Does screening and treating high cholesterol save money?

A commenter (I believe a physician) on one of my posts wrote the following: “I can prevent heart attacks and strokes (caused by atherosclerosis – “blockage”) in people (minimal cost) who have no symptoms. If I wait for their heart attack or stroke – it costs a whole lot more.”

The implication is that screening and treating high cholesterol saves money in the long run. Unfortunately, the truth is the opposite. This is an extremely common misconception among most people in healthcare, physicians included. Therefore the American people believe the same thing.

If I give a person a pneumonia shot and that person lives the rest of her life never catching pneumonia, then there is a fair chance I prevented a case of pneumonia. On the other hand, she may not have ever gotten pneumonia any way, therefore the shot was useless. There’s no way to sort that out, but classifying  a vaccine as preventing a disease is certainly fair.

What is a person with high cholesterol who doesn’t eat ideally, doesn’t take his medicine consistently, and never exercises most likely to die from? A heart attack.

What is a person with high cholesterol who eats lots of fruits and vegetables, never misses a dose of his cholesterol medicine, and has 30-60 minutes of vigorous exercise every day most likely to die of? A heart attack.

A lot of the screening/prevention work family physicians do add a few healthy months or years of life to their patients, at a cost. We don’t really save lives when we prescribe statins, we just push back the moment of injury (nonfatal angina or heart attack) or death a little. One could argue that the overall death rate from cardiovascular disease is reduced with statin treatment. That’s true. But the effect is not huge, and it just means people will die of other expensive diseases such as cancer and Alzheimer’s.

These realities drive the findings of the cost-effectiveness studies on statin treatment that calculate  to extend a low-risk person’s life with a statin costs over a million dollars per year of life extended. That’s the net cost of doctor’s visits, lab tests, and drugs, minus any future savings from fewer heart attacks and hospitalizations.

If I see a very sick patient in my office, diagnose him as having a severe kidney and blood infection, admit and care for him in the hospital, and he survives this infection, I saved his life. If I treat a low- to moderate-risk risk patient who has high cholesterol with a statin drug, I know statistically her life expectancy has now increased by a few weeks. I believe it is  hyperbole to say I saved her life. A much more humble and realistic assessment is that I extended her life. I delayed her death, on average, by a few weeks.

Here are two of the classic papers on statin cost-effectiveness if you’d like to read more.

To be very clear, I’m not suggesting that prescribing statins is a useless waste of our time. I am saying that the bang for the buck isn’t that great in many cases. (Just to confuse the issue, I also have my doubts that the risk/benefit balance of drug therapy has solid evidence behind it for low-risk patients).

My final position on this issue is that I really don’t care if the American people want me to screen and treat everyone for high cholesterol, only the high-risk patients, or none at all. It’s their money, time, and hassle. I just want them to be sure they know that as they expect more aggressive screening and treatment, their healthcare costs will rise. I can practice medicine at whatever point they want to draw the line. They just need to keep in mind that for most technology-driven preventive services, an ounce of prevention costs a ton of money.

Richard Young is a physician who blogs at American Health Scare.

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  • Debbie

    “A lot of the screening/prevention work family physicians do add a few healthy months or years of life to their patients, at a cost. We don’t really save lives when we prescribe statins, we just push back the moment of injury (nonfatal angina or heart attack) or death a little.”

    That may not be important to you, but it sure as heck is important to ME, personally. Would I rather die at 82 than 78? You bet!! Especially if I can do it in better health than I might otherwise be able to. This is the only life I will ever have, and it may not matter to you, but it matters to me.
    It’s not about living forever. It’s about better lives, healthier lives, and yes, maybe even longer lives.
    It’s about quality of life.
    Who are you to say that a longer life, or a less crippled life, is not an important thing?
    Funny when you look at statistics . . . you don’t see the humanity.

    Or, perhaps we should just die, and decrease the surplus population?

    • Neil

      Debbie,
      I think you are being a bit selective in your interpretation here and creating a straw man in the process. All Dr. Young is saying is that prevention, like any other medical intervention, costs money. This is relevant in the context of policy arguments that present chronic disease prevention as cost-reducing in the long run, which is not always true. Given this real cost, a benefit-cost judgement must be made at some point as it is with other medical treatments, ie: QALYs, etc. While we as a society seem to think the benefits of cholesterol screening is worth it, we cannot do so under the pretense that it is cost effective. Preventive medicine is an investment, like any other, that costs real money and that cannot be immune to rational debate over budgeting just because it is a popular catchphrase of the moment.

    • Dr. Mario

      Wow, Debbie… I really think you missed the point. Dr. Young specifically states that his aim is not to suggest that statins are not worthwhile:

      “To be very clear, I’m not suggesting that prescribing statins is a useless waste of our time.”

      He is merely stating (and quite well, I might add) that that small period of life gained comes at a significant cost. It is certainly a valuable and important extension of life to the patient, and by corollary the honorable physician, but in a medical system which is ever more increasingly funded by someone OTHER than the recipient of care, this cost has to be considered in decision-making.

      Not everyone will be pleased to hand over significant increases in tax dollars in order to fund the more than $1,000,000 so that someone whom they’ve never met can potentially increase their lifespan by 1 year.

    • http://www.healthscareonline.com Richard Young, MD

      Thank you Neil and Dr. Mario for making sure my points were not misunderstood.
      Debbie, I would add to their comments the observation that you overstate the average increase in life expectancy provided by statins. Depending on the individual’s risk status, it is more like a few months not 4 years. Therefore, if you didn’t take take statins you would die on average at about 81 years 10 months instead of 82 years.

    • Diora

      Debbie, there is something else that you don’t understand that isn’t addressed in the article (I am really surprised at it) which is a number of people that needs to be treated with a statin to prevent one heart attack. In terms of cost – which is what this article is about – if one needs to treat say 250 people for 10 years to prevent one heart attack, than the cost of treating these people for 10 years would be much higher than treating this one heart attack. The actual number of people needed to be treated to prevent this one (not necessarily fatal heart attack) varies based on person’s risk factors, but this article would explain it in more detail with regards to statins.

      But even in terms of benefit to you personally, the Number Needed to treat (and it’s inverse – Absolute Risk Reduction) matters as it refers to the probability that your own life will be extended by taking statins which may not be as high as you think (depending on your risk factors).

      When the doctors with us about benefits of specific preventive measures, they often use relative risk reduction as in “doing this will decrease your risk of heart attack by 30%” which for people who don’t understand the difference between absolute risk and relative risk (which are most people) makes the benefit appear larger than it is. But relative risk reduction is a completely meaningless without knowing what your infividual risk of getting a heart attack within a certain period of time is.

      If I never going to go to the ocean, my chances of being eaten by a shark is reduced by 100% – huge right? But as my chances of being eaten by a shark are low to begin with, my absolute risk reduction would be very low.

      Similarly, your actual benefit from statins depends on your absolute risk of having a heart attack within specific period of time. If your risk of dying from heart attack within next 10 years were sat 60% than 30% risk reduction would mean that your risk is reduced from 60 to 40% – a large reduction. but if your risk of dying from heart attack within next 10 years is 1% than taking a statin would reduce your risk from 1% to .7% – not that dramatic and probably not worth side effects. Now this number would be higher if you consider 20 years or 30 years, but so will be the chance of side effects.

      So whenever you think about specific preventive measures – be it preventive drugs or screening, think about your real risk and don’t simply accept meaningless relative risk reduciton numbers.

    • Diora

      Just to correct my previous comment – when I said “this article will explain it in more detail” I forgot to include a link, I meant wiki article on Number Needed to Treat, but really, one can simply google for “Number Needed to Treat statins” to get the actual numbers.

  • ninguem

    I would imagine a quick, early death from untreated hypertension at age 50 would be the most “cost-effective”.

    • http://www.healthscareonline.com Richard Young, MD

      Blunt, but true.

  • doc99

    I guess Dr. Young is opposed to the Polypill.

    • http://www.healthscareonline.com Richard Young, MD

      I’m not for it or against it. Assuming it helps a little, the magnitude of benefit will be a function of the underlying risk of the person taking the polypill, and it will certainly have the same cost-effective reality as almost everything else we do in medicine — it will make things a little better, at a cost. Whether or not the cost is worth it is an issue of allocation of resources that should not be the unilateral decision of the medical profession. We should be leading the discussion with our patients and the greater society about their options and how they want to spend their hard-earned money.

  • Mt Doc

    What Dr Young is pointing out is that the commonly heard mantra that preventive medicine saves money is often not correct – it may in fact be much more expensive than not doing the prevention. It still may be worth doing, which is a societal and individual decision, as indeed he pointed out.
    One other confounding factor is that some interventions, especially in older people, may prevent one outcome but not affect all-cause mortality. For example, you might prevent a coronary event by aggressive hypertension therapy but increase the risk of orthostatic hypotension resulting in a fall with a hip fracture, so total lifespan may not be prolonged. Indeed the early studies on cholesterol lowering medications other than statins (such as atromid) showed a decrease in coronary events but an increase in mortality from other causes (bowel cancer and gallstone related issues in the case of atromid), with no gain in the long run. It’s not as simple as it seems.

    • http://www.healthscareonline.com Richard Young, MD

      Mt Doc,

      Great example. The older fibrate studies as well as the ENHANCE trial looking at the additive effect of ezetimibe to simvastatin showed how treating numbers, in this case cholesterol levels, doesn’t necessarily translate into improved health.

    • stitch

      Excellent example on the blood pressure treatment conundrum. I had a 99 year old patient who used to walk 2 blocks to the clinic to be seen. 99. Other than hypertension she was in good health, but her blood pressure was consistently in the 160s systolic but 60s-70s diastolic. What was the benefit in treating her to goal? But under pay for performance, if her chart were to be audited (and under EMRs, all charts are subject to that) I would be dinked. Even though the right treatment, in this case, was to do nothing, and as much of it as possible. Still following the rules of the House of God.

      • Visitkarte

        This old patient of yours has no hypertension at all. It has old arteries, and you can’t compress these like you can do it in the young patients, That’s why the result of the traditional blood pressure measuring is an artifact.

        Giving statins to 90 years old Alzheimer patients is a perversion of medicine I meet on daily basis.

        • stitch

          I agree with you completely but the gods who demand medicine by the numbers don’t see it that way, because they never lay eyes, much less hands, on the patients.

  • BladeDoc

    And isn’t that classic. People try to sell “preventative care” by claiming it will save money and when someone has the temerity to point out that it actually costs money the response is OMG you hate people! you want us all to die! You are horrible people, blah blah blah.

    Debbie, read the OP again. I defy you to show me where the poster suggested that we not provide preventative care. He just pointed out that it costs money and therefore the entire “bend the cost curve thing is bull”.

  • CSmith MD

    A good post. The first study he cites however is fundamentally flawed. First, most of it’s data comes from pravastatin which the maker of the drug itself proved is an inferior statin in the PROVE-IT study. Second, the calculations assume an average wholesale price of above $100/month for therapy. Simvastatin which is generallly felt to be superior to pravastatin(although no head-to-head studies) costs $3-4 / month. Thus, the cost estimates are inflated many fold. The second study estimates that there would be an overall net savings by treating everyone in the population with a statin if the cost was 10 cents per pill which is about the going rate for simvastatin.

    • CSmithMD

      “The second study estimates that there would be an overall net savings by treating everyone in the population with a statin if the cost was 10 cents per pill which is about the going rate for simvastatin.”

      Correction:
      Everyone with an LDL above 130

  • http://www.healthscareonline.com Richard Young, MD

    Dr. C Smith,

    I think your choice of words is a smidge pejorative. There is no such thing as a perfect study, therefore all studies are fundamentally flawed.

    However, you make a good point. The source articles I used were written when the original cohort of statins were on patent and did not have generic versions. I agree with you that the actual cost-effectiveness ratios are probably better than the article calculated, but how many patients these days in the U.S. are started on one of the cheap generics as opposed to one of the patented statins that come with young drug reps?

    As a side issue, I wish the medical journals were more willing to publish updated cost-effectiveness studies where the epidemiology hasn’t changed but the costs have. I’m also suspect of many of the published C-E studies that are funded by drug companies.

    The other point is that there is more to the cost-effectiveness estimate than just the drug price. A good C-E study will also include the cost of physician office visits and labs, which have not decreased in price since these studies were published.

    • JustADoc

      Well, the overwhelming majority of my patients are started on generic pravastatin if they are close to goal and simvastatin if they are further away. They have to need a very large reduction or have not gotten to goal at max dose prava/simva to get a branded agent.

      • CSmith MD

        Most of my patients are on simvastatin and about 75% on generics. It should be close to 95% when lipitor goes generic. I think few doctors these days select statins based on how cute the drug rep is. We really need lengthy randomized trials to answer questions like this. It’s difficult to extrapolate a 30 year model based on studies of 4-5 years duration. Without randomized studies we would still be routinely precribing HRT. I’m much more concerned about the cost of frequent nuclear stress tests in asymptomatic patients which is a total scam. I’m also alarmed that I have to fill out a form in the hospital every time I don’t refer a patient with an EF<35 % for an ICD.

        • http://www.healthscareonline.com Richard Young, MD

          I suspect your generic percentage is higher than most, though lipitor going generic soon will help.

          I agree its difficult to extrapolate 30 years based on a 5-year RCT, but it would be much more difficult to conduct a 30-year RCT.

          Your nuclear test in asymptomatic patients is another perfect example of the waste in our overly aggressive healthcare system, though I’m sure there are patients and their doctors who will claim that an asymptomatic lesion was caught early by the test and it saved the patient’s life.

  • Marc Gorayeb, MD

    Hey wait a second. If ‘preventive care’ is a net cost-center, exactly how is Obamacare going to “bend the cost curve?” And because of new nationwide insurance coverage mandates, I must now subsidize free preventive care services to every insured person in this country. Isn’t it great having our medical care policies dictated to us by the new iron triangle of big pharma, technocrats, and the political class?

    • http://www.healthscareonline.com Richard Young, MD

      Even if much of the Obama law stays on the books, so much of it was designated to the Secretary of HHS to figure out later. I believe the GAO even said it wouldn’t substantially reduce costs.

  • Finn

    The most cost-effective preventive measures are the things we can do ourselves at little or no cost: handwashing, exercise, healthy diet, not smoking, using seatbelts. Many vaccines are also cost-effective, generally estimated at $3 in healthcare costs saved per $1 spent for immunization, although I have no idea when that estimate was last updated. A lot of other prevention methods are quite expensive as well as far less effective, although often worth doing anyway because money is not the only thing we value.

    I agree that we need better cost-effectiveness information so we can make better decisions about how we spend our healthcare dollars, both personally and collectively.

  • rll

    Included in this discussion should be info re: ADRs. as more pharmacogenetic studies are published, it is obvious that responses and adverse reactions to statins vary greatly.
    http://www.doria.fi/bitstream/handle/10024/4277.
    ( prevalence of either of the SNPs identified is not rare.)
    Pharmacogenetics of statins involve SNPs in SLCO1B1 gene which encodes the uptake transport protein (OATP) responsible for moving statins into hepatocytes for metabolization.
    “…The c.521C allele and the haplotypes *5 and *15 (containing the c.521T>C SNP) have been
    associated with markedly reduced uptake activity in vitro of the OATP1B1 substrates … atorvastatin, cerivastatin, pravastatin.. (Tirona et al. 2001, 2003, Iwai et al. 2004, Kameyama et al. 2005, Nozawa et al. 2005). In addition, studies in humans have associated the c.521C allele with increased plasma concentrations of the statins pravastatin, rosuvastatin and pitavastatin, the antihistamine fexofenadine and the antidiabetic drug repaglinide (Nishizato et al. 2003, Mwinyiet al. 2004, Niemi et al. 2004, 2005a,b, Chung et al. 2005, Lee et al. 2005a)….
    Genetic differences in drug metabolizing enzymes or drug transporters can also predispose to statin myotoxicity. An article published …[concerning]
    SLCO1B1 polymorphism with a considerably elevated risk for myopathy (SEARCH
    Collaborative Group 2008). In this study, two sets of patient and control groups from large trials involving approximately 12 000 and 20 000 participants were treated with 80 mg and 40 mg of simvastatin per day, respectively. A strong association was found between myopathy and two tightly linked variants in SLCO1B1, the other one being the c.521T>C variant. The odds ratio for myopathy was 4.5 per copy of the c.521C allele, and 16.9 in c.521CC, compared with the c.521TT homozygotes. In this large-scale study, approximately 60% of the simvastatin-induced myopathy cases were attributable to the c.521 variant allele. In a previous Japanese study, the SLCO1B1*15 haplotype also containing the c.521T>C SNP (c.388G-c.521G) was associated with pravastatin-induced myopathy (Morimoto et al. 2004, 2005)…”

  • CandiO, WHNP-BC

    Preventative medicine does not always save money. I think the best exapmple of it I ever heard was of a swedish (I think) study that proved it is MUCH more cost effective to let smokers keep smoking and die of lung cancer than it is to let them live for decades longer when they quit smoking. I am not advocating for people to smoke, the above is just an example! I think folks in this country just completely fail to account for the costs of anything let alone medicine.

    • http://www.healthscareonline.com Richard Young, MD

      CandiO,

      I agree that the majority of the cost-effectiveness literature concludes that spending money on people to quit smoking, such as buproprion or nicotine prescriptions, doesn’t save money. On the other hand, the bang for the buck for these interventions is a lot better than many other services we routinely provide in medicine.

  • Maribel

    Great post. I wish more people in the know had the courage to say things like this. Unfortunately many people will react as Debbie did – rational thinking regarding healthcare doesn’t seem to be something we are capable of. We want it all – the latest treatment for everything that ails us, perfect outcomes every time and someone else footing the bill.

    • http://www.healthscareonline.com Richard Young, MD

      Maribel,

      Thanks for keeping a cool head and an open mind.

  • jsmith

    Dr. Young is pretty much right. Most preventive care does not save the medical system money. If you throw in the extra non-medical costs of paying for old peoples’ retirement, it is pretty clear that prevention costs more than it saves.
    Why is this important? Not because it will make us abandon preventive care–it won”t. It’s important for educational purposes, so that Americans will not be fooled by the propaganda from government and others that says there is an easy way to save on health care costs. There isn’t.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      But is this the right way to look at health care costs?
      For example, let’s look at a person that happens to be a physician. Both society and the individual and his family have made a huge financial investment in educating this person. If he dies at 50, untreated, the cost of health care for this physician will be lower than if he dies at 75 after being preventively treated and also treated for other diseases he will develop. However, society recoups some of that cost by having this person produce and contribute for at least 15 more years. Where is this accounted for in the math?
      Also, we are calculating costs based on what we know today, but it is possible than 30 years from now the cost of treating aging related disease will be lower.
      On a different note, when I think of “preventive” care, I somehow think of preventing someone from smoking, or preventing onset of diabetes by making lifestyle changes, more than I think of treating an already existing condition so it does not deteriorate into a more serious condition. Would that type of prevention be cost effective?

      • http://www.healthscareonline.com Richard Young, MD

        Margalit,

        You ask some very deep and ethically challenging questions. As for the first one, I think it’s a stretch to assume that aggressive tech-driven prevention will make the difference between a population of people living to 75 instead of 50. The standard in medical cost-effectiveness studies is to not include lost wages — the arguments why are complicated. However it turns out that even if lost wages were included as a cost, the cost-effectiveness ratios for most preventive services don’t change very much, so it’s kind of a non-issue.

        As for your last question, I think the most accurate answer is it depends. If all Americans suddenly ate less, exercised more, and slimmed down to normal BMIs — without spending any money to achieve this goal — then I think its fair to say costs would be saved. The problem is there are lots of weight loss programs out there with widely varying costs, but none of them work particularly well across large groups of people. The difficulty capturing the actual front end costs vs. the long-term reduction in disease, diabetes in particular, lead to cost-effectiveness studies on this issue that are all over the map.

  • pj

    Re- costs of lab monitoring, it should be mentioned that the need for liver enzyme testing every 6 months is being questioned more and more. I recall Greg Rutecki, MD from the U of South Alabama Med school pointed out in Primary Care Consultant journal, that statins have been shown to be somewhat protective toward the liver. I know of at least one lipidologist who forgoes routine hepatic monitoring in those taking statins.

    No Doc I know of Rx’s brand statins regularly.

    Can someone explain what Dr Marc G means by, “technocrats?” Is that an academic Doc? Not familiar w/the term.

    • http://www.healthscareonline.com Richard Young, MD

      PJ,

      As an example of another approach, the UK NICE guidelines recommend checking the liver tests only once after starting a statin, and then never again unless there are symptoms suggestive of liver disease.

      A technocrat is a bureaucrat with a technological/analytical approach to telling other people what to do — at least I think that’s what Dr. G meant.

  • Dorothy Green

    Bravo! This is the best post I have ever read. Preventive care as described by screenings and routine this and that or mandatory starting someone on statins etc. seems way out of proportion to what preventive care really should be – healthy eating and exercise – with some vaccines thrown in and tests for high at risk.

    I am an American person and DO NOT WANT TO HAVE MY TAXES RAISED BECAUSE THE US HAS THE WORST EATING CULTURE OF ALL WEALTHY COUNTRIES and we are supposed to just accept that treating all the chonic preventive diseases caused by this culture should be treated. Yes, we need heathcare reform – we don’t need market driven healthcare insurance for basic care and the fall-outs of dropping people with pre-existing diseasees, we need better access for all.

    However, the only way we can affect change and bend the curve is to use the tobacco model of revenue collection and a very strong message – I call it R.I.S.K. – reduction in sickness kitty – on the substances -sugar, salt and the fats that are the root of our overeating (addiction). And to stop the subsidies to Agribusiness that make bad food so cheap. Where are these in the budget cuts?

    The FOOD companies know what they are doing in their “food designs”. For example, just before the budget came out – all these companies in the name of Americans against food taxes put an ad on TV saying the government trying to control us through our food. We are to ignorant in general to see it is FOOD, INC trying to control us. Then Big Pharma continues to enable this.

    I don’t think the average physician wants this continuing scenario in the US. If you have studied populations in other countries you know they do not have this nonsense as part of their culture. There are a lot more efforts to intervene in any unhealhy eating that does exist in their countries than has ever been suggesting in the US.

    With regard to the 99 yr old with isolated systolic hypertension – which the majority of seniors have, where are the studies that this particular type of hypertension is necessarily a killer as a factor itself.

    Thank you again for your honesty.

    • pj

      Dorothy- Re “I don’t think the average physician wants this continuing scenario in the US”

      Many of my colleagues here in the US seem less knowledgeable about the factors you wisely mentioned then you’d think.

      I’m amazed at how many say things like “We don’t want socialized medicine with its rationing like they have in Canada or the UK” and then complain about an insurance Co. denying a treatment to their patient!

      Most americans don’t realize we do have some socialism here, just not the type that benefits the little guy, at least not directly.

      As you pointed out, in the US we seem to have the worst of all worlds in some respects, that is, privatizing profits while socializing risk/loss. The problem is, physicians are not nearly well organized enough to take on anything as powerful as Big Food.

    • http://www.healthscareonline.com Richard Young, MD

      Dorothy,

      Thanks for your kind words. I believe personal accountability is an important part of a more affordable healthcare solution that makes sense for America. They other key is that Americans who believe that the healthcare system is not the only source of health, and want fewer of their resources sucked into the great American healthcare black hole should enjoy lower cost insurance as a result. I outline my solution proposals on my website. There is a SOLUTIONS tab on the menu bar.

      http://www.healthscareonline.com

  • http://www.healthscareonline.com Richard Young, MD

    Anybody who says we should not have rationing in U.S. healthcare is uninformed. Uninsured patients and those on Medicaid already have rationed care. The bigger question is what is the best way to get the most out of scarce resources.

    • pj

      Dr Young, by “should not have”, did u mean, “do not have?” Regardless, I am astounded at how few of our fellow Docs and pts realize or admit we do have rationing here.

      You and I seem to be among the few who will say it!

  • Dorothy Green

    Who is organized enough to take on Big Food? They are as strong or stronger than Big Oil or Big Finance. Did you know, even against protest, that Monsanto got their way with a third crop? No restrictions. Soon they will control all our crops – with our subsidies.

    Too many, I guess are too comfy with the status quo. There is enough subbsidized cheap tasty food to feed the third of the population who is obese and another third who is overweight (i.e. 66% of “we the people”) at least twice what they need. So, we all pay the pushers and the care of the victims of this addiction – probably about 15% of our budget. We have let the “Bigs” hijack our government – and then many blame the government.