Original ArticleThe economic impact of familial hypercholesterolemia on productivity
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.
References (29)
- et al.
Cascade screening based on genetic testing is cost-effective: Evidence for the implementation of models of care for familial hypercholesterolemia
J Clin Lipidol
(2014) - et al.
Understanding DALYs
J Health Econ
(1997) - et al.
Cost-effectiveness of a cascade screening program for the early detection of familial hypercholesterolemia
J Clin Lipidol
(2017) - et al.
Coronary heart disease mortality in treated familial hypercholesterolaemia: Update of the UK Simon Broome FH register
Atherosclerosis
(2018) - et al.
Overview of the current status of familial hypercholesterolaemia care in over 60 countries - The EAS Familial Hypercholesterolaemia Studies Collaboration (FHSC)
Atherosclerosis
(2018) - et al.
Familial hypercholesterolaemia: A model of care for Australasia
Atheroscler Supplements
(2011) - et al.
Effect of Long-Term Exposure to Lower Low-Density Lipoprotein Cholesterol Beginning Early in Life on the Risk of Coronary Heart Disease: A Mendelian Randomization Analysis
J Am Coll Cardiol
(2012) - et al.
Health economic evaluation of screening and treating children with familial hypercholesterolemia early in life: Many happy returns on investment?
Atherosclerosis
(2020) - et al.
Familial hypercholesterolemia: A complex genetic disease with variable phenotypes
Eur J Med Genet
(2019) - et al.
Prevalence of familial hypercholesterolemia among the general population and patients with atherosclerotic cardiovascular disease: a systematic review and meta-analysis
Circulation
(2020)
Heart Disease and Stroke Statistics—2016 Update
Circulation
Efficacy of statins in familial hypercholesterolaemia: a long term cohort study
BMJ
Effect of Bempedoic Acid vs Placebo Added to Maximally Tolerated Statins on Low-Density Lipoprotein Cholesterol in Patients at High Risk for Cardiovascular Disease: The CLEAR Wisdom Randomized Clinical Trial
JAMA
Design of the Familial Hypercholesterolaemia Australasia Network Registry: Creating Opportunities for Greater International Collaboration
J Atheroscler Thromb
Cited by (0)
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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Shared first authorship.