Subject(s)
Acute Coronary Syndrome/therapy , Angina, Unstable/therapy , Percutaneous Coronary Intervention , Platelet Aggregation Inhibitors/therapeutic use , ST Elevation Myocardial Infarction/therapy , Aspirin/therapeutic use , Cardiac Rehabilitation , Clopidogrel/therapeutic use , Combined Modality Therapy , Humans , Practice Guidelines as Topic , Prasugrel Hydrochloride/therapeutic use , Secondary Prevention/methods , Ticagrelor/therapeutic use , United KingdomABSTRACT
Clinical guidelines in the United States and United Kingdom recommend that individuals with suspected hypertension should have ambulatory blood pressure (BP) monitoring to confirm the diagnosis. This approach reduces misdiagnosis because of white coat hypertension but will not identify people with masked hypertension who may benefit from treatment. The Predicting Out-of-Office Blood Pressure (PROOF-BP) algorithm predicts masked and white coat hypertension based on patient characteristics and clinic BP, improving the accuracy of diagnosis while limiting subsequent ambulatory BP monitoring. This study assessed the cost-effectiveness of using this tool in diagnosing hypertension in primary care. A Markov cost-utility cohort model was developed to compare diagnostic strategies: the PROOF-BP approach, including those with clinic BP ≥130/80 mm Hg who receive ambulatory BP monitoring as guided by the algorithm, compared with current standard diagnostic strategies including those with clinic BP ≥140/90 mm Hg combined with further monitoring (ambulatory BP monitoring as reference, clinic, and home monitoring also assessed). The model adopted a lifetime horizon with a 3-month time cycle, taking a UK Health Service/Personal Social Services perspective. The PROOF-BP algorithm was cost-effective in screening all patients with clinic BP ≥130/80 mm Hg compared with current strategies that only screen those with clinic BP ≥140/90 mm Hg, provided healthcare providers were willing to pay up to £20 000 ($26 000)/quality-adjusted life year gained. Deterministic and probabilistic sensitivity analyses supported the base-case findings. The PROOF-BP algorithm seems to be cost-effective compared with the conventional BP diagnostic options in primary care. Its use in clinical practice is likely to lead to reduced cardiovascular disease, death, and disability.
Subject(s)
Blood Pressure Monitoring, Ambulatory/methods , Hypertension/diagnosis , Mass Screening/methods , Adult , Aged , Algorithms , Blood Pressure , Blood Pressure Monitoring, Ambulatory/economics , Cost-Benefit Analysis , England , Female , Humans , Hypertension/economics , Hypertension/epidemiology , Male , Mass Screening/economics , Middle Aged , Primary Health Care/economics , Primary Health Care/statistics & numerical data , Quality of LifeABSTRACT
BACKGROUND: The diagnosis of hypertension has traditionally been based on blood-pressure measurements in the clinic, but home and ambulatory measurements better correlate with cardiovascular outcome, and ambulatory monitoring is more accurate than both clinic and home monitoring in diagnosing hypertension. We aimed to compare the cost-effectiveness of different diagnostic strategies for hypertension. METHODS: We did a Markov model-based probabilistic cost-effectiveness analysis. We used a hypothetical primary-care population aged 40 years or older with a screening blood-pressure measurement greater than 140/90 mm Hg and risk-factor prevalence equivalent to the general population. We compared three diagnostic strategies-further blood pressure measurement in the clinic, at home, and with an ambulatory monitor-in terms of lifetime costs, quality-adjusted life years, and cost-effectiveness. FINDINGS: Ambulatory monitoring was the most cost-effective strategy for the diagnosis of hypertension for men and women of all ages. It was cost-saving for all groups (from -£56 [95% CI -105 to -10] in men aged 75 years to -£323 [-389 to -222] in women aged 40 years) and resulted in more quality-adjusted life years for men and women older than 50 years (from 0·006 [0·000 to 0·015] for women aged 60 years to 0·022 [0·012 to 0·035] for men aged 70 years). This finding was robust when assessed with a wide range of deterministic sensitivity analyses around the base case, but was sensitive if home monitoring was judged to have equal test performance to ambulatory monitoring or if treatment was judged effective irrespective of whether an individual was hypertensive. INTERPRETATION: Ambulatory monitoring as a diagnostic strategy for hypertension after an initial raised reading in the clinic would reduce misdiagnosis and save costs. Additional costs from ambulatory monitoring are counterbalanced by cost savings from better targeted treatment. Ambulatory monitoring is recommended for most patients before the start of antihypertensive drugs. FUNDING: National Institute for Health Research and the National Institute for Health and Clinical Excellence.
Subject(s)
Blood Pressure Monitoring, Ambulatory , Hypertension/diagnosis , Adult , Aged , Blood Pressure Monitoring, Ambulatory/economics , Cardiovascular Diseases/etiology , Cardiovascular Diseases/mortality , Cost-Benefit Analysis , Costs and Cost Analysis , England , Female , Humans , Hypertension/complications , Hypertension/economics , Hypertension/physiopathology , Male , Markov Chains , Middle Aged , Models, Statistical , Quality-Adjusted Life Years , Risk Factors , Sensitivity and SpecificitySubject(s)
Antihypertensive Agents/therapeutic use , Hypertension/drug therapy , Adult , Aged , Aged, 80 and over , Angiotensin Receptor Antagonists/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Black People , Blood Pressure Monitoring, Ambulatory , Calcium Channel Blockers/therapeutic use , Cost-Benefit Analysis , Drug Therapy, Combination , Female , Humans , Hypertension/diagnosis , Male , Middle Aged , Practice Guidelines as Topic , Risk Assessment , United KingdomABSTRACT
The National Clinical Guideline Centre (NCGC) develops evidence-based clinical guidelines on behalf of the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom. The U.K. Department of Health has commissioned NICE to make recommendations on the basis of both clinical effectiveness and cost-effectiveness. This article describes how cost-effectiveness is evaluated and accounted for in NCGC guidelines. Six recent case studies are presented, in which consideration of cost-effectiveness has informed recommendations in various ways for clinical guidelines on alcohol use disorders, chronic obstructive pulmonary disease, glaucoma, lower urinary tract symptoms, non-ST-segment elevation myocardial infarction and unstable angina, and venous thromboembolism prophylaxis. Some of the challenges faced in trying to account for cost-effectiveness in clinical guidelines are outlined, as well as some of the difficulties in adapting cost-effectiveness guidelines for other settings.
Subject(s)
Cost-Benefit Analysis , Evidence-Based Medicine/economics , Evidence-Based Medicine/methods , Practice Guidelines as Topic , Decision Support Techniques , England , Government Agencies , Humans , Northern Ireland , Practice Guidelines as Topic/standards , Quality Control , State Medicine , WalesSubject(s)
Practice Guidelines as Topic , Pulmonary Disease, Chronic Obstructive/therapy , Bronchodilator Agents/therapeutic use , Dyspnea/etiology , Forced Expiratory Volume/physiology , Humans , Pulmonary Disease, Chronic Obstructive/diagnosis , Respiratory Therapy/statistics & numerical data , Smoking Cessation , Vital Capacity/physiologySubject(s)
Angina, Unstable/therapy , Myocardial Infarction/therapy , Angioplasty, Balloon, Coronary , Fibrinolytic Agents/therapeutic use , Humans , Myocardial Ischemia/diagnosis , Patient Care Planning , Patient Discharge , Platelet Aggregation Inhibitors/therapeutic use , Ventricular Dysfunction, Left/diagnosisABSTRACT
OBJECTIVE: To review literature on the impact of bipolar disorder on the workplace, with respect to costs to employers, workplace productivity and functioning, and any employer-initiated programs implemented with the aim of improving work attendance and performance. STUDY DESIGN: Systematic literature review. METHODS: Original studies relating to bipolar disorder in the workplace were identified from PubMed and EMBASE using a reproducible, systematic search strategy in July 2007. There were no constraints on publication dates. Results were first evaluated by title and/or abstract. Full manuscripts of potentially relevant papers then were obtained and assessed for inclusion. Productivity data were extracted in terms of absenteeism, short-term disability, presenteeism, and any associated cost burden to US employers. RESULTS: Seventeen studies met search criteria and were included in this review. The data indicate that bipolar disorder imposes a significant financial burden on employers, costing more than twice as much as depression per affected employee. A large proportion of the total cost of bipolar disorder is attributable to indirect costs from lost productivity, arising from absenteeism and presenteeism. The presence of comorbid conditions and stigma in the workplace may lead to delays in accurate diagnosis and effective management of bipolar disorder. CONCLUSION: Bipolar disorder among the working population can have a significant, negative effect on work relationships, attendance, and functioning, which can lead to substantial costs to US employers arising from lost productivity. There is a need for workplace initiatives to address the health and cost consequences of bipolar disorder within an employed population.