Virtual care operator is likely cost-effective in cardiovascular disease secondary prevention – Lalli Nurmi

What is the problem?

Resources should be allocated as efficiently as possible in societies, maximizing the ratio of achieved utility and costs. In Finland, where the health care costs have been expanding at a faster pace than the gross national product, efficient allocation of resources requires more attention. At the same time, CVD are the number one killer and a major cause of morbidity. They incur a lot of costs.

A group of special interest is multimorbid patients. They use most of the money allocated to the health services even though they represent a small proportion of the population. At the same time, a substantial share of them do not even have a care plan. Low adherence to treatment is a problem, but a fragmented health care system, where the health service providers do not communicate, makes it worse. CVD and type 2 diabetes (T2D) are present at a large share of multimorbid patients. The low-density lipoprotein cholesterol (LDL-C) targets are not often achieved in CVD secondary prevention. LDL-C is the main cause of CVD.

What is the solution?

To mitigate the unbearable situation, a virtual care operator (VCO) is suggested. It is a virtual platform gathering all relevant information of the health statuses of the patients, treatment targets and the next steps towards those targets. The fragmentation of health care is countered by properly managing care plans and patient pathways. Read more here.

In my master’s thesis, a manifestation of a virtual care operator in the context of CVD secondary prevention, called “the prevention clinic*”, is outlined as a concept: After a cardiovascular (CV-) event has been treated at specialized care, the responsibility of the CVD secondary prevention would be shifted to the prevention clinic instead of primary care. At the prevention clinic, LDL-C would be treated in a stepwise manner until achievement of the European guideline-based treatment target.

The prevention clinic is expected to increase the adherence to treatment and reduce the risk of recurrent CV-events. As a result, the number of CV-events would reduce, resulting in better health outcomes as measured by quality-adjusted life-years (QALYs) and reduced costs of recurrent CV-events. However, effective prevention also has a cost. To determine whether the resources are efficiently allocated in this context, the ratio of incremental total net costs and incremental utility (QALYs) compared to the current system, called incremental cost-effectiveness ratio (ICER), was simulated.

How was the solution analyzed?

In my thesis, the effect of the prevention clinic, the effect of CV-events on QALYs and the main cost elements of the prevention clinic were identified and modeled. Based on this modeling, the ICER of the prevention clinic was simulated. The effect of the prevention clinic is that it improves adherence and reduces the risk for a recurrent CV-event. When the current probabilities of recurrent CV-events and CV-event deaths, and population size are known, the expected number of prevented CV-events and CV-event deaths can be simulated for each pair of adherence improvement and CV-event risk reduction. A new model for the QALY reductions associated to recurrent CV-events was developed based on literature. The health-related quality of life and the expected survival were assumed to reduce after each CV-event.

The costs related to the recurrent CV-events were obtained by analyzing real world data in the Finnish Care Register for Health Care. A cohort of all Finnish people who suffered their index CV-event in 2017 was extracted, and the recurrent CV-events were recognized. Based on this material, the current probabilities of recurrent CV-events and CV-event deaths during a 3.2-year follow-up period were determined. The accumulation of health care costs of the patients was calculated using the material from 2015 to 2020, and the modeling of the cost effects of each recurrent CV-event were based on these calculations. The same analysis was conducted separately for multimorbid patients having CVD and T2D. Preventing a CV-event would lead to a cost reduction equal to the cost of an additional event. The operating costs and the initial investment of the prevention clinic were considered to consist of labor costs, medication costs, laboratory examination costs, other costs, and the initial investment. Some of these are highly dependent on the adherence improvement effect of the prevention clinic.

The treatment paradigm of CVD should be changed

Finally, the cost-effectiveness as measured by ICER was simulated with regards to adherence improvement and CV-event risk reduction. It was found that cost-effectiveness was achieved with feasible pairs of risk reduction and adherence improvement when the society’s willingness-to-pay threshold had been set to 50 k€ per QALY. The cost-effectiveness was achieved with even more feasible pairs when the multimorbid group with CVD and T2D was examined separately. This was due to higher probabilities and costs of recurrent CV-events in the group.

The findings implicate that a change in the CVD treatment paradigm should be made towards the prevention clinic -based system. The recommendation is thus to launch the prevention clinic. It is most likely cost-effective based on the findings. The effects on the absolute amounts of costs and QALYs cannot be determined in advance but the adherence improvement and CV-event risk reduction can be observed in real life. Then the effects on costs and QALYs will be visible using the methodology developed in my thesis. The findings highlight the more efficient use of data, digital tools, and effective treatments to achieve better economic and health outcomes.

*Concept owner: Antti Iivanainen, M.D., Ph.D., specialist in general practice