Intensive systolic blood pressure targets may be cost-effective across most measurement error possibilities

1. In this microsimulation model of patients with high cardiovascular risk, an intensive systolic blood pressure (SBP) target of <120 mm Hg was found to be cost-effective across many levels of measurement error.

2. More aggressive SBP targets were associated with lower cardiovascular disease event rates but higher rates of severe adverse events.

Evidence Rating Level: 2 (Good)

Study Rundown: Measurement of blood pressure is based on imprecise methods that vary with each other, resulting in variability between clinical trials and routine clinical practice. While intensive systolic blood pressure (SBP) targets in patients at high cardiovascular risk in clinical trials have been found to significantly reduce cardiovascular events and all-cause mortality compared with higher targets, they were also found to be more costly and lead to more adverse events. Using a microsimulation model, this study aimed to assess the effect of SBP measurement error on the cost-effectiveness of various SBP targets for patients at high cardiovascular risk. Measurement error was associated with higher antihypertensive use and lower average SBP, leading to lower cardiovascular disease (CVD) event rates but also higher rates of severe adverse events (SAEs). While more intensive targets increased costs, they also increased the quality-adjusted life expectancy (QALE) and were more cost-effective overall. Sensitivity analyses showed that an intensive target of <120 mm Hg was cost-effective across many levels of SBP measurement error, while a target of <130 mm Hg was cost-effective in scenarios with very high measurement error and increased CVD risk at low SBPs. The generalizability of this study is limited by treatment heterogeneity, uncertainty in the effect of lowering SBP below 115 mm Hg, and potential overestimation of SAEs at lower SBPs. Nevertheless, this study suggests that <120 mm Hg may be a cost-effective and helpful target for controlling SBP in most scenarios, except for very high measurement error and higher-than-expected CVD risk at low SBPs.

Click to read the study in AIM

Relevant Reading: A Randomized Trial of Intensive versus Standard Blood-Pressure Control

In-Depth [prospective cohort study]: This microsimulation model aimed to assess the effect of SBP measurement error on the cost-effectiveness of 3 SBP targets for patients with high cardiovascular risk. The model simulated cost and quality-adjusted life year (QALY) measures across SBP targets of <120 mm Hg, <130 mm Hg, and <140 mm Hg, with individuals having an office visit every month in the simulation. Cost-effectiveness was defined as an incremental cost-effectiveness ratio below $100,000 per QALY. Participants were obtained from NHANES (National Health and Nutrition Examination Survey) data of individuals who were eligible for the SPRINT (Systolic Blood Pressure Intervention Trial) study; they were eligible for this model if they were 50 years or older, had an SBP of 130 to 180 mm Hg, were taking 0 to 4 antihypertensive agents, and were at high CVD risk. Measurement error was found to increase antihypertensive use and reduce average SBP, resulting in lower CVD rates but also higher rates of SAEs. With research-grade measurement (mean error, 0 mm Hg), 7020 lifetime CVD events and 910 SAEs occurred per 10,000 patients at the target of <140 mm Hg. The <130 mm Hg target resulted in 590 fewer CVD events but also 610 more SAEs, while the <120 mm Hg target resulted in 460 fewer CVD events but also 620 more SAEs compared with the <130 mm Hg target. With average measurement error, 6790 lifetime CVD events and 1160 SAEs occurred per 10,000 patients. The <130 mm Hg target resulted in 600 fewer CVD events but also 670 more SAEs, while the <120 mm Hg target resulted in 360 fewer CVD events but also 660 more SAEs compared with the <130 mm Hg target. With research-grade measurement, the <130 mm Hg target resulted in an incremental cost-effectiveness ratio (ICER) of $17,900 per QALY as compared to the  <140 mm Hg target. Compared with 130 mm Hg, the <120 mm Hg target had an ICER of $24,400 per QALY. With average measurement error, the <130 mm Hg target increased costs by $1000 and QALE by 0.048 QALYs, resulting in an ICER of $20,500 per QALY as compared to the <140 mm Hg target. Compared with 130 mm Hg, the <120 mm Hg target increased costs by $1300 and QALE by 0.031 QALYs, resulting in an ICER of $42,000 per QALY. In sensitivity analyses assuming a J-curve relationship between SBP and CVD risk, the <120 mm Hg target was cost-effective only when error was <8.8 mm Hg or when the inflection point was <116 mm Hg. Overall, this study suggests that an SBP target of <120 mm Hg was cost-effective across almost all measurement error scenarios, except for scenarios with high error and high CVD at low SBP.

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