PHYSICIAN EXTENDERS FOR COST-EFFECTIVE MANAGEMENT OF HYPERCHOLESTEROLEMIA

OBJECTIVE: Treatment of elevated cholesterol levels reduces morbidity and mortality from coronary heart disease in highrisk patients, but ca n be costly. The purpose of this study was to determine whether physic ian extenders emphasizing diet modification and, when necessary, effec tive and inexpensive drug algorithms can provide more cost-effective t herapy than conventional care. DESIGN: Randomized controlled trial. SE TTING: A Department of Veterans Affairs Medical Center. PATIENTS: Two hundred forty-seven veterans with type IIa hypercholesterolemia.INTERV ENTIONS: Patients assigned to either a cholesterol treatment program ( CTP) or usual health care provided by general internists (UHC). CTP in cluded intensive dietary therapy administered by a registered dietitia n utilizing individual and group counseling and drug therapy initiated by physician extenders for those failing to achieve goal low-density lipoprotein (LDL) levels with diet alone. A drug selection algorithm f or CTP subjects utilized niacin as initial therapy followed by bile ac id sequestrants and lovastatin. Subjects were followed prospectively f or 2 years. MEASUREMENTS: Primary outcome measurements were effectiven ess of therapy defined as reductions in LDL cholesterol (LDL-C), and w hether goal LDL-C levels were achieved; costs of therapy; and cost-eff ectiveness defined as the cost per unit reduction in the LDL-C. MAIN R ESULTS: Total program costs were higher for CTP patients than for UHC patients ($659 +/- $43 vs $477 +/- $42 per patient, p < .001). However , at 24 months the patients in CTP were more likely to achieve LDL goa l levels (65% vs 44%, p < .005), and also achieved greater reductions in LDL-C 27% +/- 2% vs 14% +/- 2% at 24 months, p < .001). Program cos ts per unit (mmol/L) reduction in the LDL-C, a measure of cost-effecti veness, was significantly lower for CTP ($758 +/- $58 vs $1,058 +/- $7 0, p = .002). CONCLUSIONS: Although more expensive than usual care, th e greater effectiveness of physician extenders implementing cholestero l treatment algorithms resulted in more cost-effective therapy.