U.S. flag

An official website of the United States government

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

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.)

Cover
  • 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.

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.

Cover of Hypertension

Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34 [Internet].

Show details

Appendix GEvidence tables – health economic studies (2011 update)

G.1. Diagnosis of hypertension

L. R. Krakoff. Cost-effectiveness of ambulatory blood pressure: a reanalysis. Hypertension 47 (1):29–34, 2006.
Study detailsPopulation & interventionsHealth outcomesCostsCost 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		NoneTotal costs (mean per patient): Intvn 1: £984None
Intvn2:Total costsIncremental (2-1)CI/p
15%WCH/conv 5%£922−£61NR
15%WCH/conv 10%£935−£49NR
15%WCH/conv 20%£955−£29NR
20%WCH/conv 5%£886−£97NR
20%WCH/conv 10%£903−£81NR
20%WCK/conv 20%£929−£54NR
25%WCH/conv 5%£850−£134NR
25%WCH/conv 10%£870−£113NR
25%WCH/conv 10%£904−£80NR
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 limitationsOverall 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

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

G.3.1. Monitoring treatment effect

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 detailsPopulation & interventionsHealth outcomesCostsCost 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 limitationsOverall 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.

G.3.2. Blood pressure targets for treatment

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 detailsPopulation & interventionsHealth outcomesCostsCost 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 limitationsOverall 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.

G.4. Pharmacological interventions

G.4.1. People aged over 80 years

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 detailsPopulation & interventionsHealth outcomesCostsCost 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 limitationsOverall 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.

Copyright © 2011, National Clinical Guideline Centre.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of National Clinical Guideline Centre to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

Bookshelf ID: NBK83279
Contents

Views

  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (11M)
  • Disable Glossary Links

In this Page

Other titles in this collection

Related NICE guidance and evidence

Recent Activity

ClearTurn OffTurn On

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...