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Lung T, Jan S, de Silva HA, Guggilla R, Maulik PK, Naik N, Patel A, de Silva AP, Rajapakse S, Ranasinghe G, Prabhakaran D, Rodgers A, Salam A, Selak V, Stepien S, Thom S, Webster R, Lea-Laba T. Fixed-combination, low-dose, triple-pill antihypertensive medication versus usual care in patients with mild-to-moderate hypertension in Sri Lanka: a within-trial and modelled economic evaluation of the TRIUMPH trial. LANCET GLOBAL HEALTH 2019; 7:e1359-e1366. [PMID: 31477545 DOI: 10.1016/s2214-109x(19)30343-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/10/2019] [Accepted: 07/19/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Elevated blood pressure incurs a major health and economic burden, particularly in low-income and middle-income countries. The Triple Pill versus Usual Care Management for Patients with Mild-to-Moderate Hypertension (TRIUMPH) trial showed a greater reduction in blood pressure in patients using fixed-combination, low-dose, triple-pill antihypertensive therapy (consisting of amlodipine, telmisartan, and chlorthalidone) than in those receiving usual care in Sri Lanka. We aimed to assess the cost-effectiveness of the triple-pill strategy. METHODS We did a within-trial (6-month) and modelled (10-year) economic evaluation of the TRIUMPH trial, using the health system perspective. Health-care costs, reported in 2017 US dollars, were determined from trial records and published literature. A discrete-time simulation model was developed, extrapolating trial findings of reduced systolic blood pressure to 10-year health-care costs, cardiovascular disease events, and mortality. The primary outcomes were the proportion of people reaching blood pressure targets (at 6 months from baseline) and disability-adjusted life-years (DALYs) averted (at 10 years from baseline). Incremental cost-effectiveness ratios were calculated to estimate the cost per additional participant achieving target blood pressure at 6 months and cost per DALY averted over 10 years. FINDINGS The triple-pill strategy, compared with usual care, cost an additional US$9·63 (95% CI 5·29 to 13·97) per person in the within-trial analysis and $347·75 (285·55 to 412·54) per person in the modelled analysis. Incremental cost-effectiveness ratios were estimated at $7·93 (95% CI 6·59 to 11·84) per participant reaching blood pressure targets at 6 months and $2842·79 (-28·67 to 5714·24) per DALY averted over a 10-year period. INTERPRETATION Compared with usual care, the triple-pill strategy is cost-effective for patients with mild-to-moderate hypertension. Scaled up investment in the triple pill for hypertension management in Sri Lanka should be supported to address the high population burden of cardiovascular disease. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Thomas Lung
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - H Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Rama Guggilla
- Department of Population Medicine and Civilization Diseases Prevention, Faculty of Medicine with the Division of Dentistry and Division of Medical Education in English, Medical University of Bialystok, Bialystok, Poland
| | - Pallab K Maulik
- The George Institute for Global Health, University of New South Wales, New Delhi, India; The George Institute for Global Health, University of Oxford, Oxford, UK
| | - Nitish Naik
- All India Institute of Medical Sciences, New Delhi, India
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Arjuna P de Silva
- Department of Medicines, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Senaka Rajapakse
- Department of Medicines, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | | | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Abdul Salam
- The George Institute for Global Health, University of New South Wales, Hyderabad, India
| | - Vanessa Selak
- Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Sandrine Stepien
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Simon Thom
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - Ruth Webster
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Tracey Lea-Laba
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Salam A, Webster R, Patel A, Godamunne P, Pathmeswaran A, de Silva HA, Rogers A, Jan S, Laba TL. Process evaluation of a randomised controlled trial of a pharmacological strategy to improve hypertension control: protocol for a qualitative study. BMJ Open 2018; 8:e022317. [PMID: 30121609 PMCID: PMC6104790 DOI: 10.1136/bmjopen-2018-022317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Globally, the prevalence of uncontrolled hypertension is high, particularly in low- and middle-income countries. There is a critical need for strategies to improve hypertension control. The early use of a fixed low-dose combination of three antihypertensive drugs (triple pill) has the potential to significantly improve hypertension control. The TRI ple Pill vs. U sual care M anagement for P atients with mild-to- moderate H ypertension (TRIUMPH) randomised controlled trial (RCT) is designed to test the effects of this strategy compared with usual care in patients with mild-to-moderate hypertension. This paper reports the protocol of a process evaluation of the TRIUMPH RCT. The objectives are to understand factors related to implementation of the intervention, mechanisms of effect, contextual factors that underpin the effectiveness of the triple pill strategy and the potential barriers and facilitators to implementing the strategy in clinical practice. METHODS AND ANALYSIS Face-to-face semistructured in-depth interviews with a purposive sample of TRIUMPH RCT participants and healthcare professionals in Sri Lanka will be conducted. Healthcare professionals will include physicians and their staff who were involved in conducting the TRIUMPH RCT. Interviewees will be recruited sequentially until thematic saturation is achieved. Interviews will be audio recorded, transcribed verbatim and analysed in NVivo using framework analysis methods. ETHICS AND DISSEMINATION The TRIUMPH RCT and process evaluation have received approval from the relevant Ethics Review Committee. All participants will be asked to provide written consent before participation. Findings from the study will be disseminated through publications and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12612001120864 , SLCTR/2015/020 ; Pre-results.
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Affiliation(s)
- Abdul Salam
- The George Institute for Global Health, University of New South Wales, Hyderabad, India
| | - Ruth Webster
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Pavithra Godamunne
- Department of Medical Education, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Arunasalam Pathmeswaran
- Department of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - H Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Anthony Rogers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Tracey-Lea Laba
- Menzies Centre for Health Policy, Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia
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Webster R, Salam A, de Silva HA, Selak V, Stepien S, Rajapakse S, Amarasekara S, Amarasena N, Billot L, de Silva AP, Fernando M, Guggilla R, Jan S, Jayawardena J, Maulik PK, Mendis S, Mendis S, Munasinghe J, Naik N, Prabhakaran D, Ranasinghe G, Thom S, Tisserra N, Senaratne V, Wijekoon S, Wijeyasingam S, Rodgers A, Patel A. Fixed Low-Dose Triple Combination Antihypertensive Medication vs Usual Care for Blood Pressure Control in Patients With Mild to Moderate Hypertension in Sri Lanka: A Randomized Clinical Trial. JAMA 2018; 320:566-579. [PMID: 30120478 PMCID: PMC6583010 DOI: 10.1001/jama.2018.10359] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Poorly controlled hypertension is a leading global public health problem requiring new treatment strategies. OBJECTIVE To assess whether a low-dose triple combination antihypertensive medication would achieve better blood pressure (BP) control vs usual care. DESIGN, SETTING, AND PARTICIPANTS Randomized, open-label trial of a low-dose triple BP therapy vs usual care for adults with hypertension (systolic BP >140 mm Hg and/or diastolic BP >90 mm Hg; or in patients with diabetes or chronic kidney disease: >130 mm Hg and/or >80 mm Hg) requiring initiation (untreated patients) or escalation (patients receiving monotherapy) of antihypertensive therapy. Patients were enrolled from 11 urban hospital clinics in Sri Lanka from February 2016 to May 2017; follow-up ended in October 2017. INTERVENTIONS A once-daily fixed-dose triple combination pill (20 mg of telmisartan, 2.5 mg of amlodipine, and 12.5 mg of chlorthalidone) therapy (n = 349) or usual care (n = 351). MAIN OUTCOMES AND MEASURES The primary outcome was the proportion achieving target systolic/diastolic BP (<140/90 mm Hg or <130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 months. Secondary outcomes included mean systolic/diastolic BP difference during follow-up and withdrawal of BP medications due to an adverse event. RESULTS Among 700 randomized patients (mean age, 56 years; 58% women; 29% had diabetes; mean baseline systolic/diastolic BP, 154/90 mm Hg), 675 (96%) completed the trial. The triple combination pill increased the proportion achieving target BP vs usual care at 6 months (70% vs 55%, respectively; risk difference, 12.7% [95% CI, 3.2% to 22.0%]; P < .001). Mean systolic/diastolic BP at 6 months was 125/76 mm Hg for the triple combination pill vs 134/81 mm Hg for usual care (adjusted difference in postrandomization BP over the entire follow-up: systolic BP, -9.8 [95% CI, -7.9 to -11.6] mm Hg; diastolic BP, -5.0 [95% CI, -3.9 to -6.1] mm Hg; P < .001 for both comparisons). Overall, 419 adverse events were reported in 255 patients (38.1% for triple combination pill vs 34.8% for usual care) with the most common being musculoskeletal pain (6.0% and 8.0%, respectively) and dizziness, presyncope, or syncope (5.2% and 2.8%). There were no significant between-group differences in the proportion of patient withdrawal from BP-lowering therapy due to adverse events (6.6% for triple combination pill vs 6.8% for usual care). CONCLUSIONS AND RELEVANCE Among patients with mild to moderate hypertension, treatment with a pill containing low doses of 3 antihypertensive drugs led to an increased proportion of patients achieving their target BP goal vs usual care. Use of such medication as initial therapy or to replace monotherapy may be an effective way to improve BP control. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12612001120864; slctr.lk Identifier: SLCTR/2015/020.
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Affiliation(s)
- Ruth Webster
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Abdul Salam
- The George Institute for Global Health, University of New South Wales, Hyderabad, India
| | - H. Asita de Silva
- Clinical Trials Unit, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Vanessa Selak
- Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Sandrine Stepien
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Senaka Rajapakse
- Department of Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | | | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Arjuna P. de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | | | - Rama Guggilla
- General Directorate of Health Affairs in Jizan, Ministry of Health, Sabya, Saudi Arabia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Pallab K. Maulik
- The George Institute for Global Health, University of New South Wales, New Delhi, India
| | | | | | | | - Nitish Naik
- All India Institute of Medical Sciences, New Delhi
| | | | | | - Simon Thom
- International Centre for Circulatory Health, Imperial College London, London, England
| | | | | | - Sanjeewa Wijekoon
- Department of Medicine, Faculty of Medical Sciences, University of Sri Jayawardenapura, Nugegoda, Sri Lanka
| | | | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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