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An economic evaluation of the JNC hypertension guidelines using data from a randomized controlled trial. Joint
S D Ramsey1, N Neil, S D Sullivan
1Department of Medicine, University of Washington, Seattle, USA.
Insights
Managing hypertension according to Joint National Committee on Hypertension (JNC) guidelines shows that chlorthalidone, a generic diuretic, is the most cost-effective initial treatment. While amlodipine offers quicker control, it incurs substantially higher long-term costs.
Area of Science:
- Pharmacoeconomics
- Cardiovascular Medicine
- Health Services Research
Background:
- Hypertension management guidelines, such as those from the Joint National Committee on Hypertension (JNC), involve complex cost considerations.
- These costs encompass drug therapy, monitoring for and treating side effects, patient compliance, and expenses associated with switching medications due to therapeutic failures.
Purpose of the Study:
- To determine the clinical cost-effectiveness of managing hypertension under current JNC guidelines.
- To compare the costs associated with different classes of antihypertensive agents.
Main Methods:
- An incidence-based Markov model was employed to simulate clinical evaluation, therapy, and monitoring for hypertension.
- The model incorporated data on efficacy, side effects, and compliance for four key antihypertensive agents: enalapril, amlodipine, acebutolol, and chlorthalidone.
- JNC-recommended monitoring schedules were followed, with medication class switches modeled for therapeutic failures. Costs were evaluated in 1995 US dollars.
Main Results:
- Chlorthalidone demonstrated the lowest initial and maintenance costs for achieving and sustaining hypertension control ($641).
- Amlodipine, while achieving control more readily, incurred higher costs ($946), followed by acebutolol ($920) and enalapril ($948).
- For most agents, drug costs constituted the largest expense, followed by office visits, laboratory monitoring, and medication switching.
Conclusions:
- Adherence to JNC guidelines can lead to higher hypertension control rates with newer agents like amlodipine (a calcium channel blocker).
- However, this improved control comes at a significantly greater cost compared to using a generic diuretic such as chlorthalidone.
Background:
We wanted to determine the clinical cost of managing hypertension when following the Joint National Committee on Hypertension (JNC) guidelines, including drug therapy, the cost of monitoring for and treating side effects, compliance, and the cost of switching after therapeutic failures.
Methods:
The base-case analysis considers antihypertensive agents from four therapeutic classes that were recently evaluated in a large randomized trial: enalapril, amlodipine, acebutolol, and chlorthalidone. Clinical evaluation, therapy, and monitoring for hypertension are modeled with an incidence-based Markov model. Clinical inputs include agent efficacy, side effects, and compliance with dosing schedules. JNC-recommended clinical and laboratory monitoring schedules are followed for each agent. Switches between classes occur for therapeutic failures. Drug and medical care costs are valued in 1995 US dollars.
Results:
Although patients whose hypertension was initially treated with amlodipine achieved control more readily than patients who were given the other agents, the initial costs to achieve and maintain hypertension control were lowest for chlorthalidone ($641), followed by acebutolol ($920), amlodipine ($946), and enalapril ($948). Maintenance costs were lowest for chlorthalidone. For all agents except chlorthalidone, drug costs were the largest component of overall costs, followed by the costs of office visits, laboratory monitoring, and switching between classes for therapeutic failures.
Conclusions:
By following JNC guidelines, a slightly higher percentage of patients will achieve hypertension control with a newer class calcium channel blocker (amlodipine) but at a substantially higher cost than with a generic diuretic (chlorthalidone).