Evidence tables – health economic studies (2011 update)

National Clinical Guideline Centre (UK)

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August 2019: NICE's original guidance on hypertension in adults was published in 2004. It was updated in 2006, 2011 and 2019. See the NICE website for the guideline recommendations and the evidence reviews for the 2019 update. This document PDF preserves evidence reviews and committee discussions for the 2011 guideline. August 2019: The guideline was updated and evidence sections affected and recommendations were removed from this full guideline PDF. November 2016: A footnote was added to PDF recommendations 46, 47, 53, 55, 57 and 58 covering angiotensin-converting enzyme (ACE) inhibitors about 2 MHRA drug safety alerts. These alerts cover ACE inhibitor use during pregnancy and breastfeeding.

Appendix GEvidence tables – health economic studies (2011 update)

Publication Details

G.1. Diagnosis of hypertension

Table

G.3. Initiating and monitoring treatment, including blood pressure targets

G.3.1. Monitoring treatment effect

Table

N = 400 Mean age = 53 years

G.3.2. Blood pressure targets for treatment

Table

N = 18,790 Countries = 26

G.4. Pharmacological interventions

G.4.1. People aged over 80 years

Table

25.8% 1.5mg indapamide SR alone 23.9% 1.5mg indapamide SR and 2mg perindopril

Publication Details

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Publisher

Royal College of Physicians (UK), London

NLM Citation

National Clinical Guideline Centre (UK). Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34 [Internet]. London: Royal College of Physicians (UK); 2011 Aug. (NICE Clinical Guidelines, No. 127.) Appendix G, Evidence tables – health economic studies (2011 update)

L. R. Krakoff. Cost-effectiveness of ambulatory blood pressure: a reanalysis. Hypertension 47 (1):29–34, 2006.

Study details	Population & interventions	Health outcomes	Costs				Cost effectiveness

Economic analysis: Cost analysis Study design: Decision analytic model Approach to modelling: Model calculates the different numbers of treated patients taking into account prevalence of white coat hypertension, annual incidence of new true hypertension in those with white coat hypertension and annual loss to follow-up and treatment. Perspective: USA, healthcare payer Time horizon: 5 years Discounting: Costs: none; Outcomes: n/a	Population: People identified as hypertensive based on CBPM Intervention 1: No further tests to confirm diagnosis, annual follow-up with CBPM Intervention 2: ABPM to confirm diagnosis and at annual follow-up	None	Total costs (mean per patient): Intvn 1: £984				None

			Intvn2:	Total costs	Incremental (2-1)	CI/p

			15%WCH/conv 5%	£922	−£61	NR

			15%WCH/conv 10%	£935	−£49	NR

			15%WCH/conv 20%	£955	−£29	NR

			20%WCH/conv 5%	£886	−£97	NR

			20%WCH/conv 10%	£903	−£81	NR

			20%WCK/conv 20%	£929	−£54	NR

			25%WCH/conv 5%	£850	−£134	NR

			25%WCH/conv 10%	£870	−£113	NR

			25%WCH/conv 10%	£904	−£80	NR

			WCH = baseline prevalence of white coat hypertension; Conv = annual conversion rate of white coat hypertension to true hypertension Currency & cost year: USA dollars, cost year unclear assumed to be 2005^† (presented here as 2005 UK pounds^‡) Cost components incorporated: ABPM; hypertension treatment (visits, diagnostic tests, pharmacotherapy).

Data sources

Health outcomes: Prevalence white coat hypertension: source not stated but rate varied in analysis 15%–20%. Incidence of new hypertension in those with white coat hypertension: based on review of literature and varied in analysis. Annual loss to follow-up and treatment: assumed 5% (limited evidence but considered conservative). Quality-of-life weights: n/a. Cost sources: Cost per ABPM use: Centre for Medicare and Medicaid Services of the United States (£47). Annual treatment cost: estimated based on 5-year survey from US MCO and report that if followed guidelines for using diuretics would reduce by 40% (£212).

Comments

Source of funding: NR. Limitations: Does not incorporate all relevant comparators. Does not incorporate health effects (possibly conservative towards ABPM). Some uncertainty about the applicability of USA costs. Discounting not applied. Source of prevalence of WCH unclear but varied in sensitivity analysis. Limited sensitivity analysis. Other: none

Overall quality^*: Potentially serious limitations			Overall applicability^**: Partially applicable

: Abbreviations: ABPM = ambulatory blood pressure monitoring; CBPM = clinic blood pressure monitoring; CI = confidence interval; NR = not reported; MCO = managed care organisation; NR = not reported.

†: Year paper accepted for publication;

‡: Converted using 2005 Purchasing Power Parities⁴⁶⁸

*: Very serious limitations / Potentially serious Limitations / Minor limitations;

**: Directly applicable / Partially applicable / Not applicable

J. A. Staessen, Hond E. Den, H. Celis, R. Fagard, L. Keary, G, and E. T. O'Brien. Antihypertensive treatment based on blood pressure measurement at = home or in the physician's office: a randomized controlled trial. Journal of the American Medical Association 291 (8):955–964, 2004.
Study details	Population & interventions	Health outcomes	Costs	Cost effectiveness
Economic analysis: CCA Study design: Within RCT analysis Perspective: Belgium health insurance system Follow-up: 1 year Discounting: Costs: n/a; Outcomes: n/a	Population: Patients with hypertension (office DBP >95mmHg) N = 400 Mean age = 53 years M = 48% Belgian 93.2%; Irish 6.8% Intervention 1: Monitoring and treatment adjustment based on CBPM (average of 3). N=203 Intervention 2: Monitoring and treatment adjustment based on average of HBPM (average of 6 per day over 1 week). N=197 Treatment intensified if DBP >89mmHg; treatment reduced if DBP <80mmHg	Blood pressure: BP was significantly lower in the office than the home group. Antihypertensive medications: Significantly more home than office group patients discontinued antihypertensive drug treatment. Left ventricular mass and reported symptoms: No significant differences.	Total costs (mean per patient): Intvn 1: £2811 Intvn 2: £2555 Incremental (2-1): −£256 (CI:NR, p=0.04 ) Currency & cost year: 2002 Belgium Euros (presented here as 2002 UK pounds^†) Cost components incorporated: Antihypertensive drugs, physician visits, HBPM	Basecase ICER (Intvn 2 vs Intvn 1): N/a. Costs were lower in the HBPM group but outcomes blood pressure control was worse. Other: n/a Subgroup analyses: None Analysis of uncertainty: n/a
Data sources
Health outcomes: Within RCT analysis; Quality-of-life weights: n/a. Cost sources: Resource use from within RCT; Belgian units costs from health insurance system for drugs and physician costs. HBPM from manufacturer.
Comments
Source of funding: AstraZeneca and Pfizer Limitations: Some uncertainty about applicability of Belgian resource use and unit costs. QALYs not used (cost consequence analysis). In terms of health effects looks at BP, hypertensive drug use, and LV mass/symptom. Given that blood pressure was significantly different other clinical events and costs of these may be relevant and time horizon may be insufficient. Within trial analysis and so does not incorporate all available evidence on differences between options (need to confirm if study included in clinical review and if other evidence exists. Other: Physician fees and drug costs significantly lower for home monitoring but partially offset by increased cost of home monitoring.
Overall quality^*: Potentially serious limitations		Overall applicability^**: Partially applicable

: Abbreviations: BP = blood pressure; CBPM = clinic blood pressure monitoring; CCA = cost-consequence analysis; CI = confidence interval; DBP = diastolic blood pressure; HBPM = home blood pressure monitoring; ICER = incremental cost-effectiveness ratio; NR = not reported; RCT = randomised clinical trial.

†: Converted using 2002 Purchasing Power Parities⁴⁶⁸.

*: Very serious limitations / Potentially serious Limitations / Minor limitations;

**: Directly applicable / Partially applicable / Not applicable.

B. Jonsson, L. Hansson, and N. O. Stalhammar. Health economics in the hypertension optimal treatment (HOT) study: costs and cost-effectiveness of intensive blood pressure lowering and low-dose aspirin in patients with hypertension. J.Intern.Med. 253:472–480, 2003.
Study details	Population & interventions	Health outcomes	Costs	Cost effectiveness
Economic analysis: Cost analysis/CCA Study design: Within RCT analysis Perspective: International resource use, Swedish costs, healthcare payer Followup: mean 3.8 years Discounting: Costs: NR; Outcomes: NR	Population: Patients with hypertension and DBP110–115mmHg N = 18,790 Countries = 26 Male = NR Mean age = 61.5years Intervention 1: Treatment to target DBP <90mmHg Intervention 2: Treatment to target DBP <85mmHg Intervention 3: Treatment to target DBP <80mmHg All patients received felodipine (CCB). Additional therapy and dose increments in four further steps were prescribed to reach the randomised target. 50% of patients were also randomised to aspirin (75mg daily).	None reported in paper for whole population (only diabetes subgroup). Paper states that differences in events were non-significant in the overall population. See clinical evidence review for more details.	Total costs – all patients (mean per patient): Intvn 1: £2200 Intvn 2: £2282 Intvn3: £2381 Incremental (2-1):£82 (CI: NR, p<0.01) Incremental (3-2):£99 (CI: NR, p<0.01) Incremental (3-1):£181 (CI: NR, p<0.01) Currency & cost year: 1995 Swedish Kroner (presented here as 1995 UK pounds^†) Cost components incorporated: Antihypertensive drugs, physician visits, hospitalisations, side effects.	Basecase ICER: Costs significantly increased as the target was lowered and there was no significant difference in cv events. Subgroup analyses: Diabetes subgroup – out of scope of guideline. Analysis of uncertainty: Cost of non-cv hospitalisations included – increased total costs, differences remained similar. Swedish patients only used – not considered relevant to guideline.
Data sources
Health outcomes: Within RCT analysis; Quality-of-life weights: N/a; Cost sources: Resource use collected within RCT; units costs were from Swedish national data sources or published studies.
Comments
Source of funding: AstraZeneca; Limitations: Some uncertainty about applicability of International resource use and Swedish unit costs. QALYs not used (although clinical outcomes reported as not significantly different). Discounting not applied. Within RCT analysis and so does not incorporate all available evidence on differences between targets; issues raised with interpretation of clinical trial as achieved BPs very similar despite different targets. Other: n/a
Overall quality^*: Potentially serious limitations		Overall applicability^**: Partially applicable

: Abbreviations: BP = blood pressure; CCA = cost-consequence analysis; CI = confidence interval; cv = cardiovascular; DBP = diastolic blood pressure; ICER = incremental cost-effectiveness ratio; NR = not reported; RCT = randomised clinical trial; QALYs = quality-adjusted life years.

†: Converted using 1995 Purchasing Power Parities⁴⁶⁸.

*: Very serious limitations / Potentially serious Limitations / Minor limitations;

**: Directly applicable / Partially applicable / Not applicable.

T. D. Szucs, B. Waeber, and Y. Tomonaga. Cost-effectiveness of antihypertensive treatment in patients 80 years of age or older in Switzerland: an analysis of the HYVET study from a Swiss perspective. Journal of Human Hypertension 24 (2):117–123, 2010.
Study details	Population & interventions	Health outcomes	Costs	Cost effectiveness
Economic analysis: CEA Study design: Decision analytic model based on single RCT (HYVET⁶³⁹). Approach to modelling: Estimated costs based on drug doses and usage in HYVET and key clinical events. Life-years gained were calculated by applying the estimated life expectancy for the population to deaths avoided with treatment. Perspective: Switzerland, healthcare payer Time horizon: 2 years Discounting: Costs: 5%; Outcomes: None	Population: Patients with hypertension and aged >80 years. Intervention 1: No antihypertensive treatment Intervention 2: Antihypertensive treatment 25.8% 1.5mg indapamide SR alone 23.9% 1.5mg indapamide SR and 2mg perindopril 49.5% 1.5mg indapamide SR and 4mg perindopril 100% compliance assumed for all patients.	Primary outcome measure: Life-years (mean per patient) Intvn 1: 1.6216 Intvn 2: 1.6672 Incremental (1–2): 0.0457 (CI: NR ) Other outcome measures (mean per patient): None	Total costs – all patients (mean per patient): Intvn 1: £1021 (undiscounted) Intvn 2: £1006 (undiscounted) Incremental (2-1): −£14 (discounted) (CI: NR, p=NR) Currency & cost year: 2007 Swiss Francs (presented here as 2007 UK pounds^†) Cost components incorporated: Antihypertensive drugs, acute management and follow-up of MI, stroke and heart failure (medication, interventions, hospitalisation, outpatient treatment, rehabilitation).	Basecase ICER: Treatment dominated no treated (lower costs and improved health outcomes) Other: None Subgroup analyses: None Analysis of uncertainty: One way sensitivity analyses of 20% variation in medication cost, cost of stroke, cost of HF, cost of MI, life expectancy. Medication cost and cost of stroke had the biggest impact. Results varied from dominant to £1097 per life year gained.
Data sources
Health outcomes: Swiss population mortality data and HYVET RCT⁶³⁹; Quality-of-life weights: N/a; Cost sources: Resource use for drugs based on HYVET with units costs from Swiss pharmacy retail prices. MI, stoke and HF costs based on published studies – each event includes acute costs and 2 years of follow-up.
Comments
Source of funding: None; Limitations: Some uncertainty about applicability of Swiss unit costs. QALYs not used. Discounting not in line with NICE reference case. Based on single RCT and so does not incorporate all available clinical evidence for patients over 80. Some methodological issues about how health outcomes and costs are calculated and attributed in model. Other: n/a
Overall quality^*: Potentially serious limitations		Overall applicability^**: Partially applicable

: Abbreviations: BP = blood pressure; CEA = cost effectiveness analysis; CI = confidence interval; DBP = diastolic blood pressure; HF = heart failure; ICER = incremental cost-effectiveness ratio; MI = myocardial infarction; NR = not reported; RCT = randomised clinical trial; QALYs = quality-adjusted life years.

†: Converted using 2007 Purchasing Power Parities⁴⁶⁸.

*: Very serious limitations / Potentially serious Limitations / Minor limitations;

**: Directly applicable / Partially applicable / Not applicable.