Search

Background: High blood pressure (BP) is the leading attributable risk for cardiovascular disease (CVD). In rural South Asia, hypertension continues to be a significant public health issue with sub-optimal BP control rates. The goal of the trial is to compare a multicomponent intervention (MCI) to usual care to evaluate the effectiveness and cost-effectiveness of the MCI for lowering BP among adults with hypertension in rural communities in Bangladesh, Pakistan and Sri Lanka., Methods/design: This study is a stratified, cluster randomized controlled trial with a qualitative component for evaluation of processes and stakeholder feedback. The MCI has five components: (1) home health education by government community health workers (CHWs), (2) BP monitoring and stepped-up referral to a trained general practitioner using a checklist, (3) training public and private providers in management of hypertension and using a checklist, (4) designating hypertension triage counter and hypertension care coordinators in government clinics and (5) a financing model to compensate for additional health services and provide subsidies to low income individuals with poorly controlled hypertension. Usual care will comprise existing services in the community without any additional training. The trial will be conducted on 2550 individuals aged ≥40 years with hypertension (with systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, based on the mean of the last two of three measurements from two separate days, or on antihypertensive therapy) in 30 rural communities in Bangladesh, Pakistan and Sri Lanka. The primary outcome is change in systolic BP from baseline to follow-up at 24 months post-randomization. The incremental cost of MCI per CVD disability-adjusted life years averted will be computed. Stakeholders including policy makers, provincial- and district-level coordinators of relevant programmes, physicians, CHWs, key community leaders, hypertensive individuals and family members in the identified clusters will be interviewed., Discussion: The study will provide evidence of the effectiveness and cost-effectiveness of MCI strategies for BP control compared to usual care in the rural public health infrastructure in South Asian countries. If shown to be successful, MCI may be a long-term sustainable strategy for tackling the rising rates of CVD in low resourced countries., Trial Registration: ClinicalTrials.gov, NCT02657746 . Registered on 14 January 2016.

Background: Treatment modifications are necessary for addressing issues related to efficacy and tolerance of first-line monotherapy, but they increase the economic burden on patients and their health plans. Understanding the differences in costs between alternative treatment modification strategies, if any, can serve as a guideline for clinical decision making and for designing cost-containment strategies., Objective: To compare the health care utilization costs between (a) addition (i.e., use of free-pill combinations [FPCs] or fixed-dose combinations [FDCs]) and uptitration as alternatives for addressing efficacy issues and (b) switching and downtitration as alternatives for addressing tolerance issues with first-line antihypertensive monotherapy., Methods: This is a retrospective cohort study that used the 2008-2012 BlueCross BlueShield of Texas claims database. Patients who had a treatment modification within 12 months of initiating antihypertensive monotherapy were identified. All-cause and disease-related health care utilization costs and drug costs were estimated from the BlueCross BlueShield health plan's perspective over a 12-month period, starting from the date of treatment modification. Propensity score-adjusted generalized linear models were used to compare costs between alternative treatment modification strategies., Results: We identified 5,998 patients who met study criteria and had a modification of treatment: FPC (n = 1,395), FDC (n = 1,207), uptitration (n = 1,659), switching (n = 1,282), and downtitration (n = 455). All-cause and disease-related health services utilization costs were estimated for 12 months following treatment modification. Mean annual drug utilization costs were highest for the FDC strategy. All-cause inpatient and outpatient services utilization costs were significantly different between strategies used for addressing issues of tolerance and efficacy, respectively. Disease-related inpatient services utilization costs were lower for the FDC strategy compared with the uptitration strategy. However, disease-related inpatient services utilization costs were not significantly different for the downtitration strategy compared with the switch strategy., Conclusions: Health care costs following treatment modifications vary by type of strategy. The high costs of FDCs may be offset by the reduction of inpatient services utilization costs. Careful consideration should be given to the differences in costs between alternative strategies., Disclosures: No outside funding supported this study. The dataset used in this study was created for dissertational research on the patterns and outcomes of treatment modification in hypertensive patients. Data and database support were provided by University of Texas School of Public Health/BlueCross BlueShield of Texas research program in payment systems and policy. Sonawane Deshmukh was an employee of Anthem BlueCross BlueShield from August 2015 to August 2016. Hansen has received consulting funds from Daichii Sankyo and has provided expert testimony for Allergan and Boehringer Ingelheim. All other authors have no known conflicts of interest. Study concept and design were contributed by Sonawane Deshmukh, Garza, Wright, and Hansen. Sonawane Deshmukh and Ganduglia Cazaban collected the data, and data interpretation was performed by Sonawane Deshmukh, Qian, Wright, and Zeng. The manuscript was written primarily by Sonawane Deshmukh, along with Qian and Garza, and revised by Sonawane Deshmukh, Qian, Ganduglia Cazaban, and Hansen.

Background: Rural settings in Sub-Saharan Africa (SSA) consistently report low participation in non-communicable disease (NCD) treatment programs and poor outcomes., Objective: The objective of this study is to assess the impact of the implementation of a patient-centered rural NCD care delivery model called Bridging Income Generation through grouP Integrated Care (BIGPIC)., Design: The study prospectively tracked participation and health outcomes for participants in a screening event and compared linkage frequencies to a historical comparison group., Participants: Rural Kenyan participants attending a voluntary NCD screening event were included within the BIGPIC model of care., Interventions: The BIGPIC model utilizes a contextualized care delivery model designed to address the unique barriers faced in rural settings. This model emphasizes the following steps: (1) find patients in the community, (2) link to peer/microfinance groups, (3) integrate education, (4) treat in the community, (5) enhance economic sustainability and (6) generate demand for care through incentives., Main Measures: The primary outcome is the linkage frequency, which measures the percentage of patients who return for care after screening positive for either hypertension and/or diabetes. Secondary measures include retention frequencies defined as the percentage of patients remaining engaged in care throughout the 9-month follow-up period and changes in systolic (SBP) and diastolic blood pressure (DBP) and blood sugar over 12 months., Key Results: Of the 879 individuals who were screened, 14.2 % were confirmed to have hypertension, while only 1.4 % were confirmed to have diabetes. The implementation of a comprehensive microfinance-linked, community-based, group care model resulted in 72.4 % of screen-positive participants returning for subsequent care, of which 70.3 % remained in care through the 12 months of the evaluation period. Patients remaining in care demonstrated a statistically significant mean decline of 21 mmHg in SBP [95 % CI (13.9 to 28.4), P < 0.01] and 5 mmHg drop in DBP [95 % CI (1.4 to 7.6), P < 0.01]., Conclusions: The implementation of a contextualized care delivery model built around the unique needs of rural SSA participants led to statistically significant improvements in linkage to care and blood pressure reduction.

Depression and hypertension frequently present together in clinical practice. Evaluating the interaction between depression and hypertension would help stakeholders better understand the value of depression prevention in primary care. This retrospective study aimed to evaluate the excessive burden of depression on overall health and on health care utilization expenditure among hypertensive patients. A total of 7019 hypertensive patients (ICD-9-CM: 401) were identified from the 2012 Medical Expenditure Panel Survey (MEPS 2012) data, of which 936 patients had depression (ICD-9-CM: 311). Hypertension with depression was associated with worse health status (physical component score, -3.97 [17.9% reduction]; mental component score, -9.14 [9% reduction]), higher utilization of health care services (outpatient visits, 6.4 [63.8% higher]; nights of hospitalization, 0.9 [100% higher]; medication prescription, 22.6 [76.8% higher]), and higher health care expenditures (inpatient, $1953.2 [72% higher]; prescription drugs, $1995.5 [82% higher]).

Contemporary hypertension guidelines strongly endorse the use of home blood pressure (BP) monitoring for hypertension diagnosis and management. However, barriers exist that prevent optimal use of home BP measurements. Patients might not follow the recommended home BP measurement protocol, might not take the required number of readings, and/or might report only selected readings to their providers. Providers might not calculate the mean (used for clinical decision-making) and/or incorporate home BP measurements into the medical record. Use of home BP telemonitoring, defined as the process by which home BP readings are securely teletransmitted and summarized within a health care portal or electronic medical record for provider use, might overcome these barriers. Telemonitoring, especially when combined with protocolized case management, leads to statistically significant and clinically important BP reductions, and improvements in overall BP control. Despite evidence supporting its use, home BP telemonitoring is not widely used in Canada. Barriers to adoption can be classified as structural and financial. Although technological advancements have made telemonitoring highly feasible, infrastructure is lacking, and implementation remains a challenge; this is especially true with respect to creating simple and cost-effective systems that are user-friendly and acceptable to patients as well as to providers. Ensuring data security is crucial to successful implementation, as is developing appropriate reimbursement models for providers. If these barriers can be overcome, home BP telemonitoring has the potential to make care provision easier and more convenient for patients and providers, while improving BP control in Canadians with hypertension., (Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Pharmacies have been used to improve population health in Peru and other countries globally, operating as a non-traditional health access point. A pharmacy-based model holds potential to improve patient management of hypertension, a leading risk factor for non-communicable diseases in low- and middle-income countries. The aim of this study was to evaluate patient acceptability of hypertension services and health membership plans, if offered through private pharmacies in the future., Methods: A cross-sectional study was conducted with 347 hypertensive individuals who purchased anti-hypertensive medications in a private pharmacy during the study period (July-October 2012). The study included a brief survey assessing patients' acceptability of and readiness-to-pay for pharmacy-based hypertension management services. Chi-square tests for differences in proportions were used to evaluate whether any demographic characteristics (e.g., binary variables for age, time since diagnosis, and type of medication usually purchased) could identify groups of hypertensive individuals that might be more or less likely to use pharmacy-based services. Multiple logistic regression was used to estimate associations between readiness-to-pay for pharmacy-based health membership plans and patient-level characteristics., Results: Over 80% of individuals indicated they would be interested in pharmacy-based hypertension services, particularly discounts on anti-hypertensive medications and free blood pressure screenings. Compared to individuals 65 years of age or older, individuals under 65 years were more interested in receiving at least one pharmacy-based service. Another 80% indicated they would be interested in purchasing a monthly health plan through a pharmacy that provided access to hypertension services each month. The vast majority of individuals interested in pharmacy-based services indicated they would pay ≤$3.69 US/month to participate in a monthly health membership plan., Conclusions: Hypertensive patients would be interested in using and ready to pay for pharmacy-based hypertension services., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Context and Objective:: One of the big challenges facing governments worldwide is the financing of healthcare systems. Thus, it is necessary to understand the factors and key components associated with healthcare expenditure. The aim here was to identify demographic, socioeconomic, lifestyle and clinical factors associated with direct healthcare expenditure within primary care, among adults attended through the Brazilian National Health System in the city of Bauru., Design and Setting:: Cross-sectional study conducted in five primary care units in Bauru (SP), Brazil., Methods:: Healthcare expenditure over the last 12 months was assessed through medical records of adults aged 50 years or more. Annual healthcare expenditure was assessed in terms of medication, laboratory tests, medical consultations and the total. Body mass index, waist circumference, hypertension, age, sex, physical activity and smoking were assessed through face-to-face interviews., Results:: The total healthcare expenditure for 963 participants of this survey was US$ 112,849.74 (46.9% consultations, 35.2% medication and 17.9% laboratory tests). Expenditure on medication was associated with overweight (odds ratio, OR = 1.80; 95% confidence interval, CI: 1.07-3.01), hypertension (OR = 3.04; 95% CI: 1.91-4.82) and moderate physical activity (OR = 0.56; 95% CI: 0.38-0.81). Expenditure on consultations was associated with hypertension (OR = 1.67; 95% CI: 1.12-2.47) and female sex (OR = 1.70; 95% CI: 1.14-2.55)., Conclusions:: Our results showed that overweight, lower levels of physical activity and hypertension were independent risk factors associated with higher healthcare expenditure within primary care.

Background: Personal hypertension management is a cornerstone in the prevention of hypertension complications. In Eritrea, the increase in the national life expectancy rate has been accompanied by an increase in hypertension complications such as stroke. Hence, this study was designed to identify barriers and facilitates to hypertension management from the perspective of the patients., Methods: This was a qualitative study of a total of 48 individual in-depth interviews and two focus group discussions. It was conducted among hypertensive patients who were attending outpatient services at two hospitals in Asmara, Eritrea., Results: This study identified barriers and facilitators of hypertension management related to the individual patient, family and community, and healthcare system. With respect to individual factors, economic barriers, stress, non-adherence to medications due to the use of traditional remedies, and difficulties and misconceptions about following physical activity guidelines were mentioned as barriers to hypertension management. Related to the community and healthcare system, low community awareness, community stigma, and inadequate health promotion materials were stated as barriers. Individual knowledge, family, and government support were reported as very important factors to the patient's success in the personal hypertension management., Conclusions: Counseling patients about adherence to medication, strengthening family and government support, and empowering families and the community with appropriate knowledge of hypertension management could potentially help in an individual's adherence.

This study estimated the epidemiological and financial indicators of hypertension in order to identify challenges in strategic planning and management for health systems in Latin America. This is a longitudinal study with a population base of 187 326 reported cases of older adults with hypertension, diagnosed at public health institutions in Mexico. The cost-evaluation method that was used was based on the instrumentation and consensus techniques. To estimate the epidemiological changes and financial consequences for 2015-2017, time series analyses and probabilistic models were constructed according to the Box-Jenkins technique. Regarding epidemiological changes for 2015 versus 2017, an increase of 8-12% is expected (p < 0.001). Comparing the economic impact in 2015 versus 2017 (p < 0.001), there is a 22% increase in financial requirements. The total amount estimated for hypertension in 2015 (in US dollars) was $1 575 671 330. It included $747 527 259 as direct costs and $829 144 071 as indirect costs. If the risk factors and the different healthcare services for older adults remain as they are currently, the financial consequences of epidemiological changes in older adults will have a major impact on the users' pockets, following in order of importance, on social security providers and on public assistance providers. The challenges and implications of our findings in the context of universal coverage reforms in Latin America reinforce the urgent need to develop more and better strategic planning for the prevention of chronic diseases. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Objective: There is an international trend towards recommending medication to prevent cardiovascular disease (CVD) in individuals at increasingly lower cardiovascular risk. We assessed the cost-effectiveness of a population approach with a polypill including a statin (simvastatin 20 mg) and three antihypertensive agents (amlodipine 2.5 mg, losartan 25 mg and hydrochlorothiazide 12.5 mg) and periodic risk assessment with different risk thresholds., Methods: We developed a microsimulation model for lifetime predictions of CVD events, diabetes, and death in 259 146 asymptomatic UK Biobank participants aged 40-69 years. We assessed incremental costs and quality-adjusted life-years (QALYs) for polypill scenarios with the same combination of agents and doses but differing for starting age, and periodic risk assessment with 10-year CVD risk thresholds of 10% and 20%., Results: Restrictive risk assessment, in which statins and antihypertensives were prescribed when risk exceeded 20%, was the optimal strategy gaining 123 QALYs (95% credible interval (CI) -173 to 387) per 10 000 individuals at an extra cost of £1.45 million (95% CI 0.89 to 1.94) as compared with current practice. Although less restrictive risk assessment and polypill scenarios prevented more CVD events and attained larger survival gains, these benefits were offset by the additional costs and disutility of daily medication use. Lowering the risk threshold for prescription of statins to 10% was economically unattractive, costing £40 000 per QALY gained. Starting the polypill from age 60 onwards became the most cost-effective scenario when annual drug prices were reduced below £240. All polypill scenarios would save costs at prices below £50., Conclusions: Periodic risk assessment using lower risk thresholds is unlikely to be cost-effective. The polypill would become cost-effective if drug prices were reduced., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Hypertension affects one billion people globally and is one of the leading risk factors for cardiovascular and renal diseases. However, hypertension management remains poor, especially in rural China., Methods: A clustered randomized controlled trial was conducted in six towns in China's Qianjiang county between 7/2012 and 6/2014, including 5462 hypertension patients above 35 years old. Six towns were randomly assigned to three groups: Group 1 had the integrated care model including a multidisciplinary team and continuous care coordination, Group 2 had both the integrated care model and provider-level financial incentives, and the control group had the usual care. Primary outcomes were systolic blood pressure and health-related quality of life measured by SF36; secondary outcomes included hypertension-related hospitalization rate and inpatient spending. Blood pressure was measured sixteen times bimonthly between 12/1/2011 and 6/30/2014, and quality of life was measured on 7/1/2012 and 6/30/2014. Inpatient data between 7/1/2010 and 8/31/2014 were used. This trial is registered at the World Health Organization's International Clinical Trials Registry, number ChiCTR-OOR-14005563., Results: We found that the integrated care model effectively lowered blood pressure by 1.93 mmHg (95% CI 0.063-3.8), improved self-assessed health-related quality of life, and reduced the rate of hypertension-related hospitalization by 0.17 percentage points (95% CI 0.094-0.24). We also found that the provider-level financial contract further lowered blood pressure by 1.76 mmHg (95% CI 0.73-2.79) and reduced rates of hospitalization and inpatient spending, but it also reduced patients' self-assessed health-related quality of life., Conclusions: Integrated care and financial incentives are effective in lowering blood pressure and reducing hospitalization rate, but financial contracts may hurt patient quality of life. This trial was registered at the Chinese Clinical Trial Registry (ChiCTR-OOR-14005563) on November 23, 2014. It was a retrospective registration.

Background and Objectives: General pediatricians and hospitalists are increasingly summoned to optimize the comorbid conditions of children with medical complexity (CMC) undergoing major surgery. We assessed the relationship between specific chronic conditions of CMC and hospital resource use with spinal fusion for scoliosis, an operation with high cost and morbidity., Methods: Retrospective analysis of 7252 children age ≥5 years with an underlying complex chronic condition undergoing spinal fusion between January 1, 2010 through December 31, 2014 in 41 children's hospitals. Hospital length of stay (LOS), cost, and 30-day readmission rate were compared across comorbid conditions by using linear and logistic regression accounting for demographic characteristics and clustering of patients by hospital., Results: Fifty-nine percent of children had ≥4 comorbid conditions. As the number of chronic conditions increased from 1-3 to ≥10, median LOS increased 60% (5 [interquartile range (IQR), 4-7] to 8 [IQR, 5-13] days); median hospital cost increased 53% ($52 319 [IQR, $37 937-71 513] to $80 429 [IQR, $58 602-$111 965]); and readmission rates increased 293% (5.4% to 15.8%) ( P < .001 for all). In multivariable analysis, conditions strongly associated with LOS and cost were chronic respiratory insufficiency (LOS: +2.1 days; cost: +$12 070; and bladder dysfunction (LOS: +0.8 days; cost: +$4014) ( P < .001 for all). Readmission likelihood was highest with bladder dysfunction (odds ratio, 1.5; 95% confidence interval, 1.1-2.0) and epilepsy (odds ratio, 1.2; 95% confidence interval, 1.0-1.5)., Conclusions: Chronic respiratory insufficiency, bladder dysfunction, and epilepsy had significant associations with hospital resource use for CMC undergoing spinal fusion. Pediatricians, patients, and families may find it useful to consider these conditions when striving to benefit the children's perioperative health and outcomes., (Copyright © 2017 by the American Academy of Pediatrics.)

Objectives: Value-based insurance design has been suggested as an effective approach to ensure access to highvalue medications in health insurance markets. Premera Blue Cross, a large regional health plan, implemented a value-based formulary (VBF) for pharmaceuticals in 2010 that explicitly used cost-effectiveness analysis to inform medication co-payments. This study assesses the impact of a VBF on adherence and patient and health plan expenditures on 3 chronic disease states: diabetes, hypertension, and hyperlipidemia., Study Design: Interrupted time series design of employer-sponsored plans from 2006 to 2013. Beneficiaries exposed to the VBF formed the intervention group, and beneficiaries in similar plans without any changes in pharmacy benefits formed the control group., Methods: We measured medication expenditures from member, health plan, and member-plus-health plan (overall) perspectives and medication adherence as proportion of days covered. We conducted an exploratory analysis of medication utilization classifying medications according to whether co-payments moved up or down in the year following VBF implementation., Results: For the diabetes cohort, there was a statistically significant reduction in member and overall expenditures of $5 per member per month (PMPM) and $9 PMPM, respectively. For the hypertension cohort, there was a statistically significant reduction in member expenditures of $4 PMPM and an increase in health plan expenditures of $3 PMPM. There were no statistically significant effects on hyperlipidemia cohort expenditures or on medication adherence in any of the 3 disease cohorts. Exploratory analyses suggest that patients in the diabetes and hyperlipidemia cohorts were switching to higher-value medications., Conclusions: A VBF can ensure access to high-value medications while maintaining affordability.

Objective: To measure and calculate the medical cost attributable to hypertension among Chinese middle and old aged residents in 12 provinces( city or region)in 2011., Methods: The data were collected in 2011 from China Health and Nutrition Survey. The sample was 45 years old and over of health male and female residents. To estimate the probability of medical usage and medical expenditure, and calculate the medical cost attributable to hypertension., Results: The results showed that, in 2011, the estimate predict that the per capita medical expenditure for a single medical event was246. 8 yuan, the medical cost attributable to hypertension was 21. 2 yuan, which amounted to 8. 6% of the total personal medical cost. Hypertension showed a positive effect on the probability of medical usage to a large extent. Female respondents had lower medical cost. New Rural Cooperative Medical Scheme was linked with higher medical expenditure and the medical cost was higher in the north., Conclusion: To some extent, the probability of medical usage and medical expenditure are affected by hypertension. The whole society, families and individuals may also have certain economic burden due to hypertension.

Objective: Acromegaly is a complex endocrine disease with multiple comorbidities. Treatment to obtain biochemical remission includes surgery, medical therapy and radiation. We aimed to describe comorbidities, treatment patterns and cost-of-illness in patients with acromegaly in Sweden., Design: A nationwide population-based study., Methods: Patients with acromegaly were identified and followed in national registers in Sweden. Longitudinal treatment patterns were assessed in patients diagnosed between July 2005 and December 2013. The cost-of-illness during 2013 was estimated from a societal perspective among patients diagnosed between 1987 and 2013., Results: Among 358 patients with acromegaly (48% men, mean age at diagnosis 50.0 (s.d. 15.3) years) at least one comorbidity was reported in 81% (n = 290). The most common comorbidities were hypertension (40%, n = 142), neoplasms outside the pituitary (30%, n = 109), hypopituitarism (22%, n = 80) and diabetes mellitus (17%, n = 61). Acromegaly treatment was initiated on average 3.7 (s.d. 6.9) months after diagnosis. Among the 301 treated patients, the most common first-line treatments were surgery (60%, n = 180), somatostatin analogues (21%, n = 64) and dopamine agonists (14%, n = 41). After primary surgery, 24% (n = 44) received somatostatin analogues. The annual per-patient cost was €12 000; this was €8700 and €16 000 if diagnosed before or after July 2005, respectively. The cost-of-illness for acromegaly and its comorbidities was 77% from direct costs and 23% from production loss., Conclusions: The prevalence of comorbidity is high in patients with acromegaly. The most common first-line treatment in acromegalic patients was surgery followed by somatostatin analogues. The annual per-patient cost of acromegaly and its comorbidities was €12 000., (© 2017 European Society of Endocrinology.)

Introduction and Objectives: The prevalence of hypertension in Portugal is between 29.1% and 42.2%. International studies show that 13% of individuals have masked hypertension and 13% of diagnoses based on office blood pressure measurements are in fact white coat hypertension. More sensitive and specific blood pressure measuring methods could avoid costs associated with misdiagnosis. The aim of this study was to review the cost-effectiveness of ambulatory blood pressure monitoring (ABPM) compared to other methods in the management of hypertension., Methods: We performed a literature search in CMA Infobase, Guidelines Finder, National Guideline Clearinghouse, Bandolier, BMJ Clinical Evidence, the Cochrane Library, DARE, Medline, the Trip Database, SUMSearch and Índex das Revistas Médicas Portuguesas. We researched articles published between January 2005 and August 2015 in Portuguese, English and Spanish, using the MeSH terms "Hypertension", "Blood Pressure Monitoring, Ambulatory" and "Cost-Benefit Analysis" and the Portuguese search terms "Hipertensão", "Monitorização Ambulatorial da Pressão Arterial" and "Análise Custo-Benefício". Levels of evidence and grades of recommendation were attributed according to the Oxford Centre for Evidence-Based Medicine scale., Results: Five hundred and twenty-five articles were identified. We included five original studies and one clinical practice guideline. All of them state that ABPM is the most cost-effective method. Two report better blood pressure control, and a Portuguese study revealed a saving of 23%., Conclusions: The evidence shows that ABPM is cost-effective, avoiding iatrogenic effects and reducing expenditure on treatment (grade of recommendation B). The included studies provide a solid basis, but further evidence of reproducibility is needed in research that is not based mainly on analytical models., (Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Medication non-adherence is a complex health care problem. Due to non-adherence, substantial numbers of cardiovascular patients benefit from their medication to only a limited extent. In order to improve adherence, a variety of pharmacist-led interventions have been developed. However, even the most effective interventions achieved only a modest positive effect. To be effective, interventions should be targeted at underlying barriers to adherence, developed in a systematic manner and tailored to specific features of a target group and setting. The current paper describes the design of the Cardiovascular medication non-Adherence Tailored Intervention (CATI) study aimed to evaluate the (cost-)effectiveness of a patient-tailored intervention programme in patients using antihypertensive medication., Methods: The CATI study is a randomised controlled trial that will be performed in 13 community pharmacies. Patients aged 45-75 years using antihypertensive medication and considered non-adherent according to pharmacy dispensing data, as well according to a self-report questionnaire, are eligible to participate. Patients in the intervention condition will receive a patient-tailored, pharmacist-led intervention programme. This programme consists of a structured interview at the pharmacy to identify patients' barriers to adherence and to counsel patients in order to overcome these barriers. The primary outcome is self-reported medication adherence measured with the MARS-5 questionnaire. Secondary outcome measures are blood pressure, illness perceptions, quality of life and societal costs. A cost-effectiveness analysis and process evaluation will also be performed., Discussion: This study will provide insight into the (cost-)effectiveness of a patient-tailored, pharmacist-led intervention programme in non-adherent patients using antihypertensive medication. This intervention programme allows community pharmacists to support their patients in overcoming barriers to adherence and improving medication adherence in a structured and patient-tailored manner. An effective intervention will not only enhance medication adherence, but may also improve health outcomes and decrease health care utilisation and costs., Trial Registration: Netherlands Trial Register (identifier: NTR5017), registered on 2 February 2015.

Background: Hypertension (HT), albeit a modifiable risk factor of cardiovascular morbidity and mortality, remains one of the main contributors to the total disease burden internationally and, thus, inevitably one of the basic cost drivers in healthcare systems., Conclusion: Taking the above into account, this brief narrative review aims at presenting the main findings of the international health economics literature on HT with regards to four key areas: a) the costs attributable to HT, b) the effects of HT on patient well-being, c) the cost-effectiveness of pharmaceutical interventions against high blood pressure, and, d) the costs and benefits of preventive measures against HT. Bearing in mind the available evidence on disease costs and the efficiency of interventions, HT must constitute a primary objective of modern health policy, internationally., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Objective: To estimate long-term costs and outcomes attributable to a physician-pharmacist collaborative intervention compared with physician management alone for treating essential hypertension., Methods: A Markov model cohort simulation with a 6-month cycle length to predict acute coronary syndrome, stroke, and heart failure throughout lifetime was performed. A cohort of 399 patients was obtained from two prospective, cluster randomized controlled clinical trials implementing physician-pharmacist collaborative interventions in community-based medical offices in the Midwest, USA. Framingham risk equations and other algorithms were used to predict the vascular diseases. SBP reduction due to the interventions deteriorated until 5 years. Direct medical costs using a payer perspective were adjusted to 2015 dollar value, and the main outcome was quality-adjusted life years (QALYs); both were discounted at 3%. The intervention costs were estimated from the trials, whereas the remaining parameters were from published studies. A series of sensitivity analyses including changing patient risks of vascular diseases, probabilistic sensitivity analysis, and a cost-effectiveness acceptability curve were performed., Results: The lifetime incremental costs were $26 807.83 per QALY (QALYs gained = 0.14). The intervention provided the greatest benefit for the high-risk patients, moderate benefit for the trial patients, and the lowest benefit for the low-risk patients. If a payer is willing to pay $50 000 per QALY gained, in 48.6% of the time the intervention would be cost-effective., Conclusion: Team-based care such as a physician-pharmacist collaboration appears to be a cost-effective strategy for treating hypertension. The intervention is most cost-effective for high-risk patients.

Background: Hypertension is a major risk factor for heart disease and stroke. Health insurance coverage affects hypertension treatment and control, but limited information is available for US adults with hypertension who are classified as underinsured., Methods and Results: Using Behavioral Risk Factor Surveillance System 2013 data, we identified adults with self-reported hypertension. On the basis of self-reported health insurance status and health care-related financial burdens, participants were categorized as uninsured, underinsured, or adequately insured. Proxies for health care received included whether they reported taking antihypertensive medications and whether they visited a doctor for a routine checkup in the past year. We assessed the association between health insurance status and health care received, adjusting for selected sociodemographic characteristics. Among 123 257 participants from 38 states and District of Columbia with self-reported hypertension, 12% were uninsured, 26% were underinsured, and 62% were adequately insured. In adjusted models using adequately insured participants as referent, both uninsured (adjusted odds ratio, 0.39; 95% CI, 0.35-0.43) and underinsured (0.83, 0.76-0.89) participants were less likely to report using antihypertensive medication than those of adequately insured participants. Similarly, adjusted odds ratio of visiting a doctor for routine checkup in the past year were 0.25 (0.23-0.28) for those who were uninsured and 0.78 (0.72-0.84) for those who were underinsured compared to those with adequate insurance., Conclusions: Uninsured and underinsured participants with hypertension were less likely to report receiving care compared to those with adequate insurance coverage. Disparities in health care coverage may necessitate targeted interventions, even among people with health insurance., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Effective policies to control hypertension require an understanding of its distribution in the population and the barriers people face along the pathway from detection through to treatment and control. One key factor is household wealth, which may enable or limit a household's ability to access health care services and adequately control such a chronic condition. This study aims to describe the scale and patterns of wealth-related inequalities in the awareness, treatment and control of hypertension in 21 countries using baseline data from the Prospective Urban and Rural Epidemiology study., Methods: A cross-section of 163,397 adults aged 35 to 70 years were recruited from 661 urban and rural communities in selected low-, middle- and high-income countries (complete data for this analysis from 151,619 participants). Using blood pressure measurements, self-reported health and household data, concentration indices adjusted for age, sex and urban-rural location, we estimate the magnitude of wealth-related inequalities in the levels of hypertension awareness, treatment, and control in each of the 21 country samples., Results: Overall, the magnitude of wealth-related inequalities in hypertension awareness, treatment, and control was observed to be higher in poorer than in richer countries. In poorer countries, levels of hypertension awareness and treatment tended to be higher among wealthier households; while a similar pro-rich distribution was observed for hypertension control in countries at all levels of economic development. In some countries, hypertension awareness was greater among the poor (Sweden, Argentina, Poland), as was treatment (Sweden, Poland) and control (Sweden)., Conclusion: Inequality in hypertension management outcomes decreased as countries became richer, but the considerable variation in patterns of wealth-related inequality - even among countries at similar levels of economic development - underscores the importance of health systems in improving hypertension management for all. These findings show that some, but not all, countries, including those with limited resources, have been able to achieve more equitable management of hypertension; and strategies must be tailored to national contexts to achieve optimal impact at population level.

Introduction: Home-based exercise programs may increase adherence to physical activity among groups with poor access to exercise facilities. However, their effectiveness to lower blood pressure of hypertensive patients remains undefined., Aims: This controlled clinical trial investigated the influence of a home-based exercise program upon blood pressure, blood metabolic profile, and physical fitness in a Brazilian cohort of low income patients diagnosed with hypertension., Methods: Twenty-nine patients (22 women, age: 53 ± 11 years) underwent 16 months of home-based exercise, including 30 min of moderate intensity walking and stretching exercises. Fourteen patients (9 women, age: 48 ± 5 years) composed a non-exercise control group. Primary outcomes were assessed each two months., Results: Body mass (3.6 ± 0.2 kg; P = 0.03) and sum of skinfolds (3.0 ± 1.2 cm; P = 0.04) increased in controls vs. baseline. Mean compliance to home-based exercise was 83 ± 7 %, which induced significant improvements from baseline vs. controls in body mass (-5.4 ± 2.0 kg; P = 0.04), body fat (-4.7 ± 0.3 %; P = 0.03), waist circumference (-6.1 ± 1.2 cm; P = 0.03), sum of skinfolds (-14.8 ± 3.7; P = 0.02); aerobic efficiency reflected by slopes of relationships between heart rate and workload (-0.05 ± 0.01; P = 0.05), trunk flexibility (7.8 ± 1.7 cm; P = 0.02), HDL (1.8 ± 0.9 mg/dL; P = 0.04), triglycerides (-12.3 ± 1.0 mg/dL; P = 0.03), and glucose (-6.9 ± 2.9 mg/dL; P = 0.05). Systolic and diastolic BP decreased until the sixth month of intervention vs. baseline and controls, remaining stable at lower levels thereafter (systolic blood pressure: -4.5 ± 0.3 mmHg; P = 0.03; diastolic blood pressure: -2.5 ± 0.6 mmHg; P = 0.05)., Conclusions: Low income hypertensive patients complied with a long-term home-based exercise program, which was effective for improving their functional capacity, blood metabolic profile, and blood pressure.

Introduction: Chronic non-communicable diseases (NCDs) are a major public health challenge, and undermine social and economic development in much of the developing world, including Bangladesh. Epidemiologic evidence on the socioeconomic status (SES)-related pattern of NCDs remains limited in Bangladesh. This study assessed the relationship between three chronic NCDs and SES among the Bangladeshi population, paying particular attention to the differences between urban and rural areas., Materials and Method: Data from the 2011 Bangladesh Demographic and Health Survey were used for this study. Using a concentration index (CI), we measured relative inequality across pre-diabetes, diabetes, pre-hypertension, hypertension, and BMI (underweight, normal weight, and overweight/obese) in urban and rural areas in Bangladesh. A CI and its associated curve can be used to identify whether socioeconomic inequality exists for a given health variable. In addition, we estimated the health achievement index, integrating mean coverage and the distribution of coverage by rural and urban populations., Results: Socioeconomic inequalities were observed across diseases and risk factors. Using CI, significant inequalities observed for pre-hypertension (CI = 0.09, p = 0.001), hypertension (CI = 0.10, p = 0.001), pre-diabetes (CI = -0.01, p = 0.005), diabetes (CI = 0.19, p<0.001), and overweight/obesity (CI = 0.45, p<0.001). In contrast to the high prevalence of the chronic health conditions among the urban richest, a significant difference in CI was observed for pre-hypertension (CI = -0.20, p = 0.001), hypertension (CI = -0.20, p = 0.005), pre-diabetes (CI = -0.15, p = 0.005), diabetes (CI = -0.26, p = 0.004) and overweight/obesity (CI = 0.25, p = 0.004) were observed more among the low wealth quintiles of rural population. In the same vein, the poorest rural households had more co-morbidities compared to the richest rural households (p = 0.003), and prevalence of co-morbidities was much higher for the richest urban households compared to the poorest urban households. On the other hand in rural the "disachievement" of health indicators is more noticeable than the urban ones., Conclusion: The findings indicate the high burden of selected NCDs among the low wealth quintile populations in rural areas and wealthy populations in urban areas. Particular attentions may be necessary to address the problem of NCDs among these groups., Competing Interests: The authors have declared that no competing interests exist.

Context: Statistical models employed in analysing patient-level cost and effectiveness data need to be flexible enough to adjust for any imbalanced covariates, account for correlations between key parameters, and accommodate potential skewed distributions of costs and/or effects. We compare prominent statistical models for cost-effectiveness analysis alongside randomised controlled trials (RCTs) and covariate adjustment to assess their performance and accuracy using data from a large RCT., Method: Seemingly unrelated regressions, linear regression of net monetary benefits, and Bayesian generalized linear models with various distributional assumptions were used to analyse data from the TASMINH2 trial. Each model adjusted for covariates prognostic of costs and outcomes., Results: Cost-effectiveness results were notably sensitive to model choice. Models assuming normally distributed costs and effects provided a poor fit to the data, and potentially misleading inference. Allowing for a beta distribution captured the true incremental difference in effects and changed the decision as to which treatment is preferable., Conclusions: Our findings suggest that Bayesian generalized linear models which allow for non-normality in estimation offer an attractive tool for researchers undertaking cost-effectiveness analyses. The flexibility provided by such methods allows the researcher to analyse patient-level data which are not necessarily normally distributed, while at the same time it enables assessing the effect of various baseline covariates on cost-effectiveness results.

Objectives: A single-blinded, randomized, crossover, noninferiority trial was conducted to evaluate clinical effectiveness and safety of low-cost brand (LCB) versus innovator brand (IB) amlodipine in essential hypertension., Materials and Methods: The primary end-point was change of systolic blood pressure (BP) from baseline to study end. Adult patients with Stage 1 hypertension or isolated systolic hypertension were randomized to receive 5 mg amlodipine LCB or IB once daily for 6 weeks in each period in a 2 × 2 crossover manner with three follow-up visits in each sequence. In 28 evaluable patients, the reduction of systolic BP (SBP), diastolic BP, and safety profile between two brands was comparable., Results: The lower bound of the 95% confidence interval of the difference in reduction of SBP (-5.04 mmHg) was within the noninferiority margin of 10 mmHg., Conclusion: LCB amlodipine is noninferior to IB in terms of BP reduction and is a cost-effective alternative as it is less expensive than IB., Competing Interests: There are no conflicts of interest.

Physician-pharmacist collaboration improves blood pressure, but there is little information on whether this model can reduce the gap in healthcare disparities. This trial involved 32 medical offices in 15 states. A clinical pharmacist was embedded within each office and made recommendations to physicians and patients in intervention offices. The purpose of the present analysis was to evaluate whether the pharmacist intervention could reduce healthcare disparities by improving blood pressure in high-risk racial and socioeconomic subjects compared with the control group. The analyses in minority subjects were prespecified secondary analyses, but all other comparisons were secondary, post hoc analyses. The 9-month visit was completed by 539 patients: 345 received the intervention, and 194 were in the control group. Following the intervention, mean systolic blood pressure was found to be 7.3 mm Hg (95% confidence interval 2.4, 12.3) lower in subjects from racial minority groups who received the intervention compared with the control group (P=0.0042). Subjects with ≤12 years of education in the intervention group had a systolic blood pressure 8.1 mm Hg (95% confidence interval 3.2, 13.1) lower than the control group with lower education (P=0.0001). Similar reductions in blood pressure occurred in patients with low incomes, those receiving Medicaid, or those without insurance. This study demonstrated that a pharmacist intervention reduced racial and socioeconomic disparities in the treatment of blood pressure. Although disparities in blood pressure were reduced by the intervention, there were still nonsignificant gaps in mean systolic blood pressure when compared with intervention subjects not at risk., Clinical Trial Registration: URL: http://clinicaltrials.gov. Unique identifier: NCT00935077., Competing Interests: Authors of this paper have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this manuscript., (© 2016 American Heart Association, Inc.)

Background: Obesity, elevated blood pressure (BP), and diabetes mellitus are rising among the general U.S. adolescent population, but prevalence estimates are not available for uninsured or Medicaid populations., Methods: This retrospective epidemiological study extracted 155,139 electronic medical records collected between 1998 and 2012 on patients aged 10-19 years, from a clinical population predominantly uninsured or insured by Medicaid. Age, sex, race, height, weight, BP, and insurance type were captured at first clinic visit. Classifications included obesity (≥95th body mass index percentile), elevated BP (≥90th percentile), and diabetes mellitus (ICD-9-250.xx)., Results: Among the 26,696 patients with complete data at first clinic visit, 24.4% were classified as obese and 39.5% had elevated BP. In logistic regression analyses, odds of obesity were significantly higher among uninsured versus commercially insured patients (odds ratio [OR]: 1.1 [95% confidence interval: 1.0-1.2]) and girls (OR: 1.3 [1.2-1.4]), but lower among older adolescents (for 15-17 years, OR: 0.7 [0.6-0.7]; for 18-19 years, OR: 0.7 [0.7-0.8]). Odds of elevated BP were significantly higher among Medicaid (OR: 1.1 [1.0-1.2]) and uninsured (OR: 1.2 [1.1-1.4]) versus commercially insured patients, but lower among African American versus White youth (OR: 0.9 [0.8-0.9]). Prevalence of type 1 diabetes was 1.46 per 1000 and prevalence of type 2 diabetes was 1.68 per 1000, with both occurring more often in girls versus boys and in Whites versus African Americans., Conclusion: In this low-income clinical population, prevalence of obesity and elevated BP were higher than national estimates. The provision of preventive healthcare to all Medicaid and uninsured youth should remain a priority., Competing Interests: Author Disclosure Statement No conflicting financial interests exist.

Importance: Among high-risk patients with hypertension, targeting a systolic blood pressure of 120 mm Hg 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 120 mm Hg (intensive management) or 140 mm Hg (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.

The objective of the present study was to systematically review the clinical and economic outcomes of olmesartan as monotherapy or in combination with other antihypertensive agents in the treatment of hypertension. A literature search was performed using PubMed and the Cochrane library until December 2015, with no limit on publication date. Eligible studies were selected using predetermined inclusion and exclusion criteria, limiting articles to those published in the English language. Background information of the study, participants' characteristics and study outcomes were collected. Meta-analysis of data was not performed. Fifty-five studies were included, of which fifty investigated the clinical efficacy of olmesartan and five the cost-effectiveness of olmesartan. In general results from clinical trials evaluating the efficacy of olmesartan as monotherapy and as combination therapy demonstrated that olmesartan provided better antihypertensive blood pressure-lowering efficacy and was generally well tolerated compared with other antihypertensive agents. Results from economic evaluations indicated that olmesartan may be more cost-effective than other ARBs such as losartan, valsartan, irbesartan and candesartan, having the potential of decreasing the overall medical costs of care for patients with hypertension. Evidence from the present systematic review confirms the antihypertensive efficacy and good safety profile of olmesartan both as monotherapy and as combination therapy. Olmesartan was also found to be cost-effective compared with other ARBs, though this area has yet relatively poor evidence and needs to further be explored., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

The purpose was to examine factors associated with medication adherence among medical-aid beneficiaries with hypertension using the Expanded Behavioral Model of Health Services Utilization. A cross-sectional study was conducted with a convenient sample of 289 patients. The instruments included scales to measure medication adherence, health literacy, general self-efficacy, and pros and cons of chronic disease management. Data collection was performed between February and March 2011. A hierarchical regression analysis was performed. The study found that 25.6% to 34.6% had low motivation and low knowledge regarding medication adherence. Those with higher health literacy and higher self-efficacy scores were more likely to have higher medication adherence, whereas widowed and those who perceived more cons of chronic disease management were more likely to have lower medication adherence than their counterparts (p < .05). Interventions incorporating significant factors associated with medication adherence are required to enhance medication adherence and to prevent complications associated with medication non-adherence., (© The Author(s) 2016.)

This paper analyzes the feasibility of the implementation of SPRINT trial results, the need to rethink the clinical practice guidelines(CPG) for the management of arterial hypertension and associated costs with daily practice applicability. SPRINT is a clinical trial comparing systolic blood pressure control <120mmHg and <140mmHg over cardiovascular complications, generating a great worldwide impact followed by publication of several studies that addressed relevance, usefulness, applicability and controversial aspects of SPRINT from different perspectives. Achieving blood pressure goals is one of the most discussed issue in widely used hypertension CPG around the world and in Latin American. SPRINT has generated and will generate a great impact on CPG, being necessary the reassessment of blood pressure goals and inclusion in future CPG, as has been considered in 2016 Canadian guideline and will be considered in NICE guideline update scheduled for June. The SPRINT trial raises new evidence for the management of hypertension, useful in people over 50 years, from urban populations, with defined cardiovascular risk without associated comorbidities. The applicability of SPRINT in Latin America is limited by increased costs associated with hypertensive patients' integrated health care, low care coverage, and lack of integrated care programs., (Copyright © 2016 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.)

Background: In 2013, it was reported that about 1 of every 3 U.S. adults has hypertension. Of these 70 million individuals, approximately 50% have their blood pressure under control. Achieving hypertension control, especially in at-risk populations, requires a multipronged approach that includes lifestyle modifications and pharmacological treatment. As provider groups, hospital systems, and integrated delivery networks optimize their care processes to promote population health activities in support of the accountable care organization (ACO) model of care, managing hypertension and other chronic diseases will be essential to their success. A critical aspect of managing populations in an ACO environment is optimization of care processes among providers to increase care efficiency and improve patient outcomes., Program Description: Launched in 2013, Measure Up/Pressure Down is a 3-year campaign developed by the American Medical Group Foundation (AMGF) to reduce the burden of high blood pressure. The goal of the campaign is for participating medical groups, health systems, and other organized systems of care to achieve hypertension control for 80% of their patients with high blood pressure by 2016, according to national standards. The role of physician leadership at Cornerstone Health Care (CHC) and Summit Medical Group (SMG) in facilitating organizational change to improve hypertension management through the implementation of the Measure Up/Pressure Down national hypertension campaign is examined., Observations: Using patient stratification via its electronic health record, SMG identified 16,000 patients with hypertension. The baseline percentage of hypertension control for this patient population was 66%. Within 7 months, SMG was able to meet the 80% goal set forth by the AMGF's Measure Up/Pressure Down campaign. CHC diagnosed 25,312 patients with hypertension. The baseline percentage of hypertension control for this subgroup of patients was 51.5% when the initiative was first implemented. To date, the organization has achieved 72% hypertension control for at-risk patients and continues work towards the 80% campaign goal. The implementation of the Measure Up/Pressure Down campaign by CHC and SMG provides some valuable lessons. To further explore important aspects of successfully implementing the Measure Up/Pressure Down campaign in real-world settings, 6 key themes were identified that drove quality improvement and may be helpful to other organizations that implement similar quality improvement initiatives: (1) transitioning to value-based payments, (2) creating an environment for success, (3) leveraging program champions, (4) sharing quality data, (5) promoting care team collaboration, and (6) leveraging health information technology., Implications: The strategies employed by SMG and CHC, such as leveraging data analysis to identify at-risk patients and comparing physician performance, as well as identifying leaders to institute change, can be replicated by an ACO or a managed care organization (MCO). An MCO can provide data analysis services, sparing the provider groups the analytic burden and helping the MCO build a more meaningful relationship with their providers., Disclosures: No outside funding supported this project. The authors declare no conflicts of interest. The authors are members of the Working Group on Optimizing Medication Therapy in Value-Based Healthcare. Odgen is employed by Cornerstone Health Care; Brenner is employed by Summit Medical Group; and Penso is employed by American Medical Group Association. Lustig, Westrich, and Dubois are employed by the National Pharmaceutical Council, an industry-funded health policy research organization that is not involved in lobbying or advocacy. Study concept and design were contributed by Lustig, Penso, Westrich, and Dubois. Lustig, Ogden, Brenner, and Penso collected the data, and data interpretation was performed by all authors. The manuscript was written primarily by Lustig, along with the other authors, and revised by Lustig, Penso, Westrich, and Dubois, assisted by Ogden and Brenner.

Background: We compared the cost-effectiveness of hypertension treatment in non-Hispanic blacks and non-Hispanic whites according to 2014 US hypertension treatment guidelines., Methods: The cardiovascular disease (CVD) policy model simulated CVD events, quality-adjusted life years (QALYs), and treatment costs in 35- to 74-year-old adults with untreated hypertension. CVD incidence, mortality, and risk factor levels were obtained from cohort studies, hospital registries, vital statistics, and national surveys. Stage 1 hypertension was defined as blood pressure 140-149/90-99mm Hg; stage 2 hypertension as ≥150/100mm Hg. Probabilistic input distribution sampling informed 95% uncertainty intervals (UIs). Incremental cost-effectiveness ratios (ICERs) < $50,000/QALY gained were considered cost-effective., Results: Treating 0.7 million hypertensive non-Hispanic black adults would prevent about 8,000 CVD events annually; treating 3.4 million non-Hispanic whites would prevent about 35,000 events. Overall 2014 guideline implementation would be cost saving in both groups compared with no treatment. For stage 1 hypertension but without diabetes or chronic kidney disease, cost savings extended to non-Hispanic black males ages 35-44 but not same-aged non-Hispanic white males (ICER $57,000/QALY; 95% UI $15,000-$100,000) and cost-effectiveness extended to non-Hispanic black females ages 35-44 (ICER $46,000/QALY; $17,000-$76,000) but not same-aged non-Hispanic white females (ICER $181,000/QALY; $111,000-$235,000)., Conclusions: Compared with non-Hispanic whites, cost-effectiveness of implementing hypertension guidelines would extend to a larger proportion of non-Hispanic black hypertensive patients., (© American Journal of Hypertension, Ltd 2016. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: The New Cooperative Medical Scheme (NCMS) in rural China has been expanding in both population coverage and benefit package. China has also established an essential medicine policy in recent years to further reduce patients' medical expenditures and financial burden. This study aims to evaluate the impact of these policies on reducing medical expenditures and financial burden of patients diagnosed with hypertension and diabetes., Methods: This study used repeated cross-sectional surveys in 2011 and 2012 in three counties of Shandong Province. Outpatient and inpatient service expenditures and catastrophic health expenditures (CHE) were measured and analyzed., Results: Medical expenditures for outpatient services significantly increased for hypertensive and diabetic patients within a 1 year period, while inpatient service expenditures remained unchanged. Although NCMS increased its reimbursement rate, hypertensive and diabetic patients still heavily suffered CHE from both outpatient and inpatient services. Outpatient services were more important factors than inpatient services contributing to non-communicable chronic diseases (NCD) patients' financial burden., Conclusions: The effects of NCMS expansion have been offset by the rapid escalation of medical expenditures. More attention should be paid to the design of NCMS benefit package to cover NCD outpatient services. There is also an urgent need to reform the current Fee for Service to other provider payment methods in order to control the escalating NCD medical expenditures.

Electronic processes and communication technologies are more and more often employed to provide healthcare services to caregivers and their patients. Such solutions are currently referred as e-health, the most popular and widely distributed being those based on telemedicine and mobile health (m-health). A specific application of telemedicine for hypertension management is blood pressure telemonitoring (BPT), which allows remote data transmission of BP and additional information on patients' health status from their living site or from a community setting to the doctor's office or the hospital. Several randomized studies have documented a significant BP reduction with regular BPT compared to usual care, particularly in high risk hypertensive patients. Additional benefits are observed when BPT is offered under the supervision of a team of healthcare professionals, including a community pharmacist. BPT may also be provided in the context of m-health solutions, which commonly include wireless diagnostic and clinical decision support tools. M-health has the potential to promote patient's self-management, as a complement to the doctor's intervention, and encourage greater participation in medical decision making. Current statistics show that half of smartphone owners gather health information through their phone and 19 % use a health app. In case of hypertensive patients the most popular apps are those with tracking function, including BPT. Thus, e-health, and in particular BPT and m-health, are progressively gaining a key role in the management of hypertensive patients, having the potential to improve the quality of the delivered care and to more effectively prevent cardiovascular consequences of high BP.

Background: The objective of the study is to estimate the frequency of multimorbidity in type 2 diabetes patients classified by health statuses in a European region and to determine the impact on pharmaceutical expenditure., Methods: Cross-sectional study of the inhabitants of a southeastern European region with a population of 5,150,054, using data extracted from Electronic Health Records for 2012. 491,854 diabetic individuals were identified and selected through clinical codes, Clinical Risk Groups and diabetes treatment and/or blood glucose reagent strips. Patients with type 1 diabetes and gestational diabetes were excluded. All measurements were obtained at individual level. The prevalence of common chronic diseases and co-occurrence of diseases was established using factorial analysis., Results: The estimated prevalence of diabetes was 9.6 %, with nearly 70 % of diabetic patients suffering from more than two comorbidities. The most frequent of these was hypertension, which for the groups of patients in Clinical Risk Groups (CRG) 6 and 7 was 84.3 % and 97.1 % respectively. Regarding age, elderly patients have more probability of suffering complications than younger people. Moreover, women suffer complications more frequently than men, except for retinopathy, which is more common in males. The highest use of insulins, oral antidiabetics (OAD) and combinations was found in diabetic patients who also suffered cardiovascular disease and neoplasms. The average cost for insulin was 153€ and that of OADs 306€. Regarding total pharmaceutical cost, the greatest consumers were patients with comorbidities of respiratory illness and neoplasms, with respective average costs of 2,034.2€ and 1,886.9€., Conclusions: Diabetes is characterized by the co-occurrence of other diseases, which has implications for disease management and leads to a considerable increase in consumption of medicines for this pathology and, as such, pharmaceutical expenditure.

Background: Hypertension is the leading preventable cause of premature death worldwide. We examined global disparities of hypertension prevalence, awareness, treatment, and control in 2010 and compared secular changes from 2000 to 2010., Methods: We searched MEDLINE from 1995 through 2014 and supplemented with manual searches of retrieved article references. We included 135 population-based studies of 968 419 adults from 90 countries. Sex- and age-specific hypertension prevalences from each country were applied to population data to calculate regional and global numbers of hypertensive adults. Proportions of awareness, treatment, and control from each country were applied to hypertensive populations to obtain regional and global estimates., Results: In 2010, 31.1% (95% confidence interval, 30.0%-32.2%) of the world's adults had hypertension; 28.5% (27.3%-29.7%) in high-income countries and 31.5% (30.2%-32.9%) in low- and middle-income countries. An estimated 1.39 (1.34-1.44) billion people had hypertension in 2010: 349 (337-361) million in high-income countries and 1.04 (0.99-1.09) billion in low- and middle-income countries. From 2000 to 2010, the age-standardized prevalence of hypertension decreased by 2.6% in high-income countries, but increased by 7.7% in low- and middle-income countries. During the same period, the proportions of awareness (58.2% versus 67.0%), treatment (44.5% versus 55.6%), and control (17.9% versus 28.4%) increased substantially in high-income countries, whereas awareness (32.3% versus 37.9%) and treatment (24.9% versus 29.0%) increased less, and control (8.4% versus 7.7%) even slightly decreased in low- and middle-income countries., Conclusions: Global hypertension disparities are large and increasing. Collaborative efforts are urgently needed to combat the emerging hypertension burden in low- and middle-income countries., (© 2016 American Heart Association, Inc.)

Objectives: Interventions to improve medication adherence are effective, but resource intensive. Interventions must be targeted to those who will potentially benefit most. We examined what heterogeneity exists in the value of adherence based on levels of comorbidity, and the changes in spending on medical services that followed changes in adherence behavior., Study Design: Retrospective cohort study examining medical spending for 2 years (April 1, 2011, to March 31, 2013) in commercial insurance beneficiaries., Methods: Multivariable linear modeling was used to adjust for differences in patient characteristics. Analyses were performed at the patient/condition level in 2 cohorts: adherent at baseline and nonadherent at baseline., Results: We evaluated 857,041 patients, representing 1,264,797 patient therapies consisting of 40% high cholesterol, 48% hypertension, and 12% diabetes. Among those with 3 or more conditions, annual savings associated with becoming adherent were $5341, $4423, and $2081 for patients with at least diabetes, hypertension, and high cholesterol, respectively. The increased costs for patients in this group who became nonadherent were $4653, $7946, and $4008, respectively. Depending on the condition and the direction of behavior change, savings were 2 to 7 times greater than the value for individuals with fewer than 3 conditions. In most cases, the value of preventing nonadherence (ie, persistence) was greater than the value of moving people who are nonadherent to an adherent state., Conclusions: There is important heterogeneity in the impact of medication adherence on medical spending. Clinicians and policy makers should consider this when promoting the change of adherence behavior.

Background: Hypertension is one of the commonest chronic diseases, yet limited data are available for related health care utilization. Our study objective was to describe the emergency department (ED) and subsequent hospitalization related health care utilization and charges due to hypertension in the U.S., Methods: We used the National ED sample (NEDS) to study hypertension-related utilization and charges. Multivariable-adjusted linear or logistic regression was used to assess hypertension-associated ED and hospitalization outcomes (disposition, length of stay, charges), adjusted for patient demographic, comorbidity and hospital characteristics., Results: There were 0.92, 0.97 and 1.04 million ED visits (0.71-0.77 % of all ED visits) with hypertension as the primary diagnosis in 2009, 2010 and 2012, respectively; 23 % resulted in hospitalization. ED charges were $2.00, $2.27 and $2.86 billion, and for those hospitalized, total charges (ED plus inpatient) were $6.62, $7.09 and $7.94 billion, in 2009, 2010 and 2012, respectively. Older age (50 to 65 years), female sex, metropolitan area residence, South or West U.S. hospital location, private insurance and the presence of congestive heart failure were each associated with higher charges for an ED visit with hypertension as the primary diagnosis. Younger age, metropolitan residence, Medicaid insurance, hospital location in the Northeast and co-existing diabetes, gout, coronary heart disease, chronic obstructive pulmonary disease, hyperlipidemia and osteoarthritis were associated with higher risk, whereas male sex was associated with lower risk of hospitalization after ED visit for hypertension. In 2012, 71.6 % of all patients hospitalized with hypertension as the primary diagnosis were discharged home. Older age, metropolitan residence and most comorbidities were associated with lower odds, whereas male sex, payer other than Medicare, South or West U.S. hospital location were associated with higher odds of discharge to home., Conclusions: Hypertension is associated with significant healthcare burden in the U.S. Future studies should assess strategies to reduce hypertension-associated cost and health care burden.

The population health effect and cost-effectiveness of implementing intensive blood pressure goals in high-cardiovascular disease (CVD) risk adults have not been described. Using the CVD Policy Model, CVD events, treatment costs, quality-adjusted life years, and drug and monitoring costs were simulated over 2016 to 2026 for hypertensive patients aged 35 to 74 years. We projected the effectiveness and costs of hypertension treatment according to the 2003 Joint National Committee (JNC)-7 or 2014 JNC8 guidelines, and then for adults aged ≥50 years, we assessed the cost-effectiveness of adding an intensive goal of systolic blood pressure <120 mm Hg for patients with CVD, chronic kidney disease, or 10-year CVD risk ≥15%. Incremental cost-effectiveness ratios <$50 000 per quality-adjusted life years gained were considered cost-effective. JNC7 strategies treat more patients and are more costly to implement compared with JNC8 strategies. Adding intensive systolic blood pressure goals for high-risk patients prevents an estimated 43 000 and 35 000 annual CVD events incremental to JNC8 and JNC7, respectively. Intensive strategies save costs in men and are cost-effective in women compared with JNC8 alone. At a willingness-to-pay threshold of $50 000 per quality-adjusted life years gained, JNC8+intensive had the highest probability of cost-effectiveness in women (82%) and JNC7+intensive the highest probability of cost-effectiveness in men (100%). Assuming higher drug and monitoring costs, adding intensive goals for high-risk patients remained consistently cost-effective in men, but not always in women. Among patients aged 35 to 74 years, adding intensive blood pressure goals for high-risk groups to current national hypertension treatment guidelines prevents additional CVD deaths while saving costs provided that medication costs are controlled., (© 2016 American Heart Association, Inc.)

Background: High blood pressure is a leading risk factor for death and disability in sub-Saharan Africa (SSA). We evaluated the costs and cost-effectiveness of hypertension care provided within the Kwara State Health Insurance (KSHI) program in rural Nigeria., Methods: A Markov model was developed to assess the costs and cost-effectiveness of population-level hypertension screening and subsequent antihypertensive treatment for the population at-risk of cardiovascular disease (CVD) within the KSHI program. The primary outcome was the incremental cost per disability-adjusted life year (DALY) averted in the KSHI scenario compared to no access to hypertension care. We used setting-specific and empirically-collected data to inform the model. We defined two strategies to assess eligibility for antihypertensive treatment based on 1) presence of hypertension grade 1 and 10-year CVD risk of >20%, or grade 2 hypertension irrespective of 10-year CVD risk (hypertension and risk based strategy) and 2) presence of hypertension in combination with a CVD risk of >20% (risk based strategy). We generated 95% confidence intervals around the primary outcome through probabilistic sensitivity analysis. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the reference scenario., Results: Screening and treatment for hypertension was potentially cost-effective but the results were sensitive to changes in underlying assumptions with a wide range of uncertainty. The incremental cost-effectiveness ratio for the first and second strategy respectively ranged from US$ 1,406 to US$ 7,815 and US$ 732 to US$ 2,959 per DALY averted, depending on the assumptions on risk reduction after treatment and compared to no access to antihypertensive treatment., Conclusions: Hypertension care within a subsidized private health insurance program may be cost-effective in rural Nigeria and public-private partnerships such as the KSHI program may provide opportunities to finance CVD prevention care in SSA.

Nature within cities will have a central role in helping address key global public health challenges associated with urbanization. However, there is almost no guidance on how much or how frequently people need to engage with nature, and what types or characteristics of nature need to be incorporated in cities for the best health outcomes. Here we use a nature dose framework to examine the associations between the duration, frequency and intensity of exposure to nature and health in an urban population. We show that people who made long visits to green spaces had lower rates of depression and high blood pressure, and those who visited more frequently had greater social cohesion. Higher levels of physical activity were linked to both duration and frequency of green space visits. A dose-response analysis for depression and high blood pressure suggest that visits to outdoor green spaces of 30 minutes or more during the course of a week could reduce the population prevalence of these illnesses by up to 7% and 9% respectively. Given that the societal costs of depression alone in Australia are estimated at AUD$12.6 billion per annum, savings to public health budgets across all health outcomes could be immense.

Objective: To study direct medical cost of hypertensive patients without complicated diseases, to analyze substitution impacts of outpatient expenditure on inpatient expenditure, and then to make recommendations to health policy makers and hypertensive patients for managing hypertension., Methods: The claims data of hypertensive patients insured by the rural new cooperative medical scheme in a city in northern China from 2008 to 2013 were analyzed, descriptive statistics employed to analyze direct medical cost of hypertensive patients and hypertensive patients without complicated diseases which was one of the three groups divided by medical treatment conditions (hypertension without complicated diseases, hypertension with complicated diseases, and other diseases), and the differences between groups compared by t test. The fixed effect two-part model was employed to analyze the substitution effect of outpatient services on inpatient services, and specific effects of outpatient times and reimbursement expenses on the inpatient expenditure were calculated by Logistic regression analysis., Results: For the hypertensive patients, the average cost of outpatients was 283.49 Yuan in 2008 and rose to 370.93 Yuan in 2013. After being divided into three groups, for hypertensive patients without complicated diseases, the average cost of outpatient was 449.79 Yuan in 2008 and rose to 582.53 Yuan in 2013. In the total cost of the outpatient, 45.73% was for the hypertensive patients without complicated diseases; in the total cost of the inpatient, only 9.29% was for the hypertensive patients without complicated diseases. By calculating the marginal effect of parameter estimation through the fixed effect two-part model, the inpatient cost could be significantly reduced by increasing the visit times of outpatient utilization or the cost of outpatient reimbursement. For example, in 2013, a 1% rise of outpatient visit times increased outpatient expenditures by 6.48 million Yuan, which could reduce inpatient expenditures by 39.86 million Yuan. The substituted ratio of outpatient cost on inpatient cost had been around 5 in 2010 and later., Conclusion: The health policy-makers and hypertensive patients should pay more attentions to the substitution of outpatient cost for inpatient cost, especially for the hypertensive patients without complicated diseases whose direct medical cost was mainly due to outpatient rather than inpatient costs.

Background: A previous economic analysis of self-management, that is, self-monitoring with self-titration of antihypertensive medication evaluated cost-effectiveness among patients with uncomplicated hypertension. This study considered cost-effectiveness of self-management in those with raised blood pressure plus diabetes, chronic kidney disease and/or previous cardiovascular disease., Design and Methods: A Markov model-based economic evaluation was undertaken to estimate the long-term cost-effectiveness of self-management of blood pressure in a cohort of 70-year-old 'high risk' patients, compared with usual care. The model used the results of the TASMIN-SR trial. A cost-utility analysis was undertaken from a UK health and social care perspective, taking into account lifetime costs of treatment, cardiovascular events and quality adjusted life years. A subgroup analysis ran the model separately for men and women. Deterministic sensitivity analyses examined the effect of different time horizons and reduced effectiveness of self-management., Results: Base-case results indicated that self-management was cost-effective compared with usual care, resulting in more quality adjusted life years (0.21) and cost savings (-£830) per patient. There was a 99% chance of the intervention being cost-effective at a willingness to pay threshold of £20,000 per quality adjusted life year gained. Similar results were found for separate cohorts of men and women. The results were robust to sensitivity analyses, provided that the blood pressure lowering effect of self-management was maintained for more than a year., Conclusion: Self-management of blood pressure in high-risk people with poorly controlled hypertension not only reduces blood pressure, compared with usual care, but also represents a cost-effective use of healthcare resources., (© The European Society of Cardiology 2015.)

Introduction and Objectives: In Spain, 0.3% of patients with hypertension are refractory to conventional treatment. The complications resulting from deficient control of this condition can lead to poor quality of life for the patient and considerable health care costs. Barostim is an implantable device designed to lower blood pressure in these patients. The aim of this study was to analyze the cost-effectiveness of Barostim compared with drug therapy in hypertensive patients refractory to conventional treatment (at least 3 antihypertensive drugs, including 1 diuretic agent)., Methods: We used a Markov model adapted to the epidemiology of the Spanish population to simulate the natural history of a cohort of patients with refractory hypertension over their lifetime. Data on the effectiveness of the treatments studied were obtained from the literature, and data on costs were taken from hospital administrative databases and official sources. Deterministic and probabilistic sensitivity analyses were conducted., Results: Barostim increased the number of quality-adjusted life years by 0.78 and reduced the number of hypertension-associated clinical events. The incremental cost-effectiveness ratio in a cohort of men reached 68 726 euros per year of quality-adjusted life. One of the main elements that makes this technology costly is the need for battery replacement. The results were robust., Conclusions: Barostim is not a cost-effective strategy for the treatment of refractory hypertension in Spain. The cost-effectiveness ratio could be improved by future reductions in the cost of the battery., (Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Hypertension constitutes a significant disease burden to the society, both in terms of the health-related repercussions as well as financial costs incurred due to morbidity and the cumulative cost of drug therapy. In the real world, it would be useful to have the opportunity to consider the appropriate use of antihypertensive drugs to inform and guide clinical practice. To evaluate the adherence of drugs prescriptions in clinical practice according to predefined standards of care, a series of indicators measurable in relation to specific conditions have been developed. This work presents four indicators: the first related to the use of drugs acting on the renin-angiotensin system in patients at high cardiovascular risk; the second related to the use of angiotensin II antagonists with expired patent; the third related the occasional prescription of antihypertensive drugs; and the fourth on the adherence to treatment with antihypertensive drugs. The four indicators were measured in the OsMed database.