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The cost-effectiveness of a uniform versus age-based threshold for one-off screening for prevention of cardiovascular disease

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Abstract

The objective of this article was to assess the cost-effectiveness of screening strategies for cardiovascular diseases (CVD). A decision analytic model was constructed to estimate the costs and benefits of one-off screening strategies differentiated by screening age, sex and the threshold for initiating statin therapy (“uniform” or “age-adjusted”) from the Spanish NHS perspective. The age-adjusted thresholds were configured so that the same number of people at high risk would be treated as under the uniform threshold. Health benefit was measured in quality-adjusted life years (QALY). Transition rates were estimated from the European Prospective Investigation into Cancer and Nutrition (EPIC-CVD), a large multicentre nested case-cohort study with 12 years of follow-up. Unit costs of primary care, hospitalizations and CVD care were taken from the Spanish health system. Univariate and probabilistic sensitivity analyses were employed. The comparator was no systematic screening program. The base case model showed that the most efficient one-off strategy is to screen both men and women at 40 years old using a uniform risk threshold for initiating statin treatment (Incremental Cost-Effectiveness Ratio of €3,274/QALY and €6,085/QALY for men and women, respectively). Re-allocating statin treatment towards younger individuals at high risk for their age and sex would not offset the benefit obtained using those same resources to treat older individuals. Results are sensitive to assumptions about CVD incidence rates. To conclude, one-off screening for CVD using a uniform risk threshold appears cost-effective compared with no systematic screening. These results should be evaluated in clinical studies.

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Fig. 1

Source of data: EPIC-CVD case-cohort study

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Acknowledgements

The national cohorts are supported by: Danish Cancer Society (Denmark); Ligue Contre le Cancer, Institut Gustave Roussy, Mutuelle Générale de l’Education Nationale, Institut National de la Santé et de la Recherche Médicale (INSERM) (France); German Cancer Aid, German Cancer Research Center (DKFZ), German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Federal Ministry of Education and Research (BMBF) (Germany); Associazione Italiana per la Ricerca sul Cancro-AIRC-Italy, Compagnia di SanPaolo and National Research Council (Italy); Dutch Ministry of Public Health, Welfare and Sports (VWS), Netherlands Cancer Registry (NKR), LK Research Funds, Dutch Prevention Funds, Dutch ZON (Zorg Onderzoek Nederland), World Cancer Research Fund (WCRF), Statistics Netherlands (The Netherlands); Health Research Fund (FIS)—Instituto de Salud Carlos III (ISCIII), Regional Governments of Andalucía, Asturias, Basque Country, Murcia and Navarra, and the Catalan Institute of Oncology—ICO (Spain); Swedish Cancer Society, Swedish Research Council and County Councils of Skåne and Västerbotten (Sweden); Cancer Research UK (14136 to EPIC-Norfolk; C8221/A29017 to EPIC-Oxford), Medical Research Council (1000143 to EPIC-Norfolk; MR/M012190/1 to EPIC-Oxford). (United Kingdom), Hyblean Association for Epidemiological Research, AIRE ONLUS, EPIC-Ragusa (Italy).

Funding

The EPIC-CVD coordinating centre was supported by core funding from the European Commission Framework Programme 7 (HEALTH-F2-2012-279233), European Research Council (268834), Novartis, UK Medical Research Council (G0800270; MR/L003120/1), British Heart Foundation (SP/09/002; RG/13/13/30194; RG/18/13/33946) and NIHR Cambridge Biomedical Research Centre (BRC-1215-20014). The study was also supported by International Agency for Research on Cancer (IARC), the Department of Epidemiology and Biostatistics (School of Public Health, Imperial College London) and the Spanish Association of Health Economics (Research Fellowship on Health Economics and Health Services, 12,000€).

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Authors and Affiliations

  1. Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Avda Monforte de Lemos 3-5, 28029, Madrid, Spain

    Zuzana Špacírová, Leticia García-Mochón, Miguel Rodríguez Barranco, María José Sánchez Pérez, Jaime Espín & Sandra M. Colorado-Yohar

  2. Escuela Andaluza de Salud Pública (EASP), Cuesta del Observatorio 4. Campus Universitario de Cartuja, 18011, Granada, Spain

    Zuzana Špacírová, Leticia García-Mochón, Miguel Rodríguez Barranco, María José Sánchez Pérez & Jaime Espín

  3. Instituto de Investigación Biosanitaria Ibs.Granada, 18012, Granada, Spain

    Zuzana Špacírová, Leticia García-Mochón, Miguel Rodríguez Barranco, María José Sánchez Pérez & Jaime Espín

  4. Cardiovascular Epidemiology Unit, Strangeways Research Laboratory, Department of Public Health and Primary Care, University of Cambridge, 2 Worts’ Causeway, Cambridge, CB1 8RN, UK

    Stephen Kaptoge & Lois Kim

  5. Department of Preventive Medicine and Public Health, University of Granada, 18071, Granada, Spain

    María José Sánchez Pérez

  6. The Danish Cancer Society Research Centre, Strandboulevarden 49, 2100, Copenhagen, Denmark

    Nicola P. Bondonno & Anne Tjønneland

  7. Institute for Nutrition Research, School of Medical and Health Sciences, Edith Cowan University, 270 Joondalup Dr, Perth, 6027, Australia

    Nicola P. Bondonno

  8. Department of Public Health, University of Copenhagen, Copenhagen, Denmark

    Anne Tjønneland

  9. International Agency for Research on Cancer, World Health Organization, Lyon, France

    Elisabete Weiderpass

  10. Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, 20133, Milan, Italy

    Sara Grioni

  11. Unit of Cancer Epidemiology, Città della Salute e della Scienza University-Hospital, Via Santena 7, 10126, Turin, Italy

    Carlotta Sacerdote

  12. Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Arthur-Scheunert-Allee 114-116, 14558, Nuthetal, Germany

    Catarina Schiborn & Matthias B. Schulze

  13. German Center for Diabetes Research (DZD), Munich, Germany

    Catarina Schiborn & Matthias B. Schulze

  14. Clinical Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network – ISPRO, Florence, Italy

    Giovanna Masala

  15. Department of Epidemiology, Murcia Regional Health Council, Murcia, Spain

    Sandra M. Colorado-Yohar

  16. Research Group on Demography and Health, National Faculty of Public Health, Univesity of Antioquia, Medellín, Colombia

    Sandra M. Colorado-Yohar

  17. Julius Center for Health Sciences and Primary Care, UMC Utrecht, Trecht University, Utrecht, The Netherlands

    Karel G. M. Moons

  18. Department of Clinical Sciences, Lund University, Malmö, Sweden

    Gunnar Engström

  19. Institute of Nutritional Science, University of Potsdam, Potsdam, Germany

    Matthias B. Schulze

  20. Ubisoft France, Floresco, 2 Avenue Pasteur, 94160, Saint-Mandé, France

    Léa Bresson

  21. Navarra Public Health Institute, Pamplona, Spain

    Concepción Moreno-Iribas

  22. IdiSNA, Navarra Institute for Health Research, Pamplona, Spain

    David Epstein

  23. University of Granada, Granada, Spain

    David Epstein

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  1. Zuzana Špacírová
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Contributions

Design of the study: LGM, JE, DE. Data collection: MRB, MJSP, AT, SG, CS, GM, GE, MBS. Estimation of the age-adjusted risk thresholds: SK, LB. Analysis and interpretation of data: ZS, DE, LB, LGM. Drafting the article: ZS, DE. Critical revision of the article: NPB, AT, EW, CS, CSch, SMCY, LK, KGMM, GE, MBS, CMI. All authors approved the final version of the article.

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Correspondence to Zuzana Špacírová.

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Špacírová, Z., Kaptoge, S., García-Mochón, L. et al. The cost-effectiveness of a uniform versus age-based threshold for one-off screening for prevention of cardiovascular disease. Eur J Health Econ 24, 1033–1045 (2023). https://doi.org/10.1007/s10198-022-01533-y

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