Elsevier

Journal of Clinical Lipidology

Volume 14, Issue 6, November–December 2020, Pages 799-806.e3
Journal of Clinical Lipidology

Original Article
The economic impact of familial hypercholesterolemia on productivity

https://doi.org/10.1016/j.jacl.2020.08.004Get rights and content

Highlights

  • Familial hypercholesterolemia increases the risk of cardiovascular disease.

  • Most people affected remain undiagnosed and untreated.

  • The productivity-adjusted life years link health status with work productivity.

  • The impact on productivity and the burden on the Australian economy is substantial.

Background

Familial hypercholesterolemia (FH) is a common inherited cause for premature coronary artery disease that increases suffering and disability in affected people. However, the extent to which FH impacts work productivity at a population level is unclear.

Objective

We aimed to quantify the burden of heterozygous FH (HeFH) in terms of productivity-adjusted life years (PALYs) lost to HeFH in Australia.

Methods

A life-table model was constructed to quantify years of life and PALYs lived by Australians with HeFH (prevalence 1 in 300) and of working age (aged 20–69 years). Follow-up was simulated until age 70 years. The model was then resimulated, but assuming the cohort did not have HeFH. Increased cardiovascular mortality and reduction in productivity attributable to HeFH were sourced from published data. Differences in total years of life, quality-adjusted life years, and PALYs lived by the “HeFH cohort” and the same cohort without HeFH (“non-HeFH cohort”) reflected the quality-adjusted life years and PALYs lost due to HeFH. All future costs and outcomes were discounted by 5% annually.

Results

In 2017, an estimated 51,587 people of working age in Australia (0.33%) had HeFH. Over their working lifetime, we predicted that 2950 excess cardiovascular deaths occurred in the current Australian population of working age individuals with HeFH, resulting in a loss of 24,727 years of life. In terms of productivity, HeFH led to the loss of 24,954 PALYs over the working lifetime. Based on gross domestic product (GDP) per full-time equivalent worker, this equated to a total of AUD 5.23 billion in lost GDP over the working lifetime, with an average of AUD 101,366 lost per person. A relative reduction of 20% in cardiovascular deaths (as can be achieved with adequate cholesterol control) would lead to 1113 PALYs and AUD 233 million in GDP saved in the HeFH cohort.

Conclusion

The impact of HeFH on work productivity is significant. Screening and prevention strategies tailored early in life are likely to exert not only a positive impact on health but also the economy.

Introduction

Familial hypercholesterolemia (FH) is an inherited condition due to a highly penetrant, autosomal dominant monogenic disorder that causes high cholesterol levels and increased risk of early atherosclerosis.1 The prevalence of heterozygous FH (HeFH) is 1 per 300 of the general population, and currently, 35 million people worldwide are estimated to have this condition.2 People affected by HeFH have a twofold the risk of cardiovascular disease and premature cardiovascular death than people with normal cholesterol levels.3

Statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, and more recently bempedoic acid are the cornerstone treatments for adult HeFH patients and can reduce the risk of myocardial infarction by up to 76%.4,5 However, most HeFH cases remain undiagnosed and untreated, and most persons with HeFH are not aware of their condition.6,7 This situation results in a high burden of premature coronary heart disease morbidity and mortality among people with HeFH. There is an urgent need for early identification and access to preventive care for individuals with HeFH.

Most countries make policy decisions about screening and treatments based on cost-effectiveness analyses. Cascade screening and treatment of HeFH in adults has been shown to be cost-effective.8 However, HeFH also affects an individual's productivity at work, and few countries include the impact of ill health on indirect costs in their health care funding decision-making. In recent years, there has been an increased interest in assessing the impact of different conditions on work productivity, which is a major indirect cost arising from ill health. A relatively new metric called the productivity-adjusted life year (PALY) is an alternative measure that may be important for decision-making. PALYs measure productivity as an outcome at a population level. PALYs are akin to quality-adjusted life years but adjust years of life lived for productivity loss attributable to disease, rather than loss of quality of life. PALYs provide information on the productivity impact imposed by ill health or health risk factors on society, in a similar way that disability-adjusted life years provide insight into the global burden of disease.9 A number of studies have used the PALY concept in Australia10, 11, 12 and China.13

In Australia, studies have measured the productivity impact of smoking,12 hypertension,10 and diabetes11 using PALYs. The results of these findings highlight the potential macroeconomic impact (in terms of gross domestic product (GDP)) of decreased productivity, ranging from AUD 388 billion due to smoking to AUD 80 billion due to diabetes. No study has hitherto assessed the extent to which HeFH impacts work productivity at a population level. This study aimed to quantify the burden of HeFH in terms of PALYs lost in Australia.

Section snippets

Model overview

The present study uses static life-table models to estimate the health and productivity burden caused by HeFH in Australia, applying yearly cycles. Life-table modeling is a tool commonly used for epidemiological and demographical studies that simulates the progress of a cohort of people over a period of time and considers age-specific data, such as risks of death and disease progression. This tool was also used in several previous studies internationally with similar outcomes of interest as the

Cardiovascular mortality and years of life lived

Based on Australian demographic data, the life-table models were populated with 15,476,219 Australians (7,786,322 women and 7,689,897 men) of working age. The modeled prevalence of HeFH (0.33%) translated into 51,587 Australians (25,954 women and 25,633 men) having HeFH. The increased mortality risk due to HeFH resulted in 2950 more cardiovascular deaths (1523 in women and 1427 in men) in the model with HeFH compared with the model that assumed people did not have HeFH, representing a 141%

Discussion

The present study shows the significant impact that HeFH may have on the health and productivity of the Australian population. Among working aged Australians, HeFH caused 2950 extra cardiovascular deaths and 24,727 years of life lost during their working lifetime. The HeFH cohort incurred 24,954 PALYs lost due to increased mortality and loss of health. This decrement in productivity resulted in AUD 5.23 billion in lost GDP in Australia using 2017 GDP data.

Improved diagnosis and management of

Acknowledgments

Authors’ contribution: Z.A. contributed to the conceptualization of the project, built the model, performed the analysis, and contributed to the writing of the first manuscript; C.M. contributed to the writing of the first manuscript and performed analyses; all other authors contributed to the revision of the manuscript. G.F.W., C.B., E.Z., A.O., R.N., and J.P. were involved in discussions about PALYs and critically reviewed drafts of the manuscript.

No funding was required for this publication.

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    Conflict of interest statement: Z.A., C.M., J.P., and C.B. declare no conflict of interest. E.Z. declares grants from Amgen, AstraZeneca, Pfizer, and Shire, outside the submitted work. G.F.W. declares grants and/or lecture fees from Amgen, Sanofi, Regeneron, Kowa, Novartis, and Ar. D.L. declares grant support from AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Pfizer, and Sanofi and past participation in advisory boards and/or receipt of honoraria from AbbVie, Amgen, Astellas, AstraZeneca, Bristol-Myers Squibb, Edwards Lifesciences, Novartis, Pfizer, Sanofi, and Shire, outside the submitted work.

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