Attainment of combined optimal lipid values and the impact of lipid medication on cardiovascular outcomes and costs in a commercially insured population in the US

Figures & data

Table 1. Classification of patients by cardiovascular prevention group factors.

	Secondary Prevention Group	Primary Prevention Group
CHD or CHD risk equivalent	A diagnosis or procedure code for one or more of the following:Myocardial infarctionAngina/ischaemic heart diseaseCerebrovascular accidentTransient ischaemic attackPeripheral vascular diseaseAortic aneurysm Diabetes mellitusCoronary artery bypass graftAngioplasty	No recorded CHD or CHD risk equivalent diagnoses or procedures
Risk factor	Any risk factors	Two of the three following risk factors:Age (males ≥45 and females ≥55)HDL-C (males <1.04 mmol/l and females <1.30 mmol/l)Hypertension diagnosis plus one or more hypertension medications

CHD, coronary heart disease; HDL-C, high-density lipoprotein cholesterol.

Table 2. Optimal lipid values as defined by NCEP ATP III, AHA and ADA guidelines.

	Non-diabetics		Diabetics	Description
	NCEP ATP III goal lipid level (Men)	AHA goal lipid level (Women)	ADA goal lipid level
LDL-C	<3.38 mmol/l(<130 mg/dl)	<3.38 mmol/l (<130 mg/dl)	n/a	‘High-risk’ primary prevention^*
LDL-C	<2.6 mmol/l (<100 mg/dl)	<2.6 mmol/l (<100 mg/dl)	<2.6 mmol/l (<100 mg/dl)	Secondary prevention and CHD risk equivalent
HDL-C	>1.04 mmol/l (>40 mg/dl)	n/a	>1.04 mmol/l (>40 mg/dl)	Below threshold considered low HDL-C in males
HDL-C	n/a	>1.30 mmol/l (>50 mg/dl)	>1.30 mmol/l (>50 mg/dl)	Below threshold considered low HDL-C in females
TG	2.2 mmol/l (<200 mg/dl)	1.65 mmol/l (<150 mg/dl)	1.65 mmol/l (<150 mg/dl)	Above threshold considered high TG

NCEP ATP III, National Cholesterol Education Program Adult Treatment Panel III; AHA, American Heart Association; ADA, American Diabetic Association; CHD, coronary heart disease; n/a, not applicable; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; TG, triglycerides. ^* This is a modified NCEP ATP III risk categorisation as the HDL-C level for women has been set at 50 mg/dl.

Table 3. Demographics and patient characteristics.

	Total population (N=52,778)	Secondary prevention (N=22,071)	Primary prevention (N=30,707)
Age in years (Mean ± sd)	54.1 ± 11.4	53.6 ± 13.3	54.5 ± 9.7^*
Male, n (%)	28,260 (53.6)	10,646 (48.2)	17,614 (57.4)^*
Lipid values at baseline (mean ± sd)
LDL-C (mmol/l)	3.22 ± 0.92	3.15 ± 0.94	3.27 ± 0.89^*
HDL-C (mmol/l)	1.22 ± 0.38	1.30 ± 0.39	1.16 ± 0.36^*
Triglycerides (mmol/l)	1.78 ± 0.88	1.67 ± 0.87	1.76 ± 0.42^*
Optimal Lipids at baseline
LDL-C	23,560 (44.6)	6,217 (28.2)	17,343 (56.5)^*
HDL-C	22,217 (42.1)	12,586 (57.0)	9,631 (31.4)^*
Triglycerides	32,629 (61.8)	13,851 (62.8)	18,778 (61.2)^*
Any 2	26,659 (50.5)	11,568 (52.4)	15,091 (49.1)^*
All 3	6,980 (13.2)	2,721 (12.3)	4,259 (13.9)^*
Baseline comorbidity index	0.37 ± 0.62	0.64 ± 0.73	0.17 ± 0.43^*
Prevalence of comorbidities at baseline, n(%)
Hypertension	30,565 (57.9)	10,260 (46.5)	20,305 (66.1)^*
Diabetes mellitus	10,303 (19.5)	10,303 (100.0)	0 (0.0)^*
Coronary heart disease	13,453 (25.5)	13,453 (60.9)	0 (0.0)^*
Metabolic syndrome	27,957 (53.0)	11,533 (52.3)	16,424 (53.5)^*

sd, standard deviation; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol. ^* p<0.05.

Table 4. Lipid-altering treatment.

n (%)	Total population (N=52,778)	Secondary prevention (N=22,071)	Primary prevention (N=30,707)
Any	16,412 (31.1)	7,561 (34.26)	8,851 (28.82)^*
Statin monotherapy	12,514 (76.25)	5,944 (78.61)	6,570 (74.23)^*
Niacin monotherapy	555 (3.38)	187 (2.47)	368 (4.16)^*
Fibrate monotherapy	1,767 (10.77)	707 (9.35)	1,060 (11.98)^*
BAS monotherapy	330 (2.01)	154 (2.04)	176 (1.99)
Ezetimibe	465 (2.83)	232 (3.07)	233 (2.63)
Other monotherapy	9 (0.05)	1 (0.01)	8 (0.09)^*
Statin combo therapy	748 (4.56)	322 (4.26)	426 (4.81)
Statin ± niacin	307 (1.87)	116 (1.53)	191 (2.16)^*
Statin ± fibrate	81 (0.49)	38 (0.5)	43 (0.49)
Statin ± ezetimibe	353 (2.15)	164 (2.17)	189 (2.14)
Other statin combo therapy	7 (0.04)	4 (0.05)	3 (0.03)
Other combo therapy	24 (0.15)	14 (0.19)	10 (0.11)

^* p<0.05.

Figure 1. Likelihood of optimal lipid level attainment during the follow-up period.

Table 5. Summary of multivariate model results: likelihood of obtaining optimal lipid values for all measures.

Parameter	Total population N=52,778
	Estimate	Standard error	Wald 95% confidence limits	p-value
Age at laboratory date	1.02	1.00	1.02–1.02	<0.0001
Male	2.70	1.02	2.58–2.83	<0.0001
Niacin/fibrate therapy	1.42	1.08	1.22–1.66	<0.0001
Hypertension prior to laboratory date	1.88	1.02	1.79–1.97	<0.0001
CV disease prior to laboratory date	0.65	1.03	0.62–0.68	<0.0001
Diabetes mellitus prior to laboratory date	0.81	1.03	0.77–0.86	<0.0001
Statin therapy	5.85	1.03	5.47–6.26	<0.0001
Baseline LDL-C value	0.98	1.00	0.97–0.98	<0.0001
Baseline HDL-C value	1.06	1.00	1.05–1.06	<0.0001
Baseline triglyceride value	0.99	1.00	0.99–0.99	<0.0001
Deyo-Charlson comorbidity index	0.85	1.02	0.81–0.89	<0.0001

Pr, ; CV, cardiovascular; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol.

Figure 2. Kaplan Meier curve for CV events by OLV attainment.

Table 6. Cardiovascular events by risk of a cardiovascular event.

Parameter	Total population N=52,778
	Estimate	Wald 95% confidence limits
Multiple goal attainment	0.86	0.78–0.95
Age	1.05	1.04–1.05
Male	1.50	1.39–1.62
Prior cardiovascular disease at baseline	2.74	2.54–2.96
Diabetes mellitus	1.67	1.52–1.83
Hypertension	1.26	1.16–1.36
Duration of follow-up	0.99	0.99–0.99

Table 7. Annual cardiovascular attributable resource utilisation and costs by last lipid goal status.

	Resource utilisation^*			Annualised costs (US dollars)^†
	OLV (N=10,645)	Non-OLV (N=41,133)	p-value	OLV (N=10,645)	Non-OLV (N=41,133)	p-value
Inpatient (mean ± sd)
Total population	3 ± 17	4 ± 21	<0.0001	$470 ± $3,560	$683 ± $5,589	<0.0001
Secondary prevention group	6 ± 23	7 ± 28	0.0002	$778 ± $4,722	$1,127 ± $7,649	0.0002
Primary prevention group	2 ± 13	2 ± 13	0.3035	$294 ± $2,669	$345 ± $3,196	0.1835
Outpatient
Total population	48 ± 153	49 ± 165	0.4927	$210 ± $1,206	$217 ± $1,042	0.5707
Secondary prevention group	90 ± 22	82 ± 22	0.0411	$360 ± $1,848	$331 ± $1,315	0.3487
Primary prevention group	24 ± 82	24 ± 99	0.9740	$124 ± $566	$130 ± $761	0.4796
Emergency department
Total population	1 ± 9	2 ± 9	0.0478	$23 ± $291	$220 ± $232	<0.0001
Secondary prevention group	2 ± 13	2 ± 13	0.1604	$43 ± $425	$37 ± $299	0.4341
Primary prevention group	1 ± 6	1 ± 6	0.6617	$12 ± $173	$11 ± $161	0.7192
Prescription claims
Total population	129 ± 281	117 ± 256	<0.0001	$123 ± $276	$108 ± $250	<0.0001
Secondary prevention group	138 ± 290	126 ± 259	0.0176	$133 ± $288	$116 ± $254	0.0006
Primary prevention group	125 ± 276	111 ± 254	0.0002	$118 ± $268	$102 ± $248	<0.0001
TOTAL (excluding prescription claims)
Total population	52 ± 164	55 ± 180	0.1855	$703 ± $3,962	$923 ± $5,907	<0.0001
Secondary prevention group	97 ± 237	91 ± 240	0.1505	$1,182 ± $5,346	$1,496 ± $8,047	0.0027
Primary prevention group	27 ± 92	27 ± 108	0.8904	$431 ± $2,860	$487 ± $3,423	0.1719

OLV, optimal lipid value.

^* # vis/100 patient years.

^† Cost are comprised as expenditures of both health plan insurers and enrollees.

Table 8. Summary of multivariate model results: costs attributable to cardiovascular disease.

Parameter	Total population (N=52,778)
	Estimate	Standard error	Wald 95% confidence limits	p-value
Multiple goal attainment	0.8989	1.0291	0.8498–0.9508	0.0002
Age	1.0482	1.0011	1.0460–1.0503	<0.0001
Male	2.0119	1.0229	1.9250–2.1031	<0.0001
Baseline LDL	1.0046	1.0003	1.0041–1.0052	<0.0001
Baseline HDL	0.9971	1.0008	0.9955–0.9987	0.0004
Baseline triglyceride	1.0016	1.0001	1.0013–1.0019	<0.0001
Comorbidity index	2.1428	1.0226	2.0509–2.2387	<0.0001
Hypertension	1.1973	1.0212	1.1490–1.2478	<0.0001
Diabetes mellitus	1.1245	1.0281	1.0650–1.1871	<0.0001

LDL, low-density lipoprotein; HDL, high-density lipoprotein.