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Non-laboratory CVD risk testing a potential alternative to lab-based assessment
Recent study data suggest that as much as 75% of cholesterol laboratory testing for CVD prevention could be safely avoided with a multistage screening approach using non–laboratory-based screening as an initial test.
The researchers analyzed primary CVD screening approaches using two analytic methods: receiver-operating characteristic (ROC) curve analysis incorporating data from 5,998 adults enrolled in the Third National Health and Nutrition Examination Survey and model-based cost-effectiveness analysis using data collected from NHANES populations during 2005-2006 and 2007-2008, as well as other published literature.
Evaluated screening approaches included the following: single-stage, Framingham risk-based approaches, in which adults aged 25 to 74 years were assigned high- or low-risk status based on Framingham CVD risk score; single-stage/non–laboratory-based approaches, similar to the single-stage/Framingham-based approach but without cholesterol testing and with risk status determined from non–laboratory-based information; and multistage screenings, in which laboratory testing was reserved only for a subset of patients whose non–laboratory-based evaluations revealed intermediate-level risk. In this strategy, patients could be defined as high risk from stage I findings (clinical/non–laboratory-based risk) or stage II findings (based on Framingham CVD risk).
The study’s main outcome of interest was 10-year CVD death. Lifetime costs, quality-adjusted life years (QALYs) and cost-effectiveness ratios also were compiled, for a total of 60 screening approaches.
Across strategies, the area under the ROC curve ranged from 0.774 to 0.780 in men, and from 0.812 to 0.834 in women, with no statistically significant differences between multistage and Framingham-based strategies. The cost-effectiveness evaluations indicated that multistage strategies had incremental cost-effectiveness ratios of $52,000/QALY for men and $83,000/QALY for women. Compared with single-stage/non–laboratory-based approaches and multistage approaches, single-stage/Framingham-based approaches had higher cost and lower QALYs, or had unfavorable incremental cost-effectiveness ratios (>$300,000/QALY).
“In our risk discrimination analyses, we found that multistage screening approaches could predict 10-year CVD death comparably with the Framingham risk score while saving 25% to 75% laboratory testing used in primary CVD screening efforts,” the researchers wrote. “… Future studies can apply this multistage screening framework in other developed countries, as well as in low- and middle-income countries, where the screening and treatment conditions would likely lead to different formulations of optimized laboratory testing and statin treatment thresholds.”
Disclosure: One researcher reports a consulting relationship with Optuminsight, a company that performs economic analyses for the pharmaceutical and device industries.