Strategies for Reducing Coronary Risk Factors in Primary Care: Which is Most Cost Effective?

Objective: To examine the relative cost effectiveness of a range of screening and intervention strategies for preventing coronary heart disease in primary care.

Subjects: 7840 patients aged 35-64 years who were participants in a trial of modifying coronary heart disease risk factors in primary care.

Design: Effectiveness of interventions assumed and the potential years of life gained estimated from a risk equation calculated from Framingham study data.

Main Outcome Measure: The cost per year of life gained.

Results: The most cost effective strategy was minimal screening of blood pressure and personal history of vascular disease, which cost 310 pounds-930 pounds per year of life gained for men and 1100 pounds-3460 pounds for women excluding treatment of raised blood pressure. The extra cost per life year gained by adding smoking history to the screening was 400 pounds-6300 pounds in men. All strategies were more cost effective in men than in women and more cost effective in older age groups. Lipid lowering drugs accounted for at least 70% of the estimated costs of all strategies. Cost effectiveness was greatest when drug treatment was limited to those with cholesterol concentrations above 9.5 mmol/l.

Conclusions: Universal screening and intervention strategies are an inefficient approach to reducing the coronary heart disease burden. A basic strategy for screening and intervention, targeted at older men with raised blood pressure and limiting the use of cholesterol lowering drugs to those with very high cholesterol concentrations would be most cost effective.