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Costs and Health Consequences of Cholesterol Screening for Asymptomatic Older Americans

Costs and Health Consequences of Cholesterol Screening for Asymptomatic Older Americans Abstract To predict the consequences of cholesterol screening among elderly Americans who do not have symptoms of heart disease, we explore the cost implications of a cholesterol screening program, evaluate evidence linking hypercholesterolemia to coronary heart disease and mortality in the elderly, and describe the likely effects of therapy of hypercholesterolemia. According to our calculations, if all Americans 65 years of age and older adhered to a cholesterol screening program similar to the one proposed by the National Cholesterol Education Program, minimum annual expenditures for screening and treatment would be between $1.6 billion and $16.8 billion, depending on the effectiveness of diet and the cost of the medications used to treat hypercholesterolemia. There is no direct evidence that this program would lessen overall morbidity or extend the lives of elderly Americans. (Arch Intern Med. 1991;151:1089-1095) References 1. US Dept of Health and Human Services. Health Statistics on Older Persons: United States, 1986 . Washington, DC: National Center for Health Statistics; 1987. US Dept of Health and Human Services publication PHS 87-1409. 2. Adult Treatment Panel, National Cholesterol Education Program. Report of the National Cholesterol Education Program expert panel on detection, evaluation, and treatment of high blood cholesterol in adults . Arch Intern Med. 1988;148:36-69.Crossref 3. US Dept of Commerce, Bureau of the Census. Projections of the Population of the United States by Age, Sex, and Race, 1983;2000: Current Population Reports, Population Estimates and Projections. Washington, DC: Government Printing Office; 1984; series P-25, No. 952. 4. US Dept of Health and Human Services. Health: United States 1987 . Washington, DC: National Center for Health Statistics; 1988. Dept of Health and Human Services publication PHS 88-1232. 5. Sempos C, Fulwood R, Haines C, et al. The prevalence of high blood cholesterol levels among adults in the United States . JAMA. 1989;262:45-52.Crossref 6. Clinical diagnostic laboratory services . Med Bull. 1989(No. (89-1) );6-9. 7. Greenland P, Levenkron JC, Radley MG, Baggs JG, Manchester RA, Bowley NL. Feasibility of large-scale cholesterol screening: experience with a portable capillary-blood testing device . Am J Public Health. 1987;77:73-75.Crossref 8. Turpeinen O, KarvonenM, PekkarinenM, Miettinen M, Elosuo E, Paavilainen E. Dietary prevention of coronary heart disease: the Finnish mental hospital study . Int J Epidemiol. 1979;8:99-118.Crossref 9. Grundy SM. Comparison of monounsaturated fatty acids and carbohydrates for lowering plasma cholesterol . N Engl JMed. 1986;314:745-748.Crossref 10. Multiple Risk Factor Intervention Trial Research Group. Multiple Risk Factor Intervention Trial: risk factor changes and mortality results . JAMA. 1982;248:1465-1477.Crossref 11. Hjermann I, Byre KV, Holme I, Leren P. Effect of diet and smoking intervention on the incidence of coronary heart disease: report from the Oslo Study Group of a randomized trial in healthy men . Lancet. 1981;2:1303-1310.Crossref 12. Drug Topics Red Book. Annual Pharmacists' Reference . Oradell, NJ: Medical Economics; 1990. 13. Martin MJ, Hulley SB, Browner WS. Serum cholesterol, blood pressure, and mortality: implications from a cohort of 361 662 men . Lancet. 1986;2:933-936.Crossref 14. Rose G, Shipley M. Plasma cholesterol concentration and death from coronary heart disease: 10-year results of the Whitehall study . BMJ. 1986;293:306-307.Crossref 15. Kannel WB, Castelli W, Gordon T. Serum cholesterol, lipoproteins, and risk of coronary heart disease: The Framingham Study . Ann Intern Med. 1971;74:1-12.Crossref 16. Goldbourt U, Holtzman E, Neufeld HN. Total and high density lipoprotein cholesterol in the serum and risk of mortality: evidence of a threshold effect . BMJ. 1985;290:1239-1243.Crossref 17. Kannel WB, Castelli WP, Gordon T. Cholesterol in the prediction of atherosclerotic disease: new perspectives based on the Framingham study . Ann Intern Med. 1979;90:85-91.Crossref 18. Neaton JD, Kuller LH, Wentworth D, Borhani NO. Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years . Am Heart J. 1984;108:759-769.Crossref 19. Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results, I: reduction in incidence of coronary heart disease . JAMA. 1984;251:351-364.Crossref 20. Frick MH, Elo O, Haapa K, Heinonen OP. Helsinki Heart Study: primary prevention trial with gemfibrozil in middle-aged men with dyslipidemia . N Engl J Med. 1987;317:1237-1245.Crossref 21. The Multiple Risk Factor Intervention Trial Research Group. Mortality rates after 10.5 years for participants in the Multiple Risk Factor Intervention Trial: findings related to a priori hypotheses of the trial . JAMA. 1990;263:1795-1801.Crossref 22. Canner PL, Berge KG, Wenger NK, et al. Fifteen-year mortality in Coronary Drug Project patients: long-term benefit with niacin . J Am Coll Cardiol. 1986;8:1245-1255.Crossref 23. Carlson LA, Rosenhamer G. Reduction of mortality in the Stockholm Ischaemic Heart Disease Secondary Prevention Study by combined treatment with clofibrate and nicotinic acid . Acta Med Scand. 1988;223:405-418.Crossref 24. Agner E, Hansen PF. Fasting serum cholesterol and triglycerides in a ten-year prospective study in old age . Acta Med Scand. 1983;214:33-41.Crossref 25. Agner E. Some cardiovascular risk markers are also important in old age . Acta Med Scand. 1985;696( (suppl) ):3-50. 26. Welborn T, Wearne K. Coronary heart disease incidence and cardiovascular mortality in Busselton with reference to glucose and insulin concentrations . Diabetes Care. 1979;2:154-160.Crossref 27. Carlson LA, Bottiger LE. Ischaemic heart disease in relation to fasting values of plasma triglycerides and cholesterol: Stockholm Prospective Study . Lancet. 1972;2:865-868.Crossref 28. Anderson KM, Castelli WP, Levy D. Cholesterol and mortality: 30 years of follow-up from the Framingham Study . JAMA. 1987;257:2176-2180.Crossref 29. Gordon T, Castelli WP, Hjortland MC, Kannel WP, Dawber TR. Predicting coronary heart disease in middle-aged and older persons: the Framingham Study . JAMA. 1977;238:497-499.Crossref 30. The Framingham Study: An Epidemiological Investigation of Cardiovascular Disease . Springfield, Va: National Technical Information Service; 1987. National Institutes of Health publication 87-2703. 31. Harris T, Cook EF, Kannel WB, Goldman L. Proportional hazards analysis of risk factors for coronary heart disease in individuals aged 65 or older: the Framingham Heart Study . J Am Geriatr Soc. 1988;36:1023-1028. 32. Barrett-Connor E, Suarez L, Khaw K-T, Criqui MH, Wingard DL. Ischemic heart disease risk factors after age 50 . J Chronic Dis. 1984;37:903-908.Crossref 33. Benfante R, Reed D. Is elevated serum cholesterol level a risk factor for coronary heart disease in the elderly? JAMA. 1990;263:393-396.Crossref 34. Manolio TA, Pearson TA, Wenger NK, Barrett-Connor E, Payne GH, Harlan WR. Cholesterol and heart disease in older persons and women: overview of a National Heart, Lung, and Blood Institute Workshop . Ann Epidemiol . In press. 35. Malenka DJ, Baron JA. Cholesterol and coronary heart disease: the importance of patient-specific attributable risk . Arch Intern Med. 1988;148:2247-2252.Crossref 36. Gordon DJ, Rifkind BM. Treating high blood cholesterol in the older patient . Am J Cardiol. 1989;63:48H-52H.Crossref 37. Salmond CE, Beaglehole R, Prior IAM. Are low cholesterol values associated with excess mortality? BMJ. 1985;290:422-424.Crossref 38. Knekt P, Reunanen A, Aromaa A, Heliovaara M, Hakulinen T, Hakama M. Serum cholesterol and risk of cancer in a cohort of 39 000 men and women . J Clin Epidemiol. 1988;41:519-530.Crossref 39. Forrette B, Tortrat D, Wolmark Y. Cholesterol as a risk factor for mortality in elderly women . Lancet. 1989;2:868-870.Crossref 40. Sherwin RW, Wentworth DN, Cutler JA, et al. Serum cholesterol levels and cancer mortality in 361662 men screened for the Multiple Risk Factor Intervention Trial . JAMA. 1987;257:943-948.Crossref 41. Feinleib M. Summary of a workshop on cholesterol and noncardiovascular disease mortality . Prev Med. 1982;11:360-367.Crossref 42. Sidney S, Farquhar JW. Cholesterol, cancer, and public policy . Am J Med. 1983;75:494-508.Crossref 43. Schatzkin A, Hoover RN, Taylor PR. Serum cholesterol and cancer in the NHANESI Epidemiologic Followup Study . Lancet. 1987;2:298-301.Crossref 44. Isles CG, Hole DJ, Gillis CR, Hawthorne VM, Lever AF. Plasma cholesterol, coronary heart disease, and cancer in the Renfrew and Paisley survey . BMJ. 1989;298:920-924.Crossref 45. Muldoon MF, Manuck SB, Matthews KA. Lowering cholesterol concentrations and mortality: a quantitative review of primary prevention trials . BMJ. 1990;301:309-314.Crossref 46. Dayton S, Pearce ML, Hashimoto S, Dixon WJ, Tomiyasu U. A controlled clinical trial of a diet high in unsaturated fat in preventing complications of atherosclerosis . Circulation. 1969;40( (suppl 2) ):II-1-II-63.Crossref 47. Nolan L, O'Malley K. Prescribing for the elderly, I: sensitivity of the elderly to adverse drug reactions . J Am Geriatr Soc. 1988;36:142-149. 48. Nolan L, O'Malley K. Prescribing for the elderly, II: prescribing patterns: differences due to age . J Am Geriatr Soc. 1988;36:245-254. 49. Montamat SC, Cusack BJ, Vestal RE. Management of drug therapy in the elderly . N Engl J Med. 1989;321:303-309.Crossref 50. Blankenhorn DH, Nessim SA, Johnson RL, Sanmarco ME, Azen SP, Cashin-Hemphill L. Beneficial effects of combined colestipol-niacin therapy on coronary atherosclerosis and coronary venous bypass grafts . JAMA. 1987;257:3233-3240.Crossref 51. Arntzenius AC, Kromhout D, Barth JD, et al. Diet, lipoproteins, and the progression of coronary atherosclerosis: the Leiden Intervention Trial . N Engl J Med. 1985;312:805-811.Crossref 52. Wysowski DK, Kennedy DL, Gross TP. Prescribed use of cholesterol-lowering drugs in the United States, 1978 through 1988 . JAMA. 1990;263:2185-2188.Crossref 53. Basinski A, Frank JW, Naylor CD, Rachlis MM. Detection and Management of Asymptomatic Hypercholesterolemia: A Policy Document by the Toronto Working Group on Cholesterol Policy . Toronto: Ontario Ministry of Health; 1989. 54. Denke MA, Grundy SM. Hypercholesterolemia in elderly persons: resolving the treatment dilemma . Ann Intern Med. 1990;112:780-792.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Costs and Health Consequences of Cholesterol Screening for Asymptomatic Older Americans

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Publisher
American Medical Association
Copyright
Copyright © 1991 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1991.00400060037007
Publisher site
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Abstract

Abstract To predict the consequences of cholesterol screening among elderly Americans who do not have symptoms of heart disease, we explore the cost implications of a cholesterol screening program, evaluate evidence linking hypercholesterolemia to coronary heart disease and mortality in the elderly, and describe the likely effects of therapy of hypercholesterolemia. According to our calculations, if all Americans 65 years of age and older adhered to a cholesterol screening program similar to the one proposed by the National Cholesterol Education Program, minimum annual expenditures for screening and treatment would be between $1.6 billion and $16.8 billion, depending on the effectiveness of diet and the cost of the medications used to treat hypercholesterolemia. There is no direct evidence that this program would lessen overall morbidity or extend the lives of elderly Americans. (Arch Intern Med. 1991;151:1089-1095) References 1. US Dept of Health and Human Services. Health Statistics on Older Persons: United States, 1986 . Washington, DC: National Center for Health Statistics; 1987. US Dept of Health and Human Services publication PHS 87-1409. 2. Adult Treatment Panel, National Cholesterol Education Program. Report of the National Cholesterol Education Program expert panel on detection, evaluation, and treatment of high blood cholesterol in adults . Arch Intern Med. 1988;148:36-69.Crossref 3. US Dept of Commerce, Bureau of the Census. Projections of the Population of the United States by Age, Sex, and Race, 1983;2000: Current Population Reports, Population Estimates and Projections. Washington, DC: Government Printing Office; 1984; series P-25, No. 952. 4. US Dept of Health and Human Services. Health: United States 1987 . Washington, DC: National Center for Health Statistics; 1988. Dept of Health and Human Services publication PHS 88-1232. 5. Sempos C, Fulwood R, Haines C, et al. The prevalence of high blood cholesterol levels among adults in the United States . JAMA. 1989;262:45-52.Crossref 6. Clinical diagnostic laboratory services . Med Bull. 1989(No. (89-1) );6-9. 7. Greenland P, Levenkron JC, Radley MG, Baggs JG, Manchester RA, Bowley NL. Feasibility of large-scale cholesterol screening: experience with a portable capillary-blood testing device . Am J Public Health. 1987;77:73-75.Crossref 8. Turpeinen O, KarvonenM, PekkarinenM, Miettinen M, Elosuo E, Paavilainen E. Dietary prevention of coronary heart disease: the Finnish mental hospital study . Int J Epidemiol. 1979;8:99-118.Crossref 9. Grundy SM. Comparison of monounsaturated fatty acids and carbohydrates for lowering plasma cholesterol . N Engl JMed. 1986;314:745-748.Crossref 10. Multiple Risk Factor Intervention Trial Research Group. Multiple Risk Factor Intervention Trial: risk factor changes and mortality results . JAMA. 1982;248:1465-1477.Crossref 11. Hjermann I, Byre KV, Holme I, Leren P. Effect of diet and smoking intervention on the incidence of coronary heart disease: report from the Oslo Study Group of a randomized trial in healthy men . Lancet. 1981;2:1303-1310.Crossref 12. Drug Topics Red Book. Annual Pharmacists' Reference . Oradell, NJ: Medical Economics; 1990. 13. Martin MJ, Hulley SB, Browner WS. Serum cholesterol, blood pressure, and mortality: implications from a cohort of 361 662 men . Lancet. 1986;2:933-936.Crossref 14. Rose G, Shipley M. Plasma cholesterol concentration and death from coronary heart disease: 10-year results of the Whitehall study . BMJ. 1986;293:306-307.Crossref 15. Kannel WB, Castelli W, Gordon T. Serum cholesterol, lipoproteins, and risk of coronary heart disease: The Framingham Study . Ann Intern Med. 1971;74:1-12.Crossref 16. Goldbourt U, Holtzman E, Neufeld HN. Total and high density lipoprotein cholesterol in the serum and risk of mortality: evidence of a threshold effect . BMJ. 1985;290:1239-1243.Crossref 17. Kannel WB, Castelli WP, Gordon T. Cholesterol in the prediction of atherosclerotic disease: new perspectives based on the Framingham study . Ann Intern Med. 1979;90:85-91.Crossref 18. Neaton JD, Kuller LH, Wentworth D, Borhani NO. Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years . Am Heart J. 1984;108:759-769.Crossref 19. Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results, I: reduction in incidence of coronary heart disease . JAMA. 1984;251:351-364.Crossref 20. Frick MH, Elo O, Haapa K, Heinonen OP. Helsinki Heart Study: primary prevention trial with gemfibrozil in middle-aged men with dyslipidemia . N Engl J Med. 1987;317:1237-1245.Crossref 21. The Multiple Risk Factor Intervention Trial Research Group. Mortality rates after 10.5 years for participants in the Multiple Risk Factor Intervention Trial: findings related to a priori hypotheses of the trial . JAMA. 1990;263:1795-1801.Crossref 22. Canner PL, Berge KG, Wenger NK, et al. Fifteen-year mortality in Coronary Drug Project patients: long-term benefit with niacin . J Am Coll Cardiol. 1986;8:1245-1255.Crossref 23. Carlson LA, Rosenhamer G. Reduction of mortality in the Stockholm Ischaemic Heart Disease Secondary Prevention Study by combined treatment with clofibrate and nicotinic acid . Acta Med Scand. 1988;223:405-418.Crossref 24. Agner E, Hansen PF. Fasting serum cholesterol and triglycerides in a ten-year prospective study in old age . Acta Med Scand. 1983;214:33-41.Crossref 25. Agner E. Some cardiovascular risk markers are also important in old age . Acta Med Scand. 1985;696( (suppl) ):3-50. 26. Welborn T, Wearne K. Coronary heart disease incidence and cardiovascular mortality in Busselton with reference to glucose and insulin concentrations . Diabetes Care. 1979;2:154-160.Crossref 27. Carlson LA, Bottiger LE. Ischaemic heart disease in relation to fasting values of plasma triglycerides and cholesterol: Stockholm Prospective Study . Lancet. 1972;2:865-868.Crossref 28. Anderson KM, Castelli WP, Levy D. Cholesterol and mortality: 30 years of follow-up from the Framingham Study . JAMA. 1987;257:2176-2180.Crossref 29. Gordon T, Castelli WP, Hjortland MC, Kannel WP, Dawber TR. Predicting coronary heart disease in middle-aged and older persons: the Framingham Study . JAMA. 1977;238:497-499.Crossref 30. The Framingham Study: An Epidemiological Investigation of Cardiovascular Disease . Springfield, Va: National Technical Information Service; 1987. National Institutes of Health publication 87-2703. 31. Harris T, Cook EF, Kannel WB, Goldman L. Proportional hazards analysis of risk factors for coronary heart disease in individuals aged 65 or older: the Framingham Heart Study . J Am Geriatr Soc. 1988;36:1023-1028. 32. Barrett-Connor E, Suarez L, Khaw K-T, Criqui MH, Wingard DL. Ischemic heart disease risk factors after age 50 . J Chronic Dis. 1984;37:903-908.Crossref 33. Benfante R, Reed D. Is elevated serum cholesterol level a risk factor for coronary heart disease in the elderly? JAMA. 1990;263:393-396.Crossref 34. Manolio TA, Pearson TA, Wenger NK, Barrett-Connor E, Payne GH, Harlan WR. Cholesterol and heart disease in older persons and women: overview of a National Heart, Lung, and Blood Institute Workshop . Ann Epidemiol . In press. 35. Malenka DJ, Baron JA. Cholesterol and coronary heart disease: the importance of patient-specific attributable risk . Arch Intern Med. 1988;148:2247-2252.Crossref 36. Gordon DJ, Rifkind BM. Treating high blood cholesterol in the older patient . Am J Cardiol. 1989;63:48H-52H.Crossref 37. Salmond CE, Beaglehole R, Prior IAM. Are low cholesterol values associated with excess mortality? BMJ. 1985;290:422-424.Crossref 38. Knekt P, Reunanen A, Aromaa A, Heliovaara M, Hakulinen T, Hakama M. Serum cholesterol and risk of cancer in a cohort of 39 000 men and women . J Clin Epidemiol. 1988;41:519-530.Crossref 39. Forrette B, Tortrat D, Wolmark Y. Cholesterol as a risk factor for mortality in elderly women . Lancet. 1989;2:868-870.Crossref 40. Sherwin RW, Wentworth DN, Cutler JA, et al. Serum cholesterol levels and cancer mortality in 361662 men screened for the Multiple Risk Factor Intervention Trial . JAMA. 1987;257:943-948.Crossref 41. Feinleib M. Summary of a workshop on cholesterol and noncardiovascular disease mortality . Prev Med. 1982;11:360-367.Crossref 42. Sidney S, Farquhar JW. Cholesterol, cancer, and public policy . Am J Med. 1983;75:494-508.Crossref 43. Schatzkin A, Hoover RN, Taylor PR. Serum cholesterol and cancer in the NHANESI Epidemiologic Followup Study . Lancet. 1987;2:298-301.Crossref 44. Isles CG, Hole DJ, Gillis CR, Hawthorne VM, Lever AF. Plasma cholesterol, coronary heart disease, and cancer in the Renfrew and Paisley survey . BMJ. 1989;298:920-924.Crossref 45. Muldoon MF, Manuck SB, Matthews KA. Lowering cholesterol concentrations and mortality: a quantitative review of primary prevention trials . BMJ. 1990;301:309-314.Crossref 46. Dayton S, Pearce ML, Hashimoto S, Dixon WJ, Tomiyasu U. A controlled clinical trial of a diet high in unsaturated fat in preventing complications of atherosclerosis . Circulation. 1969;40( (suppl 2) ):II-1-II-63.Crossref 47. Nolan L, O'Malley K. Prescribing for the elderly, I: sensitivity of the elderly to adverse drug reactions . J Am Geriatr Soc. 1988;36:142-149. 48. Nolan L, O'Malley K. Prescribing for the elderly, II: prescribing patterns: differences due to age . J Am Geriatr Soc. 1988;36:245-254. 49. Montamat SC, Cusack BJ, Vestal RE. Management of drug therapy in the elderly . N Engl J Med. 1989;321:303-309.Crossref 50. Blankenhorn DH, Nessim SA, Johnson RL, Sanmarco ME, Azen SP, Cashin-Hemphill L. Beneficial effects of combined colestipol-niacin therapy on coronary atherosclerosis and coronary venous bypass grafts . JAMA. 1987;257:3233-3240.Crossref 51. Arntzenius AC, Kromhout D, Barth JD, et al. Diet, lipoproteins, and the progression of coronary atherosclerosis: the Leiden Intervention Trial . N Engl J Med. 1985;312:805-811.Crossref 52. Wysowski DK, Kennedy DL, Gross TP. Prescribed use of cholesterol-lowering drugs in the United States, 1978 through 1988 . JAMA. 1990;263:2185-2188.Crossref 53. Basinski A, Frank JW, Naylor CD, Rachlis MM. Detection and Management of Asymptomatic Hypercholesterolemia: A Policy Document by the Toronto Working Group on Cholesterol Policy . Toronto: Ontario Ministry of Health; 1989. 54. Denke MA, Grundy SM. Hypercholesterolemia in elderly persons: resolving the treatment dilemma . Ann Intern Med. 1990;112:780-792.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jun 1, 1991

References

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