- Email: [email protected]
E8 Clinical utility of ambulatory blood pressure monitoring in a VA medical center
ASH XII ABSTRACTS
A]H-APRIL 1997-VOL. 10, NO. 4, PART 2
E5
E6
COST-EFFECTJVENESS OF FIRST-LINE DRUGS FOR UNCOMPLICATED HYPERTENSION.~, CD Furberg*, BM Psaty*, JK Kirk. Bowmse Gray Schoolof Medicine,WinstonSalem,NC andUniversityof Washington,Seattle,WA. We comparedthe cost-effectivenessofthiazide diuretics,hetablockers(~-blockers),angiotsnsinconverdngetmyme inhibitors(ACEIS), alpha-blockers (a-blockers),andwdciumcbannelblockem(CCBS)forthe preventionofstioke, myocardialinfarction(MI)andprematuredeathin middle-agsdandelderlypatientswithuncomplicatedhypertension.This analysis was bad on the numbers-needed-to-treat to prevent these complications,derived from meta-snalysesof 15 major randomized conkcdledtrialsof hypertensiontreatment;andon the averagewholesale pricesofhoththemostcommonly-prescribed, and lesst expensive,drugs in eachclass. ‘ffteeffectivenessofthe 3 tmpmvendrugclssseswss set as equal to that of diursticsand &blockers. This premisewas tested in sensitivityanalyseswhichvadedthesssumedeffectivenes.s ofa-blockers, ACEISand CCBS. Wlolesale drugcosts and total outpatienttreatment costs (TC) to preventeventswere calculated. The TC includeddrug costs,physicisnvisitsand laboratory.Costswerelowerfor diureticsand p-blockersthrmforrhe otherdrugs. Dependingupondmgselection,the TC to preventonemajorcomplicationrangedas shownin the table:
CESSATION OF ANTIHYPERTENSIVE DRUG THERAPY: A META-ANALYSIS. ~ * and S.L. Kusrnirek. Dept. of Preventive Medicine, RushPresbyterian-St. Luke’s Medical Center, Chicago, IL Although a diagnosis of hypertension often commits a patient to life-long drug therapy, JNC V indicates that “sound patient treatment” includes attempts to reduce the dose, and even to stop drug therapy, after BP has been controlled for 21 year. To estimate the proportion of patients who might be able to benefit from discontinuing medication end still maintain acceptable blood pressure (BP), a metaartalysis of the world’s literature was performed. The results could not be pooled unless the reports of systematic programs to change weight, salt intake or other lifestyle modifications (LM) were considered separately. Kaplen-Meier one-year estimates of the proportion of patienta able to maintain acceptable BPs without drug therapy (i.e., % Success) were calculated. LM? #Reports # Patienta % Succesa Std. Dev. Range Yes 4 4Y0 433 56 50-69Y0 No 26 2528 28 7% &89’YO The success rates with end without LM are statistically significantly different (P c 0.001). There was a direct correlation (r = 0.54, P = 0.02) between the success rate and year of publication of atudiea without LM, no doubt due to more caretld selection of patienta for en attempt at drug cessation recently. This meta-ertalysis confirms several individual studies demonstrating that cessation of drug therapy for hypertension can be more cornmordy achieved when LM ia performed.
Middle-aged
$54~02 to $2,041,792
Elderly
$97,263 to $365,054
smtk~
$188,673to $708,142
$120,394to $451,872
$62,427 to $234,304
$40,410 to $151,670
SensitiviVanalysesshowedthat diuretictherapyrsmainedmore costeffectiveeven if ACEIS,a-blockersand CCBSwers assumedto be so effectivethat theyprsventedall majoreventsovera 5-yearperiod,or if potsssiumsupplementationand monitoringwere alwaysrequiredwith diuretics. We concludethat genericdiureticssnd &blockersas more cost-effective than ACEIs, a-blockers and CCBS for meating uncomplicated hypertensivepsdsntswithoutconlr’sindicstiom totheiruse. Dmg selectionin middte-agedpatientshas a grsatsr impact on costeffectivenessthanit doesin the elderly. Kay Words: Cost-effectiveness, uncomplicatedhypertsttsion,drugtreatment
words: “Stepdown” Therapy, Drug Discontinuation
E8
E7 DISCONTINUATIONOF ANTIHYPERTENSIVEDRUG THERAPY: A SHORT-TERM ECONOMIC ANALYSIS. Dept. of Preventive Medicine, RushW.* Pttabyterian-St. Luke’sMedicslCenter,Chicago,IL “Step-down”therapy is recommendedfor padentswhoac blood pressures(BP) have been welt controlledfor 21 year. Ancconomicsttatysisof this practicewasperformed,usingthe ratrge of published retail prices for different classes of sntihypertensivedrugs (AmJ Hyper?ens.,1994;7:751),sttd results of a meta-analysis of studies of cessation of dmg therapy, with or without lifestyle moditlcations [LM]. The schedulesof visits for both monitoringBP and LM teaching wem taken from the two publicationswith the moat patienta; costs were estimated using national averages (HCFA). The estimated costs (or cost-savings) per patient for a year of attemptedcessationof drugtherapy,for variousdnrgs,were:
Sensitivity anafysesindicatedthat the “break-even”cost per month of dnrg therapy was $31.74 for LM or $28.60 for no LM. The better efficacy of the LM program was somewhat mitigated by the cost of initiaf LM teaching and increased frequencyof scheduledvisits.lltesedate suggeatthat, for leas expensivednrga(< $2tVmonth),programsto discontinuedrugs are not coat-saving,but that for more expensivedrugs and if other factors (e.g., patient utility) were included, such programsmaybeemmrnicallyjuadf iable. Kay
Kay
words:
,,5@om,,
tiw,
mntiw
CLINICALUTILITYOF Ambulatory
BLOODPRES~URE
MONITOIUNG IN A VA MEDICAL CENTER ~ Veta... AAinistq.tion Hospital(Newi.gton), ..d thi..rsi~ HealthCenter.Fmmmtm. CT.
, MD, of Connecticut
The ‘conse~susindications for ambulatory BP monitoring (ABPM)in clinicalpracticeare adbersdto in a Universitysstting and have a substantial impact on patient management. However, the indicationsand impact of ABPM on clinical practice in a Veteran populationarenotwellstudied.Werecentlyestablisheda BP monitoring service at a VA medicalcenter, the clinics of whicb are staffed by attendingphysicians(bothgeneralphysicitmssnd specialists),supervised msdicairesidentssndnursepractitioners.A standardtwopagereportwas generatedforeachpatientthatincludedaveragebleedpressuress wellas BP loadsandstudyinterpretation.Weprospectivelys.wsssedthe clinical impactof this servicein the managementof veteranswithhypertension. As expected,the populationstudied was mostly men (95%), white (s4%) and elderly (mean age of 62 + 13 years). Patients on antihypertensive dmgthsrapycomprissd72 %of subjects.Theclinicians requestingthe ABPMstudywers 67%physicians(21%residents),and 32%nursepractitioners.The majorityof requestscame from primary care clinicians(8S%)ratherthan specialists.The majorindicationsfor the study were: suspectedwhite-coathypertensionor effect (45%), borderlinehypertension(16%),patient on multipledregs or resistant hypertension(30%)and possiblesymptomsdue to therapy(9%). The report sent to the clinician had a substantial impact on clinical management.Of the 26 untreatedpatients witb suspectedwhite coat hypertensionm witb borderlinehypertension,54% had white-coat hypertension(BP Iosds< 40%).In the treatedhypertensivegroup,3S% werefoundmhaveacceptableBPcontrnlandavoidedfurtftsrincreasssin therapy.Overalla changeof pretestclinicalplanwas madein abouthalf 49 Increaseorstartmedications(n) S5 10 06 Reduceorstop(n) o 40 Nochange(n) 95 95 Total(n) n = numberof patients Theintroductionof an ABPMservicein a Veteransbospitalled to clinicaluse for approvedindicationswith a significmtimpacton patient management. Tbe initiation of or increase in antihypertensive therapywasavoideditt42%of subjects. Key Words: bloodpressuremeasurement,clinicalpractice, VAmedicatcenter
I
A]H-APRIL 1997-VOL. 10, NO. 4, PART 2
E5
E6
COST-EFFECTJVENESS OF FIRST-LINE DRUGS FOR UNCOMPLICATED HYPERTENSION.~, CD Furberg*, BM Psaty*, JK Kirk. Bowmse Gray Schoolof Medicine,WinstonSalem,NC andUniversityof Washington,Seattle,WA. We comparedthe cost-effectivenessofthiazide diuretics,hetablockers(~-blockers),angiotsnsinconverdngetmyme inhibitors(ACEIS), alpha-blockers (a-blockers),andwdciumcbannelblockem(CCBS)forthe preventionofstioke, myocardialinfarction(MI)andprematuredeathin middle-agsdandelderlypatientswithuncomplicatedhypertension.This analysis was bad on the numbers-needed-to-treat to prevent these complications,derived from meta-snalysesof 15 major randomized conkcdledtrialsof hypertensiontreatment;andon the averagewholesale pricesofhoththemostcommonly-prescribed, and lesst expensive,drugs in eachclass. ‘ffteeffectivenessofthe 3 tmpmvendrugclssseswss set as equal to that of diursticsand &blockers. This premisewas tested in sensitivityanalyseswhichvadedthesssumedeffectivenes.s ofa-blockers, ACEISand CCBS. Wlolesale drugcosts and total outpatienttreatment costs (TC) to preventeventswere calculated. The TC includeddrug costs,physicisnvisitsand laboratory.Costswerelowerfor diureticsand p-blockersthrmforrhe otherdrugs. Dependingupondmgselection,the TC to preventonemajorcomplicationrangedas shownin the table:
CESSATION OF ANTIHYPERTENSIVE DRUG THERAPY: A META-ANALYSIS. ~ * and S.L. Kusrnirek. Dept. of Preventive Medicine, RushPresbyterian-St. Luke’s Medical Center, Chicago, IL Although a diagnosis of hypertension often commits a patient to life-long drug therapy, JNC V indicates that “sound patient treatment” includes attempts to reduce the dose, and even to stop drug therapy, after BP has been controlled for 21 year. To estimate the proportion of patients who might be able to benefit from discontinuing medication end still maintain acceptable blood pressure (BP), a metaartalysis of the world’s literature was performed. The results could not be pooled unless the reports of systematic programs to change weight, salt intake or other lifestyle modifications (LM) were considered separately. Kaplen-Meier one-year estimates of the proportion of patienta able to maintain acceptable BPs without drug therapy (i.e., % Success) were calculated. LM? #Reports # Patienta % Succesa Std. Dev. Range Yes 4 4Y0 433 56 50-69Y0 No 26 2528 28 7% &89’YO The success rates with end without LM are statistically significantly different (P c 0.001). There was a direct correlation (r = 0.54, P = 0.02) between the success rate and year of publication of atudiea without LM, no doubt due to more caretld selection of patienta for en attempt at drug cessation recently. This meta-ertalysis confirms several individual studies demonstrating that cessation of drug therapy for hypertension can be more cornmordy achieved when LM ia performed.
Middle-aged
$54~02 to $2,041,792
Elderly
$97,263 to $365,054
smtk~
$188,673to $708,142
$120,394to $451,872
$62,427 to $234,304
$40,410 to $151,670
SensitiviVanalysesshowedthat diuretictherapyrsmainedmore costeffectiveeven if ACEIS,a-blockersand CCBSwers assumedto be so effectivethat theyprsventedall majoreventsovera 5-yearperiod,or if potsssiumsupplementationand monitoringwere alwaysrequiredwith diuretics. We concludethat genericdiureticssnd &blockersas more cost-effective than ACEIs, a-blockers and CCBS for meating uncomplicated hypertensivepsdsntswithoutconlr’sindicstiom totheiruse. Dmg selectionin middte-agedpatientshas a grsatsr impact on costeffectivenessthanit doesin the elderly. Kay Words: Cost-effectiveness, uncomplicatedhypertsttsion,drugtreatment
words: “Stepdown” Therapy, Drug Discontinuation
E8
E7 DISCONTINUATIONOF ANTIHYPERTENSIVEDRUG THERAPY: A SHORT-TERM ECONOMIC ANALYSIS. Dept. of Preventive Medicine, RushW.* Pttabyterian-St. Luke’sMedicslCenter,Chicago,IL “Step-down”therapy is recommendedfor padentswhoac blood pressures(BP) have been welt controlledfor 21 year. Ancconomicsttatysisof this practicewasperformed,usingthe ratrge of published retail prices for different classes of sntihypertensivedrugs (AmJ Hyper?ens.,1994;7:751),sttd results of a meta-analysis of studies of cessation of dmg therapy, with or without lifestyle moditlcations [LM]. The schedulesof visits for both monitoringBP and LM teaching wem taken from the two publicationswith the moat patienta; costs were estimated using national averages (HCFA). The estimated costs (or cost-savings) per patient for a year of attemptedcessationof drugtherapy,for variousdnrgs,were:
Sensitivity anafysesindicatedthat the “break-even”cost per month of dnrg therapy was $31.74 for LM or $28.60 for no LM. The better efficacy of the LM program was somewhat mitigated by the cost of initiaf LM teaching and increased frequencyof scheduledvisits.lltesedate suggeatthat, for leas expensivednrga(< $2tVmonth),programsto discontinuedrugs are not coat-saving,but that for more expensivedrugs and if other factors (e.g., patient utility) were included, such programsmaybeemmrnicallyjuadf iable. Kay
Kay
words:
,,5@om,,
tiw,
mntiw
CLINICALUTILITYOF Ambulatory
BLOODPRES~URE
MONITOIUNG IN A VA MEDICAL CENTER ~ Veta... AAinistq.tion Hospital(Newi.gton), ..d thi..rsi~ HealthCenter.Fmmmtm. CT.
, MD, of Connecticut
The ‘conse~susindications for ambulatory BP monitoring (ABPM)in clinicalpracticeare adbersdto in a Universitysstting and have a substantial impact on patient management. However, the indicationsand impact of ABPM on clinical practice in a Veteran populationarenotwellstudied.Werecentlyestablisheda BP monitoring service at a VA medicalcenter, the clinics of whicb are staffed by attendingphysicians(bothgeneralphysicitmssnd specialists),supervised msdicairesidentssndnursepractitioners.A standardtwopagereportwas generatedforeachpatientthatincludedaveragebleedpressuress wellas BP loadsandstudyinterpretation.Weprospectivelys.wsssedthe clinical impactof this servicein the managementof veteranswithhypertension. As expected,the populationstudied was mostly men (95%), white (s4%) and elderly (mean age of 62 + 13 years). Patients on antihypertensive dmgthsrapycomprissd72 %of subjects.Theclinicians requestingthe ABPMstudywers 67%physicians(21%residents),and 32%nursepractitioners.The majorityof requestscame from primary care clinicians(8S%)ratherthan specialists.The majorindicationsfor the study were: suspectedwhite-coathypertensionor effect (45%), borderlinehypertension(16%),patient on multipledregs or resistant hypertension(30%)and possiblesymptomsdue to therapy(9%). The report sent to the clinician had a substantial impact on clinical management.Of the 26 untreatedpatients witb suspectedwhite coat hypertensionm witb borderlinehypertension,54% had white-coat hypertension(BP Iosds< 40%).In the treatedhypertensivegroup,3S% werefoundmhaveacceptableBPcontrnlandavoidedfurtftsrincreasssin therapy.Overalla changeof pretestclinicalplanwas madein abouthalf 49 Increaseorstartmedications(n) S5 10 06 Reduceorstop(n) o 40 Nochange(n) 95 95 Total(n) n = numberof patients Theintroductionof an ABPMservicein a Veteransbospitalled to clinicaluse for approvedindicationswith a significmtimpacton patient management. Tbe initiation of or increase in antihypertensive therapywasavoideditt42%of subjects. Key Words: bloodpressuremeasurement,clinicalpractice, VAmedicatcenter
I