Hypertension Cost effectiveness Mark Caulfield For the British Hypertension Society The William Harvey Research Institute and Barts and The London NIHR.

Hypertension Cost effectiveness

Mark Caulfield

For the British Hypertension Society

The William Harvey Research Institute and Barts and The London NIHR Biomedical Research Unit

Queen Mary University of London

Launch: Wednesday 24th August 2011

NICE clinical guideline 127

The guideline

2004: National Institute for Health and Clinical Excellence (NICE) hypertension guideline

2006: Drug model developed as part of pharmacological update to guideline

2011: Model updated during second guideline update

National Collaborating Centre for Chronic Conditions

Model overviewPopulation

•Patients with essential hypertension seen in primary care

•Base case patient: 65-year-old men and women with 2% CVD risk, 1% HF risk and 1.1% diabetes risk

Comparators

•no intervention (NI)

•thiazide-type diuretics (TD)

•calcium-channel blockers (CCB)

•beta-blockers (BB)

•ACE inhibitors/angiotensin-II receptor antagonists (ACE/ARB)

Perspective and time horizon

•UK NHS perspective, lifetime horizon

Model overview: model structureMarkov model

Health states chosen to represent disease (simplification/data dependant)

•Transitions between health states affected by the effectiveness of treatments over time (Cycles)

Model inputs: drug effectiveness

•Systematic clinical review and meta analysis

•Head to head studies off different drug classes reporting various clinical outcomes

OutcomeThiazide-type diuretics (D)

Calcium-channel blockers (C)

Beta-blockers (B)

ACEi/ARB (A)

UA 0.893 0.881 0.984 1.01MI 0.78 0.796 0.855 0.85Diabetes 0.985 0.808 1.137 0.77Stroke 0.69 0.656 0.851 0.69Heart failure 0.53 0.731 0.761 0.65

Death 0.91 0.883 0.939 0.9

Studies included in systematic review•ALLHAT 2002

•ANBP2 2003

•ASCOT 2005

•CORD 2009

•ELSA 2002

•HAPPHY 1987

•INSIGHT 2000

•INVEST 2003

•JMIC-B 2004

•LIFE 2002

•MIDAS 1998

•MRC 1985

•MRC-0 1992

•NICS-EH 1999

•ONTARGET 2008

•PHYLLIS 2004

•SHEP-P 1985

•SHEP 1991

•STOP-H2 1999

•SYST-EUR 2000

•Tedesco 2007

•VALUE 2004

•VHAS 1998

Model inputs: drug costs

UK generic list prices (BNF)Drug used in model 2011 Yearly drug

cost (EUR)2006 Yearly drug cost (EUR)

ACEiRamipril (10mg)

£21 (€26) £30 (€49)

ARBLosartan (100mg)

£26 (€32) £217 (€287)

BBAtenolol (100mg)

£13 (€16) £13 (€17)

CCBAmlodipine (10mg)

£19 (€24) £70 (€92)

DDBendroflumethiazide (2.5mg)

£12 (€15) £17 (€22)

Interpreting cost effectiveness results•Clinical and cost effectiveness

•Cost effectiveness = Costs and health outcomes and getting the most health gain from the resources available

•Health is measured in QALYs

•Life years x QoL (Utility) = QALY

=

Cost per QALY gained

Difference in costs

Difference in QALYs

=

Incremental cost-effectiveness ratio (ICER)

Health economics of HTN therapy 2006

Health economics of HTN therapy 2011

Uncertainty - sensitivity analysis

•Varying individual parameters to test sensitivity of model results

•Risk of CVD events (HF, MI, UA etc...)•Effectiveness of drugs•Cost of drugs and events•Side effects of drugs

•Model remained fairly robust to changes

•In a few extreme scenario analyses, other drugs became cost effective (mainly diuretics)

Interpretation•Treatment of hypertension is highly cost effective

•Based on UK, generic drug prices

•CCBs are the most cost effective option with an ICER below £2,000

•The results are more robust than in the 2006 model

•As commonly used anti-hypertensives become generic it is now cheaper to treat hypertension than to do nothing

AcknowledgementsKate Lovibond

Ralph Hughes

Prof Bryan Williams

Leo Nherera

Joanne Lord

2006 hypertension (update) GDG members

2011 hypertension (update) GDGmembers

British Hypertension Society

National Institute for Health and Clinical Excellence