scholarly journals Gaps in antihypertensive and statin treatments and benefits of optimisation: a modelling study in a 1 million ethnically diverse urban population in UK

BMJ Open ◽  
2021 ◽  
Vol 11 (12) ◽  
pp. e052884
Author(s):  
Runguo Wu ◽  
Stuart Christopher Gorthorn Rison ◽  
Zahra Raisi-Estabragh ◽  
Isabel Dostal ◽  
Chris Carvalho ◽  
...  
Keyword(s):  
Primary Care ◽  
Antihypertensive Treatment ◽  
Urban Population ◽  
Statin Treatment ◽  
Uncontrolled Hypertension ◽  
Hypertension Treatment ◽  
Vascular Events ◽  
Medication Costs ◽  
Improve Life Expectancy ◽  
Life Years

ObjectivesTo characterise gaps in antihypertensive treatment in people with hypertension and statin treatment in people with cardiovascular diseases (CVD) in a large urban population and quantify the health and economic impacts of their optimisation.DesignA cross-sectional population study and a long-term CVD decision model.SettingPrimary care, UK.ParticipantsAll adults with diagnosed hypertension or CVD in a population of about 1 million people, served by 123 primary care practices in London, UK in 2019.InterventionsFollowing UK clinical guidelines, all adults with diagnosed hypertension were categorised into optimal, suboptimal and untreated groups with respect to their antihypertensive treatment, and all adults with diagnosed CVD were categorised in the same manner with respect to their statin treatment.OutcomesProportion of patients suboptimally treated or untreated. Projected cardiovascular events avoided, years and quality-adjusted life years (QALYs) gained and healthcare costs saved with optimised treatments.Results21 954 of the 91 828 adults with hypertension (24%; mean age 59 years; 49% women) and 9062 of the 23 723 adults with CVD (38%; mean age 69 years; 43% women) were not optimally treated with antihypertensive or statin treatment, respectively. Per 1000 additional patients optimised over 5 years, hypertension treatment is projected to prevent 25 (95% CI 16 to 32) major vascular events (MVEs) and 7 (3 to 10) vascular deaths, statin treatment, 28 (22 to 33) MVEs and 6 (4 to 7) vascular deaths. Over their lifespan, a patient with uncontrolled hypertension aged 60–69 years is projected to gain 0.64 (95% CI 0.36 to 0.87) QALYs with optimised hypertension treatment, and a similarly aged patient with previous CVD not optimally treated with statin is projected to gain 0.3 (0.24 to 0.37) QALYs with optimised statin treatment. In both cases, the hospital cost savings minus extra medication costs were about £1100 per person over remaining lifespan.ConclusionsOptimising cardiovascular treatments can cost-effectively reduce cardiovascular risk and improve life expectancy.

scholarly journals Antihypertensive treatment in a general uncontrolled hypertensive population in Belgium and Luxembourg in primary care: Therapeutic inertia and treatment simplification. The SIMPLIFY study

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0248471
Author(s):  
Tine De Backer ◽  
Bregt Van Nieuwenhuyse ◽  
Dirk De Bacquer
Keyword(s):  
Primary Care ◽  
Antihypertensive Treatment ◽  
Free Association ◽  
Hypertension Treatment ◽  
Cross Sectional Survey ◽  
Treatment Change ◽  
Cross Sectional ◽  
Therapeutic Adherence ◽  
Therapeutic Inertia ◽  
Stage 1

Background Despite effective treatments, blood pressure (BP) control remains suboptimal. Objective The SIMPLIFY study aimed at identifying key factors related to therapeutic inertia in Belgium and Luxembourg, and evaluating how uncontrolled treated hypertension is managed in primary care. Methods In a 2017 cross-sectional survey, 245 general practitioners (GP) collected routine clinical data from 1,852 consecutive uncontrolled (Office SBP/DBP ≥ 140/90 mmHg) hypertensive adult patients taking at least one antihypertensive drug. Results Patients were 64 years old on average, 48% were women, 61% had dyslipidemia, 33% had diabetes mellitus and 22% had established cardiovascular disease. Half of the patients had 2 or more comorbidities. Patients had been treated for hypertension for an average period of 8 years, 40% of patients were in hypertensive stages 2–3, 44% were treated with monotherapy only, 28% with free combinations and 28% with at least one single pill combination (SPC). Therapeutic adherence was rated as ‘good’ in 62% of patients. AHT treatment was modified in 84% of patients. In the group of patients with stage 2–3 hypertension, treatment remained unchanged in 5%. In the group of patients with stage 1 hypertension, treatment remained unchanged in 23% of patients. Patients treated for longer than 10 years were less likely to undergo treatment change (81%) compared to patients treated for less than 10 years (87%). Patients with 1 or 2 comorbidities were more likely to have their treatment modified (87%) compared to those with no comorbidities (61%) and those with ≥ 3 comorbidities (79%). If treatment was modified, a SPC was introduced in 90% of cases; 91% in stage 1–2 hypertension and 84% in stage 3 hypertension. SPCs were less frequently initiated in patients without comorbidities. Main reasons for the GPs to switch from a free association towards SPC were ‘better BP control’ (55%), ‘better therapeutic compliance’ (53%) and ‘simplicity for the patient’ (50%). Conclusion The SIMPLIFY study confirms therapeutic inertia in hypertension management. After an average of 8 years hypertension treatment, almost 1 in 2 uncontrolled treated patients are on monotherapy. The key inertia drivers seem to be age, mild grade hypertension, isolated systolic hypertension, longer duration of antihypertensive treatment and better therapeutic adherence. When treatment is updated by the GP, the currently preferred strategy is switching towards SPC based therapy to improve BP control, and enhance therapeutic compliance by simplifying treatment for the patient. Trial registration pharma.be visa number: VI 17/01/20/01 ISRCTN registered study: ISRCTN16199080.

scholarly journals Rationale and design of the Learning Implementation of Guideline-based decision support system for Hypertension Treatment (LIGHT) Trial and LIGHT-ACD Trial

2021 ◽  
Author(s):  
Jiali Song ◽  
Xiu-Ling Wang ◽  
Bin Wang ◽  
Yan Gao ◽  
Jia-Min Liu ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Primary Care ◽  
Decision Support ◽  
Support System ◽  
Antihypertensive Treatment ◽  
Primary Outcome ◽  
Dual Therapy ◽  
Hypertension Treatment ◽  
Care Practices ◽  
Primary Care Practices

BackgroundComputerized clinical decision support systems (CDSS) are low-cost, scalable tools with the potential to improve guideline-recommended antihypertensive treatment in primary care. Uncertainty remains about the optimal initial antihypertensive therapy in the settings of real practice.MethodsThe Learning Implementation of Guideline-based decision support system for Hypertension Treatment (LIGHT) trial is a pragmatic, cluster-randomized controlled trial of CDSS versus usual care conducted in 100 primary care practices in China. The primary outcome is the proportion of hypertension visits with appropriate (guideline-recommended) antihypertensive treatment. Among patients recruited from primary care practices of the intervention group in the LIGHT trial, we further conducted a sub-study, the LIGHT-ACD trial, to compare the effects of initial antihypertensive therapy by randomizing individual patients to receive different antihypertensive regimens of initial monotherapy or dual therapy. The primary outcome of the sub-study is the absolute change in blood pressure from baseline to 9 months.ResultsWe hypothesize that the use of CDSS will result in a higher proportion of appropriate antihypertensive treatments being prescribed during visits for hypertension control in the LIGHT trial, and that particular choices of monotherapy or combinations of dual therapy lead to greater blood pressure change in the LIGHT-ACD trial.ConclusionThese nested trials will provide reliable evidence on the effectiveness of CDSS for improving adherence to guidelines for hypertension management in primary care, and data on the effectiveness of different initial antihypertensive regimens for blood pressure reduction.Registration numberLIGHT (NCT03636334) and LIGHT-ACD (NCT03587103).

Antihypertensive treatment and blood pressure control relative to hypertension treatment guidelines

2014 ◽  
Vol 23 (12) ◽  
pp. 1294-1302 ◽  
Author(s):  
Christopher G. Rowan ◽  
John Rick Turner ◽  
Ankit Shah ◽  
Jeffrey A. Spaeder
Keyword(s):  
Blood Pressure ◽  
Blood Pressure Control ◽  
Antihypertensive Treatment ◽  
Treatment Guidelines ◽  
Pressure Control ◽  
Hypertension Treatment

scholarly journals The effect of statin treatment on survival and on the use of healthcare resources among patients with acute myocardial infarction

2018 ◽  
pp. 30-48
Author(s):  
Lien Nguyen ◽  
Unto Häkkinen ◽  
Henna Jurvanen
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Linear Models ◽  
Statin Treatment ◽  
Data Set ◽  
Hospitalised Patients ◽  
Life Years ◽  
Matched Data ◽  
The Cost ◽  
Statin Use

The aim of this study was to investigate the cost-effectiveness of statin use by newly hospitalised patients with acute myocardial infarction (AMI) in Finland. The data were from the PERFECT database of patients hospitalised for AMI and discharged in 1998–2012 in Finland. Selected patients had first-time AMI and had not used statins earlier (N=60 404). We generated a matched data set from statin non-users for statin users based on propensity matching analysis (N=28 412), which was also used. Statin use was defined as statins purchased within the first week after hospital discharge. Healthcare costs included costs of inpatient and outpatient hospital care, costs of nursing homes and costs of prescribed medicines (at 2011 prices). The follow-up time was one year. Logit and generalised linear models were used. We measured the effects of statin use as life years (LYs) gained and computed costs per LY gained. Both data were analysed for the entire period and for subperiods 1998–2001, 2002–2007 and 2008–2011, without discount rates and with a 3% discount rate. An average patient would gain 0.26–0.51 more years. The estimated costs per LY gained ranged between EUR 800 and 15 000. They were highest (EUR 12 000–15 000) in 1998–2001 by the matched data, but were actually savings in 2008–2011. The estimated costs indicate that statin use in treating AMI was very cost-effective. However, our rather long study period may suggest that the cost estimates per LY gained could be overestimated, as the life expectancy of AMI patients is likely shorter than that of the general population.Published: Online April 2018.

scholarly journals Cost-Effectiveness and Budget Impact of Emerging Minimally Invasive Surgical Treatments for Benign Prostatic Hyperplasia

2021 ◽  
Vol 8 (1) ◽  
pp. 42-50
Author(s):  
Bilal Chughtai ◽  
Sirikan Rojanasarot ◽  
Kurt Neeser ◽  
Dmitry Gultyaev ◽  
Stacey L. Amorosi ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Benign Prostatic Hyperplasia ◽  
Minimally Invasive ◽  
Budget Impact ◽  
Prostatic Hyperplasia ◽  
Minimally Invasive Surgical ◽  
Medication Costs ◽  
Life Years ◽  
Surgical Treatments ◽  
The Cost

Background: Benign prostatic hyperplasia (BPH) is one of the most prevalent and costly chronic conditions among middle-aged and elderly men. Prostatic urethral lift (PUL) and convective water vapor thermal therapy (WVTT) are emerging minimally invasive surgical treatments as an alternative to traditional treatment options for men with moderate-to-severe BPH. This study evaluated the cost-effectiveness and budget impact of PUL and WVTT for men with BPH using long-term clinical outcomes. Methods: The cost-effectiveness and budget impact models were developed from a US Medicare perspective over a 4-year time horizon. The models were populated with males with a mean age of 63 and an average International Prostate Symptom Score (IPSS) of 22. Clinical inputs were extracted from the LIFT and Rezum II randomized controlled trials at 4 years. Utility values were assigned using IPSS and BPH severity levels. Procedural, adverse event, retreatment, follow-up, and medication costs were based on 2019 Medicare payment rates and Medicare Part D drug spending. One-way and probabilistic sensitivity analyses (PSAs) were performed. Results: At 4 years, PUL was associated with greater retreatment rates (24.6% vs 10.9%), lower quality-adjusted life-years (QALYs) (3.490 vs 3.548) and higher total costs (US$7393 vs US$2233) compared with WVTT, making WVTT the more effective and less costly treatment strategy. The 70% total cost difference of PUL and WVTT was predominantly driven by higher PUL procedural (US$5617 vs US$1689) and retreatment (US$976 vs US$257) costs. The PSA demonstrated that relative to PUL, WVTT yielded higher QALYs and lower costs 99% and 100% of the time, respectively. Conclusions: Compared to PUL, WVTT was a cost-effective and cost-saving treatment of moderate-to-severe BPH. These findings provide evidence for clinicians, payers, and health policy makers to help further define the role of minimally invasive surgical treatments for BPH.

A Cohort Analysis of Statin Treatment Patterns Among Small-Sized Primary Care Practices

2022 ◽  
Author(s):  
Jingzhi Yu ◽  
Ann A. Wang ◽  
Lindsay P. Zimmerman ◽  
Yu Deng ◽  
Thanh-Huyen T. Vu ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Analysis ◽  
Statin Treatment ◽  
Treatment Patterns ◽  
Care Practices ◽  
Primary Care Practices

Abstract 65: Effects of Immediate Blood Pressure Reduction on Two-Year Mortality and Major Disability in Patients With Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jiang He ◽  
Yonghong Zhang ◽  
Tan Xu ◽  
Dali Wang ◽  
Chung-Shiuan Chen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Treatment Group ◽  
Acute Ischemic Stroke ◽  
Antihypertensive Treatment ◽  
Blood Pressure Reduction ◽  
Control Group ◽  
Antihypertensive Medications ◽  
Vascular Events

Although elevated blood pressure (BP) is very common in patients with acute ischemic stroke, the management of hypertension among them remains controversial. We tested the effect of immediate BP reduction on two-year mortality and major disability in acute ischemic stroke patients. The China Antihypertensive Trial in Acute Ischemic Stroke, a randomized, single-blind, blinded end-points trial, was conducted in 4,071 patients with ischemic stroke within 48 hours of onset and elevated systolic BP (SBP). Patients were randomly assigned to receive antihypertensive treatment (n=2,038) or to discontinue all antihypertensive medications (n=2,033) during hospitalization. Post-treatment follow-ups were conducted at 3, 12, and 24 months after hospital discharge. The primary outcome was a composite of death and major disability at the two-year follow-up visit. Mean SBP was reduced by 21.8 in the treatment group and 12.7 mm Hg in the control group within 24 hours after randomization (P<0.001). Mean SBP was 137.3 mm Hg in the treatment group and 146.5 in the control group at day 7 after randomization (P<0.001). At two-year follow-up, study outcomes were obtained in 1945 (95.4%) participants in the treatment group and 1925 (94.7%) in the control group. 78.8% of the patients in the treatment group and 72.6% in the control group reported the use of antihypertensive medications (p<0.001). SBP was 138.8 mmHg in the antihypertensive treatment group and 139.7 in the control group (p=0.02). Among patients in the antihypertensive treatment group, 24.5% (476/1945) died or had a major disability, compared with 22.1% (425/1925) in the control group (odds ratio 1.14 [95% CI 0.99 to 1.33], p=0.078). Hazard ratios for all-cause mortality (1.01 [0.81, 1.25], p=0.95), recurrent stroke (0.91 [0.73, 1.13], p=0.40), and vascular events (0.97 [0.79, 1.19], p=0.76) were not statistically significant comparing the antihypertensive treatment group to the control group. The effect of antihypertensive treatment did not differ by pre-defined subgroups. In conclusion, among patients with acute ischemic stroke, BP reduction with antihypertensive medications during hospitalization did not reduce or increase the composite outcome of death and major disability over two years.

Common mental disorders in cities

2019 ◽  
pp. 226-238
Author(s):  
Santosh K. Chaturvedi ◽  
Narayana Manjunatha
Keyword(s):  
Economic Growth ◽  
Primary Care ◽  
General Population ◽  
Urban Population ◽  
Somatoform Disorders ◽  
Common Mental Disorders ◽  
Common Mental Disorder ◽  
Healthcare Facilities ◽  
The World ◽  
Global Data

Common mental disorder (CMDs) are the most common psychiatric disorders in the general population, as well as at primary care. They include a triad of three illnesses—depression, anxiety disorders, and somatoform disorders. Global data suggest that the urban population exceeded the rural population in 2007. Cities provide an opportunity for economic growth and comparatively better healthcare facilities. However, what is worrisome is the increased vulnerability for many illnesses, especially CMDs. This chapter reviews the noteworthy literature about CMDs in cities across the world and discusses some of best practices in treating CMDs in various cities.

scholarly journals Effectiveness and cost-effectiveness of Improving clinicians’ diagnostic and communication Skills on Antibiotic prescribing Appropriateness in patients with acute Cough in primary care in CATalonia (the ISAAC-CAT study): study protocol for a cluster randomised controlled trial

Trials ◽  
2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Rafa Ruiz ◽  
Ana Moragas ◽  
Marta Trapero-Bertran ◽  
Antoni Sisó ◽  
Anna Berenguera ◽  
...  
Keyword(s):  
Primary Care ◽  
Cost Effectiveness ◽  
Communication Skills ◽  
Controlled Trial ◽  
Sensitivity Analyses ◽  
Antibiotic Prescribing ◽  
Cluster Randomised ◽  
Life Years ◽  
Effectiveness And Efficiency ◽  
Tract Infections

Abstract Background Despite their marginal benefit, about 60% of acute lower respiratory tract infections (ALRTIs) are currently treated with antibiotics in Catalonia. This study aims to evaluate the effectiveness and efficiency of a continuous disease-focused intervention (C-reactive protein [CRP]) and an illness-focused intervention (enhancement of communication skills to optimise doctor-patient consultations) on antibiotic prescribing in patients with ALRTIs in Catalan primary care centres. Methods/design A cluster randomised, factorial, controlled trial aimed at including 20 primary care centres (N = 2940 patients) with patients older than 18 years of age presenting for a first consultation with an ALRTI will be included in the study. Primary care centres will be identified on the basis of socioeconomic data and antibiotic consumption. Centres will be randomly assigned according to hierarchical clustering to any of four trial arms: usual care, CRP testing, enhanced communication skills backed up with patient leaflets, or combined interventions. A cost-effectiveness and cost-utility analysis will be performed from the societal and national healthcare system perspectives, and the time horizon of the analysis will be 1 year. Two qualitative studies (pre- and post-clinical trial) aimed to identify the expectations and concerns of patients with ALRTIs and the barriers and facilitators of each intervention arm will be run. Family doctors and nurses assigned to the interventions will participate in a 2-h training workshop before the inception of the trial and will receive a monthly intervention-tailored training module during the year of the trial period. Primary outcomes will be antibiotic use within the first 6 weeks, duration of moderate to severe cough, and the quality-adjusted life-years. Secondary outcomes will be duration of illness and severity of cough measured using a symptom diary, healthcare re-consultations, hospital admissions, and complications. Healthcare costs will be considered and expressed in 2021 euros (year foreseen to finalise the study) of the current year of the analysis. Univariate and multivariate sensitivity analyses will be carried out. Discussion The ISAAC-CAT project will contribute to evaluate the effectiveness and efficiency of different strategies for more appropriate antibiotic prescribing that are currently out of the scope of the actual clinical guidelines. Trial registration ClinicalTrials.gov, NCT03931577.

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