Cost-effectiveness and public health benefit of secondary cardiovascular disease prevention from improved adherence using a polypill in the UK

Abstract

Objective: To evaluate the public health and economic benefits of adherence to a fixed-dose combination polypill for the secondary prevention of cardiovascular (CV) events in adults with a history of myocardial infarction (MI) in the UK. Design: Markov-model-based cost-effectiveness analysis, informed by systematic reviews, which identified efficacy, utilities and adherence data inputs. Setting: General practice in the UK. Participants: Patients with a mean age of 64.7 years, most of whom are men with a recent or non-recent diagnosis of MI and for whom secondary preventive medication is indicated and well tolerated. Intervention: Fixed-dose combination polypill (100 mg aspirin, 20 mg atorvastatin and 2.5, 5, or 10 mg ramipril) compared with multiple monotherapy. Primary and secondary outcome measures: CV events prevented per 1000 patients; cost per life-year gained; and cost per quality-adjusted life-year (QALY) gained. Results: The model estimates that for each 10\% increase in adherence, an additional 6.7\% fatal and non-fatal CV events can be prevented. In the base case, over 10 years, the polypill would improve adherence by similar to 20\% and thereby prevent 47 of 323 (15\%) fatal and non-fatal CV events per 1000 patients compared with multiple monotherapy, with an incremental cost-effectiveness ratio (ICER) of 8200 pound per QALY gained. Probabilistic sensitivity analyses for the base-case assumptions showed an 81.5\% chance of the polypill being cost-effective at a willingness-to-pay threshold of 20 pound 000 per QALY gained compared with multiple monotherapy. In scenario analyses that varied structural assumptions, ICERs ranged between cost saving and 21 pound 430 per QALY gained. Conclusions: Assuming that some 450 000 adults are at risk of MI, a 10 percentage point uptake of the polypill could prevent 3260 CV events and 590 CV deaths over a decade. The polypill appears to be a cost-effective strategy to prevent fatal and non-fatal CV events in the UK.