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The cost effectiveness of ACE inhibitors as first-line antihypertensive therapy
Alain J Nordmann1, Murray Krahn, Alexander G Logan
1The Programme in Clinical Epidemiology and Health Care Research, University of Toronto, Toronto, Ontario, Canada. nordmanna@uhbs.ch
Insights
Angiotensin-converting enzyme (ACE) inhibitors are not recommended as first-line hypertension therapy due to high costs. Current evidence suggests minimal differences in outcomes compared to conventional treatments, making them less cost-effective.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Pharmacoeconomics
Background:
- Current hypertension guidelines present varying recommendations for initial antihypertensive treatments.
- Discrepancies exist regarding the optimal first-line pharmacotherapy for managing hypertension.
Purpose of the Study:
- To conduct a cost-effectiveness analysis comparing angiotensin-converting enzyme (ACE) inhibitor therapy against traditional antihypertensive agents (beta-blockers or diuretics) as a first-line treatment.
- Evaluate the economic viability of ACE inhibitors versus conventional therapies for uncomplicated hypertension.
Main Methods:
- A Markov model was developed using data from randomized trials and observational studies to compare four hypertension management strategies.
- Strategies included: universal ACE inhibitor use, universal conventional therapy, and individualized therapy based on left ventricular hypertrophy (LVH) assessment via electrocardiography (ECG) or echocardiography.
- Cost data were sourced from medical literature and focus groups, with utility values from patients on antihypertensive monotherapy. Analyses were conducted over a lifetime horizon.
Main Results:
- All four management strategies yielded negligible differences in quality-adjusted life years (QALYs), differing only at the third decimal point.
- Cost-effectiveness ratios were high, with the echocardiography-guided strategy at $US 200,000 per QALY gained and the universal ACE inhibitor strategy at $US 700,000 per QALY gained, compared to ECG-guided therapy.
- Sensitivity analyses indicated that the incremental cost-effectiveness of universal ACE inhibitor use remained above $US 100,000 per QALY.
Conclusions:
- Based on current acquisition costs, prescribing ACE inhibitors as a first-line therapy for patients without cardiovascular comorbidity is not advisable.
- Recommendations for ACE inhibitor use as first-line therapy may change if their procurement costs decrease significantly.
Background:
Current hypertension guidelines differ in their recommendations for first-line antihypertensive therapy.
Objective:
To evaluate the cost effectiveness of ACE inhibitor therapy as antihypertensive first-line therapy as compared with conventional antihypertensive therapy with beta-adrenoceptor antagonists or diuretics.
Study Design:
Cost-effectiveness analysis based on data from randomised trials and observational studies comparing the effectiveness of ACE inhibitor and conventional antihypertensive therapy, we constructed a Markov model to compare four strategies in the management of uncomplicated hypertension: (i) prescribing ACE inhibitor therapy to all patients; (ii) prescribing conventional therapy to all patients; (iii) individualised antihypertensive therapy based on the presence or absence of left ventricular hypertrophy on electrocardiography (ECG); or (iv) individualised antihypertensive therapy based on the presence or absence of left ventricular hypertrophy on echocardiography.
Methods:
Cost data were derived from the medical literature and focus groups, and utility values were derived from patients on antihypertensive monotherapy. All costs were calculated in 1999 Canadian dollars, but are reported in US dollars according to the 1999 purchasing power parity rate for medical and healthcare. The effectiveness of ACE inhibitor therapy in the presence of left ventricular hypertrophy was derived from observational studies. The time horizon was over a lifetime.
Perspective:
Third-party payer.
Patients/Participants:
A cohort of men aged 40 years without cardiovascular comorbidity requiring antihypertensive drug therapy.
Main Outcome Measures And Results:
In the baseline analysis, all four strategies resulted in expected discounted QALYs that differed from each other only at the third decimal point (i.e. less than 0.003). Given the uncertainties in the variable estimates and the small size of the differences, these differences are extremely small and unlikely to represent real differences. Even accepting the small gains as real, the resulting cost-effectiveness ratios are unattractively high: $US 200,000 per QALY gained for the echocardiography strategy (compared with ECG), and $US 700,000 for the "ACE inhibitor for all" strategy (compared with ECG). The incremental cost effectiveness of prescribing ACE inhibitor therapy to everybody was never less than $US 100,000/QALY in the sensitivity analysis.
Conclusions:
Prescribing ACE inhibitors as antihypertensive first-line therapy in patients without cardiovascular morbidity cannot be recommended at the present time unless the acquisition costs of ACE inhibitors become substantially more attractive.
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