Cost-effectiveness of Intensive Blood Pressure Management

IMPORTANCE Among high-risk patients with hypertension, targeting a systolic blood pressure of 120mmHg reduces cardiovascular morbidity and mortality compared with a higher target. However, intensive blood pressure management incurs additional costs from treatment and from adverse events. OBJECTIVE To evaluate the incremental cost-effectiveness of intensive blood pressure management compared with standard management. DESIGN, SETTING, AND PARTICIPANTS This cost-effectiveness analysis conducted from September 2015 to August 2016 used a Markov cohort model to estimate cost-effectiveness of intensive blood pressure management among 68-year-old high-risk adults with hypertension but not diabetes. We used the Systolic Blood Pressure Intervention Trial (SPRINT) to estimate treatment effects and adverse event rates. We used Centers for Disease Control and Prevention Life Tables to project age-and cause-specific mortality, calibrated to rates reported in SPRINT. We also used population-based observational data to model development of heart failure, myocardial infarction, stroke, and subsequent mortality. Costs were based on published sources, Medicare data, and the National Inpatient Sample. INTERVENTIONS Treatment of hypertension to a systolic blood pressure goal of 120mmHg (intensive management) or 140mmHg (standard management). MAIN OUTCOMES AND MEASURES Lifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually. RESULTS Standard management yielded 9.6 QALYs and accrued $155 261 in lifetime costs, while intensive management yielded 10.5 QALYs and accrued $176 584 in costs. Intensive blood pressure management cost $23 777 per QALY gained. In a sensitivity analysis, serious adverse events would need to occur at 3 times the rate observed in SPRINT and be 3 times more common in the intensive management arm to prefer standard management. CONCLUSIONS AND RELEVANCE Intensive blood pressure management is cost-effective at typical thresholds for value in health care and remains so even with substantially higher adverse event rates.