Smith Steven M, Campbell Jonathan D
Department of Clinical Pharmacy and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado.
Am J Hypertens. 2013 Nov;26(11):1303-10. doi: 10.1093/ajh/hpt099. Epub 2013 Sep 18.
A plasma renin activity (PRA)-guided strategy is more effective than standard care in treating hypertension (HTN). However, its clinical implementation has been slow, presumably due in part to economic concerns. We estimated the cost effectiveness of a PRA-guided treatment strategy compared with standard care in a treated but uncontrolled HTN population.
We estimated costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) of PRA-guided therapy compared to standard care using a state-transition simulation model with alternate patient characteristic scenarios and sensitivity analyses. Patient-specific inputs for the base case scenario, males average age 63 years, reflected best available data from a recent clinical trial of PRA-guided therapy. Transition probabilities were estimated using Framingham risk equations or derived from the literature; costs and utilities were derived from the literature.
In the base case scenario for males, the lifetime discounted costs and QALYs were $23,648 and 12.727 for PRA-guided therapy and $22,077 and 12.618 for standard care, respectively. The base case ICER was $14,497/QALY gained. In alternative scenario analyses varying patient input parameters, the results were sensitive to age, gender, baseline systolic blood pressure, and the addition of cardiovascular risk factors. Univariate sensitivity analyses demonstrated that results were most sensitive to varying the treatment effect of PRA-guided therapy and the cost of the PRA test.
Our results suggest that PRA-guided therapy compared with standard care increases QALYs and medical costs in most scenarios. PRA-guided therapy appears to be most cost effective in younger persons and those with more cardiovascular risk factors.
血浆肾素活性（PRA）指导的治疗策略在治疗高血压（HTN）方面比标准治疗更有效。然而，其临床应用进展缓慢，部分原因可能是经济方面的考虑。我们评估了在已接受治疗但血压未得到控制的高血压患者群体中，与标准治疗相比，PRA指导的治疗策略的成本效益。
我们使用状态转换模拟模型，并结合不同的患者特征情景和敏感性分析，评估了PRA指导治疗与标准治疗相比的成本、质量调整生命年（QALY）以及增量成本效益比（ICER）。基础情景中患者特定的输入数据，即平均年龄63岁的男性，反映了近期PRA指导治疗临床试验中可获得的最佳数据。转换概率使用弗明汉风险方程进行估计或从文献中推导得出；成本和效用值来自文献。
在男性的基础情景中，PRA指导治疗的终身贴现成本和QALY分别为23,648美元和12.727，标准治疗分别为22,077美元和12.618。基础情景下的ICER为每获得1个QALY需14,497美元。在改变患者输入参数的替代情景分析中，结果对年龄、性别、基线收缩压以及心血管危险因素的增加较为敏感。单因素敏感性分析表明，结果对PRA指导治疗的效果变化和PRA检测成本最为敏感。
我们的结果表明，在大多数情景下，与标准治疗相比，PRA指导治疗可增加QALY和医疗成本。PRA指导治疗在年轻人和心血管危险因素较多的人群中似乎最具成本效益。
