提示: 手机请竖屏浏览!

强化与标准血压控制的成本效益比较
Cost-Effectiveness of Intensive versus Standard Blood-Pressure Control


Adam P. Bress ... 心脑血管疾病 • 2017.08.24
相关阅读
• 中年高血压与新发痴呆:男女有别 • 收缩压,认知与种族 • SPRINT研究:生活质量和成本效益 • 强化降压与标准降压比较的随机试验 • 强化降压治疗对患者报告结局的影响 • 学习未知——SPRINT数据分析挑战赛 • JNC 8目标和SPRINT目标的估计降压效果比较 • 老年人SPRINT试验的结果

强化降压策略再添新证据

 

乔宇,张萍*

清华大学附属北京清华长庚医院,清华大学临床医学院

*通讯作者

 

一直以来,高血压患者的最佳降压靶目标水平都是学界关注的热点问题。2014年发表的美国联合委员会第八版推荐(JNC 8)中指出1,<60岁的成人及患有糖尿病或慢性肾脏病的成人降压靶目标为<140/90 mmHg,而≥60岁的高血压患者,降压靶目标为<150/90 mmHg,该推荐已经成为目前临床实践中的标准降压策略。

查看更多

摘要


背景

在收缩压干预试验(Systolic Blood Pressure Intervention Trial,SPRINT)中,心血管疾病高危并接受强化收缩压控制(目标,<120 mmHg)的成人比接受标准控制(目标,<140 mmHg)的成人有显著较低的心血管疾病事件发生率和死亡率。基于这些数据,我们希望确定,与标准控制相比,强化控制相关的终生健康获益和医疗成本。

 

方法

我们使用微观模拟模型将SPRINT治疗效果和来自美国政府的医疗成本数据应用到一个假设的符合SPRINT标准的成人队列。这一模型将收缩压强化控制与标准控制相比,预测了高血压患者的终生治疗和监测成本、心血管疾病事件和后续治疗成本、与治疗相关的严重不良事件风险和后续成本,以及质量调整寿命年(quality-adjusted life-years,QALY)。

 

结果

我们确定,接受强化控制的患者QALY平均值比接受标准控制的患者高0.27。如果5年后依从性和治疗效果下降,则QALY每增加1年,成本增加约47,000美元;如果患者余生治疗效果保持,则QALY每增加1年,成本增加约28,000美元。不论5年后治疗效果降低还是余生保持,多数模拟结果提示强化治疗符合成本效益(51%~79%低于50,000美元/QALY的支付意愿阈值,76%~93%低于100,000美元/QALY的支付意愿阈值)。

 

结论

在该模拟研究中,不论5年后治疗效果降低还是余生保持,强化收缩压控制均可预防心血管疾病事件和延长寿命,并且所需成本低于通常的每个QLAY的支付意愿阈值(美国国立心肺血液研究所等资助;SPRINT在ClinicalTrials.gov注册号为NCT01206062)。





作者信息

Adam P. Bress, Pharm.D., Brandon K. Bellows, Pharm.D., Jordan B. King, Pharm.D., Rachel Hess, M.D., Srinivasan Beddhu, M.D., Zugui Zhang, Ph.D., Dan R. Berlowitz, M.D., Molly B. Conroy, M.D., M.P.H., Larry Fine, M.D., Suzanne Oparil, M.D., Donald E. Morisky, Sc.D., Lewis E. Kazis, Sc.D., Natalia Ruiz-Negrón, Pharm.D., Jamie Powell, M.D., Leonardo Tamariz, M.D., M.P.H., Jeff Whittle, M.D., M.P.H., Jackson T. Wright, Jr., M.D., Ph.D., Mark A. Supiano, M.D., Alfred K. Cheung, M.D., William S. Weintraub, M.D., and Andrew E. Moran, M.D., M.P.H., for the SPRINT Research Group*
From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) — all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) — all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) — both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.). Address reprint requests to Dr. Bress at the University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, or at adam.bress@hsc.utah.edu. *A complete list of the investigators in the Systolic Blood Pressure Intervention Trial (SPRINT) Research Group is provided in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. Moran AE, Odden MC, Thanataveerat A, et al. Cost-effectiveness of hypertension therapy according to 2014 guidelines. N Engl J Med 2015;372:447-455

2. The ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575-1585

3. Benavente OR, Coffey CS, Conwit R, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet 2013;382:507-515

4. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014;311:507-520

5. Ambrosius WT, Sink KM, Foy CG, et al. The design and rationale of a multicenter clinical trial comparing two strategies for control of systolic blood pressure: the Systolic Blood Pressure Intervention Trial (SPRINT). Clin Trials 2014;11:532-546

6. The SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-2116

7. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:Suppl 2:S49-S73

8. Arias E, Heron M, Tejada-Vera B. United States life tables eliminating certain causes of death, 1999-2001. Natl Vital Stat Rep 2013;61:1-128

9. Identification and care of patients with CKD. In: 2015 Annual Data Report, vol. 1: Chronic kidney disease in the United States. United States Renal Data System, 2015 (https://www.usrds.org/2015/view/v1_02.aspx).

10. Iskedjian M, Einarson TR, MacKeigan LD, et al. Relationship between daily dose frequency and adherence to antihypertensive pharmacotherapy: evidence from a meta-analysis. Clin Ther 2002;24:302-316

11. Jones DE, Carson KA, Bleich SN, Cooper LA. Patient trust in physicians and adoption of lifestyle behaviors to control high blood pressure. Patient Educ Couns 2012;89:57-62

12. Xu KT, Ragain RM. Effects of weight status on the recommendations of and adherence to lifestyle modifications among hypertensive adults. J Hum Hypertens 2005;19:365-371

13. Red Book Online, 2016 (http://www.micromedex.com).

14. Centers for Medicare & Medicaid Services. Physician fees schedule, 2016 (http://wwwNaNs.gov/apps/physician-fee-schedule/overview.aspx).

15. Centers for Medicare & Medicaid Services. Lab fee schedule, 2016 (https://wwwNaNs.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files.html).

16. Healthcare Cost and Utilization Project (HCUP). Statistics on hospital stays, 2013 (https://www.hcup-us.ahrq.gov/).

17. Centers for Disease Control and Prevention. Chronic disease cost calculator, version 2. 2013 (http://www.cdc.gov/chronicdisease/calculator).

18. Trogdon JG, Murphy LB, Khavjou OA, et al. Costs of chronic diseases at the state level: the chronic disease cost calculator. Prev Chronic Dis 2015;12:E140-E140

19. Bureau of Economic Analysis. Price indexes for personal consumption expenditures by type of product (http://www.bea.gov/iTable/iTable.cfm?ReqID=12&step=1&acrdn=2#reqid=12&step=3&isuri=1&1203=16).

20. Sullivan PW, Ghushchyan V. Preference-based EQ-5D index scores for chronic conditions in the United States. Med Decis Making 2006;26:410-420

21. King JB, Shah RU, Bress AP, Nelson RE, Bellows BK. Cost-effectiveness of sacubitril-valsartan combination therapy compared with enalapril for the treatment of heart failure with reduced ejection fraction. JACC Heart Fail 2016;4:392-402

22. Yao G, Freemantle N, Flather M, Tharmanathan P, Coats A, Poole-Wilson PA. Long-term cost-effectiveness analysis of nebivolol compared with standard care in elderly patients with heart failure: an individual patient-based simulation model. Pharmacoeconomics 2008;26:879-889

23. Lloyd-Jones DM, Leip EP, Larson MG, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 2006;113:791-798

24. Haley WE, Gilbert ON, Riley RF, et al. The association between Self-Reported Medication Adherence scores and systolic blood pressure control: a SPRINT baseline data study. J Am Soc Hypertens 2016;10:857-864.e2

25. Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 2008;10:348-354

26. Bress AP, Tanner RM, Hess R, Colantonio LD, Shimbo D, Muntner P. Generalizability of SPRINT results to the U.S. adult population. J Am Coll Cardiol 2016;67:463-472

27. D’Agostino RB, Russell MW, Huse DM, et al. Primary and subsequent coronary risk appraisal: new results from the Framingham study. Am Heart J 2000;139:272-281

28. Cook NR, Ridker PM. Calibration of the pooled cohort equations for atherosclerotic cardiovascular disease: an update. Ann Intern Med 2016;165:786-794

29. Anderson JL, Heidenreich PA, Barnett PG, et al. ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2304-2322

30. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness — the curious resilience of the $50,000-per-QALY threshold. N Engl J Med 2014;371:796-797

31. Moise N, Huang C, Rodgers A, et al. Comparative cost-effectiveness of conservative or intensive blood pressure treatment guidelines in adults aged 35-74 years: the Cardiovascular Disease Policy model. Hypertension 2016;68:88-96

32. Richman IB, Fairley M, Jørgensen ME, Schuler A, Owens DK, Goldhaber-Fiebert JD. Cost-effectiveness of intensive blood pressure management. JAMA Cardiol 2016;1:872-879

33. Bress AP, Kramer H, Khatib R, et al. Potential deaths averted and serious adverse events incurred from adoption of the SPRINT (Systolic Blood Pressure Intervention Trial) intensive blood pressure regimen in the United States: projections from NHANES (National Health and Nutrition Examination Survey). Circulation 2017;135:1617-1628

34. Leung AA, Nerenberg K, Daskalopoulou SS, et al. Hypertension Canada’s 2016 Canadian Hypertension Education Program guidelines for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2016;32:569-588

35. Gabb GM, Mangoni AA, Anderson CS, et al. Guideline for the diagnosis and management of hypertension in adults — 2016. Med J Aust 2016;205:85-89

36. Husereau D, Drummond M, Petrou S, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Value Health 2013;16:e1-e5

37. Sanders GD, Neumann PJ, Basu A, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: Second Panel on Cost-Effectiveness in Health and Medicine. JAMA 2016;316:1093-1103

38. Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 2016;387:957-967

39. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet 2016;387:435-443

40. Bundy JD, Li C, Stuchlik P, et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. JAMA Cardiol 2017;2:775-781

服务条款 | 隐私政策 | 联系我们