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Smith W, Colbert BM, Namouz T, Caven D, Ewing JA, Albano AW. Remote Patient Monitoring Is Associated with Improved Outcomes in Hypertension: A Large, Retrospective, Cohort Analysis. Healthcare (Basel) 2024; 12:1583. [PMID: 39201142 PMCID: PMC11353537 DOI: 10.3390/healthcare12161583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/22/2024] [Accepted: 08/07/2024] [Indexed: 09/02/2024] Open
Abstract
Hypertension (HTN) is a chronic condition that requires careful monitoring and management. Blood pressure readings in the clinic and self-reported blood pressure readings are often too intermittent to allow for careful management. Remote patient monitoring is a solution that may have positive impacts on HTN management. Individuals at cardiac and primary care clinics were prescribed a remote patient-monitoring (RPM) program. Patients were sent blood pressure monitors that were enabled to transmit data over cellular networks. We reviewed trends in HTN management retrospectively in patients who had previously been on conventional therapy for a year and participated in RPM for a minimum of 90 days. There were 6595 patients enrolled, and the mean duration on RPM was 289 days. A total of 4370 participants (66.3%) had uncontrolled HTN, and 2476 (37.5%) had stage 2 HTN. After at least 90 days on the RPM program, the number of patients with uncontrolled HTN reduced to 2648 (40.2%, p < 0.01), and the number of patients with stage 2 HTN reduced to 1261 (19.1%, p < 0.01). Systolic blood pressure improved by 7.3 mmHg for all patients and 16.7 mmHg for stage 2 HTN. There was improvement in mean arterial pressure (MAP) in all patients with uncontrolled HTN by 8.5 mmHg (p < 0.0001). RPM is associated with improved HTN control and provides further evidence supporting telehealth programs which can aid in chronic disease management.
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Affiliation(s)
- Wesley Smith
- HealthSnap, Miami, FL 33136, USA; (W.S.); (B.M.C.)
| | | | - Tariq Namouz
- Prisma Health Upstate, Greenville, SC 29605, USA; (T.N.); (J.A.E.)
| | - Dean Caven
- Virginia Cardiovascular Specialists, Mechanicsville, VA 23116, USA;
| | - Joseph A. Ewing
- Prisma Health Upstate, Greenville, SC 29605, USA; (T.N.); (J.A.E.)
| | - Andrew W. Albano
- Prisma Health Upstate, Greenville, SC 29605, USA; (T.N.); (J.A.E.)
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Chay J, Su RJ, Kamano JH, Andama B, Bloomfield GS, Delong AK, Horowitz CR, Menya D, Mugo R, Orango V, Pastakia SD, Wanyonyi C, Vedanthan R, Finkelstein EA. Cost-effectiveness of group medical visits and microfinance interventions versus usual care to manage hypertension in Kenya: a secondary modelling analysis of data from the Bridging Income Generation with Group Integrated Care (BIGPIC) trial. Lancet Glob Health 2024; 12:e1331-e1342. [PMID: 39030063 DOI: 10.1016/s2214-109x(24)00188-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/14/2024] [Accepted: 04/23/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND The Bridging Income Generation with Group Integrated Care (BIGPIC) trial in rural Kenya showed that integrating usual care with group medical visits or microfinance interventions reduced systolic blood pressure and cardiovascular risk in participants. We aimed to estimate the incremental cost-effectiveness of three BIGPIC interventions for a modelled cohort and by sex, as well as the cost of implementing these interventions. METHODS For this analysis, we used data collected during the BIGPIC trial, a four-group, cluster-randomised trial conducted in the western Kenyan catchment area of the Academic Model Providing Access to Healthcare. BIGPIC enrolled participants from 24 rural health facilities in rural western Kenya aged 35 years or older with either increased blood pressure or diabetes. Participants were assigned to receive either usual care, group medical visits, microfinance, or a combination of group medical visits and microfinance (GMV-MF). Our model estimated the incremental cost-effectiveness of the three BIGPIC interventions via seven health states (ie, a hypertensive state, five chronic cardiovascular-disease states, and a death state) by simulating transitions between health states for a hypothetical cohort of individuals with hypertension on the basis of QRISK3 scores. In every cycle, participants accrued costs and disability-adjusted life-years (DALYs) associated with their health state. Incremental cost-effectiveness ratios (ICERs) were calculated for the entire modelled cohort and by sex by dividing the incremental cost by the incremental effectiveness of the next most expensive intervention. The main outcome of this analysis was ICERs for each intervention evaluated. This analysis is registered at ClinicalTrials.gov (NCT02501746). FINDINGS Between Feb 6, 2017, and Dec 29, 2019, 2890 people were recruited to the BIGPIC trial. 2020 (69·9%) of 2890 participants were female and 870 (30·1%) were male. At baseline, mean QRISK3 score was 11·5 (95% CI 11·1-11·9) for the trial population, 11·9 (11·5-12·2) for male participants, and 11·3 (11·0-11·6) for female participants. For the population of Kenya, group medical visits were estimated to cost US$7 more per individual than usual care and result in 0·005 more DALYs averted (ICER $1455 per DALY averted). Microfinance was estimated to cost $19 more than group medical visits but was only estimated to avert 0·001 more DALYs. Relative to group medical visits, GMV-MF was estimated to cost $29 more and avert 0·009 more DALYs ($3235 per DALY averted). Relative to usual care, GMV-MF was estimated to cost $37 more and avert 0·014 more DALYs ($2601 per DALY averted). In the first year of the intervention, usual care was estimated to be the least expensive intervention to implement ($87 per participant; $10 238 per health-facility catchment area [HFCA]), then group medical visits ($99 per participant; $12 268 per HFCA), then microfinance ($120 per participant; $14 172 per HFCA), with GMV-MF estimated to be the most expensive intervention to implement ($139 per participant; $16 913 per HFCA). INTERPRETATION Group medical visits and GMV-MF were estimated to be cost-effective strategies to improve blood-pressure control in rural Kenya. However, which intervention to pursue depends on resource availability. Policy makers should consider these factors, in addition to sex differences in programme effectiveness, when selecting optimal implementation strategies. FUNDING US National Institutes of Health.
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Affiliation(s)
- Junxing Chay
- Health Services and Systems Research, Duke-NUS Medical School, Singapore.
| | - Rebecca J Su
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Jemima H Kamano
- School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Benjamin Andama
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | - Allison K Delong
- Center for Statistical Sciences, Brown University, Providence, RI, USA
| | - Carol R Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Diana Menya
- School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Richard Mugo
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Vitalis Orango
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Sonak D Pastakia
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN, USA
| | | | - Rajesh Vedanthan
- Department of Population Health, Grossman School of Medicine, New York University, New York, NY, USA
| | - Eric A Finkelstein
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Duke Global Health Institute, Duke University, Durham, NC, USA
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Morton JI, Liew D, Ademi Z. A Causal Model for Primary Prevention of Cardiovascular Disease: The Health Economic Model for the Primary Prevention of Cardiovascular Disease. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)02791-8. [PMID: 39094690 DOI: 10.1016/j.jval.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 07/16/2024] [Accepted: 07/19/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES Our objective was to design and develop an open-source model capable of simulating interventions for primary prevention of cardiovascular disease (CVD) that incorporated the cumulative effects of risk factors (eg, cholesterol years or blood-pressure years) to enhance health economic modeling in settings which clinical trials are not possible. METHODS We reviewed the literature to design the model structure by selecting the most important causal risk factors for CVD-low-density lipoprotein-cholesterol (LDL-C), systolic blood pressure (SBP), smoking, diabetes, and lipoprotein (a) (Lp(a))-and most common CVDs-myocardial infarction and stroke. The epidemiological basis of the model involves the simulation of risk factor trajectories, which are used to modify CVD risk via causal effect estimates derived from Mendelian randomization. LDL-C, SBP, Lp(a), and smoking all have cumulative impacts on CVD risk, which were incorporated into the health economic model. The data for the model were primarily sourced from the UK Biobank study. We calibrated the model using clinical trial data and validated the model against the observed UK Biobank data. Finally, we performed an example health economic analysis to demonstrate the utility of the model. The model is open source. RESULTS The model performed well in all validation tests. It was able to produce interpretable and plausible (consistent with expectations of the existing literature) results from an example health economic analysis. CONCLUSIONS We have constructed an open-source health economic model capable of incorporating the cumulative effect of LDL-C (ie, cholesterol years), SBP (SBP-years), Lp(a), and smoking on lifetime CVD risk.
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Affiliation(s)
- Jedidiah I Morton
- Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia.
| | - Danny Liew
- Adelaide Medical School, University of Adelaide, Australia
| | - Zanfina Ademi
- Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia.
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Mei JY, Hauspurg A, Corry-Saavedra K, Nguyen TA, Murphy A, Miller ES. Remote blood pressure management for postpartum hypertension: a cost-effectiveness analysis. Am J Obstet Gynecol MFM 2024; 6:101442. [PMID: 39074606 DOI: 10.1016/j.ajogmf.2024.101442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 07/15/2024] [Accepted: 07/20/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Recognizing the importance of close follow-up after hypertensive disorders of pregnancy, many centers have initiated programs to support postpartum remote blood pressure management. OBJECTIVE This study aimed to evaluate the cost-effectiveness of remote blood pressure management to determine the scalability of these programmatic interventions. STUDY DESIGN This was a cost-effectiveness analysis of using remote blood pressure management vs usual care to manage postpartum hypertension. The modeled remote blood pressure management included provision of a home blood pressure monitor, guidance on warning symptoms, instructions on blood pressure self-monitoring twice daily, and clinical staff to manage population-level blood pressures as appropriate. Usual care was defined as guidance on warning symptoms and recommendations for 1 outpatient visit for blood pressure monitoring within a week after discharge. This study designed a Markov model that ran over fourteen 1-day cycles to reflect the initial 2 weeks after delivery when most emergency department visits and readmissions occur and remote blood pressure management is clinically anticipated to be most impactful. Parameter values for the base-case scenario were derived from both internal data and literature review. Quality-adjusted life-years were calculated over the first year after delivery and reflected the short-term morbidities associated with hypertensive disorders of pregnancy that, for most birthing people, resolve by 2 weeks after delivery. Sensitivity analyses were performed to assess the strength and validity of the model. The primary outcome was the incremental cost-effectiveness ratio, which was defined as the cost needed to gain 1 quality-adjusted life-year. The secondary outcome was incremental cost per readmission averted. Analyses were performed from a societal perspective. RESULTS In the base-case scenario, remote blood pressure management was the dominant strategy (ie, cost less, higher quality-adjusted life-years). In univariate sensitivity analyses, the most cost-effective strategy shifted to usual care when the cost of readmission fell below $2987.92 and the rate of reported severe range blood pressure with a response in remote blood pressure management was <1%. Assuming a willingness to pay of $100,000 per quality-adjusted life-year, using remote blood pressure management was cost-effective in 99.28% of simulations in a Monte Carlo analysis. Using readmissions averted as a secondary effectiveness outcome, the incremental cost per readmission averted was $145.00. CONCLUSION Remote blood pressure management for postpartum hypertension is cost saving and has better outcomes than usual care. Our data can be used to inform future dissemination of and support funding for remote blood pressure management programs.
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Affiliation(s)
- Jenny Y Mei
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA (Mei, Corry-Saavedra, Nguyen, and Murphy).
| | - Alisse Hauspurg
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, PA (Hauspurg)
| | - Kate Corry-Saavedra
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA (Mei, Corry-Saavedra, Nguyen, and Murphy)
| | - Tina A Nguyen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA (Mei, Corry-Saavedra, Nguyen, and Murphy)
| | - Aisling Murphy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA (Mei, Corry-Saavedra, Nguyen, and Murphy)
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University and Women & Infants Hospital, Providence, RI (Miller)
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Maeda T. Taking action for controlling high blood pressure: challenges in the real world. Hypertens Res 2024; 47:1894-1896. [PMID: 38769139 DOI: 10.1038/s41440-024-01711-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/12/2024] [Indexed: 05/22/2024]
Affiliation(s)
- Toshiki Maeda
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University 7-45-1 Nanakuma, Jonan Fukuoka, 814-0180, Japan.
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Zhang F, Bryant KB, Moran AE, Zhang Y, Cohen JB, Bress AP, Sheppard JP, King JB, Derington CG, Weintraub WS, Kronish IM, Shea S, Bellows BK. Effectiveness of Hypertension Management Strategies in SPRINT-Eligible US Adults: A Simulation Study. J Am Heart Assoc 2024; 13:e032370. [PMID: 38214272 PMCID: PMC10926802 DOI: 10.1161/jaha.123.032370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/01/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Despite reducing cardiovascular disease (CVD) events and death in SPRINT (Systolic Blood Pressure Intervention Trial), intensive systolic blood pressure goals have not been adopted in the United States. This study aimed to simulate the potential long-term impact of 4 hypertension management strategies in SPRINT-eligible US adults. METHODS AND RESULTS The validated Blood Pressure Control-Cardiovascular Disease Policy Model, a discrete event simulation of hypertension care processes (ie, visit frequency, blood pressure [BP] measurement accuracy, medication intensification, and medication adherence) and CVD outcomes, was populated with 25 000 SPRINT-eligible US adults. Four hypertension management strategies were simulated: (1) usual care targeting BP <140/90 mm Hg (Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care), (2) intensive care per the SPRINT protocol targeting BP <120/90 mm Hg (SPRINT intensive), (3) usual care targeting guideline-recommended BP <130/80 mm Hg (American College of Cardiology/American Heart Association usual care), and (4) team-based care added to usual care and targeting BP <130/80 mm Hg. Relative to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care, among the 18.1 million SPRINT-eligible US adults, an estimated 138 100 total CVD events could be prevented per year with SPRINT intensive, 33 900 with American College of Cardiology/American Heart Association usual care, and 89 100 with team-based care. Compared with the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care, SPRINT intensive care was projected to increase treatment-related serious adverse events by 77 600 per year, American College of Cardiology/American Heart Association usual care by 33 300, and team-based care by 27 200. CONCLUSIONS As BP control has declined in recent years, health systems must prioritize hypertension management and invest in effective strategies. Adding team-based care to usual care may be a pragmatic way to manage risk in this high-CVD-risk population.
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Affiliation(s)
- Fengdi Zhang
- Department of MedicineColumbia UniversityNew YorkNYUSA
| | | | | | - Yiyi Zhang
- Department of MedicineColumbia UniversityNew YorkNYUSA
| | - Jordana B. Cohen
- Department of Medicine and Department of Biostatistics, Epidemiology, and InformaticsUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Adam P. Bress
- Intermountain Healthcare Department of Population Health SciencesUniversity of UtahSalt Lake CityUTUSA
| | - James P. Sheppard
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordUK
| | - Jordan B. King
- Intermountain Healthcare Department of Population Health SciencesUniversity of UtahSalt Lake CityUTUSA
- Institute for Health ResearchKaiser Permanente ColoradoAuroraCOUSA
| | - Catherine G. Derington
- Intermountain Healthcare Department of Population Health SciencesUniversity of UtahSalt Lake CityUTUSA
| | - William S. Weintraub
- Department of MedicineGeorgetown UniversityWashingtonDCUSA
- MedStar Health Research InstituteWashingtonDCUSA
| | | | - Steven Shea
- Department of MedicineColumbia UniversityNew YorkNYUSA
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Whelton PK, Flack JM, Jennings G, Schutte A, Wang J, Touyz RM. Editors' Commentary on the 2023 ESH Management of Arterial Hypertension Guidelines. Hypertension 2023; 80:1795-1799. [PMID: 37354199 PMCID: PMC10527435 DOI: 10.1161/hypertensionaha.123.21592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 06/26/2023]
Abstract
Clinical practice guidelines are ideally suited to the provision of advice on the prevention, diagnosis, evaluation, and management of high blood pressure (BP). The recently published European Society of Hypertension (ESH) 2023 ESH Guidelines for the management of arterial hypertension is the latest in a long series of high BP clinical practice guidelines. It closely resembles the 2018 European Society of Cardiology/ESH guidelines, with incremental rather than major changes. Although the ESH guidelines are primarily written for European clinicians and public health workers, there is a high degree of concordance between its recommendations and those in the other major BP guidelines. Despite the large number of national and international BP guidelines around the world, general population surveys demonstrate that BP guidelines are not being well implemented in any part of the world. The level of BP, which is the basis for diagnosis and management, continues to be poorly measured in routine clinical practice and control of hypertension remains suboptimal, even to a conservative BP target such as a systolic/diastolic BP <140/90 mm Hg. BP guidelines need to focus much more on implementation of recommendations for accurate diagnosis and strategies for improved control in those being treated for hypertension. An evolving body of implementation science can assist in meeting this goal. Given the enormous health, social, and financial burden of high BP, better diagnosis and management should be an imperative for clinicians, government, and others responsible for the provision of health care services. Hopefully, the 2023 ESH will help enable this.
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Affiliation(s)
- Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (P.K.W.)
| | - John M Flack
- Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.)
| | - Garry Jennings
- Sydney Health Partners, University of Sydney and National Heart Foundation, New South Wales, Australia (G.J.)
| | - Alta Schutte
- School of Population Health, University of New South Wales, The George Institute for Global Health, Sydney, Australia (A.S.)
| | - Jiguang Wang
- Shanghai Institute of Hypertension, Shanghai Jiao Tong University School of Medicine, China (J.W.)
| | - Rhian M Touyz
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada (R.M.T.)
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Cusick MM, Tisdale RL, Chertow GM, Owens DK, Goldhaber-Fiebert JD. Population-Wide Screening for Chronic Kidney Disease : A Cost-Effectiveness Analysis. Ann Intern Med 2023; 176:788-797. [PMID: 37216661 PMCID: PMC11091494 DOI: 10.7326/m22-3228] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors have the potential to alter the natural history of chronic kidney disease (CKD), and they should be included in cost-effectiveness analyses of screening for CKD. OBJECTIVE To determine the cost-effectiveness of adding population-wide screening for CKD. DESIGN Markov cohort model. DATA SOURCES NHANES (National Health and Nutrition Examination Survey), U.S. Centers for Medicare & Medicaid Services data, cohort studies, and randomized clinical trials, including the DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease) trial. TARGET POPULATION Adults. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Screening for albuminuria with and without adding SGLT2 inhibitors to the current standard of care for CKD. OUTCOME MEASURES Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), all discounted at 3% annually. RESULTS OF BASE-CASE ANALYSIS One-time CKD screening at age 55 years had an ICER of $86 300 per QALY gained by increasing costs from $249 800 to $259 000 and increasing QALYs from 12.61 to 12.72; this was accompanied by a decrease in the incidence of kidney failure requiring dialysis or kidney transplant of 0.29 percentage points and an increase in life expectancy from 17.29 to 17.45 years. Other options were also cost-effective. During ages 35 to 75 years, screening once prevented dialysis or transplant in 398 000 people and screening every 10 years until age 75 years cost less than $100 000 per QALY gained. RESULTS OF SENSITIVITY ANALYSIS When SGLT2 inhibitors were 30% less effective, screening every 10 years during ages 35 to 75 years cost between $145 400 and $182 600 per QALY gained, and price reductions would be required for screening to be cost-effective. LIMITATION The efficacy of SGLT2 inhibitors was derived from a single randomized controlled trial. CONCLUSION Screening adults for albuminuria to identify CKD could be cost-effective in the United States. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality, Veterans Affairs Office of Academic Affiliations, and National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Marika M. Cusick
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
| | - Rebecca L. Tisdale
- VA Palo Alto Health Care System, Center for Innovation to
Implementation (Ci2i), Menlo Park, CA, USA
| | - Glenn M. Chertow
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford
University School of Medicine, Stanford, CA, USA
- Division of Nephrology, Department of Medicine, Stanford
University School of Medicine, Stanford, CA, USA
| | - Douglas K. Owens
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
| | - Jeremy D. Goldhaber-Fiebert
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
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9
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Economic evaluation of a new blood pressure target for hypertensive patients in Taiwan. Hypertens Res 2023; 46:784-786. [PMID: 36604476 DOI: 10.1038/s41440-022-01125-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/08/2022] [Indexed: 01/07/2023]
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10
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Liao CT, Toh HS, Sun L, Yang CT, Hu A, Wei D, Melgarejo J, Zhang ZY. Cost-effectiveness of Intensive vs Standard Blood Pressure Control Among Older Patients With Hypertension. JAMA Netw Open 2023; 6:e230708. [PMID: 36848091 PMCID: PMC9972197 DOI: 10.1001/jamanetworkopen.2023.0708] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
IMPORTANCE Older patients with hypertension receiving intensive systolic blood pressure control (110-130 mm Hg) have lower incidences of cardiovascular events than those receiving standard control (130-150 mm Hg). Nevertheless, the mortality reduction is insignificant, and intensive blood pressure management results in more medical costs from treatments and subsequent adverse events. OBJECTIVE To examine the incremental lifetime outcomes, costs, and cost-effectiveness of intensive vs standard blood pressure control in older patients with hypertension from the health care payer's perspective. DESIGN, SETTING, AND PARTICIPANTS This economic analysis was conducted with a Markov model to examine the cost-effectiveness of intensive blood pressure management among patients aged 60 to 80 years with hypertension. Treatment outcome data from the Trial of Intensive Blood-Pressure Control in Older Patients With Hypertension (STEP trial) and different cardiovascular risk assessment models for a hypothetical cohort of STEP-eligible patients were used. Costs and utilities were obtained from published sources. The incremental cost-effectiveness ratio (ICER) against the willingness-to-pay threshold was used to evaluate whether the management was cost-effective. Extensive sensitivity, subgroup, and scenario analyses were performed to address uncertainty. The US and UK population using race-specific cardiovascular risk models were conducted in the generalizability analysis. Data for the STEP trial were collected from February 10 to March 10, 2022, and were analyzed for the present study from March 10 to May 15, 2022. INTERVENTIONS Hypertension treatments with a systolic blood pressure target of 110 to 130 mm Hg or 130 to 150 mm Hg. MAIN OUTCOMES AND MEASURES Incremental lifetime quality-adjusted life-years (QALYs), costs, and ICER are discounted at the given rates annually. RESULTS After simulating 10 000 STEP-eligible patients assumed to be 66 years of age (4650 men [46.5%] and 5350 women [53.5%]) in the model, the ICER values were ¥51 675 ($12 362) per QALY gained in China, $25 417 per QALY gained in the US, and £4679 ($7004) per QALY gained in the UK. Simulations projected that the intensive management in China being cost-effective were 94.3% and 100% below the willingness-to-pay thresholds of 1 time (¥89 300 [$21 364]/QALY) and 3 times (¥267 900 [$64 090]/QALY) the gross domestic product per capita, respectively. The US had 86.9% and 95.6% probabilities of cost-effectiveness at $50 000/QALY and $100 000/QALY, respectively, and the UK had 99.1% and 100% of probabilities of cost-effectiveness at £20 000 ($29 940)/QALY and £30 000 ($44 910)/QALY, respectively. CONCLUSIONS AND RELEVANCE In this economic evaluation, the intensive systolic blood pressure control in older patients produced fewer cardiovascular events and had acceptable costs per QALY gained, well below the typical willingness-to-pay thresholds. The cost-effective advantages of intensive blood pressure management in older patients were consistent over various clinical scenarios across different countries.
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Affiliation(s)
- Chia-Te Liao
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan City, Taiwan
| | - Han Siong Toh
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan City, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Li Sun
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chun-Ting Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Angie Hu
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Dongmei Wei
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Jesus Melgarejo
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Zhen-Yu Zhang
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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11
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Liao CT, Toh HS, Yang CT, Hsu CY, Lee MC, Chang WT, Chen ZC, Chang HY, Strong C. Economic evaluation of new blood pressure target for hypertensive patients in Taiwan according to the 2022 hypertension clinical practice guidelines of the Taiwan society of cardiology: a simulation modeling study. Hypertens Res 2023; 46:187-199. [PMID: 36229527 DOI: 10.1038/s41440-022-01037-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/01/2022] [Accepted: 09/05/2022] [Indexed: 02/03/2023]
Abstract
With the promising cardiovascular benefits in the STEP and SPRINT trials, the 2022 Taiwan's hypertension guidelines redefined the hypertension threshold as 130/80 mmHg and a universal blood-pressure target of <130/80 mmHg. This study's objective was to examine the cost-effectiveness of the intensive blood-pressure target for hypertensive patients using estimated lifetime medical costs and quality-adjusted life years (QALY) from the Taiwan national payer's perspective. We developed a lifetime Markov model comparing the intensive and conservative blood-pressure targets. Incremental cost-effectiveness ratio (ICER) against the willing-to-pay thresholds at the one-time [US$34,000(NT$1,020,000)] and three-time [US$100,000(NT$3,000,000)] gross domestic product per capita were defined as very cost-effect and only cost-effective. The cost-effectiveness in different age stratifications and cardiovascular risks treated with a more intensive target (120 mmHg) were examined in the subgroup analyses. The new blood-pressure treatment target produced more lifetime medical costs [US$31,589(NT$947,670) versus US$26,788(NT$803,640)] and QALYs (12.54 versus 12.25), and the ICER was US$16,589(NT$497,670), which was 99.1% and 100% probability of a very cost-effective and cost-effective strategy. The ICERs in all age stratifications had more than a 90% probability of being very cost-effective, and ICERs decreased with age. More intensive control in patients with high cardiovascular risks produced a lower ICER [US$14,547(NT$436,410)]. In conclusion, Taiwan's new blood-pressure treatment target can prevent more cardiovascular events with acceptable costs per QALY below the willing-to-pay thresholds. The cost-effectiveness of intensive control is consistent across different ages and more pronounced with the increase in age and cardiovascular risk.
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Affiliation(s)
- Chia-Te Liao
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan. .,Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
| | - Han Siong Toh
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan. .,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Health and Nutrition, Chia Nan University of Pharmacy & Science, Tainan, Taiwan.
| | - Chun-Ting Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Yi Hsu
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Mei-Chuan Lee
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, Chi-Mei Medical Centre, Tainan, Taiwan
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Health and Nutrition, Chia Nan University of Pharmacy & Science, Tainan, Taiwan
| | - Zhih-Cherng Chen
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Hung-Yu Chang
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Carol Strong
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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12
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Lee YS, Lee HY, Kim TH. An economic evaluation of intensive hypertension control in CKD patients: a cost-effectiveness study. Clin Hypertens 2022; 28:32. [PMID: 36316765 PMCID: PMC9623905 DOI: 10.1186/s40885-022-00215-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Studies have suggested that intensive hypertension control in patients with a high risk of cardiovascular disease (CVD) is both effective and economically feasible. The purpose of this study is to conduct an economic evaluation of intensive hypertension control targeting chronic kidney disease (CKD) patients using the representative data in Korea. METHODS We used a Markov decision model to compare both cost and effectiveness of intensive hypertension control versus standard hypertension control in hypertensive CKD patients. Model parameters were estimated with the data from the National Health Insurance Service (NHIS)-National Sample Cohort, as well as latest literature. One-way sensitivity analysis was conducted to test the effect of variation in key parameters on the model outcome. RESULTS For CKD patients with hypertension, intensive hypertension control would cost more but increase utilities, compared to standard hypertension control. The incremental cost-effectiveness ratio (ICER) for intensive hypertension control in CKD patients was projected at 18,126 USDs per quality-adjusted life year (QALY) compared to standard hypertension control. The results of sensitivity analysis suggest that the results are overall robust. CONCLUSIONS This study finds that intensive hypertension control in CKD patients in Korea is economically sound. This information is expected to be useful for clinicians in managing hypertension of CKD patients and policymakers when making decisions.
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Affiliation(s)
- Ye Seol Lee
- grid.31501.360000 0004 0470 5905Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea ,National Traffic Injury Rehabilitation Research Institute, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Republic of Korea
| | - Hae-Young Lee
- grid.31501.360000 0004 0470 5905Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae Hyun Kim
- grid.15444.300000 0004 0470 5454Department of Healthcare Management, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
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13
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van Essen B, Voors AA, Tromp J. Risk factors for the development of heart failure in patients with or without prior myocardial infarction. Eur J Heart Fail 2022; 24:985-987. [PMID: 35560757 DOI: 10.1002/ejhf.2538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 05/04/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Bart van Essen
- University Medical Centre Groningen, Department of Cardiology, University of Groningen, Groningen, the Netherlands
| | - Adriaan A Voors
- University Medical Centre Groningen, Department of Cardiology, University of Groningen, Groningen, the Netherlands
| | - Jasper Tromp
- University Medical Centre Groningen, Department of Cardiology, University of Groningen, Groningen, the Netherlands.,Duke-NUS Medical School, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore & the National University Health System, Singapore
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14
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Zhang WL, Cai J. STEP to blood pressure management of elderly hypertension: evidence from Asia. Hypertens Res 2022; 45:576-582. [PMID: 35277670 PMCID: PMC8923999 DOI: 10.1038/s41440-022-00875-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/04/2022] [Indexed: 11/12/2022]
Abstract
With a rapidly aging population, adequate blood pressure (BP) control is critical for hypertension management and prevention of cardiovascular events. Impressive cardiovascular benefits have been observed with intensive BP control (SBP target, <120 mmHg) in the SPRINT (Systolic Blood Pressure Intervention Trial) study, even in patients 75 years of age or older. A most recent meta-analysis including 51 randomized trials with over 350,000 participants from the BPLTTC (The Blood Pressure Lowering Treatment Trialists’ Collaboration) showed that BP lowering is effective in older people for reducing major cardiovascular events. The STEP (Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients) study—a multicenter, randomized, controlled trial conducted in China, provided important evidence that intensive BP treatment (SBP target, 110 mmHg to <130 mmHg) benefits older hypertensive patients (aged 60–80 years) and reduced the incidence of cardiovascular events than standard treatment (target 130 mmHg to <150 mmHg). Because Asian people have a higher burden of hypertension and stroke than Caucasian people, intensive BP treatment has more advantages in reducing the risk of cardiovascular events including stroke in Asian hypertensive patients than in Caucasian people. Home BP monitoring is helpful to facilitate hypertension management for older patients. It should also be noted that clinical decision-making should be on a patient basis, such as fragility, diabetes, stroke, and other comorbidities, with tailored BP targets. Here we review the important clinical trials of BP control in elderly hypertension, interpretate the main findings of STEP, and also discuss the perspectives of managing hypertension in Asia.
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Affiliation(s)
- Wei-Li Zhang
- State Key Laboratory of Cardiovascular Disease, Hypertension Center, FuWai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beilishi Road 167, Xicheng District, 100037, Beijing, China.
| | - Jun Cai
- State Key Laboratory of Cardiovascular Disease, Hypertension Center, FuWai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beilishi Road 167, Xicheng District, 100037, Beijing, China
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15
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Tajeu GS, Tsipas S, Rakotz M, Wozniak G. Cost-Effectiveness of Recommendations From the Surgeon General's Call-to-Action to Control Hypertension. Am J Hypertens 2022; 35:225-231. [PMID: 34661634 DOI: 10.1093/ajh/hpab162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/08/2021] [Indexed: 12/15/2022] Open
Abstract
In response to high prevalence of hypertension and suboptimal rates of blood pressure (BP) control in the United States, the Surgeon General released a Call-to-Action to Control Hypertension (Call-to-Action) in the fall of 2020 to address the negative consequences of uncontrolled BP. In addition to morbidity and mortality associated with hypertension, hypertension has an annual cost to the US healthcare system of $71 billion. The Call-to-Action makes recommendations for improving BP control, and the purpose of this review was to summarize the literature on the cost-effectiveness of these strategies. We identified a number of studies that demonstrate the cost saving or cost-effectiveness of recommendations in the Call-to-Action including strategies to promote access to and availability of physical activity opportunities and healthy food options within communities, advance the use of standardized treatment approaches and guideline-recommended care, to promote the use of healthcare teams to manage hypertension, and to empower and equip patients to use self-measured BP monitoring and medication adherence strategies. While the current review identified numerous cost-effective methods to achieve the Surgeon General's recommendations for improving BP control, future work should determine the cost-effectiveness of the 2017 American College of Cardiology and American Heart Association Hypertension guidelines, interventions to lower therapeutic inertia, and optimal team-based care strategies, among other areas of research. Economic evaluation studies should also be prioritized to generate more comprehensive data on how to provide efficient and high value care to improve BP control.
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Affiliation(s)
- Gabriel S Tajeu
- Department of Health Services Administration and Policy, Temple University, Philadelphia, Pennsylvania, USA
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16
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Railey AF, Muller C, Noonan C, Schmitter-Edgecombe M, Sinclair K, Kim C, Look M, Kaholokula JK. Cost Effectiveness of a Cultural Physical Activity Intervention to Reduce Blood Pressure Among Native Hawaiians with Hypertension. PHARMACOECONOMICS - OPEN 2022; 6:85-94. [PMID: 34389923 PMCID: PMC8807791 DOI: 10.1007/s41669-021-00291-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 05/15/2023]
Abstract
OBJECTIVE The aim of this study was to calculate the costs and assess whether a culturally grounded physical activity intervention offered through community-based organizations is cost effective in reducing blood pressure among Native Hawaiian adults with hypertension. METHODS Six community-based organizations in Hawai'i completed a randomized controlled trial between 2015 and 2019. Overall, 263 Native Hawaiian adults with uncontrolled hypertension (≥ 140 mmHg systolic, ≥ 90 mmHg diastolic) were randomized to either a 12-month intervention group of hula (traditional Hawaiian dance) lessons and self-regulation classes, or to an education-only waitlist control group. The primary outcome was change in systolic blood pressure collected at baseline and 3, 6, and 12 months for the intervention compared with the control group. Incremental cost-effectiveness ratios (ICERs) were calculated for primary and secondary outcomes. Non-parametric bootstrapping and sensitivity analyses evaluated uncertainty in parameters and outcomes. RESULTS The mean intervention cost was US$361/person, and the 6-month ICER was US$103/mmHg reduction in systolic blood pressure and US$95/mmHg in diastolic blood pressure. At 12 months, the intervention group maintained reductions in blood pressure, which exceeded reductions for usual care based on blood pressure outcomes. The change in blood pressure at 12 months resulted in ICERs of US$100/mmHg reduction in systolic blood pressure and US$93/mmHg in diastolic blood pressure. Sensitivity analyses suggested that at the estimated intervention cost, the probability that the program would lower systolic blood pressure by 5 mmHg was 67 and 2.5% at 6 and 12 months, respectively. CONCLUSION The 6-month Ola Hou program may be cost effective for low-resource community-based organizations. Maintenance of blood pressure reductions at 6 and 12 months in the intervention group contributed to potential cost effectiveness. Future studies should further evaluate the cost effectiveness of indigenous physical activity programs in similar settings and by modeling lifetime costs and quality-adjusted life-years. TRIAL REGISTRATION NUMBER NCT02620709.
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Affiliation(s)
- Ashley F Railey
- Institute for Research and Education to Advance Community Health (IREACH), Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA.
- Department of Sociology, Indiana University, 1022 E. Third St, Bloomington, IN, 47405-7103, USA.
| | - Clemma Muller
- Institute for Research and Education to Advance Community Health (IREACH), Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Carolyn Noonan
- Institute for Research and Education to Advance Community Health (IREACH), Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | | | - Ka'imi Sinclair
- Institute for Research and Education to Advance Community Health (IREACH), Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Corin Kim
- Kilohana, University of Hawai'i at Hilo, Hilo, HI, USA
| | - Mele Look
- Department of Native Health, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Mānoa, HI, USA
| | - J Keawe'aimoku Kaholokula
- Department of Native Health, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Mānoa, HI, USA
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17
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Lee YS, Lee HY, Kim TH. Cost-effectiveness analysis of intensive blood pressure control in Korea. Hypertens Res 2021; 45:507-515. [PMID: 34934160 DOI: 10.1038/s41440-021-00774-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/10/2021] [Accepted: 09/04/2021] [Indexed: 01/09/2023]
Abstract
This study was a cost-effectiveness analysis of intensive blood pressure (BP) control among hypertensive patients in Korea. We constructed a Markov model comparing intensive versus standard BP control treatment and calculated the incremental cost-effectiveness ratio. The study population consisted of hypertensive patients over 50 years old with systolic blood pressures (SBPs) exceeding 140 mmHg and at high risk of cardiovascular disease. Treatment alternatives included lowering the SBP below 120 mmHg (intensive) and 140 mmHg (standard) for target BP. We assumed five scenarios with different medication adherence. The effectiveness variable was quality-adjusted life years (QALYs), and costs included medical costs related to hypertension (HT), complications, and nonmedical costs. In addition, we performed a sensitivity analysis to confirm the robustness of the results of this study. Scenario 5, with 100% medication adherence, showed the lowest incremental cost-effectiveness ratio (ICER) of $1,373 USD, followed by scenario 1 (first 15 years: 62.5%, 16-30 years: 65.2%, after 30 years: 59.5%), scenario 2 (first five years: 62.5% decrease by 5% every five years), and scenario 3 (first 10 years: 62.5% decrease by 10% every 10 years). The ICERs in all scenarios were lower than the willingness to pay (WTP) threshold of $9,492-$32,907 USD in Korea. Tornado analysis showed that the ICERs were changed greatly according to stroke incidence. Intensive treatment of HT prevents cardiovascular disease (CVD); therefore, intensive treatment is more cost-effective than standard treatment despite the consumption of more health resources. ICERs are considerably changed according to medication adherence, confirming the importance of patient adherence to treatment.
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Affiliation(s)
- Ye Seol Lee
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.,National Traffic Injury Rehabilitation Research Institute, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Division of Cardiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae Hyun Kim
- Department of Healthcare Management, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea.
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18
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Zhang Y, Yin L, Mills K, Chen J, He J, Palacios A, Riviere AP, Irazola V, Augustovski F, Shi L. Cost-effectiveness of a Multicomponent Intervention for Hypertension Control in Low-Income Settings in Argentina. JAMA Netw Open 2021; 4:e2122559. [PMID: 34519769 PMCID: PMC8441594 DOI: 10.1001/jamanetworkopen.2021.22559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Hypertension is highly prevalent in low- and middle-income countries, and it is an important preventable risk factor for cardiovascular diseases (CVDs). Understanding the economic benefits of a hypertension control program is valuable to decision-makers. OBJECTIVE To evaluate the long-term cost-effectiveness of a multicomponent hypertension management program compared with usual care among patients with hypertension receiving care in public clinics in Argentina from a health care system perspective. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation used a Markov model to estimate the cost-effectiveness of a hypertension management program among adult patients with uncontrolled hypertension in a low-income setting. Patient-level data (743 individuals for multicomponent intervention; 689 for usual care) from the Hypertension Control Program in Argentina trial (HCPIA) were used to estimate treatment effects and the risk of CVD. Three health states were included in each strategy: (1) low risk of CVD, (2) high risk of CVD, and (3) death. The total time horizon was the lifetime, and each cycle lasted 6 months. MAIN OUTCOMES AND MEASURES Model inputs were based on trial data and other published sources. Cost and utilities were discounted at a rate of 5% annually. The incremental cost-effectiveness ratio (ICER) between the multicomponent intervention and usual care was calculated using the difference in costs in 2017 international dollars (INT $) divided by the difference in effectiveness in quality-adjusted life-years (QALYs). One-way sensitivity analysis and probabilistic sensitivity analysis were performed to assess the uncertainty and robustness of the results. RESULTS In the original trial, the 743 participants in the intervention group (349 [47.0%] men) had a mean (SD) age of 56.2 (12.0) years, and the 689 participants in the control group (311 [45.1%] men) had a mean (SD) age of 56.2 (11.7) years. In the base-case analysis, the HCPIA program yielded 8.42 discounted QALYs and accrued INT $3096 discounted costs, while usual care yielded 8.29 discounted QALYs and accrued INT $2473 discounted costs. The ICER for the HCPIA program was INT $4907/QALY gained. The model results remained robust in sensitivity analyses, and the model was most sensitive to parameters of program costs. CONCLUSIONS AND RELEVANCE In this study, the HCPIA multicomponent intervention vs usual care was a cost-effective strategy to improve hypertension management and reduce the risk of associated CVD among patients with hypertension who received services at public clinics in Argentina. This intervention program is likely transferable to other settings in Argentina or other lower- and middle-income countries.
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Affiliation(s)
- Yichen Zhang
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Lei Yin
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Katherine Mills
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Jing Chen
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Jiang He
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Alfredo Palacios
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Andrés Pichon Riviere
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- School of Public Health, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
- CONICET (National Scientific and Technical Research Council), Buenos Aires, Argentina
| | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- CONICET (National Scientific and Technical Research Council), Buenos Aires, Argentina
| | - Federico Augustovski
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- School of Public Health, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
- CONICET (National Scientific and Technical Research Council), Buenos Aires, Argentina
| | - Lizheng Shi
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
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19
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Bellows BK, Zhang Y, Zhang Z, Lloyd-Jones DM, Bress AP, King JB, Kolm P, Cushman WC, Johnson KC, Tamariz L, Oelsner EC, Shea S, Newman AB, Ives DG, Couper D, Moran AE, Weintraub WS. Estimating Systolic Blood Pressure Intervention Trial Participant Posttrial Survival Using Pooled Epidemiologic Cohort Data. J Am Heart Assoc 2021; 10:e020361. [PMID: 33955229 PMCID: PMC8200698 DOI: 10.1161/jaha.120.020361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Intensive systolic blood pressure treatment (<120 mm Hg) in SPRINT (Systolic Blood Pressure Intervention Trial) improved survival compared with standard treatment (<140 mm Hg) over a median follow‐up of 3.3 years. We projected life expectancy after observed follow‐up in SPRINT using SPRINT‐eligible participants in the NHLBI‐PCS (National Heart, Lung, and Blood Institute Pooled Cohorts Study). Methods and Results We used propensity scores to weight SPRINT‐eligible NHLBI‐PCS participants to resemble SPRINT participants. In SPRINT participants, we estimated in‐trial survival (<4 years) using a time‐based flexible parametric survival model. In SPRINT‐eligible NHLBI‐PCS participants, we estimated posttrial survival (≥4 years) using an age‐based flexible parametric survival model and applied the formula to SPRINT participants to predict posttrial survival. We projected overall life expectancy for each SPRINT participant and compared it to parametric regression (eg, Gompertz) projections based on SPRINT data alone. We included 8584 SPRINT and 10 593 SPRINT‐eligible NHLBI‐PCS participants. After propensity weighting, mean (SD) age was 67.9 (9.4) and 68.2 (8.8) years, and 35.5% and 37.6% were women in SPRINT and NHLBI‐PCS, respectively. Using the NHLBI‐PCS–based method, projected mean life expectancy from randomization was 21.0 (7.4) years with intensive and 19.1 (7.2) years with standard treatment. Using the Gompertz regression, life expectancy was 11.2 (2.3) years with intensive and 10.5 (2.2) years with standard treatment. Conclusions Combining SPRINT and NHLBI‐PCS observed data likely offers a more realistic estimate of life expectancy than parametrically extrapolating SPRINT data alone. These results offer insight into the potential long‐term effectiveness of intensive SBP goals.
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Affiliation(s)
| | | | | | | | | | - Jordan B King
- University of Utah Salt Lake City UT.,Kaiser Permanente Colorado Aurora CO
| | - Paul Kolm
- MedStar Washington Hospital Center Washington DC
| | - William C Cushman
- Veterans Affairs Medical Center Memphis TN.,University of Tennessee Health Science Center Memphis TN
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20
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Li C, Chen K, Cornelius V, Tomeny E, Wang Y, Yang X, Yuan X, Qin R, Yu D, Wu Z, Wang D, Chen T. Applicability and cost-effectiveness of the Systolic Blood Pressure Intervention Trial (SPRINT) in the Chinese population: A cost-effectiveness modeling study. PLoS Med 2021; 18:e1003515. [PMID: 33661907 PMCID: PMC7971845 DOI: 10.1371/journal.pmed.1003515] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 03/18/2021] [Accepted: 02/02/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Systolic Blood Pressure Intervention Trial (SPRINT) showed significant reductions in death and cardiovascular disease (CVD) risk with a systolic blood pressure (SBP) goal of <120 mm Hg compared with a SBP goal of <140 mm Hg. Our study aimed to assess the applicability of SPRINT to Chinese adults. Additionally, we sought to predict the medical and economic implications of this intensive SBP treatment among those meeting SPRINT eligibility. METHODS AND FINDINGS We used nationally representative baseline data from the China Health and Retirement Longitudinal Study (CHARLS) (2011-2012) to estimate the prevalence and number of Chinese adults aged 45 years and older who meet SPRINT criteria. A validated microsimulation model was employed to project costs, clinical outcomes, and quality-adjusted life-years (QALYs) among SPRINT-eligible adults, under 2 alternative treatment strategies (SBP goal of <120 mm Hg [intensive treatment] and SBP goal of <140 mm Hg [standard treatment]). Overall, 22.2% met the SPRINT criteria, representing 116.2 (95% CI 107.5 to 124.8) million people in China. Of these, 66.4%, representing 77.2 (95% CI 69.3 to 85.0) million, were not being treated for hypertension, and 22.9%, representing 26.6 (95% CI 22.4 to 30.7) million, had a SBP between 130 and 139 mm Hg, yet were not taking antihypertensive medication. We estimated that over 5 years, compared to standard treatment, intensive treatment would reduce heart failure incidence by 0.84 (95% CI 0.42 to 1.25) million cases, reduce CVD deaths by 2.03 (95% CI 1.44 to 2.63) million cases, and save 3.84 (95% CI 1.53 to 6.34) million life-years. Estimated reductions of 0.069 (95% CI -0.28, 0.42) million myocardial infarction cases and 0.36 (95% CI -0.10, 0.82) million stroke cases were not statistically significant. Furthermore, over a lifetime, moving from standard to intensive treatment increased the mean QALYs from 9.51 to 9.87 (an increment of 0.38 [95% CI 0.13 to 0.71]), at a cost of Int$10,997 per QALY gained. Of all 1-way sensitivity analyses, high antihypertensive drug cost and lower treatment efficacy for CVD death resulted in the 2 most unfavorable results (Int$25,291 and Int$18,995 per QALY were gained, respectively). Simulation results indicated that intensive treatment could be cost-effective (82.8% probability of being below the willingness-to-pay threshold of Int$16,782 [1× GDP per capita in China in 2017]), with a lower probability in people with SBP 130-139 mm Hg (72.9%) but a higher probability among females (91.2%). Main limitations include lack of specific SPRINT eligibility information in the CHARLS survey, uncertainty about the implications of different blood pressure measurement techniques, the use of several sources of data with large reliance on findings from SPPRINT, limited information about the serious adverse event rate, and lack of information and evidence for medication effectiveness on renal disease. CONCLUSIONS Although adoption of the SPRINT treatment strategy would increase the number of Chinese adults requiring SBP treatment intensification, this approach has the potential to prevent CVD events, to produce gains in life-years, and to be cost-effective under common thresholds.
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Affiliation(s)
- Chao Li
- Department of Epidemiology and Health Statistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Global Health Trials Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Kangyu Chen
- Department of Cardiology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, United Kingdom
| | - Ewan Tomeny
- Centre for Applied Health Research & Delivery, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Yang Wang
- Medical Research and Biometrics Centre, Fuwai Hospital, National Centre for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaowei Yang
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Xiaodan Yuan
- Department of Health Education, Jiangsu Province Hospital of Integration of Chinese and Western Medicine, Nanjing, China
| | - Rui Qin
- Department of Health Education, Jiangsu Province Hospital of Integration of Chinese and Western Medicine, Nanjing, China
| | - Dahai Yu
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Zhenqiang Wu
- Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
| | - Duolao Wang
- Global Health Trials Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Tao Chen
- Department of Epidemiology and Health Statistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Global Health Trials Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
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Karády J, Mayrhofer T, Ivanov A, Foldyna B, Lu MT, Ferencik M, Pursnani A, Salerno M, Udelson JE, Mark DB, Douglas PS, Hoffmann U. Cost-effectiveness Analysis of Anatomic vs Functional Index Testing in Patients With Low-Risk Stable Chest Pain. JAMA Netw Open 2020; 3:e2028312. [PMID: 33315111 PMCID: PMC7737090 DOI: 10.1001/jamanetworkopen.2020.28312] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Both noninvasive anatomic and functional testing strategies are now routinely used as initial workup in patients with low-risk stable chest pain (SCP). OBJECTIVE To determine whether anatomic approaches (ie, coronary computed tomography angiography [CTA] and coronary CTA supplemented with noninvasive fractional flow reserve [FFRCT], performed in patients with 30% to 69% stenosis) are cost-effective compared with functional testing for the assessment of low-risk SCP. DESIGN, SETTING, AND PARTICIPANTS This cost-effectiveness analysis used an individual-based Markov microsimulation model for low-risk SCP. The model was developed using patient data from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial. The model was validated by comparing model outcomes with outcomes observed in the PROMISE trial for anatomic (coronary CTA) and functional (stress testing) strategies, including diagnostic test results, referral to invasive coronary angiography (ICA), coronary revascularization, incident major adverse cardiovascular event (MACE), and costs during 60 days and 2 years. The validated model was used to determine whether anatomic approaches are cost-effective over a lifetime compared with functional testing. EXPOSURE Choice of index test for evaluation of low-risk SCP. MAIN OUTCOMES AND MEASURES Downstream ICA and coronary revascularization, MACE (death, nonfatal myocardial infarction), cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of competing strategies. RESULTS The model cohort included 10 003 individual patients (median [interquartile range] age, 60.0 [54.4-65.9] years; 5270 [52.7%] women; 7693 [77.4%] White individuals), who entered the model 100 times. The Markov model accurately estimated the test assignment, results of anatomic and functional index testing, referral to ICA, revascularization, MACE, and costs at 60 days and 2 years compared with observed data in PROMISE (eg, coronary CTA: ICA, 12.2% [95% CI, 10.9%-13.5%] vs 12.3% [95% CI, 12.2%-12.4%]; revascularization, 6.2% [95% CI, 5.5%-6.9%] vs 6.4% [95% CI, 6.3%-6.5%]; functional strategy: ICA, 8.1% [95% CI, 7.4%-8.9%] vs 8.2% [95% CI, 8.1%-8.3%]; revascularization, 3.2% [95% CI, 2.7%-3.7%] vs 3.3% [95% CI, 3.2%-3.4%]; 2-year MACE rates: coronary CTA, 2.1% [95% CI, 1.7%-2.5%] vs 2.3% [95% CI, 2.2%-2.4%]; functional strategy, 2.2% [95% CI, 1.8%-2.6%] vs 2.4% [95% CI, 2.3%-2.4%]). Anatomic approaches led to higher ICA and revascularization rates at 60 days, 2 years, and 5 years compared with functional testing but were more effective in patient selection for ICA (eg, 60-day revascularization-to-ICA ratio, CTA: 53.7% [95% CI, 53.3%-54.0%]; CTA with FFRCT: 59.5% [95% CI, 59.2%-59.8%]; functional testing: 40.7% [95% CI, 40.4%-50.0%]). Over a lifetime, anatomic approaches gained an additional 6 months in perfect health compared with functional testing (CTA, 25.16 [95% CI, 25.14-25.19] QALYs; CTA with FFRCT, 25.14 [95% CI, 25.12-25.17] QALYs; functional testing, 24.68 [95% CI, 24.66-24.70] QALYs). Anatomic strategies were less costly and more effective; thus, CTA with FFRCT dominated and CTA alone was cost-effective (ICERs ranged from $1912/QALY for women and $3,559/QALY for men) compared with functional testing. In probabilistic sensitivity analyses, anatomic approaches were cost-effective in more than 65% of scenarios, assuming a willingness-to-pay threshold of $100 000/QALY. CONCLUSIONS AND RELEVANCE The results of this study suggest that anatomic strategies may present a more favorable initial diagnostic option in the evaluation of low-risk SCP compared with functional testing.
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Affiliation(s)
- Júlia Karády
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Alexander Ivanov
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Borek Foldyna
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michael T. Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Maros Ferencik
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland
| | - Amit Pursnani
- Cardiology Division, Evanston Hospital, Evanston, Illinois
| | - Michael Salerno
- Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville
| | - James E. Udelson
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
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22
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Eligibility of the Systolic Blood Pressure Intervention Trial (SPRINT) to the Chinese Adults. BIOMED RESEARCH INTERNATIONAL 2020; 2020:4751756. [PMID: 33134378 PMCID: PMC7591957 DOI: 10.1155/2020/4751756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/08/2020] [Accepted: 08/24/2020] [Indexed: 11/20/2022]
Abstract
Objective To explore the proportion and characteristic of Chinese adults meeting The Systolic Blood Pressure Intervention Trial (SPRINT) eligibility criteria and assess its generalizability. Method Our study was based on a cross-sectional, population-based survey with a sample of 26,093 participants aged over 20 years. The SPRINT eligibility criteria were age ≥ 50 years, elevated SBP of 130 to 180 mmHg depending on the number of antihypertensive medication classes being taken, and increased cardiovascular disease (CVD) but without diabetes, history of stroke and estimated glomerular filtration rate < 20 ml/min/1.73 m2, or receiving dialysis. Results Overall, we estimated that 4,036 (15.5%) participants would meet the SPRINT eligibility criteria. They were generally older, likely to be female, lower educational level, tended to be more overweight, and had higher Framingham risk score compared with overall population or subjects aged ≥ 50 years. Of participants eligible for SPRINT, most (56.2%) of them were not treated for hypertension, and 542 (13.4%) were not previously considered to have hypertension or need for antihypertension therapy. Among the 11,637 adults with hypertension, 3,494 (30.0%) would potentially benefit from treatment intensification. The most common antihypertensive medication class being taken was diuretic agents. Conclusion A substantial percentage of Chinese subjects meet the SPRINT eligibility criteria. Further studies are needed to assess the cost-effectiveness from treatment intensification in Chinese setting.
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23
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res 2020; 42:1235-1481. [PMID: 31375757 DOI: 10.1038/s41440-019-0284-9] [Citation(s) in RCA: 1028] [Impact Index Per Article: 257.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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24
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Fairley M, Cipriano LE, Goldhaber-Fiebert JD. Optimal Allocation of Research Funds under a Budget Constraint. Med Decis Making 2020; 40:797-814. [PMID: 32845233 DOI: 10.1177/0272989x20944875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Purpose. Health economic evaluations that include the expected value of sample information support implementation decisions as well as decisions about further research. However, just as decision makers must consider portfolios of implementation spending, they must also identify the optimal portfolio of research investments. Methods. Under a fixed research budget, a decision maker determines which studies to fund; additional budget allocated to one study to increase the study sample size implies less budget available to collect information to reduce decision uncertainty in other implementation decisions. We employ a budget-constrained portfolio optimization framework in which the decisions are whether to invest in a study and at what sample size. The objective is to maximize the sum of the studies' population expected net benefit of sampling (ENBS). We show how to determine the optimal research portfolio and study-specific levels of investment. We demonstrate our framework with a stylized example to illustrate solution features and a real-world application using 6 published cost-effectiveness analyses. Results. Among the studies selected for nonzero investment, the optimal sample size occurs at the point at which the marginal population ENBS divided by the marginal cost of additional sampling is the same for all studies. Compared with standard ENBS optimization without a research budget constraint, optimal budget-constrained sample sizes are typically smaller but allow more studies to be funded. Conclusions. The budget constraint for research studies directly implies that the optimal sample size for additional research is not the point at which the ENBS is maximized for individual studies. A portfolio optimization approach can yield higher total ENBS. Ultimately, there is a maximum willingness to pay for incremental information that determines optimal sample sizes.
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Affiliation(s)
- Michael Fairley
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Lauren E Cipriano
- Ivey Business School and the Department of Epidemiology and Biostatistics at Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
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25
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Almalki ZS, Iqbal MS, Alablan FM, Alenazi RK, Tasha AR, Daghar MF, Aldossary NM. Long Term Cost-Effectiveness of a Systolic Blood Pressure Goal of <120 mmHg in Hypertensive Patients Without Diabetes Mellitus. Value Health Reg Issues 2020; 21:157-163. [DOI: 10.1016/j.vhri.2019.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/21/2019] [Accepted: 09/09/2019] [Indexed: 11/29/2022]
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26
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Akhmimi A, Lip GYH, Shantsila A. What is the impact of the latest ACC/AHA and ESC/ESH guidelines on the management of hypertension in the UK? Expert Opin Pharmacother 2020; 21:1123-1125. [PMID: 31899988 DOI: 10.1080/14656566.2019.1707183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Azhar Akhmimi
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool, UK.,Echo-Cardiovascular Technology Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences , Riyadh, Saudi Arabia
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University , Aalborg, Denmark
| | - Alena Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool, UK
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27
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Derington CG, King JB, Bryant KB, McGee BT, Moran AE, Weintraub WS, Bellows BK, Bress AP. Cost-Effectiveness and Challenges of Implementing Intensive Blood Pressure Goals and Team-Based Care. Curr Hypertens Rep 2019; 21:91. [PMID: 31701259 DOI: 10.1007/s11906-019-0996-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Review the effectiveness, cost-effectiveness, and implementation challenges of intensive blood pressure (BP) control and team-based care initiatives. RECENT FINDINGS Intensive BP control is an effective and cost-effective intervention; yet, implementation in routine clinical practice is challenging. Several models of team-based care for hypertension management have been shown to be more effective than usual care to control BP. Additional research is needed to determine the cost-effectiveness of team-based care models relative to one another and as they relate to implementing intensive BP goals. As a focus of healthcare shifts to value (i.e., cost, effectiveness, and patient preferences), formal cost-effectiveness analyses will inform which team-based initiatives hold the highest value in different healthcare settings with different populations and needs. Several challenges, including clinical inertia, financial investment, and billing restrictions for pharmacist-delivered services, will need to be addressed in order to improve public health through intensive BP control and team-based care.
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Affiliation(s)
- Catherine G Derington
- Department of Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Jordan B King
- Department of Population Health Sciences, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84112, USA.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, 84112, USA
| | - Kelsey B Bryant
- Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Blake T McGee
- Byrdine F. Lewis College of Nursing & Health Professions, Georgia State University, Atlanta, GA, USA
| | - Andrew E Moran
- Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | | | - Brandon K Bellows
- Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Adam P Bress
- Department of Population Health Sciences, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84112, USA.
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28
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Almalki Z, Alatawi Y, Alharbi A, Almaklefi B, Alfaiz S, Almohana O, Alsaidan Y, Alanezi A. Cost-Effectiveness of More Intensive Blood Pressure Treatment in Patients with High Risk of Cardiovascular Disease in Saudi Arabia: A Modelling Study of Meta-Analysis. Int J Hypertens 2019; 2019:6019401. [PMID: 31662901 PMCID: PMC6791260 DOI: 10.1155/2019/6019401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/07/2019] [Accepted: 09/04/2019] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The current literature suggests that more intensive blood pressure (BP) treatment is clinically more effective than less intensive treatment in patients at high risk for cardiovascular disease (CVD). In this analysis, we evaluated the potential clinical benefit and cost-effectiveness of more intensive BP treatment in patients at high risk of developing CVD over their lifetimes. METHODS A Markov state-transition model was developed for the BP strategies to estimate the lifetime incremental cost-effectiveness ratio (ICER) per quality-adjusted-life-year (QALY) using evidence published from a meta-analysis. The other model inputs were retrieved from previous studies. Estimated costs were collected from five hospitals in Riyadh. The model used a lifetime framework adopting Saudi payer perspective and applied a 3% annual discount rate. Sensitivity analysis was conducted using one-way and probabilistic sensitivity analysis (PSA) to evaluate the robustness and uncertainty of the estimates. RESULTS Treating 10,000 patients with high CVD risk with more intensive BP therapy would avert a total of 873 CV events over their remaining lifetimes as compared with a less intensive strategy. The projections showed that more intensive BP therapy would be cost-effective compared to the less intensive strategy with incremental costs per QALY of $20,358. Probabilistic sensitivity analysis suggested more intensive control would be cost-effective compared with the less intensive control of BP 87.25 % of the time. CONCLUSION The result of this study showed that more intensive BP treatment appears to be a cost-effective choice for patients with a high risk of CVD in Saudi Arabia when compared with a less intensive BP strategy. Thus, this finding provides strong evidence for the adoption of this strategy within the Saudi healthcare system.
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Affiliation(s)
- Ziyad Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Yasser Alatawi
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Mecca, Riyadh, Saudi Arabia
| | - Adnan Alharbi
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Mecca, Riyadh, Saudi Arabia
| | - Bader Almaklefi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Suliman Alfaiz
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Omar Almohana
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Yasser Alsaidan
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Abdullah Alanezi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
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29
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Abstract
The Systolic Blood Pressure Intervention Trial is the first large prospective randomized controlled trial to demonstrate the benefit of an intensive systolic blood pressure (SBP) treatment target (<120 mm Hg) compared to a standard target (<140 mm Hg) in reducing cardiovascular morbidity and mortality and all-cause mortality in high-risk hypertensive patients. The impact of SPRINT on hypertension treatment has been large, but major questions remain about the feasibility of achieving the SPRINT intensive SBP target in routine practice, the generalizability of the SPRINT findings to hypertensive populations that were excluded from the trial, and the cost effectiveness of adopting the SPRINT intensive treatment goal. In this review, we discuss the generalizability of SPRINT data to the general population of adults with hypertension and with various comorbidities, the cost effectiveness of intensive SBP-lowering therapy, and the implications of SPRINT for future hypertension guideline development and clinical practice.
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Affiliation(s)
- Lama Ghazi
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota 55455;
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama 35294;
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30
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Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 74:e177-e232. [PMID: 30894318 PMCID: PMC7685565 DOI: 10.1016/j.jacc.2019.03.010] [Citation(s) in RCA: 950] [Impact Index Per Article: 190.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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31
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Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 74:1376-1414. [PMID: 30894319 PMCID: PMC8344373 DOI: 10.1016/j.jacc.2019.03.009] [Citation(s) in RCA: 729] [Impact Index Per Article: 145.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association
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32
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Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 140:e563-e595. [PMID: 30879339 PMCID: PMC8351755 DOI: 10.1161/cir.0000000000000677] [Citation(s) in RCA: 359] [Impact Index Per Article: 71.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life. 2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions. 3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. The presence or absence of additional risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning. 4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, processed meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss. 5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity. 6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist. 7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit. 8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit. 9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion. 10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.
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33
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Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 140:e596-e646. [PMID: 30879355 PMCID: PMC7734661 DOI: 10.1161/cir.0000000000000678] [Citation(s) in RCA: 1367] [Impact Index Per Article: 273.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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34
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Wang Z, Hao G, Wang X, Chen Z, Zhang L, Zhang Z, Hu H, Weintraub WS, Gao R. Clinical outcomes and economic impact of the 2017 ACC/AHA guidelines on hypertension in China. J Clin Hypertens (Greenwich) 2019; 21:1212-1220. [PMID: 31267666 PMCID: PMC8030413 DOI: 10.1111/jch.13609] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/08/2019] [Accepted: 05/25/2019] [Indexed: 11/28/2022]
Abstract
The 2017 guidelines on the diagnosis and treatment of high blood pressure in adults were published by the American College of Cardiology and the American Heart Association. The impact on clinical outcomes and costs needs to be estimated prior to adopting these guidelines in China. Data from a nationally representative sample in China were analyzed. The prevalence and treatment were calculated based on the criteria of the 2017 guidelines and 2018 Chinese guidelines among participants aged ≥35 years old. Direct medical costs, as well as the averted disability adjusted of life years and cost saving from cardiovascular disease events prevented by controlling hypertension, were also estimated. The prevalence and treatment rate of hypertension were 32.0% and 43.4% according to the 2018 Chinese guidelines. Based on the 2017 guidelines, another 24.5% of the adult population (estimated 168.1 million) would be classified as having hypertension; of whom, about 32.1 million would need to be pharmaceutically treated to reach the current treatment rate of 43.4%. As a result, an estimated additional 42.7 billion US dollars of the direct medical cost would be required for lifetime therapy. By preventing cardiovascular events, the new guidelines would reduce lifetime costs by 3.77 billion US dollars, while preventing 1.41 million disability adjusted of life years lost. Application of the 2017 guidelines in China will substantially increase the prevalence of hypertension and produce a large increase in therapy costs, although it would prevent cardiovascular disease events and save disability adjusted of life years.
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Affiliation(s)
- Zengwu Wang
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai HospitalPeking Union Medical College & Chinese Academy of Medical SciencesBeijingChina
| | - Guang Hao
- Department of Epidemiology, School of MedicineJinan UniversityGuangzhouChina
| | - Xin Wang
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai HospitalPeking Union Medical College & Chinese Academy of Medical SciencesBeijingChina
| | - Zuo Chen
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai HospitalPeking Union Medical College & Chinese Academy of Medical SciencesBeijingChina
| | - Linfeng Zhang
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai HospitalPeking Union Medical College & Chinese Academy of Medical SciencesBeijingChina
| | - Zugui Zhang
- Christiana Care Health SystemNewarkDelawareUSA
| | - Hao Hu
- China Health Technology Assessment Center, National Health Development Research CenterNational Health and Family Planning CommissionBeijingChina
| | | | - Runlin Gao
- Department of Cardiology, Fuwai HospitalPeking Union Medical College & Chinese Academy of Medical SciencesBeijingChina
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Applicability of the Systolic Blood Pressure Intervention Trial (SPRINT) to the Canadian Population. Can J Cardiol 2019; 34:670-675. [PMID: 29731026 DOI: 10.1016/j.cjca.2018.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The Systolic Blood Pressure Intervention Trial (SPRINT) showed significant reductions in major cardiovascular events and all-cause mortality with a systolic blood pressure (BP) goal of < 120 mm Hg compared with < 140 mm Hg. We sought to determine the proportion of Canadian adults who meet SPRINT eligibility criteria. METHODS We conducted a cross-sectional study using cycles 1-3 of the nationally representative Canadian Health Measures Survey to estimate the prevalence and characteristics of Canadian adults between the ages of 20 and 79 who meet SPRINT eligibility criteria: age ≥ 50 years, elevated systolic BP of 130-180 mm Hg, and increased cardiovascular risk (with chronic kidney disease, Framingham Risk Score ≥ 15% in 10 years, and/or cardiovascular disease) but without diabetes, stroke, or end-stage renal disease. RESULTS An estimated 1.3 million (5.2%) Canadian adults met SPRINT eligibility criteria; 14.3% (95% confidence interval, 10.6%-17.9%), or 182,600 people, were not previously considered to have hypertension or need for antihypertensive therapy. Of adults aged 50-79 years treated for hypertension, 18.7% (95% confidence interval, 15.5%-21.8%), or 754,400 individuals, would potentially benefit from treatment intensification. CONCLUSIONS If fully implemented, intensive systolic BP lowering to < 120 mm Hg in SPRINT-eligible high-risk individuals would substantially increase the proportion of Canadian adults receiving BP treatment initiation or intensification.
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Krishnaswami A, Kim DH, McCulloch CE, Forman DE, Maurer MS, Alexander KP, Rich MW. Individual and Joint Effects of Pulse Pressure and Blood Pressure Treatment Intensity on Serious Adverse Events in the SPRINT Trial. Am J Med 2018; 131:1220-1227.e1. [PMID: 29940151 DOI: 10.1016/j.amjmed.2018.05.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE The objective of this study was to determine individual and joint effects of pulse pressure and blood pressure treatment intensity on serious adverse events in the Systolic Blood Pressure Intervention Trial. METHODS Pulse pressure was calculated by subtracting diastolic blood pressure from systolic blood pressure. Blood pressure treatment intensity goal was ≤140mm Hg in the control arm and ≤120mm Hg in the intensive arm. The primary outcome was a 5-point composite of hypotension, syncope, electrolyte abnormalities, acute renal insufficiency, or injurious falls. RESULTS In 9361 trial participants, the incident rate for the primary outcome per 1000 person-years increased with higher pulse pressure category: ≤49 mmHg: 20.4 (17.2-24.1), 50-59 mmHg: 24.5 (21.3-28.2), 60-69 mmHg: 31.7 (27.7-36.2), ≥70 mmHg: 44.6 (39.8-49.9; Ptrend < .0001; hazard ratio [HR] of pulse pressure [every 10mm Hg] 1.23; 95% confidence interval [CI], 1.18-1.28). The intensive treatment arm had a higher incidence rate of serious adverse events than the control arm (34.2, 95% CI, 31.2-37.3, vs 26.0, 95% CI, 23.4-28.8, P = .0001; HR 1.32; 95% CI, 1.15-1.51). The combined effect was not significant in the relative risk scale (HR 0.97, Pinteraction = .48) but was significant in the risk difference scale (P = .027), contributing 2.5 additional serious adverse events per 1000 person-years for every 10mm Hg increase in pulse pressure in excess of the individual effects of pulse pressure and treatment intensity. CONCLUSIONS Wider pulse pressure and intensive blood pressure treatment were individually associated with the composite adverse event outcome. A modest effect modification of pulse pressure and treatment intensity led to additional adverse events when both were present. Clinicians should use caution when treating older patients with elevated pulse pressure to an intensive blood pressure treatment target.
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Affiliation(s)
- Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente San Jose Medical Center, CA; Department of Epidemiology and Biostatistics, Universityof California, San Francisco, CA.
| | - Dae Hyun Kim
- Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, Universityof California, San Francisco, CA
| | - Daniel E Forman
- Division of Geriatric Cardiology, University of Pittsburgh, PA; Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, PA
| | - Mathew S Maurer
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - Karen P Alexander
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Michael W Rich
- Division of Cardiology, Washington University,St. Louis, MO
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Phillips RA, Arnold RM, Peterson LE. Hypertension Guidelines. J Am Coll Cardiol 2018; 72:1246-1251. [DOI: 10.1016/j.jacc.2018.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/09/2018] [Indexed: 11/15/2022]
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Walther CP, Chandra A, Navaneethan SD. Blood pressure parameters and morbid and mortal outcomes in nondialysis-dependent chronic kidney disease. Curr Opin Nephrol Hypertens 2018; 27:16-22. [PMID: 29045334 DOI: 10.1097/mnh.0000000000000375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Observational and interventional studies provide conflicting evidence regarding optimal blood pressure (BP) control in persons with chronic kidney disease (CKD). Recent publications provide additional information to inform therapeutic decision-making. RECENT FINDINGS Targeting SBP to less than 120 mmHg, versus less than 140 mmHg, decreased cardiovascular events and all-cause mortality in persons with nondiabetic CKD. A meta-analysis of trials testing blood pressure management among nondialysis-dependent CKD patients (15 924 total patients) found more intensive therapies generally reduced mortality in all subgroups. Observational studies demonstrate that low SBP is associated with higher mortality in CKD. A recent report suggests that this is because of death from cardiovascular and noncardiovascular and nonmalignant causes, whereas higher BP is associated with death from cardiovascular causes. The shape of association between BP and cardiovascular and noncardiovascular events also appears to vary depending on baseline risk factors. Furthermore, BP measurement methodology may differ importantly between observational and interventional studies. SUMMARY We review and summarize observational and interventional literature relating BP parameters to key clinical outcomes in persons with CKD. Apart from the inherent differences between these study designs, the disparate findings from trials and observational studies may be because of differences in patient characteristics and BP measurement techniques.
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Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine
| | | | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine.,Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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Campbell DJ, Coller JM, Gong FF, McGrady M, Prior DL, Boffa U, Shiel L, Liew D, Wolfe R, Owen AJ, Krum H, Reid CM. Risk factor management in a contemporary Australian population at increased cardiovascular disease risk. Intern Med J 2018; 48:688-698. [DOI: 10.1111/imj.13678] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 10/11/2017] [Accepted: 11/01/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Duncan J. Campbell
- Department of Molecular Cardiology; St Vincent's Institute of Medical Research; Melbourne Victoria Australia
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Department of Cardiology; St Vincent's Hospital; Melbourne Victoria Australia
| | - Jennifer M. Coller
- Department of Cardiology; St Vincent's Hospital; Melbourne Victoria Australia
| | - Fei Fei Gong
- Department of Molecular Cardiology; St Vincent's Institute of Medical Research; Melbourne Victoria Australia
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Department of Cardiology; St Vincent's Hospital; Melbourne Victoria Australia
| | - Michele McGrady
- School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - David L. Prior
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Department of Cardiology; St Vincent's Hospital; Melbourne Victoria Australia
| | - Umberto Boffa
- School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Louise Shiel
- School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Alice J. Owen
- School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Henry Krum
- School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Christopher M. Reid
- School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
- School of Public Health; Curtin University; Perth Western Australia Australia
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Abstract
PURPOSE OF REVIEW The optimal blood pressure (BP) goal during treatment of hypertension has been controversial. In this report, recent articles that elaborate on this issue are reviewed. RECENT FINDINGS Results from the Systolic Blood Pressure Intervention Trial (SPRINT) have suggested substantial benefits from more intensive BP lowering than is recommended in current US BP management guidelines. SUMMARY Increasing evidence suggests that intensive BP lowering provides a cost-effective means to improve health in many adults with high BP. SPRINT provides the most convincing confirmation, but experience in other trials, alone and in pooled analyses augments and broadens the evidence base to patient groups who were not included in SPRINT. Implementation trials to document feasibility and effectiveness of SPRINT-like interventions in routine practice, including in resource-constrained settings, are warranted.
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Abstract
China has the largest population of adults with hypertension in the world. Recent clinical trials have shown that intensive hypertension control can help patients achieve lower blood pressure and reduce the incidence of major cardiovascular disease (CVD) events, but this level of hypertension control also incurs additional costs to patients and society and may result in a substantial increase in adverse events. The objective of this study is to assess the cost-effectiveness of intensive hypertension control to inform health policymakers and health care delivery systems in China in their decision-making regarding hypertension treatment strategies. We developed a Markov based simulation model of hypertension to assess the impact of intensive and standard hypertension control strategies for the Chinese population who are diagnosed with hypertension. Model parameters were estimated based on the best available data and the literature. We projected that intensive hypertension control would avert about 2.2 million coronary heart disease events and 4.4 million stroke events for all hypertensive patients in China in 10 years compared to standard hypertension control. The incremental cost-effectiveness ratio (ICER) for intensive hypertension control was estimated at 7876 CNY per quality-adjusted life year (QALY) compared to standard hypertension control. Intensive hypertension control would be more cost-effective than standard hypertension control in China. Our findings indicated that China should consider expanding intensive hypertension control among hypertensive patients given its great potential in preventing CVD.
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Schutte AE. What are the financial implications of the 2017 AHA/ACC High Blood Pressure Guideline? Eur J Prev Cardiol 2018; 25:1109-1110. [PMID: 29785883 DOI: 10.1177/2047487318777087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Aletta E Schutte
- Hypertension in Africa Research Team (HART); South African Medical Research Council Unit for Hypertension and Cardiovascular Disease; North-West University, Potchefstroom, South Africa
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Qureshi S, Lorch R, Navaneethan SD. Blood Pressure Parameters and their Associations with Death in Patients with Chronic Kidney Disease. Curr Hypertens Rep 2017; 19:92. [PMID: 29046987 DOI: 10.1007/s11906-017-0790-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Optimal blood pressure (BP) parameters among patients with chronic kidney disease (CKD) have been a matter of debate. This review critically evaluates recent literature to better define the associations of BP parameters and death among individuals with non-dialysis-dependent CKD. RECENT FINDINGS Observational studies report a "U- or J-shaped" association between BP and all-cause mortality in CKD and caution-intensive BP lowering in the elderly. Causes of death have been evaluated in a recent report noting higher cardiovascular and non-cardiovascular/non-malignant-related mortality among CKD population with SBP < 110 and > 150 mmHg. Very few randomized control trials evaluated the impact of different BP targets on patient-centered outcomes in those with CKD. Recently published SPRINT trial results suggest that intensive SBP control (<120 mm Hg) reduces cardiovascular events and all-cause death among non-diabetic patients with and without CKD. Clinical trial evidence supports lower BP target in those with mild to moderate non-diabetic CKD. However, clinical trials are warranted to further determine the beneficial effects of intensive blood pressure control in diabetic CKD population. In elderly population with CKD, BP targets might need to be individualized based on their comorbidities, life expectancy, and other factors.
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Affiliation(s)
- Samaya Qureshi
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Robert Lorch
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
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Bress AP, Bellows BK, King JB, Hess R, Beddhu S, Zhang Z, Berlowitz DR, Conroy MB, Fine L, Oparil S, Morisky DE, Kazis LE, Ruiz-Negrón N, Powell J, Tamariz L, Whittle J, Wright JT, Supiano MA, Cheung AK, Weintraub WS, Moran AE. Cost-Effectiveness of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2017; 377:745-755. [PMID: 28834469 PMCID: PMC5708850 DOI: 10.1056/nejmsa1616035] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND In the Systolic Blood Pressure Intervention Trial (SPRINT), adults at high risk for cardiovascular disease who received intensive systolic blood-pressure control (target, <120 mm Hg) had significantly lower rates of death and cardiovascular disease events than did those who received standard control (target, <140 mm Hg). On the basis of these data, we wanted to determine the lifetime health benefits and health care costs associated with intensive control versus standard control. METHODS We used a microsimulation model to apply SPRINT treatment effects and health care costs from national sources to a hypothetical cohort of SPRINT-eligible adults. The model projected lifetime costs of treatment and monitoring in patients with hypertension, cardiovascular disease events and subsequent treatment costs, treatment-related risks of serious adverse events and subsequent costs, and quality-adjusted life-years (QALYs) for intensive control versus standard control of systolic blood pressure. RESULTS We determined that the mean number of QALYs would be 0.27 higher among patients who received intensive control than among those who received standard control and would cost approximately $47,000 more per QALY gained if there were a reduction in adherence and treatment effects after 5 years; the cost would be approximately $28,000 more per QALY gained if the treatment effects persisted for the remaining lifetime of the patient. Most simulation results indicated that intensive treatment would be cost-effective (51 to 79% below the willingness-to-pay threshold of $50,000 per QALY and 76 to 93% below the threshold of $100,000 per QALY), regardless of whether treatment effects were reduced after 5 years or persisted for the remaining lifetime. CONCLUSIONS In this simulation study, intensive systolic blood-pressure control prevented cardiovascular disease events and prolonged life and did so at levels below common willingness-to-pay thresholds per QALY, regardless of whether benefits were reduced after 5 years or persisted for the patient's remaining lifetime. (Funded by the National Heart, Lung, and Blood Institute and others; SPRINT ClinicalTrials.gov number, NCT01206062 .).
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Affiliation(s)
- Adam P Bress
- 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.)
| | - Brandon K Bellows
- 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.)
| | - Jordan B King
- 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.)
| | - Rachel Hess
- 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.)
| | - Srinivasan Beddhu
- 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.)
| | - Zugui Zhang
- 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.)
| | - Dan R Berlowitz
- 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.)
| | - Molly B Conroy
- 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.)
| | - Larry Fine
- 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.)
| | - Suzanne Oparil
- 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.)
| | - Donald E Morisky
- 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.)
| | - Lewis E Kazis
- 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.)
| | - Natalia Ruiz-Negrón
- 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.)
| | - Jamie Powell
- 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.)
| | - Leonardo Tamariz
- 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.)
| | - Jeff Whittle
- 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.)
| | - Jackson T Wright
- 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.)
| | - Mark A Supiano
- 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.)
| | - Alfred K Cheung
- 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.)
| | - William S Weintraub
- 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.)
| | - Andrew E Moran
- 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.)
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Choi KH, Yu YM, Ah YM, Chang MJ, Lee JY. Persistence with antihypertensives in uncomplicated treatment-naïve very elderly patients: a nationwide population-based study. BMC Cardiovasc Disord 2017; 17:232. [PMID: 28836946 PMCID: PMC5571581 DOI: 10.1186/s12872-017-0665-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/16/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Limited studies have evaluated the medication-taking behavior in very elderly hypertensive patients. The aim of this study was to evaluate the persistence and adherence with antihypertensive agents in treatment-naïve patients, along with other related factors, according to age. METHODS Adult (19-64 years), elderly (65-79 years), and very elderly (≥80 years) uncomplicated hypertensive patients starting antihypertensive monotherapy were identified from the National Health Insurance claims database. The first-year treatment persistence and adherence rates measured using the medication possession ratio were assessed and compared in these three age cohorts. RESULTS After propensity score matching, three age cohorts with 6689 patients each were assembled from 228,925 uncomplicated hypertensive patients who began antihypertensive monotherapy in 2012. The treatment persistence and adherence rates over the first year were the lowest in the very elderly (59.5% and 62.8%, respectively) and highest in the elderly (65.2% and 67.9%, respectively) patients among the three age cohorts (p < 0.001). The adjusted risk for treatment non-persistence was significantly higher in the very elderly (adjusted hazard ratio, 1.20; 95% confidence interval, 1.13-1.27) compared with the elderly. Having more comorbidities, being a beneficiary of medical aid, and having a diagnosis of dementia were unique positive predictors for treatment persistence in the very elderly, along with common predictors such as female sex, dyslipidemia, and an initially chosen antihypertensive therapeutic class other than beta blockers and thiazide diuretics. CONCLUSIONS Very elderly patients were less likely to continue antihypertensive therapy over the first year compared with their younger counterparts. Our findings suggest that a low comorbidity index and lack of medical aid support negatively affect the treatment persistence in this population.
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Affiliation(s)
- Kyung Hee Choi
- College of Pharmacy, Sunchon National University, 255 Jungang-ro, Suncheon, Jeollanam-do, 57922, South Korea.,College of Pharmacy, Chonnam National University, Gwang-Ju, 61186, South Korea
| | - Yun Mi Yu
- College of Pharmacy & Research Institute of Pharmaceutical Sciences, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Young-Mi Ah
- College of Pharmacy, Institute of Pharmaceutical Science and Technology, Hanyang University, 55 Hanyangdaehak-ro, Sangnok-gu, Ansan, Gyeonggi-do, 15588, South Korea
| | - Min Jung Chang
- College of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, 21983, South Korea
| | - Ju-Yeun Lee
- College of Pharmacy, Institute of Pharmaceutical Science and Technology, Hanyang University, 55 Hanyangdaehak-ro, Sangnok-gu, Ansan, Gyeonggi-do, 15588, South Korea.
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Tajeu GS, Booth JN, Colantonio LD, Gottesman RF, Howard G, Lackland DT, O'Brien EC, Oparil S, Ravenell J, Safford MM, Seals SR, Shimbo D, Shea S, Spruill TM, Tanner RM, Muntner P. Incident Cardiovascular Disease Among Adults With Blood Pressure <140/90 mm Hg. Circulation 2017. [PMID: 28634217 DOI: 10.1161/circulationaha.117.027362] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Data from before the 2000s indicate that the majority of incident cardiovascular disease (CVD) events occur among US adults with systolic and diastolic blood pressure (SBP/DBP) ≥140/90 mm Hg. Over the past several decades, BP has declined and hypertension control has improved. METHODS We estimated the percentage of incident CVD events that occur at SBP/DBP <140/90 mm Hg in a pooled analysis of 3 contemporary US cohorts: the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), the MESA (Multi-Ethnic Study of Atherosclerosis), and the JHS (Jackson Heart Study) (n=31 856; REGARDS=21 208; MESA=6779; JHS=3869). Baseline study visits were conducted in 2003 to 2007 for REGARDS, 2000 to 2002 for MESA, and 2000 to 2004 for JHS. BP was measured by trained staff using standardized methods. Antihypertensive medication use was self-reported. The primary outcome was incident CVD, defined by the first occurrence of fatal or nonfatal stroke, nonfatal myocardial infarction, fatal coronary heart disease, or heart failure. Events were adjudicated in each study. RESULTS Over a mean follow-up of 7.7 years, 2584 participants had incident CVD events. Overall, 63.0% (95% confidence interval [CI], 54.9-71.1) of events occurred in participants with SBP/DBP <140/90 mm Hg; 58.4% (95% CI, 47.7-69.2) and 68.1% (95% CI, 60.1-76.0) among those taking and not taking antihypertensive medication, respectively. The majority of events occurred in participants with SBP/DBP <140/90 mm Hg among those <65 years of age (66.7%; 95% CI, 60.5-73.0) and ≥65 years of age (60.3%; 95% CI, 51.0-69.5), women (61.4%; 95% CI, 49.9-72.9) and men (63.8%; 95% CI, 58.4-69.1), and for whites (68.7%; 95% CI, 66.1-71.3), blacks (59.0%; 95% CI, 49.5-68.6), Hispanics (52.7%; 95% CI, 45.1-60.4), and Chinese-Americans (58.5%; 95% CI, 45.2-71.8). Among participants taking antihypertensive medication with SBP/DBP <140/90 mm Hg, 76.6% (95% CI, 75.8-77.5) were eligible for statin treatment, but only 33.2% (95% CI, 32.1-34.3) were taking one, and 19.5% (95% CI, 18.5-20.5) met the SPRINT (Systolic Blood Pressure Intervention Trial) eligibility criteria and may benefit from a SBP target goal of 120 mm Hg. CONCLUSIONS Although higher BP levels are associated with increased CVD risk, in the modern era, the majority of incident CVD events occur in US adults with SBP/DBP <140/90 mm Hg. While absolute risk and cost-effectiveness should be considered, additional CVD risk-reduction measures for adults with SBP/DBP <140/90 mm Hg at high risk for CVD may be warranted.
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Affiliation(s)
- Gabriel S Tajeu
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York.
| | - John N Booth
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Lisandro D Colantonio
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Rebecca F Gottesman
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - George Howard
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Daniel T Lackland
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Emily C O'Brien
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Suzanne Oparil
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Joseph Ravenell
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Monika M Safford
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Samantha R Seals
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Daichi Shimbo
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Steven Shea
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Tanya M Spruill
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Rikki M Tanner
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
| | - Paul Muntner
- From Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.); Department of Epidemiology (J.N.B., L.D.C., R.M.T., P.M.), Department of Biostatistics (G.H.), Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program (S.O.), Department of Medicine (M.M.S.), University of Alabama at Birmingham; Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Neurology, Medical University of South Carolina, Charleston (D.T.L.); Duke Clinical Research Institute, Duke University, Durham, NC (E.C.O.); Department of Population Health, New York University School of Medicine (J.R., T.S.); Department of Medicine, Weill Cornell Medical College, New York (M.M.S.); Department of Mathematics and Statistics, University of West Florida, Pensacola, FL (S.R.S.); Department of Medicine (D.S.), Departments of Medicine and Epidemiology (S.S.), Columbia University, New York
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From the Editor. ACTA ACUST UNITED AC 2017; 11:67. [PMID: 28449812 DOI: 10.1016/j.jash.2016.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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McEvoy JW, Martin SS, Dardari ZA, Miedema MD, Sandfort V, Yeboah J, Budoff MJ, Goff DC, Psaty BM, Post WS, Nasir K, Blumenthal RS, Blaha MJ. Coronary Artery Calcium to Guide a Personalized Risk-Based Approach to Initiation and Intensification of Antihypertensive Therapy. Circulation 2017; 135:153-165. [PMID: 27881560 PMCID: PMC5225077 DOI: 10.1161/circulationaha.116.025471] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 11/02/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND The use of atherosclerotic cardiovascular disease (ASCVD) risk to personalize systolic blood pressure (SBP) treatment goals is a topic of increasing interest. Therefore, we studied whether coronary artery calcium (CAC) can further guide the allocation of anti-hypertensive treatment intensity. METHODS We included 3733 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) with SBP between 120 and 179 mm Hg. Within subgroups categorized by both SBP (120-139 mm Hg, 140-159 mm Hg, and 160-179 mm Hg) and estimated 10-year ASCVD risk (using the American College of Cardiology/American Heart Assocation pooled-cohort equations), we compared multivariable-adjusted hazard ratios for the composite outcome of incident ASCVD or heart failure after further stratifying by CAC (0, 1-100, or >100). We estimated 10-year number-needed-to-treat for an intensive SBP goal of 120 mm Hg by applying the treatment benefit recorded in meta-analyses to event rates within CAC strata. RESULTS The mean age was 65 years, and 642 composite events took place over a median of 10.2 years. In persons with SBP <160 mm Hg, CAC stratified risk for events. For example, among those with an ASCVD risk of <15% and who had an SBP of either 120 to 139 mm Hg or 140 to 159 mm Hg, respectively, we found increasing hazard ratios for events with CAC 1 to 100 (1.7 [95% confidence interval, 1.0-2.6] or 2.0 [1.1-3.8]) and CAC >100 (3.0 [1.8-5.0] or 5.7 [2.9-11.0]), all relative to CAC=0. There appeared to be no statistical association between CAC and events when SBP was 160 to 179 mm Hg, irrespective of ASCVD risk level. Estimated 10-year number-needed-to-treat for a SBP goal of 120mmHg varied substantially according to CAC levels when predicted ASCVD risk <15% and SBP <160mmHg (eg, 10-year number-needed-to-treat of 99 for CAC=0 and 24 for CAC>100, when SBP 120-139mm Hg). However, few participants with ASCVD risk <5% had elevated CAC. Furthermore, 10-year number-needed-to-treat estimates were consistently low and varied less among CAC strata when SBP was 160 to 179 mm Hg or when ASCVD risk was ≥15% at any SBP level. CONCLUSIONS Combined CAC imaging and assessment of global ASCVD risk has the potential to guide personalized SBP goals (eg, choosing a traditional goal of 140 or a more intensive goal of 120 mm Hg), particularly among adults with an estimated ASCVD risk of 5% to 15% and prehypertension or mild hypertension.
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Affiliation(s)
- John W McEvoy
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.).
| | - Seth S Martin
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - Zeina A Dardari
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - Michael D Miedema
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - Veit Sandfort
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - Joseph Yeboah
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - Matthew J Budoff
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - David C Goff
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - Bruce M Psaty
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - Wendy S Post
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - Khurram Nasir
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - Roger S Blumenthal
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
| | - Michael J Blaha
- From Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (J.W.M., S.S.M., Z.A.D., W.S.P., K.N., R.S.B., M.J.Blaha); Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (M.D.M.); Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD (V.S.); Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston-Salem, NC (J.Y.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.Budoff); Department of Epidemiology, Colorado School of Public Health, Aurora (D.C.G.); Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle (B.M.P.); and Center for Healthcare Advancement and Outcomes and Miami Cardiac and Vascular Institute, Baptist Health South Florida (K.N.)
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