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Clinical and Experimental Hypertension Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/iceh20
Quantifying the economic benefits of prevention in a healthcare setting with severe financial constraints: the case of hypertension control a
a
a
Kostas Athanasakis , Ilias-Ioannis Kyriopoulos , Nadia Boubouchairopoulou , George S. b
a
Stergiou & John Kyriopoulos a
Department of Health Economics, National School of Public Health, Athens, Greece and
b
Hypertension Center, STRIDE Hellas-7, Third University Department of Medicine, Sotiria Hospital, Athens, Greece Published online: 12 Dec 2014.
Click for updates To cite this article: Kostas Athanasakis, Ilias-Ioannis Kyriopoulos, Nadia Boubouchairopoulou, George S. Stergiou & John Kyriopoulos (2015) Quantifying the economic benefits of prevention in a healthcare setting with severe financial constraints: the case of hypertension control, Clinical and Experimental Hypertension, 37:5, 375-380, DOI: 10.3109/10641963.2014.977488 To link to this article: http://dx.doi.org/10.3109/10641963.2014.977488
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http://informahealthcare.com/ceh ISSN: 1064-1963 (print), 1525-6006 (electronic) Clin Exp Hypertens, 2015; 37(5): 375–380 ! 2015 Informa Healthcare USA, Inc. DOI: 10.3109/10641963.2014.977488
Quantifying the economic benefits of prevention in a healthcare setting with severe financial constraints: the case of hypertension control Kostas Athanasakis1, Ilias-Ioannis Kyriopoulos1, Nadia Boubouchairopoulou1, George S. Stergiou2, and John Kyriopoulos1 Department of Health Economics, National School of Public Health, Athens, Greece and 2Hypertension Center, STRIDE Hellas-7, Third University Department of Medicine, Sotiria Hospital, Athens, Greece
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Abstract
Keywords
Hypertension significantly contributes to the increased cardiovascular morbidity and mortality, thus leading to rising healthcare costs. The objective of this study was to quantify the clinical and economic benefits of optimal systolic blood pressure (SBP), in a setting under severe financial constraints, as in the case of Greece. Hence, a Markov model projecting 10-year outcomes and costs was adopted, in order to compare two scenarios. The first one depicted the ‘‘current setting’’, where all hypertensives in Greece presented an average SBP of 164 mmHg, while the second scenario namely ‘‘optimal SBP control’’ represented a hypothesis in which the whole population of hypertensives would achieve optimal SBP (i.e. 5140 mmHg). Cardiovascular events’ occurrence was estimated for four sub-models (according to gender and smoking status). Costs were calculated from the Greek healthcare system’s perspective (discounted at a 3% annual rate). Findings showed that compared to the ‘‘current setting’’, universal ‘‘optimal SBP control’’ could, within a 10-year period, reduce the occurrence of nonfatal events and deaths, by 80 and 61 cases/1000 male smokers; 59 and 37 cases/1000 men non-smokers; whereas the respective figures for women were 69 and 57 cases/1000 women smokers; and accordingly, 52 and 28 cases/1000 women non-smokers. Considering health expenditures, they could be reduced by approximately E83 million per year. Therefore, prevention of cardiovascular events through BP control could result in reduced morbidity, thereby in substantial cost savings. Based on clinical and economic outcomes, interventions that promote BP control should be a health policy priority.
Blood pressure, cost, economic benefits, hypertension, prevention
Introduction Hypertension is a chronic condition in which blood pressure in the arteries is elevated. High-blood pressure represents one of the major risk factors and the main underlying cause of ischemic heart disease, stroke, renal failure and peripheral arteriopathy. Presenting a global prevalence at approximately 40% for people aged 25 and above, hypertension seems to cause 47% of deaths related to heart disease and 54% of those related to stroke (1). Notwithstanding hypertension is a highly prevalent risk factor, it is also a preventable one. It is a widely acknowledged and corroborated fact, that in individuals with hypertension, BP reduction significantly reduces cardiovascular morbidity and mortality (2,3), preventing events both, in primary and secondary level (4). Healthy diet, reduced salt intake, physical activity and pharmaceutical treatment are considered as the main interventions towards BP control (5–7). Taking into
Correspondence: Nadia Boubouchairopoulou, BSc, MSc, Department of Health Economics, National School of Public Health, Athens, Greece. Tel: +30-213-2010248; Fax: +30-210-6449571; E-mail: nadia.phar@ gmail.com
History Received 28 August 2014 Revised 2 October 2014 Accepted 13 October 2014 Published online 11 December 2014
account the aforementioned, high-blood pressure can be regarded as a major public health issue, greatly contributing to the global burden of disease and death, and therefore inducing important increases in healthcare expenditure. In the case of hypertension, the associated costs are substantial, and according to the demographic transition they are continuously rising (8,9). Globally, the cost of suboptimal BP control was estimated at US $370 billion in 2001, representing about 10% of the world’s aggregate healthcare expenditures (10). In the United States, costs of high-blood pressure (BP) were estimated at $46.4 billion for 2010, while according to projections, in 2030, the corresponding cost will approximately be $274 billion (11). Figures from Europe also support the finding of significant expenditures attributed to elevated BP (12). In light of the above, healthcare systems are obliged to efficiently manage resource allocation in order to meet patients’ needs, and therefore, clinical evidence is further enhanced when supported by data on economic implications of a given health intervention. In this framework, the present study aims to highlight the importance of effective hypertension management as a healthcare priority, by estimating potential, clinical and economic benefits of optimal SBP control, especially in a setting under financial restraints such
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as Greece. Consequently, the main objective of the analysis was to quantify the aforementioned benefits through the comparison of the present situation regarding hypertension in Greece, with the hypothesis that all hypertensives would attain optimal SBP.
Methods
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Overview of the research hypothesis The present study aimed at comparing two different scenarios; the first representing the current situation regarding hypertension in Greece, while the second one illustrating a hypothetical scenario in which all hypertensives would achieve optimal BP control. The research hypothesis was influenced by Lloyd et al., who estimated the cost and morbidity of uncontrolled hypertension in the UK, and, in specific, the number of major cardiovascular events (myocardial infarction, congestive heart failure and stroke) along with the according hospital costs that would be avoided if hypertensive patients reached optimal BP (13) (Figure 1). In this context, we aimed at presenting updated results, for a resource limited setting, according to the currently existing epidemiological data and methodological tools. The main purpose was therefore to evaluate the clinical effectiveness and economic savings that could accrue from preventive measures in the case of hypertension (14). More precisely, hypertension’s outcomes and associated costs were compared to a hypothetical strategy’s outcomes where all patients would achieve optimal BP, thus leading to clinical efficacy and cost savings. In the first scenario representing the current status, the mean systolic BP (SBP) for hypertensive patients was considered to be 164 mmHg, which is well above the recommended therapeutic targets, and implies that a large proportion of the population does not attain optimal BP levels. The SBP level considered was based on a study by Athanasakis et al., in which a cost-utility analysis was performed, using a six-state Markov model in order to simulate the occurrence of major cardiovascular events for both, treated and untreated hypertensive patients, in Greece (15). This figure is in line with a previously published survey Figure 1. Overview of the research hypothesis. Influenced by Lloyd et al. (13).
Current situaon regarding SBP (partly uncontrolled SBP
conducted by Efstratopoulos et al., including 11 950 subjects, who attended 98 primary healthcare centers in Greece, and in which mean SBP levels were 161.4 mmHg in untreated hypertensives and 164.8 mmHg in treated uncontrolled hypertensives (16). The second hypothetical scenario assumed a universal BP control, namely that all hypertensive patients reach a BP target of 5140 mmHg (SBP) as recommended by current guidelines (17). Health economics model Predictive modeling was the technique used in the present study in order to support the research hypothesis, as there was a time lag between the ‘‘current state’’ of a patient’s BP level and the occurrence of cardiovascular events, associated with hypertension. More specifically, an adaptation of a previously published Markov model was employed (Figure 2) (15). The model included six mutually exclusive health states: ‘‘healthy with hypertension’’, ‘‘myocardial infarction’’ (MI), ‘‘post-MI’’, ‘‘stroke’’, ‘‘post-MI’’ and ‘‘death’’. The state ‘‘healthy with hypertension’’ corresponded to individuals
Figure 2. The Markov model of the analysis. Athanasakis et al. (15).
Risk equaons for CVD
Burden of disease (expected CVD episodes)
Data on costs
Cost of episodes due to SBP level
Data on costs
Cost of episodes due to SBP level
Health expenditure reducon due to SBP control
Research hypothesis: universal SBP control
Risk equaons for CVD
Burden of disease (expected CVD episodes)
10 years
Economic benefits of hypertension’s prevention
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DOI: 10.3109/10641963.2014.977488
suffering from hypertension but not from subsequent cardiovascular disease. ‘‘Myocardial infarction’’ was associated with the occurrence of an event in the first 12 months, ‘‘postMI’’ with the period afterwards, whereas the same logic was followed for the states ‘‘stroke’’ and ‘‘post-stroke’’. The sixth state (Death) simulated fatalities from a cardiovascular event and thus was an absorbing state in the model. All patients included in the model commenced in the ‘‘healthy with hypertension’’ health state. At each cycle, a patient had a probability of remaining in that state, experiencing a myocardial infarction, or a stroke, or die. If the patient had a myocardial infarction, he/she would move to the ‘‘post-MI’’ or ‘‘death’’ state. Accordingly, after experiencing a stroke, the patient could either move to the ‘‘post-stroke’’ or ‘‘death’’ state. Finally, patients in ‘‘post-MI’’ or ‘‘post-stroke’’ health states could either remain in the same state or move to ‘‘death’’. The predictive model was constructed for 1-year cycles and simulated the progress of patients for a 10-year period, in which events occurred according to a given set of probabilities, depending on the population’s characteristics. Stroke and MI occurrence probabilities were derived from the Framingham Heart Study risk equation and were contingent upon to demographics and BP levels (18,19). Survival following a non-fatal cardiovascular event was modeled based on the corresponding results of an analysis of the Framingham cohort (20), by fitting an exponential function in order to project survival and using the cumulative form of the function to estimate 1-year probabilities. Deaths from cardiovascular events were estimated via the specific calibration for Greece of the SCORE risk calculator (HellenicSCORE) (21,22). All risks deriving from the risk equations were age-, sex- and smoking status-dependent and converted to 1-year probabilities. Age- and genderspecific all-cause mortality (background mortality) was also taken into account in the model. This procedure was repeated for four sub-models, differentiated by gender and smoking status. Finally, it must be mentioned that extrapolation was inevitable in order to obtain cumulative data for the entire population, since Markov models are cohort models. In the case of Greece, published data for the prevalence of hypertension (23), smoking (24) and estimates on absolute numbers in the general population (25) were used. The baseline characteristics of the population under analysis are reported in Table 1. Cost calculations Cost calculation was based on the translation of prevented morbidity and mortality into economic terms for a 10-year period. Thus, it included the number of prevented non-fatal strokes and MI events, as well as the cumulative cardiovascular deaths prevented, due to effective hypertension control (as defined by the recommended BP levels), multiplied by their respective costs. For the purpose of this analysis, only direct care costs were taken into account, and a more conservative approach was adopted. Costs of cardiovascular episodes were calculated according to the latest official Greek DRG price list of 2012
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Table 1. Base-case analysis variables. Variable
Value
Baseline demographics of the population Average age (men) 55.1 years (15) Average age (women) 57.6 years (15) Average systolic BP (current situation) (men) 163.2 mmHg (15) Average systolic BP (current situation) 165.4 mmHg (15) (women) Prevalence of hypertension (men) 40.2% (23,25) Prevalence of hypertension (women) 38.9% (23,25) Prevalence of smoking (men) 45% (24,25) Prevalence of smoking (women) 38% (24,25) Total population of men 3 736 770 (25) Total population of women 3 972 797 (25) Cost inputs (cost per episode) Average in-hospital cost of non-fatal stroke 3624.9E (27) Average cost of fatal stroke 3596.1E (27) Average cost per MI episode (fatal or non-fatal) 2978.1Ea Discount rate 3% (28) a
Average KEN-DRG rate multiplied by 2.09 in order to account for healthcare personnel costs, according to the regulations by the Ministry of Health, Hellenic Republic.
Table 2. Benefits from SBP control: avoided episodes per 1000 patients (in a period of 10 years).
Population Male smokers Male non-smokers Female smokers Female non-smokers
Avoided strokes per 1000 patients
Avoided MI per 1000 patients
Avoided deaths per 1000 patients
15 10 14 11
65 49 55 41
61 37 57 28
(26) and a local cost-of-illness analysis (27). Results were discounted at a 3% discount rate (28). Unit costs are reported in Table 1.
Results Impact of BP control on the burden of disease According to the results of the predictive model, universal BP control within the specified therapeutic targets could, in a cohort of 1000 male smokers, reduce the occurrence of nonfatal events (strokes and MIs) and deaths, by 80 and 61 cases, respectively, in 10 years. Respective figures were 59 and 37 cases for men non-smokers, 69 and 57 cases for women smokers, and 52 and 28 cases for women non-smokers (Table 2). Based on population data and according to the literature, there are approximately 3 047 599 patients suffering from hypertension in Greece (23,25). Considering the above and the smoking prevalence in Greece (24,25), among hypertensive patients 675 982 are male and 587 259 female smokers. For the aforementioned population and compared to current status of BP control, our analysis concluded that a hypothetical scenario of universal BP control could lead to 37 163 fewer strokes, 156 006 avoided MIs and 133 281 avoided deaths, for the entire Greek population of hypertensives, on a 10-year horizon (Table 3).
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Table 3. Benefits from SBP control: avoided episodes for the total population (in a period of 10 years).
Population Male smokers Male non-smokers Female smokers Female non-smokers Total
Patients with hypertension (23,24,25)
Avoided strokes
Avoided myocardial infarctions
Avoided deaths
675 982 826 200 587 259 958 159 3 047 600
10 140 8262 8222 10 540 37 163
43 939 40 484 32 299 39 285 156 006
41 235 30 569 34 648 26 828 133 281
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Table 4. Avoided cardiovascular episodes and reduction of health expenditure, as a result of SBP control (discounted costs, 3% rate). Cardiovascular episodes
Avoided episodes
Health expenditure decrease (E)
Strokes MI Cardiovascular deaths Total
37 163 156 006 133 281
119 334 821.7 397 129 180.7 313 663 094.3 830 127 096.7
Impact of BP control on health expenditure Based on the results presented above, healthcare expenditure savings, due to avoided stroke and MI cases, were estimated at E119 334 822 and E397 129 181 respectively. Moreover, prevented cardiovascular deaths, due to effective BP control, could generate additional savings of E313 663 094 (Table 4). Taking into consideration the aforementioned outcomes, overall savings were estimated at E830 127 097, over a 10year period from the attainment of BP target onwards, or on average, at E83 million per year (undiscounted estimate: E103/year), representing about 0.46% of the total health expenditures (29).
Discussion Hypertension represents a major modifiable risk factor for cardiovascular diseases worldwide (14). Optimal BP control significantly reduces cardiovascular morbidity and mortality (30,31), and, hence, the need for adequate disease management is a prerequisite for substantial healthcare cost savings. This analysis aimed at demonstrating the benefits of a hypothetical ‘‘universal BP regulation’’, in terms of burden of disease and potential economic savings in the Greek setting, constituting an interesting case study for any similar analysis, due to the current severe financial constraints and the restrictive fiscal environment. The main objective was to give an insight of the valuable outcomes, resulting from the optimal BP control and the benefits accrued from preventive health measures, nevertheless the present study does not constitute a cost-effectiveness analysis. The results of the analysis and the projections generated, based on the risk equations, suggested that effective BP control could lead to significant reduction in morbidity and mortality attributed to cardiovascular disease, especially in the population of smokers, who are at higher cardiovascular risk compared to non-smokers. Findings also implied that BP control could generate considerable savings, calculated at
approximately E83 million per year, apparently resulting from reduced morbidity. Taking into account the aforesaid, universal BP control could provide significant cost savings, which could help in relieving the pressure inflicted in economic systems under fiscal constraints, imposing severe austerity measures in the healthcare sector as observed in the case of Greece. The present findings seem generally to be in line with a rather small number of previously published studies. At that point, it must be mentioned that a paucity of data and comparable surveys has been noticed during the last decade. Therefore, only the general trends outlined from such studies can eventually be compared. Lloyd et al. (13) estimated that 58 000 cardiovascular events per year, attributed to high BP, could be avoided in the UK, while the savings, if BP of all patients was at target levels, would be approximately £97.2 million per year (2000/ 01 prices). He and MacGregor found that BP control could lead to 42 800 avoided strokes and 82 800 avoided ischemic heart disease events in the UK each year, resulting in a total reduction of 125 600 events (32). The aforementioned cost and clinical benefits occurring from BP control are comparable with the outcomes of the present study. Nevertheless, a head-to-head comparison is not feasible as the former was conducted a decade before. Another survey conducted in 2002 in five European countries (France, Germany, Italy, Sweden and the UK) concluded that the costs imposed due to uncontrolled BP were also high and more precisely calculated at E1.26 billion (33). Finally, Gaziano et al. computed the global cost of non-optimal BP at $370 billion in 2001, namely 10% of the global healthcare spending. The same study highlights that the costs may rise up to $1 trillion in the next years (34). However, the present analysis differs with regards to the analytical approach used as, to the best of our knowledge, it represents the first case of a Markov’s model use that incorporates (time-dependent) baseline population characteristics and established risk scores, for the development of the research hypothesis. Possible limitations of the present study could firstly include methodological issues. The Markov model is a stochastic model requiring homogeneity of individuals within a cohort. Moreover, the analysis was undertaken from a third-party payer perspective, and, therefore, it does not include societal costs, productivity losses related to the disease and costs of informal care. The latter constitutes an important cost variable, especially for patients whose daily activities are severely impaired by the disease. Indicatively, informal care costs can account for up to 21% or 25% of total cost, for patients who have experienced a cerebrovascular or coronary heart disease event, respectively (35,36). Mainly because of the limitations stated above, the analysis followed a rather conservative approach, implying that the presented cost-savings could probably be underevaluated, particularly due to the following: (a) the estimate did not include the cost of non-acute (outpatient) care for strokes and MI events, (b) savings due to reduced use of healthcare resources were not taken into account (medical appointments, diagnostic tests), (c) high BP could lead to several preventable consequences apart from strokes, MI episodes and worsening of patients’ quality of life, which were not included and (d) uncontrolled BP and subsequent diseases also implied an
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DOI: 10.3109/10641963.2014.977488
indirect cost due to productivity losses. Taking into account the aforesaid would certainly increase the cost of uncontrolled hypertension and, thereby, the potential benefits of BP control. However, it should be mentioned that the cost incurred by the implementation of hypertension preventive health measures was not considered, and, therefore, the shortterm cost-savings could eventually be regarded as limited, while long-term economic benefits could be significant, outweighing the intervention costs. Moreover, it is acknowledged that cardiovascular mortality is not solely an issue of increased BP, since other factors contribute, as well. Nevertheless, the present study focused on BP control and did not extend to other research hypotheses. Finally, a degree of uncertainty emanates from the use of the Framingham risk equations for some of the disease states in the model, given that there is evidence of possible overestimations of cardiovascular events in South-European populations (37). This uncertainty, however, is difficult to be quantified for our study population. Uncontrolled BP is a major public health issue in Greece and worldwide, with considerable impact on global morbidity and mortality, thus imposing an important economic burden. In this context, controlling BP could substantially improve health indicators, generate cost savings and lead to adequate disease management in several healthcare systems, especially in cases such as Greece, being financially restrained. In line with the aforesaid, the present analysis could be regarded as a reference for further studies that could be conducted in other health systems, as the methodology followed enables the extrapolation of the results to other countries. Consequently, BP control can be considered as a challenging public health issue and a priority for health policy-makers, not only as a means for improving the population’s health status, but also as a cost-containment measure.
Acknowledgements We thank Vanessa Tsiantou for helpful discussions and comments.
Declaration of interest No conflict of interest declared for all authors. No funding was provided for this project.
References 1. WHO. A global brief on hypertension. Geneva: World Health Organization; 2013. 2. MacMahon S, Peto R, Cutler J, et al. Blood pressure, stroke, and coronary heart disease. Part 1, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet 1990;335:765–74. 3. Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated with antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA 2003;289: 2534–44. 4. Rashid P, Leonardi-Bee J, Bath P. Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review. Stroke 2003;34:2741–8. 5. He J, Whelton PK, Appel LJ, et al. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000;35:544–9.
Economic benefits of hypertension’s prevention
379
6. Freis ED. Salt, volume and the prevention of hypertension. Circulation 1976;53:589–95. 7. Haapanen N, Miillunpalo S, Vuori I, et al. Association of leisure time physical activity with the risk of coronary heart disease, hypertension and diabetes in middle-aged men and women. Int J Epidemiol 1997;26:739–47. 8. Institute of Medicine (US) Committee on Preventing the Global Epidemic of Cardiovascular Disease. Meeting the challenges in developing countries. In: Fuster V, Kelly BB, eds. Promoting cardiovascular health in the developing world: a critical challenge to achieve global health. Washington, DC: National Academies Press (US); 2010:125–45. 9. A report by the World Economic Forum and the Harvard School of Public Health, September 2011. The Global Economic Burden of Non-communicable Diseases. Available from: http://www3. weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNon CommunicableDiseases_2011.pdf [last accessed 20 Sep 2014]. 10. Gaziano TA, Bitton A, Anand S, Weinstein MC. The global cost of nonoptimal blood pressure. J Hypertens 2009;27: 1472–7. 11. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics-2014 update: a report from the American Heart Association. Circulation 2014;129:399–410. 12. Leal J, Luengo-Fernandez R, Gray A, et al. Economic burden of cardiovascular diseases in the enlarged European Union. Eur Heart J 2006;27:1610–19. 13. Lloyd A, Schmieder C, Marchant N. Financial and health costs of uncontrolled blood pressure in the United Kingdom. Pharmacoeconomics 2003;21:33–41. 14. Danaei G, Finucane MM, Lin JK, et al; Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Blood Pressure). National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 54 million participants. Lancet 2011;377:568–77. 15. Athanasakis K, Souliotis K, Tountas Y, et al. A cost-utility analysis of hypertension treatment in Greece: assessing the impact of age, sex and smoking status, on outcomes. J Hypertens 2012;30: 227–34. 16. Efstratopoulos AD, Voyaki SM, Baltas AA, et al. Prevalence, awareness, treatment and control of hypertension in Hellas, Greece: the Hypertension Study in General Practice in Hellas (HYPERTENSHELL) national study. Am J Hypertens 2006;19: 53–60. 17. Mancia G, Fagard R, Narkiewicz K, et al. ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013;34:2159–219. 18. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285:2486–97. 19. D’Agostino RB, Wolf PA, Belanger AJ, Kannel WB. Stroke risk profile: adjustment for antihypertensive medication. The Framingham Study. Stroke 1994;25:40–3. 20. Peeters A, Mamum AA, Willekens F, Bonneux L. A cardiovascular lifehistory. A life course analysis of the original Framingham Heart Study cohort. Eur Heart J 2002;23:458–66. 21. Conroy RM, Pyorala K, Fitzgerald AP, et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003;24:987–1003. 22. Panagiotakos DB, Fitzgerald AP, Pitsavos C, et al. Statistical modeling of 10-year fatal cardiovascular disease risk in Greece: the HellenicSCORE (a Calibration of the ESC Score Project). Hellenic J Cardiol 2007;48:55–63. 23. Psaltopoulou T, Orfanos P, Naska A, et al. Prevalence, awareness, treatment and control of hypertension in a general population sample of 26 913 adults in the Greece EPIC study. Int J Epidemiol 2004;33:1345–52. 24. Filippidis FT, Vardavas CI, Loukopoulou A, et al. Prevalence and determinants of tobacco use among adults in Greece: 4 year trends. Eur J Public Health 2013;23:772–6.
380
K. Athanasakis et al.
Downloaded by [University of Regina] at 16:36 06 September 2015
25. National Statistical Authority of Greece. Available from: www. statistics.gr (last accessed 28 Oct 2013). 26. Hellenic Ministry of Health, KEN-DRGs. Available from: http://www.moh.gov.gr/articles/health/domes-kai-draseis-gia-thnygeia/articles/health/domes-kai-draseis-gia-thn-ygeia/articles/health/ domes-kai-draseis-gia-thn-ygeia/articles/ken-eswteriko/1079-nea-listaken-apo-1-3-2012-kostos-mdn (last accessed 27 Oct 2013). 27. Gioldasis G, Talelli P, Chroni E, et al. In-hospital direct cost of acute ischemic and hemorrhagic stroke in Greece. Acta Neurol Scand 2008;118:268–74. 28. Drummond M, O’Brien B, Stoddart G, Torrance G. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford: Oxford University Press; 2005. 29. Organisation for Economic Co-operation and Development (OECD). Available from: http://stats.oecd.org (last accessed 21 Sept 2014). 30. Collins R, MacMahon S. Blood pressure, antihypertensive drug treatment and the risks of stroke and of coronary heart disease. Br Med Bull 1994;50:272–98.
Clin Exp Hypertens, 2015; 37(5): 375–380
31. Hansson L. The benefits of lowering elevated blood pressure: a critical review of studies of cardiovascular morbidity and mortality in hypertension. J Hypertens 1996;14:537–44. 32. He FJ, MacGregor GA. Cost of poor blood pressure control in the UK: 62 000 unnecessary deaths per year. J Hum Hypertens 2003; 17:455–7. 33. Hansson L, Lloyd A, Anderson P, Kopp Z. Excess morbidity and cost of failure to achieve targets for blood pressure control in Europe. Blood Press 2002;11:35–45. 34. Gaziano TA, Bitton A, Anand S, Weinstein MC. The global cost of non optimal blood pressure. J Hypertens 2009;27:1472–7. 35. Luengo-Fernandez R, Leal J, Gray A, et al. Cost of cardiovascular diseases in the United Kingdom. Heart 2006;92:1384–9. 36. Liu JL, Maniadakis N, Gray A, Rayner M. The economic burden of coronary heart disease in the UK. Heart 2002;88: 597–603. 37. Menotti A, Puddu PE, Lanti M. Comparison of the Framingham risk function-based coronary chart with risk function from an Italian population study. Eur Heart J 2000;21:365–70.
Clinical and Experimental Hypertension Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/iceh20
Quantifying the economic benefits of prevention in a healthcare setting with severe financial constraints: the case of hypertension control a
a
a
Kostas Athanasakis , Ilias-Ioannis Kyriopoulos , Nadia Boubouchairopoulou , George S. b
a
Stergiou & John Kyriopoulos a
Department of Health Economics, National School of Public Health, Athens, Greece and
b
Hypertension Center, STRIDE Hellas-7, Third University Department of Medicine, Sotiria Hospital, Athens, Greece Published online: 12 Dec 2014.
Click for updates To cite this article: Kostas Athanasakis, Ilias-Ioannis Kyriopoulos, Nadia Boubouchairopoulou, George S. Stergiou & John Kyriopoulos (2015) Quantifying the economic benefits of prevention in a healthcare setting with severe financial constraints: the case of hypertension control, Clinical and Experimental Hypertension, 37:5, 375-380, DOI: 10.3109/10641963.2014.977488 To link to this article: http://dx.doi.org/10.3109/10641963.2014.977488
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http://informahealthcare.com/ceh ISSN: 1064-1963 (print), 1525-6006 (electronic) Clin Exp Hypertens, 2015; 37(5): 375–380 ! 2015 Informa Healthcare USA, Inc. DOI: 10.3109/10641963.2014.977488
Quantifying the economic benefits of prevention in a healthcare setting with severe financial constraints: the case of hypertension control Kostas Athanasakis1, Ilias-Ioannis Kyriopoulos1, Nadia Boubouchairopoulou1, George S. Stergiou2, and John Kyriopoulos1 Department of Health Economics, National School of Public Health, Athens, Greece and 2Hypertension Center, STRIDE Hellas-7, Third University Department of Medicine, Sotiria Hospital, Athens, Greece
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Abstract
Keywords
Hypertension significantly contributes to the increased cardiovascular morbidity and mortality, thus leading to rising healthcare costs. The objective of this study was to quantify the clinical and economic benefits of optimal systolic blood pressure (SBP), in a setting under severe financial constraints, as in the case of Greece. Hence, a Markov model projecting 10-year outcomes and costs was adopted, in order to compare two scenarios. The first one depicted the ‘‘current setting’’, where all hypertensives in Greece presented an average SBP of 164 mmHg, while the second scenario namely ‘‘optimal SBP control’’ represented a hypothesis in which the whole population of hypertensives would achieve optimal SBP (i.e. 5140 mmHg). Cardiovascular events’ occurrence was estimated for four sub-models (according to gender and smoking status). Costs were calculated from the Greek healthcare system’s perspective (discounted at a 3% annual rate). Findings showed that compared to the ‘‘current setting’’, universal ‘‘optimal SBP control’’ could, within a 10-year period, reduce the occurrence of nonfatal events and deaths, by 80 and 61 cases/1000 male smokers; 59 and 37 cases/1000 men non-smokers; whereas the respective figures for women were 69 and 57 cases/1000 women smokers; and accordingly, 52 and 28 cases/1000 women non-smokers. Considering health expenditures, they could be reduced by approximately E83 million per year. Therefore, prevention of cardiovascular events through BP control could result in reduced morbidity, thereby in substantial cost savings. Based on clinical and economic outcomes, interventions that promote BP control should be a health policy priority.
Blood pressure, cost, economic benefits, hypertension, prevention
Introduction Hypertension is a chronic condition in which blood pressure in the arteries is elevated. High-blood pressure represents one of the major risk factors and the main underlying cause of ischemic heart disease, stroke, renal failure and peripheral arteriopathy. Presenting a global prevalence at approximately 40% for people aged 25 and above, hypertension seems to cause 47% of deaths related to heart disease and 54% of those related to stroke (1). Notwithstanding hypertension is a highly prevalent risk factor, it is also a preventable one. It is a widely acknowledged and corroborated fact, that in individuals with hypertension, BP reduction significantly reduces cardiovascular morbidity and mortality (2,3), preventing events both, in primary and secondary level (4). Healthy diet, reduced salt intake, physical activity and pharmaceutical treatment are considered as the main interventions towards BP control (5–7). Taking into
Correspondence: Nadia Boubouchairopoulou, BSc, MSc, Department of Health Economics, National School of Public Health, Athens, Greece. Tel: +30-213-2010248; Fax: +30-210-6449571; E-mail: nadia.phar@ gmail.com
History Received 28 August 2014 Revised 2 October 2014 Accepted 13 October 2014 Published online 11 December 2014
account the aforementioned, high-blood pressure can be regarded as a major public health issue, greatly contributing to the global burden of disease and death, and therefore inducing important increases in healthcare expenditure. In the case of hypertension, the associated costs are substantial, and according to the demographic transition they are continuously rising (8,9). Globally, the cost of suboptimal BP control was estimated at US $370 billion in 2001, representing about 10% of the world’s aggregate healthcare expenditures (10). In the United States, costs of high-blood pressure (BP) were estimated at $46.4 billion for 2010, while according to projections, in 2030, the corresponding cost will approximately be $274 billion (11). Figures from Europe also support the finding of significant expenditures attributed to elevated BP (12). In light of the above, healthcare systems are obliged to efficiently manage resource allocation in order to meet patients’ needs, and therefore, clinical evidence is further enhanced when supported by data on economic implications of a given health intervention. In this framework, the present study aims to highlight the importance of effective hypertension management as a healthcare priority, by estimating potential, clinical and economic benefits of optimal SBP control, especially in a setting under financial restraints such
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as Greece. Consequently, the main objective of the analysis was to quantify the aforementioned benefits through the comparison of the present situation regarding hypertension in Greece, with the hypothesis that all hypertensives would attain optimal SBP.
Methods
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Overview of the research hypothesis The present study aimed at comparing two different scenarios; the first representing the current situation regarding hypertension in Greece, while the second one illustrating a hypothetical scenario in which all hypertensives would achieve optimal BP control. The research hypothesis was influenced by Lloyd et al., who estimated the cost and morbidity of uncontrolled hypertension in the UK, and, in specific, the number of major cardiovascular events (myocardial infarction, congestive heart failure and stroke) along with the according hospital costs that would be avoided if hypertensive patients reached optimal BP (13) (Figure 1). In this context, we aimed at presenting updated results, for a resource limited setting, according to the currently existing epidemiological data and methodological tools. The main purpose was therefore to evaluate the clinical effectiveness and economic savings that could accrue from preventive measures in the case of hypertension (14). More precisely, hypertension’s outcomes and associated costs were compared to a hypothetical strategy’s outcomes where all patients would achieve optimal BP, thus leading to clinical efficacy and cost savings. In the first scenario representing the current status, the mean systolic BP (SBP) for hypertensive patients was considered to be 164 mmHg, which is well above the recommended therapeutic targets, and implies that a large proportion of the population does not attain optimal BP levels. The SBP level considered was based on a study by Athanasakis et al., in which a cost-utility analysis was performed, using a six-state Markov model in order to simulate the occurrence of major cardiovascular events for both, treated and untreated hypertensive patients, in Greece (15). This figure is in line with a previously published survey Figure 1. Overview of the research hypothesis. Influenced by Lloyd et al. (13).
Current situaon regarding SBP (partly uncontrolled SBP
conducted by Efstratopoulos et al., including 11 950 subjects, who attended 98 primary healthcare centers in Greece, and in which mean SBP levels were 161.4 mmHg in untreated hypertensives and 164.8 mmHg in treated uncontrolled hypertensives (16). The second hypothetical scenario assumed a universal BP control, namely that all hypertensive patients reach a BP target of 5140 mmHg (SBP) as recommended by current guidelines (17). Health economics model Predictive modeling was the technique used in the present study in order to support the research hypothesis, as there was a time lag between the ‘‘current state’’ of a patient’s BP level and the occurrence of cardiovascular events, associated with hypertension. More specifically, an adaptation of a previously published Markov model was employed (Figure 2) (15). The model included six mutually exclusive health states: ‘‘healthy with hypertension’’, ‘‘myocardial infarction’’ (MI), ‘‘post-MI’’, ‘‘stroke’’, ‘‘post-MI’’ and ‘‘death’’. The state ‘‘healthy with hypertension’’ corresponded to individuals
Figure 2. The Markov model of the analysis. Athanasakis et al. (15).
Risk equaons for CVD
Burden of disease (expected CVD episodes)
Data on costs
Cost of episodes due to SBP level
Data on costs
Cost of episodes due to SBP level
Health expenditure reducon due to SBP control
Research hypothesis: universal SBP control
Risk equaons for CVD
Burden of disease (expected CVD episodes)
10 years
Economic benefits of hypertension’s prevention
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DOI: 10.3109/10641963.2014.977488
suffering from hypertension but not from subsequent cardiovascular disease. ‘‘Myocardial infarction’’ was associated with the occurrence of an event in the first 12 months, ‘‘postMI’’ with the period afterwards, whereas the same logic was followed for the states ‘‘stroke’’ and ‘‘post-stroke’’. The sixth state (Death) simulated fatalities from a cardiovascular event and thus was an absorbing state in the model. All patients included in the model commenced in the ‘‘healthy with hypertension’’ health state. At each cycle, a patient had a probability of remaining in that state, experiencing a myocardial infarction, or a stroke, or die. If the patient had a myocardial infarction, he/she would move to the ‘‘post-MI’’ or ‘‘death’’ state. Accordingly, after experiencing a stroke, the patient could either move to the ‘‘post-stroke’’ or ‘‘death’’ state. Finally, patients in ‘‘post-MI’’ or ‘‘post-stroke’’ health states could either remain in the same state or move to ‘‘death’’. The predictive model was constructed for 1-year cycles and simulated the progress of patients for a 10-year period, in which events occurred according to a given set of probabilities, depending on the population’s characteristics. Stroke and MI occurrence probabilities were derived from the Framingham Heart Study risk equation and were contingent upon to demographics and BP levels (18,19). Survival following a non-fatal cardiovascular event was modeled based on the corresponding results of an analysis of the Framingham cohort (20), by fitting an exponential function in order to project survival and using the cumulative form of the function to estimate 1-year probabilities. Deaths from cardiovascular events were estimated via the specific calibration for Greece of the SCORE risk calculator (HellenicSCORE) (21,22). All risks deriving from the risk equations were age-, sex- and smoking status-dependent and converted to 1-year probabilities. Age- and genderspecific all-cause mortality (background mortality) was also taken into account in the model. This procedure was repeated for four sub-models, differentiated by gender and smoking status. Finally, it must be mentioned that extrapolation was inevitable in order to obtain cumulative data for the entire population, since Markov models are cohort models. In the case of Greece, published data for the prevalence of hypertension (23), smoking (24) and estimates on absolute numbers in the general population (25) were used. The baseline characteristics of the population under analysis are reported in Table 1. Cost calculations Cost calculation was based on the translation of prevented morbidity and mortality into economic terms for a 10-year period. Thus, it included the number of prevented non-fatal strokes and MI events, as well as the cumulative cardiovascular deaths prevented, due to effective hypertension control (as defined by the recommended BP levels), multiplied by their respective costs. For the purpose of this analysis, only direct care costs were taken into account, and a more conservative approach was adopted. Costs of cardiovascular episodes were calculated according to the latest official Greek DRG price list of 2012
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Table 1. Base-case analysis variables. Variable
Value
Baseline demographics of the population Average age (men) 55.1 years (15) Average age (women) 57.6 years (15) Average systolic BP (current situation) (men) 163.2 mmHg (15) Average systolic BP (current situation) 165.4 mmHg (15) (women) Prevalence of hypertension (men) 40.2% (23,25) Prevalence of hypertension (women) 38.9% (23,25) Prevalence of smoking (men) 45% (24,25) Prevalence of smoking (women) 38% (24,25) Total population of men 3 736 770 (25) Total population of women 3 972 797 (25) Cost inputs (cost per episode) Average in-hospital cost of non-fatal stroke 3624.9E (27) Average cost of fatal stroke 3596.1E (27) Average cost per MI episode (fatal or non-fatal) 2978.1Ea Discount rate 3% (28) a
Average KEN-DRG rate multiplied by 2.09 in order to account for healthcare personnel costs, according to the regulations by the Ministry of Health, Hellenic Republic.
Table 2. Benefits from SBP control: avoided episodes per 1000 patients (in a period of 10 years).
Population Male smokers Male non-smokers Female smokers Female non-smokers
Avoided strokes per 1000 patients
Avoided MI per 1000 patients
Avoided deaths per 1000 patients
15 10 14 11
65 49 55 41
61 37 57 28
(26) and a local cost-of-illness analysis (27). Results were discounted at a 3% discount rate (28). Unit costs are reported in Table 1.
Results Impact of BP control on the burden of disease According to the results of the predictive model, universal BP control within the specified therapeutic targets could, in a cohort of 1000 male smokers, reduce the occurrence of nonfatal events (strokes and MIs) and deaths, by 80 and 61 cases, respectively, in 10 years. Respective figures were 59 and 37 cases for men non-smokers, 69 and 57 cases for women smokers, and 52 and 28 cases for women non-smokers (Table 2). Based on population data and according to the literature, there are approximately 3 047 599 patients suffering from hypertension in Greece (23,25). Considering the above and the smoking prevalence in Greece (24,25), among hypertensive patients 675 982 are male and 587 259 female smokers. For the aforementioned population and compared to current status of BP control, our analysis concluded that a hypothetical scenario of universal BP control could lead to 37 163 fewer strokes, 156 006 avoided MIs and 133 281 avoided deaths, for the entire Greek population of hypertensives, on a 10-year horizon (Table 3).
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Table 3. Benefits from SBP control: avoided episodes for the total population (in a period of 10 years).
Population Male smokers Male non-smokers Female smokers Female non-smokers Total
Patients with hypertension (23,24,25)
Avoided strokes
Avoided myocardial infarctions
Avoided deaths
675 982 826 200 587 259 958 159 3 047 600
10 140 8262 8222 10 540 37 163
43 939 40 484 32 299 39 285 156 006
41 235 30 569 34 648 26 828 133 281
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Table 4. Avoided cardiovascular episodes and reduction of health expenditure, as a result of SBP control (discounted costs, 3% rate). Cardiovascular episodes
Avoided episodes
Health expenditure decrease (E)
Strokes MI Cardiovascular deaths Total
37 163 156 006 133 281
119 334 821.7 397 129 180.7 313 663 094.3 830 127 096.7
Impact of BP control on health expenditure Based on the results presented above, healthcare expenditure savings, due to avoided stroke and MI cases, were estimated at E119 334 822 and E397 129 181 respectively. Moreover, prevented cardiovascular deaths, due to effective BP control, could generate additional savings of E313 663 094 (Table 4). Taking into consideration the aforementioned outcomes, overall savings were estimated at E830 127 097, over a 10year period from the attainment of BP target onwards, or on average, at E83 million per year (undiscounted estimate: E103/year), representing about 0.46% of the total health expenditures (29).
Discussion Hypertension represents a major modifiable risk factor for cardiovascular diseases worldwide (14). Optimal BP control significantly reduces cardiovascular morbidity and mortality (30,31), and, hence, the need for adequate disease management is a prerequisite for substantial healthcare cost savings. This analysis aimed at demonstrating the benefits of a hypothetical ‘‘universal BP regulation’’, in terms of burden of disease and potential economic savings in the Greek setting, constituting an interesting case study for any similar analysis, due to the current severe financial constraints and the restrictive fiscal environment. The main objective was to give an insight of the valuable outcomes, resulting from the optimal BP control and the benefits accrued from preventive health measures, nevertheless the present study does not constitute a cost-effectiveness analysis. The results of the analysis and the projections generated, based on the risk equations, suggested that effective BP control could lead to significant reduction in morbidity and mortality attributed to cardiovascular disease, especially in the population of smokers, who are at higher cardiovascular risk compared to non-smokers. Findings also implied that BP control could generate considerable savings, calculated at
approximately E83 million per year, apparently resulting from reduced morbidity. Taking into account the aforesaid, universal BP control could provide significant cost savings, which could help in relieving the pressure inflicted in economic systems under fiscal constraints, imposing severe austerity measures in the healthcare sector as observed in the case of Greece. The present findings seem generally to be in line with a rather small number of previously published studies. At that point, it must be mentioned that a paucity of data and comparable surveys has been noticed during the last decade. Therefore, only the general trends outlined from such studies can eventually be compared. Lloyd et al. (13) estimated that 58 000 cardiovascular events per year, attributed to high BP, could be avoided in the UK, while the savings, if BP of all patients was at target levels, would be approximately £97.2 million per year (2000/ 01 prices). He and MacGregor found that BP control could lead to 42 800 avoided strokes and 82 800 avoided ischemic heart disease events in the UK each year, resulting in a total reduction of 125 600 events (32). The aforementioned cost and clinical benefits occurring from BP control are comparable with the outcomes of the present study. Nevertheless, a head-to-head comparison is not feasible as the former was conducted a decade before. Another survey conducted in 2002 in five European countries (France, Germany, Italy, Sweden and the UK) concluded that the costs imposed due to uncontrolled BP were also high and more precisely calculated at E1.26 billion (33). Finally, Gaziano et al. computed the global cost of non-optimal BP at $370 billion in 2001, namely 10% of the global healthcare spending. The same study highlights that the costs may rise up to $1 trillion in the next years (34). However, the present analysis differs with regards to the analytical approach used as, to the best of our knowledge, it represents the first case of a Markov’s model use that incorporates (time-dependent) baseline population characteristics and established risk scores, for the development of the research hypothesis. Possible limitations of the present study could firstly include methodological issues. The Markov model is a stochastic model requiring homogeneity of individuals within a cohort. Moreover, the analysis was undertaken from a third-party payer perspective, and, therefore, it does not include societal costs, productivity losses related to the disease and costs of informal care. The latter constitutes an important cost variable, especially for patients whose daily activities are severely impaired by the disease. Indicatively, informal care costs can account for up to 21% or 25% of total cost, for patients who have experienced a cerebrovascular or coronary heart disease event, respectively (35,36). Mainly because of the limitations stated above, the analysis followed a rather conservative approach, implying that the presented cost-savings could probably be underevaluated, particularly due to the following: (a) the estimate did not include the cost of non-acute (outpatient) care for strokes and MI events, (b) savings due to reduced use of healthcare resources were not taken into account (medical appointments, diagnostic tests), (c) high BP could lead to several preventable consequences apart from strokes, MI episodes and worsening of patients’ quality of life, which were not included and (d) uncontrolled BP and subsequent diseases also implied an
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DOI: 10.3109/10641963.2014.977488
indirect cost due to productivity losses. Taking into account the aforesaid would certainly increase the cost of uncontrolled hypertension and, thereby, the potential benefits of BP control. However, it should be mentioned that the cost incurred by the implementation of hypertension preventive health measures was not considered, and, therefore, the shortterm cost-savings could eventually be regarded as limited, while long-term economic benefits could be significant, outweighing the intervention costs. Moreover, it is acknowledged that cardiovascular mortality is not solely an issue of increased BP, since other factors contribute, as well. Nevertheless, the present study focused on BP control and did not extend to other research hypotheses. Finally, a degree of uncertainty emanates from the use of the Framingham risk equations for some of the disease states in the model, given that there is evidence of possible overestimations of cardiovascular events in South-European populations (37). This uncertainty, however, is difficult to be quantified for our study population. Uncontrolled BP is a major public health issue in Greece and worldwide, with considerable impact on global morbidity and mortality, thus imposing an important economic burden. In this context, controlling BP could substantially improve health indicators, generate cost savings and lead to adequate disease management in several healthcare systems, especially in cases such as Greece, being financially restrained. In line with the aforesaid, the present analysis could be regarded as a reference for further studies that could be conducted in other health systems, as the methodology followed enables the extrapolation of the results to other countries. Consequently, BP control can be considered as a challenging public health issue and a priority for health policy-makers, not only as a means for improving the population’s health status, but also as a cost-containment measure.
Acknowledgements We thank Vanessa Tsiantou for helpful discussions and comments.
Declaration of interest No conflict of interest declared for all authors. No funding was provided for this project.
References 1. WHO. A global brief on hypertension. Geneva: World Health Organization; 2013. 2. MacMahon S, Peto R, Cutler J, et al. Blood pressure, stroke, and coronary heart disease. Part 1, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet 1990;335:765–74. 3. Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated with antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA 2003;289: 2534–44. 4. Rashid P, Leonardi-Bee J, Bath P. Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review. Stroke 2003;34:2741–8. 5. He J, Whelton PK, Appel LJ, et al. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000;35:544–9.
Economic benefits of hypertension’s prevention
379
6. Freis ED. Salt, volume and the prevention of hypertension. Circulation 1976;53:589–95. 7. Haapanen N, Miillunpalo S, Vuori I, et al. Association of leisure time physical activity with the risk of coronary heart disease, hypertension and diabetes in middle-aged men and women. Int J Epidemiol 1997;26:739–47. 8. Institute of Medicine (US) Committee on Preventing the Global Epidemic of Cardiovascular Disease. Meeting the challenges in developing countries. In: Fuster V, Kelly BB, eds. Promoting cardiovascular health in the developing world: a critical challenge to achieve global health. Washington, DC: National Academies Press (US); 2010:125–45. 9. A report by the World Economic Forum and the Harvard School of Public Health, September 2011. The Global Economic Burden of Non-communicable Diseases. Available from: http://www3. weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNon CommunicableDiseases_2011.pdf [last accessed 20 Sep 2014]. 10. Gaziano TA, Bitton A, Anand S, Weinstein MC. The global cost of nonoptimal blood pressure. J Hypertens 2009;27: 1472–7. 11. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics-2014 update: a report from the American Heart Association. Circulation 2014;129:399–410. 12. Leal J, Luengo-Fernandez R, Gray A, et al. Economic burden of cardiovascular diseases in the enlarged European Union. Eur Heart J 2006;27:1610–19. 13. Lloyd A, Schmieder C, Marchant N. Financial and health costs of uncontrolled blood pressure in the United Kingdom. Pharmacoeconomics 2003;21:33–41. 14. Danaei G, Finucane MM, Lin JK, et al; Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Blood Pressure). National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 54 million participants. Lancet 2011;377:568–77. 15. Athanasakis K, Souliotis K, Tountas Y, et al. A cost-utility analysis of hypertension treatment in Greece: assessing the impact of age, sex and smoking status, on outcomes. J Hypertens 2012;30: 227–34. 16. Efstratopoulos AD, Voyaki SM, Baltas AA, et al. Prevalence, awareness, treatment and control of hypertension in Hellas, Greece: the Hypertension Study in General Practice in Hellas (HYPERTENSHELL) national study. Am J Hypertens 2006;19: 53–60. 17. Mancia G, Fagard R, Narkiewicz K, et al. ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013;34:2159–219. 18. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285:2486–97. 19. D’Agostino RB, Wolf PA, Belanger AJ, Kannel WB. Stroke risk profile: adjustment for antihypertensive medication. The Framingham Study. Stroke 1994;25:40–3. 20. Peeters A, Mamum AA, Willekens F, Bonneux L. A cardiovascular lifehistory. A life course analysis of the original Framingham Heart Study cohort. Eur Heart J 2002;23:458–66. 21. Conroy RM, Pyorala K, Fitzgerald AP, et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003;24:987–1003. 22. Panagiotakos DB, Fitzgerald AP, Pitsavos C, et al. Statistical modeling of 10-year fatal cardiovascular disease risk in Greece: the HellenicSCORE (a Calibration of the ESC Score Project). Hellenic J Cardiol 2007;48:55–63. 23. Psaltopoulou T, Orfanos P, Naska A, et al. Prevalence, awareness, treatment and control of hypertension in a general population sample of 26 913 adults in the Greece EPIC study. Int J Epidemiol 2004;33:1345–52. 24. Filippidis FT, Vardavas CI, Loukopoulou A, et al. Prevalence and determinants of tobacco use among adults in Greece: 4 year trends. Eur J Public Health 2013;23:772–6.
380
K. Athanasakis et al.
Downloaded by [University of Regina] at 16:36 06 September 2015
25. National Statistical Authority of Greece. Available from: www. statistics.gr (last accessed 28 Oct 2013). 26. Hellenic Ministry of Health, KEN-DRGs. Available from: http://www.moh.gov.gr/articles/health/domes-kai-draseis-gia-thnygeia/articles/health/domes-kai-draseis-gia-thn-ygeia/articles/health/ domes-kai-draseis-gia-thn-ygeia/articles/ken-eswteriko/1079-nea-listaken-apo-1-3-2012-kostos-mdn (last accessed 27 Oct 2013). 27. Gioldasis G, Talelli P, Chroni E, et al. In-hospital direct cost of acute ischemic and hemorrhagic stroke in Greece. Acta Neurol Scand 2008;118:268–74. 28. Drummond M, O’Brien B, Stoddart G, Torrance G. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford: Oxford University Press; 2005. 29. Organisation for Economic Co-operation and Development (OECD). Available from: http://stats.oecd.org (last accessed 21 Sept 2014). 30. Collins R, MacMahon S. Blood pressure, antihypertensive drug treatment and the risks of stroke and of coronary heart disease. Br Med Bull 1994;50:272–98.
Clin Exp Hypertens, 2015; 37(5): 375–380
31. Hansson L. The benefits of lowering elevated blood pressure: a critical review of studies of cardiovascular morbidity and mortality in hypertension. J Hypertens 1996;14:537–44. 32. He FJ, MacGregor GA. Cost of poor blood pressure control in the UK: 62 000 unnecessary deaths per year. J Hum Hypertens 2003; 17:455–7. 33. Hansson L, Lloyd A, Anderson P, Kopp Z. Excess morbidity and cost of failure to achieve targets for blood pressure control in Europe. Blood Press 2002;11:35–45. 34. Gaziano TA, Bitton A, Anand S, Weinstein MC. The global cost of non optimal blood pressure. J Hypertens 2009;27:1472–7. 35. Luengo-Fernandez R, Leal J, Gray A, et al. Cost of cardiovascular diseases in the United Kingdom. Heart 2006;92:1384–9. 36. Liu JL, Maniadakis N, Gray A, Rayner M. The economic burden of coronary heart disease in the UK. Heart 2002;88: 597–603. 37. Menotti A, Puddu PE, Lanti M. Comparison of the Framingham risk function-based coronary chart with risk function from an Italian population study. Eur Heart J 2000;21:365–70.
