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Screening and Treatment for Subclinical Hypertensive Heart Disease in Emergency Department Patients With Uncontrolled
Michael J Twiner1, Alexander L Marinica2, Kenneth Kuper3
1Department of Emergency Medicine, Wayne State University, Detroit, MI.
Insights
A multidisciplinary program effectively identified and treated subclinical hypertensive heart disease (SHHD) in a high-risk African American community. This approach proved cost-effective, mitigating cardiovascular risks associated with uncontrolled hypertension (HTN).
Area of Science:
- Cardiology
- Public Health
- Health Economics
Background:
- Poorly controlled hypertension (HTN) is a prevalent issue.
- Untreated HTN can lead to subclinical hypertensive heart disease (SHHD), increasing heart failure risk.
- A high-risk, predominantly African American community was targeted for intervention.
Purpose of the Study:
- To determine the cost-effectiveness of a multidisciplinary program designed to detect and treat SHHD.
- To evaluate the program's impact on cardiovascular outcomes in patients with uncontrolled HTN.
Main Methods:
- A randomized controlled trial compared standard and intensive blood pressure (BP) goals over 1 year.
- Costs associated with SHHD identification and treatment were analyzed.
- Sensitivity analysis examined the impact of disease prevalence, treatment effectiveness (SHHD regression, LVH reversal, BP control), echocardiogram costs, and participant time on cost-effectiveness.
Main Results:
- The program's cost per quality-adjusted life-year (QALY) was dependent on SHHD prevalence and treatment effectiveness, not input costs.
- Cost-effectiveness (cost per QALY <$50,000) was achieved with SHHD prevalence exceeding 11.1% for SHHD regression, 4.7% for LVH reversal, and 2.9% for BP control.
- High SHHD prevalence was observed in the study cohort.
Conclusions:
- Screening and treatment for SHHD in this predominantly African American cohort with uncontrolled HTN was cost-effective.
- Multidisciplinary programs can effectively mitigate cardiovascular consequences of HTN in emergency department patients.
- The findings support the implementation of such programs in similar high-risk populations.
Objectives:
Poorly controlled hypertension (HTN) is extremely prevalent and, if left unchecked, subclinical hypertensive heart disease (SHHD) may ensue leading to conditions such as heart failure. To address this, we designed a multidisciplinary program to detect and treat SHHD in a high-risk, predominantly African American community. The primary objective of this study was to determine the cost-effectiveness of our program.
Methods:
Study costs associated with identifying and treating patients with SHHD were calculated and a sensitivity analysis was performed comparing the effect of four parameters on cost estimates. These included prevalence of disease, effectiveness of treatment (regression of SHHD, reversal of left ventricular hypertrophy [LVH], or blood pressure [BP] control as separate measures), echocardiogram costs, and participant time/travel costs. The parent study for this analysis was a single-center, randomized controlled trial comparing cardiac effects of standard and intense (<120/80 mm Hg) BP goals at 1 year in patients with uncontrolled HTN and SHHD. A total of 149 patients (94% African American) were enrolled, 133 (89%) had SHHD, 123 (93%) of whom were randomized, with 88 (72%) completing the study. Patients were clinically evaluated and medically managed over the course of 1 year with repeated echocardiograms. Costs of these interventions were analyzed and, following standard practices, a cost per quality-adjusted life-year (QALY) less than $50,000 was defined as cost-effective.
Results:
Total costs estimates for the program ranged from $117,044 to $119,319. Cost per QALY was dependent on SHHD prevalence and the measure of effectiveness but not input costs. Cost-effectiveness (cost per QALY less than $50,000) was achieved when SHHD prevalence exceeded 11.1% for regression of SHHD, 4.7% for reversal of LVH, and 2.9% for achievement of BP control.
Conclusions:
In this cohort of predominantly African American patients with uncontrolled HTN, SHHD prevalence was high and screening with treatment was cost-effective across a range of assumptions. These data suggest that multidisciplinary programs such as this can be a cost-effective mechanism to mitigate the cardiovascular consequences of HTN in emergency department patients with uncontrolled BP.
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