Simulation Models Suggest Using Combination Drugs Is More Cost Effective Than Current Standard of Care in Patients with Cardiovascular Disease

Using microsimulation models, Dr. Thomas Gaziano showed that the use of a polypill has a favorable cost profile for secondary cardiovascular disease prevention in the United States. The findings of the study published in the American Heart Journal suggest that a polypill would be economically advantageous for both the patients and the payers.

Over half of patients with coronary or cerebrovascular disease are not compliant to at least one of their medication. This includes anti-platelet agents, beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers and statins. Therefore, initiating and maintaining patients on these medications can be a challenge. The polypill approach is one potential concept that could potentially improve adherence. This approach combines medication that reduces the incidence and recurrence of cardiovascular disease into a single formulation that would hopefully improve adherence and lead to better outcomes. In this study, the investigators compared the different polypill combinations and usual care strategies for secondary prevention and to assess the financial and health impact of the polypill approach.

Using the CVD PREDICT model, the investigators compared the current standard of care to three different versions of a polypill for secondary prevention in patients with previous ischemic heart disease and stroke. The CVD PREDICT model was previously validated to predict CVD based on current demographic trends. The polypill components were a combination of aspirin 81 mg, atenolol 50mg, ramipril 5mg, and either simvastatin 40mg (Polypill 1), atorvastatin 80 mg (Polypill 2), or rosuvastatin 40 mg (Polypill 3). The outcomes of interest included a reduction in myocardial infarction and stroke. Additionally, from a cost-effectiveness perspective, the cost per improvement in quality-adjusted life years (QALY) and healthcare costs were estimated using the model.

When compared to the current standard of care, on an annual basis, there 6450 (18%) or 8815 (24.8%) myocardial infarctions per million population for those taking Polypill 1 (simvastatin) or Polypill 2 (atorvastatin), respectively. Additionally, there was a reduction in strokes when Polypill 1 (2700 (10.4%)) and Polypill 2 (3700 (14.4%)) were compared to usual care. This would mean t 130,000 to 178,000 fewer myocardial infarctions and 54,000 to 74,000 fewer strokes per year using Polypill 1 and 2, respectively. The expected life expectancy of those taking Polypill 2 (simvastatin), or either Polypill 2 (atorvastatin) or 3 (rosuvastatin), was increased by four to six months when compared to the current standard of care. When assessing for cost-effectiveness, the incremental cost-effectiveness ratio for Polypill I when compared to the current standard of care was $20,073 per quality-adjusted-life-year (QALY). When compared to Polypill 1, Polypill 2 had an incremental cost-effectiveness ratio of $21,818/QALY. Polypill 2 produced similar QALYs to Polypill 3 but at a lower cost. Over a 5-year period, those taking Polypill I and II saved approximately $12 and $6 per-patient-per-year alive.

The investigators demonstrated that using a polypill has a favorable economic profile for the secondary prevention of cardiovascular disease in the United States. The results of the study showed that using any of the three possible Polypill formulations would have led to an improvement in morbidity and mortality. While any of the three formulations performed better than usual care, formulations with either atorvastatin or rosuvastatin seemed to perform better. When discussing the results of the study, Dr. Gaziano wrote, “Overall, the underutilization of both highly effective and inexpensive medications in millions of Americans with very high CVD risk is a national travesty. Large numbers of premature deaths and significant disability could be preventive with improved adherence to these medications. Medicines are prescribed with high rates at discharge from hospitalization from acute CVD, but their continuation in the outpatient setting is more limited with reduced adherence in the long term.” Ultimately, the study highlights the potential of a polypill strategy in improving quality of life while simultaneously being cost effective.