfarin were £885, £502 and £1075 per LYG, respectively. These findings were consistent across all age groups (Figure 1). Exercise-based rehabilitation, ACE inhibitors and statins were progressively more expensive, costing £1957, £3398 and £4246 per LYG. respectively (Figure 1, Table 3).
Chronic angina therapies
Aspirin proved a reasonably cost-effective treatment for chronic angina across all age groups (£1236–£2591 per LYG). The cost effectiveness ratios were two- to three-fold higher for revascularization treatments; between £3239 and £4601 per LYG for CABG surgery and between £3845 and £5889 per LYG for angioplasty, and up to ten-fold higher for statins (£11 978–£25 101) (Figure 1, Table 3).
Unstable angina
Aspirin, alone or in combination with low molecular weight heparin, was extremely cost-effective for unstable angina in all age groups, at <£500 per LYG. However, platelet glycoprotein IIb/IIIa inhibitors were up to ten-fold as expensive, irrespective of age, costing between £2257 and £4615 per LYG (Table 3).
Heart failure
Aspirin, beta blockers and spironolactone all proved extremely cost-effective in the treatment of chronic heart failure, both for patients initially admitted to hospital and those treated in the community (Figure 1). The cost-effectiveness ratios were consistently <£700 per LYG across all age groups. ACE inhibitors were slightly more expensive, averaging £2173 per LYG for hospital patients and £2237 per LYG for community patients (Table 3).
Statins for primary prevention
The cost-effectiveness ratio across all age groups was £27 828 per LYG. However, both age and sex had a powerful effect. Statins were extremely expensive in the youngest age groups (men aged 35–44, £69 373 per LYG), but cost-effectiveness improved with age, reaching £9159 per LYG in those few eligible men aged 75–84 years. Corresponding costs were even higher in women (£10 455–£94 645 per LYG) (Figure 2).
|
Expected total costs to the NHS
Discounted incremental costs and benefits showed a comparable spectrum, ranging from £58 per LYG (aspirin for unstable angina) to £27 828 per LYG (Statins for primary prevention) (Table 4).
|
Sensitivity analyses
The relative cost-effectiveness of specific treatments remained consistent, irrespective of whether maximum or minimum estimates were used (Figure 1). The largest variation in cost-effectiveness estimates were observed for primary PTCA and statins for primary prevention. These, however, represent extreme scenarios based on LYG calculations. For all other treatments, sensitivity analyses consistently generated cost-effectiveness ratios of <£30 000 per LYG (Figure 1).
|
Discussion |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAppendix 1Appendix 2AcknowledgementsReferencesReferences for Appendix II |
|---|
Medical and surgical treatments for CHD in the UK now cost over £2 billion annually;1 economic analyses are thus crucial. This is the first UK-based cost-effectiveness analysis since the mid 1990s to use a standardized methodology to compare the cost effectiveness of diverse cardiological treatments. Furthermore, it is comprehensive, including all standard therapies used in 2000. The data were based on the entire adult population in England and Wales and are therefore not subject to sampling errors. Data quality was generally good or adequate. Furthermore, the underlying IMPACT modelling methodology has now been replicated in a number of countries.3–5,19–22 The cost-effectiveness levels for cardiological treatments considered in this analysis varied by over 100-fold. Aspirin and beta-blockers (for myocardial infarction, secondary prevention, angina or heart failure) were generally extremely cost-effective, with cost-effectiveness ratios of <£1500 per LYG. Other secondary prevention therapies (rehabilitation, warfarin and ACE inhibitors) also appeared cost-effective, at <£5000 per LYG. However, many eligible patients were actually not receiving the appropriate treatments.31 They represent an important target for the CHD NSF programme.9
Revascularization for angina or myocardial infarction also demonstrated relatively favourable cost-effectiveness levels, ranging from around £4000 per LYG (for chronic angina treatment) to approximately £7500 per LYG (for primary PTCA) over a 10-year period. Revascularization may also represent one of the most potent therapies for suitable patients with impaired left ventricular function.
However, cost-effectiveness for statins was more mixed, ranging from £3000 per LYG in heart failure patients, to almost £70 000 per LYG for primary prevention in younger subjects.
Comparison with other studies
The cost-effectiveness of statin treatment has been studied extensively.12,13,16,32–34 Our results are generally consistent with those of previous UK-based studies,12,13 bearing in mind that unit costs for statins almost halved between 1996 (£550 per annum) and 2000 (£387 per annum). The estimated cost-effectiveness of statins for primary prevention was previously reported as £5100–12 500 per LYG in the UK, and US$8100–40 000 per QALY in the USA, depending on the annual risk of CHD.12,13,16,32 Total costs will be substantial, if 15–25% of adults are treated, as recently suggested.35
Our estimates for ACE inhibitors ranged from approximately £2000 per LYG for heart failure patients up to £3500 for secondary prevention patients. This is consistent with the estimated cost effectiveness of ramipril (£4000 per LYG in high-risk groups at 5 years, decreasing to £100 per LYG for lifetime treatment).36
Aspirin treatment proved to be consistently very cost-effective across different disease groups and age groups in our analysis, with cost effectiveness ratios of £60 to £900 per LYG. This is consistent with UK work,12,13 but contrasts with one surprisingly high estimate from Gaspoz et al. in the USA.37
Cost-effectiveness ratios were slightly higher for revascularization, averaging £4000 per LYG for CABG surgery and £4500 for angioplasty. Previous estimates have ranged from £2000–20 000 per LYG or QALY.14,15,17 These remain relatively cost-effective when compared with many other treatments funded within the NHS, such as renal dialysis, or some forms of cancer chemotherapy approaching the (rather generous) NHS cost-effectiveness threshold value of £30 000 per QALY.29,38
Reassuringly, our cost-effectiveness estimates are generally consistent with the published literature. Furthermore, the sensitivity analysis suggested that the results were reasonably robust. The relative cost-effectiveness of specific treatments remained fairly consistent, irrespective of whether best maximum or minimum estimates for treatment efficacy, life expectancy and unit costs were used.
Results were based on 2000 costs. The price of statins should progressively reduce due to patent expiration; however, the transition to generics may be slow.
Limitations of this study
The primary aim of this paper was to compare a range of therapies using a standard methodology. We therefore focused on average net treatment costs for each life year gained. We did not explicitly capture reductions in admissions, follow-up visits, costs associated with adverse events or potential costs avoided (such as further infarcts, or further revascularisation). The use of more complex modelling techniques, while theoretically desirable, was not feasible. However, that approach certainly represents a future research target. Meanwhile, evidence suggests that the inclusion of long-term cost consequences in other studies may make surprisingly little difference.13 Each treatment relative risk value in the model was based on a meta-analysis comparison with an older therapy, or in some cases with placebo if relevant. A perfect economic analysis for informing optimal resource allocation in the health system would use data from real-life clinical practice and the treatment-mix offered to patients, to establish a common baseline. While not ideal, the IMPACT Model produced an approximation to this, by recognizing that most patients in most groups were receiving multiple therapies.
Implications for research and clinical care
Earlier analyses intriguingly suggested that preventative strategies are consistently more cost-effective than treating established disease.39–41 Further studies are now indicated, using standardized methodology to measure the cost-effectiveness of risk factor reductions across the entire spectrum of primary and secondary prevention.
The implications for clinicians and policy makers are clear. CHD funding in the NHS currently seems to emphasize revascularization and waiting lists. Over 90% of NSF monies have been spent on pathways to revascularization, (promoting referral and assessment), and on the high-cost procedures themselves.9 However, in the UK as in other countries, secondary prevention and heart failure therapies still consistently offer better value for money than CABG surgery, angioplasty or statins.
|
Appendix 1 |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAppendix 1Appendix 2AcknowledgementsReferencesReferences for Appendix II |
|---|
Sensitivity analysis: cost-effectiveness ratios for all treatment scenarios
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Appendix 2 |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAppendix 1Appendix 2AcknowledgementsReferencesReferences for Appendix II |
|---|
Clinical efficacy of interventions used in IMPACT model: relative risk reductions obtained from meta-analyses, and randomized controlled trials
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
*Relative risk calculated as (1–odds ratio).
|
Notes |
|---|
*Dr Fidan was employed at the National Institute for Clinical Excellence (London, UK) and London School of Hygiene and Tropical Medicine when this work was completed, but is currently employed as a Senior Health Economist by sanofi-aventis.
|
Acknowledgements |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAppendix 1Appendix 2AcknowledgementsReferencesReferences for Appendix II |
|---|
BU was funded by a North West Regional Research and Development Training Fellowship. We also thank the UK Data Archive and many colleagues in London and Liverpool for constructive comments. DF was a member of the Appraisals Team at the National Institute for Clinical Excellence (NICE) when this study was undertaken, but is now an employee of sanofi-aventis Bagneux, France. The views expressed in this paper are those of the authors alone, and do not represent the views of NICE or sanofi-aventis.
|
References |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAppendix 1Appendix 2AcknowledgementsReferencesReferences for Appendix II |
|---|
1. British Heart Foundation Statistics Database. Coronary Heart Disease Statistics. 2002. [http://www.bhf.org.uk/professionals/uploaded/bhf%20heartstats%202003%20-%204-page.pdf] Accessed 13 October 2006.
2. Hunink MG, Goldman L, Tosteson AN, Mittleman MA, Goldman PA, Williams LW, et al. (1997) The recent decline in mortality from coronary heart disease, 1980–1990. The effect of secular trends in risk factors and treatment. JAMA 277 535–42.
3. Unal B, Critchley J, Capewell S. (2004) Explaining the decline in coronary heart disease mortality in England and Wales, 1981–2000. Circulation 109 1101–7.
4. Laatikainen T, Critchley J, Vartiainen E, Salomaa V, Ketonen M, Capewell S. (2005) Explaining the decline in coronary heart disease mortality in Finland between 1982 and 1997. Am J Epidemiol 162 764–73.
5. Bennett K, Kabir Z, Unal B, Shelley E, Critchley J, Perry I, et al. (2006) Explaining the recent decrease in coronary heart disease mortality rates in Ireland, 1985–2000. J Epidemiol Comm Health 60 322–7.
6. Capewell S, Beaglehole R, Seddon M, McMurray J. (2000) Explanation for the decline in coronary heart disease mortality rates in Auckland, New Zealand, between 1982 and 1993. Circulation 102 1511–16.
7. Liu JL, Maniadakis N, Gray A, Rayner M. (2002) The economic burden of coronary heart disease in the UK. Heart 88 597–603.
8. Luengo-Fernandez R, Leal J, Gray A, Petersen S, Rayner M. (2006) Cost of cardiovascular diseases in the United Kingdom. Heart 92 1384–9.
9. Boyle R. Delivering better heart services: NSF services progress report 2003. [http://www.dh.gov.uk/assetRoot/04/07/52/80/04075280.pdf] Accessed 2 May 2006.
10. BHF Statistics Website: Prescriptions. [http://www.heartstats.org] Accessed 25 May 2006.
11. All Parliamentary Group on Heart Disease. [www.bhf.org.uk/appg/] Accessed 25 May 2006.
12. NHS Centre for Reviews and Dissemination. (1998) Cholesterol and coronary heart disease: screening and treatment. Effective Health Care Bull 4 1–16.
13. Pickin DM, McCabe C, Ramsay JG, Payne N, Haq IU, Yeo WW, et al. (1999) Cost effectiveness of HMG-CoA reductase inhibitor (statin) treatment related to the risk of coronary heart disease and cost of drug treatment. Heart 82 325–32.
14. Cleland JG and Walker A. (1998) Therapeutic options and cost considerations in the treatment of ischemic heart disease. Cardiovasc Drugs Therapy 12Suppl. 3, 225–32.[CrossRef]
15. Weinstein MC. (2003) Coronary Artery bypass surgery is still cost-effective: using calibrated models to update clinical trials. Am J Med 115 410–11.[CrossRef][Web of Science][Medline]
16. Prosser LA, Stinnett AA, Goldman PA, Williams LW, Hunink MG, Goldman L, et al. (2000) Cost-effectiveness of cholesterol-lowering therapies according to selected patient characteristics. Ann Intern Med 132 769–79.
17. Favarato D, Hueb W, Gersh BJ, Soares PR, Cesar LA, da Luz PL, et al. (2003) Relative cost comparison of treatments for coronary artery disease: the First Year Follow-Up of MASS II Study. Circulation 108Suppl. 1, II21–3.[Medline]
18. Fox KF, Wood DA, Wright M, Bond S, Nuttall M, Arora B, et al. (2002) Evaluation of cardiac prevention and rehabilitation programme for all patients at first presentation with coronary artery disease. J Cardiovasc Risk 9 355–9.[CrossRef][Web of Science][Medline]
19. Capewell S, Morrison CE, McMurray JJ. (1999) Contribution of modern cardiovascular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994. Heart 81 380–6.
20. Capewell S, Beaglehole R, Seddon M, McMurray J. (2000) Explaining the decline in Coronary Heart Disease Mortality in Auckland, New Zealand between 1982 and 1993. Circulation 102 1511–16.
21. Unal B, Critchley J, Fidan D, Capewell S. (2005) Life-years gained from modern cardiological treatments and population risk factor changes in England and Wales, 1981–2000. Am J Public Health 95 103–8.
22. Critchley J, Liu J, Zhao D, Wei W, Capewell S. (2004) Explaining the increase in coronary heart disease mortality in Beijing between 1984 and 1999. Circulation 110 1236–44.
23. Unal B, Critchley J, Fidan D, Capewell S. (2005) Life-years gained from modern cardiological treatments and population risk factor changes in England and Wales, 1981–2000. Am J Public Health 95 103–8.
24. Taylor RS, Brown A, Ebrahim S, Jolliffe JA, Noorani H, Rees K, et al. (2004) The effectiveness of exercise based interventions for patients with coronary heart disease: systematic review and meta-analysis of randomised controlled trials. Am J Med 116 682–92.[CrossRef][Web of Science][Medline]
25. NHS Reference Costs. (2000) London Department of Health.
26. British National Formulary. (2000) London HMSO No. 40.
27. Myocardial infarction—early thrombolysis treatment.. NICE Appraisal Guidance No. 52 (2004).
28. Gray AM, Bowman GS, Thompson DR. (1997) The cost of cardiac rehabilitation services in England and Wales. J Roy Coll Phys London 31 57–61.[Web of Science][Medline]
29. National Institute for Clinical Excellence. (2004) Guide to the Technology Appraisal Process (reference N0514).
30. Briggs A, Sculpher M, Buxton M. (1994) Uncertainty in the economic evaluation of health care technologies: the role of sensitivity analysis. Health Econ 3 95–104.[Medline]
31. Capewell S, Unal B, Critchley J, McMurray JJ. (2006) Over 20 000 avoidable coronary deaths in England and Wales in 2000: the failure to give effective treatments to many eligible patients. Heart 32 521–3.
32. Pignone M, Earnshaw S, Tice JA, Pletcher MJ. (2006) Ann Intern Med 144 326–36.
33. Tonkin AM, Eckermann S, White H, Friedlander D, Glasziou P, Magnus P, et al. (2006) Cost-effectiveness of cholesterol-lowering therapy with pravastatin in patients with previous acute coronary syndromes aged 65 to 74 years compared with younger patients: results from the LIPID study. Am Heart J 151 1305–12.[CrossRef][Web of Science][Medline]
34. Franco OH, Peeters A, Looman CW, Bonneux L. (2005) Cost effectiveness of statins in coronary heart disease. J Epidemiol Community Health 59 927–33.
35. Manuel DG, Kwong K, Tanuseputro P, Lim J, Mustard CA, Anderson GM, et al. (2006) Effectiveness and efficiency of different guidelines on statin treatment for preventing deaths from coronary heart disease: modelling study. Br Med J 332 1419.
36. Malik IS, Bhatia VK, Kooner JS. (2001) Cost effectiveness of ramipril treatment for cardiovascular risk reduction. Heart 85 539–43.
37. Gaspoz JM, Coxson PG, Goldman PA, Williams LW, Kuntz KM, Hunink MG, et al. (2002) Cost effectiveness of aspirin, clopidogrel, or both for secondary prevention of coronary heart disease.[comment]. N Engl J Med 346 1800–6.
38. Devlin N and Parkin D. (2004) Does NICE have a cost-effectiveness threshold and what other factors influence its decisions? A binary choice analysis. Health Econ 13 437–52.[CrossRef][Web of Science][Medline]
39. Phillips CJ and Prowle MJ. (1993) Economics of a reduction in smoking: case study from Heartbeat Wales. J Epidemiol Community Health 47 215–23.
40. Kristiansen IS, Eggen AE, Thelle DS. (1991) Cost effectiveness of incremental programmes for lowering serum cholesterol concentration: is individual intervention worth while? Br Med J 302 1119–22.
41. Goldman L, Phillips KA, Coxson P, Goldman PA, Williams L, Hunink MG, et al. (2001) The effect of risk factor reductions between 1981 and 1990 on coronary heart disease incidence, prevalence, mortality and cost. J Am Coll Cardiol 38 1012–17.
|
References for Appendix II |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAppendix 1Appendix 2AcknowledgementsReferencesReferences for Appendix II |
|---|
1. Julian DG and Norris RM. (2002) Myocardial infarction: is evidence-based medicine the best? Lancet 359 1515–16.[CrossRef][Web of Science][Medline]
2. Tunstall-Pedoe H, Bailey L, Chamberlain DA. (1992) Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS Study): methods and overall results. Br Med J 304 1347–51.
3. Cobbe SM, Dalziel K, Ford I, Marsden AK. (1996) Survival of 1476 patients initially resuscitated from out of hospital cardiac arrest. Br Med J 312 1633–7.
4. Collins R, MacMahon S, Flather M, Baigent C, Remvig L, Mortensen S. (1996) Clinical effects of anticoagulant therapy in suspected acute myocardial infarction: systematic overview of randomised trials. Br Med J 313 652–9.
5. Estess JM and Topol EJ. (2002) Fibrinolytic treatment for elderly patients with acute myocardial infarction. Heart 87 308–11.
6. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Br Med J (2002) 324 71–86.
7. Cucherat M, Bonnefoy E, Tremeau G. (2000) Primary angioplasty versus intravenous thrombolysis for acute myocardial infarction. Cochrane Database Syst Rev CD001560.
8. Freemantle N, Cleland J, Young P, Mason J, Harrison J. (1999) beta Blockade after myocardial infarction: systematic review and meta regression analysis. Br Med J 318 1730–7.
9. Latini R, Maggioni AP, Flather M, Sleight P, Tognoni G. (1995) ACE inhibitor use in patients with myocardial infarction: Summary of evidence from clinical trials. Circulation 92 3132–7.
10. Flather MD, Yusuf S, Kober L, Pfeffer M, Hall A, Murray G. (2000) Long-term ACE-inhibitor therapy in patients with heart failure or left- ventricular dysfunction: a systematic overview of data from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group. Lancet 355 1575–81.[CrossRef][Web of Science][Medline]
11. Pignone M, Phillips C, Mulrow C. (2000) Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials. Br Med J 321 983–6.
12. Lau J, Antman EM, Jimenez-Silva J, Kupelnick B, Mosteller F, Chalmers TC. (1992) Cumulative meta-analysis of therapeutic trials for myocardial infarction. N Engl J Med 327 248–54.[Abstract]
13. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. (2004) Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. AM J Med 116 682–92.[CrossRef][Web of Science][Medline]
14. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW. (1994) Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 344 563–70.[CrossRef][Web of Science][Medline]
15. Pocock SJ, Henderson RA, Rickards AF, Hampton JR, King SB III, Hamm CW. (1995) Meta-analysis of randomised trials comparing coronary angioplasty with bypass surgery. Lancet 346 1184–9.[CrossRef][Web of Science][Medline]
16. Folland ED, Hartigan PM, Parisi AF. (1997) Percutaneous transluminal coronary angioplasty versus medical therapy for stable angina pectoris: outcomes for patients with double-vessel versus single-vessel coronary artery disease in a Veterans Affairs Cooperative randomized trial. Veterans Affairs ACME Investigators. J Am Coll Cardiol 29 1505–11.[Abstract]
17. Oler A, Whooley MA, Oler J, Grady D. (1996) Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina. A meta-analysis. JAMA 276 811–15.
18. Boersma E, Harrington RA, Moliterno DJ, White H, Theroux P, Van de WF. (2002) Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet 359 189–98.[CrossRef][Web of Science][Medline]
19. Shibata MC, Flather MD, Wang D. (2001) Systematic review of the impact of beta blockers on mortality and hospital admissions in heart failure. Eur J Heart Fail 3 351–7.
20. Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A. (1999) The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 341 709–17.
21. Collins R, Peto R, MacMahon S, Hebert P, Fiebach NH, Eberlein KA. (1990) Blood pressure, stroke, and coronary heart disease. Part 2, Short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet 335 827–38.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  H Bethell, R Lewin, and H Dalal Cardiac rehabilitation in the United Kingdom Heart, February 1, 2009; 95(4): 271 - 275. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Capewell Will screening individuals at high risk of cardiovascular events deliver large benefits? No BMJ, August 28, 2008; 337(aug28_2): a1395 - a1395. [Full Text]
|
|
|
|
|
|
S Capewell and M O'Flaherty Maximising secondary prevention therapies in patients with coronary heart disease Heart, January 1, 2008; 94(1): 8 - 9. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||