Apolipoprotein B (apoB) may be used as a cost-effective marker to improve population health and guide lipid-lowering therapy (LLT) in primary prevention, according to a computer simulation study published April 8 in JAMA.
Samuel Luebbe, MD, et al., constructed a cohort of 250,000 statin-eligible and atherosclerotic cardiovascular disease (ASCVD)-free adults in the U.S. from 2005 to 2016 using the National Health and Nutrition Examination Survey (n=4,149). The economic evaluation then used a computer simulation model to examine the cost-effectiveness of LLT intensification using high-intensity statins or ezetimibe, guided by LDL-C, non–HDL-C or apoB targets.
After lipid screening, individuals entered the simulation and received statin therapy based on the 2018 AHA/ACC guidelines. Model inputs were drawn from national survey datasets, pooled longitudinal cohorts and published literature, with uncertainty evaluated through deterministic and probabilistic sensitivity analyses. During the simulation, LLT was intensified if individuals did not achieve treated LDL-C levels <100 mg/dL, non–HDL-C <118 mg/dL or apoB <78.7 mg/dL.
The primary outcome was the incremental cost-effectiveness ratio, based on lifetime quality-adjusted life-years (QALYs) and costs (in 2025 U.S. dollars), discounted 3% annually. Strategies were deemed cost-effective at a threshold of $120,000 per QALY gained.
Results showed that a non–HDL-C goal, when compared with an LDL-C goal, would result in 965 QALYs (−3,551 to 5,341 QALYs) gained, alongside a $2.1 million (−$94.2 million to $92.0 million) reduction in costs. Additionally, compared with a non–HDL-C goal, 1,324 QALYs (−2,602 to 5,669 QALYs) would be gained with an apoB goal, alongside a $40.2 million (−$43.6 million to $134 million) increase in costs, resulting in an incremental cost‑effectiveness ratio of $30,300 per QALY.
Moreover, an apoB goal was optimal in 65% of probabilistic analyses and a non–HDL-C goal was optimal in 25% at a willingness-to-pay threshold of $120,000 per QALY gained. Higher costs of apoB testing reflected longer life expectancy and prolonged preventive treatment.
The authors note that their simulation study results showed that “an apoB goal was estimated to produce the largest reduction in ASCVD events and the largest gain in population health.” They note that although there is an added cost to obtain an apoB assay, “the increased cost of the assay itself plays a minimal role in the cost-effectiveness of using an apoB goal compared with an LDL-C or non–HDL-C goal.”
“The cost-effectiveness analysis findings by [Luebbe, et al.] have potential clinical implications,” write Ankur Pandya, PhD, and Jinyi Zhu, PhD, in an accompanying editorial. “Additional evidence in lower-risk populations and data on clinical feasibility will be needed to determine whether this broader strategy should inform future guideline recommendations.”
