pregnancy who uses no method of contraception is $1,267 ($1,079 for unintended pregnancy and $188 for STDs) in the private sector and $677 ($541 for unintended pregnancy and $137 for STDs) in the public sector. After one year of use private-sector savings from adolescent contraceptive use ranged from $308 for an implant designed to prevent ovulation to $946 for the male condom. Public-sector savings rose from $60 for the implant to $525 for the male condom. Both the use of male condoms with another method and the advance provision of backup emergency contraceptive pills provided additional savings.

Shifting to an example of the cost effectiveness of cholesterol-lowering therapies, Prosser et al. (2000) found that ratios varied according to different risk factors. Specifically, incremental cost effectiveness ratios were found for primary prevention with a low fat, low cholesterol diet (National Cholesterol Education Program step I), ranging from $1,900 per quality-adjusted life-year (QALY) gained to $500,000 per QALY depending on risk subgroup characteristics. Primary prevention with a statin (a cholesterol-lowering drug) compared with diet therapy was $54,000 per QALY to $1.4 million per QALY. Secondary prevention with a statin cost less than $50,000 per QALY for all risk subgroups. Primary prevention with a step I diet seems to be cost effective for most risk subgroups defined by age, sex, and the presence of additional risk factors. It may not be cost effective for otherwise healthy young women. In addition, primary prevention with a statin may not be cost effective for younger men and women with few risk factors, given the option of secondary prevention and of primary prevention in older age groups. Secondary prevention with a statin seems to be cost effective for all risk subgroups and is cost saving for some high-risk subgroups.

As a further illustration, an economic evaluation was conducted alongside a randomized controlled trial of two lifestyle interventions (e.g., education and video to assess risk factors, program plan for risk factor behavior change) and a routine care (control) group to assess cost effectiveness for patients with risk factors for cardiovascular disease (Salkeld et al., 1997). The cost per QALY for males ranged from $152,000 to $204,000. Further analysis suggested that a program targeted at high-risk males would cost $30,000 per QALY. The lifestyle interventions had no significant effect on cardiovascular risk factors when compared to routine patient care. There remains insufficient evidence that lifestyle programs conducted in general practice are effective. Resources for general-practice-based lifestyle programs may be better spent on high-risk patients who are contemplating changes in risk factor behaviors. Alternatively, the extensive literature on the economics of coronary heart disease prevention (Brown and Garber, 1998) suggests that many programs (e.g., exercise, smoking cessation, de-



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