Tuesday, February 12, 2013

Cholesterol Screening: A cost to benefit analysis

As more and more employers realize the importance of maintaining a healthy working staff, the number of companies participating in cholesterol screening as part of a risk assessment protocol has increased.  There are obvious financial and ethical benefits to having happy, healthy workers.  A happier worker is more productive and tends to cost less from a health insurance standpoint.  The problem is, will cholesterol screening actually achieve that stated goal?  In other words, if I put my worker bees through a cholesterol screening, will this save me some scratch?  Let's explore this a little further.

The point of putting workers through a cholesterol screen is to identify those who are at risk for heart disease and/or future coronary events.  Once identified, these people will be put on the appropriate therapy to ensure that they avoid experiencing the big one and needing the higher medical costs of dealing with the problem as it arises.  In other words, we can all agree that an ounce of prevention is worth a pound of cure.  However, let's see if that is actually what we are accomplishing.

Unless you have been hiding under a rock for the past several decades you have heard of statin drugs.  Statin drugs are currently the standard of care for treating people with heart disease, despite there being no real evidence that they prevent heart attacks in anyone other than middle aged men who have already had a heart attack.  In this very small sample of people, cholesterol screenings are unnecessary because these men are already on statins.  For the remainder, let's take a look at what you are buying in to.

Let's say I have a large business with 1000 employees who are not currently on statins and they all sign up for cholesterol screening.  The criteria for high cholesterol puts approximately 1 in 3 people in this group, so let's say 333 of your employees are diagnosed with high cholesterol.  Most physicians will not prescribe a statin based solely on high cholesterol, so let's assume only 200 of your employees are recommended to take statin drugs.  What can we expect to see in terms of results?

If you listen to the way these drugs are marketed, you would realize that statins reduce heart attack risk by 36%, but what does this mean in a way that is pertinent to our discussion?  Probably the most clear cut way would be to look at a number that gives you the risk to benefit ratio.  In the pharmaceutical world, this is referred to as the number needed to treat (NNT).  The NNT is the number of people you would need to treat with the drug in order to prevent 1 person from experiencing the adverse event you are trying to prevent.  In other words, in the case of statins, the NNT is the number of people you would need to treat to prevent 1 heart attack.  When we look at this number, we get a much clearer picture of what we are getting.  The NNT to prevent 1 heart attack varies between 70-250 people depending on the study you look at.  When you take in to consideration that this NNT also includes people who have already had a coronary event, the NNT for people that will be undergoing cholesterol screening is closer to 1 in 250.  In other words, 249 of the people you are treating with this drug are not benefiting from taking it.  Furthermore, you would need to treat all 250 of these people for 5 years with the drug before you would prevent that 1 heart attack.

It is highly likely that every one of the 200 employees you have identified as candidates for statin therapy will receive no benefit from the drug, and you as well as they get to pay for that therapy.  In addition, recent research has shown that statin therapy induces diabetes in 1 out of 200 people taking the drugs.  So, while you have prevented zero heart attacks you have actually increased your healthcare costs by adding a diabetic to the payroll.  By the way, people with Type 2 Diabetes have the same risk of heart attack or dying from heart disease as people who have already had a heart attack.  Framed in that context, does that cholesterol screening really sound like something that is going to prove beneficial to your organization or does it seem more like a way to sell you something that is not really going to benefit you at all?

There is, of course, very large healthcare costs associated with someone experiencing a heart attack.  You may even hear that spending all of that money treating people with a drug that is not benefiting them in any way may make sense when you look at the cost savings of preventing a heart attack.  Ethical considerations aside, this benefit does not exist.  High cholesterol isn't even a good indicator of future heart disease.  The actual data shows that 50% of the people who die of heart disease have normal cholesterol.  In other words, you are financing a screen that has the same likelihood of predicting a heart attack as a coin flip, and investing a large sum of money in it's ability to do that.