M Mohsen Ibrahim, MDCARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY

MINIMAL vs OPTIMAL MEDICAL CARE

Minimal Versus Optimal Care

• Resources more than science dictate

the type of care that can be provided.

• Guidelines have to make a compromise

between what is possible (minimal

care) and what is ideal (optimal care).

• No Health Care System Has Unlimited

Resources

EHS Guidelines - 2003

“Where resources are limited it becomes

imperative to direct drug treatment to

individuals in the high and very high risk

before considering their use in the lower

risk patients” (WHO-ISH GUIDELINES)

Minimal Care Optimal Care

• Age• Family History• Past History of ACVD• Smoking• Body Weight• Blood Sugar• Total Cholesterol /LDL-C• HDL-C• Triglycerides• S Creatinine• ECG• Hs-CRP

ASSESSMENT OF HIGH RISK STATUS

•Age

•Family History

•Past History of ACVD

•Smoking

•Body Weight

Evaluation of Hypertensive Patients

Minimal Care Optimal Care Detailed History- Physical Exam. +++ ++ Urine dipstick + + Blood Sugar + + ECG + + Blood tests: urea, creatinine, lipid profile, K+

- +

Optic Fundus - +

+++: strongly recommended. +: recommended. - : not done+: done if facilities are available.

EHS Guidelines - 2003

Therapy

Minimal Care

Optimal Care Duration of blood pressure

monitoring before starting drug therapy

Weeks to months Weeks to months

Life style and diet therapy +++ ++

160/100 160/100 150/90 140/90

Threshold Blood Pressure Low risk group Intermediate risk group High risk group 140/85 135/85 Drug of first choice Small dose thiazide Individualize Target Blood Pressure Low & intermediate risk groups High risk group

< 140/90 < 135/85

< 140/90 < 135/85

EHS Guidelines - 2003

21

79

never stopped

stopped

Ever Stopped Your Antihypertensive Drug Ever Stopped Your Antihypertensive Drug

TherapyTherapy

1940 patients1940 patients

Egyptian HTN Physician & Patient Survey*

Ibrahim - 1998

Reasons of Poor Compliance Reasons of Poor Compliance Doctors SurveyDoctors Survey

71

5651

40

24

85

0

10

20

30

40

50

60

70

80

Cost HTN has noSymp

Drug SideEffects

Forgetfulness Friend'sAdvice

No Effect onBP

DR's Advice

Egyptian HTN Physician & Patient Survey*

Ibrahim - 1998

%

METHODS TO REDUCE THE COSTS OF HYPEERTENSIVE TREATMENT

• Improve Effectiveness of Treatment - Accurate classification of BP - Maximize life style change - Balance benefits vs risks of treatment - Adherence to treatment regimen - Control of other CV risk factors

• Reduce Costs - Start treatment with lower cost medications - Limit office visits to clear clinical objective - Limit laboratory test to necessary ones

CHANGES IN MEAN BLOOD PRESSURE OVER TIME-Australian Therapeutic Trial in Mild Hypertension*

0

50

100

150

200

mmHg

Line 1

SBP(mmHg) 157.4 154.1 152.3 144.6 144.6 146.4 142.9 144.2 144.6 142.2 144.2

Line 3

DBP(mmHg) 102 98 96.9 92.2 92.2 93.6 91 91.6 91.6 90 90.7

First screenin

g2 weeks 4 weeks 4 months 8 months

12 months

16 months

20 months

24 months

32 months

36 months

*1119 subjects given placebo and observed for 3 years Lancet:1980

BLOOD PRESSURE VARIABILITY

1559

999855

567

0

200400

600800

10001200

14001600

1800

All HTN Untreat HTN

HTN Patients

EGYPTIAN NHP

54.8%

Diagnosis of Hypertension

No TOD

Visit 1

Visit 2

Visit 3

Visit 4

Visit 5

Visit 2

Visit 3

Visit 1

TOD / BP > 160/100mmHg

>140/90 mmHg

EHS Guidelines - 2003

Risk Categorization

• Hypertensive patients can be categorized according to their risk profile

(adopted from JNC VI):

• Group A (low risk): no TOD, no other risk factors and no

associated cardiovascular disease.

• Group B (intermediate risk): one or more additional risk factors

but not diabetes or TOD.

• Group C (high risk): diabetes, TOD and/or associated

cardiovascular disease.

EHS Guidelines - 2003

Drug InitiationRisk

Category

A

B

C

160/100 mmHg

140/90-150/90 mmHg

140/85-135/85 mmHg

BP Threshold

6-12 month

3-6 month

1-3 month

BP Monitoring

EHS Guidelines - 2003

DRUG COSTS TO PREVENT ONE MI, STROKE OR DEATH(UNCOMPLICATED MILD TO MODERATE HYPERTENSION)

Drug Class Treatment Middle-aged Elderly

Diuretic HCTZ $4731 $1595

B-Blocker Atenolol $105,092 $35,438

ACE-I Enalapril $156,520 $52,780

Alpha-blocker

Doxazosin $151,188 $50,982

Calcium blocker

Nifedipine GITS

$346,236 $116,754

Source: Pearce et al. Am J Hypertens , 1998

IMPROVE COST EFFECTIVENESSIMPROVE COST EFFECTIVENESS

Evaluation of Therapeutic Intervensions

•Clinical Effectiveness

•Safety

•Cost

Comparing a New Therapy and a Standard Therapy

Clinical Effectiveness --------------------------------------------------------------Net Cost New>Std New=Std New<Std-----------------------------------------------------------------------------------New>Std CEA needed Standard Rx. cost- saving Use Standard Rx

New=Std New Rx. Better Toss-up Standard Rx. better

New<Std Use New Rx. New Rx. cost-saving CEA needed----------------------------------------------------------------------------------------------------------CEA: Cost-effectiveness analysisModified After Mark and Hlatky . 2002

Cost - Effectiveness Analysis

CE = -------------------------------- HB/new – HB/usual care

C/new – C/usual care

-----------------------------------------------------------------------CE: cost-effectiveness; C: costs; HB: health benefits

Assessment of Health Benefits

Sensible units :

-mmHg blood pressure change

-No of myocardial infarctions prevented

-Minutes of exercise increased

Number of added life-years (LYs) Primary therapeutic goal is to prolong life expectancy

Quality- adjusted life-year (QALY) One year of life in excellent health = 1.0 QALY

COST ASSESSMENT

• Costs of Intervention : -Drugs -Lab tests -Physician

• Costs of Morbidity after an Event : - Direct costs (health care costs) - Indirect costs (loss of productivity)

MINIMAL vs OPTIMAL MEDICAL CARE

M Mohsen Ibrahim, MDCARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY

NUMBERS-NEEDED-TO TREAT TO PREVENT CV EVENTS OR DEATH IN PATIENTS WITH MILD-TO-

MODERATE HYPERTENSION

Event Risk RatioTreated/Control

5-Year NNT

Middle-agedFatal or nonfatal CHD 0.91 390

Fatal or nonfatal stroke 0.56 135

Nonfatal event or death 0.82 86

ElderlyFatal or nonfatal CHD 0.82 70

Fatal or nonfatal stroke 0.65 45

Nonfatal event or death 0.84 29Pearce et al. 1998

COST-EFFECTIVENESS OF TREATMENT FOR HYPERTENSION

DBP (mmHg)

Men Women Men Women

>104 $73,700 $125,000 _ _

100-104 $106,500 $232,500 $500 _

95-99 $130,700 $317,200 $2300 $1200

90-94 $158,600 $419,800 $4200 $3500

Approximate net cost per life-year gained in US dollars Source: Johannesson M,1995

<45 YEARS >69 YEARS

PREVENTION PRIORITIESPRIMARY PREVENTION

• Population Approach

2% reduction of mean population BP (about 3 mmHg in DBP)

Prevent every year by 2020 in Asia Pacific Region : -1.2 million deaths from stroke ( about 15% of all deaths from stroke) -0.6 million deaths from CHD (6% of all deaths from CHD)

Reducing Salt Content of Manufactured Food

• Individual Approach

• Population Approach

PREVENTION PRIORITIESPRIMARY PREVENTION

Cost-Effectiveness

Therapeutic Modality Cost-Effectiveness Range (dollars/year of life saved)

Antihypertensive therapy

$4,000 to 93,0000

Renal dialysis $20,000 to 79,000CABG (LM/3VD) $2,3000 to 27,000Exercise to prevent CHD Cost-saving to $38,000Aspirin to prevent CHD Cost-saving to $5,000Smoking cessation to prevent CHD

Cost-saving to $13,000

Cost-Effectiveness

• <$50.000 per LY is economically acceptable

• >$100.00 per LY is economically unacceptable

Cost-Effectiveness in Hypertension

• Costs of drugs and other medical expenses required to prevent one MI, stroke or death

• Medications account for 50% to 90% of the direct costs of hypertension treatment

• NNT: number of patients needed to treat for 5 years to prevent one event

• Cost-effectiveness of drug therapy = average whole sale price of drug for 5 years of treatment X (5-y NNT)

Cost-Effectiveness

Cost-Effectiveness

• Event Rate = No of events/P-Yof observation• Risk Difference = Control – Treatment event

rate• Cost –Effectiveness of Drug (Cost to Prevent

an Event) = AWP(5y trt) X 5y NNT -AWP : average whole sale prices -5y NNT : No of patients treated for 5

years to prevent one event

• Cost of QALY gained: - < $40.000 – highly cost-effective - = $60.000 – reasonable cost-effective - > $100.000 – not cost-effective• If society is willing to pay $60.000 to gain a

QALY treatment should be started if the 5-year-risk of CHD exceeded

-For men -For women 35 y 2.4% 2.0% 50 y 4.6% 3.5% 70 y 10.4% 10.4%

Cost-Effectiveness