Financial and health costs of uncontrolled blood pressure in the United Kingdom

Physicians' perception of task sharing with non-physician health care workers in the management of uncomplicated hypertension in Nigeria: A mixed method study

INTRODUCTION

Task sharing and task shifting (TSTS) in the management of hypertension is an important strategy to reduce the burden of hypertension in low-and middle-income countries like Nigeria where there is shortage of physicians below the World Health Organization's recommendations on doctor-patient ratio. The cooperation of physicians is critical to the success of this strategy. We assessed physicians' perception of TSTS with non-physician health workers in the management of hypertension and sought recommendations to facilitate the implementation of TSTS.

MATERIALS AND METHODS

This was an explanatory sequential mixed method study. TSTS perception was assessed quantitatively using a 12-item questionnaire with each item assigned a score on a 5-point Likert scale. The maximum obtainable score was 60 points and those with ≥42 points were classified as having a good perception of TSTS. Twenty physicians were subsequently interviewed for in-depth exploration of their perception of TSTS.

RESULTS

A total of 1250 physicians participated in the quantitative aspect of the study. Among the participants, 56.6% had good perception of TSTS in the management of hypertension while about two-thirds (67.5%) agreed that TSTS program in the management of hypertension could be successfully implemented in Nigeria. Male gender (p = 0.019) and working in clinical settings (p = 0.039) were associated with good perception. Twenty physicians participated in the qualitative part of the study. Qualitative analysis showed that TSTS will improve overall care and outcomes of patients with hypertension, reduce physicians' workload, improve their productivity, but may encourage inter-professional rivalry. Wide consultation with stakeholders, adequate monitoring and evaluation will facilitate successful implementation of TSTS in Nigeria.

CONCLUSION

This study showed that more than half of the physicians have good perception of TSTS in hypertension management while about two-thirds agreed that it could be successfully implemented in Nigeria. This study provides the needed evidence for increased advocacy for the implementation of TSTS in the management of hypertension in Nigeria. This will consequently result in improved patient care and outcomes and effective utilization of available health care personnel.

The Cost of Uncontrolled Blood Pressure in Australian General Practice: A Modelling Study Using Electronic Health Records (MedicineInsight)

BACKGROUND

Hypertension is the most common condition seen in Australian general practice. Despite hypertension being amenable to lifestyle modifications and pharmacological treatment, only around half of these patients have controlled blood pressure levels (< 140/90 mmHg), placing them at an increased risk of cardiovascular disease.

OBJECTIVE

We aimed to estimate the health and acute hospitalisation costs of uncontrolled hypertension among patients attending general practice.

METHODS

We used population data and electronic health records from 634,000 patients aged 45-74 years who regularly attended an Australian general practice between 2016 and 2018 (MedicineInsight database). An existing worksheet-based costing model was adapted to calculate the potential cost savings for acute hospitalisation of primary cardiovascular disease events by reducing the risk of a cardiovascular event over the next 5 years through improved systolic blood pressure control. The model estimated the number of expected cardiovascular disease events and associated acute hospital costs under current levels of systolic blood pressure and compared this estimate with the expected number of cardiovascular disease events and costs under different levels of systolic blood pressure control.

RESULTS

The model estimated that across all Australians aged 45-74 years who visit their general practitioner (n = 8.67 million), 261,858 cardiovascular disease events can be expected over the next 5 years at current systolic blood pressure levels (mean 137.8 mmHg, standard deviation = 12.3 mmHg), with a cost of AUD$1813 million (in 2019-20). By reducing the systolic blood pressure of all patients with a systolic blood pressure greater than 139 mmHg to 139 mmHg, 25,845 cardiovascular disease events could be avoided with an associated reduction in acute hospital costs of AUD$179 million. If systolic blood pressure is lowered further to 129 mmHg for all those with systolic blood pressure greater than 129 mmHg, 56,169 cardiovascular disease events could be avoided with potential cost savings of AUD$389 million. Sensitivity analyses indicate that potential cost savings range from AUD$46 million to AUD$1406 million and AUD$117 million to AUD$2009 million for the two scenarios, respectively. Cost savings by practice range from AUD$16,479 for small practices to AUD$82,493 for large practices.

CONCLUSIONS

The aggregate cost effects of poor blood pressure control in primary care are high, but cost implications at the individual practice level are modest. The potential cost savings improve the potential to design cost-effective interventions, but such interventions may be best targeted at a population level rather than at individual practices.

Purinergic receptors in the carotid body as a new drug target for controlling hypertension

In view of the high proportion of individuals with resistance to antihypertensive medication and/or poor compliance or tolerance of this medication, new drugs to treat hypertension are urgently needed. Here we show that peripheral chemoreceptors generate aberrant signaling that contributes to high blood pressure in hypertension. We discovered that purinergic receptor P2X3 (P2rx3, also known as P2x3) mRNA expression is upregulated substantially in chemoreceptive petrosal sensory neurons in rats with hypertension. These neurons generate both tonic drive and hyperreflexia in hypertensive (but not normotensive) rats, and both phenomena are normalized by the blockade of P2X3 receptors. Antagonism of P2X3 receptors also reduces arterial pressure and basal sympathetic activity and normalizes carotid body hyperreflexia in conscious rats with hypertension; no effect was observed in rats without hypertension. We verified P2X3 receptor expression in human carotid bodies and observed hyperactivity of carotid bodies in individuals with hypertension. These data support the identification of the P2X3 receptor as a potential new target for the control of human hypertension.

Quantifying the economic benefits of prevention in a healthcare setting with severe financial constraints: the case of hypertension control

Hypertension significantly contributes to the increased cardiovascular morbidity and mortality, thus leading to rising healthcare costs. The objective of this study was to quantify the clinical and economic benefits of optimal systolic blood pressure (SBP), in a setting under severe financial constraints, as in the case of Greece. Hence, a Markov model projecting 10-year outcomes and costs was adopted, in order to compare two scenarios. The first one depicted the "current setting", where all hypertensives in Greece presented an average SBP of 164 mmHg, while the second scenario namely "optimal SBP control" represented a hypothesis in which the whole population of hypertensives would achieve optimal SBP (i.e. <140 mmHg). Cardiovascular events' occurrence was estimated for four sub-models (according to gender and smoking status). Costs were calculated from the Greek healthcare system's perspective (discounted at a 3% annual rate). Findings showed that compared to the "current setting", universal "optimal SBP control" could, within a 10-year period, reduce the occurrence of non-fatal events and deaths, by 80 and 61 cases/1000 male smokers; 59 and 37 cases/1000 men non-smokers; whereas the respective figures for women were 69 and 57 cases/1000 women smokers; and accordingly, 52 and 28 cases/1000 women non-smokers. Considering health expenditures, they could be reduced by approximately €83 million per year. Therefore, prevention of cardiovascular events through BP control could result in reduced morbidity, thereby in substantial cost savings. Based on clinical and economic outcomes, interventions that promote BP control should be a health policy priority.

Blood pressure status during consultation: a primary care study

INTRODUCTION

Blood pressure control needs to be assessed at a primary care level, which is the first contact with patients.

AIMS

To evaluate blood pressure readings among patients visiting a primary care clinic at a teaching university hospital in Riyadh, Saudi Arabia.

METHODS

A cross-sectional study was conducted in a primary care clinic at the King Khalid University Hospital from April to September 2013. Blood pressure readings were measured by trained nurses working in a primary care clinic during patients' visits.

RESULTS

The study showed that only 33.6 % of participants had a normal blood pressure reading, and 49.3 % of participants were diagnosed as hypertensive patients. The study showed that 74.7 % do not exercise, and 45 % have high stress levels in their life.

CONCLUSION

Uncontrolled blood pressure was common at this hospital-based primary care clinic, so it is recommended to educate primary care physicians to take care of blood pressure management and to educate and encourage patients about non-pharmacological advice like losing weight and coping with stress.

Hypertension-associated expenditures for medication among US adults

BACKGROUND

We sought to estimate how much the presence of hypertension adds to annual per capita and total expenditures for medication among US adults.

METHODS

The sample included 21,782 civilian noninstitutionalized adults aged ≥ 18 years who participated in the 2007 Medical Expenditure Panel Survey. Hypertension was defined as having a diagnosis of high blood pressure (except during pregnancy) or taking a blood pressure medication. We used a 2-part model to examine all-cause medication expenditure associated with hypertension.

RESULTS

The prevalence of hypertension was 32.2%. Overall, 66.7% of adults purchased prescribed medications, with this proportion higher among hypertensive (93.0%) than normotensive (54.4%) adults (P < 0.001). Hypertensive adults were more likely to have medication expenditures than were normotensive adults (odds ratio (OR) = 6.42; P < 0.001). Among hypertensive adults, those aged ≥ 45 years were more likely to incur medication expenditure than those aged 18-44 years (OR = 3.00, P < 0.001 for those aged 45-64 years; OR = 5.95, P < 0.001 for those aged ≥ 65 years), whereas women were 2.91 times as likely as men to have medication spending (P < 0.001). Hispanics were less likely than non-Hispanic whites to have such spending (OR = 0.51; P < 0.001). Among those purchasing medications, the average cost was $1,510 higher among hypertensive persons ($2,337) than normotensive persons ($827). Hypertension-associated expenditures for medication were estimated at $68 billion in the US civilian non-institutionalized population in 2007.

CONCLUSIONS

The presence of hypertension among US adults is associated with an increase of all-cause expenditures for medication, with this increase varying across groups by age and sex.

Hypertension and common complications --analysis of the ambulatory treatment cost

AIM

Retrospective analysis of the prescribing practice and cost of ambulatory treatment of hypertension and its common complications--heart failure, sequelae of cerebrovascular disease, and angina pectoris.

METHODS

Analysis of 3,240 reimbursable ambulatory prescriptions for hypertension, heart failure, sequelae of cerebrovascular disease and angina pectoris according to the complexity of the therapy and frequency of the prescribed medicines. Modeling and calculation of the expected monthly cost for outpatient therapy by using the "decision tree model". Sensitivity analysis is performed within the +/- 30% interval.

RESULTS

65% of the prescription were for the hypertension, and 35% for the observed complications. 1,297 prescriptions for hypertension include one medicine, 647 include two medicines, and only 8% of prescriptions were for three medicines. ACE inhibitors have been prescribed in 41% of all hypertension prescriptions, followed by beta-blockers (19%), Ca channel blockers (16%), diuretics (15%) etc. The prescriptions for hypertension complications are more diverse as therapeutic groups. The expected monthly cost of prescribed medicines per patient with hypertension alone is 6.90 Euro and in case of complications it is 10.71 Euro according to the prevalence of the complexity of therapy, and weighted monthly cost of medicines. The overall ambulatory cost is expected to be around 148 million Euro per year for near 1.5 million patients with 44% reimbursement. The cost of the therapy is sensitive more to changes in the medicine's prices than to its complexity.

CONCLUSION

This study is a first step in providing information for evidence-based cost containment measures or policy decisions at ambulatory level in Bulgaria and for the assessment of the share of complications' therapy on the overall hypertension cost.

Economic impact of switching from valsartan to other angiotensin receptor blockers in patients with hypertension

BACKGROUND

The approaching availability of lower-cost generic angiotensin receptor blockers (ARBs) may affect formulary policies for patients maintained on the ARB valsartan.

OBJECTIVE

Estimate the economic impact of switching from valsartan (including valsartan-based single-pill combinations) to other ARBs without apparent medical reasons.

RESEARCH DESIGN AND METHODS

Patients with essential hypertension and at least 6 months of continuous valsartan treatment free of hospitalization, cardiovascular events, renal events or ARB-associated adverse events were identified from the MarketScan administrative claims database from January 1, 2004 to March 31, 2008. Those who subsequently switched to a different ARB with at least a 5% copayment decrease (switchers) were matched to those who did not switch (maintainers) according to propensity score quintiles and selected baseline characteristics. Refills were not required after the index fill for the switched-to ARB or maintained valsartan. Matched switchers and maintainers were compared in terms of medication discontinuation, healthcare resource use and costs during the 6 months following the index fill.

RESULTS

A total of 99,926 valsartan maintainers and 2150 switchers (with a mean copayment decrease of $16.5 per month) were identified and matched. After matching, switching from versus maintaining valsartan was associated with an 8% higher risk of medication discontinuation (p < 0.008), 19.1 additional outpatient visits/100 patients (p = 0.002) and 9.3 additional hypertension-related inpatient days/100 patients (p = 0.030). Concurrently, switching from versus maintaining valsartan was associated with higher total medical costs by $748/patient (p < 0.001), driven largely by higher costs for hypertension-related medical services by $492/patient (p = 0.004).

LIMITATIONS

Exact reasons for switching were not available and the study assessed only the short-term impacts of switching.

CONCLUSIONS

Hypertension patients maintained on valsartan who switched to a different ARB with a lower copayment experienced substantial increases in medication discontinuation, healthcare resource use and costs compared to those who maintained valsartan treatment.

Hospitalization costs associated with hypertension as a secondary diagnosis among insured patients aged 18-64 years

BACKGROUND

We estimated the hospitalization costs associated with hypertension as a secondary diagnosis among insured adults aged 18-64 years by using data from 2005 MarketScan Commercial Claims and Encounters (CCAE) inpatient admissions.

METHODS

We analyzed costs for four patient groups (N = 455,944): (i) all selected patients; (ii) patients with the primary diagnosis of ischemic heart disease (IHD); (iii) patients with the primary diagnosis of cerebrovascular disease; and (iv) patients with neither IHD nor cerebrovascular disease as the primary diagnosis. We conducted propensity score matching to control possible bias in cost estimates due to sample selections and estimated the costs of hypertension by using a regression model on the matched populations that controlled for subjects' age, sex, length of hospital stay, Charlson comorbidity index (CCI), region of residence, and urbanization of residence.

RESULTS

For all patients with hypertension as a secondary diagnosis, the estimated average annual hospitalization cost per patient was $21,094, of which $2,734 (13%; P < 0.01) was associated with hypertension. The estimated average costs were $31,106 for patients with a primary diagnosis of IHD, $17,298 for those with a primary diagnosis of cerebrovascular disease, and $18,693 for those without a primary diagnosis of IHD or cerebrovascular disease; hypertension-associated costs for these patients were $3,540 (11.4%; P < 0.01), $1,133 (6.5%; P < 0.01), and $2,254 (12.1%; P < 0.01), respectively.

CONCLUSIONS

Hypertension-associated hospitalization costs are substantial among insured US patients aged 18-64 years with hypertension as a secondary diagnosis and suggest a need for cost-effective programs to prevent, manage, and control hypertension.

International open-label studies to assess the efficacy and safety of single-pill amlodipine/atorvastatin in attaining blood pressure and lipid targets recommended by country-specific guidelines: the JEWEL programme

BACKGROUND

Single-pill amlodipine/atorvastatin targets the two most common modifiable cardiovascular risk factors, hypertension and dyslipidaemia. We evaluated the clinical utility of this single pill to help patients across Europe and Canada achieve country-specific targets for blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C).

DESIGN

Two 16-week, open-label studies conducted in 122 study centres across the United Kingdom and Canada (JEWEL 1) and 113 centres across 11 European countries (JEWEL 2).

METHODS

Patients with uncontrolled BP and controlled/uncontrolled LDL-C qualifying for treatment according to local governing guidelines were administered single-pill amlodipine/atorvastatin with appropriate lifestyle modification. Eight dosages of amlodipine/atorvastatin (5/10-10/80 mg) were titrated to achieve country-specific BP and LDL-C targets. The primary outcome was the percentage of patients reaching country-specific BP and LDL-C targets in 16 weeks.

RESULTS

Among 2245 patients enrolled in the studies (JEWEL 1, n = 1138; JEWEL 2, n = 1107), 62.9% in JEWEL 1 and 50.6% in JEWEL 2 achieved both country-specific BP and LDL-C goals. BP was reduced by 20.4/10.7 and 21.8/12.6 mmHg in JEWEL 1 and JEWEL 2, respectively, and reductions in LDL-C were 0.90 mmol/l (34.8 mg/dl) and 1.09 mmol/l (42.2 mg/dl), respectively. The most common adverse events were peripheral oedema (11.0%), joint swelling (2.9%) and headache (2.9%), of which, only oedema was linked to study treatment.

CONCLUSION

Single-pill amlodipine/atorvastatin is an effective and well-tolerated treatment, which in a real-world setting helped more than half of the patients achieve both BP and LDL-C targets as recommended by local guidelines. Although fewer patients met their goals in JEWEL 2 than JEWEL 1, reductions in BP and LDL-C were slightly greater in JEWEL 2, suggesting that the observed differences are likely because of more stringent targets in Europe than in the UK/Canada.

Disciplining death: hypertension management and the production of mortal subjectivities

Medicine powerfully mediates the relationship between life and death. This article argues that in the name of health, modern medicine constitutes a pathological mortal subjectivity, encouraging individuals to experience death as disease, to understand mortality as morbidity, and to approach living instrumentally as a means to longevity. This article uses the example of hypertension management to illustrate how this vision of death is transformed into a form of life. Through the analysis of a number of disciplinary technologies--from technical definitions of health to blood pressure monitoring--it illustrates how individuals are incited to relate to death in an antagonistic, impersonal, and technical fashion. While contemporary forms of capital accumulation in the health field require an intensification of such relations, this article suggests that there much to be gained from exploring visions of health that are not at odds with death.

Cost-effectiveness analysis of guidelines for antihypertensive care in Finland

BACKGROUND

Hypertension is one of the major causes of disease burden affecting the Finnish population. Over the last decade, evidence-based care has emerged to complement other approaches to antihypertensive care, often without health economic assessment of its costs and effects. This study looks at the extent to which changes proposed by the 2002 Finnish evidence-based Current Care Guidelines concerning the prevention, diagnosis, and treatment of hypertension (the ACCG scenario) can be considered cost-effective when compared to modelled prior clinical practice (the PCP scenario).

METHODS

A decision analytic model compares the ACCG and PCP scenarios using information synthesised from a set of national registers covering prescription drug reimbursements, morbidity, and mortality with data from two national surveys concerning health and functional capacity. Statistical methods are used to estimate model parameters from Finnish data. We model the potential impact of the different treatment strategies under the ACCG and PCP scenarios, such as lifestyle counselling and drug therapy, for subgroups stratified by age, gender, and blood pressure. The model provides estimates of the differences in major health-related outcomes in the form of life-years and costs as calculated from a 'public health care system' perspective. Cost-effectiveness analysis results are presented for subgroups and for the target population as a whole.

RESULTS

The impact of the use of the ACCG scenario in subgroups (aged 40-80) without concomitant cardiovascular and related diseases is mainly positive. Generally, costs and life-years decrease in unison in the lowest blood pressure group, while in the highest blood pressure group costs and life-years increase together and in the other groups the ACCG scenario is less expensive and produces more life-years. When the costs and effects for subgroups are combined using standard decision analytic aggregation methods, the ACCG scenario is cost-saving and more effective.

CONCLUSION

The ACCG scenario is likely to reduce costs and increase life-years compared to the PCP scenario in many subgroups. If the estimated trade-offs between the subgroups in terms of outcomes and costs are acceptable to decision-makers, then widespread implementation of the ACCG scenario is expected to reduce overall costs and be accompanied by positive outcomes overall.

The need for combination antihypertensive therapy to reach target blood pressures: what has been learned from clinical practice and morbidity-mortality trials?

Pharmacological treatment of hypertension represents a cost-effective way for preventing cardiovascular and renal complications. To benefit maximally from antihypertensive treatment blood pressure (BP) should be brought to below 140/90 mmHg in every hypertensive patient, and even lower (< 130/80 mmHg) if diabetes or renal disease co-exists. Most of the time such targets cannot be reached using monotherapies. This is especially true in patients who exhibit a high cardiovascular risk. The co-administration of two agents acting by different mechanisms considerably increases BP control. Such preparations are not only efficacious, but also well tolerated, and some fixed low-dose combinations have a tolerability profile similar to placebo. This is for instance the case for the preparation containing the angiotensin-converting enzyme inhibitor perindopril (2 mg) and the diuretic indapamide (0.625 mg), a fixed low-dose combination that has recently been shown in controlled interventional trials to be more effective than monotherapies in reducing albuminuria, regressing cardiac hypertrophy and improving macrovascular stiffness. Fixed-dose combinations are becoming more and more popular and are even proposed by current hypertension guidelines as a first-line option to treat hypertensive patients.

The Health and Life device (HL888HA): accuracy assessment in an adult population according to the British Hypertension Society protocol

OBJECTIVE

Over the last two decades, concerns over mercury toxicity have given rise to the continuous release of new and improved automated blood pressure measurement devices as a replacement for the mercury sphygmomanometer. Out-of-office blood pressure monitoring has been shown to have various advantages, including a reduced white-coat effect and observer error, as well as better prediction of cardiovascular risk/complications. We assessed the accuracy of the Health and Life device (HL888HA) (Health and Life Co. Ltd., Taipei, Taiwan) in an adult population according to the British Hypertension Society protocol.

METHODS

Local ethics committee approval was obtained and participants were recruited from a large teaching hospital. Nine blood pressure measurements were taken from each participant, alternating between a mercury sphygmomanometer and the test device. Data from 85 participants who fulfilled the British Hypertension Society criteria were analysed according to the protocol guidelines.

RESULTS

The device achieved the highest possible grade (A/A) according to the British Hypertension Society protocol. The mean difference and SD of 0.5 (7.3) mmHg for systolic and -2.1 (7.8) mmHg for diastolic pressure, which complies with the standard of the American Association for the Advancement of Medical Instrumentation.

CONCLUSION

The Health and Life device (HL888HA) can be recommended for use in an adult population according to the criteria of the British Hypertension Society protocol.

Temporal changes in the control of blood pressure in an older Australian population

Trends in blood pressure prevalence and control have important public health implications. We aim to document trends in hypertension prevalence, awareness and control in the older Australian population, a group at greatest risk of blood pressure related diseases. The Blue Mountains Eye Study (BMES) is a population-based study of residents aged 49 years or older, in two postcode areas of the Blue Mountains, Australia. The first cross-section (BMES I, 1992-1994) included 3654 participants (82.4% of eligible). The second cross-section (BMES II, 1997-2000) included 3509 participants, 2335 (75.1% of BMES I survivors) and 1174 (85.2% of newly eligible residents who qualified because of age or moved into the area). Detailed history and examinations were conducted. The prevalence of hypertension increased significantly from 45.4% (95% confidence interval, CI 43.7-47.0%) to 52.2% (CI 50.6-53.9%) from 1992-1994 to 1997-2000, paralleled by an increase in the population mean body mass index (BMI) from 26.1 kg/m2 (CI 26.0-26.3 kg/m2) to 27.7 kg/m2 (CI 27.5-27.9 kg/m2). Hypertension awareness decreased significantly from 79.8 to 73.0%, while treatment and control rates decreased from 71.1 to 67.3% and 56.3 to 46.5%, respectively (P<0.0001). Our results showed that elevated BMI (P<0.0001), lack of exercise (P<0.002) and serum triglyceride >2 mmol/l (P<0.0001) were significantly associated with prevalence of hypertension. We found that the prevalence of hypertension in the older Australian population was increasing while awareness, treatment and control rates decreased. Programmes to improve community awareness of hypertension, and its association with BMI may lead to further reductions in blood pressure and the burden of cardiovascular disease.

Development of a parametric simulation model for forecasting goal-oriented treatment outcomes

BACKGROUND

Treatment-to-goal (TTG) analyses are frequently used to predict guideline-directed population control rates for drug therapies based on mean efficacy data. Nevertheless, estimates are commonly inaccurate because variability in efficacy is not considered. A new methodology was developed to improve TTG forecasting.

METHODS

Patient-level blood pressure (BP) lowering data sets, designed to simulate clinical trial results, were generated for testing from three underlying distributions: normal, lognormal, and beta. To emulate real-world conditions where patient-level data are unavailable, two approaches were considered: parametric--simulated BP lowering data were generated using the mean and standard deviation of the test data sets; and point-estimate--BP lowering was uniformly assigned as the mean lowering. BP control (systolic BP < 140 and diastolic BP < 90 mmHg) was forecasted by subtracting values generated by these two methods from baseline BP values in untreated hypertensive patients (n = 2483) from the Third National Health and Nutrition Examination Survey. Estimated control rates were compared to analyses where the patient-level data sets were bootstrapped.

RESULTS

We assumed mean (+/- SD) BP lowering of 20 (12) mmHg systolic and 14 (7) mmHg diastolic. Parametric method predicted a BP control rate of 66.9% [95% confidence interval (CI) 65.7-67.9], similar to the bootstrapping approach (67.3%, 95% CI 65.9-68.8). The control rate projected based on the point-estimate method was 75.5%. The point-estimate method frequently led to substantially different results under a wide range of model assumptions.

CONCLUSIONS

A new parametric-based forecasting method, which addresses underlying variability, improves on estimates based on mean efficacy only. In the absence of patient-level data, this method is generalizable to different therapeutic areas.