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Effect of Systolic Blood Pressure Measurement Error on the Cost-Effectiveness of Intensive Blood Pressure Targets
Karen C Smith1, Thomas A Gaziano2, Alvin I Mushlin3
1Department of Orthopedic Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (K.C.S.).
Insights
An intensive systolic blood pressure target of less than 120 mm Hg is cost-effective for high cardiovascular risk patients, even with measurement error. However, a less intensive target may be preferred if blood pressure measurement error is high.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Clinical Trial Analysis
Background:
- Clinical trial analyses suggest an intensive systolic blood pressure (SBP) target (<120 mm Hg) is cost-effective for high cardiovascular disease (CVD) risk patients.
- Current guidelines recommend a target of <130 mm Hg, considering potential blood pressure measurement errors in routine practice.
Purpose of the Study:
- To evaluate the impact of measurement error on the cost-effectiveness of intensive SBP targets.
- To compare SBP targets of <120 mm Hg, <130 mm Hg, and <140 mm Hg.
Main Methods:
- A microsimulation model was developed to simulate varying SBP measurement errors.
- Data from the Systolic Blood Pressure Intervention Trial (SPRINT) and published literature were utilized.
- The analysis considered a lifetime time horizon from a healthcare sector perspective.
Main Results:
- With research-grade measurement (0 mm Hg error), the incremental cost-effectiveness ratio (ICER) for <120 mm Hg vs. <130 mm Hg was $24,400 per QALY.
- With average measurement error (7.3 mm Hg), the ICER increased to $42,000 per QALY.
- In high error scenarios (≥14.6 mm Hg), the ICER exceeded $100,000 per QALY, particularly with increased CVD risk at lower SBPs or medication disutility.
Conclusions:
- A systolic blood pressure target of <120 mm Hg appears cost-effective for SPRINT-eligible patients at high cardiovascular risk, even with typical measurement errors.
- In situations with substantial measurement error and increased CVD risk at lower SBPs, a target of <130 mm Hg may become more cost-effective.
Background:
Analyses of clinical trials find that an intensive systolic blood pressure (SBP) target of less than 120 mm Hg is cost-effective compared with a target of less than 140 mm Hg for patients at high cardiovascular disease risk. However, guidelines from the American College of Cardiology and American Heart Association recommend a target of less than 130 mm Hg, citing blood pressure measurement error in routine practice.
Objective:
To evaluate the effect of measurement error on the cost-effectiveness of intensive SBP targets.
Design:
Microsimulation model varying SBP measurement error.
Data Sources:
SPRINT (Systolic Blood Pressure Intervention Trial) data and published literature.
Target Population:
Patients at high cardiovascular risk.
Time Horizon:
Lifetime.
Perspective:
Health care sector.
Intervention:
SBP targets of less than 120 mm Hg, less than 130 mm Hg, and less than 140 mm Hg.
Outcome Measures:
Incremental cost-effectiveness ratios (ICERs).
Results Of Base-Case Analysis:
With research-grade SBP measurement (mean error, 0 mm Hg), the ICER for the target of less than 120 mm Hg versus less than 130 mm Hg was $24 400 per quality-adjusted life-year (QALY). With average measurement error (mean error, 7.3 mm Hg in the <120-mm Hg target), the ICER increased to $42 000 per QALY.
Results Of Sensitivity Analysis:
The ICER for the target of less than 120 mm Hg was greater than $100 000 per QALY in scenarios with high error (mean error, ≥14.6 mm Hg in the <120-mm Hg target), when an inflection point for increasing risk for cardiovascular disease (CVD) was at or above 116 mm Hg, and in scenarios with a medication-taking disutility of at least 0.003 per antihypertensive medication.
Limitation:
Uncertainty in the relationship between low treated SBP (for example, <115 mm Hg) and cardiovascular risk.
Conclusion:
For SPRINT-eligible patients at high cardiovascular risk without diabetes or prior stroke, a target of less than 120 mm Hg seems cost-effective across most settings with SBP measurement error. In scenarios with high error and an increase in CVD risk at low SBPs, a target of less than 130 mm Hg may become cost-effective.
Primary Funding Source:
National Science Foundation and National Institute of Neurological Disorders and Stroke.
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