This study aimed to assess the potential cost-effectiveness of screening men for their angiotensin-converting enzyme (ACE)-genotype before starting statin therapy. We used a combination of decision-analytic and Markov modelling techniques to evaluate the long-term incremental clinical and economic effects associated with genetic testing of men with hypercholesterolemia before starting treatment with statins. The study was performed from a health care payer perspective. We used data from the Rotterdam study, a prospective population-based cohort study in the Netherlands, which was started in 1990 and included 7983 subjects aged 55 years and older. Men treated with cholesterol-lowering drugs at baseline or with a baseline total cholesterol ≥ 6.5 mmol/l were included. The ratio of difference in lifelong costs between the screening strategy and the no screening strategy to difference in life expectancy between these strategies was calculated. We also performed a cost-utility analysis. The base case was a 55-year-old man with hypercholesterolemia who was initially untreated. Several univariate sensitivity analyses were performed. All costs were discounted with an annual rate of 5%. Screening men for their ACE-genotype was the dominant strategy for the base case analysis, because the screening strategy saved money (€851), but life expectancy was not changed. Screening was the dominant strategy for all age-groups in our cohort. Even in 80-year-old subjects, with the shortest life-expectancy, it was cheaper to screen than to give lifelong treatment to men with a DD genotype without success. Even if all DD subjects were treated with other (non-statin) cholesterol-lowering drugs, screening remained the cost-effective strategy. The results of the cost-utility analysis were similar. Discounting the effects with 5% per year also had no major impact on the conclusions. If other studies confirm that men with the DD genotype do not benefit from treatment with statins, screening for ACE genotype in men most likely will be a cost-effective strategy before initiating statin therapy.
aDepartment of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands, bDepartment of Epidemiology and Biostatistics, Erasmus Medical Center, Rotterdam, the Netherlands, cDepartment of Pharmacy, University of Washington, Seattle, Washington, USA and dDepartment of Vascular Medicine. Academic Medical Center, Amsterdam, the Netherlands.
Sponsorship: This study was financially supported by the Netherlands Heart Foundation, grant number NHF-2000.170. The Rotterdam Study is funded by the Netherlands Organization for Scientific Research (NWO) and the Municipality of Rotterdam.
Correspondence and requests for reprints to Dr B.H.Ch. Stricker, Pharmaco-epidemiology Unit, Department of Epidemiology and Biostatistics, Erasmus Medical Centre, PO Box 1738, 3000 DR Rotterdam, the Netherlands. Tel: +31 10 408 7489; fax: +31 10 408 9382; e-mail: firstname.lastname@example.org
Received 17 July 2003 Accepted 9 October 2003