MINIMAL vs OPTIMAL MEDICAL CARE
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MINIMAL vs OPTIMAL MEDICAL CARE. M Mohsen Ibrahim, MD CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY. EHS Guidelines - 2003. Minimal Versus Optimal Care. Resources more than science dictate the type of care that can be provided.

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MINIMAL vs OPTIMAL MEDICAL CARE

M Mohsen Ibrahim, MD

CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY


Minimal versus optimal care

EHS Guidelines - 2003

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


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)


Assessment of high risk status

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


EHS Guidelines - 2003

Evaluation of Hypertensive Patients

+++: strongly recommended. +: recommended. - : not done

+: done if facilities are available.



EgyptianHTN Physician & Patient Survey*

Ever Stopped Your Antihypertensive Drug Therapy1940 patients

Ibrahim - 1998


EgyptianHTN Physician & Patient Survey*

Reasons of Poor Compliance Doctors Survey

%

Ibrahim - 1998


Methods to reduce the costs of hypeertensive treatment
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
CHANGES IN MEAN BLOOD PRESSURE OVER TIME-Australian Therapeutic Trial in Mild Hypertension*

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


Blood pressure variability

EGYPTIAN NHP Therapeutic Trial in Mild Hypertension*

BLOOD PRESSURE VARIABILITY

54.8%


EHS Guidelines - 2003 Therapeutic Trial in Mild Hypertension*

Diagnosis of Hypertension

No TOD

TOD / BP > 160/100mmHg

Visit 1

Visit 1

Visit 2

Visit 2

>140/90 mmHg

Visit 3

Visit 4

Visit 3

Visit 5


Risk categorization

EHS Guidelines - 2003 Therapeutic Trial in Mild Hypertension*

Risk Categorization

  • Hypertensivepatients 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 Therapeutic Trial in Mild Hypertension*

Drug Initiation

BP Monitoring

Risk Category

BP Threshold

A

6-12 month

160/100 mmHg

140/90-150/90 mmHg

B

3-6 month

140/85-135/85 mmHg

1-3 month

C


Drug costs to prevent one mi stroke or death uncomplicated mild to moderate hypertension

IMPROVE COST EFFECTIVENESS Therapeutic Trial in Mild Hypertension*

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

Source: Pearce et al. Am J Hypertens , 1998


Evaluation of therapeutic intervensions
Evaluation of Therapeutic Intervensions Therapeutic Trial in Mild Hypertension*

  • Clinical Effectiveness

  • Safety

  • Cost


Comparing a new therapy and a standard therapy
Comparing a New Therapy and a Standard Therapy Therapeutic Trial in Mild Hypertension*

Clinical Effectiveness

--------------------------------------------------------------

Net CostNew>Std New=Std New<Std

-----------------------------------------------------------------------------------New>StdCEA needed Standard Rx. cost- saving Use Standard Rx

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

New<StdUse New Rx. New Rx. cost-saving CEA needed

----------------------------------------------------------------------------------------------------------

CEA: Cost-effectiveness analysis

Modified After Mark and Hlatky . 2002


Cost effectiveness analysis
Cost - Effectiveness Analysis Therapeutic Trial in Mild Hypertension*

C/new – C/usual care

CE = --------------------------------

HB/new – HB/usual care

-----------------------------------------------------------------------

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


Assessment of health benefits
Assessment of Health Benefits Therapeutic Trial in Mild Hypertension*

  • 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
COST ASSESSMENT Therapeutic Trial in Mild Hypertension*

  • 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 Therapeutic Trial in Mild Hypertension*

M Mohsen Ibrahim, MD

CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY


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


Cost effectiveness of treatment for hypertension
COST-EFFECTIVENESS OF TREATMENT FOR HYPERTENSION PATIENTS WITH MILD-TO- MODERATE HYPERTENSION

>69 YEARS

<45 YEARS

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


Prevention priorities primary prevention
PREVENTION PRIORITIES PATIENTS WITH MILD-TO- MODERATE HYPERTENSION PRIMARY 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


Prevention priorities primary prevention1
PREVENTION PRIORITIES PATIENTS WITH MILD-TO- MODERATE HYPERTENSION PRIMARY PREVENTION

  • Individual Approach

  • Population Approach


Cost effectiveness
Cost-Effectiveness PATIENTS WITH MILD-TO- MODERATE HYPERTENSION


Cost effectiveness1
Cost-Effectiveness PATIENTS WITH MILD-TO- MODERATE HYPERTENSION

  • <$50.000 per LY is economically acceptable

  • >$100.00 per LY is economically unacceptable


Cost effectiveness in hypertension
Cost-Effectiveness in Hypertension PATIENTS WITH MILD-TO- MODERATE 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 effectiveness2
Cost-Effectiveness PATIENTS WITH MILD-TO- MODERATE HYPERTENSION


Cost effectiveness3
Cost-Effectiveness PATIENTS WITH MILD-TO- MODERATE HYPERTENSION

  • 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 effectiveness4
Cost-Effectiveness PATIENTS WITH MILD-TO- MODERATE HYPERTENSION

  • 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%


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